Mired in 'Muddy Studies'

By Noel Koch

As a result, two “classes” of wounded have evolved:

• Those with physical damage that can be seen, understood, and repaired

• Those with “invisible” damage to the brain, the psyche, and the soul

I spent a great deal of time in the execution of my responsibilities for wounded, ill, and injured warriors simply being with these individuals and their families. The most heartening and amazing engagements invariably were with those young soldiers who had suffered physical impairment—the more severe, the more amazing. There are, to be sure, long, intensely painful, and frustrating steps along the way from, say, the loss of a limb to getting past that loss through acceptance and rehabilitation. But for most who suffer physical damage there is an end point and, for that reason, hope.

That hope is the ineffable quality that infuses the atmosphere in the workout rooms of military treatment facilities where young warrior/athletes bounce about enjoying and showing off their restored dexterities.

The Wounds Within

There are others, however, watching from the sidelines as their physically wounded comrades defiantly fight their way back to capacity. They are individuals suffering some degree of traumatic brain injury, and many of them take no delight in these scenes of exuberance. On separate occasions I heard young men use, with bitter sincerity, the same words while watching their comrades: “I really hate those f---ing guys.”

Are such impulsive expressions of anger driven by envy and self-regard? Or do they stem from the impairment of judgment affecting social behavior that can result from traumatic brain injury? Or both? Either or both, the number of military personnel who suffer from traumatic brain injury greatly exceeds the number coping with physical wounds. (A RAND Corporation study in 2008 numbered the former at 320,000.) The most egregious distinction between the two is that quantum strides have been made—and continue to be—in dealing with the physical wounds.

One source sums it up this way: “The military’s awakening [to] the severity of the traumatic brain injury comes nine years after the flow of victims began. Critics such as Cheryl Lynch, founder of American Veterans With Brain Injuries, say the delayed response is nothing short of a dereliction that has left severely injured veterans suffering for years.” 2 If current studies are any indication, those same severely injured veterans will continue to suffer in the years to come, and their suffering may worsen.

Trying To Understand TBI

Authorities rank traumatic brain injuries as mild, moderate, or severe, with a mild TBI (mTBI) being a concussion and heretofore a matter of lesser concern than the higher-ranked TBIs. 3 Now it appears mTBI is cause for greater concern than first believed. [See “TBI Is Not Just Concussion,” p. 78] A study published by the New England Journal of Medicine (NEJM) concedes that “little is known about the nature of these ‘mild’ injuries, and the relationship between traumatic brain injury and outcomes remains controversial.” The abstract of the study begins: “Blast-related traumatic brain injuries have been common in the Iraq and Afghanistan wars, but fundamental questions about the nature of these injuries remain unanswered.” The study, conducted in collaboration with Landstuhl Regional Medical Center, was published June 2011. 4

Traumatic brain injuries are evaluated using standard computed tomography (CT) scans. Where circumstances permit, a magnetic resonance imaging (MRI) scan may be used. 5 The NEJM study employed an advanced MRI technology called diffusion tensor imaging (DTI). It discovered that blast victims clinically diagnosed as having mTBIs actually had brain damage that had not been detected by CT or MRI scans. Further to this discovery, the study noted that “Follow-up DTI scans in subjects with traumatic brain injury 6 to 12 months after enrollment showed persistent abnormalities that were consistent with evolving injuries.” In other words, the blast effects were dynamic: the victims’ conditions were worsening.

This study suggests progress, however belated, in the effort to deal with traumatic brain injury, but that would be an overly optimistic conclusion. In a news article discussing the study, Katherine Helmick, the deputy director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury is quoted as wishing the study might “help us understand what blast is doing to the brain, and help us get what we really want in diagnosing traumatic brain injury, which is objective markers.” 6 So, not much progress after all.

And apparently not much coordination of effort either. Less than two weeks earlier doctors at Fort Campbell, Kentucky, were reported using a different scanning technology called single-photon emission computed tomography (SPECT) since 2010 to identify brain damage not detected by standard CT scans. The Army officer in charge of this effort, Major Andrew Fong, is quoted as saying the technology is underused in the military, with Fort Campbell being one of only two military treatment facilities using it. 7

Studies in Ambiguity

Meanwhile, as the search for an agreed-upon methodology for determining the medical consequences of traumatic brain injury goes on, so does the search for ways to mitigate the behavioral consequences of TBI as well as other behaviors, e.g. excessive risk-taking, depression, suicide, whose associations with military life are problematical. This search is led by the military services, chiefly the Army, and it also relies on studies. The results themselves often appear to be a study in cognitive dissonance.

The common thread linking these studies mirrors that characterizing the search for answers to TBI, i.e., by the time they produce results, assuming they ever do, the problems they are studying will have been adversely transformed by the passing of time. Along the way, findings and characterizations of findings contribute to further confusion.

Joint Mental Health Advisory Team 7 (J-MHAT-7) surveyed Army and Marine maneuver units in Afghanistan in 2010 and reported its findings in February 2011. These were striking, pointing to a “significant decline” in morale and “significantly higher” acute stress rates (baselines in both cases being 2009 and 2005). 8

Regarding the effects of multiple deployments: “Soldiers on their third/fourth deployment report significantly more psychological problems and use of mental health medications than Soldiers on their first or second deployment”; “Marines on three or more deployments report lower morale than those on first deployment. Multiple deploying Marines also show increased psychological problems.”

The correlation between multiple deployments and adverse outcomes ranging from divorce to suicide is difficult to establish statistically. Anecdotally, however, support for the link accumulates weekly in media accounts of military suicides and homicides. One of the factors complicating analysis of multiple deployments as a contributor to adverse outcomes is the role of circumstantial and environmental change over time.

Missing the Forest for the Trees

The continuum on which repeated deployments accumulate also includes other events. Change in the recruiting demographic is such an event.

From roughly 2005 to 2007, when a strong economy sent potential soldiers looking elsewhere for jobs with better pay, the Army lowered its recruiting and retention standards to meet the demands of two wars. As a result . . . tens of thousands of recruits were granted waivers for the kind of behavior, including felonies, that would have kept them out of the service in earlier years. 9

The preceding is drawn from a 350-page, 15-month study by the Army that attempts to tie suicides to leaders so preoccupied with preparing the force for combat that they are ignoring disciplinary problems such as drug abuse and criminal behavior. 10 This tautological argument is curiously self-exculpating, viz. “we are working so hard fighting a war that we are missing the problems associated with fighting a war.”

While reports from the field such as J-MHAT-7 affirm the connection between multiple deployments and “significantly more psychological problems,” the Army study torturously links suicides to preoccupied leaders and ill-behaved soldiers rather than to those greater psychological problems found to result from multiple deployments (and their concomitant: limited dwell times). Putting the “preoccupied leadership” argument to further dubious use, the study declares that “enforcement of policies designated to ensure good order and discipline has atrophied. This, in turn, has led to an increasing population of soldiers who display high risk behavior which erodes the health of the force.” So, it is poor leadership rather than the recruitment and retention of poor soldiers that is to blame for “the health of the force” (the latter being a euphemism for the high suicide rate). 11

The Army recognizes drug use as high-risk behavior, and it is indisputable that some of this has been “imported” through reduced recruiting standards. But that misstep accounts for only a portion, and almost certainly a lesser portion, of the problem. In other wars, Vietnam being the first of note, the enemy was the drug provider. This time, it’s us. Repeatedly, as I visited Warrior Transition Units and Military Treatment Facilities, I confronted people who were so heavily medicated they were barely communicative. An article subtitled “Distressed Combat Veterans and Handfuls of Prescription Drugs” notes that “psychiatric drugs have been used more widely across the military than in any previous war [and] those medications, along with narcotic painkillers, are being increasingly linked to a rising tide of other problems, among them drug dependency, suicide, and fatal accidents.” 12

The Army study suggests internal uncertainty over how to deal with a self-generated problem, e.g., “As we continue to wage war on several fronts, data would suggest we are becoming more dependent on pharmaceuticals to sustain the force. In fact, anecdotal information suggests that the force is becoming increasingly dependent on both legal and illegal drugs.” Yet, following that acknowledgment, the report comes back to its central thesis, that this is a leadership problem: “Serial drug abuse contradicts Army values. The large number of soldiers with three or more positive drug tests demonstrates that the Army by its inattention [emphasis added] is condoning high risk behavior. . . . One should question the readiness and fitness of a soldier who has been identified as a serial abuser.”

General Peter Chiarelli, the Army’s vice chief of staff suggests that these people should be put out of the service. Apart from the issues that might arise from the Army discharging its drug problem into the civilian sector, the effect such discharges would have on the morale and readiness of the force must be considered. Soldiers in the field are regularly prescribed drugs for battle stress, and to help them get up and back in the fight. Authorities might be hard put to distinguish between those and “serial abusers.”

The Alarm Has Been Sounded

But in fact this is neither a failure of leadership nor, in the first instance, bad behavior by soldiers. It is a result chiefly of a shortage of medical manpower. The limited number of therapists available to help service members deal with stress-induced problems forces doctors to rely instead on medication. Moreover, “given the depth of the medical problems facing combat veterans, as well as the medical system’s heavy reliance on drugs, few experts expect the widespread use of multiple medications to decline significantly anytime soon.” 13

If there are reasons for hope in the studies and reports being piled up against the problem of mTBI and all the behavioral health issues associated with it, with the best will in the world it is difficult to find them. It may be argued that the research referred to here is far too limited to justify pessimism about the prospects for a breakthrough in the search for a “cure” for traumatic brain injury, and that may be so. At this point, however, the literature does not appear to encourage optimism. Anyone who can contradict that conclusion with objective evidence will be welcomed by sufferers and those who care for them.

There is no way now to know whether earlier attention to TBI might have produced mitigating measures in the areas of prevention or extenuation. What can be said is that we are starting late, and in doing so have already catalogued hundreds of thousands of victims. There is one more study worth noting. It falls, like so many others, into the category of a “muddy study,” one that explains in elaborate detail that we are in the swamp—and it may even tell us how we got there. It just doesn’t tell us how to get out. But this particular study does have the virtue of sounding the proverbial “fire bell in the night.”

It was reported on 18 July at the Alzheimer’s Association International Conference in Paris. 14 It concurred with the studies cited here, which found that mild traumatic brain injury was not “mild” in the sense that it did not compare with moderate or severe TBI as a producer of significant pathologies. The study is characterized as the most expansive veteran-focused look at brain injury ever carried out. It looked at veterans at least 55 years of age. Of the 281,540 medical records studied, 4,902 had suffered a traumatic brain injury of some severity, including concussion or mTBI. None of the veterans had been diagnosed with dementia at the outset of the study.

Over the life of that study “more than 15 percent of those who had suffered a brain injury were diagnosed with dementia versus only 7 percent of the others (i.e., those who had not suffered any type of brain injury)—a more than doubled risk. Severity of the injury made no difference in the odds of developing dementia. ” [Emphasis added.]

If we take the study’s 4,902 veterans who had suffered a TBI, and whose incidence of dementia is more than double that of the general population, and we match that with the approximately 320,000 TBI victims in the RAND estimate, we have a rough approximation of the magnitude of the wave of behavioral problems that will confront our nation generally and our veterans and their families specifically in the years to come. 15 On precedent we can expect those problems to include homelessness, substance abuse (exacerbated by soldiers having been weaned onto drugs during their service), broken families, depression, and suicide. (The high incidence of suicide troubling the Army today includes soldiers on active duty, not veterans.)

A Less-Than-Optimistic Diagnosis

Is there a ray of light anywhere in the perceived darkness ahead? It is difficult to find one. There certainly is none in the state of the nation’s economy and general acceptance that spending must be curtailed. That point was made in a New York Times article of 28 July 2011, “Cost of Treating Veterans Will Rise Long Past Wars.” It notes that the Department of Veterans Affairs likely will have to make do without budget increases and that “new research into things like traumatic brain injury” will suffer.

The studies will keep coming. The latest, in the Journal of the American Medical Association on 3 August, announced that an antipsychotic drug brand-named Risperdal, used to treat victims of post-traumatic stress (PTS), doesn’t work. Risperdal is part of a family of powerful antipsychotics approved only for schizophrenia, bi-polar disorder, and complications associated with autism. The Food and Drug Administration did not approve it for use with PTS sufferers. Nevertheless, it has been widely administered “off-label” (i.e., put to a use for which it is not approved) for years, its effectiveness being assumed “because it was so widely [used].”

In 2009, more than 85,000 veterans diagnosed with PTS were administered an antipsychotic like Risperdal. When the value of Risperdal was tested against a placebo, it was found those taking the placebo fared better. Those on Risperdal experienced weight gain, fatigue, and sleepiness. 16

The conclusion? “These findings should stimulate careful review of the benefits of these medications in patients with chronic PTSD” (post-traumatic stress disorder).

The next to look for will be a $50 million joint Army-National Institutes of Health five-year “Study to Assess Risk and Resilience of Service Members.” In addition to suicide, it is targeting depression, anxiety disorders, and PTSD. It is due in 2013. It will be instructive to see if it validates the finding in the Army’s 2010 study that bad leadership is responsible for the high number of suicides.



1. The post-conflict medical issues flowing from the Iraq-Afghanistan conflicts are complex and significant. It is not the author’s intention to address the spectrum of these issues. The rate of co-morbidity between traumatic brain injury (TBI) and post-traumatic stress (PTS) is one of the deferred complexities. See, for example, Murray B. Stein and Thomas W. McAllister, “Exploring the Convergence of Posttraumatic Stress Disorder and Mild Traumatic Brain Injury,” American Journal of Psychiatry , 15 May 2009.

2. The Washington Post , “It Changes Who We Are,” 3 October 2010.

3. There does not appear to be a solid consensus attending these definitions. Mild, moderate, and severe will serve for present purposes.

4. Christine L. Mac Donald, et al, “Detection of Blast-Related Traumatic Brain Injury in U.S. Military Personnel,” New England Journal of Medicine , 2 June 2011.

5. MRI cannot be used where the victim’s wound may contain metallic shrapnel.

6. The New York Times , “Advanced Scans Reveal Veterans’ Brain Injuries,” 2 June 2011

7. The Philadelphia Inquirer , “Army tries new scans to find damage to brain,” 24 May 2011.

8. These were for the Army; findings for the Marines were comparable.

9. The New York Times , “Army Studies Thrill-Seeking in Its Ranks,” 31 October 2010.

10. “Health Promotion, Risk Reduction, and Suicide Prevention Report,” U.S. Army, 30 July 2010.

11. Unless one follows these arguments closely it is easy to miss the nexus between multiple deployments and the reduced recruiting standards that brought drug addicts and felons into the force. That nexus is the All Volunteer Military.

12. The New York Times , “A Deadly Mixture,” 13 February 2011.

13. Ibid.

14. Associated Press, “Brain injury raises dementia risk, US study finds,” 19 July 2011.

15. The RAND figure is now three years old; the number has to have increased substantially in the interval.

16. In an unrelated study, researchers found a high use of antipsychotic drugs with elderly nursing home residents suffering from dementia, despite such use not being approved and an increased risk of death. The same government audit discovered the use of antipsychotics was driven by kickbacks from pharmaceutical companies.

Mr. Koch served for 11 months as Deputy Under Secretary of Defense for Wounded Warrior Care and Transition Policy in the Obama administration. He also served as Principal Deputy Assistant Secretary of Defense for International Security Affairs, Deputy Assistant Secretary of Defense for Africa, and Director of Special Planning with responsibility for anti-terrorism and counter-terrorism as well as the restoration of special operations forces during the Reagan administration.
 

Mr. Koch served for 11 months as Deputy Under Secretary of Defense for Wounded Warrior Care and Transition Policy in the Obama administration. He also served as Principal Deputy Assistant Secretary of Defense for International Security Affairs, Deputy Assistant Secretary of Defense for Africa, and Director of Special Planning with responsibility for anti-terrorism and counter-terrorism as well as the restoration of special operations forces during the Reagan administration.

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