Posttraumatic Stress Disorder in Veterans

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.

Psychiatric morbidity

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.

PTSD treatment

The treatment of PTSD is, at first blush, fairly straightforward. The Cochrane Collaboration, a leading source in evidence-based medicine, has published 3 systematic reviews related to PTSD treatment. The 2006 pharmacotherapy review of randomized controlled trials found that medications, primarily SSRIs, are effective in reducing core PTSD symptoms and associated depression and disability.⁸ The overall response rate was 59.1% compared with a 38.5% placebo response, leading to an overall number needed to treat of approximately 5. Not surprisingly, medications were found to be less well tolerated than placebo. These results concur with the common clinical practice of using SSRIs to treat PTSD; indeed, sertraline and paroxetine are the only FDA-approved treatments for PTSD.

The recently published psycho-therapy review reported that CBT or, more specifically, trauma-focused CBT with exposure therapy and eye-movement desensitization and reprocessing, was effective and should be considered for persons with PTSD.⁹ Non-trauma-focused therapies were found to be ineffective. The authors noted that there was some evidence of a greater dropout rate in the active treatment groups; this does not seem surprising given that avoidance is a hallmark of PTSD, and these treatments share exposure to trau-matic memories as the basis of their effectiveness.

The recent Institute of Medicine report evaluated the effectiveness of psychotherapy and pharmacotherapy and found that only exposure-based therapies had sufficient evidence of efficacy. The report, however, pointed out that this should not be misconstrued to imply that only exposure-based therapies should be used. The authors noted it was mostly indicative of a lack of appropriately designed studies for other treatments.

The third Cochrane review pertinent to PTSD treatment evaluated the effectiveness of psychological debriefing, including the often-used Critical Incident Stress Debriefing.¹⁰ To be blunt, single-session psychological debriefing does not work and actually may be harmful. Despite its wide intuitive appeal, there is no evidence from any of the studies that such treatments, although still frequently used, have any significant benefits. More alarming, the studies with the longest follow-up indicate that debriefing may actually increase the risk for PTSD or at least impair the natural healing process. This seems somewhat obvious in retrospect, because a single-session exposure seems more likely to cause sensitization than desensitization.

Treatment of PTSD in veterans is more complicated than such reviews would suggest. First, there is some evidence that medications are not as effective for combat veterans as they are for civilians, and there is very little research on antidepressants in combat veterans. An early, small study using fluoxetine to treat PTSD in veterans and nonveterans reported that veterans showed much less improvement than nonveterans.¹¹ Another study, which was conducted more than a decade ago but published this year, evaluated the benefits of sertraline in Vietnam veterans with combat-related PTSD.¹² This VA-funded, 12-week, multicenter study treated 169 veterans with chronic PTSD with sertraline (mean dose, 135 mg) or placebo. Most of the patients were Vietnam veterans who had experienced symptoms for more than 20 years.

The authors found that there were no differences between sertraline and placebo on any symptom outcome measure. This is a disappointing finding, although it is not entirely surprising given the chronic nature of these veterans' symptoms. Clearly, there is a difference between recently traumatized female rape victims and male Vietnam veterans whose trauma may have occurred decades before treatment; SSRI treatment may be useful for some forms of PTSD and not others. In addition, other issues, such as VA compensation for disability, may affect both the presentation of PTSD in VA settings and response to treatment. It also remains uncertain whether SSRI treatment is beneficial when used more acutely following combat exposure.

One medication, prazosin, has predominantly been studied in veteran populations with chronic PTSD and appears to show particular promise for treatment of disabling nightmares and sleep disturbances. Prazosin is a centrally acting α₁-blocker; it is believed that prazosin attenuates physiological responses to elevated norepinephrine levels that are frequently found in chronic PTSD. Several small studies have shown benefits of prazosin for combat and non-combat-related PTSD using both daytime and evening doses.

The largest and most recent study involved 40 combat veterans with PTSD.¹³ In this 8-week, placebo-controlled study, prazosin was titrated to a mean dose of 13.3 mg, given at bedtime. The investigators found large differences in the effects of prazosin compared with placebo on measures of sleep quality and traumatic nightmares. Interestingly, patients also reported a normalizing of their dreams-moving from experiences of traumatic nightmares to less troubling dreams.

Unfortunately, other PTSD symptoms were not improved, although 71% of patients treated with prazosin were regarded as "moderately or markedly improved" on a global measure compared with only 12% in the placebo group. This global benefit seemingly relates to the profound effect that nightmares and sleep disturbance have on the general well-being of patients with PTSD. Larger studies are currently evaluating whether additional daytime dosing with prazosin could improve overall PTSD symptoms. Curiously, the authors found no effect on blood pressure from the antihypertensive agent, although our clinical experience is that some patients do not tolerate the high doses usually associated with hypertension.

Prazosin is not FDA-approved and studies to date have been limited. Thus, future research is needed before prazosin is accepted as an evidence-based treatment for PTSD.

Summary

The war in Iraq and the Afghanistan operation have had, and will continue to have, profound effects on military service members returning from combat. Psychiatrists will be faced with treating psychological conditions that historically have not responded well to treatment. The patients have complex social, psychological, and medical needs, and a range of biopsychosocial treatments may be necessary to help them.

Novel treatments, such as virtual reality exposure therapy, have yet to be proved effective. Standard treatments, such as vocational rehabilitation and substance abuse treatment, may help with the difficulties often associated with combat experience. The pharmacotherapy of PTSD should begin with SSRIs, and practitioners should remember that only sertraline and paroxetine have been FDA-approved. Preliminary research has shown that prazosin may be helpful for sleep disturbances associated with PTSD. However, more research is clearly needed in the treatment of combat- related PTSD, a vexing mental illness that haunts many veterans.

References:

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