http://www.medscape.com/viewarticle/739142?src=mp&spon=24March 17, 2011 (San Antonio, Texas) — Despite their young age, returning veterans from the current conflicts in Iraq and Afghanistan carry a heavy burden of physical illness — most predominantly musculoskeletal disorders — and this load is particularly striking in those who develop posttraumatic stress disorder (PTSD), substance use disorders (SUD), or both, new research suggests.
A large cross-sectional study presented here at the American Psychosomatic Society 69th Annual Scientific Meeting shows that compared with their counterparts with no mental health conditions (MHCs), returning female veterans from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) with comorbid PTSD and SUD had a more than 2-fold increased risk of having a medical diagnosis, whereas male veterans had a 1.5-fold increased risk.
"Despite their young age, men and women OEF/OIF veterans overall carry a heavy burden of illness. Medical burden was particularly associated with PTSD in both sexes. Further, veterans who had either PTSD only or comorbid PTSD and SUD demonstrated a robust association with medical conditions," said lead investigator Deborah Nazarian, PhD, Veterans Administration (VA) Palo Alto Health Care System, Menlo Park, California.
Dr. Nazarian noted there is a large body of evidence from past conflicts, including the Vietnam War, demonstrating a strong association among PTSD, SUD, and medical disease. Veterans from these wars, she noted, were significantly affected by a heavy burden of late-life medical illness.
However, she added, there is limited research examining this association in returning OEF/OIF veterans.
In addition, she said, research suggests that this population is at increased risk of developing PTSD and alcohol and drug use disorders. Further, she noted, they are less likely to present to specialty mental health clinics because of a concern about potential stigma attached to seeking mental healthcare.
Furthermore, said Dr. Nazarian, the increased numbers of female service members serving in the current conflicts offer a new avenue of research to understand the mental health and medical needs of women veterans.
Unique Opportunity
"The VA has a unique and time-sensitive opportunity to develop interventions that address comorbid mental health and medical disease among OEF and OIF veterans that can prevent the late-life burden of medical illness that we have observed in older vets from previous cohorts," she told Medscape Medical News.
She also noted that although recent research conducted by Judith Andersen, PhD, and colleagues also showed a robust link between mental health conditions, specifically PTSD, and physical disease among returning OEF/OIF veterans in the VA Healthcare Network of Upstate New York, the current study analyzed national administrative data of veterans who use Veterans Health Administrative primary care services.
Dr. Judith Andersen
The study had 2 main aims — to determine the most frequent medical diagnoses in returning men and women with PTSD alone, SUD alone, or comorbid PTSD/SUD in returning OEF/OIF veterans and to determine whether there is an increased likelihood of medical problems among those with mental health problems vs no MHCs.
The cohort included a nationally representative population of 73,720 returning OEF/OIF veterans who used primary care services and 15% were female. Most of the study population was younger than 35 years, and approximately one-third had more than 1 deployment.
Clinician-diagnosed mental health and medical conditions were obtained from International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The researchers calculated adjusted odds ratios for 10 specific medical condition categories in relation to 4 mutually exclusive groups of veterans — those with a diagnosis of PTSD alone, those with SUD alone, those with comorbid PTSD/SUD, and those with no MHCs.
Musculoskeletal Disorders Most Common
The investigators, who included Rachel Kimerling, PhD, and Susan Frayne, MD, MPH, found that diseases of the musculoskeletal system had the highest frequency across the 4 study groups.
"More generally," said Dr. Nazarian, "we observed high frequencies of diagnoses for several of these medical categories regardless of mental health status."
Adjusted odds ratios (AORs) of having a diagnosis among the 5 most prevalent medical diagnoses among women were statistically significant, she added. Compared with women with no MCHs, women veterans with SUD alone (AOR, 2.20) or PTSD/SUD (AOR, 2.19) were more than twice as likely to have any medical diagnosis.
Male veterans with PTSD or PTSD/SUD had a 1.5 greater odds of having any medical diagnosis relative to their counterparts with no MHC.
The 3 most frequent medical diagnoses among women were disease of the musculoskeletal, nervous, and genitourinary systems. In men they were diseases of the musculoskeletal, nervous, and digestive systems.
Although there were some differences in odds ratios among medical categories, Dr. Nazarian said her team was struck by the significantly high AORs in the injury and poisoning category among women veterans with PTSD/SUD (AOR, 3.80) or PTSD (AOR, 2.54) compared with women with no MHCs.
Dr. Nazarian said the association between musculoskeletal conditions and PTSD/SUD is concerning because musculoskeletal conditions may lead to the development of chronic pain. This comorbidity may make it challenging for primary care physicians to independently manage the care of these patients.
Eradicating Stigma
Finally, she said, the high frequency of genitourinary conditions in women veterans is an area that warrants further research. It may be that this is a problem specific to women veterans that may relate to conditions during deployment, including a lack of access to washrooms, temperature, and hygiene issues.
"Our findings suggest that these veterans have complex and unique mental health and medical needs, which may be challenging for primary care physicians to independently manage their care and suggests a comprehensive interdisciplinary treatment approach may be best," she said.
Dr. Nazarian added that embedding mental health clinicians in primary care clinics may help reduce potential stigma related to seeking mental healthcare services, which has previously been shown to be a barrier to care among OEF/OIF military personnel.
She pointed out that the Veterans Health Administration has embraced this concept of providing a "one-stop" shop where veterans can have all of their physical and mental healthcare needs addressed in a streamlined way.
PTSD Education Needed
Commenting on the study, Judith Andersen, PhD, Center for Integrated Healthcare at the Department of Veterans Affairs Medical Center in Syracuse, New York, said that longitudinal research conducted by her team shows that PTSD and physical illness, including serious medical conditions, are definitely linked.
"We've shown that 30-year-olds are developing cardiovascular conditions 5 years post war. And it's not only cardiovascular disease but respiratory disease, immune suppression, and so forth. So we need to take mental health conditions like PTSD seriously. These are serious predictors of chronic disease at a young age," Dr. Andersen told Medscape Medical News.
She added that there is still a great deal of resistance to the idea that mental illness can be a catalyst for physical illness, and so education of government, policymakers, and the public is essential.
Dr. Nazarian added she hopes this work will lead to a better understanding of the link between chronic medical illness and mental illness and ultimately lead to more effective interventions that will prevent today's veterans from the burden of late-life medical illness that was the fate of many of their predecessors from earlier conflicts.
Dr. Nazarian and Dr. Andersen have disclosed no relevant financial relationships.