Category: Post Traumatic Stress Disorder (PTSD)
Bret Stetka, MD; Richard H. Weisler, MD; Henry A. Nasrallah, MD; Harold Kudler, MD
Since September 11th, 2001,
roughly 2.2 million American service members have served in Iraq or
Afghanistan. As a result, the Veteran's Administration (VA) has seen
167,000 new cases of related post-traumatic stress disorder (PTSD),
195,000 cases of depressive conditions and affective psychoses, and
103,000 cases of anxiety disorders. Worse still, the suicide rate in the
Army and Marine Corps has, for the first time on record, reached that
of the civilian population. With 2 ongoing wars and a growing pool of
returning veterans, effective psychiatric care for our active and former
military personnel is crucial. Yet with the exception of military and
VA psychiatrists, few clinicians receive training on the unique
challenges associated with delivering mental healthcare to this
Medscape recently interviewed
psychiatrists Dr. Harold Kudler, Dr. Richard H. Weisler, and Dr. Henry
A. Nasrallah on the history of psychiatric care in the military, the
magnitude and impact of mental illness in active military personnel and
veterans, and means of improving care in our venerable service men and
Mental Health and Illness in Military and Veteran Populations: Introduction
Medscape: Dr. Kudler, can you speak to
the prevalence of mental illness among soldiers and veterans in past
wars compared with that seen in Iraq and Afghanistan?
Dr. Kudler: The history of the modern
medical study of war-related traumatic stress issues probably began
with the American Civil War, with research done by Da Costa. These
issues were then known variously as irritable heart syndrome, effort
syndrome, Da Costa syndrome, and finally as soldier's heart.
Da Costa was a cardiologist who noticed that
many Civil War veterans were having problems with anxiety, shortness of
breath, palpitations, inability to work, and a number of other symptoms,
which we would now see as anxiety disorders, functional disorders, or
maybe as depression. But being a cardiologist, Da Costa considered them
to be a heart problem and this is how war-related stress symptoms were
thought of until we got to shell shock in World War I (WWI). At the
beginning of that war, shell shock was thought to be a purely physical
disorder caused by the vibration of the brain and disruption of nerve
cells, due to the explosion of artillery shells or, perhaps, from
noxious gases associated with those explosions. By the end of the war,
though, most military doctors came to realize that shell shock was
likely a psychological response to the stress of war, which didn't
necessarily involve any shell concussions at all.
Dr. Nasrallah: Given what we now know
about the vibration-induced traumatic brain injury (TBI) from
explosives, probably both theories are correct; our soldiers are
experiencing some physical brain damage along with a psychological
Dr. Kudler: Yes, looking at it now we
can see both components. Although, what was known as shell shock in WWI
was primarily gross functional problems like not being able to speak or
walk -- these were really more traumatic neuroses or hysterical
problems. I'm afraid that the subtler problems, which we now recognize
as mild TBI, were rarely noticed in those days, though certainly
moderate or severe TBI was probably recognized even then. The bottom
line is by the end of WWI people were looking for psychological issues
more than they had been.
Dr. Weisler: Wasn't shell shock also sometimes referred to as battle fatigue, Harold?
Dr. Kudler: Yes, and it was actually
for a practical reason. It was General Omar Bradley, I believe, who
said, "Look, my men aren't sick and they are not broken. They are just
tired and we are going to call this fatigue." And actually, they
developed a form of debriefing where they would have people talk about
their experiences; they also had a scale where the more stress they had
been under the more they would allow them to talk -- it seemed to be
A lot of World War II (WWII) psychiatric
intervention centered on prevention using the PIE (Proximity, Immediacy,
Expectancy) model. When people began to have
psychological issues during the war, ie, the "thousand-yard stare",
social or emotional withdrawal, irritability, dissociation or conversion
problems, they were treated in close proximity to the battlefront. They
were also treated with high immediacy. The response called for "three
hots and a cot" – affected soldiers got to sleep, which people in the
front didn't often get to do, and they got to eat regularly, which
people in the front didn't do either; they remained in uniform and
whenever possible were given jobs to do. They were generally not allowed
to lie around in a bed because it was found that people who laid around
or were sent to the rear, were more likely to remain disabled, whereas,
people treated with proximity and immediacy could often return to duty.
Finally, they were treated with high expectancy of improvement, and
this expectation was usually justified.
Dr. Weisler: What percentage of soldiers was able to return to duty when this approach was used?
Dr. Kudler: I haven't seen numbers
for WWII but in Vietnam and Operation Enduring Freedom/Operation Iraqi
Freedom (OEF/OIF), 95% percent returned to duty. At the beginning of
WWII, the number of psychiatric casualties was skyrocketing. The PIE
model, developed by US Army Medical Officer Thomas Salmon back in WWI,
was rediscovered and instituted and the casualty rate dropped
Dr. Kudler: By the time we get to
Vietnam, use of the PIE model was a standard part of military medical
doctrine. Later the "S" was added to PIE (for Simplicity) to make PIES.
During Vietnam, there were very positive reports of the success achieved
in preventing acute breakdown in the field such as had been seen in WWI
and at the start of WWII. The only problem was nobody was thinking
about what happened when the troops got home. So by the late 70s and
early 80s, in the aftermath of Vietnam, we begin to see a lot of people
talking about what at first was called Vietnam stress syndrome. Books
and articles were coming out by people like Charles Figley and
eventually this became the first version of post-traumatic stress
Dr. Nasrallah: I remember when we did
not have an official diagnosis of PTSD. I worked in the VA in the
post-Vietnam era and we called it delayed stress syndrome. Was that the
beginning of the invention of PTSD as a category?
Dr. Kudler: Well, yes. The DSM-I from
1952 drew heavily from work by WWII General William Menninger from
Military and VA experience and included a so-called "gross stress
reaction." This was dropped in DSM-II in the 1960s. By the time we get
to DSM-III, we have PTSD derived, as you say, from Vietnam stress
syndrome or delayed stress reaction. Following the Vietnam War, the VA
created a number of PTSD programs for veterans, one of them being the
Vet Center, a group of storefront operations often staffed by Vietnam
veterans with counseling, psychology, or social work degrees. These
centers continue to this day and provide outreach, counseling, and PTSD
diagnostic services along with support for family members. But by the
1980s Congress was saying, "Look, the war has been over since 1975. Do
we still need to fund these Vet Centers?"
In order to help them to decide, they funded the National Vietnam Veteran Readjustment Study.
Its findings were published in 1990, and showed that in a community
sample of Vietnam veterans identified from Department of Defense DoD
personnel records, there was a 30% lifetime incidence of PTSD among
Vietnam combat veterans; also, half of those Vietnam combat veterans who
had ever had PTSD still had it at the time of the study.
Dr. Weisler: And that's just PTSD. There are also comorbidities. In a 2005 review article,
Kathleen Brady commented on the high prevalence rates of alcohol and
drug abuse in military veterans with PTSD, which were significantly
higher than the elevated rates seen in civilian populations with the
same disorder. Thomas and colleagues in a recent study of
National Guard and active duty troops returning from OIF found that
about one half had alcohol or aggressive behavior if they screened
positive for PTSD or depression in post-deployment surveys.
Dr. Kudler: Exactly. Findings from different studies[6,7]
suggest that among veterans with PTSD, up to 84% meet the criteria for
having comorbid alcohol abuse in their lifetime, while up to 44% meet
the criteria for a lifetime drug use disorder (including nicotine). The
rate of depression is very high in this population as well.
Mental Health in Iraq and Afghanistan
Medscape: In general, how does the mental health of troops returning from OEF/OIF compare with that of Vietnam vets?
Dr. Weisler: Let's look at the issue
of improved medical care on the battlefield. I believe in WWI there was
roughly 1 wounded person for every person who died. In WWII there were
approximately 2 wounded soldiers for every person that died. The number
jumps to 3 in Vietnam and now in Iraq and Afghanistan the medical care
and body armor has improved even more dramatically, so we have much
higher rates of people being wounded, which is very good but at the same
time increases the risk for PTSD. Percentage-wise, injuries that may
predispose somebody to depression, PTSD, or cognitive issues are much
higher than we have seen in past wars. There are, what, about 4500
casualties in the 2 wars so far? Just having your body armor or helmet
hit by shrapnel or bullets -- even if there is no physical injury -- can
lead to the development of PTSD in some soldiers.
Dr. Kudler: Over 5000 American troops have died in Iraq and Afghanistan to date.
Dr. Weisler: And in Vietnam there were?
Dr. Kudler: Over 58,000 deaths.
Looking at the denominator, we deployed about 2.7 million people in
country in Vietnam over the 10 years we were there. We have deployed 2.2
million people to Iraq and Afghanistan.
Dr. Weisler: Right, and when you go
back to WWII, or even the Civil War, the number of casualties was huge.
In the Battle at Gettysburg, I believe around almost 8000 soldiers were
killed, and there were over 46,000 casualties and losses (Table 1).
Dr. Kudler: Yes, the number of troops
killed in the 4 days of fighting at Gettysburg was far greater than the
combined totals from Iraq and Afghanistan.
Dr. Weisler: Because we are doing a
much better job protecting people and caring for people once they have
been wounded, we are going to have higher rates of mental health
problems; I think that is going to put a very big strain on the VA
system and the public system. We have to think about ways to deal with
Table 1. Casualties and Losses in the Battle of Gettysburg (July 1–3, 1863; Adams County, PA)
|United States (Union)
Total Casualties: 23,055
Total Casualties: 23,231
Dr. Nasrallah: I think there are also
other factors contributing to the high rate of PTSD with the 2 current
wars, one of them being that the bar has been lowered in order to
recruit more volunteer soldiers. They are accepting people who otherwise
would not have been recruited before -- people with anxiety,
depression, bipolar, or a history of psychiatric problems are more
likely to be recruited and those are predisposing factors for PTSD in a
very stressful war. Granted, our troops are undergoing incredible stress
there, but to have a pre-existing psychiatric vulnerability could
exacerbate the problem.
Dr. Weisler: I definitely agree. I
know that when I first went into practice in 1980, if someone had any
psychiatric history they were basically excluded from joining the
military and would not be drafted. What I often hear now is that if a
patient doesn't take any medicine for 6 months, they are often
Dr. Nasrallah: Certainly, we have a
lot of healthy people going into the military, but the proportion of
individuals who may not have been draftable or enlistable before is much
higher in the current 2 wars than in the past.
Dr. Kudler: The fact is, when we talk
about these premorbid factors, the same argument was made about the
Vietnam generation. These were people who didn't make it into college,
some of whom were swept up off the street. But in fact, the Vietnam
Veteran Readjustment Study showed that those who went to
Vietnam, became ultimately, better educated and had higher incomes than
people who did not go. Throughout the history of military medicine you
find people trying to find ways to ferret out who should not be sent to
war because they are at risk for breaking down. A low level of education
is probably a risk factor, and past history of trauma is known to be a
risk factor for PTSD, but I have got to tell you when you face a stress
like combat, almost everyone, whether they have pre-existing
vulnerability factors, or not, is at risk for PTSD and its related
Dr. Weisler: Studies do suggest that
early traumas may predispose to PTSD, but an amazing number of people
still do quite well and some of it may be genetic; some of it may be
coping strategies and styles that people have learned over the years.
Dr. Nasrallah: It is called resilience and is a hot area of research now.
Dr. Weisler: Right, plus Vietnam
soldiers came back to a very different environment in terms of public
acceptance than what we are seeing now.
Dr. Nasrallah: Nowadays we are warmly
welcoming returning troops. It's a much more positive atmosphere
compared with the Vietnam days. In the Vietnam era postwar very few
people were looking at traumatic stress syndrome and the psychological
injuries of war -- now we are paying so much attention to it there could
be a case-finding bias.
Dr. Kudler: There was a tremendous
bias against seeking mental health services at the time that Vietnam
veterans were returning home from the war. The National Vietnam Veteran
Readjustment Study found that 80% of Vietnam veterans who
actually had PTSD using the best diagnostic measures available in the
late 1980s, never asked the VA for mental healthcare or benefits. One
major worry is that the same stigma, while perhaps less severe, still
interferes with veterans seeking care today. Early on in OEF/OIF, only a
relatively small proportion of these veterans were seeking mental
healthcare from VA but the good news is that now just over half of the
1.2 million OEF/OIF veterans who are eligible for VA health services
have presented to VA for at least 1 episode of care. That is very
promising and suggests that substantial efforts on the parts of DoD and
VA to overcome the stigma associated with reporting post-deployment
mental health problems may be succeeding. On the other hand, just over
49% of these eligible OEF/OIF veterans have not yet presented to VA, and
it is possible that many of them remain concerned about reporting such
problems. It would be nice to believe that those who have yet to seek
help simply don't need that help but the findings of the National
Vietnam Veteran Readjustment Study, which I just noted, make me
concerned about this nonhelp-seeking group.
Medscape: Are there data on the prevalence of PTSD in returning OEF/OIF troops?
Dr. Kudler: Let me share some data
from the VA's universal electronic database. As I've mentioned that at
this point about 2.2 million American service members have served in
Iraq and/or Afghanistan since September 11th. Of those, 1.2
million are already eligible for VA services, half of whom have already
come to VA for at least 1 episode of care -- this is pretty impressive.
The single most common set of health issues are musculoskeletal
problems, but if we drill down into the mental health of these folks, as
of the fourth quarter 2010, we are seeing that 50.2% of the roughly
625,000 OEF/OIF veterans who have come to VA so far, are getting at
least 1 mental health working diagnosis. 27% of the 625,000, or 167,000
veterans are being diagnosed with PTSD.
Dr. Weisler: But you have got to give
it more time. There are people in whom PTSD surfaces as they get older.
Often people manage to cope for long periods and illness doesn't become
obvious until later in life.
How Many Tours of Duty Is Too Many?
Dr. Weisler: I think the other thing
that keeps coming up -- and Harold, I'm curious to hear what you think
-- is the whole issue of length of deployment and multiple tours of
duty. As you mentioned, Vietnam went on for 10 years, but would people
have as many tours of duty and would they be the 12- to 15-month length
that we are now seeing?
Dr. Kudler: Yes, this could play a
role. Most people in Vietnam served 1 tour for 12 months, except for the
Marines who did 13-month tours because, well, they're Marines!
Back in 2004, Charles Hoge published a study in the New England Journal of Medicine
that suggested the rate of PTSD among soldiers and marines, depending
on which groups you were looking at, was somewhere between 8% and 15%.
He found that length and number of deployments was the single strongest
predictor of PTSD.
Dr. Weisler: I have seen and talked
to plenty of people who have served 2, 3, sometimes even 4 tours of duty
in OEF/OIF, each one being 12-15 months.
Dr. Kudler: The length and the
intensity of service are certainly predictors. The amount of time
between deployments or "dwell time" may also be a factor. The kinds of
things that happen (ie, the death of a friend, death of a valued
officer) may carry more risk than an injury to your own body. So there
is a mixture of simple statistics and complex psychological meaning at
Modern Day Stigma and Suicide
Medscape: How has the acceptance of psychiatric illness in the military changed over time?
Dr. Kudler: Hoge's 2004 study
strongly indicated that stigma remained an important barrier to getting
care. In fact, what Hoge showed was that if a soldier came back from the
war with significant PTSD symptoms, he/she was only half as likely to
say "I would ask for help if I needed it." And when asked why they would
or would not get help, the most common reasons were things like "my
buddies would think less of me, my leadership would think less of me, or
I would think less of myself."
I think the problem is getting better and I
really do believe that the military and VA have moved heaven and earth
to reduce stigma. The Pentagon and command leadership get it, but it's
still a slow cultural change. The military understands that receiving
mental healthcare when needed is good for both the mission and the
warriors. This is now official policy, but I am not sure it is yet fully
in the culture at the level of the rank and file from noncommissioned
Medscape: In 2009, the rate of suicides in the Army and the Marine Corps reached the civilian rate for the first time. Can you comment on this alarming increase in prevalence and touch on some possible explanations?
Dr. Weisler: An estimated 18 US veterans a day are dying by suicide according to the VA.
In recent years, suicide in both the Army and Marines often rivals
deaths in combat for allied troops in Iraq and Afghanistan. For example,
in 2009 throughout the Army more than160 soldiers died by suicide,
while 160 named soldiers died while serving in Iraq. Additionally, in
2009 worldwide another 146 Army soldiers died from unintentional drug
overdoses, murders, or from other causes that the Army terms risky
behaviors. The Army also reported over 1700 known suicide attempts in
The suicide rate in 2009 for the US Marines
was 24/100,000, which was even higher than the 22/100,000 rate of the US
Army. Both of these rates are higher than the age-adjusted US
Taken together this suicide data clearly
highlight the need for continuing expanded treatment and suicide
prevention efforts in all branches of the services. Unfortunately, the
numbers of suicides and suicide attempts have remained very high in the
Army and Marines in 2010 despite these considerable efforts to date. The
medical literature and our clinical experience tell us that effectively
treating any significant underlying affective, anxiety, and/or
substance use disorder is the most effective way of reducing though not
eliminating suicide and unintentional drug poisoning deaths. Of course
providing effective treatment requires that the stigmas and barriers,
which interfere with troops and veterans seeking mental healthcare, be
further reduced as Harold just noted.
Ideally we need to make active duty troops
and veterans as well as their families and friends aware of the VA's
Suicide Prevention Hotline which can be reached at 1-800-273-TALK
(1-800-274-8255) for round-the-clock access to trained counselors. About
half of suicide attempts in a recent study by Deisenhamer
are impulsive and occur 10 minutes or less after the first current
suicidal thought. This is one of the reasons why it is so important to
try and create a support system for each soldier, for providers are much
less likely to have contact with them during that critical time period.
Dr. Nasrallah: Suicide tends to be
more of a risk under severe stress. Unlike females, males tend to commit
suicide when they get depressed much quicker and with more lethal
means; unfortunately this is what we are seeing with our returning vets.
I also want to point out that this is a
different war. Our soldiers are not fighting a traditional warfare for
which they are trained. Except for the invasion of Iraq in which we
engaged an army in the classic sense, our current troops are like
sitting ducks waiting for an explosive device to go off. It is like
living in constant stress. Also again, it is very stressful to do 1, 2,
or 3 tours of duty. On top of that, politically speaking, our troops are
being handcuffed as to what they can and cannot do in order to
cultivate a relationship with and avoid alienating the locals. We cannot
have soldiers being trained one way and then being told to engage the
enemy in another way without having some resulting cognitive dissonance
and a stress reaction.
Dr. Kudler: Absolutely. One thing
that is different about these wars is that about 12%-14% of the service
members we have sent to Iraq and Afghanistan are women. Officially,
women are not in combat but because, as you just pointed out, you can't
be in Iraq or Afghanistan and not be in harm's way. Also women are
performing dangerous noncombat duties like being a military police (MP).
Women MPs are kicking down doors in the middle of the night and looking
for bad guys. Women are driving in convoys. It is not officially combat
but they are as likely to be blown up as the men are.
Dr. Nasrallah: So what is the rate of suicide by gender?
Dr. Kudler: Well, the rate among
women is going up and the completion rate among women is going up. They
are using more lethal means like firearms.
Mental Disorders Beyond PTSD
Medscape: We've talked at length about
PTSD and suicide. What other psychiatric conditions and concerns are we
seeing in OEF/OIF soldiers and veterans?
Dr. Kudler: I mentioned there were
167,000 new cases of PTSD from OEF/OIF in the VA system so far. When you
add up the number of depressive disorders and affective psychoses in
the same population, the total is over 195,000.
Then there are about 103,000 cases of anxiety
disorders, 37,000 reported cases of alcohol dependence, 28,000
nondependent drug abusers, and more than 85,000 veterans with tobacco
use disorders; you really have got to smoke like a chimney to get that
diagnosis and it may be a good marker for traumatic stress that we need
Drug dependence among veterans is often
iatrogenic including patients being treated for chronic pain. There was a
similar situation after the American Civil War with soldiers becoming
addicted to morphine.
Dr. Weisler: Bret and I contributed to a Medscape article
earlier this year looking at unintentional poisoning deaths in the
United States, which in many states have passed deaths and motor vehicle
accidents and suicides. Are you seeing a lot of unintentional poisoning
deaths in either active duty troops or in veterans?
Dr. Kudler: I don't have hard numbers
on that but there certainly has been concern, both about accidental
poisonings and potentially dangerous mixtures of medicines being
Dr. Nasrallah: I have read articles
in the media about our soldiers receiving huge doses of atypical
antipsychotics, selective serotonin reuptake inhibitors and mood
stabilizers, often in combination with each other. Are psychotropic
drugs being overused compared with the old days?
Dr. Kudler: Atypical antipsychotics
are being used frequently in DoD and VA settings despite concerns raised
about them in existing VA/DoD Clinical Practice Guidelines for the
Management of Traumatic Stress. Military psychiatrists are, by and
large, really outstanding and a pretty conservative group but new
medicines and combinations are finding their way into our armamentarium.
I think that we have a lot to learn about the effects of mixing these
medicines, especially in this population.
Dr. Weisler: Opiates and some other
pain medications are especially concerning when they are mixed with
benzodiazepines and other kinds of psychotropic drugs with regard to the
risk for unintentional drug poisoning deaths. In many cases they are
also mixed with alcohol by active duty troops and veterans with at times
Clinical Challenges to Be Aware of
Medscape: We've touched on a lot of
mental health issues in the military population. In general, what are
the biggest challenges facing community psychiatrists and PCPs related
to the mental healthcare of soldiers and veterans?
Dr. Weisler: Aswe've
discussed, rates of PTSD, depression, and TBI are very high, as are
rates of substance use disorders. It's also important to recognize that
patient family members can have similar kinds of problems.
Dr. Nasrallah: In treating Vietnam
veterans first-hand, I've witnessed a number of specific challenges.
There is a lot of depression, suicidal ideas, and completed suicides.
Also aggression and violence among the Vietnam vets with PTSD is quite
common as are personality changes, impulsivity, and asociality;
homelessness, substance use, and lack of trust in the VA were also
Dr. Kudler: And it'snot just
about finding a diagnoses that meet our medical model, treating the
"sick ones," and sending everyone else home. If we do this, we're going
to miss the boat on the true nature of in-deployment mental health. The
diagnosis might be PTSD, but there are also issues like joblessness and
homelessness to consider. I have often thought if we could find every
one of these veterans in a good job, we might see fewer diagnoses, less
homelessness, and a lot more intact families. We have the double whammy
right now of people coming back from a war to a prolonged recession.
Are Community Docs Adequately Trained?
Medscape: Compared with community
practitioners, do military and VA psychiatrists receive additional
training on psychiatric issues commonly associated with military
Dr. Nasrallah: Having served as Chief
of Psychiatry at the VA in the past for many years, I think the VA
recruits psychiatrists from wherever they can due to the shortage. These
include psychiatrists not necessarily trained to treat military issues.
However, they get on-the-job training and with time they get better and
better. In terms of military centric medical school, I think we only
have the Uniformed Services University of Health in Washington. Harold,
are there any other medical schools that focus on the military?
Dr. Kudler: Not that I'm aware of but
there should be more military medical training available. There is a
real need to build medical curricula so that all doctors know something
about military culture, about military medicine, and particularly, about
Dr. Nasrallah: Yes, and most
residency programs do not contain such training. I have taught at 5
different universities and I don't recall a single one of them having a
course about the military population. We talk about children,
geriatrics, pregnant women, and various special-needs groups, but I
don't recall anybody giving a single lecture about the special needs of
military personnel even though they are all around us.
Dr. Kudler: Two point two million
people is less than 1% of the American population, so it's easy to think
of OEF/OIF veterans as a very small and insular group with its own
medical support in DoD and VA and not worry about them. But as we've
already discussed, 49% of this group are not using the VA. Even those
who use it often get at least some portion of their care in the
community as well. There probably isn't a community doctor in America
that isn't affected by some of the health issues connected to the wars.
Training in this area is needed as part of a public health approach to
going to war.
Dr. Weisler: I agree with you fully,
Harold. Under the Department of Personnel Management Act, the Navy
Marine Corp is limited I was told to just 100 active duty psychiatrists
for the world and they only had about 87 last year I think. The Army had
112 active duty psychiatrists I believe in 2009. Now, the services have
done a great job getting more psychiatrists, nurse practitioners,
physician assistants, psychologists, and other mental health
professionals involved on a contract basis, but if you look at all of
the 2.1 million people who have been deployed it is still a very small
number of clinicians. And in most base areas -- in my state of North
Carolina for example we have Fort Bragg, Camp Lejune, and Pope Air Force
Base – the number of patients needing psychiatric care can't possibly
be treated at the base by only active duty personnel. Military personnel
are frequently sent offsite to community mental health providers, as
are most of their family members who require mental health evaluation
Dr. Kudler: So now you have got an
issue where we want providers across the country to be responsible for
this huge and very special population, yet we don't have a curriculum or
credentialing for them. I am not saying you need formal credentialing
to do this, but I am saying a curriculum in medical schools is a good
Improving Community Care: What Can You Do?
Dr. Kudler: The bottom line is we
really do need a public health approach to these issues. We need
different levels of intervention and training that begin before
deployment, and continue during a tour as well as after people come
home. This would include effective surveillance in order to be aware of
who is at risk and finding ways to make it easier for them to connect
with care. We need to continue breaking down stigma while educating
patients, families, and community doctors. We also need to start
educating other sectors of society where veterans and their family
members are likely to congregate. A lot of these folks are going to use
the GI bill to go to college, which is wonderful. But who is teaching
the deans and the admissions officers and the college counseling
services about the special problems that combat vets are going to face
When we go to war we go to war as a nation
and we can't respond to public health issues unless we respond at the
national level in a coordinated way.
Dr. Weisler: In terms of treatment,
for PTSD, some of the most important therapies are prolonged exposure
therapy, cognitive behavioral therapy, family therapy, and substance
abuse education therapy. We need to involve counselors in the training
process as well and encourage everybody try to work as a team.
Dr. Kudler: We might consider
approaching these patients with the recovery model approach – letting
them know that problems readjusting to the community after a war
situation are normal. We can offer help in terms that they are more
likely to value and accept: "How can I help you get your feet on the
ground? How about some help with a job? How about letting me help you
put your GI bill privileges to work? How can I help you get into school
and stay in school? How can I help you and your family make sure that
you have your budget under control?"
I think we need to pull together as a nation
so that all citizens are at least aware and thoughtful about the people
who risk their lives to protect us. It's easy to ignore that. Some
military people joke that the military goes to war and the nation goes
to the mall. They feel unsupported, which is in itself a risk factor for
psychiatric issues. We can improve public health by making sure that
the whole nation understands and supports our military when they come
home and disperse into society.
Helpful Resources to Assist Your Practice
Medscape: Short of a major public health
initiative, what resources can clinicians use to help familiarize
themselves with approaching and managing mental health issues related to
Dr. Kudler: The VA's National Center for PTSD has developed outstanding resources and free training for Veterans, their families, and clinicians. Also, the VA's homepage
contains a number of helpful services, which can be of use to patients,
including disability assessment, a resource to sign up for care, and
suicide prevention resources. There is Military One Source,
which you can think of as the military's Employee Assistance Program;
they will answer the phone any time of the day or night or will email
you with answers to your questions. They have tremendous resources with
information, medical information, but also financial information,
benefits information, which a provider can call upon to get help. If I
am a psychiatrist asking where can my patient go for this or that
assistance anywhere in the nation, this group can help you do it. There
is also Give an Hour where clinicians volunteer their services.
The Defense Centers of Excellence offers outstanding online support
and a 24/7 Outreach Hotline, 866-966-1020. And again, the VA's Suicide
Prevention Hotline can be reached at 1-800-273-TALK (1-800-274-8255) for
round the clock access to trained counselors.
Also, the Substance Abuse and Mental Health Services Administration (SAMHSA) has been leading a process called Paving the Road Home
where they have been encouraging state-level partnerships of VA/DoD
states and communities in support of OEF/OIF veterans and their
Our own VA team has worked with the Area of Health Education Centers
(AHEC) in North Carolina and nationally and a group called Citizen
Soldier Support Program, a Federally funded program at the University of
North Carolina, Chapel Hill, which works to develop better programs for
Guard and Reserve members and their families. We have now trained over
9000 healthcare providers and stakeholders over the last couple of
years, 6000 of them online, on military culture, deployment stress and
deployment mental health including PTSD, TBI, and special issues
affecting women Veterans. This free, accredited training can be found here.
Dr. Weisler: We also have the North
Carolina Depression and Bipolar Support Alliance (NCDBA), which provides
support for individuals and family members of the military in eastern
I do volunteer medical advising, fund raising, and morale and awareness raising event work for Hope for the Warriors;
this group and others, both on a national and local level, help a lot
of military troops and their families. I personally find this work very
fulfilling, and mental health and medical professionals can easily get
New Directions In Research And Therapy
Dr. Nasrallah: I can't leave this
discussion without at least alluding to some need for research
addressing unmet needs. I am fascinated by what happens to someone
subjected to continuous stress and the continual threat of death for a
long period of time, who is then immersed back into civilian life and
told, "You can now live happily ever after." They can't! In addition to
the social impact, there are considerable biological changes that occur
in a brain exposed to this situation that predispose our vets to a
multitude of psychiatric symptoms. We need more research in this area.
Dr. Weisler: And let's look at TBI in
veterans, which can make it more difficult for people to function and
cope with stressors. A lot of the people may be exposed to multiple
improvised explosive device explosions over the years, which can make
coping even harder and therapy (ie, cognitive behavioral therapy) less
Dr. Nasrallah: For many years, I have
wanted to do a study of closed head injuries, which includes TBI due to
severe vibration of explosives nearby. My hypothesis is that there is a
disruption of white matter connectivity so you don't see any gray
matter disease but you see that the white matter, which is the
connectivity within the brain that integrates information, emotions,
mood, cognition – everything really -- is so affected because the fibers
are jarred. We now have methods to study this with diffusion tensor
imaging and have found a lot of abnormalities in white matter in
bipolar, schizophrenia, and depression. It is a common finding in
psychiatric disorders without TBI; so imagine there's additional trauma
to the brain I am sure that we will find something interesting. This is
an area of research that nobody has embarked on.
Dr. Weisler: There is a very interesting article by Pompili in the European Archives of Psychiatry
from 2007 exploring the association of white matter hyperintensities
with suicidality in people with major affective disorder. Basically it
looks like there is an association between minor hyperintensities and
suicidality in children and young adults with depression or bipolar
We also did a study as part of an National Institutes of Health grant at Duke
looking at MRI correlates to suicide attempts. Abnormal MRI findings
again show people who are going to be at higher risk for mood disorders
and suicide attempts because of disruption of clinical neuroanatomic
Dr. Kudler: I think you are
absolutely right. A lot of good work is going on in lots of labs. As new
evidence comes out it needs to be integrated into clinical care.
Dr. Weisler: Perhaps we need a STAR*D-type study
for what clinicians should do with a veteran who comes back with, say,
PTSD and/or depression if the first treatment step doesn't work. What to
do next and in what order in veterans with comorbid psychiatric and
medical disorders needs to be more evidence based.
Dr. Kudler: I want to remind
clinicians that VA/DoD clinical practice guidelines do exist with some
excellent evidence-based algorithms for the treatment of PTSD, TBIs,
substance abuse, depression, and psychotic disorders, as well as for
more ill-defined Gulf War-type syndromes. These are in the public domain
and can be accessed here.
A clinical practice guideline is a lovely thing but still, a STAR*D
study looking at a mixed population of people with PTSD, TBI, and
various functional problems would be of tremendous importance.
Dr. Weisler: My wish list for
research in addition to the STAR*D-like study also includes the urgent
development program for new medications and improved diagnostic and
treatment approaches for providers to use as they care for active duty
troops or veterans with TBI and mental disorders. Our need for new
clinical treatments is especially important in the context of so many
veterans having other psychiatric and medical comorbidites, which are
often the norm for this population? For example, clinical trials of
current treatments for PTSD almost universally demonstrate that
available medications are more effective in civilian study populations
than in veterans. Those PTSD study findings are strong enough that many
PTSD studies have excluded veterans for that reason. One thing is
certain, which is that the four of us and most Americans strongly
believe that these men and women who have served our country, as well as
their families, deserve the best psychiatric and medical care that we
can give them.
Harold Kudler, MD, has disclosed no relevant financial relationships.
- Solomon Z, Benbenishty R. The role of proximity,
immediacy, and expectancy in frontline treatment of combat stress
reaction among Israelis in the Lebanon War. American Journal of Psychiatry. 1986;143:613-617.
- Figley C R Stress Disorders among Vietnam Veterans: Theory, Research, and Treatment. In the Psychosocial Stress Book Series. New York: Brunner/Mazel; 1978.
- Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War Generation: Report of Findings From the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel; 1990.
- Brady KT, Sinha R. Co-occurring mental and substance use disorders: the neurobiological effects of chronic stress. Am J Psychiatry. 2005;162:1483-1493.
- Thomas JL, Wilk JE, Riviere LA, et al. Prevalence of
mental health problems and functional impairment among active component
and national guard soldiers 3 and 12 months following combat in Iraq. Arch Gen Psychiatry. 2010;67:614-623.
- Keane T, Kaloupek D. Comorbid psychiatric disorders in PTSD.Ann NY Acad Sci. 1998;24-32.
- Kulka RA, Schlenger WE, Fairbank JA, et al. National Vietnam Veterans Readjustment Study (NVVRS): Description, Current Status, and Initial PTSD Prevalence Estimates. Washington, DC: Veterans Administration; 1988.
- Busey JW, Martin DG. Regimental Strengths and Losses at Gettysburg. 4th ed. Hightstown, NJ: Longstreet House; 2005.
- Hoge CW, Castro CA, Messer SC, et al. Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care. N Engl J Med. 2004;351:13-22.
- Department of Veterans Affairs Website. Available at: http://www.mirecc.va.gov/visn19/research/VISN_19_Military_Suicide_Research_Consortium.asp Accessed December 15, 2010.
- Army Times Website. 18 veterans commit suicide each day. Available at: http://www.armytimes.com/news/2010/04/military_veterans_suicide_042210w/ Accessed January 11, 2011.
- USA Today. No let up in marine suicides. Available at: http://www.usatoday.com/news/military/2010-06-07-marine-suicides_N.htm Accessed January 11, 2011.
- Deisenhammer EA, Ing CM, Strauss R, Kemmler G,
Hinterhuber H, Weiss EM. The duration of the suicidal process: how much
time is left for intervention between consideration and accomplishment
of a suicide attempt? J Clin Psychiatry. 2009;70:19-24.
- Pompili M, Ehrlich S, De Pisa E, et al. White matter
hyperintensities and their associations with suicidality in patients
with major affective disorders. EuroArch of Psych. 2007;257:494-499.
- Ahearn EP, Jamison KR, Steffens DC, et al. MRI correlates of suicide attempt history in unipolar depression. Biol Psych. 2001;50:266-270.
- Sequenced treatment alternatives to relieve depression Website. Available at: http://www.edc.pitt.edu/stard/ Accessed December 15, 2010.