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Statement of Dr. Laurence G. Brown, MD
Medical Director, Department of State
BEFORE SUBCOMMITTEE ON MIDDLE EAST AND SOUTH ASIA
House Committee on Foreign Affairs
HEARING ON Working in a War Zone: Post Traumatic Stress Disorder in Civilians Returning from Iraq
June 19, 2007

Introduction

Good afternoon Mr. Chairman and members of the Committee.

I am Larry Brown, Medical Director for the Department of State and the Foreign Service. Dr. Raymond De Castro, Chief for Mental Health Services for the Department of State, joins me.

I appreciate the opportunity to appear today to present some information on Post Traumatic Stress Disorder (PTSD) in Foreign Service employees. I will briefly describe PTSD, let the subcommittee know how the Department planned for and continues to give mental health support pre-departure, during service, and after return from Iraq and other high stress assignments, and describe how we are currently gathering information about the effect of high stress assignments on our employees.

What is Post Traumatic Stress Disorder?

In the world of emotional and behavioral disease, Post Traumatic Stress Disorder (PTSD) is not encountered so frequently as depression or alcohol abuse, nor is it as uncommon as schizophrenia. In the general population, as many as 10% will have the condition at some point during the course of a lifetime.

Patients with this disorder in the United States are often victims of motor vehicle accidents, rape or other violent crimes, or physical and sexual abuse in childhood. Certain occupations carry increased risk of developing PTSD, such as law enforcement, firefighters, emergency medical technicians and of course the military.

Unlike some illnesses in which genetics may play a greater role than environmental factors, PTSD is by definition dependant upon a sentinel experience. Our understanding indicates that, while some individuals are at greater at risk than others, there is no person who will not respond with many of the cardinal symptoms under the impact of a trauma of a certain quality and of sufficient intensity. This was increasingly recognized over the latter part of the 20th century as the consequences of its wars were studied in an increasingly science based medical profession.

The essential feature of PTSD is the development of certain characteristic symptoms after direct personal exposure to an extreme stressor involving actual or threatened death or serious injury, or learning about the same in regard to a family member or close associate. The immediate emotional reaction includes intense fear, helplessness or horror. The characteristic symptoms that subsequently emerge cluster in three domains: persistent re-experiencing of the event (dreams, nightmares or intrusive recollections); persistent avoidance of stimuli associated with the event and generalized numbing of emotional responsiveness; and persistent symptoms of increased arousal (insomnia, irritability, exaggerated startle response, poor concentration or hyper-vigilance).

The presentation of symptoms after such an event can vary markedly from one individual to another. In one person they may appear immediately, be of relatively short duration, and resolve spontaneously; in another they may emerge more than 6 months after the event and become chronic; and there are wide variations between these two, including many sub-clinical presentations in which only one or a few symptoms emerge from only one or two of the domains, and of insufficient intensity or duration to become diagnostically significant.

Similarly, the person experiencing these responses symptoms is less likely to seek treatment if the distress is of short duration, lesser intensity and presents only intermittently. As in most of modern psychiatry, diagnosis and treatment is dependent upon the severity and duration of subjective distress, and the presence of impairment from previous levels of functioning.

The Department's Office of Medical Services [1] has been aware for many years that employees may develop a variety of anxiety and stress related problems, including post-traumatic stress disorder (PTSD), as a reaction to stressors while living overseas. Foreign Service employees have never been immune to causative agents for the condition, and in fact have always served in environments that pose increased challenges of social instability with greater attendant dangers, including much higher rates of traffic fatalities, criminal or political violence, and civil unrest. The East Africa bombings in Nairobi and Dar es Salaam in 1998, the terrorist attack in New York and Washington DC of September 11, 2001 and the subsequent release of anthrax into the US and diplomatic pouch mail system, the terrorist attack on the consulate in Jeddah Saudi Arabia in 2004, the Karachi consulate bombing of March 2006, are only recent examples of a traumatic sentinel event that can affect employees exposed to this violence.

The war in Afghanistan and in Iraq represent another level of stressor due to the high levels and widespread incidence of violence that involve greater numbers of serving Foreign Service employees than past incidents. This has undoubtedly resulted in larger numbers of acute anxiety reactions - I will give more detail about this further on - and we might well expect an increase in numbers of those with PTSD as well.

Mental Health Support for Employees in Iraq

In December 2003 the Deputy for Mental Health Services and the Mental Health Chief for Crisis Response, two psychiatrists from the Department of State's Office of Medical Services (MED) visited Baghdad in response to a request from post for additional mental health services. Although they found morale to be good at the time, there were a number of issues contributing to an extremely stressful work situation, including:

• Constant work
• Lack of diversion
• Physical danger

Beginning in November 2003 Department employees assigned to Baghdad were mandated to attend a two week Diplomatic Security Anti-Terrorism Course (DSAC) to better prepare for their service in Iraq. Training includes the Bureau of Near East Affairs' overview of policy objectives and life at post; country and language familiarization (FSI Area Studies and Language); and Iraq specific personal security training (emergency medical, weapons familiarization, improvised explosives recognition, hostage survival, chemical/biological threat awareness, surveillance detection, and coping with stress). This course has been renamed and is now called Foreign Affairs Counter-Threat course (FACT).

When the Office of Medical Services opened a Foreign Service Health Unit in Baghdad in July 2004, a psychiatrist was part of the medical team (including a general medical officer, two nurse practitioners, and a registered nurse) deployed for support. The psychiatrist was moved nearby to Amman, Jordan in December 2005 to better cover the region, including Baghdad. A Master of Social Work (MSW) clinical counselor familiar with stress and PTSD issues was then added to the Baghdad Health Unit staff specifically for mental health support.

In anticipation of additional mental health needs for FSOs returning from Iraq, MED held a 2-day informational and planning conference in July 2004. All 15 medical officer/psychiatrists were in attendance. They heard from officials in the Department from the Office of the Director General for Human Resources (DGHR), various geographic regional bureaus, and a panel of Iraq returnees. Additionally they heard from three national experts whose expertise is in dealing with people following traumatic events: Dr. Carol North, Professor of Psychiatry, Washington University; Dr. James McCarroll, Professor of Psychiatry, Uniformed University of the Health Sciences; and Dr. Robert Ursano, Professor of Psychiatry, Uniformed Sciences University and Chair, American Psychiatric Association Work Group on Practice Guidelines for the Treatment of Patients with PTSD.

MED decided, based on information and recommendations from this conference, to offer an out briefing session to all Iraq returnees. These sessions are given in conjunction with the DGHR and the Foreign Service Institute (FSI). The out briefings, made mandatory in August 2004, give employees information on:

• What to expect as a stress reaction
• Healthy coping mechanisms for these situations
• Where to get further help with the Department if needed
• Other administrative details for Iraq returnees

Specifically these sessions were not set-up to offer psychotherapy or counseling, and did not constitute a clinical contact for security reporting purposes. They are not critical incident stress debriefings as these have been shown to be more harmful than beneficial. MED wanted employees to feel free to come to these sessions. In Washington these sessions are held regularly at FSI; overseas the session are offered by the RMO/Ps or other FS medical staff at the employee's post of assignment. Recently out briefings have been formally scheduled as part of an onward assignment for Department employees, and supported with per diem during attendance.

The Iraq out brief medical facilitator gives special emphasis to insomnia and problems relating to a spouse or partner. Chronic insomnia is itself a risk factor for further decline and offers a non-psychiatric entrée to a medical professional to begin talking about any changes that are worrying them. When an anticipated happy reunion with family is instead sabotaged by unwanted and unpleasant feelings of resentment, the disappointment can be enormous and may lead to an emotional distancing that bodes poorly for the long-term health of the relationship. The point is made in the out brief that short-term counseling offers very good results in these circumstances.

For those who require counseling, or just a few sessions of sharing their experiences in Iraq, the Department's Employee Consultation Service provides a confidential service for this. Six trained MSW level counselors familiar with the Foreign Service and familiar with service in Iraq staff this employee assistance program. For those employees with more serious or long-term mental health issues we maintain several referral sources in the Washington area. For employees stationed overseas, all of our practitioners are trained in primary care counseling, and the Department's psychiatrists are readily available for individual consultations as well.

What should the Department of State expect with employees assigned to war zones?

Among veterans of the Vietnam War and the Gulf War, 15% were diagnosed with PTSD. Of about 245,000 soldiers discharged from service in Iraq and Afghanistan, more than 12,000 sought counseling for symptoms of PTSD; and in a survey of 3,671 soldiers and Marines involved in combat in those theatres, 17% reported symptoms consistent with major depression or anxiety, including PTSD. Those with PTSD did not significantly vary from those without in regard to sex, race or age, but there were significant differences based on the characteristics of the military service, i.e. the level of combat exposure predicts the risk of the mental disorder; combat stress, then, poses greater risk of a mental disorder than deployment stress. Those statistics and conclusions are consistent with studies on the consequences of the Oklahoma City bombing and the attacks on the World Trade Center and the Pentagon.

While the traumatic event itself and its nature is the most predictive variable of a pathological response, evidence also indicates that persons with a previous history of a psychiatric problem are at greater risk of PTSD. It is the policy of the DOS Office of Medical Services that only officers with a class 1 medical clearance will be approved for assignment to the embassy missions in war zones.

What is the Department of State actually finding in our returnees from Iraq?

The Office of Medical Services has been gathering anecdotal information from those who have attended the Iraq out briefs; those few who have sought treatment; those evaluated for medical clearance to an onward assignment; and from a very few individual officers who simply reach out to share their experiences either in service to the Department or in complaint. MED finds that almost all are affected in some way by their service there, more so than the average overseas assignment.

Commonly these employees have one or several of these reactions:

• Insomnia for up to several months, the most common symptom
• "Easy to startle" response for several months
• Irritability and anger outbursts
• Some numbness and emotional distance; "The color is out of life"
• Trouble concentrating, particularly noted in those studying a new language for an onward assignment
• Problems relating to a spouse or partner; sometimes a re-negotiating of relationships is needed, particularly with loved ones

A large percentage of employees have some of these stress-related symptoms, but there have been very few whom actually present with a full-blown picture that meets the criteria for a diagnosis of PTSD. Most employees experiencing one or more of these symptoms improve over several months with brief counseling or without any counseling at all.

There have not been any employees who lost their medical clearance because of PTSD or PTSD-like symptoms. Some employees (I estimate fewer than 20) may have had their medical clearance changed from unlimited worldwide availability to a post specific availability. This change would allow MED to assure that a post of assignment had counseling or treatment services, if needed, for the employee. Those employees with diagnosed PTSD that require ongoing therapy would fall into this category of post-specific clearance for assignment.

In the previous and following sections I refer to Foreign Service or Department employees. Although many employees working in Iraq are direct-hire Foreign Service employees, others are Civil Service employees working on a Limited Non-Career Appointment (LNA) or 3161's: Civil Service employees appointed on a temporary basis under 5 USC 3161. All of these employees come under the Department's medical program in Iraq and must have a worldwide medical clearance to be posted there. They are eligible for pre-assignment training, medical and mental health services while in Iraq, and post-assignment out briefings. Although medical services for the "3161s" end with termination of their employment, they are covered by worker's compensation for injuries or occupational health conditions that developed in performance of duty or as a direct result of employment. As with all work related injuries or occupational health concerns a causal link to employment must be established and claims submitted in a timely manner with supporting evidence to the Department of Labor, the adjudicating agency.

Some contractor personnel in Iraq are personal services contractors (PSC) that have the same medical support as do direct hire employees. Other contract personnel are either non-personal services or professional services contracts. While all the large contract companies have full responsibility for medical and mental health care and follow-up for their employees, there are several smaller contract companies who are authorized to use Government furnished medical support in Baghdad.

What more is the Department planning to do?

In an effort to find out more about our employee's reaction to service in Iraq (and other unaccompanied danger posts), MED worked with the Family Liaison Office to develop a survey for all returnees from unaccompanied posts. This anonymous survey opened on the Department's intranet on June 1. The survey period will run for a month, and we hope to capture information from most of the approximately 2000 Foreign Service employees who have served under difficult circumstances, including those who have served in Iraq. The survey asks specifics about what stresses and dangerous situations an employee was exposed to, what they did about it, and what counseling or other treatments they may have sought since. A group of the questions was taken from standard PTSD questionnaires so that we can compare the information that we get with other similar surveys done by the military and other organizations. We will use the information from the survey to better hone the information given to employees prior to and post-deployment in Iraq, and to develop additional support programs or services if needed.

In July MED in conjunction with the Department's Family Liaison Office MED will offer support groups in the Department for returnees from unaccompanied high-stress assignments.

Summary

In summary the Department's Office of Medical Services is doing the following for those assigned to Iraq and other unaccompanied posts:

• As part of the FACT Course prior to deployment, Mental Health Services discusses stressors and other mental health issues

• A full DOS Health Unit supports those employees in Baghdad: a medical officer physician, two nurse practitioners, one registered nurse, and one MSW. All are trained in mental health counseling in addition to their standard medical training

• A short, elective and well-attended briefing session is given in Baghdad by the clinical social worker prior to an employee leaving post permanently. Employees are educated on the various support services in Washington DC and at their next assignments/post. Some employees use this opportunity to discuss their experience, and they are encouraged to share them during the formal out briefing sessions.

• Out briefing sessions, now mandated, are given to employees in Washington or overseas for informational purposes.

• ECS is available for confidential counseling for those in Washington. Referrals are made to outside resources if needed or if asked for by the employee. Overseas the medical program has primary care providers and psychiatrists for care and consultation.

• The Department through MED and DGHR assist with any issues that involve the Worker's compensation system

In the future:

• Study results of the June 2007 survey of all returnees to ascertain what other services would be useful and then implement them.

• Begin support groups for returnees in July 2007, modifying the group focus and size when more clinical experience is gathered.

Mr. Chairman, this concludes my prepared remarks. We are available to answer any questions you may have.

Cited references:

Friedman, M. (2004). Acknowledging the Psychiatric cost of War. The New England Journal of Medicine. Vol 351 (1) pgs 75-77.

Friedman, M. (2006). Posttraumatic Stress Disorder Among Military Returnees from Afghanistan and Iraq. American Journal of Psychiatry. Vol 163(4(, pgs 586-593).

Friedman, M. (2005). Veterans' Mental Health in the Wake of War. The New England Journal of Medicine. Vol. 352 (13), pgs. 1287-1290

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[1] The Department of State Office of Medical Services has a headquarters staff here in Washington that provides management of the program. In the overseas setting physician medical officers, nurse practitioners, physician assistants and medical technologists provide medical support and services at United States embassies and consulates. Medical officer psychiatrists also provide overseas mental health support. All of these providers cover a region as well as their home posts.