War's Invisible Wounds


Sep 28, 2008

A soldier hugging his wife or girlfriend upon his return from deployment

Photo by JPecha/iStock

This commentary originally appeared in Pittsburgh Post-Gazette on September 28, 2008.

The scars of war can be both physical and psychological. Nearly 300,000 Iraq and Afghanistan service veterans who have returned home -- about one in five -- may suffer from combat-stress-related mental health problems.

While these mental wounds are not visible, the problems they cause are real -- from reduced work productivity to divorce, substance abuse, criminal behavior and suicide.

Our veterans ought to get the best available treatments our nation can offer. But they don't.

Post-combat mental health problems are well documented and highly publicized. The military and the general public knew to expect them when the Iraq and Afghanistan wars began. And researchers have been preparing to handle these injuries for the past 30 years, designing and demonstrating effective treatments for post-traumatic stress disorder with the help of hundreds of millions of federal dollars.

Prolonged exposure therapy has been identified by the Institute of Medicine as the treatment with the best evidence of effectiveness. A structured process that typically requires about 15 hours with a therapist, it has been shown to reduce anxiety when a veteran encounters reminders of combat.

Unfortunately, proven treatments like this are unavailable to most Iraq and Afghanistan veterans. Those few who get treated at all usually receive treatments that have not been demonstrated to be effective. This is true whether they obtain care from military, civilian, public health or Veterans Affairs clinicians. The reasons for this failure are complex, and they cut across the many health systems that care for service members and veterans.

At the heart of the problem is a mental health care system that does not ensure providers deliver effective care. For example, clinicians are not required to have training in effective therapies for PTSD in order to provide treatment to patients who have it. Indeed, most psychologists, psychiatrists and clinical social workers have not been trained in effective PTSD therapies.

This failure to deliver the best possible care should not be blamed on dedicated, and often overworked, mental health care clinicians. The problem stems from a system that does not systematically encourage the adoption of effective treatments. To improve the quality of mental health care, it may be necessary to provide training, monitoring and external incentives for clinicians to adopt the practices that work best.

Current efforts in the military and Veterans' Affairs health systems to increase the number of veterans who seek mental health services are not helpful if the therapies are ineffective. Many service members with mental health problems know or suspect the treatments available are of low quality, so they are reluctant to seek treatment. With hundreds of thousands of new cases of PTSD being added to an already overburdened treatment system, now is the time to act.

We should make a simple promise to returning service members with PTSD: You will be guaranteed access to treatments that have been proven effective.

Making good on this promise will require broad changes in our mental health care system. National leadership is necessary to develop a consensus on how to achieve this goal and to bring to the table the many relevant parties, including private insurers, health care companies, professional associations, the military, the VA and veterans organizations.

The policy debate must move beyond merely insuring that patients can get appointments and focus on the quality of the treatment provided. The debate will have to move beyond a narrow focus on Veterans' Affairs, which does more to promote effective mental health care than the broader set of clinicians serving veterans in the private and public sectors.

This debate should be motivated by the very high, long-term costs of untreated -- or unsuccessfully treated -- mental illness for employers, family members and the criminal justice system, rather than on concerns about the short-term budgetary implications of improving treatment. We conservatively estimate that adopting a best-practices approach to veterans' mental health care would pay for itself over time, saving more than $1.5 billion over two years.

We have an opportunity to do the right thing for the men and women who have served our nation, and we can save money by doing it. Can we afford to wait any longer?

Terry Schell is a senior behavioral scientist at the RAND Corp., a nonprofit research organization. Terri Tanielian is co-director of RAND's Center for Military Health Policy Research and Lisa Jaycox is a clinical psychologist and senior behavioral scientist at RAND.

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