Meeting the Mental Health Needs of Veterans of the Wars in Iraq and Afghanistan: An Expert Interview With Colonel Elspeth Cameron Ritchie, MD, MPH

November 29, 2005

Editor's Note:
With US military personnel facing deployment and redeployment in Afghanistan, Iraq, and elsewhere, the mental health of veterans has grown in importance, particularly with regard to pos traumatic stress disorder (PTSD). Indeed, some have found the incidence of PTSD in Iraq and Afghanistan war veterans to be as high as 20%. On behalf of Medscape, Randall F. White, MD, FRCPC, interviewed Colonel Elspeth Cameron Ritchie, MD, MPH, Psychiatry Consultant to the US Army Surgeon General, Washington, DC, to discuss the mental health implications of today's wars and several new programs that have been put in place by the Department of Defense to identify mental health problems in these recent veterans. Jaime Cavazos, Media Relations Officer, MEDCOM Public Affairs, San Antonio, TX, contributed to the development of and participated in this interview.

Medscape: Although severe disorders are usually detected before discharge from service, and the service members are then eligible for treatment at Veterans Administration (VA) medical facilities, some problems may not be identified. What measures does the military take to screen members who are leaving service for mental disorders, including posttraumatic stress disorder (PTSD)?

Elspeth Cameron Ritchie, MD, MPH: All wars produce stress reactions. We've learned a lot from the last 100 years about how to screen for, mitigate, and prevent stress disorders. We're learning from this war and we're adjusting the way we do things as we go.

There are a range of things we do to screen service members, and not just when they're leaving the military. We screen them when they deploy to, and when they redeploy from the theater, which is called a postdeployment health assessment; and we screen them for both medical and physical problems.

As they leave the military they have an exit process, which may include a physical and which provides a lot of information about VA benefits.

Medscape: Is a mental health screening available on request?

Dr. Ritchie: Yes, the service member can always self-refer for a mental health evaluation, and if there's an identified posttraumatic stress disorder, depending on the severity of his or her symptoms, the soldier may be eligible for a medical review with consideration of benefits.

We have a brand-new program, a postdeployment health reassessment. [This is] a screening of all service members, including those who've left service, at 3 to 6 months after redeployment, because we recognize that many people will not positively identify themselves as they're coming back [from the war].

Medscape: Will that reassessment be mandatory for those who have left active duty?

Dr. Ritchie: The screen will not be mandatory; it will be offered to everybody, but it will not be mandatory for them to undergo.

Medscape: Does the Department of Defense (DOD) yet have an estimate of the prevalence of PTSD in members who have been deployed to Iraq or Afghanistan?

Dr. Ritchie: We have a number of different surveys. One done on troops in theater, the Mental Health Advisory Team II, was released in July 2005.[1] The prevalence of PTSD was 12% in women and 13% in men.

Another assessment, by Hoge et al, was an anonymous survey of people 3 to 6 months after they returned from the theater, and the researchers will continue to follow that cohort.[2] There is a range of different ways we're surveying soldiers, and we're finding pretty consistent numbers, somewhere between 12% and 20% prevalence of PTSD.

Medscape: What factors are associated with development of PTSD in the military population?

Dr. Ritchie: We know based on the data of Hoge et al that there is a relationship between exposure to firefights, combat, and PTSD symptoms.

Medscape: Are there any factors that may predispose service members to PTSD?

Dr. Ritchie: In the data for this conflict so far, we haven't asked questions about childhood development. Historically, those who have a history of traumatic events are more likely to get PTSD. One of the things I would like to call attention to is that women usually have a higher rate of PTSD, but in our data from the Mental Health Advisory Team II study, the rate is almost exactly the same as in men.[1]

Medscape: And women would in general have not been exposed to firefights. Is that true?

Dr. Ritchie: No, that's not true. Women are serving as military police, they're serving in signal corps, they're serving in all kinds of jobs. They're not in infantry and combat arms, so their exposure to firefights is probably less.

Mr. Cavazos: Part of the reason they're exposed to combat is because a lot of them are in the logistical support arena, so they're on the road a lot.

Dr. Ritchie: I'd like to caution that the initial data from Hoge et al had very few women in it, because it was gathered from combat-arms troops, whereas the recent Mental Health Advisory Team II did include a lot of women in the survey sample.

Medscape: Can you discuss other problems civilian mental healthcare providers should be concerned about in patients who had been deployed to Iraq or Afghanistan?

Dr. Ritchie: One of the things we're concerned about is the presence of head trauma, especially mild traumatic brain injury in those who may have been exposed to a blast, perhaps knocked unconscious, but who did not seek medical treatment. It's important for providers to ask questions about the possibility of traumatic brain injury because it can present along with PTSD symptoms, or as nonspecific symptoms such as irritability and trouble concentrating.

We have high-risk populations, which include the wounded, the highly exposed personnel such as in mortuary affairs, and chaplains and medical personnel themselves. Another high-risk population is members of the National Guard and the Army Reserve, who leave active duty and may not have a military community to come back to. [They may experience] a sense of isolation.

Another concern is that PTSD has historically been comorbid with substance abuse; we're not seeing a large increase in that right now, but providers should monitor for that, and for domestic violence.

Medscape: What resources are available to civilian providers to assist them in treating veterans and for referring those who may be eligible for military or VA assistance?

Dr. Ritchie: Some of the best resources are on the Web site of the National Center for PTSD.[3] There's an Iraqi war clinician's guide there, authored by military health care providers. There are also resources on the web site of the Uniformed Services University of the Health Sciences, at "Courage to Care."[4] That's mainly oriented toward family members rather than clinicians.

Medscape: If somebody has PTSD that was not detected at separation from the military, would that person still possibly be eligible for benefits through the VA?

Dr. Ritchie: Yes, and at the 3 to 6 month postdeployment health reassessment, it's possible that they may be brought back on active duty for care. Also, veterans of Operation Iraqi Freedom and Operation Enduring Freedom have been moved to high priority within the VA system.

Everybody who comes back from the wars has eligibility at the VA for 2 years.[5,6] The VA has a priority system, and in most cases, a person is eligible for care if their condition is service-connected, but in this case, all veterans are eligible at the VA for 2 years. In addition, there is a Tricare benefit available to them for a period of time after they return.[7]

Medscape: According to the United States Department of Defense, about 7,200 US troops have been injured during the wars in Iraq and Afghanistan requiring them to leave theater.[8] What are the psychiatric issues important in the care and rehabilitation of these young people?

Dr. Ritchie: The psychological issues for those who have been wounded have to do, especially if they're severely wounded, with the loss of their functioning. One of the hardest things for them is having to leave their unit and their buddies.

The psychiatry staff at Walter Reed Army Medical Center [in Washington, DC] are also paying attention to the children of service members and how they are reunited with the wounded. They want to make sure that the children are prepared to see their wounded parents.

Another concern is in the burn unit at Brooke Army Medical Center [at Fort Sam, Houston, Texas] because burns can be disfiguring, and a lot of attention is paid to the psychological needs of these soldiers. There's been a lot of publicity given to the amputees, and the patients are actually doing very well with their prostheses, but some of the other injuries, such as severe traumatic brain injury and disfiguring injuries, require a lot of support.

One of the things I'd like civilian providers to know is that the high-risk period is after the transition from the hospital to home, and that is the time civilian [medical personnel] may see [veterans].

Medscape: Can you discuss the epidemiology and clinical correlates of suicide in the armed forces, and what measures are taken to prevent suicide among service members?

Dr. Ritchie: The Department of Defense takes the whole question of suicide prevention very seriously, and there are a number of programs in place. Having said that, we're continually reassessing what we're doing and how we're doing it. For instance, every year the DOD has a suicide prevention conference that brings in experts.

Historically, we run about 10 to 12 suicides per 100,000 per year, which is lower than civilian rates, but every suicide is taken seriously.[9] The risk factors for completed suicide, based on retrospective analyses over the past 20 years, include failure of intimate relationships, legal difficulties, and occupational difficulties.

Medscape: I suspect that soldiers who return home may begin having problems in their primary relationships, which could prove to be a time of risk for suicidal behavior.

Dr. Ritchie: Yes, and that's one of the reasons for our postdeployment health reassessment. We realize that there may be a honeymoon period initially when people come home, but over time the relationship problems surface.

Mr. Cavazos: There are a number of services the Army provides to both the spouses and soldiers to help them cope with marital stress, including army community services and social work services.

Dr. Ritchie: Yes, thank you. One of the things we do is tell the soldiers before they come home about these issues, and that the family may have changed, and there may not be the honeymoon that they are expecting. However, we realize that soldiers may or may not actually hear that, and there are ongoing education and outreach efforts. In addition, there's something called Military Onesource, which offers 6 free and confidential counseling sessions.[10] That's not for psychotherapy for major mental disorders; it focuses on counseling and offers marital therapy.

Medscape: Some veterans of the Persian Gulf War of 1991 have had a chronic, multisymptom illness, popularly known as "Gulf War syndrome."[11] This is often associated with mood and cognitive disturbances. What do we know about the possible causes or contributors to this disorder?

Dr. Ritchie: There has been so much written and speculated about that condition, without a definitive cause ever being found. Personally, I think it's probably a combination of environmental stressors and psychological stressors that disrupt the immune system. That's my personal belief and not the official statement of the DOD.

What I can say is that we are looking for similar patterns in this conflict, which is another reason for the postdeployment health reassessment. The reassessment does not cover just mental health, but physical health as well. We're not seeing a lot of multiple unexplained physical symptoms, which is what we call it now, but I would not be at all surprised if we see them over time. There are a lot of environmental toxins over in the theater.

Medscape: Is there anything more that you can say about those?

Dr. Ritchie: Little is regulated in terms of human and other waste, although US military health personnel will do an assessment of where facilities are set up. There are dust, sand, rabid dogs, sand fleas (which may cause leishmaniasis), and other threats.

Medscape: Do you have any additional advice for general psychiatrists and psychologists who may evaluate members recently discharged from the armed services?

Dr. Ritchie: First of all, ask if [the patient is] a veteran. Remember, in this conflict, 40% of the forces over there are Guard and Reserve members, and so there will be a range of ages. Fifteen percent of the force is female; and many of the younger ones will be coming back to college. People have too much of an image of a veteran as being the older Vietnam veteran.

PTSD treatment guidelines have been recently published, both by the American Psychiatric Association [12] and by DOD-VA.[13] There are also postdeployment health guidelines, and those cover a wide range of issues.[14]

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