Mental Health Effects of the Iraq War on Soldiers

1. Mental Health Effects of the Iraq War on Soldiers J. Douglas Bremner, MD Atlanta VAMC; Emory University, Atlanta, Georgia

2. Posttraumatic Stress Disorder Intrusive memories, nightmares, flashbacks, arousal, avoidance, startle, sleep disturbance, gaps in memory and concentration Associated with threat to life or other with fear/horror/helplessness (A) Affects 15% of traumatized individuals 16% of women with sexual abuse 8% lifetime PTSD prevalence (10% women)

3. Historical Timeline of the Development of Concepts of Psychological Trauma Description of Railway Injuries-UK Lancet-Railway injury without physical trauma DaCostas Syndrome (US)- Soldiers Heart, nervousness and startle, cardiovascular etiology Erichsen (UK) On Railway and Other Injuries of the Spine and Nervous System � confusion, amnesia,back pain, paralysis (related to unseen cord trauma) Charcot (Fr) �Traumatic hysteria� H. Oppenheim (Ger) �Traumatic neurosis� Freud Studies in Hysteria � developed seduction theory, then quickly abandoned it. Struggles over �pension neurosis� (Ger) Great War � �shell shock� (UK) � mental symptoms from impact of shells (ie, physical); �war neurosis� �combat hysteria� repressed wish to run from the battlefield (Freud); implied weakness of character;defeat of �traumatic neurosis� in Europe; compensation in US Rise of psychoanalysis in the US, emphasizes fantasy over reality (eg, trauma) WWII- Gross Stress Reaction in soldiers (US) (similar to hysteria) Rise of biological psychiatry in US lays foundation for viewing a physical role in the developmentof symptoms whose etiology is emotional trauma DSMIII � PTSD � central role of trauma emphasized (US) � VN veterans only Biological research in PTSD, popular acknowledgement of both VN combat and child sexual trauma (US) Backlash of �false memory� movement Returning veterans from Operation Iraqi Freedom� Let�s do it better this time.

4. Change In Rank Order Of Disease Burden Worldwide 1990 1. Lower respiratory infection 2. Diarrhea 3. Perinatal 4. Major depression 5. Ischemic heart disease 6. Cerebrovascular 9. Road traffic accidents 16. War 19. Violence

5. PTSD: Risk Factors Vietnam combat veterans with childhood abuse had 4-fold increased relative risk of PTSD (Bremner et al 1992) Most significant factor after adjusting for level of combat exposure, months in Vietnam, participation in atrocities Other risk factors: years of education, prior psychiatric illness, young age Twin studies: ~12% genetic

6. Mental Health Effects of OIF 150,000 soldiers are currently deployed in Iraq as part of Operation Iraqi Freedom (OIF). 15% of Vietnam combat veterans developed chronic PTSD. Thus of the 2,594,000 veterans who served in Vietnam, 389,100 developed chronic PTSD. A recent survey of OIF veterans showed rates of PTSD of 12%;2 less than 40% of these veterans spontaneously sought treatment for their disorders.

7. Mental Health Effects of OIF Posttraumatic stress disorder (PTSD) Depression Substance abuse Physical problems such as increased risk for heart disease. Loss of work productivity Greater health care utilization

8. Mental Health Effects of OIF Intervening soon after the trauma is critical for long-term outcomes With time traumatic memories become indelible and resistant to treatment. Diminished efficacy of treatment over time is shown by the fact that trials of Vietnam veterans have shown less efficacy over the years. Animal studies show that pretreatment before stress with antidepressants reduces chronic behavioral deficits related to stress.

9. Mental Health Effects of OIF However, treatment is not indicated for all individuals Some early interventions negative Therefore identifying people who need an intervention and those who would be better off left alone will be critical to developing new treatments Can brain imaging and genetic factors identify those at risk?

10. PTSD Prevention in OIF Mindfulness Based Stress Reduction (MBSR) represents a possible method of PTSD prevention that has many inherent advantages. MBSR is manualized program involving 8 weekly classes and a single 6 hour silent retreat session during the 6th week. The program is based on a systematic procedure to develop enhanced non-reactive awareness of the moment-to-moment experience of perceptible mental processes.

11. PTSD Prevention in OIF Clinical trials have shown MBSR to be highly effective for patients with pain, anxiety, depression, and other complaints. Current study to perform brain imaging, randomize to MBSR or supportive group therapy, and repeat brain imaging after treatment (404) 712-9571

12. Georgia National Guard 48th Combat Brigade Returning Guard OIF soldiers have special health needs Questions about access to health care and followup Survey physical and mental health of returning OIF soldiers at 6 months 1800 members of the Georgia 48th

13. Stress and Psychopathology

14. Hippocampal Volume Reduction in PTSD NORMAL PTSD MRI scan of the hippocampus in a normal control and patient with PTSD secondary to childhood abuse. The hippocampus, outlined in red, is visibly smaller in PTSD. Overall there was a 12% reduction in volume in PTSD.

15. Deficits in Verbal Memory inCombat-Related PTSD

16. Medial Prefrontal Cortical Dysfunction with Traumatic Memories in PTSD

17. Increased Blood Flow with Fear Acquisition versus Control in Abuse-related PTSD

18. Stress and Depression and Cardiovascular Disease 4-5 fold increase in mortality in patients with heart disease and co-morbid depression (Vaccarino et al) Increased catecholamine function and hypercortisolemia in depression and PTSD Changes in brain regions that modulate peripheral sympathoadrenal function (frontal cortical areas with outputs to hypothalamus)

19. Effects of Stress on Myocardial Ischemia

20. Stress Induced Ischemia in a Representative Subject with Depression and Trauma

21. Neural Correlates of Stress in CHD Patients with Depression versus CHD Patients without Depression

22. Controlled Trials in PTSD�More Effective Than Placebo Paroxetine for civilians and veterans (N=551)1 Sertraline for mostly civilians (N=208)2 Sertraline for mostly civilians (N=187)3 Fluoxetine for civilians (N=53)4 Fluoxetine for civilians and veterans (N=64)5 Amitriptyline for veterans (N=46)6 Phenelzine for veterans (N=34)7; (N=60)8 Imipramine for veterans7,8 Brofaromine for civilians and veterans with PTSD >1 year (N=45)9 Talk: Managing PTSD Speaker: Randall D. Marshall, M.D. Meeting: Addressing the Symptom Cluster Triad: Diagnosing and Treating PTSD / GSK 2001 T2Talk: Managing PTSD Speaker: Randall D. Marshall, M.D. Meeting: Addressing the Symptom Cluster Triad: Diagnosing and Treating PTSD / GSK 2001 T2

23. Increased Hippocampal Volume With Paxil in PTSD

24. Effects of Phenytoin onBrain Structure in PTSD

25. Empirically Tested Behavioral Treatments for PTSD Psychological Debriefing for immediate reactions CBT for Acute Stress Disorder Prolonged Exposure for chronic PTSD Stress Inoculation Training for chronic PTSD Cognitive Processing Therapy for chronic PTSD EMDR for chronic PTSD Additional Treatments with limited validation: Psychodynamic Interpersonal

26. Psychological Debriefing (PD) A single session intervention Typically within 72 hours post-trauma Delivered in a group or individual setting Encourage a full narrative account of the trauma (facts, cognitions, feelings) Normalize emotional reactions Prepare for later emotional reactions

27. The effects of early interventions on PTSD are equivocal: All control studies failed to detect benefit from Psychological Debriefing. Some studies show that PD impedes natural recovery. Most studies on short CBT intervention show some benefitThe effects of early interventions on PTSD are equivocal: All control studies failed to detect benefit from Psychological Debriefing. Some studies show that PD impedes natural recovery. Most studies on short CBT intervention show some benefit

28. CBT Prevention Program for Acute PTSD Four to five weekly sessions Typically within 2-5 weeks post-trauma Delivered in individual setting Intervention Includes: Discussions of normal reactions to assault Breathing retraining Deep muscle relaxation Recounting the assault: imaginal exposure Cognitive restructuring Exposure in vivo assignments

29. Prolonged Exposure, Stress Inoculation Training and Supportive Counseling for Acute Stress Disorder Acute stress disorder in trauma survivors permits early identification of those who are at risk for developing posttraumatic stress disorder, and provides an opportunity for preventive intervention. This study1 compared the relative efficacy of prolonged exposure (PE; N=14), prolonged exposure combined with anxiety management through stress inoculation training (PE/SIT; N=15), and supportive counseling (SC; N=16) in preventing development of PTSD. Patients were given 5 treatment sessions within two weeks of their trauma. At the end of the treatment phase, and at 6 month follow-up, there were fewer cases of PTSD in the PE and PE/SIT groups than in the SC group. The slide on Brief Prevention, along with this study, suggest that treatments that encourage more trauma processing accelerate recovery more than treatment than do not address the trauma. Addressing the PTSD symptoms and discussing them in several meetings is also helpful. The studies so far have involved only small sample sizes, and we still have much to learn. However, the data presented is what�s in the literature. Acute stress disorder in trauma survivors permits early identification of those who are at risk for developing posttraumatic stress disorder, and provides an opportunity for preventive intervention. This study1 compared the relative efficacy of prolonged exposure (PE; N=14), prolonged exposure combined with anxiety management through stress inoculation training (PE/SIT; N=15), and supportive counseling (SC; N=16) in preventing development of PTSD. Patients were given 5 treatment sessions within two weeks of their trauma. At the end of the treatment phase, and at 6 month follow-up, there were fewer cases of PTSD in the PE and PE/SIT groups than in the SC group. The slide on Brief Prevention, along with this study, suggest that treatments that encourage more trauma processing accelerate recovery more than treatment than do not address the trauma. Addressing the PTSD symptoms and discussing them in several meetings is also helpful. The studies so far have involved only small sample sizes, and we still have much to learn. However, the data presented is what�s in the literature.

30. Summary: Stage-Based Pharmacotherapy for PTSD: Shalev, 2000 First hours: reduce terror, fear conditioning Adrenergic blockers (Pitman 2000; Vaiva 2003) First days: reduce sensitization, memory consolidation Adrenergic blockers, mood stabilizers First months: reduce symptoms SSRIs and low dose trazadone for sleep After first year: reduce symptoms and comorbidity SSRIs, adrenergic blockers, mood stabilizers

31. Summary: Recommendations for the Immediate Management of Trauma Victims: First Hours Move to safety Debriefing: low arousal, facilitate cognitive processing Education and support Screening for risk factors and follow Propranolol for persistent anxiety Low dose trazadone for sleep Anxiety management therapy: deep diaphragmatic breathing, progressive muscle relaxation

32. Factors of Resilience Seeking support Seeking purpose in life Belief in ability of self to overcome adversity and to influence events and outcomes Belief one can learn from and grow from experience Self enhancement Repressive coping Positive emotion laughter

33. Altruism Bonding Cooperation Optimism Contingency planning Reframing Revisiting Factors of Resilience

34. Self Healing from Trauma Seek Safety and Support. Talk about your trauma with those who are supportive. Translate feelings into words. Action, move beyond your restricted sphere. Use Altruism as a way to movebeyond your trauma. Re-visit the scene of the trauma. Re-live it with new eyes. Research the event. Re-write the story of what happened in a more realistic way Transform yourself from victim into survivor. Transform society to make it a better place