Relevant and even prescient commentary on news, politics and the economy.

Post-traumatic stress disorder (PTSD) responses

Past Angry Bear posts started in 2007, but here are four later posts 2008 and 2009:

Brain injury awareness
Pattern of misconduct
PTSD and our military response
What are we going to do now is your choice

GAO report 12-154 addresses the notion that this sort of thing is being taken care of. There are about 80 projects now ongoing to determine best practice within the military culture and organization, which is of course very different than civilian demands placed on personnel. :

Post-traumatic stress disorder (PTSD), which falls into the broader field of psychological health (PH), and traumatic brain injury (TBI) are recognized as the signature wounds of the wars in Afghanistan and Iraq. In two reports issued in 2011 (GAO-11-219 and GAO-11-611), GAO cited numerous management weaknesses at the Defense Center of Excellence for PH and TBI (DCOE). For the present report, GAO reviewed (1) funding for DOD’s PH and TBI activities in fiscal years 2007 through 2010 and the accuracy of its reporting on these activities to Congress and (2) DOD’s ability to coordinate its PH and TBI activities to help ensure that funds are used to support programs of the most benefit to service- members. GAO interviewed DOD officials, reviewed legislation and DOD’s annual reports, and obtained relevant documentation.

From fiscal year 2007 through fiscal year 2010, DOD activities for the treatment and research of PH and TBI received more than $2.7 billion. In fiscal year 2007, funding for these activities totaled $900 million; in fiscal year 2008, it was $573.8 million; in fiscal year 2009, $395 million; and in fiscal year 2010, $838.6 million. GAO found, however, that the reports DOD provided to Congress on these activities did not include expenditures, as required by law, and that the obligations data they contained were unreliable. Governmentwide policies call for agencies to have effective internal controls to assure accurate reporting of obligations and expenditures. 

However, the Office of the Assistant Secretary of Defense for Health Affairs has not developed quality control mechanisms to help ensure that data on PH and TBI activities are complete and accurate. Further, although DOD listed patient care among reported costs, it did not specify what those costs included, making it difficult for decisionmakers and Congress to fully understand the costs.
No one organization coordinates DOD’s PH and TBI activities.

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PTSD for kindergarten kids

Pediatrics also included a short description of work done in the field on treatments for children age 4-7. Nothing earth shaking, but a reminder of who else gets scared in theater, wherever that occurs.

Adler Center for Research in Child Development and Psychopathology, Department of Psychology, Tel Aviv University, Ramat Aviv, Israel
OBJECTIVE. The goal was to assess stress reactions in young children during and after war and the effects of a new brief intervention.

METHODS. Two separate studies were conducted. In study I, we assessed war exposure and stress reactions of 74 children (2–7 years of age) in a sheltered camp during the second Israel-Lebanon war (July to August 2006). Their exposure to war experiences and their stress reactions were assessed through parental reports during the last week of the war. In addition to standard care, 35 children received a brief intervention (Huggy-Puppy intervention) aimed at encouraging them to care for a needy Huggy-Puppy doll that was given to them as a gift. The effects of the Huggy-Puppy intervention were assessed in a follow-up interview 3 weeks after the war. Study II assessed the efficacy of group administration of the Huggy-Puppy intervention to 191 young children, compared with 101 control subjects. The effects of the intervention on stress-related symptoms after the war were assessed in telephone interviews with the parents.
RESULTS. Study I indicated that, during the war, most children had significant exposure to war-related experiences and had severe stress reactions. The Huggy-Puppy intervention was associated with significant reductions in stress reactions in the postwar assessment. A higher level of attachment and involvement with the doll was associated with better outcomes. The results of study II indicated that group administration of the Huggy-Puppy intervention was associated with significant reductions in stress reactions.

Childhood stress and trauma affect kids, and often how it is handled at the time or shortly after is important. Like any trauma, how often it happens, how catastrophic and sometimes life threatening the event appears to be or how intense the reaction is, how it is framed by surrounding trusted adults plays a role in impact on a child.

This is anecdotal and in theater triage, but I think it gives the adults as much structure and focus to help kids and selves as it is the kids responding to the focus and human messages involved. Perspective, feeling protected and protecting, and having someone or thing to take care of is important.

Children who have ptsd can lose their normally easy to find sense of safety and intimacy, and are hyper-sensitive to perceived threat. When they grow up is another story needs telling.

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PTSD meta-analysis

Treatment of PTSD 2008 is a comprehensive meta-analysis of studies done for the government on treatments for PTSD. I will have some follow through later this week. The 212 page document is one of the more throrough I have seen, so I mention this for any readers who have time and are curious. No surprises but some great questions.

Propranolol had no research indicating efficacy for combat ptsd.

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Psycological Kevlar

Psychological Kevlar Act of 2007
introduced by Patrick Kennedy was to help PTSD and brain trauma research expand.

It has come to my attention that the DoD is thinking about using propranolol as a prophylactic to help reduce ptsd symptoms during conflict and after. I had found this articlefrom a wife of a soldier who had killed himself, and who had testified in a Dec. 12, 2007 congressional hearing on suicide among veterans that is apparently on the rise. She has a strong and passionate viewpoint, but that is not for the post.

Propranolol (brand name Inde by Wyeth) is used for a number of diagnosis not related to ptsd. In addition it is used in the psychological Anxiety area as a beta blocker among other uses, for example for rape victims ptsd to help defuse the intensity of the experience in order to work in therapy. Its efficacy is still experimental and not encouraging.

Failing to locate such information, I am wondering if readers may have leads. While an econ blog, many here are also veterans. Thanks. Further information is coming if warranted. I have e-mailed relevant experts that I know.

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PTSD and TBI at home

PBS has a very short description of the effects of PTSD and TBI by several authors that might help in sorting out why the diagnosis is important both for policy, treatment, and moral judgements we as Americans are prone to use to avoid costs of war.

As you stand with other parents watching the kids play soccer, discussing sports or the weather, and your body screams danger. Or a light touch makes you mentally jump a foot into the air as you return the caress. It is a hard tightrope to walk even when you know what is going on. Lack of sleep makes it impossible for some.


Assessments of the many ways in which transitioning from high-stress combat war zones to a peaceful home community environment can be the hardest part of military service. Explaining the difficulties and what can be done to help are psychiatrist and author Jonathan Shay; VA psychiatrist Andrew Pomerantz; retired Navy psychologist Dennis Reeves; Col. Thomas Burke, director for mental health policy for the Dept. of Defense; Vietnam vet and VA counselor Jim Dooley; and Fred Gusman, a director of the VA National Center on PTSD. These excerpts are drawn from their extended FRONTLINE interviews.

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Reader Dan on PTSD and Medical Care, Part 5

This one is by Reader Dan.

What does supporting the troops mean to you? If you ignore looking at these things, can you claim you are in the support category?

“Lead researcher Mark Kaplan of Portland State University in Oregon” reports that

male U.S. veterans are twice as likely to die by suicide than people with no military service, and are more likely to kill themselves with a gun than others who commit suicide….

The study tracked 320,890 U.S. men, about a third of whom served in the U.S. military between 1917 and 1994. The rest had no military background.

Of the veterans, about 29 percent served in the Vietnam War, 28 percent in World War Two, 16 percent in the Korean War and the rest in other conflicts up through the 1991 Gulf War.

Those who committed suicide were more likely to have been white, better educated and older than the other men, the researchers found. The most acute risk was among veterans with some sort of a health problem that made them unable to participate fully in home, work or leisure activities.

The researchers said unlike some previous studies on suicides among U.S. military veterans, theirs did not focus on Vietnam War-era veterans or veterans who get health care through the Department of Veterans Affairs system. They said three-quarters of veterans do not receive health care through VA facilities.

Both the VA and the Pentagon in recent weeks have acknowledged a need to improve “mental health treatment”. Jan Kemp, a VA associate director for education who works on mental health, has estimated there are up to 1,000 suicides a year among veterans within the VA system, and as many as 5,000 a year among all living veterans.

A recent investigation by the Government Accountability Office found that just 22 percent of U.S. troops returning from Iraq and Afghanistan who showed signs of PTSD were being referred by Pentagon health care providers for mental health evaluation, citing inconsistent and subjective standards in determining when treatment was needed.

Penny Coleman is the widow of a Vietnam Veteran who took his own life after coming home. Her latest book, Flashback: Posttraumatic Stress Disorder, Suicide and the Lessons of War, was released on Memorial Day, 2006. In a moving and compassionate way she outlines how ignoring this cost as an externality reverberates for years. She includes in her book how new discussions of human costs of war re-trigger old wounds and, in my mind, might have something to do with the irritability that readers mention about people they know.

And off topic but another problem faces soldiers. Military and family law experts don’t know how big the problem is, but 5.4 percent of active duty members — more than 74,000 — are “single parents”, the Department of Defense reports. More than 68,000 Guard and reserve members are also single parents. Divorce among service personnel is rising.

Custody battles for male or female soldiers is a problem. Hence we have not looked at what conflicts might exist between reasonable laws of family, children, and supporting troops. Family court versus federal law. Why not? is a well known problem, and tangled.

To summarize posts to date:

The military admits to recognizing a real problem that warrants funding in addition to regular care.

To admit to symptoms means loss of career advancement for many. The actual hostility (soldier to soldier and superiors) to admitting symptoms is quite robust, but to date I have only anecdotal evidence.

To seek help is to run into major barriers in VA, Tricare, and private insurers, depending on how you access your insurance. This includes your family as well.

The costs in the short run, much less long run remains as an externality to the cost of war. On the other hand, as more is known, it is harder to ignore.

The system to date appears to prevent best practice and good research from taking the lead as the metric seems to be geared to demand reduction rather than treatment efficacy in this realm of the cognitive sciences. Both public and private funding sources appear to use this metric.

Research is headed in the direction that PTSD is brain based and body based, and has been around awhile, and could help most soldiers and ex-soldiers and families. It is clearly diagnosable and treatments are successful.

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Reader Dan: Medical Care, Part 3

Reader Dan, part 3 on medical care.

Hat tip to Angry Bear reader Buffpilot for joining voices in a liberal/conservative plea for doing the right thing. Please refer to this post for context on PTSD, healthcare, and Therapist1 comments. Clearly there is great need to increase funding for cognitive sciences and occupational therapy needed for our soldiers and their families in Tricare.

Next a post on medical care and cognitive science reimbursements in a scholarly piece by Dr. Jerome Groopman is useful to further thoughts on our next step to thinking about our health system, cognitive sciences, and other medical fields. Hat tip to Angry Bear reader Coberly.

Another piece in the New England Journal of Medicine that I found of interest was a series of letters about medical education. I feel strongly that it is time to integrate cognitive psychology into the curriculum. Physicians are making decisions all the time under conditions of uncertainty, with limited data. The human mind is wired to take shortcuts, and our biases and emotions can strongly color our reasoning. Scant attention is paid to this critical cognitive dimension which underlies misdiagnosis.

Changing behavior is difficult, but, in my experience, most likely succeeds when there is time allotted to the discussion, a close bond between the patient and doctor, and continuing encouragement. It boils down to words and positive feelings, and the health benefits can be extraordinary. Much of what primary care physicians do involves preventive medicine. Unfortunately, the system, based on its payments, is telling us that this has meager value.

As Ginsburg and Berenson point out (in the New England Journal of Medicine), there are powerful lobbying forces against changing payment schedules, and even though a bone is thrown on occasion to increase payment for a certain cognitive practice, at the same time, payments are reduced for other kinds of thinking medicine. It ends up as a wash, if not a reduction in rewards for those doctors who are trying to prevent disease or make a thoughtful diagnosis that takes time.

The question remains, who is a good doctor, and, moreover, who is the right doctor for any individual? The best answer that I have found for myself and my family is a doctor who thinks with us, explains clearly what is in her mind, how she arrived at her working diagnosis, and why the offered treatment makes sense for us as individuals. She may refer to guidelines and “best practices,” but clearly takes into account the spectrum of human biology and customizes our care to fit both our clinical needs as well as our emotional, social, and psychological dimensions.

We currently have a system that costs too much but appears to have professionals leaving in significant numbers because the pay is too low. It was developed as a cost containment structure based on metrics and evidenced based best practice as developed by insurance companies. The question then is to ask who gets rewarded, and what kinds of procedures are rewarded. Clearly it is not cognitive sciences. Who else?

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Reader Dan on PTSD – Part 2

This one is by Reader Dan


New reports are of concern. Is this hype, cowardice, welfare cheating, the decline of the American soldier, or something about the nature of current conflicts and the military structure?

PTSD Part 2

U.S. troops returning from combat in Iraq and Afghanistan suffer “daunting and growing” psychological problems — with nearly 40 percent of soldiers, a third of Marines and half of the National Guard members reporting symptoms — but the military’s cadre of mental-health workers is “woefully inadequate” to meet their needs, a Pentagon task force reported yesterday.

The task force found that 38 percent of soldiers, 31 percent of Marines, 49 percent of Army National Guard members and 43 percent of Marine reservists reported symptoms of PTSD, anxiety, depression or other problems, according to military surveys completed this year by service members 90 and 120 days after returning from deployments.

Two “signature injuries” from Iraq and Afghanistan are PTSD and traumatic brain injury, it said. Symptoms include nightmares and other sleep problems, trouble concentrating, anger, recklessness, and self-medication with drugs and alcohol.

The task force identified several barriers to care, including the stigma associated with seeking help, poor access to providers and facilities, and disruptions in care as service members move locations.

“Stigma in the military remains pervasive and often prevents service members from seeking needed care,” the report said, citing anonymous surveys that show most members with symptoms of mental health problems do not seek help.

Some soldiers underreport problems because they want to stay with their units, and military officials note that many soldiers undergoing treatment for stress or other mental problems are allowed to deploy again after a screening to determine the intensity of their symptoms or depending on what medications they are taking. Those on lithium, for example, should not deploy while those on another class of medications similar to Prozac may be able to, said Army Col. Elspeth Cameron Ritchie, who assisted the task force.

National Guard and reserve members — who often live far from military bases and return from deployments to rural communities — face “particularly constrained” access to clinical care as well as to the military chaplains and family support networks that active-duty personnel can tap, the report said.

“The current complement of mental health professionals is woefully inadequate” to prevent and treat members of the military and their families, the report said. But it called the process for recruiting additional trained personnel — both civilian and military — “time consuming and cumbersome,” stating for example that the number who could be recruited over the next six months would be “well below” the number required to meet the needs.

The shortage is deepening as active-duty mental-health professionals, also stressed by repeated deployments and other frustrations, are leaving the military in growing numbers, the report said. The Air Force has lost 20 percent of mental health workers from 2003 to 2007, while the Navy lost 15 percent between 2003 and 2006, and the Army lost 8 percent from 2003 to 2005.

Financial resources for mental health treatment in the military are also lacking, the report found. Congress provided a boost of $600 million for PTSD and traumatic brain injury in the 2007 supplemental war funding, but more will be needed, S. Ward Casscells, assistant secretary of defense for health affairs, said at the news conference.

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Reader Dan on Combat, PTSD and the US

This one is by Reader Dan

Adopting best practice procedures in our healthcare system is complicated and deserves careful attention. Several problems come to mind immediately:

1. Determining what is best practice over time is problematic in general medicine, and often enough what is called best practice now later falls out of favor or is replaced by a ‘new’ procedure. Journal of Medicine Association (JAMA) is a good source for this issue, but I do not have a subscription. This blog is worth a read.

2. Best practice is established and arbitrated in a variety of ways. A policy goal might be to help develop best practice and establish baseline quality as in the UK.

3. Chronic conditions such as diabetes versus acute conditions such as heart surgery or use of stents plays an important role in how we allocate resources. Innovation is rewarded in particular ways that impact care and our health.

4. Efficiency is gained in various ways, some negative and some positive, but to date costs are huge.

5. Profit margins defines what is a medical problem and what is not in the form of research and insurance payment schedules. Maximizing % of profit margin appears to predominate as opposed to more marginal gains that might have better overall outcomes over time.

Incentives to treat soldiers are a huge issue:

Regulars know that I prefer starting with an example before I get to aggregates or huge policy issues. This one is dear to all our hearts I am sure. While this is specifically stated as a government oriented problem using Tricare insurance for military, retirees, families and others, it is not specific to government functions because private insurers are only marginally better in this arena.

EMDR is one of the most researched interventions round the world for PTSD and in particular combat PTSD. This best practice guideline recommending CBT and EMDR, published in March 2005 by the UK ’s National Institute for Clinical Excellence names it specifically as one of treatment of choice. Good general information is here.

The VA system approves its use finally at a late date in the research as one of four preferred treatments. Psychopharmacology is a resource mentioned. AMA, APA, NASW approve its use.

At EMDRIA’s (organization advocating the use of this method) request in 2005, TRICARE did a review of EMDR for the treatment of PTSD and concluded that the treatment was “unproven”. In April 2006, TRICARE agreed to do a “more in-depth review, but in an August 31, 2006 policy document TRICARE said that “EMDR is not psychotherapy”. The credential as regards innovation in our health system is for another post, but thought some might want to check the issue with their own sources (so I mention it here) since military in particular will be of interest to several readers.
With credential established, I find this interesting:
Soldiers returning from war are finding it more difficult to get mental health treatment because military insurance is cutting payments to therapists, on top of already low reimbursement rates and a tangle of red tape.

Wait lists now extend for months to see a military doctor and it can takes weeks to find a private therapist willing to take on members of the military. The challenge appears great in rural areas, where many National Guard and Reserve troops and their families live. To avoid the hassles of Tricare, the military health insurance program, one frustrated therapist opted to provide an hour of therapy time a week to
Iraq and Afghanistan veterans for free. Barbara Romberg, a clinical psychologist in the Washington, D.C., area, has started a group that encourages other therapists to do the same.
Instead of quoting from an article, from personal knowledge the problem goes like this:

A psychologist or clinical social worker becomes specially trained and licensed for either treatment modality. Market rate without insurance in this area is pegged at $125-150/session. Insurance payment is a percentage of this market rate, or set at $89.50/hr./session for Blue Cross/Blue Shield of MA, and Tricare will pay a maximum of about $79 hr./session. The billing is done on face-to-face time, so the costs of billing and quality controls are included in this charge, with frequent attendant problems regarding billing procedures and changing quality control criterion. It is a significant cost factor in all insurance and more so in Tricare. Many therapists in this area do not accept this insurance, and many are not accepting any insurance as private practitioners. Remember most private practitioners pay their own health insurance costs (about $12,000/year family), rent, etc.

There are several problems involved, and I do not see either government or private health care dealing with it adequately. What are the incentives for a hospital (where conditions also are becoming much harsher in this area) or private practitioner to provide this service as a normal part of care? Is it important, and how should we respond?

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