Elsevier

Journal of Anxiety Disorders

Volume 31, April 2015, Pages 98-107
Journal of Anxiety Disorders

Review
The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans: A meta-analysis

https://doi.org/10.1016/j.janxdis.2015.02.003Get rights and content

Highlights

  • This meta-analysis examined 33 studies published between 2007 and 2013 involving 4,945,897 OEF/OIF veterans.

  • PTSD prevalence among OEF/OIF veterans was estimated at 23%.

  • Publication year and percentage of Caucasian participants and formerly active duty participants explained significant variability in prevalence across studies.

  • To date, most studies have estimated prevalence among OEF/OIF veterans using VA medical chart review which limited the generalizability of findings primarily to the prevalence of PTSD in medical records of OEF/OIF veterans who use VA services.

  • Additional research is needed with randomly selected, representative samples of veterans who have been administered PTSD diagnostic interviews.

Abstract

Literature on posttraumatic stress disorder (PTSD) prevalence among Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans report estimates ranging from 1.4% to 60%. A more precise estimate is necessary for projecting healthcare needs and informing public policy. This meta-analysis examined 33 studies published between 2007 and 2013 involving 4,945,897 OEF/OIF veterans, and PTSD prevalence was estimated at 23%. Publication year and percentage of Caucasian participants and formerly active duty participants explained significant variability in prevalence across studies. PTSD remains a concern for a substantial percentage of OEF/OIF veterans. To date, most studies have estimated prevalence among OEF/OIF veterans using VA medical chart review. Thus, results generalize primarily to the prevalence of PTSD in medical records of OEF/OIF veterans who use VA services. Additional research is needed with randomly selected, representative samples administered diagnostic interviews. Significant financial and mental health resources are needed to promote recovery from PTSD.

Introduction

In recent years, several reviews have examined posttraumatic stress disorder (PTSD) prevalence estimates among U.S. service members deployed to Iraq and/or Afghanistan (Gates et al., 2012; Kok, Herrell, Thomas, & Hoge, 2012; Ramchand et al., 2010; Richardson, Frueh, & Acierno, 2010; Sundin, Fear, Iversen, Rona, & Wessely, 2010). Across studies in these reviews, PTSD prevalence estimates ranged from 1.4% to 60%. The authors identified factors that may contribute to variability in PTSD prevalence estimates among military personnel, including sampling strategy (e.g., random versus non-random), method of PTSD diagnosis, anonymity of reporting, level of combat exposure, military component (e.g., active duty versus reserve), and military context (e.g., operational infantry unit samples).

Although these reviews represent considerable progress in our understanding of the epidemiology of PTSD among military personnel, studies with samples of deployed and returning service members may not adequately capture the mental healthcare needs of veterans who have separated from military service. Research suggests that early symptoms of psychological distress and PTSD are not good predictors of long-term adaptation. A review of studies of military service members deployed to Iraq found that although few studies have examined rates of PTSD longitudinally post-deployment, the few studies that do exist on this topic suggest that rates of PTSD increase through at least 12 months post-deployment (Sundin et al., 2010). In addition, service members may face unique barriers to endorsing mental health problems and seeking mental health treatment including concerns that seeking mental health treatment could affect how they are perceived by military leadership and their unit (Hoge et al., 2004). Such concerns may contribute to underreporting of mental health symptoms among military service members who have not yet separated. Accordingly, prevalence estimates among service members may not be representative for veterans.

A better understanding of PTSD prevalence among U.S. veterans is important for informing public policy decisions regarding allocation of mental healthcare resources. Widely discrepant prevalence estimates have limited utility for informing treatment efforts and projecting healthcare needs. The cost of underestimating rates and undertreating is high particularly because PTSD is associated with increased rates of psychiatric and medical comorbidity, health care utilization, disability, substance abuse, and suicide (Breslau, 2001; Calhoun, Bosworth, Grambow, Dudley, & Beckham, 2002; Cohen, Marmar, Ren Bertenthal, & Seal, 2009; Frayne et al., 2004; Kessler, Chiu, Demler, & Walters, 2005; Perkonigg, Kessler, Storz, & Wittchen, 2000). Moreover, once veterans manifest protracted adaptation difficulties, PTSD symptoms tend to remain chronic across the lifespan (Prigerson, Maciejaewski, & Rosenheck, 2002) and become resistant to treatments that have demonstrated efficacy with acute PTSD symptomatology (Schnurr, Lunney, Sengupta, & Waelde, 2003). In contrast, overestimating PTSD prevalence among OEF/OIF veterans could also have significant costs. A higher percentage of OEF/OIF veterans are seeking compensation following military service than veterans of earlier eras (Marchione, 2012, McNally and Frueh, 2013). During the 2012 fiscal year, PTSD was the third most prevalent disability among veterans receiving compensation for any type of disability (e.g., physical injury, medical condition, mental health condition; Department of Veteran Affairs Benefits Administration, 2012). Furthermore, knowledge of the base rate of a condition in the population can improve the accuracy of our diagnostic and conclusions (Meehl & Rosen, 1955). Accordingly, the purpose of the current investigation was to present a systematic and quantitative review of PTSD prevalence among U.S. OEF/OIF veterans separated from military service. A secondary aim was to investigate potential causes for the variability across prevalence estimates.

Section snippets

Selection of studies

PubMed, PsycINFO, and PILOTS (Published International Literature on Traumatic Stress) databases were searched for the terms “OEF OR Afghanistan OR Iraq OR OIF” combined with the terms “post traumatic OR posttraumatic OR posttraumatic stress OR posttraumatic stress disorder” and “veteran” between October 7, 2001 and May 31, 2013. The reference lists of recently published review articles (Gates et al., 2012) and articles included in the meta-analysis were also searched. These combined searches

Study and participant characteristics

Across studies, 85.3% of the participants were male. Racial group membership of participants was reported in 28 studies, with 66.7% of participants in those studies being Caucasian. The average age of participants was reported in 9 of the studies; the weighted average age of participants across the remaining 24 studies was 32.2 years. Forty-one percent of participants were married in the 23 studies that reported marital status data. Seventeen studies reported participants' military component

Discussion

In the decade since the OEF and OIF conflicts began, numerous epidemiological studies with returning military service members have been published, improving our understanding of the scope of mental health concerns in this cohort and of the characteristics of those at highest risk. Previous reviews have examined PTSD prevalence among active service members (e.g., Ramchand et al., 2010) and mixed samples of both active service members and veterans (e.g., Gates et al., 2012). This review is unique

Conclusions

In conclusion, this review highlights the need for researchers, clinicians, and policy-makers to consider methodological differences across studies, including sample characteristics and selection criteria, when gauging and comparing PTSD prevalence among OEF/OIF veterans. While the findings must be interpreted in light of the high heterogeneity in studies and specific limitations of the extant literature, the estimated prevalence of PTSD in OEF/OIF veterans from the current comprehensive

Conflict of interest

The authors have no conflicts of interest to declare.

Acknowledgments and disclosures

Amie Schry's contributions to this manuscript were partially supported by the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment, the Durham Veterans Affairs Medical Center, and the Department of Veterans Affairs Mid-Atlantic Region Mental Illness Research, Education, and Clinical Center (MIRECC).

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    The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the VA or the U.S. Government. Since the authors are employees of the U.S. Government and contributed to this manuscript in part as part of their official duties, the work is not subject to U.S. copyright.

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