Among war veterans, mental health issues are of concern, as military personnel returning home can be significantly affected by difficulties, including combat-related PTSD, depression, and alcohol or substance abuse.

These factors result in significant distress for both the veterans and family, and significant impairment in quality of life and functioning. Veterans are also at risk for long-term disability and limitations from their injuries.

Prevalence of PTSD

The prevalence of PTSD in the military remains unclear, with most estimates ranging from 5% to 20% among previously deployed veterans. Prevalence estimates are, however, found to be significantly higher among those who seek treatment. As well, the risk of PTSD may also increase with multiple deployments.

Definition, cluster of symptoms and its course

PTSD is an anxiety disorder that develops when a person experiences, witnesses or is confronted with an extreme traumatic event, often involving threats to their safety or that of others. A traumatic event makes a person feel intensely fearful, helpless or horrified.

There are three main types/clusters of PTSD symptoms, and not everyone will experience these in the same way:

1) Re-experiencing symptoms – this involves intrusive and upsetting memories of the traumatic event; bad dreams, flashbacks or a sense of reliving the event; feelings of intense psychological distress when reminded of the trauma (e.g., through specific smells, noises, sounds or locations); intense physical reactions to reminders of the event (e.g., heart pounding, shortness of breath, nausea or sweating). Feelings such as anger and guilt are found to be very common among veteran populations.

2) Avoidance symptoms – this involves avoiding thoughts, feelings, or conversations associated with the trauma; avoiding activities, places or people that are reminders of the trauma; an inability to remember important aspects of the trauma; loss of interest in activities; feeling detached from other people or feeling emotionally numb; having a sense of a limited future.

3) Increased arousal symptoms – this includes difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hyper-vigilance, or being constantly "on guard"; feeling jumpy and easily startled.

Such reactions are typically seen shortly after a traumatic event. These are normal reactions. However, if the symptoms persist over four weeks, increase or become more distressing over time and begin to interfere with daily activities, then a person might be suffering from PTSD. Seeking help is essential in that case.

PTSD symptoms usually begin within the first three months after the trauma, although there may be a delay of months, or even years, before symptoms appear. Delayed-onset PTSD occurs when the onset of the disorder is at least six months following traumatic exposure.

PTSD is also associated with increased rates of other mental health conditions, such as mood disorders, substance disorders, and other types of anxiety disorders.

PTSD in military tends to become chronic for many. For example, studies found that among Australian Vietnam veterans, the rates of PTSD had remained mostly stable 30 years after the war; among Israeli War Veterans, moderately high rates of PTSD were found 20 years later. Among those post-deployment from Iraq and Afghanistan, those with initial low symptoms remained stable, however, those with initial higher symptoms had increased symptoms over time. This finding highlights the importance of identifying early those who are at risk for prevention and early intervention.

Risk factors and protective factors

Studies have found that certain risk factors for PTSD include experiencing more stressors prior to deployment, not feeling prepared prior to deployment, exposure to combat and to combat's aftermath; and experiencing more stressful life after deployment. Social support after deployment is found to be a protective factor.

PTSD treatment

Trauma-Focused Cognitive Behavioural Therapy (CBT) is considered a first-line intervention in the treatment of PTSD by various clinical practice guidelines. Trauma-focused CBT includes understanding reactions to trauma; anxiety management skills and strategies; exposure interventions, including imaginal exposures to traumatic memories, and "in-vivo exposure interventions," which involves gradually confronting a hierarchy of feared, but safe, trauma-related situations/places/activities and to situations avoided due to psychological distress; cognitive interventions to help address thoughts and beliefs associated with distress.

Trauma-focused CBT also includes cognitive processing therapy, which means exposure to the trauma memory by writing a trauma narrative and repeatedly reading it. It is combined with cognitive therapy focused on themes such as safety, trust, power/control, and esteem.

As part of CBT for trauma, exposure therapy is broadly considered the frontline intervention for combat-related PTSD. Findings indicate that prolonged exposure is an effective treatment for combat-related PTSD.

Eye movement desensitization and reprocessing (EMDR) has also often been used for treatment of PTSD. EMDR includes imaginal exposure to a trauma while simultaneously performing bilateral eye movements or another form of bilateral stimulation. Studies have found that the mechanism of action within the EMDR is likely exposure, and that treatment gains are likely due to cognitive processing, exposure to the traumatic memory and the practice of coping and mastery responses.

Psychological treatment combined with pharmacotherapy where possible is also often recommended by most clinical practice guidelines.

Treatment could also be provided to active-duty militants with PTSD within primary care settings. Some early findings of PTSD treatment within active-duty military have shown reduction in PTSD symptoms as well as in depression and improvement in overall functioning and quality of life.

Barriers to treatment

Significant barriers to receiving treatment include: not seeking mental health care services or following up with treatment recommendations or referrals, stigma attached to mental illness in regards to seeking mental heath services; and difficulties with accessing or receiving services. As well, while on active duty, stigma attached to mental health issues tend to be more pronounced with veterans and they might be less likely to disclose psychological issues for the fear of stigma and impact on their career.

We need to move forward by focusing on prevention, early identification of those who are at risk, and early intervention focusing on effective evidence-based trauma focused treatment.

Dr. Katy Kamkar, Ph.D., is a Clinical Psychologist at the Work, Stress and Health Program/Psychological Trauma Program, at the Centre for Addiction and Mental Health (CAMH). She provides Cognitive-Behavioural treatment for Mood and Anxiety Disorders and is a frequent contributor to the CTV.ca Health blog