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Research required for PTSD post-Afghanistan

Mental health problems such as posttraumatic stress disorder (PTSD) occur in a significant minority of veterans deployed to Afghanistan and to past peacekeeping missions but military-related PTSD often presents with complex psychiatric co-morbidity with severe psychosocial dysfunction.

Military-related PTSD is often chronic and treatment refractory when compared to civilian PTSD, creating the need for more research to better understand military-related PTSD to improve treatment outcomes. The Canadian Institute for Military and Veteran Health Research (CIMVHR) will connect researchers from across Canada in their studies on PTSD to ensure the most efficient conclusions are drawn and applied to the military environment.

The 12 month and lifetime prevalence rate of PTSD in the Canadian Regular Forces has been reported as 2.8% and 7.2% respectively. In Canadian veterans pensioned with a medical condition, the one-month prevalence was 10.3%. In American soldiers returning from Iraq, the rates of PTSD have been reported at 13% while the UK military have reported lower rates of 4.8%. In peacekeepers, the rates of PTSD vary from 3-20%. Variation in PTSD rates may be related to the time lapse between the end of a mission and the start of a mental health evaluation, the nature and frequency of potentially traumatic events during the mission or the length of deployment.

Research has consistently demonstrated that military-related PTSD rarely presents as one diagnosis but with co-morbidities such as depression and substance abuse and dependence. The presence of PTSD symptoms increases the possibility of suicidal ideation. Studies have estimated that more than 50 percent of PTSD patients have symptoms of a major depressive disorder, but in the veteran population, possibly due to delayed treatment, the percentage may be much higher. Co-morbid depression also significantly increases suicide risk.

Anger and aggressive behavior, including homicidal thoughts, are also well documented in war veterans. More research is desperately needed to better understand co-morbidity in the entire field of posttraumatic mental health as traumatic exposure is associated with a range of sequalae not only PTSD, but depression, alcohol or other anxiety disorders like panic disorder.

There has been a growing body of evidence examining the association between PTSD and physical health, including cardiovascular problems, gastrointestinal disorders, musculoskeletal problems, respiratory problems, dermatological problems, endocrine/metabolic problems, neurological/nervous system disorders, pain/fibromyalgia problems and physical complaints. Physical injury during deployment is a major risk factor for PTSD, which is independently associated with not returning to work. This is important, as there is a significant association between soldiers diagnosed with psychiatric conditions such as PTSD and high attrition rates from the military.

More research is needed on risk factors to better identify at-risk veterans returning from deployments. While women are more likely to develop PTSD, men still vastly outnumber women in the military and more research is needed to understanding the influence of gender in military-related PTSD.

Other pre-trauma risk factors include younger age, marital status and lower socioeconomic status. Peritraumatic risk factors such as trauma severity and life threat, bodily injury and the number of operational deployments, have received extensive attention. However, post-traumatic risk factors such as lack of access to treatment, stigmatization, ongoing life stressors and lack of social support appear to be more important in predicting PTSD in exposed populations. Although there is an understanding of a number of the factors that might put someone at risk for mental health problems post-deployment, it is still not possible to predict at an individual level who will to develop PTSD.

Despite significant advances in both pharmacologic and psychotherapeutic treatment modalities, including comprehensive treatment guidelines, treatment outcomes continue to be disappointing. More research is needed to both develop an accepted definition for recovery and efficacy research in clinical populations in veterans presenting with PTSD with traumatic brain injury and comorbid psychiatric conditions.

Although most military members returning from operational deployments will readjust to civilian life, a significant proportion will develop PTSD. It is incumbent that clinicians and researched work together through CIMVHR to better understand how to best treat and prevent the psychosocial dysfunction and disability often associated with this disease.

J. Don Richardson, MD, FRCPC, is a consultant psychiatrist at the Parkwood Operational Stress Injury Clinic of St Joseph’s Health Care in London, ON, and adjunct professor for the Department of Psychiatry, University of Western Ontario. He is also the consultant psychiatrist for the National Centre for Operational Stress Injuries (OSI) with Veterans Affairs Canada. Jitender Sareen, MD, FRCPC, is a professor of psychiatry at the University of Manitoba and director of Research and Anxiety Services in the Department of Psychiatry at the Health Sciences Centre in Winnipeg. He is also a consultant psychiatrist at the Deer Lodge Operational Stress Injury Clinic, Winnipeg.

Author: J. Don Richardson and Jitender Sareen from the Oct/Nov 2011 issue published

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