War and its impact on American health

For veterans who witnessed combat, there’s more to look for than PTSD, new analysis of health outcomes finds.

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.

First the stud, then the sequela

At last, the news that horrified parents everywhere have been waiting for: piercing certain parts of one’s anatomy might not be so healthy. Last year, Yale physicians Richard A. Martinello, M.D., and Elizabeth L. Cooney, M.D., linked a young woman’s brain infection to the tongue-piercing she received a month earlier. “The bacteria that caused the abscess in this patient were those typically found in people’s mouths,” said Martinello. A few days after the piercing, the patient’s tongue was swollen and tender and produced a foul-tasting discharge. The symptoms cleared up after she removed the jewelry, but a month later she presented with headaches, fever, nausea and vomiting, and a CT scan showed an abnormality in her brain. Six weeks of treatment with intravenous antibiotics led to a full recovery. The physicians presented the case at the annual meeting of the Infectious Disease Society of America in October.

Et Cetera

No laughing matter

A new study suggests there might be something to the notion, first proposed by physicians in ancient Greece, that seasonal mood swings are caused by “humors.” According to Yale investigators, patients with seasonal affective disorder (SAD) have lower nocturnal levels of the bile pigment bilirubin. The study is the first scientific investigation of circadian levels of bilirubin in the blood of people with depression. Psychiatrist Dan A. Oren, M.D. ’84, HS ’88, and colleagues found that nighttime bilirubin levels were lower in nine patients with SAD, compared to a group of seven healthy volunteers. The patient group’s levels of bilirubin increased after exposure to a light source, a standard therapy for the disorder. The article was published in the March 1 issue of the journal Biological Psychiatry.

Cocaine vaccine advances

Scientists at Yale are exploring a new method to help cocaine users stay clean and sober. A vaccine that produces antibodies that dull the cocaine high has been found safe in a phase I clinical trial, according to a report in the January 15 issue of the journal Vaccine. The vaccine, TA-CD, is recommended for people who are already trying to kick the habit. “We found that the vaccine is safe and that there is no significant toxicity,” said principal investigator Thomas R. Kosten, M.D., HS ’81, professor of psychiatry, who is testing the vaccine for Xenova Group plc. of Cambridge, England, which owns and is developing the compound. Subjects who received the highest dosages also produced the most euphoria-depressing antibodies.

A boost from nicotine

Why do so many patients with schizophrenia smoke? It may be because nicotine improves one aspect of cognitive function and helps compensate for other brain impairment associated with schizophrenia. “This is one of only a few studies to suggest that nicotine has a beneficial effect on spatial working memory, which is known to be impaired in schizophrenic patients,” said principal investigator Tony P. George, M.D., who published findings in the journal Neuropsychopharmacology in January. Smokers without schizophrenia did not show an improvement in spatial working memory, and in fact, nonschizophrenic smokers had an impairment of this cognitive function, which improved when they quit smoking.


			Originally published in Yale Medicine, Spring 2002. Copyright © 2002 Yale University School of Medicine. All rights reserved.