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At War With Mental Illness: Caring For Troops and Veterans

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.


 

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.

www.medscape.com/psychiatry

Authors and Disclosures

Interviewer

Bret Stetka, MD

Editorial Director, Medscape Features Group

Disclosure: Bret Stetka, MD, has disclosed no relevant financial relationships.

Interviewees

Richard H. Weisler, MD

Adjunct Associate Professor of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina; Adjunct Professor of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Private Practice, Richard H. Weisler, MD, PA & Associates, Raleigh, North Carolina

Disclosure: Richard H. Weisler, MD, has disclosed the following relevant financial relationships:
Served as consultant for: Abbott Laboratories; AstraZeneca Pharmaceuticals LP; Bristol-Myers Squibb Company; CeNeRx BioPharma; Eli Lilly and Company; GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Otsuka Pharmaceutical Co., Ltd.; Pfizer Inc.; Prophase; sanofi-aventis; sanofi-synthelabo; Shire; Takeda Pharmaceuticals North America, Inc.; Validus Pharmaceuticals, LLC
Served as member of speakers bureau for: Abbott Laboratories; AstraZeneca Pharmaceuticals LP; Bristol-Myers Squibb Company; Cephalon, Inc.; GlaxoSmithKline; Merck & Co, Inc.; Novartis Pharmaceuticals Corporation; Organon Pharmaceuticals USA, Inc.; Otsuka Pharmaceutical Co., Ltd.; Pfizer Inc.; sanofi-aventis; sanofi-synthelabo; Schering-Plough Corporation; Shire; Validus Pharmaceuticals, LLC
Received grants for clinical research from: AstraZeneca Pharmaceuticals LP; Bristol-Myers Squibb Company; CeNeRx BioPharma; Cephalon, Inc.; CoMentis; Dainippon Sumitomo Pharma America; Eli Lilly and Company; Forest Laboratories, Inc.; GlaxoSmithKline; Janssen Pharmaceutica Products, L.P.; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Merck & Co, Inc.; National Institute of Mental Health (NIMH); Neurochem; New River Pharmaceuticals; Novartis Pharmaceuticals Corporation; Otsuka Pharmaceutical Co.; Pfizer Inc.; Repligan Corporation; sanofi-aventis; sanofi-synthelabo; Schwabe/Ingenix; Sepracor Inc.; Shire; Synaptic Pharmaceutical Corporation; Takeda Pharmaceuticals North America
Owns or has owned stock from: Merck & Co. Inc.; Pfizer Inc.; Bristol-Myers Squibb Company; Cortex Pharmaceuticals, Inc.

Henry A. Nasrallah, MD

Professor of Psychiatry and Neuroscience, University of Cincinnati College of Medicine; Director, Schizophrenia Program, University Hospital, Cincinnati, Ohio

Disclosure: Henry A. Nasrallah, MD, has disclosed the following relevant financial relationships:
Served as a consultant for: AstraZeneca Pharmaceuticals LP; Pfizer Inc.; Janssen Pharmaceutica Products, L.P.; Merck & Co., Inc.; Novartis Pharmaceuticals Corporation; Sepracor Inc.
Served as a speaker or a member of a speakers bureau for: AstraZeneca Pharmaceuticals LP; Pfizer Inc.; Janssen Pharmaceutica Products, L.P.; Merck & Co., Inc.; Novartis Pharmaceuticals Corporation; Sepracor Inc.
Received research grant from: Forest Laboratories, Inc.; Janssen Pharmaceutica Products, L.P.; Otsuka Pharmaceutical Co., Ltd.; Shire
Received income in an amount equal to or greater than $250 from: AstraZeneca Pharmaceuticals LP; Pfizer Inc.; Janssen Pharmaceutica Products, L.P.; Merck & Co., Inc.; Novartis Pharmaceuticals Corporation; Sepracor Inc.

Harold Kudler, MD

Associate Clinical Professor, Department of Psychiatry and Behavioral Science, Duke University; Associate Director, VISN-6 Mental Illness Research, Education and Clinical Center (MIRECC), VA Medical Center, Durham, North Carolina

Disclosure: Harold Kudler, MD, has disclosed no relevant financial relationships.

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