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Let’s Not Forget Older Veterans

Wilbur Cohen’s account of his post-war suffering in Arthur Kleinman’s wonderful book, What Really Matters1 begins with the following: “The war. It’s what happened to me in the war. I could never get over it. But I learned to live with it. Then all of a sudden on my sixtieth birthday it became a terrible weight. I couldn’t put it out of mind. I feel so very depressed about it. Sometimes I sit for hours, brooding over the past.”

Mr. Cohen had been in hand-to-hand combat in the Pacific theatre in World War II. After the war he had gone to college, become financially successful, and raised a family. Only after he had fulfilled his responsibilities as an adult did his profound sense of horror about the war return. Was it because he had time now to relive the past? Was it a symptom of major depressive disorder? Was it the recurrence of post-traumatic stress disorder? Was it because his cognitive abilities were on the decline and he could no longer hold off what he had kept buried in his unconscious for nearly 40 years? Whatever the cause, Mr. Cohen’s experience as he aged is not unique.

For many veterans, old psychic wounds re-emerge as they age. But, older veterans with mental health needs have not received nearly as much attention as the men and women who have been deployed in the wars in Iraq and Afghanistan and returned with mental disorders.

This is entirely understandable. Veterans of our nation’s current wars often suffer terribly and deserve all the support that our nation can muster.

But the fact of the matter is that veterans of these recent wars make up only 10-15% of our nation’s veterans. Currently, over 50% of veterans are 60 or older, and about 45% are 65 or older. Unfortunately, they too are a higher risk than the general population for mental disorders—including post-traumatic stress disorder (PTSD), which can continue for years or can re-occur in old age.

It is not my intention to pit veterans of prior periods of history against the veterans of the recent wars. But it is important to acknowledge that veterans of past periods also deserve our nation’s concern. Here are some key facts:

  • The Department of Veterans’ Affairs (VA) projects that the current age distribution of veterans—roughly 45% aged 65 or over and roughly 55% 60 or older—will continue at least until 2035. During this period there will be a decline in the proportion of veterans from World War II and the Korean Conflict, but a very substantial increase in the proportion who are Vietnam veterans.2
  • Most Vietnam Veterans are part of the elder boom now occurring in the United States and are affected by the mental health challenges that confront that generation. It is likely, however, that they have a higher prevalence of major depressive disorder, anxiety disorders such as PTSD, and even dementia than those who did not serve in the military. For example:
  • “According to the VA’s National Registry for Depression, 11% of Veterans aged 65 years and older have a diagnosis of major depressive disorder, a rate more than twice that found in the general population of adults aged 65 and older.”3
  • Nearly 40 percent of Veterans age 60 and over in treatment for depression also have a diagnosis of PTSD.4
  • 12% of older veterans getting primary physical health care had symptoms of PTSD, according to a recent study.5
  • “A study of Vietnam vets 20 years after the conflict found that a quarter of vets who served in Vietnam still had full or partial PTSD.”6
  • In 2011, “more than 476,000 veterans received treatment for PTSD from VA hospitals and clinics, up dramatically from about 272,000 in 2006. Iraq and Afghanistan veterans make up a large portion of that increase but still account for only about one-fifth of all PTSD patients. More than half of the new cases come from earlier wars.”7 (Emphasis added.)
  • Aging veterans also face heightened risk of co-occurring mental and physical disorders. Obesity and high cholesterol, diabetes, and side effects of psychotropic medication are more common in individuals suffering from depression and PTSD, as are substance misuse, smoking, and poor health.8
  • Older veterans are at high risk for suicide. It appears that older veterans complete suicide 50% more frequently than people of the same age who are not veterans.9 A recent report claimed that in California, World War II-era veterans are taking their own lives at a rate that’s nearly four times higher than that of people the same age with no military service.10
  • Although the prevalence of dementia among veterans is roughly the same as that of the general population,11 the prevalence of dementia among veterans who have had PTSD may be as much as double the prevalence among those who have not had PTSD.12, 13, 14 It is unclear whether PTSD contributes to the development of dementia or if late onset PTSD is a consequence of dementia.
  • Like all people disabled by dementia, veterans rely heavily on family members for care and support. And, like all family caregivers, caregivers of veterans with dementia experience are at high risk of social isolation, depression, and anxiety.15

In addition to being at risk for diagnosable mental disorders, older veterans are risk for Late-Onset Stress Symptomatology (LOSS). According to the National Center on PTSD, “Many older Veterans have functioned well since their military experience. Then later in life, they begin to think more or become more emotional about their wartime experience. This process can trigger LOSS. People with LOSS might live most of their lives relatively well. … Then they begin to confront normal age-related changes such as retirement, loss of loved ones, and increased health problems. As they go through these stresses, they may start to have more feelings and thoughts about their military experiences.”16

Treatment Works—When Used

Treatment of depression and other affective disorders as well as of anxiety disorders, including PTSD, is often effective. There is good evidence that it works for veterans as well as for people who have not had military experience. For example, a recent study indicates that older veterans with PTSD respond well to prolonged exposure therapy.17

In addition, new models of treatment are emerging for veterans. For example, VA researchers “are developing, testing and implementing new models of primary care to improve the outcomes among veterans affected by depression. Translating Initiatives for Depression into Effective Solutions (TIDES) is a model of care for veterans with depression that involves collaboration between primary care providers and mental health specialists with support from a depression-care manager. The program has shown impressive results with eight out of ten veterans effectively treated in three VA regions without the need for referrals to additional specialists.”18

Unfortunately, even though treatment can be effective, a recent study of depression treatment of older adult veterans concluded: “The odds of receiving depression treatment decreased with increasing age. Many depressed older veterans may have limited or no treatment.19

VA Initiatives for Older Veterans

Over the past few years, the VA has significantly increased its efforts to respond to the mental health needs of veterans. In 2005 it promulgated a mental health strategic plan in which returning veterans from Iraq and Afghanistan were the greatest focus of concern. But older veterans have also benefited from efforts to prevent suicide, increase accessibility to treatment, to use evidence-based treatments, and to build delivery systems that integrate physical and behavioral health services.

More recently, an Executive Order, “Improving Access to Mental Health Services for Veterans, Service Members, and Military Families”, which was released in August of this year, dictates that the VA “establish pilot projects whereby the Department of Veterans Affairs contracts or develops formal arrangements with community based providers, such as community mental health clinics, community health centers, substance abuse treatment facilities, and rural health clinics, to test the effectiveness of community partnerships in helping to meet the mental health needs of veterans in a timely way.”20 Over time, this should substantially expand access to mental health care for veterans who live in communities where VA services are not readily available.

In addition, the VA has undertaken several initiatives that are specific to older veterans. In part, this is a continuation of the work done by the Geriatric Research, Education and Clinical Center (GRECC) that was established in the 1970s.21 But there are also new initiatives that are an outgrowth of the VA’s mental health strategic plan. One initiative specific to older adults involves “integration of a full-time mental health provider on…home-based primary care teams” to work with both veterans and their families. Another initiative is the integration of mental health providers into the VA’s long-term care centers, which are now called “community living centers.” Other settings in which mental health services are now included and reach many older veterans are hospice and palliative care settings, spinal cord injury centers, and rehabilitation centers for the blind.22

Promises to Keep: Criticism of VA Initiatives for Older Veterans

Although the VA has substantially stepped up its efforts to expand and improve mental health care for older veterans, it has been subject to considerable criticism from advocates for veterans such as Vietnam Veterans of America and Veterans for Common Sense.

Critics have noted, for example, that over the past five years the number of veterans seeking mental health services has grown by a third, and while the\ VA has increased services and staff, it has struggled to keep up with the demand….23

Critics have also pointed to a VA investigation revealing that the VA does not consistently live up to its policy requiring that “all first-time patients referred to or requesting mental health services receive an initial evaluation within 24 hours and a more comprehensive diagnostic and treatment planning evaluation within 14 days.”24 Veterans for Common Sense is now suing the VA over delays in treatment.

The VA Cannot Do It Alone

Even as the VA works to step up its efforts, as all agree it should, some advocates maintain that it cannot do the whole job.

The fact of the matter is that most veterans do not use the VA. (According to the Veterans’ Health Council, almost 70% of veterans do not use the VA for their health care). There are many reasons for this—limited eligibility, not being in priority populations, distance to VA centers, dissatisfaction with service in some facilities, etc.

But it’s not just inadequate capacity and resources in the VA that keeps many veterans away. Many have returned to civilian life, to work and family, and want to get their health care from local health and mental health providers as they generally did before they went into the military. Unfortunately, many of these providers are simply not prepared to deal with the special issues that older adults bring to them let alone the special issues of older veterans.25

Conclusion

Although virtually all of the growing concern about the emotional struggles of veterans has focused—quite understandably—on those returning from Iraq and/or Afghanistan, in fact a majority of veterans are over 60 and from prior periods of history. They too need and deserve attention to their mental health needs.

In addition to increasing the pace of expansion and improvement of the VA’s mental health services, efforts need to be made to insure that older veterans as well as veterans of current wars benefit, including:

  • Outreach to older veterans designed to overcome the stigma, which is a barrier to the use of services that are available
  • Increased support and training for primary care and mental health providers in the community regarding the culture and special needs of older veterans
  • Enhanced support for family caregivers.

Most importantly we need to acknowledge, thank, and honor our older veterans for their service and sacrifice and assure them that our nation will stand by them throughout their lives.

Michael B. Friedman teaches at Columbia University’s schools of social work and of public health. He is the co-founder of the Veteran’s Mental Health Coalition of NYC and the Geriatric Mental Health Alliance of New York. He can be reached at mbfriedman@aol.com.

Ashley Milco, a student at Columbia University School of Social Work, provided research assistance for this article.

Footnotes

  1. Kleinman, A. “Chapter 2: Winthrop Cohen” in What Really Matters: Living A Moral Life Amidst Uncertainty and Danger. Oxford University Press, 2006. http://www.oup.com/us/catalog/general/subject/Anthropology/SocialCultural/?view=usa&ci=9780195331325
  2. National Center for Veterans Analysis and Statistics. “Veteran Population Projections: FY 2000 to FY 2006.” December 2010. https://www.va.gov/vetdata/Veteran_Population.asp
  3. VA’s National Registry for Depression http://www.va.gov/health/NewsFeatures/20110624a.asp
  4. U.S. Department of Veterans Affairs. “One In Ten Older Vets Is Depressed” http://www.va.gov/health/NewsFeatures/20110624a.asp
  5. Durai, et al. “Exposure to Trauma and Posttraumatic Stress Disorder Symptoms in Older Veterans…”. Journal of the American Geriatrics Society, June 2011. http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2011.03407.x/abstract
  6. Rosenberg, T. “For Veterans, A Surge of New Treatments for Trauma” The New York Times, September 26, 2012 http://opinionator.blogs.nytimes.com/2012/09/26/for-veterans-a-surge-of-new-treatments-for-trauma/
  7. Shane L. “Retirement May Unleash PTSD Symptoms in Vietnam Vets” in Stars and Stripes, October 15, 2012. http://www.stripes.com/news/retirement-might-unleash-ptsd-symptoms-in-vietnam-veterans-1.180888
  8. Trief, P. M. “Post-traumatic Stress Disorder and Diabetes: Co-Morbidity and Outcomes in a Male Veterans Sample” in Journal of Behavioral Medicine, 2006 http://www.springerlink.com/content/x254m61214208713/2
  9. Wood, Matt. “Crunching The Numbers on the Rate of Suicide Among Veterans” in Science Life, April 27, 2012. http://sciencelife.uchospitals.edu/2012/04/27/crunching-the-numbers-on-the-rate-of-suicide-among-veterans/
  10. Glantz, A. “Suicide Rates Soar Among World War II Vets” in The Bay Citizen November 11, 2010 http://www.baycitizen.org/veterans/story/suicide-rates-soar-among-wwii-vets/
  11. Krishnan, L. et al. “Prevalence of Dementia among Veterans Affairs Medical Care System Users” in Dementia and Geriatric Cognitive Disorders, 2005.
  12. Qureshi SU, et al. “Greater prevalence and incidence of dementia in older veterans with posttraumatic stress disorder.” In Journal of the American Geriatrics Society, September 2010. http://www.ncbi.nlm.nih.gov/pubmed/20863321
  13. Sagon, C. “Older Vets With Post-traumatic Stress May Face Greater Risk of Dementia” in AARP Bulletin September 3, 2010. http://www.aarp.org/health/conditions-treatments/info-09-2010/older_veterans_with_posttraumatic_stress_may_face_greater_risk_of_dementia.htm
  14. Yaffe K., et. al “Posttraumatic stress disorder and risk of dementia among US veterans.” Archives of General Psychiatry, June 2010. http://archpsyc.jamanetwork.com/article.aspx?articleid=210821
  15. Bass, D. et al. “Negative Caregiving Effects Among Caregivers of Veterans With Dementia”. American Journal of Geriatric Psychiatry, March 2012. http://scholar.qsensei.com/content/1s9005
  16. VA. “Aging Veterans and Post-Traumatic Stress Symptoms”. Information on Trauma and PTSD. 12/20/2011 http://www.ptsd.va.gov/public/pages/ptsd-older-vets.asp
  17. Thorp S., et al. “Prolonged Exposure Therapy for Older Veterans” American Journal of Geriatric Psychiatry, March 2012. http://www.ncbi.nlm.nih.gov/pubmed/22273763
  18. National Alliance on Mental Illness. “Depression and Veterans Fact Sheet”. October 2009. http://www.nami.org/Template.cfm?Section=Depression&Template=/ContentManagement/ContentDisplay.cfm&ContentID=88939
  19. Burnett-Ziegler, et al. “Depression Treatment in Older Adult Veterans”. American Journal of Geriatric Psychiatry, March 2012.
  20. The White House. “Executive Order: Improving Mental Health Services for Veterans” http://www.whitehouse.gov/the-press-office/2012/08/31/executive-order-improving-access-mental-health-services-veterans-service. August 31, 2012.
  21. Katz, I. “Geriatric Psychiatry in the Department of Veterans Affairs: Serving the Needs of Aged and Aging Veterans” in The American Journal of Geriatric Psychiatry, March 2012
  22. Karlin, B. and Zeiss, A. “Transforming The Mental Health Care of Veterans in the Veterans Health Administration” in Generations, Summer 2010. http://www.highbeam.com/doc/1P3-2262823451.html
  23. Abramson, L. “VA Struggles To Provide Vets With Mental Health Care” National Public Radio. April 25, 2012. www.npr.org/2012/04/25/151319599/va-struggles-to-provide-vets-with-mental-health-care
  24. VA. “Veterans Health Administration: Review of Veterans Access to Mental Health Services” April 23, 2012. http://www.va.gov/oig/pubs/VAOIG-12-00900-168.pdf
  25. Karlin, B. and Zeiss, A. “Transforming The Mental Health Care of Veterans in the Veterans Health Administration” in Generations, Summer 2010. http://www.highbeam.com/doc/1P3-2262823451.html

One Response

  1. Permission to reprint article on aging veterans. 757-515-6171

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