National Guard and Army Reserve troops constitute an estimated 30% to 40% of the 1 million-plus U.S. military personnel deployed in Iraq and Afghanistan.1-3 Many of these civilian soldiers—once considered “weekend warriors”—are serving a first combat tour, returning home, and being redeployed for additional tours of duty.
Because of these unprecedented deployment policies, civilian psychiatrists will likely play a greater role in treating combat-related mental health problems than in any previous U.S. war. You may need to provide initial and long-term psychiatric care for reservists and Guard members returning to your community during 2006 and beyond.
To help you prepare, we discuss the combat situations these soldiers are experiencing, types of psychiatric problems they are reporting in anonymous surveys, and their attitudes about seeking psychiatric care. We also offer practical resources on combat-related posttraumatic stress disorder (PTSD) for nonmilitary or Veterans Administration clinicians.
A soldier’s story: ‘He’s always jumpy’
Mr. L, age 39, is supervisor for a local construction company and a sergeant first class with 18 years of Army Reserve service who returned from Iraq 7 months ago. He tells you, “My wife made me come see you—I didn’t want to.”
Though he does not think he needs a psychiatrist, his irritability and poor sleep worry his wife. “He isn’t the same anymore,” she says. “He’s always jumpy.”
Reported psychiatric problems
Stress-related symptoms. Within 4 months of returning home from Iraq or Afghanistan, 3 in 10 soldiers have developed “stress-related mental health problems” such as anxiety, depression, nightmares, anger, and concentration difficulties, reports Army Surgeon General Lt. Gen. Kevin Kiley.4 An unknown smaller percentage were reportedly diagnosed with PTSD.
Strained marriages, suicidal thoughts/feelings, nightmares or flashbacks, and fear of losing control or injuring someone else were among problems soldiers acknowledged during post-deployment health assessments between January and August 2005. In these surveys, 28% of 193,000 returnees endorsed mental health problems, according to the Army Center for Health Promotion and Preventive Medicine (Table 1).5
Table 1
Mental health problems reported by troops returning from combat in Iraq*
Problem | Number among 193,000 U.S. soldiers |
---|---|
Nightmares or unwanted war recollections | 20,000 |
Might “hurt or lose control” with someone else | 3,700 |
Suicidal thoughts/feeling better off dead | 1,700 |
* 28% of returnees reported mental health problems in post-deployment surveys between January and August 2005. | |
Source: Army Center for Health Promotion and Preventive Medicine, reference 5. |
Unfortunately, this new information may underestimate the number of returnees with psychiatric problems and the severity of those problems. In an anonymous survey of returning Army and Marine soldiers, Hoge et al7 found that those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis (Table 2).
Table 2
Perceived barriers to seeking mental health services cited by U.S. soldiers after combat duty in Iraq and Afghanistan*
Perceived barrier | Met screening criteria for a mental disorder? | |
---|---|---|
Yes (N=731) | No (N=5,422) | |
I would be seen as weak | 65% | 31% |
My unit leadership might treat me differently | 63% | 33% |
Members of my unit might have less confidence in me | 59% | 31% |
I would have difficulty getting time off work for treatment | 55% | 22% |
My leaders would blame me for the problem | 51% | 20% |
It would harm my career | 50% | 24% |
It is difficult to schedule an appointment | 45% | 17% |
It would be too embarrassing | 41% | 18% |
I don’t trust mental health professionals | 38% | 17% |
Mental health care costs too much money | 25% | 10% |
Mental health care doesn’t work | 25% | 9% |
I don’t know where to get help | 22% | 6% |
I don’t have adequate transportation | 18% | 6% |
* Anonymous survey. Those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis. | ||
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22. |
Gender per se may not be the most important variable; age, number of years in the military, type of military unit, and ethnic group are also risk factors for developing a war-related psychiatric disorder. Further studies of OIF- and OEF-related psychiatric disorders are needed to determine whether female veterans’ clinical needs differ in important ways from those of male veterans.