**1. Introduction**

50 Post Traumatic Stress Disorders in a Global Context

Williams, I. & Bernstein, K. (2011). Military Sexual Trauma Among U.S. Female Veterans.

Military-related posttraumatic stress disorder (PTSD) occurs in a significant minority of veterans and often presents with complex psychiatric co-morbidity (Kessler et al., 1995, Keane and Kaloupek, 1997, Keane and Wolfe, 1990, Forbes et al., 2003, Kulka et al., 1990, Sareen et al., 2004). Twelve month and lifetime prevalence rates of PTSD in the Canadian Regular Forces has been reported as 2.8% and 7.2% respectively (Statistics Canada, 2002). In Canadian veterans pensioned with a medical condition, the 1 month prevalence was 10.3% (Richardson et al., 2006). Other military samples have shown 6 month and lifetime prevalence rates of 11.6 and 20.0% respectively (O'Toole et al., 1996). The large variation in PTSD rates might be a function of the time elapsed between the end of a mission and the start of the mental health evaluation, the nature and frequency of potentially traumatic events within each mission and differences in measurement used i.e. self-report screening tools vs. diagnostic interview.

Patients with PTSD often present first to their primary care clinician with mental health issues, (Del Piccolo et al., 1998) and as such demonstrate increased healthcare service use and costs (Kulka et al., 1990, Ronis et al., 1996, Marshall et al., 1998, Hankin et al., 1999, Kessler et al., 1999, Switzer et al., 1999, Elhai and Ford, 2005, Elhai et al., 2005, Gavrilovic et al., 2005, Richardson et al., 2006). Studies indicate that military-related PTSD is more prone to somatisation (McFarlane et al., 1994) and is associated with more physical health problems (Boscarino, 1997, Boscarino and Chang, 1999, Schnurr and Jankowski, 1999, Schnurr et al., 2000, Sledjeski et al., 2008, Jakupcak et al., 2008, Sareen et al., 2007, Elhai et al., 2007). Evidence also shows that PTSD is often associated with significant comorbidity including major depression, substance abuse, suicidality, (Kessler et al., 1995, Keane and

Psychiatric Management of Military-Related PTSD: Focus on Psychopharmacology 53

Military members face barriers to rapid, effective treatment for mental illness (Hoge et al., 2004b). Military culture, fear of stigmatization and concerns of career debasement can deter help-seeking , particularly at an early stage when symptoms may be more likely to respond to treatment (Hoge et al., 2002, Elhai et al., 2005, Gavrilovic et al., 2005, McFall et al., 2000, Hoge et al., 2004b). Such delays in accessing treatment may further contribute to the

Military-related PTSD responds to both psychotherapeutic and psychopharmacological treatments. (Foa, 2006, Benedek et al., 2009). However, psychotherapy meta-analysis showed that military-related PTSD has the lowest effect size when compared to civilian PTSD (Bradley et al., 2005). Treatment response for PTSD related to a car accident, sexual assault or other more-typically civilian trauma, might not garner the same response for a militaryrelated PTSD. Recent psychotherapy studies have been more encouraging, demonstrating effectiveness in randomized controlled trials including cognitive behavioral psychotherapy, prolonged exposure and cognitive processing therapy (Monson et al., 2006, Nacasch et al.,

Pharmacological treatment has also demonstrated poor response in military-related PTSD (Schoenfeld et al., 2004a, Shalev et al., 1996, Friedman, 1997). Factors such as chronicity, high comorbidity rates (Friedman, 1997, Shalev et al., 1996, Forbes et al., 2003) and anger that is often present in military-related PTSD (Forbes et al., 2005) have been identified as predictors of poor response. Prior trauma history and past history of psychiatric illness has also been identified as important predictors of treatment outcome (Hourani and Yuan, 1999). Military specific factors, such as the nature of deployment, which often involves months of persistent hyperarousal and hypervigilance in unfamiliar surroundings away from their social support, have also been demonstrated as being a negative predictor in veterans with combat exposure (Foa et al., 2009, King et al., 1995, Creamer and Forbes, 2004). Although a recent Cochrane review demonstrated the effectiveness of pharmacological interventions for PTSD, especially serotonin specific reuptake inhibitors (SSRIs) (Stein et al., 2006 ), the American Psychiatric Association PTSD Treatment Guideline update concluded that there was insufficient evidence demonstrating the benefit of an SSRI in the veteran population

Due to the complex nature of the clinical presentation of PTSD, from the continuum of adjustment disorders and subthreshold PTSD to 'full-blown' PTSD, this paper aims to confine itself to a general overview of the psychiatric management of military-related PTSD. Despite the challenges researchers face in conducting studies on the effectiveness of military-related PTSD treatment (Institute of Medicine (IOM), 2008), if evidence-based practices are utilized using established guidelines (American Psychiatric Association, 2004, Australian Centre for Post Traumatic Mental Health and National Health and Medical Research Council, 2007) remission can be achieved in 30%–50% of cases of PTSD (Friedman,

The presentations of military-related PTSD is often complex. Military members and veterans may initially present indirectly with an emotional, behavioural or addiction concern or an unrelated, less stigmatizing somatic problem such as a physical complaint (Australian Centre for Post Traumatic Mental Health and National Health and Medical Research

functional impairment often associated with PTSD.

2010, Tuerk et al., 2011, Morland et al., 2010).

(Benedek et al., 2009).

**2. Psychiatric management** 

2006).

**2.1 Assessment** 

Kaloupek, 1997, Keane and Wolfe, 1990, Forbes et al., 2003, Kulka et al., 1990, Gradus et al., 2010, Nepon et al., 2010, Sareen et al., 2005) and chronic disability contributing to impaired quality of life (Mills et al., 2006, Richardson et al., 2008 , Richardson et al., 2010).

Military personnel are more likely to be exposed to trauma than the general public (Breslau et al., 1991). Potentially traumatic events can include combat, imprisonment, torture, witnessing atrocities, comrades being wounded or killed, or rescue missions following natural disasters. Peacekeeping missions to Bosnia, Somalia and Rwanda have also involved complex rules of engagement that prevented immediate and active intervention, with a resultant sense of intense vulnerability to attack (Litz et al., 1997b, Litz et al., 1997a, American Psychiatric Association, 2004, Litz, 1996). However military members can also be exposed to non-military specific trauma including rape, motor vehicle accidents, assault and natural disasters.

Risk factors for the development of PTSD have been extensively studied in the military and veteran population. Pre-trauma risk factors for PTSD include a family and/or personal history of psychiatric illness, past trauma including history of childhood abuse (Brewin et al., 2000, Ozer et al., 2003a, Sandweiss et al., 2011). Women are twice as likely to develop PTSD, although men are more likely to be exposed to a traumatic events (Kessler et al., 1995, Breslau et al., 1998). In the military, men still vastly outnumber women, especially in trades that involved combat. Other proposed pre-trauma risk factors from community studies include: younger age, single marital status and lower socioeconomic status (Breslau et al., 2006, Richardson et al., 2007).

Suggested peri-traumatic risk factors include: trauma severity and life threat, (Brewin et al., 2000, Hoge et al., 2004a, Richardson et al., 2007) bodily injury (Koren et al., 2005) and the number of operational deployments (Richardson et al., 2007, Statistics Canada, 2002). The dose-response effect between number of operational deployments was confirmed in a recent re-analysis of PTSD's prevalence among U.S. male Vietnam veterans (Dohrenwend et al., 2006)and in American soldiers deployed in Afghanistan (Hoge et al., 2004b). The emotional response at the time of the trauma, such as feeling unable to control a situation and peritraumatic dissociation, (Brewin et al., 2000, Yehuda, 1999, Ozer et al., 2003a) has also been identified as significant peri-traumatic risk factors. Although more recent studies have cast some doubt on the vailidity of the importance of peri-traumatic dissociation (Candel et al., 2003). More recent studies have demonstrated that pain control in trauma care was significantly associated with a lower risk of PTSD after injury (Holbrook et al., 2010), and both increase heart rate at the time of the trauma (Bryant et al., 2011) and intensive care admission following traumatic injury (O'Donnell et al., 2010) were associated with increased risk of developing PTSD.

Post-traumatic risk factors may include: lack of access to treatment, stigmatization, ongoing life stressors and lack of social support (Brewin et al., 2000, Ozer et al., 2003b, Yehuda et al., 1998). Access to treatment is important, as there is a significant association between soldiers diagnosed with a psychiatric conditions and high attrition rates from the military (Hoge et al., 2002). Deployed members are frequently exposed to long separations from their families and friends and ongoing financial strain might add to the distress a deployed member might face after they return home. Shame and guilt are also posttraumatic risk factors (Yehuda et al., 1998) that military members frequently often face.

Formal psychometric instruments have been developed to assess deployment risk and resiliency factors in relation to mental health outcomes, such as the Deployment Risk and Resilience Inventory (King et al., 2006).

Military members face barriers to rapid, effective treatment for mental illness (Hoge et al., 2004b). Military culture, fear of stigmatization and concerns of career debasement can deter help-seeking , particularly at an early stage when symptoms may be more likely to respond to treatment (Hoge et al., 2002, Elhai et al., 2005, Gavrilovic et al., 2005, McFall et al., 2000, Hoge et al., 2004b). Such delays in accessing treatment may further contribute to the functional impairment often associated with PTSD.

Military-related PTSD responds to both psychotherapeutic and psychopharmacological treatments. (Foa, 2006, Benedek et al., 2009). However, psychotherapy meta-analysis showed that military-related PTSD has the lowest effect size when compared to civilian PTSD (Bradley et al., 2005). Treatment response for PTSD related to a car accident, sexual assault or other more-typically civilian trauma, might not garner the same response for a militaryrelated PTSD. Recent psychotherapy studies have been more encouraging, demonstrating effectiveness in randomized controlled trials including cognitive behavioral psychotherapy, prolonged exposure and cognitive processing therapy (Monson et al., 2006, Nacasch et al., 2010, Tuerk et al., 2011, Morland et al., 2010).

Pharmacological treatment has also demonstrated poor response in military-related PTSD (Schoenfeld et al., 2004a, Shalev et al., 1996, Friedman, 1997). Factors such as chronicity, high comorbidity rates (Friedman, 1997, Shalev et al., 1996, Forbes et al., 2003) and anger that is often present in military-related PTSD (Forbes et al., 2005) have been identified as predictors of poor response. Prior trauma history and past history of psychiatric illness has also been identified as important predictors of treatment outcome (Hourani and Yuan, 1999). Military specific factors, such as the nature of deployment, which often involves months of persistent hyperarousal and hypervigilance in unfamiliar surroundings away from their social support, have also been demonstrated as being a negative predictor in veterans with combat exposure (Foa et al., 2009, King et al., 1995, Creamer and Forbes, 2004). Although a recent Cochrane review demonstrated the effectiveness of pharmacological interventions for PTSD, especially serotonin specific reuptake inhibitors (SSRIs) (Stein et al., 2006 ), the American Psychiatric Association PTSD Treatment Guideline update concluded that there was insufficient evidence demonstrating the benefit of an SSRI in the veteran population (Benedek et al., 2009).

Due to the complex nature of the clinical presentation of PTSD, from the continuum of adjustment disorders and subthreshold PTSD to 'full-blown' PTSD, this paper aims to confine itself to a general overview of the psychiatric management of military-related PTSD. Despite the challenges researchers face in conducting studies on the effectiveness of military-related PTSD treatment (Institute of Medicine (IOM), 2008), if evidence-based practices are utilized using established guidelines (American Psychiatric Association, 2004, Australian Centre for Post Traumatic Mental Health and National Health and Medical Research Council, 2007) remission can be achieved in 30%–50% of cases of PTSD (Friedman, 2006).
