War comes home: the traumatic brain injury epidemic

“We are facing a massive mental health problem as a result of our wars in Iraq and Afghanistan. As a country we have not responded adequately to the problem. Unless we act urgently and wisely, we will be dealing with an epidemic of service related psychological wounds for years to come.”

–   Bobby Muller, President Veterans for America

“The multiple nature of it [multiple tours and longer deployments] is unprecedented. People just get blasted and blasted and blasted.”

– Maj. Connie Johnmeyer, 332^nd Medical Group

According to official Defense Department (DOD) figures, 332,000 soldiers have suffered brain injuries since 2000, although most independent experts estimate that the number is over 400,000. Many of these are mild traumatic brain injuries (mTBI), a term that is profoundly misleading.

As David Hovda, director of the Brain Injury Research Center at the University of California at Los Angeles, points out, “I don’t know what makes it ‘mild,’ because it can evolve into anxiety disorders, personality changes, and depression.” It can also set off a constellation of physical disabilities from chronic pain to sexual dysfunction and insomnia.

MTBI is defined as any incident that produces unconsciousness lasting for up to a half hour or creates an altered state consciousness. It is the signature wound for the wars in Iraq and Afghanistan, where roadside bombs are the principal weapon for insurgents.

Most soldiers recover from mTBI, but between five and 15 percent do not. According to Dr. Elaine Peskind of the University of Washington Medical School, “The estimate of the number who returned with symptomatic mild traumatic brain injury due to blast exposure has varied from the official VA [Veterans Administration] number of 9 percent officially diagnosed with mTBI to over 20 percent, and, I think, ultimately it will be higher than that.”

Serious consequences from mTBI are increased when troops are subjected to multiple explosions and “just get blasted and blasted and blasted,” in the words of Maj. Connie Johnmeyer. Out of two million troops who have served in Iraq and Afghanistan, over 800,000 have had multiple deployments, many up to five times or more.

But mTBI is difficult to diagnose because it does not show up on standard CAT scans and MRIs. “Our scans show nothing,” says Dr. Michael Weiner, professor of radiology, psychiatry and neurology at the University of California at San Francisco and director of the Center for Imaging Neurodegenerative Disease at the Veteran’s Administration Medical Center.

They do now.

An MRI set to track the flow of water through the brain’s neurons, has turned up anomalies that indicate the presence of mTBI. However, the military has blocked informing patients of results of the research, and if history is any guide, the Pentagon will do its best to shelve or ignore the results.

The DOD has long resisted the diagnosis of mTBI, as it has avoided paying for a successful – but expensive – way to treat it. The price of that resistance is escalating suicide rates and domestic violence incidents among returning soldiers. In 2010, almost as many soldiers committed suicide as fell in battle.

MTBI is hardly new. Some 5.3 million people in the U.S. are currently hospitalized or in residential facilities because of it, and its social consequences are severe.

A Mt. Sinai Hospital study of 100 homeless men in New York found that 80 percent of them had suffered brain trauma, much of it from child abuse. A study of 5,000 homeless people in New Haven, Conn., discovered that those who had suffered a blow that knocked them unconscious or into an altered state were twice as likely to have alcohol and drug problems and to be depressed. It also found mTBI injuries were correlated with suicide attempts, panic attacks, and obsessive-compulsive disorders. And a recent study by Dr. Elaine Peskind of the University of Washington School of Medicine found that mTBI is a risk factor for developing Alzheimer’s disease.

In spite of the documented consequences of mTBI, the military has been extremely tardy in dealing with it. Part of the problem is military culture itself. The Pentagon found that 60 percent of the soldiers who suffered from the symptoms of mTBI refused help because they feared their unit leaders would treat them differently. Many were also afraid that if they reported their condition it would prevent them from getting jobs as police and fire fighters after they got out of the service.

Even if soldiers wanted treatment, there are few resources available to them. “There are two things going on regarding vets,” says Col. (ret) Will Wilson, chair of the American Psychological Association’s Division 19 (Military Psychology). “One, there are not enough care providers available, and, two, there are not enough people focusing on the problem outside the military.”

Indeed, there are not enough military psychologists to treat the problem, and since the military pays below-market rates for civilian psychologists, up to 30 percent of private psychologists are unwilling to take on soldiers as patients. The cheapest and easiest solution is to shoot up the vets with drugs. A study by Veterans for America found that some soldiers were taking up to 20 different medications, many of which canceled out the effect of others.

The situation appears to be even worse for National Guard and Reserve units, who make up almost 50 percent of the troops deployed in Iraq and Afghanistan. The Veterans for America found that such troops “are experiencing rates of mental health problems 44 percent higher than their active duty counterparts” and that their health care is generally inferior.

A Harvard study found that 1.8 million vets under 65 have no health care or access to the Veterans Administration. “Most uninsured veterans are low-to-middle income workers who are too poor to afford private coverage but are not poor enough to qualify for Medicaid or free VA care,” the study found.

Treating mTBI injuries is difficult, but by no means impossible. Dr. Alisa Gean, chief of Neuroradiology at San Francisco General Hospital, who has worked with wounded soldiers at U.S. Army’s Regional Medical Center at Landstuhl, Germany, says the old conventional wisdom that brain damage was untreatable is wrong. “We now know that the brain can heal. It has an intrinsic plasticity that allows it to recover, and this is particularly true for the young brain.”

A recent study by the Massachusetts Institute of Technology found that “neurons in the adult brain can remodel their connections,” thus “overturning a century of prevailing thought.”

One method that has worked effectively is cognitive rehabilitation therapy (CRT) that retrains patients for tasks like counting, cooking, and memory. But CRT takes time and it can be expensive, ranging from $15,000 to $50,000 per patient. However, the DOD’s health program – Tricare – refuses to endorse CRT, because it says there is no scientific evidence that justifies the expense involved.

However, an investigation by T. Christian Miller of ProPublica and Daniel Zwerdling of National Public Radio found that the vast majority of researchers, even those associated with the DOD, sharply disagreed with Tricare’s evaluation of CRT. According to the two reporters, “A panel of 50 civilian and military brain specialists convened by the Pentagon unanimously concluded that cognitive therapy was an effective treatment and would help many brain damaged troops.”

The therapy is also endorsed by the National Institutes of Health, the National Academy of Neurophysiology and the British Society of Rehabilitative Medicine.

Instead of accepting the advice of its own researchers, however, Tricare hired ECRI – a company which had already done a study concluding that CRT was ineffective – to examine the therapy. Critics charge that the study was so narrow, and the assumptions behind it so loaded, that it was almost a given that the study would conclude the benefits of cognitive therapy were “inconclusive.” Outside researchers blasted the ECRI study, one of them describing it as “hooey” and “baloney.”

In spite of the criticism, then Deputy Secretary of Defense Gordon England concluded, “The rigor of the research … has not met the required standard.”

However, Miller and Zwerdling concluded that Tricare’s resistance to CRT was not about science, but the bottom dollar. According to the reporters, a Tricare-sponsored study found “that comprehensive rehabilitative therapy could cost as much as $51,480 per patient. By contrast, sending patients home from the hospital to get a weekly phone call from a therapist amounted to only $504 a patient.”

Defense Secretary Robert Gates has already made it clear that he intends to cut the military’s $50 billion annual health budget. No matter how effective CRT is, it’s not likely to get past the brass, who would rather spend the money on weapon systems than on healing the men and women who they so casually put in harm’s way.

So far, the military has put the clamps on the new MRI technique. Dr. David L. Brody, an author of the study, told the New York Times that researchers were blocked from giving the MRI results to patients. “We were specifically directed by the Department of Defense not to so,” adding, “It was anguishing for us, because as a doctor I would like to be able to help them in any way. But that was not the protocol we agreed to.”

Given that mTBI is so difficult to diagnose, and sufferers are many times told there is nothing wrong with them, that seems an especially cruel protocol. “Many of them [the doctors] were hoping we could give results to their care providers to document or validate their concerns.”

In the end it will come down to treatment, and whether the wounded vets will get the care they need, or sit by a phone and wait for their once a week call from a therapist.

Originally published at Dispatches From the Edge.  

Photo; U.S. Army Pfc. is taken to a military helicopter for evacuation after being injured by a roadside bomb, June 17, in the Kandahar Province of Afghanistan. U.S. Navy Lt. j.g. Haraz N. Ghanbari/AP