Surge in Mental Health Conditions in War Veterans

The media is full of alarming stories about veterans who return from the conflicts in Iraq and Afghanistan with various behavioral health issues, notably posttraumatic stress disorder (PTSD), major depression, traumatic brain injury (TBI), and alcohol abuse. Let’s review the professional literature data on the prevalence of these conditions in war veterans.

In a preface article to a special issue of the Journal of Clinical Psychology devoted to psychological services for returning veterans and their families, Sammons and Batten¹ make 3 points worth emphasizing:

• At no other time in history has greater attention been paid to the psychological effects of engaging in armed conflict.
• This is the first time in recorded warfare that the number of psychological casualties resulting from combat has far outstripped the number of physical injuries or deaths. In World War II, 22% of US soldiers wounded in combat died of their injuries, and in the Vietnam conflict, 16% of those injured in battle died. In the current conflicts, to date 8.8% of those injured in battle have died of their wounds.
• Most service members and their families, like most other people, demonstrate remarkable resilience in the face of adversity.

PTSD, Depression, and TBI
Rand Corporation researchers2 conducted a review of epidemiological studies to examine mental health and cognitive conditions among service members deployed to Iraq and Afghanistan and found that:

• PTSD is more prevalent than depression, affecting about 5% to 15% of deployed service members compared with a prevalence of 2% to 10% for depression.
• The prevalence of PTSD and depression increases as the time from returning from deployment increases.
• Service members who experience combat exposure and who have been wounded are much more likely than others to meet criteria for PTSD later on.
• Service members deployed to Iraq and Afghanistan are more likely to meet criteria for PTSD and depression than nondeployed troops; the rates of PTSD and depression are higher for those deployed to Iraq than for those deployed to Afghanistan.

The Rand researchers also reported that although TBI has been deemed, along with PTSD, a “signature wound” of the current conflicts, data on the prevalence of TBI are lacking.² They noted, however, that according to the Defense and Veterans Brain Injury Center, approximately 2700 military personnel serving in Iraq and Afghanistan have had a TBI, and potentially hundreds of thousands more (at least 30% of service members engaged in active combat in those 2 countries for 4 months or more) may have had a mild TBI as a result of improvised explosive devices.

In addition, research that was conducted many years after previous conflicts has produced prevalence estimates of mental health conditions among war veterans that are equal to if not higher than those associated with the current conflicts. In a 1992 survey of 8169 veterans of the Vietnam conflict, approximately 72% of respondents reported a lifetime history and 36% reported a 12-month history of at least 1 psychiatric disorder.³ The most prevalent disorders included alcohol abuse and/or dependence (54%, lifetime history; 17%, 12-month history) and PTSD (10%, lifetime history; 4.5%, 12-month history). Veterans of the first Gulf War also reported a significantly higher prevalence of current anxiety disorders (PTSD, panic disorder, and generalized anxiety disorder) than nondeployed military personnel (5.9% vs 2.8%; odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3 - 3.1).⁴ However, it is not easy to compare figures, given the emergence of symptoms over time (eg, delayed-onset PTSD) and increases in treatment-seeking behavior. The phenomenon of delay also means that the need for mental health services for service members deployed to Iraq and Afghanistan will likely increase over time. Targeted mental health interventions should focus on those who served in combat roles and those who have physical wounds.

Alcohol Abuse
Receiving somewhat less attention than the prevalence of PTSD, depression, or TBI is the considerable risk of alcohol abuse among war veterans. Using data from the Millennium Cohort Study, a self-report questionnaire filled out at baseline (2001 - 2003) and again at follow-up (2004 - 2006) by about 55,000 military personnel, researchers determined that new-onset rates of heavy weekly drinking, binge drinking, and alcohol-related problems were more likely in personnel deployed to Iraq and Afghanistan than in nondeployed personnel.⁵ Among active-duty military personnel, new-onset rates were 6.0%, 26.6%, and 4.8%, respectively. Reserve and National Guard personnel who deployed and reported combat exposures were significantly more likely to experience new-onset heavy weekly drinking (OR, 1.63; 95% CI, 1.36 - 1.96), binge drinking (OR, 1.46; 95% CI, 1.24 - 1.71), and alcohol-related problems (OR, 1.63; 95% CI, 1.33 - 2.01) than nondeployed personnel. The youngest service members were at highest risk for all alcohol-related outcomes: new-onset heavy weekly drinking (OR, 3.74; 95% CI, 2.90 - 4.83), binge drinking (OR, 6.90; 95% CI, 5.42 - 8.79), and alcohol-related problems (OR, 4.82; 95% CI, 3.53 - 6.57).

Findings about the alcohol abuse increase among Reserve and National Guard troops are consistent with those of another recently published study of more than 88,000 soldiers returning from Iraq: 11.8% of active-duty military personnel and 15.0% of Reserve and National Guard troops admitted to alcohol-related problems on a 2-item alcohol screen done as part of the newly implemented Post-Deployment Health Reassessment.⁶

Significantly, very few service members who reported problems related to alcohol use were referred for alcohol-related treatment and were infrequently followed up when referred.⁶ This problem may reflect the particulars of the current military treatment policy, wherein a soldier’s commander is automatically informed about alcohol treatment, while the provision of other types of mental health care has some medical confidentiality protections.

Comorbidity
Not only are PTSD, depression, TBI, and alcohol abuse all common in the military population, but these conditions may also occur together. For example, a study of 2525 US Army infantry soldiers 3 to 4 months after their return from a year-long deployment to Iraq showed that of those reporting an episode of mild TBI with loss of consciousness or altered mental status (eg, dazed or confused), 43.9% of those with loss of consciousness and 27.3% of those with altered mental status met criteria for PTSD.7 In comparison, 16.2% of soldiers with other injuries and 9.1% of soldiers with no injury met criteria for PTSD. Soldiers with mild TBI were also significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somatic and postconcussive symptoms than were soldiers with other injuries. However, after adjustment for comorbid PTSD and depression, TBI was no longer significantly associated with these physical health outcomes, except for headache. PTSD and depression may explain much of the relationship between mild TBI and ongoing physical health problems.

Conclusion
Many returning veterans have a variety of complaints and symptoms related to PTSD, depression, TBI, or alcohol abuse, or a combination of 2 or more of these conditions. The relationships among these conditions are not always clear, which may confound the ability to clearly measure the effects and severity of each condition. Although military personnel are trained for combat and peacekeeping operations, deployment-related exposure to traumatic events is associated with an increase in the prevalence of mental health problems.⁸ ?

References:

References
1. Sammons MT, Batten SV. Psychological services for returning veterans and their families: evolving conceptualizations of the sequelae of war-zone experiences. J Clin Psychol. 2008;64:921-927.
2. Tanielian T, Jaycox LH. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Center for Military Health Policy Research; 2008. http://wwwcgi. rand.org/pubs/monograph/2008/RAND_MG720.pdf#page= 477. Accessed March 9, 2009.
3. Eisen GA, Griffith KH, Xian H, et al. Lifetime and 12-month prevalence of psychiatric disorders in 8169 male Vietnam War era veterans. Mil Med. 2004; 169:896-902.
4. Black DW, Carney CP, Peloso PM, et al. Gulf War veterans with anxiety: prevalence, comorbidity, and risk factors. Epidemiology. 2004;15:135-142.
5. Jacobson IG, Ryan MA, Hooper TI, et al. Alcohol use and alcohol-related problems before and after military combat deployment. JAMA. 2008;300:663-675.
6. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA. 2007;298:2141-2148.
7. Hoge CW, McGurk D, Thomas JL, et al. Mild traumatic brain injury in U.S. soldiers returning from Iraq. N Engl J Med. 2008;358:453-463.
8. Sareen J, Cox BJ, Afifi TO, et al. Combat and peacekeeping operations in relation to prevalence of mental disorders and perceived need for mental health care: findings from a large representative sample of military personnel. Arch Gen Psychiatry. 2007;64:843-852.