Post-traumatic stress disorder is a serious public health challenge. It is estimated that about eight million people in the U.S. (2.5 percent of the total population) suffer from it. This rate jumps to about 11 to 20 percent among Iraq and Afghanistan veterans who suffer from diagnosed or undiagnosed PTSD.
Affected individuals might lose their career or family or even commit suicide due to the consequences of PTSD. The effects go beyond the individuals coping with it, extending to their family, friends, colleagues and communities.
Both military personnel and veterans can be affected by PTSD. However, the exact prevalence of PTSD among these two groups is unknown. This not only makes it hard to know how many people actually have PTSD but also makes it even harder to project how many will in the future. And if we don’t know how many people actually have PTSD, it can be hard to find out what policies work best to mitigate it.
To address these concerns, my colleagues Navid Ghaffarzadegan and Alireza Ebrahimvandi at Virginia Tech and I decided to take a systems science approach which lets us study how parts of a large system, such as the Department of Veterans Affairs and the Department of Defense, interconnect.
We developed a simulation model to project the prevalence of PTSD by 2025 among military personnel and veterans and to find out what policies actually reduce the burden. Our study presenting the model was recently published in PLOS ONE.
The challenge of estimating PTSD prevalence
Because screening of PTSD is based on self-reported surveys, estimating its true prevalence among veterans and current military personnel is hard to do. Answers to surveys can suffer from patients’ errors.
But more importantly, some PTSD patients may intentionally underplay their mental health condition to avoid being labeled as mentally ill. In a few cases, patients may exaggerate their problems for motives of secondary gain, such as disability compensation.
Our task was to put all of this information together to gain a true sense of the future prevalence of PTSD among military personnel and veterans.
PTSD is a multi-organizational challenge
Another challenge is that we are talking about two different populations: people currently in the military, and veterans.
The VA and the military are two systems within a larger system. They establish different policies, which may result in improvements in their own sectors, but are not so effective in the larger system. For instance, policies implemented in the early stages of a person’s military career, when combat readiness is a major concern, can cause serious consequences years after separation from the military.
In systems science, this is called “shifting the burden.” Unless the military and the VA come together to develop integrated policies, the big picture of the system will be missed by disjointed policies implemented in each organization.
Since PTSD is a multi-organizational challenge, estimates should take both populations into account simultaneously, which is what we did in our model.
Simulating the burden of PTSD
Our model includes both military personnel and veterans affected by PTSD in a “system of systems.” It uses historical data on PTSD prevalence among military personnel and veterans from the DOD, the Institute of Medicine, the VA and other sources, from 2000 to 2014. This let us validate our model and generate a more exact estimate of PTSD prevalence.
Our approach also allows us to ask “what-if” questions about the consequences of current policies – such as what if we focus solely on improving screening or improving screening and treatment.
Then we used the model to forecast PTSD prevalence over the next decade under several scenarios. These scenarios are based on common “what-ifs,” including different levels of U.S. involvement in future wars and improvements in prevention, screening and treatment.
What happens if we fight another war?
In an optimistic scenario where 1 percent of all military personnel are deployed to combat zones (which reflects deployment in 2014) that no war happens in the next decade, we estimate that 7 percent of military personnel and 10 percent of veterans will have PTSD by 2025.
But that could increase to 20 percent in the military and more than 11 percent among veterans in 2025 if the U.S. gets involved in a war requiring 5 percent deployment of all military personnel on battlefield. For perspective, from 2001 to 2014, on average, 6.6 percent were deployed annually. Larger wars with higher deployment rates will noticeably increase the prevalence of PTSD.
We also estimated the delay in mitigating the effects of a hypothetical war. Let’s assume that the U.S. involves in a five-year war with 10 percent troop deployment (similar to the maximum deployment in Iraq in 2008).
After the end of this hypothetical war, it will take about 40 years for PTSD prevalence to go back to its initial rate. This estimation shows how long the effects of war can endure.
What policies work best?
We also tried to get a sense of what policies work best at mitigating the problem of PTSD. Using the model, we examined the long-term effects of policies within the individual components of the system, the VA and the DOD, as well as across the entire system.
We found that, before and during wars, prevention interventions (focusing on resiliency-related training) are the most effective policy to decrease the prevalence of PTSD. Improving resiliency can work as a “vaccine” or early treatment before the onset of the cascading effects of PTSD.
However, social barriers such as the stigma of PTSD are still in place, affecting willingness to receive early treatment.
Overall, our results show that in a post-war period there is no easy solution for overcoming the problem of PTSD, and the current screening and treatment policies used by the VA and the DOD must be revolutionized to have any noticeable effect.
The VA and the DOD should work together and try to offer timely service to patients. However, we showed that they cannot do much to decrease health care costs. These are the consequences of wars.
We hope that the findings of this study will help the military, the VA, and other government entities identify more effective strategies. The results also show the importance of effective interaction among these large entities. We have provided the model online, in an interactive interface and easy-to-interpret fashion, for the use of the public and policymakers.