Research on military personnel and veterans regarding posttraumatic stress
disorder (PTSD), depression, anxiety, substance use, and other disorders
sometimes resulting from extended overseas deployments continues to lag behind
the need, psychologist Terence Keane, Ph.D., told a conference in Washington,
D.C., sponsored by the National Institute on Drug Abuse in January. Keane is
with the Boston VA and Boston University School of Medicine.
"Among veterans coming into the VA for services, there is a higher
rate of PTSD (79 percent) compared with Gulf War I vets (55 percent), but less
alcohol misuse (21 percent vs. 34 percent), drug use (6 percent vs. 16
percent), or violence (21 percent vs. 42 percent)," said Robert
Rosenheck, M.D., a professor of psychiatry, epidemiology, and public health at
Yale University and the New Haven VA.
"The problems with trying to deal with alcohol use combined with
PTSD, TBI [traumatic brain injury], insomnia, et cetera in military
populations is that the evidence base is thin. You can't do evidence-based
medicine without evidence," said Mark Willenbring, M.D., director of the
Treatment and Recovery Research Division of the National Institute on Alcohol
Abuse and Alcoholism.
There are rewards as well as significant challenges in conducting mental
health and substance abuse research in active-duty military and veteran
populations, said Keane. More funding has recently become available, but that
availability is not the only reason to pursue such projects.
"Participants are motivated to take part in research, not for money,
but because they are interested in helping other people who have been through
what they have experienced," said Keane.
The impact of such research often spreads beyond its military subjects as
well, he added. For instance, the conception of opiate addiction broadened
from an emphasis on biological dependence to include contextual aspects of
addiction as a result of research with Vietnam War veterans, he noted.
Any research on military personnel and veterans must consider that the
Pentagon takes a different position on drug use than it does on alcohol
There is a zero-tolerance policy toward use of illicit drugs, backed up by
randomized urine testing conducted by personnel officials, not health staff. A
confirmed test results in immediate separation from the service without
veterans benefits. However, soldiers who admit to a problem and request help
will not be prosecuted by military authorities. They may be offered treatment
and are still discharged, but not with a bad-conduct designation. In contrast,
soldiers whose dependence arose as a side effect of prescribed medication are
seen as having a medical problem, and they are treated and retained in the
Alcohol consumption is not illegal in the military, except in Iraq and
Afghanistan, said Navy forensic psychiatrist Capt. Edward Simmer.
"The focus is on 'responsible use,' but with severe consequences for
inappropriate use, especially driving under the influence," he said."
Surveys have shown that 50 percent of military personnel self-report
binge drinking, so the services do a lot of education and treatment, focusing
on intervening early."
Tobacco use is "strongly discouraged," he added, although
nicotine use rises during deployments as former smokers react to stress and
take up the habit again.
Despite the need, there are still barriers that researchers wishing to
study military populations must consider, said psychiatrist Jeffrey Pyne,
M.D., a staff physician at the Central Arkansas Veterans Healthcare System in
Research approvals that include personnel from more than one service must,
for example, go through each service branch's medical authority, he said.
Often more than one institutional review board must sign off on projects.
Cooperative research-and-development agreements must be hammered out between
the service and the researcher. These agreements can become complex and time
consuming to put together, especially when third parties, such as
universities, get involved, said Pyne.
Written personnel contracts, like those governing how much time will be
spent on research and how much on clinical activities, have the force of
military orders and may lack the flexibility to which civilian researchers may
be accustomed. Researchers also must plan ahead to allow for the reality that
on-site investigators or subjects may be deployed to other bases or overseas
during the course of the research.
Also, researchers must assuage the concerns of military health care
providers who may be concerned that they will "lose" a patient to
a research project, preventing the providers from keeping up with the
requirement that they be current on a patient's clinical and administrative
status. And base commanders must approve recruitment flyers but cannot apply
any influence on an individual's decision to participate in a study.
That process raises the question of whether members of the military
services are "vulnerable populations" in an ethical sense,
analogous to children or prisoners, said David Festinger, Ph.D., director of
the law and ethics research section of the Treatment Research Institute in
Philadelphia and an adjunct assistant professor of psychiatry at the
University of Pennsylvania.
Vulnerable populations are those whose decision to provide informed consent
can be influenced by economic hardship, cognitive deficits, medical problems,
social dysfunction, or coercion, explained Festinger. Military personnel may
be influenced by two types of coercion. Institutional coercion is explicit
pressure by superior officers, he noted, while deferential coercion is the
implicit pressure that leads soldiers to believe that something negative will
happen to them if they do or do not take part in a medical study.
"Many veterans seeking treatment at the VA have a variety of medical,
economic, and social problems," said Festinger. "We must pay extra
attention to human-risk protections for them and to increasing their
understanding of informed consent."
"Members of the armed forces place their lives and the well-being of
their families at risk, so it is up to us to do our best to drive our science
to the table to help them," said Keane.
"Addressing Substance Abuse and Comorbidities Among Military
Personnel, Veterans, and Their Families: A Research Agenda" is posted at<www.sei2003.com/nida/1014036/Agenda.doc>.▪