Bob Roehr

November 06, 2007

November 6, 2007 (Washington, DC) -- Estimates of the rate of posttraumatic stress disorder (PTSD) among veterans returning from Iraq range from 12% to 20%. With deployment topping 1.5 million this summer, and the Department of Veterans Affairs (VA) having treated more than 52,000 persons, the greatest effect of those mental health issues has yet to be experienced. These problems and interventions were presented here at the American Public Health Association 135th Annual Meeting.

Evan Kanter, MD, PhD, staff psychiatrist in the PTSD Outpatient Clinic of the VA Puget Sound Health Care System, said that estimates are for a minimum of 300,000 psychiatric casualties from service in Iraq, to this point, with an estimated lifetime cost of treatment of $660 billion. That is more than the actual cost of the war to date ($500 billion).

"A study of the first 100,000 [Iraq and Afghanistan] veterans seen at VA facilities showed that 25% of them received mental health diagnoses. Of these, 56% had 2 or more mental health diagnoses. The most common were PTSD, substance abuse, and depression," Dr. Kanter said. "The younger the veterans are, the more likely they are to have mental health conditions."

Evaluation immediately on return from deployment suggested that 5% of active duty and 6% of reserve personnel had a significant mental health problem. When reassessed 3 to 6 months later, 27% of active duty and 42% of reserve personnel received that evaluation.

Dr. Kanter said there are 2 reasons for that difference. "At the time of return, people want to get home and get to their families. They perceive that if they answer yes to the question, it is going to take time [and delay their return home]. So, there is tremendous underreporting. The other is that PTSD and other mental health conditions have an insidious and delayed onset."

The official 17 symptoms of PTSD can be placed into 3 broad groups.

  • Reexperiencing: intrusive memories, nightmares, flashbacks, triggered distress;

  • Avoidance: isolation, withdrawal, emotional numbing, detachment, memory gaps; and

  • Hyperarousal: insomnia, irritability, anger outbursts, poor concentration, hypervigilance, exaggerated startle.

Beyond the official diagnosis are associated features that result in poor occupational and social function. They include depression, suicidal ideation, alcohol and drug abuse, guilt, shame, inability to trust, overcontrolling, few or no close relationships, extreme isolation, unemployment, divorce, domestic violence, and child abuse.

Within the general population, going back to World War I, combat veterans historically are twice as likely to die of suicide as the nonveteran. Within the current Army, the rate of suicide is the highest it has been in the 26 years that records have been kept.

"One of the risk factors for PTSD is the unprecedented multiple deployments" to a combat zone, Dr. Kanter said. The intensity and duration of the trauma predicts PTSD, "There is a dose response. People who have been multiply deployed are much sicker, and it is going to be more costly to take care of them." More than a half million persons have been deployed 2 or more times.

The effect on families also is great. "You see more marital problems, more behavioral problems in children, more family violence, and the potential for the generational transmission of violence. In the Vietnam cohort, those with PTSD were 3 to 6 times more likely to get divorced," he said.

Dr. Kanter is guardedly hopeful that a greater understanding of PTSD and earlier intervention will result in better outcomes than those seen from the Vietnam era, but significant barriers to accessing care remain.

Perhaps the most difficult obstacle to overcome is the attitude of the typical 20-something solider returning to civilian life. "It is hard to get a 22-year-old tocome in to see the doctor for any reason," Dr. Kanter noted. "The stigma of PTSD and mental illness in general runs very high. There also is a lot of distrust, avoidance, and denial that are inherent in the disorder. People are worried about their military careers and that if they get a mental health diagnosis, they will be drummed out."

Dr. Kanter stressed that recovery is a process that takes time. Successful coping strategies include limiting exposure to triggers such as news coverage of war, restoring balance in one's life, attending to physical and emotional needs, and limiting use of alcohol and stimulants.

In a subsequent conversation with Medscape Public Health & Prevention, Dr. Kanter spoke of what families and nonpsychiatric healthcare workers can do to assist these veterans. "You do need to repeat the urges to get help, in a gentle way. Information about trauma is critical" for the vets and their families.

Framing the discussion is key: It should not be in terms of psychiatry but, rather, as "postdeployment stress, readjustment, reintegration. We have in the VA a postdeployment health clinic model: one-stop shopping for all your needs," Dr. Kanter said. Mental health screening is part of the continuum of health services that everyone must pass through, he added, with referrals to a PTSD specialty clinic as need.

This is the first conflict in which women are serving in combat situations in large numbers. When pressed as to whether he has seen differences in PTSD between male and female veterans, Dr. Kanter said he has not yet seen enough women in his own practice to know for sure. He pointed out that that the broader literature on PTSD shows "that when they are exposed to the same trauma, women are twice as likely to get PTSD."

Captain Steve Trynowsky, an Army reserve medical corps officer in Washington, DC, largely agreed with Dr. Kanter's evaluation of the situation. However, he criticized the current VA disability structure for creating "a zero sum game" where there is an incentive for young men "to assume a sick role" so as not to lose their benefits.

In a subsequent discussion with Medscape Public Health & Prevention, he used himself as an example. Having suffered severe frostbite on 2 toes on each foot, he has a lifetime classification of 40% disabled from the VA, even though on his last evaluation he received a maximum score on the run portion of the Army's physical fitness test.

"The VA is a perverse system: Once you are a 22-year-old just out of the Marines and you are branded as an 80% disabled PTSD case, what is the incentive to become 40% disabled -- you are losing half your benefits."

Captain Trynowsky said, "We are trying to graft our current medical understanding of PTSD on to [the] 1945" structure of the VA. He suggested establishing the expectation of periodic reevaluation of most disabilities so as not to lock persons into a victim's role.

Dr. Kanter said studies have shown that very few people are "gaming" the VA system. "The [numbers of] those who fall through the cracks and don't get the care they need are so many times greater than anyone who may be trying to game the system, it is just not worth worrying about."

He strongly recommended the free online resources made available by the psychiatry department at Walter Reed Army Medical Center: and

The speakers have disclosed no relevant financial relationships.

American Public Health Association 135th Annual Meeting: Abstract 165759. Presented November 5, 2007.


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