Veterans of the conflicts in Iraq and Afghanistan may well see civilian
psychiatrists in the United States for mental health care even as the Pentagon
advances services closer to the battlefield and the Department of Veterans
Affairs (VA) gears up for treating returning soldiers. Psychiatric care may be
complicated, however, by the nature of the mental stresses and physical
injuries experienced by men and women serving in combat zones, according to
"We've tried to put many lessons from other conflicts to use,"
said Col. E. Cameron Ritchie, M.C., a psychiatry consultant to the U.S. Army
surgeon general, in an interview. "Initial treatment—which may
involve rest, relaxation, and hot meals along with counseling—takes
place as close to the battlefield as possible so that troops can return to
Troops on active duty are covered by the military health care system, and
many discharged soldiers have access to the VA system. However, unlike during
the Vietnam War, 40 percent of the troops in Iraq and Afghanistan belong to
the National Guard or the reserves. They have access to VA hospitals for
almost any health issues related to their active service for two years after
discharge. After that period, they must demonstrate a service connection for
their complaint or meet low-income standards, said VA psychiatrist Mark
Shellhorse, M.D., in an interview. Shellhorse is acting deputy officer for
mental health for patient care services at the VA, based in Durham, N.C.
About 394,000 U.S. troops serving in the two current theaters of war have
completed active-duty enlistments. A study by Col. Charles Hoge, M.C., and
colleagues published in the July 1, 2004, issue of the New England Journal
of Medicine (NEJM), found that about 16 percent of the troops
who served in Iraq and 11 percent of those who served in Afghanistan met
screening criteria for major depression, generalized anxiety, or posttraumatic
stress disorder (PTSD) three or four months after their return. Troops serving
in ground units of the Army or Marine Corps were 3.7 times more likely to have
PTSD than members of the Navy or Air Force, according to a VA study in the
March 31 NEJM. The rate of PTSD in enlisted personnel was twice that
After soldiers complete their service in Iraq or Afghanistan, many head
back to civilian jobs or enroll in universities, where they are likely to
encounter civilian psychiatrists, said Ritchie.
"[Civilian psychiatrists] are not likely to see a stereotypic
soldier—either a young guy with short hair or a chronically homeless
Vietnam vet," she said. Veterans of the current conflicts have a wide
range of ages and occupations, and 15 percent are women.
Civilian psychiatrists may also occasionally see active duty soldiers home
on leave, brought to an emergency room by mothers or spouses concerned about
their loved one's behavior or suicidal ideation, she said. Such soldiers
should be referred to the military's medical system for follow-up care, she
In less-acute settings, asking a new patient whether he or she is a veteran
may be the simplest way of screening and initiating a discussion of the vet's
experiences. Risk factors for psychiatric sequelae include both the horrors of
war and comorbid disorders, said Ritchie. They may have seen dead children or
mutilated bodies, or were unable to help their comrades while under attack.
Too often, such mental trauma is accompanied by physical injury in patterns
that differ from those of previous wars.
"Because of protective gear that soldiers wear, they're more likely
to survive when wounded than in past conflicts, so consultation-liaison
service has become very important, especially to those with injuries to limbs,
which are not protected by body armor," said Robert J. Ursano, M.D., a
professor of psychiatry and neuroscience and chair of the department of
psychiatry at the Uniformed Services University of the Health Sciences (USUHS)
in Bethesda, Md. "PTSD accompanying an injury is an important component
The effects of placing in-theater mental health services nearer to the
front are not yet clear, said Ursano. However, wounded soldiers are seen for
psychiatric evaluation at every stage of medical evacuation: close to the
battlefield, in forward field hospitals, at Landstuhl in Germany, and at
Walter Reed Medical Center in Washington, D.C.
"Screening programs that include mental health are in place to get
them to the services they need," said Ursano. "The mental health
questions are new. You can debate how effective they are, but what's different
is that it's happening, and that is a major step forward."
Most importantly, given the frequency of roadside bombs, clinicians should
also ask about the possibility of head injury. At least one-fifth of U.S.
casualties in Iraq and Afghanistan had injuries to the head, neck, or face.
The proportion may be even higher, since many cases of closed brain injury are
not diagnosed immediately.FIG1
Col. E. Cameron Ritchie, M.C.: "Head trauma may be the signature
wound of this war."
"Head trauma may be the signature wound of this war," said
Traumatic brain injury can affect several areas of brain function, wrote
Susan Okie, M.D., in the May 19 New England Journal of Medicine.
Symptoms may include headaches; sleep disturbances; sensitivity to light or
noise; disturbances in attention, memory, or language; or mood changes,
depression, anxiety, impulsiveness, emotional outbursts, or inappropriate
Finally, clinicians encountering returning veterans should screen for risky
behavior, said Ritchie. "They've been in the field for a year with no
alcohol and have saved up their money. They come home, buy a motorcycle, and
drive fast, so look for preventive strategies."
Substance abuse is generally not a problem for troops in Iraq, but problems
may arise when they get back to the United States, she said. "We don't
have good numbers on how many are abusing alcohol after their
Screening can provide an educational benefit for families as well as
soldiers, to help them understand what has happened and to open the way for
treatment. Symptoms can resolve, and medication can help these patients, she
The military medical services offer help for soldiers and their families
before and during overseas deployment. Soldiers are now screened on their
return and assessed for mental and physical health six months after their
return. Soldiers who request help are offered six free confidential counseling
Nevertheless, some veterans have expressed concern about the availability
of mental health services for returning troops.
"Mental illness could be the Agent Orange of this generation of
veterans," said Paul Rieckhoff, executive director and founder of
Operation Truth, a nonpartisan advocacy organization for veterans of the Iraq
and Afghanistan wars. Rieckhoff served as an Army 1st lieutenant in Baghdad in
2003 and 2004.
"There is a wave of mental illness coming, and the VA is unprepared
to handle it," he said in an interview. Besides the stresses of combat,
Rieckhoff said that multiple tours of duty, repeatedly delayed returns to the
United States, and the shifting rationales for the war weigh on the minds of
those who serve.
Adequate services are available during enlistment and after discharge,
counter the USUHS's Ursano and the VA's Shellhorse.
Removing barriers to care is important, said Ursano. Increasing access,
having multiple modes of care, creating supportive communities, and educating
families and commanders can all aid soldiers who need help. There may be
subtle differences between the two departments, however.
The Department of Defense tries to encourage soldiers to discuss their
psychological concerns in confidence, but many hesitate, concerned about
effects on their careers, said the VA's Shellhorse. Although many vets still
perceive mental illness as a failing and are reluctant to talk, it is a lesser
issue among those already discharged and using the VA system.
"When they come to us, they're usually asking for help," he
said. "They've already crossed the barriers to care."
The Pentagon sends names of service members to the VA as they are
discharged. If a veteran comes to a VA hospital or clinic, a VA staffer will
receive an automated reminder to ask the vet about depression, PTSD, substance
abuse, and illnesses (like parasitic diseases) specific to the theater where
he or she served.
The VA has set up several programs to cover care for veterans who live too
far from VA facilities. Veterans can use a fee card to purchase services from
local providers. In some areas, the VA may contract with local providers for
care. The department is also expanding its telepsychiatry installations in its
community-based outpatient clinics. There are 207 readjustment counseling
centers across the country offering supportive counseling to help former
soldiers and families.
These counseling centers represent a paradoxical source of care for women
service members, said Rieckhoff. While the number of women soldiers is
increasing, it is still hard to find female peer counselors, he said.
Civilian doctors should be aware of the need for care for any returning
veteran, said Ursano. Primary care providers should ask vets about any
traumatic events they may have experienced, and that includes war. They should
also be able to diagnose PTSD, depression, and substance abuse.
Civilian psychiatrists can prepare themselves to assess or treat veterans
of the current conflicts by reading the "Iraq War Clinician Guide"
by the National Center for PTSD, a branch of the Department of Veterans
Affairs, said Shellhorse.
"Courage to Care," a series of fact sheets for veterans
and their families, is posted at<www.usuhs.mil/psy/courage.html>.
The "Iraq War Clinician Guide" is posted at<www.ncptsd.va.gov/war/guide/IraqGuide.pdf>.▪