published in July 2013 in the Canadian Medical Association Journal found that fourteen percent of Canadian Forces who served in Afghanistan have been diagnosed either with post-traumatic stress disorder (PTSD) or other mental health disorders. That same report found less than a third of returning soldiers receive counselling and related mental health services. Now an article
just published in the Canadian Medical Association Journal (apologies for the paywall) zeroes in on one cause and how to fix it.
As to why Canadian soldiers and veterans are failing to get the treatment they need, it's hard to get any treatment at all if you aren't being diagnosed with PTSD. The simple fact is that many soldiers returning from areas of combat and those who have left the service some time ago are highly unlikely to volunteer enough information so that the doctor can diagnose PTSD - things like flashbacks or memories of traumatic events that intrude on their sleep, avoiding thoughts or feelings, people or places that trigger the memory and irritable and even aggressive behaviour.
This is true of returning soldiers and it's also true of paramedics, fire fighters and police officers, who make up the bulk of the civilians with PTSD that isn't diagnosed. The article in the CMAJ points out that often, doctors don't make the diagnosis because they don't know the right questions to ask. It tries to fix the problem by teaching MDs what to look for and what to ask to get soldiers to talk about their symptoms.
The consequences of unidentified and untreated PTSD can be devastating. Soldiers with PTSD have very high rates of depression with suicidal thoughts. In the past two weeks alone, four young Canadians
who served in Afghanistan died, with three of the deaths being ruled suicides at the time of this writing. Until someone in authority says otherwise, we're left to wonder whether PTSD may have played a role.
Rates of alcohol and drug abuse are higher than in the general population. Many diagnosed with PTSD can no longer function within the military and are discharged. Soldiers who are diagnosed often end up discharged from the service, a fact that may discourage soldiers still on active duty from seeking help. Those who return to civilian life find it difficult to re-integrate into society. Often, they can't find work. At home, frequent mood swings and angry outbursts put marriages in jeopardy. Children of soldiers with PTSD are often traumatized as well. All of this may be going on right under the nose of the soldier's physician.
We've been hearing much more about PTSD lately. A big question is whether the problem is geting worse. Some have suggested
that PTSD is no worse now than it was during the Vietnam War or the Korean and Second World Wars. They called it shell shock and other names back then, but the problem of being exposed to highly traumatic events that leave an indelible mark on soldiers existed back then. PTSD didn't even get its name until the 1980s.
Some have argued that any increase in the incidence of PTSD comes from better recognition of the problem. The author of the article in CMAJ said there is no clear evidence of an increased risk of mental health problems and PTSD from deployment in Afghanistan. However, she said there is evidence of a strong link between exposure to combat, the witnessing of atrocities and the development of PTSD. Thus, one might be able to build a case that one war is more likely to lead soldiers to develop the disorder if one can make a convincing case that the atrocities witnessed are more profound.
Some researchers wonder if other factors could be playing a role in PTSD. One of the things that distinguish twenty-first century warfare from what took place in the last century is the use of powerful improvised explosive devices or IEDs. With IEDs, we tend to focus on the fact that these devices either kill soldiers or cause them to lose their limbs. What researchers are beginning to pay attention to are the invisible injuries caused by IEDs. Frequently, it's the brain that bears the brunt of the explosion. The thing is, IEDs can cause traumatic brain injuries that damage the frontal lobes - causing mood swings, violent outbursts, poor impulse control and substance abuse - symptoms that to me sound a lot like PTSD.
Researchers aren't saying all cases of PTSD are caused by head injuries, but they wonder how often these two conditions co-exist
, or if brain injuries are at least a factor in the severity of PTSD symptoms.
Conventional treatment consists mainly of medications and counselling. Antidepressants are prescribed to relieve depression and suicidal thoughts, while mood stabilizers are prescribed to help prevent rapid mood swings. Anti-psychotic drugs are used to improve sleep.
Counselling can help; in particular research shows that cognitive behavioural treatments (CBT) including exposure and cognitive restructuring are beneficial for many veterans. Physical exercise programs have also been shown to be helpful.
At best, around half of all soldiers respond to treatments and few are cured. The aim is to control symptoms so that the patient is able to function better at home and perhaps go to work or take retraining. The failure of conventional treatment has spawned efforts to discover alternative therapies. Some experts recommend a treatment called trans-cranial electrical stimulation in which a mild electrical current is passed through the brain. Others recommend hyperbaric oxygen, a treatment in which the patient is put into a chamber in which they breathe oxygen at two to three atmospheres of pressure. The treatment is standard therapy for patients with decompression sickness (an illness that occurs in scuba divers who ascend too rapidly). Proponents believe that hyper-baric treatment works by making more oxygen available to the damaged brain, and by doing so improving the symptoms of PTSD.
Some doctors worry that interest in alternative treatments is fueled by a search for the quick fix. That so many treatments are recommended tells you that no one has a handle on it. Therefore, the hope is that early recognition can increase the odds of successful treatment.