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)

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Historical Timeline of the Development of
Concepts of Psychological Trauma
1830184018501860187018801890190019101920
19301940195019601970198019902000

• 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
  characterdefeat 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
  Lets do it better this time.

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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

2020 1. Ischemic heart disease 2. Major
depression 3. Road traffic accidents
4. Cerebrovascular 5. COPD 8. War 12. Violence
Murray and Lopez. Lancet. 19973491498.
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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

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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 122 less than 40 of these veterans
  spontaneously sought treatment for their
  disorders.

Hoge et al (2004). Combat duty in Iraq and
Afghanistan, mental health problems, and barriers
to care. New England Journal of Medicine 351,
13-22.
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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

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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.

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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?

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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.

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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
• [phone]

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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

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Stress and Psychopathology
Stress may lead to a range of outcomes that do
not have validity as discrete constructs These
trauma-related disorders have been termed Trauma
Spectrum Disorders From Bremner JD Does Stress
Damage the Brain? Understanding Trauma-related
Disorders from a Mind-Body Perspective. New
York W. W. Norton, 2002.
Foreshortened future (suicidality)
Alcohol/substance abuse (self destructiveness)
avoidance
Panic Somatization Eating Disorders
Decreased Concentration
Sleep disturbance
Feeling cut off (flat affect)
flashbacks (depersonalization, derealization)
Hyperarousal, hypervigilance (agitation)
startle
Intrusive memories (ruminations)
amnesia
nightmares
Feeling worse with reminders (Depressed mood)
Identity disturbance (dissociative identity d.o.)
Decreased interest
Genetics, prior stressors
Numbing (anhedonia)
Dissociative Disorders
PTSD
BPD
depression
Stress
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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.

Bremner et al., Am. J. Psychiatry 1995
152973-981 Bremner et al., Biol. Psychiatry
1997 4123-32
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Deficits in Verbal Memory inCombat-Related PTSD
plt.05


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Medial Prefrontal Cortical Dysfunction with
Traumatic Memories in PTSD
Medial PFC (BA 25)
AC (BA32)
Decreased function in medial prefrontal cortical
areas Anterior Cingulate BA 25, BA 32 in veterans
with PTSD compared to Veterans without PTSD
during viewing of combat-related slides
sounds Z score gt3.00 plt.001
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Increased Blood Flow with Fear Acquisition versus
Control in Abuse-related PTSD
Orbitofrontal Cortex
Superior Temporal Gyrus
Left Amygdala
Yellow areas represent areas of relatively
greater increase in blood flow with paired vs.
unpaired US-CS in PTSD women alone, zgt3.09
plt0.001
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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)

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Effects of Stress on Myocardial Ischemia
20
Stress Induced Ischemia in a Representative
Subject with Depression and Trauma
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Neural Correlates of Stress in CHD Patients with
Depression versus CHD Patients without Depression
Right hippocampus
Anterior cingulate
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Controlled Trials in PTSDMore Effective Than
Placebo

• Paroxetine for civilians and veterans (N551)1
• Sertraline for mostly civilians (N208)2
• Sertraline for mostly civilians (N187)3
• Fluoxetine for civilians (N53)4
• Fluoxetine for civilians and veterans (N64)5
• Amitriptyline for veterans (N46)6
• Phenelzine for veterans (N34)7 (N60)8
• Imipramine for veterans7,8
• Brofaromine for civilians and veterans with PTSD
  gt1 year (N45)9

1Marshall et al 2001 2Davidson et al, 2001
3Brady et al, 2000 4Connor et al, 1999 5van der
Kolk et al, 1994 6Davidson et al, 1990 7Frank
et al, 1988 8Kosten et al, 1991 9Katz et al,
1995
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Increased Hippocampal Volume With Paxil in PTSD
plt.05


Effects of 9-12 months of treatment with 10-40 mg
paroxetine. Vermetten et al. Biol Psychiatry.
2003.
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Effects of Phenytoin onBrain Structure in PTSD

plt.05

• Phenytoin resulted in a significant increase in
  right brain volume similar increases in
  hippocampal volume were seen but not significant
  after controlling for changes in whole brain
  volume
• Bremner et al 2005 J Psychopharmacology

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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

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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

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Effects of Psychological Debriefing (PD) on MVA
Victimswith High and Low Initial Impact of Event
Scale (IES)
Randomized
Controlled Trial
IES
Mayou et al. Br J Psychiatry. 2001178182-183
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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

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Prolonged Exposure, Stress Inoculation Training
and Supportive Counseling for Acute Stress
Disorder
Motor Vehicle Accident/Assault Victims with Acute
Stress Disorder
Impact of Event Scale
Bryant RA, et al. Am J Psychiatry.
19991561780-1786.
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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

Shalev AY, Bonne E. In Shalev AY et al, eds.
International Handbook of Human Response to
Trauma. New York, NY Klumer/Plenum Publishers
1999.
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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

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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

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Factors of Resilience

• Altruism
• Bonding
• Cooperation
• Optimism
• Contingency planning
• Reframing
• Revisiting

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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