Commentary: Women in combat and the risk of post-traumatic stress disorder and depression

Abstract

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). Studies of general military populations in garrison have paralleled findings from civilian studies. Research on the gender differences associated with military deployment, such as Vietnam, Persian Gulf War, or peacekeeping operations, 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. 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. 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 colleagues 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 crosssectional 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. 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. 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, posttraumatic 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, 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 y 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.’’