WASHINGTON — Combat conditions in Iraq and Afghanistan that foster posttraumatic stress disorder are creating a need for interventions among returning veterans to prevent substance abuse that can emerge as a coping mechanism, according to mental health experts.
Combat is a known stressor with about 15% of Vietnam War veterans still experiencing PTSD 30 years after that conflict officially ended. Vietnam veterans account for some 500,000 current PTSD cases in the United States, said Terence Keane, Ph.D., director of the behavioral science division at the National Center for Posttraumatic Stress Disorder at the VA Boston Healthcare System.
Studies have estimated that 15%-30% of veterans of Iraq and Afghanistan have mental health issues, including PTSD. Almost 2 million people have been deployed to those two theaters; there have been more than 4,500 deaths and 35,000 injuries. About 164,000 personnel are currently deployed, according to John Rodolico, Ph.D., of the psychology department at Harvard Medical School, Boston, and a former U.S. marine who spoke at the Association for Medical Education and Research in Substance Abuse annual meeting, which was also sponsored by Brown Medical School.
Dr. Keane and a colleague, D.H. Barlow, proposed an etiologic model of the many factors that contribute to the condition.
The model posits that a genetic vulnerability combined with a biologic vulnerability in the face of trauma creates an alarm, which then turns into a kind of permanent alarm in the face of new traumas. The anxious apprehension that an event will happen again leads to adverse coping mechanisms such as drinking and drug taking.
Specific aspects of the Iraq and Afghanistan conflicts and the makeup of the current military personnel are contributing to an increase of PTSD cases, said Dr. Keane and Dr. Rodolico. Half the military personnel are reservists, which means that they return to the civilian world instead of a military base, where they might be met with more understanding of their combat experiences.
Soldiers in the Iraq and Afghanistan conflicts have multiple tours of duty. Many studies have shown that increased exposure to combat gives rise to a greater likelihood of occurrence of PTSD, said Dr. Keane. Improvised explosive devices (IEDs) and hidden enemies pose constant threats, he said. The summer and winter temperatures are extreme. Many soldiers feel a sense of shame from the treatment of prisoners at Abu Ghraib and Guantanamo Bay, Cuba, said Dr. Keane.
Effective therapies for PTSD are available but veterans aren't getting access to them, he said. Some are turning to drugs and alcohol, but the problem has not yet been quantified, said Dr. Keane. One challenge for mental health professionals in the combat context is to determine how traumatic brain injury, chronic pain, and addictions affect PTSD and its treatment, said Dr. Keane.
After the media reported on the lack of mental health treatment for veterans, the military began an operation in 2005 to increase access and awareness, said Dr. Rodolico. The Department of Defense established mental health clinics in base areas of Iraq and Afghanistan, and prescribers were given a whole host of new drugs to offer patients. But the professionals still weren't reaching soldiers where they were fighting, he said.
The mental health providers began accompanying soldiers on missions—a tough sell for commanders, who didn't want anyone slowing down the missions, or perhaps, removing soldiers from combat, said Dr. Rodolico. But the mental health teams were able to convince the military command of the benefits of interventions.
During Dr. Rodolico's time in Iraq, 98% of soldiers who were seen by mental health professionals were returned to active duty. The most common problems were combat stress reactions such as sleep disturbances, fatigue, concentration disturbances, anxiety, dysphoria, and emotional numbing, he said.
It will be interesting to study how soldiers are coping after their return, said Dr. Rodolico. Alcohol abuse is not common in the combat theater—or at least not in the open—as it supposedly is a “dry” operation. There are cultural and religious prescriptions against alcohol in those countries, and there is a general order forbidding drinking in Iraq and Afghanistan, said Dr. Rodolico.