Enduring Injuries to Brain and Mind: Medical Consequences of the Iraq War

Dr McCue is Clinical Professor of Medicine, University of California, San Francisco, and CMO/COO, Tuolumne General Hospital, Sonora, Calif.

The Veterans Administration (VA) is struggling to cope with the physical and mental wounds of the Iraq war. The authors of a recent study, Karen H. Seal, MD, University of California, San Francisco, and the San Francisco VA Medical Center, and colleagues, observed that VA and non-VA mental health and primary care services are not well equipped to handle co-occurring psychosocial and mental health problems in Afghanistan and Iraq war veterans.¹ They noted that prompt action is critical to prevent chronic mental illness associated with the effects of “high-intensity guerrilla warfare and the chronic threat of roadside bombs and improvised explosive devices…multiple tours of duty…traumatic injury, and [the fact that] more of the wounded survive than ever before.”

The Life of Reason

Internists who practiced in the 1980s have heard this before, and many of us still see the ravages of the many years of the Vietnam War—chronic psychiatric illnesses, drug addiction, and cirrhosis from hepatitis C and alcoholism—that had their roots in Vietnam and are still with us today. Of these, Vietnam War–related posttraumatic stress disorder (PTSD) and its consequences are problems that physicians in public and VA hospitals still treat on a frequent basis. And now for the next few decades we will be seeing the consequences of PTSD from the Iraq and Afghanistan wars.¹ George Santayana’s often misquoted statement in (1905), “Those who cannot remember the past are condemned to repeat it,” comes to mind.

Journal of the American Medical Association

Although not literally first described as a consequence of service in Vietnam, the diagnosis of PTSD was nearly unknown until it began to be recognized in war veterans. A literature search on PubMed for “Vietnam veterans” yielded more than 1250 publications since 1967. The first 66 articles were predominantly medical in orientation, concentrating on war wounds. In 1981, with the publication of 2 studies in the ,^2,3 there was a growing accumulation of papers dealing with the recognition, consequences, and treatment of PTSD that now encompasses the great majority of medical publications on Vietnam War veterans to the present day.

PTSD is an anxiety disorder that develops after a terrifying event in which grave physical harm occurred or was threatened. According to the National Institute of Mental Health, each year nearly 4% of American adults (aged 18-54 years) have PTSD.⁴

Patients with PTSD may experience flashbacks, nightmares, frightening thoughts, emotional numbness, sleep disturbances, depression, anxiety, irritability, or anger outbursts. Anxiety-related physical symptoms include headaches, gastrointestinal distress, dizziness, and chest pain. Related disorders include depression, alcoholism, and drug abuse. We often treat these symptoms and disorders, without being aware that they stem from PTSD.

About 30% of Vietnam War veterans had PTSD at some point after the war. The disorder also has been detected in up to about 10% of Persian Gulf War veterans.⁴ The symptoms are more common in women, and women are now much more likely to have traumatic war experiences than was true in the Vietnam War era. Considering the lag time before the severity of the public health problem with PTSD after Vietnam was recognized, it is safe to assume that current figures for Iraq- and Afghanistan-related PTSD will increase, probably by several-fold.

New England Journal of Medicine

But there are some real differences in the medical and psychological consequences associated with our current wars, as described in 2 recent articles published in the on traumatic brain injuries (TBI) related to improvised explosive devices.^5,6 These articles paint a reality that those who send our young men and women into harm’s way in a useless war surely wish to ignore.

As of 6 months ago, more than 22,600 US soldiers have been wounded in ongoing conflicts in Iraq, Afghanistan, and elsewhere. The majority of the injuries have been caused by blasts, and 59% of blast-exposed patients at Walter Reed Army Medical Center have a TBI, about half of which are moderate or severe.^5,6

The consequences of TBI include speech and language deficits, as well as loss of cognitive skills. Some deficits may improve as brain swelling recedes, but others require prolonged therapy, may never resolve completely, or may leave victims with serious disabilities. TBI is more common because explosives are now easy to obtain, more powerful, and easier to hide.

Paradoxically, TBI is also more common because of Kevlar body armor and helmets, which have contributed to at least a 3-fold reduction in mortality from injuries, including TBI, since the Vietnam War era, when about 75% of the injuries were fatal.⁶ As a result, more Iraq and Afghanistan veterans with severe TBI survive, with serious cognitive deficits. Symptoms of TBI and PTSD overlap, and not surprisingly many (or most?) patients with TBI have PTSD.

A study published in 2002 indicated that decades after the Vietnam War ended, high-combat veterans, compared with medium- or low-combat veterans, had lower incomes, less happiness in their marriages and lives, and were more likely to smoke.⁷ TBI and PTSD are enduring consequences of war. Just as we relive the consequences of the Vietnam War—the injuries to mind and body that were sustained more than 40 years ago—so will we relive the medical consequences of our current wars well beyond 2050.

References

Arch Intern Med

1. Seal KH, Bertenthal D, Miner CR, et al. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. . 2007; 167:476-482.

JAMA

2. Lemere F. Psychotherapy to Vietnam veterans. . 1981; 246:125.

JAMA

3. Walker JI. The psychological problems of Vietnam veterans. . 1981; 246:781-782.

4. National Institute of Mental Health. “Reliving Trauma: Post-Traumatic Stress Disorder.” Available at: www.nimh.nih.gov/publicat/reliving.cfm

N Engl J Med

5. Okie S. Reconstructing lives—a tale of two soldiers. . 2006; 355: 2609-2615.

N Engl J Med

6. Okie S. Traumatic brain injury in the war zone. . 2005; 352:2043-2047.

Ann Epidemiol

7. Stellman S, Stellman J, Koenen K. Enduring social and behavioral effects of exposure to military combat in Vietnam. . 2000; 10:480.