Wednesday, April 04, 2012

PTSD

A new study of PTSD by UCLA's Semel Institute (and published in the Journal of Affective Disorders) is garnering attention. Stephanie O'Neill (KPCC -- link is text and audio) reports, "The new study suggests that a person is more likely to suffer from Post Traumatic Stress Disorder or if they carry two particular gene variations that interfere with the body’s ability to produce Serotonin. That's the brain chemical that regulates, mood, sleep and alertness." Medical News Today quotes the study's lead author, Dr. Armen Goenjian, stating, "People can develop post-traumatic stress disorder after surviving a life-threatening ordeal like war, rape or a natural disaster ... If confirmed, our findings could eventually lead to new ways to screen people at risk for PTSD and target specific medicines for preventing and treating the disorder." Science Daily notes, "PTSD can arise following child abuse, terrorist attacks, sexual or physical assault, major accidents, natural disasters or exposure to war or combat. Symptoms include flashbacks, feeling emotionally numb or hyper-alert to danger, and avoiding situations that remind one of the original trauma." The study examined 200 survivors of the December 7, 1988 Armenian earthquake which claimed at least 45,000 lives.

On the topic of PTSD, Randy Griffith (Tribune-Democrat) explains, "There are three general characteristics of the disorder, Zitnay said. They are re-experiencing the trauma, avoidance and hyper-arousal. Those with PTSD re-experience the event through nightmares, flashbacks and increased anxiety when reminded of the event. Avoidance is characterized by seclusion, amnesia of the incident and taking pains to stay away from locations, people or objects associated with the trauma." Shuka Kalantari (KALW) reports on PTSD by speaking to Iraqi refugee Jasmine who studies engineering in California.

Shuka Kalantari: Jasmine remembers one of those flashbacks. She was at a women's studies class at her college in San Jose. They were watching a documentary about a war in Chile. After the film, the teacher asked students to try and imagine how their life would be if they lived in war.

Jasmine: So she tried like to make the student feel like the feelings of these people. So she stated [. . .] to the class, "You imagine that you lost your husband." As she came to me, "You imagine that they tried to kidnap you."

Shuka Kalantari: Jasmine didn't have to imagine.

Jasmine: I feel like I'm out of air. I left the class and I remained outside -- for over like 20 hours just like crying in a way.

Shuka Kalantari: For the next her mind was flooded with bad memories. She said that even seemingly unrelated things would trigger her symptoms.

Jasmine: Sometimes like part of songs would make me like really like sad and depression if something happened to me. I feel like I'm out of the war for a couple of days.

Shuka Kalantari speaks to the Center for Survivors of Torture's Dr. James Livingston who explains PTSD is fairly common among those forced to flee their homes. Jasmine's father was shot dead in Baghdad and she left the country when it appeared she was being targeted for kidnapping.


The editorial board of the Oregonian weighs in on several issues having to do with PTSD:

The Army had sent so many soldiers to war so many times that its longstanding medical evaluation process simply couldn't keep up with the demand. This imbalance, Horoho told committee chairman Patty Murray, D-Wash., was especially acute for those suffering from invisible wounds such as post-traumatic stress disorder or PTSD.
The Army overhauled its medical evaluation system in 2007, but all the services are still scrambling to catch up. And the effort can be messy.
The latest evidence comes from up the highway at Joint Base Lewis-McChord, the military base near Tacoma that most Oregon National Guard soldiers have passed through on their way home from deployments to Iraq and Afghanistan. Investigators are studying whether medical officers at Madigan Army Medical Center deliberately chose not to diagnose soldiers suffering from PTSD in order to limit costs to the government.
Those costs are substantial. In 2008, Congress granted a 50 percent disability rating for any service member who left the military with a PTSD diagnosis. That means each diagnosis puts the government -- the taxpayers -- on the hook for a lifetime of benefits.

Senator Patty Murray is the Chair of the Senate Veterans Affairs Committee. Horoho is Army Surgeon General Lt Patricia Horoho. Dropping back to the March 28th snapshot for that exchange:

Senator Patty Murray: General Horoho, you and I have had a number of discussions about the invisible wounds of war and the challenges soldiers are facing seeking behavioral health care and, as you well know, Madigan Army Medical Center in my home state of Washington is dealing now with how to handle these wounds and provide our soldiers quality consistent care -- especially for our soldiers who are going through the Integrated Disability Evaluation System. Now I think that some of the issues that have been raised at Madigan are unique to that facility but I do continue to have a number of concerns not only about the situation at Madigan today but the implication for our soldiers really across the Army who may have also struggled to get a proper diagnosis, adequate care and an honest evaluation during the Integrated Disability Evaluation System process. I wanted to ask you today, prior to 2007, Madigan did not use the forensic psychiatry to evalate soldiers in the medical evaluation process. And wanted to ask you today, why was that system changed in 2007.

Army Surgeon Gen Lt Gen Patricia Horoho: Thank you, Senator, for the question. The first thing I'd like to do is just pick up on the word, when you said "invisible wounds." I know it has been said during this war that the signature wound is an invisble wound, I would submit that it is not invisible to the family nor is it invisible to the soldier that's undergoing that -- those, uhm, challenges, behavioral health challenges. The reason -- and I'm-I'm guessing on this, ma'am, because I wasn't there prior to -- but, uh, prior to 2007, we were a nation that entered into war in about 2001 when we were attacked in 2002 timeframe. And we had a very old system. That was the Methold -- a methold system, which was two separate systems, how we managed those service members, active and reserve component, and that was a system which has been in place for many, many years. And what we've found with the large number of deployments and service members that were exposed to physical wounds as well as behavioral health wounds is that we found that the Army system was overwhelmed. And that really is what was found in the 2007 timeframe -- is that we didn't have the administrative capability as well as the logistical support that needed to be there and that's why we stood up our Warrior Transition Units. So we had a large volume going through the disability process that was an old, antiquated process and we had an overwhelming demand on our army that we needed to restructure to be able to support and sustain.

Senator Patty Murray: But prior to 2007, there wasn't a forensic psychiatry that added an additional level of scrutiny.

Army Surgeon Gen Lt Gen Patricia Horoho: It's --

Senator Patty Murray: Correct? Is that correct?

Army Surgeon Gen Lt Gen Patricia Horoho: It's -- I honestly will need to take that for the record because I don't know in 2006 if they had forensics or not. So I can't answer that question for you. I would like to give you a correct answer, so if I could take that one for the record.

Senator Patty Murray: I would appreciate that. And, as I mentioned, I am really concerned that soldiers, Army wide, have been improperly diagnosed and treated by the Army. What have you found under your investigation of soldiers getting incorrect MEPB evaluations at other facilities?

Army Surgeon Gen Lt Gen Patricia Horoho: Ma'am, if I could just, uh, When soldiers are getting diagnoses of PTS or PTSD, we use the same diagnostic tool within the Army, Navy and the Air Force which is the same tool that is used in the civilian sector. So it is one standard diagnostic tool that is very well delineated on the types of symptoms that you need to have in order to get a diagnosis of PTS or PTSD. So we are using that standard across the board and we have been using that standard across the board so --

Senator Patty Murray: But we do know now at Madigan there were soldiers were incorrectly diagnosed. And we're going back through. There were investigations going on to re-evaluate and my question is: There's been a lot of focus at Madigan, I'm concerned about that system-wide. And you're doing an investigation system-wide to see if other soldiers have been incorrectly diagnosed, correct?

Army Surgeon Gen Lt Gen Patricia Horoho: Yes, ma'am. So if I can just lay things out and reiterate some of our past conversations. We have one investigation that is ongoing. Actually, it completed and it's with the lawers that's being reviewed. The Deputy Surgeon General, General Stone, initiated that investigation and that was to look into --

Senator Patty Murray: System-wide?

Army Surgeon Gen Lt Gen Patricia Horoho: No, ma'am, that is the one at Madigan that's looking at the forensics. Then there's another investigation that was launched by the Western Region Medical Command into the command climate at Madigan Army Medical Center. And then what I initiated was an IG assessment that looked at every single one of our medical treatment facilites and the provision of care to see whether or not we had this practice of using forensic psychiatric and psychological medical evaluation process.

Senator Patty Murray: Okay, well my question was whether you had found other facilities with incorrect diagnosis and I want you to know that I have asked my Veterans Affairs staff to begin reviewing cases from throughout the country of service members involved in this process. And we are just beginning our review right now but we have already encountered cases in which a service member was treated for PTSD during their military service, entered the disability evaluation process and the military determined that the service member's PTSD was not an unfitting condition. So my concern is the significant discrepancy now between the Army's determination and the VA's finding that the soldier had a much more severe case of PTSD. Now our review on my Committee's ongoing but besides bringing individual cases to your attention, I wanted to ask you what specific measures do you look at to evaluate whether soldiers are receiving the proper diagnoses and care and honest evaluation?

Army Surgeon Gen Lt Gen Patricia Horoho: It's, uh, we are within the Army, our role as the physician is to evaluate the patient not-not to determine a disability. So they evaluate and identify a diagnoses and a treatment plan and then once that is done during the treatment and if they are determined where they need to go into the disability system, then once they're in the disability system, now because of IDES that occurred in 2010, they now have that evaluation done by the VA, the compensation examp, that's the C and P that's done by the VA. And then they are brought back into the disability systems. But the physical evaluation board, the PEB, is actually where the determination for disability is made. That is not a medical, that is an administrative action that falls under our G1. So I just want to make sure that we don't mix what we do within the medical community in treating and evaluating and what gets done in the disability process that's an administrative process that is reviewing the evaluation from the VA and then the evaluation from the medical to determine disability.

Senator Patty Murray: My concern is that every single soldier who has mental health disability, PTSD, gets the care that they need and that they get the support that they need and they're adequately cared for whether they leave the service or are sent back overseas or whatever. So we're going to continue to look at the system-wide and, as you know, the problems at Madigan were allowed to go on for years and I'm really concerned that lack of oversight over the disability evaluation system is much more broad. And we're going to be following to see what steps you take to ensure that this process is maintained not just at Madigan where there's a severe focus right now but nation-wide.


As noted in that snapshot, I was at a House Veterans Affairs Subcommittee hearing and Wally attended the hearing Murray questioned Horoho in and provided us with the transcript (thank you to Wally for that). Today Senator Patty Muarry holds a field hearing in Tacoma. Her office noted yesterday:

FOR PLANNING PURPOSES

Tuesday, April 03, 2012
Contact: Murray Press Office
(202) 224-2834

TOMORROW: MURRAY TO HOLD SENATE HEARING IN TACOMA ON THE CHALLENGES OUR VETERANS AND SERVICEMEMBERS FACE RETURNING HOME

Official U.S. Senate Veterans' Affairs Committee hearing will bring to top VA and Pentagon officials to the region to answer questions and discuss mental health care concerns, putting local veterans to work, and improving transition services
Hearing will also feature the stories of local veterans and servicemembers, veterans advocates, and businesses in order to highlight challenges and ongoing community efforts

(Washington, D.C.) -- Senator Patty Murray, Chairman of the Senate Veterans' Affairs Committee, will hold a field hearing tomorrow in Tacoma on the unique opportunities and challenges that the South Sound and Washington state continue to face as thousands of veterans return to the region. This official Senate Veterans' Affairs Committee field hearing will explore how the military, veterans, business, and non-profit communities can work together to improve the transition home for those returning to Washington state. In particular, the hearing will focus on improving mental health care, employment opportunities, and community outreach for returning veterans.

The hearing will feature testimony from top VA and Pentagon officials, local servicemembers and veterans, business leaders, and veterans' advocates. Members of the public are encouraged to RSVP if they plan to attend the hearing to fieldhearing@murray.senate.gov


WHAT: U.S. Senate Committee on Veterans' Affairs Field Hearing
"Washington's Veterams: Helping the Newest Generation Transition Home"

WHO: U.S. Senator Patty Murray, Chairman, Senate Veterans' Affairs Committee
Dr. Robert A. Petzel, Under Secretary for Health, Veterans Health Administration,
Department of Veterans Affairs
Dr. Susan Pendergrass, Director, VA Northwest Network (VISN 20), Veterans Health Administration, Department of Veterans Affairs
Willie Clark, Western Area Director, Veterans Affairs
Dr. Jo Ann Rooney: Acting Under Secretary of Defense for Personnel and Readiness, Department of Defense
Lieutenant General Thomas P. Bostick, Deputy Chief of Staff, G-1, United States Army
Major General Richard W. Thomas, Commanding General Western Regional Medical Command, Senior Market Executives for TRICARE Puget Sound, United States Army
Local Servicemembers and Veterans
Business Leaders
Veterans' Advocates

WHEN: TOMORROW: Wednesday, April 4, 2012
Hearing Starts at 10:39 A.M. PST | Doors Open at 9:45 A.M. PST | Cameras
are encouraged to come early for set-up

WHERE: The STAR Center
3873 South 66th Street
Tacoma, WA 98409
Map it
Public Transportation Routes: Pierce Transit Bus Route 53
Parking On-site Parking is available

For more information about this hearing or other activities of the Senate Veterans' Affairs Committee, please visit www.veterans.senate.gov

Press interested in coming are encouraged to RSVP to eli_zupnick@murray.senate.gov

The following community sites -- plus Watching America, Ms. magazine and Antiwar.com -- updated last night and this morning:


Watching America
Lessons of the War on Iraq
38 minutes ago
Ms Magazine Blog
The Femisphere: Welcome to a New Series
1 hour ago





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