The prevalence of what have become known as the “signature wounds” of the Iraq and Afghanistan conflicts – post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) – has been obvious from the beginning, but until 2008, the evidence was largely anecdotal.

When the RAND corporation released its landmark comprehensive study, “Invisible Wounds of War,” documenting the mental health and cognitive needs of returning service members and veterans, the numbers were sobering: Of the 1.64 million service members who had been deployed to Iraq or Afghanistan, about 19 percent had symptoms consistent with a diagnosis of PTSD or depression and about 20 percent reported experiencing a TBI during deployment.

Of those needing treatment, the study reported, only about half sought treatment, and half of that number, in turn, received minimally adequate care.

The RAND study sparked sweeping policy changes and a surge in the efforts of both public and private institutions to ensure that programs were mobilized to get returning service members the care they needed.

 

A Joint Effort

One of the first changes made in the wake of the RAND report was the Pentagon’s implementation of mandatory screening programs for all personnel returning from war zones, both for PTSD and TBI. For TBI, the screening, detection, tracking, research, and outreach activities of both the Department of Defense (DoD) and the Department of Veterans Affairs (VA) are carried out by the Defense and Veterans Brain Injury Center (DVBIC).

In addition, the VA’s National Center for Post-Traumatic Stress Disorder, working through seven divisions throughout the country, carries out research, education, and training programs on identifying and treating trauma and PTSD.

Neither center, however, provides direct clinical care, which remains the work of the military medical and VA health systems. At VA, treatment for PTSD and TBI is provided largely at the department’s four polytrauma rehabilitation centers and their associated support clinics, whose care model emphasizes the knowledge that extended deployments in Iraq and Afghanistan have created unprecedented exposures to the physical and psychological traumas of war.

The similarity in the numbers of RAND study subjects with diagnoses of PTSD and those reporting TBI hinted at something that has, over the past several years, become substantiated by VA-led studies: The two conditions often occur together.

Dr. Robin Hurley is associate chief of staff for research and education at the W.G. Hefner VA Medical Center in Salisbury, N.C., as well as associate director for education at the VA’s Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Her research has revealed a physiological link between PTSD and TBI. “The places where those three most common injuries to the brain occur – a subdural bleed, a contusion, or a third thing that we call diffuse axonal injury – are exactly the areas that control your emotion and memory circuits,” she said. “That’s exactly why we’re seeing the co-occurrence of mental health conditions along with the things that we traditionally see with brain injury, such as dizziness, nausea, vomiting, and confusion.”

The frequent comorbidity of PTSD and TBI have led to a revision of the VA’s clinical practice guidelines, finalized in 2011, for the treatment of PTSD that include sections about frequently comorbid diagnoses, including TBI.

Emerging evidence suggests, also, that treatments for service members with PTSD can be successful regardless of whether a patient has suffered a TBI. As Dr. Matthew Friedman, executive director of the National Center for PTSD, explained, the two best treatments for PTSD are psychotherapies: prolonged exposure therapy, which requires emotional processing of the event and becoming conditioned to fears, and cognitive processing therapy, which involves understanding the ways in which trauma has changed a patient’s view of him/herself and the world. “There was speculation that a person with mild TBI [mTBI] wouldn’t be able to do the emotional processing, that it would be too intense for them – or that a person would be unable to do the cognitive work that’s necessary,” Friedman said. “We simply don’t know.” Preliminary data from ongoing studies by VA’s leading experts, however, suggest that patients with TBI have outcomes comparable to non-TBI patients who are undergoing these two types of therapies for PTSD.

“It’s not conclusive,” said Friedman, “but so far it looks as if they’re going to be able to benefit from those therapies, whether they have TBI or not.”

 

The National Intrepid Center of Excellence (NICoE)

In the summer of 2010, the Department of Defense’s effort to diagnose and treat combat-related TBI and psychological health conditions received a $65 million shot in the arm from the private sector, in the form of the National Intrepid Center of Excellence. Officially dedicated in June 2010, the center, located on the campus of the Walter Reed National Military Medical Center in Bethesda, Md., is dedicated to expanding the knowledge base among physicians and developing innovative models of care for service members.

As Dr. James Kelly, NICoE’s director, points out, the center’s work is designed to supplement, rather than to replace, the work of primary care providers within the DoD: “We’re a research institute that does clinical care.” While innovative clinical care – sometimes involving the use of alternative therapies such as acupuncture, yoga, and Reiki – is delivered at the NICoE, it occurs in an outpatient setting, in three-week sessions. Any member of the armed services is eligible for care at the NICoE, but because of limited time and space, the center focuses on those who have not yet responded to traditional models of care and who want to return to service.

The NICoE’s privately funded clinical care involves state-of-the-art technology and methodologies: high-resolution neuroimaging equipment; moveable walking platforms surrounded by virtual environments; kinetic “suits,” like those used in CGI animation modeling, which measure a patient’s gait and motor control. “What we’re doing is creating an interdisciplinary model of care that is essentially an intensive care outpatient model,” said Kelly. “The patients are with us all day, every day, five days a week, for three weeks, with very detailed diagnostic workups and treatments. When they leave, they’ll go back to where they came from, one of the military centers around the country, and continue their care.”

The NICoE’s intensive regimen is delivered by two separate teams of expert clinicians to 20 patients at a time; each element of a patient’s care plan – psychology, neurology, physical therapy, occupational therapy, and more – is coordinated within the three-week cycle. The center treats about 200 to 300 patients a year before returning them to a system whose physicians are, through training and information dissemination programs, increasingly able to deliver the kind of alternative therapies offered at NICoE. However, TRICARE, the military health insurance plan, does not currently offer reimbursement for such therapies, leaving patients to pay for these treatments themselves.

Expanding Access to Care

The NICoE’s conspicuous position at the leading edge of PTSD and TBI care, offering innovative treatments that are unavailable to the vast majority of service members and veterans, underscores the biggest challenge facing the VA and the Pentagon: how to expand access to care for the huge numbers of people returning from Iraq and Afghanistan needing treatment for combat-related TBI and psychological health conditions.

In May 2011, the beleaguered VA was slapped with a ruling by the Ninth Circuit Court of Appeals demanding reform in the handling of disability claims by veterans who suffered from PTSD and other psychological health conditions. Veterans, the ruling said, were waiting far too long – sometimes months – for treatment, and they were suffering.

408,167 veterans with a primary or secondary diagnosis of PTSD received treatment at VA medical centers and clinics in 2010; this number, combined with another statistic – by the VA’s own estimation, only about 36 percent of the veterans who are eligible for its benefits and programs sign up to receive them – suggests that many, perhaps tens of thousands, are simply being missed by an overburdened system.

While both the VA and the Pentagon struggle to enhance the capacity of their health care systems to deal with large numbers of patients, each has taken substantial steps toward overcoming barriers to care for Iraq and Afghanistan warriors with PTSD and/or TBI. In the summer of 2011, for example, the VA established a national phone and Internet crisis hotline at the VA Medical Center in Canandaigua, N.Y., staffed by 120 people who try to connect veterans with available services

Taking advantage of community-level resources – a move that can only increase access to care for veterans while taking some pressure off the military and veterans health care systems – has long been advocated by veteran support groups, but the VA and DoD, for different reasons, have had difficulty capitalizing on them. Col. James McDonough (USA-Ret.), president and CEO of the Veterans Outreach Center in Rochester, N.Y., said: “There is room under the tent for other people to partake and participate in a community where six of every 10 veterans are more likely [to] access health care through their employer-based plan or self-pay.”

Cmdr. René Campos (USN-Ret.) is the lead advocate for wounded warriors at the Military Officers Association of America (MOAA). “You’ve got a lot of organizations, like Give an Hour [which provides free mental health services to military personnel and families], and community-level organizations that want to help, but there are policy impediments,” she said. Among other barriers, old protocols designed to keep predatory payday lenders and other solicitors away from service members are now keeping service organizations from entering military facilities and connecting with them. “VA and DoD, the Army, they’re all working to try to get some of these chartered veteran service organizations on base,” Campos said. “But everybody is very busy and there isn’t a central source to vet these organizations and people.”

In recent months, the National Center for Telehealth and Telemedicine (T2) – a component of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury – has released several technological tools to improve access for veterans and service members – not only to push assistance out to veterans and service members who live far from the nearest resource, but also to connect with a generation increasingly comfortable with the use of the Internet, social networking, and mobile phone applications to help solve problems.

In the summer of 2011, T2 and the National Center for PTSD released the latest in a series of mobile applications that can be downloaded for free to most smartphones: PTSD Coach. Along with other apps, such as Mood Tracker or the Mild TBI Pocket Guide, PTSD Coach provides an additional resource – not a substitute for professional treatment, but a tool for self-assessment and information. Another recent T2 development is its Virtual PTSD Experience, which offers a virtual space, based in the Second Life virtual world and accessible through the T2’s website, where combat veterans can learn about PTSD causes, symptoms, and resources for information and care.

The technological resources being developed by the T2 have the additional advantage of preserving the anonymity of service members who may, for a number of reasons, be hesitant to seek help for PTSD and/or TBI. Fears of damaged military career prospects, the RAND study pointed out, were well-founded, and one of the first moves made by then-U.S. Defense Secretary Robert M. Gates after the report’s release was to modify the Department of Defense’s security clearance application – which included questions about whether an applicant had ever sought mental health treatment – to diminish the potential stigma associated with psychological care. The stigma, however, remains for many service members. “There’s still an impact on pay,” said Campos, “and there’s an impact on promotion that people are worried about.” All the more reason, Campos said, for military members – especially Guard and Reserve personnel – to connect with community-level resources, vet centers, and Military OneSource, which maintains a non-medical counseling component.

The perceived stigma associated with psychological conditions such as post-traumatic stress disorder will certainly diminish over time, as the Pentagon and VA educate the military and veteran populations – and the American public – about the realities of PTSD and TBI, two conditions that are, on a basic level, simply about altered brain circuitry and function. “Psychiatry is not something that happens in the ether,” said Friedman of the National Center for PTSD. “In 1995, Doug Brenner, who is now at the National Institutes of Mental Health [NIMH], demonstrated that the hippocampus – which is a major brain structure, does lots of important things – in PTSD patients, it was shrunken. He showed it both in veterans with PTSD and women who had sexual trauma. Based on this, NIMH was willing to catalogue PTSD as a major mental illness. They only do that when there’s demonstrable brain disregulation or damage.”

According to Hurley and Friedman, PTSD and TBI are conditions that should concern anyone – but they shouldn’t be feared. “Most people who are exposed to a mild concussion or brain injury are just fine and don’t have any long-term symptoms,” said Hurley. “Sometimes patients get really scared because of other reports and cases they’ve seen about patients with severe injuries. For those who do, the VA is well ahead of the curve in terms of screening and in terms of having a standardized, national, comprehensive system to care for them through our polytrauma program.”

Friedman wants veterans and service members to know that they can benefit greatly – perhaps more than most are aware – from treatment. “One of the things we’re learning … is that it doesn’t make sense to try to tease these things apart and say, ‘Which is the TBI and which is the PTSD?’” he said. “There’s a lot of overlap, both at the basic neurobiological level as well as at the clinical level. TBI and the PTSD can be treated concurrently, and people can benefit both in terms of their PTSD symptoms and their cognitive or memory deficit. Anyone who thinks he or she might be having some problems of this sort ought to be evaluated and let us do what we’re capable of doing – because we’re capable of doing a great deal.”

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.