Editorial
Prevention of Psychiatric Problems among Military Personnel and Their Spouses
N Engl J Med 2010; 362:168-170January 14, 2010
- Article
It is always important to capture information generated from clinical databases to advance theory and practice. This is certainly the case with two articles in this issue of the Journal. One article addresses the secondary prevention of post-traumatic stress disorder (PTSD) by the administration of morphine during resuscitation and early trauma care in U.S. Navy and Marine Corps personnel injured in combat.1 The other article describes increased mental health problems among wives of deployed U.S. Army personnel.2
The search for a “morning-after pill” after exposure to traumatic stress is obviously of great importance. It would be valuable if it could be established that certain pharmacologic interventions, administered shortly after exposure to traumatic stress, could prevent or reduce the likelihood of the development of PTSD later on. In this issue of the Journal, Holbrook and colleagues1 report that the use of morphine among injured Navy and Marine Corps personnel during early (usually <1 hour) resuscitation and trauma care was significantly and protectively associated with a lower risk of PTSD. This finding adds to a small but growing body of observational and experimental studies that have reported similar results.3,4 Since physical injury from a traumatic event (especially injury that is associated with severe pain) is a risk factor for the later development of PTSD, such findings suggest a potential for prophylactic use of rapid pain reduction among injured, traumatized persons in both military and civilian acute care settings.
What about persons with minor injuries or no injuries in the aftermath of major trauma who do not need morphine to attenuate physical pain? It is possible that the routine administration of morphine could protect them from subsequent PTSD, but it is unlikely that this could become acceptable in clinical practice. This disorder is understood to develop from Pavlovian fear conditioning in which the adrenergic activation of the amygdala during the traumatic event facilitates encoding of traumatic memories.3,5,6 Indeed, microinjections of norepinephrine into the amygdala in rats7 can enhance fear conditioning, and this response can be blocked by propranolol. Adrenergic activation can also be blocked by morphine operating at mu-opioid receptors located both in the amygdala and the locus ceruleus (which houses most of the brain's adrenergic neurons). Presynaptic inhibitory α2-noradrenergic receptors operate synergistically with opiate mu-opioid receptors and also blunt adrenergic activation in both the amygdala and the locus ceruleus.
In short, the thoughtful observations of Holbrook and associates are consistent with current theories about the adrenergic mediation of fear-conditioned traumatic memories. Clearly, the relative contributions of morphine-induced analgesia versus morphine-induced suppression of adrenergic activity must be understood, and the fact that these two mechanisms are not mutually exclusive must be recognized. These results should motivate researchers to redouble efforts to test adrenergic antagonists such as propranolol and clonidine (an α2-adrenergic agonist) in the search for a morning-after pill to prevent the later development of PTSD among persons after major trauma.5,6
The study by Mansfield and colleagues2 has a very different focus: the relationship between the deployment of military personnel and the mental health of their wives. Using medical-record data for outpatient care received by more than 250,000 wives of Army personnel (69% of whom had been deployed to Iraq, Afghanistan, or both war zones), Mansfield et al. found that the wives of deployed soldiers, as compared with the spouses of soldiers who were not deployed, had more outpatient visits for depressive disorders, anxiety, sleep disorders, and acute stress reaction and adjustment disorders. Furthermore, deployments of more than 11 months were associated with the use of more mental health services than deployments of 1 to 11 months.
These important findings raise many questions and should serve as an impetus for more fine-grained, hypothesis-driven research. Since the investigators did not have the exact dates of deployment of the soldiers, they could not assess the temporal relationship between deployment and a mental health diagnosis. In other words, was the presence or absence of the soldier more likely to be associated with mental health problems in the wife? If the former, one might consider the literature showing a relationship between spousal distress and marital dissatisfaction associated with deployment.8,9 PTSD after exposure to combat in male veterans has been associated with distress and the poor psychological well-being of their wives, domestic anger and violence, marital problems due to the numbing and avoidance symptoms of PTSD, a negative effect on parenting, and developmental and behavioral problems among children.10-12 However, if spousal distress was more likely to occur during the deployment itself, one must wonder about the difficulties of being a single parent, constant worry about the safety of the deployed partner, and ongoing behavioral and maturational problems expressed by children dealing with their own concerns about the absent parent.
The answers to other questions should influence policy and clinical practice for the care of spouses and families of military personnel affected by the emotional cycle of deployment. Is it deployment per se, with all the complications of separation and worry about loved ones, that is contributing to more mental health problems? Is the intensity of soldiers' exposure to combat during deployment the critical factor? Is the deleterious effect of deployment on spouses mediated by the presence of PTSD or some other combat-related problem such as physical injury, traumatic brain injury, another psychiatric or substance-use disorder, aggressive or violent behavior, problems expressed by children, other factors, or all of the above? These questions need to be answered. Since social support provides the strongest protection against the development of psychiatric disorders, and since the family is the major source of social support, improvement in the mental health of spouses and children should also pay dividends in improving the mental health of troops throughout the deployment cycle.
The authors of both articles have generated provocative findings from administrative data sets with important implications for preventive strategies. The observations by Holbrook and colleagues on preventing subsequent PTSD by the administration of morphine during resuscitation and early trauma care raise theoretical and practical questions that require rigorous follow-up. Establishing the efficacy of adrenergic antagonists or some other medications as effective prophylaxis against the later development of PTSD would have a considerable effect on emergency medicine for military personnel and civilians. The observations by Mansfield and colleagues on the effect of the deployment of military personnel on the mental health of their wives have public health implications. Besides the obvious importance of developing appropriate programs to fortify wellness and resilience among spouses and children, such programs might also be expected to prevent psychiatric morbidity among the troops themselves.
Financial and other disclosures provided by the author are available with the full text of this article at NEJM.org.
Source Information
From the National Center for PTSD, Department of Veterans Affairs, VA Medical Center, White River Junction, VT, and the Departments of Psychiatry and Pharmacology and Toxicology, Dartmouth Medical School, Hanover, NH.
- References
References
1
Holbrook TL ,Galarneau MR ,Dye JL ,Quinn K ,Dougherty AL . Morphine use after combat injury in Iraq and post-traumatic stress disorder. N Engl J Med 2010;362:110-117
Full Text | Web of Science | Medline2
Mansfield AJ ,Kaufman JS ,Marshall SW ,Gaynes BN ,Morrissey JP ,Engel CC . Deployment and the use of mental health services among U.S. Army wives. N Engl J Med 2010;362:101-109
Full Text | Web of Science | Medline3
Saxe G ,Stoddard F ,Courtney D , et al. Relationship between acute morphine and the course of PTSD in children with burns. J Am Acad Child Adolesc Psychiatry 2001;40:915-921
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Friedman MJ. The role of pharmacotherapy in early interventions. In: Blumenfield M, Ursano RJ, eds. Intervention and resilience after mass trauma. Cambridge, England: Cambridge University Press, 2008:107-25.
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Pitman RK ,Delahanty DL . Conceptually driven pharmacologic approaches to acute trauma. CNS Spectr 2005;10:99-106
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Liang KC ,Juler RG ,McGaugh JL . Modulating effects of posttraining epinephrine on memory: involvement of the amygdala noradrenergic system. Brain Res 1986;368:125-133
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Newby JH ,McCarroll JE ,Ursano RJ ,Fan Z ,Shigemura J ,Tucker-Harris Y . Positive and negative consequences of a military deployment. Mil Med 2005;170:815-819
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Renshaw KD ,Rodrigues CS ,Jones DH . Psychological symptoms and marital satisfaction in spouses of Operation Iraqi Freedom veterans: relationships with spouses' perceptions of veterans' experiences and symptoms. J Fam Psychol 2008;22:586-594
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Galovski T ,Lyons JA . Psychological sequelae of combat violence: a review of the impact of PTSD on the veteran's family and possible interventions. Aggress Violent Behav 2004;9:477-501
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Milliken CS , Auchterlonie,Hoge CW . Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq War. JAMA 2007;298:2141-2148
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Litz BT, Schlenger WE. PTSD in service members and new veterans of the Iraq and Afghanistan wars: a bibliography and critique. PTSD Research Quarterly. Vol. 20. No. 1. Winter 2009:1-7. Washington, DC: Department of Veterans Affairs. (Also available at http://www.ptsd.va.gov/professional/newsletters/research-quarterly/V20N1.pdf.)
- Citing Articles (3)
Citing Articles
1
Tanja Jovanovic, Andrew Kazama, Jocelyne Bachevalier, Michael Davis. (2012) Impaired safety signal learning may be a biomarker of PTSD. Neuropharmacology 62:2, 695-704
CrossRef2
Karen H. Seal, Greg Cohen, Angela Waldrop, Beth E. Cohen, Shira Maguen, Li Ren. (2011) Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001–2010: Implications for screening, diagnosis and treatment. Drug and Alcohol Dependence 116:1-3, 93-101
CrossRef3
Polly H Noël, John E Zeber, Mary J Pugh, Erin P Finley, Michael L Parchman. (2011) A pilot survey of post-deployment health care needs in small community-based primary care clinics. BMC Family Practice 12:1, 79
CrossRef
