FREE NEJM E-TOC    HOME   |   SUBSCRIBE   |   CURRENT ISSUE   |   PAST ISSUES   |   COLLECTIONS   |   Search Term  Advanced Search

Sign in | Get NEJM's E-Mail Table of Contents — Free | Subscribe

Previous Volume 351:13-22 July 1, 2004 Number 1 Next

	Full Text PDF PDA Full Text PowerPoint Slide Set Editorial by Friedman, M. J. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear PubMed Citation

ABSTRACT

Background The current combat operations in Iraq and Afghanistan have involved U.S. military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans.

Methods We studied members of four U.S. combat infantry units (three Army units and one Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or three to four months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and post-traumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments.

Results Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care.

Conclusions This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care.

Source Information

From the Department of Psychiatry and Behavioral Sciences, Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command, Silver Spring, Md. (C.W.H., C.A.C., S.C.M., D.M., D.I.C.); and First Naval Construction Division, Norfolk, Va. (R.L.K.).

Address reprint requests to Dr. Hoge at the Department of Psychiatry and Behavioral Sciences, Walter Reed Army Institute of Research, 503 Robert Grant Ave., Silver Spring, MD 20910, or at charles.hoge{at}na.amedd.army.mil.

Full Text of this Article

Related Letters:

Combat Duty in Iraq and Afghanistan and Mental Health Problems
Gross R., Neria Y., Engel A. G., Aquilino C. A., Hoge C. W., Messer S. C., Castro C. A.
Extract | Full Text | PDF  
N Engl J Med 2004; 351:1798-1800, Oct 21, 2004. Correspondence

This article has been cited by other articles:

• Tuerk, P. W., Grubaugh, A. L., Hamner, M. B., Foa, E. B. (2009). Diagnosis and Treatment of PTSD-Related Compulsive Checking Behaviors in Veterans of the Iraq War: The Influence of Military Context on the Expression of PTSD Symptoms. Am. J. Psychiatry 166: 762-767 [Abstract] [Full Text]  
• Owens, G. P., Herrera, C. J., Whitesell, A. A. (2009). A Preliminary Investigation of Mental Health Needs and Barriers to Mental Health Care for Female Veterans of Iraq and Afghanistan. Traumatology 15: 31-37 [Abstract]  
• Wilson, J., Jones, M., Fear, N. T., Hull, L., Hotopf, M., Wessely, S., Rona, R. J. (2009). Is Previous Psychological Health Associated With the Likelihood of Iraq War Deployment? An Investigation of the "Healthy Warrior Effect". Am J Epidemiol 169: 1362-1369 [Abstract] [Full Text]  
• Burnam, M. A., Meredith, L. S., Tanielian, T., Jaycox, L. H. (2009). Mental Health Care For Iraq And Afghanistan War Veterans. Health Aff (Millwood) 28: 771-782 [Abstract] [Full Text]  
• Phillips, A. C., Batty, G. D., Gale, C. R., Deary, I. J., Osborn, D., MacIntyre, K., Carroll, D. (2009). Generalized Anxiety Disorder, Major Depressive Disorder, and Their Comorbidity as Predictors of All-Cause and Cardiovascular Mortality: The Vietnam Experience Study. Psychosom. Med. 71: 395-403 [Abstract] [Full Text]  
• LeardMann, C. A, Smith, T. C, Smith, B., Wells, T. S, Ryan, M. A K, for the Millennium Cohort Study Team, (2009). Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: prospective US military cohort study. BMJ 338: b1273-b1273 [Abstract] [Full Text]  
• Benedek, D. M., Ursano, R. J. (2009). Posttraumatic Stress Disorder: From Phenomenology to Clinical Practice. Focus 7: 160-175 [Abstract] [Full Text]  
• Duffy, F. F., Craig, T., Moscicki, E. K., West, J. C., Fochtmann, L. J. (2009). Performance in Practice: Clinical Tools to Improve the Care of Patients with Posttraumatic Stress Disorder. Focus 7: 186-203 [Abstract] [Full Text]  
• Benedek, D. M., Friedman, M. J., Zatzick, D., Ursano, R. J. (2009). Guideline Watch (March 2009): Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Focus 7: 204-213 [Full Text]  
• (2009). Bibliography for PTSD and Disaster Psychiatry. Focus 7: 214-216 [Full Text]  
• KUBZANSKY, L. D., KOENEN, K. C. (2009). Is posttraumatic stress disorder related to development of heart disease? An update*. Cleveland Clinic Journal of Medicine 76: S60-S65 [Abstract] [Full Text]  
• Bobo, W. V., Nevin, R., Greene, E., Lacy, T. J. (2009). The Effect of Psychiatric Third-Year Rotation Setting on Academic Performance, Student Attitudes, and Specialty Choice. Acad. Psychiatry 33: 105-111 [Abstract] [Full Text]  
• Fikretoglu, D., Elhai, J. D., Liu, A., Richardson, J. D., Pedlar, D. J. (2009). Predictors of Likelihood and Intensity of Past-Year Mental Health Service Use in an Active Canadian Military Sample. Psychiatr. Serv. 60: 358-366 [Abstract] [Full Text]  
• Wortzel, H. S., Binswanger, I. A., Anderson, C. A., Adler, L. E. (2009). Suicide Among Incarcerated Veterans. J Am Acad Psychiatry Law 37: 82-91 [Abstract] [Full Text]  
• Frisman, L. K., Griffin-Fennell, F. (2009). Commentary: Suicide and Incarcerated Veterans--Don't Wait for the Numbers. J Am Acad Psychiatry Law 37: 92-94 [Abstract] [Full Text]  
• Elizur, Y., Yishay-Krien, N. (2009). Participation in Atrocities Among Israeli Soldiers During the First Intifada: A Qualitative Analysis. Journal of Peace Research 46: 251-267 [Abstract]  
• Iversen, A. C., Greenberg, N. (2009). Mental health of regular and reserve military veterans. Adv. Psychiatr. Treat. 15: 100-106 [Abstract] [Full Text]  
• Jacobson, I. G., Smith, T. C., Smith, B., Keel, P. K., Amoroso, P. J., Wells, T. S., Bathalon, G. P., Boyko, E. J., Ryan, M. A. K., for the Millennium Cohort Study Team, (2009). Disordered Eating and Weight Changes After Deployment: Longitudinal Assessment of a Large US Military Cohort. Am J Epidemiol 169: 415-427 [Abstract] [Full Text]  
• Insel, T. R. (2009). Translating Scientific Opportunity Into Public Health Impact: A Strategic Plan for Research on Mental Illness. Arch Gen Psychiatry 66: 128-133 [Abstract] [Full Text]  
• La Bash, H. A. J., Vogt, D. S., King, L. A., King, D. W. (2009). Deployment Stressors of the Iraq War: Insights From the Mainstream Media. J Interpers Violence 24: 231-258 [Abstract]  
• Greenberg, N., Langston, V., Fear, N. T., Jones, M., Wessely, S. (2009). An evaluation of stress education in the Royal Navy. Occup Med (Lond) 59: 20-24 [Abstract] [Full Text]  
• Vogt, D. S., Proctor, S. P., King, D. W., King, L. A., Vasterling, J. J. (2008). Validation of Scales From the Deployment Risk and Resilience Inventory in a Sample of Operation Iraqi Freedom Veterans. Assessment 15: 391-403 [Abstract]  
• Sareen, J., Belik, S.-L., Afifi, T. O., Asmundson, G. J. G., Cox, B. J., Stein, M. B. (2008). Canadian Military Personnel's Population Attributable Fractions of Mental Disorders and Mental Health Service Use Associated With Combat and Peacekeeping Operations. Am. J. Public Health 98: 2191-2198 [Abstract] [Full Text]  
• Tarn, M., Greenberg, N., Wessely, S. (2008). Gulf War syndrome - has it gone away?. Adv. Psychiatr. Treat. 14: 414-422 [Abstract] [Full Text]  
• Hoge, C. W. (2008). Re: "Psychiatric Diagnoses in Historic and Contemporary Military Cohorts: Combat Deployment and the Healthy Warrior Effect. Am J Epidemiol 168: 1095-1096 [Full Text]  
• Smith, T. C., Ryan, M. A. K., Smith, B., Gackstetter, G. D., Wells, T. S., Amoroso, P. J., Hooper, T. I., Boyko, E. J., for the Millennium Cohort Study Team, (2008). Re: "Psychiatric Diagnoses in Historic and Contemporary Military Cohorts: Combat Deployment and the Healthy Warrior Effect". Am J Epidemiol 168: 1094-1095 [Full Text]  
• Larson, G. E., Highfill-McRoy, R. M., Booth-Kewley, S. (2008). The Authors Reply. Am J Epidemiol 168: 1096-1098 [Full Text]  
• Dohrenwend, B. P., Sloan, D. M., Marx, B. P., Kaloupek, D., Keane, T. M. (2008). Re: "Psychiatric Diagnoses in Historic and Contemporary Military Cohorts: Combat Deployment and the Healthy Warrior Effect". Am J Epidemiol 168: 1093-1094 [Full Text]  
• Ouimette, P., Coolhart, D., Sugarman, D., Funderburk, J. S., Zelman, R. H., Dornau, C. (2008). A Pilot Study of Posttraumatic Stress and Associated Functioning of Army National Guard Following Exposure to Iraq Warzone Trauma. Traumatology 14: 51-56 [Abstract]  
• Browne, T, Iversen, A, Hull, L, Workman, L, Barker, C, Horn, O, Jones, M, Murphy, D, Greenberg, N, Rona, R, Hotopf, M, Wessely, S, Fear, N T (2008). How do experiences in Iraq affect alcohol use among male UK armed forces personnel?. Occup. Environ. Med. 65: 628-633 [Abstract] [Full Text]  
• Seal, K. H., Maguen, S., Bertenthal, D., Gima, K., Marmar, C. R. (2008). SEAL ET AL. RESPOND. Am. J. Public Health 98: 1542-1543 [Full Text]  
• Satcher, D., Higginbotham, E. J. (2008). The Public Health Approach to Eliminating Disparities in Health. Am. J. Public Health 98: S8-S11 [Abstract] [Full Text]  
• Jacobson, I. G., Ryan, M. A. K., Hooper, T. I., Smith, T. C., Amoroso, P. J., Boyko, E. J., Gackstetter, G. D., Wells, T. S., Bell, N. S. (2008). Alcohol Use and Alcohol-Related Problems Before and After Military Combat Deployment. JAMA 300: 663-675 [Abstract] [Full Text]  
• Boscarino, J. A. (2008). A Prospective Study of PTSD and Early-Age Heart Disease Mortality Among Vietnam Veterans: Implications for Surveillance and Prevention. Psychosom. Med. 70: 668-676 [Abstract] [Full Text]  
• Schneiderman, A. I., Braver, E. R., Kang, H. K. (2008). Understanding Sequelae of Injury Mechanisms and Mild Traumatic Brain Injury Incurred during the Conflicts in Iraq and Afghanistan: Persistent Postconcussive Symptoms and Posttraumatic Stress Disorder. Am J Epidemiol 167: 1446-1452 [Abstract] [Full Text]  
• McLAY, R. N., DEAL, W. E., MURPHY, J. A., CENTER, K. B., KOLKOW, T. T., GRIEGER, T. A. (2008). On-the-Record Screenings Versus Anonymous Surveys in Reporting PTSD. Am. J. Psychiatry 165: 775-776 [Full Text]  
• Bormann, J. E., Thorp, S., Wetherell, J. L., Golshan, S. (2008). A Spiritually Based Group Intervention for Combat Veterans With Posttraumatic Stress Disorder: Feasibility Study. J Holist Nurs 26: 109-116 [Abstract]  
• Larson, G. E., Highfill-McRoy, R. M., Booth-Kewley, S. (2008). Psychiatric Diagnoses in Historic and Contemporary Military Cohorts: Combat Deployment and the Healthy Warrior Effect. Am J Epidemiol 167: 1269-1276 [Abstract] [Full Text]  
• Whealin, J. M., Ruzek, J. I., Southwick, S. (2008). Cognitive-Behavioral Theory and Preparation for Professionals at Risk for Trauma Exposure. Trauma Violence Abuse 9: 100-113 [Abstract]  
• Seal, K. H., Bertenthal, D., Maguen, S., Gima, K., Chu, A., Marmar, C. R. (2008). Getting Beyond "Don't Ask; Don't Tell": an Evaluation of US Veterans Administration Postdeployment Mental Health Screening of Veterans Returning From Iraq and Afghanistan. Am. J. Public Health 98: 714-720 [Abstract] [Full Text]  
• Adelman, W. P. (2008). Basic Training for the Pediatrician: How to Provide Comprehensive Anticipatory Guidance Regarding Military Service. Pediatrics 121: e993-e997 [Full Text]  
• Binder, E. B., Bradley, R. G., Liu, W., Epstein, M. P., Deveau, T. C., Mercer, K. B., Tang, Y., Gillespie, C. F., Heim, C. M., Nemeroff, C. B., Schwartz, A. C., Cubells, J. F., Ressler, K. J. (2008). Association of FKBP5 Polymorphisms and Childhood Abuse With Risk of Posttraumatic Stress Disorder Symptoms in Adults. JAMA 299: 1291-1305 [Abstract] [Full Text]  
• Satcher, D., Higginbotham, E. J. (2008). The Public Health Approach to Eliminating Disparities in Health. Am. J. Public Health 98: 400-403 [Abstract] [Full Text]  
• Gould, M., Sharpley, J., Greenberg, N. (2008). Patient characteristics and clinical activities at a British military department of community mental health. Psychiatr. Bull. 32: 99-102 [Abstract] [Full Text]  
• Smith, T. C, Ryan, M. A K, Wingard, D. L, Slymen, D. J, Sallis, J. F, Kritz-Silverstein, D., for the Millennium Cohort Study Team, (2008). New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study. BMJ 336: 366-371 [Abstract] [Full Text]  
• Bonanno, G. A., Mancini, A. D. (2008). The Human Capacity to Thrive in the Face of Potential Trauma. Pediatrics 121: 369-375 [Abstract] [Full Text]  
• Hoge, C. W., McGurk, D., Thomas, J. L., Cox, A. L., Engel, C. C., Castro, C. A. (2008). Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq. NEJM 358: 453-463 [Abstract] [Full Text]  
• Sharpley, J. G., Fear, N. T., Greenberg, N., Jones, M., Wessely, S. (2008). Pre-deployment stress briefing: does it have an effect?. Occup Med (Lond) 58: 30-34 [Abstract] [Full Text]  
• Kinder, L. S., Bradley, K. A., Katon, W. J., Ludman, E., McDonell, M. B., Bryson, C. L. (2008). Depression, Posttraumatic Stress Disorder, and Mortality. Psychosom. Med. 70: 20-26 [Abstract] [Full Text]  
• Satcher, D., Friel, S., Bell, R. (2007). Natural and Manmade Disasters and Mental Health. JAMA 298: 2540-2542 [Full Text]  
• Castro, C. A., McGurk, D. (2007). The Intensity of Combat and Behavioral Health Status. Traumatology 13: 6-23 [Abstract]  
• Chapman, P. L. (2007). A Commentary on the MHAT IV Final Report: A Former Guardsman's Point of View. Traumatology 13: 50-52  
• Pols, H., Oak, S. (2007). WAR & Military Mental Health: The US Psychiatric Response in the 20th Century. Am. J. Public Health 97: 2132-2142 [Abstract] [Full Text]  
• Milliken, C. S., Auchterlonie, J. L., Hoge, C. W. (2007). Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War. JAMA 298: 2141-2148 [Abstract] [Full Text]  
• Jones, E., Fear, N. T., Wessely, S. (2007). Shell Shock and Mild Traumatic Brain Injury: A Historical Review. Am. J. Psychiatry 164: 1641-1645 [Abstract] [Full Text]  
• Rosenheck, R. A., Fontana, A. F. (2007). Recent Trends In VA Treatment Of Post-Traumatic Stress Disorder And Other Mental Disorders. Health Aff (Millwood) 26: 1720-1727 [Abstract] [Full Text]  
• Stecker, T., Fortney, J. C., Hamilton, F., Ajzen, I. (2007). An Assessment of Beliefs About Mental Health Care Among Veterans Who Served in Iraq. Psychiatr. Serv. 58: 1358-1361 [Abstract] [Full Text]  
• Rona, R. J, Fear, N. T, Hull, L., Greenberg, N., Earnshaw, M., Hotopf, M., Wessely, S. (2007). Mental health consequences of overstretch in the UK armed forces: first phase of a cohort study. BMJ 335: 603-603 [Abstract] [Full Text]  
• Russell, M., Silver, S. M. (2007). Training Needs for the Treatment of Combat-Related Posttraumatic Stress Disorder: A Survey of Department of Defense Clinicians. Traumatology 13: 4-10 [Abstract]  
• Weissmann, G. (2007). The Experimental Pathology of Stress: Hans Selye to Paris Hilton. FASEB J. 21: 2635-2638 [Full Text]  
• Greenberg, N., Henderson, A., Langston, V., Iversen, A., Wessely, S (2007). Peer responses to perceived stress in the Royal Navy. Occup Med (Lond) 57: 424-429 [Abstract] [Full Text]  
• ENGELHARD, I. M., VAN DEN HOUT, M. A., WEERTS, J., ARNTZ, A., HOX, J. J. C. M., MCNALLY, R. J. (2007). Deployment-related stress and trauma in Dutch soldiers returning from Iraq: Prospective study. Br. J. Psychiatry 191: 140-145 [Abstract] [Full Text]  
• Sareen, J., Cox, B. J., Afifi, T. O., Stein, M. B., Belik, S.-L., Meadows, G., Asmundson, G. J. G. (2007). Combat and Peacekeeping Operations in Relation to Prevalence of Mental Disorders and Perceived Need for Mental Health Care: Findings From a Large Representative Sample of Military Personnel. Arch Gen Psychiatry 64: 843-852 [Abstract] [Full Text]  
• Reeves, R. R. (2007). Diagnosis and Management of Posttraumatic Stress Disorder in Returning Veterans. JAOA: Journal of the American Osteopathic Association 107: 181-189 [Abstract] [Full Text]  
• Fisher Wilson, J. (2007). Posttraumatic Stress Disorder Needs to Be Recognized in Primary Care. ANN INTERN MED 146: 617-620 [Full Text]  
• Rona, R. J, Fear, N. T, Hull, L., Wessely, S. (2007). Women in novel occupational roles: mental health trends in the UK Armed Forces. Int J Epidemiol 36: 319-326 [Abstract] [Full Text]  
• Sareen, J., Cox, B. J., Stein, M. B., Afifi, T. O., Fleet, C., Asmundson, G. J. G. (2007). Physical and Mental Comorbidity, Disability, and Suicidal Behavior Associated With Posttraumatic Stress Disorder in a Large Community Sample. Psychosom. Med. 69: 242-248 [Abstract] [Full Text]  
• Acierno, R., Ruggiero, K. J., Galea, S., Resnick, H. S., Koenen, K., Roitzsch, J., de Arellano, M., Boyle, J., Kilpatrick, D. G. (2007). Psychological Sequelae Resulting From the 2004 Florida Hurricanes: Implications for Postdisaster Intervention. Am. J. Public Health 97: S103-S108 [Abstract] [Full Text]  
• Seal, K. H., Bertenthal, D., Miner, C. R., Sen, S., Marmar, C. (2007). Bringing the War Back Home: Mental Health Disorders Among 103 788 US Veterans Returning From Iraq and Afghanistan Seen at Department of Veterans Affairs Facilities. Arch Intern Med 167: 476-482 [Abstract] [Full Text]  
• Kremen, W. S., Koenen, K. C., Boake, C., Purcell, S., Eisen, S. A., Franz, C. E., Tsuang, M. T., Lyons, M. J. (2007). Pretrauma Cognitive Ability and Risk for Posttraumatic Stress Disorder: A Twin Study. Arch Gen Psychiatry 64: 361-368 [Abstract] [Full Text]  
• Hoge, C. W., Terhakopian, A., Castro, C. A., Messer, S. C., Engel, C. C. (2007). Association of Posttraumatic Stress Disorder With Somatic Symptoms, Health Care Visits, and Absenteeism Among Iraq War Veterans. Am. J. Psychiatry 164: 150-153 [Abstract] [Full Text]  
• Zatzick, D., Roy-Byrne, P. P. (2006). From Bedside to Bench: How the Epidemiology of Clinical Practice Can Inform the Secondary Prevention of PTSD. Psychiatr. Serv. 57: 1726-1730 [Abstract] [Full Text]  
• Maren, S., Chang, C.-h. (2006). Recent fear is resistant to extinction. Proc. Natl. Acad. Sci. USA 103: 18020-18025 [Abstract] [Full Text]  
• Rona, R. J, Hooper, R., Jones, M., Hull, L., Browne, T., Horn, O., Murphy, D., Hotopf, M., Wessely, S. (2006). Mental health screening in armed forces before the Iraq war and prevention of subsequent psychological morbidity: follow-up study. BMJ 333: 991-991 [Abstract] [Full Text]  
• Grieger, T. A., Cozza, S. J., Ursano, R. J., Hoge, C., Martinez, P. E., Engel, C. C., Wain, H. J. (2006). Posttraumatic Stress Disorder and Depression in Battle-Injured Soldiers. Am. J. Psychiatry 163: 1777-1783 [Abstract] [Full Text]  
• Fay, J., Kamena, M. D., Benner, A., Buscho, A. (2006). A Residential Milieu Treatment Approach for First-Responder Trauma. Traumatology 12: 255-262 [Abstract]  
• MacKenzie, E. J., Bosse, M. J. (2006). Factors Influencing Outcome Following Limb-Threatening Lower Limb Trauma: Lessons Learned From the Lower Extremity Assessment Project (LEAP). J Am Acad Orthop Surg 14: S205-S210 [Abstract] [Full Text]  
• Rasmusson, A. M., Picciotto, M. R., Krishnan-Sarin, S. (2006). Smoking as a complex but critical covariate in neurobiological studies of posttraumatic stress disorders: a review. J Psychopharmacol 20: 693-707 [Abstract]  
• Fiellin, D. A., Saxon, A., Renner, J. A. Jr (2006). Mental health after deployment to Iraq or Afghanistan.. JAMA 296: 515-515 [Full Text]  
• Hoge, C. W., Auchterlonie, J. L., Milliken, C. S. (2006). Mental Health After Deployment to Iraq or Afghanistan--Reply. JAMA 296: 516-516 [Full Text]  
• Vasterling, J. J., Proctor, S. P., Amoroso, P., Kane, R., Heeren, T., White, R. F. (2006). Neuropsychological outcomes of army personnel following deployment to the Iraq war.. JAMA 296: 519-529 [Abstract] [Full Text]  
• Hotopf, M., Wessely, S. (2006). Neuropsychological changes following military service in Iraq: case proven, but what is the significance?. JAMA 296: 574-575 [Full Text]