Part #2: Veterans & Mental Health
Mental illness is a term that describes a broad range of mental and emotional conditions. Mental illness also refers to one portion of the broader ADA term mental impairment, and is different from other covered mental impairments such as mental retardation, organic brain damage, and learning disabilities. The term ‘psychiatric disability’ is used when mental illness significantly interferes with the performance of major life activities, such as learning, working and communicating, among others. Someone can experience a mental illness over many years. The type, intensity and duration of symptoms vary from person to person.
They come and go and do not always follow a regular pattern, making it difficult to predict when symptoms and functioning will flare-up, even if treatment recommendations are followed. The symptoms of mental illness often are effectively controlled through medication and/or psychotherapy, and may even go into remission. For some people, the illness continues to cause periodic episodes that require treatment. Consequently, some people with mental illness will need no support, others need only occasional support, and still others may require more substantial, ongoing support to maintain their productivity.
Anxiety Disorders
Anxiety disorders, the most common group of mental illnesses, are characterized by severe fear or anxiety associated with particular objects and situations. Most people with anxiety disorders try to avoid exposure to the situation that causes anxiety.
• Panic disorder – the sudden onset of paralyzing terror or impending doom with symptoms that closely resemble a heart attack
• Phobias
– excessive fear of particular objects (simple phobias), situations that expose a person to the possible judgment of others (social phobias), or situations where escape might be difficult (agoraphobia)
• Obsessive-compulsive disorder
– persistent distressing thoughts (obsessions) that a person attempts to alleviate by performing repetitive, intentional acts (compulsions) such as hand washing
• Post-traumatic stress disorder (PTSD)
– a psychological syndrome characterized by specific symptoms that result from exposure to terrifying, life-threatening trauma such as an act of violence, war, or a natural disaster.
Military Veterans with PTSD as a Distinct Population
“PTSD acquired within a military context can be differentiated in several ways from the civilian experience. PTSD behaviors are often reinforced by military training or combat experience, while the opposite is generally true of civilian life. Take for example the common symptom of hyper vigilance. While rarely useful in civilian life, hyper vigilance is often a necessary and rewarded component of combat training. Many civilian suffers of PTSD were passive victims in their traumatic experience.
“Combat-related PTSD can have a latency period that may last for years before symptoms develop” “Serving Those Who Served: Veterans Treatment Courts in Theory and Practice”
By contrast, many combat veterans who develop PTSD were active participants in the traumatic event, having to react and participate in events that survivors of car accidents do not. Finally, many civilian experiences that lead to PTSD entail a single, relatively brief event. Military personnel on the other hand are often subject to repeated traumas over the course of weeks or months during extended combat tours. It does appear that there exist significant differences in demographics, presentation of symptoms, and reaction to treatment between civilian and combat veteran PTSD populations. Current research into exactly how these differences contribute to ultimate outcomes is sparse, but the differences themselves are undeniable.”
PTSD and Criminal Charges
PTSD and other combat-acquired stress disorders can create or contribute to criminal issues in several different ways. Perhaps the most prominent is through substance abuse, often connected to a veteran’s desire to self-medicate rather than, or supplementary too, seeking professional assistance. Increased rates of substance abuse predictably lead to both criminal possession charges, and the commission of other crimes associated with drug and alcohol abuse as a risk factor.
The estimated lifetime prevalence of PTSD (of any duration) in:
• Prevalence of PTSD for American men is approximately 3.6%
• Percentage of women is generally much higher at 9.7% for PTSD.
• By contrast, the lifetime PTSD prevalence for male Vietnam veterans is estimated at 30.9%.
• A recent study of OIF/OEF veterans found an approximately 13.8% prevalence of PTSD.
• Other studies have found up to 20% of Marine Corps and Army (which bear the brunt of combat actions) forward deployed personnel meet at least some of the diagnostic criteria for PTSD.
Of the approximately 1.7 million forward deployed veterans, estimates predict as many as 30-40% will have some form of serious mental-health injury, with at least 300,000 currently suffering from PTSD.
“One study from the 1980s found a correlation between PTSD and four particular crimes: driving while intoxicated, disorderly conduct, weapons charges, and assault” “Serving Those Who Served: Veterans Treatment Courts in Theory and Practice”
Domestic violence is useful because it is both excluded for eligibility by most veterans courts, and because there has been a relatively substantial amount of research done concerning a connection with PTSD. According to the National Vietnam Veterans Readjustment Study, a full one third of male veterans with PTSD perpetrated an act of domestic violence, at least double their non-PTSD affected peers; this data was specific to the year preceding the survey, so the total figure of lifetime domestic violence incidents is probably higher. More recent studies have reinforced this presumption, such as a 2006 finding that veterans with PTSD were at least 5 times more likely to perpetrate a violent domestic incident, and over 26 times more likely to commit an act of severe violence.
DUI is another crime for which veterans suffering from PTSD have an increased propensity to commit, is relatively minor, yet excluded from most VTC. Many behavioral consequences of PTSD contribute to this offense, and convincing evidence has directly linked its prevalence to PTSD. A lack of respect for authority figures is one common psychological feature of PTSD. Another American study found a clear correlation between PTSD and DUI, noting that individuals with PTSD had a higher recidivism rate.
Crimes that are associated with career criminality, or are indicative of a high degree of logical planning in furtherance of a criminal objective are not typical of offenses associated with PTSD. Offenses related to PTSD are usually spontaneous, often related to an incident or trigger that would seem relatively benign to a normal individual; normal behavioral motivations will often fail to provide an explanation for the criminal conduct.
One potential problem of under-inclusivity is the tendency for many military personnel and veterans to deny PTSD and related symptoms even when present. Stigmatization of mental health problems continues to be prevalent in military culture. Of the large numbers of front line personnel from the most recent Iraq conflict who meet at least some diagnostic criterion for mental health problems, less than half had any interest in mental health care, and perhaps less than a quarter actually received any.
Complex PTSD
Many traumatic events (e.g., car accidents, natural disasters, etc.) are of time-limited duration. However, in some cases people experience chronic trauma that continues or repeats for months or years at a time. The current PTSD diagnosis often does not fully capture the severe psychological harm that occurs with prolonged, repeated trauma. People who experience chronic trauma often report additional symptoms alongside formal PTSD symptoms, such as changes in their self-concept and the way they adapt to stressful events.
Dr. Judith Herman of Harvard University suggests that a new diagnosis, Complex PTSD, is needed to describe the symptoms of long-term trauma (1). Another name sometimes used to describe the cluster of symptoms referred to as Complex PTSD is Disorders of Extreme Stress Not Otherwise Specified (DESNOS)(2). A work group has also proposed a diagnosis of Developmental Trauma Disorder (DTD) for children and adolescents who experience chronic traumatic events (3).
Because results from the DSM-IV Field Trials indicated that 92% of individuals with Complex PTSD/DESNOS also met diagnostic criteria for PTSD, Complex PTSD was not added as a separate diagnosis classification (4). However, cases that involve prolonged, repeated trauma may indicate a need for special treatment considerations.
What types of trauma are associated with Complex PTSD?
During long-term traumas, the victim is generally held in a state of captivity, physically or emotionally, according to Dr. Herman (1). In these situations the victim is under the control of the perpetrator and unable to get away from the danger.
Examples of such traumatic situations include:
• Concentration camps
• Prisoner of War camps
• Prostitution brothels
• Long-term domestic violence
• Long-term child physical abuse
• Long-term child sexual abuse
• Organized child exploitation rings
What additional symptoms are seen in Complex PTSD?
An individual who experienced a prolonged period (months to years) of chronic victimization and total control by another may also experience the following difficulties:
• Emotional Regulation. May include persistent sadness, suicidal thoughts, explosive anger, or inhibited anger.
• Consciousness. Includes forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one's mental processes or body (dissociation).
• Self-Perception. May include helplessness, shame, guilt, stigma, and a sense of being completely different from other human beings.
• Distorted Perceptions of the Perpetrator. Examples include attributing total power to the perpetrator, becoming preoccupied with the relationship to the perpetrator, or preoccupied with revenge.
• Relations with Others. Examples include isolation, distrust, or a repeated search for a rescuer.
• One's System of Meanings. May include a loss of sustaining faith or a sense of hopelessness and despair.
What other difficulties are faced by those who experienced chronic trauma?
Because people who experience chronic trauma often have additional symptoms not included in the PTSD diagnosis, clinicians may misdiagnose PTSD or only diagnose a personality disorder consistent with some symptoms, such as Borderline, Dependent, or Masochistic Personality Disorder.
Care should be taken during assessment to understand whether symptoms are characteristic of PTSD or if the survivor has co-occurring PTSD and personality disorder. Clinicians should assess for PTSD specifically, keeping in mind that chronic trauma survivors may experience any of the following difficulties:
• Survivors may avoid thinking and talking about trauma-related topics because the feelings associated with the trauma are often overwhelming.
• Survivors may use alcohol or other substances as a way to avoid and numb feelings and thoughts related to the trauma.
• Survivors may engage in self-mutilation and other forms of self-harm.
• Survivors who have been abused repeatedly are sometimes mistaken as having a "weak character" or are unjustly blamed for the symptoms they experience as a result of victimization.
Treatment for Complex PTSD
Standard evidence-based treatments for PTSD are effective for treating PTSD that occurs following chronic trauma. At the same time, treating Complex PTSD often involves addressing interpersonal difficulties and the specific symptoms mentioned above. Dr. Herman contends that recovery from Complex PTSD requires restoration of control and power for the traumatized person. Survivors can become empowered by healing relationships which create safety, allow for remembrance and mourning, and promote reconnection with everyday life (1).
References
1. Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York: Basic Books.
2. Ford, J. D. (1999). Disorders of extreme stress following war-zone military trauma: Associated features of Posttraumatic Stress Disorder or comorbid but distinct syndromes? Journal of Consulting and Clinical Psychology, 67, 3-12.
3. van der Kolk, B. (2005). Developmental trauma disorder. Psychiatric Annals, 35(5), 401-408.
4. Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F. S. (1997). Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV field trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress, 10, 539-555.
Mood Disorders
Mood disorders are also known as affective disorders or depressive disorders. These illnesses share disturbances or changes in mood, usually involving either depression or mania (elation). With appropriate treatment, more than 80% of people with depressive disorders improve substantially.
• Major depression – an extreme or prolonged episode of sadness in which a person loses interest or pleasure in previously enjoyed activities
• Bipolar disorder (also referred to as manic-depressive illness) – alternating episodes of mania (“highs”) and depression (“lows”)
• Dysthymia – continuous low-grade symptoms of major depression and anxiety
A study for the Journal of the American Academy of Psychiatry and the Law compared the characteristics of veterans contacted while incarcerated in a Los Angeles jail with those of homeless veterans contacted in the community setting.
• 21% of veterans contacted in jail reported long-term homelessness (more than six months)
• 73% were unemployed
• 37% current drug abuse
• 50% current alcohol abuse Psychiatric illness, as assessed by a counselor, was reported in
• 35% of the jailed veterans assessed with psychiatric illness by a counselor with,
• 23% having a dual diagnosis
• 15% had mood disorders
• 7% had schizophrenia
• 6% had PTSD
Of note, emerging data indicate that military deployment to war zones, even without combat exposure, carried substantial mental health effects, with associated psychiatric disorders (mood and anxiety), substance abuse, and family conflict. Stress in war zones extends beyond that instilled by combat and includes exposure to isolation, poor living conditions, sexual trauma, family separation, and exposure to environmental hazards. Even absent combat exposure resulting in PTSD, substance abuse, psychiatric symptoms, traumatic life events, and homelessness remain significant risk factors among incarcerated veterans.
Mental Health for Women Veterans
In February, 2016, the House passed a bill that would require the VA to examine whether its programs for mental health and suicide prevention are meeting the needs of female veterans. says De'Cha LaVeau, a 38-year-old Navy veteran, who has PTSD from military sexual trauma, says she has struggled to get timely appointments with counselors. The VA is known for having long wait lists. "It's rough," she says, crying over the phone. "You call to get an appointment when you're having a bad day—you're thinking you're going to get in within a couple of weeks. And it took call after call after call to get a letter saying you have an appointment six months later."
Article: Improving the Quality of Mental Health Care for Veterans
Veterans, especially those who deployed overseas, face elevated risks of mental health conditions. Veterans who have served since the September 11, 2001, attacks are especially vulnerable (see Figure 1). Roughly one in five veterans experiences mental health problems, including posttraumatic stress disorder (PTSD), major depression, and anxiety. Deployment can also increase the risk of unhealthy alcohol and drug use, substance use disorders, and suicidal behavior. If left untreated, these conditions can have long-lasting and damaging consequences, impairing relationships, work productivity, quality of life, and overall well-being for veterans and their families.
RAND Corporation researchers have conducted multiple studies of the quality of mental health care received by veterans across the systems that deliver this care. This brief summarizes the main lessons from this work and shares recommendations for policies and further research.
It is important that veterans who experience mental health conditions and substance use problems receive treatment and get the best quality care available. Evidence-based treatment improves recovery rates. It also reduces the likelihood of other negative consequences that can follow from mental health and substance use conditions, such as health deterioration and problems in relationships and work.
High quality in health care was defined by the Institute of Medicine in its 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century as care that is safe, patient centered, effective, equitable, timely, and efficient. Much research has focused on understanding the availability and use of treatment that is effective. Effective treatments are those that have been shown to work, based on scientific research and clinical experience. Evidence-based practice (EBP) refers to specific forms of care that meet these criteria (see Figure 2). EBPs have been peer reviewed by scientists and clinicians, and there is empirical evidence for their effectiveness. In some cases, EBPs have been proven to produce significant reductions in symptoms in controlled experimental research studies, which represent the gold standard of scientific evidence for medical treatments. Clinical practice guidelines are systematically developed statements based on scientific evidence that help providers and patients make decisions about appropriate health care practices for specific clinical circumstances, according to the Institute of Medicine's 2011 report Clinical Practice Guidelines We Can Trust. Guidelines are based on reviews of the scientific literature and expert consensus. Treatment recommendations are assigned a grade of A, B, C, or D based on the strength of the scientific evidence, with a grade of A being the equivalent of "strongly recommended."
The three components of evidence-based practice are
• Client/patient values
• Clinical expertise
• Current best evidence
It is important that veterans who experience mental health conditions and substance use problems receive treatment and get the best quality care available. Evidence-based treatment improves recovery rates. It also reduces the likelihood of other negative consequences that can follow from mental health and substance use conditions, such as health deterioration and problems in relationships and work. Poor-quality care, by contrast, is less likely to lead to recovery. Furthermore, poor experiences with care can discourage veterans from seeking further care. There are also substantial monetary costs associated with substandard and inaccessible mental health care. In 2008, RAND researchers estimated the two-year societal costs of post-deployment mental health problems, such as PTSD and depression, among veterans who had served since the September 11, 2001, attacks to be approximately $6.2 billion (in 2007 dollars) (Tanielian and Jaycox, 2008). The study estimated that if all veterans received high-quality care for these conditions, these costs could be reduced by $1.2 billion (in 2007 dollars). Thus, high-quality care can stem adverse consequences for veterans and families and also reduce the economic burden on society.
https://www.rand.org/pubs/research_briefs/RB10087.html
Article: “New Federal Study Shows Half of Incarcerated Veterans Have Mental Disorder”
A study released in December of 2015 by the Department of Justice Bureau of Justice Statistics (BJS), for the period of 2011 to 2012, shows that although the percentage of veterans in the state and federal prison population has declined slightly, fully half have been diagnosed with some form of mental disorder. Prisoner rights advocates have long maintained, and many correctional officials agree, that jails and prisons do not offer adequate mental health treatment to the incarcerated.
The share of prisoners who previously served our country's military peaked in the late 1970's at 24%, shortly after the close of the Vietnam War, and has declined since that time, but now holds steady at approximately 8%. Over 60% of those diagnosed as needing treatment were in combat, more than half of the veterans serving time had three or more previous arrests, many of which were for violent offenses.
This study follows other BJS of Justice studies that have shown that over a third and as many as 50% of incarcerated prisoners suffer from some form of a mental disorder. Local law enforcement officials who operate county jails have long maintained that this is a serious problem. Cook County, Illinois Sheriff Tom Dart, maintains that his jail, the largest county jail in the country, is his state's largest repository of people with mental disorders.
Unfortunately, although the percentage of veterans in custody has declined in past decades, there is little statistical evidence that the policies of correctional officials have had any role in that decrease, and as an older crop of veterans leaves jail, they are replaced by a newer, younger group of offenders. The BJS study showed that, "From 2001 to 2012, veterans discharged during Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn accounted for 13% of veterans in prison and 25% of veterans in jail."
The only bright spot in the study is that most of the incarcerated veterans, well over 60%, in jail in recent years had been told by the military that they suffered from a mental disorder. Clearly, both the military and governmental agencies have quantified and identified the problem, and it now becomes even more urgent for legislators and correctional officials on both the state and federal level to implement policies to effectively deal with it and while it is known of the issues facing veterans and the organizations that serve them, few steps have been taken to help these at risk veterans especially when the justice system gets involved. While often times, the military is responsible for mental illness, the veteran suffering because of military service is more likely to successfully complete a treatment program with long lasting positive results.
Sources:
