The Shock of Sudden Violence

The shock of sudden violence is so severe it takes your breath away.

When it happens in a time and place where it is unexpected, it does more than just remind us that no one is immune to it.  It also reminds us how pervasive it is, how much it affects us all, and how important it is that we do something about it. 

In the summer of 1989, I imagined that sudden, random violence was something far removed from my hometown.  But I was about to learn differently.

An article in The Atlantichas just detailed the event, dredging up some quarter century old memories of a day that changed my community’s life.

I was running for Mayor of Middletown, Connecticut, at the time, and had reserved a booth at the city’s annual Sidewalk Sale in late July.  I was handing out yardsticks, asking for a vote “for government that measures up to your expectations.”

Suddenly, there was a commotion about a block north of where I was standing.  I noticed people running in two directions, both toward and away from the Woolworth’s store in the center of downtown. 

A young girl, randomly chosen, had been grabbed outside the store and then repeatedly stabbed by a 38 year old man.  She died on the spot.  Hundreds of people witnessed the event.

Over the next weeks and months, Middletown was in shock, just as other communities – Newtown, Aurora, Tucson, Blacksburg VA, Littleton CO, and others – have been shocked since.

The trauma in Middletown almost killed our downtown.  Its suddenness and randomness made everyone feel unsafe.  It killed much of our sense of community and personal safety.

The healing didn’t happen very quickly.

It took at least a decade or two of steady changes to the Main Street area for that to happen.  These changes were so significant that – with the exception of a few businesses, nonprofits, and restaurants that remain from that time – one would barely recognize the Middletown of twenty-five years ago in its vibrant downtown today.

The trauma to which Sandy Hook and other communities have been exposed is even greater. 

To appreciate fully the scale of the Sandy Hook tragedy, we must realize that because of it Newtown’s 27611 residents – who experienced zero murders in 2011 – may well have experienced the highest homicide rate in the nation in 2012.

The healing time will be long.  And, at some level, my limited personal experience in Middletown suggests that a community exposed to that level of violence may never fully recover.

And this suggests something even more frightening about the shock of violence in communities across the nation.

There were 14,612 murders in the United States in 2011.  That’s 4.7 homicides for every 100,000 people.

In Middletown, Newtown, and Blacksburg, the homicide rate was zero.  In Aurora, it was 3.  In Littleton, it was 5.  Even in Tucson, which lived through the shopping center massacre that year, it was under 10.

Murders are uncommon in these communities, contributing to their newsworthiness.

But elsewhere, the everyday shock and trauma of violence is so much more powerful.  And because it is so prevalent, media headlines cannot capture fully its true effect. 

The murder rate per thousand in Miami in 2011 was 17, in Philadelphia 21, in Jackson 30, in St. Louis 35, in Detroit 48, and New Orleans 58.

Here is another way to look at this.  The Aurora massacre this past summer will double Aurora’s homicide rate in 2012, by a factor of 3.6 per hundred thousand residents. 

The people of St. Louis collectively live through the trauma of an Aurora-level massacre an average of once every six weeks, the people of Detroit live through it every month, and the people of New Orleans live through it every three weeks.  No one gets used to this.

If this is hard to absorb, imagine what these war zones must be like for the children and families living in them.  Every year, 3.5% of adults have diagnosable PTSD, and almost 8% will have it at some point in their lives.  Half will have PTSD before they reach the age of 18.

What are we doing about the traumatic effect of all of this violence in all of our neighborhoods – including those where it is commonplace?  And, more importantly, what are we doing to prevent such violence in the first place?

Email Paul Gionfriddo at gionfriddopaul@gmail.com.  Follow Paul Gionfriddo on Twitter: @pgionfriddo.

Mental Disorders in the Armed Forces

“In 2011, mental disorders accounted for more hospitalizations of U.S. service members than any other diagnostic category.” – Armed Forces Health Surveillance Center Medical Surveillance Monthly Report, June 2012

Recently, my daughter Elizabeth told me about a friend who stopped in to see her at the mall where she works while attending college.  Like her, he’s in his early twenties.  They worked together at a toy store a few years ago, and she hadn’t seen him since then.

He had enlisted in the army.  He was deployed overseas twice, and served a tour in a war zone.  He sustained a minor physical injury, now healed, while serving.

She said that he seemed a little down in the dumps when she saw him.  He told her that he is having trouble with his relationships since his return, but doesn’t think there’s anything wrong with him.  He’s pretty sure he doesn’t have PTSD, and sees no reason to seek counseling or other mental health supports.

Instead, he mostly keeps to himself and drinks a little more than he thinks he should.

Elizabeth is concerned about him, and should be.

Nearly one million (936,283 to be exact) active duty service members were diagnosed with at least one mental disorder from 2000 to 2011.

And, according to the most recent Armed Forces Health Surveillance Center Medical Surveillance Monthly Report, both the numbers and rates of service members diagnosed with mental disorders increased by 65% during the same period.

These just count active duty military personnel who are diagnosed with a mental disorder.  They don’t include either veterans or the young people who – like Elizabeth’s friend – have no formal diagnosis.

Mental disorders now account for more hospitalizations among U.S. service members than any other diagnostic category.  Suicide is the second leading cause of death among active service members (behind combat injuries), and mental disorders are the third most common reason for ambulatory care visits, behind musculoskeletal disorders and routine health care.  

Between 2003 and 2011, the rates of certain mental disorders with a significant environmental component soared as our involvement in Iraq and Afghanistan deepened.

• The rates of depression and adjustment disorders doubled.
• The anxiety rate tripled.
• The PTSD rate went up six-fold.

On the other hand, the combined rate of alcohol and substance abuse and dependence remained nearly the same (alcohol dependence was lower; other substance dependence was higher), as did the rates of schizophrenia and other psychoses. 

Just as worrisome is that the rates of the more environmentally-influenced mental disorders have not gone down as we’ve wound down our combat roles.  Between 2009 and 2011:

• The depression rate was about the same.
• The rate of adjustment disorders was 10% greater.
• The PTSD rate was 12% greater.
• The anxiety rate was 23% greater.

The surveillance report noted that all these numbers should be viewed in a broader context – that one in two adults will meet the criteria for a mental disorder at some point in their lifetimes.

Here’s the problem with that comparison.  There are only about 3 million total OEF/OIF (Iraq and Afghanistan) veterans and active duty personnel combined.  So the “lifetime” prevalence of mental disorders among the still mostly young people in these groups is already at least 30% - and could already be much higher.

As Elizabeth pointed out, “If they don’t get help today, where will they be ten years from now?”

Good question. 

So what should we do?

For one thing, we need to beef up mental health services to both active duty personnel and veterans, including planning the transition to from military to civilian life much more carefully than we have done in the past. 

We might also consider a couple of prevention strategies.  Adjustment disorders are twice as common in active duty teenagers as in any other military age group.  If we were to increase the age of recruitment by a year or two, we could prevent a lot of these.  In addition, anxiety and depression both peak when active duty personnel are in their late twenties.  If we restricted multiple deployments and limited separation from growing families, we might curtail these, too.

We also need to improve adult mental health services in general.  There are still too many policy leaders who avoid tackling this problem by pretending that mental disorders are personality weaknesses. 

But when they effectively paint at least 30% of brave, young active duty military personnel and veterans with this sloppy old brush, the real weaknesses are the policymakers’—most notably their own denial of reality.  

You can read more about service gaps in meeting the needs of veterans by clicking on the names of each of the following columns: Answering the Call, Veterans and Mental Illness, Veterans Dazed Not Dazzled by Mental Health Care, and Iraq and Back.

Answering the Call

It is worth noting on this “traditional” Memorial Day of May 30^th that over 6,400 service people have lost their lives so far while fighting our two most recent wars.

Unless we put more money into health and mental health care, many thousands more will eventually lose their lives fighting the physical and mental effects of these wars.

This past weekend, we learned that 45% of returning Iraq and Afghanistan War veterans are seeking compensation for service-related injuries. 

The challenge of finding the billions of dollars needed to treat these men and women will test us as a nation. 

It will likely stoke the fires of yet another protracted battle about “public option” health care in America.

This fight is about to take place because of two reasons.

The first is that the percentage of veterans seeking compensation is twice what it was in past wars.  “Invisible” injuries with behavioral manifestations, like PTSD and traumatic brain injury, account for much of the difference.

The second is that the VA system has too little capacity to meet the needs of even the lower percentages of those who have survived past wars and made similar claims for assistance.

This usually means that we begin by denying the existence of injuries we don’t easily see. 

I remember a Memorial Day parade I attended when I was a youngster in Middletown, Connecticut.  Then, as it still does today, Middletown closed its mile-long Main Street to traffic as a collection of high school and middle school bands, children’s sports teams, public safety officers, public officials, and groups escorted war veterans past cheering crowds.

The particular parade I recall featured two of Middletown’s earliest returning Vietnam veterans.  I remember standing on the roof of a two-story building watching them as they rode in a convertible down the parade route.  They were impressive in their dress uniforms, waving to the crowd.  One, as I recall, had lost a leg in battle.  The other, an arm and an eye.

Their injuries were undeniable.

The thing about parades, though, is that once one float passes by, we always turn our heads to see what comes next. 

And with Vietnam veterans, what injuries came next weren’t always so easy to see.  Agent Orange affected thousands, addiction affected tens of thousands, and PTSD affected hundreds of thousands.  As a matter of public policy, we ignored all of these for years as the Vietnam War’s real death toll mounted. 

The ongoing lack of capacity to serve the health and mental health needs of veterans is an even bigger threat to the well-being of veterans today.

A March 2012 Gulf War Veterans’ Illnesses Task Force Report provided some recent, statistical insight into this.  It noted that of the over 500,000 service members who served in Operation Desert Shield, 152,126 filed successful service-connected disability claims.  But only half – 79,415 – received VA healthcare.  The same was true of the almost 600,000 Desert Storm service members.  165,596 filed successful service-connected disability claims, but only 87,612 received VA healthcare.

There are three times as many Iraq and Afghanistan veterans as there were Desert Shield or Desert Storm veterans.  By percentage, twice as many returning Iraq and Afghanistan service veterans are filing claims as did Gulf War-era veterans. 

Based on the current numbers of claims being filed, over 750,000 may ultimately file successful claims, and at least 400,000 already need treatment for mental illnesses.  The VA system has the capacity to provide health and mental health care to only a fraction of them.

These are wars for which most of the rest of us have been called on to make no sacrifice by public officials who dishonor the sacrifices of brave veterans when they cower in fear at the word “taxes.” 

This may seem harsh, but we were asked to pay no new taxes for these wars, in spite of the billions of dollars we spent on them and the thousands of lives we sacrificed.  Does that seem right?

We would say that we meant it when we honored the sacrifices of veterans – especially those who have died fighting our wars – when we flew our flags, visited our cemeteries, and attended our parades this week.

So here’s our choice.  Will we answer the call when asked to sacrifice more tax dollars for health and mental health care for all? 

Or will we turn our backs on our veterans once the parades have passed us by?

Veterans Dazed, Not Dazzled, By Mental Health Care

Nearly 2.1 million veterans received mental health care from the Veterans Administration between 2006 and 2010.  According to a Government Accountability Office report released in October, 1.2 million veterans received mental health treatment in 2010 alone.

Almost 30% of the 7.2 million veterans who received treatment from the VA received mental health treatment.  So did 38% of Iraq and Afghanistan (“OEF/OIF”) veterans.  Many more probably needed it. 

The GAO report shows how pervasive mental illness is among veterans, and how co-occurring mental illnesses overwhelm both veterans and their service delivery system.

Younger veterans and reservists are especially affected.

We now have over 22 million living American veterans, but only 4 million served during World War II or the Korean War.  Seven million served during the Vietnam War, and almost 6 million are OEF/OIF veterans. 

OEF/OIF veterans accounted for 12% of all those receiving VA mental health services in 2010, a three-fold increase in just five years.  The GAO said this was expected “because of the nature of OEF/OIF veterans’ military service – veterans of this era typically had intense and frequent deployments.” 

Another October 2011 report entitled Losing the Battle: The Challenge of Military Suicide quantifies the tragic effect of this.  We lost 33 active and reserve duty Army personnel to suicide in July 2011 alone, and veterans – less than 10% of our population – account for 20% of all suicides in America.

There are three reasons why we lose so many veterans to suicide.  They are

• Traumatic brain injury, resulting in disability;
• Chronic pain from bodily injury; and
• Post Traumatic Stress Disorder (PTSD).

PTSD is far and away the most significant of these reasons.  I wrote about this in an earlier column.  As both the GAO report and the chart accompanying this column show, nearly half of the veterans receiving VA mental health care in 2010 had PTSD.  Most had at least one other mental health diagnosis, too.

It is a national failure that we don’t do a better job of identifying suicide risk factors and intervening earlier.

VA screening protocols may be part of the reason.  The authors of Losing the Battle report that returning veterans have historically been discouraged from admitting to mental health problems as they fill out their post-deployment screening forms.  As a result, the GAO reports the VA now “requires veterans treated in primary care settings to be screened for mental health conditions such as PTSD, depression, substance abuse disorders, as well as a history of military sexual trauma.”

And it turns out that veterans are more dazed than dazzled by the mental health care they are offered.

They avoid it, the VA told the GAO, because of stigma, lack of understanding about available services, logistical challenges accessing health services, and concerns about the quality of VA care.

• Mental illnesses are stigmatizing largely because many people still believe that they are “behavioral” weaknesses, not serious and life-threatening diseases that can shorten life expectancy by 25 years.
• Many also believe that services are only for people who are severely mentally ill.  They avoid seeking care for fear they will be labeled “whiners” and “psychosomatics.”
• Veterans, reservists, and non-veterans have logistical challenges in accessing services.  The VA does not have a full complement of mental health providers.  At least those they have get paid.  Major insurance companies are cutting reimbursements to community mental health providers, so patients who find providers outside of the VA often can no longer afford the out-of-pocket cost.
• It is impossible to have a quality mental health care system unless non-mental health professionals don’t just screen for – but are trained in managing – mental illnesses.

A 2009 SAMSHA reportfound similar reasons given by the 5.1 million civilians who also reported unmet mental health needs.

We can begin to fix this if we do four things:

1. Commit a fraction of the resources we committed to the wars to fight the mental illnesses they have caused – in the VA and in the community, wherever veterans, reservists, and non-veterans receive services.
2. Increase training of primary and specialty care providers so they recognize, diagnose, manage, and refer patients with mental illnesses.
3. Make periodic mental health screening a part of wellness exams for everyone, starting with young children.
4. Insist that insurers honor the mental health parity mandate.

We remember the sacrifices of our veterans when we fly our flag.  We honor those sacrifices when we take care of the men and women who made them.

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Veterans and Mental Illness

On a sultry June morning in our national’s capital last Friday, I visited the Vietnam Veterans Memorial. 

Scores of people moved silently along the Wall, viewing the names of the men and women who died in that war.  Some stopped and took pictures.  One group of men about my age surrounded one name for a photo.  Two young women posed in front of another, perhaps a grandfather or great uncle they never got to meet.

It is always an incredibly moving experience to visit the Wall.  It treats each of the people it memorializes with respect. There is no rank among those honored.  Officer or enlisted, rich or poor, each is given equal space and weight.

It is a form of acknowledgement and respect for which many veterans still fight.

Brave Vietnam veterans returned from Southeast Asia to educate our nation about the effects of war and violence.

I didn’t know anything about Post Traumatic Stress Disorder when I entered the Connecticut Legislature in the late 1970s.  I had only vaguely heard of “shell shock” from which some World War I and II veterans suffered.  At that time, the condition, like the way we thought of other mental illnesses, suggested some sort of stigmatizing weakness inherent in the individual.
Vietnam veterans changed our thinking.

They knew that PTSD was a real mental illness caused by violence. 

It took courage and strength to deliver this message to a nation not ready to hear it.  We didn’t know then that the violence of war, the violence of neighborhoods and families, and the trauma of natural disasters cause this illness.

As a result of their advocacy, the National Vietnam Veterans’ Readjustment Study (NVVRS) was conducted in 1983.

It found that a startling 830,000 Vietnam Veterans (26%) reported symptoms of PTSD, and many thousands more had other mental illnesses, such as Depression.  As the National Center for PTSD summarizes, a re-analysis of the data twenty years later suggested that up to a staggering 80% of Vietnam veterans reported at least some symptoms related to PTSD.

The Persian Gulf War introduced a new illness, Gulf War Syndrome, to our lexicon.  It is characterized by both physical and mental health problems. Only 8% of Gulf War veterans have been diagnosed with PTSD, possibly because their exposure to violence was of shorter duration.  But nearly 38%, or 263,000, Gulf War veterans sought treatment from the VA alone for illnesses and chronic conditions, many related to Gulf War Syndrome.

According to the U.S. Department of Veterans Affairs, an estimated 10% to 18% of returning Iraq and Afghanistan War veterans have PTSD, and up to 25% will have Depression.

Mental illness is as devastating in veterans as it is in any population.  According to the National Coalition on Homeless Veterans, on any given night 107,000 veterans are homeless.  76% of these men and women have behavioral health illnesses.  140,000 are imprisoned.  Half of these have mental health problems.

While I was in Washington, I attended a dinner with my wife Pam and her colleagues at Mental Health America and its affiliates around the country, at the completion of their annual conference and before the ringing of their symbolic freedom bell, forged from the chains once worn by people locked in mental institutions.  The 2011 Clifford Beers Award winner, Dr. Patricia Deegan, a survivor of schizophrenia, spoke of the courage of those who refuse to give in to the diagnosis of serious mental illness and to let it define them.

The Vietnam veterans who lobbied me had such courage, and refused to let PTSD define them.

We have fought three seemingly endless ten-year-plus wars in the last fifty years, and another one which caused significant physical and mental damage to its participants.  Millions of veterans and their families have been affected by PTSD.

Thousands of others who have been exposed to violence, terrorism, and natural disasters also share this experience.  

This should teach us an important lesson.

Mental illness doesn’t cause violence, but exposure to violence causes mental illness.

One of the things I love most about America is that although we are so diverse, we share a common purpose.   

The people whose names are on our national monuments - Washington, Lincoln, and the 58,272 on the Wall – remind us that this common purpose involves an entitlement to life, liberty, and the pursuit of happiness.

June 27 is PTSD Awareness Day.  It is a good day to remind ourselves why the bells of freedom mean so much to us all, especially the 7% of all adult Americans with PTSD.

The people whose names are on that Wall are remembered for sacrificing to give the rest of us a safer, more secure life.  They would not have forgotten those who came home with mental illness.

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