ACCORDING to a report from its inspector general, the Department of Veterans Affairs is now paying compensation for post-traumatic stress disorder to nearly twice as many veterans as it did just six years ago, at an annual cost of $4.3 billion. What's more surprising is that the flood of recent applicants does not, for the most part, consist of young soldiers just returned from Iraq and Afghanistan. Rather they are Vietnam veterans in their 50's and 60's who claim to be psychologically crippled now by their service of decades ago.
This leads to an obvious question: Can it really take up to 40 years after a trauma before someone realizes he can no longer cope with the demands of civilian life? The answer: possibly, but it is often hard to know which applicants can be helped with short-term psychiatric care, which are seeking a free ride and which are truly deserving of the diagnosis of post-traumatic stress disorder and thus long-term care and payments of up to $2,300 a month for life. The task before the Veterans Affairs Department is to come up with criteria.
Medically speaking, there is some evidence to support what psychiatrists call "reactivated" post-traumatic stress disorder. The literature is dotted with cases of veterans of World War I, World War II and the Korean War who, after briefly showing signs of stress disorders in the immediate aftermath of their ordeals, led productive lives for decades before breaking down in their 60's and 70's. Little is known about the treatment of reactivated symptoms, but there is reason to be optimistic that patients will recover nicely in view of their having functioned well for so long.
But it's also very likely that some of the veteran baby boomers who have filed claims in recent years did so not out of medical need but out of a desire for financial security in their retirement years. Indeed, 40 percent of last year's claimants had been out of the military for 35 to 49 years.
In any case, the rush of applications for long-term disability entitlements reflects the extent to which the culture of the Department of Veterans Affairs since Vietnam has become fixated on post-traumatic stress disorder. While claims for all other forms of mental illness, like schizophrenia and bipolar illness, have declined by about 12 percent of patients at veterans' hospitals over the last decade, the number of veterans receiving compensation for post-traumatic shock has nearly tripled.
Having worked as a psychiatrist at a Veterans Affairs hospital, I can attest to the good intentions with which the department created its post-traumatic stress disorder programs. But as the bureaucracy has become entrenched — and politicians and veterans' groups have applied pressure — a culture of trauma has blossomed. If a veteran can demonstrate service in Vietnam and simply list a few symptoms of the disorder (terrifying nightmares, bad memories, anxiety, survivor guilt and so on), there is a good chance he will be granted the diagnosis and a tax-free monthly stipend.
The problem in giving a diagnosis so long after a patient saw combat is that it can be very difficult to know whether traumatic exposure was the true cause. Yet many Veterans Affairs doctors and officials simply assume that participation in war results, de facto, in post-traumatic stress disorder. Whatever other problems a veteran may have — alcohol abuse, erratic employment, domestic violence — are seen as a product of the war experience.
Surely some of these applicants have "never been right," as their spouses often say, since their discharge from the military. Over the years they drifted further away from their families and communities. By the time they come to a veterans' hospital for treatment, they are seen as having "malignant P.T.S.D." — that is, severe symptoms of post-traumatic stress disorder complicated by drug and alcohol abuse and other mental problems like depression.
The Veterans Affairs Department has to begin differentiating between several categories of delayed-benefit applicants. First are the chronically afflicted veterans who were probably damaged by the war but never got adequate treatment after discharge. These veterans fit the description of war casualties; their long-standing problems make them hard to treat, and thus they are good candidates for long-term care and subsidies.
The second group consists of those who are experiencing genuine "reactivated" symptoms from war trauma. Such patients will probably respond to therapy and not require long-term support.
Third are the veterans who managed to get diagnoses of post-traumatic stress disorder decades after their military service. They have made use of a system that has coalesced around the idea that combat is the root of all anguish. They deserve treatment to the extent that it can help, but rarely long-term disability payments.
As the department tries to distinguish among these groups, verification of exposure to trauma is vital. The inspector general's office found that for one-quarter of Vietnam veterans claiming post-traumatic stress, the department could not confirm any incidents of traumatic stress. A study in a leading psychiatric journal last year could not verify such history in 59 percent. True, military personnel records are not perfect — a cook who endured a terrifying rocket attack on an airbase at which he was stationed may be unable to produce documentation of it. However, such records could indeed disprove the fabrications of a cook who claimed he was traumatized by a firefight on infantry patrol.
Most important, more rigor in diagnosing will conserve resources for veterans who are truly deserving. With a new generation of soldiers returning from Iraq and Afghanistan, the Veterans Affairs Department needs to look at post-traumatic stress disorder in a new way: the department must regard it as an acute but treatable condition. Only in rare instances should veterans be eligible for lifetime disability; and perhaps there should be a deadline of years after service by which claims must be submitted.
Someday, the diagnostic techniques may be sophisticated enough to help us parse the varieties of claimants; but for now we must be skeptical of veterans who file claims as retirement approaches. The Veterans Affairs Department should be spending its time and money helping our newest veterans now, when the psychological consequences of war have fresh meaning and patients have an excellent chance at recovery. Decades after a war is too late to make sense of post-traumatic stress disorder.
Sally Satel, a psychiatrist and resident scholar at the American Enterprise Institute, is a co-author of "One Nation Under Therapy."
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vaf
Op-Ed Contributor
For Some, the War Won't End
By SALLY SATEL
Published: March 1, 2006
Washington
ACCORDING to a report from its inspector general, the Department of Veterans Affairs is now paying compensation for post-traumatic stress disorder to nearly twice as many veterans as it did just six years ago, at an annual cost of $4.3 billion. What's more surprising is that the flood of recent applicants does not, for the most part, consist of young soldiers just returned from Iraq and Afghanistan. Rather they are Vietnam veterans in their 50's and 60's who claim to be psychologically crippled now by their service of decades ago.
This leads to an obvious question: Can it really take up to 40 years after a trauma before someone realizes he can no longer cope with the demands of civilian life? The answer: possibly, but it is often hard to know which applicants can be helped with short-term psychiatric care, which are seeking a free ride and which are truly deserving of the diagnosis of post-traumatic stress disorder and thus long-term care and payments of up to $2,300 a month for life. The task before the Veterans Affairs Department is to come up with criteria.
Medically speaking, there is some evidence to support what psychiatrists call "reactivated" post-traumatic stress disorder. The literature is dotted with cases of veterans of World War I, World War II and the Korean War who, after briefly showing signs of stress disorders in the immediate aftermath of their ordeals, led productive lives for decades before breaking down in their 60's and 70's. Little is known about the treatment of reactivated symptoms, but there is reason to be optimistic that patients will recover nicely in view of their having functioned well for so long.
But it's also very likely that some of the veteran baby boomers who have filed claims in recent years did so not out of medical need but out of a desire for financial security in their retirement years. Indeed, 40 percent of last year's claimants had been out of the military for 35 to 49 years.
In any case, the rush of applications for long-term disability entitlements reflects the extent to which the culture of the Department of Veterans Affairs since Vietnam has become fixated on post-traumatic stress disorder. While claims for all other forms of mental illness, like schizophrenia and bipolar illness, have declined by about 12 percent of patients at veterans' hospitals over the last decade, the number of veterans receiving compensation for post-traumatic shock has nearly tripled.
Having worked as a psychiatrist at a Veterans Affairs hospital, I can attest to the good intentions with which the department created its post-traumatic stress disorder programs. But as the bureaucracy has become entrenched — and politicians and veterans' groups have applied pressure — a culture of trauma has blossomed. If a veteran can demonstrate service in Vietnam and simply list a few symptoms of the disorder (terrifying nightmares, bad memories, anxiety, survivor guilt and so on), there is a good chance he will be granted the diagnosis and a tax-free monthly stipend.
The problem in giving a diagnosis so long after a patient saw combat is that it can be very difficult to know whether traumatic exposure was the true cause. Yet many Veterans Affairs doctors and officials simply assume that participation in war results, de facto, in post-traumatic stress disorder. Whatever other problems a veteran may have — alcohol abuse, erratic employment, domestic violence — are seen as a product of the war experience.
Surely some of these applicants have "never been right," as their spouses often say, since their discharge from the military. Over the years they drifted further away from their families and communities. By the time they come to a veterans' hospital for treatment, they are seen as having "malignant P.T.S.D." — that is, severe symptoms of post-traumatic stress disorder complicated by drug and alcohol abuse and other mental problems like depression.
The Veterans Affairs Department has to begin differentiating between several categories of delayed-benefit applicants. First are the chronically afflicted veterans who were probably damaged by the war but never got adequate treatment after discharge. These veterans fit the description of war casualties; their long-standing problems make them hard to treat, and thus they are good candidates for long-term care and subsidies.
The second group consists of those who are experiencing genuine "reactivated" symptoms from war trauma. Such patients will probably respond to therapy and not require long-term support.
Third are the veterans who managed to get diagnoses of post-traumatic stress disorder decades after their military service. They have made use of a system that has coalesced around the idea that combat is the root of all anguish. They deserve treatment to the extent that it can help, but rarely long-term disability payments.
As the department tries to distinguish among these groups, verification of exposure to trauma is vital. The inspector general's office found that for one-quarter of Vietnam veterans claiming post-traumatic stress, the department could not confirm any incidents of traumatic stress. A study in a leading psychiatric journal last year could not verify such history in 59 percent. True, military personnel records are not perfect — a cook who endured a terrifying rocket attack on an airbase at which he was stationed may be unable to produce documentation of it. However, such records could indeed disprove the fabrications of a cook who claimed he was traumatized by a firefight on infantry patrol.
Most important, more rigor in diagnosing will conserve resources for veterans who are truly deserving. With a new generation of soldiers returning from Iraq and Afghanistan, the Veterans Affairs Department needs to look at post-traumatic stress disorder in a new way: the department must regard it as an acute but treatable condition. Only in rare instances should veterans be eligible for lifetime disability; and perhaps there should be a deadline of years after service by which claims must be submitted.
Someday, the diagnostic techniques may be sophisticated enough to help us parse the varieties of claimants; but for now we must be skeptical of veterans who file claims as retirement approaches. The Veterans Affairs Department should be spending its time and money helping our newest veterans now, when the psychological consequences of war have fresh meaning and patients have an excellent chance at recovery. Decades after a war is too late to make sense of post-traumatic stress disorder.
Sally Satel, a psychiatrist and resident scholar at the American Enterprise Institute, is a co-author of "One Nation Under Therapy."
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