For Some, The War Is Never Over

The New York Times, March 1, 2006

By Sally Satel

According to a report from its inspector general, the Department of Veterans Affairs is paying compensation for post-traumatic stress disorder to nearly twice as many veterans as six years ago, at an annual cost of $4.3 billion.

What’s more surprising is that the flood of recent applicants does not, for the most part, consist of young soldiers returned from Iraq and Afghanistan. Rather they are Vietnam veterans in their 50s and 60s who claim to be psychologically crippled now by their service of decades ago.

Can it really take up to 40 years after a trauma before someone realizes he can no longer cope with the demands of civilian life?

The answer: Possibly, but it is often hard to know which applicants can be helped with short-term psychiatric care, which are seeking a free ride and which are truly deserving of the diagnosis of post-traumatic stress disorder (and long-term care and payments of up to $2,300 a month for life). The VA’s task is to come up with criteria.

Medically speaking, there is some evidence to support what psychiatrists call “reactivated” post-traumatic stress disorder.

The literature is dotted with cases of veterans of World War I, World War II and the Korean War who, after briefly showing signs of stress disorders immediately after their ordeals, led productive lives for decades before breaking down.

Little is known about the treatment of reactivated symptoms, but there is reason to be optimistic patients will recover in view of their functioning well for so long.

But it’s also very likely that some of the veteran baby boomers who have filed claims in recent years did so not out of medical need but out of a desire for financial security in their retirement years. Indeed, 40 percent of last year’s claimants had been out of the military for 35 to 49 years.

In any case, the rush of applications for long-term disability entitlements reflects the extent to which the VA culture since Vietnam has become fixed on post-traumatic stress disorder.

Claims for all other forms of mental illness have declined by about 12 percent of patients at VA hospitals over the past decade but the number of vets getting compensation for post-traumatic shock has nearly tripled.

Having worked as a psychiatrist at a VA hospital, I can attest to the good intentions with which the department created its post-traumatic stress disorder programs. But as the bureaucracy has become entrenched, and politicians and veterans’ groups have applied pressure, a culture of trauma has blossomed.

If a veteran can demonstrate service in Vietnam and list a few symptoms of the disorder (terrifying nightmares, bad memories, anxiety, survivor guilt), there is a good chance he will be granted the diagnosis and a tax-free monthly stipend.

The problem in giving a diagnosis so long after a patient saw combat is it can be very difficult to know if traumatic exposure was the true cause. Yet many VA doctors and officials simply assume that participation in war results, de facto, in post-traumatic stress disorder.

Surely some of these applicants have “never been right” since their discharge. Over the years they drifted further away from their families and communities.

By the time they come to a veterans’ hospital for treatment, they are seen as having “malignant PTSD” – that is, severe symptoms of post-traumatic stress disorder complicated by drug and alcohol abuse and other mental problems such as depression.

The VA has to begin differentiating between several categories of delayed-benefit applicants.

First are the chronically afflicted veterans who were probably damaged by the war but never got adequate treatment after discharge. The second group consists of those who are experiencing genuine “reactivated” symptoms from war trauma. Third are the veterans who managed to get diagnoses of post-traumatic stress disorder decades after their military service.

As the VA tries to distinguish among those groups, verification of exposure to trauma is vital. The office of the inspector general found that for one-quarter of Vietnam veterans claiming post-traumatic stress, the department could not confirm any incidents of traumatic stress.

Most important, more rigor in diagnosing will conserve resources for veterans who are truly deserving. With a new generation of soldiers returning from Iraq and Afghanistan, the VA needs to look at post-traumatic stress disorder in a new way: The department must regard it as an acute but treatable condition.

Only in rare instances should veterans be eligible for lifetime disability; and perhaps there should be a deadline of years after service by which claims must be submitted.

The VA should spend its time and money helping our newest veterans now, when the psychological consequences of war have fresh meaning and patients have an excellent chance at recovery. Decades after a war is too late to make sense of PTSD.

NOTES: Sally Satel, a psychiatrist and resident scholar at the American Enterprise Institute, is a co-author of “One Nation Under Therapy.” Copyright 2006 The New York Times.