ANA SYMPOSIUM EXAMINES COSTS, LESSONS OF IRAQ CONFLICT

Traumatic brain injury has become known as the signature injury of the current conflicts in Iraq and Afghanistan, yet it may represent just the tip of the iceberg when it comes to the long-term neurological and financial costs of the wars. Post-traumatic stress disorder and post-traumatic epilepsy add enormously to the burden, speakers at the Presidential Symposium of the annual ANA meeting said, and the long-term, disabling nature of these problems will help push the eventual cost of the Iraq conflict alone to more than $3 trillion, according to one expert.

“Over 4,000 US soldiers have died, and many, many more have been injured,” said American Neurological Association (ANA) President Tim Pedley, Chairman of Neurology at Columbia, in introducing the speakers. “The changed nature of warfare in Iraq has led to a higher number of brain injuries and persistent disabilities, including epilepsy and neuropsychiatric disorders.” Pedley said he selected the topic for this year’s symposium – Neurological Injuries Caused by War: What Have We Learned from Iraq and Afghanistan? – to examine not only the type of injury and subsequent disability, but also why head injuries are more common and what the long-term financial impact might be on society.

 

A patient is loaded onto an aeromedical evacuation flight July 10 at Ramstein Air Base, Germany. (U.S. Air Force photo/Airman 1st Class Kenny Holston) Image from http://www.af.mil/photos/

One lesson that stands out so far is how difficult it can be to nail down prevalence data on conflict-related TBI, particularly milder cases that are not associated with loss of consciousness. Closed-head concussions or “blast injuries” resulting from the shock wave of a nearby explosion are by far the most common type of injury in Iraq and Afghanistan.

Sorting Out Concussion Effects

“Many numbers that are bandied about for TBI include the 90 percent or so that are concussions,” Col. Cornelius Maher, the deputy chief in the U.S. Army Medical Corps and also the chief consultant to the Army Surgeon General, said at the symposium. He cited June 2008 statistics from the Defense and Veterans Brain Injury Center, showing that 32 percent of soldiers who were medically evacuated for any battle injury in Iraq had some degree of brain injury. Nine in 10 of these are “probably mild – i.e., concussions,” Maher said.

During his tour of duty as the sole neurologist at an Iraqi hospital for several months in 2004, Maher said post-concussive syndrome was the most frequent diagnosis (after headache). Because sophisticated mental health teams are now deployed in Iraq, few soldiers with neuropsychiatric disorders are steered to neurologists; Maher said severe concussion, even in the absence of war injuries, was “one that stands out.”

There is a growing recognition, in part due to the experience of sports concussions, that mild TBI, especially if repeated, may present latent neuropsychological problems that can be associated with significant disability. The long-term impact of such injuries is largely unknown but is expected to be a major driver of the drawn-out financial ramifications of the conflicts.

Complicating Factors

Psychological symptoms can complicate the identification and medical care of mild TBI. “PTSD can look very much like post-concussive syndrome,” Maher said. “If you have a concussion, you’ve suffered trauma, so it can be pretty hard to tease those out. Looking for better ways of making that distinction is important, because there may well be different ways to treat.”

 

Cornelius Maher, MD, Colonel, Neurologist, U.S. Army Medical Command, Fort Sam Houston, TX Image of Dr. Maher courtesy of Digital Blue Photography. Printed with permission.

Charles Marmar, a neurologist with the University of California, San Francisco and the San Francisco VA Medical Center who is leading PTSD studies for the VA, agreed: “We do not have perfect ways of distinguishing between PTSD and the effects of mild TBI.” Some investigators have made the case that PTSD and depression explain much of the relationship between mild TBI and physical health problems such as headache and cognitive problems, he said, but the issue remains controversial.

What is clear, Marmar said, is that PTSD and other mental health diagnoses are increasing in VA populations. “At each cross sectional look from 2002 to 2007, the rates have continued to grow,” he said. PTSD diagnoses, for example, have increased at every two-year window examined, to about 21 percent currently among Iraq and Afghanistan war veterans who sought VA services. The few population-based studies of veterans have found somewhat higher rates, suggesting a prevalence range from about a quarter to a third for any mental health disorder. In one study of 103,000 Iraq/Afghan veterans, two-thirds had multiple co-occurring mental health diagnoses.

‘Generational Challenge’

“When you look at cumulative rates over time, there is an increase within each disorder – PTSD, depression, and alcohol use,” Marmar added. The reasons behind the increase are complex and not completely understood. Repeated exposures to trauma in the war zone clearly increase risk, and delays in seeking treatment – despite a “massive education program in the VA to train clinicians to screen for and identify mental health problems” – contribute to the cumulative rise.

“It’s tough to know why the rates are growing,” he said, “but it has profound implications for service planning in the future.” He noted that the best available evidence-based treatments for PTSD – cognitive behavioral therapy and selective serotonin reuptake inhibitors – are generally less effective in combat trauma than in civilian populations. “A lot of work needs to be done,” he concluded. “It will be a generational challenge in terms of the neuropsychological health of these soldiers.”

Future Wave of Epilepsy?

A future wave of post-traumatic epilepsy among survivors of war induced TBI represents another challenge that the United States and Iraq may be ill-equipped to deal with, according to a review of data presented by Dan Lowenstein, UCSF vice chair of neurology and director of the UCSF epilepsy center. Studies from four previous wars, from World War I to Vietnam, show a “remarkably consistent pattern,” he said, with five-year incidence ranging from 22 percent to 43 percent (median: 34 percent) among combatants. As many as half develop epilepsy within a year of the injury, studies suggest, but in a significant number, epileptic seizures first appear several years later, even a decade or more in some cases. The four studies that examined epilepsy rates 10 or more years after head injury, representing a total of more than 3,000 participants, found that approximately 45 percent of those with penetrating wounds had developed epilepsy at 10 years post-injury.

Given the sometimes-delayed onset of symptoms, combined with the lack of solid data on the prevalence of moderate and severe TBI in combatants and civilians (who have also been exposed to blasts associated with traumatic brain injury), the number of people in the current wars who may eventually develop epilepsy is “essentially unknown.”

“Post-traumatic epilepsy is a common and predictable cause of epilepsy, with a 35 to 45 percent incidence among combatants, and no anti-epilepsy therapy exists that has been shown to prevent the development of epilepsy following TBI,” Lowenstein concluded. “This is an area ripe for clinical translation.”

Calculating the Price Tag

Epilepsy, PTSD, and other chronic effects of war trauma generally and TBI specifically will significantly impact the societal cost of the current conflicts for generations to come, in terms of both direct medical care and disability pay for veterans and in terms of indirect social and economic costs. Linda Bilmes, an economist at Harvard’s Kennedy School of Government and author (with Nobel-winning economist Joseph Stiglitz) of a recent book on war costs, said at the symposium that mild TBI – a condition not accounted for in her original cost analysis – will add roughly $28 billion in long-term medical and disability costs, and about $29 billion in social costs. She characterized these estimates, which assume that about eight percent of combatants will seek medical care and file disability claims due to mild TBI, as “very modest” and possibly a “significant underestimate,” especially as disability compensation regulations for TBI are revised.

As of late September, Congress had appropriated about $850 billion to fight the wars. For comparison purposes, Bilmes said that the amount of private and public money spent currently on autism research, about $125 million, is spent in Iraq in six hours. And money already appropriated for the war pales in comparison to Bilmes and Stiglitz’s overall projection of $3 trillion-plus price tag, once future budgetary costs are factored in. “The long-term costs are where the major costs come in,” she said.

Delays in getting treatment for mental health disorders and mild TBI – already a recognized problem among veterans – will lead to even higher long-term costs, Bilmes said. “At the very time when they are most vulnerable and least able to cope, returning soldiers have to face a very complicated process of securing the paperwork that will enable them to get disability status and even treatment, in some cases. It’s a very confusing process for anyone, much less for a soldier coming back with PTSD or TBI in the period when they are probably least able to cope with these complications.”

Learning from War

Historically, every war the U.S. has fought has held lessons for medical science. Douglas Lanska, a neurologist at the VA Medical Center and University of Wisconsin, Madison, said that by the end of the Civil War, the U.S. military hospital system was the best in the world, in large part due to the nature of the damage inflicted by lead bullets and the high number of amputations necessary. The large number of nerve injuries – a once rare condition that became quite commonplace during and after the war – led to the first detailed clinical study of traumatic peripheral nerve injuries in the 1860’s. In World War I, the high incidence of occipital and parietal brain injuries (due to the inadequate protection of the standard helmets of the day) led to better mapping of the visual cortex, which ultimately overturned the prevailing dogma of how the visual system was organized, Lanska said.

With that history as a guide, there are undoubtedly many lessons to be learned from the current conflicts regarding the neurological and psychological effects of trauma. Recent efforts to study the effects more diligently hold promise that this knowledge will eventually come, as society grapples with how best to care for the military men and women who will bear the scars of war long after the conflicts are resolved.

Lanska invoked the words of Abraham Lincoln that have been adopted as the VA motto: “To care for him who shall have borne the battle, as well as for his widow and his orphan.”

“As neurologists,” Lanska said, “we have a duty to continue this tradition.” AN

Brenda Patoine