The incidence of interpersonal conflict had quadrupled from the earlier survey. This finding, which is particularly relevant for civilian ED staff, underscores the need for treatment not just of the soldier, but of the military family as well. Alcohol(Drug information on alcohol) problems were frequently identified; nevertheless, few soldiers were referred for treatment. The authors of a JAMA article that compared the results of the PDHRA to the earlier PDHA suggest that this may be related to concerns about stigma and confidentiality that could affect the military careers of reservists and National Guard troops.13 Indeed, the study found that most of the soldiers who received mental health treatment were self-referred—a result echoing the earlier report by Hoge and colleagues.14
Drilling down into this and other literature identifies important diagnostic information for ED clinicians who treat returning soldiers. National Guard and Army Reserve veterans had much higher rates of PTSD, interpersonal conflicts, depression, and overall mental health risk than active duty soldiers (35.5% to 27.1%, respectively), as well as increased rates of referral for mental and physical health concerns.13 Rates of PTSD identified in returning veterans range from 12% to 19%; the most frequently quoted average is 15% to 16%, and rates are higher in OIF than in OEF veterans.15-17
The high prevalence of PTSD in service personnel involved in the wars in Iraq and Afghanistan has been much publicized in the public and professional press, but the elevated rates of other serious mental health disorders—in particular the comorbidity of substance abuse and PTSD—has been underappreciated. Up to 35% of soldiers meet criteria for major depressive disorder, and figures for problem alcohol use range from 11% to 40%, depending on definitions employed, methods of screening, and cohort examined.12,15,16 Respondents with lower education and lower income were more likely to have problematic alcohol use. Several studies have shown that returnees who engage in hazardous drinking are less likely to seek and receive appropriate diagnosis and treatment.12,15
There is a general trend across the research on returning veterans for young cohorts to have more serious mental health problems, including substance abuse and suicidal behavior. Soldiers with mental health issues consistently endorse an overall lower quality of health and life,15,18 higher distress, and functional impairment.16 A PTSD diagnosis alone is associated with more sick calls, missed worked days, worse general health, and a greater number and severity of somatic symptoms.19,20 All of this suggests that many OIF/OEF veterans may present to community EDs with physical symptoms that have a substantial psychosomatic component.20,21 A disturbing finding of emerging research is that returnees, especially OIF veterans with PTSD, have high levels of anger, hostility, and aggression22 and manifest more violent behavior than Vietnam veterans.23
ASSESSMENT OF PTSD
As the above-mentioned demographics indicate, PTSD—often co-occurring with other physical and mental health disorders—will probably be the most common presentation among veterans in community EDs. Thus, it is important for ED mental health professionals, especially emergency psychiatrists, to develop familiarity with the signs and symptoms that characterize the diagnosis as well as with validated screening instruments that can improve the accuracy of a clinical diagnosis. PTSD, acute stress disorder (ASD) and adjustment disorder—all of which can be seen in returning veterans—are unique in the DSM-IV-TR because their etiology in trauma and stress is specified.
PTSD is classified as an anxiety disorder in which there must be exposure to a traumatic event. Criterion A requires that:
1. The individual experiences directly or indirectly, by witnessing or confronting, an event or events that involved the actual or perceived threat of death or serious injury or disruption of physical integrity to the self or another human being.
2. The individual responds to the traumatic exposure with a sense of intense fear, helplessness, or horror.
In addition, a specified number of symptoms from criteria B through D are required and are listed in Table 1. Grouping of the symptoms in 4 core clusters (re-experiencing, avoidance, numbing, and hyperarousal) helps to both understand and recognize the primary dimensions of the disorder.
To distinguish PTSD from ASD, criterion D requires that the symptoms must last longer than 1 month and must cause clinically significant distress or impairment in social, occupational, or other areas of functioning to meet criterion E. PTSD can be classified as either acute, if the symptoms last for less than 3 months, or chronic if they persist longer. There is also a delayed-onset qualifier when criteria are only met for the disorder 6 months after the traumatic event, which several studies suggest may be the pattern in OIF veterans with comorbid depression and battle injuries.24-26
There are several specific assessments that can help the ED clinician identify PTSD. Among the most widely used is the Clinician-Administered PTSD Scale (CAPS),27 a 30-question evaluation corresponding to DSM-IV criteria that assesses severity, frequency, and intensity of current and past PTSD symptoms, as well as multiple areas of psychosocial functioning.28 Many of the more structured interviews have strong psychometric reliability and validity but require more training and time than can be expected in an ED setting. Fortunately, there are also a number of self-report measures that can easily be used in the ED, such as the National Center for PTSD Checklist for veterans.
A scale that has proved useful in the primary care area—the Primary Care PTSD Screen (PTSD-PC)—is also a good fit for the ED.29 It consists of 4 yes/no questions, takes about 2 minutes to administer, and requires no specialized training.
Obviously, positive screens on these briefer self-report measures warrant a comprehensive evaluation. Given the protean nature of the effects of PTSD on all aspects of life and the epidemiology reviewed above, the ED assessment should briefly touch on interpersonal and work functioning, recreation and self-care, physical health, and overall psychological state—including pre-deployment functioning and traumatic events. Note that soldiers experience traumatic experiences other than in combat situations, such as training accidents, exposure to chemical and biological weapons, and family stressors, and that women as well as many men all too frequently are victims of sexual harassment and trauma.30