High Rates of Severe Functional Impairment Found in Returning Soldiers Due to PTSD, Depression

Caroline Cassels

June 15, 2010

June 15, 2010 — Approximately 10% of US Army soldiers returning from Iraq have severe functional impairment attributed to posttraumatic stress disorder (PTSD) or depression, new research shows.

A population-based, cross-sectional study conducted by investigators at the Walter Reed Army Institute of Research, Silver Spring, Maryland, found prevalence rates for serious functional impairment ranged from 8.5% to 14%. Furthermore, those with some impairment ranged from 23.2% to 31.1%.

Led by Jeffrey L. Thomas, PhD, the study is published in the June issue of Archives of General Psychiatry.

According to the study, a growing body of literature shows PTSD and depression are highly prevalent among military service members serving in Iraq and Afghanistan. However, investigators note, previous studies have shown "varying prevalence rates of these disorders based on different case definitions and have not assessed functional impairment, alcohol misuse, or aggressive behavior as comorbid factors occurring with PTSD and depression."

"To our knowledge, functional impairment measures have not been incorporated into any case definitions. The lack of consistent definitions and functional impairment measures has made it difficult to determine the true effects of combat service in Iraq and Afghanistan or accurately project mental health service needs," the study authors write.

Data from anonymous health surveys from 18,302 US Army soldiers 3 and 12 months after deployment were collected. Of these 13,226 were from veterans of Operation Iraqi Freedom, and these were used for the analysis. The soldiers were members of 4 Active Component (nonreserve) and 2 National Guard (reserve) infantry brigade combat teams.

The study's primary outcome measures were current depression, functional impairment, alcohol misuse, and aggressive behavior.

The researchers examined 7 case definitions of PTSD that ranged from liberal to strict. PTSD was assessed using the posttraumatic stress disorder checklist, which is scored by summing the answers to 17 questions. According to the study, a stringent cutoff of 50 or higher has been most widely used in military populations, the study authors note.

Three case definitions of depression were examined using the 9-item Patient Health Questionnaire (PHQ-9), which is based on Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria.

Functional impairment for depression and PTSD was assessed using a single question from the PHQ-9 about work and home life, as well as interpersonal relationships.

Soldiers were asked a single question about alcohol use before and after deployment. Aggressive behaviors were assessed based on questions about angry outbursts within the past month, including physical violence.

The study results showed that using the least stringent definition of PTSD the prevalence rates across the Active Component and National Guard study groups ranged from 20.7% to 30.5%. Depression rates ranged from 11.5% to 16%.

"Using the strictest definitions with high symptom rates and serious functional impairment, PTSD prevalence ranged from 5.6% to 11.3% and depression prevalence from 5% to 8.5%," the study authors write.

Alcohol misuse or aggressive behavior — including slamming a door, punching a wall, or threatening or perpetrating physical violence in anger — was present in about half of the soldiers with PTSD or depression.

Although both study groups experienced similar rates of combat exposure, the investigators found that between the 3- and 12-month time points, depression and/or PTSD symptoms significantly increased in the National Guard across all case definitions. In contrast, the Active Component remained stable with respect to symptoms of depression, but PTSD symptoms increased.

Owing to similar rates of combat exposure and similar prevalence rates of mental health problems 3 months after deployment, the investigators speculate that the differences between the 2 groups at 12 months "likely does not have to do with differences in the health effects of combat but rather with other variables related to readjustment to civilian life or access to health care."

According to the investigators, the study makes an important contribution to the literature because it demonstrates how different case definitions can influence prevalence rates of PTSD and depression in this patient population.

The study authors add that the findings have implications for care of returning soldiers and their families, as well as their fellow soldiers.

"The findings of the study show that at 12 months following combat, the prevalence of mental health problems among veterans does not abate, and in many cases, increases. It is a virtual certainty that soldiers who remain in service will deploy again; this study shows that a sizable proportion (9%-14%) have depression or PTSD symptoms with serious functional impairment.

"If soldiers who are struggling with serious functional impairment as the result of a previous deployment are deployed again, there is potential that this could impair their performance in combat. This has implications for the safety of unit members and mission success," the investigators write.

The study authors have disclosed no relevant financial relationships. The study was supported by the Military Operational Medicine Research Area Directorate, US Army Medical Research and Materiel Command, Fort Detrick, Maryland.

Arch Gen Psychiatry. 2010;67:614-623.

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