American soldiers and Marines engaged in ground combat operations in Iraq
last year developed more mental health problems than soldiers on the ground in
Afghanistan in 2002.
The study, published in the July New England Journal of Medicine,
is the first to examine the mental health status of soldiers returning from
combat operations in Iraq and Afghanistan.
The military researchers surveyed about 6,000 U.S. Army soldiers and
Marines anonymously last year. Lead author Charles Hoge, M.D., told
Psychiatric News, "We surveyed three Army and Marine units
three months after they returned from Iraq and Afghanistan and one large Army
unit one week before deployment to Iraq in January."
Hoge is chief of psychiatry and behavioral sciences at Walter Reed Army
Institute of Research in Washington, D.C. "This is a longitudinal study
in which we track soldiers through assigning numbers since we can't use their
names," said Hoge.
The Army researchers are taking a proactive approach to identifying mental
health problems in returning soldiers from Iraq in particular. "We
learned only years after soldiers returned from Vietnam that many of them had
posttraumatic stress disorder [PTSD], which delayed treatment," said
Hoge and his colleagues at Walter Reed.
They used standardized checklists to screen the soldiers for the presence
of PTSD, major depression, and generalized anxiety. Two screening definitions
were used for each disorder.
Both definitions used the DSM-IV symptom criteria, but the broad
definition excluded criteria for functional impairment, while the strict
definition "required a self-report of substantial functional impairment
or a large number of symptoms," according to Hoge and his
The percentage of soldiers who met the strict screening definition for
major depression, generalized anxiety, or PTSD was significantly higher after
duty in Iraq (17 percent) than after duty in Afghanistan (11 percent) or
before duty in Iraq (9 percent), the researchers reported.
The researchers found that combat exposure was related to the presence of
psychiatric disorders. The highest rates of disorders were among the 1,700
Army infantry soldiers and Marines whose tour of duty started with the
U.S.-led invasion of Iraq on March 20 and ended six to eight months later.
This group of soldiers reported engaging in heavy combat during the
invasion, more frequent combat, and more frequent contact with the enemy than
soldiers who returned from Afghanistan.
Rates of PTSD were significantly higher after combat duty in Iraq than
before deployment. PTSD was highest in soldiers who had been shot at, handled
dead bodies, killed enemy combatants, or knew someone who had been killed,
Hoge and his colleagues reported.
When mental health care was offered to the respondents with functional
impairment or the greatest number of symptoms, only about 40 percent were
interested in seeking help, and only about 30 percent reported receiving help
in the preceding year, the researchers stated.
Stigma and concerns about confidentiality were the main barriers to seeking
mental health care, the authors reported.
Hoge commented that military clinicians have an obligation to maintain
patient confidentiality but, unlike their civilian counterparts, are also
responsible for assessing a soldiers' fitness for duty. "If a soldier is
severely impaired and can't safely operate highly technical weapons or
equipment, that is a compelling reason to notify his commander," said
He emphasized that most soldiers who receive mental health care function
well with medication and support.
Hoge and his research team briefed military leaders last year on the
results and recommendations of the study. The recommendation to provide
confidential counseling sessions through employee-assistance programs was
implemented last fall, Hoge said.
The researchers also recommended that screening for PTSD be implemented in
military primary care settings, where soldiers are usually screened for