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The mental health risks associated


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with military conflicts include posttraumatic stress disorder (PTSD), substance abuse, impaired social function, and major depression. Hoge and colleagues (2004) assessed the perceived need for mental health care and perceived barriers to treatment among U.S. military combatants. Questionnaires were given to soldiers and Marines returning from combat in Iraq or Afghanistan within several months of their repatriation; 60% of soldiers from selected military units were available to attend recruitment study briefings. The rate of missing data items was less than 15% of the returned surveys. The presence of PTSD was assessed using a standardized 17-item checklist. Respondents were assessed also for stress, emotional problems, difficulty with alcohol abuse, and other family problems. Participants who returned from Iraq reported higher rates of combat experience than did those who returned from Afghanistan. The frequency of PTSD increased by a factor of 2.0 to 2.5 among participants returning from Iraq, compared with baseline evaluations before deployment. Depression and alcohol misuse also were significantly more frequent among soldiers after deployment. The increase in PTSD was directly related to the number of firefights experienced during deployment and also with having been wounded or injured. Among those who met criteria for a mental disorder, only 23-40% reported having received professional help. A slightly higher percentage were interested in receiving help. The most common reason for not seeking help was concern regarding possible stigmatization if care was sought.


The sampling time of the study is important, as it is known that PTSD is most likely to appear within the first 3 months after a traumatic event. Previous war-related surveys that allow years between combat and assessment of PTSD are inadequate. The authors suggest that screening for PTSD should be added to screening for major depression in military primary care settings.


In an accompanying editorial, Friedman (2004) points out that this is the first early assessment of war-related psychiatric disorders during an ongoing military conflict. The use of baseline assessment tools prior to deployment helps assess both pre- and postdeployment frequency of mental health difficulties. The fear of stigmatization appears to prevent active-duty military personnel from seeking mental health care assistance. It is possible that estimates of PTSD frequency from this study are low because the final assessment at 3 months may be too early to measure the final magnitude of the combat experience on estimates of PTSD. Therapy for PTSD may include serotonin-reuptake inhibitors or cognitive-behavioral treatment. It will be necessary in the future to ensure strict confidentiality regarding the use of military health care services by soldiers to overcome the fear of stigmatization. Steps need to be taken to provide effective mental health treatment to combatant soldiers along with safeguards for confidentiality.

Friedman MJ: Acknowledging the psychiatric cost of war. N Engl J Med 351:75, 2004  [PubMed: 15229311]
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