Mental Health of Iraq War Veterans in Basra
A Review of Clinical Outcomes
DOI:
https://doi.org/10.59680/anestesi.v3i4.2240Keywords:
Basra, Clinical Outcomes, Depression, Iraq War Veterans, Mental HealthAbstract
This meta-analytic study examines the mental health condition of Iraq War veterans deployed in Basra during the 2003–2011 period, with particular emphasis on clinical outcomes derived from 27.482 veterans whose medical records were systematically documented in military databases. Employing a random-effects model approach, the prevalence of PTSD was recorded at 47.3% (95% CI: 44.8–49.8%), with significantly higher levels of severity observed among veterans exposed to direct combat (OR = 3.24, p < .001). Major depressive disorder was identified in 38.6% of veterans (95% CI: 36.1–41.1%), of whom 42.7% demonstrated strong comorbidity with anxiety (r = .68, p < .001). Logistic regression analyses identified deployment duration (B= .34, p < .001) and combat intensity (B= .41, p < .001) as significant predictors of severity outcomes. Subsequent meta-regression revealed variation in therapeutic effectiveness, with CBT (g = 0.82), EMDR (g = 0.78), and pharmacotherapy (g = 0.65) showing the greatest effect sizes. In contrast to findings reported by Seal et al. (2009) and Jamil et al. (2011), which documented PTSD prevalence rates of 35–40% among Iraq War veterans in general populations, this study reveals significantly higher psychiatric morbidity within the Basra context. These findings underscore the urgency of developing intervention protocols tailored to the specific characteristics of conflict zones.
References
Aldwin, C. M., Levenson, M. R., & Spiro, A. (1994). Vulnerability and resilience to combat exposure: Can stress have lifelong effects? Psychology and Aging, 9(1), 34–44. https://doi.org/10.1037/0882-7974.9.1.34
Ancheta, M. L. C. (2020). Combat-related trauma, posttraumatic stress disorder, and moral injury in combat medics: A comprehensive survey of the literature and critical analysis (Doctoral dissertation, Alliant International University). ProQuest Dissertations Publishing.
Bellamy, R. F., Maningas, P. A., & Vayer, J. S. (1986). Epidemiology of trauma: Military experience. Annals of Emergency Medicine, 15(12), 1384–1388. https://doi.org/10.1016/S0196-0644(86)80920-9
Bergman, B. P., Mackay, D. F., Smith, D. J., & Pell, J. P. (2016). Long-term mental health outcomes of military service: National linkage study of 57,000 veterans and 173,000 matched nonveterans. Journal of Clinical Psychiatry, 77(6), e1071–e1078. https://doi.org/10.4088/JCP.15m09837
Borenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2010). A basic introduction to fixed-effect and random-effects models for meta-analysis. Research Synthesis Methods, 1(2), 97–111. https://doi.org/10.1002/jrsm.12
Buydens-Branchey, L., Noumair, D., & Branchey, M. (1990). Duration and intensity of combat exposure and posttraumatic stress disorder in Vietnam veterans. Journal of Nervous and Mental Disease, 178(9), 582–587. https://doi.org/10.1097/00005053-199009000-00005
Callahan, C. D. J. (2010). Combat-related mental health disorders: The case for resiliency in the long war. Journal of the American Osteopathic Association, 110(9), 520–527.
Caspi, Y., Slobodin, O., & Klein, E. (2015). Cultural perspectives on the aftereffects of combat trauma: Review of a community study of Bedouin IDF service members and their families. Rambam Maimonides Medical Journal, 6(2), e0021. https://doi.org/10.5041/RMMJ.10205
Castro, C. A., & McGurk, D. (2007). The intensity of combat and behavioral health status. Traumatology, 13(4), 6–23. https://doi.org/10.1177/1534765607309950
Cesur, R., Sabia, J. J., & Tekin, E. (2013). The psychological costs of war: Military combat and mental health. Journal of Health Economics, 32(1), 51–65. https://doi.org/10.1016/j.jhealeco.2012.09.001
Ciarleglio, M. M., Aslan, M., Proctor, S. P., Concato, J., Ko, J., Kaiser, A. P., & Vasterling, J. J. (2018). Associations of stress exposures and social support with long-term mental health outcomes among US Iraq war veterans. Behavior Therapy, 49(5), 653–667. https://doi.org/10.1016/j.beth.2018.01.002
Creamer, M., & Forbes, D. (2004). Treatment of posttraumatic stress disorder in military and veteran populations. Psychotherapy: Theory, Research, Practice, Training, 41(4), 388–398. https://doi.org/10.1037/0033-3204.41.4.388
Currier, J. M., Holland, J. M., & Drescher, K. D. (2014). Residential treatment for combat-related posttraumatic stress disorder: Identifying trajectories of change and predictors of treatment response. PLoS ONE, 9(7), e101741. https://doi.org/10.1371/journal.pone.0101741
Egger, M., Davey Smith, G., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315(7109), 629–634. https://doi.org/10.1136/bmj.315.7109.629
Ellis, A. (2020). Reconceptualizing urban warfare in Canada: Exploring the relationship between trauma, post-traumatic stress, and violence among male combat soldiers and “street soldiers” (Doctoral dissertation, University of Toronto).
Fraser, J. G., Lloyd, S., Murphy, R., Crowson, M., Zolotor, A. J., Coker-Schwimmer, E., & Viswanathan, M. (2013). A comparative effectiveness review of parenting and trauma-focused interventions for children exposed to maltreatment. Journal of Developmental & Behavioral Pediatrics, 34(5), 353–368. https://doi.org/10.1097/DBP.0b013e31828a7dfc
Garfinkel, S. N., & Liberzon, I. (2009). Neurobiology of PTSD: A review of neuroimaging findings. Psychiatric Annals, 39(6), 370–381. https://doi.org/10.3928/00485713-20090527-01
Guyatt, G. H., Oxman, A. D., Vist, G. E., Kunz, R., Falck-Ytter, Y., Alonso-Coello, P., & Schünemann, H. J. (2008). GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 336(7650), 924–926. https://doi.org/10.1136/bmj.39489.470347.AD
Higgins, J. P. T., Altman, D. G., & Sterne, J. A. C. (2011). Assessing risk of bias in included studies. In J. P. T. Higgins & S. Green (Eds.), Cochrane handbook for systematic reviews of interventions (pp. 187–241). The Cochrane Collaboration. https://doi.org/10.1002/9780470712184.ch8
Higgins, J. P. T., Thompson, S. G., Deeks, J. J., & Altman, D. G. (2003). Measuring inconsistency in meta-analyses. BMJ, 327(7414), 557–560. https://doi.org/10.1136/bmj.327.7414.557
Hundt, N. E., Barrera, T. L., Robinson, A., & Cully, J. A. (2014). A systematic review of cognitive behavioral therapy for depression in veterans. Military Medicine, 179(9), 942–949. https://doi.org/10.7205/MILMED-D-14-00128
Jamil, H., Hamdan, T. A., Grzybowski, M., & Arnetz, B. B. (2011). Health effects associated with geographical area of residence during the 1991 Gulf War: A comparative health study of Iraqi soldiers and civilians. U.S. Army Medical Department Journal, 86.
Kammad, Z., & Alsabbagh, A. (2020). Prevalence of post-traumatic stress disorder among civilian volunteers and military soldiers in war against ISIS from Basra City. Iraqi National Journal of Medicine, 2(1), 51–60. https://doi.org/10.37319/iqnjm.2.1.5
Karstoft, K. I., Armour, C., Elklit, A., & Solomon, Z. (2013). Long-term trajectories of posttraumatic stress disorder in veterans: The role of social resources. The Journal of Clinical Psychiatry, 74(12), e1163–e1168. https://doi.org/10.4088/JCP.13m08482
Kitchiner, N., Roberts, N., Wilcox, D., & Bisson, J. (2012). Systematic review and meta-analyses of psychosocial interventions for veterans of the military. European Journal of Psychotraumatology, 3(1), 19267. https://doi.org/10.3402/ejpt.v3i0.19267
Liberzon, I., Britton, J. C., & Luan Phan, K. (2003). Neural correlates of traumatic recall in posttraumatic stress disorder. Stress, 6(3), 151–156. https://doi.org/10.1080/1025389031000136242
Maguen, S., & Burkman, K. (2013). Combat-related killing: Expanding evidence-based treatments for PTSD. Cognitive and Behavioral Practice, 20(4), 476–479. https://doi.org/10.1016/j.cbpra.2013.05.003
Marchand, W. R., Yabko, B., Herrmann, T., Curtis, H., & Lackner, R. (2019). Treatment engagement and outcomes of mindfulness-based cognitive therapy for veterans with psychiatric disorders. The Journal of Alternative and Complementary Medicine, 25(9), 902–909. https://doi.org/10.1089/acm.2018.0511
Martindale, S. L., Ord, A. S., & Rowland, J. A. (2020). Influence of blast exposure on cognitive functioning in combat veterans. Neuropsychology, 34(7), 735–743. https://doi.org/10.1037/neu0000672
McLay, R., Fesperman, S., Webb-Murphy, J., Delaney, E., Ram, V., Nebeker, B., & Burce, C. M. (2023). Post-traumatic stress disorder treatment outcomes in military clinics. Military Medicine, 188(5–6), e1117–e1124. https://doi.org/10.1093/milmed/usab454
Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA, 298(18), 2141–2148. https://doi.org/10.1001/jama.298.18.2141
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLOS Medicine, 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097
Newport, D. J., & Nemeroff, C. B. (2000). Neurobiology of posttraumatic stress disorder. Current Opinion in Neurobiology, 10(2), 211–218. https://doi.org/10.1016/S0959-4388(00)00080-5
Osterman, J. E., & De Jong, J. T. V. M. (2007). Cultural issues and trauma. In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.), Handbook of PTSD: Science and practice (pp. 425–446). Guilford Press.
Pietrzak, R. H., & Cook, J. M. (2013). Psychological resilience in older U.S. veterans: Results from the National Health and Resilience in Veterans Study. Depression and Anxiety, 30(5), 432–443. https://doi.org/10.1002/da.22083
Randles, R., & Finnegan, A. (2022). Veteran help-seeking behaviour for mental health issues: A systematic review. BMJ Military Health, 168(1), 99–104. https://doi.org/10.1136/bmjmilitary-2021-001903
Richardson, J. D., Ketcheson, F., King, L., Shnaider, P., Marlborough, M., Thompson, A., & Elhai, J. D. (2017). Psychiatric comorbidity pattern in treatment-seeking veterans. Psychiatry Research, 258, 488–493. https://doi.org/10.1016/j.psychres.2017.08.091
Ritchie, E. C. (2015). Cultural competency and treatment of veteran and military patients with mental health disorders. Federal Practitioner, 32(Suppl 3), 12S–13S.
Seal, K. H., Bertenthal, D., Maguen, S., Gima, K., Chu, A., & Marmar, C. R. (2008). Getting beyond “Don’t ask; don’t tell”: An evaluation of U.S. Veterans Administration postdeployment mental health screening of veterans returning from Iraq and Afghanistan. American Journal of Public Health, 98(4), 714–720. https://doi.org/10.2105/AJPH.2007.115519
Seal, K. H., Metzler, T. J., Gima, K. S., Bertenthal, D., Maguen, S., & Marmar, C. R. (2009). Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002–2008. American Journal of Public Health, 99(9), 1651–1658. https://doi.org/10.2105/AJPH.2008.150284
Shahmiri Barzoki, H., Ebrahimi, M., Khoshdel, A., Noorbala, A. A., Rahnejat, A. M., Avarzamani, L., & Avakh, F. (2023). Studying the prevalence of PTSD in veterans, combatants and freed soldiers of Iran-Iraq war: A systematic and meta-analysis review. Psychology, Health & Medicine, 28(3), 812–818. https://doi.org/10.1080/13548506.2021.1981408
Smid, G. E., Lind, J., & Bonde, J. P. (2022). Neurobiological mechanisms underlying delayed expression of posttraumatic stress disorder: A scoping review. World Journal of Psychiatry, 12(1), 151–165. https://doi.org/10.5498/wjp.v12.i1.151
Solomon, Z., & Mikulincer, M. (2006). Trajectories of PTSD: A 20-year longitudinal study. American Journal of Psychiatry, 163(4), 659–666. https://doi.org/10.1176/ajp.2006.163.4.659
Stang, A. (2010). Critical evaluation of the Newcastle-Ottawa Scale for the assessment of the quality of nonrandomized studies in meta-analyses. European Journal of Epidemiology, 25(9), 603–605. https://doi.org/10.1007/s10654-010-9491-z
Straud, C. L., Siev, J., Messer, S., & Zalta, A. K. (2019). Examining military population and trauma type as moderators of treatment outcome for first-line psychotherapies for PTSD: A meta-analysis. Journal of Anxiety Disorders, 67, 102133. https://doi.org/10.1016/j.janxdis.2019.102133
Thomas, M. M., Harpaz-Rotem, I., Tsai, J., Southwick, S. M., & Pietrzak, R. H. (2017). Mental and physical health conditions in U.S. combat veterans: Results from the National Health and Resilience in Veterans Study. The Primary Care Companion for CNS Disorders, 19(3), Article 17m02118. https://doi.org/10.4088/PCC.17m02118
Tovar, M. A., Bell, R. S., & Neal, C. J. (2021). Epidemiology of blast neurotrauma: A meta-analysis of blast injury patterns in the military and civilian populations. World Neurosurgery, 146, 308–314. https://doi.org/10.1016/j.wneu.2020.11.093
Troyanskaya, M., Pastorek, N. J., Scheibel, R. S., Petersen, N. J., McCulloch, K., Wilde, E. A., & Levin, H. S. (2015). Combat exposure, PTSD symptoms, and cognition following blast-related traumatic brain injury in OEF/OIF/OND service members and veterans. Military Medicine, 180(3), 285–289. https://doi.org/10.7205/MILMED-D-14-00256
van Rooij, S. J. H. (2015). Getting better: Neurobiological mechanisms of recovery from combat-related PTSD (Doctoral dissertation, Utrecht University).
Vasterling, J. J., Aslan, M., Proctor, S. P., Ko, J., Marx, B. P., Jakupcak, M., & Concato, J. (2016). Longitudinal examination of posttraumatic stress disorder as a long-term outcome of Iraq war deployment. American Journal of Epidemiology, 184(11), 796–805. https://doi.org/10.1093/aje/kww151
Verstrael, S., van der Wurff, P., & Vermetten, E. (2013). Eye movement desensitization and reprocessing (EMDR) as treatment for combat-related PTSD: A meta-analysis. Military Behavioral Health, 1(2), 68–73. https://doi.org/10.1080/21635781.2013.827088
Xue, C., Ge, Y., Tang, B., Liu, Y., Kang, P., Wang, M., & Zhang, L. (2015). A meta-analysis of risk factors for combat-related PTSD among military personnel and veterans. PLoS ONE, 10(3), e0120270. https://doi.org/10.1371/journal.pone.0120270
Zilberstein, K. (2022). Trauma in context: An integrative treatment model. Journal of Child & Adolescent Trauma, 15(2), 487–500. https://doi.org/10.1007/s40653-021-00416-3
Zohar, J., Fostick, L., Cohen, A., Bleich, A., Dolfin, D., Weissman, Z., & Shalev, A. Y. (2009). Risk factors for the development of posttraumatic stress disorder following combat trauma: A semiprospective study. The Journal of Clinical Psychiatry, 70(12), 1839–1845. https://doi.org/10.4088/JCP.08m04378blu
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