NIMH supports a wide-ranging program of research on PTSD, aimed at helping people and communities cope with the effects of traumatic events and preventing lasting mental health consequences. Although the institute’s research encompasses different populations and types of trauma, one area of renewed focus is the psychological cost of war.
With a rapidly growing need in recent years for mental health care of military personnel generated by sustained conflicts in Iraq and Afghanistan, the Institute is working with the Department of Defense (DoD) and the Department of Veterans Affairs (VA) to identify research priorities and potential areas of collaboration, and to support high quality research by investigators within and outside of the military. The insights gained from research on the mental health consequences of war will reach beyond the military. They will contribute to our understanding of risk and resilience in responses to all types of trauma and how to care better for those exposed to traumatic events.
The psychological reactions of individuals to trauma are varied and complex. Most people recover, but a significant minority experience severe stress-related symptoms for long periods. Depression, panic disorder, generalized anxiety disorder, and substance abuse, as well as PTSD, are among the spectrum of reactions to trauma. Approximately 3.6 percent of American adults age 18 and older—about 7.7 million American adults—have PTSD in a given year; over a lifetime, nearly 7 percent of American adults develop PTSD. PTSD can develop at any age, including childhood.
NIMH War-Related Research Past and Present
The need to understand the effects of war-related trauma in particular was one of the major catalysts for the creation of NIMH more than 60 years ago. Recognition of the psychological consequences of trauma during World War II stimulated interest in research and helped reshape systems of mental health care within the military, a change that subsequently influenced community health care. In helping these soldiers, both overseas and upon their return home, clinicians gained insights into treatment needs, systems, and resources for anyone who needed mental health care.
The wars in Afghanistan and Iraq have generated an urgent need for research on the risk and resilience factors for and treatment of PTSD and accompanying conditions. Since March 2003, about 1.6 million U.S. troops have been deployed to both countries (http://www.rand.org/pubs/monographs/MG720/). Moreover, screening of combat veterans on their return home and six months later found that 20.3 percent of active and 42.4 percent of soldiers in the reserves required mental health treatment (Milliken, Auchterlonie, and Hoge, 2007). The conflicts now underway have features that distinguish them from previous wars with several additional stressors for combatants:
- The overseas force includes an all-volunteer army along with substantial numbers of reserve and National Guard personnel.
- Multiple tours of duty are common.
- More wounded survive with injuries that would have been fatal in previous wars.
The ubiquity of improvised explosive devices adds to the chaos of the war zone and is a contributor to a high rate of traumatic brain injury.
NIMH, DoD, and the VA are collaboratively addressing a broad array of issues related to PTSD, among them how gender, race, and other socioeconomic factors influence the development of trauma spectrum disorders; standards for clinical trials in PTSD; prevention of posttraumatic stress adjustment problems in emergency responders and military and law enforcement personnel; and best practices for early interventions after mass trauma.
NIMH has joined DoD and the VA in planning pre- and post-deployment assessment studies of PTSD and the genetics of PTSD. In recent years, NIMH has issued several requests for applications (RFA) inviting researchers to apply for grant funding for PTSD-related research. DoD and the VA joined NIMH in an RFA in 2006, for example, focused on intervention and practice research for combat related mental disorders. Another joint NIMH-VA RFA sought teams of investigators to conduct studies to develop PTSD assessment tools.
Suicide in the military and among veterans is also a concern. Under a recently signed memorandum of agreement with the U.S. Army, NIMH will conduct a multi-year research study that will evaluate the risk and protective factors that are associated with suicide. This NIMH-DoD collaboration promises to be the largest study ever conducted of the risk and resilience factors for suicide. The study, modeled on the Framingham study for heart disease, will include active-duty forces, the National Guard and Army Reserve, and veterans. The goal is to provide information the Department of Defense can use to develop strategies to promote resilience and prevent suicides
Research Efforts in Military Populations
NIMH funds a variety of studies on PTSD in military personnel examining the epidemiology, natural history, and risk factors for PTSD, and new approaches to prevention and treatment. The following are some examples:
- Investigators are looking at the factors associated with mental health problems following deployment in reservists and National Guard personnel. Knowledge of how such features of military life as length of time in service, unit cohesion, training, rank, and separation from family influence post-combat concerns will help guide training and development of interventions.
- Several studies seek to identify the risk factors for PTSD and to track the course of development of symptoms. One study is looking for genes that may contribute to negative interpersonal behavior in intimate relationships, including verbal hostility and physical aggression. In another study, veterans use personal digital assistants to record daily assessments of life stresses and any PTSD symptoms in an effort to gather a picture of how PTSD emerges and either resolves or becomes chronic.
- Research suggests that only a minority of the Afghanistan and Iraq war veterans who screen positive for mental disorders seek mental health care. The stigma associated with seeking care is among the reasons for not seeking help; others include the accessibility and perceived effectiveness of mental health care (Hoge, Castro, Messer, McGurk, Cotting, and Koffman, 2004). If shown effective, Internet-based approaches would provide easy accessibility and privacy for veterans hesitant about seeking formal treatment. Complementary research is aimed at identifying the beliefs that determine whether veterans seek treatment and developing ways to overcome biases that discourage treatment-seeking.
- PTSD and accompanying depression can complicate a veteran’s resumption of relationships with spouse and children. Spouses are at elevated risk of psychological distress, marital difficulties, and intimate partner violence. Studies are aimed at developing ways to help returning veterans and their spouses handle the transition between deployment and return. One study focuses directly on developing an Internet-based intervention to help spouses understand and cope with PTSD in their returning partners.
Research in military personnel has begun to demonstrate the effectiveness of new treatment approaches for PTSD. Early data from an NIMH-sponsored double-blind study of 24 war veterans showed a marked reduction in acoustic startle—the reflex response to sudden loud sounds—in those treated with virtual reality exposure therapy combined with either d-cycloserine, an antibiotic that has been shown to facilitate the extinction of fear memories; pill placebo; or the anxiety medication alprazolam (Xanax). The study is continuing to examine the effectiveness of d-cycloserine. Another pilot study showed that an Internet-based, self-managed cognitive behavioral therapy can help reduce symptoms of PTSD and depression, with effects that last after treatment has ended.
Brain Stress Mechanisms
NIMH-supported research is investigating the spectrum of factors that may influence the risk of developing PTSD and those that promote resilience. These include the genetic background and past experiences of the individual; the nature, intensity, and duration of trauma; social support; and the availability of timely, effective treatment. Among the central targets of recent research are the brain’s stress circuitry and the role of genetic factors in resilience and vulnerability. A better understanding of the neurochemistry of fear reactions is helping researchers develop medications to help treat PTSD.
Although the nature and pattern of stresses experienced by someone in war may differ in important ways from, for example, those encountered by a hurricane survivor, the brain mechanisms that underlie PTSD in both are the same. Research on genetic factors in military and non-military populations can inform treatment in both. A recent NIMH-supported study reported that a traumatic event is much more likely to result in PTSD in adults who had experienced past traumatic child abuse and also had certain variations in a specific stress-related gene. Each factor alone—child abuse or genetic factor—was not enough to raise risk, but the combination raised it substantially.
It is hoped that PTSD research can help military personnel continue in their military careers or return to civilian life without being hampered by the psychological consequences of their experience in war. That alone makes the need for these efforts compelling. In addition, what we learn from research on the effects of war on mental health in military personnel will help in designing interventions for others exposed to trauma of all types. It is especially important to develop effective, accessible ways to help individuals early and prevent deepening, long-term difficulties with post-traumatic stress.