An analysis of data on nearly 104,000 veterans of the Afghanistan and Iraq wars who sought help from the Department of Veterans Affairs (VA) system confirms that substantial numbers returned from their tour of duty with psychiatric problems.
The study covered veterans separated from duty in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) who were first seen at VA facilities between September 30, 2001, and September 30, 2005. Some 25% of the vets, or more than 25,000 individuals, received a mental health diagnosis, and 56% of these had 2 or more mental health diagnoses. Fifty-two percent of the records examined were of active duty personnel and 48% from National Guard personnel and from reservists.
"These results indicate a large burden of co-occurring mental health disorders associated with service in Iraq and Afghanistan," according to Dr Karen Seal, of the University of California, San Francisco, the lead author of the study published in the Archives of Internal Medicine.1
"This burden will likely increase with time as new cases emerge and unresolved disorders become chronic, posing logistical and fiscal challenges for VA and non-VA mental health services as well as primary care medical services," the investigators warned.
The mental health diagnoses recorded included posttraumatic stress disorder (PTSD), anxiety disorders, adjustment disorder, depressive disorders, and substance use disorders. When "other" mental health disorders (including psychoses, schizophrenia, affective disorders, neurotic disorders, personality disorders, sexual disorders, depressive disorders not otherwise classified) were added in, more than 32,000 veterans were affected. The report noted that "the single most common mental health diagnosis was PTSD, coded in 13,205 . . . veterans, representing 52% of those receiving mental health diagnoses and 13% of all . . . veterans in our study population."
It was notable that about 29% of returned OEF/OIF vets enrolled in VA health care during this period, a historically high rate; in contrast, about 10% of Vietnam veterans enrolled. Also notable was that most mental health diagnoses were made initially in non-mental health settings, mostly primary care (but 90% of the diagnoses remained the same on mental health follow-up). The median time from service separation to the first VA clinic visit was less than 3 months, and the median time from that visit to the first mental health diagnosis was just 13 days.
High-intensity exposure
Unlike in most previous wars, including the war in Vietnam, personnel in OEF/OIF experienced constant exposure to danger, with little opportunity for relief.
"The majority of military personnel experience high-intensity guerrilla warfare and the chronic threat of roadside bombs and improvised explosive devices," the authors wrote. "Some soldiers endure multiple tours of duty, many experience traumatic injury, and more of the wounded survive than ever before."
PTSD became a major focus of attention during the Vietnam war, but the conditions that led to high rates of stress among combatants in that conflict were different from those faced by today's fighters, according to Mary Helen Davis, MD, who chairs the American Psychiatric Association's Ad Hoc Work Group on Veterans Affairs and Military Initiatives.
"In Iraq, you have combat-related exposures in both the support and combat venues. You have to be hypervigilant and hyperalert at all times," she said. "And there are gender issues this time. Typically, women have been more in support roles. Today there are more women receiving combat-related trauma exposure, as well as sexual harassment and sexual trauma. Those are some things that are unique to this conflict. In addition, you now have multiple deployments and the impact on the family."
"In Vietnam, the troops could stand down and go to a safer area. You had R&R in country and out of country. There were places to go for recuperation, like Hawaii and Australia," added Deborah Barnes, LCSW, a Houston-based clinical social worker who served as a Red Cross caseworker in Vietnam. "I assume they're doing that, but you don't hear of it.
"I had one client who was talking about coming home on leave at the 6- month point. The only trouble was, he had to go back."
