TIME Mental Health/Psychology

How Effective Are PTSD Treatments for Veterans?

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Though many treatments for PTSD can alleviate symptoms, veterans continue to meet the criteria for the disorder

A new study published Tuesday suggests commonly used first-line treatments for PTSD in veterans may not work as well as medical experts once thought.

The number of American veterans who suffer from PTSD continues to be a serious national public health problem. Recent data show that more than 200,000 Vietnam War veterans still have PTSD, and other research shows that around 13% of Iraq or Afghanistan veterans who experienced combat have PTSD. The numbers continue to climb. As TIME previously reported, PTSD diagnoses among deployed troops grew by 400% from 2004 to 2012.

Now new research, published Tuesday in the Journal of the American Medical Association, reveals that go-to treatments for the disorder may not be as effective as many in the medical community may have believed or hoped. To reach their findings, researchers from the Steven and Alexandra Cohen Veterans Center for Post-Traumatic Stress and Traumatic Brain Injury at NYU Langone Medical Center reviewed 36 randomized control trials of psychotherapy treatments for veterans suffering from PTSD over a 35-year span. Two of the most commonly used treatments—and the most widely studied—are cognitive processing therapy (CPT) and prolonged exposure (PE) therapy.

CPT is a treatment that focuses on changing dysfunctional thoughts, and exposure therapy is meant to help patients face what’s causing them stress and fear.

The research showed that while up to 70% of the men and women who received CPT or PE experienced symptom improvements, around two-thirds of people receiving the treatments still met the criteria for a PTSD diagnosis after treatment. The researchers note that current veterans affairs policies emphasize the use of the two methods as treatments of choice.

The researchers also argued that veterans with PTSD are likely to have worse outcomes from treatment compared to civilians with PTSD. Though the researchers are unsure why that is, there’s some speculation: “Compared to civilian traumas such as car accidents and natural disasters, military deployment involves repeated and extended trauma exposure,” says study author Maria M. Steenkamp, an assistant professor of psychiatry at NYU Langone. “It also involves not just life-threat, but exposure to traumatic losses and morally compromising experiences that create shame and guilt.” Veterans are also more likely to have additional mental health issues such as anxiety or substance abuse, she adds.

The researchers also raise the question of whether focusing on trauma during PTSD treatment is really that effective. Based on their review of the trials, they found that when CPT and PE were compared to non-trauma focused psychotherapy, patients showed similar improvement.

However, not everyone agrees that the findings should be cast in such a light. Dr. Paula Schnurr, the executive director of the National Center for PTSD under the U.S. Department of Veterans Affairs says there’s not consensus that veterans have a more difficult time overcoming PTSD symptoms compared to civilians, and adds that some people who treat veterans feel avoiding fears and trauma perpetuates problems, rather than processes them. In addition, symptom improvement is an important part of PTSD treatment since it improves veterans’ quality of life. Schnurr was not involved in the study, though some of her own research was analyzed in it.

“If a person has a meaningful response, they have a meaningful improvement in their quality of life,” says Schnurr, adding that many treatments for other mental health conditions have similar outcomes. “As scientists we will always try to enhance the effectiveness of these treatments for more people…My takeaway message [from the study] is one of optimism and also encouragement for people to seek treatment.”

The researchers say other treatment options should continue to be explored, and there are practitioners who are trying different methods, from acupuncture to healing touch therapy. Another new study published Tuesday in JAMA looked at 116 veterans with PTSD who either underwent mindfulness-based stress reduction therapy that focused on being present and non-judgmental in the moment or a present-centered group therapy that focused on current life problems. The results showed that those in the mindfulness group had a greater improvement in self-reported PTSD symptom severity. However, they were no more likely to lose their PTSD diagnosis.

There may not be a cure yet for PTSD, but the amount of research looking into how to improve or innovate treatments is encouraging. Veterans who need support can find resources here.

TIME Mental Health/Psychology

Why You Should Worry About Picky Eaters

Despite the fact that many doctors dismiss picky eating as just a phase, a new study shows it may be a sign of deeper issues

Rare is the child who will eat pretty much anything. Most toddlers develop specific favorite foods and, of more concern, absolute no-go foods.

To a certain extent, that’s normal. But when eating preferences make it difficult for the child to eat with others, that could be a sign of more serious sensitivities, say scientists in a report appearing in Pediatrics.

Nancy Zucker, director of the Duke University Center for Eating Disorders, and her colleagues looked into the implications of picky eating when she made a connection between more and more adults with eating-related issues who reported having been picky eaters as children. No studies had looked in depth at the longer term effects of selective eating during childhood, so Zucker studied 917 children two to nearly six years old who were enrolled in an anxiety study. The children’s parents recorded their eating habits, and the researchers conducted tests to determine how the children scored on measures of anxiety and symptoms of mood disorders.

About 20% of the children were picky eaters, meaning they either ate only a restricted number of foods or could not eat with others because of their limited range of food preferences. Only about 3% fell into the latter category of severe selective eaters. Those children were more than twice as likely to be diagnosed with depression or social anxiety. Even children in the moderately picky eating group were more likely to show symptoms of depression, social anxiety or attention deficit-hyperactivity disorder compared to children who weren’t picky eaters.

Zucker says the findings shouldn’t alarm parents, but should help them and their doctors to start being more specific about when picky eating is normal and when it should be seen as a sign of possible anxiety issues. What may be happening, she says, is that selective eating may be a symptom of a broader hyper sensitivity. So for certain children who see, feel, hear and taste their world more intensely, being picky about which foods they eat may be a way of coping with an otherwise overwhelming influx of sensory information. “The restriction and narrowness in eating is a way of simplifying their rich, overwhelming world,” she says.

She stresses that it’s only a theory, but in her study, there was evidence that for the severe picky eaters, and for some of the moderately picky ones, their aversion to certain food tastes and textures wasn’t just ‘yuck’ but involved gagging.

While Zucker doesn’t want to turn picky eating into a “medical” condition, she does feel that parents need more guidance from pediatricians about what to do if their children become selective eaters. Parents are already confused by advice from pediatricians that includes urging them to feed their children a varied diet, including fruits and vegetables, to help their development, but at the same time telling them not to worry if their child refuses to eat certain foods.

Her advice? “Try to get meal times back,” she says. That means not trying to force children to eat foods they don’t like at meals, since they’ll start associating the table with unpleasant experiences. Instead, try introducing them to new or non-favorite foods at different times, as part of food adventures, to help them become more comfortable with and willing to try new things.

Read next: This Is How Much It Costs To Raise A Ballerina

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TIME On Our Radar

See the Lives of China’s Mentally Ill

Ian Parry scholarship winner Yuyang Liu documents the dire reality of mental disease in China.

To live with mental illness in China is to live in an invisible world.

Of the more than 100 million victims living with some form of mental illness in China, 16 percent are classified as severe, according to a 2009 report by China’s National Center for Mental Health. Yet, inadequate psychiatric care and social stigmas have pushed many out of the public sphere, denying family members the much-needed support they need.

This year’s Ian Parry scholarship recipient, 23-year-old Chinese photographer Yuyang Liu, has set about illuminating this invisible world. He recently documented families crippled by mental disease across the southern province of Guangdong, one of China’s wealthiest regions. “It is often the case that one family is impoverished because of a family member’s illness,” Liu tells TIME.

The project, At Home With Mental Illness, which aims to highlight the inefficient government efforts, won him his scholarship.

Liu first became aware of the issue when he received a newsletter from a Chronicle Disease Prevention Center in a small town, which mentioned its effort in helping those struggling with mental health issues and their families. “I was blown away,” Liu says. “[I realized] that although the patients are largely invisible in the society, they and their families do live a real life.”

With leads provided by local NGOs and online forums, Liu gained access to six houses, photographing the interactions among the mentally ill, their families and the larger society. “I don’t want to photograph how miserable they are even though some of the pictures will inevitably convey that, but I want to focus more on the support between them and their families, and capture the viewers’ attention that way,” Liu says.

Among them, the Xiao family’s situation is especially grim. With a mother suffering from severe mental illness at home, Xiao, a father of two, has to work every morning. Before leaving, he used to tie his five-year-old daughter with a rope attached to a wooden stake so she wouldn’t be able to wander off. When social workers discovered the girl, she did not wear any pants. The father had thought that since no one could untie her to use a bathroom, it would prevent her from wetting her clothes.

Liu immediately partnered with Chinese Internet and technology giant, Tencent, after photographing the Xiao family’s situation, and raised 4,000 RMB ($645) for the child. But he hoped that the fundraising would benefit more than one family and that he would be able to raise awareness for the socially disadvantaged group as a whole, he says. Now with the scholarship’s support of £3,500 ($5,450), Liu plans to expand his coverage to other regions in China.

The scholarship, named after photojournalist Ian Parry, who died while covering the Romanian revolution in 1989, is given every year to an aspiring photographer under 24, the age Parry died. “[The prize] is a great encouragement for me personally,” Liu says. “There’re so many amazing photographers as my predecessors, and I’m really happy to be included in the family.”

Early this year, Liu had contemplated going into commercial photography for a better income, but soon dismissed the idea, and winning the award serves as a major encouragement for him to push through a short period of hesitancy.

“The judges felt this was an outstanding and brave body of simple, honest images,” said the jury in a statement. Along with Liu, Hosam Katan of Syria was highly commended this year. Hashem Shakeri of Iran, Isadora Kosofsky, who was published on TIME LightBox last year, and Salahuddin Ahmed of Bangladesh were also commended. Each of them will receive a cash award of £500 ($780). “Every single portfolio selected for this year’s scholarship has human interest at its heart, and that’s why this award is so special,” said Don McCullin, combat photographer and a trustee on the scholarship’s board.

See Isadora Kosofsky’s winning story below.

Ye Ming is a contributing writer to TIME LightBox. Follow her on Twitter @yemingphoto and Instagram.

TIME Mental Health/Psychology

More Than 200,000 Vietnam Vets Still Have PTSD

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New research reveals considerable PTSD in some vets, even decades after war

Many veterans who served in the Vietnam War still have war-zone-related post-traumatic stress disorder, according to a new study published in JAMA Psychiatry.

The researchers, led by Dr. Charles R. Marmar, of the New York University Langone Medical Center, wanted to look at the prevalence of PTSD over time. Thanks to the National Vietnam Veterans Longitudinal Study, a study of PTSD in Vietnam vets done more than 25 years ago, they had historic data on the prevalence of PTSD; they conducted a follow-up to the study by gathering new data from the 1,450 veterans who were still alive and willing to participate in another round of PTSD assessments. From 2012-2013, researchers gathered from each vet a self-report health questionnaire, a telephone health survey or a clinical interview by phone. (Some vets participated in two or all three of the measures.)

MORE: Meet 15 Extraordinary Wounded Warriors Who Are Stronger Than Ever

The team determined that even now—40 years after the war ended—about 271,000 Vietnam vets have full war-zone-related PTSD plus war-zone PTSD that meets some diagnostic criteria. More than a third of the veterans who have current war-zone PTSD also have major depressive disorder.

MORE: “Hidden Wounds”: Battling PTSD With Music

Men who served in the Vietnam war had a war-zone-related PTSD prevalence of 4.5%; when factoring in vets who met some of the criteria, that number climbed to almost 11%. For women veterans, those prevalences were about 6% and 9%, respectively.

“An important minority of Vietnam veterans are symptomatic after four decades, with more than twice as many deteriorating as improving,” the study authors write. “Policy implications include the need for greater access to evidence-based mental health services; the importance of integrating mental health treatment into primary care in light of the nearly 20 percent mortality; attention to the stresses of aging, including retirement, chronic illness, declining social support and cognitive changes that create difficulties with the management of unwanted memories; and anticipating challenges that lie ahead for Iraq and Afghanistan veterans.”

TIME Mental Health/Psychology

These Antidepressants May Be Riskier For Pregnant Women, Study Says

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Treating depression properly is important, but a new analysis found a link between certain SSRIs and birth defects

In a study published in the BMJ, researchers conducted the most thorough study to date looking at how popular SSRI antidepressants taken by pregnant women affect their unborn children.

Previous studies, most of which investigated individual medications and their potential effects on the still-developing fetus, have resulted in conflicting results; some have found associations between the antidepressants and birth defects, while others have not.

In the BMJ study, Jennita Reefhuis, team lead in the birth defects branch at the U.S. Centers for Disease Control and Prevention, and her colleagues analyzed data from six existing studies of selective serotonin reuptake inhibitors, called SSRIs—a class of antidepressants—and their relationship with birth defects, as well as the National Birth Defects Prevention Study, which collected birth defect information from hospitals in 10 U.S. cities. The added data from nearly 18,000 mothers who had children with birth defects provided more power to the analysis that Reefhuis and her team performed.

MORE: Therapy and Antidepressants Work Better Together Than Just Pills Alone

Overall, they found that two SSRIs—fluoxetine (Prozac) and paroxetine (Paxil)—were linked to seven specific birth defects, including those involving heart structures, abnormal brain formation and the growth of the intestines outside of the body. The other SSRIs studied—citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft)—did not show strong associations with birth defects.

The researchers don’t yet know exactly why these SSRIs were linked to birth defects, and Reefhuis stresses that the risks she uncovered are small. For example, a heart structural defect occurs normally in about 10 per 10,000 births, and for women taking paroxetine, that risk doubled to 24 per 10,000. “But two times a small number is still a small number,” she says.

MORE: Why Some Antidepressants Make You Feel Worse Before Better

Still, the results should provide better information for doctors and women who want to start families about how to balance the benefits of antidepressants like SSRIs in treating depression and the potential risks the medications can pose to the baby. “I think our data points in the direction that maybe they could choose an SSRI that has not been shown to be associated with, or has been associated with fewer, birth defects,” she says. But more studies like this are needed to confirm and expand on what we know about how specific antidepressants are linked to specific birth defects. “This information is most helpful in trying to unravel this mystery,” says Reefhuis. “I really hope it provides options for treating women who need treatment for depression during pregnancy.”

TIME Mental Health/Psychology

How Fireworks Can Trigger PTSD

Fireworks will be going off with a bang all weekend, but for some, they cause more anxiety than celebration

You may see the signs popping up around your neighborhood this July 4—red, white and blue notices that indicate the home of a vet with the request to “Please be courteous with fireworks.”

The signs are the work of a Facebook-launched nonprofit, Military With PTSD, begun by Shawn Gourley, whose husband, Justin, served in the Navy for four years and returned with post traumatic stress disorder (PTSD). Sudden and loud noises can trigger episodes of PTSD, bringing veterans back to traumatic experiences they have lived through during their service. According to the U.S. Department of Veteran Affairs, up to 20% of military personnel who served in Iraq or Afghanistan experience PTSD each year.

The signs are posted on the lawns of veterans’ homes to alert people to be more considerate when setting off fireworks in the area. According to Gourley, who spoke to CNN, the group has mailed 2,500 signs, some of which were paid for by donations and others by the vets themselves, while 3,000 people remain on a waiting list.

The signs are not meant to quash any Fourth of July celebrations, but to raise awareness that the explosive sounds, flashes of light and smell of powder may trigger unwelcome memories for some. “If you are a veteran, on the one hand July 4th should be one of the most patriotic holidays that you feel a part of,” says Dr. John Markowitz, professor of psychiatry at Columbia University. “On the other hand, the rockets’ red glare and the bombs bursting in air are likely to evoke traumatic memories, and you might want to hide. It’s a tricky one.”

Having advanced knowledge of a fireworks display can help some people with PTSD to better prepare and cope with any symptoms they may experience. “A big component of the startle response and PTSD is the unexpected,” says Rachel Tester, program director of the Law Enforcement, Active Duty, Emergency Responder (LEADER) Program at Harvard Medical School’s McLean Hospital. “When people are able to anticipate, they are able to put into place mechanisms they have to cope ahead of time.”

That might include things such as relaxation techniques or being able to see the fireworks show and therefore know that they’re coming, as well as having headphones, music or other distractions at the ready.

Such strategies may not work for every PTSD patient, but being more aware that the explosive celebrations of the holiday might affect those with PTSD is an important step toward ensuring that everyone can enjoy the holiday without fear, anxiety or pain.

TIME Crime

U.S. Police Killed Someone in Mental or Emotional Crisis Every 36 Hours This Year, Report Says

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In most cases, police were called not because of a crime but by a concerned bystander or loved one

Reporting released by the Washington Post on June 30 depicts an apparently stark reality when it comes to confrontations between police and people with mental illness in the U.S. The article draws from the newspaper’s tracking of every fatal police shooting in the country in the first six moths of 2015 — 462 in all — to present an in-depth look at those confrontations involving disturbed or distressed individuals.

During that time, police killed someone in mental or emotional crisis every 36 hours, including three men within 10 hours on April 25, the Post reports.

In most of those cases, the paper says, officers were not called to the scene because of reports of a crime but were rather responding to concerned bystanders or loved ones. Out of the 124 shootings examined in the report, 50 involved explicitly suicidal individuals. In 45 cases, police were explicitly asked for medical assistance or called after the individual had attempted to get medical assistance elsewhere. Nearly a dozen of those killed were veterans, and several suffered from PTSD.

Many of the responsible police agencies do not train their officers adequately to deal with distressed people, the article concludes. According to the Police Executive Research Forum, officers in training spend up to 60 hours learning to handle a gun and only eight hours each learning to neutralize taut situations and interact with mentally ill individuals. In fact, many of the tactics learned in training, such as shouting commands, can worsen the situation for already fragile people.

“This a national crisis,” Chuck Wexler, executive director of the Police Executive Research Forum, told the Post. “We have to get American police to rethink how they handle encounters with the mentally ill. Training has to change.”

Read more at the Washington Post

TIME Innovation

Why Women’s Soccer Is a Feminist Issue

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

These are today's best ideas

1. Women’s soccer is a feminist issue.

By Maggie Mertens in the Atlantic

2. Can community service journalism save local news?

By Steven Waldman in the Columbia Journalism Review

3. This 99¢ app connects kids to thousands of scholarships.

By Fitz Tepper in TechCrunch

4. America is more afraid of peace than war.

By Gregory A. Daddis in the National Interest

5. Here’s how the LAPD is addressing use of force on the mentally ill.

By Noelle Swan in the Christian Science Monitor

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME Innovation

The High Cost of the American Dream

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

These are today's best ideas

1. We’re pricing the American Dream out of existence.

By Mechele Dickerson in the Conversation

2. Syria’s future might be like Somalia’s: Permanent anarchy.

By Aron Lund at the Carnegie Endowment for International Peace

3. The UN wants to share its sustainability goals with the world, so it’s turning to comics.

By Chris Arrant in Newsarama

4. Museums are doing a pretty bad job of connecting people to art.

By Michael O’Hare for Democracy Journal

5. Most kids with mental illness aren’t receiving treatment.

By Arielle Duhaime-Ross in the Verge

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME Crime

Colorado Gunman’s Notebook of Ramblings Becomes Evidence

Holmes Shooting Notebook
AP A portion of Aurora shooter James Holmes' notebook, after it was presented as evidence in the Holmes murder trial on May 26, 2015, in Centennial, Colo.

Copies of a journal kept by the man on trial for the Aurora theater shooting have been distributed to the jury that will help determine his fate

A notebook containing James Holmes’s ramblings, sketches and thoughts on topics ranging from the meaning of life to murder was presented on Tuesday at his trial for the 2012 mass shooting in an Aurora, Colo., movie theater that killed 12 people and injured 70 others.

It’s a key piece of evidence for prosecutors trying to prove the 27-year-old plotted the killings and for defense lawyers who argue he was experiencing a psychotic episode on July 20, when he opened fire on moviegoers at a premiere of The Dark Knight Rises.

Holmes’s notebook reveals references to violence and death and is stepped in nihilism. He writes about a “self diagnosis of broken mind” and several pages are covered with the question “Why?” over and over again. “When mankind can’t find truth,” he mentions at one point, “untruth is converted to truth via violence.”

The former doctoral student in neuroscience is pleading not guilty by reason of insanity. Prosecutors are seeking the death penalty. Holmes sent the notebook to his University of Colorado psychiatrist, Dr. Lynne Fenton, eight days before the shooting, but the package was not discovered until several days after the massacre. Fenton had warned authorities that Holmes was a danger to the public.

Holmes describes in the journal a number of fantasies about different ways to kill, but quickly rules them out. He says a bomb is too regulated and suspicious, biological warfare requires extensive knowledge of chemicals and serial murder is “too personal, too much evidence, easily caught after few kills” before settling on a “mass murder spree.” He writes that he chose this method because it would provide “maximum casualties, easily performed with firearms, although primitive in nature. No fear of consequences, being caught 99% certain.”

At one point, he rules out certain venues, like airports, because he didn’t want his mass killing to be misinterpreted as a terrorist act. Airports have “too much of a terrorist history,” he writes. “Terrorism isn’t the message. The message is there is no message.” The journal also includes diagrams of different theaters within the movie complex, as well as pros and cons for each one.

“And finally, the last escape, mass murder at the movies,” he writes. “Obsession onset: > 10 years ago.”

Holmes describes his psychological struggles as “the real me is fighting the biological me,” and notes that work and romantic failures aren’t the reason for his action, although both are “expediting catalysts.” Instead, he claims, his “state of mind for the last 15 years” is to blame for his actions.

He notes a particular set of symptoms and behaviors that accompanied his self-diagnoses of a “broken mind,” including a “recurring return to mirror to look at appearance, particular attention focused on hair styling. 10+ times a day.” At the time of the shooting, Holmes’s hair was dyed a bright red-orange. He also describes at least one childhood accident that injured his genitals, which he alleges led to an “allergic reaction to sex.”

In one particularly chilling passage, Holmes alludes to the name of the movie he selected for the attack: “I was fear incarnate. Love gone, motivation directed to hate and obsessions, which didnt disapear for whatever reason with the drugs,” he writes. “No consequences, no fear, alone, isolated, no work for distractions, no reason to seek self -actualization. Embraced the hatred, a dark knight rises.”

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