It is mystifying that this administration didn’t plan for huge numbers of returning vets with PTSD.

Did they just cling to the original shock and awe plan, and assume no one would be injured after that? Did they hope the private sector would step up? Did they just not care? The mind reels.

Like so much else, I believe they just did not concern themselves with the boring details on the consequences should things not go as they deemed it to go.

Maybe they thought it was going to be a piece of cake, like the first Gulf War. But even the first Gulf War costs us nearly $2 billion every year in bills to take care of its vets. The current annual figure for taking care of our OEF/OIF wounded is now up to $2.3 billion. Every year. So, your question leads us to an important point:

We need to update the way wars are planned and and budgeted for.

We should demand these costs be factored into any war plan budget before we even go to war. But Defense Secretaries are just not going to do it on their own because it might turn out that the costs are deemed too high by society, and perhaps they won’t want to wage war.

Author Penny Coleman (Flashback: Posttraumatic Stress Disorder, Suicide, and the Lessons of War) wrote generous foreword to Moving a Nation to Care. In her book she profers that perhaps war would then be too costly in our eyes.

While they have been less than honest about the funding of the war from the outset (remember Wolfowitz and others in the administration saying it would cost us practically nothing, that Iraq’s oil revenues would pay for everything?), the DoD is still playing games with us and with the troops in their care.

The DoD today is still not screening across-the-board for PTSD, or even TBI, traumatic brain injury. Why not? We’ve known since 2004 that these issues were going to take center stage; indeed, TBI is called the “signature wound” of the Iraq War — and yet, the DoD is still not screening everyone involved in an IED blast for it. Why?

And what about all of the troops who have been booted out of the military with a less-than-honorable discharge for self-medicating? Or the 22,000 turned out with Personality Disorder (some perhaps coping with PTSD)? What about them?

How do we go back into their lives today and help them recover, when they don’t even have any VA benefits to fall back on? We’re eventually going to have to pick up the tab — either coming or going. Wouldn’t it be better to do it at the outset, rather than wait until entire families and lives are shattered?

The way the system works today, the answer is clearly ‘no’.

Chacounne @ 24

My question is: How do we make sure that covert military members get the treatment they need and deserve?

My condolences, Heather, over Dan’s loss.

Moving a Nation to Care includes the suicide of just such a seventeen-year Army Special Forces Green Beret soldier based out of Fort Carson. He had returned home in 2004, filled out the usual post-deployment health assessment form saying that he was fine, and then dug himself in deeper by dulling his pain through alcohol. One day he snapped and nearly killed his wife in a blind rage; instead he ended his life by lifting the gun to his head in his yard as police officers and his wife stood by and watched helplessly.

One of his Special Forces friends said at the time that soldiers at his level especially are stigmatized from reaching out for help. They have a great fear that if they come forward and tell the truth about their nightmares or reliance on drugs or alcohol to mask the pain, that they won’t be able to get their promotion or be assigned to the next great mission, or they worry that they’ll let down their team if they show any ‘weakness’.

We need to turn things on their head a bit.

Currently, troops suffering the most have to find a way to work past the very real stigma and fear and retribution of coming forward that exists today. Families who’ve been dealing with the fallout of war say, “Wouldn’t it be better if *everyone* returning automatically had to do some form of ‘bootcamp in reverse’ or some type of holistic reintegration session 2, 3, 4 months after their return from combat?”

It should be mandatory, it should include reaching out to family members and including them in the process, and it should be supported and demanded by society of our military.

We can move the military culture in the right direction if we want to do it. Fortunately, there really is no better window of opportunity than right now to our doing just that.

I think the concept of a reverse bootcamp is brilliant – i for one will keep this thought going.

Elliott @ 87

There was hopeful discussion in the Wed hearing/meeting about integrating care. First working on making the transfer from military coverage to the VA seamless, but also figuring out a way to have these soldiers treated in their own location using non VA doctors, if there isn’t a VA facilty near them. That would be a huge help for all those vets who do need medical care but live in rural areas.

of course, it’s only talk so far.

Elliott, did you happen to note if the hearing discussed telepsychiatry?

This may seem like a small thing – but in VA psych care, it’s huge.

US psychiatrists are overwhelmingly located in (wealthier) urban/ suburban areas.

Enlisted personnel and the majority of US shrinks don’t live near each other.

(And the majority of US shrinks lack thorough training in diagnosis/treatment of PTSD.)

The minority of shrinks and psychologists with PTSD training tends to live in urban areas large enough to support medical/psychological research.

Most of rural America doesn’t live near a med school (or a major VA PTSD facility).

The effective PTSD treatments don’t happen in a single visit.

Hence effective PTSD treatment is not currently accessable to most rural Americans.

Telepsychiatry (video/audio) works – that’s why Medicare authorizes payment. Telepsychiatry is also a very efficient way for skilled/expert clinicians to provide diagnostic evals for distant patients (and patients housebound from severe behavioral symptoms).

Barring a cultural revolution in academic medicine/psychology, I don’t see the trained cadre of PTSD clinicians moving out to Green Acres anytime soon.

So I guess that’s why this seemingly arcane question of technology may help meet the tremendous need for effective PTSD assessment and treatment among Iraq war veterans.

And help out a whole lot of vets’ families, as well.

When I first explored PTSD and went looking for effective “cures” – I wanted to hear from Veterans and Active Duty people about helped. Nothing turned up here. In Canada I found someone who provided tele-consulting to Canadian Veterans. He referred me to what was then, in his opinion, the state of the art. http://www.acpmh.unimelb.edu.au/

Then I found Davo http://www.davep.info/index.html

The family wreckage link at Davo should be very helpful and encouraging for those caught up in PTSD.

Opening new medical schools requires increasing budgets.

Yes, I’ve heard this. I think the key is increasing the number of seats at Med schools that currently exist.

Every year the AAMC dreamt of expanding medical education – and every year they fought just to keep the Medicare “pass-through” funds for the existing level of med schools/ residency training.

Kirk, I’m grateful for the response.

Law schools are not dependent on lawyers to open up law schools. The same is true for accountants, engineers, chemists, biologists, nurses, computer science, ….. There are not the gross shortages in any of those fields that exist in Medicine.

If you say the bottleneck is not the LCME, I’m certainly eager to learn more about that. My guess is that because of the shortage of physicians, that drives up the cost of the teaching faculty. If Medical schools cannot turn a profit on each student they graduate, that’s a very serious business problem. I don’t think Medicare is going to solve it.

In WI, we just had the Aurora medical group and all its physicians tell Medicaid to “get lost.” The shortage of physicians is so acute, they don’t need Medicaid patients to meet their income goals, so they just won’t accept them as patients. There are too many patients chasing too few physicians.

I was impressed by your reference to video conferencing above for treatment. My guess is that Medical schools could save a ton of money if they invested in that technology. It doesn’t eliminate the need for Med students to see a high volume of symptoms (patients), but it might reduce the per capita cost of educating Med students if it were used in the earlier stages.

Muzzy, the other thing is the Liaison Committee on Medical Education. As you know, that’s the arm of the AMA that artificially restricts the number of US Medical students that graduate every year. The laws of supply and demand are good enough for lawyers, and accountants, it’s good enough for physicians. I understand that getting an adequate supply of physicians into the marketplace will decrease some incomes, but imvho the shortage of physicians is one thing that drives the errors that lead to so many malpractice suits.

John Casper, as a med student I served on the board of the Association of American Medical Colleges (AAMC) Office of Student Representatives.

For three years, I attended the AAMC’s annual meetings and their quarterly DC meetings.

The LCME has two parents: the AMA and the AAMC.

(When the LCME goes out to do inspections, the “inspectors” are from academic medicine.)

Every year the AAMC dreamt of expanding medical education – and every year they fought just to keep the Medicare “pass-through” funds for the existing level of med schools/ residency training.

Since Reagan, US medical education budgets have declined. Opening new medical schools requires increasing budgets.

The description you provide is wholly inconsistent with the reality I observed over those three years.

(However, I certainly do believe that within specific lucrative specialties, some practicing specialists oppose extending the practioner pool because of anti-competitive desires.)

kirk murphy >

“…Telepsychiatry (video/audio) works – that’s why Medicare authorizes payment. Telepsychiatry is also a very efficient way for skilled/expert clinicians to provide diagnostic evals for distant patients (and patients housebound from severe behavioral symptoms)…”

I think this is an excellent insight (of course I`m a big fan of tele-technology) & one that might be boot strapable by concerned individuals since the basic tools are available.

Do you have any specific links to more information & maybe some suggestions how a group of interested parties might start to move on this without “official” authorization etc ?

I think this is right up there with idea of post experience reentry “boot camp” etc as beiing very important for actual success

[snip]

Thanks, daCascadian – but no credit due *here. All the heavy lifting was done years ago by the APA.

This idea has been around for years, with questions about when it would fly.

I hope it will now.

(*though when my analyst moved to Portland, we kept working for a few years via old-style videophones. Worked well enough for our established relationship, butwe both agreed the tiny screen wouldn’t really do for new patients. Fortunately, two iMacs can do it now….)

____________

Elliott, thanks for the link and your kind comment!

Here in WI, the State put NAMI (a for profit arm of NAMI) on it’s payroll. That’s one of the reasons NAMI won’t criticize them, they don’t want to lose the revenue. It’s these people in the state who get paid to make sure the tax payers and the mentally ill receive something back of value for their tax dollars that are supposed to support the mentally ill.

One of the things that Kissinger’s series highlighted was that the caseworkers and psychiatrists were billing Medicaid’s brains out for patients who were being taken care of by unlicensed “landladies” who were paying the rent to slum landlords. I think a lot of the good psychiatrists figured that they didn’t have any leverage and that complaining might make the situation worse. Unfortunately, that was where NAMI could have given them some cover, but it didn’t. It blamed the caseworkers. I agree the caseworkers have some responsibility, but they aren’t the decision makers. Milwaukee County told them that these houses had been approved for housing the mentally ill. Surprise, the State had no record of it. First the State started to prosecute some of the landlords and then they stopped. They realized they had no place to put them.

WI has laws about the licensing that is required to take care of people with serious mental illness. The state didn’t want to enforce the laws. It was a form of union busting. Milwaukee County could pay less to these landladies. One of the problems, however, was the rats that these disasters attracted, because there was crap all over the place. That drives down property values, which again hurts the tax base. Milwaukee also has a shortage of housing for the working poor. These landlords like that Federal check that comes in every month like clockwork from Social Security for the mentally ill. It’s a lot more dependable than the other paychecks that they get. They want to take care of the mentally ill, as long as they can pay some unskilled landlady to do it as minimum wage. Now you’ve got a shortage of low-income housing in addition to completely substandard housing for the mentally ill.