Dr. Harold Kudler began working with the Veterans Administration healthcare system two decades ago, before there was an official diagnosis of Post Traumatic Stress Disorder. Over time, the Durham VA Medical Center psychiatrist has seen major advances in how the combat-related illness is recognized and treated--including strategies for prevention.
As the VA braces for a new wave of soldiers returning from Iraq and Afghanistan, many of whom are suffering from or at risk for PTSD, Kudler says the system is more prepared than ever to help them. There are new drugs and therapies for handling PTSD; experts now know that if you catch the symptoms early, you can keep them from getting worse; and they know that the most important thing of all is getting vets to seek care.
But, concedes Kudler, who co-chairs the VA's Special Committee on PTSD, the agency doesn't have enough money to help everyone who needs it.
"We're trying to run a race in order to build the system that we need," he says, "and it will take more time than we have."
His committee's latest report found that "PTSD services are lacking in many VA medical centers and are severely limited at Community Based Outpatient Clinics." It warns that without additional resources, the VA "does not have sufficient capacity" to help new combat veterans while continuing to care for veterans of past wars.
In North Carolina, that adds up to a lot of people. The state's veteran population has increased by about 8 percent over the last decade to 780,000, according to the state Division of Veterans Affairs. And many of those vets are over 65. Because North Carolina is home to two major military bases, it will see a greater proportion of returning vets than many other parts of the country.
While Congress has recently provided $10 million for new PTSD programs at the VA--$5 million for general programs and $5 million for programs aimed at veterans of Iraq and Afghanistan--only 86 of the nation's 163 VA Medical Centers have PTSD teams in place. Despite urgent pleas from Kudler's committee, not a single new team has been added this year. (North Carolina is among the better equipped--all four of the state's VA hospitals have PTSD teams.)
If given the resources, Kudler says doctors know what to do about combat-related illness. By focusing on outreach and prevention, he says, the VA has a chance to avoid what happened after the Vietnam War, when many vets did not receive treatment for PTSD until long after their symptoms had become chronic, or had morphed into tragedies like suicide, domestic violence, joblessness and drug abuse.
VA leaders are trying to learn from the mistakes of the past by getting to veterans early and stressing wellness rather than illness in handouts about PTSD. Rather than set up a whole new network of specialty clinics, the idea is to reach veterans where they live in settings that go beyond the traditional clinic.
"What we're trying to do is reach out to communities of people who don't come to the VA," says Kudler, a member of the Duke University Medical Center faculty and co-director of a new national research center on post-deployment mental health housed at the Durham VA. "I do think we'll end up coming out of this with a more efficient, effective approach."
But outreach is a major challenge. A 2003 U.S. Army report found that while 15 percent of soldiers serving in Operation Iraqi Freedom were interested in receiving mental health services, almost half of those surveyed did not know how to find those services or saw barriers to getting care.
And some returning soldiers say they are singled out if they do seek help.
"One guy I know who is in our group meetings was career [military] and he just absolutely would not go in for treatment," says Ken Ashe, a Vietnam veteran and a leader of the North Carolina chapter of Veterans for Peace. "He knew as soon as he went in it would be the end of his career. There is definitely a stigma."
Efforts are being made to gear up quickly for returning combat veterans. The Army has launched a "Deployment Cycle Support Program" that briefs soldiers and families about combat stress at several points during their tours. The VA is in the process of hiring 50 peer outreach counselors to work with returning soldiers at their points of deployment, be they military bases or specialty hospitals. VA leaders are also pushing for more cooperation with the Department of Defense to identify new veterans at risk for PTSD and to get information to them and their families within the first 30 days after their return.
What's needed now is for the resource question to move to the top of the agenda--something committees like Kudler's are not in a position to lobby for. He hopes the current war situation will do the pushing for them. "I think the VA and the DOD are on the point of recognizing that caring for these soldiers on their return is a part of the cost of war and needs to be built into the cost of war," Kudler says.
Greg Inman knows something about those costs. He drove a Bradley fighting vehicle in the first Gulf War when he was barely in his 20s. Now, he's team leader of the Raleigh Vet Center, part of a front-line support system for returning soldiers that goes back to the Vietnam era.
When many Vietnam veterans were reluctant to seek care at large government-run hospitals, the VA set up a network of storefront counseling centers in low-key community settings. The Raleigh center is in a small commercial building off Capital Boulevard North, wedged between a cellphone store and an antique mall.
Inman says the center sees 8,000 veterans annually from a 10-county area--most of them, Vietnam vets. Anticipating the arrival of a new crop of former soldiers from Iraq and Afghanistan, the center is hiring another counselor, bringing its total staff to four.
Like Kudler, Inman feels the system has a lot to offer veterans with PTSD. And vet centers have an advantage when it comes to outreach in that they are community based and staffed by peers.
"We feel prepared," Inman says. "We can help people if we can get them in here."
But that's a big if. Experts say one of the biggest walls to be broken down is the shame still attached to mental health care--especially among soldiers who are trained not to betray any weakness or vulnerability.
A U.S. Army report published in July in the New England Journal of Medicine found that between 15 percent and 17 percent of soldiers returning from Iraq showed signs of anxiety, depression and PTSD. Yet less than half of them (between 23 percent and 40 percent) sought mental health services. In fact, the study showed, veterans whose responses were positive for a mental disorder were twice as likely as others to express concerns about seeking therapy.
Lou Plummer, an Army National Guard veteran from Fayetteville who is active in Military Families Speak Out, says he's heard complaints from soldiers still on duty about obstacles to receiving care. One friend stationed in Mosul in an area where there had been a lot of car bombs told Plummer that "combat stress counseling was available every Friday about five miles from the base camp. But it's so dangerous to travel that it took a three-vehicle convoy to get you to your session. So you'd be reluctant to go. Or if you did, everyone would know where you were going."
Military officials insist there are no policies in place that would penalize soldiers for seeking care. And they say the culture of the military is more accommodating to the notion of therapy than in the past. "The newer generation of Army leadership has grown up with mental health and they are more used to it," says Capt. Mary Dorritie, a staff psychologist at Womack Army Medical Center at Fort Bragg. "We've had lot of success with removing that stigma."
Still, some veterans worry that they will suffer more than shame if they seek mental health services. In an e-mail to the Independent, a woman whose son is stationed at Fort Bragg described his reluctance to get counseling for depression after he returned from Iraq.
"He told me that doing so would give him a 24-hour escort (which would drive him nuts), he would be allowed nowhere near weapons of any sort, it would be a black mark on his service records and that it could end up being a mental health discharge which would be a black mark for the rest of his life, especially if he applies for a government job," said the woman, who asked that her name and her son's name be kept private since he plans not to reenlist and "they are making his life difficult."
And there are other barriers, especially for members of the National Guard and reservists who don't live on or near military bases where they'd have easier access to care.
Denver Jones is one of those. The Gulf War veteran and U.S. Army Reserve Specialist was wounded in August 2003 in a truck accident on an Iraqi highway that shattered his spine and left him unable to walk more than short distances without the help of a crutch or wheelchair.
After returning home to rural Oak Hill near Boone, Jones had to fight to get the military to recognize his injury as "combat related" so he could receive benefits. After a year-long review, the Army finally awarded him $1,300 a month, according to an Oct. 27 story about him in AlterNet (www.alternet.org/story/20314).
Jones is aware of group therapy and other services offered by the VA. (Such services are now free to members of the guard and reservists for up to two years after tours in combat zones like Iraq.) But the nearest VA hospitals are in Asheville or Johnson City, Tenn., an agonizing drive of more than 75 miles away.
Jones says he saw a psychiatrist at an Army hospital in Kuwait right after he was hurt. But it wasn't until he was back in the United States at Walter Reed Army Medical Center many months later that he was diagnosed with PTSD. "The case nurse could tell I was having some problems," Jones says. "He told me I needed to see a psychiatrist. The Army psychiatrist wouldn't acknowledge it. They think if you're not shot or raped, you can't have PTSD."
The 36-year-old father of three says he still has frequent nightmares and daytime flashbacks of scenes from his tour in Iraq. He avoids TV because he can't bear news reports about the war. When he took his family to see The Incredibles recently, he made sure they went to an early matinee when the theater would be nearly empty.
"I could handle that," says Jones, who had been working as a mechanic for United Parcel Service before he reenlisted shortly after 9/11."I don't do too well around crowds"
For Inman of the Raleigh Vet Center, it's not the surge of new combat veterans in need of care that worries him most. It's the idea that too many of them, like Jones, won't show up at his door.
"We hope we don't have to wait 30 years for Iraq War vets to come in here the way we did with Vietnam vets," Inman says. "We want to see them right now."
Ashe, the Vietnam veteran, says the real cost of the war comes due when people don't get the help they need. He struggled for years with symptoms of PTSD that led to lost jobs, failed marriages and time spent living on the street before turning his life around.
He knows there are new approaches that can make a big difference in helping vets cope with the disorder. But he worries that a resource-strapped VA system won't be able to make good on those promises quickly enough.
If it doesn't, the lessons of the last 20 years will go unlearned, he says.
"I saw a bumper sticker that said, 'Iraq is Arabic for Vietnam' and we know what that means," Ashe says. "There's a fair number of people who will come back from Iraq and could be treated and get their attitudes adjusted and back in the right frame. But without treatment, they're going to end up going down the same road we did."
Veterans Administration: www.va.gov
Veterans Benefits Information: www.vga.va.gov
Information for Iraqi Freedom Veterans: www.va.gov/gulfwar
Afghanistan Service Information: www.va.gov/environagents/
The Center for Women Veterans: www.va.gov/womenvet
National Center for PTSD: www.ncptsd.org
Army One Source: www.onestoparmy.com (go to Helpful Links and click on Health and Wellness)
U.S. Army Online Health and Wellness: www.hooah4health.com
National Gulf War Resource Center: www.ngwrc.org
Veterans for Peace: www.veterans4peace.org
Military Families Speak Out: www.mfso.org
GI Rights Hotline: www.girights.org
Raleigh Vet Center: 856-4616
Durham VA Medical Center: 286-0411
Disabled American Veterans, Raleigh: 833-5567