PTSD: The Suffering Continues for Vets

Posttraumatic stress disorder (PTSD) did not officially exist when several Vietnam War veterans took the head of the U.S. Department of Veterans Affairs (VA) hostage in his own office one morning in 1975. Equipped with C-rations, portable toilets, and evidence, they hammered the door shut. They wanted his undivided attention to tell him the stories of the many returning soldiers who shared a distressing syndrome of nightmares, flashbacks, and anger that was driving some to suicide.

After that tactic did not succeed, their counseling group leaders took the vets and their case to meet with the chair of the American Psychiatric Association task force that was revising the psychiatric bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM). Add the post-Vietnam syndrome to the next edition, they urged. This worked, eventually. PTSD entered the psychiatric lexicon in the 1980 DSM-III.

With that imprimatur, Congress passed legislation requiring the VA to provide mental health services and specialized PTSD treatment programs. Now, decades later, military and civilian mental health professionals can draw on evidence-based treatment and practice guidelines. The VA places a high priority on treating PTSD among returning Iraq and Afghanistan veterans. In contrast to the delayed diagnoses and services for Vietnam vets, experts are urging immediate postwar screening and preventive interventions.

Despite these advances, PTSD remains a legacy of Vietnam veterans. Almost 30 years after their return from Vietnam, 10 percent of veterans continue to experience severe PTSD symptoms, report Karestan Koenen, HSPH assistant professor of society, human development, health, and epidemiology, and her co-authors in the February Journal of Traumatic Stress.

“Our findings demonstrate that exposure to combat during the Vietnam War continues to place veterans at risk for a wide variety of adverse psychological and social outcomes,” Koenen and her colleagues write. “Persisting PTSD was associated with worse family functioning, more smoking and drinking, less life satisfaction and happiness, more mental health service use, and more nonspecific health complaints.”

The study helps fill the gap in understanding the long-term outlook of combat-related PTSD. The longitudinal follow-up study has implications for the new generation of war veterans and their health care providers.

March 20 marked the five-year anniversary of the United States–led invasion of Iraq by a multinational coalition. “What was planned as a short and decisive intervention in Iraq has become a grueling counterinsurgency that has put American troops into sustained close-quarters combat on a scale not seen since the Vietnam War,” The New York Times reported on Dec. 16, 2004, in a front page story titled, “A deluge of troubled soldiers is in the offing, experts predict.”

In a 2006 paper, a survey of 238,938 Army and Marine personnel returning from the Middle East found that 19 percent of those serving in Iraq and 11 percent of those serving in Afghanistan reported symptoms of PTSD and other mental health problems. The new study by Koenen provides a potential scenario of what the future may hold for them.

Koenen and her colleagues investigated factors and impacts related to PTSD over time as part of a larger project characterizing exposure to herbicides in Vietnam. The project is headed by co-author Jeanne Mager Stellman, now at the State University of New York Downstate Medical Center.

The data come from 1,377 people in a random sample of 12,000 American Legionnaires in six states who served in Vietnam or its surrounding waters or airspace between 1961 and 1975 and returned questionnaires. Stellman and her colleagues first surveyed them in 1984 and repeated the process in 1998.

The same definition of PTSD applied at both times. The disorder requires exposure to a traumatic event, such as combat, plus three clusters of symptoms—re-experiencing the traumatic event, avoidance of traumatic reminder and emotional numbing, and hyperarousal.

In 1994, the definition of trauma expanded to include people reacting with fear, helplessness, and horror not just to a traumatic experience of their own, but to news of a trauma experienced by someone else, said Richard McNally, professor and director of clinical training at the Harvard University Psychology Department. McNally served on the core committee overseeing that and other changes in the current version of the psychiatric manual, DSM-IV, but now he argues that the definition of trauma is so broad that the PTSD diagnosis has become misleading and ineffective for the larger population now included. This controversy does not apply to combat, which remains an unequivocal qualifying stressor, McNally said.

In Koenen’s study, the overall prevalence of severe PTSD dropped from 11.8 percent in 1984 to 10.5 percent in 1998. Among individuals, about half met PTSD criteria both times. High combat exposure was the strongest predictor for PTSD at both times.

The results from the Legionnaires cohort are consistent with a re-analysis of data from the National Vietnam Veterans Readjustment Study in Science in 2006. Using raw data from one-on-one interviews and cross-checking with military records, the researchers found 19 percent of the 1,200 vets had developed PTSD during their lifetimes and 9 percent were still suffering 11 to 12 years after the war. Koenen was a co-author on that paper, which appeared in Science two years ago.

It is hard to compare and contrast the different studies. They were conducted with different methods and on different populations. Koenen and her co-authors consider the Legionnaires the “best-case scenario,” because they are living in the community and functioning well enough to join a veterans’ support organization.

“Our data show a lifelong cost of war, ” said Stellman, who estimates the actual figures may be higher. “One of the hallmarks of PTSD is withdrawal and avoidance. Countless numbers of people have spent their lives suffering and don’t know how or why to seek help. ”

A recent report on trends in VA treatment of PTSD in the journal Health Affairs seems to confirm their findings. From 1997 to 2005, mental-health–service use among veterans of the Persian Gulf era has greatly increased, especially in the last five years and among younger veterans. Veterans from early service eras surprised researchers with a fivefold increase in use, especially among Vietnam vets with PTSD. The system is straining at the seams, the researchers observed. The increased demand seems to be met by fewer visits per veteran.

“The vast majority of men who served in the Vietnam theater are now in the 47- to 66-year age group and represent almost 13 percent of their generation,” Koenen writes. “This group’s demands on the health care system will likely increase as they age.” The brunt of the burden for diagnosing and referring veterans with PTSD is likely to fall on primary care providers, Koenen and others predicted.