Saturday, April 19, 2008

Invisible Wounds of War - Self-Inflicted

“Maybe you'll believe Rand Corp. The lifetime incidence for Major Depression is 20% in the general population. 20% in the Vet population is certainly an anomaly.”

So e-mailed a reader of Strong as an Ox etc.

Apparently he was reacting to something I wrote, possibly to my post debunking CBS’s fallacious report on an epidemic of military suicides, when I found that United States military members have a lower suicide rate than that of entire nations, and lower than the same sex, same age group of Americans.

Then there was the equally fraudulent study by the New York Times of a supposedly high veteran murder rate, which turned out to be far lower than the rates for most major United States cities.

I probably annoyed the reader with my smug certainty about how poorly these studies were constructed and supported. Drawing my attention to this Rand study of military depression is probably his way of rubbing my nose in the damages wrought by our military involvement in Iraq and Afghanistan.

The study the reader draws my attention to, Invisible Wounds of War, was produced by the Rand Corporation, and publicized by the National Alliance on Mental Illness (NAMI). Since I’m not a mental health professional, and since I’m not an actor and have never played a mental health expert (and therefore won’t be called to testify about mental health before a fawning Congress), I’m at a distinct disadvantage in reviewing the work of the highly credentialed preparers of this report.

Except I can draw on old adages, “When the only tool you have is a hammer, every problem looks like a nail.”

Also, “The certitude of the summary usually doesn’t reflect the ambiguities of the details.”

I just made up that last old adage.

As I look at this RAND study I am struck that it raises more questions than answers. For example, from its sample of 1,965 service members from 24 communities across the country, RAND concluded that 300,000 of the 1.6 million who have served in Iraq or Afghanistan report symptoms of post traumatic stress disorder or major depression.

Is reporting symptoms the same as having it?

Apparently NAMI thinks so.

Are the members in the 24 communities across the country representative of the 1.6 million that served in the war zone?

Did the millions who served during World War II, who experienced more dying, deprivation, suffering, and separation than our troops today, exhibit the same levels of depression and post traumatic stress disorder (PTSD)? If they did, where did they find the strength of character to become “The Greatest Generation”?

First, I need to put the findings in some sort of context. When I debunked the military suicides and murders studies, it was very easy and straightforward to establish their contexts: I was able to find many tables of suicide statistics by gender, age, and nationality, and murder rates by gender, age, and American city or locality. In both studies these provided objective and easily demonstrated proofs that the veteran suicide and murder rates were not only normal and expected for predominantly young American males, but were lower than their civilian counterparts and, for suicides, much lower than the rates for all sexes and all ages of entire countries – Japan, to name one of several.

What causes depression? Do we know? According to the prestigious Mayo Clinic, we don’t know specifically.

It's not known specifically what causes depression. As with many mental illnesses, it's thought that a variety of biochemical, genetic and environmental factors may cause depression:
Biochemical. Some evidence from high-tech imaging studies indicates that people with depression have physical changes in their brains. The significance of these changes is still uncertain but may eventually help pinpoint causes. The naturally occurring brain chemicals called neurotransmitters, which are linked to mood, also may play a role in depression. Hormonal imbalances also could be a culprit.
Genes. Some studies show that depression is more common in people whose biological family members also have the condition. Researchers are trying to find genes that may be involved in causing depression.
Environment. Environment is also thought to play a causal role in some way. Environmental causes are situations in your life that are difficult to cope with, such as the loss of a loved one, financial problems and high stress.

Although the precise cause of depression isn't known, researchers have identified certain factors that seem to increase the risk of developing or triggering depression, including:
Having other biological relatives with depression
Having family members who have taken their own life
Stressful life events, such as the death of a loved one
Having a depressed mood as a youngster
Illness, such as cancer, heart disease, Alzheimer's or HIV/AIDS
Long-term use of certain medications, such as some drugs used to control high blood pressure, sleeping pills or, occasionally, birth control pills
Certain personality traits, such as having low self-esteem and being overly dependent, self-critical or pessimistic
Alcohol, nicotine and drug abuse
Having recently given birth
Being in a lower socioeconomic group

What can depression be related to? Occupation, for one.

Among the 21 major occupational categories, the highest rates of experiencing a major depressive episode (MDE) among full-time workers aged 18 to 64 were found in the personal care and service occupations (10.8 percent) and the food preparation and serving related occupations (10.3 percent). The occupational categories with the lowest rates of past year MDE were engineering, architecture, and surveying (4.3 percent); life, physical, and social science (4.4 percent); and installation, maintenance, and repair (4.4 percent).

However, being unemployed was most depressing, and being fully employed least depressing.

Combined data from 2004 to 2006 indicate that the prevalence of past year MDE among adults aged 18 to 64 was higher among the unemployed and those of "Other" employment status than among persons employed part time or full time. Among adults aged 18 to 64, an estimated 12.7 percent of those who were unemployed and 12.7 percent of those in the "Other" group experienced an MDE in the past year compared with 9.3 percent of those employed part time and 7.0 percent of those employed full time.

Do all of these studies diagnose depression the same way?

The study cited above uses the definition in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), which specifies a period of 2 weeks or longer during which there is either depressed mood or loss of interest or pleasure and at least four other symptoms that reflect a change in functioning, including problems with sleep, eating, energy, concentration, and self-image.

Does depression persist when factors change, such as leaving a stressful environment like a war zone?

I’ve looked at expert information about depression, and have come away with the impression that there are many factors causing and involved in it, and of course there are varying degrees of depression.

The Rand Corporation appears to be breaking new ground with this study. To me that means it should be taken with a grain of salt.

In the first analysis of its kind, researchers estimate that post traumatic stress disorder (PTSD) and depression among returning service members will cost the nation as much as $6.2 billion in the two years following deployment — an amount that includes both direct medical care and costs for lost productivity and suicide. Investing in more high-quality treatment could save close to $2 billion within two years by substantially reducing those indirect costs, the 500-page study concludes.

The RAND study contains estimates that state the high end of expected costs, and the high end of expected benefits. I think there is probably a big difference between “could save close to $2 billion in two years” and what it “would save in two years.”

The RAND study estimates the societal costs of PTSD and major depression for two years after deployment range from about $6,000 to more than $25,000 per case. Depending whether the economic cost of suicide is included, the RAND study estimates the total society costs of the conditions for two years range from $4 billion to $6.2 billion.

Apparently the cost of suicides is about $1.1 billion per year for the Iraqi and Afghanistan veteran group (using the RAND numbers above gives $6.2 billion minus $4 billion divided by two years equals $1.1 billion).

According to CBS News, the veteran suicide rate is 19 per 100,000 per year, while the active military suicide rate is 11 per 100,000 per year. Instead of an “epidemic of veteran suicides” as reported by CBS News and Perky Katie Couric, veterans match the rate for same-age males; the suicide rate among active military is about half of the general population rate; forty nations have higher male suicide rates than our veterans; and the overall veterans’ rate of 19 is the same or lower than the rate for BOTH SEXES in Japan (24.0), Belgium (21.1), Finland (20.3), Cuba (18.3), and France, Austria, Korea, and Switzerland.

The question then becomes, so where is the $2 billion in savings coming from? If exposure is causing depression in veterans of war, resulting in increased suicides, then why doesn’t the veteran suicide rate show that? If such exposure is causing suicides in the active military, why is their suicide rate half that of same-age civilian males?

According to the numbers, there would be about 240 suicides per year from amongst the 1.6 million veterans exposed to war. If the 1.6 million were predominantly young males who had never served in the military, there would be about 304 suicides, or 64 more per year. If we made a comparison to 1.6 million Frenchmen of all ages (including children), there would be 440 suicides, or 200 more per year.

At this point I’m left wondering what was the point of this study? War is traumatic. Many terrible things happen. Our diagnoses and treatments of mental problems among military members is not perfect. However, based on the numbers I have seen, it is probably better than the mental health services that most Americans, and from the suicide statistics, most foreign citizens receive.

I question the methods and conclusions, particularly if the bottom line is, as it appears to be, that reporting symptoms of depression resulted in the military member being classified as if diagnosed with depression. From that point projections of mental health care costs and indirect costs from lower productivity and suicides were calculated, and from the same spurious information savings were projected.

And above and beyond all else, there are ample statistics from over five years of fighting that would indicate whether or not the expected problems were appearing and being identified.

I’m not denying that our military members have suffered, and some have problems. Combat fatigue has been noted in many wars in many places. When we invaded Iwo Jima, over 21,000 Japanese and 6,800 Americans – more than in five years of combat in Iraq and Afghanistan - died in a month in 1945. A few months before, 135,000 Germans perished in the firestorms resulting from three days of fierce Allied aerial bombardment. After all that, and a lot more, America, Germany, Japan, and Britain gave the world half a century of the high achievement and progress.

Now we have RAND going where more and more are going.

Imagined problems, imagined solutions, imagined costs, imagined savings.

It’s a virtual study in a virtual world.

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