World Report

Coming home
Thousands of US veterans of the Iraq and Afghanistan wars are returning home with high
rates of psychological disorders and brain injuries, according to recent research. But is their
health system ready to meet the challenge? Norra MacReady investigates.

War is hell, and few people emerge of Veterans Affairs (VA). All in all, the The total lifetime costs of treating
unscathed from combat, even if authors estimated that only about the psychiatric problems incurred by
they bear no physical wounds. A half of the veterans in need received veterans of the Iraq war could climb
recent report documents the fragile treatment that could be considered to $660 billion—more than the
mental health of many veterans as even minimally adequate. $500 billion spent on the entire war
well as something campaigners have Indeed, although its numbers are so far—according to a presentation by
been saying for a long time: that smaller, the Army’s own statistics Evan Kanter, staff psychiatrist in the
the mental-health care available for PTSD outpatient clinic of the VA Puget
veterans falls short. “The total lifetime costs of Sound Health Care System, at the
Researchers at the Rand Corporation, treating the psychiatric annual meeting of the American Public
a non-profit research organisation, problems incurred by veterans Health Association in November, 2007.
surveyed a representative sample of of the Iraq war could climb to These findings reflect, in part,
veterans and current service members $660 billion...” an awareness of PTSD and other
to determine their mental-health needs psychological consequences of warfare
after returning from deployment. confirm that the incidence of PTSD is that did not exist previously, said Jaycox,
In particular, their needs associated swelling: from 9500 new cases in 2006 who is a senior behavioural scientist
with post-traumatic stress-related to 14 000 in 2007—an increase of 32% at the Rand Corporation. “This [Iraq] is
disorder (PTSD), major depression, in one year, and nearly 600% more the first prolonged conflict where we
and traumatic brain injury. In the than the 2003 figure of 1632. understood PTSD, so we are talking
resulting report—Invisible Wounds of In addition to improving health, about these problems and measuring
War: Psychological and Cognitive Injuries, prompt evaluation and treatment them differently than we have in
Their Consequences, and Services to for PTSD and other combat-related previous wars. Also, we are looking for
Assist Recovery—editors Terri Tanielian psychiatric problems makes good it immediately and following people
and Lisa H Jaycox explained that they economic sense, the Rand authors over time, unlike the war in Vietnam,
undertook the study because there are wrote. They put the total societal in which we did not start looking at the
still large gaps in understanding the costs of PTSD and major depression impact until years later.”
mental-health and cognitive needs of at around US$4–6·2 billion. Providing PTSD is a risk factor for other
this population. these patients with effective, evidence- emotional disorders, so addressing
Since October, 2001, around based treatment could reduce the cost these problems quickly might also
1·64 million Americans have served by $1·7 billion. help reduce the staggering rates of
in Afghanistan or Iraq. Of the 1965
people who responded to the survey,
18·5% met the diagnostic criteria for
PTSD and 14%, for major depression,
whereas 19·5% had a probable
traumatic brain injury. About 7% had
both a mental-health problem and The printed journal
traumatic brain injury. Extrapolating
from these numbers, the authors includes an image merely
calculated that about 300 000 people
would return home with PTSD or for illustration
depression, and 320 000 with a possible
traumatic brain injury.
The study also found a wide gulf
between the need for mental-health
Reuters

care and the availability and quality of

the services offered by the Department Around 1·64 million Americans have served in the wars in Afghanistan and Iraq

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 World Report

Others are more blunt. “There was said. In response to allegations that
no planning for this war [Iraq]. It has veterans sometimes encounter wait
been a mess”, said Shad Meshad, a times of 30 days or more before they
Vietnam veteran and social worker can see a mental-health practitioner,
who founded the National Veterans she said the VA’s policy is to contact
The printed journal Foundation—a private advocacy group
for veterans—in 1985.
and evaluate anyone needing mental-
health care within 24 h and provide
includes an image merely The Iraq war is one of the first to rely
on an all-volunteer army, and drew
non-urgent treatment within 14 days.
Zeiss admitted that “we are still
for illustration many of its ranks, at least initially, from
reservists and the National Guard, who
working on it”, but said that by the
end of March, the 14-day deadline
kept their regular jobs and lives while was being met in 93% of cases, close
training for the military on weekends. to the VA’s goal of 95%.
Then they were “pulled away from their In fairness, the VA is a huge system:
AP

careers and families”, and, returning the total number of veterans and their
A shelter for homeless veterans in the USA: 23–40% of homeless adults are veterans
home after several deployments, dependants who are eligible for VA
homelessness and substance abuse often faced the loss of their families, benefits and services exceeds 70 million.
among veterans, Jaycox said. marriages, jobs, and regular income, Of those people, about 5·5 million
Veterans represent only 9% of the with little training on how to resume actually receive medical care from the
total population of the USA, but, civilian life, he explained. VA. “They are actively trying to moni-
according to the National Alliance to The current conflict is not com- tor quality of care, but it is a big job”,
End Homelessness, they account for parable to the earlier Persian Gulf Jaycox said. According to Zeiss, one
23% to 40% of homeless adults. And war, which was “quick and clean” and of the biggest challenges is reaching
their problems do not stop there. did not involve massive numbers out to veterans who live in remote,
“91% of the patients in VA homeless of troops, he added. The needs of rural areas, without easy access to a VA
programmes have alcohol or drug today’s combatants, not only for medical centre. The VA has contracted
problems”, said Richard A McCormick, health care but for financial and edu- with private practitioners in some
a clinical psychologist and senior cational assistance, have been “just areas, but the quality of care delivered
scholar for the Center of Health Care overwhelming”. in those circumstances varies widely
Research and Policy at Case Western Toni Zeiss, Deputy Director of Mental among states, local communities, and
Reserve University, Cleveland, OH, USA. Health Services for the VA, pointed individual clinicians. In other places, the
He pointed out that “young sailors out that the administration has been VA is experimenting with telemedicine
and soldiers come to treatment not “transforming” its mental-health for assessment, diagnosis, and even
with full-blown PTSD, but with earlier services since 2005, including more treatment. Nevertheless, Zeiss said
signs, such as relationship or marital use of evidence-based psychotherapies that “it is a challenge; it will take some
problems or alcohol-related problems”, and psychosocial treatment. “We have creative thinking”.
such as arrests for drunk driving. PTSD mental-health staff at every Jaycox believes these issues reflect
“One of the motivations behind the VA facility in the country”, usually the problems bedevilling mental-
recommendations in our report was supported by a full clinical team, she health care in the USA as a whole.
the knowledge that treatment and said. “We offer outpatient services When it comes to evidence-based
support can stem the tide of those throughout the system”, including treatment, Americans “broadly have
cascading consequences”, said Jaycox. cognitive therapy and prolonged problems getting high-quality care in
“We know more in this war [Iraq] exposure treatments, both of which general—it is not readily available”.
than we ever knew before about were recommended by the Institute Others say the VA’s efforts are simply
the effect of deployment on mental of Medicine in a 2006 report on PTSD too little, too late: “more rhetoric than
health”, McCormick said. But this that was commissioned by the VA. All anything else”, Shad Meshad asserted.
war has placed unique demands on in all, the administration has more “It is an old system that is operating in
service members: the tours of duty than 90 mental-health programmes the 21st century.” Jaycox added that
are long and multiple deployments around the USA. “We have spent the VA has a duty to provide prompt
are not unusual. Many soldiers have nearly $1 billion on mental health and effective treatment to service
been called back three, four, five, and enhancement since 2005, in addition members, saying, “we really owe
even seven times, with the risk of to our basic mental-health services, them” good quality care.
psychological problems increasing and we have hired about 4000 new
correspondingly. mental-health staff members”, Zeiss Norra MacReady

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