What is now known as PTSD, or post-traumatic stress disorder, was called shell shock back in the days of the first world war. Sufferers have harrowing flashbacks, and alternate between emotional numbness and outbursts of rage, guilt and depression. Previously well-adjusted soldiers suffer impaired memory and attention, insomnia and anxiety, and are more likely to take drugs and alcohol later in life. That much is well recognised.
What is less well known is that PTSD can trigger physical as well as psychological ill health. And as the US agonises over how long its soldiers should stay in Iraq, New Scientist has pieced together evidence showing that veterans will be paying the price of combat for decades to come. Recent and soon-to-be published research reveals that soldiers who fought in theatres as diverse as Vietnam and Lebanon are not only more likely to die from an accident on their return, but are also twice as likely to develop cardiovascular disease, diabetes and even cancer later in life. And these problems are particularly likely to afflict troops who experience the close-quarters fighting taking place in Iraq.
Last year researchers from the US Centers for Disease Control and Prevention (CDC) revisited more than 18,000 Vietnam veterans who had been subjects of a detailed health survey in 1985, to see who had died and how. For the first five years after their return home, men with combat experience appeared more likely to have died of accidents, overdoses and the like. After that, they seemed no more at risk than comrades who had spent the war in non-combat roles (Archives of Internal Medicine, vol 164, p 1908).
The CDC study took no account of whether the soldiers were suffering from PTSD. But now Joseph Boscarino of the New York Academy of Medicine has re-analysed the 1985 data to assess which men were suffering from the condition. That analysis, to be published in Annals of Epidemiology, reveals stark differences in death rates persisting 30 years after the end of the Vietnam conflict. All men with PTSD, whether from combat experience or not, were more likely to die from "external causes" such as accidents, drugs or suicide. But men who developed PTSD as a consequence of combat were also more likely to die of heart disease and, surprisingly, various kinds of cancer.
"Other studies have found a link between heart disease and stress, but this is the first time there has been such a direct association with PTSD so many years later," Boscarino told New Scientist. "The cancer surprised us, and it isn't explained by differences in smoking."
People with PTSD may experience long-term changes in various immune reactions, and in levels of the stress hormone cortisol and chemicals such as adrenalin and dopamine that underlie fight-or-flight reflexes, Boscarino says. He found a direct relationship between the amount of combat exposure and the reduction in cortisol levels. "The excess deaths in both PTSD groups show that stress can kill," he says. "But the much greater effect among the combat veterans shows there is something especially bad about that."
He is not alone in his conclusion. In March this year Yael Benyamini and colleagues at Tel Aviv University in Israel reported that among Israeli veterans of fighting in Lebanon in 1982, those who developed PTSD are now twice as likely to have high blood pressure, ulcers and diabetes, and five times as likely to have heart disease and headaches, as those who did not develop the disorder (Social Science and Medicine, vol 61, p 1267). "PTSD is the key mechanism that leads from the trauma to poorer health," they say.
Other studies have found clear associations between war-related PTSD and cardiovascular disease in veterans of the second world war, the Korean war, and recent conflicts in Croatia and Lebanon.
Last year, a study by US army scientists at the Walter Reed Army Medical Center in Silver Spring, Maryland, concluded that some 18 per cent of US veterans from Iraq could be affected by PTSD, which would translate to around 60,000 people so far (The New England Journal of Medicine, vol 351, p 13). And the more firefights Iraq veterans experienced, the more likely they were to have PTSD.
Boscarino is a Vietnam veteran, and he predicts that levels of PTSD in Iraq veterans will be similar to those seen in troops who fought in Vietnam. "It's a similar war, with the roadside bombs, ambushes and the civil insurgency."
Timely psychological help might mitigate the problem. Yet The Walter Reed group found only a third of Iraq veterans with PTSD were getting help from a mental health professional a year after their return. British soldiers get no routine mental health screening before or after deployment, though 1 in 10 troops airlifted out of Iraq for medical reasons had mainly psychological problems.
In February, the General Accounting Office of the US congress reported that the Department of Veterans Affairs had not fully met any of the recommendations its own advisers have been making, in some cases since 1985, for improving treatment of PTSD, such as checking whether screening and counselling are being implemented.
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THIS ARTICLE APPEARS IN NEW SCIENTIST MAGAZINE ISSUE: 27 AUGUST 2005
Author: Debora MacKenzie
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