Monday, May 11, 2009

Study: Communities must do more for vets

Study: Communities must do more for vets

By Kelly Kennedy - Staff writer
Posted : Wednesday May 6, 2009 13:36:12 EDT

The military prides itself on taking care of its own. But a researcher who has studied post-traumatic stress disorder said local communities must play a larger role in the safety net for combat veterans.

If local organizations do not reach out proactively to the Defense and Veterans Affairs departments to become more engaged in treating the veterans returning to their communities, they can expect the veterans’ pain to affect their families, their ability to contribute to society, and even their ability to care for themselves, said Audrey Burnam, senior behavioral scientist at the Rand Corp. think tank.

Burnam said vets returning from the wars in Afghanistan and Iraq represent a “historic opportunity” for communities to learn more about PTSD, educate others about the illness and come together to deal with it.

Burnam, who spoke at a Health Affairs Journal panel May 5 in Washington, is the lead author of a new Rand report, “Mental Health Care for Iraq and Afghanistan War Veterans,” that makes a case for a broad reform of services that looks beyond VA.

She said American communities can expect the return of as many as 300,000 veterans dealing with symptoms of PTSD or traumatic brain injury. Though many will get the help they need while still in uniform, or their symptoms will resolve on their own, many more will deal with sleep disorders, nightmares, relationship issues, anger and flashbacks until they get the help they need.

But in addition to a continued reluctance among veterans to seek care, there are only about 500,000 mental health care professionals nationwide. Some areas have as few as eight psychiatrists per 100,000 people.

The report said policy reform is needed to push health insurance plans, professional organizations, states and local communities to improve veterans’ access to high-quality services, citing example of mental health workers in New York state who have offered services pro bono, and a free PTSD counseling program in Washington state that also trains school teachers about the effects of deployment on children.

Burnam sharply criticized using only medication or counseling programs that have not been proven effective on combat vets. She recommended evidence-based treatments such as cognitive behavioral therapy, prolonged exposure therapy and eye-movement desensitization and reprocessing.

She said psychotherapy is much more effective for PTSD than medications, and such treatments have been proven to work.

“Effective treatments for PTSD and depressions exist,” Burnam wrote. “Yet they are not being provided systemically to most affected veterans because of significant challenges that extend beyond the [Defense Department] and VA service systems to the broader communities in which veterans reside.”

In some cases, veterans don’t qualify for VA services because their incomes are too high, or they go through their own employer-based health insurance, she said.

Matthew Friedman, executive director of VA’s National Center for PTSD, agreed with Burnam’s study, but said he thinks VA and the Defense Department can meet the clinical needs of service members and veterans — if people are reached early.

Thousands of VA clinicians have undergone training for prolonged exposure and cognitive behavioral therapy, and there has also been “large-scale” training in the Defense Department, he said.

Still, he acknowledged, “I’m convinced many civilian mental-health providers are not adequately trained.”

That can be an issue when a combat veteran sees a family therapist who has no idea how to use exposure treatments, what military acronyms mean or where Fallujah is. Friedman also agreed that medications are not yet as effective as psychotherapy in treating PTSD.

He added that there may soon be new treatments using medications that mediate new learning and could turn a 10-appointment treatment into a five-appointment treatment, or determining a genotype that lets doctors know when someone is more at-risk for PTSD, or finding a “psychological vaccine” that makes people more resilient to trauma exposure.

Burnam of the Rand Corp. think tank proposes six ways to improve mental-health services for veterans:

• Give combat vets confidential treatment for combat stress, unless they have a severe illness or need medication.

• Teach combat vets about evidence-based treatments so they can be their own advocates.

• Train and certify the mental-health workforce in those evidence-based treatments

• Encourage more people to go into mental health care fields.

• Study and craft quality-improvement for veterans health care.

• Offer technical assistance to states seeking to offer or expand programs for combat veterans.

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