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PTSD research reaching underserved groups.

SANTA ANA PUEBLO, N.M. -- With the nation increasingly aware of posttraumatic stress disorder in soldiers returning from Iraq and Afghanistan, some researchers are asking whether more attention should be paid to other underserved groups.

These include older Vietnam War veterans, National Guard and reserve forces, peacekeepers, and the subgroup of soldiers who kill during their military service.

Several experts presented studies in these populations at the annual meeting of the Anxiety Disorders Association of America.

Older Vietnam War Veterans

Vietnam veterans (average age 63 years) responded positively to prolonged exposure therapy for posttraumatic stress disorder (PTSD) in a small pilot study at the VA San Diego Healthcare System.

Scores on the Clinician-Administered PTSD scale (CAPS) dropped significantly from 94 before the 12-week intervention to 48 afterward (P less than .05), Steven R. Thorp, Ph.D., reported, putting the cutoff for PTSD at 60. The mean number of PTSD symptoms also dropped from 15 to 8, and 75% of participants no longer met PTSD criteria.

Dr. Thorp cautioned, however, that the results need to be taken with a grain of salt. The study was tiny--11 men enrolled, of whom 8 completed treatment. In addition, operating on a shoestring budget, he did the therapy and the assessments himself.

That said, it was still the largest psychotherapy study ever in older adults with PTSD, he maintained: larger than all previous studies combined. And self-reports showed improvement on a variety of measures, including the Impact of Events scale (IBS), Beck Depression Inventory (BDI), and Subjective Units of Distress scale (SUDS).

Many clinicians are reluctant to do exposure therapy in older adults, according to Dr. Thorp, also from the VA Center of Excellence for Stress and Mental Health at the University of California, San Diego. The population is thought to be too frail to handle exposure to their traumas.

"Even though we don't have any data, people have opinions," he said.

Meanwhile, older veterans are seeking help, he continued. They have a worsening of symptoms, perhaps fomented by scenes of Iraq and Afghan combat on the evening news.

If retired, they also may have more time on their hands to think about old traumas. In many cases, wives and girlfriends encourage the veterans to seek help.

Most of the eight men who completed the study were married (63%), retired (88%), and white (88%). On average 39 years had passed since their traumas; half the participants had previous psychotherapy; and a quarter had a history of psychiatric hospitalization. At the time of the study 38% took psychiatric medications.

The next step for Dr, Thorp is a 5-year randomized trial comparing exposure therapy to relaxation therapy in adults ages 60 and older with PTSD. He has received a Mid-Level VA Career Development Award to conduct the study, which is to enroll 100 adults.

The protocol calls for independent clinical assessments, repeated follow-up assessments every 6 months during the study, and neuropsychological testing.

National Guard/Reserve Forces

National Guard and Reserve forces are coming home from Afghanistan and Iraq with higher levels of combat exposure than did their counterparts in the Gulf War and in Iraq and Afghanistan before 2004, Keith D. Renshaw, Ph.D., reported. Many recent reservists experienced combat exposure comparable to that of active-duty troops.

Dr. Renshaw of the University of Utah, Salt Lake City, based his finding on surveys of male returnees. Most of those surveyed were Mormons who had participated in marital relationship workshops. He compared the data from a pilot study in 50 veterans who served abroad in the National Guard from 2005 to 2006 and a second more recent sample of 203 National Guard and reserves returnees with published data on Gulf War and pre-2004 returnees.

Among reservists who served in 2007-2008, combat exposure levels were much higher in returnees from Afghanistan, compared with those from Iraq as well as with earlier returnees from Afghanistan. "It depends on when and where you were deployed," Dr. Renshaw said.


Peacekeeping is not necessarily peaceful or benign, according to Dr. Jitender Sareen of the University of Manitoba, Winnipeg. Depending on the mission and the location, troops sent to areas of conflict as peacekeepers may experience substantial stress and violence.

He found PTSD rates of 5%-12% in a literature review of peacekeeper studies. These rates were associated with poor health and increased rates of medical service utilization, he reported, but firm conclusions were hard to draw. While many studies found higher level of post-deployment mental disorders, distress, and suicide, some did not. Moreover, very few long-term studies had been attempted.

Among the areas that need investigation, he suggested, are the different levels of trauma exposure in peacekeeping missions, national differences in training of peacekeepers, physical injuries to peacekeepers, and interventions for peacekeepers. "Studies are needed that focus on risk factors for mental illness and empirical interventions that may prevent mental illness in this population," he concluded.

Soldiers Who Kill

In a study of data collected in the 1980s for the National Vietnam Veterans Readjustment Study, Rachel MacNair, Ph.D., found that soldiers who killed during that war were more likely to experience PTSD than those who did not.

Soldiers who killed had higher Mississippi Scale PTSD scores (93.4 vs. 71.9) as did those who were directly involved in the killing of civilians or prisoners, compared with those who only saw such events (105.6 vs. 79.4), said Dr. MacNair, director of the Institute for Integrated Social Analysis in Kansas City, Mo.

She said she had requested data on soldiers from Iraq and Afghanistan from the military for a similar analysis, but has yet to receive any information.
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Author:MacNeil, Jane Salodof
Publication:Clinical Psychiatry News
Date:May 1, 2009
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