How To Get Mental Health Care Right For Today’s Veterans


Charles R. Marmar, M.D.

Observations of combat-related stress disorders appear as early as the writings of Homer in descriptions of returning Trojan war veterans. During the Civil War, PTSD was characterized as soldier’s heart, in World War I it was shell shock, in World War II it was battle fatigue and during the Vietnam War it was Vietnam Syndrome. With the 1980 inclusion of Post-traumatic Stress Disorder (PTSD) in the “American Psychiatric Association Diagnostic and Statistical Manual,” PTSD has been officially designated as one of the anxiety disorders. Key features of PTSD include re-experiencing painful memories, numbing of positive feelings, avoiding reminders and being alert and on guard, even in safe situations.
The lifetime risk for PTSD in the general American population has been estimated to be 7.8 percent (1). The best estimate of the rates of PTSD in combat has been derived from the National Vietnam Veterans Readjustment Study (NVVRS) (2,3). The NVVRS found that 20 percent of those who served in the Vietnam War developed deployment-related PTSD, with those suffering from PTSD having increased rates of depression, alcohol and drug abuse, family adjustment problems and interpersonal violence. Children of Vietnam veterans with PTSD had higher levels of behavioral and emotional problems. Greater combat exposure, including multiple tours of duty and greater exposure to personal life threat and killing predicted greater risk of combat related PTSD.
The U.S. invaded Afghanistan on October 7, 2001 and Iraq on March 20, 2003. To date, more than 1.6 million men and women have served in Afghanistan and Iraq. Milliken and colleagues (4) conducted a longitudinal study of 88,235 soldiers returning from Iraq. Screening was conducted immediately following return from the warzone and again three to six months later. Based on combined screening, 20.3 percent of active-duty and 42.4 percent of reservists screened positive for mental health disorders. Seal and colleagues (5,6) reported on the growing burden of mental disorders, including trends and risk factors for mental health diagnosis in new users of Veteran Affairs health care. Between April 2002 and March 2008, data was reported on 289,328 Iraq and Afghanistan veterans using VA healthcare for the first time; 36.9 percent received one or more mental health diagnoses; 21.8 percent received a diagnosis of PTSD; 17.4 percent a diagnosis of depression, 7 percent for alcohol use disorder and 3 percent for substance abuse disorder. Those with PTSD and depression had elevated cardiac risk, including higher blood pressure, elevated cholesterol and adult-onset diabetes.
Despite the lessons learned from Vietnam, engaging OEF and OIF veterans in mental health care remains a challenge. Young men and women returning from Afghanistan and Iraq service with warzone-related PTSD and other related mental health problems struggle to confront these problems and reach out for mental health services. They have busy lives, concerns about childcare, financial pressures, concerns about an adverse impact on their military or civilian careers from being labeled with PTSD, and perceptions of being weak in a culture critical of vulnerability and prone to shaming mental illness. Practical concerns regarding access to care, transportation, and childcare also constitute obstacles to receiving much needed mental health services.
DOD and VA have adopted a number of innovative strategies to overcome the obstacles to care. Integrated, co-located care where mental health services are provided inside primary care is one approach, with a well-established evidence base for the successful treatment of depression in civilians in co-located mental health primary care clinics (7). Efforts are being made to de-stigmatize mental health services by reframing them as stress management training for combat operational stress, rather than psychiatric treatment for mental disorders. In an effort to address geographic barriers to care and stigma, innovations are being made to bring care to veterans utilizing internet and telephone care as an alternative to traditional clinic visits. Motivational interviewing techniques are used to directly address the stigma concerns. By employing these novel strategies, the hope is to reduce the risk of delayed treatment seeking, which will inevitably result in higher rates of depression, alcohol and drug use, interpersonal violence, physical health problems and occupational disability.
The past two decades have seen rapid advances in evidence-based treatment for both combat and civilian PTSD. Among the psychotherapies, those with greatest empirical support are cognitive behavioral therapy that emphasizes vividly re-imagining the traumatic events in the safety of the relationship with the therapist, confronting reminders of the events in everyday life and correcting irrational beliefs related to traumatic exposure. There is preliminary support for the use of marital and family therapy. A recent review of medication studies for PTSD (8) reported 35 randomized control trials, with clinical improvement occurring in 59.1 percent of those in the active pharmacological treatment conditions, versus 38.5 percent receiving placebo. Antidepressant medications, including drugs such as Zoloft and Paxil, are effective for both PTSD and associated depression, and may be helpful for pain. Other helpful medications for combatting PTSD include trazodone for insomnia, prazosin for nightmares, mood stabilizing drugs for anger outbursts and naltrexone and topiramate for alcohol abuse (9).

1. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. 1995. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 52:1048-1060.
2. Schlenger WE, Kulka RA, Fairbank JA, Hough RL, Jordan BK, Marmar CR, Weiss DS. 1992. The prevalence of post-traumatic stress disorder in the Vietnam generation: A multimethod, multisource assessment of psychiatric disorder. J Trauma Stress 5:333-363.
3. Jordan BK, Schlenger WE, Hough R, Kulka RA, Weiss D, Fairbank JA, Marmar CR. 1991. Lifetime and current prevalence of specific psychiatric disorders among Vietnam veterans and controls. Arch Gen Psychiatry 48:207-215.
4. Milliken CS, Auchterlonie JL, Hoge CW. 2007. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA 298:2141-2148.
5. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. 2007. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med 167:476-482.
6. Seal KH, Metzler TJ, Gima KS, Bertenthal D, Maguen S, Marmar CR. In press. Increasing prevalence of mental disorders among Iraq and Afghanistan veterans: trends and risk factors for mental health diagnoses in new users of VA healthcare, 2002-2008. Am J Public Health..
7. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. 2006. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 166:2314-2321.
8. Stein DJ, Ipser JC, Seedat S. 2006. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 1:CD002795.
9. Berger W, Mendlowicz MV, Margues-Portella C, Kinrys G, Fontenelle LF, Marmar CR, Figueira I. 2009. Pharmacologic alternatives to antidepressants in posttraumatic stress disorder: A systematic review. Prog Neuropsychopharmacol Biol Psychiatry 33:169-180.

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