2. “…for the first time in recorded warfare, psychological
morbidity is likely to outstrip physical injury associated
with combat.” (Sammons & Batten, 2008, p. 921)
3. Introduction
• Over 2 million U.S. soldiers have deployed to Iraq
and Afghanistan since the beginning of the war in
2003.
• It is estimated that at least 300,000 have or may be
diagnosed with PTSD.
– This may just be the ‘tip of the iceberg’.
(Golding, 2011; Hafemeister & Stackey, 2010; Stiglitz & Bilmes, 2012; Tanielian & Jaycox, 2008;
Zeber, Noel, Pugh, Copeland & Parchman, 2010)
4. Introduction
• Current troop composition
– All volunteer forces
– Active Duty, Reserves, National Guard
– More women
– Troops are older
– Pre-existing medical conditions
– Tours of duty are longer
– Many veterans have served multiple tours in both Iraq &
Afghanistan
5. PTSD – The Diagnosis
• Concept developed in 1980 by the American
Psychiatric Association
– Majority of its’ use dealt with those involved in war.
– Definition expanded in 2000.
– Most recent revision, Diagnostic and Statistical Manual V
(DSM-V), May 2013.
• Criteria for diagnosis (American Psychiatric Association, 2013)
– The trigger
• Exposure to a very severe stressor – actual or potential
– Additional requirements
6. PTSD – The Diagnosis
• Cluster of attributes (American Psychiatric Association, 2013)
– Re-experiencing of the traumatic event
• Frequent upsetting dreams & painful memories
– Avoidance
• Experiences which provoke remembrance of the trauma
– Negative cognitions and mood
• Separation from others; Inaccurate perceptions of guilt related
to self or others; amnesia regarding significant parts of the
event
– Arousal
• Violent, uncontrolled, self-injurious behavior; problems with
sleeping; hyper-alertness
• The timeline
7. Understanding Why
• Tours of duty
– Longer
– Multiple tours in both Iraq and Afghanistan
• Increased risk of PTSD by 50%
(Demers, 2009)
• Challenges provided by these wars
– No “front lines”
– Differentiating combatants from non-combatants
– All members are at risk.
8. Understanding Why
• Groups at increased risk
– Women
• Lower rate than men, but increased chronicity
• Sexual assaults
• Combat
– Minorities
– Those who:
• Have suffered a previous traumatic event
• Lack a social support system
• Have other mental health diagnoses
• Have family members with mental health problems
• Department of Defense (DOD) Task Force on
Mental Health
9. The Stigma of Mental Illness
• Those who need care the most are the least likely
to seek it.
• What is stigma?
10. The Stigma of Mental Illness
• The stigma of mental illness
– Special considerations in the military
• Adverse career implications
• Inability to obtain a security clearance
• Perceived negative effects of medications
• Belief that help from relatives and colleagues is more beneficial
• Loss of faith in their abilities by others
(Harrison et al, 2004)
• Loss of self-worth and self-confidence
• Societal labeling
• Bias and inequity
(Corrigan et al, 2004)
11. The Impact of PTSD
• The member
• Co-workers
• Society
• Major issues
– Maintaining employment
– Estrangement
– Homelessness
• Veterans versus non-veterans
• Men vs. women
– Violence
(Harrison, Satterwhite & Ruday, 2010; Sammons & Batten, 2008)
12. Impact on the Family
• The effects of deployment
– At the end of 2009, more than 50% of deployed
personnel were married and 85% of them had dependent
children. (Hinojosa, Hinojosa, Nelson & Nelson, 2010)
• PTSD and the family
– Increase in domestic violence
– Increase in divorce
– Decreased social support for the veteran
• Increase in stress and worsening of the PTSD
(Khaylis, Polusny, Erbes, Gerwitz & Rath, 2011)
13. Other Factors to Consider
• When care is sought
– Who
• The veteran or their family member
– What
• Medical complaints vs. mental health issues
• Attempts to self-treat
– When
• Immediate vs. delayed
– Where
• Military, VA, Civilian provider
14. The Burden of Care
• The Veteran’s Affairs Health System
– “the largest health care system in the world”
(Iverson, Cornell & Smits, 2009, p.62)
– Overburdened in all respects
– Why they cannot respond as needed
• Chronically ill and aging Korean and Vietnam War veterans
• Numbers currently served (Geiling, Rosen & Edwards, 2012; Stiglitz &
Bilmes, 2012)
• Financial, materiel & personnel shortfalls – the most
significant being behavioral health (Bilmes, 2009)
– Access to care
• Rural areas
• Wait times
15. VA – Military - Civilian
• Preparing the civilian community to handle the
burden & recognize the problem
– Not adequately prepared – especially in the area of
PTSD
– Relating to the experience of war
– Need early screening, detection and treatment in primary
care clinics (Geiling, Rosen & Edwards, 2012)
• Looking past the initial diagnosis to prevent co-morbidities
16. Costs of Care
• Costs of care for PTSD & Major Depression (2007)
– 4-6.2 billion over a 2 year period
• Cost and availability of evidence-based care
• Projected cost of disability benefits and care for OIF
and OEF vets during their lifetime
– 589-934 billion (Stiglitz & Bilmes, 2012)
17. Things to Remember
• Veterans from previous conflicts may “re-experience”
their PTSD symptoms as a result of hearing about and
watching events in current conflicts and reliving past
events.
• Because of the failure or reluctance of those
experiencing post-traumatic stress to seek mental
health care, and the lack of mental health providers,
primary care providers are the health care providers
most frequently sought out.
• (Geiling, Rosen & Edwards, 2012; Prins, Kimerling & Leskin, 2007)
18. Conclusions
• The enormity of the situation
– Iraq
• Lingering issues
– Afghanistan
• Volatile setting
• Faceless insurgents in a war without front lines.
– Invisible effects of battle
– Where the needs are
• What we as healthcare providers need to do
20. References
• Bilmes, L. (2007). Soldiers Returning from Iraq and Afghanistan: The
Long-term Costs of Providing Veterans Medical Care and Disability
Benefits. Harvard University, John F. Kennedy School of
Government, Faculty Research Working Paper Series, RWP07-
001, 1-20.
• Blakely, K. & Jansen, D.J. (2013). Post-Traumatic Stress Disorder and
Other Mental Health Problems in the Military: Oversight Issues for
Congress. Congressional Research Service, 7-5700, www.crs.gov,
R43175.
• Corrigan, P. (2004). How Stigma Interferes with Mental Health Care.
American Psychologist, 59, 614-625.
21. References
• Demers, A. (2009). The War at Home: Consequences of Loving a
Veteran of the Iraq and Afghanistan Wars. The Internet Journal of
Mental Health, 6, www.ispub.com.
• Frances, A., First, M.B., & Pincus, A.B. (2004). DSM-IV-TR Guidebook.
Washington, DC: American Psychological Association.
• Golding, H.L.W. (2011). Potential Costs of Health Care for Veterans
of Recent and Ongoing U.S. Military Operations. Statement before
the Committee on Veterans’ Affairs, United States Senate.
Washington, DC: Congressional Budget Office.
22. References
• Hafemeister, T.L. & Stackey, N.A. (2010). Last Stand!? The Criminal
Responsibility of War Veterans Returning from Iraq and
Afghanistan with Post-traumatic Stress Disorder. Indiana Law
Journal, 85, 88-141.
• Harrison, J.P., Satterwhite, L.F. & Ruday, W. (2010). The Financial
Impact of Post-traumatic Stress Disorder on Returning U.S. Military
Personnel. Journal of Healthcare Finance, 36, 65-74.
• . Hinojosa, R., Hinojosa, M.S., Nelson K., & Nelson, D. (2010). Veteran
Family Reintegration Primary Care Needs and the Benefit of the
Patient-Centered Medical Home Model. Journal of the American
Board of Family Medicine, 23, 770-774.
• Iverson, D.A., Cornell, M., & Smits, P. (2009). Medicine & Society – The
“Army of Lost Souls”. Virtual Mentor, American Medical
Association Journal of Ethics, 11, 61-71. www.virtualmentor.org
23. References
• Khaylis, A., Polusny, M.A., Erbes, C.R., Gerwitz, A., & Rath, M. (2011).
Posttraumatic Stress, Family Adjustment, and Treatment
Preferences Among National Guard Soldiers Deployed to
OEF/OIF. Military Medicine, 176, 126-131.
• Koo, K.H. & Maguen, S. (2014). Military Sexual Trauma and Mental
Health Diagnoses in Female Veterans Returning from Afghanistan
and Iraq: Barriers and Facilitators to Veterans Affairs Care.
Hastings Women’s Law Journal, 25, 27-38.
• Litz, B. & Orsillo, S.M. (2007/2010). The Returning Veteran of the Iraq
War: Background Issues and Assessment Guidelines. National
Center for PTSD. Retrieved from
http://www.ptsd.va.gov/professional/pages/vets-iraq-war-
guidelines.asp
24. References
• Nayback, A.M. (2008). Health Disparities in Military Veterans with PTSD:
Influential Sociocultural Factors. Journal of Psychosocial Nursing
and Mental Health Services, 46, 42-53.
• Prins,A., Kimerling, R. & Leskin, G. (2007). PTSD in Iraq War Veterans:
Implications for Primary Care. National Center for PTSD.
Retrieved from
http://www.ptsd.va.gov/professional/pages/assessments/pc-
ptsd.asp.
• Prins, A., Ouimette, P., Kimerling, R., Cameron, R.P., Hugelshofer, D.S.,
Shaw-Hegwer, J., Thrailkill, A., Gusman, F.D., & Skeikh, J.I.
(2003/2010). Primary Care PTSD Screen (PC-PTSD). National
Center for PTSD. Retrieved from
http://pwww.ptsd.va.gov/professional/pages/ptsd-iraq-vets-primary-
care.aspcare.asp
25. References
• Romanoff, M.R. (2006). Assessing Military Veterans for Posttraumatic
Stress Disorder: A Guide for Primary Care Clinicians. Journal of
the American Academy of Nurse Practitioners, 18, 409-413.
• Sammons, M.T. & Batten, S.V. (2008). Psychological Services for
Returning Veterans and Their Families: Evolving
Conceptualizations of the Sequelae of War-Zone Experiences.
Journal of Clinical Psychology, 64, 921-927.
• Seal, K.H., Bertenthal, D.., Maguen, S. Gima, K., Chu, A., & Marmar,
C.R. (2008). Getting Beyond “Don’t Ask; Don’t Tell”: An Evaluation
of US Veterans Administration Post deployment Mental Health
Screening of Veterans returning From Iraq and Afghanistan.
American Journal of Public Health, 98, 714-720.
26. References
• Seal, K.H., Bertenthal, D., Miner, C., Sen, S. & Marmar, C. (2007).
Bringing the War Back Home. Archives of Internal Medicine, 167,
476-482.
• Stecker, T., Fortney, J.A., Hamilton, F. & Azjen, I. (2007). An
Assessment of Beliefs About Mental Health Care Among Veterans
Who Served in Iraq. Psychiatric Services, 58, 1358-1361.
• Tanielian, T. & Jaycox, L.H. (Ed.) (2008). Invisible Wounds of War:
Psychological and Cognitive Injuries, Their Consequences and
Services to Assist Recovery. The Rand Corporation
• U.S. Department of Veterans Affairs, National Center for PTSD.(2010).
Traumatic Stress in Female Veterans. Retrieved from
http://www.ptsd.va.gov/professional/pages/traumatic_stress_in_
female_vets.asp.
27. References
• U.S. Department of Veterans Affairs, National Center for PTSD.
(2007/2010). PTSD Screening and Referral: For Health Care
Providers. Retrieved from
http://www.ptsd.va.gov/professional/pages/screening-and-
referral.asp.
• Vogt, D. (2007). Research on Women, Trauma and PTSD. National
Center for PTSD. Retrieved from
http://www.ptsd.va.gov/professional/pages/women-trauma-
ptsd.asp
• Zeber, J.E., Noel, P.H., Pugh, M.J., Copeland, L.A. & Parchman, M.L.
(2010). Family Perceptions of Post-Deployment Healthcare Needs
of Iraq/Afghanistan Military Personnel. Mental Health in Family
Medicine, 7, 135-143.
