Editor’s Note: Our goal throughout this issue of Health Progress is to raise awareness of the health care needs of our military veterans — not all of which are being, or can be, met by the U.S. Department of Veterans Affairs(VA) — and to point to some areas in which Catholic health care providers might better care for this underserved population. You will find below some facts and potentially useful information, along with some recommendations and resources.
• Amid a blitz of news reports about an alarming rate of active-duty suicides in the military — 349 in 2012, or nearly one per day — the VA recently released an equally alarming report on suicides among military veterans: 22 per day in 2010, or almost one per hour. That rate is estimated to be 21 percent of all suicides in the nation, though vets represent only about 7 percent of the total population. Surprisingly, according to the department’s Suicide Data Report 2012, nearly 70 percent of veteran suicides were carried out by men and women aged 50 and older. Further, according to a study published last year in the American Journal of Public Health,1 veterans aged 17 to 24 are almost four times more likely to take their own lives than non-veterans in that age group.
• According to a projection model produced by the VA’s actuarial office (VetPop2011), the number of living U.S. veterans of all wars was 22.6 million in late 2011, or just over 7 percent of the population. The largest cohort of male veterans in 2011 had served in Vietnam (34.7 percent); the largest cohort of women had served after September 2001, either in Iraq (27.7 percent) or during peacetime (27.6 percent).
• As the high rate of suicides among older vets suggests, older veterans are more likely to suffer from mental disorders than members of the general population. Post-traumatic stress disorder (PTSD) and other war-related problems can surface or resurface later in life, according to an article posted on the “National Center for PTSD” section of the VA website. “Many older Veterans have functioned well since their military experience. Then later in life, they begin to think more or become more emotional about their wartime experience,” the article states. Another article, published in 2011 in the Journal of the American Geriatric Society, states, “PTSD symptoms are common in a substantial minority of older veterans in primary care, and careful inquiry about these symptoms is important for comprehensive assessment in geriatric populations.”2
• According to a 2008 RAND report (Invisible Wounds of War), only 30 percent of veterans who are shown through health screenings to have serious emotional problems seek help from a mental health professional.
• Although the rate of homelessness among U.S. veterans is declining, on a single night in January 2012, 62,619 veterans were homeless, according to the U.S. Department of Housing and Urban Development (HUD), down from 67,495 in the previous year. HUD reported that the national rate of homelessness was 21 homeless people per 10,000 people in the general population, compared to 31 for veterans. Further, the Center for American Progress, a progressive think tank based in Washington, D.C., said in a December 2011 report, that more than 1 million veterans were at risk of becoming homeless.
“Though research indicates that veterans who served in the late Vietnam and post-Vietnam era are at greatest risk of homelessness, veterans returning from the recent conflicts in Afghanistan and Iraq often have severe disabilities that are known to be correlated with homelessness,” the HUD report said. The VA, challenged by U.S. President Barack Obama to end homelessness among veterans by the end of 2015, plans to dedicate $1.4 billion to programs for homeless veterans this year, along with $4.4 billion for health care for this population if its $140 billion proposed 2014 budget is approved.
• According to the VA, about 1 in 5 female veterans has PTSD related to military sexual trauma. Among homeless vets, females are the fastest-growing group.
• Studies show a link between PTSD and traumatic brain injury (TBI) and substance abuse, and correlations of substance abuse and mental disorders with homelessness are well established. Further, according to the 2008 RAND report, The Invisible Wounds of War, brain injuries and related substance abuse are associated with unfavorable military discharge, which in many cases results in a denial of veteran’s benefits (see below).
• Although solid data on the number of veterans in prison is lacking, the U.S. Department of Justice, in the most recent, but now-outdated 2007 report, estimated the number in 2004 to be 223,000, most of them Vietnam-era vets. However, many familiar with veterans’ issues contend that number was even then too low, and new information suggests that, with the rise in PTSD among veterans of the Iraq and Afghanistan wars, younger vets are more likely to end up behind bars than veterans of earlier wars. For instance, a 2009 report by the Naval Health Research Center in San Diego of 77,881 enlisted Marines shows that those diagnosed with PTSD were 11 times more likely to be discharged for misconduct than those without the diagnosis. Those vets are unlikely to be eligible for VA benefits and therefore less likely to get treatment.
Another study, published in December 2012 in the Journal of Consulting and Clinical Psychology, correlates PTSD and criminal misbehavior.3 Experts note that many veterans in prisons have mental health problems that go untreated, though they may have psychological problems linked to past combat trauma. Across the country, dozens of communities have established special veterans’ courts that offer monitored treatment and rehabilitation as an alternative for violators with military records who commit nonviolent crimes.
• Post-9/11 veterans have a 2.2 percent higher rate of unemployment than nonveterans — 9.9 percent compared to 7.9 percent in 2012, though the rate has improved slightly in recent years. Unemployment rates for women are higher than for men, and younger vets fare much more poorly: the unemployment rate in 2012 for male veterans who served on active duty at any time after September 2001, age 18 to 24, was 20 percent, compared to 16.4 percent of nonveterans of the same age group. The numbers are from the latest report from the U.S. Bureau of Labor Statistics, released March 20, 2013. Those studying the problem note that, in addition to a poor employment market, many younger vets lack college degrees or the special skills employers seek, or they are unable to effectively demonstrate how military skills translate to the civilian workplace.
• In early January 2013, a subcommittee of the Institute of Medicine’s Committee on Gulf War and Health published a report noting that the so-called “Gulf War Syndrome,” chronic, multi-symptom illness related to exposure to toxic substances, may be affecting not only 1 in 3 Gulf War veterans, but veterans of Iraq and Afghanistan as well. New federal legislation requires that military leaders receive guidance on tracking such exposures, and efforts are underway to better assess the long-term health risk to service members and veterans. Overall, rates of neurological, respiratory and cardiovascular disorders in the military have risen dramatically — 251 percent,
47 percent and 34 percent, respectively — according to USA Today, which analyzed military morbidity records from 2001 to 2010.
• In a Feb. 6, 2013, lecture at Duke University School of Nursing, Linda S. Schwartz, commissioner of the Department of Veterans Affairs in Connecticut, urged health care providers outside the VA to identify veterans when taking medical histories. Further, J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization, said hospices should take steps to identify veterans in their care, as veterans may have special end-of-life needs related to their military service.
• In January 2013, as criticisms of VA backlogs in processing benefit and disability claims grew increasingly shrill, President Obama underscored the need for health care providers outside the VA to join the effort to meet veterans’ health care needs. As many as 60 percent of veterans of prior wars with PTSD have sought help outside the VA system, Obama said, and only half of Iraq and Afghanistan veterans have sought any type of care through the VA.
“What this tells us is that we have to meet our veterans and military families where they live,” he said. “We have to engage all of this country’s doctors, nurses, health care providers on the variety of health issues these families face, especially on issues of mental health.”
A year earlier, in January 2012, 130 medical colleges affiliated with the American Association of American Medical Colleges or the American Association of Colleges of Osteopathic Medicine pledged to improve training for care of veterans’ needs. Stephen C. Shannon, D.O., president and CEO of the osteopathic group, told U.S. Medicine, a monthly publication that serves health care professionals working in the VA, Department of Defense and U.S. Public Health Service, that “educating medical students even on simple steps, such as reminding them to ask patients if they have a military history, can help them better care for patients.”
• A significant number of vets lack access to VA care within their communities. Access is especially difficult for veterans in rural areas. Further, veterans with an other-than-honorable discharge, which may stem from substance abuse and other behavioral problems in the military, are denied veteran’s benefits, and many vets — like members of the general population — may lack private health insurance or be ineligible for Medicaid. To help address the gap, the National Council for Community Behavioral Healthcare urged an expanded role for community-based care in a November 2012 report, “Meeting the Behavioral Health Needs of Veterans.” The council offers an online evidence-based curriculum leading to a Serving Our Veterans Behavioral Health Certificate. See www.nationalcouncil.org.
Under rules issued during the Iraq War, members of the military may receive an honorable discharge if they are diagnosed with PTSD. However, PTSD was not identified until 1980, meaning that Vietnam-era vets with the disorder went undiagnosed or were diagnosed years after their combat experiences. The National Vietnam Veterans Readjustment Study, mandated by Congress in 1983, found that at the time of the study, approximately 830,000 Vietnam veterans, or 26 percent, had symptoms or functional impairments in keeping with PTSD (and often were in poorer physical health than their nonveteran peers). A more recent reanalysis of the data, combined with other research, found that 4 of 5 Vietnam vets, or 80 percent, reported recent symptoms of PTSD in interviews conducted 20 to 25 years after the war.
• As in the health care system in the United States generally, studies have demonstrated racial and ethnic disparities in the VA health care system. A related 2007 report, “Racial and Ethnic Disparities in the VA Healthcare System,” is available at www.hsrd.research.va.gov/publications/esp/RacialDisparities-2007.pdf.
• In December 2011, veterans of Iraq and Afghanistan who had been discharged with PTSD and denied veteran’s benefits won a victory in a class-action suit that, among its provisions, requires the U.S. military to pay 1,029 veterans lifetime disability retirement benefits which had previously been denied. The settlement was approved by the U.S. Court of Federal Claims. A similar class-action suit against the armed forces, filed in December 2012 in Federal District Court in Connecticut, argues that more than 250,000 Vietnam vets were dishonorably discharged and that thousands of those probably suffered from undiagnosed PTSD.
A wealth of information about U.S. veterans is available online, and several resources are cited above and in articles throughout this issue of Health Progress. We especially recommend the following:
• The Invisible Wounds of War, the 453-page, gold-standard, 2008 RAND report by its Center for Military Health Policy, is a comprehensive overview of post-deployment health needs related to PTSD, major depression and TBI among veterans of wars in Iraq and Afghanistan. The report discusses the available health care system, gaps in care and associated costs of care. The report is available online, as is a companion document, Invisible Wounds of War: Summary and Recommendations for Addressing Psychological and Cognitive Injuries.
• The National Center for PTSD (www.ptsd.va.gov) is a VA-sponsored center for research and education established to provide expertise on psychological problems related to trauma of all types, from natural disasters, violence and terrorism to military combat. Resources on the center’s website range from information for veterans, their families and the general public to online courses and training materials to help professionals with assessment and treatment.
• An article by clinical psychologist Roger Brooke about helping veterans adopt an archetypal perspective on their combat experience appears in the Fall 2012 issue of the Bulletin of the American Academy of Clinical Psychology. This is the approach favored by Edward Tick, author of War and the Soul (See page 14). Brooke is professor of psychology at Duquesne University and director of the Military Psychological Services, a network of free services for service members, veterans and their families and loved ones. Brooke’s article is available online at www.aacpsy.org/userfiles/file/Volume%2013,%20Number%201.pdf. A compendium of books and articles about the archetypal approach is included among Brooke’s references.
• The Red Sox Foundation and Massachusetts General Hospital formed a partnership in 2009 to sponsor the Home Base Program, which provides clinical care for veterans of Iraq and Afghanistan, to offer community education and to conduct ongoing research related to PTSD and TBI. For clinicians outside the hospital, the program offers a free online educational series, “From the War Zone to the Home Front: Supporting the Mental Health Needs of Veterans and Families.” Home Base actively reaches out to veterans and their families and sponsors outdoor adventure and sporting events to help strengthen family relationships. The program also provides free online parenting advice for military families and materials for schools to help support children of members of the armed forces. See www.homebaseprogram.org for more information.
- Robert D. Gibbons, C. Hendricks Brown and Kwan Hur, “Is the Rate of Suicide Among Veterans Elevated?” American Journal of Public Health 102, no. S1 (March 2012): S17-S19.
- U. Nalla B. Durai et al., “Exposure to Trauma and Posttraumatic Stress Disorder Symptoms in Older Veterans Attending Primary Care: Comorbid Conditions and Self-Rated Health Status,” Journal of the American Geriatrics Society 59, no. 6 (2011); 1087-92.
- Eric B. Elbogen et al, “Criminal Justice Involvement, Trauma, and Negative Affect in Iraq and Afghanistan War Era Veterans,” Journal of Consulting and Clinical Psychology 80, no. 6 (2012), 1097-1102.
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