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Let’s Not Call It What It Really Is


Since my last column, results of the latest study of PTSD among Iraq and Afghanistan veterans were published in the March 1 issue of the Journal of the American Medical Association. The study was conducted by Col. Charles Hoge, M.D., and colleagues at Walter Reed Army Institute of Research. They also are responsible for the PTSD study of Iraq and Afghanistan veterans published in the July 2004 issue of The New England Journal of Medicine. The study has good news and bad news.

The newest study reports that American troops returning from Iraq are more likely to report mental health problems than those coming back from Afghanistan. In addition, 35 percent of troops who served in Iraq used mental health services in their first year home, although only one-third of them had received a mental health diagnosis. Mental health problems were closely tied to posting location and combat exposure, the authors said. “These findings highlight the challenges in assuring that staffing levels of mental health services
are sufficient to meet the needs of returning veterans,” according to Dr. Hoge.

Information for the new study was drawn from the three-page Post-Deployment Health Assessment (PDHA) given to all service members upon their return from any deployment. The researchers followed 303,905 Army soldiers and Marines for up to one year or until they left the service. That figure represents 82 percent of all returning troops. Active-duty Marines were slightly over-represented among the 18 percent without a PDHA. The PDHA includes questions about depression, Post-traumatic Stress Disorder, suicidal ideation, interpersonal relationships, and interest in receiving care. Troops also are interviewed immediately after filling out the PDHA by a physician, nurse, or physician assistant who decides whether they should be referred for further evaluation or treatment.

Service in Iraq was more hazardous to soldiers’ mental health than serving in Afghanistan or elsewhere, the researchers found. “Overall, 19.1 percent of soldiers and Marines who returned from Iraq met the risk criteria for a mental health concern, compared with 11.3 percent for Afghanistan and 8.5 percent for other locations,” they said. The latter rate is close to baseline levels from soldiers surveyed before initial service in Iraq and Afghanistan.

Soldiers and Marines returning from Iraq were twice as likely to screen positive for PTSD as were those who had served in Afghanistan (9.8 percent versus 4.7 percent) and were twice as likely to be referred for mental health care (4.3 percent versus 2.0 percent). There were only minor differences in mental-health issues when comparing active service troops with National Guard or Reserve members, but there were some gender differences. Overall, 28.4 percent of Iraq veterans and 16.0 percent of Afghanistan veterans were referred for medical follow-up. Veterans of Iraq were hospitalized more often during deployment (6.6 percent) than Afghanistan veterans (3.6 percent), which may serve as a marker for injury.

The need for mental health services is a function of combat experience, and ground service in Iraq entailed a greater exposure to combat, according to the PDHA data. Compared with troops in Afghanistan, troops in Iraq more frequently saw comrades killed or wounded and were three times more likely to have fired their weapons. Half the soldiers and Marines in Iraq had felt in great danger of being killed, twice the rate of those who served in Afghanistan.

According to an article in Psychiatric News, the nature of the war and deployment practices may account for differences in mental health outcomes in the two theaters. “There are no safe zones in Iraq,” Col. Elspeth Cameron Ritchie, a psychiatry consultant to the U.S. Army surgeon general, said. “Danger can come from any direction, and it’s hard to tell friend from foe.”

The multiple, year-long deployments to the war zone are tough on troops and their families. During World War II, soldiers, sailors, and Marines knew they were in for the duration of the war. In Vietnam, troops served only for one year. But those serving today in Iraq or Afghanistan may be there for a year, return, adjust to life back home, and then have to ship out again when their units are called up. They must face the threat of roadside bombs and stresses on family life at the same time.

That pressure was reflected in the use of mental health services. About 35 percent of Iraq veterans used mental health services in the year after they returned from overseas. The comparable rate for all active Army and Marine officers and enlistees has steadily risen in recent years, from 14.5 percent in 2000 to 22.2 percent in 2004.

“All wars take a psychological toll on soldiers, and the higher percentage of service members being treated reflects the exigencies of the present war and is a sign that barriers to evaluation and care have been reduced,” Ritchie said.

That more than one-third of these troops are using mental health services shortly after returning home is “exactly what we want service members to do and leaders to encourage,” Col. Hoge said.

Of that 35 percent, 12 percent were diagnosed with an ICD-9 mental disorder, but 23 percent received no psychiatric diagnosis.
“It is not clear why there was such high use of mental health services without a mental health diagnosis,” Hoge and his colleagues wrote, but they suggested that less specific codes were used to “lessen the stigma of a mental health diagnosis.” Ritchie said that the system is catching “troubling” symptoms before they rise to the level of diagnoses.

Immediate screening may mask problems that crop up later. Military health personnel will now screen returned troops again 90 and 180 days after their return, since they are twice as likely to report mental-health concerns then than in the glow of homecoming.

Some veterans’ groups, including VVA, have noted delays in getting help, but both Army and VA sources said they are committed to monitoring and caring for service members with mental health problems. The Department of Defense offers a program called Military OneSource to troops and their families. It does not offer treatment but does provide free, confidential counseling and referral, if needed. Military chaplains also have a program to help families of troops assigned to the war zones. And “because so many Reserve and National Guard units have been sent to the war zones, civilian mental health professionals may likely see many veterans in their practices,” Ritchie said.

“The present study may underestimate the total utilization of service for mental health problems, but its outcomes may help inform planning for mental health services for returning veterans, whether in military, VA, or civilian settings,” Hoge and his team concluded.

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