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Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder; Board on the Health of Select Populations; Institute of Medicine. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington (DC): National Academies Press (US); 2014 Jun 17.

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Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment.

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2Diagnosis, Course, and Prevalence of PTSD

Posttraumatic stress disorder (PTSD) affects hundreds of thousands of U.S. service members and veterans. The phase 1 report presented information on the number of service members and veterans who have received diagnoses of PTSD and on how the Department of Defense (DoD) and the Department of Veterans Affairs (VA) are dealing with this growing mental health problem. To put the number of service members and veterans who have PTSD in perspective, this chapter begins with a brief discussion of recent revisions of the diagnostic criteria for PTSD as given in the American Psychiatric Association’s (APA’s) (2013)Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5). That is followed by a description of the several avenues of diagnosis, treatment, and consequences that service members or veterans who have PTSD may experience over their lifetimes. The chapter then provides an overview of the prevalence of PTSD in the general U.S. population and in U.S. military and veteran populations.

DIAGNOSTIC CRITERIA FOR PTSD

In May 2013, the American Psychiatric Association released revised PTSD criteria in DSM-5 (see Table 2-1). PTSD is now categorized under “trauma- and stressor-related disorders,” rather than as an anxiety disorder as in Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, Text Revision (DSM-IV-TR) (VA, 2013a). The trigger for PTSD must be exposure to actual or threatened death, serious injury, or sexual violation, as directly experienced or experienced through repeated or extreme exposure to aversive details of the traumatic event, witnessed, or (for traumatic events occurring to close family members or friends) learned about by a person. In addition, the person must experience clinically significant distress or functional impairment. The DSM-IV-TR A2 criterion that the person’s response to a traumatic event involved intense fear, helplessness, or horror, has been removed. The 17 symptoms from DSM-IV-TR remain, and three have been added. DSM-5 requires that the symptoms continue for more than a month and no longer distinguishes between acute and chronic phases of PTSD. Two subtypes of PTSD have been added: a clinical subtype with prominent dissociative symptoms for people who, in addition to meeting the criteria for PTSD, experience depersonalization and derealization symptoms and PTSD in children 6 years old and younger (APA, 2013).

TABLE 2-1. Comparison of DSM-IV-TR and DSM-5 Criteria for PTSD.

TABLE 2-1

Comparison of DSM-IV-TR and DSM-5 Criteria for PTSD.

The DSM-5 diagnostic criteria for PTSD may affect the incidence and prevalence of PTSD in both military and civilian populations. Part of the difficulty in assessing and treating for PTSD is the inherent heterogeneity in presentation. For example, Galatzer-Levy and Bryant (2013) found that DSM-IV-TR criteria could result in 79,794 PTSD symptom combinations and that DSM-5 criteria could result in 636,120 symptom combinations. However, as of December 2013, neither DoD or VA had accepted or implemented the revised criteria, so the impact of the diagnostic changes on military and veteran populations is yet to be determined. For the studies cited in this report, DSM-IV-TR criteria have been used to diagnose PTSD.

COURSE OF PTSD

Diagnosis

Diagnosis of PTSD can be challenging because of the variable onset of symptoms and the inherent heterogeneity in presentation. For example, symptoms of PTSD may occur soon after exposure to a traumatic event or may be delayed, sometimes for years (Bryant et al., 2013). In the first month after exposure to a trauma, some people may experience acute stress reactions or be relatively asymptomatic. Many people will never have all the symptoms or the right combination of symptoms required for a full diagnosis of PTSD but may have subsyndromal PTSD, which may impair functioning as well (Norman et al., 2007; Pietrzak et al., 2012). In one study, of those who developed PTSD in the first year, about one-third remitted within 3 months without treatment, 39% had a chronic course, and only 3.5% developed PTSD more than 3 months after exposure (Santiago et al., 2013). In the case of delayed PTSD, initial and later traumas, and the accrued impact of multiple traumas, might contribute to the development of PTSD, including subsyndromal PTSD, and comorbidities.

Treatment

Although some data support the idea that some early interventions can decrease the development of chronic PTSD by 50% (Rothbaum et al., 2012), other studies (discussed in the phase 1 report) suggest that other interventions, such as psychological debriefing, are not effective and might even do harm (Agorastos et al., 2011). For those who seek treatment, treatment may result in recovery or conversion to subsyndromal PTSD. Numerous factors influence treatment outcomes, and no single treatment, even ones that have substantial evidence bases, has been demonstrated to be effective for everyone who has PTSD. It has been suggested that about 33% of people in the general population who have PTSD are resistant to treatment; the non-response rates for cognitive behavioral therapy may be as high as 50% and for selective serotonin reuptake inhibitors about 20–40% (Green, 2013). Pérez Benítez et al. (2012) found that in patients who received PTSD treatment in primary care settings, the course of the disorder was chronic, with a 38% likelihood of recovery and a 30% likelihood of recurrence. Finally, the proportion of service members and veterans who have PTSD and recover without intervention is unknown.

Consequences

Exposure to traumatic events is associated with an increased risk of adverse physical health, such as cardiovascular disease and stroke (Boscarino, 2008; Cohen et al., 2009, 2010; Dirkzwager et al., 2007; Dong et al., 2004; Kubzansky et al., 2007, 2009). In the National Comorbidity Study, Kessler et al. (1995) found that having PTSD significantly increased the odds of onset of comorbid conditions. A recent meta-analysis found that 52% of people with current PTSD had co-occurring major depressive disorder (Rytwinski et al., 2013). Kornfield et al. (2012) found that in a group of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and other era veterans who had subsyndromal PTSD and presented to a VA primary care clinic, 43.9% had comorbid depression. In addition to comorbidities directly associated with PTSD, such as depression and substance use disorder, assessment of and treatment for PTSD may be compounded by chronic conditions of aging. For example, Vietnam veterans who have PTSD may also have cardiovascular, endocrine, and neurological symptoms and comorbidities (Boscarino, 2008; Owens et al., 2005).

If PTSD becomes chronic, various physical and mental comorbidities and psychosocial factors may require treatment. These include depression, suicidal behavior, high-risk behaviors (such as excessive use of alcohol and other drugs or intentional engagement in dangerous activities) (Marshall et al., 2001; Resnick and Rosenheck, 2008; Zatzick et al., 1997), metabolic syndrome (Cohen et al., 2009; Weiss et al., 2011), and increased inflammatory response (O’Toole and Catts, 2008).

Work performance and social relationships in the family, workplace, and community can also be adversely affected. For example, heightened partner conflict and PTSD-related hyperarousal may contribute to intimate partner violence and child maltreatment in the family.

Furthermore, a traumatic event in the life of a loved one can be traumatic for family members as well. Spouses and partners of service members and veterans who have PTSD may experience PTSD symptoms themselves (Eaton et al., 2008; Klarić et al., 2012; Renshaw et al., 2011), and can experience relationship distress in response to the service members’ or veterans’ PTSD symptoms (Renshaw and Caska, 2012). However, the committee’s charge did not include consideration of PTSD in family members or other members of a service member’s or veteran’s support network.

It bears noting that PTSD is not the only health problem that service members and veterans may have; many of them have no PTSD, whether they were exposed to a traumatic event or not, but they may have other mental and physical health conditions not only as a result of their military service but from aging, lifestyle, and family history. Diagnosis and treatment of any mental or physical health conditions that service members and veterans may have are important for their functioning and quality of life.

PREVALENCE OF PTSD

Although this report focuses on PTSD in service members and veterans, PTSD is not unique to these populations. Members of the general population also can develop PTSD in the aftermath of exposure to a range of traumatic experiences. To provide a context for the prevalence of PTSD in U.S. military and veteran populations, data on the overall prevalence of the disorder and other mental health disorders in the general U.S. population are discussed below.

Prevalence of PTSD in the U.S. General Population

Although most civilians have not experienced combat, PTSD may be present in these populations as a result of exposure to other traumas, such as childhood abuse, sexual abuse, and life-threatening experiences (Basile et al., 2004; Harrison and Kinner, 1998; Hoge et al., 2004; Lowe et al., 2014; Neria et al., 2007; Punamaki et al., 2010). Because people may have symptoms of PTSD for many years before seeking treatment, or have subsyndromal PTSD, the prevalence of PTSD may be underreported.

The National Comorbidity Survey–Replication, conducted in 2001–2002, estimated that the 12-month prevalence of PTSD in the U.S. adult population was 3.6% and that the lifetime prevalence was 6.8%. Women were more likely than men to have PTSD (9.7% vs 3.6% for lifetime), and the prevalence of PTSD increased with age from 18 to 59 years, but then decreased substantially in those over 60 years old (Harvard Medical School, 2007a,b). Another national survey, the 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions, found a lifetime prevalence of PTSD of 7.3% (Roberts et al., 2011). For comparison, the 12-month and lifetime prevalence of major depressive disorder in the adult U.S. population was 6.8% and 16.9%, respectively. The 12-month and lifetime prevalences of any mental health disorder were estimated to be 32.4% and 57.4%, respectively (NIMH, 2013).

Prevalence and Incidence of PTSD in U.S. Military Populations

In 2012, more than 1,453,000 active-duty personnel and 354,000 reservists and National Guard were eligible for health care in the DoD military health system (MHS), as were 396,000 retirees.1 Of those, 846,822 active-duty service members and 210,193 National Guard and reservists had been deployed (Kennell and Associates, 2013). The length of deployment varies in each service branch; for example, Marine Corps deployments are typically 7 months, whereas Army deployments prior to January 2012 were 12–15 months and about 9 months after that. Of all service members who have deployed, 43% have deployed more than once, averaging 1.7 deployments (range 1–47). Of those, Army and Marines Corps personnel had the greatest average cumulative deployment lengths of 21 months and 16 months, respectively (IOM, 2013) since the beginning of OEF and OIF. Members of the Navy had an average cumulative deployment length of 13 months, followed by the Air Force with 12 months (IOM, 2013). Rona et al. (2007) report that United Kingdom forces who deployed for 13 months or more in a 3-year time frame “were more likely to fulfill the criteria for posttraumatic stress disorder.” The frequency and duration of exposure to traumatic events during deployment has been associated with an increased risk for the development of PTSD (Tanielian and Jaycox, 2008; see the phase 1 report for a more detailed discussion of deployment-related risk factors for PTSD).

Data from DoD indicate that the number of service members who are eligible to receive care in the MHS and have received a diagnosis of PTSD has grown since 2004 (see Table 2-2). Monahan et al. (2013) reported that the incidence of PTSD in recruit trainees throughout the service branches in 2000–2012 was 3.3 per 1,000 person-years or 0.1% of the total recruit trainee population, and the incidence was higher in female than in male recruit trainees (11.5 vs 1.7 per 1,000 person-years). The increase in PTSD is seen in all the service branches, particularly in the Army and Marine Corps. Men and women who have been deployed have the same prevalence (8%) of PTSD, although among all service members it is more common in women than in men (13.2% vs 8.9%) (see Table 2-3). Women comprise about 14% of active-duty service members.

TABLE 2-2. Number of Eligible Service Members Who Have a Primary or Secondary Diagnosis of PTSD.

TABLE 2-2

Number of Eligible Service Members Who Have a Primary or Secondary Diagnosis of PTSD.

TABLE 2-3. Number of Service Members Who Have a Primary or Secondary Diagnosis of PTSD, by Branch, Component, Sex, Race, and Rank.

TABLE 2-3

Number of Service Members Who Have a Primary or Secondary Diagnosis of PTSD, by Branch, Component, Sex, Race, and Rank.

Specific data on the incidence and prevalence of PTSD in eligible service members among the service branches was obtained from DoD. Table 2-2 shows that from 2004 to 2012 the fraction of all eligible service members who had a PTSD diagnosis increased from 0.4% (7,826 people) to 5.2% (123,337 people); and for service members previously deployed from 2004 to 2012, the prevalence of PTSD increased from 0.7% to 8%. The breakdowns by subgroups of service members are also noteworthy (see Table 2-3). From 2004 to 2012, the PTSD rate increased from 1.2% to 7.0% in active-duty service members, from 1.8% to 6.7% in reservists, and from 4.0% to 20.7% in retirees (see Table 2-3). Most of the cases of PTSD were seen in service members who had deployed. The data on ranks shows that 2012 rates were lower in officers (4–5%) and warrant officers (7%) than in junior and senior enlisted personnel (11% and 10%, respectively) (Kennell and Associates, 2013). Also of note is the relationship between the severity of an injury and PTSD symptom severity. In a study of 1,402 OEF and OIF veterans, McLay et al. (2012) found that the prevalence of combat-related PTSD and symptom severity increased with the severity of the injury. The prevalence of PTSD was 8% in those without any injuries, 13% in those with a penetrating injury, 29% with blunt trauma, and 33% with combination injuries.

Data from the Armed Forces Health Surveillance Center shows that from January 1, 2000, to December 31, 2012, there were 11,033 hospitalizations of active-duty service members (all service branches) for PTSD compared with 55,586 for depression and 28,645 for alcohol abuse and dependence. Individuals hospitalized for PTSD had the highest percentage of comorbid mental health diagnoses (77.3%), and this percentage increased every year from 2006 to 2012; alcohol abuse or dependence was a frequent comorbidity (27.8%) (Armed Forces Health Surveillance Center, 2013).

PTSD was one of the top five reasons for referrals to the behavioral health restoration center in Afghanistan in 2009 and 2010. The Army Mental Health Advisory Team (MHAT-7) found that the fraction of referrals due to PTSD increased from 4% in 2009 to 7% in 2010, but most of the referrals were for occupational issues (37%), adjustment disorders (20%), and relationship problems (15%) (MHAT-7, 2011).

Among all service members who had a primary diagnosis for PTSD in 2012, alcohol dependence was the comorbidity with the most health care costs (number of service members was not given). Anxiety, sleep apnea, and depression were also among the ten most costly comorbidities in terms of both dollars and total health care services used; other comorbid physical conditions that had the most service use and costs included “care involving other physical therapy” and lumbago (Kennell and Associates, 2013).

Prevalence and Incidence of PTSD in U.S. Veteran Populations

As of September 2013, there were about 22 million veterans, of whom about 2.2 million were OEF and OIF veterans. The VA projects that the number of OEF and OIF veterans will increase to about 3–4 million in 2040 and that almost 18% of them will be female (VA, 2014).

Today, 54% of OEF and OIF veterans use VA health care services (Schiffner, 2011) compared with the overall rate of 27.9% for all veterans (VA, 2010, 2013b). A recent survey of active-duty service members found that 60% intend to use VA health care services (Westat, 2010).

Tables 2-4 and 2-5 show the overall increase in the number of veterans who are using VA health services and that have been diagnosed with PTSD. These tables highlight the markedly higher prevalence of PTSD in the growing cohort of OEF and OIF veterans. In 2012, more than 502,000 veterans made at least two visits to VA for PTSD outpatient care (VA, 2012). Those veterans make up 9.2% of all users of VA health care, up from 4.1% in 2002 (VA, 2011). The data on OEF and OIF veterans are even more dramatic; in 2011, 99,610 veterans—24.4% of all OEF and OIF veterans who used VA health care—had a diagnosis of PTSD (VA, 2012). It is likely that these numbers do not capture the full extent of PTSD among veterans. The vast majority of eligible veterans receive their health care at facilities other than VA (such as community or private providers) or receive no health care at all. VA data show that 47% of veterans who entered specialized outpatient PTSD programs in 2012 were of the OEF and OIF era, 20% were of the 1990–1991 Gulf War era, and 34% were of the Vietnam era (VA, 2012). The prevalence and incidence of PTSD in female users of VA health services are rising: In 2008, 24,157 female veterans had PTSD (7% of all veterans who had PTSD in VA), and 7,773 of the cases were new (8% of all new PTSD cases); in 2012, the corresponding figures had risen to 42,514 (8.5%), and 12,023 (10%) (NEPEC, 2013).

TABLE 2-4. Number and Percent of VA Health Care Service Users with PTSD.

TABLE 2-4

Number and Percent of VA Health Care Service Users with PTSD.

TABLE 2-5. Number of VA Patients with PTSD and New PTSD Patients by Era and Sex.

TABLE 2-5

Number of VA Patients with PTSD and New PTSD Patients by Era and Sex.

Like the figures for their service-member counterparts, data from VA show the frequency of comorbidities with a primary diagnosis of PTSD. In VA, the most common co-occurring mental health disorders among all veterans (male, female, OEF and OIF, and non-OEF or OIF) in 2013 were dysthymia, anxiety disorder, major depressive disorder, alcohol or drug use disorders, and bipolar disorders. The prevalence of those comorbidities has not changed substantially since 2008 (NEPEC, 2013).

The Veterans Benefits Administration (VBA) has data on service-connected disability that underscore the burden that PTSD is in VA. Veterans may apply for service-connected status for a disorder, including PTSD, at any time. They then receive a comprehensive clinical assessment by VA to determine whether they meet the criteria for PTSD and the degree of disability associated with the diagnosis. The VBA database includes many veterans who do not seek health care at VA but have been found in a VA assessment to have PTSD. In 2003, 196,641 OEF and OIF veterans had service-connected PTSD; however, as of 2013, 653,249 veterans had service-connected PTSD, or 17.5% of all veterans who were receiving compensation for service-connected health conditions in 2013. Of those, about 451,500 were adjudicated to be at least 50% disabled and so qualified for priority group 12 for VA care, and another 165,500 were at least 30% disabled but less than 50% and so qualified for priority group 2. PTSD is the third most common major service-connected disability, after hearing loss and tinnitus (VBA, 2014).

Data from DoD and VA show marked increases in PTSD among military service and veteran populations. Although these numbers are likely to underestimate the incidence and prevalence of PTSD, they demonstrate that action is needed to respond to this growing problem.

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Footnotes

1

The number of service members who were eligible for health care in the MHS was restricted to those service members who were on active duty (including National Guard and reservists) at any point from 2004-2012. There were many more retirees eligible for care in the MHS, but they were not on active duty during 2004–2012 and so are not included in this number. If they were on active duty from 2001–2003, but not 2004–2012, they also were not counted in the 2012 cohort; it is expected, however, that the former group would be relatively small compared with the group that is included in the 2012 number of eligibles.

2

See the phase 1 report or http://www​.va.gov/healthbenefits​/resources/priority_groups​.asp for more information on priority groups (accessed January 10, 2014).

Copyright 2014 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK224874
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