PTSD in Returning Iraq War Veterans: Need for Mental Health Services, Veterans Health System Readiness, Implications for Community Counseling, and Treatment Guidelines
The University of Memphis
The Iraq War, as the first protracted infantry war since Vietnam, promises to create a high number of mental health casualties. The pertinent attributes of the war, the relative impotency of military interventions, questions about the ability of the Veterans Administration (VA) to handle the increased caseload, and barriers to treatment are reviewed. Research since Vietnam has improved our knowledge of PTSD attributes, which include delayed onset, biological changes, high prevalence long after combat, and coping styles and supports that predict positive outcomes. The high exposure to trauma from the Iraq War, the limited ability of the VA, and delayed onset predict an increasing caseload for community agencies. Current assessment and intervention standards of practice are reviewed in preparation.
PTSD in Returning Iraq War Veterans: Need for Mental Health Services, Veterans Health System Readiness, Implications for Community Counseling, and Treatment Guidelines
The war in Iraq represents the first protracted infantry war since Vietnam, a type of war likely to create high numbers of mental health casualties. This paper will discuss the attributes of the war that will lead to higher rates of Post Traumatic Stress Disorder, military and Veterans Administration (VA) plans for coping with the increase, their capacity to do so, barriers to treatment for returning soldiers, and the impact on community counseling agencies. The impact on Memphis, Tennessee will be reviewed specifically. In preparation for that impact, this paper will review the latest knowledge relative to PTSD, its course, biopsychosocial aspects, comorbidities, and clinical recommendations relative to assessment and intervention.
Post Traumatic Stress Disorder (PTSD) is defined as the development of a specific set of symptoms after exposure to trauma. The diagnosis requires that the trauma involve experiencing or witnessing event(s) that “involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others” (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 467). In addition, the person’s response to the event must have involved “intense fear, helplessness, or horror” (DSM-IV-TR, p. 467). Additional criteria involve reexperiencing the trauma, avoidance of reminders of the trauma, numbing of general responsiveness, increased arousal (startle reflex, sleep difficulties, irritability, difficulty concentrating, hypervigilance) symptoms, duration of over one month, and significant distress or impairment. Reexperiencing symptoms include recurrent and intrusive recollections or dreams, feeling as if the trauma is recurring, or reactivity to cues that symbolize or resemble the event (DSM-IV-TR). PTSD can be specified as acute (duration less than 3 months) or chronic (duration greater than 3 months; DSM-IV-TR).
PTSD can have a delayed onset, which is defined as the appearance of symptoms at least 6 months after the traumatic event (DSM-IV-TR, 2000). Research results have shown that the probability of having PTSD is directly related to the frequency and intensity of exposure to trauma (Wolfe, Erickson, Sharkansky, King, & King, 1999). PTSD is differentiated from Acute Stress Disorder (ASD), which has earlier timing and shorter duration (symptoms lasting two days to one month), and a heavier emphasis on dissociative symptoms.
Prevalence of PTSD among Veterans
The National Vietnam Veterans Readjustment Study (NVVRS; Kulka, Schlenger, Fairbank, Hough, Jordan, Marmar, & Weiss, 1990) found PTSD prevalence to be 15% twenty years after the war, and as high as 36% among veterans in actual combat. An additional 11% had partial PTSD symptoms. Almost 31% of male veterans had full PTSD at some time in their life, with an additional 22.5% having partial lifetime symptoms. In a 2004 study, the prevalence of PTSD in Iraq War veterans 3-4 months after a 6-8 month deployment was over 12% (Hoge, Castro, Messer, McGurk, Cotting, & Koffman, 2004).
How Will Iraq Veterans Differ?
The Iraq War has several attributes that may lead to higher PTSD as compared to previous wars. There is ongoing fear among soldiers of exposure to nuclear, biological, and chemical weapons based on history of the Gulf War (Litz & Orsillo, 2004). There are no front lines, so all are exposed to combat. Guerilla style attacks and roadside bombs cause a need for constant vigilance, and there is a continuous threat from civilians, coupled with a desire to avoid harming innocents (Litz & Orsillo; “War stress blamed”, 2005). The ratio of U.S. wounded to killed soldiers is higher than any war in history (Litz & Orsillo). Soldiers are more mobile, rather than operating from secure bases (“War stress blamed”), and therefore more vulnerable. Combat exposure is extraordinarily high, with reports from soldiers indicating that 89-95% have been attacked or ambushed, 93-97% shot at, and 86-87% knowing someone seriously injured or killed (Hoge et al., 2004). The advent of the helicopter in Vietnam, and the mobility it brought, raised exposure to combat from 40 days of a four-year tour in World War II, to 240 days of a one-year deployment in Vietnam (Hayes, 2004).
National Guard and Reserve troops, referred to as the Reserve Component (RC), make up a greater percentage of combat troops than in the past (Cozza, Benedek, Bradley, Grieger, Nam, & Waldrep, 2004), and there is evidence that they have a higher prevalence of PTSD than active troops (Operation Iraqi Freedom Mental Health Advisory Team [OIF-II], 2005; Wolfe et al., 1999). This difference is believed to be due to: (a) their return from war directly to pre-deployment jobs, rather than to their unit where they decompress with peers (U.S. Senate Committee on Veterans’ Affairs, 2005); (b) stress associated with reintegrating into the workplace and associated career stagnation relative to peers (Ruzek, Curran, Friedman, Gusman, Southwick, Swales, Walser, Watson, & Whealin, n.d.); (c) being ill prepared for service in Iraq (Litz & Orsillo, 2004; OIF-II); and (d) the war being a greater disruption to their normal lives (Wolfe et al., 1999).
Military and VA Approach to the Mounting Problem
The VA has been responsible for leading the world in research relative to PTSD and this research has resulted in new understanding and treatment of the disorder.
Some conclusions of research are that: (a) PTSD has biological as well as psychological aspects, (b) early intervention can mitigate chronic PTSD, (c) certain post-trauma coping styles and supports aid recovery (Wolfe, Keane, Kaloupek, Mora, & Wine, 1993), (d) significant post-deployment stress increases impairment (Litz & Orsillo, 2004), and (e) future trauma or stress can cause relapse (Charney, Deutch, Krystal, Southwick, Davis, 1993; Friedman, Donnelly, & Mellman, 2003).
Much research over the last 15 years has been directed toward biophysical changes that occur with PTSD, which has implications for pharmacological treatment. The stress response system is the target of most research. This involves the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis. Southwick and Friedman (2001) reported that these systems operate abnormally in many people with PTSD, but only in response to stressors that are similar to the original trauma. These systems seem to become sensitized to particular stressors, and there appears to be a conditioning function that occurs between the trauma and neutral sensory stimuli such as smell or sound. However, rather than this response extinguishing over time due to a lack of pairing with the adverse stimuli, the response seems to be inhibited, and can recur later in response to new unusual stress (Charney et al., 1993). Additional findings include increased blood flow to the amygdala and other brain structures associated with processing emotions, and a decrease in hippocampal volume in people with PTSD (Southwick & Friedman).
Research has shown PTSD to be comorbid with substance abuse, crime, interpersonal and family problems (National Center for PTSD, n.d.; Litz & Orsillo, 2004), homelessness (Rosenheck, Leda & Gallup, 1992), diminished problem-solving ability, aggressive behavior, occupational problems (Litz & Orsillo), suicide (Hudenko, n.d.), panic disorder, major depression (Ruzek et al., n.d.), and Social Phobia Disorder (Orsillo, 1997).
Military and VA Plans
Research outcomes have driven changes in PTSD treatment. In the field, if the symptoms are mild, the soldier is kept nearby and given “rest, hot meals, and supportive therapy” (Lehmann, 2003). The objective is to return him or her to duty as quickly as possible and as of 2005, 86% of soldiers were being returned to the battlefield (OIF-II, 2005).
Additional changes have occurred relative to the soldier who has completed his or her tour and is returning to the U.S. The first is decompression time before returning to their families. In addition, a post-deployment assessment is performed, which covers a number of health issues, including PTSD. Those needing it are offered treatment (Cozza et al., 2004). Although the VA promotes early intervention as a means of reducing the prevalence of PTSD (Brant, 2005), the primary intervention occurs after the tour of duty, as if the tour were one trauma. One or more traumas and symptoms may have occurred earlier in the tour, indicating chronic PTSD. The VA’s examination of returning veterans for ASD as a preventive mechanism for PTSD (Brant, 2005) is not empirically justified given the timing, evidence that ASD is a relatively poor predictor of PTSD (Litz & Orsillo, 2004), and the potential for delayed onset.
Media reports have raised questions recently about the capability of the military and VA to deal with the mental health concerns of returning veterans. Many of these have involved incidents of violent acts by returning soldiers, long waits for treatment (“War stress blamed”, 2005; Daugherty, 2005), or inability to obtain disability status (Welch, 2005).
Healthcare Availability for Discharged Veterans
Once a veteran leaves active duty, healthcare is available via several channels. For any illness or injury that is conceivably combat related, the VA provides care without cost for two years, after which there is a co-pay. Treatment by the Readjustment Counseling Service (RCS) is available for life, at no cost, at 207 Vet Centers (J. Buchanan, personal communication, October 14, 2005). Optionally, the veteran can sign up for TRICARE, which is health insurance that allows the veteran to choose his or her provider. RC veterans are considered veterans for VA benefits if they were ordered to federal active duty (A. Strickland, personal communication, October 13, 2005).
Military and VA Capacity
A current report from the Department of Defense (DOD; OIF-II, 2005) indicates that only 41% of soldiers report receiving adequate training relative to stress control, and only 40% of soldiers with mental health problems report receiving help while in Iraq.
Back in the U.S., it is unclear if current VA staffing can handle the spike in caseloads that will occur. A number of recent testimonies to the U.S. Congress have decried the ability of the VA to meet the needs of returning veterans from Iraq (Edsall, 2005), including testimony by the medical director of the American Psychiatric Association, Dr. James Scully, who testified that the VA’s spending for mental health services had dropped 25% since 1996, that the number of severe PTSD diagnoses had increased 42%, and that funding for PTSD treatment had only increased 22% (Daugherty, 2005; Mulligan, 2004). A recent Government Accountability Office report (2004) reported that the VA did not know how many veterans it was treating for PTSD, so therefore did not know the capacity it had for handling returning soldiers from Iraq.
In the Memphis area, there is a VA Medical Center and a Vet Center, along with four community-based outreach centers in Mississippi, Tennessee, and Arkansas. Readjustment counseling services are offered at the Vet Center. John Buchanan (personal communication, October 14, 2005), the RCS team leader in Memphis, reported that the VA recently added 50 outreach positions nationwide, and that one was assigned to the Memphis center. There has been no increase in clinical staffing. Mr. Buchanan also reported that the local RCS office takes walk-ins and that it is easy to get an appointment. Sessions are essentially confidential, as records are not turned over to the military or the local medical center. Aaron Strickland (personal communication, October 13, 2005), from the Dallas regional office that serves Memphis, reported that there are no projections relative to future caseloads.
Military and VA Treatment Utilization
Hoge et al. (2004) found that veterans with PTSD were twice as likely to have concerns about seeking treatment. Barriers to treatment included stigmatization, difficulty in getting appointments (Hoge et al.), distance to VA facilities (Brant, 2005), depression, lack of trust in the government (Wolfe et al., 1993), and desire to return home quickly (Ruzek et al., n.d.). For soldiers remaining in the military, there is no guarantee of confidentiality, and many reported fearing negative career impact (Ruzek et al.; Brant).
Course of the Disorder
PTSD symptoms may occur immediately after trauma, or occur much later. Schnurr, Lunney, Sengupta, & Waelde (2003) found that 9.4% of Vietnam veterans with lifetime full or partial PTSD had late onset symptoms that started an average of 6.4 years after the war, and that 40% of all such veterans had symptoms that started at least two years after the war.
A study of Gulf War veterans showed that PTSD prevalence increased over time from three percent five days after return to the U.S., to eight percent 18-24 months later. The degree of combat exposure was significantly related to rates of PTSD at both times, and RC soldiers were twice as likely as active duty soldiers to have PTSD at the later time (Wolfe et al., 1999).
PTSD is a persistent disorder, possibly due to physiological changes that occur with it (Wolfe et al., 1999). Schnurr et al. (2003) found that 58.3% of Vietnam veterans with lifetime full or partial PTSD continued to have a high density of symptoms twenty years later.
It has been shown that the degree of post-deployment stress correlates to PTSD impairment (King, King, Fairbank, Keane, & Adams 1998). Unusual stress in later life can also cause the reappearance of PTSD symptoms (Charney et al., 1993).
Once PTSD becomes chronic, it often causes problems throughout the lifespan and seems to be more resistant to treatment in veterans than in survivors of other forms of trauma (Litz & Orsillo, 2004), perhaps due to the relative duration and intensity of the trauma.
Differences for Minorities and Females
Most studies find women more likely than men to develop chronic PTSD (Schnurr, Lunney, Sengupta, & Waelde, 2003). Wolfe et al. (1999) found prevalence of PTSD to be twice as high for women, both on return from the Gulf War and 18-24 months later, and hypothesized that the higher rate was due to higher levels of discrimination, harassment, and sexual assault compared to men. This has been partially validated by Wolfe, Sharkansky, Read, Dawson, Martin, and Ouimette (1998) who found a linear correlation between degree of reported sexual harassment and degree of reported PTSD symptomology in female Gulf War veterans. The 7.3% of female veterans who had been sexually assaulted exhibited an increase in symptoms equivalent to a one standard deviation increase in combat exposure.
In the NVVRS (Kulka et al., 1990), non-white veterans were found to have significantly higher rates of current and lifetime full PTSD than their Caucasian counterparts. Differential combat exposure explained this for African Americans but not for Hispanic veterans.
Pole, Best, Metzler, & Marmar (2005) in a study of urban police officers, found the same overrepresentation of Hispanic officers with PTSD symptoms, and found that peritraumatic dissociation accounted for 20% of the variance, with coping style explaining an additional 12% of the difference between Caucasians and Hispanics. Pole et al. proposed that the Hispanic culture promotes avoidance as a coping style for stress, and that avoiding behaviors prevent cognitive processing of trauma. It was also found that Hispanic officers engaged in more wishful thinking and self-blame as coping mechanisms, both of which have been shown to lead to poorer outcomes (Wolfe et al., 1993).
Several factors have been identified as leading to the higher rate of PTSD in minority veterans, after controlling for greater exposure to trauma (Loo, n.d.). Among these are: (a) Identification with the enemy as an oppressed group, (b) having the same physical appearance as the enemy, and (c) racial discrimination and harassment by both U.S. and Vietnamese troops.
The implication for clinicians of these findings is that trauma and wartime stress should be explored broadly with the client, rather than focusing directly on combat experiences (Loo, n.d.). With 16% of current armed forces being female, and 24-40% being ethnic minorities, depending on branch of service (Cozza et al., 2004), it will be important to consider these issues when individualizing therapy.
Implications for Community Counseling in the Memphis Area
The attributes of the Iraq War, when looked at as a whole, arguably predict a record incidence of PTSD. The degree, frequency, and duration of exposure to trauma are greater than any previous war. Females, minorities, and RC troops, all of whom have higher prevalence rates than active duty, Caucasian males, are a record high percentage of the fighting force. Early measures by the DOD indicating lower PTSD rates of around 10% (OIF-II, 2005) in soldiers returning from Iraq are of minimal value, given that onset of symptoms is often delayed by over two years. Active measures taken by the military to cope with battlefield stress, when reviewed against major research findings, can be expected to be largely ineffective. Only on the battlefield is one expected to recover from acute trauma in a few days and return to the traumatic situation. Back home, the VA is apparently under-prepared for an onslaught of new cases. The decline in the World War II veteran population will not appreciably offset the increase from recent wars due to the difference in combat exposure. The overall prevalence of veteran PTSD can be expected to increase markedly.
Memphis appears to be adequately staffed for the current caseload, and beginning an active outreach program. However, there is no increase in clinical staffing, and the reviewed barriers to treatment make it likely that only a small percentage of veterans will pursue treatment for PTSD at the VA. In addition, the prevalence rate can be expected to go up over time, with veterans not recognizing the symptoms for what they are, and appearing in mental health agencies with concerns due to comorbid issues such as sleep, anxiety, depression, and interpersonal problems.
It will also be important for community agencies to include veterans in their catchment areas as a target for active outreach efforts. Some of these veterans will be homeless, while others will not seek treatment due to isolation or other demands on their time (Litz & Orsillo, 2004). Community counselors need to be aware of the unique needs of each veteran, and up to date on assessment and treatment guidelines.
Because of the prevalence of PTSD in veterans, it is good practice to assess any veteran client with a short PTSD screening instrument. The PTSD Checklist (PCL) is a widely used, reliable, valid instrument and requires five minutes to complete (Weathers, Litz, Herman, Huska, & Keane, 1993). Carlson (2004) recommends using the civilian version for veterans so that the whole spectrum of trauma is assessed.
Perhaps the best assessment instrument for diagnosing PTSD is the Clinician-Administered PTSD Scale (CAPS). In addition to diagnosis, it can be used to measure progress (Keane, Street, & Orcutt, 2000), and symptom severity (Smith, Redd, DuHamel, Vickberg, & Ricketts, 1999).
For veterans diagnosed with PTSD, Carlson(2004) recommends use of the Deployment Risk and Resilience Inventory for assessing the context and events that are especially troubling to the veteran, and provides assessment instruments for PTSD, trauma history, depression, dissociation, complicated grief, and alcohol abuse. Other areas to explore with the client include guilt, current medications, adequate sleep, and whether basic needs are being met (Veterans Health Administration & Department of Defense (VA/DOD, 2004), relational supports and high risk behaviors (American Psychiatric Association [APA], 2004), current stressors, losses, and whether other trauma occurred prior to military service. If possible, it can be helpful to include the veteran’s family in the assessment, particularly relative to interpersonal behavior (VA/DOD).
Another area for assessment is the veteran’s style relative to his or her traumatic experiences. Blaming, repression, stoicism, wishful thinking, externalization, and extreme avoiding have been found to be the most maladaptive, with social support, active problem solving, cognitive processing, suppression, or diversion providing better outcomes (Wolfe et al., 1993; APA, 2004).
Psychological treatment for PTSD is multifaceted, including psychoeducation, individual therapy, family therapy, group therapy, and preventive therapy relative to relapse. There are often comorbid disorders to be considered as well.
Although treatment objectives should be specific to the individual, the general goals are to help the client: (a) Reduce reexperiencing, avoiding, numbing, hyperarousal, anxiety, reactivity, and sleep disturbance symptoms; (b) manage the stress associated with memories and minimize it over time; (c) reduce high risk and impairing behaviors; (d) prevent and treat comorbid disorders; (e) restore a sense of trust, adaptive functioning, and normal development; (e) limit generalization of a sense of threat; (f) foster resilience and build coping skills relative to new stressors; (g) learn to even out moods and irritability; (h) protect against relapse; and (i) integrate the experience in such a way that personal meaning is made, with new understandings relative to risk, safety, prevention, and protection (APA, 2004).
The first priority is to help stabilize the client and to ensure that basic needs are met. Normal crisis assessment and intervention should be performed. Pharmacological intervention should be considered for severe sleep problems, overwhelming psychological pain, rage, agitation, or dissociation (APA, 2004), psychosis, or severe anxiety or depression. The counselor may need to act as case manager and advocate in leveraging community resources to assist the veteran in meeting housing, food, and other basic needs. The therapist should ensure that the client’s relational supports are encouraged, mobilized, and leveraged to every degree possible, since they are a strong predictor of recovery (APA; King et al., 1998).
Once the client’s basic needs are met and the client is stable, it is important to educate the client, and his or her family if possible, relative to the symptoms and causes of PTSD, and how symptoms may impact relationships at home and at work (APA, 2004). Effective and ineffective coping strategies should be reviewed. It is then helpful to provide information on treatment options, the pros and cons of each, and prognosis. The reality of potential relapse should be discussed; however, the potential for success should be emphasized, along with the knowledge that tools are available for prevention and treatment of relapse, should that occur.
It is critical during this introductory time to build a therapeutic alliance with the client, in a safe, secure, confidential environment, that is accepting of the client’s person, regardless of how he or she may have behaved during or since the trauma. The client should be given an opportunity to recount his or her story, and how that personal experience fits with the typical symptoms and traumatic experiences described earlier (APA, 2004). It is also important to listen to the client relate how the symptoms, potential forms of treatment, and original trauma fit into his or her overall social and family context (APA), and to help the client normalize thoughts, feelings, and behaviors relative to the traumatic experience.
Treatment options should be discussed with the client, and with the family if possible. Exposure therapy should be discussed, along with the probability that some symptoms will become worse before getting better (APA, 2004), and that this could increase the urge to abuse alcohol or other substances (Keane et al., 2000). The client should be assured that he or she will not be pushed to reexperience the trauma . The treatment plan should add interventions over time as needed to deal with problematic symptoms, and should be collaborative, to facilitate empowerment and return of a sense of control (APA).
One particular area for decision-making is the order in which to pursue exposure therapy, eye motion desensitization and reprocessing (EMDR) therapy, and/or pharmacological treatment. The first and third are first line treatments, while the second is still controversial. Before proceeding with exposure therapy, it is important that the client be safe and stable. With some clients, supportive therapy may be indicated until he or she can tolerate exposure to traumatic memories (APA, 2004).
Since exposure therapy involves voluntarily reexperiencing the trauma, it is critical to have informed consent from the client before beginning, to educate the client about the method, to assure the client that he or she will be in control, to allow calming time at the end of sessions (APA, 2004), and to continually encourage the client to persist through the discomfort.
The first step is to teach the client relaxation and breath control techniques, and to work with the client in identifying and labeling emotions (Keane et al., 2000). These skills lay a foundation for exposure therapy and will be helpful for dealing with anxiety in general.
Imaginal exposure therapy is the primary approach to use, moving on to in vivo exposure if indicated. It is important to have the client describe traumatic events with as much sensory and emotional detail as he or she can (APA, 2004; Keane et al., 2000). The level of this detail should increase with the number of sessions and level of event exposure.
While therapy is ongoing, assessment should be ongoing as well. The client’s indication of subjective units of distress since the previous session and the therapist’s global assessment of functioning (DSM-IV-TR) are good measures for every session. The PCL is a quick, effective instrument for assessing PTSD at appropriate milestones in the treatment process. Adherence to the pharmacological treatment plan should be monitored as well.
EMDR is a treatment in which the client describes a traumatic image, and a problematic cognition and degree of anxiety associated with the image. A motion that causes the eyes to move back and forth, tones in alternating ears, or vibrations in alternate hands are then used to stimulate the client in a bilateral manner (James & Gilliland, 2005). This process continues through the same and other events until the irrational cognitions lose their validity and the associated anxiety is greatly diminished. Additionally, cognitions that are more positive can be installed using a similar method (James & Gilliland). Although there are mixed outcome studies relative to EMDR in the treatment of PTSD (EMDR Institute, 2004), James and Gilliland concluded that in their subjective experience, EMDR is probably as effective as cognitive-behavioral therapy (CBT) in treating PTSD.
In addition to exposure therapy or EMDR, cognitive restructuring can be useful in helping the client deal with negative thoughts, guilt, eliminating the generalization of perceived threat (APA, 2004), and integrating the traumatic experience into his or her belief system (Litz & Orsillo, 2004). Stress inoculation therapy can help the client learn to better cope with future stressors, an important coping skill in preventing relapse. Training in anger management and interpersonal skills will also be needed for some clients. Additionally, CBT can be helpful in dealing with comorbid disorders such as generalized anxiety, major depression, or complicated grief (Center for Advancement of Health, 2003).
Group therapy has a long history of success with veterans, especially if the group is made up of veterans with PTSD, and is either led or co-led by a combat-experienced veteran. Group therapy is especially useful in providing a support network for the veteran, and providing an understanding audience for recounting traumatic memories. Group therapy in this context is also useful for rebuilding trust; dealing with shame, rage, fear, grief, doubt, self-condemnation, and guilt; normalizing PTSD reactions; and bringing the focus from the past to the present (APA, 2004). The group context can also be useful for education, teaching relaxation and emotion recognition/expression, and reinforcing continuance of exposure therapy (APA). In addition, when PTSD reactions of the veteran have led to maladaptive patterns within the family, family therapy may be helpful.
Relapse prevention is an important aspect of intervention, as veterans who have once had a PTSD diagnosis are more likely to have recurrent symptoms due to new stressors or trauma (Charney et al., 1993). Veterans should be educated about possible anniversary reactions and warning signs, such as the recurrence of PTSD symptoms, irritability or chronic anger, and the urge to use alcohol or other substances (APA, 2004). Sertraline (Zoloft) has been found to be effective in preventing relapse (Friedman, Donnelly, & Mellman, 2003). Follow up assessments should be conducted with veterans every three months (VA/DOD, 2004).
Fifteen years of research into the biophysical aspects of PTSD have not resulted in the degree of pharmacological results that one might expect. Only the selective serotonin reuptake inhibitor (SSRI) category has shown reasonably consistent efficacy, and only sertraline has been approved by the Food and Drug Administration for treatment of PTSD (Friedman, Davidson, Mellman, & Southwick, 2000). SSRIs address hyperarousal, intrusive thoughts, flashbacks, irritability, anxiety, depression, and poor concentration symptoms. Their efficacy, relative safety, positive effect on numerous comorbid disorders, ease of administration, and ability to prevent relapse (Davidson, Pearlstein, Londborg, Brady, Rothbaum, Bell, Maddock, Hegel, & Farfel, 2001) make SSRIs the first choice for PTSD (Khouzam & Donnelly, 2001; Friedman et al.). Other drugs that target the serotonin system and that have received research focus are nefazodone and trazodone. These can be used with SSRIs to alleviate sleep difficulties sometimes associated with those medications (Friedman et al.).
Antiadrenergic drugs work to dampen the effects of the sympathetic nervous system, and have been used to target reexperiencing and hyperarousal symptoms (Khouzam & Donnelly, 2001). Clonidine, guanfacine, and propanolol have been specific targets of non-randomized studies (Friedman et al., 2000). These drugs are primarily for controlling hypertension, so may be useful for clients experiencing high blood pressure, and should be used with caution otherwise.
Although there have been some findings to the contrary, the weight of evidence is that phenelzine, an MAOI, is effective in many patients, providing some overall improvement, but particularly relative to reexperiencing symptoms (Friedman et al., 2000). There are dietary restrictions with MAOIs that can have serious consequences if not followed, and MAOIs can be dangerous when mixed with alcohol.
Two tricyclic antidepressants (TCAs), imipramine and amitriptyline, have had positive results in randomized clinical trials, while a third, desipramine, had negative results (Friedman et al., 2000). Results with TCAs tend to be less positive than outcomes with MAOIs or SSRIs, but it is possible that they might be more efficacious than SSRIs for veterans (Friedman et al.). TCAs are contraindicated with suicidality, as overdose is potentially fatal (Khouzam & Donnelly, 2001).
The VA/DOD clinical practice guideline (2004) recommends only SSRIs as the first line treatment, with TCAs and MAOIs as the second approach if the first is not satisfactory. Once treatment starts, change is not recommended for at least 12 weeks.
This study has examined the nature of PTSD, and the attributes of the Iraq War that make it likely that the PTSD prevalence rate from the war will be historically high. It has also examined DOD and VA preparations and capacity for dealing with this problem, barriers to utilization of mental health services, and the special issues of PTSD relative to females, ethnic minorities, and reserve component soldiers. The likelihood is that this combination will result in higher caseloads for community agencies, with presentation as comorbid disorders, versus PTSD. In response to the expected impact, this study has reviewed the latest assessment and treatment capabilities for detecting PTSD and helping clients recover. This information, when combined with adequate needs assessment for the individual catchment area, should help community agencies prepare for the future with appropriate funding, staffing, and training.
American Psychiatric Association. (2004). Practice guideline for treating patients with acute stress disorder and posttraumatic stress disorder: A quick reference guide. Retrieved September 30, 2005, from http://www.psych.org/psych_pract/treatg/pg/PTSD-PG-PartsA-B-C-New.pdf
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed., text revision). Washington, DC: Author.
Brant, M. (2005, July 5). ‘I was shell shocked’. Retrieved September 5, 2005, from the MSNBC Web site: http://www.msnbc.msn.com/id/8471505/site/newsweek/print/1/displaymode/1098/
Carlson, E. (2004). Assessment of Iraq War veterans: Selecting assessment instruments and interpreting results. In P. P. Schnurr & S. J. Cozza (Eds.), Iraq War clinician guide (pp. 108-125). Retrieved September 9, 2005, from the National Center for PTSD Web site: http://www.ncptsd.va.gov/war/guide/
Center for the Advancement of Health (2003). Report on bereavement and grief research. Retrieved November 5, 2005, from http://www.cfah.org/pdfs/griefreport.pdf
Charney, D.S., Deutch, A.Y., Krystal, J.H., Southwick, S.M., Davis, M. (1993). Psychobiologic mechanisms of posttraumatic stress disorder. Archives of General Psychiatry, 50, 294-305.
Cozza, S.J., Benedek, D.M., Bradley, J.C., Grieger, T.A., Nam, T.S., & Waldrep, D.A. (2004). Topics specific to the psychiatric treatment of military personnel. In P. P. Schnurr & S. J. Cozza (Eds.), Iraq War clinician guide (pp. 4-19). Retrieved September 9, 2005, from the National Center for PTSD Web site: http://www.ncptsd.va.gov/war/guide/
Daugherty, J. (2005, August 22). Vets’ war has second front: Recovering from wounds both physical and mental is another battle for Jose Mateo. Palm Beach Post. Retrieved September 6, 2005, from http://www.ngwrc.org/index.cfm?page=Article&ID=2039
Davidson, J., Pearlstein, T., Londborg, P., Brady, K.T., Rothbaum, B., Bell, J., Maddock, R., Hegel, M.T., & Farfel, G. (2001). Efficacy of sertraline in preventing relapse of posttraumatic stress disorder: Results of a 28-week double-blind, placebo controlled study. American Journal of Psychiatry, 158, 1974-1981.
Edsall, T.B. (2005, June 30). Senate votes for $1.5 billion in extra Veterans Affairs funds. The Washington Post (p. A21). Retrieved September 20, 2005, from http://www.washingtonpost.com/wp-dyn/content/article/2005/06/29/AR2005062902714.html
EMDR Institute (2004). Summary of PTSD research. Retrieved October 8, 2005, from http://www.emdr.com/sumofptsd.htm
Friedman, M.J., Davidson, R.T., Mellman, T.A. & Southwick, S.M. (2000). Pharmacotherapy. In E.B. Foa, T.M. Keane, & M..J. Friedman (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (pp. 84-105). Retrieved September 9, 2005, from the National Center for PTSD Web site: http://www.ncptsd.va.gov/documents/friedman__pharmacother_15706.pdf
Friedman, M.J., Donnelly, C.L., & Mellman, T.A. (2003). Pharmacotherapy for PTSD. In P. P. Schnurr & S. J. Cozza (Eds.), Iraq War clinician guide (pp. 169-174). Retrieved September 9, 2005, from the National Center for PTSD Web site: http://www.ncptsd.va.gov/war/guide/
Government Accountability Office. (2004). VA and Defense health care: More information needed to determine if VA can meet an increase in demand for post-traumatic stress disorder services. (GAO Publication No. 04-1069). Retrieved September 5, 2005, from http://www.gao.gov/new.items/d041069.pdf
Hayes, P. (2004). A new generation of combat stress. Retrieved September 5, 2005, from the Military.com Web site: http://www/military.com/NewContent/0,13190,Defensewatch_012104_Stress,00.html
Hoge, C.W., Castro, A.C., Messer, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351, 13-22.
Hudenko, W. (n.d.). PTSD and suicide. Retrieved September 11, 2005, from the National Center for PTSD Web site: http://www.ncptsd.va.gov/facts/problems/fs_suicide.html
King, L.A., King, D.W., Fairbank, J.A., Keane, T.M., & Adams, G.A. (1998). Resilience-recovery factors in post-traumatic stress disorder among female and male Vietnam veterans: Hardiness, postwar social support, and additional stressful life events. Journal of Personality and Social Psychology, 74, 420-434.
Kulka, R.A., Schlenger, W.E., Fairbank, J.A., Hough, R.L., Jordan, B.K., Marmar, C.R., & Weiss, D.S. (1990). Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.
Lehmann, C. (2003, May 16). 21st-Century war alters military combat-stress response. Psychiatric News, 38, 20. Retrieved September 5, 2005, from http://pn.psychiatryonline.org/cgi/content/full/38/10/20
Litz, B., & Orsillo, S.M. (2004). The returning veteran of the Iraq War: Background issues and assessment guidelines. In P. P. Schnurr & S. J. Cozza (Eds.), Iraq War clinician guide (pp. 21-32). Retrieved September 9, 2005, from the National Center for PTSD Web site: http://www.ncptsd.va.gov/war/guide/
Loo, C.M. (n.d.). PTSD among ethnic minority veterans. Retrieved September 4, 2005, from http://www.ncptsd.va.gov/facts/veterans/fs_ethnic_vet.html
Mulligan, K. (2004). VA gets insufficient funds for PTSD care, APA testifies. Psychiatric News, 39, 12. Retrieved September 5, 2005, from http://pn.psychiatryonline.org/cgi/content/full/39/8/12
National Center for PTSD. (n.d.). Epidemiological facts about PTSD. Retrieved September 11, 2005, from http://www/ncptsd.va.gov/facts/general/fs_epidemiological.html
Operation Iraqi Freedom Mental Health Advisory Team. (2005). Operation Iraqi Freedom (OIF-II) Mental Health Advisory Team (MHAT-II) report. Retrieved October 30, 2005, from http://www.armymedicine.army.mil/news/mhat_ii/OIF-II_REPORT.pdf
Orsillo, S. M. (1997). Social avoidance and PTSD: The role of comorbid social phobia. NCP Clinical Quarterly. Retrieved September 11, 2005, from the National Center for PTSD Web site: http://www/ncptsd.va.gov/publications/cq/v7/n3/orsillo.html
Pole, N., Best, S.R., Metzler, T., & Marmar, C.R. (2005). Why are Hispanics at greater risk for PTSD? Cultural Diversity and Ethnic Minority Psychology, 22, 144-161.
Rosenheck, R., Leda, C., & Gallup, P. (1992). Combat stress, psychosocial adjustment, and service use among homeless Vietnam veterans. Hospital and Community Psychiatry, 43, 145-149.
Ruzek, J.I., Curran, E., Friedman, M.J., Gusman, F.D., Southwick, S.M., Swales, P., Walser, R.D., Watson, P.J., & Whealin, J. (n.d.). Treatment of the returning Iraq War veteran. Retrieved September 4, 2005, from the National Center for PTSD Web site: http://www/ncptsd.va.gov/war/treatment_ret_iraq.html
Schnurr, P.P., Lunney, C.A., Sengupta, A., & Waelde, L.C. (2003). A descriptive analysis of PTSD chronicity in Vietnam veterans. Journal of Traumatic Stress, 16, 545-553.
Smith, M.Y., Redd, W., DuHamel, K., Vickberg, S.J. & Ricketts, P. (1999). Validation of the PTSD Checklist-Civilian Version in survivors of bone marrow transplantation. Journal of Traumatic Stress, 12, 485-499.
Southwick, S. & Friedman, M.J. (2001). Neurobiological models of posttraumatic stress disorder. In Gerrity, E., Keane, T.M., & Tuma, F. (Eds.), The mental health consequences of torture (pp. 73-87). New York: Kluwer Academic/Plenum.
U.S. Senate Committee on Veterans’ Affairs. (2005, July 29). Idaho field hearing Monday to look at the “return readiness” for National Guard and Reservists. Washington, DC: Author. Retrieved September 20, 2005, from http://www.senate.gov/~veterans/index.cfm?FuseAction=Newsroom.PressReleases&month=7&year=2005&id=140
Veterans Health Administration & Department of Defense. (2004). VA/DoD clinical practice
guideline for the management of post-traumatic stress. Retrieved September 30, 2005, from http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=5187&nbr=3569
War stress blamed for shooting by vets. (2005, August 22). Associated Press. Retrieved August 22, 2005, from http://www.cnn.com/2005/HEALTH/conditions/08/12/stress.disorder.ap/
Weathers, F.W., Litz, B.T., Herman, D.S., Huska, J.A., & Keane, T.M. (1993). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the Annual Meeting of International Society of Traumatic Stress Studies, San Antonio, TX. Retrieved October 15, 2005, from http://www.pdhealth.mil/library/downloads/PCL_sychometrics.doc
Welch, W.M. (2005, February 28). Trauma of Iraq War haunting thousands returning home. USA Today. Retrieved September 6, 2005, from http://www.commondreams.org/headlines05/0228-01.htm
Wolfe, J., Erickson, D.J., Sharkansky, E.J., King, D.W., & King, L.A. (1999). Course and predictors of posttraumatic stress disorder among Gulf War veterans: A prospective analysis. Journal of Counseling and Clinical Psychology, 67, 520-528.
Wolfe, J., Keane, T.M., Kaloupek, D.G., Mora, C.A., & Wine, P. (1993). Patterns of positive readjustment in Vietnam combat veterans. Journal of Traumatic Stress, 6, 179-193.
Wolfe, J., Sharkansky, E.J., Read, J.P., Dawson, R., Martin, J.A., & Ouimette, P.C. (1998). Sexual harassment and assault as predictors of PTSD symptomatology among U.S. female Persian Gulf War military personnel. Journal of Interpersonal Violence, 13, 40-57.