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Prisoners of war: long-term health outcomes
s22
Prisoners of war: long-term health outcomes
USA (Prof R J Ursano MD, D M Benedek MD) (e-mail: [email protected])
Robert J Ursano
Robert Ursano is chairman of the Department of Psychiatry and director of the Center for the Study of Traumatic Stress, Uniformed Services University, School of Medicine, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA. David Benedek is director of the National Capital Consortium and of the Forensic Psychiatry Fellowship Program, Walter Reed Army Medical Center, Washington, DC, USA.
risoners of war (POWs) are soldiers, sailors, aircrew, and marines who are captured in wartime. They are often subjected to extreme physical and psychosocial stressors. Physical trauma and injury can arise during conflict, capture, or internment. Nutritional deprivation, maltreatment, torture, political exploitation, isolation, humiliation, lack of medical care, and, at times, deliberate indifference to illness or injury on the part of captors, are typical. Such traumatic life experiences affect immediate and long-term physical and mental health and function directly—eg, injury or malnutrition—and indirectly, eg, altered health behaviours or stress. The captivity experience of POWs can vary greatly. Knowledge of the effects of POW experience on health is based on those who survive. The
P
AP
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
POWs behind the barbed wire of an Italian internment camp
Australian army’s 8th division, captured in 1942 after the fall of Singapore, endured many months of maltreatment, malnutrition, and disease. 40 years after their release, these POWs had more medical diagnoses and somatic symptoms and used a greater number of non-psychoactive drugs than did members of other non-POW divisions. Gastrointestinal disorders (predominantly peptic ulcer disease and gastritis), musculoskeletal disorders, and cognitive disorders—excluding head injury, stroke, and dementia—were significantly more prevalent in POWs. Alcohol or tobacco use, level of education, and socioeconomic status did not differ between groups. The POW experience was postulated to play a part in premature or abnormal ageing. 20-year follow-up of US naval Vietnam POWs also recorded increases in musculoskeletal injury, peptic ulcer disease, and peripheral neuropathies. For the first 30 years after repatriation, US POWs of World War II and the Korean conflict had lower death rates for heart disease and stroke than did non-POW veteran controls. However, results of a subsequent analysis showed POWs aged 75 years and older were at significantly higher risk for heart disease-related deaths and stroke mortality. Similar analyses revealed a high risk of cirrhosis-related deaths only in WWII POWs, especially over the first 30 years of follow-up, and in POWs aged 50 years or older. Results of an earlier study also showed increased cirrhosis-related mortality and higher rates of death from liver cancer in British WWII POWs than in controls. In a 46-year follow-up study, neurological sequelae of British WWII POWs were compared with expected rates from the general population of England and Wales. Death rates from Parkinson’s disease in former POWs did not differ from the national average, nor were differences noted in rates of multiple sclerosis or dementia. However, comparison of POWs with national rates fails to
THE LANCET Extreme medicine ■ Vol 362 ■ December 2003 ■ www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
s23
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
AP
control for the fact that service members are typically the most healthy subset of a population, reflecting the so-called healthy worker effect. Results of studies of British WWII and US Vietnam POWs have shown a high frequency of extremity peripheral neuropathies and persistent pain and diminished functional status resulting from injuries. Those POWs from WWII who lost the most weight or who had oedema during captivity were at greatest risk of peripheral neuropathies. Psychiatric and mental-health effects are most typically seen in POWs. For individuals with severe captivity experiences, apathy, dependence, seclusiveness, and irritability and anxiety have usually been reported on return home. Results of large-scale studies of US WWII and Korean POWs showed increased mortality from accidents and tuberculosis in Pacific WWII POWs, whereas results of subsequent studies showed greater psychological symptoms in POWs than in controls. In 1992, extensive follow-up, including comprehensive medical examination and structured clinical interview, identified amplified rates of post-traumatic stress disorder, depressive disorder, and generalised anxiety in POWs, which were generally greater in Pacific WWII and Korean POWs than in European WWII POWs. At 40-year follow-up, rates of depressive symptoms were three to five times higher than those of the general population, and were greatest in young POWs and those who underwent the most harsh treatment. Across studies of POWs of different wars, rates of lifetime post-traumatic stress disorder and depression are about 35–50% and 50–80% higher, respectively, in POWs than in controls. Of repatriated US Gulf War POWs, 10% were diagnosed with a captivity-related psychiatric illness on their return home, and about a third had psychiatric symptoms or disorders needing follow-up. The severity of captivity has consistently been associated with increased psychiatric morbidity in all wars. US Air Force POWs captured in Vietnam before 1969 underwent much greater maltreatment and deprivation than did those captured after 1969 (in 1969, bombing was stopped), and had greater psychiatric disturbance and more abnormal psychological test scales on the Minnesota multiphasic personality inventory. An intriguing single case design of six former Vietnam era US airforce POWs, who had coincidently been seen psychiatrically years before their captivity, also showed that individuals previously selected for mental health and excellent stress coping can
Military personnel after liberation from a POW camp in Japan
develop psychiatric illness after POW experiences. Studies of protective factors have suggested various coping strategies as effective in protecting from negative psychiatric outcomes; however, none are well established. Increased death rates arise in the early years after severe POW captivity experiences, from accidents and infection. Furthermore, POWs are at increased risk of somatic complaints, musculoskeletal disorders, gastrointestinal disorders, and peripheral neuropathies compared with their combat counterparts. Psychiatric illness including post-traumatic stress disorder, depression, and generalised anxiety can present early and persist for decades after captivity. Although remarkable resiliency to terrifying and physically disabling stressors is normal for those surviving POW captivity, their medical and psychiatric illness and disability can require care and support for years. Further reading Nice DS, Garland CF, Hilton SM, Baggett JC, Mitchell RE. Long-term health outcomes and medical effects of torture among US Navy prisoners of war in Vietnam. JAMA 1996; 276: 375–81. Page WF, Tanner CM. Parkinson’s disease and motor-neuron disease in former prisoners of war. Lancet 2000; 355: 843. Page WF. The health of former prisoners of war. Washington DC: National Academies Press, 1992. Ursano RJ, Rundell JR, Fragala MR, et al. The prisoner of war. In: Ursano RJ, Norwood AE, eds. Emotional aftermath of the Persian Gulf War: veterans, families, communities and nations. Washington, DC: American Psychiatric Publishing, 1996: 443–76.
THE LANCET Extreme medicine ■ Vol 362 ■ December 2003 ■ www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
Prisoners of war: long-term health outcomes
USA (Prof R J Ursano MD, D M Benedek MD) (e-mail: [email protected])
Robert J Ursano
Robert Ursano is chairman of the Department of Psychiatry and director of the Center for the Study of Traumatic Stress, Uniformed Services University, School of Medicine, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA. David Benedek is director of the National Capital Consortium and of the Forensic Psychiatry Fellowship Program, Walter Reed Army Medical Center, Washington, DC, USA.
risoners of war (POWs) are soldiers, sailors, aircrew, and marines who are captured in wartime. They are often subjected to extreme physical and psychosocial stressors. Physical trauma and injury can arise during conflict, capture, or internment. Nutritional deprivation, maltreatment, torture, political exploitation, isolation, humiliation, lack of medical care, and, at times, deliberate indifference to illness or injury on the part of captors, are typical. Such traumatic life experiences affect immediate and long-term physical and mental health and function directly—eg, injury or malnutrition—and indirectly, eg, altered health behaviours or stress. The captivity experience of POWs can vary greatly. Knowledge of the effects of POW experience on health is based on those who survive. The
P
AP
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
POWs behind the barbed wire of an Italian internment camp
Australian army’s 8th division, captured in 1942 after the fall of Singapore, endured many months of maltreatment, malnutrition, and disease. 40 years after their release, these POWs had more medical diagnoses and somatic symptoms and used a greater number of non-psychoactive drugs than did members of other non-POW divisions. Gastrointestinal disorders (predominantly peptic ulcer disease and gastritis), musculoskeletal disorders, and cognitive disorders—excluding head injury, stroke, and dementia—were significantly more prevalent in POWs. Alcohol or tobacco use, level of education, and socioeconomic status did not differ between groups. The POW experience was postulated to play a part in premature or abnormal ageing. 20-year follow-up of US naval Vietnam POWs also recorded increases in musculoskeletal injury, peptic ulcer disease, and peripheral neuropathies. For the first 30 years after repatriation, US POWs of World War II and the Korean conflict had lower death rates for heart disease and stroke than did non-POW veteran controls. However, results of a subsequent analysis showed POWs aged 75 years and older were at significantly higher risk for heart disease-related deaths and stroke mortality. Similar analyses revealed a high risk of cirrhosis-related deaths only in WWII POWs, especially over the first 30 years of follow-up, and in POWs aged 50 years or older. Results of an earlier study also showed increased cirrhosis-related mortality and higher rates of death from liver cancer in British WWII POWs than in controls. In a 46-year follow-up study, neurological sequelae of British WWII POWs were compared with expected rates from the general population of England and Wales. Death rates from Parkinson’s disease in former POWs did not differ from the national average, nor were differences noted in rates of multiple sclerosis or dementia. However, comparison of POWs with national rates fails to
THE LANCET Extreme medicine ■ Vol 362 ■ December 2003 ■ www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
s23
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
AP
control for the fact that service members are typically the most healthy subset of a population, reflecting the so-called healthy worker effect. Results of studies of British WWII and US Vietnam POWs have shown a high frequency of extremity peripheral neuropathies and persistent pain and diminished functional status resulting from injuries. Those POWs from WWII who lost the most weight or who had oedema during captivity were at greatest risk of peripheral neuropathies. Psychiatric and mental-health effects are most typically seen in POWs. For individuals with severe captivity experiences, apathy, dependence, seclusiveness, and irritability and anxiety have usually been reported on return home. Results of large-scale studies of US WWII and Korean POWs showed increased mortality from accidents and tuberculosis in Pacific WWII POWs, whereas results of subsequent studies showed greater psychological symptoms in POWs than in controls. In 1992, extensive follow-up, including comprehensive medical examination and structured clinical interview, identified amplified rates of post-traumatic stress disorder, depressive disorder, and generalised anxiety in POWs, which were generally greater in Pacific WWII and Korean POWs than in European WWII POWs. At 40-year follow-up, rates of depressive symptoms were three to five times higher than those of the general population, and were greatest in young POWs and those who underwent the most harsh treatment. Across studies of POWs of different wars, rates of lifetime post-traumatic stress disorder and depression are about 35–50% and 50–80% higher, respectively, in POWs than in controls. Of repatriated US Gulf War POWs, 10% were diagnosed with a captivity-related psychiatric illness on their return home, and about a third had psychiatric symptoms or disorders needing follow-up. The severity of captivity has consistently been associated with increased psychiatric morbidity in all wars. US Air Force POWs captured in Vietnam before 1969 underwent much greater maltreatment and deprivation than did those captured after 1969 (in 1969, bombing was stopped), and had greater psychiatric disturbance and more abnormal psychological test scales on the Minnesota multiphasic personality inventory. An intriguing single case design of six former Vietnam era US airforce POWs, who had coincidently been seen psychiatrically years before their captivity, also showed that individuals previously selected for mental health and excellent stress coping can
Military personnel after liberation from a POW camp in Japan
develop psychiatric illness after POW experiences. Studies of protective factors have suggested various coping strategies as effective in protecting from negative psychiatric outcomes; however, none are well established. Increased death rates arise in the early years after severe POW captivity experiences, from accidents and infection. Furthermore, POWs are at increased risk of somatic complaints, musculoskeletal disorders, gastrointestinal disorders, and peripheral neuropathies compared with their combat counterparts. Psychiatric illness including post-traumatic stress disorder, depression, and generalised anxiety can present early and persist for decades after captivity. Although remarkable resiliency to terrifying and physically disabling stressors is normal for those surviving POW captivity, their medical and psychiatric illness and disability can require care and support for years. Further reading Nice DS, Garland CF, Hilton SM, Baggett JC, Mitchell RE. Long-term health outcomes and medical effects of torture among US Navy prisoners of war in Vietnam. JAMA 1996; 276: 375–81. Page WF, Tanner CM. Parkinson’s disease and motor-neuron disease in former prisoners of war. Lancet 2000; 355: 843. Page WF. The health of former prisoners of war. Washington DC: National Academies Press, 1992. Ursano RJ, Rundell JR, Fragala MR, et al. The prisoner of war. In: Ursano RJ, Norwood AE, eds. Emotional aftermath of the Persian Gulf War: veterans, families, communities and nations. Washington, DC: American Psychiatric Publishing, 1996: 443–76.
THE LANCET Extreme medicine ■ Vol 362 ■ December 2003 ■ www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.