A while ago I started Paper in a Day to get young trauma researchers together. It has been engaging and productive (if you’re interested, the upcoming ISTSS conference will feature one). In a recent edition, four clever minds – Drs Averill, Eubanks Fleming, Holens and Larsen – have thought through research gaps in the PTSD literature. They published a commentary and I wanted to share their thoughts here. They reflect on one of the biggest areas of trauma research, the experiences of military personnel:
As the wars in Afghanistan and Iraq continue, and military service members continue to return home from these two conflicts, more research has been conducted to examine rates of PTSD among these service members (known in the US as OEF/OIF Veterans i.e. Veterans of Operation Enduring Freedom/Operation Iraqi Freedom). This research is important so that we have an understanding of the need for healthcare in newer returning Veterans (which may differ from previous generations). In reviewing some of these articles, many of which are quite well-designed, we noticed a need for some further study to understand the nuances of who develops PTSD and why.
In particular, it would be useful to examine how PTSD prevalence in US OEF/OIF Veterans depends on 1) Veterans Affairs services use (with a particular focus on non-VA users), 2) relationship status, and 3) sexual orientation.
VA status
First, we would encourage future studies to examine how PTSD rates vary among VA-users and non-VA-users. Many OEF/OIF Veterans do not use available Veterans Affairs services, especially mental health care. This highlights the need to understand the differences between those who use and do not use the VA. Research with older Veterans found that those who use the VA tend to be more ill and have more psychosocial difficulties, but we don’t yet know if that’s true for OEF/OIF Vets. The high rates of PTSD-related concerns in non-VA users also points to a need to understand whether—and where—Veterans are seeking care outside the VA. Within the VA, there has been a strong program designed to roll out the use of standardized trauma-focused, evidence-based psychotherapies for PTSD.
But outside the VA, it is not clear how many practitioners have access to training or supervision in these same treatments. Given that many Veterans never access the VA services, and also that many Veterans are concerned about seeing outside providers for fear that they will not understand military-related concerns, it will be critical to disseminate and track access to such treatments for Veterans in the community.
Relationship status
We would also encourage study of how PTSD varies by relationship status. Social support, especially from a spouse, can buffer the development of PTSD; however, relationship discord has the potential to exacerbate PTSD. Divorce rates among military couples increased by almost 50% over the first decade of the OEF/OIF era, suggesting that marital distress in military/Veteran couples is alarmingly high, and is likely playing a role in returning Veterans developing PTSD symptoms. Existing research points to the need to understand how relationship quality (above and beyond categories of marital status) affects PTSD.
Sexual orientation
Finally, we think it is imperative to study PTSD among sexual minority Veterans. This is important because 1) they are at higher risk of trauma exposure, 2) military climate is changing with the 2011 repeal of the US Military “Don’t Ask, Don’t Tell” policy (and the changes in overall climate with the US Supreme Court decision legalizing gay marriage in 2015), and 3) the VA is emerging as likely the largest health care provider for sexual minority Veterans in the US.
In fact, one estimate is that LGBT individuals account for 2.2% of all military personnel, a number that is only likely to increase. There have been very few studies on LGBT mental health in the military and in Veteran populations, and even fewer focusing on OEF/OIF Veterans. As the VA starts to provide treatment to LGBT Veterans—and as the legal and social norms change for LGBT Veterans and civilians—it will be important to further document the prevalence and consequences of trauma and PTSD and how they change over time.
Summing it up…
There has been a lot of focus in the US media on the difficulties with access to the VA. But many younger Veterans aren’t even getting to the VA, or getting help for PTSD. More nuanced research would help us better understand who most needs help, who we need to reach out to, and what issues practitioners should attend to with younger Vets. This is important both for those within the VA, and for those who will never use the VA. Better understanding of PTSD is a first step to fulfilling our obligation
“to care for him who shall have borne the battle and for his widow, and his orphan” (Abraham Lincoln).
What do you think about this topic, and especially about putting more emphasis on demographic characteristics? Necessary? Counter-productive? Something else? Let us know…
About the authors (who contributed equally and are listed alphabetically):
Lynnette Averill is a Research Fellow at the Clinical Neurosciences Division of the National Center for PTSD / Yale University School of Medicine in the USA.
CJ Eubanks Fleming is a Postdoctoral Research Fellow at Duke University Medical Center in Durham, North Carolina in the USA.
Pamela Holens is an Assistant Professor at the Department of Clinical Health Psychology, University of Manitoba and Clinical Psychologist at the Winnipeg Operational Stress Injury Clinic in Canada.
Sadie Larsen is an Assistant Professor at the Medical College of Wisconsin in the USA and a Staff Psychologist at the Milwaukee VA.
The article:
Averill, L., Fleming, C., Holens, P., & Larsen, S. (2015). Research on PTSD prevalence in OEF/OIF Veterans: expanding investigation of demographic variables European Journal of Psychotraumatology, 6 DOI: 10.3402/ejpt.v6.27322
Trauma Recovery Lab 
Pingback: Why Demographics – Including Sexual Orientation – Matter In PTSD research | True Blue Line
Very interesting article, Eva.
Here a comment: I had the opportunity to treat, from a psychiatric / psychotherapeutic point of view, soldiers from the NATO. Some of them were deployed in Irak in the frontline during several periods of time.
One of the cases, a person with a higher responability, very much realted to warfare, had his wife and two children waiting for him at home for years. The wife, an intelligent and very qualified nurse, was atonished when she came to met her husband for the first time in Europe, brought the whole family here, and one day, by chance, she discovers that her husband had dozens of sexual affaires over the years, in the time he was deployed overseas.
She was very angry, met eventualy with one of these ladies who was a comrade of her husband (“she was like his mother”, I remember she was saying) and asked for help and counselling in my office, in order to take the right decission: a traumatic divorc for her and her children who loved the father, a second opportunity for him and / or a dennouncement to the Army authorities etc.
I can not explain more of this case because of professional reasons, but I commented later on the case with a colleague and friend with profound international experience in the field of traumatic stress. He mentioned, after having heard the clinical vignete, that the levels of testosterone very much rise in situation of high stress as the ones related to warfare.
So, it should be considered by the army psychologists and psychiatrists, that soldiers who are in very stresful situations may have an enhanced sexual drive and therefore a continuos need of sexual relations despite of the marital status. This may account also for the elevated ratio of divorces and marital problems in the Armies and under Uniformed Services professionals in stress.
In short, the families of soldiers that remain in the country of origin, just waiting month after month for the return of the loved persons who are fighting for freedom and democracy (this is what they believe and this is why these people preserve their relations at all), can be absolutely frustrated when they discovered that their loved ones do not respected the boundaries and had dozens of sexual relations, even some of them without precautions of any type, and may have infected their wifes with AIDS, siphilis etc.
This major question should be adressed by those responsable for the mental and physical health of soldiers and their families, IMO.
Thank you for your thoughtful comments. A recent article entitled, “The effect of deployment to a combat zone on testosterone levels and the association with the development of posttraumatic stress symptoms: A longitudinal prospective Dutch military cohort study” (Psychoneuroendocrinology, January 2015) by Reijnen, Geuze, and Vermetten noted that plasma testosterone levels in military men do indeed increase shortly after deployment. Interestingly, the authors also found that it was the pre-deployment testosterone levels, not the changes in testosterone levels after deployment, that predicted the development of PTSD symptoms. Irrespective of whether the development of PTSD is related to testosterone changes, deployment-related changes in testosterone level certainly have the potential to impact upon behaviour and are worthy of further investigation. Thank you for bringing this idea to our attention.