IJE Advance Access originally published online on March 21, 2007
International Journal of Epidemiology 2007 36(2):327-329; doi:10.1093/ije/dym013
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Commentary: Women in combat and the risk of post-traumatic stress disorder and depression
* Corresponding author. Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Medical Research and Materiel Command, 503 Robert Grant Avenue, Silver Spring, Maryland, 20910, USA. E-mail: charles.hoge{at}us.army.mil
Accepted 25 January 2007
Studies among civilian populations have consistently shown that when compared with men, women have significantly higher prevalence rates of depression and anxiety disorders, including post-traumatic stress disorder (PTSD).1,2 Studies of general military populations in garrison have paralleled findings from civilian studies.3–5 Research on the gender differences associated with military deployment, such as Vietnam, Persian Gulf War, or peacekeeping operations,6–12 has found inconsistent results. These studies are not representative of current extended combat deployments in Iraq or Afghanistan, war zones that lack traditional front lines and in which women are serving in roles that put them at greater risk than in the past.
Although women are excluded from serving in direct combat specialties, such as infantry or armour, and are therefore not at the same risk as male soldiers, they do serve in a variety of support positions where they travel outside military bases, work alongside combat soldiers, come under direct fire and may become casualties. These positions include military police, transportation, intelligence, pilots, medics, mechanics, civil affairs and other roles. Among the 3004 US fatalities from Iraq reported through 31 December 2006, 66 (2.2%) were women; among 127 UK fatalities, 3 (2.4%) were women.13 About two-thirds of these deaths involved hostile fire. In contrast, only one woman was reported to have died by hostile fire in Vietnam and five in the Persian Gulf War.14
An important unanswered question is whether there are gender differences in the risk of PTSD and other mental health problems among men and women exposed to similar levels of combat. The article by Dr Rona and colleagues15 is notable for being one of the first studies of gender differences in mental health concerns associated with deployment to the Iraq combat theatre. This study paves the way for future efforts to understand gender differences in the mental health impact of operations in Iraq and Afghanistan. The article reports a number of different findings among veterans of two wars and era controls that includes a trend analysis of changes in the health of UK military veterans between 1997 and 2005 in addition to the gender comparisons.
The trend analysis is difficult to interpret due to the cross-sectional design, lack of uniformity in the survey instruments (especially for the alcohol measure), demographic differences between the samples, differences in the prevalence of combat experiences and markedly different time frames for surveying following the return from deployment. Within the context of this larger effort, however, there are important comparisons of the prevalence of mental health concerns by gender for each cross-sectional deployed sample.
Among the deployed Iraq War study group in the Rona et al. study, 26.7% of women compared with 19.8% of men reported high levels of psychological distress on the General Health Questionnaire (GHQ), a measure made up of questions pertaining mostly to depression. However, this difference in prevalence between men and women is considerably smaller than the differences found in most studies of civilian and non-deployed military populations.1–5 In terms of post-traumatic stress symptoms among Iraq War veterans, most notable was the lack of gender differences, which contrasts with the marked gender differences reported in many studies on PTSD in both civilian and military populations.1,2,4,5,9–11 In the study by Rona et al., 8.4% of women and 7.1% of men met the criteria for post-traumatic stress reaction and a smaller percentage met full criteria for PTSD. This finding suggests that combat deployment to Iraq is not associated with a higher risk of mental health problems among female compared with male service members, at least during the time frame that was measured, relatively proximal to homecoming.
Some additional evidence from the United States supports the findings by Rona and colleagues regarding the minimal gender differences in mental health outcomes. All US troops receive a brief mental health assessment for depressive symptoms, post-traumatic stress symptoms, and concerns about family and relationship functioning when they return from deployment. Among the first 222 620 Army and Marine service members (10.6% of whom were women) who completed this assessment after returning from Iraq, 24% of the women reported some sort of mental health concern compared with 19% of the men,16 prevalences remarkably similar to the GHQ measures seen among UK–Iraq War service members.
A more detailed survey was conducted among a sample of 2064 US soldiers (including 288 females) from infantry and combat support units during the middle of a year-long deployment to Iraq or Kuwait (August–October 2004). Among this sample, 13% of the male soldiers and 12% of the female soldiers met the criteria for PTSD or depression.17,18 Among those individuals from support units serving in Iraq (178 women and 530 men), the prevalence of PTSD was similar for males and females (11% vs 12.4%, respectively).18
Males and females from these support units reported similar overall rates of combat experiences in Iraq, although there were some differences in the nature of these experiences. For example, 56% of males and 61% of females reported knowing someone seriously injured or killed; 67% of males and 72% of females reporting being in serious danger of being injured or killed, and 92% of males and 87% of females reporting receiving incoming rocket, artillery, or mortar fire.18 Male soldiers from support units were somewhat more likely to report being in fire fights (47% of males soldiers reported receiving small arms fire compared with 36% of female soldiers; 15% of males and 7% of females reported shooting or directing fire at the enemy), whereas female soldiers were more likely to be involved in handling human remains (29% males, 38% females), a result of more females being in medical specialties.
These findings suggest that military duty in Iraq confers a similar risk of PTSD and depression by gender. It is likely that this risk has more to do with the intensity and frequency of combat experiences than gender. However, other variables need to be assessed in future studies to better understand the relationship of direct combat to mental health outcomes among women compared with men. These variables include the specific nature of the combat experiences,19 the prevalence of mental health problems prior to deployment,1–5 complicating factors such as sexual harassment or abuse in the deployed environment20,21 and the trajectory of gender differences over time following return from deployment.9–11 As further studies emerge it is likely that there will not be a simple conclusion about the relationship of gender and combat to the mental health of veterans of this war. The available data point to an important hypothesis that combat duty in Iraq or Afghanistan, due to the high intensity and persistent level of threat, acts as a great equalizer of risk, resulting in similar rates of PTSD and depression for men and women. The article by Rona and colleagues underscores the importance of continued research and efforts by clinicians, policy makers and military leaders to address mental health problems among male and female war veterans.
 |
Acknowledgements |
|---|
 Top Acknowledgements References |
|---|
The views expressed are those of the authors and do not reflect the official position of the US Army or institutional affiliations noted. We thank Dr Amy Adler for her review.
|
Notes |
|---|
To accompany the article by Rona RJ, Fear NT, Hull L, Wessely S. "Women in novel occupational roles: mental health trends in the UK armed forces." 
|
References |
|---|
|
TopAcknowledgementsReferences |
|---|
1 Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey replication. Arch Gen Psychiatry (2005) 62:617–27.
2 Tolin DF, Foa EB. Sex differences in trauma and post-traumatic stress disorder: a quantitative review of 25 years of research. Psychol Bull (2006) 6:959–92.
3 Hoge CW, Lesikar SE, Guevara R, et al. Mental disorders among U.S. Military personnel in the 1990s: association with high levels of health care utilization and early military attrition. Am J Psychiatry (2002) 159:1576–83.
4 Riddle JR, Smith TC, Smith B, et al, for the Millennium Cohort Team. Millennium Cohort: the 2001–2003 baseline prevalence of mental disorders in the US military. J Clin Epidemiol (2007) 60:191–202.
5 Hourani LL, Yuan H. The mental health status of women in the Navy and Marine Corps: preliminary findings from the perceptions of wellness and readiness assessment. Mil Med (1999) 164:174–81.[ISI][Medline]
6 Adler AB, Huffman AH, Bliese PD, Castro CA. The impact of deployment length and experience on the well-being of male and female soldiers. J Occup Health Psychol (2005) 10:121–37.[CrossRef][ISI][Medline]
7 Vogt DS, Pless AP, King LA, King DW. Deployment stressors, gender, mental health outcomes among Gulf War 1 veterans. J Traumatic Stress (2005) 18:115–27.[CrossRef][ISI][Medline]
8 Schlenger WE, Kulka RA, Fairbank JA, et al. The prevalence of post-traumatic stress disorder in the Vietnam generation: a multimethod, multisource assessment of psychiatric disorder. J Traumatic Stress (1992) 5:333–63.[CrossRef][ISI]
9 Orcutt HK, Erickson DJ, Wolfe J. The course of PTSD symptoms among Gulf War Veterans: a growth mixture modeling approach. J Traumatic Stress (2004) 17:195–202.[CrossRef][ISI][Medline]
10 Wolfe J, Erickson DJ, Sharkansky EJ, King DW, King LA. Course and predictors of posttraumatic stress disorder among Gulf War Veterans: a prospective analysis. J Counsel Clin Psychol (1999) 67:520–28.[CrossRef]
11 Fiedler N, Ozakinci G, Hallman W, et al. Military deployments to the Gulf War as a risk factor for psychiatric illness among US troops. Br J Psychiatry (2006) 188:453–59.
12 Unwin C, Hotopf M, Hull L, Ismail K, David A, Wessely S. Women in the Persian Gulf: lack of gender differences in long-term health effects of service in United Kingdom Armed Forces in the 1991 Persian Gulf War. Mil Med (2002) 167:406–13.[ISI][Medline]
13 Iraq coalition casualty count. (accessed 1 January 2006). Available at: www.iCasualties.org.
14 Women after war: the casualties. US Deaths in Iraq mark increased presence: more killed in action than in any other war. Washington Post (2006) December 31. A18.
15 Rona RJ, Fear NT, Hull L, Wessely S. Women in novel occupational roles: mental health trends in the UK armed forces. Int J Epidemiol (2006) 36:319–26.[Medline]
16 Hoge CW, Auchterlonie JL, Milliken, CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA (2006) 295:1023–32.
17 Operation Iraqi Freedom (OIF-II) Mental Health Advisory Team (MHAT-II) report: chartered by U.S. Army Surgeon General, Annex A. (2005) January 30. (accessed 2 January 2006). Available at: www.armymedicine.army.mil (news and media link).
18 Clark JC, Eaton KM, Castro CA, Hoge CW. Combat exposure and mental health during deployment: does gender matter? (2006) August 10. New Orleans: American Psychological Association Annual Convention.
19 Hoge CW, Castro CA. Post-traumatic stress disorder in UK and US forces deployed to Iraq [Letter]. Lancet (2006) 368:837.[ISI][Medline]
20 Kang Han, Dalager N, Mahan C, Ishii E. The role of sexual assault on the risk of PTSD among Gulf War Veterans. AEP (2005) 15:191–5.[Medline]
21 Wolfe J, Sharkansky EJ, Read JP, Dawson R, Martin JA, Oimette PC. Sexual harassment and assault as predictors of PTSD symptomatology among U.S. female Persian Gulf War military personnel. J Interpers Violence (1998) 13:40–57.[Abstract]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||