Social Disadvantage and the Mental Health of Military Personnel Returning from Iraq and Afghanistan

With attention in the United States now focused on the mental health of military personnel returning from Iraq and Afghanistan (Hoge et al. 2004, 2006) clinical experience with Vietnam era veterans with PTSD should offer a cautionary tale. Frueh et al. (Frueh et al. 2007) have made the case that unlike other PTSD populations, Vietnam era veterans with PTSD are not only less responsive to psychotherapy, but also that their self reported symptoms get worse, not better with time. In addition, once they reach 100% disability there is a dramatic drop off in participation in treatment. They attribute these outcomes, in part, to flaws in the Department of Veterans Affairs disability compensation system that encourage dependence. But this unfortunate situation may be better understood in the context of the social disadvantage experienced by many of these veterans. From such a perspective, an increased pension, not mental health treatment addresses many veterans’ more pressing needs. The poor outcomes during treatment and withdrawal from treatment after maximizing pensions show what we already know, that mental health treatment has a limited ability to overcome social disadvantage (Draine et al. 2002). Social disadvantage has been strongly linked to PTSD in Vietnam era vets. The Vietnam Veterans Readjustment Study (Kulka et al. 1990) found that rates of PTSD were roughly doubled in those who lacked a high school degree were unemployed, or had a low income with pre-military factors such as coming from a poor family, having childhood behavioral problems, and abuse of substance before entering the military, being strong predictors of subsequently developing PTSD. How much PTSD causes poverty or how much poverty causes PTSD will remain a subject of debate (Hudson 2005). But, without getting caught up in the chicken and egg conundrum we probably can all agree that at some point in their lives, for many Vietnam era veterans with chronic PTSD, psychiatric symptoms may be a lesser problem than their social disadvantage: years of homelessness, unemployment, erratic or non-existent relationships, and involvement in the criminal justice system. Not surprisingly, patients seek access to those interventions that at least indirectly address their needs (safety, housing, etc.,). But these are provided only as long as one remains in treatment. In lieu of a means test mental health workers are using DSM-IV criteria and willingness to participate in treatment to determine who should have their social disadvantage mitigated. Professionals have the choice of providing treatment, and therefore meeting the socially disadvantaged veterans’ needs in an indirect, expensive and temporary fashion or not providing treatment and not addressing these needs at all. This dilemma can be resolved by separating the provision of basic resources (such as safe housing) from participation in treatment. An example of this is the ‘‘Housing First’’ model in which mentally ill, substance abusing; homeless people are offered an apartment that is not contingent on their participation in treatment or staying abstinent. Assertive Community Treatment is readily available to those who might want it but is not a condition of participation. A randomized controlled study of this approach in New York City showed greater housing stability and no difference on D. J. Luchins (&) Jesse Brown VAMC, 820 S. Damen Ave, Chicago, IL 60612, USA e-mail: daniel.luchins@va.gov; danl@yoda.bsd.uchicago.edu