Mental Health and the Combat Veteran: It's Not All PTSD

Yesterday, I went off a little on David Dobbs. He wrote an article on PTSD in Scientific American that I was somewhat less than impressed with, and I made my displeasure fairly clear. There were points raised by Dobbs that I do agree with, and which I think deserve much more discussion than they've received so far. One of the most important of these, I think concerns the extent of the psychiatric cost of war.

For many - possibly most - of you, I suspect that "PTSD" was the first thing to pop into mind when you read "psychiatric cost of war." It certainly seems to get the lion's share of the attention, and that's not necessarily a good thing. As Dobbs points out in his article, PTSD is only one of a range of psychological symptoms that combat experiences can produce. Focusing on PTSD to the point where it interferes with the proper diagnosis of other conditions can be as bad as failing to acknowledge the reality of PTSD.

One of the studies that's frequently mentioned in the context of PTSD and the current conflicts is a 2007 paper by a team of researchers based out of Walter Reed, and lead by Dr. Charles Milliken. The paper appeared in JAMA, and received a great deal of attention. Most of that attention focused on their finding that many soldiers who reported having no mental health problems when they returned reported problems when they were re-evaluated months later, but that's only part of the picture. The paper was about much more than just PTSD and delayed reactions. It was a fairly comprehensive look at overall mental health in the population of new veterans shortly after their return, and it identified quite a few issues that are worth noting.

Milliken and his team had access to two health surveys that all returning Army soldiers are required to fill out after they've been deployed. One of these is given very soon after the soldier returns - typically within the first two or three days after arrival at the home base. The second assessment is done somewhere around the six month mark following the deployment. Milliken's group had access to both surveys from a group of more than 88,000 soldiers, which made it possible for them to take a more detailed look than had been done previously.

They reported some their main findings in Table 1 of the paper (click for enlarged version):

Table 1 - from Milliken et. al 2007

As you can see (at least if you enlarge the table), the only group that decreased in size from the first to the second survey was the group reporting suicidal ideation. Every other symptom increased in prevalence, if only slightly. The kicker, though, is that about 60% of the people who reported either depressive or PTSD symptoms on the first survey improved before the second.

This seems to suggest that we're looking at a number of different presentations and resolutions of mental health problems. There is clearly a group who report problems early on, but who seem to adjust fairly quickly. There's another group who are symptomatic from the start, and remain symptomatic for at least a period of many months. A third group do not report problems initially, but do later on. Why is this?

It's fairly easy to see how people could report symptoms in the first survey but not the second. People are resilient, and can mentally recover from stressful and traumatic incidents. It may take them some time to readjust, but if they get the time they need, they do get better. It's also easy to explain the second group. Not everyone adjusts well, and not everyone will recover without help.

At least at first glance, it looks harder to explain why some symptoms don't surface until later. Anecdotally, I can tell you that at least some soldiers are reluctant to report symptoms on the initial survey for fear that their much-needed leave will be delayed by a follow-up referral, but I strongly doubt that explains more than a fraction of the cases. I'm hardly an expert on the topic, but looking at the questions that are asked, I suspect that it might take someone a while to recognize that they're having some of the symptoms.

The combat zone is a very different place from home, and what's normal in one place might not be in another. A level of awareness that is appropriate when driving an ammo truck from Kuwait City to Baghdad is abnormal on most American roads. Seeing this in yourself - or believing someone else who is pointing it out - can take some time.

It's clear that not everyone who reports trouble after returning home is equal. What's not quite as clear is what this means for diagnosis and treatment. Both areas need more improvement and attention.