Mental health impact of Afghanistan and Iraq deployment: meeting the challenge of a new generation of veterans

Observations of combat-related stress disorders appear as early as the writings of Homer in descriptions of returning Trojan war veterans. During the civil war, PTSD was characterized as soldiers heart, in WWI shellshock, in WWII battle fatigue and during the Vietnam War as Vietnam Syndrome. In 19th Century Europe, which experienced an epidemic of railroad crashes, trauma survivors with characteristic features of PTSD were labeled as suffering from “Railroad Spine,” a condition at that time believed to be caused by compression of the spinal column. With the 1980 inclusion of PTSD in the American Psychiatric Association Diagnostic and Statistical Manual (DSM), Third Edition, PTSD has been officially designated as one of the anxiety disorders. Inclusion of PTSD in the DSM is in large measure, a legacy of the Vietnam War, with a growing understanding of the impact of exposure to traumatic events, key features of PTSD including re-experiencing, numbing and avoidant and hyperarousal symptoms, time course of response, and the impact of symptoms on functioning. The lifetime risk for PTSD in the general American population has been estimated to be 7.8%.1 The best estimate of the prevalence and course of PTSD and related mental health disorders in combat has been derived from the National Vietnam Veterans Readjustment Study (NVVRS).2, 3 The NVVRS reported a life-time prevalence of warzone-related PTSD of 30.9% among the 3.1 million men and women who served during the Vietnam War. Current prevalence rates, estimated between 15 and 25 years following combat exposure are 13.2% with an additional 11.1% experiencing features of partial PTSD. Among men who served in Vietnam, half of those who ever developed warzone-related PTSD had it 15 or more years later. Among women who served, mostly combat nurses, one-third of those who ever developed warzone-related PTSD met full diagnostic criteria 15–25 years following their deployment to Vietnam. In a recent reanalysis of the NVVRS data, which examined additional military records for confirmation of levels of combat exposure,4 a lower bound estimate for the lifetime occurrence of warzone-related PTSD was reported to be 20%. In summary, between one-fifth and one-third of men and women who served in the Vietnam War developed deployment-related PTSD, with those suffering from PTSD having increased rates of depression, alcohol and drug abuse, family adjustment problems, and interpersonal violence. Arguably, PTSD and associated co-morbidities are the most prevalent and disabling health problems related to Vietnam service. The legacy of the Vietnam War was a generation of war fighters, who experienced chronic psychiatric problems, adverse impact on family functioning, misdiagnoses, delays in treatment seeking, progressive co-morbidities including depression and substance use, and, in the first two decades following the war, under-resourced mental health systems within both DOD and VA to provide care to the psychologically injured war fighters and their families. The NVVRS and other research has demonstrated that greater combat exposure, including multiple tours of duty and greater exposure to personal life threat and killing predicted greater risk of combat-related PTSD. Recovery of traumatized war fighters from Vietnam was further complicated by a hostile political climate in which blaming the warrior for the war was the norm. Vietnam Veterans chronic PTSD symptoms resulted in irritability, anger, and emotional isolation, leading to adjustment problems in their spouses and children. This contributed to a negative feedback cycle in which the veteran's PTSD disrupted family functioning, and distress in spouses, partners, and children further weakened the ability of the veterans to recover from their PTSD. Complicating this picture, the lack of evidence-based behavioral and pharmacological treatments for combat-related PTSD in the early years following the Vietnam War limited VA and DOD mental health responses. The US invaded Afghanistan on October 7, 2001, and Iraq on March 20, 2003. To date, over 1.6 million men and women have served in Afghanistan (Operation Enduring Freedom; OEF) and Iraq (Operation Iraqi Freedom; OIF). Based in part on the painful lessons learned from Vietnam, Congress funded the VA to provide 2 years of free health and mental healthcare for OEI and OIF veterans injured during deployment, and recently extended this benefit to 5 years. Although the first large-scale surveys of the mental health impact of the Vietnam War did not occur until nearly two decades following the end of the war, a number of important DOD and VA studies have already been conducted to assess the impact of deployment in OEF and OIF. Hoge et al.5 evaluated 2,530 men and women in four US combat infantry units, before the deployment to Iraq, and an additional 3,671 after return from Iraq and Afghanistan. Rates of PTSD, major depression, and generalized anxiety ranged from 15.6 to 17.1% after duty in Iraq and 11.2% after duty in Afghanistan. Those with mental health disorders reported greater barriers to mental healthcare. A population study of Army soldiers and Marines6 who completed health assessments between May 2003 and April 2004, reported that among those returning from Iraq 19.1% were found to be experiencing PTSD, depression, or other related mental health disorders, and 11.3% returning from Afghanistan reported these disorders. This is compared with a rate of 8.5% for these mental health disorders for personnel returning from other deployments. Thirty-five percent of Iraq war veterans accessed mental healthcare in the first year after redeployment. Milliken et al.7 conducted a longitudinal study of 88,235 soldiers returning from Iraq. Screening was conducted immediately following return from the warzone and again 3–6 months later. Based on combined screening, 20.3% of active-duty and 42.4% of reservists screened positive for mental health disorders. Soldiers were much more likely to report PTSD symptoms for the first time at the second screening. Of those who reported PTSD symptoms at the first screening, 50% reported improvement at the follow-up screening 3–6 months later. In a study of PTSD and mild traumatic brain injury (TBI) in 2,525 Army infantry evaluated 3–4 months after Iraq's service,8 4.9% reported injuries with loss of consciousness and 10.3% reported head injuries with altered mental status, including being dazed or confused. Among those with loss of consciousness, 43.9% had PTSD, and among those with altered mental status 27.3% had PTSD. Among those who reported physical injuries without either loss of consciousness or altered mental status, 16.2% developed PTSD, and 9.1% developed PTSD without any history of physical injury. Of note, PTSD and depression symptoms mediated the relationship between mild TBI and physical health problems. In a random digit dialing study conducted by Rand Corporation,9 nearly 2,000 participants were surveyed by telephone with approximately 18.5% of OEF and OIF veterans reporting PTSD or depression. Nearly 20% reported experiencing a traumatic brain injury during deployment. Only half of those in need of treatment sought mental health or neurological consultation. Barriers to care included concerns about stigma and treatment side effects. The investigators concluded that improving access to evidence-based care can be both cost effective and improve recovery rates. In the first large-scale studies of OEF and OIF veterans in VA healthcare, Seal et al.10, 11 reported on the growing burden of mental disorders including trends and risk factors for mental health diagnosis in new users of VA healthcare. Between April 2002 and March 2008, data were reported on 289, 328 Iraq and Afghanistan veterans using VA healthcare for the first time; 36.9% received one or more mental health diagnoses; 21.8% received a diagnosis of PTSD; 17.4% a diagnosis of depression; 7% for alcohol use disorder; and 3% for substance abuse disorder. Adjusted 2-year prevalence rates of PTSD increased 4–7 times after the invasion of Iraq. Active duty veterans under the age of 25 had the highest rates of PTSD and alcohol and drug use disorder diagnoses compared to active-duty veterans greater than age 40. In both active duty and guard and reserve components women had higher rates of depression than male veterans, and male veterans were at twice the risk for both alcohol and drug use disorders compared with women veterans. A growing body of research has demonstrated that both veterans and civilians with PTSD, compared to trauma exposed and non-exposed individuals without PTSD, have more negative health self-perceptions, higher rates of self-reported medical problems, and in selected studies higher rates of medical problems documented by physician examination.12 In a study of 157 Brazilian police officers13 those with PTSD reported their physical health was significantly poorer, and had more medical consultations during the past 12 months. In a cross-sectional study of 1,022 men and women with coronary heart disease14 participants with PTSD, after adjusting for cardiovascular risk factors and objective measures of cardiac function, had greater symptom burden, physical limitation, and worse quality of life. Among patients with heart disease, PTSD was found to be more strongly associated with patient-reported cardiovascular health status than objective measures of cardiac function. In a cross-sectional survey of 118 active-duty male police officers,15 after controlling for confounding influences of demographics, BMI, tobacco alcohol, and medication use, PTSD was associated with increased serum levels of cholesterol and triglycerides. The association between PTSD and abnormal serum lipid profile, with a tendency for higher BMI in those with PTSD, suggests that individuals with PTSD are at increased risk for developing metabolic syndrome. In a longitudinal descriptive study of 180,324 veterans from Iraq and Afghanistan, who were new users of VA healthcare between October 2001 and September 200616 veterans with PTSD and related mental health diagnoses had significantly greater utilization of primary care, subspecialty care, and ciliary services, laboratory tests and diagnostic procedures, emergency services, and inpatient medical hospitalizations. Prior research documents that military families are significantly affected by a service members' war-related mental health problems, as well as the chronic stress of multiple and extended wartime deployments, with diminished service member “dwell” time between deployments. Findings from the NVVRS reported that children of veterans with PTSD had higher levels of behavioral and emotional problems than children of combat-exposed veterans without PTSD. Families of veterans with PTSD are also more likely to suffer domestic violence or intimate partner violence than families of veterans without PTSD. Newby et al.17 found that in the US Army younger couples and those with a previous incident of domestic violence are at greatest risk for an episode of domestic violence postdeployment. Adverse childhood experiences, including having a parent with PTSD and exposure to domestic violence, have been found to contribute to negative adolescent development, including early school drop out, substance abuse, obesity, and promiscuity. In related research, adverse childhood experiences have been found to contribute significantly to adverse adult outcomes, including depression, PTSD, substance abuse, poor medical health, and low occupational attainment. A major challenge for DOD and VA is to mitigate the effects of warzone PTSD on the health and functioning of spouses and children. Despite the lessons learned from Vietnam, engaging OEF and OIF veterans in mental healthcare remains a challenge. Young men and women returning from Afghanistan and Iraq service with warzone-related PTSD and related mental health problems struggle to confront these problems and reach out for mental health services. They have busy lives, concerns about childcare, financial pressures, concerns about an adverse impact of being labeled with PTSD on their military or civilian careers, and perceptions as being weak in a culture critical of vulnerability and prone to the shame of mental illness. Practical concerns regarding access to care, transportation, and childcare also constitute obstacles to receiving much needed mental health services. DOD and VA have adopted a number of innovative strategies to overcome the obstacles to care for returning war fighters from Iraq and Afghanistan. Integrated, co-located care where mental health services are provided inside primary care is one approach, with a well-established evidence-base for the successful treatment of depression in co-located mental health primary-care clinics.18 Efforts are being made to de-stigmatize mental health services by reframing them as stress management training for combat stress reactions, rather than psychiatric treatment for mental disorders. In an effort to address geographic barriers to care and stigma, efforts are being made to bring care to veterans utilizing Internet and telephone care as an alternative to traditional clinic visits. Motivational interviewing techniques are used to directly address the stigma concerns. By employing these novel strategies the hope is to reduce the risk of delayed treatment seeking, which will inevitably result in higher rates of co-occuring depression, alcohol and drug use, interpersonal violence, physical health problems, and occupational disability. The past two decades have seen rapid advances in evidence-based treatment for both combat and civilian PTSD. Among the psychotherapies, those with greatest empirical support are cognitive behavioral therapy emphasizing the combination of imaginal and in vivo exposure, and cognitive processing therapy, addressing irrational beliefs related to traumatic exposure. There is some preliminary support for the use of marital and family therapy. A recent meta-analysis of pharmacotherapy for PTSD19 reported 35 randomized control trials of medications for PTSD with 17 positive placebo control trials. Clinical improvement occurred in 59.1 of those in the active pharmacological treatment conditions vs. 38.5% receiving placebo. Amomg pharmacotherapies the strongest evidence is for selective serotonin reuptake inhibitors (SSRIs). Antidepressant medications, including SSRIs, are effective for both PTSD and co-morbid depression, with PTSD treatment benefits not explained by improvements of depression symptoms. Other evidence-based pharmacotherapies include trazodone for initial insomnia, prazosin for nightmares, anti-convulsants for persistent anger and irritability, atypical antipsychotic for paranoia and trauma-related hallucinations, disulfiram, naltrexone, and topiramate for co-morbid alcohol abuse, and selective norepinephrine reuptake inhibitors for pain.20 An important limitation of current screening procedures is the reliance on self-report measures and clinical interviews to make the diagnosis of PTSD. These methods are subject to a number of biases, including underreporting of PTSD symptoms because of stigma of mental illness and concerns about adverse effects on military and civilian careers, and exaggeration of symptoms in those seeking compensation for service connected disability. In sharp distinction with medical disorders such as cancer, coronary artery disease, and diabetes for which there are objective biomarkers for diagnosis, illness severity, and response to treatment, the assessment of PTSD cannot be independently confirmed by biological markers. Identification of biomarkers of PTSD is critical for DOD and VA for use in postdeployment medical screening, treatment selection, treatment outcome monitoring, disability evaluations, and for informing novel targets for treatment development. Current biomarker research in PTSD includes functional and structural brain imaging, genotyping and gene expression, neuroendocrinology, acoustic startle and fear conditioning, and sleep physiology studies. Prospective research is being conducted to assess biomarkers before and after life threat exposure in order to differentiate risk factors from diagnostic markers. Clinical trials are incorporating biomarkers before and after treatment to advance treatment selection and establish objective criteria for treatment response. Additionally, biomarkers hold great potential for explaining and mitigating the association between war zone-related PTSD and physical health problems, including cardiovascular and metabolic disorders. Identification of biological markers for warzone PTSD will also inform stress innoculation strategies for resilience building before combat exposure and early preventative interventions that can be deployed for use in battlefield medicine. Charles R. Marmar, M.D. is a Professor and Vice Chair of Psychiatry at the University of California, San Francisco. He is also Associate Chief of Staff for Mental Health and Director, PTSD Research Program, San Francisco VA Medical Center. He has served as past president of the Society for Psychotherapy Research and past president of the International Society for Traumatic Stress Studies. He was a co-recipient of the Robert S. Laufer Award for outstanding scientific achievement to the field of traumatic stress studies from the International Society for Traumatic Stress Studies for his contributions to the National Vietnam Veteran Adjustment Study. He also received the J. Elliott Royer Award in recognition for significant contribution to the advancement of psychiatry from the University of California, San Francisco. Dr. Marmar has many recent and current research projects in the area of traumatic stress disorders. He is conducting a 5-year NIMH-funded prospective study of 400 police academy recruits in the Bay Area and New York to test individual differences in psychophysiological and neuroendocrine reactivity to stress challenge testing during training as a predictor of vulnerability to critical incident stress during police service. He has recently completed an NIMH-funded randomized clinical trial of cognitive behavior therapy for secondary responders to the World Trade Center attacks. He has also recently been awarded a 3-year DODfunded grant to determine if the addition of D-cycloserine, an NMDA partial agonist that facilitates fear extinction in animal models, to CBTwill accelerate recovery from combat PTSD in returning Afghanistan and the Iraqi veterans. Finally, As Program Director for a UCSF Foundation supported project on compassionate practices in death notification following sudden loss and survivor care, he and his colleagues have developed training protocols for the United States Army casualty assistance and casually notification units, modifications of these training protocols for use with the New York Police Department and London Metropolitan Police Department, and are presently conducting research on 850 law enforcement officials in United States to determine the value of specific training in death notification practices.