Advancements In PTSD Research

"Post-traumatic stress disorder (PTSD) is a type of anxiety disorder that's triggered by a traumatic event. You can develop post-traumatic stress disorder when you experience or witness an event that causes intense fear, helplessness or horror..." The Mayo Clinic Staff

Thursday, September 22, 2011

Veterans Crisis Line Website

The Veterans Crisis Line connects Veterans in crisis and their families and friends with qualified, caring Department of Veterans Affairs responders through a confidential toll-free hotline and online chat. Veterans and their loved ones can call 1-800-273-8255 and Press 1 or chat online to receive confidential support 24 hours a day, 7 days a week, 365 days a year. More about the Veterans Crisis Line

http://www.veteranscrisisline.net/

You can show support for our Nation’s Veterans and their families and encourage them to get the care they’ve earned. Download Veterans Crisis Line materials and use them to help spread the word about this free and confidential service for all Veterans and their families.

Web ads in a variety of standard sizes are available for use on public and VA websites. You can also download Veterans Crisis Line logos, posters, and other materials to print, hand out, and display in your community.

Share the Veterans Crisis Line with your online network. Like us on Facebook, share the Veterans Crisis Line website and PSA with your friends and followers, or embed a Veterans Crisis Line PSA on your own website.


Thursday, September 1, 2011

Brain Scan Offers First Biological Test in Diagnosis of Post-Traumatic Stress Disorder

Brain Scan Offers First Biological Test in Diagnosis of Post-Traumatic Stress Disorder

Researchers use a brain-scanning technique to find differences in the neural connections of PTSD patients that could help researchers understand and treat the disorder

By Carina Storrs | Friday, January 22, 2010 | 16

Researchers find differences in the brain networks of PTSD patients that could help diagnose and treat the disorder.

An event such as sexual assault or a battlefield injury is physically agonizing at the time, but it also can eventually sentence a person to a host of mental symptoms—often vivid flashbacks, anxiety and emotional detachment—known as post-traumatic stress disorder (PTSD). The disorder afflicts 3.4 percent of men and 9.7 percent of women in the U.S., according to research estimates.

Diagnosing PTSD is not necessarily simple. Psychological evaluations for PTSD cannot always easily distinguish it from other mental illnesses, such as depression, or determine if a patient is over- or underreporting the symptoms. Now, a brain- scanning technique called magnetoencephelography (or MEG) could offer the first biological test to help specifically diagnose and treat those with PTSD. In a study published January 20 in Journal of Neural Engineering, MEG correctly identified 97 percent of patients that psychologists previously determined were suffering from PTSD.

MEG, which was developed in the 1960s for military purposes, offers a unique insight into the neural communications within the brain, says Apostolos Georgopoulos, a neuroscientist at the University of Minnesota Medical School and lead author of the study. The instrument measures the magnetic field created as electrical current passes between areas of the brain. In MEG studies about two years ago, Georgopoulos found that, whereas healthy people shared similar patterns of neural communication, people with Alzheimer's and schizophrenia had distinct, disease-specific patterns.

In the current study Georgopoulos and his colleagues scanned 74 people diagnosed with various degrees of PTSD through a standard question-and-answer session with psychologists, along with 250 people who reported having no mental problems. For their MEG scans, the participants simply sat under a dome-shaped instrument for one minute. They fixed their eyes on a spot of light so that researchers could measure the brain in an "idle" state, when it is not stimulated by having a task to perform. During that minute, the instrument captured a map of the brain's electrical activity once every millisecond. (For comparison, functional magnetic resonance imaging, which measures brain activity indirectly, takes measurements about every three seconds.)

For 72 of the 74 patients previously diagnosed with PTSD, MEG scans detected a pattern of neural communications that was different from the healthy participants, but shared among the PTSD group. On the flip side, 31 of the 250 healthy patients had abnormal scan results.

"I think [the specificity] is what still has us shaking our heads in disbelief," says Brian Engdahl, a psychologist at the U.S. Department of Veterans Affairs Medical Center in Minneapolis, who helped evaluate the patients included in the study. He adds that he and others hope to perform a more thorough evaluation to see if those 31 supposedly healthy patients might have PTSD.

Engdahl adds that MEG might serve several uses in addition to diagnosis. For one, neural patterns detected by MEG could be used to assess how well PTSD treatments, from antidepressants and sleep medications to counseling, are working for a patient. In addition, having MEG results could help patients who are reluctant to report their PTSD symptoms. "You can think about it as a means to help people feel less stigma. Because there's something different with [the] brain…it doesn't have to do with personal weakness," he says. "That's almost a sigh-of-relief moment for the patient."

Bringing MEG to patients will not, however, be possible for many hospitals in the U.S. Georgopoulos estimates that only 20 to 30 have a $2-million MEG instrument. "[But] I think it will become a major application as we speak…for all kinds of ways of looking very sensitively at brain function," he says.

Rajendra Morey, a psychiatrist at the Duke–U.N.C. Brain Imaging and Analysis Center in Durham, N.C., who was not involved in the study, says that he could see MEG being used "as an adjunct to the more conventional way of diagnosing." Although a biology-based diagnosis for PTSD would be helpful, he says, using MEG in the clinic is still a ways off.

Tuesday, August 9, 2011

PTSD More Common Among Migraine Sufferers

By Teri Robert,

http://www.healthcentral.com/migraine/related-conditions-287522-5_pf.html

We've known for some time now that Migraine disease and major depressive disorder (MDD) tend to be comorbid conditions. That means that we frequently see people who have both simultaneously, but neither condition causes the other. Now, research is showing a similar connection to post-traumatic stress disorder (PTSD).

The objective of a new study by Peterlin et. al. was:

"To evaluate the relative frequency of posttraumatic stress disorder (PTSD) in episodic migraine (EM) and chronic daily headache (CDH) sufferers and the impact on headache-related disability."1

Background information:

The prevalence of PTSD in the general population is estimated to be 8%. Two earlier studies have looked at PTSD in patients with headache disorders. One study seemed to show that Migraine and headache patients have a higher risk of developing PTSD than those without the disorders. Unfortunately, Migraineurs and tension-type headache patients were studied together in one group and compared to patients with pain unrelated to headache disorders. Thus, it was impossible to draw information specific to Migraine from the study. A second study might have shown PTSD as a risk factor for Migraine advancing from episodic to chronic. However it was a very small study group, and assessment of depression was self-reported by the patients and not clinically verified.

Study methods:

  • The study was conducted with patients from six Migraine and headache treatment centers.
  • All study participants were examined by a Migraine and headache specialist.
  • Patients were recruited in the age group of 18 to 65.
  • Headache disorder diagnoses were classified in accordance with the International Headache Society's International Classification of Headache Disorders, Second Edition (ICHD-II).

Study results:

  • Analysis included 593 patients who fulfilled the criteria for episodic Migraine (EM) or chronic daily headache (CDH).
  • PTSD was diagnosed in 30.3% of the participants with CDH.
  • PTSD was diagnosed in 22.4% of the participants with Migraine.
  • Participants with both major depressive disorder and PTSD were more likely to have CDH (24.6% of participants) than EM (15.79%).
  • Disability was greater in participants with EM and PTSD.

Study conclusions:1

  • "The frequency of PTSD in Migraineurs, whether episodic or chronic, is higher than the historically reported prevalence of PTSD in the general population.
  • In addition, in the subset of Migraineurs with depression, PTSD frequency is greater in CDH sufferers than in episodic Migraineurs.
  • Finally, the presence of PTSD is independently associated with greater
    headache-related disability in Migraineurs."

Study author comments:

"Despite the clinical perception that military combat is the most common (cause), the most common causes of PTSD are interpersonal traumas, including sexual abuse... In women, the lifetime prevalence of PTSD is twice that of men... The implications are such that abuse causes not just psychological distress from PTSD but also physical pain such as migraine, and there is an increased disability seen in those migraine sufferers with PTSD than those without PTSD." ~~B. Lee Peterlin, DO3

"Pharmacologically, dual action antidepressants have efficacy for both migraine and PTSD, but the serotonin-reuptake inhibitor antidepressants regarded as first-line treatments for PTSD have performed poorly for migraine prophylaxis." ~~Dr. James L. Griffith2, 3

Summary and comments:

The data from this study clearly establishes that PTSD is more common among those with Migraine and chronic daily headache. Dr. Griffith's comments in his research commentary are well placed. There are significant treatment implications to the increased prevalence of PTSD in those with Migraine and chronic daily headache. Some Migraine and headache specialists are now leaning more toward SNRI antidepressants that affect both serotonin and norepinephrine than the SSRI antidepressants that affect serotonin only. The SNRIs are working quite well for Migraine and headache prevention in some patients.

Hopefully, more research will be forthcoming about the connections between Migraine and major depressive disorder, and PTSD, and other mental health issues. The development of additional treatments that could be used to treat both headache disorders and mental health disorders could be quite beneficial.
____________

Resources:

1 B. Lee Peterlin, DO; Gretchen E. Tietjen, MD; Jan L. Brandes, MD; Susan M. Rubin, MD; Ellen Drexler, MD; Jeffrey R. Lidicker, MSc; Sarah Meng, DO. "Posttraumatic Stress Disorder in Migraine." Headache 2009;49:541-551.

2 James L. Griffith, MD. "Posttraumatic Stress Disorder in Headache Patients: Implications for Treatment." Headache 2009;49:554-554.

3 Rauscher, Megan. "Post-traumatic stress common in migraine sufferers." Reuters. April 3, 2009.


Tuesday, August 2, 2011

Forrmer Child Soldiers With PTSD Improve After Targeted Treatment Intervention

02 Aug 2011
Written by Grace Rattue
http://www.medicalnewstoday.com/articles/232122.php

According to a study of JAMA, (August 3 theme issue on violence and human rights) former child soldiers from Northern Uganda who underwent a short-term trauma-focused intervention showed a greater reduction of symptoms of post-traumatic stress disorder than soldiers who received other therapy.

Current estimates state that approximately 250,000 children under the age of 18 are currently active as child soldiers in hostilities in 14 countries or territories worldwide. The Northern Uganda civil war lasted over 2 decades and has virtually affected the entire population.

According to background information in the article:

"The Northern Ugandan communities have been confronted with large numbers of formerly abducted children, adolescents, and young adults returning after their rescue, flight, or release throughout the war and thereafter. The successful reintegration of these former child soldiers continues to be a major challenge. Despite high rates of impairment, there have been no randomized controlled trials examining the feasibility and efficacy of mental health interventions for former child soldiers."



Verena Ertl, Ph.D., of Bielefeld University, Bielefeld, Germany, and her fellow researchers conducted a randomized controlled trial testing the feasibility and effectiveness of narrative exposure therapy for treating former child soldiers with posttraumatic stress disorder (PTSD).

Narrative exposure therapy (NET) is a short-term treatment for trauma victims developed for use in low-resource countries affected by crisis and war. NET enables participants to recollect details of their traumatic and often fragmented experiences in cooperation with a therapist who reconstructs their memories of traumatic events to achieve habituation. The trial consisted of 85 former child soldiers between the ages of 12 to 25 with PTSD from a population-based survey of 1,113 Northern Ugandans and was conducted in internal displacement camps between November 2007 and October 2009.

Participants were randomly split into 1 of 3 groups consisting of narrative exposure therapy (n = 29), an academic catch-up program with elements of supportive counseling (n = 28), or a waiting list (n = 28) with treatments carried out in 8 sessions by trained local lay therapists in their respective communities.

The symptoms of PTSD, depression, and related impairment were evaluated before treatment commenced and at 3 months, 6 months, and 12 months post-intervention using various analytic tools. Researchers discovered that the severity of PTSD symptoms improved significantly more in the NET group compared to the academic catch-up and waiting-list groups.

During one measure of clinically significant change, 80% (20 of 25 participants) in the NET group had reduced the severity of their PTSD.

The authors wrote:

"In the academic catch-up and waiting-list conditions, 11 of 23 (47.8%) and 14 of 28 (50%), respectively, showed clinically relevant improvement. Subgroup comparisons revealed that improvement was significantly greater in the narrative exposure therapy group vs. the academic catch-up group and the narrative exposure therapy vs. the waiting-list groups."



After 12 months of trial, 68% of NET participants, 52.2% of academic catch-up participants, and 53.6% of waiting-list participants no longer fulfilled criteria for PTSD. The 12-month follow up revealed that NET participants experienced a larger within-treatment effect of 51.6% of reducing the severity of PTSD compared to 30.9% of the academic catch-up group and 30.4% of the waiting list group.

The Researchers stated:

"Moreover, results indicated that there were additional positive effects of treatment on associated problems not primarily targeted, such as depression, suicidal ideation, feelings of guilt, and important indicators of readjustment such as stigmatization and functioning."



The author concludes that the results of this study indicate that community-based lay therapists without a mental health or medical background can apply narrative exposure therapy successfully.

Monday, April 18, 2011

Survivor's Guilt Haunting the Military

By Dr. Keith Ablow

Published April 18, 2011 | FoxNews.com

On March 31, 2011, Clay Hunt, a 28-year-old Marine veteran who had served with great honor in Iraq and Afghanistan, receiving a Purple Heart, finally succumbed to the psychological fallout of that service, killing himself in his Sugar Land, Texas, apartment.

Hunt, a leading voice in helping other veterans get psychological help, had struggled publicly with the demons of war, especially the loss of four friends in his platoon.

“Two were lost in Iraq, and the other two were killed in Afghanistan,” his mother, Susan Selke, told the Houston Chronicle. “When that last one went down, it just undid him.”

Suicide rates are up across all branches of the military, even the National Guard, where the rate has increased 82 percent since 2009.

Posttraumatic stress disorder (PTSD)—marked by distressing, intrusive traumatic memories, flashbacks and a feeling of extreme emotional detachment from others—is one of the reasons. “Survivor’s guilt” of the kind Clay Hunt experienced is a particular manifestation of PTSD.

Survivor’s guilt is a psychological syndrome in which someone believes he has done wrong by surviving a traumatic situation that claimed the lives of others. It was prominent in survivors of Nazi concentration camps who came to believe—irrationally—that they must have lacked courage or been otherwise morally flawed in order to have lived through the horrors that brought death to their spouses or children or parents or friends.

Those with survivor’s guilt can torture themselves with unfair, unending questions like whether they could or should have done more to prevent catastrophe befalling those they cared deeply about, whether they should have offered themselves instead, whether their ability to avoid being killed was actually due to self-interest, or a willingness to curry favor with the enemy, or blind luck of which they were very undeserving.

Perhaps some of these questions plagued Clay Hunt.


Maybe they plagued many of the other veterans who have taken their lives after returning from Iraq and Afghanistan. Maybe many are more hobbled by guilt than by terror, awakened in the night not by flashbacks to their own near-death experiences, but to the deaths of others; not by terror, but by guilt—by the very fact that they somehow do not deserve to be alive, even that others died because of something lacking in them.

Survivor’s guilt is like empathy or selflessness gone awry, twisted back on itself until it becomes a dagger through the heart or a bullet through the brain. It is testimony to how the best qualities of the human soul can be made malignant by psychological trauma.

We are, it turns out, exquisitely—miraculously—sensitive creatures. We can care deeply about our fellow man. And, while we would never trade our sensitivity for callousness, that sensitivity also makes us vulnerable to psychiatric illness.

This is the way that some of the best of us, heroes like Clay Hunt, come to believe we are reprehensible, rightly guilty, worthy of scorn, representing the worst of us. This is the way that such valuable lives as Hunt’s are lost long after distant battles have ended.

It is time that the U.S. military, which has focused far too much attention on concepts, actually designed to make soldiers feel less--like desensitization and learned optimism—begins to join soldiers in the spiritual, moral and emotional journeys that begin when they return home and feel so much more.

Saturday, February 12, 2011

A combat veteran's struggle of the soul

Greg Valentini served in Afghanistan and Iraq, returning home with post-traumatic stress disorder. With the help of Volunteers of America, he's taking classes, trying to stay off drugs and keep on the right path.

Steve Lopez

February 13, 2011


Greg Valentini's room in Hollywood is bigger than a jail cell, but not by much. It's a home, though, and better than lockup.

"I'm sick of going to jail," he says, telling me he can't even remember how many times he's been arrested since his second tour with the Army ended in 2004.

Valentini is a tall, bulky man of 33, a die-hard Clippers fan who's fidgety as a kid. While seated on a chair, his feet tap, his weight shifts. It's as if he might run, or as if there's something in him that can't be quieted.

There's a lot of that weightless stirring in the converted church where Valentini lives, a place of recovery for nearly 40 men who fought in Iraq and Afghanistan. Having survived war, they came home and discovered they couldn't handle peace. Some ended up homeless, others landed in jail, and now they're trying to make sense of their lives in a residential program run by Volunteers of America.

"I try to stay busy," says Valentini, revealing his simple strategy for getting through each day. He reads, plays basketball, watches television and goes to school at Los Angeles City College.

On Thursday morning, he climbed out of bed and went to his psychology class. After school, he took a nap to rest up for his evening anthropology class. There's a red Long Beach City College batting helmet on his dresser and a little poster on his desk that says "Draft Beer, Not Soldiers."

Not that this son of a Vietnam vet regrets having enlisted in the year 2000, after finding little joy in a job with the Lakewood parks department.

"There were two reasons I signed up," says Valentini, who grew up middle class with a dad who raised him alone and still works in heating and air conditioning in Lakewood. "The first is that my dad said you have a right to say what you want if you've served. And the other reason was education."

The G.I. Bill, in other words, would send him to college. But in 2000, he couldn't know that he'd have to pay tuition by serving in two wars, first in Afghanistan and then in Iraq, with the 101st Airborne Division.

Six years later, Valentini can still hear the fury and chaos, see himself freezing in his first firefight in Kandahar, feel the butt of the rifle that a buddy used to bust him in the chops and snap him out of paralysis.

He began shooting, and shooting, and shooting, and during nine bloody months of heavy combat in Afghanistan, Valentini came to understand fear, absorb it, get comfortable with it. What was fear of death but a reverence for life?

"I appreciated how beautiful the country was," he says of Afghanistan. "The mountains, the clean air. I wouldn't have minded dying there."

I let Valentini's thought linger, scribble the words in my notebook and pause over them, wondering what it would be like to feel that sort of dark clarity. The mission called for flushing the Taliban out of caves, and Valentini says there were times he could see the eyes of his enemies. They were like "primitive warriors," he says, hinting at a level of respect for their willingness to die.

When I ask how many members of his own unit he lost in Afghanistan and Iraq, he tries earnestly to come up with a fair number. Yes, he saw a lot of men go down, many of them close friends. He doesn't know what kept him alive, but such is the random nature of war. There's a mysterious indiscriminate force out there on the battlefield, and it goes on tormenting you years after the shooting stops.

"I don't know, probably not quite a dozen," Valentini says.

He says he felt lost when he came home. There were jittery nights when he noticed a familiar glow, looked to the heavens and found a full moon filling the Southern California sky. The Taliban used the light of a full moon to launch attacks on his unit.

He knew he had a problem on his first Fourth of July back home, when he broke into a sweat at the sound of fireworks and flares in Lakewood. Valentini felt unappreciated and unknowable. How could he explain to anyone where he'd been?

He drank, he got hooked on meth, he frustrated the dad he dearly loves, he moved out of the house and lived in a tent by Long Beach Airport. At night he'd gaze up at the same stars that shine over Afghanistan.

Thieving and selling the goods kept Valentini supplied with food and drugs. He got caught, went to jail, then back to his airport bunker. The burglary of a Lakewood country club was a bigger deal. His haul included a big flat-screen TV that he sold for $100, but he got nailed and was hit with a two-year sentence.

Last August, after a few months in jail, he was bounced over to the VOA program in Hollywood to serve out his time and get drug treatment and counseling for post-traumatic stress disorder.

Getting sprung from jail was a break for a man who served. A chance to make a life.

It's impossible not to pull for him, but can he do it?

Valentini is honest. He doesn't know.

But he likes the manager of the program. Jim Zenner, who is roughly Valentini's age, also served, came home with issues, then got his master's degree in social work. Now he tries to help fellow soldiers pick themselves up.

Valentini can see himself doing that — going from trained killer to social worker. And to that end, he tells me, it's time to end our conversation for the day.

He goes to his room, gets his textbook and walks along Sunset Boulevard on his way to anthropology class, years of school ahead of him, lots of pain still to bury, so much at stake.

Friday, January 7, 2011

The War That Comes Home: How PTSD Affects Our Children

Leila Levinson
January 7, 2011 08:56 AM

This year, all our troops that have been deployed in Iraq will return home. Record numbers of the ones who have already returned -- about one-third -- have been diagnosed with post-traumatic stress disorder, or PTSD. An unprecedented number of them have committed suicide, and it's quickly becoming clear that our society cannot afford to ignore their invisible wounds -- especially the way we ignored those of our older veterans, namely World War II soldiers.

What words would you use to describe the World War II combat veterans you have known? Humble? Hard-working? Dedicated to their families? Silent about their war experiences?

I'll bet that almost all of us -- especially we children of those veterans -- would agree to the last choice. Our fathers never talked about what they did in the war.

My father's silence spilled beyond the topic of his war years to engulf my childhood home. As we sat down for dinner, he would place Barbara Streisand and Yale Whiffenpoof albums on the stereo, their doleful songs substituting for conversation. On Sundays, he took my family for drives to a Holiday Inn where we ate dinner before driving back home. The whirring of the tires lulled me to sleep in both directions.

At his office, he was a different person. There he smiled, nodded as he listened to his patients, wrapped his arm around their shoulders. There, his eyes twinkled -- even at me. That is where I went to tell him I wanted to drop out of law school, that I needed therapy, that I couldn't bear my depression any longer -- because at his office, there was a chance that he would answer.

After my father's death, however, I discovered what his silence concealed.

I found his army trunk in his office basement. It contained a box of photographs that he had taken during World War II, beginning with crossing the English Channel en route to Utah Beach for D-Day, across France, then Belgium where he tended the wounded at the Battle of the Bulge, into Germany. Photos labeled "Nordhausen Concentration Camp, April 11, 1945" showed countless skeletal bodies. An aunt explained that he had treated survivors for two weeks before suffering a mental breakdown.

This information astounded me, and I set out to meet other World War II veterans who had liberated the concentration camps. I found that veteran after veteran has never talked about it with their children, and that they have told very little to their spouses. Veteran after veteran choked up as they began describing what they witnessed in the camps. Many could not continue to talk. Many told me that they would have nightmares that night.

"I was never the same; I was never the same," a liberator of Dachau said.

"Did I ever change back?" a liberator of Ohrduf asked himself.

"I never spoke of it because there were no words," said a doctor who treated Dachau's survivors.

"I could not talk about it. Literally, could not talk," explained a liberator of Buchenwald.

"When I saw the crematorium, the shock was complete and total."

The over 70 men and one woman I met are still traumatized, 65 years later. The grip of the trauma is unyielding, even for those who have turned to art and writing for healing.

Could these people have post-traumatic stress disorder? I asked myself. They showed no rage, no signs of alcoholism, no nervousness or numbness. There were no indications of domestic problems -- all the indicators of what the media has presented as the hallmarks of PTSD.

Since the invasion of Iraq, we have finally begun to pay attention to combat PTSD. But the media's reporting of it has skewed our understanding of how PTSD can manifest itself. Yes, it often shows up in outbursts of rage, in substance abuse and violence. But as I learned in my travels across the country interviewing World War II veterans, the much more common face of combat PTSD is one of depression, melancholy, silence, distance, avoidance of the memories.

Our veterans desperately want to shield their families from the horrors of war, and so they turn to silence, knowing no other way to keep the awful memories from polluting their homes. They don't tell us about their awful nightmares (though many children remember being awakened by their fathers' moans or cries during the night), and they don't speak of any negative emotion, as to open oneself to sadness or grief would open the flood gates.

And the effect of the trauma -- a distortion of perception -- keeps them from perceiving how this silence shapes their children.

Children are sponges, absorbing whatever emotion and behavior they observe. They take on their parents' attributes, and so I inherited my father's depression, his emotional distancing. I inherited his war.

Children of Vietnam veterans recognize the connection between their emotional lives and their fathers's war, but children of World War II veterans still resist making similar connections. Perhaps this is because we, the generation that made Prozac and therapy household terms, still need to idealize World War II as "the good war" and our fathers as the "Greatest Generation." But I believe that that label has burdened them, made it more difficult for them to admit their pain and find help. Delayed onset of PTSD among World War II veterans has not received much attention from the media, despite the significant increase of diagnosis of PTSD among World War II veterans in just the last 10 years.

Our misperceptions of what PTSD looks like not only keeps World War II veterans from getting the help they need, but it will affect the level of support available to our soldiers returning from Iraq and Afghanistan. It is time to realize that there is no good war, and there is no victor. Everyone returns from war wounded, bringing their war home into the hearts of their families. That is the cruelest aspect of going to war, that the veteran isn't able to protect that which he or she holds most dear: his or her family.

Our responsibility is to mitigate that harm as much as we are able. We must support our veterans, not with a bumper sticker but with heartfelt commitment and engagement. We must do all we can to help them heal and know peace.