Posttraumatic stress disorder (PTSD), as a consequence of combat experience, is believed to be a significant risk factor for substance abuse. This theory has been undermined to some extent by recent findings which suggest mental illness, apart from PTSD, may be a stronger predictor. Although combat-related PTSD may significantly contribute to the prevalence of substance abuse among veterans, the dominant substance abuse risks are the same for both civilians and combat veterans. This conclusion suggests than combat may represent a minor risk factor for substance abuse.
The Association between Combat and Substance Abuse
Veterans of the wars in Iraq and Afghanistan are faced with many of the same problems that previous combat veterans have had to face, including posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI). While most veterans suffering from these conditions will successfully cope with the challenges they face through treatment and social support networks, others will turn to destructive coping mechanisms such as drug and alcohol abuse.
A significant body of research examining the relationship between combat exposure and substance abuse has been created since the Vietnam War. This research shows a clear association; however, not all veterans are destined to abuse drugs. This essay will examine what is known about the relationship between combat exposure and substance abuse, including the factors that render some veterans more susceptible to abusing psychoactive substances.
Combat-Related PTSD and Substance Abuse
The clinical diagnosis of PTSD often depends on the identification of the traumatic event or events that led to its development (reviewed by Adamou and Hale, 2003). PTSD is an anxiety disorder characterized by three main symptoms: hyperarousal, avoidance, and intrusive memories of the traumatic event. The reasons why a traumatic event is capable of inducing these symptoms is because the victim is forced to confront in real-time the possibility of imminent death or serious injury to themselves or others. The emotions that are often triggered by this experience are profound fear, helplessness, and horror.
While some combat soldiers and veterans may turn to substance abuse to cope with these symptoms, other will engage cognitive mechanisms to suppress the unwanted memories and the feelings of fear and helplessness they trigger. These mechanisms include active suppression, emotional detachment, and passive rumination about the event or events (reviewed by Williams, Alishia D. And Moulds, 2007). While there may be short-term psychological advantages to these coping strategies, such as being able to continue engaging in combat, the long-term effects are destructive to veterans and their loved ones. The use of detachment or rumination increases the risk of developing major depression within 6 months and depression is a significant risk factor for substance abuse. In light of these findings, the only viable treatment for PTSD symptoms is facing the traumatic event in a supportive and professionally supervised therapeutic setting.
A person must be experiencing symptoms for a month or longer before they will receive a diagnosis of PTSD (Bagalman, 2011). The prevalence of PTSD in all veterans who participated in Operations Enduring Freedom and Iraqi Freedom is unknown; however, the prevalence among veterans of these operations who sought health care through the Veterans Administration (VA) between 2002 and 2010 was 27%. In this population, the rate of alcohol abuse and drug abuse was 7 and 3%, respectively; therefore not all veterans suffering from PTSD will abuse alcohol or drugs and vice versa. Best estimates suggest that 1 in 5 veterans with PTSD will have a substance abuse problem and 1 in 3 veterans who abuse drugs and alcohol will have PTSD (National Center for PTSD, 2011). For this reason, PTSD is considered a strong risk factor for substance abuse, and by extension, so would combat exposure.
Other Combat-Relevant Substance Abuse Risk Factors
Adolescence and young adulthood is a particularly susceptible period for development of PTSD (reviewed by Nooner et al., 2012). Best estimates suggest that close to 80% of all adolescents will experience a traumatic event during their childhood, but only about 10 to 15% will develop PTSD as a result. Trauma type influenced how likely an adolescent would develop PTSD, with sexual abuse producing the highest rates (48%), followed by physical injury (29.1%), witnessing violence (18.3%), physical abuse (14.8%), threat of serious injury (13.0%), and natural disasters (8.6%). The categories that would be analogous to combat would be physical injury, witnessing violence, and the threat of physical injury.
The increased susceptibility of adolescents to PTSD is relevant because the average age of U.S. Army recruits between 2001 and 2011 was 21.5 years (U.S. Army, 2011). Given that recruits must be between 18 and 35 to begin training, a significant percentage of troops entering combat are still teenagers. The peak PTSD-susceptibility age range is between 16 and 17 years (reviewed by Nooner et al., 2012), thus a large percentage of soldiers on the front lines are close to the age when they are most susceptible psychologically to traumatic events.
Despite the young age of combat troops, the use of illicit drugs is much lower than the rates among their civilian counterparts (reviewed by Sirratt, Ozanian, and Traenkner, 2012). In the U.S. civilian population, illicit drug use is estimated to be about 8.9%, but in the military the rate is 2.3%. This difference is believed to be due to the use of random drug screening by the U.S. Department of Defense. However, 26% of military personnel between the ages of 18 and 25 engaged in heavy alcohol use compared to 16% of the age-equivalent civilian population. Although older military personnel still engaged in heavy alcohol use, the difference between their civilian counterparts was smaller. These statistics suggest that military personnel have substituted alcohol for drugs due to the military's policy of random drug screening. It should be noted that these statistics represent all military personnel regardless of combat experience; therefore, simply being in the military at a young age is a significant risk factor for alcohol abuse.
Mental disorders, including PTSD, have been found to be a significant risk factor for substance abuse in both civilian and military populations (reviewed by Petrakis, Rosenheck, and Desai, 2011). This is relevant because combat experience seems to aggravate this association. When comparing Vietnam and Non-Vietnam Era veterans, those who experienced combat were more likely to develop alcohol abuse problems (13.7% vs. 9.2%), anxiety (4.9% vs. 3.2%), and depression (4.5% vs. 2.3%) (reviewed by Sirratt, Ozanian, and Traenkner, 2012). These findings reveal what appears to be a clear association between combat experience and alcohol abuse.
In a large VA Health Care System epidemiological study examining the health records of approximately 1 million veterans, the association between mental health problems and substance abuse was significant (Petrakis, Rosenheck, and Desai, 2011). The substance abuse prevalence among veterans with PTSD was 21.7%, unipolar affective disorders 23.6%, anxiety disorders 22.5%, bipolar disorders 34.7%, and schizophrenia 27.9% (all disorders had a p < 0.0001). Despite reaching statistical significance, the magnitude of the association was quite small for PTSD since 21.1% of veterans without PTSD also abused alcohol or drugs. By comparison, the substance abuse prevalence among veterans without a diagnosis of bipolar disorder or schizophrenia was 20.0 and 20.7%, respectively. This finding suggests that PTSD is not a strong predictor of substance abuse among military personnel compared to bipolar disorder or schizophrenia. It should be noted however, that the authors of this study did not distinguish between PTSD due to combat or civilian trauma.
Mental health problems among veterans can frequently lead to homelessness. In a sample of 994 homeless male and female veterans who served in Operations Enduring Freedom, Iraqi Freedom, and New Dawn and who sought help through a housing program co-administered by the Housing and Urban Development (HUD) and the VA, 769 had seen combat (Tsai, Pietrzak, and Rosenheck, 2012). Of these homeless combat veterans, 54.3% had a substance abuse problem. Of the 225 homeless veterans who did not experience combat, 46.7% had a substance abuse problem. Based on these findings, combat experience may represent a minor, statistically insignificant risk factor for substance abuse.
PTSD prevalence among homeless combat veterans was found to be 74.4% (Tsai, Pietrzak, and Rosenheck, 2012). By comparison, only 40.0% of homeless veterans without combat experience had PTSD. This finding suggests there is a strong correlation between combat exposure and the incidence of PTSD among homeless veterans, while also providing a measure of internal validity for this study. When other mental disorders were examined, the prevalence rate was found to be 99.0 and 89.3% among homeless combat and non-combat veterans, respectively. These finding indicate a strong relationship between homelessness and mental health problems among veterans, which may be aggravated by combat experience. This relationship would in turn increase the risk of substance abuse; however, it should be noted that the only psychiatric condition found to be significantly associated with combat experience among homeless veterans was PTSD. Substance abuse did not reach statistical significance and the relationship between PTSD and substance abuse was not examined