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PTSD after deployment to Iraq: conflicting rates, conflicting claims

Published online by Cambridge University Press:  12 August 2009

J. Sundin*
Affiliation:
Academic Centre for Defence Mental Health, Department of Psychological Medicine, Institute of Psychiatry, King's College London, London, UK
N. T. Fear
Affiliation:
Academic Centre for Defence Mental Health, Department of Psychological Medicine, Institute of Psychiatry, King's College London, London, UK
A. Iversen
Affiliation:
King's Centre for Military Health Research, Department of Psychological Medicine, Institute of Psychiatry, King's College London, London, UK
R. J. Rona
Affiliation:
King's Centre for Military Health Research, Department of Psychological Medicine, Institute of Psychiatry, King's College London, London, UK
S. Wessely
Affiliation:
King's Centre for Military Health Research, Department of Psychological Medicine, Institute of Psychiatry, King's College London, London, UK
*
*Address for correspondence: Miss J. Sundin, Academic Centre for Defence Mental Health, Weston Education Centre, 10 Cutcombe Road, London SE5 9RJ, UK. (Email: Josefin.sundin@kcl.ac.uk)

Abstract

Background

Post-traumatic stress disorder (PTSD) has been called one of the signature injuries of the Iraq War. In this review prevalence estimates of PTSD are summarized and discrepancies are discussed in relation to methodological differences between studies.

Method

We searched for population-based studies with a minimum sample size of 300. Studies based on help-seeking samples were excluded. We identified 60 possible papers, of which 19 fulfilled the inclusion criteria. Prevalence estimates and study characteristics were examined graphically with forest plots, but because of high levels of heterogeneity between studies, overall estimates of PTSD prevalence were not discussed.

Results

The prevalence of PTSD in personnel deployed to Iraq varied between 1.4% and 31%. Stratifying studies by PTSD measure only slightly reduced the variability in prevalence. Anonymous surveys of line infantry units reported higher levels of PTSD compared to studies that are representative of the entire deployed population. UK studies tend to report lower prevalence of PTSD compared with many US studies; however, when comparisons are restricted to studies with random samples, prevalences are similar. US studies that have assessed personnel more than once since return from deployment have shown that PTSD prevalence increases over the 12 months following deployment.

Conclusions

Differences in methodologies and samples used should be considered when making comparisons of PTSD prevalence between studies. Further studies based on longitudinal samples are needed to understand how the prevalence of PTSD changes over time.

Type
Review Article
Copyright
Copyright © Cambridge University Press 2009

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References

Bliese, PD, Wright, KM, Adler, AB, Thomas, JL, Hoge, CW (2007). Timing of postcombat mental health assessments. Psychological Services 4, 141148.CrossRefGoogle Scholar
Boyle, MH (1998). Guidelines for evaluating prevalence studies. Evidence-Based Mental Health 1, 3739.CrossRefGoogle Scholar
Browne, T, Hull, L, Horn, O, Jones, M, Murphy, D, Fear, NT, Greenberg, N, French, C, Rona, RJ, Wessely, S, Hotopf, M (2007). Explanations for the increase in mental health problems in UK reserve forces who have served in Iraq. British Journal of Psychiatry 190, 484489.CrossRefGoogle ScholarPubMed
Cabrera, OA, Hoge, CW, Bliese, PD, Castro, CA, Messer, SC (2007). Childhood adversity and combat as predictors of depression and post-traumatic stress in deployed troops. American Journal of Preventive Medicine 33, 7782.CrossRefGoogle ScholarPubMed
Carlson, EB (2001). Psychometric study of a brief screen for PTSD: assessing the impact of multiple traumatic events. Assessment 8, 431441.CrossRefGoogle ScholarPubMed
Caspi, Y, Carlson, EB, Klein, E (2007). Validation of a screening instrument for posttraumatic stress disorder in a community sample of Bedouin men serving in the Israeli defense forces. Journal of Traumatic Stress 20, 517527.CrossRefGoogle Scholar
Castro, CA, McGurk, D (2007). The intensity of combat and behavioural health status. Traumatology 13, 6–23.CrossRefGoogle Scholar
CDC (1988). Health status of Vietnam veterans. I. Psychosocial characteristics. The Centers for Disease Control Vietnam Experience Study. Journal of the American Medical Association 259, 27012707.CrossRefGoogle Scholar
Dohrenwend, BP, Turner, JB, Turse, NA, Adams, BG, Koenen, KC, Marshall, R (2006). The psychological risks of Vietnam for U.S. veterans: a revisit with new data and methods. Science 313, 979982.CrossRefGoogle ScholarPubMed
Engelhard, IM, Huijding, J, van den Hout, MA, de Jong, PJ (2007 a). Vulnerability associations and symptoms of post-traumatic stress disorder in soldiers deployed to Iraq. Behaviour Research and Therapy 45, 23172325.CrossRefGoogle ScholarPubMed
Engelhard, IM, van den Hout, MA (2007). Preexisting neuroticism, subjective stressor severity, and posttraumatic stress in soldiers deployed to Iraq. Canadian Journal of Psychiatry 52, 505509.CrossRefGoogle ScholarPubMed
Engelhard, IM, van den Hout, MA, McNally, RJ (2008). Memory consistency for traumatic events in Dutch soldiers deployed to Iraq. Memory 16, 39.CrossRefGoogle ScholarPubMed
Engelhard, IM, van den Hout, MA, Weerts, J, Arntz, A, Hox, JJ, McNally, RJ (2007 b). Deployment-related stress and trauma in Dutch soldiers returning from Iraq. Prospective study. British Journal of Psychiatry 191, 140145.CrossRefGoogle ScholarPubMed
Erbes, C, Westermeyer, J, Engdahl, B, Johnsen, E (2007). Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan. Military Medicine 172, 359363.CrossRefGoogle Scholar
Felker, B, Hawkins, E, Dobie, D, Gutierrez, J, McFall, M (2008). Characteristics of deployed Operation Iraqi Freedom military personnel who seek mental health care. Military Medicine 173, 155158.CrossRefGoogle ScholarPubMed
Fontana, A, Rosenheck, R (2008). Treatment-seeking veterans of Iraq and Afghanistan: comparison with veterans of previous wars. Journal of Nervous and Mental Disease 196, 513521.CrossRefGoogle ScholarPubMed
French, C, Dandeker, C, Greenberg, N, Hatch, S, Riley, P, van Staden, L, Wessely, S (in press). Laying down their rifles: the changing influences on retention of Volunteer British Army Reservists returning from Iraq. Armed Forces and Society.Google Scholar
French, C, Rona, RJ, Jones, M, Wessely, S (2004). Screening for physical and psychological illness in the British Armed Forces. II: Barriers to screening – learning from the opinions of Service personnel. Journal of Medical Screening 11, 153157.CrossRefGoogle ScholarPubMed
Gahm, GA, Lucenko, BA, Retzlaff, P, Fukuda, S (2007). Relative impact of adverse events and screened symptoms of posttraumatic stress disorder and depression among active duty soldiers seeking mental health care. Journal of Clinical Psychology 63, 199211.CrossRefGoogle ScholarPubMed
Gray, GC, Reed, RJ, Kaiser, KS, Smith, TC, Gastanaga, VM (2002). Self-reported symptoms and medical conditions among 11,868 Gulf War-era veterans: the Seabee Health Study. American Journal of Epidemiology 155, 10331044.CrossRefGoogle Scholar
Grieger, TA, Cozza, SJ, Ursano, RJ, Hoge, C, Martinez, PE, Engel, CC, Wain, HJ (2006). Posttraumatic stress disorder and depression in battle-injured soldiers. American Journal of Psychiatry 163, 17771783.CrossRefGoogle ScholarPubMed
Helmer, DA, Rossignol, M, Blatt, M, Agarwal, R, Teichman, R, Lange, G (2007). Health and exposure concerns of veterans deployed to Iraq and Afghanistan. Journal of Occupational and Environmental Medicine 49, 475480.CrossRefGoogle ScholarPubMed
Higgins, JP, Thompson, SG, Deeks, JJ, Altman, DG (2003). Measuring inconsistency in meta-analyses. British Medical Journal 327, 557560.CrossRefGoogle ScholarPubMed
Hoge, CW, Auchterlonie, JL, Milliken, CS (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association 295, 10231032.CrossRefGoogle ScholarPubMed
Hoge, CW, Castro, CA (2006). Post-traumatic stress disorder in UK and US forces deployed to Iraq. Lancet 368, 837.CrossRefGoogle ScholarPubMed
Hoge, CW, Castro, CA, Messer, SC, McGurk, D, Cotting, DI, Koffman, RL (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351, 1322.CrossRefGoogle ScholarPubMed
Hoge, CW, Terhakopian, A, Castro, CA, Messer, SC, Engel, CC (2007). Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. American Journal of Psychiatry 164, 150153.CrossRefGoogle ScholarPubMed
Hotopf, M, Hull, L, Fear, NT, Browne, T, Horn, O, Iversen, A, Jones, M, Murphy, D, Bland, D, Earnshaw, M, Greenberg, N, Hacker Hughes, J, Tate, AR, Dandeker, C, Rona, RJ, Wessely, S (2006). The health of UK military personnel who deployed to the 2003 Iraq war: a cohort study. Lancet 367, 17311741.CrossRefGoogle Scholar
HPA&E (2006). 2003–2004 Active Duty Health Study. Revised by Health Program Analysis & Evaluation (HPA&E). TRICARE Management Activity: Falls Church, VA.Google Scholar
Iversen, AC, Fear, NT, Ehlers, A, Hacker Hughes, J, Hull, L, Earnshaw, M, Greenberg, N, Rona, RJ, Wessely, S, Hotopf, M (2008). Risk factors for post-traumatic stress disorder among UK Armed Forces personnel. Psychological Medicine 38, 511522.CrossRefGoogle ScholarPubMed
Jakupcak, M, Conybeare, D, Phelps, L, Hunt, S, Holmes, HA, Felker, B, Klevens, M, McFall, ME (2007). Anger, hostility, and aggression among Iraq and Afghanistan War veterans reporting PTSD and subthreshold PTSD. Journal of Traumatic Stress 20, 945954.CrossRefGoogle ScholarPubMed
Jakupcak, M, Luterek, J, Hunt, S, Conybeare, D, McFall, M (2008). Posttraumatic stress and its relationship to physical health functioning in a sample of Iraq and Afghanistan War veterans seeking postdeployment VA health care. Journal of Nervous and Mental Disease 196, 425428.CrossRefGoogle Scholar
Jones, E, Wessely, S (2007). A paradigm shift in the conceptualization of psychological trauma in the 20th century. Journal of Anxiety Disorders 21, 164175.CrossRefGoogle Scholar
Jones, M, Fear, NT, Greenberg, N, Jones, N, Hull, L, Hotopf, M, Wessely, S, Rona, RJ (2008). Do medical services personnel who deployed to the Iraq war have worse mental health than other deployed personnel? European Journal of Public Health 18, 422427.CrossRefGoogle Scholar
Kang, HK, Hyams, KC (2005). Mental health care needs among recent war veterans. New England Journal of Medicine 352, 1289.CrossRefGoogle ScholarPubMed
Kolkow, TT, Spira, JL, Morse, JS, Grieger, TA (2007). Post-traumatic stress disorder and depression in health care providers returning from deployment to Iraq and Afghanistan. Military Medicine 172, 451455.CrossRefGoogle ScholarPubMed
Kulka, R, Schlenger, W, Fairbank, J, Hough, R, Jordan, B, Marmar, R, Weiss, D (1988). Contractual report of findings from the National Vietnam Veterans Readjustment Study, vol. 1. Veterans Administration: Washington, DC.Google Scholar
Lapierre, CB, Schwegler, AF, Labauve, BJ (2007). Posttraumatic stress and depression symptoms in soldiers returning from combat operations in Iraq and Afghanistan. Journal of Traumatic Stress 20, 933943.CrossRefGoogle ScholarPubMed
Larson, GE, Highfill-McRoy, RM, Booth-Kewley, S (2008). Psychiatric diagnoses in historic and contemporary military cohorts: combat deployment and the healthy warrior effect. American Journal of Epidemiology 167, 12691276.CrossRefGoogle ScholarPubMed
LeardMann, CA, Smith, TC, Smith, B, Wells, TS, Ryan, MAK, Millennium Cohort Study Team (2009). Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: prospective US military cohort study. British Medical Journal 338, b1273.CrossRefGoogle ScholarPubMed
Martin, CB (2007). Routine screening and referrals for post-traumatic stress disorder (PTSD) after returning from Operation Iraqi Freedom in 2005, US Armed Forces. Medical Surveillance Monthly Report 14, 27.Google Scholar
McDonald, SD, Beckham, JC, Morey, R, Marx, C, Tupler, LA, Calhoun, PS (2008). Factorial invariance of posttraumatic stress disorder symptoms across three veteran samples. Journal of Traumatic Stress 21, 309317.CrossRefGoogle ScholarPubMed
McGhee, LL, Maani, CV, Garza, TH, Desocio, PA, Gaylord, KM, Black, IH (2009). The effect of propranolol on posttraumatic stress disorder in burned service members. Journal of Burn Care and Research 30, 9297.CrossRefGoogle ScholarPubMed
McGhee, LL, Maani, CV, Garza, TH, Gaylord, KM, Black, IH (2008). The correlation between ketamine and posttraumatic stress disorder in burned service members. Journal of Trauma: Injury, Infection, and Critical Care 64, S195S198.Google ScholarPubMed
McLay, RN, Deal, WE, Murphy, JA, Center, KB, Kolkow, TT, Grieger, TA (2008). On-the-record screenings versus anonymous surveys in reporting PTSD. American Journal of Psychiatry 165, 775776.CrossRefGoogle ScholarPubMed
MHAT (2003). Mental Health Advisory Team (MHAT) report from Operation Iraqi Freedom. Chartered by the Office of the Surgeon General United States Army Medical Command and HQDA G-1. Washington, D.C.Google Scholar
MHAT-II (2004). Mental Health Advisory Team II (MHAT-II) report from Operation Iraqi Freedom II. Chartered by the Office of the Surgeon General Multinational Forces-Iraq and Office of the Surgeon General United States Army Medical Command. Washington, D.C.Google Scholar
MHAT-III (2006). Mental Health Advisory Team III (MHAT-III) report from Operation Iraqi Freedom 04–06. Chartered by the Office of the Surgeon General Multinational Forces-Iraq and Office of the Surgeon General United States Army Medical Command. Washington, D.C.Google Scholar
MHAT-V (2008). Mental Health Advisory Team V (MHAT-V) report from Operation Iraqi Freedom 06–08 and Operation Enduring Freedom 8. Chartered by the Office of the Surgeon General Multinational Forces-Iraq and Office of the Surgeon General United States Army Medical Command. Washington, D.C.Google Scholar
Milliken, CS, Auchterlonie, JL, Hoge, CW (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. Journal of the American Medical Association 298, 21412148.CrossRefGoogle ScholarPubMed
Peterson, AL, Baker, MT, McCarthy, KR (2008). Combat stress casualties in Iraq. Part 2: Psychiatric screening prior to aeromedical evacuation. Perspectives in Psychiatric Care 44, 159168.CrossRefGoogle ScholarPubMed
Petitti, DB (2001). Approaches to heterogeneity in meta-analysis. Statistics in Medicine 20, 36253633.CrossRefGoogle ScholarPubMed
Pietrzak, RH, Johnson, DC, Goldstein, MB, Malley, JC, Rivers, AJ, Morgan, CA, Southwick, SM (2009 a). Psychosocial buffers of traumatic stress, depressive symptoms, and psychosocial difficulties in veterans of Operations Enduring Freedom and Iraqi Freedom: the role of resilience, unit support, and postdeployment social support. Journal of Affective Disorders. Published online: 20 March 2009. doi:10.1002/da.20558.Google ScholarPubMed
Pietrzak, RH, Johnson, DC, Goldstein, MB, Malley, JC, Southwick, SM (2009 b). Psychological resilience and postdeployment social support protect against traumatic stress and depressive symptoms in soldiers returning from Operations Enduring Freedom and Iraqi Freedom. Depression and Anxiety. Published online: 13 May 2009. doi:10.1016/j.jad.2009.04.015.CrossRefGoogle ScholarPubMed
Renshaw, KD, Rodrigues, CS, Jones, DH (2009). Combat exposure, psychological symptoms, and marital satisfaction in National Guard soldiers who served in Operation Iraqi Freedom from 2005 to 2006. Anxiety, Stress and Coping 22, 101115.CrossRefGoogle ScholarPubMed
Riddle, MS, Sanders, JW, Jones, JJ, Webb, SC (2008). Self-reported combat stress indicators among troops deployed to Iraq and Afghanistan: an epidemiological study. Comprehensive Psychiatry 49, 340345.CrossRefGoogle ScholarPubMed
Rona, RJ, Hooper, R, Jones, M, Hull, L, Browne, T, Horn, O, Murphy, D, Hotopf, M, Wessely, S (2006). Mental health screening in armed forces before the Iraq war and prevention of subsequent psychological morbidity: follow-up study. British Medical Journal 333, 991996.CrossRefGoogle ScholarPubMed
Rona, RJ, Hooper, R, Jones, M, Iversen, AC, Hull, L, Murphy, D, Hotopf, M, Wessely, S (2009 a). The contribution of prior psychological symptoms and combat exposure to post Iraq deployment mental health in the UK military. Journal of Traumatic Stress 22, 1119.CrossRefGoogle ScholarPubMed
Rona, RJ, Jones, M, Iversen, A, Hull, L, Greenberg, N, Fear, NT, Hotopf, M, Wessely, S (2009 b). The impact of posttraumatic stress disorder on impairment in the UK military at the time of the Iraq war. Journal of Psychiatric Research 43, 649655.CrossRefGoogle ScholarPubMed
Rosenheck, RA, Fontana, AF (2007). Recent trends in VA treatment of post-traumatic stress disorder and other mental disorders. Health Affairs 26, 17201727.CrossRefGoogle ScholarPubMed
Rundell, JR (2006). Demographics of and diagnoses in Operation Enduring Freedom and Operation Iraqi Freedom personnel who were psychiatrically evacuated from the theater of operations. General Hospital Psychiatry 28, 352356.CrossRefGoogle ScholarPubMed
Schell, T, Marshall, G (2008). Survey of individuals previously deployed for OEF/OIF. In Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery (ed. Tanielian, T. and Jaycox, L.). RAND Corporation: Washington, D.C.Google Scholar
Schneiderman, AI, Braver, ER, Kang, HK (2008). Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: persistent postconcussive symptoms and posttraumatic stress disorder. American Journal of Epidemiology 167, 14461452.CrossRefGoogle ScholarPubMed
Seal, KH, Bertenthal, D, Maguen, S, Gima, K, Chu, A, Marmar, CR (2008). Getting beyond ‘Don't ask; don't tell’: an evaluation of US Veterans Administration postdeployment mental health screening of veterans returning from Iraq and Afghanistan. American Journal of Public Health 98, 714720.CrossRefGoogle ScholarPubMed
Seal, KH, Bertenthal, D, Miner, CR, Sen, S, Marmar, C (2007). Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine 167, 476482.CrossRefGoogle Scholar
Shen, YC, Arkes, J, Pilgrim, J (2009). The effects of deployment intensity on post-traumatic stress disorder: 2002–2006. Military Medicine 174, 217223.CrossRefGoogle ScholarPubMed
Smith, TC, Ryan, MA, Wingard, DL, Slymen, DJ, Sallis, JF, Kritz-Silverstein, D (2008 a). New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study. British Medical Journal 336, 366371.CrossRefGoogle ScholarPubMed
Smith, TC, Wingard, DL, Ryan, MA, Kritz-Silverstein, D, Slymen, DJ, Sallis, JF (2008 b). Prior assault and posttraumatic stress disorder after combat deployment. Epidemiology 19, 505512.CrossRefGoogle ScholarPubMed
Smith, TC, Wingard, DL, Ryan, MAK, Kritz-Silverstein, D, Slymen, DJ, Sallis, JF; Millennium Cohort Study Team (2009). PTSD prevalence, associated exposures, and functional health outcomes in a large, population-based military cohort. Public Health Reports 124, 90102.CrossRefGoogle Scholar
Tanielian, T, Jaycox, L (2008). Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. RAND Corporation: Washington, D.C.Google Scholar
Terhakopian, A, Sinaii, N, Engel, CC, Schnurr, PP, Hoge, CW (2008). Estimating population prevalence of posttraumatic stress disorder: an example using the PTSD checklist. Journal of Traumatic Stress 21, 290300.CrossRefGoogle ScholarPubMed
Thompson, SG, Higgins, JPT (2002). How should meta-regression analyses be undertaken and interpreted? Statistics in Medicine 21, 15591573.CrossRefGoogle ScholarPubMed
Turner, SW, Bowie, C, Dunn, G, Laidon, S, Yule, W (2003). Mental health of Kosovan Albanian refugees in the UK. British Journal of Psychiatry 182, 444448.CrossRefGoogle ScholarPubMed
Turner, MA, Kiernan, MD, McKechanie, AG, Finch, PJC, McManus, FB, Neal, LA (2005). Acute military psychiatric casualties from the war in Iraq. British Journal of Psychiatry 186, 476479.CrossRefGoogle ScholarPubMed
Vasterling, JJ, Proctor, SP, Amoroso, P, Kane, R, Heeren, T, White, RF (2006). Neuropsychological outcomes of army personnel following deployment to the Iraq war. Journal of the American Medical Association 296, 519529.CrossRefGoogle Scholar
Vasterling, JJ, Schumm, J, Proctor, SP, Gentry, E, King, DW, King, LA (2008). Posttraumatic stress disorder and health functioning in a non-treatment-seeking sample of Iraq war veterans: a prospective analysis. Journal of Rehabilitation Research and Development 45, 347358.CrossRefGoogle Scholar
Vogt, DS, Samper, RE, King, DW, King, LA, Martin, JA (2008). Deployment stressors and posttraumatic stress symptomatology: comparing active duty and National Guard/Reserve personnel from Gulf War I. Journal of Traumatic Stress 21, 6674.CrossRefGoogle ScholarPubMed
Wilson, J, Jones, M, Fear, NT, Hull, L, Hotopf, M, Wessely, S, Rona, RJ (2009). Is previous psychological health associated with the likelihood of Iraq War deployment? An investigation of the ‘healthy warrior effect’. American Journal of Epidemiology 169, 13621369.CrossRefGoogle ScholarPubMed
Wright, KM, Bliese, PD, Thomas, JL, Adler, AB, Eckford, RD, Hoge, CW (2007). Contrasting approaches to psychological screening with U.S. combat soldiers. Journal of Traumatic Stress 20, 965975.CrossRefGoogle ScholarPubMed