One in eight soldiers returning from service during the first year of the Iraq war was diagnosed with post-traumatic stress disorder or some other mental illness, according to the most comprehensive study yet of the effects of war on the mental health of veterans.
More than one-third of the veterans had sought psychological help in the year after their return, but the majority required only one or two visits to resolve their concerns, said the team at Walter Reed Army Institute of Research that conducted the study.
The results, reported today in the Journal of the American Medical Assn., are based on a study of computerized medical records of 300,000 soldiers and are thought to be the most accurate indicator to date of the percentage of soldiers requiring mental health services.
The results did not surprise those involved in the care of veterans.
“I think it’s probably on a par with what you would expect,” said Dr. Charles W. Hoge of Walter Reed.
In the Persian Gulf War, he said, the rate of post-traumatic stress disorder among combat soldiers was about 10% to 12%.
Nonetheless, the new study shows that mental health issues represent a problem for many veterans.
“The study confirms what we’ve heard from our members for the last two years -- that mental health issues and [post-traumatic stress disorder] are among the No. 1 issues facing Iraq veterans,” said Paul Rieckhoff, executive director of the Iraq and Afghanistan Veterans of America.
Some experts speculated that the percentage could grow in coming years, because stress disorders often take months or years to appear and because of the strong upsurge in roadside bombings and other attacks by insurgents in Iraq.
Long-term studies after the Vietnam War showed that as many as one-third of the veterans of that conflict required psychological care.
Balancing those concerns, Hoge and others argue that there are many new factors in this war that may help reduce stress, including better living conditions in war zones, Internet and phone access that keep soldiers in contact with distant family members, and the military’s increasing efforts to provide care and remove the stigma from those who accept it.
“We’ve learned from past wars that war has psychological effects, and we are trying to do something about that,” Hoge said.
Combat stress was documented in the late 19th century after the Franco-Prussian War. After the Civil War, doctors called the condition “nostalgia” or “soldier’s heart.” In World War I, soldiers were said to suffer shell shock. In World War II and Korea, it was called combat fatigue or battle fatigue.
But it wasn’t until 1985 that the American Psychiatric Assn. gave a name to the condition that had sent tens of thousands of Vietnam veterans into lives of homelessness, crime or despair.
Post-traumatic stress disorder is a debilitating condition that often follows a terrifying physical or emotional event. It causes the person who survived the event to have persistent, frightening thoughts and memories, or flashbacks, of the ordeal. Symptoms include emotional numbing, sleep problems, irritability, hyper vigilance, depression, anxiety and poor concentration.
The latest study was based on the military’s Post-Deployment Health Assessment, required of all returning soldiers since May 2003 -- two months after the invasion of Iraq. The study covered all veterans who returned before the end of April 2004, and followed them for another year.
The study included 222,620 Army soldiers and Marines who were deployed to Iraq, 16,318 deployed to Afghanistan and 64,967 deployed in Bosnia-Herzegovina, Kosovo and other locations.
The team also was able to access electronic treatment records for the soldiers, a feat that had not been possible in previous wars.
Answers provided by soldiers in the post-deployment survey showed that 19.1% of those returning from Iraq reported mental problems, compared with 11.3% of those returning from Afghanistan and 8.5% of those returning from other overseas postings, mostly in noncombat areas.
By the end of the first year, 35% of Iraq veterans had sought mental care. A portion of those, 12% of the total, were diagnosed with post-traumatic stress disorder, depression or another serious disorder.
Hoge and his colleagues released a similar study in 2004 showing that about one in six returning soldiers faced severe mental disorders, but those conclusions were based on interviews with about 6,000 soldiers.
In the latest study, exposure to combat was found to be the one factor most closely associated with mental problems. Among the 21,822 Iraq veterans who reported symptoms of post-traumatic stress disorder, 79.6% had engaged in combat or witnessed people being wounded or killed. Among the 200,798 who did not have the disorder, 47.8% had done so.
Psychologist Richard J. McNally of Harvard University said the results of the study pointed to a glaring weakness in the post-deployment survey.
Almost 90% of those ultimately diagnosed with post-traumatic stress disorder, he said, did not meet the criteria for that illness according to their answers on the original questionnaire, indicating that the survey had little predictive value.
On the positive side, he said, the fact that 35% of the soldiers sought help “indicates that the stigma barrier may be falling.”
To further improve the monitoring of veterans, the military is starting another mandatory mental health screening, this one to take place three to six months after a soldier’s return from a tour of duty.
The findings come at a time when the Department of Veterans Affairs budget is the subject of debate in Washington. President Bush has called for a 6% increase in the VA budget, but congressional critics say that increase is contingent on cuts of more than $1 billion in some areas of the VA budget and on increased fees and co-payments for veterans.
“Every veterans organization thinks the VA budget is short $3 billion,” Rieckhoff said.
But Dr. Michael J. Kussman, deputy undersecretary for health at the VA, said the agency had a “very aggressive” mental health outreach program.
Times have changed since the Vietnam War, when clinicians were only beginning to name the disorder and figure out how to treat it, Kussman said.
“The antidepressants, the other medications we’re using now, the studies being done on the inability to sleep or bad dreams, the psychotherapy that goes along with it, the reality testing and cognitive behavioral therapy that we use -- all these modalities we didn’t think about back then,” he said.
Kussman said the agency spent $3.2 billion per year on mental health and, over the last two years, had added $300 million for soldiers returning from Iraq and Afghanistan.
Rieckhoff, who spent a year with the Army in Iraq, thinks the survey underestimates the number of problems.
“I had 38 guys under my command. One shot himself in the leg to go home. Seven of them got divorces, one is in a mental institution, and one took his own life a few months after he got back,” he said. “Not everyone comes home with post-traumatic stress disorder, but no one comes home unchanged.”