It’s the question Richard McNally, an eminent PTSD scholar in the US, posed in Science earlier this month. The journal devoted a special issue to human conflict and McNally zoomed in on PTSD after combat duty. His comments are worth sharing and have implications that go beyond the military:

The first point he makes regards the prevalence of PTSD. The wars in Afghanistan and Iraq have caused PTSD in army personnel but at a far lower rate than was expected. While the original estimations were around 30% of troops deployed to war zones, actual numbers were only a fraction of that: about 4% of the people deployed (8% in those reporting combat exposure), according to the most rigorous studies. This fits well with Bonanno’s argument about humans’ capacity to thrive in the face of adversity.

Even though the rates are lower than anticipated, PTSD is a serious problem for those affected and their families. One of the main, persistent issues regards the stigma about seeking help. How to reduce stigma is relatively under researched is my impression from the article. McNally indicates that when social cohesion is strong and leadership is excellent, people tend to have fewer worries about stigma. May be these two factors point to just one avenue to reduce stigma in the specific context of military units, but it is a hopeful start.

When it comes to treatment of veterans, there has been an enormous endeavor to train clinicians in evidence-based cognitive behavioral therapies (Prolongued Exposure, Cognitive Processing). For the dissemination, a train-the-trainer model with intensive supervision was used. It looks like this has been a highly effective way of disseminating and implementing evidence-based treatment. McNally points out that vital conditions had been met for a successful implementation: administrative support, guaranteed time for therapists to deliver the treatment optimally, and incentives/directives to secure maintenance.

Finally, it is still a difficult choice between investing in PTSD prevention (with the risk of spending money on screening people who will be resilient anyway) and PTSD treatment (which only takes place after damage is done). However, McNally mentions promising new preventative initiatives targeting high-risk groups. One is Battlemind debriefing, for platoons returning from combat duty. While the word ‘debriefing’ may have got all your alarm bells ringing, this is actually not the ‘ventilating emotions’ type of debriefing. It focuses on building confidence and coping skills. And makes me wonder whether it would be a helpful program for first responders such as fire fighters and paramedics as well.

Therefore, while reading McNally’s article, these questions/reminders came up:

• How can we find a balance between keeping people’s resilience in mind and paying enough attention to the seriousness of the problem for those struggling with PTSD?
• We should put more research effort in discovering what are effective ways to reduce stigma.
• Could we make more use of the train-the-trainer model to disseminate evidence-based practice than we do now?
• Would programs like Battlemind debriefing have elements that are helpful for first responders?

What’s your take on it?

McNally’s paper:
McNally, R. (2012). Are We Winning the War Against Posttraumatic Stress Disorder? Science, 336 (6083), 872-874 DOI: 10.1126/science.1222069