War and its impact on American health

For American society, the war in Vietnam was unlike any other. It spawned widespread protests, a questioning of the nation’s role in the world and, in the medical field, a new diagnosis. Society, as well as medicine, recognized that soldiers could not go from firefight to firefight without psychological consequences. What had once gone by the names “shell shock” and “combat fatigue” got a new name. Post-traumatic stress disorder (PTSD) was what happened to people who had fought for their lives and seen their comrades die. But it was just one of the many consequences of surviving battle.

Years after soldiers came home, the ghosts of combat haunted them in the form of not only PTSD but also divorce, depression, drug and alcohol abuse and domestic violence. These lingering effects of combat have affected society as well as individual soldiers, according to epidemiologist Holly G. Prigerson, Ph.D., FW ’91. How, she asked, do the experiences of combat veterans burden society as a whole? “No one had looked at societal outcomes,” said Prigerson, an associate professor of psychiatry and of epidemiology and public health.

Using as her database interviews with about 2,500 men between the ages of 18 and 54 from the 1992 National Comorbidity Survey, which examined psychiatric disorders in the United States, Prigerson focused on the roughly 7 percent who had seen combat, mostly in Vietnam. “How are these vets doing now?” Prigerson asked. “The answer is, not very well. And these are not just the vulnerable few.” Prigerson noted that the survey did not single out men who reported problems stemming from combat. “They just asked: ‘Did you witness combat?’”

The numbers of respondents with psychiatric problems and other adverse outcomes, Prigerson found, were “really huge. We were struck by the magnitude of the effects this long after combat.” And men who avoided developing PTSD were not off the hook: decades later, even without suffering from PTSD, combat veterans were significantly more likely than noncombatants to lose jobs, to divorce and to abuse drugs or alcohol. “Our findings,” said Prigerson, “have important implications for the thousands of Americans now involved in military strikes against Afghanistan. Depending on what the soldiers there see and do, their lives may be disrupted for longer than they may anticipate.”

Prigerson’s analysis showed that a significant portion of societal problems could be linked to combat exposure. In the year preceding the survey, combat veterans accounted for 7.4 percent of major depression nationally, 8 percent of substance abuse and 27.8 percent of PTSD. They accounted for 21 percent of current spouse abuse, 8.9 percent of unemployment and 7.8 percent of current divorce or separation.

Compared to other men in the study, a combat veteran was six times as likely to be suffering from PTSD, more than twice as likely to be suffering from recent major depression or substance abuse and more than twice as likely to be separated, divorced or unemployed. The likelihood that he had lost a job in the past year was almost triple the norm and that he’d abused his spouse, more than quadruple.

Combat veterans, Prigerson said, “have assumed huge risks. Recognizing what the outcomes of war are likely to be can help policy makers determine how to help them reintegrate into society as civilians.” When a veteran does not show signs of PTSD, she said, “The assumption shouldn’t be that everything’s well and good.”

Results of Prigerson’s study appeared in the January issue of the American Journal of Public Health. Co-investigators were Paul K. Maciejewski, Ph.D., associate research scientist in psychiatry, and Robert A. Rosenheck, M.D., HS ’77, professor of psychiatry and of epidemiology and public health.