In Part I of this series, we described the problem of inappropriate care in the United States and how solutions to cost and quality in health care can be effectively dealt with at the organizational level.

We began a consideration of the sequential phases of evidence-based quality improvement work, starting out with readying an organization for evidence-based quality improvement. Now, let’s look at details of using the five A’s (1) of evidence-based medicine to identify and close quality and cost gaps in health care organizations.

Once an organization creates the structural components, such as committees and work groups, and establishes processes for those groups, and once it ensures that staff have the needed knowledge, skills and tools to carry out the five A’s of evidence-based clinical improvement (Asking, Acquiring, Appraising, Applying, A’s Again), each group can begin to identify “fixable” or “closable” quality, cost, satisfaction and uncertainty gaps in clinical care.

The sequential steps in this evidence-based process are outlined in Table 1.

The Institute of Medicine outlined six quality domains (Table 2) which are useful in determining areas within an organization where there may be quality gaps and where quality may be improved. (2)

The size of the gap should justify the effort it will take to close it. To determine the size of the performance gap in a potential work area, groups need to compare internal organizational data (usually obtained from organizational databases) with the best available evidence (obtained from content resources, such as sources for guidelines, clinical recommendations or the medical literature itself.)

All the data must be appraised for validity unless they come from a trusted source such as Cochrane, Clinical Evidence or the Database of Reviews of Effects (DARE)–and must be updated and assessed for usefulness.

In Part I of this series, we indicated that frequently physicians, as well as quality improvement professionals and other decision-making health care professionals, lack the skills to effectively and efficiently search for, critically appraise and synthesize scientific evidence using processes that yield valid, useful and usable content likely to improve desired outcomes.

Individuals doing quality improvement work may benefit from training that can successfully provide the skills and tools for evaluating the medical literature. Training should improve competencies in finding and utilizing studies with appropriate designs, valid methods and useful results.

An approach we have found useful is to teach these skills using the five “A”s of evidence-based medicine:

* Ask — How to construct effective clinical questions

* Acquire — Tips and strategies for systematically capturing potentially useful content through awareness of the best sources for information, application of successful search techniques and filtering strategies

* Appraise — Concepts and methods for evaluating content for validity, usefulness and usability, along with organizational considerations (e.g., cost, legal, marketing, public relations and other value considerations)

* Apply — Using valid and useful content, how to synthesize the body of evidence, creating information, decision and action aids for use by clinicians, patients and others

* “A”s Again — When and how to repeat the process to ensure information is current

These sequential steps are summarized in Table 3 and can be made easier by utilizing various tools.

After completing the evidence synthesis, we strongly recommend making evidence-based estimates regarding local quality and cost outcomes followed by the development of information, decision and action tools, implementation plans and measurement plans. We will describe the details of these steps in Part III of this series. (Watch for it in the May/June 2005 issue of The Physician Executive.)

The biomedical literature has exploded over the past 50 years. The purpose of this study was to track the growth of drug therapy literature using the online provider PubMed. We utilized the first 20 Disease [C] MeSH listed on the 2005 MeSH tree structures for our study. Drug therapy literature was searched using the disease MeSH with the ending / drug therapy or / chemically induced. Publication numbers were compiled each year from 1966 to 2003. Disease articles increased by 612% from 1966 to 2003. Drug therapy articles increased by 1,116% during the same period. As a percentage of all disease articles, drug therapy publications increased from 11% to 18% over this time period. Drug therapy review articles grew by 10,521% over the time period; drug therapy randomized clinical trials increased by 5,228%. Geriatric drug therapy articles increased at a greater rate than pediatric literature (1,210% vs. 637%). Infectious disease (14%), oncology (14%), immunologic diseases (10%), cardiovascular disease (9%), and neurologic/psychiatric diseases (8%) constitute the highest percentages of all drug therapy articles. Drug therapy literature is growing at a faster rate than the disease literature on PubMed. Drug therapy review articles alone are approaching 10,000 articles/year and are the fastest growing subsection of the drug therapy literature on PubMed.

It is impossible for any clinician to keep up with all the biomedical literature published today. Haynes et al. (1) stated the problem: “If physicians were to read everything of possible biomedical relevance, they would need to read 5,500 articles per day.” Of course, this statement was published in 1986, when there were approximately 20,000 biomedical journals published in the world. Today, there are over 40,000 journals, so a clinician now has to read over 10,000 articles per day to keep up (2). It seems clear that the biomedical literature is proliferating at an accelerated rate. But, does the entire body of literature grow uniformly? Are there subsections of the literature growing at a faster or slower rate? Obviously, there are scientifically “hot” areas that probably expand rapidly for a period of time. We were curious regarding the growth of the pharmacotherapy literature relative to the disease literature and the biomedical literature as a whole.

Bibliometrics can be defined as “the use of statistical methods in the analysis of a body of literature to reveal the historical development of subject fields and patterns of authorship, publication, and use” (3). Medical bibliometrics is often narrowly thought of as the use of citation analysis or impact factors to assess publication patterns (4-6). On the contrary, medical bibliometric methods have been used to evaluate the geography of biomedical publications (7-12) and the publication patterns of individual and therapeutic classes of drugs (13-15).

The purpose of this study was to utilize bibliometric methods to track the growth of drug therapy literature using the online provider PubMed.

METHODS

All searches were performed during the months of February and March 2005 using the online provider PubMed. We searched the first 20 Disease [C] Medical Subject Headings (MeSH®) listed on the 2005 MeSH tree structures [C01] through [C20], excluding [C21] through [C23] (Table 1). Literature was searched using the search strategies listed in Table 2. Search strategy 1 was used to search drug therapy-related articles; search strategy 2 was used for disease articles; and search strategy 3 was used to search for drug-induced disease articles. Searches were further classified using the limit fields “publication type” and “subsets” and publication dates. Additional qualifiers included English language and human selection on the PubMed limit search option. Publication numbers were compiled each year from 1966 to 2003. Data were converted to logarithms for graphical representation. We did not include 2004 data because some were still being indexed into the Medlars system in February and March 2005.

RESULTS

Figure 1 represents the growth of disease articles, drug therapy articles, and drug-induced disease articles from 1966 to 2003. Percentage increase over this time was greater for the subset of disease articles that are drug therapy articles (1,116%) than for all disease articles (612%) (see Table 3). The drug-induced disease literature appears to be a slower-growing subsection of the literature compared to, for example, review articles, randomized clinical trials, and acquired immunodeficiency syndrome (AIDS) or cancer drug literature. As a percentage of all disease articles, the subset of drug therapy has increased from 11% in 1966 to 18% in 2003. Figure 2 maps the growth of the cancer, AIDS, and complementary and alternative medicine drug therapy literature, along with the specialty practice areas of pediatric and geriatric drug literature. The AIDS drug literature follows the expected time course consistent with the identification of the disease and its growth (3,226%).

y 2020, depression will move into second place on the list of top-ranked illnesses, just behind cardiovascular disease, according to the Global Burden of Disease Study conducted by the World Health Organization (WHO), the World Bank, and Harvard University (Murray & Lopez, 1996). There is also a link between coronary heart disease and depression. Data from the National Health and Nutrition Examination Survey (NHANES 1) identified that men and women with depression are more at risk for coronary artery disease (Ferketich, Schwartzbaum, Frid, & Moeschberger, 2000).

Depression in the first 18 months after a myocardial infarction is a significant predictor of mortality in both men and women (Frasure-Smith, Lesperance, & Talajic, 1995). The experience of depression also increases the risk of cardiac arrest due to the physiologic edge produced by imbalanced catecholamine circulation (Empana et al., 2006). Ziegelstein et al. (2000) suggest that patients with depression after a myocardial infarction are less likely to choose healthier lifestyle habits (e.g., diet, exercise, social support) or take their medications as instructed. In order to help patients maintain the highest possible level of health, it is imperative that APRNs screen patients carefully for physiologic symptoms attributable to coronary heart disease events and those diagnostic for major depression (Valentine, Byers, & Peterson, 2001).

Early in my practice, I became involved with Bristol Hospital’s Phase II Cardiopulmonary Rehabilitation program called Heart Works. The mental health segment consisted of a 12-week, psychoeducational class format that included information on stress management and cognitive behavioral techniques. Attendance was typically small, and patients complained they did not like being “in school.” After discussion with the program director we eliminated the classroom model, and we established interviews during the orientation to the program with both the Psychiatric Consultation Liaison Nurse (PCLN) and the dietician. The PCLN interview format offers both the patient and family an opportunity to share their perception of their illness/recovery experience, to identify current health promotion behaviors, and to participate in a traditional mental status exam; it also offers an opportunity to screen for depression. We encourage patients to invite any family members they wish to accompany them. Naturally, patients always have the option to refuse the interview.

Content of the Interview

No single assessment tool met my need for a holistic focus; therefore, I created a format that is systemically based, assessing multiple levels of a system and using theory to guide the questions I ask. Included are family nursing theory (Wright & Leahey, 1989), behavioral domains from the Health Promotion Lifestyle Profile (HPLP II) (Walker, Sechrist, & Pender, 1987), and stages of change theory/motivational interviewing (Miller & Rollnick, 1991). The purpose of the interview and depression screening is explained to each patient/ family member. The beginning of the discussion focuses on the beliefs that the patient/family have regarding etiology, diagnosis/prognosis, role of patient/family/providers in recovery, and the impact of the event on the family’s routines. One strategy to elicit the patient’s experience involves the use of interventive interviewing, meaning that you create a conversation inviting change.

Karl Tomm (1988) defined four categories of questions: lineal, circular, strategic, and reflexive. Lineal questions are simple and factual (”Do you have heart disease in your family?”). Circular questions help the patient think about the feedback in relationships (”Who worries the most about your recovery?”). Strategic questions help expand the options to change (”What kinds of help would you need to stay smoke free?”). Reflexive questions help the patient think differently about an issue (”If you succeeded in making your house smoke free, what other concerns might come up?”). Finally, inclusion of a genogram provides a window into the patient’s living room and explores multiple perspectives.

My assessment of current health promotion behaviors covers independent activities of daily living, including the perception of the role of spirituality in recovery. The topics were adapted from the original HPLP II tool, which addressed self-actualization, health responsibility, exercise, nutrition, interpersonal support, and stress management. I created a question about the patient’s perceptions of coping, the perception of family coping, and the expected utility of Heart Works. This is a self-report score from 1 to 10 with 10 being highest. This was added so that staff might compare results at their 6-month follow-up phone call.

The mental status exam is straightforward and includes a brief assessment of present/prior medical illness and how those experiences impact the patient’s perception of the here and now process of recovery. Substance use is also discussed during the evaluation. I have found the brief intervention strategy model, developed by Miller and Rollnick (1991), very helpful. Finally, the patient is given a self-report depression screening questionnaire to complete at home and is requested to return it to staff. There are many tools available, and we currently use the Zung Depression Scale (Zung, 1965). The Zung is a self-administered, 20-item scale that is short, simple, and quantitative. It is sensitive to severity of depression across many patient subgroups with unipolar depression. It is less specific to symptoms common to atypical depression.

PURPOSE. The Adaptive Information Processing Model (AIP), originally developed by Shapiro (2001), provides a model for understanding how trauma affects the brain and how healing occurs.

CONCLUSIONS. The effects of trauma are thought to be much broader than the diagnosis of PTSD and overlap with many other diagnostic categories. Recent physiological research supports the complexity of neurobiological responses to childhood stress and trauma.

PRACTICE IMPLICATIONS. The Treatment Hierarchy, AIP model, and evidence-based treatment framework presented here provide the context and a compass for holistic PMH-APRN practice for working with traumatized patients.

Search terms: Adaptive information processing, disorders of extreme stress (DESNOS), healing trauma, posttraumatic stress disorder (PTSD)

Trauma is an inescapable part of the human experience and affects all dimensions of the person. Psychological trauma has been posited to underlay or contribute to a wide range of psychiatric disorders and medical problems (Hennessey, Ford, Mahoney, Ko, & Siegfried, 2004; Morrison, Frame, & Larkin, 2003; Scaer, 2005; Teicher, Polcari, Andersen, Anderson, & Navalta, 2003). Trauma disconnects the person physiologically, emotionally, spiritually, cognitively, interpersonally, and socially. The National Comorbidity Study found that 60.7% of men and 51.2% of women interviewed reported having experienced at least one major traumatic event in their lifetime (Kessler et al., 1999), and of those exposed to trauma, the prevalence rate for posttraumatic stress disorder (PTSD) is approximately 25% overall in the United States (Foa, Keane, & Friedman, 2000).

Findings (Amsel & Marshall, 2003) from the World Trade Center disaster indicate that many people did have significant symptomatology afterward, such as insomnia, irritability, general anxiety, vigilance, and impaired concentration. However, those problems that people sought help for did not fit into the diagnostic categories of the DSM-IV-TR. Van der KoIk (2003) says that single incident traumas account for those diagnosed with PTSD but that most adults who seek psychotherapy have had numerous traumatic events and suffer from a variety of psychological problems, most of which do not fall within this diagnostic category. Broadly speaking, these fall into problems in aggression, self-hatred, dissociation, somatization, depression, distrust, shame, relationship problems, and affect regulation.

The Effects of Trauma Beyond PTSD

The effects of trauma are thought to be much broader than the diagnosis of PTSD and overlap with many other diagnostic categories. This is true for adults as well as children. One study (Teicher et al., 2003) found that almost two thirds of children with documented abuse do not suffer from PTSD but from a variety of other psychiatric disorders, such as dissociative disorders, borderline personality, bipolar and unipolar depression, substance abuse, eating disorders, oppositional defiant disorder, and attention deficit disorder.

An individual’s vulnerability to trauma depends on the developmental stage, genetic vulnerability, gender, past experiences, preexisting neural physiology, cognitive deficits, emotional maturity, coping skills, hardiness, relationships with others, socioculturel factors, and a host of other factors (Antai-Otong, 2002). If the trauma is particularly prolonged and/or severe and/or the person is vulnerable, pervasive personality problems develop. The person may then develop complex PTSD or disorders of extreme stress not otherwise specified (DESNOS) (Herman, 1992). Although not a DSM-IV diagnosis yet, six deficit areas for DESNOS have been delineated, which include: dysregulation of affect and impulses, disorders of attention and consciousness, disorders of self-perception, distorted interpersonal relationships, distortions of systems of meaning, and somatization of external stress manifesting in the body as disease or physical disorders (Dworkin, 2005). These individuals, referred to as the chronically disempowered by Chu (1998), are often survivors of childhood abuse and require long-term treatment extending over several years.

Shapiro (2001) expanded the concept of trauma from what we traditionally consider Big T events, such as natural disasters, terrorist activities, war, incest, physical abuse, car accidents, and other major lifethreatening events, to include small t traumas. Small t traumas are those that occur often and to most people, such as emotional neglect or indifference, humiliation, and family issues and do not rise to the level of a Big T trauma, yet may create problems and long-term sequelae, both physically and emotionally. For example, childhood experiences such as caregiver depression, chronic mother-infant misattunement, being bullied, chronic loneliness, separation from parents, feeling stupid and humiliated in the classroom setting, significant physical illness, relationship and/or personality problems between parents, economic hardships, family instability, frequent moving and/or change of school, taking care of an alcoholic parent, and many other life events impact the developing child’s brain.

Clinical Vision. The Information Technology Business of McKessonHBOC, Inc., Alpharetta, GA, announced an expanded commitment to improved patient safety and reduced costs with [Horizon.sup.WP] Clinicals, an integrated suite of solutions. The suite features an expert physician order entry system with real-time clinical decision support, developed in conjunction with Vanderbilt University Medical Center, which has experienced a $3.5 million annual reduction in its pharmacy costs, www.hboc.com

For nearly a century, there was little change in the complex processes and procedures to develop, handle, transport and store hard-copy X-ray films.

Automation and manufacturing advances increased the speed of the film processing. However, at its core, it remained a chemical process. Even in the past decade, the stations at which hard-copy films could be viewed also went relatively unchanged–basically, a simple light box with no zoom or rotation capabilities.

Then, seemingly overnight, PACS arrived to supplant that technology, displacing tried and true methods with digital systems to examine and archive medical images. The new technology revolutionized the capture, movement, storage and display of medical images, and though old methods can die hard, innovative institutions, such as Oregon Health & Science University (OHSU) in Portland, Ore., found themselves, out of necessity, in a race to increase functionality.

Out With the Old, In With the New

OHSU’s approach to PACS somewhat mirrors the rise of their institution over the past 200 years. What began in 1867 as a medical education department at Willamette University in Salem, Ore., today sits on 263 acres atop Portland’s Marquam Hill. The OHSU campus encompasses two hospitals, OHSU Hospital and Doernbecher Children’s Hospital, with 447 beds and 31 buildings including clinics, administration, research labs and classrooms. Dental clinics, an eye institute and a child development and rehabilitation center are part of the institution, as well as a school of science and engineering, a primate research center, the Neurological Sciences Institute, and the Vaccine and Gene Therapy Institute. In 2005, OHSU provided more than 175,000 ambulatory services, with more than 39,000 ED visits, 24,900 hospital discharges, and 730,000 medical and dental outpatient visits.

OHSU purchased Agra’s IMPAX PACS in 1998, to address a growing need for a centralized repository of radiological images that could effectively service the entire organization, though, initially, only the radiology and pediatrics departments used it. Film cost was the primary motivation for switching to a PACS system, says Jon Hanada, systems manager, diagnostic imaging. “As soon as we converted, though, ,are knew it was more than just film cost we would be saving, it was time. Time to get the images from the modality to the radiologists, and still get the same studies, the same images to the clinicians.”

OHSU’s radiology department is quite decentralized, says Erwin Schwarz, director of diagnostic imaging services. It is spread out between eight different locations at five different buildings, with pediatric services offered in all five. As OHSU grew, moving images among the various branches of the institution became problematic. According to Schwarz, “PACS was able to facilitate the transfer of images across the enterprise better than the traditional method of film.”

From 1998 to 2000, OHSU converted their children’s hospital from film to digital. They also scanned decades of prior film studies and slowly reduced their image library staff. Though their ROI initially was small, as a portion of OHSU’s entire operating budget, the full benefit was not yet realized. “The total volume of the children’s hospital is less than 10 percent of the institution,” says Schwarz, “so the full payback didn’t happen until we implemented the system enterprisewide.” After that, OHSU’s expenditures dropped from more than $500,000 dollars per year they were spending on film and image library FTEs to less than $25,000 on just film.

Digital Automation

Today, IMPAX is fully integrated into OHSU’s clinical and radiological systems, and the institution’s image library is a fully automated database. X-ray techs digitally capture a CR study, for example, examine it for anomalies, and, if necessary, rotate or brighten the images. Then the study is sent to the PACS with a header containing the patient’s name, medical record number and study I.D. This information is drawn from the RIS in HL7 format and converted into DICOM data that can be understood by the PACS.

When the study arrives at the IMPAX gateway (a server that identifies the study’s “type” by its DICOM header), another server, the broker, verifies that the study belongs to the correct patient and communicates that to the gateway. Then, based on routing rules defined by radiology, the gateway forwards the study to its next destination. If that destination is the Web, which is outside of the PACS, the Web server converts the data into formats that can be viewed by the clinicians at their locations.

Differing Workflows and Version 6

OHSU’s IMPAX PACS is an enterprisewide system in use by surgeons and radiologists, as well as clinicians to view images at the POC. More than 3,000 PCs are on the system, according to Schwarz, and they are primarily used by non-radiologists. “Anybody who needs to look at an image for healthcare delivery can use the PACS, whether it’s a nurse practitioner, an emergency room physician, a physician’s assistant or a surgeon,” he says.

CONSIDER the following hypothetical case. Someone invents a pill that prevents heart disease but has one side effect: if taken by a pregnant woman, it induces an abortion. Plainly, we would allow it onto the market because it has a universally acknowledged therapeutic use, Equally plainly, we would tie its sale to a doctor’s prescription to prevent abortion on demand far beyond the limits to which Roe v.

Wade has been carried. But would not some doctors, either financially unscrupulous or fanatically pro-abortion, then prescribe the pill to healthy pregnant women for use.

In July, more than 1,300 technology and health leaders attended the Secretarial Summit on Health Information Technology. At the conference, HHS released a report, “The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care,” prepared by David Brailer, M.D., Ph.D.

The report outlines four major goals and strategic action plans for reaching those goals. It stresses the need to bring information to the point of care, interconnect physicians and hospitals with interoperable electronic health record systems, give patients access to their medical records, and use health-related technology to track and measure quality of care. In addition, the report identified potential policy options for providing incentives for using electronic health records and three phases of implementing the action plan.

Research on women’s pregnancy and childbirth experiences suggests that the use of medical technology alienates many women by minimizing the importance of their roles and their level of control over their bodies and birth experiences (Davis-Floyd, 1992, 1994; Sandelowski, 1994). Little research focuses on the experience of expectant fathers, either during pregnancy and labor, in general, or with medical professionals and technology, in particular. We address this gap in this study by examining the influence of medical technology on the pregnancy and childbirth experiences of both expectant mothers and their husbands.

This focus is important for two reasons. First, despite the cultural impetus favoring greater participation of fathers in childbirth, many men perceive a lack of emotional involvement–defined as a perceived closeness to or emotional investment in the pregnancy (May, 1982). Little is known, however, about the factors that influence this state. Identifying these factors is important because some evidence indicates that greater levels of perceived involvement among expectant fathers result in stronger attachment with the infant and lower levels of stress and conflict across the transition to parenthood (Ferketich & Mercer, 1989; May, 1982; Peterson, Leiderman, & Herbert, 1979).

Second, comparing expectant mothers’ and fathers’ experiences with medical technology can inform theories about the social control functions of medicalization. Medicalization is defined as “a process by which nonmedical problems become defined and treated as medical problems” (Conrad, 1992, p. 209). Theories that frame medicalization as a form of social control often suggest that women experience this form of social control more frequently and to a greater extent than men (Conrad, 1992; Riessman, 1983). Most studies of childbirth experiences in medical settings, however, include only women. This obscures the possibility that the medical environment may influence the behavior and experiences of expectant fathers as well as expectant mothers.

The potential for medical technology to influence the perceived involvement of expectant fathers has grown as their presence at their partner’s medical office visits and in the delivery room has become more common. The few studies that examine this influence, however, focus only on experiences during pregnancy. Our approach allows us to expand on previous work by examining the impact of medical technology on expectant fathers’ involvement, not only during their partner’s pregnancy, but also during labor and delivery.

Although men’s health, per se, is not medicalized during childbirth, the medical profession may still have an opportunity to exert control over expectant fathers by discouraging their active participation. Alternately, the medical context and the use of medical technology may encourage and facilitate greater father involvement. If the latter is true, it may have consequences for the ability of the expectant mother to exert control over the birth process. For example, as fathers–aided by the use of medical technology–participate more in childbirth, they may encroach upon their female partner’s ability to exert control over labor and delivery. Comparing the experiences of expectant mothers and their husbands allows us to determine whether differences exist in the impact of medical technology on expectant mothers’ and fathers’ perceptions of involvement in and control over pregnancy and childbirth.

Expectant Mothers, Medicine, and Control

Since the mid-1980s, much attention has been given to the role of the medical profession in women’s lives. This body of theoretical and empirical work provides evidence of the power of the medical profession, enhanced by its use of technology, to construct, define, and, ultimately, to control women’s reproductive health (Rothman, 1991). The medicalization of childbirth has been particularly important in this regard. Many people argue that the definition of pregnancy and childbirth as illnesses transforms women’s natural bodily processes into deviant behavior in need of correction and gives the medical profession the power to construct women’s views about the meaning of pregnancy and birth and to control, on a more immediate level, their involvement in these processes (Davis-Floyd, 1992; Martin, 1992; Rothman, 1991).

Cultural and historical analyses describe the process through which childbirth came to be medicalized (Starr, 1982; Sullivan & Weitz, 1988). Prior to the 19th century, childbirth was treated largely as a natural process requiring little or no medical intervention (Sullivan & Weitz, 1988). In the mid- to late-1800s, however, a number of social and cultural factors converged to open the door for medical involvement in the birth process. Primary among these was the struggle of medical practitioners to gain cultural authority and economic power in the United States and to increase demand for their services (Starr, 1982). A central component of this effort was the medicalization of pregnancy and childbirth and the elimination of the competition of midwives.

Culture provides the unwritten rules that inform and shape expected behaviors. To date, little research has been conducted into the attitudes or opinions that service personnel hold toward mental health issues. This article examines current literature and research into the recognition of mental health problems in the military and potential organizational barriers to care including stigma and the specific characteristics of a military culture such as the significant reliance on buddy support. We conclude that the barriers to care which operate in both military and civilian populations are not insignificant. Western militaries in fact currently face an uphill struggle to combat the substantial barriers to care that exist.

Military personnel are at a high risk of exposure to potentially traumatic events. As such, this makes tiiem an “atrisk group” who are vulnerable to suffering from psychological distress and mental health problems including depression, family violence, substance abuse, and post-traumatic stress disorder (PTSD), all of which are problems for the military services and a threat to occupational functionality.1 The impact of mental health on decision making is especially of significance given the high technology, fast-paced warfare of the 21st century, the battlefield which leaves little margin for error. Furthermore, many military forces have to cope with increasingly complicated conflicts with an ever decreasing number of soldiers available to fulfill these duties.2 Troops therefore need to function at peak efficiency and inefficiencies imposed by work stress and mental health problems may have very serious consequences.

Recent claims from soldiers and commanders inside the theaters of Iraq and Afghanistan have raised questions about the state of mental healtii in the U.K. military.4,5 This article attempts to explore the issue of military culture in relation to stress (traumatic or otiierwise) and examines how the military environment may exacerbate psychological problems because of barriers to care including stigma.

The Different Types of Stressors within a Military Environment

The potential of being exposed to traumatic stressors is an ever present issue for individuals who choose the military as their occupation. Furthermore, additional work-related stressors, such as length of deployment or exposure to adverse living condition, may exacerbate the effects of traumatic stress.3 In this section, relevant research on the two different types of stressors will be discussed.

Studies have shown that the degree of psychological trauma from operational duties is proportionally related to the type of warfare fought.6 One of the adverse outcomes of wartime trauma is PTSD. Rates of PTSD in combat veterans have been measured on numerous occasions and vary from 15 to 31%.7·8 These rates are in excess of the 2 to 3% prevalence of PTSD symptoms recorded in the U.K. general population.9 However, focusing on PTSD alone may not give the full picture of operationally induced psychological distress. For instance, it has been reported that up to 50% of Falkland War veterans have symptoms of PTSD even though they may not have sufficient or intense enough symptoms to warrant a formal diagnosis of PTSD.

Some of the variation in rates of PTSD and prevalence of traumatic stress symptoms may be accounted for by differences in study design. For instance, there are many types of instruments used to measure PTSD and many different ways of classifying military missions.11 Furthermore, questionnaires usually overestimate the prevalence of psychiatric conditions.12 Studies which use semistructured instruments such as the Clinician-Adniinistered PTSD Scale are likely to give a better estimate of the true prevalence figure. Studies also vary in their use of terminology and it is important to remember that suffering with PTSD symptoms does not always prevent individuals from working or having fulfilling social lives. Symptoms are not the same as disorder, altiiough it would be foolish to merely dismiss subdiagnostic symptoms as being irrelevant: they may well affect quality of life.

Aside from operationally related traumatic stress, there are numerous other work-related stressors which significantly affect the lives of service personnel. Pflanz et al.3 investigated sources of stress and their prevalence in the U.S. military. Significant work stress was reported by 26% of troops and another 15% described significant emotional distress related to work stressors. The study revealed tiiat being in combat, exposure to heavy casualties, and unexpected deployments all correlated with increased levels of psychological distress.

Mental disorders, whether they are the result of traumatic or work stressors, appear to have had a significant impact on manpower and retention rates. Hoge et al.1 conducted a population-based analysis of hospitalizations occurring at U.S. military medical facilities between 1990 and 1999 among active duty personnel. Results showed that mental disorders were the leading cause of medical discharge among men and the second leading category among women, accounting for 13% of all hospitalizations. Overall, 23% of all inpatient bed days were attributed to mental disorders.