Estimating the Disease Burden of Combat-Related Posttraumatic Stress Disorder in United States Veterans and Military Service Members

  • M. C. Freed
  • R. K. Goldberg
  • K. L. Gore
  • C. C. Engel


 Posttraumatic stress disorder (PTSD) is chronic, disabling, but treatable and potentially preventable anxiety disorder characterized by re-experiencing, avoidance, and hyperarousal symptoms following a traumatic event. The World Health Organization (WHO) characterized disease burden in the general population and listed PTSD among the top 20 most “burdensome” diseases. The WHO Global Burden of Disease study estimated a  disability weights for PTSD of 0.11 (0 = perfect health; 1 = dead), but other studies have estimated weights up to 0.66, a figure closer to estimates for severe major depression. Limited research exists on the disease burden of PTSD, and to date, no literature estimated the disease burden of combat-related PTSD in the US military and Veterans Affairs (VA) healthcare systems. Extant PTSD literature is arguably sufficient in scope and content needed to calculate reasonable estimates of disease burden of PTSD in these populations. We review five key components to estimating the disease burden of PTSD in the US military and VA: disorder  prevalence; course of illness; disability weights; impact on the healthcare system; and prevention and treatment efficacy.

Current PTSD prevalence estimates vary, but range from 4.2 to 24.5% in  servicemembers returning from Operation Iraqi and Enduring Freedom, depending on the subpopulation and assessment method. PTSD often develops months to years after traumatic exposure, and 40% of Vietnam veterans with PTSD reported symptom chronicity over 20 years. PTSD is associated with low quality of life, high rates of medical service utilization, interpersonal conflict, co-morbidity, and work impairment compared to persons without PTSD.

PTSD is a chronic, disabling, but treatable and perhaps preventable condition. Disease burden estimates of PTSD could be used to better determine the need for and utility of therapeutic interventions designed to alleviate symptoms of PTSD and associated impairment.


Veteran Affair Disease Burden Health Utility Standard Gamble Preference Weight 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

List of Abbreviations:


cross sectional


disability adjusted life year


diagnostic interview


department of defense


diagnostic and statistics manual


global burden of disease


Institute of Medicine




36 medical outcome survey short form-36


medical record review


National Research Council


operation enduring freedom


operation Iraqi freedom


odds ratio




primary care- posttraumatic stress disorder (screen)


posttraumatic stress disorder check list


post-deployment health assessment


post-deployment health re-assessment


 person tradeoff


posttraumatic stress disorder


 quality adjusted life year


short form-6 dimensional health state classification


self-report screen


substance used disorder


United States


veterans affairs


veterans health administration


World Health Organization


year of life with disability


years of life lost


  1. Adler AB, Wright KM, Bliese PD, Eckford R, Hoge CW. (2008). J Trauma. 21: 301–308.Google Scholar
  2. Adler AB, Castro CA, McGurk D. (2007). US Army Medical Research Unit-Europe Research Report 2007–001. USAMRU-E, Heidelberg, Germany.Google Scholar
  3. American Psychiatric Association. (1980). Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. American Psychiatric Association, Washington, DC.Google Scholar
  4. American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, (text revision). American Psychiatric Association, Washington, DC.Google Scholar
  5. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th ed, (text revision). American Psychiatric Association, Washington, DC.Google Scholar
  6. Andrews G, Issakidis C, Sanderson K, Corry J, Lapsley H. (2004). Br J Psychiatry. 184: 526–533.PubMedCrossRefGoogle Scholar
  7. Andrews G, Sanderson K, Beard J. (1998). Br J. Psychiatry. 173: 123–131.PubMedCrossRefGoogle Scholar
  8. Army Medical Surveillance Activity. (2004). Defense Medical Epidemiology Database (DMED 3.7) [computer software]. Available at:
  9. Bennett KJ, Torrance GW. (1996). Measuring health state preferences and utilities: rating scale, time trade-off, and standard gamble techniques. In B. Spiker (ed.), Quality of Life and Pharacoeconomics in Clinical Trials, 2nd ed. Lippincott-Raven Publishers, Philadelphia, PA.Google Scholar
  10. Berzon RA, Mauskoph JA, Simeon GP. (1996). Choosing a health profile (descriptive) and/or a patient-preference (utility) measure for a clinical trial. In B.  Spiker (ed), Quality of Life and Pharacoeconomics in Clinical Trials, 2nd ed. Lippincott-Raven Publishers, Philadelphia, PA.Google Scholar
  11. Bisson JI, Ehlers A, Matthews R, Pilling S, Richards D, Turner S. (2007). Br J Psychiatry. 190: 97–104.PubMedCrossRefGoogle Scholar
  12. Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD, CharneyDS, Keane TM. (1995). J Trauma Stress. 8: 75–90.PubMedCrossRefGoogle Scholar
  13. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. (1996). Behav Res Ther. 34: 669–673.PubMedCrossRefGoogle Scholar
  14. Bradley R, Greene J, Russ E, Dutra L, Westen D. (2005). Am J Psychiatry. 162: 214–227.PubMedCrossRefGoogle Scholar
  15. Brazier J, Roberts J, Deverill M. (2002). J Health Econ. 21: 271–292.PubMedCrossRefGoogle Scholar
  16. Breslau N, Davis GC, Andreski P, Peterson E. (1991). Arch Gen Psychiatry. 48: 216–222.PubMedGoogle Scholar
  17. Breslau N, Kessler RC. (2001). Biol Psychiatry. 50: 699–704.PubMedCrossRefGoogle Scholar
  18. Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. (1998). Arch Gen Psychiatry. 55: 626–632.PubMedCrossRefGoogle Scholar
  19. Davidson JR. (2006). J Clin Psychiatry. 67: 34–39.PubMedGoogle Scholar
  20. Davidson JRT, Foa EB. (1991). J Abnorm Psychology. 100: 346–355.CrossRefGoogle Scholar
  21. Freed MC, Engel CC. (2006). Behavioral Health Track at the U.S. Army Center for Health Promotion and Preventive Medicine-hosted Force Health Protection Conference, Albuquerque, NM.Google Scholar
  22. Freed MC, Yeager D, Liu X, Gore KL, Engel CC, Magruder KM. (2007). Behavioral Health Track at the U.S. Army Center for Health Promotion and Preventive Medicine-hosted Force Health Protection Conference, Louisville, KY.Google Scholar
  23. Friedman MJ. (2006). Am J Psychiatry. 163: 586–593.PubMedCrossRefGoogle Scholar
  24. Garza AG, Wyrwich KW. (2003). Acad Emerg Med. 10(4): 360–363.PubMedCrossRefGoogle Scholar
  25. Gold MR, Siegel JE, Russell LB, Weinstein MC. (1996). Cost-Effectiveness in Health and Medicine. Oxford University Press, New York.Google Scholar
  26. Gold MR, Stevenson D, Fryback DG. (2002). Annu Rev Public Health. 23: 115–134.PubMedCrossRefGoogle Scholar
  27. Gore KG, Engel CC, Freed MF, Liu XL, Armstrong DW. (2008). Gen Hosp Psychiatry. 30: 391–397.Google Scholar
  28. Gore KG, Freed MC, Messer SC, Engel CC. (2006). Behavioral Health Track at the U.S. Army Center for Health Promotion and Preventive Medicine-hosted Force Health Protection Conference, Albuquerque, NM.Google Scholar
  29. Grieger TA, Cozza SJ, Ursano RJ, Hoge C, Martinez PE, Engel CC, Wain HJ. (2006). Am J Psychiatry. 163: 1777–1783.PubMedCrossRefGoogle Scholar
  30. Hepp U, Gamma A, Milos G, Eich E, Adjacic-Gross V, Rossler W, Angst J, Schnyder U. (2006). Eur Arch Psychiatry Clin Neurosci. 256: 151–158.PubMedCrossRefGoogle Scholar
  31. Hidalgo RB, Davidson JR. (2000). J Clin Psychiatry. 61: 5–13.PubMedGoogle Scholar
  32. Hoge CW, Auchterlonie JL, Miliken CS. (2006). JAMA. 295: 1023–1032.PubMedCrossRefGoogle Scholar
  33. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. (2004). N Engl J Med. 351: 13–22.PubMedCrossRefGoogle Scholar
  34. Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. (2008). N Engl J Med. 358: 453–463.PubMedCrossRefGoogle Scholar
  35. Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC. (2007). Am J Psychiatry. 164(1): 150–153.PubMedCrossRefGoogle Scholar
  36. Institute of Medicine (IOM), National Research Council (NRC), Committee on Veterans Compensation for Posttraumatic Stress Disorder. (2007). PTSD Compensation and Military Service. National Academies Press, Washington, DC. Available at:
  37. Institute of Medicine (IOM), Subcommittee on Posttraumatic Stress Disorder of the Committee of Gulf War and Health. (2006). Posttraumatic Stress Disorder: Diagnosis and Assessment. National Academies Press, Washington, DC. Available at:
  38. Ipser J, Seedat S, Stein DJ. (2006). S Afr Med J. 96: 1088–1096.PubMedGoogle Scholar
  39. Jones E, Wessely S. (2007). J Anxiety Disord. 21: 164–175.PubMedCrossRefGoogle Scholar
  40. Kessler RC. (2000). J Clin Psychiatry. 61: 4–12.PubMedGoogle Scholar
  41. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. (1995). Arch Gen Psychiatry. 52: 1048–1060.PubMedGoogle Scholar
  42. Kiberd BA, Lawson T. (2000). Transplantation. 70(7): 1121–1127.PubMedCrossRefGoogle Scholar
  43. Kimerling R, Gima K, Smith MW, Street A, Frayne S. (2007). Am J Public Health. 97: 2160–2166.PubMedCrossRefGoogle Scholar
  44. Kruijshaar ME, Hoeymans N, Spijker J, Stouthard ME, Essink-Bot ML. (2005). Bull World Health Organ. 83: 443–448.PubMedGoogle Scholar
  45. Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, Marmar CR, Weiss DS. (1990). Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. Brunner/Mazel, New York.Google Scholar
  46. Magruder KM, Frueh BC, Knapp RG, Davis L, Hamner MB, Martin RH, Gold PB, Arana GW. (2005). Gen Hosp Psychiatry. 27: 169–179.PubMedCrossRefGoogle Scholar
  47. McFarlane A. (2004). Soc Psychiatry Psychiatr Epidemiol. 39: 874–882.PubMedCrossRefGoogle Scholar
  48. Melse JM, Essink-Bot ML, Kramers PG, Hoeymans N. (2000). Am J Public Health. 90: 1241–1247.PubMedCrossRefGoogle Scholar
  49. Michaud CM, McKenna MT, Begg S, Tomijima N, Majmudar M, Bulzacchelli MT, Ebrahim S, Ezzati M, Salomon JA, Kreiser JC, Hogan M, Murray CJ. (2006). Popul Health Metr. 4:11.PubMedCrossRefGoogle Scholar
  50. Michaud CM, Murray C, Bloom B. (2001). JAMA. 285: 535–539.PubMedCrossRefGoogle Scholar
  51. Milliken CS, Auchterlonie JL, Hoge CW. (2007). JAMA. 298: 2141–2148.PubMedCrossRefGoogle Scholar
  52. Murray CJL, Lopez AD (eds). (1996). The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 Projected to 2020. Harvard School of Public Health, Cambridge, MA.Google Scholar
  53. Prins A, Ouimette P, Kimerling R, Cameron RP, Hugeishofer DS, Shaw-Hegwer J, Thraikill A, Gusman FD, Sheikh JI. (2003). Primary Care Psychiaty. 9: 9–14; Corrigendum (2004) Primary Care Psychiatry. 9(4): 151.CrossRefGoogle Scholar
  54. Revicki DA, Wood M. (1998). J Affect Disord. 48: 25–36.PubMedCrossRefGoogle Scholar
  55. Sanderson K, Andrews G. (2001). Aust N Z J Psychiatry. 35: 668–676.PubMedCrossRefGoogle Scholar
  56. Sassi F. (2006). Health Policy Plan. 21: 402–408.PubMedCrossRefGoogle Scholar
  57. Schnurr PP, Hayes AF, Lunney CA, McFall M, Uddo M. (2006). J Consult Clin Psychol. 74: 707–713.PubMedCrossRefGoogle Scholar
  58. Schnurr PP, Lunney CA, Sengupta A, Waelde LC. (2003). J Trauma Stress. 16: 545–553.PubMedCrossRefGoogle Scholar
  59. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. (2007). Arch Intern Med. 167(5): 476–482.PubMedCrossRefGoogle Scholar
  60. Seedat S, Lochner C, Vythilingum B, Stein DJ. (2006). Pharmacoeconomics. 24: 989–998.PubMedCrossRefGoogle Scholar
  61. Sherbourne C, Unutzer J, Schoenbaum M, Duan N, Lenert LA, Sturm R, Wells KB. (2001). Med Care. 39: 1246–1259.CrossRefGoogle Scholar
  62. Smith TC, Ryan MA, Wingard DL, Slymen DJ, Sallis JF, Kritz-Silverstein D. (2008). BMJ. 336: 366–371.PubMedCrossRefGoogle Scholar
  63. Tsevat J. (2000). Med Care. 38(9) II160–II164.PubMedGoogle Scholar
  64. Veterans Health Administration (VHA), Department of Defense (DoD). (2004). VA/DoD0 Clinical Practice Guideline for the Management of Post-Traumatic Stress. Veterans Health Administration, Department of Defense, Washington, DC.Google Scholar
  65. Vos T, Mathers C, Herrman H, Harvey C, Gureje O, Bui D, Watson N, Begg S. (2001). Soc Psychiatry Psychiatr Epidemiol. 36: 53–62.PubMedCrossRefGoogle Scholar
  66. Ware JE, Sherbourne CD. (1992). Med Care. 30: 473–483.PubMedCrossRefGoogle Scholar
  67. Weathers FW, Keane TM. (2007). J Trauma Stress. 20: 107–121.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media LLC 2010

Authors and Affiliations

  • M. C. Freed
  • R. K. Goldberg
  • K. L. Gore
  • C. C. Engel

There are no affiliations available

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