From War to Home: Psychiatric Emergencies of Returning Veterans

Since the time of Homer, warriors have returned from battle with wounds both physical and psychological, and healers from priests to physicians have tried to relieve the pain of injured bodies and tormented minds.¹ The "soldier’s heart" of the American Civil War and the shell shock of World War I both describe the human toll of combat that since Vietnam has been clinically recognized as posttraumatic stress disorder (PTSD).² The veterans of Operation Iraqi Freedom (OIF) and of Operation Enduring Freedom (OEF) share with their brothers and sisters in arms the high cost of war. As of August 2009, there have been 4333 confirmed deaths of US service men and women and 31,156 wounded in Iraq. As of this writing, 796 US soldiers have died in the fighting in Afghanistan.³

Yet, there are also unique aspects of the combat experience of these veterans that influence their psychiatric presentations in acute settings.

First, far more of the troops (up to 45%) are reserve or National Guard rather than active duty compared with earlier wars.⁴ Their combat exposure, severity of PTSD, and impairments in interpersonal functioning are more similar to those experienced by career military.⁵ These individuals are most likely to appear in crises in community emergency departments (EDs); they may present with problems that may be different from veterans of previous wars or from soldiers in active military duty.

Typical presenting symptoms are marital stress from unexpectedly long deployments of 15 months (rather than the standard 12), employment concerns, financial stresses, and overall difficulty in reintegrating into civilian life. The absence of a strong military identity and cohesion, geographical separation from comrades, greater stigma, and misunderstanding from communities without exposure to the military or combat trauma serve as formidable barriers to care for these citizen-soldiers.

Second, multiple deployments have become the expectation. Many soldiers serve 2, 3, or even 4 tours of duty-a phenomenon unparalleled in other conflicts. Data from the Mental Health Advisory Team V report show that 11% of soldiers on their first deployment experienced mental health problems; that figure rose to 27% for those on their third tour.⁶

Third, it is estimated that up to 15% of all soldiers deployed to Iraq are women⁷; they have assumed an unprecedented combat support role in the war, resulting in greater risk for trauma. (See “Female Veteran Who Had Been Sexually Assaulted” case vignette.)Sadly, these women are also all too frequently victims of sexual harassment and assault. Although estimates from this conflict are not yet available, a study of female outpatients from Veterans Affairs hospitals found 23% had experienced sexual assault and 44% sexual harassment.⁸

Fourth, the enormous progress of battlefield medicine has created an unprecedented situation in which warriors who would have died in all previous wars from their injuries now survive. They must struggle with multiple devastating wounds-most commonly traumatic brain injuries (TBIs)⁹ often with co-occurring PTSD.¹⁰ Emergency physicians and mental health consultants who work in the ED often encounter returning veterans with subtle forms of cognitive impairment and medical conditions that have gone undiagnosed or untreated.

The goal of this review is to assist ED clinicians and psychiatrists who are faced with the challenges of caring for increasing numbers of returning veterans with combat-related physical and mental trauma. An overview of the epidemiology of mental health conditions identified in OIF/OEF veterans will serve as background for subsequent sections in which evidence-based assessment of PTSD, suicidality, and substance abuse in returning soldiers are the focus.^11,12 Management approaches-including crises stabilization, initiation of psychotherapeutic and psychopharmacological treatments when clinically indicated, and (most important) education and counseling of patient and family regarding their mental health issues, safety, and arrangement of proper referral-will then be presented. Case vignettes will also be presented to illustrate these concepts.

It is hoped that the information, clinical guidance, and referral resources offered here will raise the comfort and competence level of ED clinicians so that they may see visits from our returning soldiers as a rewarding opportunity to serve those who have served.

EPIDEMIOLOGICAL BACKGROUND

One of the most comprehensive and authoritative sources for information about the mental health problems of returning soldiers is a 2007 longitudinal assessment of active duty and reserve soldiers returning from Iraq.¹³ In response to earlier methodological concerns about underestimation of the extent of mental health problems in OIF soldiers, the Department of Defense (DOD) conducted a Post-Deployment Health Re-Assessment (PDHRA) screening of 88,235 soldiers. Screening was administered immediately after return from deployment and then 3 to 6 months later. When compared with the prior study that utilized the Post-Deployment Health Assessment (PDHA), the population-based study that used the PDHRA documented significantly higher rates of mental health issues.¹⁴ Clinicians who administered the screening found that 20.3% of active duty and 42.4% of reserve soldiers required treatment for mental health issues. These findings highlight the need for effective outreach to reservists.

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 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.

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