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Invisible Wounds of War
By Kayla Williams with the Invisible Wounds of War Study Team, Virginia
Going to War
When I joined the Army in 2000, war seemed like a remote possibility. But on 9/11, it was no longer a question of whether I would go to war, only where and when. I was part of the initial invasion of Iraq as a soldier in the 101st Airborne Division, and as an Arabic linguist, I was one of the few soldiers who could communicate with Iraqis.
One afternoon in Baghdad, when unexploded ordnance went off, I translated while we provided emergency medical care to three injured Iraqis. One did not survive. It was nothing like the movies: he screamed for hours, calling out for God's mercy. For months, the images from that day intruded on my thoughts.
"While I tried to help Brian face his demons, I was struggling with my own readjustment. The July Fourth fireworks were horrible. Fear caused me to continually swerve to avoid trash in the road, irrationally believing it could be an IED." -Kayla Williams
A few months later, I met a fellow soldier, Brian, to whom I was immediately attracted. We promised to get to know one another better when we got home. Days later, a call came over the radio that a convoy had been hit by an improvised explosive device. Brian had been severely wounded - shrapnel pierced his skull. He was evacuated to Baghdad by helicopter, and doctors didn't expect him to survive. Amazingly, he did, and we were soon able to stay in touch by email.
Coming Home
There was little real preparation for the difficulty of readjusting when we returned to the United States. Brian was treated at Walter Reed Army Medical Center, but even after he was sent home he couldn't sleep at night. He had terrible nightmares, frequently seemed down, suffered debilitating headaches and often forgot things.
Over time, I learned these were symptoms of very real problems identified as post traumatic stress disorder (PTSD), depression and traumatic brain injury (TBI). Each of these conditions has been linked to combat related experiences among military service members.
PTSD can occur after experiencing or witnessing a traumatic event involving the threat of serious injury or death. Symptoms often include re-experiencing the traumatic event through nightmares or recurring images, numbing or hyper-arousal and avoiding things reminiscent of the trauma.
While depression alters an individual's mood and frequently interferes with their everyday functioning, TBI results from a trauma to the brain in which brain function is either temporarily or permanently disrupted. These injuries range in severity from mild, like a concussion, to severe, like Brian's.
I also learned that we are not alone. According to a recent RAND Corporation study about these "Invisible Wounds of War," 18.5 percent of Operation Enduring Freedom and Operation Iraqi Freedom veterans are suffering from PTSD or depression and need appropriate treatment, and 19.5 percent report experiencing a TBI during deployment.
While most soldiers with mild TBIs recover fully, some suffer long-term cognitive deficits. Those with moderate to severe TBIs often have some type of life-long impairments. Being exposed to an explosion can easily cause both PTSD and TBI, and 7.3 percent of those in the RAND study have, like my husband, a mental health condition and TBI.
While I tried to help Brian face his demons, I was struggling with my own readjustment. The July Fourth fireworks were horrible. Fear caused me to continually swerve to avoid trash in the road, irrationally believing it could be an IED.
When I went through an Army leadership course a few months after my return, most soldiers in my class had been to Iraq. All of us admitted to having trouble sleeping, losing our tempers more easily, and flinching at loud noises. It was a huge relief to realize that it was normal to have a hard time readjusting. Like many people, though, I got over the worst of my feelings within a few months.
Brian did not. He turned to alcohol and sporadically attended group therapy sessions before returning to Walter Reed. Care for combat veterans suffering from TBI and PTSD were, meanwhile, among the concerns increasingly being raised by various commissions and task forces. These reports included recommendations for improving services to meet the needs of the veterans.
However, despite efforts to increase health services capacity within the Department of Defense and Department of Veterans Affairs, there remains a large gap between the need for mental health services and their use. The RAND study showed that only 53 percent of returning troops that met the criteria for current PTSD or major depression sought help in the past year. Some of this stems from personal and cultural factors, like being afraid that seeking help will hurt careers. But lack of provider availability also plays a role: returning service members may face long wait times for appointments.
There are also gaps in quality. According to the RAND study, slightly more than half of returning service members who sought care for their PTSD or depression received minimally adequate treatment. Fewer received high-quality care.
The Pentagon and the VA have begun training providers in evidence-based practices; however, their efforts to improve training have not been integrated into a larger system redesign that provides incentives for quality improvement.
Moving Forward
Brian and I were married after I left the Army in 2005, and he was medically retired soon after. Despite slow, gradual improvements, he sometimes sinks into deep depressions for months, continues to have a hard time envisioning a positive future, and still has a hard time sleeping because of nightmares. He also has cognitive and memory problems as a result of the TBI. We're still trying to get him rehabilitation and adequate care. And we have both sought different ways to cope with the after-effects of war.
Brian began working with a nonprofit organization, VoteVets (www.votevets.org) that helps elect veterans of the Iraq and Afghanistan wars to public office and seeks to hold elected officials responsible for their votes on military and veterans' issues. He speaks publicly about his own struggles with depression, PTSD and TBI to bring attention to the problems injured service members face and encourages others to seek help.
I began working at RAND (www.rand.org), a non-profit research institution, where I was able to apply my analytic skills to research on national security and defense-related issues.
Recently I worked as part of the study team on the RAND "Invisible Wounds of War" study. The study provides policymakers an objective assessment and overview of issues facing returning veterans with these conditions as well as recommendations for confronting them. The study gives families like mine the knowledge that we are not alone in facing these challenges, and points us toward evidence-based treatments.
Since October 2001, approximately 1.6 million U.S. troops have been deployed as part of Operation Enduring Freedom and Operation Iraqi Freedom. Many have been exposed for prolonged periods to combat-related stress. Although most readjust successfully, like me, many may be suffering from mental disorders, like my husband. The number could easily exceed 300,000 veterans who need treatment. Closing the gap in access to care and quality of care for veterans suffering PTSD, depression and TBI should be a national priority.
"Despite slow, gradual improvements, he sometimes sinks into deep depressions for months, continues to have a hard time envisioning a positive future, and still has a hard time sleeping because of nightmares. He also has cognitive and memory problems as a result of the TBI. We’re still trying to get him rehabilitation and adequate care.quot; -Kayla Williams
Improving access to high-quality care would also have economic benefits for society. Untreated PTSD, depression and TBI can have a high economic toll due to family strain, lost productivity, increased rates of suicide and other damaging consequences. Delivering effective, evidence-based care and restoring veterans to full mental health can significantly reduce these long-term costs.
However, this will require nationwide, system-level changes. The RAND report includes four major recommendations:
- Increase the group of providers who are trained and certified to deliver proven care so that capacity is adequate for current and future needs.
- Change policies to encourage active duty personnel and veterans to seek needed care.
- Deliver proven, evidence-based care to service members and veterans in all settings.
- Invest in research to close information gaps in the health care system and plan effectively.
Taken together, the RAND recommendations suggest a national approach to closing gaps in access and quality care for veterans. All veterans should have access to, and feel comfortable seeking, evidence-based care. The decision makers in government now have a place to start in order to offer them to future generations of veterans.
Kayla is a Project Associate with the RAND Corporation. The study discussed in this article was conducted by the RAND Corporation and published in April 2008. Kayla served as one of 31 researchers on this study, contributing her analytic skills to the team examining the systems of care for those suffering from traumatic brain injuries. More details, the full report, and resources for veterans and their families are available at http://veterans.rand.org.
