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The Unique Circumstances and Mental Health Impact of the Wars in Afghanistan and Iraq

By Brett T. Litz

The wars in Afghanistan and Iraq will produce a new generation of veterans at risk for the chronic mental health problems that result, in part, from exposure to the stress, adversity, and trauma of war-zone experiences. These risks have been described and discussed repeatedly in the media and have absorbed the attention of policy makers and care providers in the Departments of Defense and Veterans Affairs. Many of the challenges soldiers face in these new wars reflect well-researched universal psychological themes of combat (e.g., life threat, killing). However, it is important to appreciate the specific demands and contexts of these new wars in order to raise the awareness of civilians back home, to prepare loved ones for soldiers' return,to estimate the need for clinical services, and to make other policy recommendations.

The wars in Afghanistan and Iraq are the most sustained combat operations since the Vietnam War. A wealth of research has shown convincingly that the frequency and intensity of exposure to combat experiences is strongly associated with the risk of chronic post-traumatic stress disorder (PTSD; APA, 1994) and related impairment (Kaylor, King, & King, 1987). As a result, there is good reason to be more concerned about the long-term mental health toll associated with these new wars than with the toll of other post-Vietnam War operations, such as the mission to Somalia (Litz, Orsillo, Friedman, Ehlich, & Batres, 1997)and the 1991 Persian Gulf War (Wolfe, Erickson, Sharkansky, King, & King, 1999). Only one comprehensive study has examined the mental health impact of the wars in Afghanistan and Iraq (Hoge et al., 2004). This study evaluated active-duty soldiers' reports of various war-zone experiences and the rates of mental health problems; the estimated risk for PTSD from service in the Iraq War was much higher than from service in the Afghanistan mission (18% vs. 11%, respectively). In both contexts, reports of combat exposure were highly associated with the risk of PTSD.

However, combat is not the exclusive source of danger, conflict, and severe stress in a war-zone; nor is it the necessary and sufficient cause of military-service-related PTSD (King, King, Foy, Keane, & Fairbank, 1999). A variety of war-zone experiences contribute to veterans' risk of chronic PTSD and impaired functioning in relationships, work, and self-care. The examination of the long-term risks for veterans of any war also requires an evaluation of the unique socio-economic-cultural contexts that dynamically shape soldiers' recovery and adaptation across the life span (Friedman, 2004; Weathers, Litz, & Keane, 1995). It is too early to definitively describe the factors that these soldiers will struggle with as they reemerge into their families, their communities, and the culture at large. The first step in the process of understanding these new wars is to appreciate the demands that soldiers face, which will affect recovery and adaptation.

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Guerilla Warfare in Urban Environments

Especially since the end of formal combat operations, the Iraq War has exposed soldiers to potentially traumatizing contexts that affect coping capacities and adaptation. The conflict in Iraq has been fraught with the dangers that ensue from guerilla warfare and terrorist actions (e.g., roadside bombs) stemming from ambiguous civilian threats (Hoge et al., 2004). In this context, there is no safe place and no safe duty, although some duties are particularly high-risk, such as patrolling dangerous areas and driving trucks. In Iraq, soldiers are required to maintain an unprecedented degree of vigilance and to respond cautiously to threats. There is great concern that soldiers will mistakenly think civilians who mean them no harm are actually combatants. Soldiers also need to be careful about possibly causing collateral damage to civilians in urban environments. The latter can cause chronic anxiety and strain (Litz et al., 1997). In Iraq, 62% of soldiers reported being in threatening situations where they were unable to respond aggressively because of the understandably constrained rules of engagement (Hoge et al., 2004). Taken together, these unique features of the war in Iraq create the conditions whereby stress hormones are released excessively, with unknown, but likely significant, consequences regarding health maintenance, restoration, and coping capacity. It is of note that although formal ground combat lasted only four days in the first Persian Gulf War, rates of chronic PTSD were surprisingly high because of the chronic stress and strain of possible chemical or biological attack (Wolfe et al., 1988).

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The Aftermath of Violence

In Iraq, the ratio of wounded to killed-in-action is the highest in United States history (Ricks, 2004). This is in part because of the type of life threats incurred (e.g., 94% of soldiers in Iraq endorsed receiving small-arms fire; Hoge et al., 2004) and the advances in protective gear and acute medical care. Soldiers in Iraq are thus not only at risk for being maimed but also for witnessing, or suffering from, the aftermath of violence. For example, 86% of soldiers in Iraq reported knowing someone who was seriously injured or killed, 68% reported seeing dead or seriously injured Americans, and 51% reported handling or uncovering human remains (Hoge et al., 2004). Witnessing the aftermath of violence and death has been shown to create risk for anxiety, anger and aggressive behavior, somatic complaints, and PTSD (McCarrol, Ursano, & Fullerton, 1997).

Witnessing mass destruction, especially the suffering of civilians, also contributes to the risk of developing PTSD (Litz et al., 1997). On the other hand, the lasting psychological consequences of causing destruction and perpetrating violence have been strikingly under-researched. For some, the shame and guilt induced by killing of any kind in combat can arguably be uniquely scarring. Hoge et al. (2004) found that 77% of soldiers deployed to Iraq reported shooting or directing fire at the enemy, 48% reported being responsible for the death of an enemy combatant, and 28% reported being responsible for the death of a noncombatant.

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Erosion of Meaning, Acceptance, and Support?

Several factors may erode morale and mission-related beliefs and attitudes: the significant human toll, the contentious nature of the extensive and extended sacrifice made by soldiers (especially national-guard and reserve troops) and their families, and concerns about whether veterans will be sufficiently taken care of when they return to the states. Public opinion and material and emotional support have been shown to affect the impact of deployment sacrifices and exposure to trauma (Bolton, Litz, Glenn, Orsillo, & Roemer, 2002; Koenen, Stellman, Stellman, & Sommer, 2003). Many soldiers may find meaning and gratification in their helper roles in Iraq and Afghanistan, however, the positive impact of humanitarian duty and nation-building can be trumped by potential threats and global support for the mission (Litz et al., 1997). Although the public support for a mission is no longer conflated with support for soldiers, as was the case with the Vietnam War, it is likely that morale and the sense of purpose have degraded since the formal combat operation ended in Iraq. However, there is no available research on the topic.

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The Trajectory of Adaptation to the Trauma of War

It is prudent to prepare to meet the mental health needs of soldiers and veterans as these needs become clear over time. Decisions about how to meet these mental health needs must be informed by empirical evidence and existing scientific literature about recovery from trauma. The Departments of Defense and Veterans Affairs have collaborated in an unprecedented fashion to conduct standardized examinations of all soldiers when they return from Iraq and Afghanistan. While this is important and laudable, any one-shot evaluation of a soldier's mental health will prove to be insufficient, especially if it is very soon after redeployment. This is because there is a wealth of evidence from longitudinal studies of trauma survivors that early distress and symptoms of PTSD are not very good predictors of long-term adaptation (Litz, Gray, Bryant, & Adler, 2002). Approximately 70% of trauma survivors who have acute stress disorder (ASD; a condition that is ostensibly PTSD and occurs within a month after exposure) go on to develop chronic PTSD; however, approximately 40% of individuals who have chronic PTSD did not initially have ASD (Bryant, 2004). Thus, although Hoge et al. (2004) reported that 18% of soldiers newly redeployed from Iraq have PTSD, a rate that is alarmingly high (their study suggests that approximately 2 out of every 10 soldiers are significantly impaired), it is important to note that the study was conducted cross-sectionally, while soldiers were still on active duty. What we can glean from existing research on adaptation to trauma is that the trajectory is fluid, and it is more likely than not that the prevalence rate will decrease over time. On the other hand, if the mission is experienced as a failure, if soldiers deploy more than once, if new veterans who need services do not get the support they need, or if postdeployment demands and stressors mount, the lasting mental health toll of the wars in Afghanistan and Iraq may increase over time.

Ultimately, many factors will affect the trajectory of soldiers' responses to trauma in the war zone over the life-course; some will maintain a chronic level of PTSD and functional impairment, some will recover to their predeployment level of homeostasis, and some will grow and mature from their experiences. Studies suggest that in the face of severe military service demands, including horrific combat, most men and women appear to do remarkably well across their life spans.

While it is true that the majority of soldiers become productive and effective veterans, even maturing and growing from their service experiences (Dohrenwend et al., 2004), it is also true that chronic postservice mental health problems, such as PTSD and associated psychosocial dysfunction, are pernicious and disabling and represent a significant public health problem. For example, veterans with PTSD are heavy service users and they have a variety of comorbid mental health and medical conditions (Beckham et al., 1998; Buckley, Mozley, Bedard, Dewulf, & Grief, in press; Kulka et al., 1990). Veterans with PTSD also manifest a variety of chronic impairments in functioning, such as unemployment and income disparities (Savoca & Rosenheck, 2000), problems in relationships (Riggs, Byrne, Weathers, & Litz, 1998), poor problem-solving capacity and aggressive behavior (McFall, Fontana, Raskind, & Rosenheck, 1999), poor self-care, and poor quality of life (Buckley et al., in press).

The most troubling aspect of military-related PTSD is its chronic course. There is evidence that once veterans manifest chronic post-traumatic adaptation difficulties, these difficulties remain chronic across the life span (Prigerson, Maciejewski, & Rosenheck, 2001) and are resistant to treatments that have been shown to work for acute trauma patients and other forms of chronic PTSD (Schnurr et al., 2003). Thus, it is vitally important to provide early intervention to reduce the risk of chronic impairment in veterans.

However, there are troubling initial signs that soldiers from the all-volunteer professional military are reluctant to seek help or help may not be readily available. For example, Hoge et al. (2004) found that although approximately 80% of Iraq and Afghanistan veterans who had a serious mental health disorder, such as PTSD, acknowledged that they had a problem, only approximately 40% stated that they were interested in receiving help. In addition, only 26% reported receiving formal mental health care. Modern career soldiers are very concerned about stigma and may be ashamed of opening themselves up to professionals. They are also very concerned about taking on a 'sick' or 'weak' persona and expect that it will negatively impact their careers.

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Risk Research

Before the diagnosis of PTSD was formulated in 1980, it was assumed that post-traumatic mental health disturbances were caused by previous developmental trauma and conflict. With the PTSD diagnosis, professionals assumed that a trauma could create pathology in anyone exposed - everyone is at equal risk. The field has advanced to a point where a diathesis-stress framework predominates. There is ample evidence that exposure to trauma is necessary but not sufficient cause for the emergence of chronic PTSD. Multivariate research conducted on veterans has shown convincingly that person and history variables as well as posttraumatic-recovery-environment variables are as important in the etiology of PTSD as exposure to trauma is (King et al., 1999).

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Predictors of PTSD in veterans

Predeployment factors. There appears to be a general familial predisposition to chronic PTSD. Research has suggested both shared unknown genetic factors and shared adversity and familial disturbance contributes to the risk of PTSD in veterans (Davidson, Swartz, Storck, Krishman, & Hammett, 1985; True et al., 1993).

Several studies have shown an association between indicators of global intelligence and the development of combat-related PTSD. For example, Macklin et al. (1998) found that lower pre-war intelligence predicted greater postwar PTSD in Vietnam veterans. Cognitive deficits could be a liability because they impact on problem solving and resourcefulness.

Prior trauma and adversity is a robust predictor of military-related PTSD. This underscores that soldiers may have mental health burdens that they bring with them to dangerous deployments. Indeed, life-span traumas are extensive in military personnel. For example, Bolton, Litz, Britt, Adler, and Roemer (2001) found that 74% of soldiers reported being exposed to at least one potentially traumatic event-separate from their time in military service-in their lifetimes, and 60% reported being exposed to more than one across their life spans, with the majority of these incidents occurring prior to military service. King et al. (1999) found that the extent of early trauma was associated with the development of PTSD for both men and women. Bremner, Southwick, Johnson, Yehuda, and Charney (1993) found that after controlling for combat exposure, Vietnam veterans who experienced a greater number of traumatic events prior to joining the military were more likely to have PTSD. Childhood physical abuse was particularly predictive of combat-related PTSD.

Deployment variables. Traditional combat is not the only source of severe stress in a war-zone; nor is it the necessary and sufficient cause of military-service-related PTSD (King et al., 1999). War-zone demands are multifaceted, and contextual features such as poor diet, bad weather, and poor accommodations shape how soldiers cope during and after deployments. In addition, perceived life-threat is an important determinant of long-term adaptation (King et al., 1999).

Postdeployment factors. The association between social support and the development of PTSD is very robust in combat veterans compared to civilians exposed to interpersonal violence (Brewin, Andrews, & Valentine, 2000). Vietnam veterans who report active engagement in the community are less likely to have PTSD (Koenen et al., 2003). Sutker, Davis, Uddo, and Ditta (1995) also found that a lack of family cohesion predicted the development of PTSD in Persian Gulf veterans. A tendency to use social supports specifically to disclose personal problems and to talk about events experienced during a deployment are also associated with adjustment. For example, Vietnam veterans who discussed their military experiences demonstrated decreased rates of PTSD (Green, Grace, Lindy, & Glesser, 1990). Koenen et al. (2003) found that veterans who reported discomfort in disclosing their Vietnam service experiences to friends or family demonstrated an increased risk for developing PTSD.

Generally, stressful demands and adversity after a mission affect the degree of post-traumatic impairment. For example, King et al. (1999) found that male and female Vietnam veterans who had postwar experiences that were more stressful reported more severe PTSD. Wolfe et al. (1998) found that the relationship between sexual harassment and PTSD symptoms was affected by a number of postservice stressful life events in Persian Gulf veterans.

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There are initial signs that veterans of the wars in Iraq and Afghanistan are at significant risk for PTSD and other mental health problems. There is much we don't know about how soldiers manage the enormous and diverse demands and traumas in these new war zones, and it is too soon to know the full extent of the need for clinical services. We also have a great deal to learn about how to help those who have a higher risk for the development of postdeployment problems. Because not all veterans require services (most adapt due to their own resourcefulness), it is important to appreciate the factors that create risk for chronic PTSD. In examining the risks for veterans of the Afghanistan and Iraq wars, we must acknowledge the socio-economic-cultural context and the personal variables that dynamically shape soldiers' adaptation across the life span.

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