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

More Than 200,000 Vietnam Vets Still Have PTSD

American flag Vietnam Veterans Memorial
Getty Images

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

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 Innovation

Why Doubling the Value of Food Stamps Helps Families Eat Better

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

These are today's best ideas

1. Want to help poor families get healthy food? Double the value of food stamps.

By Jay Cassano in Fast Co.Exist

2. How training service dogs is giving veterans a reason to live.

By Chris Peak in Time

3. Can saltwater quench our growing thirst?

By Brian Bienkowski in Ensia

4. High school sets up autistic kids to fail when they reach college. Here’s how to fix the problem.

By Noel Murray in Vox

5. The next big idea for ending poverty is thinking small.

By Jacob Lief in Huffington Post

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 Mental Health/Psychology

Military Suicides Aren’t Linked to Deployment, Study Finds

Military soldier with bag in airport, low section
Mike Powell—Getty Images Military soldier with bag in airport, low section

Service members who were not honorably discharged had a 21% higher suicide rate than those with honorable discharges

In certain branches of the military, suicide rates have almost doubled in the last decade. Now, sweeping new research published in the journal JAMA Psychiatry suggests that the reasons are much more complicated than just deployment. In a comprehensive new study that looked at all 3.9 million members of the U.S. military from 2001-2007—including the Air Force, Army, Army National Guard, Army Reserve. Marine Corps and Navy—suicide was not associated with deployment in the U.S.’s two most recent major conflicts: Operation Enduring Freedom and Operation Iraqi Freedom.

Those findings may be counterintuitive, says study author Mark A. Reger, PhD, Deputy Director at the National Center for Telehealth and Technology and chief of research, outcomes, and investigations, but some interesting theories have emerged.

“As the wars went on and deployments were occurring among our service members, the suicide rates were rising at the same time, so it’s very tempting to assume that it must be because of the deployment,” Reger says. But the strongest research from the Vietnam and Gulf War eras shows there’s not a significant difference in suicide rates between those who are deployed and the general population, he says. And that held true for the more recent conflicts. The authors looked at deployment in the Iraq and Afghanistan operations and found no association between deployment and suicide.

MORE: Military Suicides Down Overall, But National Guard Rates Up

He suspects part of the reason is that military members who are chosen for deployment may be among the most mentally fit. Prior to deployment, all service members go through pre-deployment screening to ensure that they’re mentally and physically ready for the challenges. “It is possible that those who deploy are healthier than those who did not deploy,” Reger says, although he adds that they didn’t have data to confirm that.

The authors didn’t look at data related to mental health status, medical status, combat exposure or combat injuries, so they were unable to see if those factors were linked to increase suicide risk. “All of these deserve future study,” Reger says.

Some patterns linked to suicide risk factors did emerge, however. Those who left the military early had a 63% higher suicide rate than people who had not separated from service. People with the fewest years of military service were also most at risk; service members who left the military after just a short stint of less than four years were at higher risk for suicide than those who left after serving four or more years, regardless of whether or not they’d been deployed. The study didn’t look at possible reasons for this, but the authors speculate that difficulty finding work, losing their military identity and having to find new social support may all play a role.

MORE: 22 Veterans Die By Suicide Every Day

Another big risk factor, the study authors concluded, was the nature of a service member’s discharge. Those who were not honorably discharged from the military had a 21% higher suicide rate than those who had an honorable discharge.

Making use of limited resources to prevent suicide is a key objective of the military, Reger says. Based on these findings, it’s possible that targeting prevention efforts more narrowly to those who leave the military early and those with a less-than-honorable discharge may be more efficient and impactful than casting a wide net and focusing prevention efforts on everyone who’s deployed, Reger says.

“I think the entire nation has a responsibility for working with service members and veterans, wherever they end up,” he says. “If our paper has the effect of influencing some of those in the prevention community beyond the military, that would be a good outcome.”

TIME photography

Bearing Witness to the Legacy of War

Photographer Giles Duley, who lost three limbs in Afghanistan, speaks about his new project

In 2011, photographer Giles Duley began a project that would document the lasting effects of war on people living in cities and towns across the globe where the fighting had ended many years, even decades ago.

That year, while patrolling in Afghanistan with American troops, Duley stepped on an Improvised Explosive Device. The blast nearly took his life; he lost both legs and an arm. After a year in the hospital and nearly 30 operations, Duley returned to photography with a new determination to finish his project, which he calls Legacy of War. The project encompasses 14 countries and comprises photographs, original poetry and music.

Last month, he launched a Kickstarter campaign to help fund the project, which you can contribute to here. Below, TIME Multimedia Editor Mia Tramz caught up with Duley as he continued his work on the project from Cambodia.

TIME LightBox: What’s the scope of the project and the idea behind it?

Giles Duley: The idea came to me I guess four or five years ago. A lot of my work has been documenting the effects of conflict over the years. One of the things I noticed was that there was a lot of commonality between the stories that I heard, and so I became interested in trying to bring all these different stories together. I was actually going to Afghanistan to start the project when I got injured, so I thought it would never actually happen. My plan was if I could get working again, I would return to doing this project.

The thing that really strikes me is that a war doesn’t end when a peace treaty is signed. In school, as you’re growing up, you’re always taught about the dates of a particular conflict. And I was interested [by] what happens after this final date; what happens when the conflict is supposedly finished. Because what I’ve experienced in my work was that the war is not over if people are still dying from it, if they’re still injured, if their lives are still impaired by it.

My idea was to try and bring together stories from approximately 14 countries, showing various themes that kind of crop up in post-conflict countries. That might be land contamination from land mines, from UXOs and it might be the effects of things like Agent Orange or depleted uranium. But it’s also looking at the physical effects on people who are living with injuries, and people living with the psychological trauma of conflict. I wanted to bring all these different stories together and just get people to reflect on the fact that conflict doesn’t end when a peace treaty is signed.

TIME LightBox: Which countries will you be covering and how did you choose them?

Giles Duley: One of the things I kind of want to do is to bring together stories that may be a little bit more familiar to us with stories that are less familiar. Hopefully, by bringing them together, you get to understand the similarities. In the United States, I wanted to look at the effects of trauma on former combatants, especially soldiers from [the] Vietnam War, how their lives have been affected. The same in the U.K. looking at injured servicemen and [those] with PTSD. Then it’s countries like Vietnam with Agent Orange and UXO; Cambodia, Colombia, Laos and other countries like it by land mines. I’ll be doing stories in Angola, which has a huge legacy of war; in Congo or the DRC, I’ll be looking at the effects of sexual abuse in both men and women. In Northern Ireland, I’m looking at the effects of the troubles, [which have] caused poverty and other social issues.

Other countries [will include] Gaza, [where] I’ll be looking at the long-term effects of conflict there. I’ve already done a story on the refugees in Lebanon, a country which really had two tiers of refugees from war. I’ll be looking at refugees in Sahel Sahara. It’s a vast cross-section of stories.

TIME LightBox: How did you arrive at the aesthetic for this project?

Giles Duley: I actually decided to use film for this project — a mixture of 35 mm and medium format. The main reason for film is that I wanted the images to both have a timeless feel and to serve as documents. Many of the photographs will reflect the period when the conflict happened and at the same time, a print made from a negative has a sense of true documentation. In a period when many question the role of Photoshop and other manipulation in documentary photography, I wanted to return to a simpler process.

TIME LightBox: Outside of the photography, what other components are you working into the project?

Giles Duley: I want this to be more than just a set of photographs. As a child, I was really influenced by the poets of the First World War and the black-and-white photographs covering the Vietnam War. They were the two things that really changed my opinion as a very young teenager about conflict. I grew up as a kid [thinking] that I wanted to join the army. I was fascinated by military history. But as I say, it was reading this poetry of people like Sassoon and Wilfred Owen and looking at the photographs of people like Don McCullin that really galvanized something in me, that made me realize the true consequences of war.

I’m very interested in the educational component. I realized that schools are still studying poetry from the First World War. So what I want to do is update that and get poets and musicians writing about current conflicts and their long-term consequences. For me as a photographer, I hope that the poetry and the music will add a different dimension to the work, so that it’s more accessible to people.

TIME LightBox: What’s your process working with these musicians and poets? Are they seeing the photographs you’re making from those particular parts of the world, or are they just writing or creating from their own experiences, or a mix of both?

Giles Duley: Anybody that’s working with me on this project will either be traveling with me at a later stage in the project, or it will be a process of me meeting them, showing them the photographs, and probably most importantly sharing the testimonies of the people who are photographed.

TIME LightBox: What has surprised you most since you started working on this project about what you’re finding?

Giles Duley: I don’t know if it surprised me, but what I’m becoming very aware of is just the enormity of how conflict affects life. [For example], in Vietnam, Laos and Lebanon and Cambodia — you start to look at one story, and immediately that opens up 10 other stories. It’s often in less expected ways or [something] you just don’t think about. Some of the stories are more obvious, like land mines, etc. But when you look at the long-term impact of a child that was born to a woman who was raped, that is a real legacy of war. And they live with that legacy for all of their lives — the psychological trauma of people affected by war is something that is not often talked about or documented, but whole generations of civilians have been traumatized by conflict.

TIME LightBox: Can you talk about where you see the project living when it’s finished and in what form?

Giles Duley: This is a project that has four phases. The first phase is the photographic phase, which is to go out there and document the initial stories. The second phase is to work with poets and musicians to give more depth to the stories. The third phase is then looking at how that body of work comes together through exhibitions and a book. For me that stage is very important because the exhibitions have to be in public spaces. They have to be in places where people interact with these stories who wouldn’t normally go to a photographic gallery.

And I’m also very interested in taking the project back to the countries that I’ve photographed. One of the things that most surprised me is how interested people are in the other countries I’m photographing. People in Northern Ireland are asking me about the people in Rwanda. The people in Vietnam are very interested in stories that I’m going to be doing in Angola, for example.

One of the key elements is, as well as having the photographs exhibited in the public spaces in Western countries, it’s for the exhibitions to return to the countries where these stories first came from, so the stories are shared. Because that’s what it’s all about. It’s about sharing stories. I have no judgments, I have no opinions. I’m merely going out there to try and gather the stories of people affected by conflict and to share those stories.

And then the final stage, the fourth stage, will be educational. And that’s about taking it to schools. It’s about getting it on the curriculum, [so that when] people are taught the historical facts of a conflict, they’re also taught about how a conflict continues to affect people [long after it’s over]. That’s how I see it developing. And hopefully, in the end, it will be something that will kind of take on a life of its own and I can step back and people can continue to share these stories.

TIME LightBox: Your story is also woven into this. How has your experience informed your approach to this project and how it has been integrated into it?

Giles Duley: No matter what I choose to do for the rest of my life, I will live with the scars, both physically and mentally of what happened. So it’s given me a great understanding. But I think more than that it’s kind of focused my ambition and determination to carry this project through because, as I say, every day now I live with a reminder of what conflict does.

It has opened up communication with a lot of people that may have been more suspicious of why I was doing this story; people who see my personal experience and can relate to it. I guess weirdly, although I may be a lot slower as a photographer now and it may be a bit harder for me to work, there’s probably not a photographer in a better position to actually tell these specific stories about the legacy of war.

TIME LightBox: What do you see as the biggest challenges in getting this project done?

Giles Duley: The biggest challenges on a personal level are the travel, the work. I have no legs and I’ve got one hand, and I travel on my own to do this work. It’s not easy. I must admit last year when I found myself in paddy fields in the rainy season in Laos, trying to carry all my cameras and a backpack and my legs getting stuck in the mud, I was thinking, “O.K., who came up with this idea?” [Laughs.] So the obvious challenges like that are there, that in a weird way as I say, also drive me on to complete the story.

Aside from that, obviously this is a project that I’m self-funding. It’s something that I think is important. A lot of NGOs and nonprofits and charities are helping me with the stories. I have years and years of working with NGOs and they’ve been fantastic in supporting this project. So the likes of MAG, which is a de-mining charity; Handicap International; UNHCR; Emergency, which is an Italian NGO; and Find a Better Way, which is another land-mine charity, have all been supporting it. But at the end of the day, I have to find a way to finance these stories, or at least finance the physical costs of the photographic side of it.

The project really I think for me is the defining project of my life. It will probably be the last major overseas project I do because it’s simply so physically draining and difficult for me. But I am determined to carry this out to the utmost of my ability.

This interview has been edited for length and clarity

Giles Duley is a freelance photographer and an Honorary Fellow of the Royal Photographic Society. Follow him on Twitter @gilesduley.

Mia Tramz is a Multimedia Editor for TIME.com. Follow her on Twitter @miatramz.

TIME Innovation

Five Best Ideas of the Day: February 24

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

1. For some returning from war, a ‘G.I. bill for farming’ eases the transition home.

By Abby Wendle at Harvest Public Media

2. In Egypt, a class project to fight sexual harassment has grown into a campus-wide movement encouraging women to “Speak Up.”

By Ahmed Fouad in Al-Monitor

3. Your kid’s school is missing the tech revolution, and it’s all your fault.

By Jason Tanz in Wired

4. Community courts focus on rehabilitation and compassion for non-violent offenders.

By Henry Gass in the Christian Science Monitor

5. A new ‘Uber for packages’ service is partnering with Waffle House to build a network of delivery points around the south.

By Amar Toor 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

Vietnam Vet Loses Bid to Stop Execution on PTSD Claim

Andrew Brennan was convicted of shooting and murdering a 22-year-old cop

A decorated Vietnam veteran who argued he was suffering from post-traumatic stress when he killed a sheriff’s deputy in 1998 lost a bid for clemency on the eve of his scheduled execution. The Georgia Board of Pardons and Parole declined to commute the death sentence of Andrew Brannan to life in prison after hearing from prosecutors and defense lawyers at a Monday hearing.

Brannan was convicted of murdering Laurens County deputy Kyle Dinkheller, who had stopped him for driving 98 mph. Dash-cam video showed Brannan dancing in the street and saying “shoot me” before he pulled a rifle from his car and…

Read the rest of the story from our partners at NBC News

TIME Veterans

Killed in Action, Far From the Battlefield

Iraq Archive 2007
Benjamin Lowy / Getty Images Iraq, 2007: Both a VA psychologist and the veteran who allegedly killed him served in Iraq that year.

VA psychologist gunned down by Iraq war vet

If you check the latest toll at icasualties.org, 4,489 Americans died in the Iraq war. But a killing Tuesday at a Department of Veterans Affairs clinic in El Paso, Texas, should have pushed that figure to 4,490—one of many additional KIAs in the Iraq war that will never be added to its final tally.

KIA means “killed in action,” and might not seem to apply to the death of Timothy Fjordbak, 63, allegedly at the hand of Jerry Serrato, 48, on the fourth floor of the El Paso clinic at Fort Bliss.

But, unfortunately, it does.

Serrato, 48, had served in Iraq for several months in 2007. He was discharged from the Army in 2009 for undisclosed physical reasons. He worked for a short time at the clinic in 2013, where Fjordbak, 63, was the chief psychologist.

A former employee at the clinic has told the Washington Post that Serrato was upset that the clinic had found his claim of post-traumatic stress disorder unwarranted.

“Although we do not know all the details, what we know of the case suggests anger at the VA for denial of benefits,” says Elspeth Ritchie, who served as the Army’s top psychiatrist before retiring in 2010. “Unfortunately, the scenario of angry patients killing their doctors is way too common, both in and out of the military.”

In October, 2013, Serrato allegedly threatened Fjordbak at a grocery store after Fjordbak didn’t recognize him, the FBI said following the murder. “It was a verbal threat —real or not—his (Serrato’s) perception was some wrong had been committed against him,” bureau agent Douglas Lindquist said.

“I know what you did,” Lindquist quoted Serrato telling Fjordbak, “and I will take care of it.” Fjordbak reported what he perceived to be a threat to local police.

Mid-afternoon Tuesday, Serrato went to the top floor of the four-story clinic and killed Fjordbak with a .380-caliber handgun.

VADr. Timothy Fjordbak

Fjordbak left a private practice after 9/11 because he wanted to help veterans, officials said. He had served in Iraq for several months in 2007, just as Serrato did. There was no known doctor-patient or workplace relationship between the two men.

Fjordbak was lauded by troops he had treated, as well as colleagues and friends. “His main thing was that he could differentiate between symptoms of PTSD and traumatic brain injury,” Michael Rushton, a U.S. Air Force veteran treated by Fjordbak in November, told the El Paso Times. “It was a five-hour appointment and it was a very comprehensive series of tests. He was amazing and an excellent guy.”

The tragic case highlights the fog that is PTSD. Few PTSD sufferers are violent, and it’s challenging to attribute specific acts to the malady. “Although PTSD is associated with an increased risk of violence, the majority of veterans and non-veterans with PTSD have never engaged in violence,” according to the National Center for PTSD.

Was Serrato mentally ill? Angry over how the VA handled his case? Suffering from PTSD? Or some combination of those factors?

Victoria County, Tex., Sheriff's Office
Victoria County, Tex., Sheriff’s OfficeJerry Serotta, following a 1997 drunk-driving arrest

We’ll probably never know. After killing the psychologist, Serrato went into a restroom on the clinic’s third floor and killed himself.

Better up that toll to 4,491.

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