By Gopal Ratnam and Michelle Fay Cortez, Bloomberg News
No one knows better than Connie Chapman that almost 150 years since troops came home with "soldier's heart" after the Civil War, the U.S. military is still struggling to identify and treat what's now called PTSD.
When the now-retired Army captain and her Washington state National Guard unit returned from Iraq in 2005, she said they mustered on a racquetball court at Fort Lewis where mental-health screeners shouted at them, "Are you suicidal? Do you have flashbacks?"
It was difficult for anyone to acknowledge suffering from post-traumatic stress disorder in so public a setting, said Chapman, 45, who later underwent four years of therapy for symptoms such as flashbacks from the incessant mortar and rocket attacks on the logistics base in Balad where she served.
The Pentagon still has "no consistent diagnosis, no consistent tools and different levels of professionals" working on solutions, Senator Patty Murray, chairman of the Senate Veterans Affairs Committee, said in an interview.
In an effort to change that, the military says it's trying to find cases sooner by embedding therapists in combat units and spending $40 million to study 20 treatments, some of which may work within weeks. Among them is a therapy that sends some troops on a 45-minute trip through a Wal-Mart store.
About 20 percent of the 2.4 million U.S. troops who served in Afghanistan and Iraq since 2001 may meet criteria for PTSD from the chaos of wars marked by intense combat with no clear enemy lines, according to congressional researchers and the Rand Corp.
Big-box retailers, movie theaters and restaurants are "often busy and noisy, and some people may be hidden behind things -- and all those are perceived as dangerous" by warriors who dodged roadside bombs and watched buddies die in Iraq or Afghanistan, Alan Peterson, director of a Pentagon-funded project at the University of Texas Health Science Center in San Antonio, said in an interview.
Doctors in the program sometimes recommend that soldiers confront their fears by visiting a Wal-Mart Stores Inc. (WMT) location and staying until anxieties "fade away on their own," Peterson said in an interview.
The South Texas Research Organizational Network Guiding Studies on Trauma and Resilience, or Strong Star, headed by Peterson, is conducting the 20 studies on potential treatments. The program, begun in 2008, is aimed primarily at active-duty military personnel.
While the military brass realize that PTSD is "the signature wound" of the wars in Iraq and Afghanistan, "there's a cultural issue within the Defense Department that makes it extremely difficult" to diagnose and treat troops, Senator Murray said. "There's a culture of â€˜man up' that continues to send signals to soldiers that a mental-health diagnosis is not something they should own up to," said Murray, a Democrat from Washington state.
"Frankly, we have not learned how to effectively deal with that, and we have to," Defense Secretary Leon Panetta said at a Feb. 28 hearing of Murray's committee.
The Army suspended the head of the Madigan Army Medical Center at Joint Base Lewis-McChord in Washington state last month in a dispute over whether PTSD diagnoses were being withheld.
A psychiatrist at the center had cautioned against "rubber-stamping" cases as PTSD, saying that a soldier diagnosed with the condition may receive as much as $1.5 million during his or her lifetime and the costs could bankrupt the Army and Veterans Affairs Department, according to a memo from an Army ombudsman provided by Murray's office.
Treating a veteran for PTSD and related conditions costs an average of $8,300 in the first year and $4,200 in the second, according to a February report by the Congressional Budget Office.
The U.S. military has 88,817 cases of PTSD among active-duty personnel after more than a decade of wars, according to Peter Graves, a spokesman for the Defense Department's office of health affairs. An additional 223,609 veterans have been seen for the condition, according to the Department of Veterans Affairs.
About 21 percent of Iraq and Afghanistan veterans who sought medical treatment from 2004 to 2009 were diagnosed with PTSD, the Congressional Budget Office said in a February report. The Rand Corp. estimated in 2008 that 20 percent of those who served in the wars met the criteria for PTSD.
Army suicides rose 80 percent from 2004 to 2008 after the deployments to Iraq and Afghanistan, according to a report published in the journal Injury Prevention on a study by the U.S. Army Public Health Command.
A soldier with an amputated limb is seen as a hero, "but you see someone diagnosed with PTSD and say, â€˜What's wrong with them?'" said Chapman, the former Washington National Guard soldier, who went on to be trained as a therapist and is now a Seattle-based senior manager for a combat-stress recovery program with the Wounded Warrior Project, a Jacksonville, Florida-based advocacy group.
Some in the military have questioned whether the PTSD name, designated by the American Psychiatric Association in 1980, carries its own stigma that discourages service members from seeking help and brands them as unstable.
General Pete Chiarelli, who retired at the end of January as the Army's vice chief of staff, said the designation should be changed to "post-traumatic stress injury."
For some people, "if you label them as having a disorder, somehow it makes it sound like it's a pre-existing condition or that they're a weaker person," Chiarelli said in an interview before leaving office.
As an alternative to changing the name, the psychiatric association is considering creating a separate category for PTSD that results from combat stress, said John Oldham, the group's president and chief of staff at the Menninger Clinic in Houston.
The new combat category may be included next year in the fifth edition of the association's Diagnostic and Statistical Manual of Mental Disorders, Oldham said in an interview. The guide is used to determine how patients are diagnosed and treated and what insurers will cover.
In addition to being used for those suffering the mental wounds of war, PTSD is a diagnosis for victims of rape or witnesses to murder. The condition follows events that cause intense fear and helplessness, and it can develop shortly after the event or take several years, according to the psychiatric association's website.
The symptoms may include re-experiencing the traumatic event through nightmares, obsessive thoughts and flashbacks that may lead people to avoid situations or objects reminding them of the original events, according to the association. About 7.7 million Americans are affected by PTSD in a given year, according to the National Institutes of Health.
Not everyone is convinced that changing the name or reclassifying the illness for soldiers is even the first step toward dealing with inadequate treatment.
Labeling a mental illness a disorder sometimes is helpful, said Lisa Jaycox, a researcher at the Rand Corp. in Arlington, Virginia. In the case of depression, calling it a disorder has helped patients get treatment, because the designation changed the illness from "something that's wrong with you to a medical problem that is treatable," she said in an interview.
Visiting Wal-Mart or another crowded spot is part of a treatment for PTSD called prolonged exposure therapy that encourages a patient to recount traumatic events that cause flashbacks, Peterson of the Strong Star group said.
The benefits of 10 such therapeutic sessions within either two or eight weeks are being studied, and the early results suggest the treatments are so effective that some active-duty military personnel have been able to return to war zones, Peterson said. About 360 military personnel are getting the exposure therapy, he said.
Greg Rossiter, a spokesman for Wal-Mart of Bentonville, Arkansas, the world's largest retailer, had no comment on the store visits as a treatment.
A second treatment called cognitive processing therapy is being tested with an additional 400 warriors.
In this approach, a therapist helps patients see how traumatic events have affected their lives, such as constant self-blame for not having done more to save a fellow warrior on the battlefield. In later sessions, the therapist helps warriors understand such unhelpful thinking patterns and ways to challenge such self-doubt.
If larger studies validate the results of the therapies, which may take two more years, the military may be able to treat troops suffering from battlefield trauma within weeks after it manifests itself, Peterson said.
While treatments are improving, the "biggest issue is that a majority of service members and veterans don't come to see us, and those who do come don't complete care or drop out," said Charles Hoge, a former psychiatrist at the Army's Walter Reed Medical Center and author of the book, "Once a Warrior --Always a Warrior."
The military is trying to attach mental-health personnel to deployed units in an effort "to lower the bar to seek help," according to Navy Captain Paul Hammer.
"When you look at PTSD, what 10 years of war has taught people is you don't go to war and come back unchanged," Hammer, director of the Pentagon's Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, said in an interview. "If you did, you would be a sociopath. In some cases, people are affected deeply."
The Pentagon is also running a "Real Warriors" campaign of television and Web ads featuring military personnel who have sought treatment for PTSD without damage to their military or post-retirement civilian careers.
The goal of the campaign is to show that "it takes courage to buck the trend and say, â€˜Yes, I had a problem, and I sought treatment,'" Hammer said.