Stop Loss

A Nation Weighs the Tangible Consequences of Invisible Combat Wounds

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Christopher Voeller says he now battles with post-traumatic stress disorder.
AP IMAGES/THE HUTCHINSON NEWS/ 
CHRISTOPHER HANEWINCKEL 
Christopher Voeller, who was shipped to Iraq in late 2005 and returned to his home in Hutchinson, Kansas, in late 2006, says he now battles with post-traumatic stress disorder.

Costly Consequences

Left untreated, PTSD, major depression, and TBI can have far-reaching, damaging, and costly consequences. Individuals with these conditions tend to miss more days of work, report being less productive while at work, and are more likely to be unemployed. The presence of any of these conditions predicts a greater likelihood that an individual will experience other psychiatric problems, such as substance abuse. All three conditions increase an individual’s risk for attempting suicide. All three have been associated with higher rates of unhealthy behaviors — such as smoking, overeating, and unsafe sex — higher rates of physical health problems, and higher mortality rates. There is also a possible link between these conditions and homelessness.

Populations with high rates of PTSD, major depression, or TBI are likely to demonstrate high rates of family difficulties as well. Each disorder accounts for a greatly increased risk of distressed relationships, domestic violence, and divorce among the afflicted. The interpersonal deficits that interfere with emotional intimacy in the romantic relationships of servicemembers who have these disorders appear likely to interfere also with their interactions with their children. Thus, the effect of post-combat mental disorders may extend beyond the lifespan of an afflicted veteran, stretching across generations. It may take decades to count the costs of these afflictions, and decades more to heal from them.

The manifold consequences can exact a high economic toll. Most attempts to measure the economic costs have concentrated solely on medical costs to the government. However, the direct costs of treatment are just a fraction of the total costs. Far higher are the long-term individual and societal costs stemming from lost productivity, reduced quality of life, domestic violence, family strain, homelessness, and suicide. Restoring veterans to full mental health has the potential to reduce these long-term costs significantly.

But because reliable data are unavailable to quantify many of these costs, we are able to factor in only the treatment cost, lost productivity (including reduced employment and lower earnings), and the cost of lives lost to suicide. (We ascribe a value of $7.5 million to each “statistical life” lost to suicide. A statistical life represents a hypothetical individual who might be saved by a particular intervention or policy change.)

Figure 4 —

The Cost Per Case of PTSD or Major Depression Can Vary Greatly Depending on the Number of Suicides

The Cost Per Case of PTSD or Major Depression Can Vary Greatly Depending on the Number of Suicides
SOURCE: Invisible Wounds of War, 2008.
NOTE: The estimated costs per case are based on a weighted average of the costs for servicemembers returning from Iraq or Afghanistan with the ranks of E-4, E-5, E-7, and O-2.
  

Figure 5 —

Delivering Evidence-Based Treatment to All Veterans Returning Home with PTSD or Major Depression Would Pay for Itself in Just Two Years

Delivering Evidence-Based Treatment to All Veterans Returning Home with PTSD or Major Depression Would Pay for Itself in Just Two Years
SOURCE: Invisible Wounds of War, 2008.
NOTES: The total cost estimates assume that 15 percent of the troops returning home developed PTSD within two years, that half of these cases were comorbid with major depression, and that an additional 7.2 percent of returning troops suffered from major depression only. These prevalence rates were taken from published literature, not from the RAND survey of veterans.
  

Figure 6 —

Lost Productivity Can Be a Large Driver of the Societal Costs Associated with PTSD and Major Depression

Lost Productivity Can Be a Large Driver of the SocietalCosts Associated with PTSD and Major Depression
SOURCE: Invisible Wounds of War, 2008.
NOTES: The cost components are based on a two-year projection for 50,000 servicemembers returning from Iraq or Afghanistan at the age of 25 at a rank of E-5 with five to seven years of service. The low-cost and high-cost scenarios incorporate different assumptions about wage reductions, relapse probabilities, and suicide attempts among veterans with mental health conditions. Both scenarios assume that 30 percent of those in need receive treatment and that 30 percent of this treatment is evidence based.

Using a mathematical model to estimate the costs of PTSD and major depression, we first compute the total two-year costs of treatment, lost productivity, and suicide among a prototypical population of servicemembers who returned home from Iraq or Afghanistan in 2005. We then derive the average two-year costs per case of PTSD, major depression, and comorbid PTSD and major depression in this population. Based on these average costs per case, we then extrapolate the two-year costs incurred for these conditions among all servicemembers who have returned from Iraq or Afghanistan since 2001.

We limit our time horizon to two years because we do not have enough information either to break down costs or to project the course of remission and relapse over a longer time frame. This calculation thus omits the costs of any chronic or recurring cases that linger beyond two years.

On a cost-per-case basis, the estimated two-year cost for each case of PTSD alone ranges from $5,900 to $10,300; for each case of major depression alone, from $15,460 to $25,760; and for each case of comorbid PTSD and major depression, from $12,430 to $16,890 (see Figure 4). The cost for comorbid PTSD and major depression is lower than the cost for major depression alone because individuals who develop late-onset comorbid PTSD and depression do not become sick until near the end of our two-year time horizon. (Depression does not develop as a late-onset illness unless coupled with PTSD).

In all cases, the low estimates exclude the cost of lives lost to suicide, whereas the high estimates include this cost. Although the cost of a completed suicide is extremely high, the probability of committing suicide — even among those with a mental disorder — is very low. As a result, the estimates can vary widely depending on the expected number of suicides. Because of the high degree of uncertainty regarding the number of completed suicides that might occur as a result of PTSD or major depression, we consistently present results with and without the costs associated with lives lost to suicide.

Applying the per-case costs to the entire population of 1.6 million veterans who have returned from Iraq or Afghanistan since 2001, we estimate that PTSD and major depression have cost the nation between $4 billion and $6.2 billion in just the first two years following deployments, depending on whether we account for the lives lost to suicide.

Savings Opportunities

We also predict the likely costs and savings that would result from treating more of those in need and improving their care. We begin with the following key assumptions about the treatment “status quo”: Only 30 percent of individuals with PTSD or major depression receive treatment, and only 30 percent of those in treatment receive evidence-based care (medical care to which evidence gained from the scientific method has been applied). These assumptions are drawn from scientific research conducted elsewhere.

Relative to the status quo, we consider three alternative scenarios: (a) 50 percent of those in need receive treatment and 30 percent of it is evidence based, (b) 50 percent of those in need receive treatment and all of it is evidence based, and (c) 100 percent of those in need receive treatment and all of it is evidence based.

In the latter scenario, we find that society could save up to $2,310 per person with PTSD alone, up to $3,000 per person with comorbid PTSD and major depression, and up to $9,240 per person with major depression alone — all in just the first two years following deployments — by ensuring that 100 percent of those in need receive evidence-based care. When we exclude the cost of lives lost to suicide, expanding access to evidence-based care for everyone in need would save money only for major depression. This finding reflects the high cost of PTSD treatment and the limited evidence of its benefits.

Figure 5 shows the results on a national basis. The two-year national cost for PTSD and major depression could be reduced by as much as $1.7 billion — or $1,063 per returning veteran — if evidence-based treatment were delivered to all in need. The savings would come from increased productivity and fewer suicides. Even excluding the cost of suicides, the nation could still save $60 million by treating both mental disorders.

Lost productivity can be a large driver of the costs associated with PTSD and major depression. Fully 95 percent of the costs can be attributed to reduced productivity when we exclude the cost of suicides. When we include the cost of suicides, reduced productivity still accounts for 55 percent of the total estimated costs (see Figure 6).

Given these results, evidence-based treatment for PTSD and major depression would pay for itself within two years. If the costs stemming from substance abuse, homelessness, family strain, and other indirect consequences were included, the savings gained from quality treatment would be even greater. Investing in evidence-based treatment makes sense to society at large and to the U.S. Department of Defense as an employer, not only because of higher remission and recovery rates but also because such treatment would increase the productivity of servicemembers and veterans. The benefits in retention and increased productivity would outweigh the higher costs of providing evidence-based care.

Next section: Traumatic Brain Injury
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