Mental Health Care Needs among Recent War Veterans
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《新英格兰医药杂志》
Fifteen percent or more of some populations of veterans of the Vietnam War and the 1991 Gulf War have received diagnoses of post-traumatic stress disorder (PTSD).1,2 Given this history and the fact that U.S. troops in Iraq and Afghanistan are serving for prolonged periods in a hazardous combat environment, we expect the mental health care needs of our newest veterans to be great. In a survey of 3671 Army soldiers and Marines who were involved in combat in Iraq and Afghanistan, up to 17 percent of those returning reported symptoms consistent with major depression, generalized anxiety, or PTSD.3
Since October 2003, the Department of Defense has been sending the Department of Veterans Affairs (VA) information about troops who have become eligible for VA benefits after active duty in Iraq and Afghanistan. The roster is used to check the VA's electronic patient records, in which the standard diagnostic codes are used to classify health problems. (The data available for this analysis are mainly administrative, however, and are not based on a careful review of each patient record or a confirmation of each diagnosis.)
As of mid-February 2005, these veterans numbered 244,054, and 20 percent of them (48,733) had received health care at a VA facility since returning home. Although these veterans do not represent a random sample of all deployed troops, their use of health care offers some indication of what to expect as more troops return.
Combat veterans have presented with a variety of conditions. The most common diagnoses involve the musculoskeletal system and the digestive system, in 36 percent and 28 percent of evaluated veterans, respectively. Possible mental disorders have been reported in 26 percent. The most common diagnoses were adjustment disorders, among them PTSD — a possible diagnosis of which was recorded in 10 percent of these patients.
Whereas the frequency of cardiovascular illness (to take one physical disorder) has remained steady, the frequency of mental health problems has increased (see graph). It is uncertain whether this change represents a true increase in the number of veterans with a mental disorder, a self-referral bias, or an ascertainment bias. War veterans are eligible for two years of free health care from the VA for any condition that may be related to combat, and VA clinicians receive reminders to evaluate veterans for war-related mental disorders.
Mental Health and Cardiovascular Disorders among Veterans of Iraq and Afghanistan Treated at the VA through 2004.
The proportion of patients with possible PTSD did not vary substantially according to sex, race, or age, but there were significant differences according to characteristics of military service: the proportion of patients reported to have PTSD was 3.7 times as high among those who served in ground units of the Army or Marines as among members of the Navy or Air Force (11 percent vs. 3 percent), and rates were twice as high among members of the enlisted ranks as among officers (10 percent vs. 5 percent). Proportions were similar among veterans from the Reserve or the National Guard and members of active-duty units (10 percent and 9 percent, respectively). These data suggest that the level of exposure to combat predicts the risk of a mental disorder.
The influx of veterans with possible mental disorders underscores the need to plan for increased mental health care. Of course, only well-designed epidemiologic studies can definitively answer questions about the risk of psychiatric problems in this population. Until such studies are performed, we should be wary of generalizing, because erroneously portraying these veterans as ill would add to the substantial challenges they face in reentering civilian society. Moreover, even with such studies, the projections of future needs will be imprecise, since we cannot predict the duration of the conflicts, the level of violence that will be maintained, or the total number of troops that will be deployed.
The opinions expressed in this article are those of the authors and do not necessarily reflect the views of the U.S. government or the Department of Veterans Affairs.
Source Information
Dr. Kang is the director of the War-Related Illness and Injury Study Center, Department of Veterans Affairs, and Dr. Hyams is the chief consultant for occupational and environmental health at the Department of Veterans Affairs Central Office — both in Washington, D.C.
References
Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War generation: report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel, 1990.
Kang HK, Natelson BH, Mahan CM, Lee KY, Murphy FM. Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: a population-based survey of 30,000 veterans. Am J Epidemiol 2003;157:141-148.
Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.(Han K. Kang, Dr.P.H., and)
Since October 2003, the Department of Defense has been sending the Department of Veterans Affairs (VA) information about troops who have become eligible for VA benefits after active duty in Iraq and Afghanistan. The roster is used to check the VA's electronic patient records, in which the standard diagnostic codes are used to classify health problems. (The data available for this analysis are mainly administrative, however, and are not based on a careful review of each patient record or a confirmation of each diagnosis.)
As of mid-February 2005, these veterans numbered 244,054, and 20 percent of them (48,733) had received health care at a VA facility since returning home. Although these veterans do not represent a random sample of all deployed troops, their use of health care offers some indication of what to expect as more troops return.
Combat veterans have presented with a variety of conditions. The most common diagnoses involve the musculoskeletal system and the digestive system, in 36 percent and 28 percent of evaluated veterans, respectively. Possible mental disorders have been reported in 26 percent. The most common diagnoses were adjustment disorders, among them PTSD — a possible diagnosis of which was recorded in 10 percent of these patients.
Whereas the frequency of cardiovascular illness (to take one physical disorder) has remained steady, the frequency of mental health problems has increased (see graph). It is uncertain whether this change represents a true increase in the number of veterans with a mental disorder, a self-referral bias, or an ascertainment bias. War veterans are eligible for two years of free health care from the VA for any condition that may be related to combat, and VA clinicians receive reminders to evaluate veterans for war-related mental disorders.
Mental Health and Cardiovascular Disorders among Veterans of Iraq and Afghanistan Treated at the VA through 2004.
The proportion of patients with possible PTSD did not vary substantially according to sex, race, or age, but there were significant differences according to characteristics of military service: the proportion of patients reported to have PTSD was 3.7 times as high among those who served in ground units of the Army or Marines as among members of the Navy or Air Force (11 percent vs. 3 percent), and rates were twice as high among members of the enlisted ranks as among officers (10 percent vs. 5 percent). Proportions were similar among veterans from the Reserve or the National Guard and members of active-duty units (10 percent and 9 percent, respectively). These data suggest that the level of exposure to combat predicts the risk of a mental disorder.
The influx of veterans with possible mental disorders underscores the need to plan for increased mental health care. Of course, only well-designed epidemiologic studies can definitively answer questions about the risk of psychiatric problems in this population. Until such studies are performed, we should be wary of generalizing, because erroneously portraying these veterans as ill would add to the substantial challenges they face in reentering civilian society. Moreover, even with such studies, the projections of future needs will be imprecise, since we cannot predict the duration of the conflicts, the level of violence that will be maintained, or the total number of troops that will be deployed.
The opinions expressed in this article are those of the authors and do not necessarily reflect the views of the U.S. government or the Department of Veterans Affairs.
Source Information
Dr. Kang is the director of the War-Related Illness and Injury Study Center, Department of Veterans Affairs, and Dr. Hyams is the chief consultant for occupational and environmental health at the Department of Veterans Affairs Central Office — both in Washington, D.C.
References
Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War generation: report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel, 1990.
Kang HK, Natelson BH, Mahan CM, Lee KY, Murphy FM. Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: a population-based survey of 30,000 veterans. Am J Epidemiol 2003;157:141-148.
Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.(Han K. Kang, Dr.P.H., and)