The Unseen War still waging inside the Minds of Many Veterans


Most people probably think wars end when the shooting stops.

But that’s not the case for those who do the fighting. For them, the war lives on long after they return home and try to resume normal lives.

One of us, Max Cleland, knows from experience. He lost both legs and his right arm to a grenade explosion in Vietnam in the 1960s. Even after the physical injuries healed, even after the rehabilitation was over, the emotional anguish continued. And in truth, nearly 50 years later, that aspect still hasn’t completely healed.

Sadly, today as military men and women return home from war zones, there’s still plenty of room for improvement in mental health care for veterans. The suicide rate is unacceptably high and the success rates for PTSD, depression and anxiety disorders haven’t improved in years.

Meanwhile, veterans, their families and society as a whole will be dealing with the fallout from the wars in Iraq and Afghanistan for another 70 years — at least. PTSD, depression, and traumatic brain injuries (TBI) all increase the risk of Alzheimer’s disease and other forms of dementia.

That’s why the United States must do whatever it can to improve mental health care for those injured in war. It’s a moral obligation.

From firsthand experience, Max can tell you that the treatment path can be slow, frustrating and sometimes terrifying. Often those treatments are ineffective, and that can be demoralizing and make those who suffer reluctant to seek further care.

There are also practical problems. Many veterans wounded in wars can’t undergo a brain MRI because of the shrapnel in their bodies. CT scans are possible, but they don’t show the full picture of what’s happening with the brain.

But an alternative is emerging. An imaging study called SPECT (single photon emission computed tomography) measures how well blood flows through the brain and can be performed safely on veterans who have shrapnel.

Two recent studies, one with 196 veterans and another with more than 20,000 patients, reported that SPECT could distinguish between PTSD and TBI with clinically significant accuracy. The study with the larger number of patients, led by Dr. Amen, was highlighted as one of the Top 100 Stories in Science for 2015 by Discover Magazine.

Being able to distinguish between PTSD and TBI is important because they can have overlapping symptoms, such as insomnia, anxiety, depression and concentration problems. But the treatments for them are different. Some treatments that help people with PTSD can actually be harmful to those with TBI.

The results of a SPECT scan also might give veterans who suffer from these conditions a new perspective on themselves.

Fewer than half of people with mental health problems ever seek help. One major reason: No one wants to be labeled mentally ill, defective or abnormal. This is especially true in the military where bravery and self-reliance are highly valued, and many believe that asking for help is a sign of weakness, or even a moral failing.

Seeing their own abnormal functional scans could help these veterans reframe their problems as brain-based and medical, rather than as moral, decreasing the shame and the stigma. At least that’s how it worked for Max, who had a SPECT scan that showed evidence of both PTSD and TBI.

In addition, knowing that the structure of the brain is normal, but the function abnormal, can give them hope that they could get better if they are diligent about rehabilitation.

So consider this: What if we reimagine mental health as brain health? This one simple idea could shift the negative attitudes many people have about mental illness, decrease stigma, and increase the willingness to get help among those who most need it.

We envision a time — hopefully not too far into the future — when mental health problems will be evaluated and treated like other medical issues, and physicians will use functional imaging tools, genetics, and other markers to guide treatment — just as cardiologists, oncologists or orthopedists do to help their patients today.

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Daniel Amen & Max Cleland
Daniel Amen, M.D., is a clinical neuroscientist and brain imaging expert who heads Amen Clinics in Orange County, Calif., Atlanta, San Francisco, New York City, Washington, D.C., and the Seattle area. He has written numerous books, including Healing ADD, and Change Your Brain, Change Your Life. Dr. Amen also has appeared as a guest on such TV shows as "The View" and was a consultant for the movie Concussion. Max Cleland is a disabled U.S. Army veteran of the Vietnam War, a recipient of the Silver Star for valor, former head of the Veterans Administration, and U.S. Senator from Georgia. He is a strong advocate for veterans and all of those who struggle with mental health issues.


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