The use of complementary and alternative medicine therapy is increasingly widespread, both in the civilian world and the military, particularly as the number of drug refractory cases of posttraumatic stress disorder increases. This issue of Psychiatric Annals begins a 6-month series of looking at how the use of complementary and alternative medicine in the military, particularly in the treatment of posttraumatic stress syndrome, is impacting the field of psychiatry.
Posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) have been called the “signature wounds” of the wars in Iraq and Afghanistan. Improvised explosive devices or other roadside bombs are considered the “signature weapons” of war in today’s world, particularly in the Middle East. Blasts from these weapons may cause PTSD, TBI, hearing loss, pain, and disability. These conditions may be mild or severe, and may or may not lead to discharge from the military and/or treatment by the Veteran’s Health Administration.
The psychological injuries of war are related both directly to combat and related horrors of all kinds. PTSD is the phrase used by the general public for such trauma-related psychological injuries. However, there are others: grief and loss are common for service members who have lost comrades. Difficulty with re-integration to civilian life is increasingly being recognized as its own risk factor in contributing to posttraumatic stress symptoms, depression, and substance abuse. The act of killing another, even if sanctioned under the laws of war, may cause scars. There is increasing discussion in this context about so called “moral injury.”
While service members may self-refer to primary care for insomnia or pain from head injuries, they are typically reluctant to seek mental health treatment for fear of being stigmatized. Service members do not like entering a clinic with the sign on the outside of the clinic saying “Army Behavioral Health” or “Army Substance Abuse.” I have been told often, “Soldiers will not follow me into battle if they think I have a mental problem.” Service members are also worried about how having psychiatric treatment will impact their ability to receive security clearances and promotions.
Complementary and alternative medicine (CAM) therapy is one modality that allows service members to get nurturing care and treatment outside of the conventional mental health clinic. It also relies less on verbal interaction and disclosure, which may be hard for many service members. In the words of Capt. Robert Koffman, MD, one of the authors whose work will be included in this series, who uses acupuncture to treat insomnia in combat troops in Afghanistan, “They come for the needles, they stay for therapy.”
The problem of how exactly to define CAM (sometimes referred to as integrated medicine) in order to more accurately measure it is tackled in the first article in this six-part series by Robert McLay, MD; Lt. George Loeffler, MD; and Maj. Gary Wynn, MD. They discuss some of the challenges of developing evidence-based treatments in CAM, and explore how to meet the current lack of data from rigorous, randomized trials.
Other articles in this series on alternative treatments for PTSD will explore the stellate ganglion block technique; novel uses in military medicine; acupuncture; virtual reality; and animal-assisted therapy.
A note on nomenclature: throughout this series, we use the terms “military” and “service members” interchangeably, referring to members of the Army (soldiers), Navy (sailors), Air Force, and Marines. Service members may either be active duty or in the reserves. The term “veterans” is usually used after service members are no longer on active duty, although they may still be part of the reserve. “Combat veterans” refers to service members who have been in combat. After 11 years of wars in Iraq and Afghanistan, the majority of service members are combat veterans.
There is a long tradition of military medicine leading in advances in medicine; we hope that this issue will inform civilian providers as to new directions in military medicine.