Injured Soldiers' Symptoms May Worsen Over Time

The psychological effects of combat trauma on U.S. soldiers seem to increase during the first year after they are wounded in Iraq or Afghanistan. Severely wounded soldiers had higher rates of posttraumatic stress disorder (PTSD) or depression seven months after their injuries than at one month, reported Army researchers in the October American Journal of Psychiatry.

“A one-time evaluation doesn't give you the story of what's to come,” said co-author Capt. Thomas Grieger, M.C., an associate professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., in an interview. “Even among those who don't have PTSD at seven months, something may trigger symptoms in the next year or two.”

About 79 percent of those who screened positive for PTSD or depression at seven months screened negative for both conditions at one month, wrote Grieger and six colleagues in their report. Greater severity of physical injury was the prime predictor of later PTSD or depression.

“The course of illness in battle-injured soldiers is complex, and the initial assessments in this study were not predictive of the health or life impact of such injuries six months later,” they wrote.

“Symptoms wax and wane over time,” Grieger told Psychiatric News. “Some individuals come close but don't meet the criteria at one point, but then cross over at another time.”

The study included the first 613 U.S. soldiers hospitalized at Walter Reed Army Medical Center after being wounded in combat in Iraq or Afghanistan between March 2003 and September 2004. They all had multiple, serious injuries, including amputations and head trauma. In addition to their medical care, all were given psychiatric evaluations within 48 hours of arriving at Walter Reed and provided with psychiatric care while they were in the hospital.

The soldiers were screened at one, four, and seven months; 243 soldiers underwent all three assessments (see chart for data on this group). Length of time in the war zones and information about specific traumatic events while deployed served to measure war exposure. The researchers used the National Center for PTSD Checklist and the Patient Health Questionnaire-9 depression scale to assess psychiatric symptoms.

The Patient Health Questionnaire somatic symptoms severity scale measured severity of physical problems. This scale is based on subjective self-reports and was initially used to guide the patient's care. It was used in contrast to objective scales of injuries—those assessing loss of blood or missing limbs, for instance—that tend to be used more by trauma surgeons or emergency departments, Grieger said.

The number of soldiers diagnosed varied with time. At the one-month assessment, 4.2 percent of the 613 soldiers met criteria for PTSD, 4.4 percent for depression, and 2 percent for both. Younger soldiers (under age 25) and those who were married were three times more likely to meet the standards for either disorder than older or unmarried soldiers.

At four months, 12.2 percent of the 395 soldiers available for follow-up met the criteria for PTSD, 8.9 percent for depression, and 7.6 percent for both. At seven months, 12.0 percent of 301 soldiers met the criteria for PTSD, 9.3 percent for depression, and 6.3 percent for both.

The researchers were able to assess the soldiers in the hospital, but lost track of about half after they returned home. However, the demographics and combat exposure in the one-month and seven-month cohorts were the same, said Grieger.

If all soldiers who were diagnosed with PTSD at any time during the course of the study were combined, the rate would approach 17 percent, he said. That figure is close to the 18.9 percent reported in a recent reanalysis of the 1988 National Vietnam Veterans Readjustment Study.

There were no demographic differences associated with PTSD or depression at the four- and seven-month evaluations. At one month, combat exposure was associated with PTSD but not depression, but at four or seven months, combat exposure was not associated with either PTSD or depression.

Wounded soldiers have much going for them but also face obstacles in their return to life after combat, said Grieger. During their rehabilitation at Walter Reed, many display positive attitudes, close relations with their families, command support, and the camaraderie of fellow soldiers going through rehab. However, their ongoing physical problems may complicate their recovery once they leave the hospital.

“We haven't studied it yet, but i'm especially concerned about reservists, who will go back to their hometowns where they may not have the same access to medical care or comrades to talk to,” he said.

“Posttraumatic Stress Disorder and Depression in Battle-Injured Soldiers” is posted at<http://ajp.psychiatryonline.org> under the October issue. ▪