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Mental Health at War and at Home

At its best, posttraumatic stress disorder (PTSD) is “the common cold of psychiatric illness,” according to Robert Ursano, M.D. Like a cold, its symptoms are common and usually temporary. 

But as some colds become pneumonias, some PTSDs become life-threatening. At its worst, PTSD ends in suicide.  

“It is that connection [between PTSD and suicide] that makes it important,” said Ursano, the professor and chair of the Department of Psychiatry in the Uniformed Services University School of Medicine and director of the Center for the Study of Traumatic Stress, who presented the 18th Annual Seymour Perlin, M.D., Grand Rounds on Suicidology, October 13.

During his lecture titled “From Battlefront to Home and Home to Battlefront: Prevention and Care for Self-Injurious Behavior,” Ursano outlined current trends and research in suicide and PTSD, particularly in the military. He also discussed challenges and potential solutions related to their prevention and treatment. 

“Within the military, mental health comprises a large component of the burden of disease,” he said.

While disorders like PTSD and depression tend to be some of the more severe psychiatric responses to war and trauma, Ursano stressed that they are not the only ones. Distress responses like difficulty sleeping and health risk behaviors like excessive drinking are more common reactions that also pose critical public health implications.

“Anything that is behavior is our domain — not just disorder,” he said. “Behavior is of great importance as to how it influences risk of morbidity and mortality.”

Ursano said that one health risk behavior is suicide.

Risk for suicide in the military is of particular importance today, as rates have doubled in recent years, he said. Traditionally, suicide rates in the army are about half that of the civilian population — amounting to about 10 to 12 per one hundred thousand people. But currently, the rates equal or exceed that of the civilian population.  “There is more understanding of suicide, but there is no decrease in suicidal behaviors,” said Ursano.

One of the major challenges in suicide prevention is the lack of “good predictors” among psychiatric patients, he said. While in the general population, mental disorders predict suicide ideation, or frequent thoughts of suicide, this criteria is only slightly helpful among psychiatric patients who are already likely to present these symptoms.

“Mental disorders predict suicidal ideation, but this isn’t a good predictor because, as psychiatrists, this is our pool,” he explained.

Additionally, while suicide ideation is relatively common — even “rampant,” according to Ursano — suicide attempt or completion is relatively rare, making it difficult to research with high levels of confidence.

Despite these drawbacks, there are some criteria that help psychiatrists predict which of their patients are most likely to go on to make a suicide plan or attempt, he said. For instance, disorders characterized by anxiety and poor impulse control are more likely than other types to lead to suicide, though they only account for about 10 percent of all psychiatric illnesses.

Another factor to take into consideration is length of suicide ideation, Ursano told the psychiatrists in the audience. People who have experienced thoughts of suicide for a longer period of time — but have never taken action — are less likely to attempt suicide than those who report the thoughts more recently. “The past predicts the future,” he explained.

Ursano also pointed out some factors that increase the risk of PTSD among members of the military, including a high number of firefights and a severe injury or injuries. In general, “the higher intensity of war, the higher the psychiatric casualty,” he said. Risk for PTSD also increases as length of “dwell time,” or time between deployments, decreases.

While understanding the risk factors associated with PTSD and suicide is important, Ursano said that these conditions can be better prevented in the first place. Because PTSD is often linked to injury, he endorsed basic public health concepts like seatbelt use. “Wearing a seatbelt is a psychiatric intervention,” he said. Ursano also suggested that emergency departments regularly screen for PTSD in order catch and treat the disorder earlier.

Ursano was optimistic that ongoing research will continue to help psychiatrists intervene with patients who are most at risk to attempt or commit suicide. In particular, he praised the U.S. Department of Health and Human Services and the U.S. Army for a major, five-year series of studies called Army STARRS that aims to identify factors that help protect a soldier’s mental health, and others that put mental health at risk.

“This is a marvelous collaboration…in trying to address what is a truly national need and a national security need,” he said. “It will have great implications not only for the army, but for the nation. Suicide is a national problem.”