In the Shadow of Iraq: Posttraumatic Stress Disorder in 2007
David L. Greenburg, MD, MPH and Michael J. Roy, MD, MPH
Department of Medicine, Uniformed Services University, Room A3062, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
© 2007 Society of General Internal Medicine 2007;22:888–889
raq has become a more effective incubator for posttrau-
matic stress disorder (PTSD) in the American service
members than any mad scientist could conceivably design.
The combat zone in Iraq has no frontline, no safe zone, and the
embattled soldier has little with which to differentiate friend
from foe, no warning of when or where the next improvised
explosive device will be detonated. It is hardly surprising that we
are seeing high rates of depression, PTSD, and other anxiety
disorders in service members who have been deployed to Iraq.
The moniker of PTSD was established in a similar war
environment, Vietnam, but the condition has been present for
as long as men have fought wars over religion, ethnicity, land, or
greed. Homer’s saga of Achilles in The Iliad represents perhaps
the oldest detailed account of the ravages of PTSD in the soldier,
a portrayal vividly dissected by psychiatrist Jonathan Shay.
PTSD and depression are by no means unique to combat
veterans—they are common in the primary care setting, where
they are underdiagnosed and undertreated.
There are a
variety of reasons for this. Five of six primary care patients
with a chief complaint ultimately attributed to a mental
disorder present with a somatic complaint, invariably obfus-
cating the diagnosis.
Primary care physicians have a myriad
of other issues to deal with in their patients, including
diabetes, hyperlipidemia, and hypertension, all featuring dis-
crete numbers that demand attention. Patients with mental
disorders also fear stigmatization and tend to minimize
psychological symptoms. However, the advent of relatively
safe, well-tolerated, and effective selective serotonin reuptake
inhibitors put effective treatment modalities in the hands
of primary care physicians, and manufacturers’ direct-to-
consumer advertisements have helped to overcome stigma. Of
equal importance, the development and validation of the
Patient Health Questionnaire-9 (PHQ-9) provide physicians
with an effective tool to diagnose depression and a score to
gauge responsiveness to interventions.
is no similarly effective instrument for PTSD, and whereas
there are effective treatments available, pharmacotherapy
does not seem to be quite as facile for PTSD as for depression.
Thus, it is not a great surprise that Liebschutz et al.
PTSD was rarely diagnosed (identified in the medical record for
only 11% of those meeting criteria) in an urban primary care
population, reported in this issue of Journal of General Internal
Medicine. Misdiagnosis was commonplace, with a diagnosis of
depression recorded for 43% of those who met the criteria for
PTSD but not depression. PTSD was also three times more
common (adjusted prevalence 35%) in those who did have
depression in this population of predominantly poor, inner
city, unmarried African Americans than those who did not
(11%). Nearly identical depression–PTSD comorbidity rates
were identified by Campbell et al.,
also in this issue, in
predominantly older white males receiving primary care
at Veterans Administration facilities; similar rates have been
Whereas the comorbidity appears com-
pelling, these are both cross-sectional studies, so it is im-
possible to say which condition developed first. Moreover, as
Liebschutz et al. demonstrate, this relationship is hardly
unique to depression; those with other anxiety disorders also
had three times the rate of PTSD, and those with chronic pain
or irritable bowel syndrome each had twice the rate of PTSD as
those who did not. Because the overall prevalence of PTSD in
this inner city population was 23%, a cogent argument can be
made to screen all comers for PTSD, rather than trying to
target those at even greater risk, but the cost-effectiveness of
each approach should be assessed.
The problem that primary care physicians then face is what
instrument should they use to screen for PTSD? The Clinician
Administered PTSD Scale is the gold standard, but its 17-page
length, detailed instructions, and complex scoring render it
impractical for use in primary care. The 17-item PTSD Check-
list has a scoring mechanism similar to the PHQ-9, but had a
sensitivity of only 32% among 400 primary care patients.
7-item scale was reported to moderate sensitivity (85%) and
specificity (84%) in 134 primary care patients, but requires
confirmation in larger studies.
Campbell et al. opted for the
PC-PTSD, a 4-item Primary Care PTSD screen, based upon a
prior study in 188 VA patients that identified an optimal cutoff
score of three positives out of the four items. However, a more
recent, larger study yielded a sensitivity of only 46% at this
threshold in 690 OIF/OEF veterans, whereas a threshold of
two had a sensitivity of 73% with a specificity of 86%.
Additional research is necessary to determine the optimal brief
screen for PTSD.
Identification of PTSD is important because it is associated
with markedly higher rates of depression and other psycho-
logical conditions, poorer physical health, unemployment and
missed work, impaired function at work and at home, and
significantly higher health care costs.
Moreover, the combi-
nation of PTSD and depression is linked to greater depression
Published online March 21, 2007