September 29, 2017
Find out what the VA and Congress are doing to fight this national crisis.
This week, the VA winds down its suicide prevention awareness month campaign and outreach efforts.
During September, the VA released findings of a detailed analysis of veteran suicide data from all 50 states, as well as Puerto Rico and the District of Columbia. The analysis was part of its earlier comprehensive examination of more than 55 million records, from 1979 to 2014, as the VA sought to develop and evaluate suicide prevention across the country.
“These findings are deeply concerning, which is why I made suicide prevention my top clinical priority,” said VA Secretary Dr. David Shulkin in a press release earlier this month.
“I am committed to reducing Veteran suicides through support and education.” Shulkin said. “We know that of the 20 suicides a day that we reported last year, 14 are not under VA care. This is a national public health issue that requires a concerted, national approach.”
Closing out the month, Congress held a hearing this week to consider several bills to address mental health services in the VA and veteran suicides, as well as a hearing on Wednesday, Sept. 27, where Shulkin offered testimony to the Senate Committee on Veterans’ Affairs regarding how he is addressing suicide prevention in his department.
“Suicide is a terrible, terrible loss of life – a preventable loss of life,” said committee chair Sen. Johnny Isakson (R-Ga.) in his opening remarks before the committee. “It is a disease, and it is preventable, and there are many things we can do to set the example, including promoting training through our staff and throughout government.”
As the largest integrated suicide prevention program in the country, the VA has over 1,000 mental health professionals, but more must be done to address the mental health needs of veterans accessing the system, six of whom die by suicide every day, as well as the larger number of veterans-the 14 committing suicide each day who aren’t accessing the system because there are not enough health care providers or because other barriers preventing them from getting the necessary care in or outside the system.
While Shulkin outlined a number of initiatives undertaken in recent months, including establishing a suicide prevention advisory group, developing a patient record flagging system to identify and monitor patients, and establishing a suicide prevention program at every facility, the secretary urged the committee’s support in helping him to get more mental health professionals into the VA system, more research dollars, and more public awareness across America, as suicide is everyone’s business.
“Our goal is to eliminate suicide,” said Shulkin. “As stated earlier, six Americans will die during the course of this hearing – I think about this every day – I think about how many veterans are dying every day because we aren’t effective at addressing this problem.”
He went on to emphasize data show VA health care treatment saves lives, but it can’t help those veterans not in its system. The VA intends to remain committed to eliminating veteran suicides through more aggressive efforts aimed at risk identification, effective treatments, research, and strategic partnerships.
Additionally, the House Committee on Veterans’ Affairs held a hearing the day prior to consider several bills aimed at preventing suicide and providing enhanced care for veterans suffering from mental health conditions. Some of these bills include:
The message in both hearings this week was clear: There is much more to be done to reverse the trend on veteran suicides, and MOAA will work with the secretary and members of Congress to make sure the VA has the tools and resources it needs to address this critical public health problem in order to eradicate veteran suicide.
MOAA members can help too. Learn more about the VA’s suicide prevention program and how you can Be There to Save a Life .
PTSD is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event.
It is natural to feel afraid during and after a traumatic situation. Fear triggers many split-second changes in the body to help defend against danger or to avoid it. This “fight-or-flight” response is a typical reaction meant to protect a person from harm. Nearly everyone will experience a range of reactions after trauma, yet most people recover from initial symptoms naturally. Those who continue to experience problems may be diagnosed with PTSD. People who have PTSD may feel stressed or frightened even when they are not in danger.
Not every traumatized person develops ongoing (chronic) or even short-term (acute) PTSD. Not everyone with PTSD has been through a dangerous event. Some experiences, like the sudden, unexpected death of a loved one, can also cause PTSD. Symptoms usually begin early, within 3 months of the traumatic incident, but sometimes they begin years afterward. Symptoms must last more than a month and be severe enough to interfere with relationships or work to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic.
A doctor who has experience helping people with mental illnesses, such as a psychiatrist or psychologist, can diagnose PTSD.
To be diagnosed with PTSD, an adult must have all of the following for at least 1 month:
Re-experiencing symptoms may cause problems in a person’s everyday routine. The symptoms can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing symptoms.
Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.
Arousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic events. These symptoms can make the person feel stressed and angry. They may make it hard to do daily tasks, such as sleeping, eating, or concentrating.
Cognition and mood symptoms can begin or worsen after the traumatic event, but are not due to injury or substance use. These symptoms can make the person feel alienated or detached from friends or family members.
It is natural to have some of these symptoms after a dangerous event. Sometimes people have very serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD. When the symptoms last more than a month, seriously affect one’s ability to function, and are not due to substance use, medical illness, or anything except the event itself, they might be PTSD. Some people with PTSD don’t show any symptoms for weeks or months. PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.
Children and teens can have extreme reactions to trauma, but their symptoms may not be the same as adults. In very young children (less than 6 years of age), these symptoms can include:
Older children and teens are more likely to show symptoms similar to those seen in adults. They may also develop disruptive, disrespectful, or destructive behaviors. Older children and teens may feel guilty for not preventing injury or deaths. They may also have thoughts of revenge. For additional information, visit the Learn More section below. The National Institute of Mental Health (NIMH) offers free print materials in English and Spanish. These can be read online, downloaded, or delivered to you in the mail.
Anyone can develop PTSD at any age. This includes war veterans, children, and people who have been through a physical or sexual assault, abuse, accident, disaster, or many other serious events. According to the National Center for PTSD , about 7 or 8 out of every 100 people will experience PTSD at some point in their lives. Women are more likely to develop PTSD than men, and genes may make some people more likely to develop PTSD than others.
Not everyone with PTSD has been through a dangerous event. Some people develop PTSD after a friend or family member experiences danger or harm. The sudden, unexpected death of a loved one can also lead to PTSD.
It is important to remember that not everyone who lives through a dangerous event develops PTSD. In fact, most people will not develop the disorder.
Many factors play a part in whether a person will develop PTSD. Some examples are listed below. Risk factors make a person more likely to develop PTSD. Other factors, called resilience factors, can help reduce the risk of the disorder.
Some factors that increase risk for PTSD include:
Some resilience factors that may reduce the risk of PTSD include:
Researchers are studying the importance of these and other risk and resilience factors, including genetics and neurobiology. With more research, someday it may be possible to predict who is likely to develop PTSD and to prevent it.
The main treatments for people with PTSD are medications, psychotherapy (“talk” therapy), or both. Everyone is different, and PTSD affects people differently so a treatment that works for one person may not work for another. It is important for anyone with PTSD to be treated by a mental health provider who is experienced with PTSD. Some people with PTSD need to try different treatments to find what works for their symptoms.
If someone with PTSD is going through an ongoing trauma, such as being in an abusive relationship, both of the problems need to be addressed. Other ongoing problems can include panic disorder, depression, substance abuse, and feeling suicidal.
The most studied medications for treating PTSD include antidepressants, which may help control PTSD symptoms such as sadness, worry, anger, and feeling numb inside. Antidepressants and other medications may be prescribed along with psychotherapy. Other medications may be helpful for specific PTSD symptoms. For example, although it is not currently FDA approved, research has shown that Prazosin may be helpful with sleep problems, particularly nightmares, commonly experienced by people with PTSD.
Doctors and patients can work together to find the best medication or medication combination, as well as the right dose. Check the U.S. Food and Drug Administration website (http://www.fda.gov/ ) for the latest information on patient medication guides, warnings, or newly approved medications.
Psychotherapy (sometimes called “talk therapy”) involves talking with a mental health professional to treat a mental illness. Psychotherapy can occur one-on-one or in a group. Talk therapy treatment for PTSD usually lasts 6 to 12 weeks, but it can last longer. Research shows that support from family and friends can be an important part of recovery.
Many types of psychotherapy can help people with PTSD. Some types target the symptoms of PTSD directly. Other therapies focus on social, family, or job-related problems. The doctor or therapist may combine different therapies depending on each person’s needs.
Effective psychotherapies tend to emphasize a few key components, including education about symptoms, teaching skills to help identify the triggers of symptoms, and skills to manage the symptoms. One helpful form of therapy is called cognitive behavioral therapy, or CBT. CBT can include:
There are other types of treatment that can help as well. People with PTSD should talk about all treatment options with a therapist. Treatment should equip individuals with the skills to manage their symptoms and help them participate in activities that they enjoyed before developing PTSD.
How Talk Therapies Help People Overcome PTSD
Talk therapies teach people helpful ways to react to the frightening events that trigger their PTSD symptoms. Based on this general goal, different types of therapy may:
It may be very hard to take that first step to help yourself. It is important to realize that although it may take some time, with treatment, you can get better. If you are unsure where to go for help, ask your family doctor. You can also check NIMH’s Help for Mental Illnesses page or search online for “mental health providers,” “social services,” “hotlines,” or “physicians” for phone numbers and addresses. An emergency room doctor can also provide temporary help and can tell you where and how to get further help.
To help yourself while in treatment:
Caring for yourself and others is especially important when large numbers of people are exposed to traumatic events (such as natural disasters, accidents, and violent acts). For more information, see the Learn More section, below.
In the last decade, progress in research on the mental and biological foundations of PTSD has lead scientists to focus on better understanding the underlying causes of why people experience a range of reactions to trauma.
Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions, including PTSD. During clinical trials, treatments might be new drugs or new combinations of drugs, new surgical procedures or devices, or new ways to use existing treatments. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individual participants may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.
Doctors at NIMH are dedicated to mental health research. The studies take place at the NIH Clinical Center in Bethesda, Maryland and require regular visits. After the initial phone interview, you will come to an appointment at the clinic and meet with one of our clinicians. Find NIH-funded studies currently recruiting participants with PTSD by using ClinicalTrials.gov (search: PTSD).
To search for a clinical trial near you, you can visit ClinicalTrials.gov . This is a searchable registry and results database of federally and privately supported clinical trials conducted in the United States and around the world. ClinicalTrials.gov gives you information about a trial’s purpose, who may participate, locations, and phone numbers to call for more details. This information should be used in conjunction with advice from health professionals.
You can download or order free copies of the following booklets and brochures in English or en Español:
Despite change in leadership and promises to address ongoing problems with its veteran suicide line, nearly 30 percent of calls to the Department of Veterans Affairs were redirected to outside emergency centers, according to an inspector general report released Monday.
“We found that [Veterans Crisis Line] staff did not respond adequately to a veteran’s urgent needs during multiple calls to the VCL and its backup call centers,” the report said.
When the VCL program was started in 2007, VA management initially estimated that approximately 10 percent of calls would be rolled over to a backup center.
In fact, call rollover to backup centers increased between April and November 2016, peaking at more than 108,000, or a 28.4 percent rate.
In November, calls to the backup centers hit a peak of nearly 18,000 – a nearly 35 percent rollover rate.
In February 2016, the IG issued a report detailing how some suicide calls were being sent to voicemail or callers did not always receive immediate assistance from VCL and/or backup center staff.
The IG then called for the department to implement seven separate recommendations, but as of December 16, 2016 none were in place, Monday’s report said.
House Committee on Veterans’ Affairs Chairman Phil Roe, M.D. (R-Tenn.) expressed frustration, saying it is “unacceptable that issues with the Veterans Crisis Line have still not been addressed.”
Communications Director Tiffany McGuffee Haverly told Fox News the committee will hold a hearing April 4 to examine ongoing issues with the Veterans Crisis Line.
Sen. Johnny Isakson, R-Ga., chairman of the Senate Committee on Veterans’ Affairs, echoed Roe’s reaction to the IG report.
“The findings in this latest report identify an unacceptable disconnect between the Clinical Advisory Board and the Veterans Crisis Line in obtaining the clinical input necessary to make policy decisions. The Veterans Crisis Line should be collaborating with clinical services every step of the way,” he said in a statement.
Amanda Maddox, spokesperson for Isakson, told Fox News the committee was “informed by the inspector general that they do not believe there is a need for legislation. Our committee is currently looking into additional oversight options as well.
The IG also reported that management had not set any standards for the length of wait times when a veteran calls.
“We found that VCL leadership had not established expectations or targets for queued call times or thresholds for taking action on queue times. A veteran could be queued for 30 minutes, for example, and that wait time might not be reflected in hold time data; however, the result of the delay is the same, whether the veteran was in a queue or on hold,” the IG said.
The IG also criticized the absence of sustained and permanent leadership at the VCL, which functioned without a director for 10 months in 2015 before a permanent replacement was named.
But that director resigned in June 2016 and as of December 2016, no permanent director has been hired. Furthermore, supervisory staff did not identify the deficiencies in their internal review of the matter.
Recent veterans have committed suicide at a much higher rate than people who never served in the military, according to a new analysis that provides the most thorough accounting so far of the problem.
The rate was slightly higher among veterans who never deployed to Afghanistan or Iraq, suggesting that the causes extend beyond the trauma of war.
“People’s natural instinct is to explain military suicide by the war-is-hell theory of the world,” said Michael Schoenbaum, an epidemiologist and military suicide expert at the National Institute of Mental Health who was not involved in the study. “But it’s more complicated.”
The study brings precision to a question that has never been definitively answered: the actual number of suicides since the start of the recent wars.
Though past research has also found elevated suicide rates, those results were estimates based on smaller samples and less reliable methods to identify veteran deaths. The government has not systematically tracked service members after they leave the military.
“People’s natural instinct is to explain military suicide by the war-is-hell theory of the world. But it’s more complicated.”
— Michael Schoenbaum, an epidemiologist and military suicide expert at the National Institute of Mental Health
The new analysis, which will be published in the February issue of the Annals of Epidemiology, included all 1,282,074 veterans who served in active-duty units between 2001 and 2007 and left the military during that period.
The analysis matched military records with the National Death Index, which collects data on every U.S. death. It tracked the veterans after service until the end of the 2009, finding a total of 1,868 suicides.
That equates to an annual suicide rate of 29.5 per 100,000 veterans, or roughly 50% higher than the rate among other civilians with similar demographic characteristics.
The issue of veteran suicide has become a political cause for activists and legislators. One statistic has become a rallying cry: 22 veterans take their own lives each day.
That figure is a national estimate based on a Department of Veterans Affairs analysis of death records from 21 states. Though it is usually cited in the context of the recent wars, most of those suicides involved older veterans, who account for the vast majority of the nation’s 22 million former service members.
Among veterans in the current study, there was one suicide a day.
The rates were highest during the first three years out of the military.
Veterans who had been enlisted in the rank-and-file committed suicide at nearly twice the rate of former officers. Keeping with patterns in the general population, being white, unmarried and male were also risk factors.
Men accounted for 83% of the veterans in the study and all but 124 of the suicides. They were three times more likely than women to take their own lives.
Female veterans, however, killed themselves at more than twice the rate of other women — a difference much bigger than the gap between male veterans and non-veterans.
A likely explanation is that women with military experience are much more likely than other women to attempt suicide with firearms, dramatically increasing the likelihood of death, said Mark Kaplan, an epidemiologist and suicide expert at UCLA.
Overall, the suicide rates for recent veterans set them apart from veterans of past generations.
In the Vietnam era, suicide rates were elevated for veterans suffering from post-traumatic stress or those wounded in action. But on the whole, suicide rates for veterans in their first few years out of the military were lower than in the general population, according to research.
The elevated rate today could reflect differences in who served, the study’s authors speculate. In the days of the draft, troops represented a wider cross-section of society. The long wars in Afghanistan and Iraq may have attracted more volunteers prone to risk-taking and impulsive behaviors.
“We don’t have the data to know,” said Tim Bullman, a mortality expert and health statistician at the VA and coauthor of the paper.
Another possibility, he said, is that a weak economy during the recent wars made the transition to civilian life more difficult.
More puzzling is the suicide rate for veterans who never went to Afghanistan or Iraq. It was 16% higher than for those who did.
Bullman said one reason could be that service members with psychological problems were often held back from deployment. He added that that suicide prevention efforts had focused on service members and veterans who did go to war.
Experts have also suggested that the military may have become a less forgiving and nurturing place over the course of the wars. “The stresses are not limited to the individuals who are sent to war,” Schoenbaum said.
A more detailed accounting of veteran mortality is on the horizon. A massive new data trove is being assembled by the Pentagon and the VA. Known as the Suicide Data Repository, it links national death records to military and healthcare data.
Among veterans who have served since 1974, the project has identified more than 2 million deaths of all types between 1979 and 2011, according to Robert Bossarte, a VA epidemiologist helping oversee the effort.
For each death, researchers will be able to learn the veteran’s deployment history, education and other information.
Researchers plan to build on the current study — which does not include reservists or veterans who served after 2007 — and look at suicide rates for all 3.7 million veterans who served since 2001.
Brig. Gen. Donald C. Bolduc, commander of American Special Operations Forces in Africa, tells soldiers that it is all right to get help for brain injuries and mental health problems. CreditAndrew Harnik/Associated Press
STUTTGART, Germany — It might have been the 2,000-pound bomb that dropped near him in Afghanistan, killing several comrades. Or maybe it was the helicopter crash he managed to survive. It could have been the battlefield explosions that detonated all around him over eight combat tours.
Whatever the cause, the symptoms were clear. Brig. Gen. Donald C. Bolduc suffered frequent headaches. He was moody. He could not sleep. He was out of sorts; even his balance was off. He realized it every time he walked down the street holding hands with his wife, Sharon, leaning into her just a little too close.
Despite all the signs of post-traumatic stress disorder, it took 12 years from his first battlefield trauma for him to seek care. After all, he thought, he was a Green Beret in the Army’s Special Forces. He needed to be tough.
General Bolduc learned that not only did he suffer from PTSD, but he also had a bullet-size spot on his brain, an injury probably dating to his helicopter crash in Afghanistan in 2005.
Now, after three years of treatment, General Bolduc is doing better. And, in his role as commander of American Special Operations Forces in Africa, he has become an evangelist for letting soldiers know that it is all right to get help for brain injuries and mental health problems.
“I’ve really seen a difference in myself,” General Bolduc, 54, said. “There are still the nonbelievers. We’ve got to get to them.”
That means changing attitudes that equate mental illness with weakness. Donald J. Trump, the Republican presidential candidate,said in a speech this week that some veterans returning from war “can’t handle” the stress. Mr. Trump was arguing for mental health services, but the remark drew scorn from veterans’ groups that work to reduce the stigma. Mr. Trump’s campaign has said his remarks were taken out of context. A spokesman for General Bolduc declined to comment.
On a recent afternoon, General Bolduc, his starched uniform weighed down by a giant patch of colorful ribbons and medals across his chest, stood ramrod straight at the Stuttgart headquarters from which he commands Special Operations fighters battling the Islamic State, Boko Haram, the Shabab and other terrorist groups in Africa, and he declared, “I’m in counseling.”
General Bolduc wants soldiers under his command — who are stationed in some of the continent’s most difficult parts — to know that seeking help will not hurt their careers. In his opinion, PTSD is the same as a broken arm.
“The powerful thing is that I can use myself as an example,” General Bolduc said. “And thank goodness not everybody can do that. But I’m able to do it, so that has some sort of different type of credibility to it.”
Other high-ranking officers have come forward to talk about their struggles with post-combat stress and brain injuries. And in recent years, Special Operations commanders have become more open about urging their soldiers to get treatment.
Gen. Joseph L. Votel, then the head of the United States Special Operations Command, spoke to CNN last spring about ending the stigma tied to seeking treatment. “It is absolutely normal and expected that you will ask for help,” he said.
The stigma can be particularly acute in specialized military units, like the Green Berets and the Navy SEALs, that are trained for the toughest assignments and consider intervention a sign of weakness.
Yet the Department of Defense estimates that almost a quarter of all injuries suffered in the conflicts in Afghanistan and Iraq were brain injuries. As many as 20 percent of veterans of those two conflicts experience PTSD.
Traumatic brain injuries and PTSD share symptoms like headaches, depression and, sometimes, suicidal behavior. The consequences of not getting help can be severe: In the past four years, more than 2,000 active and reserve military personnel have killed themselves, according to the department.
Across the military base in Stuttgart, suicide prevention and PTSD brochures are positioned on desktops and hallway tables. The base has a Preservation of the Force and Family center, a program created specifically for Special Operations Forces, where anyone can seek help for behavioral issues, including alcohol or drug abuse, and counseling for family and financial problems.
When commanders rented a movie theater last year for a screening of the latest “Star Wars” movie, General Bolduc made sure that the free tickets had to be picked up at the center, to get soldiers comfortable with stepping inside the door.
On base, officers talk openly about mood swings, making their wives cry and other indicators that led them to seek help.
General Bolduc, who took command in April 2015, encourages these kinds of honest conversations. In speeches to his leadership team and in visits to his troops in Africa, and every time a new soldier comes into his fold, he tells his personal story and urges anyone experiencing the same kinds of symptoms to get help.
A native of Laconia, N.H., General Bolduc said he had wanted to join the Special Forces ever since as a young boy he watched the movie “The Green Berets” with his grandfather.
“For all Bolduc males, service to country is a requirement,” said General Bolduc, whose two brothers also joined the Special Forces. “My grandfather didn’t care what service, but he did feel that it was an obligation.”
He earned his ROTC commission in 1989, graduating from Salem State College in Massachusetts, and later earned a master’s degree in security technologies from the United States Army War College.
Last month, General Bolduc awarded a Purple Heart to an airman 11 years after he had received a brain injury during a mortar attack in Iraq. The airman, Tech. Sgt. David Nafe, had experienced memory loss and migraines for years.
General Bolduc made a fuss, summoning his staff to a ceremony for the award. The military publication Stars and Stripes published an articleabout Sergeant Nafe on its front page. In front of the audience gathered for the ceremony, the general told the soldier he could relate to him.
“When people look at you, you look completely normal,” General Bolduc said. “And then they see how you act and they say, ‘God bless, what’s wrong with that guy?’ ”
The Defense Department and the Veterans Health Administration have worked to improve mental health services. Yet many service members do not regularly seek care, according to a 2014 report from the RAND Corporation, a think thank that conducts government studies.
That procrastination is exacerbated by the hypermacho culture of Special Operations, General Bolduc said, where high-stress tours leave members especially vulnerable. Members wait an average of 13 years and 3 months to seek treatment for injuries that are not catastrophic, according to Sarah McNary, a nurse in charge of traumatic brain injury cases at Landstuhl Regional Medical Center in Germany, who first persuaded General Bolduc to submit to a brain examination.
When a bomb dropped on his position in Afghanistan in 2001 — a friendly fire accident — General Bolduc’s hip was badly damaged. He declined medical treatment and pushed ahead with the mission, an offensive on Kandahar, and later needed hip-replacement surgery.
An average-size man at 5-foot-7 and 145 pounds, General Bolduc is so fit and focused that even if he were wearing overalls he would probably be identifiable as a Green Beret. Yet he has a soft side, offering a handshake or a hug to everyone he meets on a stroll around the base.
“He’s Captain America,” said Lt. Col. Nathan Broshear, a spokesman for Special Operations Command Africa.
Now, the general goes to counseling sessions with his wife, who for years urged him to seek treatment.
“The doctors love it because I’m still guarded,” he said. “First of all, you feel funny even talking about it. You’re not likely to give them your real symptoms. But your wife is going to say, ‘That’s a load of crap.’ ”
About a month ago, while visiting a team under his command, General Bolduc asked how many of the men had been close to blasts, bombs and mortar shells. Everyone raised a hand.
“Then I said, ‘How many of you have sought treatment?’ ” he said. “No one’s hand went up.”
General Bolduc told them his own story, and afterward, all of the men decided to get exams. Doctors found a tumor in one soldier’s brain.
He was flown to Walter Reed National Military Medical Center, near Washington, where he is being evaluated.
Although it is assumed to be high, relatively little is known about the actual prevalence of sleep disturbances in veterans with PTSD. Any clinician who treats veterans with PTSD will likely tell you that most, if not all, of their patients suffer from sleep problems to some degree.
Relatedly, it is assumed that sleep disturbances improve with evidence-based PTSD treatments. However, to what degree is unclear.
In an effort to gain better clarity on these issues, researchers from the University of Texas Health Science Center at San Antonio, and colleagues from several other prestigious academic institutions, asked these questions to over 100 active-duty service members. Their findings were published in the November issue of Psychological Trauma and were shocking.
Not surprisingly, insomnia was the most frequently reported PTSD symptom prior to treatment. A whopping 92 percent acknowledged some degree of difficulty falling or staying asleep. Although not as high as insomnia, 69 percent of the same group reported suffering from nightmares.
The surprising, and somewhat disheartening news, is that approximately three-fourths of service members still reported insomnia as a problem after PTSD treatment. And around half still struggled with nightmares.
The researchers took an even deeper look into the results and found additional important information. For those service members who no longer met criteria for PTSD after successful treatment, more than half continued to report insomnia, and 13 percent continued to report problems with nightmares. Again, this is from those troops who made such significant improvement that they no longer had enough symptoms to retain the PTSD diagnosis.
In my opinion, there are two important take-home messages from this study.
First, sleep problems will likely continue in many people with PTSD, even in those service members who benefit greatly from treatment. Therefore, it is important to manage expectations. There are few — if any — complete “cures” in psychology and psychiatry, but this doesn’t mean you can’t go on to lead a rewarding and fulfilling life. Keep in mind, many people without PTSD struggle with sleep.
Second, you may want to ask to be referred for a sleep-focused therapy in addition to the PTSD treatment. Treatments like Imagery Rehearsal Therapy and Cognitive-Behavioral Therapy for Insomnia have been proven successful for nightmares and insomnia.
Bret A. Moore, Psy.D., is a board-certified clinical psychologist who served two tours in Iraq. Email him at kevlarforthemind@
(RALEIGH (NC) NEWS & OBSERVER 28 NOV 16) … Gavin Stone
DURHAM – A well-known treatment for post-traumatic stress disorder in civilians significantly reduced PTSD symptoms in active-duty military personnel who took part in a study published last week by the Duke University School of Medicine.
The study, in the journal JAMA Psychiatry, is the largest randomized clinical trial to date to apply cognitive processing therapy, or CPT, which has been used among civilians for decades, to active-military patients who are suffering from PTSD. It found that while using the treatment in both group and individual sessions significantly reduced PTSD symptoms, individual treatment was nearly twice as effective.
The study divided 268 participants from the U.S. Army’s Fort Hood in Killeen, Texas, into two groups, one that would receive the individualized CPT, while the other half participated in group CPT sessions. While both groups showed significant improvement to their mental health over the course of 12 sessions, close to 50 percent of participants who were given individual CPT were able to progress to a point where they were no longer medically classified as suffering from PTSD. About 37 percent of the participants in the group sessions progressed to this point.
CPT is a method of treatment that involves evaluating the thoughts and beliefs associated with a patient’s traumatic experience, which for many in the military involves blaming themselves for events in combat that are out of their control, according to Patricia Resick, a professor of psychiatry and behavioral sciences at the Duke University School of Medicine and lead author of the study.
Resick said that this tendency comes from the belief that in a “just world” good things happen to good people, which for some could also mean that if something bad happens it’s because you’re a bad person.
“Instead of looking to the perpetrator of the trauma, they look to themselves to assign blame,” Resick said. “What we do is we systematically lead them through a series of steps to teach them to ask themselves questions so they can make more balanced statements about themselves.”
Resick developed CPT in the 1980s to treat victims of rape and other interpersonal trauma. But the treatment was not applied to combat-related PTSD and related conditions in military personnel and veterans until 2008 when the U.S. Departments of Defense and Veterans Affairs formed a national research consortium called STRONG STAR to study methods of detection, prevention, diagnosis, and treatment of the disorder.
Lt. Col. Alan Peterson, director of the STRONG STAR Consortium and professor of psychiatry at the University of Texas Health Science Center San Antonio, said civilian research groups had not tested CPT on military personnel because they had a difficult time modifying their treatments to meet the needs of those who have been in combat.
Peterson said that getting treatment for PTSD carries a stigma of weakness that can prevent patients from seeking it out, or even acknowledging that there is a problem.
“Sometimes they would rather deploy and walk across a mine field than sit down and tell someone what happened to them,” Peterson said. “If we called it the ‘PTSD Consortium,’ then no one would come in.”
Peterson said that the most important outcome of the study for him was that PTSD treatment need only last months, not a lifetime.
“Without the proper type of treatment, yes, people can suffer for a lifetime,” Peterson said. “That’s what we’re trying to correct.”
There are many ways to cope with PTSD, Peterson said, such as using service dogs, going hiking or on camping retreats, rafting, music, art and yoga, but these things do not get at the root cause of the patient’s PTSD.
“Part of what causes PTSD is there’s one or more really horrible events that have occurred, and you need to drill down on the thoughts and memories that go with that,” Peterson said. “CPT drills down on the beliefs the people have about themselves and the world and the future.”
Peterson said the Duke study has already spawned five new clinical trials which will seek to determine whether more individualized treatment plans than the standard 12-session model will be more effective in reaching those with more complex cases of PTSD who were part of the 50 percent that showed slower progress.
VA Suicide Prevention Program
Facts about Veteran Suicide
VA believes every Veteran suicide is a tragic outcome. Regardless of the numbers or
rates, one Veteran suicide is one too many. We continue to spread the word
throughout VA that “Suicide Prevention is Everyone’s responsibility.” These new data
about Veteran suicide will inform our Suicide Prevention programs and policies,
especially for groups at elevated risk for suicide, including older and female Veterans.
VA continues to address Veterans’ needs through strategic partnerships with
community and federal partners and seeks to enhance these partnerships.
Meanwhile, we continue to serve as a leader in evidence-based care for suicide
VA relies on multiple sources of information to identify deaths that are likely due to
suicide and has undertaken the most comprehensive analyses of Veteran suicide
rates in the U.S. We have examined over 50 million Veteran records from 1979 to
2014 from every state in the nation. This effort extends VA’s knowledge from the
previous report issued in 2010, when over 3 million Veteran records from 20 states
Veteran Suicide Statistics, 2014
§ In 2014, an average of 20 Veterans died from suicide each day. 6 of the 20 were
users of VA services.
§ In 2014, Veterans accounted for 18% of all deaths from suicide among U.S.
adults, while Veterans constituted 8.5% of the US population. In 2010, Veterans
accounted for 22% of all deaths from suicide and 9.7% of the population.
§ Approximately 66% of all Veteran deaths from suicide were the result of firearm
§ There is continued evidence of high burden of suicide among middle-aged and
older adult Veterans. In 2014, approximately 65% of all Veterans who died from
suicide were aged 50 years or older.
§ After adjusting for differences in age and gender, risk for suicide was 21%
higher among Veterans when compared to U.S. civilian adults. (2014)
§ After adjusting for differences in age, risk for suicide was 18% higher among
male Veterans when compared to U.S. civilian adult males. (2014)
§ After adjusting for differences in age, risk for suicide was 2.4 times higher among
female Veterans when compared to U.S. civilian adult females. (2014)
Overview of data for the years between 2001-2014
§ In 2014, there were 41,425 suicides among U.S. adults. Among all U.S. adult
deaths from suicide, 18% (7,403) were identified as Veterans of U.S. military
§ In 2014, the rate of suicide among U.S. civilian adults was 15.2 per 100,000.
• Since 2001, the age-adjusted rate of suicide among U.S. civilian adults
has increased by 23.0%.
§ In 2014, the rate of suicide among all Veterans was 35.3 per 100,000.
• Since 2001, the age-adjusted rate of suicide among U.S. Veterans has
increased by 32.2%.
§ In 2014, the rate of suicide among U.S. civilian adult males was 26.2 per
• Since 2001, the age-adjusted rate of suicide among U.S. civilian adult
males has increased by 0.3%.
§ In 2014, the rate of suicide among U.S. Veteran males was 37.0 per 100,000.
• Since 2001, the age-adjusted rate of suicide among U.S. Veteran males
has increased by 30.5%.
§ In 2014, the rate of suicide among U.S. civilian adult females was 7.2 per
• Since 2001, the age-adjusted rate of suicide among U.S. civilian adult
females has increased by 39.7%.
§ In 2014, the rate of suicide among U.S. Veteran females was 18.9 per 100,000.
• Since 2001, the age-adjusted rate of suicide among U.S. Veteran
females has increased by 85.2%.
VA Aggressively Undertaking New Measures to Prevent Suicide
Veterans Crisis Line Expansion
§ The 24/7 Veterans Crisis Line (VCL) provides immediate access to mental
health crisis intervention and support. Veterans call the national suicide
prevention hotline number, 1-800-273-TALK (8255) and then “Press 1” to reach
highly skilled responders trained in suicide prevention and crisis intervention.
VCL also includes a chat service and texting option. We are continuing to
modify phone systems to allow for direct connection to the VCL by dialing “7”
when calling the VA medical center.
o We are hiring over 60 new suicide intervention responders/counselors for
o Each responder receives intensive training on a wide variety of topics in
crisis intervention, substance use disorders, screening, brief intervention,
and referral to treatment.
§ Since the establishment of the VCL through May 2016 the VCL:
o Has answered over 2.3 million calls, made over 289,000 chat connections,
and over 55,000 texts;
o Has initiated the dispatch of emergency services to callers in imminent
suicidal crisis over 61,000 times;
o Has provided over 376,000 referrals to a VA Suicide Prevention
Coordinator (SPC) thus ensuring Veterans are connected to local care;
Using Predictive Analytics to identify those at risk and intervene early
§ Screening and assessment processes have been set up throughout the
system to assist in the identification of patients at risk for suicide.
§ The VA will use predictive modeling to determine which Veterans may be at
highest risk of suicide, so providers can intervene early.
§ Veterans in the top 0.1% of risk (who have a 43-fold increased risk of death
from suicide within a month) are identified before clinical signs of suicide are
evident in order to save lives before a crisis occurs.
§ Patients who have been identified as being at high risk receive an enhanced
level of care, including missed appointment follow-ups, safety planning,
follow-up visits and individualized care plans that directly address their
Bolstering Mental Health Services for Women
Since 2005, VA has seen a 154 percent increase in the number of women Veterans
accessing VHA mental health services. In FY 2015, 182,107 women Veterans
received VA mental health care.
• VA has enhanced provision of care to women Veterans by focusing on training
and hiring Designated Women’s Health Providers (DWHP) at every site where
women access VA, with 100% of VA Medical Centers and 90% of Community-
Based Outpatient Clinics having Designated Women’s Health Providers.
• VA has trained nearly 2,500 providers in women’s health and continues to train
additional providers to ensure that every woman Veteran has the opportunity to
receive her primary care from a DWHP.
• VA now operates a Women Veterans Call Center (WVCC), created to contact
women Veterans to inform them about eligible services. As of February 2016,
the WVCC received 30,399 incoming calls and made about 522,038 outbound
calls, successfully reaching 278,238 women Veterans.
Expanding TeleMental Health Services
• VA is leveraging telemental health care by establishing four regional telemental
health hubs across the VA healthcare system.
• In FY 2015, 12% of all Veterans enrolled for VA care received telehealth-based
care, totaling more than 2 million telehealth visits that touched 677,000 Veterans,
including 380,000 telemental health encounters.
• Since FY 2003, VHA has provided more than 2 million telemental health
encounters, expanding its role as a world leader in telehealth and telemental
health services, including services provided directly into the Veteran’s home.
Free Mobile Apps to Help Veterans and their Families
VA has deployed a suite of 13 award-winning mobile apps to support Veterans and their
families with tools to help them manage emotional and behavioral concerns. These
• PTSD Coach (released 2011; 233,000 downloads in 95 countries) is a VA and
DoD joint project and is widely acclaimed, winning numerous awards. It is a tool
for self-management of PTSD, and includes: a self-assessment tool; educational
materials about PTSD symptoms, treatment, related conditions, and forms of
treatment; relaxation and focusing exercises designed to address symptoms; and
immediate access to crisis resources, personal support contacts, or professional
• CBT-i Coach for insomnia (released 2013; 86,000 downloads in 87 countries)
was a collaborative effort between the Department of Veterans Affairs’ National
Center for PTSD (NCPTSD), Stanford University Medical Center, and the
Department of Defense’s National Center for Telehealth and Technology (T2).
CBT-i Coach is a mobile phone app designed for use by people who are having
difficulty sleeping and are participating in Cognitive Behavioral Therapy for
Insomnia guided by a healthcare professional.
• ACT Coach for depression (released 2014; 23,000 downloads in 93 countries)
supports people currently participating in Acceptance and Commitment Therapy
(ACT) who want to use an app in conjunction with their therapist to bring ACT
practice into daily life.
• Mindfulness Coach, (released 2014; 39,000 downloads in 95 countries) provides
tools to assist users in practicing mindfulness meditation.
• Moving Forward (released 2014; 5,400 downloads in 54 countries) teaches
problem solving skills and can be used in a stand-alone fashion or while
participating in Problem Solving training.
Leveraging VA Vet Centers and Readjustment Counselors
Vet Centers are community-based counseling centers that provide a wide range of
social and psychological services including professional readjustment counseling to
Veterans and active duty Service members, including members of the National Guard
and Reserve components who served on active military duty in any combat theater or
area of hostility.
• There are 300 community-based Vet Centers, and 80 mobile Vet Centers located
across the 50 states, the District of Columbia, American Samoa, Guam, Puerto
Rico, and the US Virgin Islands (www.vetcenter.va.gov).
• In FY 2015, the Vet Centers Vet Centers provided over 228,000 Veterans,
Service members and families with over 1,664,000 visits.
• To use Vet Center services, Veterans or Service members:
o Do not need to be enrolled with VA Medical Centers;
o Do not need a disability rating or service connection for injuries from either
the VA or the DOD, and;
o Can access Vet Center services regardless of discharge character.
• The Vet Center Combat Call Center is an around-the-clock confidential call
center where combat Veterans and their families can talk with staff comprised of
fellow combat Veterans from several eras. In FY 2015, the Vet Center Combat
Call Center took over 113,000 calls from Veterans, Service members, their
families, and concerned citizens.
Telephone Coaching for Families of Veterans
Coaching Into Care (www.va.gov/coachingintocare) assists family members and friends
in helping a Veteran seek care. Coaching Into Care provides a motivational “coaching”
service for family and friends of Veterans who see that a Veteran in their life needs help.
Coaching involves helping the caller figure out how to motivate the Veteran to seek
services. The service is free and provided by licensed clinical social workers and
psychologists. Since the inception of the service in January 2010 through November
2014, Coaching Into Care has logged 18,088 total initial and follow-up calls.
Innovative Public-Private Partnerships to Reach Veterans
VA is working with public and private partners across the country with the goal of
ensuring that wherever a Veteran lives, he/she can access quality, timely mental health
VA is working with universities, colleges and health professional training institutions
across the country to expand their curricula to address the new science related to
meeting the mental and behavioral health needs of our Nation’s Veterans,
servicemembers, and their families.
• VA has recently partnered with the University of Michigan Health System and its
Military Support Programs and Networks (M-Span) to support student Veterans
as they transition from military to student life. Their Peer Advisors for Veteran
Education (PAVE) program which is expanding to 42 campuses across the
country and VA’s Veterans Integration to Academic Leadership (VITAL) and VA’s
Peer Support Program will coordinate referrals, share resources and
collaboratively help student Veterans successfully navigate college life and
VA is also supporting community provider organizations through innovative
• VA recently partnered with the Bristol Myers Squibb Foundation (BMS-F) to
share subject matter expertise across a range of topics relevant to Veterans
and their families including: Student Veteran Programs, Caregiver Training
Programs, Faith/Chaplain/Spirituality-based mental health Programs and other
mental health and well-being programs.
• VA has also recently partnered with Give an Hour (GAH) to share training
resources on various mental health topics to be disseminated to GAH’s
provider network, so more Veterans have access to evidence-based mental
health care and are competent in military culture. In addition, VA’s Make the
Connection Veteran focused outreach campaign is collaborating with GAH’s
Change Direction Campaign to reduce negative perceptions associated with
seeking mental health care and promote mental health literacy among Veterans
and the general public.
• VA has also partnered with Psych Armor Institute (PAI) to share subject matter
expertise on a range of mental health and caregiving topics to help civilians
better serve Veterans through training that PAI is delivering free of charge to the
public and VA.
• VA Campus Toolkit (www.mentalhealth.va.gov/studentveteran) is a resource for
faculty, staff, and administrators to find resources to support student Veterans
and learn about their strengths, skills, and needs.
• VA is hosting annual Community Mental Health Summits at each VAMC. Each
facility will focus on building new partnerships and strengthening existing
partners to meet the needs of Veterans and Veteran families residing in their
• Each VAMC has appointed a Community Mental Health Point of Contact to
provide ready access to information about VA eligibility and available clinical
services, ensure warm handoffs at critical points of transition between systems of
care, and provide ongoing liaison between VA and Community Partners.
Maintaining the High Quality of VA Mental Health Care
The Altarum/RAND report, Veterans Health Administration Mental Health Program
Evaluation (2011) concluded that, “Timeliness for mental/behavioral healthcare in VHA
is as good as or better than in commercial and public plans.”
A recent publication comparing VA mental health care to private sector care examined
medication treatment for mental disorders, finding:
• Across 7 performance indicators, VA “performance was superior to that of the
private sector by more than 30%.”
• The authors conclude that: “Findings demonstrate the significant advantages
that accrue from an organized, nationwide system of care. The much higher
performance of the VA has important clinical and policy implications.”
Proactive Outreach to Reach Veterans Needing Care
§ VA works proactively to connect Veterans and their families with the
resources they need. In addition to VA’s Make the Connection outreach
campaign and extensive suicide prevention outreach, many specific mental
health programs and services have outreach as part of their efforts. Suicide
Prevention Coordinators are required to conduct at least five outreach
activities per month in all of their local communities and are able to provide a
Community version of Operation S.A.V.E. to Veterans and others.
§ Partnering with community organizations has broadened VA’s outreach efforts
and promotes more positive outcomes from community providers.
§ Make the Connection is VA’s award-winning mental health public awareness
campaign. Its primary objectives are to highlight Veterans’ true and inspiring
stories of mental health recovery, reduce negative perceptions about mental
health and seeking mental health care and to connect Veterans and their
family members with local, mental health resources.
§ Over the past four years, Make the Connection has seen tremendous
engagement with Veterans, Veteran family members, and supporters. Via
MakeTheConnection.net, the campaign’s outreach efforts, and social media
properties including Facebook and YouTube pages, the following has been
achieved (through May 2016):
o 10.5 million website visits;
o 333,000 resource locator uses (local VA and other community sources
o 14.4 million video views;
o 19,700 YouTube subscribers;
o 3.4 million likes on the MTC Facebook page, making it one of the
largest government Facebook communities in the country;
o 39.8 million engagement actions on Facebook (likes, comments and/or
o More than 2 billion impressions of the campaign’s Public Service
Announcements, earning more than $27M in free, donated airplay;
o Outreach has resulted in over 190 organizations broadcasting
campaign messaging through their communication platforms and
o More than 730,000 pieces of material distributed nationwide
For more information, Veterans currently enrolled in VA health care can speak with
their VA mental health or health care provider. Other Veterans and interested parties
can find a complete list of VA health care facilities, Vet Centers, their local Suicide
Prevention Coordinators, and other resources under the resource section of
www.veteranscrisisline.net or at www.va.gov.
For more information about this Fact Sheet, contact Dr. Caitlin Thompson, National
Mental Health Director for Suicide Prevention and Community Engagement at 202-