There have been nearly 1.5 million military deployments to the southwest Asian combat zone since the start of the Afghanistan operation and Iraq war in 2001 and 2003, respectively. There have been many casualties, some of which have been highly profiled, such as service members being killed in action, losing limbs, or suffering blast injuries to their brain. Although these casualties are tragic and life-altering—both for the soldiers and their families—they represent a fraction of the morbidity associated with the war. Mental illnesses appear to be far more common consequences of the combat experience than the more dramatic ones previously noted. As in earlier protracted wars, military personnel returning from combat experience a wide array of psychological problems, including anxiety disorders (eg, posttraumatic stress disorder [PTSD] and panic disorder), depressive disorders, substance abuse, family disruption, and suicide. Although we do not know the exact rate of PTSD associated with the current conflicts, the National Vietnam Veterans Readjustment Study found a 15.2% rate of PTSD associated with that war.1
In the current war, military hospitals and Department of Veterans Affairs (VA) hospitals have seen many patients for the treatment of mental illness. The VA hospital system alone has seen thousands of veterans for treatment of mental illnesses related to the conflicts in Afghanistan and Iraq, and patients continue to present for treatment.
Troops serving in Iraq and Afghanistan may be more vulnerable to mental disorders for several reasons:
- Because of the lack of a formal battlefront, soldiers deal with constant threat and combat uncertainty.
- Many of the troops are from National Guard units; as such, these soldiers frequently receive much less training than active-duty units.
- Tours of duty are long and they frequently include direct combat exposure.
- Many military service members face redeployment.
A recent editorial in the Journal of General Internal Medicine noted "Iraq has become a more effective incubator for posttraumatic stress disorder (PTSD) in the American service members than any mad scientist could conceivably design."2
This article reviews the data on returning service members and the associated mental illness consequences.
The earliest published report of psychological outcomes for soldiers deployed in Iraq (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]) found high rates of exposure to traumatic situations and combat.3 According to the study, about 33% of soldiers in Afghanistan and 71% to 86% of soldiers in Iraq experienced a firefight. PTSD rates ranged from 6.2% for veterans of Afghanistan's OEF to more than 12% for OIF veterans. The risk of PTSD was found to increase linearly with the number of firefights (Figure). Having been wounded, a condition previously found to be predictive of PTSD, was also significantly associated with PTSD. As is commonly found in patients with PTSD, rates of depression and alcohol use also increased following combat exposure.
Unfortunately, less than half of the soldiers who met criteria for a mental disorder indicated any interest in receiving treatment, and only 23% to 40% received treatment. Many soldiers expressed concern about the stigma associated with receiving professional help; those who were most in need of help were also most likely to report concern about being stigmatized. A follow-up study conducted 1 year after their return from combat duty in Iraq found that 17.1% of the soldiers were wounded or injured and 16.6% met criteria for PTSD.4 As with World War II, Korean War, and Vietnam War veterans, those with PTSD were much more likely to report poor health, with OIF veterans reporting many missed workdays and a variety of somatic symptoms.
In a study that evaluated more than 100,000 computerized medical records of OIF and OEF veterans who were seen at VA health care facilities between September 2001 and September 2005, 31% received a mental health diagnosis or a V-code (indicating a psychosocial problem), and 25% received a specific mental illness diagnosis.5 Not surprisingly, PTSD was the most frequently diagnosed psychiatric condition, occurring in more than 13,200 veterans, or 13% of the soldiers. Moreover, PTSD was seen in more than half of the veterans who received any mental illness diagnosis. Because these data are now more than 2 years old, there is no doubt that the number of veterans with PTSD who have been treated in the VA is vastly higher. Of note, the authors pointed out that almost 30% of OIF and OEF veterans have already enrolled for health care at the VA, compared with only 10% of Vietnam veterans. With such high service use and high rates of mental disorders, finding enough qualified mental health care providers to treat the onslaught of symptomatic veterans will be a tremendous challenge.
The largest report of mental health problems following deployment to Iraq and/or Afghanistan comes from the Defense Medical Surveillance System, a database that includes medical encounters of US military service members and reimbursed or contracted care for both active-duty and reserve soldiers.6 The database does not include care provided at the VA or in private settings, nor does it give any information about people who never sought treatment; however, it does offer one of the most comprehensive views of health care among those in OIF and OEF.
According to the database, of the 865,674 service members deployed to Iraq and/or Afghanistan, 12% received a specific mental disorder diagnosis. The highest rates were seen in women (17.4%), who accounted for more than 10% of the entire deployed force. Overall rates for PTSD were quite low—only 2.3%—which probably represents the low rates of treatment-seeking behavior while soldiers are on active duty. This rate is considerably lower than that found in other studies. Of interest, there was a different relationship between age and the rates of mental disorders between the active-duty and reserve components of the Armed Forces. While rates for any mental disorder and PTSD decreased with age in active-duty soldiers, they increased with age in the reserve component. There is no clear explanation for this difference nor for the unusual finding that older age was associated with increased PTSD.
The report also noted that the stigma associated with seeking mental health care may be stronger among the active-duty soldiers than among the reservists. There are several possible explanations. Active-duty soldiers may be concerned about repercussions to their careers for seeking mental health treatment. It may be that because reservists are only eligible for military care within 90 days after returning from active duty that they report problems earlier. Finally, reservists, especially older ones, may have more difficulties with the stresses associated with long-term and multiple deployments.
Stigma as impediment to treatment
Stigma associated with treatment may be a serious problem for soldiers returning from OIF and OEF. A recent study from our institution evaluated beliefs about mental health care among a small convenience sample of 20 National Guard soldiers who had served in Iraq.7 The findings highlight some concerns and shed some hope about soldiers' attitudes toward treatment and access to care.
More than half of the group screened positive for mental health disorders, including depression, panic disorder, generalized anxiety disorder, alcohol abuse, and PTSD, but only half of those individuals received any formal treatment. As with previous findings, soldiers reported concern with the stigma associated with seeking mental health care, including perceptions that they would be labeled "crazy" and that there might be negative consequences for their military career. Military officers were concerned about perceptions of their leadership abilities, and lower-ranking enlisted soldiers were concerned with becoming nondeployable or not receiving promotions.
Soldiers were able to identify several advantages to treatment, including possible improvements in sleep and relationships as well as being able to talk with someone who understood what they were going through. On an encouraging note, 75% of those interviewed felt that everyone, including the military, would support their decision to seek care. Surprisingly, and possibly a testament to the efforts of the Department of Defense and the VA to improve awareness of and access to mental health care, none of the soldiers reported concerns regarding access to care.
It appeared that the most common barrier to care was the soldiers' own beliefs; more than half of the soldiers believed they should handle it on their own or did not want to believe they had a problem. Consequently, the investigators noted that preference for and access to treatment may not be sufficient to prompt soldiers to seek mental health care, and more focused interventions, such as cognitive-behavioral therapy (CBT) targeting their beliefs about care, may be needed. This was a small sample of patients, and thus this finding may not be true of larger samples; nonetheless, it highlights the fact that soldiers' concerns about stigma may be a significant barrier to treatment. Our own clinical experience supports the fact that soldiers avoid treatment; we see patients who are only just seeking treatment, although they have had symptoms since returning from combat several years ago.
1. Price JL. Findings from the National Vietnam Veterans' Readjustment Study. Available at: http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_nvvrs.html?opm=1&rr=rr45&srt=d&echorr=true. Accessed December 26, 2007.
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3. Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351:13-22.
4. Hoge CW, Terhakopian A, Castro CA, et al. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. Am J Psychiatry. 2007;164: 150-153.
5. Seal KH, Bertenthal D, Miner CR, et al. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007;167:476-482.
6. Medical Surveillance Monthly Report. 2007;14: 2-8.
7. Stecker T, Fortney JC, Hamilton F, et al. An assessment of beliefs about mental health care among veterans who served in Iraq. Psychiatr Serv. 2007;58: 1358-1361.
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9. Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2007;(3):CD003388.
10. Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2002; (2):CD000560.
11. van der Kolk BA, Dreyfuss D, Michaels M, et al. Fluoxetine in posttraumatic stress disorder. J Clin Psychiatry. 1994;55:517-522.
12. Friedman MJ, Marmar CR, Baker DG, et al. Randomized, double-blind comparison of sertraline and placebo for posttraumatic stress disorder in a Department of Veterans Affairs setting. J Clin Psychiatry. 2007;68:711-720.
13. Raskind MA, Peskind ER, Hoff DJ, et al. A parallel group placebo controlled study of prazosin for trauma nightmares and sleep disturbance in combat veterans with post-traumatic stress disorder. Biol Psychiatry. 2007;61:928-934. Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2007;(3):CD003388.Stein DJ, Ipser JC, Seedat S. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2006;(1):CD002795.