Backstopping the Boston study that was the subject of my last blog (“Disturbing New Study”), a different team of researchers reported this week that National Football League retired players are four times more likely than the general population to die of brain diseases.

Dr. Ann McKee, a pathologist and co-director of the Center for the Study of Traumatic Encephalopathy at Boston University, told the Los Angeles Times that the new research “opens new avenues for research and validates our neuropathological findings…. It raises our concern about the risk of CTE, dementia and ALS and the way these conditions overlap.”

McKee’s team studied the brains of four military vets and four athletes, all of whom had been subjected to previous concussions, and compared them with four people with no history of brain damage. All the vets and the athletes showed symptoms of chronic traumatic encephalopathy (CTE), but none of the others did, the team reported last May. After showing that they could replicate that degenerative brain disorder in blast-exposed laboratory mice, the team concluded that everyone who suffered a brain injury — even a mild concussion — could be at risk of developing degenerative brain diseases later in life that can lead to memory loss, bad judgment, depression, outbursts of anger, thoughts of suicide and potential dementia.

The new study, reported Wednesday in the journal Neurology, was much broader. A team from the National Institute of Occupational Safety and Health, which is part of the Centers for Disease Control, tracked 3,439 retired football players with five or more seasons in the NFL.

The bad news is that they found these athletes four times as likely as other men their age to die of Alzheimer’s disease or amyotrophic lateral sclerosis (ALS), better known as Lou Gehrig’s disease. And it found that the league’s speed players, those who built up more speed before they made a tackle or were brought down by one, were at even greater risk.

The good news is that the risk is still relatively small. Among the 3,439 players the researchers tracked, 1,116 died during the study period. Of those, only 27 were found to have a neurodegenerative disease as an underlying or contributing cause of death.

“Although the results of our study do not establish a cause-effect relationship between football-related concussion and death from neurodegenerative disorders, they do provide additional support for the findings that professional football players are at an increased risk of death from neurodegenerative causes,” the study concluded.

Still, it was enough to shake up the NFL, which announced on Wednesday a $30 million contribution to the Foundation for the National Institutes of Health to support “research on serious medical conditions prominent in athletes and relevant to the general population.” It was the largest single philanthropic donation ever made by the NFL in its 92-year history.

“We hope this grant will help accelerate the medical community’s pursuit of pioneering research to enhance the health of athletes past, present and future,” said NFL Commissioner Roger Goodell. “This research will extend beyond the NFL playing field and benefit athletes at all levels and others, including members of our military.”

Good for the NFL. More research is clearly needed. But we also ought to be thinking about whether we can justify risking this kind of brain damage in sports or in wars that are not clearly in defense of our homeland.

For years, we’ve known that military vets make up an abnormally large percentage of our prison population, but new studies are showing that prison inmates are seven times more likely than the general population to have suffered a brain injury.

According to Scientific American magazine, about 8.5 percent of all Americans have a history of traumatic brain injury, with about 2 percent being disabled as a result. But it said that 60 percent of the prison population has had at least one TBI, which can alter behavior, emotion and impulse control.

On average, each year that a brain-injured person spends behind bars costs taxpayers $29,000.  Then think of the lost productivity and the lost lives of more than 2 million Americans in our system of so-called “corrections.”

That’s a loss so huge that it boggles the mind.

A profoundly disturbing report came out a couple of months ago, one that has ominous implications for hundreds of thousands of vets.

Basically, it says that everyone who suffered a brain injury — even a mild concussion – could be at risk of developing degenerative brain diseases later in life that can lead to memory loss, bad judgment, depression, outbursts of anger, thoughts of suicide and potential dementia.

That’s a huge concern because traumatic brain injuries are one of the signature wounds of our wars in Iraq and Afghanistan. According to the most recent Pentagon data, military doctors have confirmed traumatic brain injury in more than 244,000 of the 2.5 million troops who fought in those wars.   And the VA says that more than half the Iraqi/Afghan vets are seeking medical help after returning from service, and that half of them (28 percent of the returning 1.3 million vets) are seeking mental health treatment for PTSD, TBI or major depression.

This new study, “Chronic Traumatic Encephalopathy in Blast-exposed Military Veterans and a Blast Neurotrauma Mouse Model,” was released last May by a national consortium led by Boston University School of Medicine and the Department of Veteran Affairs.   It’s a very small study, comparing the brains of four dead soldiers, four athletes (three football players and a wrestler), and four others who had no history of brain injuries. But it’s a very significant study because, as one of the co-authors told me, it’s not easy for the family of a fallen warrior to donate his brain for research.

For years, doctors have believed that the brain heals itself after injuries. But this study casts doubt on that. It found evidence that even relatively mild brain injuries can worsen over time and end up as chronic traumatic encephalopathy (CTE), a degenerative brain disorder for which there is no treatment.

In all four of the vets and all four of the athletes, doctors found evidence of the beginnings of CTE: dead or dying brain cells, damaged axon fibers that communicate between nerve cells, and abnormal clumps of a toxic protein called protein tau. Protein tau is a normal part of the structure of nerve cells and provides what can be thought of as a railroad track providing nutrients to nerve cells; abnormal clumps of protein tau weaken the structure of nerve cells and reduce their flow of nutrients, according to Dr. Ann McKee, one of the study’s co-authors.

Those symptoms were not present in the third group with no reported concussions.

That merely confirms the conclusions already formed by McKee, co-director of the Center for the Study of Traumatic Encephalopathy at Boston University. A doctor who also directs the neuropathology center for the New England VA Medical Center, McKee has studied the brains of 68 people diagnosed postmortem with chronic traumatic encephalopathy, including 21 military vets, three of whom had previously been diagnosed with PTSD.

“We can show an association, but we don’t understand why a brain injury can trigger progressive neurological degeneration,” McKee told me.

But the team took one additional (and critical) step by developing a blast tube that created a force equivalent to a 120-millimeter mortar round which they aimed at mice.  The study’s other co-author, Lee Goldstein, an Alzheimer’s researcher at the Boston University School of Medicine, told me that it’s important to note that the blast tube didn’t replicate the variable blast conditions in the field – rather it replicated the same brain injury in the mice that doctors had found in human victims. “A single blast imitates a military blast and replicates virtually all aspects of CTE neuropathology found in humans,” Goldstein said.

First a supersonic blast force (a sudden and abrupt release of energy within a localized area) passed through the mice brains, doing relatively little damage. Almost simultaneously, a blast wind of more than 330 mph shook the mice heads, creating what’s called a “bobble-head” effect.

“Even though a shock wave rolled through the mice heads at supersonic speeds, there was no bleeding, no contusions, no rips in the tissue,” said Goldstein. “They looked for all the world like what we see in human cases of traumatic brain injury – the invisible injury that people have been talking about since World War I.”

Two weeks later after blasting the mice, Goldstein and his team found they were experiencing losses of short-term memory and learning capability. Later, when the mice brains were examined under microscopes, scientists found the early signs of CTE, including specialized cells called astrocytes strangling blood vessels, axons crumbling, and long tangles of the tau protein that doctors had previously observed in human Alzheimer’s patients. Goldstein told me that the blast wind damaged two of the longer structures in the mouse brains: small blood vessels and small nerve cells, leading to neural inflammation.

The new study did say that long-term behavioral deficits in mice could be prevented by immobilizing the head, a finding that could be useful to military commanders.

“Our results provide compelling evidence linking blast exposure to long-lasting brain damage,” the study concluded. “Specially, our study raises concerns that blast exposure may increase risk for later development of CTE and associated neurobehavioral sequelae.”

Again, the risk is unclear. “The incidence and prevalence of this disorder are completely unknown,” McKee told me.

But it’s not only combat vets who are at risk. It’s also kids playing combat sports like boxing and football. “The effects of blast exposure, concussive injury, and mixed trauma (blast exposure and concussive injury) were indistinguishable,” said the report.

Finally, it potentially affects all the rest of us who have ever suffered brain injuries. Personally, a quarter of a century ago, I slammed on the brakes and went over the handlebars of a bike.  I landed on my head without a helmet (never again!) and was unconscious from about suppertime until I woke up in an emergency room about dawn the next morning. This report says an injury less severe would put me at risk.

Mitt Romney may also have cause for concern. The Republican presidential nominee, famous for his explosive temper and his verbal gaffes such as introducing vice-presidential nominee Paul Ryan as “the next president of the United States,” was knocked unconscious in 1968 in an auto wreck in France that was so severe that he was mistakenly declared dead at the scene.

It’s unclear how many people afflicted with this kind of head injury will develop a degenerative brain disorder. “We have no idea of the level of risk,” said McKee. “All we can say is that we have identified it, and it is a problem with some individuals.”

Goldstein, however, said the study marked an important step in understanding this injury. “Now we have a mechanism and a model,” he explained, “so we’re well on the road to developing methods of prevention, treatment and rehabilitation.”

Last week, I wrote about alternative therapies for post-traumatic stress disorder and got a number of very interesting responses. We’ll delve into some profoundly troubling research and some promising future remedies in the next few weeks.

But today’s column is about one of the therapies I mentioned last week, a small hand-held device called Alpha-Stim that clips onto each earlobe and blows an alpha wave across the brain.  The alpha wave, the same wave produced during deep meditation, calms hyper-active patients and allows them to sleep. I saw it used at the Rimrock Foundation in Billings, Mont., where the founders raved about it.

But my column drew an anguished blast from Dr. Daniel Kirsch, chairman of the board of Electromedical Products International, which produces Alpha-Stim. He charged that the federal Food and Drug Administration has been trying to shut down his product and others like it, which are called cranial electrotherapy stimulation (CES) devices, even though they’ve been safely used by thousands of patients over the past 40 years.

By coincidence, Stars and Stripes also wrote about the controversy last weekend.

According to its article, the FDA has been regulating medical devices since 1976, but the Safe Medical Devices Act of 1990 required it to evaluate even devices that had previously been grandfathered in to determine which classification they should carry: Class I, II, or III. Class III is considered a life-sustaining or life-support device.

The FDA concluded earlier this month that CES devices were Class III, which requires extensive and expensive trials for market approval. And it concluded that it couldn’t use previously conducted research. “FDA reviewed scientific literature provided by CES manufacturers and other available information, and concluded that the effectiveness of CES has still not been established by adequate scientific evidence,” said the FDA in a statement provided me in lieu of an interview with the official who signed the order.

“They threw out all our studies, which left us with no research,” said Kirsch.

That’s a problem because CES sales to the military have grown steadily in the past five years. EPI has filled 3,000 prescriptions for the Department of Defense, Tricare and the Veteran’s Administration in that period, and the Army Office of the Surgeon General’s Pain Management Task Force recommended CES for pain management in 2010.

According to Stars and Stripes, Jerry Wesch, director of the Warrior Combat Stress Reset Program at the Darnall Army Medical Center at Fort Hood, Texas, called CES a key component of PTSD treatment, as well as pain management. “I am reluctant to treat PTSD in our population without this tool in the mix,” he wrote the FDA, adding that about 80 percent of the 500 soldiers who completed the program had decided to continue to use CES devices during their follow-up treatment.

Dr. Stephen Xenakis, a retired Army brigadier general and psychiatrist in Washington, D.C., told Stars and Stripes he had been prescribing CES devices for about two years. “I like it for patients who’ve been on many drugs and you don’t want to give them another drug,” he said.

It’s an issue that has come to public attention because PTSD and traumatic brain injuries are the signature injuries in our wars in Iraq and Afghanistan. According to the most recent Pentagon data, military doctors have confirmed traumatic brain injury in more than 244,000 of the 2.5 million troops who fought in those wars.   And the VA says that more than half the Iraqi/Afghan vets are seeking medical help after returning from service and that half of them (28 percent of the returning 1.3 million vets) are seeking mental health treatment for PTSD, TBI or major depression.

“We are working as expeditiously as possible towards final adjudication of these devices and the other remaining Class III pre-amendment device types to minimize uncertainty for industry and other stakeholders,” said the FDA’s statement.

“My feeling is, from the standpoint of the military, we’re facing what I’d say is an epidemic,” Xenakis told Stars and Stripes. “We’ve got hundreds of thousands of people with problems with alcohol and misconduct and suicide risk, all those kinds of things. We’ve got treatments that are safe that might work. We’ve got to jump on it.”

I couldn’t agree more. Sleep is the time when the brain repairs, rewires and heals itself. And a device that calms an agitated, anxious soldier down enough that he can sleep at night is a valuable tool.

There’s been a long silence between my last two posts. I’d like to apologize … and explain why.

Living in West Virginia now, we got slammed by the June 29^th derecho. Susie and I were on the eastbound Amtrak that day, heading up to Connecticut to see our children and granddaughter. The storm – 600 miles long with winds up to 80mph – was actually chasing us east, but we didn’t know it. In Virginia, we saw the westbound Amtrak pass us; later, I learned that the train was stopped by downed trees in West Virginia and that 320 passengers sat on the train for 20 hours waiting for crews to clear the track.

When we got home five days later, we found that a big oak had crashed across our driveway, five others were down around the house, and a dozen more trees had been blown over on a ridgeline just behind our house. Some had been uprooted, but many trees were just sheared off midway, leading 20-foot-tall stumps.

Mercifully, the house and garden were undamaged.

However, we were without power for 13 days and without internet/cable/telephone for 15 days. In fact, our main power line was repaired by 10 emergency crews on loan from New Orleans.

So it has taken some time to catch up on the many things that needed to be done while we were without power, phone and internet. And that also explains the long silence.

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I’d also like to fill you in on an ambitious campaign by my publisher, Idyll Arbor Press, to get copies of my latest book, Faces of Combat: PTSD & TBI, into the hands of as many veterans as possible.

Idyll Arbor is sending a copy of my book to every VFW state headquarters.  And it promises to donate one book to a VFW post for every book it sells.

So if you haven’t read Faces of Combat, this is a great time to do so. If you buy a copy today, Idyll Arbor will send a free book to a VFW post where it can be help vets and their families understand the emotional and neurological injuries they may have brought home from combat.

Or if you’ve already been moved by Faces of Combat and want to make a donation, Idyll Arbor has an even better offer. “If someone wants to buy a few books to donate somewhere, we’ll give them a 50% discount and send out the same number of books to VFWs,” says my publisher, Tom Blaschko. “It’s like getting four books to people who can use them for the price of one.”

So please help us get more of these books into the hands of vets and their families.

Combat veterans who suffer from post-traumatic stress disorder or traumatic brain injury could benefit from some non-traditional treatment that could be approved under legislation now pending in Congress.

But all vets need to be alert because the Senate is poised to undermine a very important PTSD/TBI treatment expansion initiative that has already been approved by the House of Representatives.

Congressmen Mike Thompson of California and Pete Sessions of Texas added language to the National Defense Authorization Act (HR4310) that would create a new five-year, $10 million pilot program to ensure that alternative therapy treatments are available for active-duty soldiers and veterans.

Called the “PTSD/TBI treatment expansion initiative,” the pilot program would encourage vets to seek treatment from private providers outside the Department of Defense and the Veterans Administration.

If a patient can prove a demonstrable improvement, the pilot program would pay for the treatment.

Furthermore, the program would be required to report its progress annually to Congress. And the secretaries of Defense and Veterans Affairs would also be required to report how they planned to incorporate successful alternative treatment methods into their own medical facilities, thus encouraging a constant flow of innovative and effective treatments.

All too often, government treatment for vets has been limited to pharmaceuticals and group therapy. This bill could open the door to therapies like eye movement desensitization and reprogramming, emotional freedoms techniques, and the Alpha-Stim device, which have not been available to many vets through government programs.

“Our troops and veterans have earned the very best treatment and care that we can provide,” says Thompson, co-chair of the bipartisan Military Veterans Caucus. “But sometimes the best treatments aren’t available at military and veterans medical facilities. My amendment will make sure that our heroes who return from combat with TBI and PTSD have access to the highest quality care that our nation has to offer.”

The treatment expansion initiative was part of the National Defense Authorization Act which passed the House last May 12. It was then sent to the Senate Armed Services Committee, which passed it out June 4.

But the Senate version is far different — and substantially worse .

In the Senate version of the bill, the Secretary of Defense would be required to devise a plan to streamline programs “that address psychological health and traumatic brain injury among members of the Armed Forces.”  It would require him to fill any gaps in service and eliminate any redundancies, but there’s no mention of alternative treatments.

The secretary would also be authorized – but not required – to carry out a research program with community partners to “engage in research on the causes, development, and innovative treatment of mental health and substance use disorders and traumatic brain injury in members of the National Guard and Reserves, their family members, and their caregivers.” But there’s no funding attached to the so-called research program.

Finally, the Senate bill only deals with active-duty soldiers, not with vets being treated by the VA.

As of last year, 1.3 million of the 2 million-plus soldiers serving in Iraq and Afghanistan since 2002 had left military service and were eligible for VA health care. About 700,000 of them (53 percent) have sought health care from the VA.

According to the VA’s statistics, 367,749 Iraqi and Afghan vets have sought mental health care treatment. That’s 51.7 percent of the total caseload—and also 28.2 percent of the returning 1.3 million vets—a number that’s sure to grow larger as those who returned home recently begin acknowledging cases of delayed PTSD. It’s common for vets not to begin experiencing combat until after the euphoria of being home has waned, typically six months to a year or more.

For years, vets have complained that the treatment options offered in military and VA clinics have been inadequate, that they should be able to explore alternative therapies being offered by primary care providers. Under the House bill, that would have been possible.

So this is a time for all vets to write their senators and tell them that they should amend the National Defense Authorization Act to restore the Thompson/Sessions language in the House bill.

There’s new hope for combat vets who have what I’ve been calling “wounded souls.” (See my blogs Wounded Souls I-III)

Last week, the military newspaper “Stars and Stripes” reprinted an article about a new treatment facility called the Soul Repair Center at the Brite Divinity School at Texas Christian University.

It reflects a growing recognition that post-traumatic stress disorder is a medical diagnosis that’s too broad. Part of PTSD involves the stress of being targeted, shot at, mortared or bombed; warriors have experienced these symptoms for thousands of years. But after observing returning Iraq and Afghanistan vets, some mental-health professionals, military chaplains and civilian ministers now call some of those symptoms “moral injuries.”

“In the medical model, all the bad mental-health things that can happen come from PTSD,” Brett Litz, a clinical psychologist and professor in Boston who is conducting research funded by the Defense and Veterans Affairs departments, told the Fort Worth Star-Telegram. “That’s simplistic thinking. It says that the only harmful aspects of war are about life threats. That’s too narrow. Even though it’s controversial, it is critically important that we think about other ways that war affects people psychologically, biologically, spiritually and morally.”

About 2.6 million men and women have served in Iraq or Afghanistan, including hundreds of thousands of National Guardsmen and reservists. Most of them have served multiple tours of duty in guerilla warfare combat. Roughly 2 million of them have already left military service, and the VA is finding that one vet in three is seeking medical help for emotional injuries such as PTSD, anxiety or major depression.

According to the current DSM-4, PTSD is a medically defined anxiety problem caused by a life-threatening event, with symptoms that include flashbacks, nightmares, hypervigilance and emotional withdrawal.

Moral injuries are different in that they are brought about by “perpetrating, failing to prevent or bearing witness to acts that transgress deeply held moral beliefs and expectations,” according to the VA. While an individual can have both PTSD and moral injuries, experts said, the causes of moral injuries are often different.

One of my friends came back from Vietnam, where he’d been a dog handler, and told me that he had violated every moral principle that he’d been taught in church and in the Boy Scouts. While medical and counseling treatments are available for PTSD, there is a growing recognition that moral injuries need to be treated differently.

“The VA can’t do anything for someone who says, ‘I have sinned,'” said D. Newell Williams, president of the Brite Divinity School. “Religious communities have answers to confessions of sin.”

Brite intends to develop a curriculum to teach divinity students how to work with veterans; conduct research and publish papers; work with other divinity schools nationwide; reach out to military chaplains; and build a Web site for clergy to consult when someone in their congregation is struggling.

The school also intends to form a “think tank” of scientists, clergy, mental-health professionals and combat veterans to drive all of its missions, Williams told the Star-
Telegram.

“Five years from now, what we’d like to see is, if you are a veteran who lives on the West Coast or in the Northeast, that there would be a trained clergyperson you could go to within a day’s drive and talk to,” Williams said. “If, after five years, all there is is a center at TCU that helps veterans in this area, we will have failed.”

You might say that Matthew Pennington found his own life while playing another.

A severely wounded combat vet, Pennington was deeply into post-traumatic stress disorder – but didn’t know it. Life seemed pretty normal to him, just as it does to someone suffering from hypothermia. You don’t know you’re in trouble until you’re really in trouble.

Then Nicholas Brennan, a film major at New York University, invited him to play the main character in a film he’d written called “A Marine’s Guide to Fishing.” It starred a young Marine who came home to Maine after the war in Iraq with one leg missing and a severe case of PTSD.

It was a neat fit. Pennington is a former Army sergeant who served three tours of duty in Afghanistan and Iraq. A roadside bomb removed his left leg, shattered his right leg and scorched his lungs. After a year of inpatient and outpatient treatment at the Walter Reed Medical Center in Washington, D.C., he also came home to Maine.

When I went back to Maine, I thought I’d be helping others. Instead, I was the one who needed help,” Pennington told me last week. “I never re-acclimated. I just came home and started shutting down.”

Pennington’s relationships, particularly with his wife, were deteriorating rapidly. Drinking heavily, he seldom left the house except for late-night runs for food and beer. “I didn’t like civilians, and I didn’t like to deal with them,” he explained. “I saw a lot of ungrateful people who had every privilege and amenity, but they’re always complaining and bickering. So to avoid dealing with them, it kept me pretty well housebound.”

Working with a group of New York City vets, Brennan had created a script that Pennington could identify with, so he decided to try his hand at acting. “I thought acting would be so out of the normal that it would force me to deal with things,” Pennington told the New York Times, which profiled his story six months ago. “I wanted my life back.”

Pennington and Brennan were in Charleston, W.Va., last week to screen their film before an audience at the Covenant House, an inner-city institution that provides help to the homeless and indigent.

“As I acted this part, I was able to identify with PTSD for the first time,” Pennington told the group. “I realized what it was, and I recognized that I had it. I went to the VA for treatment, but I always came out with a big bag of drugs.  So I began to go to the Vet Center. They can’t prescribe drugs, but they taught me coping skills.”

Now drug-free, Pennington relies on what he calls the “three-step trick” to help him focus on the present instead of sliding back into traumatic memories. When he begins to feel antsy, he closes his eyes and conjures up a strong memory of home.  Then he opens his eyes and checks his wristwatch for the time and date. Finally, he checks to see where he is at that particular moment and how he is going to get home.

“That puts me in the present instead of the past,” he explained.

But it took some time for Pennington to learn it. “There’s one scene (in the movie) in which the main character tries to go fishing and wind down, but he can’t wind down,” he said. “Instead, he’s always thinking about over there. That really hit home with me.”

The 15-minute film, which Brennan said finally came together after 14 drafts and two years of research and writing, sparked a lot of comments and questions from the audience. Two Vietnam vets talked about how much they identified with the main character, although PTSD did not become a medically recognized disorder until 1980 and they didn’t realize the extent of their emotional wounds.

But even having the diagnosis is a double-edged sword, Pennington said.

“There’s a stigma to PTSD,” he said. “People read about vets with PTSD shooting themselves or shooting someone else or running amok, and they treat you like you’re some kind of psycho. It’s not a label you want to be associated with. Any vet who can tough through it and not admit he has PTSD is going to go that route.”

The film screening was sponsored by Patriots for Peace, an anti-war group that has been active in opposing the Iraqi war. “For years, we’ve been protesting the war and demanding that we bring our kids home,” said Jim Lewis, a retired priest who was one of the organizers. “Now we felt it was important to change our focus and work on how to help the vets once they get home.”

To learn more about the film or to buy a DVD, visit this Web site: http://amarinesguide.com/

Recently, I wrote about a whitewater rafting program in Montana, the X Sports 4 Vets program, as therapy for post-traumatic stress disorder, and I remember talking with a vet named Steve Hale, who deployed to Iraq in 2004-05 with the Washington National Guard and who came home depressed and unable to socialize with others. The river outings gave him great exercise, an adrenaline rush and a feeling of teamwork with his rafting buddies, who were also vets.

“Every time I get out on the river, I come home with stories and big pleasant memories,” Hale told me. “It does me a lot more good than the pills they’ve been throwing at me.”

Perhaps, just perhaps, the Army is beginning to get a piece of this picture.

Last month, the U.S. Army Medical Command issued a report changing its policy on pharmaceuticals. It said that only Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) have shown evidence that they do enough good for a patient to justify the prescription.

It strongly cautioned against prescribing benzodiazepines and atypical antipsychotics, saying that they do more harm than good. “There is evidence to suggest that benzodiazepines may actually potentiate the acquisition of fear responses and worsen recovery from trauma,” it said. As to atypical antidepressants, and specifically Risperidone, it said: These medications have shown disappointing results in clinical trials in the treatment of PTSD.”

Last weekend, the Philadelphia Inquirer quoted the assistant secretary of defense, Dr. Jonathan Woodson, as saying that prescription rates for atypical antidepressants increased 10 times between 2002 and 2009: from 0.1 percent to 1 percent. It said AstraZeneca’s Seroquel was prescribed to 1.4 percent of Army personnel and 0.7 percent of the Marines in fiscal 2010.

AstroZeneca reportedly made nearly $6 billion on 14.1 million prescriptions for versions of Seroquel last year.

It told the Philadelphia Inquirer: “Seroquel is not approved for the treatment of PTSD or indicated for use as a sleep aid. Atypical antidepressants, like many other medications, are often prescribed by mental-health professionals for indications beyond those set forth in the FDA-approved labels. Like patients, we trust doctors to use their medical judgment to determine when it is appropriate to prescribe medications. Patient safety is a core priority for AstraZeneca, and we believe that Seroquel is a safe and effective medication when used as recommended.”

Risperidone was the second most-prescribed antipsychotic drug during that period with 12.2 million prescriptions written nationwide.

The Army also broadened its preferred list of psychotherapies for soldiers, saying that trauma-focused PTSD treatment can include narration (including imaginal exposure), cognitive restructuring, in-vivo exposure, relaxation or stress modulation skills, and psycho-education. It specifically mentioned programs such as Prolonged Exposure Therapy, Cognitive Processing Therapy, Eye Movement Desensitization and Reprocessing (EMDR), or “other forms of trauma-focused cognitive behavioral therapy, all of which have been shown to have generally equivalent effectiveness.”

Since PTSD often occurs in conjunction with other mental health problems, it encouraged multidisciplinary approaches, including hypnosis, art therapy, bio/neurofeedback, yoga, acupuncture, and massage.

The new policy noted that some patients may prefer such therapies to pharmaceuticals. “Matching evidence-based components to patient preferences is likely to help in fostering engagement and willingness to remain in treatment, which ultimately is one of the strongest predictors of overall treatment efficacy,” it said.

Attached to the report was a chilling article written last year for JAMA, the Journal of the American Medical Association. Dr. Charles W. Hoge of the Walter Reed Army Medical Center concluded: “With only 50 percent of veterans seeking care and a 40 percent recovery rate, current strategies will effectively reach no more than 20 percent of all veterans needing PTSD treatment.”

According to the Army, up to 25 percent of the more than 2 million troops deployed to combat zones in Iraq and Afghanistan may experience PTSD “with combat frequency and intensity being the strongest predictor of this condition.”

But four years ago, the Rand Corp. interviewed 1,965 vets and projected in its controversial 2008 report that 18.5 percent of all returning service members would meet the criteria for either PTSD or depression (14 percent for each, but there’s some overlap), and that another 19.5 percent would experience a probable traumatic brain injury while overseas. Again after taking into account that overlap, it said 31 percent of all returning troops would suffer from one or all of those ailments.

The VA’s actual treatment figures show 28.5 percent of the returning vets are seeking mental health care, which is right on track with the Rand Report. But while the Rand Report projected that some 320,000 American soldiers would need help for TBI, the VA says only 54,070 vets (a little over 4 percent of the returning vets) qualified for that diagnosis.

We’re walking along a dusty gravel road in the valley between two West Virginia ridges when the Iraqi War hero that I’m interviewing suddenly notices something troubling.

“I planted a bamboo shoot beside that stream and arranged some rocks as a memorial to a fallen soldier who was a friend of mine,” says James. L. McCormick, his voice tightening a little. As I look down toward the stream, I can see a hole where the bamboo has been ripped out and the stone memorial has been kicked apart.

McCormick has seen a number of friends fall, but many more foes drop. He won his first Bronze Star and a Purple Heart for leading attacks on enemy bunkers during Desert Storm as a scout squad leader. Then he was awarded two more Bronze Stars and two more Purple Hearts for his service in Iraq. And the retired Army captain has also been nominated for the Distinguished Service Cross and the Silver Star, the nation’s second- and third-highest military awards for valor.

“This guy is the Audie Murphy of the truck drivers,” says Rich Killblane, the U.S. Army Transportation Corps historian based in Fort Lee, Va. “No truck driver has been in as many ambushes as he has, and all the big ones.”

These days, McCormick has bought a 15-acre farm a few miles east of the Ohio River for his own peace of mind and to help his fellow vets. He calls it the “Raising Cane Farm,” and for erosion control on steep hillsides, he plants as much bamboo as he can afford at nearly $20 a plant.

“I provide jobs for some vets out of my own pocket,” he says. “Others just come out here to walk and relax. And we bring a bunch of guys out here for the deer hunting each fall.”

Taking care of his fellow vets remains important to McCormick. “I’ve told a bunch of my battalion commanders that just because you retire doesn’t mean that you can retire your responsibilities,” he says.

Those responsibilities weigh heavily on McCormick, especially when someone desecrates his memorial to a fallen comrade.

“I’m about half tempted to mount an ambush, catch this guy red-handed if he returns, and whip him with the bamboo he was attempting to steal,” says McCormick, trying to laugh off a growing sense of outrage.

Killblane says McCormick was no one to mess with. “Before he turned his life over to Christ, if he threatened to kill you, he probably would have,” he observes.

Killblane is writing a book about convoy ambush case studies that teach convoy commanders how to fight ambushes and a history of convoy operation during the war in Iraq. He says McCormick was one of the most instinctive warriors he has seen. “His philosophy was to punish the enemy to deter him from attacking any more convoys,” he says. “Of all the ambushes I’ve researched, it’s McCormick who stands out the most.”

The days leading up to Easter Sunday, 2004, prove Killblane’s point.

First, McCormick and his gun truck crew ran into their first ambush on March 22 when they turned back into the kill zone. That was when the lieutenant was wounded in the calf earning his second Purple Heart Medal.

Despite his protests, McCormick was sidelined while his platoon left on a mission without him.  Then on April 7, after the radical young cleric Muktada al Sadr called for a jihad against coalition forces, McCormick and picked up an all volunteer crew to provide security for a convoy hauling supplies to Baghdad International Air Port (BIAP), where the convoy ran into an L-shaped ambush with a sniper positioned on an overpass in front of them.

McCormick was hit in the chest, with his body armor absorbing the blow. Still he was knocked backward off his feet, while a second round hit his machine gun ammunition belt, sending shrapnel into his hand, says Killblane.

“Remembering what a Vietnam veteran told him, when insurgents approached, McCormick fired a flare at them and they scattered thinking it was a rocket,” Killblane says. “That gave him enough time to re-load his machine gun, and then he splattered the sniper who was then about to shoot his driver.”

The next day, Good Friday, all hell broke loose as the enemy ambushed any convoy trying to get in or out of BIAP. The next day, all convoys were shut down but the 1^st Cavalry Division, which drew its supplies from BIAP was running critically short.

On Easter Sunday, McCormick and his crew volunteered to escort a convoy hauling critical ammunition to the Green Zone, just eight miles away, but about noon a sea of insurgents began storming their compound with the intent to breech the wall and kill the hundreds of truck drivers parked behind it.  “When his Humvee gun truck mounted the ramp overlooking the wall, all he could see were Iraqis in black.” says Killblane. “For five to ten minutes, McCormick and his crew held off the attack by themselves and then for the next forty minutes only a dozen truck drivers defended the wall.”

Thirty minutes after repelling that attack, McCormick and his emotionally exhausted crew provided security for an ammunition convoy running a gauntlet eight miles to the Green Zone. Since the commander broke his convoy into four smaller convoys, the gun trucks had to make the dangerous run four times.

“They were driving thin-skinned (not armored) trucks, and they got hammered while other armored gun trucks turned tail and ran,” says Killblane. “On the next run, they got ambushed again, but McCormick turned his gun truck into the enemy and it seemed to work because there was less gunfire on the next convoy, and the fourth run was almost incident-free.” By the end of the day, four of the five crew members in his gun truck had been wounded and would still follow him anywhere, says Killblane.

For the ambush going into BIAP, McCormick was awarded the Bronze Star. McCormick later earned another Bronze Star, but has been nominated for the Distinguished Service Cross for his action on Easter Sunday and the Silver Star for his leadership during 40-minute firefight on January 30, 2005. “Lt. McCormick’s warrior spirit and leadership under fire saved hundreds of lives, protected critical military cargo and inflicted heavy enemy casualties upon a ruthless and determined enemy,” said the citation nominating McCormick for the Distinguished Service Cross, which is still pending review.

“His actions were probably the most heroic of any truck driver in Iraq,” Killblane says. “He was grossly overlooked.”

After he left Iraq, McCormick says he spent a year and a half in the VA’s poly-trauma unit in Huntington, W.Va.  “I couldn’t do anything for myself,” he explains. “I slept with a loaded revolver and drank heavily and smoked like a freight train. I had panic attacks and I couldn’t find anything to bring me down, so I did a lot of heavy drinking. When I had nightmares, they terrified my wife, and she’d go out and sleep on the couch.”

Buying the farm between Huntington and Point Pleasant helped.

“This is a place where vets can come and realize that we’re finally at peace,” he says. “This place has so much more healing power than anything you get out of a bottle, either alcohol or pills.”

But McCormick’s 13-year-old son Jimmy had been watching him closely. “You’re really upset about that memorial, aren’t you Dad?” he asked, just as I was leaving.

McCormick emailed this resolution to me the next day: “I said yes it did son, very much so, because we planted it for all fallen troops and to see that just brought back a wave of bad memories on how people died that I personally knew. To me when I saw it, I could hear the crying and see the death all over again. It was simply a violation in the worse way to me, and since it is well know what we do out on the farm I couldn’t help but see it as an intentional slap in the face of not only me but every Gold Star family I know.

“My son is very much in tune with his feelings and looked at me and said. ‘Let’s plant another one, Dad, in the same spot and let me do something to honor your friends.’ He walked the length of that stream picking out all the stone to lay the walkway, he planted the plant again and asked me to help him with the cross, and truly he did most of that as well. I asked him what if someone tears it up again. He said well then we will just come back and build again only this time bigger. On Sunday, he bought flower seeds and next weekend we will plant them around the outline of the cross, again his idea. Got to love that boy.”

I wrote recently that neuroplasticity has the potential to be very helpful to combat vets because a “plastic” brain that has been changed by trauma can continue to change. Good memories can layer over and alleviate the bad ones. My last blog on whitewater rafting as a therapy for post-traumatic stress disorder (PTSD) suggests that this concept works.

But there’s a downside that vets are particularly susceptible to. Dr. Norman Doidge, author of the best-selling book “The Brain That Changes Itself,” calls it “the plastic paradox.” Because the brain is neuroplastic, mental experiences can change it and create completely novel circuits in the brain. There’s a lot of flexibility in the brain, but not all change is good.  The same plasticity that can give rise to flexible behaviors can, if mental experiences are repeated over and over, lead to rigid, repetitive behaviors.

Doidge, a medical doctor and a psychiatrist affiliated with both the University of Toronto and Columbia University, says this occurs in vets with PTSD. PTSD is a neuroplastic disorder par excellence because a person with a functioning nervous system experiences an event, the meaning of which is so overwhelming to the mind that soon the brain is completely rewired by it.

Let’s walk through how this works.

First, the trauma of an intense firefight or your buddy dying in your arms overwhelms your brain, causing it to change its structure and function. It’s now on high alert for a new threat. “The event so overwhelmed the brain when it first occurred that it overwhelmed the circuitry that allows the victim to turn the event from a perception into a memory, something our brain normally does the moment an event is over,” Doidge told me.

And that’s the cause of flashbacks, Doidge says. “Each time people have ‘flashbacks,’ they are experiencing unfiled perceptions of the horrible event — not memories. (We mistakenly call them memories because they seem to be repeats of what happened, but subjectively, flashbacks are more like perceptions, and sometimes almost more like hallucinations.) And since the brain thinks the event is still happening, this triggers the threat system in the brain. Neurons that fire together wire together, so each time the flashback occurs, it more deeply connects the images involved in the flashback with the threat system. Soon the threat system is on when it shouldn’t be,” says Doidge.

With the threat system on high alert, vets don’t live normal lives. And this is generally accompanied by depression, anger and compromised thinking ability, which lead vets to isolate themselves. Doidge says: “As they withdraw from activities, the circuitry for those activities begins to weaken. (Another plastic principle is that it is a use-it-or-lose-it brain, and neuronal connections that are not reinforced will atrophy or weaken.) They might try and do high-level activities, but their brains have trouble with them. Soon they develop something called learned non-use. Learned non-use is not a form of laziness; it is what the brain takes away from repeated efforts to do something, and finding it can’t.”

That is to say, when the brain repeatedly tries and fails to do something, it deploys its resources in other areas. If a vet needs companionship, but his brain can’t force itself to mingle with other people in a crowd, it will ultimately quit trying. And so harmful habits can become part of learned behavior too, Doidge points out.

Compounding these problems is a lack of sleep. Many vets are plagued with nightmares, sometimes called night terrors, which are like sleeping flashbacks. Others are on alert waiting for a night attack or patrolling the perimeters of their backyards to keep their kids safe from the bad guys. But that lack of sleep inhibits healing.

“With the threat system so often on, screaming ’emergency,’ they can’t sleep normally, concentrate, do high-level thought, and they withdraw from their normal activities,” says Doidge. “This adds a new burden on the nervous system. Sleep is necessary for resetting the brain, consolidating new learning, working through trauma, and the healing and the immune system.”

That helps to explain why vets have been helped by devices like Alpha-Stim, which wafts an alpha wave through someone’s brain from earlobe to earlobe. At the Rimrock Foundation in Billings, Mont., in about 20 minutes of therapy, I watched a young drug addict and beating victim change from a tense young woman who couldn’t sleep to a very tired teenager who badly wanted a nap. Now there are also recordings that do pretty much the same thing.

So sleep helps the brain to restore some of the damage. Here are some other therapy suggestions from Doidge, whose book, “The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science,” is about the neuroplasticity revolution and how it is helping people like our combat vets. It’s a remarkable book.

Doidge says: “What is required is a treatment that can do two things. We know that to actually change a circuit, at some point we have to activate it, and then it enters a more malleable state. And we have to activate it while the person’s threat system is turned down. A number of treatments can do this: Eye Movement Desensitization, and Reprocessing (if done while the person’s mental resources are maximized), a related treatment called Brainspotting by David Grand, some energy therapies, certain kinds of hypnosis, and a new treatment that has people read over detailed narratives of their traumas while taking (for a few hours) an old antihypertensive drug called Propranolol which quiets the autonomic nervous system. In many cases, they can all accomplish this successfully. These are all neuroplastic interventions because they use mental experience to alter brain circuits.”

So there you have it, one of the best neurological explanations of PTSD that I’ve seen. But we’re going to have to continue working on the therapies.