The Official Voice of Vietnam Veterans of America, Inc. ®
An organization chartered by the U.S. Congress

March/April 2004

Is the VA Ready to Provide Adequate Medical
and Mental Health Care for Iraq War Veterans?


Post-traumatic Stress Disorder (PTSD) has become inextricably linked to Vietnam veterans, but not because Vietnam was the first conflict in which soldiers experienced acute postwar reactions to stress. PTSD has been experienced by veterans of every war in history. As a diagnosable psychological injury, however, PTSD has been recognized by the Department of Veterans Affairs since 1980, when it was no longer possible to ignore Vietnam veterans needing treatment.

VVA National Chaplain Father Phil Salois, who works with PTSD patients at the VA,
remembers the long, hard fight for recognition of PTSD. "We were forced to swallow everything because we were so unwelcome. We shoved everything down," he said. "Only until veterans started to appear at the door of the VA, did we know something was wrong."

And something was terribly wrong. The National Vietnam Veterans Readjustment Survey (NVVRS) estimated that more than 50 percent of Vietnam veterans have experienced at least partial PTSD at some point in their lives. As a consequence, a veteran of the Vietnam War is at higher risk for health problems and health-threatening behaviors such as arrest, alcohol and drug abuse, and divorce. Many do not seek treatment for PTSD, but the number of those who have gone for help is staggering. It is estimated that today some 180,000 veterans have service-connected PTSD.

The psychologically wounded veterans from the current conflicts have yet to be counted.  According to the Defense Manpower Center's preliminary figures released in January, nearly 438,000 troops have served in Operation Iraqi Freedom. Today some 130,000 troops are in theater in Iraq. When they return home, they will be relieved by some 110,000 replacements in the largest U.S. troop rotation since World War II. Given that the military expects to have 100,000 troops in Iraq for the next two years, it is reasonable to assume that at least three quarters of a million American soldiers will have served in Iraq by 2006. The question: How many will seek VA care for mental health problems?

According to the VHA Office of Public Health and Environmental Hazards, in January there were 83,732 separated Iraqi Freedom veterans, 12 percent (9,753) of whom have sought health care from the VA. Of those who sought care, 14 percent were diagnosed with mental health problems, including drug abuse, adjustment reaction, depressive or neurotic disorders, affective psychoses, and acute reaction to stress. This does not include those who are on active duty and are being treated for mental health problems. The military is unusually tightlipped about the exact figures. Investigations by United Press International, however, indicate that as many as 10
percent of the soldiers evacuated to the Army's largest hospital in Europe, Landstuhl in Germany, had "psychiatric or behavioral health'' issues.

According to Dr. Jonathan Shay, a psychologist with the VA in Boston who has written on the subject, the number of troops from this conflict who will suffer from PTSD symptoms is difficult to estimate. ``If the Vietnam War is any guide, then in the neighborhood of 17 percent of those in theater will eventually have it,'' he said. "I believe the overwhelming majority of psychological injuries are going to show up more than a year and perhaps five years after the fighting is over.''

Dr. Mark Brown, director of Environmental Agents Service at the VA, also is convinced that PTSD will be a major issue. "For every soldier who gets killed, there are a half dozen or more present. That's got to leave a mark,'' he said. Brown added that PTSD is just one mental health problem among the many psychological issues to be dealt with in war, including those resulting from losing an arm or other limb.

Suicide is one of the worst outcomes for those with mental health problems. Veterans of the Iraq War may be exposed to conditions that place them at unusually high risk for suicide. The Pentagon's response to this issue has been contradictory.

On January 14, William Winkenwerder, Jr., Undersecretary of Defense for Health Affairs, said that Army suicides in Iraq were somewhat higher than the Pentagon expected. On January 28, Army Col. Thomas Burke, program director for mental health policy for the Assistant Secretary of Defense, told a different story. He said that the Army's suicide rate was not significantly higher than the levels the Army has seen during the last decade. He said media reports of high suicide rates were "false."

The Army sent a team to Iraq in 2003 to assess the situation. That team has yet to issue a report, even though it was due out last Thanksgiving. Suicide number crunching has been left to advocacy groups and the media.

Since the war began in March 2003, the Army confirms that at least 21 soldiers have killed themselves in Iraq or Kuwait. This figure does not include those who committed suicide after returning home after a tour in Iraq. The 67 stateside military suicides in 2004 could include a significant number of returning Operation Iraqi Freedom veterans. If added to the number of those who killed themselves in Iraq, the suicide rate linked to the current deployment is well above "normal.''

Some are pointing to the drug Lariam as a possible cause. Also known as mefloquine, this anti-malaria drug was first developed at Walter Reed Army Institute of Research during the Vietnam War. Currently produced by Swiss pharmaceutical Hoffmann La Roche, Lariam was approved for use by the FDA in 1989. It has been routinely administered to American troops in malaria endemic regions, including Somalia, Afghanistan, and Iraq. It is also given to those who may be required to deploy rapidly to these regions.

"I believe, in light of the latest scientific evidence, that the FDA would be hesitant to approve Lariam today,'' said Susan Rose, co-director of Lariam Action USA and a faculty member at the Department of Environmental and Occupational Health at George Washington University. Rose cited recent studies indicating that 30 to 40 percent of patients who take Lariam experience moderate to severe neuropsychiatric side effects. PTSD and Lariam toxicity, in fact, have similar symptoms. Those who take Lariam frequently report being in a fog and a state of confusion for days, experiencing panic attacks, anxiety, depression, and agitation. There are other alternatives to this drug. The question is, given that Lariam has such alarming side effects, why is it being prescribed to troops in a war zone?

Even more disturbing are reports that the drug is being distributed to troops by military medical personnel who "bulk draw" Lariam, handing it out with vague instructions and no warnings about the serious negative side effects. When the drug is given out in this manner, it is not recorded in troops' medical records. According to Susan Rose, the lack of documentation and tracking makes it difficult, if not impossible, for the military to report accurately the numbers of soldiers who are currently taking Lariam.

The suicide of Marine Lt. Christopher Shay illustrates the lack of attention the military is paying to this issue. After he returned from Iraq, Shay took his own life. This came after daily requests for assistance and 12 visits to a military doctor in the last 36 hours of his life. Shay's family was baffled, asking why a top Marine with no prior history of depression would have taken his own life. At first, the military denied he had even taken Lariam. After conducting its own civilian forensic investigation, the family found this was not true. They also discovered that a second suspected suicide may be linked to Lariam use. It involved a man who had disappeared overboard. Additionally, Shay's former Gunnery Sergeant committed suicide 24 hours after he
returned to port in San Diego.

In a December 2003 response to a congressional inquiry, Winkenwerder reaffirmed the use of Lariam, but denied that Marines received incomplete information on Lariam's side effects. "The Armed Forces Epidemiological Board has studied and supported continued use of mefloquine as the primary preventive measure against malaria,'' he said.

Failed attempts to get a straight answer from the military about suicide rates and Lariam toxicity have forced families of victims and veterans' advocacy groups to turn to Congress and the media for help. On February 25, in response to mounting pressure, Winkenwerder reversed his position. He told a House Armed Services Committee that the Pentagon would look into the issue.

The Pentagon has announced that it will stop giving Lariam to troops in some regions, including Iraq, because of alternatives to the drug. Lt. Shay's mother is not comforted. She noted that Winkenwerder said the panel he is forming could take months, if not years, to complete its review. The question remains: Why did it take so long for the Army to acknowledge the potential dangers of Lariam and why is the Pentagon dragging its feet when it comes to looking for answers?

Revised DD Form 2276 is a four-page post-deployment screening questionnaire required to be filled out by all military personnel no later than five days after returning home from deployment.  It is supposed to be completed in the presence of a health-care provider. Questions 7-13 comprise the metal health portion of the form.

Question 12 reads: "In your life have you had any experiences that were so frightening, horrible or upsetting that, in the past month, you:

1. Have had nightmares about it or thought about it when you did not want to?
2. Tried hard not to think about it or went out of your way to avoid situations
that reminded you of it?
3. Were constantly on guard, watchful, or easily startled?
4. Felt numb or detached from others, activities, or your surroundings?"

According to the National Center for PTSD, a positive response to two of the four sub-questions is associated with a PTSD diagnostic accuracy of .82 and indicates the need for additional assessment.

DD Form 2276 is a response to lessons learned from the 1991 Gulf War, where inadequate and incomplete medical information was gathered from returning soldiers. Public Law 105-85 requires these medical screenings and mental health assessments. DoD Instruction 6490, dated August 7, 1997, also mandates pre- and post-deployment medical screenings, a mental health assessment, and the collection of blood serum samples. Noting that ``the identification of health threats and rapid dissemination of information relevant to troop health has proven of inestimable value in recent operations,'' the aim of this military-wide mandate is to develop a more comprehensive approach to monitoring and assessing the health consequences of deployment.

Is the military conducting pre- and post-deployment mental health assessments that meet the intent of the law, or is it doing little more than meeting the letter of the law by handing out medical questionnaires?

"They didn't even pick up a stethoscope," reported a Reserve Navy Lieutenant Commander when asked about his post-deployment screening. After his unit spent more than a year in Kuwait during Operation Iraqi Freedom, he added, "They pushed us off active duty as fast as they could.  They haven't learned a whole lot [from the 1991 Gulf War]."

Steve Robinson, executive director of the National Gulf War Resource Center, is convinced the current screenings are not adequate. "We want the Department of Defense and the Department of Veterans Affairs to conduct aggressive face-to-face post-deployment counseling, rather than waiting for problems to arise,'' he said. Robinson is working with VA officials to create new, pro-active programs that will connect troops with other combat veterans. The intent of the program is to share experiences and alleviate the stigma of reporting mental health concerns.

The lessons learned from the Vietnam War and the 1991 Gulf War have resulted in significant positive responses on the part of the military and VA when it comes to dealing with PTSD and other mental health issues.

Since the Vietnam War, PTSD has been studied extensively. The government has funded many projects that address PTSD and the effects of stress on health. The National Center for PTSD was created in 1989 to advance the clinical care and treatment of military-related PTSD.

The Pentagon deployed nine combat-stress teams in Iraq and has placed a psychologist, psychiatrist, and social worker in each division. After being separated from active duty, veterans may go to some 205 Vet Centers around the country for help. The Vet Centers are staffed and run, in most cases, by veterans. Bereavement counseling is available for families of fallen troops.

It isn't all positive news, however. In addition to unanswered questions about suicides, treatment of many war-wounded veterans has been slow and inadequate. Late last year, the U.S. Senate National Guard Caucus reported on the substandard treatment of returning veterans at Fort Stewart, Georgia. The report revealed that 650 Army Reserve soldiers on medical hold were receiving inadequate medical attention and were being housed in accommodations inappropriate for their conditions. Most of these troops had returned to Fort Stewart as a result of wounds, injury, or illness after being deployed overseas.

According to Shay, improper treatment of soldiers may exacerbate mental health problems such as PTSD. ``If someone betrays a set of expectations about how power is going to be used in a high stakes situation,'' he said, "the human body may code this as a physical attack.''

Poor treatment may also make some troops hesitant to come forward with their mental health concerns. One Special Forces soldier who suffered a panic attack after seeing a dead Iraqi soldier was charged with cowardice and sent home after he tried to get help. He was taking Lariam at the time. The charges were eventually dropped, but cases like his may be sending the wrong message to others who might be afraid to ask for help.

The VA's resources also are being stretched thinly. Tom Berger, chairman of VVA's
PTSD/Substance Abuse Committee, is concerned about that. "Vet Centers are already under-funded,'' he said. "The contract I signed says I will be given adequate medical care, and it is not available.''

When asked how veterans are being treated in this current conflict, Shay said, "The history of psychiatry of the Vietnam War is only now being written. One thing that is really clear is that there can be a hideous mismatch between good intentions and outcomes.''

Although well intentioned, there is evidence that the scale and scope of the present conflicts are putting a strain on military and VA medical resources.

According to Mark Brown, the VA has "some pretty good clinical programs. We think we're ready, but you never know. Adjustments may have to be made.''



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