[humanser] The Wars Come Home: The Traumatic Brain Injury Epidemic

[Mary Ann Robinson]

The Wars Come Home: The Traumatic Brain Injury Epidemic
  By Conn Hallinan
  Dispatches From The Edge
  June 18, 2011
  "We are facing a massive mental health problem as a result of
our wars in Iraq and Afghanistan.  As a country we have not
responded adequately to the problem.  Unless we act urgently and
wisely, we will be dealing with an epidemic of service related
psychological wounds for years to come."
  Bobby Muller, President Veterans for America
  "The multiple nature of it [multiple tours and longer
deployments] is unprecedented.  People just get blasted and
blasted and blasted."
  Maj.  Connie Johnmeyer, 332nd Medical Group
  According to official Defense Department (DOD) figures, 332,000
soldiers have suffered brain injuries since 2000, although most
independent experts estimate that the number is over 400,000.
Many of these are mild traumatic brain injuries (mTBI), a term
that is profoundly misleading.
  As David Hovda, director of the Brain Injury Research Center at
the University of California at Los Angeles, points out, "I don't
know what makes it `mild,` because it can evolve into anxiety
disorders, personality changes, and depression." It can also set
off a constellation of physical disabilities from chronic pain to
sexual dysfunction and insomnia.
  MTBI is defined as any incident that produces unconsciousness
lasting for up to a half hour or creates an altered state
consciousness.  It is the signature wound for the wars in Iraq
and Afghanistan, where roadside bombs are the principal weapon
for insurgents.
  Most soldiers recover from mTBI, but between five and 15
percent do not.  According to Dr.  Elaine Peskind of the
University of Washington Medical School, "The estimate of the
number who returned with symptomatic mild traumatic brain injury
due to blast exposure has varied from the official VA [Veterans
Administration] number of 9 percent officially diagnosed with
mTBI to over 20 percent, and, I think, ultimately it will be
higher than that."
  Serious consequences from mTBI are increased when troops are
subjected to multiple explosions and "just get blasted and
blasted and blasted," in the words of Maj.  Connie Johnmeyer.
Out of two million troops who have served in Iraq and
Afghanistan, over 800,000 have had multiple deployments, many up
to five times or more.
  But mTBI is difficult to diagnose because it does not show up
on standard CAT scans and MRI's.  "Our scans show nothing," says
Dr.  Michael Weiner, professor of radiology, psychiatry and
neurology at the University of California at San Francisco and
director of the Center for Imaging Neurodegenerative Disease at
the Veteranbs Administration Medical Center.  They do now.
  An MRI set to track the flow of water through the brainbs
neurons, has turned up anomalies that indicate the presence of
mTBI.  However, the military has blocked informing patients of
results of the research, and if history is any guide, the
Pentagon will do its best to shelve or ignore the results.
  The DOD has long resisted the diagnosis of mTBI, as it has
avoided paying for a successful -- but expensive -- way to treat
it.  The price of that resistance is escalating suicide rates and
domestic violence incidents among returning soldiers.  In 2010,
almost as many soldiers committed suicide as fell in battle.
  MTBI is hardly new.  Some 5.3 million people in the U.S.  are
currently hospitalized or in residential facilities because of
it, and its social consequences are severe.  A Mt.  Sinai
Hospital study of 100 homeless men in New York found that 80
percent of them had suffered brain trauma, much of it from child
abuse.  A study of 5,000 homeless people in New Haven discovered
that those who had suffered a blow that knocked them unconscious
or into an altered state were twice as likely to have alcohol and
drug problems and to be depressed.  It also found mTBI injuries
were correlated with suicide attempts, panic attacks, and
obsessive-compulsive disorders.  And a recent study by Dr.
Elaine Peskind of the University of Washington School of Medicine
found that mTBI is a risk factor for developing Alzheimerbs
disease.
  In spite of the documented consequences of mTBI, the military
has been extremely tardy in dealing with it.  Part of the problem
is military culture itself.  The Pentagon found that 60 percent
of the soldiers who suffered from the symptoms of mTBI refused
help because they feared their unit leaders would treat them
differently.  Many were also afraid that if they reported their
condition it would prevent them from getting jobs as police and
fire fighters after they got out of the service.
  Even if soldiers wanted treatment, there are few resources
available to them.  "There are two things going on regarding
vets," says Col.  (ret) Will Wilson, chair of the American
Psychological Associationbs Division 19 (Military Psychology).
"One, there are not enough care providers available, and, two,
there are not enough people focusing on the problem outside the
military."
  Indeed, there are not enough military psychologists to treat
the problem, and since the military pays below-market rates for
civilian psychologists, up to 30 percent of private psychologists
are unwilling to take on soldiers as patients.  The cheapest and
easiest solution is to shoot up the vets with drugs.  A study by
Veterans for America found that some soldiers were taking up to
20 different medications, many of which canceled out the effect
of others.
  The situation appears to be even worse for National Guard and
Reserve units, who make up almost 50 percent of the troops
deployed in Iraq and Afghanistan.  The Veterans for America found
that such troops "are experiencing rates of mental health
problems 44 percent higher than their active duty counterparts"
and that their health care is generally inferior.
  A Harvard study found that 1.8 million vets under 65 have no
health care or access to the Veterans Administration.  "Most
uninsured veterans are low-to-middle income workers who are too
poor to afford private coverage but are not poor enough to
qualify for Medicaid or free VA care," the study found.
  Treating mTBI injuries is difficult, but by no means
impossible.  Dr.  Alisa Gean, chief of Neuroradiology at San
Francisco General Hospital, who has worked with wounded soldiers
at U.S.  Armybs Regional Medical Center at Landstuhl, Germany
says the old conventional wisdom that brain damage was
untreatable is wrong.  "We now know that the brain can heal.  It
has an intrinsic plasticity that allows it to recover, and this
is particularly true for the young brain." A recent study by the
Massachusetts Institute of Technology found that "neurons in the
adult brain can remodel their connections," thus "overturning a
century of prevailing thought."
  One method that has worked effectively is cognitive
rehabilitation therapy (CRT) that retrains patients for tasks
like counting, cooking, and memory.  But CRT takes time and it
can be expensive, ranging from $15,000 to $50,000 per patient.
However, the DOD-BS health program -- Tricare -- refuses to
endorse CRT, because it says there is no scientific evidence that
justifies the expense involved.
  However, an investigation by T.  Christian Miller of ProPublica
and Daniel Zwerdling of National Public Radio found that the vast
majority of researchers, even those associated with the DOD,
sharply disagreed with Tricarebs evaluation of CRT.  According to
the two reporters, "A panel of 50 civilian and military brain
specialists convened by the Pentagon unanimously concluded that
cognitive therapy was an effective treatment and would help many
brain damaged troops." The therapy is also endorsed by the
National Institutes of Health, the National Academy of
Neurophysiology and the British Society of Rehabilitative
Medicine.
  Instead of accepting the advice of its own researchers,
however, Tricare hired ECRI- a company which had already done a
study concluding that CRT was ineffective-to examine the therapy.
But critics charge that the study was so narrow, and the
assumptions behind it so loaded, that it was almost a given that
the study would conclude the benefits of cognitive therapy were
"inconclusive." Outside researchers blasted the ECRI study, one
of them describing it as "hooey" and "baloney." In spite of the
criticism, then Deputy Secretary of Defense Gordon England
concluded, "The rigor of the researchbandhas not met the required
standard."
  However, Miller and Zwerdling concluded that Tricare's
resistance to CRT was not about science, but the bottom dollar.
According to the reporters, a Tricare-sponsored study found "that
comprehensive rehabilitative therapy could cost as much as
$51,480 per patient.  By contrast, sending patients home from the
hospital to get a weekly phone call from a therapist amounted to
only $504 a patient."
  Defense Secretary Robert Gates has already made it clear that
he intends to cut the military's $50 billion annual health
budget.  No matter how effective CRT is, it's not likely to get
past the brass, who would rather spend the money on weapon
systems than on healing the men and women who they so casually
put in harmbs way.
  So far, the military has put the clamps on the new MRI
technique.  Dr.  David L.  Brody, an author of the study, told
the New York Times that researchers were blocked from giving the
MRI results to patientsdd"We were specifically directed by the
Department of Defense not to so," adding, "It was anguishing for
us, because as a doctor I would like to be able to help them in
any way.  But that was not the protocol we agreed to."
  Given that mTBI is so difficult to diagnose, and sufferers are
many times told there is nothing wrong with them, that seems an
especially cruel protocol.  "Many of them [the doctors] were
hoping we could give results to their care providers to document
or validate their concerns."
  In the end it will come down to treatment, and whether the
wounded vets will get the care they need, or sit by a phone and
wait for their once a week call from a therapist.