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At War With Mental Illness: Caring For Troops and Veterans


Bret Stetka, MD; Richard H. Weisler, MD; Henry A. Nasrallah, MD; Harold Kudler, MD

Posted: 02/10/2011

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 population.

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 women.

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 stress component.

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 somewhat helpful.

A lot of World War II (WWII) psychiatric intervention centered on prevention using the PIE (Proximity, Immediacy, Expectancy) model.[1] 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 precipitously.

Enter PTSD

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 disorder (PTSD).[2]

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.[3] 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,[4] 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[5] 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 this.

Table 1. Casualties and Losses in the Battle of Gettysburg (July 1–3, 1863; Adams County, PA)[8]

United States (Union) CSA (Confederacy)
3155 killed
14,531 wounded
5369 captured/missing
Total Casualties: 23,055
4708 killed
12,693 wounded
5830 captured/missing
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 considered eligible.

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[3] 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 problems.

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[3] 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[9] 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 work.

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 officers down.

Medscape: In 2009, the rate of suicides in the Army and the Marine Corps reached the civilian rate for the first time.[10] 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.[11] 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 2009.

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 population rates.[11,12]

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[13] 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 to follow.

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 prescribed.

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 deadly consequences.

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 commonly encountered.

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 service?

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 military psychiatry.

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 and treatment.

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 idea.

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 on campus?

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 military service?

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 families.

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 North Carolina.

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 involved.

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 effective.

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[14] 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 disorder.

We also did a study as part of an National Institutes of Health grant at Duke[15] 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 pathways.

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[16] 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.

Disclosure:
Harold Kudler, MD, has disclosed no relevant financial relationships.
From Medscape Psychiatry & Mental Health

References

  1. 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.
  2. Figley C R Stress Disorders among Vietnam Veterans: Theory, Research, and Treatment. In the Psychosocial Stress Book Series. New York: Brunner/Mazel; 1978.
  3. 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.
  4. Brady KT, Sinha R. Co-occurring mental and substance use disorders: the neurobiological effects of chronic stress. Am J Psychiatry. 2005;162:1483-1493.
  5. 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.
  6. Keane T, Kaloupek D. Comorbid psychiatric disorders in PTSD.Ann NY Acad Sci. 1998;24-32.
  7. 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.
  8. Busey JW, Martin DG. Regimental Strengths and Losses at Gettysburg. 4th ed. Hightstown, NJ: Longstreet House; 2005.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. Ahearn EP, Jamison KR, Steffens DC, et al. MRI correlates of suicide attempt history in unipolar depression. Biol Psych. 2001;50:266-270.
  16. Sequenced treatment alternatives to relieve depression Website. Available at: http://www.edc.pitt.edu/stard/ Accessed December 15, 2010.
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