VA Statistics Show Large Number of Vets With Psychiatric Diagnoses

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."

Gender issues: sexual harassment and trauma
The high incidence of women in combat and front-line support roles represents a major difference between the contemporary wars-particularly Iraq-and the war in Vietnam.

"In Vietnam, for the most part, the only women there until 1970 were nurses," said Barnes. "Now we have ev- eryone from supply clerks to tank drivers to F-16 pilots. I do have women clients; most are coming for other than combat-related issues, principally sexual trauma. And that's not just dealing with Iraq. I have clients from the first Gulf War as well. The women I am seeing span those two wars. Really, with the exception of one, all of them have non-combat-related trauma. They served in a combat theater, but this is an additional assault."

"The military is still struggling with the issue of sexual trauma," according to Shannon Middleton, deputy director for health care for the American Legion. "The Department of Defense has started a new office called Sexual Assault Prevention Response. It also educates the victims about their rights and sets a standard for all the services. This is not the first time the issue has come up: many female Vietnam vets are still struggling with sexual trauma issues. But the military has instituted a change in policy with regard to reporting an incident. Before, you had to have an investigation if you asked for treatment. Now you can get treatment without a follow-up investigation. It's a choice that you have. Choice is always good."

Younger age a risk factor
In the Archives article, the University of California researchers reported that 13% of the veterans in the group they studied were women. Twenty-six percent of the women received at least 1 mental health diagnosis, compared with 25% of the men. Overall, 11% of the women received a diagnosis of PTSD, compared with 13% of the men.

"We found minimal absolute differences between men and women, racial and ethnic subgroups, and component types regarding risk for receiving mental health and PTSD diagnoses. In contrast, similar to another recent study, we found both an absolute and statistically significant trend toward increased risk for mental health and PTSD diagnoses with younger age, with the youngest group of . . . veterans (aged, 18 to 24 years) at the highest risk compared with veterans 40 years or older," they wrote.

Although screening was not addressed in this report, some experts believe that better screening of personnel before combat assignments are made could substantially reduce the incidence of PTSD.

"There is an increasing body of evidence that patients who experience PTSD have biological or genetic pedigrees and or previous traumatic experiences that predispose to both the psychological and biochemical symptoms of PTSD," according to Murray A. Brown, MD, professor of psychiatry at the University of California, Los Angeles. The Surgeon General's Report on Mental Health similarly noted, "The likelihood of developing PTSD is related to pre-trauma vulnerability (in the form of genetic, biological, and personality factors), magnitude of the stressful event, preparedness for the event, and the quality of care after the event."²

On the positive side, the authors of the Archives report point out that the "relatively high rate of VA enrollment and the speed with which separated OEF/OIF veterans are seen and diagnosed provide the opportunity to implement early evidence-based interventions . . . to decrease chronic military service-related mental illness and disability." The findings of their study, they added, "suggest that enhanced prevention, detection, and treatment should be targeted at the . . . OEF/OIF veterans younger than 25 years, particularly those in the active duty components."

References:

References1. Seal KH, Bertenthal D, Miner CR, et al. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007;167:476-482.
2. Satcher D. Mental Health: A Report of the Surgeon General. Available at: http://www.surgeongeneral.gov/library/mentalhealth/home.html. Accessed April 9, 2007.