The Rest of the Story

Charles W. Hoge, M.D., Carl A. Castro, Ph.D., Stephen C. Messer, Ph.D., Dennis McGurk, Ph.D., Dave I. Cotting, Ph.D., and Robert L. Koffman, M.D., M.P.H.
ABSTRACT

Background: The current combat operations in Iraq and Afghanistan have involved U.S. military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans.

Methods: We studied members of four U.S. combat infantry units (three Army units and one Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or three to four months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and post-traumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments.

Results: Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care.

Conclusions: This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care.

Volume 351:75-77 July 1, 2004 Number 1

Matthew J. Friedman, M.D., Ph.D.
The data presented by Hoge and associates in this issue of the Journal1 about members of the Army and the Marine Corps returning from Operation Iraqi Freedom or Operation Enduring Freedom in Afghanistan force us to acknowledge the psychiatric cost of sending young men and women to war. It is possible that these early findings underestimate the eventual magnitude of this clinical problem. The report is unprecedented in several respects. First, this is the first time there has been such an early assessment of the prevalence of war-related psychiatric disorders, reported while the fighting continues. Second, there are predeployment data, albeit cross-sectional, against which to evaluate the psychiatric problems that develop after deployment. Third, the authors report important data showing that the perception of stigmatization has the power to deter active-duty personnel from seeking mental health care even when they recognize the severity of their psychiatric problems. These findings raise a number of questions for policy and practice. I focus here on post-traumatic stress disorder (PTSD), because there is better information about this disorder than about others and because PTSD was the biggest problem noted in the responses to an anonymous survey among those returning from active duty in Iraq or Afghanistan. [...]

Collaboration between mental health professionals in the Department of Defense and those in the Department of Veterans Affairs is at an all-time high. For example, the Veterans Affairs National Center for PTSD and the Defense Department's Walter Reed Army Medical Center collaborated to develop the Iraq War Clinician Guide (available at www.ncptsd.org/topics/war.html) and to conduct a multisite, randomized trial of cognitive–behavioral therapy for PTSD among female veterans and female active-duty personnel. [...]

Hoge and associates suggest that the perception of stigmatization can be reduced only by means of concerted outreach — that is, by providing more mental health services in primary care clinics and confidential counseling through employee-assistance programs. The sticking point is skepticism among military personnel that the use of mental health services can remain confidential. Although the soldiers and Marines in the study by Hoge and colleagues were able to acknowledge PTSD-related problems in an anonymous survey, they apparently were afraid to seek assistance for fear that a scarlet P could doom their careers.

Our acknowledgment of the psychiatric costs of war has promoted the establishment of better methods of detecting and treating war-related psychiatric disorders. It is now time to take the next step and provide effective treatment to distressed men and women, along with credible safeguards of confidentiality.

Of particular interest here is the link to the Iraq War Clinician Guide.  Despite the name, there is a lot of information there that is non-technical and suitable for patients and families.  One of the great tragedies of the Vietnam War was the lack of acceptance and understanding of veterans with PTSD.  It is extremely important that we not repeat that mistake.  Therefore, I urge everyone to become acquainted with the information at www.ncptsd.org/topics/war.html.  For example:

Personal Emergency Preparedness Brochure from the Department of Veterans Affairs

Preparedness Brochure (download)

The Family Deployment Guide by Department of the Army, Headquarters, 88th Regional Support Command, 506 Roeder Circle, Fort Snelling, MN 55111-4009

Preparing for Deployment
Leaving Your Loved Ones Behind
Children and Deployment
Communication
Finances
Resources
Military Benefits
Glossary

For a good quick reference to the clinical aspects of PTSD, see this link.  The clinical diagnosis of PTSD has been controversial.  Although the controversy is resolving slowly, it certainly has not gone away.  For some insight into the history of the controversy, see this link, to an article by Rachel Yehuda.  Dr. Yehuda points out that the original concept of PTSD was that it was essentially a normal response to extreme stress.  She points out, though, that the concept had to be revised when a distinct set of neurobiological changes was documented in various research studies.   A counterpoint is presented by Derek Summerfield, here.  Dr. Summerfield's article is entitled: The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category.  Personally, I think Dr. Summerfield has it all wrong.  The publisher of his article, the British Medical Journal, also has online a bunch of letters  written in response to Dr. Summerfield's article.  A particularly amusing one was written by Dr. Arieh Y Shalev, who is a psychiatrist in Jerusalem, who undoubtedly has vast experience treating PTSD patients.   

The neurobiology of PTSD is, at this point, very well documented.  It really is beyond controversy to say that there really is something wrong, biologically, in patients with PTSD.  I can't legally post the entire text of Dr. Yehuda's summary article on the neurobiology of PTSD, but I did upload an illustration:

(Click to enlarge)

(from: N Engl J Med, Vol. 346, No. 2 - January 10, 2002)

It simply is not reasonable to attribute this to a "social construct."  The abnormalities of the HPA axis are profound, the observations have been replicated by numerous researchers, and the specificity of the finding to PTSD patients is striking.  There are many other examples of neurobiological abnormalities in PTSD.  See this article  from Discover magazine for more information, of a less technical sort. 

In summary, we see that there is evidence that there is a significant risk for PTSD among American service personnel in Iraq, that the military is taking steps to address this, that some persons feel that the military is not doing enough, and that  -- despite the earlier controversy -- there is substantial, compelling evidence for a distinct set of abnormal neurobiological processes in patients with PTSD.  Although some may continue to argue that PTSD is not a real disease, that position is becoming increasingly untenable.  In order to avoid a repetition of the secondary trauma that was experienced by so many Vietnam vets, it would be good for the entire public in the USA to become more familiar with these issues. 

The official George W. Bush <air quotes>Blog</air quotes> has a curious post.  On 6/18/2004, they posted the following:

Poll: Bush Has the Highest Number of Positive Supporters in Recent History, Kerry the Lowest

A Pew poll out today shows a seven-point shift in President Bush's direction in the election and rising confidence in the mission in Iraq. Furthermore, the poll confirms something we've suspected for a long time, while President Bush's grassroots overwhelmingly supports him because of his leadership and positive agenda, an unusually low number of Kerry supporters are inspired anything having to do with the candidate's agenda or leadership qualities. For Kerry supporters, it's mostly about anger.

73% of President Bush’s supporters say that their choice is a vote "for" him, rather than a vote "against" Kerry, while just 37% of Kerry’s supporters say that their vote is "for" him. Pew has been asking this question since 1988, and Kerry had the lowest percentage of positive support ever while President Bush had the highest.

Candidate/Year	% Pro	% Anti	Pro-Anti
Kerry 2004	37	59	-22
Dole 1996	47	47	+0
Clinton 1992	48	46	+2
Bush 1992	54	37	+17
Dukakis 1988	55	36	+19
Bush 1988	62	32	+30
Gore 2000	64	31	+33
Clinton 1996	65	29	+36
Bush 2000	66	29	+37
Bush 2004	73	23	+50

The negativity in Kerry's support is unprecedented. To put these numbers in context, during Bill Clinton successful challenger campaign in 1992, more voters said theirs was a vote "for" him. When Bob Dole challenged Bill Clinton in 1996, just half of his voters said theirs was a vote "against" Clinton. And during the closely contested 2000 election, a roughly similar percentage of voters cast "for" votes for either candidate.

You can read more about the poll here and see the full results here.

This is odd, because one would expect that the Bush-Cheney Official Blog would post only information that is favorable to their candidates.  They try to put a positive spin on the numbers, by pointing out that just 37% of Kerry’s supporters say that their vote is "for" him.  That is not exactly flattering for Mr. Kerry, true.  But it also means that an historically unprecedented number of people plan to vote against President Bush in 2004.  Is this really good news for Bush???  This means that Bush has a greater number of active detractors now than Clinton had in 1996! 

The Pew Foundation analysis of the poll includes the following quote:

Notably, all of Bush's gains occurred after Reagan's death on June 5.

There are two surviving Republican ex-presidents now, and neither shows any signs of imminent demise.  So Bush can't count or a repeat of that boost.  Also of interest, in the Pew analysis, is the following:

The significance of this is that people are getting inured to the constant stream of bad news from Iraq.  Thus, it would appear that a good strategy for the Democrats to follow would be to make sure that people stay emotionally engaged in the Iraq situation.  There is an interesting wrinkle to this.  Some of the conservative bloggers have bemoaned the fact that the news media in the USA tend to focus on the bad news coming out of Iraq.  We do not hear about new schools being built, improvements in the power grid, etc.  The implication is that perhaps the President would not look so bad, if the media would provide more balanced coverage. 

As an ABB blogger, I am pleased to note that it would not help the President if the media increased the coverage of positive developments in Iraq.  In fact, it would hurt his chances for reelection.  Why?  Because it would make it harder for people to ignore the bad news.  The contrast between good and bad would steadily draw attention to the situation: if the news never changes, it ceases to draw attention.  If the media were to start presenting up-close-and-personal accounts of individuals in Iraq who are doing well, it would heighten our interest; it also would heighten our despair, when the inevitable bad news came along.  It is easy to stop caring about people whom you do not know.  Likewise, it is hard to ignore bad news when it happens to someone you care about. 

Therefore, I urge everyone, conservatives and liberals. authoritarians and libertarians, to join together for a common cause, and start to post more about the positive things that are happening in Iraq.  Togetherness is good.  Cooperation is good.  Even if we can't agree on anything else, let's cooperate on this one thing. 

While everyone is preoccupied with "The Lies of Michael Moore," let's not forget about the lies and squandered opportunities of George W. Bush.  

Waxman: U.S. Imposes New Limits on Scientists
From: Reuters: UK
Fri 25 June, 2004 05:32 (Also see the LA Times article  for more details)

These two developments, namely, the requirement that government scientists receive clearance before consulting with WHO, and the withdrawal of scientific presentations at the International AIDS Society conference, are highly worrisome developments.  It would be nice to know why these things were done, but our dear leaders in Washington apparently do not see fit to tell the people who elected them why they are doing what they are doing.

Just a couple of weeks ago, Bush was boasting about his commitment to the worldwide effort to eradicate polio, as well as playing up his pledge to spend 15 billion dollars to fight the AIDS epidemic.  From the President's press briefing on June 8, 2004:


And from June 10, 2004:


Now, we learn that he is preventing 28 CDC experts  from attending an important AIDS conference.  Yet, when HHS is asked about this, what are we told?

Lawmakers say Bush administration forced 28 CDC researchers out of AIDS conference
from: The Advocate
July 26, 2004


The Secretary of Health and Human Services said:


Fine, we all are in favor of cost-cutting.  But after pledging 15 billion dollars to fight AIDS, they can't afford to send 28 scientists to a conference???  If it costs $2000 per scientist, that would be 3.7333x10^-8% of the 15 billion dollar budget.  (Sorry about the use of scientific notation.  My calculator can't display enough zeroes to present the number in a more familiar format.)

Bush and his spokespersons have denied repeatedly the allegations that he plays politics with science.  They trumpet his commitment to pressing health issues at every opportunity.  But the facts tell a different story.

By the way, the polio eradication effort has hit some snags.  President Bush should be mobilizing an army of scientists and diplomats to deal the final blow to this terrible disease.  Other than read a few prepared statements, written by someone else, he has done almost nothing.  As reported on Foreign Dispatches  and Winds of Change,  the Kano state governor, Ibrahim Shekarau, had pledged to restart the polio vaccination program, after it had been stopped due to allegations that the polio vaccine contained a contraceptive.  This was part of a rumor that Western forces wanted to decrease the Muslim population in Nigeria.  But a report in The Economist  indicates that he has not yet taken any action on his pledge.

Another health disaster in Africa Jun 23rd 2004 From The Economist Global Agenda [...] The new outbreak is a triumph of superstition over science. The polio cases have spread from the state of Kano, in the mainly Muslim north of Nigeria. There, clerics have preached nonsense about the polio vaccination, claiming it was a western plot to depopulate Africa by rendering girls infertile, or even giving its recipients AIDS. Kano’s state government, under pressure from the militant clerics, has suspended vaccinations. [...] In May, Kano’s government announced that vaccination would begin again, but this has not yet happened.

An African child receives polio vaccine

This is an unprecedented opportunity for the leader of the Free World to take decisive action, in an effort that literally could change the course of history for the better.  With more principled action, not only could Bush help with the eradication of a major disease, he could help improve the worldwide reputation of the United States of America.  Mobilizing Muslim clerics and scientists, as well as truly cooperating with WHO, we could stamp out this disease forever.  It would take a massive public relations campaign to convince the Nigerian public that the vaccine is safe.  Using supplies from an Indonesian vaccine manufacturer, certified by prominent clerics, supported volunteers from Médecins Sans Frontières,  or perhaps the Peace Corps, President Bush could really make a difference.