Iraq and Afghanistan Veterans’ PTSD Problems

PTSD in Iraq and Afghanistan Veterans

Post-Traumatic Stress Disorder (PTSD) is defined as a mental health problem that some people develop after experiencing or witnessing a life-threatening event, like combat, a natural disaster, a car accident, or sexual assault (U.S. Department of Veterans Affairs, 2018).

The Armed Forces Health Surveillance Branch (AFHSB) uses the following criteria to define PTSD for surveillance purposes:

One hospitalization with and of the defining diagnoses of PTSDin the first or second diagnostic position; or two outpatient medical encounters, within 180 days of each other, with any of the defining diagnoses of PTSD in the first or second diagnostic position; or one outpatient medical encounter in a psychiatric or mental health care specialty setting, identified by Medical Expense and Performance Reporting System (MEPRS) code BF, with the defining diagnosis of PTSD in the first or second diagnostic position (Armed Forces Health Surveillance Branch, 2014).

Data for PTSD can be found through the U.S. Department of Veterans Affairs (VA), as well as the National Institute of Mental Health (NIMH). In 2017, the VA listed the following U.S. PTSD statistics: Roughly 8 million adults (7-8% of the general U.S. population) suffer from PTSD in the U.S. Of the 50% of women experience at least one trauma in their life, only around 10% will develop PTSD; in men, around 60% experience a trauma but only 4% develop PTSD (VA, 2017). In 2017, the NIMH reported an estimated 3.6% of U.S. adults had PTSD in the past yearPTSD among adults was higher for females (5.2%) than for males (1.8%), and the lifetime prevalence of PTSD was 6.8% (NIMH, 2017)

PTSD is not person characteristic specific. According to the NIMH, risk factors include:
Living through dangerous events and traumas; getting hurt; seeing another person hurt, or seeing a dead body; childhood trauma; feeling horror, helplessness, or extreme fear; having little or no social support after the event; dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home; and having a history of mental illness or substance abuse (NIMH, 2016).

According to a report published by the Congressional Budget Office (CBO) in 2012, the total cost for healthcare provided to PTSD patients among combat veterans was $1,420,000,000 (p. 18). Though this writer was unable to find specific healthcare costs for veterans, one estimate states, the annual cost to society of anxiety disorders is estimated to be significantly over $42.3 billion, often due to misdiagnosis and under treatment. This includes psychiatric and non-psychiatric medical treatment costs, indirect workplace costs, mortality costs, and prescription drug costs (PTSD United, 2013).

Specific morbidity and mortality rate was unable to be accessed by this writer due to not having clearance to access this data from the VA. PTSD does not discriminate based on rural versus urban populations.

Descriptive Epidemiology

PTSD can happen to anyone, at any age. PTSD does not discriminate between age, race, sex, ethnicity, or socioeconomic status. Koo, Herbenstreit, Madden, and Maguen (2016) present the following data in Table 1.
According to the VA, experts estimate that up to 20% of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans, up to 10% of Gulf War veterans, and up to 30% of Vietnam War veterans have experienced PTSD; Consequently, demand for PTSD treatment continues to grow. In the past year alone the number of diagnosed cases in the military jumped 50% and that's only the reported and diagnosed cases; 17% of combat troops are women; 71% of female military personnel develop PTSD due to sexual assault within the ranks (PTSD United, 2013).
PTSD is not a place or time sensitive condition. It can happen anywhere, and at any time. This writer was unable to find statistics breaking PTSD down by time and place characteristics.

Prevention

Research on resilience factors for PTSD is ongoing. There are no set guidelines for preventing PTSD. The NIMH (2016) indicates some factors that may reduce the risk of PTSD including:

Seeking out support from other people such as friends and family; finding a support group after a traumatic event; learning to feel good about one's own actions in the face of danger; having a positive coping strategy, or a way of getting through the bad event and learning from it; and being able to act and respond effectively despite feeling fear.

A study published in Military Medicine in 2012, specifically targeting OEF/OIF/[Operation New Dawn]OND Service Members states, the risk of PTSD is heightened by female gender, divorce, exposure to family psychiatric illnesses, domestic violence, abuse, or violence before military induction, enlisted status, and diminished psychological or physical health before combat (Hermann, Shiner, & Friedman, 2012, p. 2). Genetics may play a part in those with PTSD, but research is still being investigated. The length and number of deployments, perceived threat of danger, and greater combat exposure have all been associated with PTSD studies.

Primary prevention efforts include early intervention, before the patient is exposed to the traumatic event. Primary prevention can also include pharmacological measures such as prophylactic propranolol administration, as well as, hydrocortisone administration in those with low cortisol levels. Another field-based finding was the acute (usually within 1-3 hours) administration of narcotic agents. It appeared to result in significantly lower rates of PTSD several months later than compared with nonadministration (Hermann et al., 2012, p. 3).

Another primary prevention strategy is psychological debriefing. The Army has developed Battlemind stress management training (or Military Resilience Training), and the Navy and Marines have the Combat and Operational Stress Control (COSC) program.

In the predeployment phase, Battlemind informs soldiers about what they are likely to encounter while deployed. In the postdeployment phase, Battlemind addresses safety concerns, relationship issues, normalized combat-related mental health reactions, and symptoms, in addition to providing guidance regarding signs that one should seek mental health support (Hourani, Council, Hubal, & Strange, 2011, p. 727).

The Battlemind training has been modified and now includes a postdeployment intervention, Battlemind Debriefing. This is a single session form of [psychological debriefing] PD administered within 2 weeks of returning from deployment and aimed at providing education, normalizing transition challenges, and encouraging social support (Hermann et al., 2012, p. 4).

The COSC program enables a cohesive ready force and promotes long-term health and well being [sic] among Marines, attached Sailors, and their family members. The COSC program assists commanders, Marines and attached Sailors, in maintaining warfighting capabilities by preventing, identifying, and managing the impacts of combat and operation al stress on Marines and Sailors. (Milstead Jr., 2013).

Another primary prevention method is predeployment coping skills and Stress Inoculation Training [SIT] approaches. The most widely acknowledged preventive approach relevant to military-related PTSD is stress inoculation training (SIT) SIT is an effective method of reducing arousal levels in response to powerful stressors by inoculating individuals to potentially traumatizing stressors (Hourani et al., 2013, p. 727).

Secondary prevention methods include psychological debriefing through various methods such as postdeployment surveys, and medical questionnaires. There are multiple websites available that offer education and support including Health.mil, and the VA has the National Center for PTSD https://www.ptsd.va.gov/, and PTSDunited.org.

Conclusion

PTSD can affect anyone, anywhere, and at any time. It is not exclusive to a specific race, gender, or socioeconomic status. It is not strictly related to time spent in combat, and can affect non-military members as well. The military is conducting ongoing research to determine possible genetic causes for PTSD.

One upstream social determinant is that until recently, PTSD wasn't recognized as a real disorder. After Vietnam it was called shell shock but it was still something that was not formally diagnosed or discussed. Mental health issues still carry a social stigma to this day, even regarding common conditions such as depression or anxiety.

PTSD was once considered a psychological condition of combat veterans who were shocked by and unable to face their experiences on the battlefield. Soldiers with symptoms of PTSD often faced rejection by their military peers and were feared by society in general. Those with PTSD symptoms were often labeled as weak and removed from combat zones, or sometimes discharged from military service. (PTSD united, 2013)

Veterans are often labeled as a hero, strong, fearless, invincible, and brave. These labels, though made with good intentions, may hinder the veteran from seeking psychological treatment. A hero might look weak in the eyes of society or even a fellow veteran. As shown in Table 2, those with PTSD may fear judgment and embarrassment at the idea that they can't handle it. This lack of support, and fear of judgment may cause them to avoid seeking treatment and continue trying to deal with it in their own way.

Table 2: Barriers to seeking mental health services, 2006 and 2007
Factors that Affect the Decision to Seek Mental Health Treatment 2006 2007
I would be seen as weak 53 50
Members of my unit might have less confidence in me 51 45
My leaders would blame me for the problem 43 39
It would harm my career 34 29
It would be too embarrassing 37 34

Table 2: adapted from (National Council on Disability, 2009, p. 52)
Fortunately, there are many online networks and support groups for people with PTSD, both civilian and military; as well as for family members of those with PTSD. This anonymous access lessens the potential fear of judgment and makes mental health more accessible to everyone. Telehealth counseling is a valuable resource for everyone, but especially those in rural areas who may not be able to make it to a therapist for frequent visits.

As a Psychiatric Mental Health Nurse Practitioner, this writer wants to specialize in treating veterans with PTSD. This writer will start by having the patient fill out questionnaires or screening tools regarding their combat history. Upon analysis, it will be determined, between the patient and this writer, how best to treat their symptoms. Medications, therapy, and mindfulness will all be discussed. This writer will also look into Telehealth counseling as well. If the patient cannot come to therapy, therapy will come to them.

References

1. Armed Forces Health Surveillance Branch. (2014, May). Surveillance case definitions - post-traumatic stress disorder (PTSD). Retrieved from Health.mil: https://www.health.mil/Reference-Center/Publications/2014/05/01/PTSD
2. Congressional Budget Office. (2012, February 9). The Veterans Health Administration's treatment of PTSD and traumatic brain injury among recent combat veterans. Retrieved from Congressional Budget Office: https://www.cbo.gov/sites/default/files/cbofiles/attachments/02-09-PTSD.pdf
3. Hermann, B. A., Shiner, B., & Friedman, M. J. (2012). Epidemiology and prevention of combat-related post-traumatic stress in OEF/OIF/OND service members. Military Medicine, 177, 1-6.
4. Hourani, L. L., Council, C. L., Hubal, R. C., & Strange, L. B. (2011, July). Approaches to the primary prevention of posttraumatic stress disorder in the military: A review of the stress control literature. Military Medicine, 176, 721-730.
5. Koo, K. H., Hebenstreit, C. L., Madden, E., & Maguen, S. (2016). PTSD detection and symptom presentation: Racial/ethnic differences by gender among veterans with PTSD returning from Iraq and Afghanistan. Journal of Affective Disorders, 189, 10-16. doi:10.1016/j.jad.2015.08.038
6. Milstead Jr., R. E. (2013, February 22). Publications. Retrieved from Marines: https://www.marines.mil/Portals/59/Publications/MCO%205351.1.pdf
7. National Council on Disability [NCD]. (2009). Invisible wounds: Serving service members and veterans with PTSD and TBI. Retrieved from https://ncd.gov/rawmedia_repository/veterans.pdf
8. National Institute of Mental Health. (2016, February). Post-traumatic stress disorder. Retrieved from National Institute of Mental Health: https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
9. National Institute of Mental Health. (2017, November). Post-traumatic stress disorder (PTSD) Statistics. Retrieved from National Institute of Mental Health: https://www.nimh.nih.gov/health/statistics/post-traumatic-stress-disorder-ptsd.shtml#part_155467
10. PTSD United. (2013). PTSD statistics. Retrieved from PTSD United: https://www.ptsdunited.org/ptsd-statistics-2/
11. U.S. Department of Veterans Affairs. (2017, December 14). PTSD: By the numbers. Retrieved from Make The Connection: https://maketheconnection.net/whats-new/ptsd-statistics
12. U.S. Department of Veterans Affairs. (2018, September 27). PTSD: National Center for PTSD - PTSD Basics. Retrieved from U.S. Department of Veterans Affairs: https://www.ptsd.va.gov/understand/what/ptsd_basics.asp

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