Feature

In her work with U.S. veterans, psychologist Kaye Baron, PhD, may be seeing the opening salvos of a new war--one for mental health. The private practitioner in Colorado Springs, Colo., near the Fort Carson Army Base, serves a lot of military families affected by U.S. operations in Iraq and Afghanistan. She is also a contract psychologist for a local government agency for which she has evaluated more than 75 military personnel who have returned from Iraq showing depression and irritability and reliving intense emotional trauma--some of the classic signs of post-traumatic stress disorder (PTSD).

"I've seen a lot of PTSD symptoms, if not full-blown PTSD," Baron says. "The social withdrawal, the nightmares, the sleep disturbances, the memory and concentration problems, the anger, the lack of trust--I'm seeing all this within the troops coming back from Iraq."

Baron's contacts through her evaluations and work with military families are among the first of what at least one study says could be many more military personnel returning from Iraq suffering--or who will later suffer--from PTSD. While the majority of troops show resilience from the stresses of war, some do or will need help with PTSD symptoms.

Already, in one recent army report, more than 1,000 troops reported PTSD symptoms--and troops' reluctance to admit problems may mean the real number is higher. In a war characterized by intensely stressful surprise attacks and street fighting, that number may only increase, some psychologists predict. Unfortunately, a lack of research means psychologists are still working to fully understand PTSD.

Service providers have observed what is now known as PTSD for decades. Called anything from operational fatigue to shell shock, the disorder acquired its current name only in 1980, when PTSD was added to the third edition of the Diagnostic and Statistical Manual of Mental Disorders. And research on the early signs and symptoms of combat trauma is scant. Most research on Vietnam War veterans did not take place until 1980s.

Yet despite the challenges, the conflict in Iraq offers mental health researchers an unprecedented chance to gather data on troops before combat as well as after. Their findings could help this war's veterans--and future ones--more effectively fight the mental battles that can occur long after the physical battles in this war end.

"We hope to follow soldiers beyond this one point in time and attempt to learn what the aftermath is like," says psychologist Jennifer Vasterling, PhD, who is one such researcher collecting baseline and postdeployment data and studying PTSD among troops. "That way, we can know how to help them when the dust has settled."

Trauma's scope

More than 1,500 U.S. troops have died and over 11,000 have been injured since the war in Iraq began two years ago. Thousands more could be suffering--or eventually could suffer--from stress-induced mental health problems such as depression, anxiety and PTSD. In fact, in a report appearing last July in the New England Journal of Medicine (Vol. 351, No. 1, pages 13-22), "Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care," 19 percent of Marine respondents and 17 percent of Army respondents in four infantry units in Iraq and Afghanistan reported major depression, general anxiety or PTSD. Rates were much higher in Iraq than in Afghanistan.

The particularly intense combat characterizing the Iraq war--the daily urban fighting, the suicide bombers and the guerilla tactics of insurgents who blend into the general public--creates an extra layer of stress that takes its toll on a soldier, say psychologists Lynda King, PhD, and Daniel King, PhD, of the National Center for PTSD and the Massachusetts Veterans Epidemiology Research and Information Center.

"One very potent predictor of later mental health problems is the sense of a constant, perceived threat of attack," which in Iraq is particularly acute, Lynda King says.

Another well-known PTSD predictor is high exposure to traumatic events--also prevalent in Iraq. The New England Journal of Medicine study reported that more than 90 percent of surveyed troops in Iraq had seen bodies or human remains or had been shot at. About half had killed an enemy combatant.

Other problems for U.S. troops abound. The New England Journal of Medicine report suggested the number of troops suffering from PTSD symptoms is likely higher than indicated by those it polled, and that only two in five who reported mental health problems sought help--possibly because of the stigma that still surrounds mental health among the military. Troops cited fear of appearing weak as a main deterrent.

Baron concurs. "I've seen a lot of people walking around that have PTSD symptoms but who are dealing with it in other ways," she says. "They appear reluctant to get help through the military as a result of the stigma or mentality that says you have to suck it up."

For these reasons, getting a grasp on PTSD's extent is tremendously difficult, the Kings say. What's more, trauma's effects vary for each person. Some never show PTSD symptoms, others show them immediately and other people will have problems that emerge years after battle. And researchers still aren't sure why.

"We tend to think of PTSD as this discrete disorder that is a steady state," says Brett Litz, PhD, the associate director for the Behavioral Sciences Division of the National Center for PTSD. "But research suggests it's much more dynamic. Trauma for some can be a lifelong burden, but the symptoms and impairments can wax and wane over time."

Relief through research

Unlike past wars, the Iraq conflict offers a new opportunity to research trauma's effect on military personnel--one that psychologists and the military are pouncing on. For the first time in military history, psychologists had the opportunity to collect mental health data on troops prior to combat. Vasterling, the associate director for research at the veterans Affairs South Central Mental Illness Research, Education and Clinical Center in New Orleans, is one psychologist tapping that opportunity. She and Susan Proctor, DSc, of the Veterans Affairs Boston Healthcare System, along with a team of VA and DoD researchers, collected baseline data on 1,600 troops before they departed for Iraq--something researchers haven't been able to do in previous conflicts.

"It's been so difficult to interpret PTSD information from past deployments without baseline data, and we were on a mission to do it right this time," she says.

Vasterling's team surveyed troops at Washington's Fort Lewis, Texas' Fort Hood and Mississippi's Camp Shelby throughout 2003 and 2004. They gave troops objective neuropsychological tests of their attention, memory and motor skills. Now they are beginning follow-up tests with units as they return from Iraq. A month after their return, they ask about their mood, PTSD symptoms, health and exposure to stress in Iraq, and they re-administer the neuropsychological tasks. They'll compare that data with similar units that didn't go abroad.

Vasterling hopes to identify risk factors for PTSD to aid in developing intervention programs, as well as to learn which troops are at greater risk for exhibiting PTSD.

"We know PTSD has a lot to do with stress exposure, but there are all these modifying variables that affect PTSD," she explains. For example, how do social support and unit cohesion help buffer the effects of stress?

"We're happy to have this baseline information because now we can talk about how stress and modifying factors actually interact in determining psychological outcomes," Vasterling adds.

She says the Army's help in her research--both from an administrative level and from individual soldiers--is especially encouraging.

"The Department of Defense [DoD] heard the need for the study and along with the VA funded it, while the Army helped us identify appropriate units and facilitated our access to them," Vasterling says. "And the individual soldiers say it means a lot to them that somebody is concerned about how they fare."

Indeed, such VA-DoD cooperation signals a recent attitude change, Lynda King says: "A decade ago, the DoD fought the war and the VA took over the health of the soldiers afterwards. They were two different entities. Now we see a lot of cooperation in research, education and treatment."

Help in the here-and-now

Psychologists are taking many paths to immediately address the issues the New England Journal of Medicine study raised, such as stigmas surrounding treatments and barriers to mental health care. For example, the Uniformed Services University of the Health Sciences offers troops online fact sheets about returning home after deployment. Prior to deployment, troops receive briefings on how to manage stress. While deployed, Army soldiers receive help through a new program called Combat Stress Control and the Navy and Marines use a program called OSCAR (Operational Stress Control and Readiness). The two programs embed mental health providers with units to provide help while serving overseas. The providers help troops formally and informally in camp--often just chatting with troops to alleviate stress.

"OSCAR affords quicker access to address stress-related symptoms to figure out what are normal stress reactions and when people need to receive the next level of care," says Cmdr. Anthony Doran, PsyD, a special assistant to the Navy on suicide prevention.

In his role, Doran ensures that Navy personnel go through a yearly suicide prevention briefing that trains them to identify a friend who might be in trouble. New to the training this year is videotaped interviews with Navy officers who have dealt with suicides under their command.

"We want to be proactive," Doran says. "Rather than having a doctor explain suicide to sailors, we wanted to have a peer describe how it affected their unit. That will make it more real for younger sailors."

Meanwhile, the government is looking to reduce barriers to mental health care for veterans and families of active-duty troops. Congress commissioned DoD in 2001 to create a one-year trial program to increase participation in Tricare, the military's managed health-care system.

The program ran from January through December 2003. It aimed to remove some restrictions to health-care services. For example, Tricare beneficiaries formerly needed physician referrals to see licensed and certified mental health counselors. The program dropped these restrictions.

The think tank RAND just completed an independent analysis of the program's effectiveness, says Lisa Meredith, PhD, a RAND senior behavioral scientist. She, Terri Tanielian, Michael Greenberg, PhD, JD, and others interviewed service providers who contract with Tricare and surveyed people who used Tricare's mental health services. Then RAND compared the differences between regions with and without the program.

The results--and whether DoD will continue without the old restrictions--are still unknown, but the undertaking shows the government's interest in making sure the military has effective access to mental health care, she says.

Other psychologists are working to remove the stigma of counseling.

"Because soldiers are reluctant to seek care, we need an effective stigma-reducing program that provides early interventions," says Litz of the National Center for PTSD.

A new program he's developed may fit the bill. His Internet-based self-help intervention to treat PTSD lets military personnel work by themselves at their own pace to develop coping strategies in response to trauma. Therapists assist troops as much or as little as the troops want during the eight-week program, but they primarily undergo intervention by completing daily homework assignments that teach coping skills. Lesson examples include deep breathing and muscle-relaxation exercises.

"We frame it as stress-management training, not psychotherapy, so soldiers find it more palatable," Litz explains. "That way, it can reach more soldiers than otherwise would consent or consider being in psychotherapy."

Another benefit: It can effectively treat more people because it requires less face-to-face work with therapists. For more program details, see December's Professional Psychology: Research and Practice (Vol. 35, No. 6, pages 628-634).

The National Institute of Mental Health initially funded the program to treat victims of the Pentagon attack on 9/11 and expanded it to treat Iraq War troops recovering from injuries at Walter Reed Medical Center in Washington, D.C.

Litz cautions that the program's style isn't for everyone. Some troops, he says, still need other therapy. But it's a start to help combat stress in a war that seems to have all too much of it.

"It's not a panacea," he says. "It shouldn't eliminate clinics or therapists or long-term psychotherapy, but as a tool, we think it's quite invaluable."