Hidden Cost Of War .

The most comprehensive study ever undertaken of Australia’s Vietnam Veterans has revealed that post traumatic stress disorder (PTSD) is now twice as prevalent as it was 15 years ago. More than 40% of those who have taken part in the study now show symptoms of PTSD, compared with about 20% in the same group of Veterans in 1993, and 2.3% among males in the wider Australian community.

These are among the early findings as Dr Brian O’Toole analyses the results of his research, conducted among a random sample of Vietnam Veterans nationwide initially from 1991-93, and updated over the past two years.

“The Veterans are not a well group, as a whole,” says Dr O’Toole, who is based at the ANZAC Research Institute at Concord Hospital in Sydney. “They seem to be less healthy than the general population in a number of ways.”

The study also suggests that Vietnam Veterans are eight times more likely to have alcohol problems; 25 times more prone to suffer major depression; four times more likely to think about suicide; and probably in poorer physical health if they suffer PTSD.

Dr O’Toole is leading a team of researchers from the ANZAC Institute and from Queensland and Newcastle Universities into the long term effects of war service. He began his study in the late 1980s by taking a random sample of 1000 Vietnam Veterans from army records, and interviewing 641 men after tracking them down through electoral rolls, telephone directories and ex-service organisations.

For the second wave of interviews, during 2005-06, the researchers also had access to Bureau of Statistics software, data and methods, and were able to compare their results with the first ABS national survey on mental health conducted in 1997 and the National Health Survey conducted in 2004-05.

In wave1, conducted in the early 1990s, the study found that 50 of the cohort had died, eight of them in Vietnam, and by the second wave in 2004-05, Dr O’Toole found that a further 75 of his original sample had died - giving a post-war mortality risk of 11.9%, which is broadly in line with the general population. He then covered 85,000 km by road, with his son’s border collie Angus McDog for company, driving through all states and territories in Australia, conducting interviews that lasted at least four hours, with 450 Veterans. He was backed by extra researchers in the major capital cities.

His early findings suggest that in general, the physical health of Vietnam Veterans is affected by their service, although this is not generally across the board for all illnesses or indeed for all Veterans.

“Some Veterans are getting along very well in their lives, but others are not,” he says. “Using ABS data allows us to determine how many individuals in the sample should have each medical condition For example, you’d expect 34.6 cases of gout from the national data, weighted for age and sex, and we got 36. Rheumatism - you’d expect 5.5 cases and we got 2. But in the case of arthritis, for example - you’d expect 113, but we got 154 (It would be interesting to know the breakdown by type eg oestio or rheumatoid etc – 174%). We also would expect about 20 cases of a current diagnosis of cancer, but we found 60 (300%).

“SO it looks like things such as diabetes and gout are not necessarily much more prevalent in the Veterans compared to the Australian population. But when you switch to mental illnesses, that’s where things start to become more concerning.” His preliminary estimate that more than 40% suffer PTSD is just one disturbing result.

“One of the things we assess is suicidal ideation - have you ever thought ~ou might commit suicide, have you made a plan, have you ever attempted, and so on. Suicidal ideation is very common in the general population, but seems much more common among the Veterans.

“Early indications are that it’s nearly four times more prevalent in the Veterans than in the general population. And suicide attempts are four times higher. So we’re looking at a large increase since the first wave.”

Dr O’Toole does point out that the peak age for suicide among Australian males is in their mid-fifties, and Vietnam Veterans have reached that age range.

Vietnam Veterans are 25 times more likely to suffer major depression, and 10 times more likely to undergo dysthymia, a low level depression lasting over two years where the patient may be reduced to tears but doesn’t experience a major breakdown that requires treatment.

Social phobia, or withdrawal, is seven times more likely among the Veterans. O’Toole illustrates this by describing two men he interviewed, living within a few kilometres of each other in semi-urban Victoria, but unaware of each other’s existence.

“To meet the first Veteran, you go through these windy little streets to the top of the hill, and there’s his house with the bush behind, and he can see everything that comes. Nobody’s going to creep up on this guy. And in the afternoon, to the other side of the main road, I saw the other Veteran and it’s almost identical - through the side streets, up a cul-de-sac and right at the top of the hill, with his back to the bush, and able to look down, there’s the other Digger. And they often do that.
“You go into an RSL and there’s a subtle tussle to see who can sit along the wall. They’ve got to see out. They’re also often found to be socially withdrawn. Social phobia is particularly frequent with these guys. Many of them withdraw from circumstances where they expect to encounter crowds, so going to the supermarket or shopping centre can become a chore, especially for wives.”

Alcohol abuse is also very common. Statistics suggest there should have been 10.9 cases of alcohol dependence, but O’Toole has found 92. He concludes that Vietnam Veterans are up to eight times more likely to suffer alcohol disorders, and that can lead, in many cases, to a breakdown in physical health.

“One poor fellow was the saddest case I’ve seen. He was a warrant officer and, in my experience, the blokes who were warrant officers are exceptional individuals. On his tour in Vietnam he was in an ambush and he suffered severe injuries in a RPG attack. He stayed in the army and was given a non-active role, and started to drink heavily Several years post-Vietnam he took his discharge and off he went. I was in that guy’s house 15 minutes and his wife was in tears, because all this started to come rushing out. He was badly overweight, had had several heart attacks, he’d had a stroke, he was diabetic, he’d had PTSD, and a variety of other things. The poor man was on more than 20 medications a day. His life would have been very different but for his service in Vietnam.”

O’Toole’s conclusion that the prevalence of PTSD has doubled in 15 years has raised a new question of accepted wisdom. It is generally accepted in psychiatry that people showing symptoms of PTSD in later life, for example in their sixties, probably showed symptoms much earlier, perhaps in their twenties.

“What I’m trying to work out, as a scientist, is whether there’s any evidence of the phenomenon of delayed reaction - which is quite controversial in the literature. In other words, whether they got on with their lives until things changed, like a marriage breakdown, or being retrenched, or a child’s severe illness, and the symptoms then emerged out of the blue, or whether these symptoms were going on all the time and they just buried them until things got on top of them. That’s an interesting psychiatric scientific question because it has implications for the timing and appropriate intensity for treatment interventions.”

What he has discovered is that those Veterans with PTSD often suffer physical illness, particularly with inflammatory diseases such as arthritis, asthma, gastro­intestinal disorder and some kinds of vascular disease. His research now suggests there may be a protein involved, with some evidence that PTSD may affect the immune system (oh no not the dreaded agent orange again!!).

The most common symptoms of PTSD are re-experiencing symptoms, such as nightmares and flashbacks. An example, says O’Toole, could be a Veteran working in the bush, coming to the crest of a hill and suddenly imagining it’s a hill where he came under fire in Vietnam; or nightmares where the man is running in his sleep, or suddenly sits bolt upright and prowls the house at night, “checking the perimeter”, or thrashes out, often colliding with his sleeping wife. These things are not under his direct control but they are upsetting for the Veteran, and his wife. And in some cases, they never seem to go away.

It is very difficult to erase the experiences of Vietnam — the smells, the sounds of helicopters, the feelings of being on edge - from the memory. The brain is just “too good”, it won’t let you forget. It is very common for Veterans to report that they have hit the deck when a car backfired. They all seem to know where the exits are when they venture into a shopping centre or an enclosed space like a movie theatre or a club. And a Veteran can be as deaf as a post, but he will often still be the first one in the room to hear a helicopter approaching.
Funding from the Rotary Health Research Foundation has enabled Dr O’Toole and his team to do follow-up interviews with the wives and ex-wives of the same group of Veterans. Evidence from the early interviews suggest that Vietnam Veterans are no more likely than anyone else to experience divorce or domestic violence, but now the researchers are trying to discover what effect the men’s combat exposure and mental disorders has on the wives’ well-being, and whether the women also develop mental illness as a result.

“It’s a fair bet that we’re going to find Veterans’ combat experience and PTSD is related to their wives’ mental health,” says Dr O’Toole.

“These women are subject to men who are cranky, because anger outbursts and periods of agitation are symptoms of PTSD,” O’Toole explains. “They live in an environment where, as one woman said, we walk on eggshells all the time.

“There was one fellow I met who was a Veteran of Long Tan - a lovely man who under different circumstances would have had a completely different life. He had to put the interview off several times and when I finally met him, he said, ‘Can we meet at the local club?’ Because he’d just been in a difficult situation at home with one of his kids until the wife intervened.”

Most of the Veterans with mental disorders are receiving treatment, although Dr O’Toole suggests many are not. Veterans in general are more likely to use health services than the general population, partly through need and partly because the services are more readily available for Veterans. But some refuse assistance. O’Toole describes one Veteran who was prominent in his ex­service club in northern Queensland who broke down in tears when he admitted he needed help.

“His problem was he was stuck. He thought, ‘I’m the strong man here. I’m the leader. I’ve been elected and no one else is interested in looking after this place. I’m the one who’s got to do it.’ He’s been damaged himself by his war service, he’s doing his best for his mates, but feeling that he himself can’t be seen to be getting help, as a sign of failure or, even worse, nepotism, using the system to his own advantage. This honourable man was caught between loyalties and his own need for help.”

Dr O’Toole is now hoping for further funding to take his research one step further: he wants to interview the children of the same Veterans, to see if and how they have been affected. Eventually a study could be conducted that would take blood samples from the men, their wives and the children, to test for genetic links to PTSD, but this is a long way off and highly dependent upon grant funds.

“One lovely man I spoke to told me his son had battled over a long time with depression. But then he said his wife had been in and out of hospital with depression, so had her sister, and their mother, with depression. So if anything, the evidence would suggest the depression is coming from that side of the family, rather than from his war service. It might have been made worse by his war service but on the other hand, it is possible that the Veteran himself acted as a buffer, as a strong support for his family, without which the problems might have been worse. I have met many Veterans who have been a pillar of strength for their families in times of adversity.”

The ANZAC Research Institute study of Vietnam Veterans is the most comprehensive undertaken anywhere and is already throwing new light on the long term effects of wartime service. One element uncovered by the first wave of interviews in the 1990s is that more Veterans with PTSD reported that their fathers had been affected by service in WWII than those without PTSD. Whether this effect is genetic or a result of learned emotional behaviours is a critical scientific question. (And what about this affect in populations of high veteran content like the soldier settlement land schemes post WW1 and WW11 – did this increase this factor?)

It also has implications for potentially protecting servicemen and women from lasting effects of combat exposure and trauma. And the study of wives may throw light on the role of partners in coping with loved ones who have been traumatised. In the future, and with appropriate funding support, the long-term effects of war service on the warriors and their families may be better measured and understood.