About 2.5 million U.S. service members have served in conflicts since September 11, 2001. Estimates of the numbers of service members who have deployed to Iraq and Afghanistan and have posttraumatic stress disorder (PTSD) range from 15% to 25%. 1-3
This special issue contains several excellent articles about PTSD and comorbidities, including insomnia and depression. Although there are service members who have pure PTSD, in the experience of most clinicians, that is the exception rather than the rule. 2 For example, insomnia may lead to patients’ excessive drinking to try to sleep. Numbing and avoidance from the excessive drinking leads to relationship problems and often divorce. Relationship problems are subsequently a key driver of suicide. 4,5
Also included in this issue is a series of articles examining the case study of William, who has multiple sclerosis (MS), a disease usually in the domain of neurologists, rather than psychiatrists. However, given the physical, cognitive, and social stresses of MS, it is not surprising that comorbid depression is extremely common, appearing in about half of patients with MS over their lifetime. 6 The multidisciplinary approach to care described in this series is critical for successful treatment.
There are well-established guidelines for the treatment of PTSD, developed by the American Psychiatric Association, DoD, and VA, often referred to as evidence-based treatments. However, there are many patients who are either unwilling or unable to adhere or who do not respond to the evidence-based treatments. Although these patients are often called treatment-resistant or refractory, it is also likely that the treatments are not engineered toward service members. That may be due to (1) unacceptable adverse effects from medication; (2) difficulties attending frequent appointments, especially for cognitivebehavioral treatments; (3) the reluctance of many service members to relive their trauma and/or talk about it; or
(4) the stigma of seeking treatment. 2,7
The physical stresses of military service, including wounds and injuries, involve corresponding pain and disability. Alcohol, depression, PTSD, and traumatic brain injury have long been associated with one another, but sometimes musculoskeletal injuries are left out of the discussion. The musculoskeletal issues have led to service members being treated with opiates, which can cause dependence and addiction. 4,5 In both military and civilian populations, many patients switch from legal opiates to illegal heroin. Many service members, especially after discharge from the military, thus start a slide into substance dependence, unemployment, and homelessness. Unfortunately, death by heroin overdose is increasingly common. 8
Suicide rates among U.S. Army personnel have been increasing since 2004, surpassing comparable civilian suicide rates in 2008. The other service branches have not seen such a dramatic rise, but suicide is still a troubling problem. Suicide rates peaked in army active-duty troops over the past few years but are still rising in reservists. Suicides are most prevalent among young white males but have been increasing in older ages and females
as well. 4,5
Risk factors for suicide among active-duty members are well known, because data are systemically collected. These include relationship difficulties, financial and occupational problems, pain and physical disability, and access to weapons. 4,5