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Surviving War, Falling to Suicide

Brain injuries, post-traumatic stress, and depression are as hazardous as any battlefield -- and kill more of our veterans.

The photograph on the front page of the Washington Post showed an Afghanistan veteran with two internally powered prosthetic legs besting his friend — an Army sergeant who works with amputees at the Walter Reed National Military Medical Center — in a playful wrestling match on the floor.

So common are these images today – virile young ex-soldiers and Marines running marathons, prevailing in tests of endurance and strength despite their robotic extremities – that we’ve started to see past their horrific injuries and how they got them.

But how do we replace the spirit of a soldier who lost the will to live somewhere on the road between Ramadi and Fallujah or in the hills of southeastern Afghanistan? Can a damaged brain be reinvented? For every advance the government has made in achieving renewed physical independence for our wounded veterans, it has continued to struggle with ways to restore their mental fitness. The wars overseas might be winding down, but they are coming home with a quiet vengeance.

The more we learned last year about the complexity of mild traumatic brain injury (TBI) in military veterans — and its association with declining cognitive skills, personality changes, memory loss — Post Traumatic Stress Disorder (PTSD), and the emerging suicide epidemic, the more challenging proper diagnosis and treatment have become.

Researchers are now connecting the devastating long-term effects typically associated with boxing injuries — known as chronic traumatic encephalopathy (CTE), a progressive degenerative disease that attacks brain tissue — with repetitive mild concussions experienced by football players and soldiers with blast injuries. CTE might begin with mild symptoms like headaches and memory loss but can lead to depression, angry outbursts, and full-blown dementia. The issue came to a head in the news with the third in a string of NFL concussion-related suicides in May and a massive class action suit alleging that the NFL has known much more about the dangers of play than it has let on.

The most comprehensive study on concussions and CTE to date found that military veterans are experiencing similar rates of CTE similar to those of athletes, probably due to traumatic brain injuries. Published in the December issue of the scientific journal Brain (.pdf), the study found that “for some athletes and war fighters, there may be severe and devastating long-term consequences of repetitive brain trauma that has traditionally been considered only mild.”

This a significant development, but it’s only one piece of the puzzle. In 2009, the Pentagon estimated that up to 360,000 Iraq and Afghanistan War veterans may have suffered brain injury, mostly from blasts caused by improvised explosive devices (IED’s). Not all of these troops suffered repetitive injuries, nor were they necessarily knocked unconscious. Many were instead left feeling “dazed and confused.” Some were comprehensively treated for their concussions, others with less obvious symptoms were sent right back into battle. Countless veterans slipped through a feeble screening process and are now dealing with symptoms that often lead to self-medication and alienation from friends and family.

And the 360,000 figure was provided by the Pentagon three years ago, before IED attacks against U.S. forces in Afghanistan spiked in consecutive summers. While military officials say the number of TBI cases dropped by nearly half in Afghanistan in 2012, it is not clear whether that’s due to the declining number of troops in the country, better screening and treatment of concussions in the field, or both.

The military has certainly made strides in attempting to understand the impact of TBI, but there’s still much we don’t know, says Paul Rieckhoff, founder and president of Iraq and Afghanistan Veterans of America (IAVA).

“I think we’re really at the tip of the iceberg when it comes to traumatic brain injury,” he said in an interview with TAC. Rieckhoff noted the hundreds of millions of dollars that have been earmarked for TBI research and educational efforts for Veterans Administration physicians. But diagnosis and treatment remain elusive.

“A lot of the veterans don’t know the symptoms themselves,” he added. “This is something we will be dealing with for decades.”

Making it more difficult, the extent of the damage from mild TBI can’t always be discerned with a ordinary MRI or CAT scans. Some of its symptoms are indistinguishable from those related to PTSD, with which approximately 4,000 new Iraq and Afghanistan veterans are diagnosed each month. Research continues to probe the association of more serious TBI incidents (for instance, when a solider temporarily loses consciousness) with long-term physical and mental problems. A 2008 study found that vets with concussions who had been knocked out suffered from higher rates of poor health afterward but concluded that, according to one synopsis, “one must use caution when attributing health problems to mild traumatic brain injury, because associated PTSD and depression may be the primary problem.”

Suffering an IED blast on the battlefield is most certainly a traumatic event, especially when accompanied by witnessing the death or injury of other service members or civilians. Untangling the physical from the mental damage is never easy.

But doctors and veterans’ advocates feel that they are running out of time, given the skyrocketing rates of suicide among active-duty soldiers and veterans. According to the most recent statistics, Army and Navy suicides are at a record high: 2012 was the worst year for self-inflicted deaths since the military began tracking them in 2001. Secretary of Defense Leon Panetta last summer called the situation an “epidemic” — with approximately 3,000 military suicides on record since 9/11.

The numbers are even worse for veterans — an estimated 18 veterans kill themselves each day, 6,570 a year. That’s comparable, advocates point out, to the approximately 6,600 men and women we’ve lost in Iraq and Afghanistan since 2001.

“We’re a decade behind where we should be,” says Rieckhoff. “If I had to say, it is the most urgent issue we face. The suicide problem is out of control.”

IAVA has counselors on staff who work one-on-one with veterans every day. “It’s not only one thing that leads to suicide, it’s a culmination of a couple of things,” says Rieckhoff. “What you’ve got is a generation of veterans who have shouldered the weight of combat through unprecedented long tours, repeated tours, compounded by a bad economic situation and a really bad bureaucratic situation with the VA” when they finally get home. “There’s a lot of issues piling up.”

Add that to TBI, drug and alcohol abuse, and PTSD, and the brew is toxic. “The suicide numbers have been bad for a long time,” says Rieckhoff. “This is not new.”

“We were not planning for it,” he added, just like the VA hadn’t planned on the influx of nearly 840,000 Iraq and Afghanistan veterans into its healthcare system over the last decade. In addition, the VA remains buried under a backlog of 900,000 pending disability claims and 250,000 additional appeals.

On the other hand, officials say the VA’s national suicide hotline has answered 650,000 calls since its launch in 2007 and has made 23,000 “life-saving rescues.” It’s been a “tremendous success,” said Reickhoff, but more veterans need to be aware of it, and long-term problems connected to suicide, like TBI and PTSD, are much bigger than the VA. “From a public health standpoint, the VA can’t do this alone, the Pentagon can’t do this alone.”

“It’s a real challenge, but hopefully the tone is changing … It’s going to be a generational fight,” he said. “We’re going to keep plugging away.”

Kelley Beaucar Vlahos is a Washington, D.C.-based freelance reporter and TAC contributing editor. Follow her on Twitter.



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