As troops return from deployments to Iraq or Afghanistan, the need for posttraumatic stress disorder (PTSD) treatment is expected to increase. National Guard and Reserve troops account for a high proportion of troops in the war zones, and as they return to their homes—some of them relatively far from Veterans Affairs health care facilities—community psychiatrists are likely to encounter more combat veterans seeking help.

Matthew J. Friedman, MD, PhD, Executive Director of the VA’s National Center for PTSD in White River Junction, Vermont, told NeuroPsychiatry Reviews that these vets are coming home to a more supportive environment and to more informed and effective medical treatment than was the case for soldiers returning from Vietnam. The major changes are:

• Diagnostic standards and understanding of PTSD, a diagnosis that did not exist when the Vietnam veterans came home.

• Treatments that have been proven effective in clinical trials.

• Greater understanding of some of the factors that either increase or decrease the risk that normal reactions to combat stress will become chronic PTSD.

• A growing body of research on the neural and biochemical underpinnings of PTSD.

PTSD STATISTICS

In July 2004, Hoge et al published a landmark study of combat-related mental health problems and barriers to care that included predeployment and three-to-four month postdeployment surveys of over 3,000 soldiers who had been deployed either to Iraq or to Afghanistan. The subjects were members of four combat infantry units (three Army, one Marines). Outcomes included major depression, generalized anxiety, and PTSD. The anonymous survey showed that rates of major depression, generalized anxiety, or PTSD were 9.3% before deployment but increased to 15.6% to 17.0% after duty in Iraq and to 11.2% after duty in Afghanistan.

The difference in risk related to Iraq versus Afghanistan parallels differences in the intensity of combat exposure. Hoge et al found that 71% to 86% of soldiers and Marines who had been deployed reported having engaged in at least one firefight, versus 31% of those deployed to Afghanistan. The median number of firefights reported was five for Iraq versus two for Afghanistan; the prevalence of PTSD increased in a linear manner with the number of firefights. In addition, 11.6% of troops deployed to Iraq but only 4.6% of troops deployed to Afghanistan reported being wounded or injured, which significantly increased the risk of PTSD.

"Respondents to our survey who had been deployed to Iraq reported a very high level of combat experiences, with more than 90% of them reporting being shot at and a high percentage reporting handling dead bodies, knowing someone who was injured or killed, or killing an enemy combatant," Hoge et al reported.

ODDS OF RECOVERY

Long-term research on veterans of the Vietnam war has shown that most soldiers in war zones do not develop PTSD, and that most of those who do eventually recover to a great extent. Data from the National Vietnam Veterans’ Readjustment Study showed that, in 1992, 15.2% of male Vietnam veterans and 8.5% of female Vietnam veterans met the criteria for diagnosis of current PTSD. At that same time, 30.9% of males and 26.9% of females reported having PTSD at some time.

These data have been widely misinterpreted by the consumer media, in which many stories said that PTSD rates in males were 15.2% but increased to 30.9% over a lifetime. In fact, as Dr. Friedman pointed out, the data show an opposite and much more optimistic picture. Fully half of the veterans who had PTSD at some point following service in Vietnam no longer met diagnostic criteria at the time of the study, 15 to 20 years later.

A sizable minority of Vietnam vets (11.1% of males, 7.8% of females) continued to suffer some symptoms, even though they did not meet the criteria for PTSD diagnosis. Helping those affected by PTSD requires identifying them, and Dr. Friedman thinks this should include widespread, routine screening for PTSD, much as is done for depression.

TREATMENTS THAT WORK

"We now have tested, validated treatment options for PTSD that have been shown to be effective by high standards of evidence-based medicine," Dr. Friedman said. "Two SSRIs are approved for treatment of PTSD. There is also definitive evidence for the effectiveness of cognitive behavioral therapy [CBT], including prolonged exposure therapy and cognitive processing therapy. Eye movement desensitization and reprocessing is somewhat controversial but also supported by clinical trial data.

"One major problem is that CBT is the most effective treatment for PTSD but is also the modality having the fewest trained personnel nationwide," Dr. Friedman added. "Consequently, clinicians not trained in CBT should turn to SSRIs as firstline treatment."

Sertraline and paroxetine are approved by the FDA for treatment of PTSD, he continued. Patients showing a partial response are sometimes treated with other medications that may be tailored to the specific residual symptoms. These might include antiadrenergic medications for arousal, insomnia, and reexperiencing symptoms; venlafaxine for broad-spectrum symptomatic relief; anticonvulsants and mood-stabilizing drugs for mood swings, impulsivity, or violent behavior; trazodone for sleep problems; and atypical antipsychotics for patients whose symptoms are refractory to other agents. Benzodiazepines are not recommended because they have proven ineffective in randomized trials and due to the risk of drug dependence.

Dr. Friedman cautioned that even patients successfully treated with SSRIs are at risk of recurrence if treatment is discontinued. He recommended maintaining SSRIs for six to 12 months before attempting to discontinue them.

Another problem is that SSRIs and other antidepressants may—in rare instances—"produce activation side effects which may exacerbate PTSD-related arousal symptoms." Dr. Friedman recommended "starting low and going slow" with these drugs due to concern that they may increase physical restlessness and insomnia.

Most patients with PTSD who are likely to recover will do so within the first two years, by which time more than half will have recovered. Another 20% will recover over the next five years. About 50% of patients with PTSD will achieve complete remission with CBT alone and about 30% with SSRIs alone. "Obviously, we hope to do better with the new drugs under development, Dr. Friedman said. "The big unanswered questions are whether to combine treatments, which to combine, and how to identify the patient likely to need combination treatment."

PTSD RISK FACTORS

The answers to some of those questions are likely to involve new advances in research, Dr. Friedman said. Twin studies have shown that genetic factors account for some of an individual’s vulnerability to developing PTSD after exposure to an extreme stressor. Imaging studies have shown increased activity in the amygdala and reduced activation of the anterior cingulate gyrus and medial prefrontal gyrus during recall of traumatic memories as some of the changes in brain function in PTSD.

Protective factors are also being identified, the most promising of which is neuropeptide-Y (NPY). "We learned that the most resilient special forces soldiers are better at mobilizing NPY than other subjects. People with PTSD have lower NPY. Animal studies have shown that NPY has anxiolytic properties. We need to look at NPY in a variety of populations, because it may be possible to help people acquire the skill of mobilizing NPY and thereby protect themselves in situations of extreme stress. This would be useful not only for soldiers but also for others such as firemen, policemen, and disaster workers," Dr. Friedman said.

Finally, "the most important factor in whether an acute stress reaction will become chronic PTSD is social support, including support from the soldier’s combat unit, family, community, and wider society," Dr. Friedman said. "Because of the political polarization of the nation during Vietnam, some people took their displeasure out on the troops, young men and women who had risked their lives, when their real anger was directed at decisions made by the country’s leaders. Our nation has grown up, and I think we are now sophisticated enough not to confuse our feelings about the war with our feelings about the warrior."

—Janis Kelly

Suggested Reading
Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2005;351:13-22.
Price JL. Findings from the National Vietnam Veterans’ Readjustment Study. A National Center for PTSD Fact Sheet. Available at: www.ncptsd.va.gov/facts/veterans/fs_NVVRS.html. Accessed January 3, 2006.

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