Delayed Reaction: Study Shows Iraq Vets' Mental Health Issues Often Develop Months After Return

By Thomas Maugh, Los Angeles Times. Posted November 14, 2007.

Overall, about 20% of active-duty Army soldiers and more than 40% of National Guardsmen and reservists were referred for care or had sought care on their own, a military team reported in the Journal of the American Medical Assn.

Psychologists hope that catching problems early and getting soldiers into treatment will prevent the type of long-term mental health problems that afflicted many soldiers who fought in Vietnam, said Dr. Charles S. Milliken of the Walter Reed Army Institute of Research, who led the study.

"We know from civilian studies and others . . . that if you can get to these problems earlier, the chances of effectively treating them are much better," he said.

The incidence of mental health problems during the Vietnam War was about the same as that of the current war, he noted. But studies have shown that as many as 10% of Vietnam vets still suffer chronic and disabling symptoms.

The trends reported by Milliken and his colleagues are similar to those seen in smaller studies of returning Iraqi veterans, but some experts cautioned that the absolute numbers of troubled soldiers may be artificially high because of the nature of the questionnaires used.

Psychologist Richard J. McNally of Harvard University noted that he and Dutch colleagues published a study on Dutch soldiers earlier this year using a similar questionnaire. The questionnaire showed that about 20% of the professional soldiers suffered symptoms of depression and post-traumatic stress disorder (PTSD).

But when the subjects underwent clinical interviews, they found, only about 4% actually suffered the disorders.

Milliken conceded that the large numbers did not represent clinical diagnoses.

"We have intentionally set the bar pretty low," he said. "We're hoping to find early symptoms and intervene before they can become full-fledged clinical diagnoses."

The study reflects an increased emphasis by the military on catching incipient mental health problems when veterans return from combat duty. Beginning in May 2003, the Department of Defense began administering the Post-Deployment Health Assessment to all returning soldiers.

Milliken, Dr. Charles W. Hoge of Walter Reed and their colleagues reported in March 2006 on the first results from the survey. They found that about one in eight soldiers suffered from PTSD or other disorders, but they speculated that the number would grow as the soldiers began re-integrating into society.

A small preliminary assessment confirmed that speculation, and the Army initiated a second survey six months after the soldiers' return.

The new report details the outcome for the first 88,235 soldiers who took both surveys.

Of those, 4.4% were referred for mental health care in the first screening, and an additional 11.7% were referred during the second screening.

Three-quarters of those who later received mental health care had not been referred for care, but sought it out themselves. Overall, 20.3% of active-duty personnel and 42.2% of reservists and guardsmen surveyed underwent some form of treatment.

The results were not surprising, said Paul Rieckhoff, executive director of Iraq and Afghanistan Veterans of America. The initial screening was performed while the troops were on the way home, and soldiers may have minimized symptoms for fear that admitting to an illness would delay their reunions with their families.

There is also a well-known "honeymoon period" after return that persists until their experiences begin to sink in.

The higher rates among reservists and guardsmen are also not surprising, Rieckhoff said. A stigma is still associated with mental health problems, and career soldiers may be less likely to admit to them.

But the reservists may be more likely to suffer problems because they are dropped back into society without having the fellowship of a community of others who shared their experiences.

"You can literally be in Baghdad one week and Brooklyn the next," he said. "That's a pretty tough shift."

The quadrupling of those reporting interpersonal conflicts also was understandable, experts said. Despite the wide availability of telephone calls and Internet connections in this war, the soldiers were still isolated from their family and friends at the time of the first assessment, so few conflicts would be expected.

But after six months of close contact with friends and family, frictions would be much more likely.

One surprising finding of the new study was the lack of correlation between treatment and improvement in symptoms. More than half of those identified as having problems in the original study "improved without treatment," and many of those who received treatment did not improve, Milliken said.

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