[Congressional Record Volume 150, Number 93 (Thursday, July 8, 2004)]
[House]
[Pages H5388-H5390]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                            WAR WITHOUT END

  The SPEAKER pro tempore. Under a previous order of the House, the 
gentleman from Washington (Mr. McDermott) is recognized for 5 minutes.
  Mr. McDERMOTT. Madam Speaker, another four soldiers died today in 
Iraq. Families mourn the loss of loved ones. Our Nation mourns the loss 
of brave soldiers. Over 900 Americans have died in Iraq so far. As many 
as 10 times that number have been injured. Americans spent $150 
billion, and we know tens of billions dollars more will be spent this 
year. If only one soldier had died, the number would be too high, but 
the casualties and the grief are much worse.
  The truth is we have not even begun to see the casualties of the Iraq 
war. The truth is that thousands of soldiers will face a lifetime of 
injury from the war. The truth is we will have not even begun to count 
the casualties that will come from post-traumatic stress disorder.
  The magnitude of the coming casualties among returning U.S. soldiers 
is staggering. The prestigious New England Journal of Medicine in its 
most recent issue, which I will enter into the Record, gives a glimpse 
into the coming medical crisis facing our soldiers, families, and the 
Nation. The journal is known for credibility, thoughtful and factual 
reporting and analysis. The journal conservatively estimates that one 
in five soldiers will be afflicted with PTSD. In many cases, the 
symptoms will not even surface for a year or more. The casualties from 
the President's war of choice will affect tens of thousands of 
soldiers. There are 160,000 soldiers in Iraq today. Using the journal's 
conservative estimate, 30,000 U.S. soldiers will become post-traumatic 
stress disorder casualties in this war. Most do not even know that they 
are sick yet. Most do not exhibit any symptoms outwardly and will not 
for months or years. Tragically, when symptoms do appear, many soldiers 
will not ask for help.
  Call it the tough-guy stigma. Soldiers are trained to be fearless no 
matter what the danger. Too many consider it a sign of weakness to need 
help. They will try to suffer in silence, but PTSD is as powerful as an 
artillery shell. Without help, PTSD can tear too many brave military 
men and women to shreds psychologically. I know. I was a Navy doctor 
and psychiatrist who treated soldiers returning from Vietnam with the 
post-traumatic stress disorder. Gut-wrenching is the only polite way to 
describe the anguish and suffering these soldiers experienced. Many of 
them still struggle against the demons of this disease.
  As a doctor, you can do everything you can to help. All too often it 
is not enough, and all too often the only thing you can do is comfort 
the afflicted. You realize just how inadequate modern medicine is.
  Some wonder why I strongly oppose the President's war of choice. 
Because I have seen the casualties. I have seen the pain inside the 
mind that no bandage can cover. I have treated the wounded, only to 
know in the dead of night just how little I and every doctor could do. 
We wanted to end the suffering. Who would not? We wanted to heal their 
wounds. Who would not?
  Years later, long after the Vietnam War, years later after the media 
moved on to other issues, PTSD was still there haunting soldiers' 
minds. I saw it when I was a doctor working and treating prisoners in 
the King County jail. They include former soldiers who got into trouble 
because they struggled keeping their emotions under control. They 
struggled with PTSD. People who had served their country with no prior 
history of mental illness suddenly found themselves on the wrong side 
of the law. Were they felons or fallen heroes in need of help? I know 
what I think.
  PTSD preys on the peace and happiness every American deserves, 
especially those who were drafted to fight in a war which this country 
came to loathe. After Vietnam, soldiers did not even have the thanks of 
a grateful Nation. We blamed them for the government's arrogance. It 
took decades before the wounds of the Nation began to heal. Thousands 
of names on a wall made us realize how much we had lost, how little we 
had gained, and how wrong it all was.
  At least today America honors our soldiers, even as the opposition to 
the President's war grows. And it should. We are just beginning to 
realize the consequences of the President's war of choice. America has 
about 10,000 soldiers already dead or wounded. We face another 30,000 
casualties. The wounds have already been inflicted. They are just not 
visible yet.
  And they wonder why I strongly oppose the President's war of choice. 
The administration keeps inventing new reasons why we had to invade 
Iraq. They cannot even explain why 10,000 have already suffered or why 
30,000 more will.
  This is not about my opposition to the war, though. This is about 
preparing to help the men and women coming home from war. This is about

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honoring our soldiers by facing the truth about the coming wave of 
casualties here at home from PTSD. This is about a call to action in 
every city and town across America and in every home and every 
workplace. We must help them.
  This is about a call to action in every city and town across America, 
in every home, in every workplace, PTSD is as real, as painful, as 
devastating as any shrapnel wound. If the effects could be seen like a 
bullet wound, we'd race the patient to the hospital for immediate care.
  But PTSD doesn't work that way. It's silent. It's almost invisible. 
It's a war raging inside a person and we have to help. We can help by 
debunking the tough guy stigma. We can help by talking, listening and 
watching for signs of stress as our loved ones come home. We must help 
by demanding that the Veteran's Administration receives the funding to 
treat our returning soldiers. It's not a one-year supplement.
  It is the recognition of the long-term consequences of the Iraq War. 
It is the commitment to treat our soldiers afflicted with PTSD with the 
best possible care for as long as necessary--and it will be years for 
many.
  Every night the evening news graphically shows us the latest 
casualties and consequences of this war. It's awful. It didn't have to 
happen. And the overwhelming number of casualties are ahead of us, not 
mission accomplished. Before it is over, Iraq's casualties will top 
40,000 U.S. soldiers. For what? Nothing at all.

        [From The New England Journal of Medicine, July 1, 2004]

               Acknowledging the Psychiatric Cost of War

                 (By Matthew J. Friedman, M.D., Ph.D.)

       The date presented by Hoge and associates in this issue of 
     the Journal about members of the Army and the Marine Corps 
     returning from Operation Iraqi Freedom or Operation Enduring 
     Freedom in Afghanistan force us to acknowledge the 
     psychiatric cost of sending young men and women to war. It is 
     possible that these early findings underestimate the eventual 
     magnitude of this clinical problem. The report is 
     unprecedented in several respects. First, this is the first 
     time there has been such an early assessment of the 
     prevalence of war-related psychiatric disorders reported 
     while the fighting continues. Second, there are 
     predeployement data, albeit cross-sectional, against which to 
     evaluate the psychiatric problems that develop after 
     deployment. Third, the authors report important data showing 
     that the perception of stigmatization has the power to deter 
     active-duty personnel from seeking mental health care even 
     when they recognize the severity of their psychiatric 
     problems. These findings raise a number of questions for 
     policy and practice. I focus here on post-traumatic stress 
     disorder (PTSD), because there is better information about 
     this disorder than about others and because PTSD was the 
     biggest problem noted in the responses to an anonymous survey 
     among those returning from active duty in Iraq or 
     Afghanistan.
       The rigorous evaluation of war-related psychiatric 
     disorders is relatively new, having begun with the National 
     Vietnam Veterans Readjustment Study. This national 
     epidemiologic survey of male and female veterans of Vietnam 
     was conducted in the mid-1980s. The veterans were therefore 
     assessed 10 to 20 years after their service in Vietnam. The 
     prevalence of current PTSD was 15 percent among men and 8 
     percent among women. The lifetime prevalence of PTSD was 
     higher--30 percent among male veterans and 25 percent among 
     female veterans.
       A retrospective cohort study of veterans of the Gulf War 
     that was conducted between 1995 and 1997 showed a prevalence 
     rate of 10.1 percent for PTSD among those who had experienced 
     combat duty, in contrast to a prevalence rate of 4.2 percent 
     in a matched cohort of Gulf War-era veterans who had not seen 
     combat. The adjusted odds ratio for PTSD for those who had 
     been in combat was 3.1; this is similar to the odds ratios in 
     the present study of 2.84 for soldiers and 2.66 for Marines 
     after deployment to active duty, as compared with soldiers 
     before deployment.
       In a longitudinal study of New England veterans of the Gulf 
     War, the prevalence of PTSD more than doubled between the 
     initial assessment performed immediately after their return 
     to Fort Devens, Massachusetts, and the follow-up assessment 
     performed two years later. The rates increased from 3 percent 
     to 8 percent among male veterans and from 7 percent to 16 
     percent among female veterans. Higher levels of symptoms have 
     been reported among members of the National Guard and the 
     Reserves than among active-duty personnel.
       Finally, a retrospective survey of American male and female 
     soldiers deployed to Somalia between 1992 and 1994 showed an 
     estimated prevalence of PTSD of approximately 8 percent, with 
     no difference according to sex. When the focus of this 
     mission shifted from a United Nations' humanitarian 
     peacekeeping operation to a more traditional military 
     deployment to subdue to Somali warlords, there was greater 
     exposure to traumatic situations and a higher prevalence of 
     PTSD among the American troops.
       It is unclear at this time whether the prevalence of PTSD 
     among those returning from Operation Iraqi Freedom or 
     Operation Enduring Freedom will increase or decrease. On the 
     one hand, it is encouraging that the Department of Defense 
     has been active in providing mental health care in the war 
     zone and psychiatric resources in the United States and has 
     demonstrated a commitment to monitor psychiatric disorders, 
     as reflected by the present report. Furthermore, the findings 
     of the National Vietnam Veterans Readjustment Study suggest 
     that considerable recovery for PTSD among veterans is 
     possible, as shown by the difference between the lifetime and 
     the current prevalence of this disorder.
       On the other hand, the National Vietnam Veterans 
     Readjustment Study cannot tell us whether the onse of PTSD 
     occurred while Vietnam veterans were still in uniform or at 
     some time later, during the 10 to 20 years between their 
     exposure to war and the survey for the study. Indeed, there 
     is reason for concern that the reported prevalence of PTSD of 
     15.6 to 17.1 percent among those returning from Operation 
     Iraqi Freedom or Operation Enduring Freedom will increase in 
     coming years, for two reasons. First, on the basis of the 
     findings of the Fort Devens study, the prevalence of PTSD may 
     increase considerably during the two years after veterans 
     return from combat duty. Second, on the basis of studies of 
     military personnel who served in Somalia, it is possible that 
     psychiatric disorders will increase now that the conduct of 
     war has shifted from a campaign for liberation to an ongoing 
     armed conflict with dissident combatants. In short, the 
     estimates of PTSD report by Hoge and associates may be 
     conservative not only because of the methods used in their 
     study but also because it may simply be too early to assess 
     the eventual magnitude of the mental health problems related 
     to deployment to Operation Iraqi Freedom or Operation 
     Enduring Freedom.
       A recent reanalysis of the data from the National Vietnam 
     Veterans Readjustment Study and the Hawaii Vietnam Veterans 
     Project suggest that after the development of PTSD, the risk 
     factors for persistent PTSD are ``primarily associated with 
     variables relating to the current time frame: current 
     emotional sustenance, current structural social support, and 
     recent life events.'' This information is clearly useful for 
     mental health policy and planning, because it raises the 
     hopeful possibility that PTSD may be reversible if patients 
     can be helped to cope with stresses in their current life.
       There are obviously important distinctions between the 
     period after the Vietnam War and the present. Americans no 
     longer confuse war with the warrior, those returning from 
     Iraq or Afghanistan enjoy nation support, despite sharp 
     political disagreement about the war itself. In addition, the 
     field of study of PTSD has matured to the point where 
     effective evidence-based treatment and practice guidelines 
     are available for use by the Departments of Defense and 
     Veterans Affairs and by civilian mental health practitioners. 
     Cognitive--behavioral therapies have been successful in the 
     treatment of PTSD, and two selective serotonin-reuptake 
     inhibitors have been approved by the Food and Drug 
     Administration. Practitioners in the Departments of Defense 
     and Veterans Affairs are sophisticated and strongly motivated 
     to continue to improve their skills in treating PTSD. 
     Collaboration between mental health professionals in the 
     Department of Defense and those in the Department of Veterans 
     Affairs is at an all-time high. For example, the Veterans 
     Affairs National Center for PTSD and the Defense Department's 
     Walter Reed Army Medical Center collaborated to develop the 
     Iraq War Clinician Guide (available at www.ncptsd.org/topics/
war.html) and to conduct a multisite, randomized trial of 
     cognitive--behavioral therapy for PTSD among female veterans 
     and female active-duty personnel.
       In the best-case scenario, active-duty, Reserve, and 
     National Guard personnel as well as veterans of Operation 
     Iraqi Freedom or Operation Enduring Freedom with symptoms of 
     PTSD will take advantage of the many mental health services 
     available through the Departments of Defense and Veterans 
     Affairs. Educational initiatives will be implemented to help 
     veterans and active-duty personnel recognize that the loss of 
     social support or the effect of recent adverse life events 
     may precipitate a return of the symptoms of PTSD. Veterans 
     and active-duty personnel will also be encouraged to monitor 
     their psychological health and to seek treatment if and when 
     it becomes necessary.
       Alas, there is also a worst-case scenario that demands 
     immediate attention. Hoge and associates report that concern 
     about possible stigmatizaion was disproportionately greatest 
     among the soldiers and Marines most in need of mental health 
     care. Owing to such concern, those returning from Operation 
     Iraqi Freedom or Operation Enduring Freedom who reported the 
     greatest number of the most severe symptoms were the least 
     likely to seek treatment for fear that it could harm their 
     careers, cause difficulties with their peers and with unit 
     leadership, and become an embarrassment in that they would be 
     seen as weak.
       These findings are consistent with those in an earlier 
     report that showed low use of mental health services among 
     Navy and Marine Corps personnel. In contrast to a rate of 
     28.5 percent among male civilians with a psychiatric disorder 
     who sought

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     treatment, only 19 percent of servicemen with a psychiatric 
     disorder sought treatment, Furthermore, among military 
     personnel with PTSD, the rate of seeking treatment was only 
     4.1 percent, which is substantially lower than that for other 
     psychiatric disorders. This finding may indicate that within 
     the military culture, ``succumbing'' to PTSD is seen as a 
     failure, a weakness, and as evidence of and innate deficiency 
     of the right stuff.
       Hoge and associates suggests that the perception of 
     stigmatization can be reduced only by means of concerted 
     outreach--that is, by providing more mental health services 
     in primary care clinics and confidential counseling through 
     employee-assistance programs. The sticking point is 
     skepticism among military personnel that the use of mental 
     health services can remain confidential. Although the 
     soldiers and Marines in the study by Hoge and colleagues were 
     able to acknowledge PTSD-related problems in an anonymous 
     survey, they apparently were afraid to seek assistance for 
     fear that scarlet P could doom their careers.
       Our acknowledgment of the psychiatric costs of war has 
     promoted the establishment of better methods of detecting and 
     treating war-related psychiatric disorders. It is now time to 
     take the next step and provide effective treatment to 
     distressed men and women, along with credible safeguards of 
     confidentiality.


                           Source Information

       From the National Center for PTSD, Department of Veterans 
     Affairs, White River Junction, Vt.; and the Departments of 
     Psychiatry and Pharmacology and Toxicology, Dartmouth Medical 
     School, Hanover, N.H.

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