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Notes on Post-Traumatic Stress Disorder (PTSD)
and related problems among veterans of Afghanistan and Iraq

• Soldiers' Stress: What Doctors Get Wrong about PTSD
  David Dobbs, Scientific American Magazine (13 April 2009)
  
  Key Concepts
  • The syndrome of post-traumatic stress disorder (PTSD) is under fire because its defining criteria are too broad, leading to rampant overdiagnosis.
  • The flawed PTSD concept may mistake soldiers' natural process of adjustment to civilian life for dysfunction.
  • Misdiagnosed soldiers receive the wrong treatments and risk becoming mired in a Veterans Administration system that encourages chronic disability.
  There are many comments appended to this article, including one by the author, who writes:
  
  [...] This is an extremely difficult and touchy subject, and the positions have been staked out and dug in so deeply, and so tainted with politics, that it's sometimes hard to see new ideas clearly and evaluate them without assuming certain motives.
  
  Let me repeat: PTSD exists, and where it exists we must treat it. But the VA's track record of success treating PTSD, despite their use of some therapies that work in civilian populations, suggests that we need to consider not necessarily doing LESS for vets with PTSD, but forging a response that's different -- one that actively encourages recovery in every way, and that provides help for other mental-health and economic readjustment issues as well.
  
• Post-traumatic stress disorder
  CBC News (3 April 2009)
  
  Post-traumatic stress disorder has made headlines in recent years, but is not new. The disorder has been known to exist as far back as ancient Greece, but has had different names throughout history. In the American Civil War, it was called soldier's heart. In the First World War it was called shell shock and in the Second World War it was known as war neurosis. In the Vietnam War, the symptoms were described as combat stress reaction.
  
  Now, more Canadian soldiers than ever are coming forward to make claims for psychiatric disabilities, such as post-traumatic stress disorder (PTSD). The military ombudsman's office in Ottawa made 31 recommendations in a report on PTSD in 2002. In a follow-up report that was released on Dec. 17, 2008, the ombudsman noted that 18 of the 31 recommendations had not been fully implemented. [...]
  
• Suicide after Leaving the UK Armed Forces — A Cohort Study
  Kapur N, While D, Blatchley N, Bray I, Harrison K. PLoS Med 2009.6(3): e1000026. doi:10.1371/journal.pmed.1000026
  
  Background
  Few studies have examined suicide risk in individuals once they have left the military. We aimed to investigate the rate, timing, and risk factors for suicide in all those who had left the UK Armed Forces (1996–2005).
  Methods and Findings
  We carried out a cohort study of ex-Armed Forces personnel by linking national databases of discharged personnel and suicide deaths (which included deaths receiving either a suicide or undetermined verdict). Comparisons were made with both general and serving populations. During the study period 233,803 individuals left the Armed Forces and 224 died by suicide. Although the overall rate of suicide was not greater than that in the general population, the risk of suicide in men aged 24 y and younger who had left the Armed Forces was approximately two to three times higher than the risk for the same age groups in the general and serving populations (age-specific rate ratios ranging from 170 to 290). The risk of suicide for men aged 30–49 y was lower than that in the general population. The risk was persistent but may have been at its highest in the first 2 y following discharge. The risk of suicide was greatest in males, those who had served in the Army, those with a short length of service, and those of lower rank. The rate of contact with specialist mental health was lowest in the age groups at greatest risk of suicide (14% for those aged under 20 y, 20% for those aged 20–24 y).
  Conclusions
  Young men who leave the UK Armed Forces were at increased risk of suicide. This may reflect preservice vulnerabilities rather than factors related to service experiences or discharge. Preventive strategies might include practical and psychological preparation for discharge and encouraging appropriate help-seeking behaviour once individuals have left the services.
  
• New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study
  Smith TC, Ryan MA, Wingard DL, Slymen DJ, Sallis JF, Kritz-Silverstein D; Millennium Cohort Study Team.
  BMJ 2008;0(2008):bmj.39430.638241.AEv1 (15 January), doi:10.1136/bmj.39430.638241.AE
  
  Objective To describe new onset and persistence of self reported post-traumatic stress disorder symptoms in a large population based military cohort, many of whom were deployed in support of the wars in Iraq and Afghanistan.
  
  Design Prospective cohort analysis.
  
  Setting and participants Survey enrolment data from the millennium cohort (July 2001 to June 2003) obtained before the wars in Iraq and Afghanistan. Follow-up (June 2004 to February 2006) data on health outcomes collected from 50 184 participants.
  
  Main outcome measures Self reported post-traumatic stress disorder as measured by the posttraumatic stress disorder checklist—civilian version using Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria.
  
  Results More than 40% of the cohort were deployed between 2001 and 2006; between baseline and follow-up, 24% deployed for the first time in support of the wars in Iraq and Afghanistan. New incidence rates of 10-13 cases of post-traumatic stress disorder per 1000 person years occurred in the millennium cohort. New onset self reported post-traumatic stress disorder symptoms or diagnosis were identified in 7.6-8.7% of deployers who reported combat exposures, 1.4-2.1% of deployers who did not report combat exposures, and 2.3-3.0% of non-deployers. Among those with self reported symptoms of post-traumatic stress disorder at baseline, deployment did not affect persistence of symptoms.
  
  Conclusions After adjustment for baseline characteristics, these prospective data indicate a threefold increase in new onset self reported post-traumatic stress disorder symptoms or diagnosis among deployed military personnel who reported combat exposures. The findings define the importance of post-traumatic stress disorder in this population and emphasise that specific combat exposures, rather than deployment itself, significantly affect the onset of symptoms of post-traumatic stress disorder after deployment.
  
• Combat and Peacekeeping Operations in Relation to Prevalence of Mental Disorders and Perceived Need for Mental Health Care: Findings From a Large Representative Sample of Military Personnel
  Arch Gen Psychiatry. 2007;64(7):843-852
  
  Main Outcome Measures: The DSM-IV mental disorders (major depressive disorder, posttraumatic stress disorder, generalized anxiety disorder, panic disorder, social phobia, and alcohol dependence) were assessed using the World Mental Health version of the World Health Organization Composite International Diagnostic Interview, a fully structured lay-administered psychiatric interview. The survey included validated measures of selfperceived need for mental health treatment, mental health service use, and suicidal ideation. Lifetime exposure to peacekeeping and combat operations and witnessing atrocities or massacres (ie, mutilated bodies or mass killings) were assessed.
  Results: The prevalences of any past-year mental disorder assessed in the survey and self-perceived need for care were 14.9% and 23.2%, respectively. Most individuals meeting the criteria for a mental disorder diagnosis did not use any mental health services. Deployment to combat operations and witnessing atrocities were associated with increased prevalence of mental disorders and perceived need for care. After adjusting for the effects of exposure to combat and witnessing atrocities, deployment to peacekeeping operations was not associated with increased prevalence of mental disorders.
  Conclusions: This is the first study to use a representative sample of active military personnel to examine the relationship between deployment-related experiences and mental health problems. It provides evidence of a positive association between combat exposure and witnessing atrocities and mental disorders and self-perceived need for treatment.
  
• The Need for Outreach in Preventing Suicide among Young Veterans
  Sareen J, Belik S-L. PLoS Med 2009.6(3): e1000035. doi:10.1371/journal.pmed.1000035 Discusses "Suicide after leaving the UK Armed Forces — A cohort study." The authors reference the following initiatives of the US Air Forse Suicide Prevention Program. [Link added.]
  
  
  The 11 Initiatives of the US Air Force Suicide Prevention Program

  1. Leadership involvement in the spectrum of community-based suicide initiatives.
  2. Addressing suicide prevention through professional military education.
  3. Guidelines for commanders on how and when to use mental health services.
  4. Community preventive services, including updating reporting systems to track patient care and prevention services.
  5. Annual suicide prevention training for all military and civilian employees.
  6. Changes in policies to ensure that individuals under investigation for legal problems (who are at increased suicide risk) are assessed for suicide potential.
  7. Trauma stress response to help personnel deal with their reactions to traumatic incidents such as terrorist attacks.
  8. Integrated Delivery System and Community Action Information Board, which provide a forum for cross-organizational review and resolution of individual, family, installation, and community issues.
  9. Limited Privilege Suicide Prevention Program, i.e., those at suicide risk are afforded increased confidentiality when seen by mental health professionals.
  10. Integrated Delivery System Consultation Tool, administered upon the commander's request, which allows commanders to assess unit strengths and identify areas of vulnerability.
  11. Suicide event surveillance system. Adapted from http://afspp.afms.mil/ and [Canadian Psychiatric Association Position Paper: Media guidelines for reporting suicide.].
  
  
• Post-traumatic stress disorder surges among Canadian veterans
  Canadian Press, CBC News (29 February 2008)
  
  The number of former soldiers suffering from post-traumatic stress has more than tripled since Canada first deployed troops to Afghanistan, according to new figures released by Veterans Affairs Canada. With the country's involvement in the war set to continue until 2011, the numbers are only expected to get worse...
  
• Medical marijuana could help our war-stressed soldiers - The Ottawa Citizen (18 June 2008)
  
  Israel has been testing treating their soldiers who suffer from Post Traumatic Stress Disorder (PTSD) with medical marijuana, and having positive results...
  
• Reports of stress disorder leap in military
  Barbara Starr, CNN Pentagon Correspondent (28 May 2008)
  
• Virtual Reality Therapy May Help PTSD Patients
  
  [6 May 2008] (HealthDay News) -- People suffering from post-traumatic stress disorder may ultimately benefit from a combination of prescription medication and cutting-edge virtual reality psychotherapy, new research suggests. The study findings are preliminary. But, early results with Iraq war veterans point to a potent way to help PSTD patients through the use of drugs along with exposure to interactive reenactments of the sights, sounds, smells, and movements related to a highly traumatic experience...
  
• Canada's military suicide rate doubled in a year, documents show
  CBC News (18 April 2008)
  
• Canadian soldiers' mental health at risk after deployment
  The Canadian Press, CBC News
  (29 October 2007)
  
• National Defence and the Canadian Forces
   DND Centre for the support of Injured and Ill Members, and their Families
   POST DEPLOYMENT CLINICS
  
• The National Center for PTSD (NCPTSD) [U.S.]
  
  aims to advance the clinical care and social welfare of U.S. Veterans through research, education and training on PTSD and stress-related disorders. Educational resource on PTSD and traumatic stress, for veterans, mental health care providers, researchers and the general public.
  
• National Coalition for Homeless Veterans > Facts & Media > Background & Statistics
  
  The U. S. Department of Veterans Affairs (VA) says the nation's homeless veterans are mostly males (4 % are females). The vast majority are single, most come from poor, disadvantaged communities, 45% suffer from mental illness, and half have substance abuse problems... According to the National Survey of Homeless Assistance Providers and Clients (U.S. Interagency Council on Homelessness and the Urban Institute, 1999), veterans account for 23% of all homeless people in America...
  
• Seeing relief from post-traumatic stress: Therapists trained in eye movement desensitization and reprocessing at Landstuhl
  Steve Mraz, Mideast edition, Stars and Stripes
  (7 August 2007)
  
• POINT: Eye Movement Desensitization and Reprocessing: Is Psychiatry Missing the Point?
  David Servan-Schreiber MD PhD, Psychiatric Times
  (July 2000, XVII:7)
  
• EMDR Institute, Inc.
  EMDR, a complex psychological methodology, accelerates the treatment of a wide range of pathologies and self-esteem issues related to upsetting past events and present life conditions.