Post-traumatic stress disorder in the military: the need for legislative improvement of mental health care for veterans of Operation Iraqi Freedom and Operation Enduring Freedom.

• Author: McGrane, Madeline

1. INTRODUCTION II. OVERVIEW OF PTSD AND THE UNITED STATES MILITARY A. PTSD: Definition and Treatment B. Traumatic Brain Injury C. Problems Resulting from Undiagnosed PTSD D. Reasons PTSD is Frequently Undiagnosed E. Stumbling Blocks for Receiving Treatment: Denial of Coverage and Inadequate Health Care Facilities III. CONGRESSIONAL AND MILITARY SOLUTIONS A. The Joshua Omvig Veterans Suicide Prevention Act B. Other Acts C. Individual Programs Implemented by the Department of Defense and Individual Branches of the Military IV. PROPOSED LEGISLATIVE SOLUTIONS, BUDGETARY CONCERNS, AND INTERMEDIARY STATE ACTION A. Mandatory Mental Health Screening B. Increase the Number of Health Care Facilities and Professionals C. Reduce the Stigma Associated with PTSD through Outreach and Education E. Budgetary Concerns F. Proactive Solutions on the State Level 1. Veterans Treatment Courts 2. PTSD, the Insanity Plea and the Death Penalty VI. CONCLUSION I. INTRODUCTION

   Sergeant Christian E. Bueno-Galdos came to the United States with his family in 1992. (1) He was seven when he began life in the United States, but it was not until he joined the Army that he became a United States citizen. (2) Bueno-Galdos loved being in the army and re-signed to complete a second tour of duty after returning home from his first tour in Iraq. (3) Though married, Bueno-Galdos also supported his parents with his military paycheck. (4) Tragically, Sergeant Bueno-Galdos arrived home on a 747, dead at the age of twenty-five; his coffin was draped with an American flag. (5) Four more soldiers died that same day on May 11, 2009. (6)

   Also on that day, during Sergeant John M. Russell's third tour of duty, Sergeant Russell snapped. (7) Walking into a stress clinic at Camp Liberty in Baghdad, Russell took the lives of five American soldiers, including that of Bueno-Galdos. (8) One week prior to the tragic shooting, Russell had been referred to counseling and his weapon had been taken away. (9) His actions are described as "the single deadliest episode of soldier-on-soldier violence among American forces since the United States-led invasion" began in 2003. (10)

   Although the motive for Russell's attack remains unclear, the fact that he had been referred to counseling at the stress clinic suggests the attack was a result of a mental disorder. (11) Major General Daniel Bolgier told the media that mental health issues come with a "stigma" and "[n]ot all injuries are physical, and so you've got to have that door open for the guys ... it's particularly challenging for a fellow like Sgt. Russell." (12) Large numbers of military personnel suffer from Post-Traumatic Stress Disorder ("PTSD") which results in increased homicides and suicides committed by veterans. (13) In 2005, Congress proposed the Veterans Mental Health Services Enhancement Act ("Service Enhancement Act") to offer rigorous mental health treatment programs to veterans of both Operation Iraqi Freedom ("OIF") and Operation Enduring Freedom ("OEF"). (14) While the bill failed to pass Congress, the problem of mental health disorders for OIF and OEF veterans remains. To solve this problem, Congress should enact legislation, similar to the Service Enhancement Act and other proposed Acts, that have the following goals: I) reduce stigma surrounding PTSD; 2) lower the rates of suicides and homicides committed by veterans; and 3) assist veterans in diagnosing and treating PTSD. This legislation should increase the number of health care professionals and the efficacy of care, improve nationwide outreach and education, and implement mandatory mental health screening requirements.

   This Note argues that legislation requiring improved mental health treatment for veterans of OIF and OEF is necessary to protect American service members from the dangers of mental illness. In order to prevent crimes and suicides committed by veterans of OIF and OEF as a result of undiagnosed PTSD, the United States Congress should enact legislation imposing requirements on all branches of the military that: 1) mandates screening of all veterans at risk for PTSD upon their return from deployment; 2) ensures veterans are provided with adequate and timely mental healthcare; and 3) increases education and outreach regarding mental health disease as serious and legitimate battle wounds. Perhaps if Sgt. Russell had been subject to immediate screening upon returning from his first two tours of duty, instead of commencing counseling during his third tour, the lives of Sergeant Russell and the five men he killed would have been spared. Part II of this Note details the relationship between the military and PTSD. Part III describes efforts already made by Congress and the military in responding to the challenges presented by PTSD and veterans of OIF and OEF. In Part IV, this Note suggests policy solutions that will help to decrease the number of veterans who suffer from PTSD, and thus decrease the number of suicides and homicides committed by them. Part IV also addresses budget concerns for implementing such legislation, and offers statewide programs that will assist veterans in the alternative of the suggested legislation.

2. OVERVIEW OF PTSD AND THE UNITED STATES MILITARY

   The United States military is fighting two wars halfway across the world. Many service members are serving multiple tours of duty with little time at home in between. Physical war wounds are obviously identifiable, but mental wounds are difficult to spot and need special attention. PTSD is a mental war wound that is affecting the military in large numbers. (15) PTSD occurs after someone witnesses a stressful event involving severe injury or death and "causes feelings of extreme fear, helplessness, or horror." (16) Symptoms of PTSD arise after the stressful event, and can include "trouble sleeping ... nightmares or daytime memories of the event and feel[ing] emotionally numb and cut off from others." (17) From 2003 to 2009, the Military Health System recorded 39,365 cases of PTSD. (18) Because veterans of OIF and OEF are serving multiple tours of duty, they suffer from PTSD in greater numbers than veterans of any other war. (19)

   1. PTSD: Definition and Treatment

      Early diagnosis is essential to a successful treatment program for military members suffering from PTSD. The United States Department of Veterans Affairs ("VA") diagnoses PTSD using the American Psychiatric Association's ("APA") diagnostic criterion set forth in the fourth edition of its Diagnostic and Statistical Manual of Mental Disorders ("DSM-IV-TR"). (20) There are six criteria: 1) a stressor; 2) intrusive recollection; 3) avoidant/numbing; 4) hyper-arousal; 5) duration of the symptoms lasts more than one month; and 6) a functional significance, causing clinical disturbance or social, occupational or other impairment. (21) To satisfy the stressor requirement, the person must have been exposed to a traumatic event that dealt with death or serious injury to oneself or another, and the person's response must have "involved intense fear, helplessness, or horror." (22) The traumatic event must be re-experienced by either recurrent images or dreams. (23) These recurring images or dreams are marked by an intense psychological distress, generated by "cues" that resemble an aspect of the original event, or by physiological reaction to those same cues. (24) The third criterion is an avoidance of stimuli and numbing of responsiveness associated with the event. (25) Three of the following seven characteristics must be present to satisfy the avoidant/numbing criterion: 1) avoiding all "thoughts, feelings, and conversations associated with the trauma"; 2) avoiding all places, people, and activities that bring back recollections of the trauma; 3) an inability to remember "an important aspect of the trauma"; 4) a "diminished interest or participation in significant activities"; 5) experiencing feelings of "detachment or estrangement from others"; 6) "a restricted range of affects" such as being unable to have loving feelings; or 7) a lack of ability to sense any sort of future such as a career or family life. 26 Finally, to satisfy the requirement of hyper arousal, a person must experience at least two of the following: "I) difficulty falling or staying asleep; 2) irritability or outbursts of anger; 3) difficulty concentrating; 4) hyper-vigilance; or 5) an exaggerated startled response." (27) Fulfilling the preceding requirements can be difficult for soldiers as they are often unable to produce proof of their injuries and symptoms when seeking treatment from the VA. (28)

      Once diagnosed, a variety of treatments are available for PTSD ranging from therapy to medication. Studies show that the most effective types of psychotherapy are cognitive behavioral treatments and Eye Movement Desensitization and Reprocessing (EMDR). (29) Cognitive behavioral therapy helps a patient understand the traumatic event they witnessed and the stress caused by it. (30) With this therapy, a therapist helps the patient to identify the stress in his or her life caused by the traumatic event and to replace it with less distressing thoughts. (31) Patients learn to cope with the anger, fear, and guilt associated with a traumatic event, and most importantly for some soldiers, patients learn the stressful event was not their fault. (32) EMDR "is an integrative, comprehensive treatment approach that contains many elements of effective psychodynamic, cognitive-behavioral, experiential, interpersonal, and physiological therapies." (33) This type of therapy is relatively new and is used to help a patient react differently to memories of the traumatic event they experienced. (34) Exposure therapy is also used to treat PTSD. The goal of exposure therapy "is to have less fear about your memories. It is based on the idea that people learn to fear thoughts, feelings, and situations that remind them of a past traumatic event." (35) Exposure therapy requires...