Posttraumatic Stress Disorder
Necessary Improvements the United States Department of Veterans Affairs and United States Department of Defense Must Make

Abstract
Posttraumatic stress disorder (PTSD), a mental anxiety disorder, affects 13% to 20% of armed force members returning from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) (Hoge, et. al, 2004), in addition to a large population of Vietnam Veterans. Within the past 32 years, awareness of this disorder has escalated and the realism of the severity of this disorder has been noticed. Efforts to screen and treat PTSD in military veterans have been established by the United States Department of Veterans Affairs (VA). Screening is conducted once military personnel return from deployment and treatments including Cognitive Behavioral Therapy, Eye Movement Desensitization and Reprocessing, Exposure Therapy, and medications are used to relieve the symptoms of PTSD. These screening and treatment methods are evaluated and s suggestion for improvement is made.

Necessary Improvements the United States Department of Veterans Affairs and the United States Department of Defense Must Make With Regards to Posttraumatic Stress Disorder In current political debate, the United States is arguing where budget cuts should be made and how the U.S. should go about spending money. The U.S. military is consistently brought up in these considerations. In such considerations, topics such as downsizing the military and the military’s budget overall is discussed. The military budget comes into play when considering posttraumatic stress disorder (PTSD) among military personnel. Mark Creamer shared: It was not until 1980 that PTSD was recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM), a system created by the American Psychiatric Association used to organize, define, and diagnose mental disorders (Creamer, Wade, Fletcher, & Forbes, 2011, p. 1). Since 1980, awareness of PTSD has slowly become more acknowledged and research to further understand the components of this disorder has been and currently is conducted. Although the U.S. Department of Veterans Affairs (VA) and the United States Department of Defense (DOD) argue they are providing adequate services for military victims of posttraumatic stress disorder, the level of care is inadequate with regards to screening and treatment. Screening and treatment must be improved to ensure an acceptable quality of life for the men and women who risk their lives for the United States.
What is Posttraumatic Stress Disorder? PTSD adversely impacts the mental state of an individual. The National Institute of Mental Health (2012) defines PTSD: “Posttraumatic stress disorder is an anxiety disorder that some people get after seeing or living through a dangerous event” (para.1). PTSD affects normal individuals under extremely stressful conditions. This disorder develops after experiencing or witnessing a life-altering, traumatic event such as combat exposure, sexual and physical abuse, terrorist attacks, serious accidents, and natural disasters (“Understanding PTSD Treatment,” 2011, p.1-2). Combat exposure is the primary focus for PTSD of Military Veterans. Because of fighting and serving in war, U.S. veterans have engaged in and witnessed traumatic events. Many of them have experienced the unimaginable, such as watching the person right next to them die. Unfortunately, for some members of the armed forces, exposure to these devastating events leads to PTSD. Gregory G. Garske (2011), explains that the National Vietnam Veterans Readjustment Study, a study conducted in 1990 to evaluate the mental state of Vietnam Veterans, discovered that 31% of male and 27% of female veterans were diagnosed with PTSD at one point throughout their life (p.31). The Vietnam War left many soldiers distraught. Additionally, since 2001, PTSD affected somewhere between 13% and 20% of military personnel who have returned from Operation Enduring Freedom and Operation Iraqi Freedom (Hoge, et. al, 2004).The life that soldiers, airmen, sailors, and marines live once being diagnosed with PTSD is inadequate for an acceptable form of life.
Symptoms of Posttraumatic Stress Disorder Symptoms of PTSD usually start within days of the traumatizing experience, but in some cases may not begin for months. Also, this disorder may come and go throughout one’s life. Matthew J. Friedman (2011), explains several symptoms of PTSD. Symptoms of this disorder include re-experiencing the event, such as flash backs and nightmares. Additionally, avoiding situations that remind one of traumatic events, including avoidance of beliefs and feelings associated with the stressor is also a common symptom of PTSD along with hyperarousal, which consists of sleep problems and irritability (Friedman, Resick, Bryant, & Brewin, 2011, p. 752). This serious disorder affects individuals everyday. PTSD makes one feel stressed and afraid when one is no longer in an area of danger; it affects everyone around them (National Institute of Mental Health, 2012). The severity and long lasting symptoms of PTSD can drastically impair one’s quality of life and ability to function normally.
VA and DOD Position on PTSD
Currently, the VA health care system has 1,500 facilities for all types of veteran health care (United States Department of Veterans Affairs, 2012, p.1). This makes the VA largest provider for armed forces returning from Iraq and Afghanistan. Additionally, the United Stated Department of Defense’s mission is to “provide the military forces needed to deter war and to protect the security of our country” (U.S. Department of Defense, 2012). The DOD is responsible for military personnel throughout their course of service in the U.S. military.
Included in the health care that the VA provides is screening and treatment for mental health. Brian Shiner and his partners analyzed current works to calculate the amount of Iraq and Afghanistan veterans who used VA health services. They calculated, from 2002 to 2010, 593,569 who served in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) attended, at minimum, one appointment with a VA facility, and of them, 161,507 were diagnosed with PTSD by the VA (Shiner, Drake, Watts, Desai, & Schnurr, 2012, p.818). This amount of military personnel diagnosed with PTSD within eight years of fighting OIF and OEF is horrifying.
Screening
The VA asserts they are doing a good job of screening patients. Their screening process, titled 4-Item Primary Care PTSD Screen, consists of a series of four yes or no questions that determine if one needs to be further assessed. These questions address nightmare instances, avoidance of situations that remind one of traumatizing events, constantly fearing danger, and feeling separated from every day life. Answering yes to three of the four questions shows that one may have symptoms of PTSD and will be sent on for further evaluation. If one is recommended for further evaluation, he or she will be given an interview where they are expected to elaborate on the initial series of yes or no questions. Additional questions may be asked to make certain that the patient is showing symptoms of PTSD. (Prins, et al., 2003).
Treatment
The VA explains that the treatment that they use works. Treatments they offer include counseling and medication. Cognitive behavioral therapy (CBT), a psychotherapy (counseling), involves therapist meetings for an average of three to six months. Prolonged exposure therapy (PE) is a type of CBT. This type of counseling repeatedly exposes one to feelings, thoughts, and situations of the trauma that one has been avoiding until distress minimizes. (“Understanding PTSD Treatment”, 2011, p.2-4). The VA shares their experience with PE: “This therapy works by helping you approach trauma-related thoughts, feelings, and situations that you have been avoiding due to the distress they cause” (United States Department of Veterans Affairs, 2011, para.1). Also included in CBT is Cognitive processing therapy (CPT), which changes the way one feels about the trauma by examining and discussing challenging thoughts about the trauma. Tara Galovski (2011), shares her experiences and results when taking a CPT approach to treat patients, “When people come back for a three-month or six-month follow-up visit, many times I have walked out into the waiting room and not even recognized the person!” (as cited in “Understanding PTSD Treatment”, 2011, p.3). This shows how some patients benefit from the treatments that the VA offers. Another type of counseling, Eye Movement Desensitization and Reprocessing (EMDR), created in 1987 by American psychologist, Francine Shapiro, PhD, is a learning process that can help one cope how he or she reacts to their memories of trauma and turn negative memories into positive memories through static eye and hand movements (Greyber, Dulmus, & Cristalli, 2012, p. 412). Additionally, the type of medication used by the VA is Selective Serotonin Reuptake Inhibitors (SSRI). The purpose of SSRI’s is to help one improve by increasing the level of serotonin in the brain. For example, George, a medic in the Vietnam War who accessed the VA for PTSD overcame his traumatic experience of a Vietnamese child passing away in his arms. It took years for George to overcome his disorder and be able to hold children without bringing back horrid memories (“Understanding PTSD Treatment”, 2011, p. 6-8).
Opposing Position While the VA feels that their screening methods and treatments for PTSD are effective, valid evidence and arguments show that improvements must be made to their practices to ensure a good quality of life for the men and women who have returned from overseas. The mental conditions that U.S. soldiers, sailors, airmen, and marines are suffering from because of traumatic exposures are serious and swift action from the VA needs to be taken. If military personnel risk their lives for our country, the least the VA can do is provide adequate services.
PTSD Can Lead to Suicide In some cases, suicide can be a result from mental health problems in soldiers returning from war. Suicide rates of Army personnel increased 80 percent between the years of 2007 and 2008. Also among 2007 and 2008, 255 soldiers committed suicide. Seventeen percent of those were diagnosed with a mental health problem and 50 percent of them reached out for help concerning their mental state (Bachynski et al., 2008). The amount of lives taken by suicide because of mental damage to military personnel is disturbing. It has been researched that anxiety disorders, such as PTSD, correlate to suicide among military personnel. Additionally, 113 members of the National Guard killed themselves in 2010. Suicide rates of veterans resulting from mental disorders are rapidly increasing and needs to halt. Since 2001, more than 2,500 members of active-duty have committed suicide (Thompson, 2011). This clearly shows that the VA does not perform good enough to successfully help soldiers with PTSD. If military members can survive through war, they have the ability to overcome PTSD, provided treatments are effective.
Primary Example of PTSD Affecting an Individual After a tour in Iraq, National Guard member, Matthew Magdzas, not only killed himself, but also his 26-year-old wife, April Magdzas, his one-year-old daughter, and undelivered baby scheduled for a caesarian section the following day. "None of us believed that anyone could ever suffer from PTSD bad enough to shoot your own 1-year-old baby," (as cited in Thompson, 2011, p.1) said Shawn Oles, April's older brother. It is absurd to think that a veteran can go through tremendous pain and not receive the proper care that he or she needs. Crystal Durm, Magdzas close friend from high school, said that Magdzas repeatedly talked about the VA. Durm claims that Magdzas said: "They pretty much sit me in the room, and they make me rehash only the things that happened in the war… I'm having worse nightmares that don't go away. They're not helping me get over it. They just listen to my stories and send me out the door" (as cited in Thompson, 2011, p.4). Magdzas explained that the VA did not provide adequate care for him. His severe case of PTSD rapidly continued to worsen. It was stated that the VA noted Magdzas’ decline and reacted by supplying him with anti-depressants and regular counseling sessions. The VA did all they could do to help Magdzas and it simply was not enough; treatments were not effective and tragedy struck. Oles, who served as a Marine in 1990 for four years, explains, "I don't think our government and our country is doing all they can to help these guys when they come home" (as cited in Thompson, 2011, p.1). Oles is correct. With horrifying tragedies like Magdzas’ suicide and homicide, it is clear that the VA is not putting forth enough effort to cure veterans with PTSD.
Prevention is Not Developed by the VA Prevention of PTSD is rarely mentioned by the VA and not focused on. Additionally, the DOD does not show success in preventing this disorder. David S. Riggs argues: “Efforts to prevent chronic PTSD continue to fall short” (Riggs, Sermanian, 2012, p.14). If prevention efforts were made, the amount screening and treatment that is now necessary would minimize.
Screening Needs Improvement As stated above, the VA conducts screening after deployment to determine if one has symptoms of PTSD, but works by the VA do not include effective screening methods. To improve the wellbeing of our military personnel, progress must be made in screening that our veterans are receiving. The responsibility of screening should be to recognize if an individual has PTSD, to identify high-risk individuals, to detect symptoms early on, and to continue screening in order to catch late onset cases of PTSD. The VA has established the 4-Item Primary Care system for PTSD screening after military personnel return from deployment, but they have not developed it. Charles C. Engel states, “Although preclinical mental health screening programs exist for U.S forces returning from deployment, little is known about the relative risks and benefits of these mass screening programs in the military” (Engel et al., 2008, p.936). Familiarization and advancement of screening would improve the mental health of veterans. The screening method that is being used by the VA is not accurate. Simple yes and no questions do not make the cut. Riggs shares how screening should be developed. “Existing screening processes have problems and systematic research is needed to improve them… any effective screening effort will need to assess multiple factors and develop an algorithm that takes into account the results of multiple tests or indicators” (Riggs et al., 2012, p.18). Improvements to develop new screening methods will help define the severity of the diagnosis and how symptoms are affecting the veteran. It will also direct health care professionals to exact treatments that are specifically designed for the severity and symptoms of each individual case of PTSD to get veterans back up on their feet to enjoy life. Improvement of screening methods will save time and help the patient heal faster.
Pre-deployment Risk Assessment Screening Included in screening methods, the DOD needs to offer pre-deployment risk assessments. Risk assessments identify individuals at high risk for PTSD who have not shown symptoms (Wisco, Marx, & Keane, 2012, p.7). Risk assessments are important to acquire an advanced notice on individuals who are at a high risk of developing mental disorders. Riggs explains factors that qualify one for a risk assessment. “Candidates for pre-deployment screening include biologically based factors…psychological health characteristics, such as previous psychiatric diagnoses…and individual and family history factors, such as aversive childhood experiences and family history of psychopathology” (Riggs et al., 2012, p.15). This straightforward process would be easy for the DOD to implement into the Military and would help identify risks of PTSD in individuals early on to ensure a close eye is kept on them throughout deployment.
Consistent Screening Throughout Deployment is Necessary In addition to conducting pre-deployment risk assessments, screening must be regularly conducted throughout deployment to detect PTSD early on. Riggs explains that it would be helpful to have screening tests available at all times throughout the deployment, especially immediately following a traumatic event. “One clear need is an easily administered and accurate measure of risk that can be administered close to the time of the traumatic exposure so that treatment could start as soon as possible” (Riggs et al., 2012 p.16). If soldiers were screened throughout their deployment, cases of PTSD would be caught early on and action to treat PTSD could be immediately started. William P. Nash shares, “Recommended interventions within the first four days after a potentially traumatic event include attending to safety and basic needs and providing access to physical, emotional, and social resources” (Nash, & Watson, 2012, p.637). Treatment within the first four days of the traumatic event is crucial towards the wellbeing, healing and recovery of the individual, but the screening necessary to recognize individuals with PTSD symptoms within days of exposure to traumatic events is not offered by the DOD. Garske makes it clear that significant amounts of veterans returning from OIF and OEF are seeking help. “Roughly 29% of the veterans returning from Operation Iraqi Freedom and Operation Enduring Freedom have already enrolled in VA healthcare, a historically high rate compared with 10% of Vietnam Veterans” (Garske, 2011, p. 31). This shows that without screening throughout deployment to help catch and treat cases early, the development of this disorder, among other health issues, have built up in military personnel. The DOD is responsible for the mental health of military personnel throughout deployment and therefore needs to take better care of their soldiers, sailors, marines, and airmen by implementing screening during deployments.
Screening Must Continue After Deployment Along with consistent screening throughout deployment, screening must extend beyond deployment. Because of the prolonged start for some cases of PTSD, a onetime screening once military personnel arrive back from overseas does not catch all cases of PTSD, leaving a handful of soldiers distraught. New York Senator, Kristen Gillibrand, brought the need of post deployment screening to the attention of Assistant Secretary of Health Affairs, Charles Rice: I urge you to consider the possibility of implementing a second assessment six or twelve months after a service members return. This would ensure that our returning soldiers, sailors, airmen and marines who have experienced trauma in their service, but whose symptoms may not have developed until after their return would still be captured by screening, and provide an opportunity for these men and women to receive appropriate treatment and care for their mental health wounds. (Gillbrand, 2012, para.15)
As many veterans notified Senator Gillbrand that a one-time screening was not adequate, the addition of this service would benefit the members of the armed forces who acquire late onset PTSD.
Necessary Advancements in Treatments of PTSD Furthermore, not only does screening need to improve, but advances in treatments need further progression. Nina A. Sayer, conducted a study with several partners. This study consisted of 40 interviews from VA health care providers from the United States who specialize in PTSD services. From these interviews it was concluded that, “Providers reported that OIF/OEF veterans returning with war-related TBI, PTSD, and other comorbidities present challenges for the VA’s existing care structures and treatment approaches” (Sayer et al., 2009, p. 713). This indicates that the care being provided for veterans is not affective for the population of veterans returning from Iraq and Afghanistan. The treatment needs to be improved to treat victims of OIF and OEF along with affectively treating veterans from previous wars, such as the Vietnam War.
Education is the First Step to Improvement of Treatment Improvement in treatments begins with education. Creamer illuminates, “We still have much to learn about prevention, early identification, and effective treatment of this disabling condition on our service personnel” (Creamer et al., 2011, p.164). We need continuous strides in research to fully understand this disorder. Right now we are unaware of many aspects of this disorder such as understanding how to approach it and how to individualize treatments to benefit specific cases of PTSD. With healthcare professionals unable to completely understand the disorder themselves, it is difficult for them to help those affected by the disorder. In addition to further education of health care providers, the DOD needs to educate soldiers, sailors, airmen, and marines on all aspects of posttraumatic stress disorder. Before deployment, they need to understand PTSD. At minimum, they should understand the disorder be able to recognize symptoms in themselves and their subordinates. Soldiers must also be informed where to get help while deployed and after deployment. Regularly familiarizing one on this topic would make it more comfortable to discuss and prevent cases of this traumatizing disorder. Knowledge about this disorder prior to deployment can significantly reduce the amount of soldiers returning with PTSD and minimize the severity of the disorder by early and self-recognition.
Prolonged Exposure Therapy Needs Improvement Also leading to the belief of positive results in PTSD treatment is the use of prolonged exposure therapy, The VA uses this type of therapy with the veterans and claim that it is effective. Evidence shows that exposure therapy does not remove PTSD symptoms completely. Through research, Garske explains, “Studies show that a considerable amount of PTSD patients, about 25% to 45%, still fulfill diagnostic criteria for PTSD at the end of treatment” (Garske, 2011, p.34). Though exposure therapy may lead to improvement in PTSD symptoms for some individuals, it does not recover all cases. After a veteran takes months to complete PE and shows little or no improvement, time is wasted, the quality of life remains inadequate, and veterans become frustrated with little hope to improve. Improvements in PE need to be made to increase the rate of success for PTSD victims or alternate treatments should be used.
Medication Used for Treatment Needs Improvement As mentioned before, medication is being used to help patients who suffer from PTSD. The two antidepressants that are U.S. Food and Drug approved for treatment of mental disorders are Zoloft and Paxil. These medications are intended to better the quality of life in PTSD patients, but SSRIs do not always work. “These drugs are very helpful for certain patients and not much helpful for others” (Garske, 2011, p.33). The consistency lacks in these drugs. The VA convinces patients that medication works to treat PTSD, but research shows that less than 50% of those who take medication to relieve PTSD symptoms actually show signs of improvement (Foa, Franklin, & Moser, 2002, p.992). That leaves more than half of the patients who take SSRIs without any improvement in their mental state. Treatment that will ensure all of our veterans are improving is necessary.
Suggestion for Possible Treatment Improvements After deployment, National Guard and reserve members of our armed forces return back home and meet once a month to drill and train. This becomes a problem when seeking help and treatment for PTSD because VA facilities are not always near or within a close commute their home. Fleming (2012) reflects upon a PTSD Treatment study and suggests that the VA should use technology and Internet based approaches towards PTSD treatment (para.2). This would improve treatment and may be a more comfortable way for military personnel to improve. Some may feel uncomfortable talking in person and discussing their problems to a complete stranger, but working it out by themselves with guidance from Internet and technological sources can lead to an effective treatment method. Additionally, this would allow everyone access to treatment if they are in a remote location.
Conclusion
Although the United States Department of Veterans Affairs and the United States Department of Defense believe their efforts to help members of the armed forces who are suffering from posttraumatic stress disorder are adequate, evidence shows the level of care is insufficient. Posttraumatic stress disorder seriously affects veterans every day. For example, Magdzas’ suicide and homicide case shows that the VA brought forth all possible efforts to help his condition, including several types of treatment, but they were unable to succeed, resulting in tragedy. Types of screening and treatment must be further developed to relieve soldiers from PTSD symptoms to live a normal and enjoyable life. In addition to the initial improvement of screening after returning from deployment, risk assessments, screening throughout deployments, and screening for six to twelve months after deployments must be implemented. Military members complete their job of protecting America; the VA and DOD need to do their job of providing affective screening and treatments. Based on research, Michael J. Roy summarizes, “Overall it appears that pharmacotherapy results have a response rate of 40-60% of patient, and non-pharmacological approaches are not appreciably better” (Roy, & Kraus, 2006, p.63). These rates of improvement are unacceptable. In support, Creamer (2011) agrees that development of effective screening and treatment of PTSD is necessary, “As long as we continue to send our young men and women to war, and to assist in humanitarian disasters, we must also continue to search for answers to this archetypical disorder” (164). Our armed forces are risking their lives to ensure that Americans live good lives, the least the VA and DOD can do for out veterans is provide an adequate quality of life once returning from war.
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