North Carolina AHEC Program
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Invisible Wounds

More than ever, soldiers coming home with traumatic brain injuries and stress disorders, flooding our mental health facilities and often defying conventional treatments. What can we do?

By Whitney L.J. Howell

AHEC CSSP training programFor Robert and Holly Mullis, both staff sergeants in the Army, Robert’s return from frontline combat wasn’t the happy homecoming that they envisioned. The anticipated family picnics and laughter never materialized. In their place, Robert and Holly found their lives were full of anxiety and loneliness. “I have a constant ringing in my ears. I can’t sit in a group unless I know everyone. I can’t sit with my back to the door,” Robert says. “I have to know everything that’s going on all the time.”

Photo right: AHEC/CSSP training sessions are scheduled in military time, and commence with the color guard and the national anthem, in an effort to create a military culture "eye-opener" for providers. Photo courtesy of the CSSP.

It wasn’t until the night he took at least four Ambien sleep aid pills that he realized he needed help for his mental condition. While the pills didn’t help him sleep, he said, they did make him black out. He has no memory of his actions over a 32-hour period during which he dressed for work, filled his truck’s gas tank, and then returned home to crawl in bed with his loaded pistol. Holly discovered him and, fearing he would try to hurt himself, called an ambulance to take him to the hospital. He woke up laying in an intensive care unit and surrounded by police officers.

For Holly, though, the biggest issue was isolation and loneliness. Rather than concentrating on rekindling their married life, she says, Robert wanted to see his “battle buddies” to make sure they were safe. She felt that her experiences paled in comparison to his, so she didn’t want to burden Robert with her emotions.

“I just had to keep all my feelings bottled up,” Holly says. “But having anyone to listen to me would just help so much.”

Similar conversations play out in doctors’ offices across the country on military bases, in veterans’ hospitals, and in private practices every day. Since Operation Iraqi Freedom (OIF) in Iraq and Operation Enduring Freedom (OEF) in Afghanistan began in 2001, more than 1.9 million men and women have served abroad. Many return home unscathed. However, others aren’t so fortunate. According to the New England Journal of Medicine, mental health problems are the second most common ailment behind orthopedic needs for returning military personnel.

Technological advancements in medicine and military equipment save lives and limbs with up to 90 percent of wounded service members surviving their injuries. But, it’s the unseen injuries—the invisible wounds of war—that now plague returning service men and women the most.

In 2007, the RAND Center for Military Health Policy Research estimated that 300,000 military personnel currently suffer from post-traumatic stress disorder (PTSD) or major depression, and roughly 320,000 individuals potentially sustained a minor traumatic brain injury (TBI) during deployment. More recent RAND statistics published in the February 2010 Journal of Traumatic Stress indicate that at least 15 percent of returning personnel have symptoms specifically of PTSD or depression.

“The best indicator for PTSD is the amount of combat exposure a service member has,” says Lisa Jaycox, PhD, a RAND senior behavioral scientist and clinical psychologist. “It affects their relationships, their ability to work, their physical health, and can contribute to substance abuse.” Overall post-deployment psychological problems, not only depression and possible TBIs, but also various psychoses, are more prevalent. A 2007 Department of Defense (DoD) Task Force on Mental Health stated that 38 percent of soldiers, 31 percent of Marines and 49 percent of National Guard reservists revealed they developed a mental health issue associated with their service.

The DoD postulates that National Guard reservists have a greater proclivity to report problems, accounting for their seemingly higher incidence level of mental health issues. Unfortunately, admitting to a mental health problem doesn’t mean a service member will actively seek help. Only 30 percent of OIF and OEF service members with an official mental health diagnosis endeavor to do so, according to RAND statistics from the February study. Those who don’t are putting themselves at greater risk for unemployment, lower incomes, chronic health conditions, and homelessness, Jaycox says. The decision to get help isn’t an easy one for a service member, and it also doesn’t mean that he or she can.

Barriers to care

Despite the growing mental health needs in the US, clinical investigations show there simply aren’t enough licensed providers. A 2009 Psychiatric Services study conducted at the UNC Cecil G. Sheps Center for Health Services Research found that 96 percent of counties nationwide have too few mental health practitioners to meet the needs in their respective communities.

According to Richard Weisler, MD, adjunct psychiatry professor at the UNC School of Medicine and a practicing community psychiatrist, the military community in North Carolina mirrors the same provider shortage.

“For the nearly 400,000 service members at Fort Bragg and Camp Lejeune, there are only five psychiatrists,” Weisler says. “When you compare that to the data from RAND or other organizations, you see these men and women simply don’t have enough resources for mental health care.”

Not being able to schedule an appointment is only one obstacle service members face. Military culture itself will often dissuade someone from asking for help, said Harold Kudler, MD, a mental health services coordinator for the Department of Veterans’ Affairs (VA). It’s important that providers learn to “speak military,” he says. “We don’t often think about the military as a distinct culture in society that requires a certain cultural competency,” he says. “But individuals in this culture are less likely to ask for help. They don’t want to be stigmatized or ‘admit they’re crazy,’ and they don’t want to be taken out of the field because they would feel like they let their buddies down.”

In fact, Kudler says, many service members refer to mental health providers as “wizards,” not because they miraculously make the problems disappear, but because service members who make appointments suddenly vanish from the field.

Many don’t even think of themselves as veterans because they didn’t experience gunfire or were never in the most dangerous positions. This viewpoint can prevent a service member from seeking the care they need, Kudler says, because they do not feel their experiences were traumatic enough to warrant medical attention.

Service members also fear their commanding officers will find out if they seek help for a mental health issue and will consider them unfit to serve, Kudler says. This concern is large enough that the DoD allows individuals to deny, on official forms, any previous mental health services they’ve received, and many service members will forego the medical care available on a military base or at a veterans’ clinic simply to keep their needs a secret.

Seeking help from a provider in the community, though, can also be an obstacle due to cost. Care in the community is often more expensive, and many nonmilitary physicians do not accept TriCare, the military-provided insurance program, because it provides lower reimbursements than most coverages. Providers farther away from a military installation, particularly those in rural areas, are less likely to accept TriCare despite the presence of service members in the community.

The women’s issue

OIF and OEF are the first military engagements in which women were allowed to serve on the front lines, although there is still an official restriction against women being in the line of fire. Based on VA statistics, 12 percent of the more than 45,000 OIF and OEF servicewomen have sought some type of mental health care. They experience many of the same symptoms as men, but some problems are unique to women.

According to Kudler, servicewomen are more likely to develop depression rather than PTSD when they return home. They also develop more personality disorders than men and, often, become hyper-protective of their children.

Women also experience different barriers to care when searching for treatment. Although the VA system is the traditional health care setting for returning veterans, the system has been slow to accept women as military personnel, and, thus, doesn’t offer the myriad of primary and specialty care services most women require. But women can also work against themselves by holding the belief that a PTSD diagnosis carries a stigma. They believe PTSD makes them bad mothers, so they refuse to acknowledge it and get help.

Carolina’s contribution

North Carolina has a base for every military branch and is among the most military-friendly states. Approximately 700,000 people, nearly 10 percent of the state’s population, have served or are serving in the military. The state’s contribution to the OIF and OEF efforts is unique, because roughly 30 percent of NC service members belong to the National Guard and do not live close to a large base. The result is that up to 50 percent of veterans live in rural or highly rural areas that are historically underserved and far away from most veterans’ clinics or other health care environments designed to help them. Consequently, many forego the treatment they need.

UNC, its clinicians, and its researchers are working to improve the services available to these men and women,as well as make them more accessible. The Citizen Soldier Support Program (CSSP) at The Odum Institute for Research in Social Science connects the military to the services available in the community and trains providers in the most effective ways to treat military personnel suffering with mental health problems.

“We need to train clinical providers so they truly understand the issues of returning reservists and their families,” says Bob Goodale, CSSP director. “It’s never been more important. Providers need to understand military culture — they need to know what military conflict is really like.”

First and foremost, Goodale said, providers must remember to ask the gateway question: “Have you or anyone in your family ever served in the military?” Without the answer to that question, he said, mental health specialists and primary care providers (who are the first to see 70 percent of these problems) cannot appropriately treat a patient’s needs.

One of CSSP’s biggest achievements, Goodale says, is its provider database. Practitioners who are qualified to address military mental health needs, who accept TriCare, and who want to make their services available, register with this database. Service members looking for a provider can search the database and easily find someone in their area who can give the treatment they need.

To ensure community providers know how to treat service members effectively, CSSP partners with the North Carolina Area Health Education Centers Program (AHEC) to provide educational sessions across the state. Some sessions are offered as in-person seminars, but others are webinars or podcasts devoted to specific mental health problems, including PTSD and TBI. In 2008–2009, these courses were offered 15 times and trained more than 1,000 health care professionals, says Karen Stallings, associate director of AHEC. One of AHEC’s main concerns, she says, is to educate more providers and encourage them to choose to become resources for mental health care in rural settings rather than urban ones.

According to Sheryl Pacelli, director of mental health and disaster preparedness at the South East AHEC, AHEC and CSSP are developing a DVD toolkit that will guide other organizations through creating a PTSD or TBI training course, securing logistics and designing the education aspects. “We want our programs to be a cultural eye-opener for providers,” Pacelli says. “With the face-to-face trainings, we open the day with the color guard, we play the national anthem, and we do the schedules in military time.”

Rather than teach providers to understand the intricacies and idiosyncrasies of war, she said, the AHEC/CSSP partnership hopes to train them to listen to military personnel more effectively to really hear their concerns and understand the events behind them.

Many of these providers take this training back to the VA system to treat returning service members. The initial therapies for TBI and other mental health issues predominantly occur at the VA because the system is smoothly connected to military bases. There are, however, times when the VA simply doesn’t have the physical capacity to provide care for a veteran despite the individual’s right to access.

These are the instances when these same service members will arrive at the UNC Health Care System, says Harry Marshall, MD, assistant professor of surgery in the UNC School of Medicine’s Division of Trauma and Critical Care Surgery. UNC had nearly 30,000 visits from service members with TriCare insurance in 2009. In many cases, the individual experienced an accident in the civilian world that exacerbated his or her old mental health issues.

“Sometimes simple things unrelated to war cause difficulties, like the headaches, trouble sleeping, and depression associated with a TBI or PTSD, to flare up. And these individuals are likely already dealing with decreased motility, lost limbs or, maybe, a facial deformity,” says Marshall, who also served two tours of duty as a National Guard reservist. “What Agent Orange was to Vietnam, PTSD and TBI will be to the Iraq and Afghanistan conflicts.”

Just as UNC offers all manner of mental health services, from counseling to cognitive therapy to prescriptions for antidepressants, its researchers are also delving into the causes of mental health issues in returning service members but with a twist.

Eric Elbogen, MD, assistant professor of psychiatry at the UNC School of Medicine and researcher at the VA Hospital in Durham, NC, investigated what protective factors could improve a service member’s readjustment into civilian society. His study was published in the May 2010 issue of the American Journal of Psychiatry.

Through a survey of 676 OIF and OEF service members, Elbogen determined that service members do not all experience PTSD the same way. Instead, there are three symptoms: flashbacks, avoidance of anything that reminds the individual of the trauma, and a state of hyperarousal and jumpiness. Within these symptoms, he said, anger also manifests itself differently as either typical anger, aggressive impulses, and, at the extreme end of the spectrum, an inability to control violent behavior. Knowing the difference is important to properly treat the patient.

“If we know what factors are related to each symptom, we will know how to target effective therapies,” Elbogen says. “This research gives clinicians the skill set to tailor their treatment just because one vet who walks into the office has anger, it doesn’t mean it’s an identical situation to the next vet who comes in.”

It will be several years, however, before the medical community understands the details of the mental health issues OIF and OEF veterans face. The higher survival rate among wounded service members vaulted health care providers into unchartered territory because long-term studies on the effects of PTSD and its treatments haven’t been possible to date. Over the next few years, however, the health care field hopes to have more definitive data to create evidence-based care for suffering veterans. “There is one aspect of therapy that we know is fact now,” Elbogen says. “It’s clear that veterans who have the chance to speak with someone about their feelings and problems have better outcomes than someone who never gets the opportunity.”

Reprinted with permission from the UNC Medical Bulletin summer 2010 issue.

Editor's Note: The Citizen Soldier Support Project and AHEConnect offers a free accredited online course series titled Treating the Invisible Wounds of War. Each course offers continuing education credit, depending on course material. Visit AHEConnect for registration information.