War’s Silent Stress: The Family at Home

depressionWar’s Silent Stress: The Family at Home originally appeared on the Opinion page of the Virginian Pilot on August 9, 2009.

MUCH LIKE the news of servicemen killed in action in Iraq and Afghanistan, last month’s news of the death of a military spouse at Ft. Bragg made only local headlines.

A 40-year-old Army wife, who was four months pregnant, was found dead of what appeared to be a self-inflicted gunshot wound. The woman had called 911 with threats of hurting herself, but the police arrived too late. Her husband is an Army sergeant who worked in Civil Affairs and had been deployed multiple times.

When the news broke, there was a short burst of e-mail traffic among the leadership of Blue Star Families, a nonprofit, nonpartisan group of military spouses working to promote awareness of the myriad issues facing today’s military families.

“I don’t know why I find this so surprising but the story says she was 40,” wrote the wife of a Special Forces NCO. “I guess I assumed that someone in that state of despair would be younger — like maybe she’d have better coping skills at 40.”

The majority of the Blue Star Families members are veterans of three, four and five deployments, and at least one member has endured eight deployments in the past seven years. Often these deployments last well beyond a year, as anniversaries, holidays, births and birthdays tick by, never to be celebrated together.

My husband, a recently retired Marine Corps officer, deployed only once in the five years we have been married. A difficult seven months, but it was, after all, only one deployment.

Post-conflict disorder and depression are being addressed by our military for the service members who return from Iraq and Afghanistan. But the effects of these deployments on spouses and families are just beginning to get some attention. While statistics on depression and mental illness among military spouses are not available, some Blue Star members are openly surprised that suicide among the spouses of deployed troops is not more prevalent. In fact, the stereotypical overwhelmed military spouse is 19 to 22 years old, the wife of a junior enlisted service member, whose ranks make up almost 44 percent of our active duty military. Many of these spouses have very young children, are far removed from extended family, are on a limited and usually single income — approximately $1,500 per month for a family of four — and few have the coping skills that come with age and experience. But mental health experts remind us that depression knows no boundaries — not age, income level or military rank.

Sadly, last month’s tragedy was not an isolated incident, though news stories about suicides can be hard to find because many media outlets honor an old journalism standard of not reporting suicides. On Nov. 28, 2006, police in Fayetteville, N.C., discovered a 39-year-old mother and her two children dead inside the family car. The mother had killed herself and her two young children with carbon monoxide poisoning. Although no one knows what went through her mind when she climbed inside the vehicle and strapped her two children into their car seats, the military wife had a history of postpartum depression. Nonetheless, she was described as a positive and upbeat woman who mostly kept to herself. Her husband, a lieutenant colonel in the Army, had been deployed to Iraq just two months before, just after the birth of the couple’s daughter.

A few members of Blue Star Families’ leadership have admitted to being treated for depression. One member said that the combination of her husband’s three recent heavy-combat tours to the dangerous Helmand Province of Afghanistan and the stress of taking care of two young children led her to deep despair, thoughts of suicide and hopelessness and, eventually, to a depression diagnosis and a prescription for Wellbutrin.

She described how military spouses get addicted to news reports during deployments, despite knowing the information will make them miserable. The Internet allows the family to catch every bit of reporting on the area where their soldier, Marine, airman or sailor is deployed. This has the effect of almost putting the spouse into combat with them. “There is nothing as intense as doing a Google search to find out if the love of your life, the father of your children, is dead or alive,” she said. While the family member can be literally paralyzed with worry, she also must raise kids, work, pay bills and deal with the sometimes infuriating and insensitive comments of civilians around her.

Officers and senior NCO’s are trained to detect Combat Stress Disorder in their men and women serving in combat. Often a precursor to Post Traumatic Stress Disorder, a crippling mental state, the men or women who show signs of combat stress are given rest, a good hot meal, a DVD or book and a strong verbal reminder that they are going back into the fight after their short break. Unlike the military, their spouses are not trained to detect symptoms of depression, burn-out or what another generation called “combat fatigue” — in themselves or each other.

Thankfully, much already is being done to help military families. There is a push for more mental health counselors on bases. Teams of Military Family Life Consultants funded by the Department of Defense are available to all services. They provide counseling to service members and their families, and there is no chain of command notification and no paperwork. Nonetheless, many spouses — even in the Blue Star leadership — have never heard of these services.

In addition, studies are beginning to surface about Secondary PTSD — a mental health issue that has been lurking around in this country since at least the Vietnam War. Secondary PTSD has shown up when the spouse and/or family respond to their changed environment with anger, substance abuse or violence, replacing a peaceful and loving home life. Repeatedly, Blue Star Families have found with so many of the good programs out there, the challenge is letting families know what is available.

Now more than ever, communication is key. As media reports query the long range effects of multiple deployments on children, and with the increased awareness for detecting and treating PTSD in our military, it is time to close the loop on mental health and our military families and begin talking about the potentially harmful effects of repeated longterm deployments on the spouses of our service members.

Civilian or military, the first step to help for depression is talking about it.

Rosemary Freitas Williams is a director of communications for Alexandria-based Blue Star Families, whose members on 70 military bases work to educate those who make decisions about military life and its unique challenges.

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Alternative Medicine and the Military

Alternative medicine blog photoI recently read an article in the June/July 2009 issue of Ode Magazine titled “The U. S. Military’s New Medical Frontline.” What is this “new” medical view? Apparently, it is alternative medicine. Yoga, acupuncture, and meditation are all part of the fold. I commend author Carmel Wroth for writing about this intriguing and overlooked subject, although I would hasten to say that I don’t believe it is necessarily a novel idea for the military.

Alternative medicine is now being touted as some sort of new treatment for the U.S. Armed Forces. The aforementioned article states that a new research program funded by the Department of Defense is slated “to find new tactics for combating post-traumatic stress disorder (PTSD), other stress-related conditions, and traumatic brain injury.” Accordingly, the “Defense Centers of Excellence [DCoE] for Psychological Health and Traumatic Brain Injury launched the initiative, spending nearly $5 million last year – more than 10 percent of its research budget – investigating alternative and complementary medical techniques.” This initiative, called the Real Warriors Campaign, was established to address the stigma associated with PSTD and depression by supporting service members and their families in getting help to deal with psychological and TBI issues.

It is well known that due to the OIF and OEF conflicts, more and more of our soldiers returning home are suffering from PTSD and TBI. Estimates from DoD show that about 43,000 service members have been diagnosed with PSTD and 36,000 with TBI. Yet, it is also known that many service members experiencing psychological problems have not been diagnosed at all. According to the RAND Corporation’s recent study titled “Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery,” 57 percent had not been evaluated by a doctor for TBI. The study also states that about 1 out of 5 service members suffer from PSTD and 19 percent suffer from TBI.

What is surely recognized is that there is still an insurmountable gap in the psychological care that our soldiers are receiving. And, of those of our soldiers and wounded warriors suffering from these invisible wounds of war, receiving care often means heavily prescribed and numerous medications, perhaps while they also receive psychological therapy and care. But taking prescriptions and occasionally speaking with a therapist may not be the only answer for many soldiers and wounded veterans. It is about time that the military and the DoD examined alternative medicine as a definite possibility.

The truth of the matter is that many of our military hospitals, including the Walter Reed Army Medical Center, have been using acupuncture and yoga for a few years now. In fact, yoga nidra, an integrative restoration and extreme relaxation treatment, is being offered at the VA Center in Washington, DC. While many of these alternatives may not be extensively available to military service members and their families, another central issue with alternative and complementary medicine is similar to that of our civilian counterparts: many of us still think it is all hocus pocus. The military is no exception. Getting wounded soldiers and their families to partake in yoga nidra, meditation and acupuncture can be a daunting task.

As a wounded warrior who had PSTD and TBI, my husband has been receiving acupuncture by a very nice practitioner (I shall call her Sue), who has donated her services for nearly three years now. My husband was on over 20 medications, and now takes only one regularly, depending on his pain level, along with aspirin and Tylenol. And, I go to Sue for monthly acupuncture sessions because it relieves pain and stress, and combats insomnia, a problem I had after my husband returned from OIF and could not sleep through the night. Sure, Ambien worked like a charm, but I became dependent on it, even though I was only taking it two to three times per week.

So, as I have used acupuncture and practiced yoga for some time, I say to those doubters and naysayers of alternative and complementary treatment: don’t knock it unless you have tried it.

INVISIBLE WOUNDS OF WAR by Saralyn Mark, MD

Saralyn Mark photo

UPDATE:  Last Friday, after the hearing Sara talks about below, The U.S. Senate Armed Services Committee voted unanimously to adopt the Montana model for assessing returning combat vets for post-traumatic stress disorder.  Check out the story here

Last Wednesday, I had an opportunity to present to Congress my thoughts on the “invisible wounds” of war. According to a 2008 RAND report, nearly 20% of veterans who have returned from Iraq and Afghanistan suffer from post traumatic stress disorder (PTSD) or major depression. I think that these numbers are actually low, since the report was based on extrapolated data from a survey of less than 2,000 troops. We now know that the number of Army suicides has increased every year since the Iraq War began, and this is the first time since the Vietnam War that the Army suicide rate has surpassed the civilian suicide rate.

The briefing was in the Dirksen Senate Office Building and was sponsored by Senators Max Baucus (D-Montana), Mike Johanns (R-Nebraska), and Jon Tester (D-Montana). The Senate hearing room, with its elegant wood paneling and high ceilings, was filled to the brim and every seat was taken. People were even standing near the windows and out in the doorway. I was seated in the middle of a very long table and was flanked by two colonels: Colonel Jeff Ireland, Director of the Montana National Guard, and Colonel Peter Duffy (retired), Deputy Director of the National Guard Association. We were joined by three others including two psychologists and Mr. Patrick Campbell, Chief Legislative Counsel for Iraq and Afghanistan Veterans of America. Mr. Campbell shared his experiences of how difficult it was to get mental healthcare while on active duty and how he was inappropriately questioned about his symptoms and needs when he returned home to the U.S.

During the briefing, staffers took copious notes and the audience remained completely silent. I don’t think I’ve ever spoken to a more attentive group of people. I usually don’t like to use prepared remarks, but we had tight time limits and I wanted to be sure I conveyed all my points. I’ve included my remarks here in this blog; many passages were actually taken from my prior BeWell blogs (“A Nation of Ghosts” and “Shock and AWE”), which focused on these issues. Congress is considering legislation to help veterans suffering from PTSD and other mental health issues. This was a chance to raise the level of awareness for other Senate offices to support this legislation. (I’ve since learned that other Senators signed on to support S.711-The Post Deployment Health Assessment Act of 2009 after hearing the briefing).

I must admit that it was cathartic to be able to formally share my viewpoints. I was having my own flashbacks to March of this year when I was on Capitol Hill to speak to congressional offices about pancreatic cancer. In some ways, talking about the mental health needs of the military was harder. Both touch my life very closely and I feel a need and a responsibility to make a difference and help others, as well as my own family. But talking about PTSD — or as I would like to call it “AWE” (Adaptation to the Extreme Environment of War) — was a more delicate topic for me.

Perhaps because I think that there is an understanding that military wives are not to speak out, especially to tell Congress that “it is not ethically or morally acceptable to send our loved ones off to war without the resources that they need to protect themselves.” I can only guess that other spouses might feel that they cannot talk about the painful changes they are seeing in their partners. It is a taboo topic filled with stigma, as if our loved ones are weak and not made of the “right stuff” for the military. I wonder if this silence is like a cancer that eats away at our loved ones and our families.

After the briefing, I stayed in the room for an extra 45 minutes taking questions from the audience, including Senate staffers who were officers in the military. Their stories were so poignant and courageous. I felt like we were their voices and I hope that we did them justice.

My three points that I wanted to make in that briefing room were the following: 1) War changes everyone and people adapt. Those changes (AWE) are a normal reaction to an abnormal situation with PTSD at the other end of the continuum, where the adaptation process has progressed to a dysfunctional state; 2) We should offer mandatory surveillance and rehabilitation before, during and post-deployment; 3) Family members need to be involved. Currently we have no where to go to confidentially report changes that we see in our loved ones without causing potential damage to their careers.

After the briefing I left the hearing room with Colonel Ireland we walked together to the train station. I felt a sense of sadness and exhaustion as I entered the Metro. It was an honor to have had the opportunity to speak and share ideas, but the weight of what we still need to accomplish is huge. I know that I am but one voice representing many. I hope that my message encourages others to speak out, as well, and to demand action. We are blessed to have a First Lady who is committed to the well-being of military families and her advocacy can make a big difference.

If we can afford to go to war, we have to afford to take care of the mental health of our troops. We must stop viewing mental health care as a luxury. It is a necessity to ensure that our troops, our loved ones, can defend our nation and come back and be productive members of our society and our families.

Saralyn Mark, MD

http://www.bewell.com Medical Editor

President, SolaMed Solutions, LLC

Associate Professor adjunct of Medicine

Yale and Georgetown University Schools of Medicine

Affiliate Professor

George Mason University School of Public Policy

Shock & Awe by Saralyn Mark, MD

PTSD, depression, and suicide

“Shock and awe” is a phrase that was introduced and quickly woven into our conversations during March 2003. We knew that it conveyed our military’s strength and superiority fighting the enemy in Iraq. We were transfixed by the fireworks illuminating the night’s sky over Baghdad. Six years have gone by since “shock and awe” transformed our lexicon and eight years since our troops landed in Afghanistan. Battles have been fought in distant lands to protect our freedom and security.

Now we are finally acknowledging that this war is coming home. On March 18, 2009, in two locations in our nation’s capital, the truth about this war reached our shores. For years we knew that this was coming, but it was difficult to face. The casualties are not just our troops”the collateral damage includes their families. At the Pentagon, the secretary of Veterans Affairs and the deputy secretary of defense hosted a screening of the PBS special “Coming Home: Military Families Cope with Change”–a show that highlights families who have faced amputations, traumatic brain injuries and post traumatic stress disorder. While at the same time, there was a hearing of the Senate Armed Services Committee to discuss the rise of suicides among military personnel.

What connects these two events is shock and AWE. It is time for our nation to accept and understand a new version of this concept–one still grounded in military strength but now associated with a benevolent action rather than destruction. Military jargon is filled with acronyms. So to continue that long-standing tradition, AWE can be an acronym for “Adaptation to the War Environment.” AWE is a normal process that the body and psyche experiences to adapt to the extreme environment of battle in order for a person to survive. By just changing the nomenclature, we can begin to change a climate filled with stigma, fear and humiliation. Instead of saying post traumatic stress disorder or PTSD to describe the signs and symptoms that our troops experience–which can imply victimization, weakness, disability or disease–we can describe it as AWE, a normal reaction to an abnormal situation.

During the Senate hearing, every military leader expressed concern over the soaring rates of military suicides. These rates are higher than the general population. In 2009, 24 Army soldiers may have committed suicide and possibly another 18 in February, despite an increase in suicide prevention programs. General Peter W. Chiarelli, vice chief of staff of the Army cited long deployments and separations from family and the perceived stigma and shame associated with getting help. This point was also expressed by Admiral Patrick Walsh, vice chief of Naval Operations.

Recently, General Carter Ham and Brigadier General Gary Patton courageously went public about their reactions to the stress of war and the need for mental healthcare. They wanted to encourage service members to come forward and ask for help. Some junior officers and enlisted personnel may still be reluctant to do this, believing that the generals were able to be open about their situations because they were at the pinnacles of their careers, and if they seek help they will be passed over for promotions. This conception will be hard to change if the climate is not dramatically altered.

We need to not only provide the superficial modification of wording from PTSD to AWE, but also dispel the notion that only a few are affected by war. Everyone comes back changed. We are fighting an unconventional war that will continue for years. It is now time to take an unconventional approach to prevention and treatment of this issue. Otherwise, we will continue to be a nation haunted by ghosts. I have written that even when our loved ones return, some with physical injuries, it is the invisible injuries that damage the fabric of lives. They may have come home, but emotionally they have disappeared. Family members, holding on to these precious spirits, disparately search for healthcare which could bring back their loved ones. We have created this environment because our mental health care programs have failed.

It is time that we come forward and state that we expect that all our troops will return with reactions to the extreme environment of war. It is the norm rather than an abnormality. It then becomes a shared experience and not associated with shame or dishonor. This approach has worked in other settings such as within NASA. For example, it is expected that all astronauts will experience bone loss secondary to the microgravity environment in space. Astronauts undergo training to achieve maximum fitness before they fly, utilize countermeasures such as physical activity during flight to mitigate loss and all go through extensive rehabilitation programs when they return. The severity of the bone loss and recovery varies by astronaut, but they know that they will all lose and will require assistance to protect their health at home and “flight readiness” for their missions.

This model could work for our military. We can help our troops better prepare in advance for the stresses of war, have countermeasures in the field such as well trained mental health personnel and mandatory rehabilitation and surveillance upon return to a non-hostile environment. If we assume that everyone will have adapted to the war environment (AWE) and will require mental healthcare, it removes the stigma associated with it.

This novel approach can help to protect the “fight readiness” of our troops for the battlefield and for their adjustment to the home front. Imagine the day when it will be a badge of courage and honor to say “I’m in AWE.”

Saralyn Mark, MD, BeWell Expert

Associate Professor of Medicine adjunct
Yale and Georgetown University Schools of Medicine

Affiliate Professor
George Mason University School of Public Policy

Senior Medical Advisor
NASA
*The opinions expressed are the views of the author and not of NASA.