Long-term Course of PTSD Revealed

Pam Harrison

August 13, 2014

Posttraumatic stress disorder (PTSD) is a chronic and prolonged condition that appears to significantly increase mortality risk as well as risk for several chronic diseases, new research suggests.

A longitudinal study in Vietnam War veterans shows that PTSD is associated with a 2-fold increased risk for death as well as a significantly increased risk for cancer.

"The majority of war zone Vietnam veterans are reporting low levels of PTSD symptoms after the war at follow-up now," study investigator Nida Corry, PhD, associate, Abt Associates, Milwaukee, Wisconsin, told Medscape Medical News.

"However, about 20% of Vietnam War veterans are experiencing either consistently elevated PTSD symptoms or worsening symptoms, so there remains a great need to address the impact of trauma for this cohort long after the war."

The results were presented at the recently held American Psychological Association 2014 Annual Convention in Washington, DC.

Need for Mental Health Services

For the analyses, investigators collected data on 2348 participants enrolled in the National Vietnam Veterans Readjustment Study (NVVRS), carried out between 1986 and 1988.

The National Vietnam Veterans Longitudinal study (NVVLS) was a follow-up of the original NVVRS and assessed health outcomes of Vietnam veterans 25 years later. The average age of participants at the NVVLS assessment point was approximately 67 years.

Out of the initial NVVRS cohort, 16% of veterans who were alive during the mid to late 1980s are now deceased.

The investigators found that the most common causes of death among veterans were cancer and heart disease.

However, among male Vietnam War veterans who developed PTSD as a result of war zone stress, there was nearly a 2-fold increased mortality risk 24 years later compared with Vietnam War veterans who did not develop PTSD.

Among Vietnam War veterans who developed PTSD, cancer rates were 3 times higher compared with cancer mortality rates among veterans who did not develop PTSD (hazard ratio [HR] = 3.0).

Death rates from external causes among the same PTSD subgroup were almost 7 times higher than rates among the veterans overall (HR = 6.7).

However, Dr. Corry cautioned, because of the small number of war zone veterans who died of external causes, the confidence intervals were very wide around this HR, suggesting that the risk for mortality from external causes among Vietnam War veterans with PTSD might be considerably lower.

External causes of mortality included accidents, accidental poisoning, suicide, and homicide.

Disturbing long-term trends in the persistence of PTSD symptoms could be tracked over time, as other members of the NVVLS reported. As noted by Clare Henn-Haase, PsyD, New York University Langone Medical Center, New York City, measures of PTSD were collected both in 1988 and again in 2013.

Slightly more than 75% of Vietnam War veterans with war zone PTSD reported having a low level of PTSD symptoms at both time points.

However, 7% reported that they were highly symptomatic at both time points, and 13% reported that they had substantial increases in PTSD symptoms over time.

Only 4.6% of those with PTSD at the earlier assessment point reported a decrease in symptomatology at follow-up assessment.

"Findings underscore the need for mental health services for veterans with PTSD," Dr. Henn-Haase concluded.

Chronic Health Problems

Investigators also found that war zone PTSD was significantly associated with many current and lifetime chronic health conditions.

The top 3 most common current health conditions were disorders of the musculoskeletal, circulatory, and nervous systems and sensory organ disease.

An estimated 11.2% of Vietnam War veterans are still living with war zone–related PTSD, while 12.2% are living with any current PTSD, the investigators note.

This would indicate that approximately 283,000 male and 400 female Vietnam War veterans living today have PTSD.

Many other Vietnam War veterans are also living with subthreshold PTSD.

Subthreshold PTSD does not mean that the disorder is not affecting the individual's quality of life and that the individual does not need treatment but simply that the veterans' symptoms are not florid enough to meet diagnostic criteria for the disorder.

"One thing to keep in mind is that Vietnam veterans were the first veterans to come home in which their physician might know about PTSD, because there was no PTSD in psychiatry or any other place ― it wasn't in the lexicon until 1980," William Schlenger, PhD, principal scientist, Abt Associates, Durham, North Carolina, told Medscape Medical News.

"So the finding that there are almost 300,000 Vietnam veterans who have PTSD today 4 decades after they left the battlefield is a very important finding, and it lets us know what's likely going to happen in the folks who have come home from Iraq and Afghanistan. The study's key take-away is that for many veterans with PTSD, the war is not over."

Some Findings "Puzzling"

Commenting on the findings for Medscape Medical News, Bruce Dohrenwend, PhD, professor of epidemiology and psychiatry, Columbia University Mailman School of Public Health, New York City, told Medscape Medical News that some of the findings were puzzling.

For example, investigators did not find an elevated rate of heart disease among PTSD veterans, yet other studies, including one reported by Medscape Medical News, have shown that individuals with PTSD have a clearly elevated risk for heart disease compared with those without the disorder.

He was also uncertain as to the precise proportion of Vietnam War veterans who still have symptoms of PTSD, because that proportion depends on which scale is used to measure PTSD.

Nevertheless, "this is a tremendously important effort," Dr. Dohrenwend said.

"We have nothing else like this, and we need to dig in and figure out what these results mean."

The study was congressionally mandated and funded by the US Department of Veterans Affairs. The NVVLS investigators and Dr. Dohrenwend have disclosed no relevant financial relationships.

American Psychological Association. Presented August 8, 2014.

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