Operation Iraqi Freedom

1. Operation Iraqi Freedom

2. I feel more a sense of anger sometimes. You see an Iraqi just looking at you, and you wonder why is he looking at you. Is there anything else he could be doing other than looking at you? Or a car that won't get out of the way -- sometimes you just get angry and want to ram it off the road. Sometimes I sit here, and I wonder if a mortar round is going to come through these walls, or if I go to chow now or wait until after -- you never know if the mortar round will hit you or not if you wait five more minutes. They tell you hearts and minds. Then you got to be mean, then nice. You don't know what to be. On the roads you have to run people off the road. There could be a VBIED [vehicle-born improvised explosive device, or car bomb] or a guy taking his kids to school. So you have to be all things at once. That is the hardest part. You're always thinking which one you are going to be, a nice guy or a mean guy. ... Pvt. Josue Reyes

3. Chapter 1: Nine Men Strong: A Company of Misfits (9:30)Chapter 2: Under Siege from an Invisible Enemy (10:15)Chapter 3: Death of A Soldier (5:55-7:00, 8:15-9:30, 12:00-end)Chapter 4: The Battle Becomes Even More Personal (0-3:40) http://www.pbs.org/wgbh/pages/frontline/shows/company/view/

13. The Numbers • Over 1 million soldiers deployed to Iraq (OIF) and Afghanistan (OEF) since March 2003 • As of July 11, 2006- * Unknown if psychiatric injuries are included in these numbers. Some data suggests that in the first few months of war that 6-7% of all Evac’s were for psychiatric reasons, making it one of the top 5 reasons for evac. Stetz, M., McDonald, J., Lukey, B., & Gifford, R. (2005). Psychiatric diagnoses as a cause of medical evacuation. Aviation Space Environmental Medicine, 7(7Suppl), C15-20.

14. Iraqi Casualties • Civilians reported killed by military intervention in Iraq • Min38960 • Max 43397 www.iraqbodycount.net • Roberts, L., Lafta, L., Garfield, R., Khudhairi, J., & Burnham, G. (2004). Mortality before and after the 2003 invasion of Iraq: cluster sample survey. The Lancet, 364, 1857-1864.

15. Hoge, C.W., Castro, A., Messer, S., McGurk, D., Cotting, D., & Koffman, R. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351(1), 13-22.

16. Sequela of War for Soldiers • PTSD and other mental illnesses • Physical illness- Fibromyalgia, Headaches, • Substance Abuse • Poor social and occupational functioning • Interpersonal Violence –(15-58% depending on study size- (Marshall 2005)) • Related to: psychopathology variables (depression, ASPD), childhood trauma variables (history of personal assault by family), military service factors (length of deployment, combat, participation in killing and rank), relationship adjustment, and demographic factors (race and age).

18. Rates of PTSD • 2 studies by Hoge, et. al. One published in 2004 in NEJM, and one in 2006 in JAMA. • Mandated screening by DoD provided the data. • Study #1- 15.6-17.1 % of all Iraq study participants (n=1705) 3-4 months post-deployment, screened positive for a mental disorder, mostly PTSD. (Afghanistan troops experienced a 11.2%) • 71-86% of these soldiers engaged in a firefight, the median # of fights was 5. (Afghanistan- 31% and 2) • 11.6% were injured, and 4.6% for Afghanistan, and was significantly correlated to developing symptoms of PTSD. • Only 23-40% of those that screened positive reported receiving treatment.

19. Rates of PTSD • Study #2- • Population based descriptive study of ALL Army soldiers and Marines who completed the PDHA in a one year period from Iraq or Afghanistan (Iraq n= 222,620, Afghanistan n= 16318, and other locations n=64967) • Prevalence of mental health problem; Iraq=19.1%, Afghanistan=11.3%, Other=8.5% • 35% of OIF vets accessed mental health services within one year of returning home.

20. Risk Factors • Combat exposure and numerous exposures increase risk of development of PTSD. • National Guard or Reservist (Less likely to have social support and treatment options post-deployment) • Military sexual trauma • Survival after serious injury • Lack of support • Ongoing Stressors- Marital or family discord, workplace or social settings. • Personal Characteristics- coping skills, interpersonal relatedness, attachment, shame, stigma sensitivity, past trauma history, and motivation for treatment. • Co-morbid psychiatric or medical disorders • Previous history of trauma • Race, Gender, Socioeconomic Status

21. Protective Factors • Personal Characteristics- Coping skills, interpersonal relatedness, attachment, etc. • Social Support- use and acceptance of social resources • Good social and occupational functioning prior to trauma • Age (Under age 44) • Education • Socioeconomic Status

22. Why only 40% • Stigma • Fear loss of opportunity for promotion • Loss of security clearance • Elimination from the service • Fear that they will let their “buddies” down • Culture of the Military – A sign of Weakness

23. Why only 40% • Those that are symptomatic, are more likely to feel this way, and less likely to seek treatment (Hoge et. al. 2004). • Members of my unit might have less confidence in me • My unit leadership might treat me differently • My leaders would blame me for the problem • I would be seen as weak • It would harm my career • There would be difficulty getting time off work for treatment

24. A Soldier’s Heart: Chapter 1: Homecoming Chapter 2: The Psychological Impact of War http://www.pbs.org/wgbh/pages/frontline/shows/heart/view/

25. Websites • National Center for PTSD- http://www.ncptsd.va.gov/index.html • Post Traumatic Stress Disorder Guidelines (joint VA/DoD)- http://www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm • PBS- Frontline- “A Soldier’s Heart”-http://www.pbs.org/wgbh/pages/frontline/shows/heart/ • PBS- Frontline – “A Company of Soldiers”- http://www.pbs.org/wgbh/pages/frontline/shows/company/ • DoD Mental Health Screening- http://www.mentalhealthscreening.org/military/index.aspx • http://www.defenselink.mil/multimedia/ & Wikimedia commons for photos

26. References • Ballenger, J., Davidson, J., Lecrubier, Y., Nutt, D., Marshall, R., Nemeroff, C., Shalev, A., and R. Yehuda. (2004). Consensus Statement Update on Posttraumatic Stress Disorder From the International Consensus Group on Depression and Anxiety. The Journal of Clinical Psychiatry, Vol. 65 (supplement 1), p. 55-62. • Brewin, CR (2001). Invited Essay: A cognitive neuroscience account of posttraumatic stress disorder and its treatment. Behaviour research and therapy, 39. 373-393 • Friedman, M.J. (2006). Posttraumatic stress disorder among military returnees form • Afghanistan and Iraq. American Journal of Psychiatry, 163 (4), 586-593. • Hoge, C.W., Castro, A., Messer, S., McGurk, D., Cotting, D., & Koffman, R. (2004). • Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351(1), 13-22. • Hoge, C.W., Auchrterlonie, J., & Milliken, C.S. (2006). Mental health problems, use of • mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association, 295 (9), 1023-1032. • Jones, E., and Wessely, S., (2003). “Forward Psychiatry” in the Military: Its Origins and Effectiveness. Journal of Traumatic Stress. Vol 16:4, 411-419. • Management of Post-Traumatic Stress. Washington, DC: VA/DoD Clinical Practice Guideline Working Group, Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense, December 2003.  Office of Quality and Performance publication 10Q-CPG/PTSD-04. • Marshall, A., Panuzio, J., & Taft, C. (2005). Intimate partner violence among military veterans and active duty servicement. Clinical Psychology Review, 25(7), 862-876. • Prigerson, H., Maciejewski, P., & Rosenheck, R. (2001). Combat trauma: trauma with highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemployment and abuse among men. The Journal of Nervous and Mental Disease, 189(2), 99-108. • Roberts, L., Lafta, L., Garfield, R., Khudhairi, J., & Burnham, G. (2004). Mortality before and after the 2003 invasion of Iraq: cluster sample survey. The Lancet, 364, 1857-1864. • Stetz, M., McDonald, J., Lukey, B., & Gifford, R. (2005). Psychiatric diagnoses as a cause of medical evacuation. Aviation Space Environmental Medicine, 7(7Suppl), C15-20.