In the Shadow of Iraq: Posttraumatic Stress Disorder in 2007

Abstract

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 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 ofJournal 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., 7 also in this issue, in predominantly older white males receiving primary care at Veterans Administration facilities; similar rates have been reported elsewhere. 8,9 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