Evidence-Based Reviews

U.S. troops returning home: Are you prepared?

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Their psychiatric problems go beyond posttraumatic stress because of unique combat in Iraq and Afghanistan.



National Guard and Army Reserve troops constitute an estimated 30% to 40% of the 1 million-plus U.S. military personnel deployed in Iraq and Afghanistan.1-3 Many of these civilian soldiers—once considered “weekend warriors”—are serving a first combat tour, returning home, and being redeployed for additional tours of duty.

Because of these unprecedented deployment policies, civilian psychiatrists will likely play a greater role in treating combat-related mental health problems than in any previous U.S. war. You may need to provide initial and long-term psychiatric care for reservists and Guard members returning to your community during 2006 and beyond.

To help you prepare, we discuss the combat situations these soldiers are experiencing, types of psychiatric problems they are reporting in anonymous surveys, and their attitudes about seeking psychiatric care. We also offer practical resources on combat-related posttraumatic stress disorder (PTSD) for nonmilitary or Veterans Administration clinicians.

A soldier’s story: ‘He’s always jumpy’

Mr. L, age 39, is supervisor for a local construction company and a sergeant first class with 18 years of Army Reserve service who returned from Iraq 7 months ago. He tells you, “My wife made me come see you—I didn’t want to.”

Though he does not think he needs a psychiatrist, his irritability and poor sleep worry his wife. “He isn’t the same anymore,” she says. “He’s always jumpy.”

Reported psychiatric problems

Stress-related symptoms. Within 4 months of returning home from Iraq or Afghanistan, 3 in 10 soldiers have developed “stress-related mental health problems” such as anxiety, depression, nightmares, anger, and concentration difficulties, reports Army Surgeon General Lt. Gen. Kevin Kiley.4 An unknown smaller percentage were reportedly diagnosed with PTSD.

Strained marriages, suicidal thoughts/feelings, nightmares or flashbacks, and fear of losing control or injuring someone else were among problems soldiers acknowledged during post-deployment health assessments between January and August 2005. In these surveys, 28% of 193,000 returnees endorsed mental health problems, according to the Army Center for Health Promotion and Preventive Medicine (Table 1).5

Table 1

Mental health problems reported by troops returning from combat in Iraq*

ProblemNumber among 193,000 U.S. soldiers
Nightmares or unwanted war recollections20,000
Might “hurt or lose control” with someone else3,700
Suicidal thoughts/feeling better off dead1,700
* 28% of returnees reported mental health problems in post-deployment surveys between January and August 2005.
Source: Army Center for Health Promotion and Preventive Medicine, reference 5.
Low estimates? In 1997, the U.S. military began universal medical screening of troops before and after military deployments.6 This important step allows the military to address baseline health needs of returning soldiers and measure effects from combat. There are no comparable sources of data from previous wars.

Unfortunately, this new information may underestimate the number of returnees with psychiatric problems and the severity of those problems. In an anonymous survey of returning Army and Marine soldiers, Hoge et al7 found that those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis (Table 2).

Table 2

Perceived barriers to seeking mental health services cited by U.S. soldiers after combat duty in Iraq and Afghanistan*

Perceived barrierMet screening criteria for a mental disorder?
Yes (N=731)No (N=5,422)
I would be seen as weak65%31%
My unit leadership might treat me differently63%33%
Members of my unit might have less confidence in me59%31%
I would have difficulty getting time off work for treatment55%22%
My leaders would blame me for the problem51%20%
It would harm my career50%24%
It is difficult to schedule an appointment45%17%
It would be too embarrassing41%18%
I don’t trust mental health professionals38%17%
Mental health care costs too much money25%10%
Mental health care doesn’t work25%9%
I don’t know where to get help22%6%
I don’t have adequate transportation18%6%
* Anonymous survey. Those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis.
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.
Female personnel. Women are overrepresented by a factor of two among personnel evacuated primarily for psychiatric reasons from combat phases the military calls Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) (unpublished data, Dr. Rundell).8 Women comprise 10% of returning OIF and OEF veterans and 19% of psychiatric evacuees.

Gender per se may not be the most important variable; age, number of years in the military, type of military unit, and ethnic group are also risk factors for developing a war-related psychiatric disorder. Further studies of OIF- and OEF-related psychiatric disorders are needed to determine whether female veterans’ clinical needs differ in important ways from those of male veterans.


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