Study: For most Vietnam veterans with PTSD, symptoms worse over time

More than 40 years after fighting in Vietnam, about 11 percent of combat veterans still suffer from post-traumatic stress disorder, a new study finds, and far more of them are getting worse than are getting better.

The study confirms that “most people who serve in war are resilient,” said Dr. Charles Marmar, one of the authors of the study, who is chairman of the psychiatry department at New York University Langone Medical Center and director of the NYU Cohen Veterans Center.

But among the minority of those who do develop post-traumatic stress, the study shows, “if they’re going to recover, they’re going to recover early on,” Marmar said.

The study finds that some 271,000 Vietnam veterans suffer from PTSD, with symptoms like flashbacks, nightmares and startle reactions, with a third of them also suffering from depression or anxiety.

“An important minority of Vietnam veterans are symptomatic after four decades, with more than twice as many deteriorating as improving,” the study says. That finding raises policy questions about access to mental-health services and attention to the stresses of aging that may amplify symptoms.

It is also key to predicting the future of veterans of the Iraq and Afghanistan wars, in which troops have been diagnosed with PTSD at similar rates, said Dr. Charles Hoge of the Walter Reed Army Institute of Research, who wrote a companion editorial for JAMA Psychiatry, a publication of the Journal of the American Medical Association, which published the study Wednesday.

“This is a very important study,” he said in an interview. “It tells us we may well see a chronic course in our veterans of Iraq and Afghanistan if they can’t get the treatment they need. Hopefully, things will look a little different 40 years from now.”

The study builds on the National Vietnam Veterans Readjustment Study, a historic effort funded by the Department of Veterans Affairs to track a large, nationally representative sample of troops as they continued their lives. First published in 1992, it brought PTSD to national attention as an injury of war and prompted treatment of and disability payments for affected veterans.

That study of 2,348 Vietnam-era veterans found that about 30 percent of them had had PTSD at some point in the years since the war. By the late 1980s, about 15 percent still qualified for the diagnosis.

In the new analysis, researchers contacted nearly 80 percent of the original group, who in 2012 and 2013 filled out questionnaires and participated in phone interviews. The team assessed symptoms and performed intensive clinical interviews on 400 of the veterans, now in their 60s.

“This methodologically superb follow-up of the original NVVRS cohort offers a unique window into the psychiatric health of these veterans 40 years after the war’s end,” Hoge wrote in the editorial. “No other study has achieved this quality of longitudinal information, and the sobering findings tell us as much about the Vietnam generation as about the lifelong impact of combat service in general, relevant to all generations.”

The study also looked at the mental health outcomes of female Vietnam veterans, most of whom were nurses. Although they had roughly the same PTSD rates as other troops in the early part of the study, the women fared better as time went on, Marmar said, with only about 6 percent still suffering from PTSD symptoms. “They’re more likely to recover,” he said.

The reasons why some people got better while others got worse is now being assessed, Marmar said. He said probable factors included the intensity and repetition of traumatic events, whether a physical injury was sustained, age and background of troops when they went to Vietnam, education level and support received when they returned home. Members of minority groups who enlisted before finishing high school were especially likely to develop war-related trauma, the study has found, as were veterans who had killed multiple times in combat.

Aging also plays a role, he said, in that it is often accompanied by diminished health and social support, and with changes in cognition. And midlife distractions from symptoms — family, career, a rich social life — might be gone in later years. “You’ve got a lot of time to reminisce about Vietnam,” Marmar said, “and not always for the good.”

Both Marmar and Hoge said the study in no way brought into question the efficacy of PTSD treatments; both said that evidence-based treatments were available but that affected veterans often did not access them or left treatment too soon.

Marmar acknowledged that disability payments for PTSD could be problematic. Veterans are deserving of compensation, he said, but “in making their compensation contingent on those symptoms you give a disincentive to their recovery.”

Asked if that might be a factor in the veterans whose PTSD symptoms appeared later in life or did not improve, Marmar, demurred. “I’ll tell you my honest opinion: For every veteran who might be exaggerating their symptoms, there are many, many more who say nothing because of stigma.”

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