Forty years after the end of the Vietnam War, an estimated 271,000 veterans who served in the war zone continue to experience full or subthreshold posttraumatic stress disorder (PTSD), and more than one-third of those with war-zone PTSD have current major depressive disorder, according to a study published in JAMA Psychiatry.
The National Vietnam Veterans Longitudinal Study (NVVLS), led by Charles R. Marmar, M.D., of New York University Langone Medical Center, is the first follow-up to the original National Vietnam Veterans Readjustment Study (NVVRS), which was carried out from 1984 through 1988. The current study re-examined the original cohort between July 2012 and May 2013. Of the 1,920 survivors from the NVVRS cohort at the start of NVVLS, 1,839 were eligible for follow-up and 1,450 (78.8%) participated in at least one phase of the NVVLS, providing a nationally representative window into the long-term psychiatric health of Vietnam theater veterans.
The NVVLS used validated clinical instruments to assess PTSD and related conditions, including the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), the PTSD Checklist for DSM-5 items (PCL-5), the Mississippi Scale for Combat-Related PTSD, and structured clinical interviews. Based on these assessments, the authors estimated prevalence rates for current war-zone PTSD among theater veterans by gender.
Among male theater veterans, current PTSD prevalence was estimated at 4.5% based on CAPS-5 criteria for a full diagnosis. When including subthreshold cases that meet some diagnostic criteria, the prevalence rises to 10.8%. Using the PCL-5-based measure for current war-zone PTSD, the prevalence was estimated at 11.2% in male veterans. Among female theater veterans, estimates were 6.1% for a full CAPS-5 diagnosis, 8.7% when full and subthreshold cases are combined, and 6.6% using the PCL-5 measure. The study also reported prevalence values for non–war-zone PTSD and highlighted substantial comorbidity: 36.7% of veterans with current war-zone PTSD also met criteria for current major depressive disorder.
The longitudinal course of symptoms showed variability across the cohort. Approximately 16.0% of theater veterans reported a worsening of symptoms, defined as an increase greater than 20 points on the Mississippi Scale, while 7.6% reported an improvement of greater than 20 points. The study emphasizes that an important minority of veterans remain symptomatic four decades after their wartime service, with more than twice as many showing deterioration as improvement.
Policy and Clinical Implications
The authors underscore several policy and clinical implications. First, the findings point to a persistent need for broad access to evidence-based mental health care for aging veterans. Second, they recommend integrating mental health services into primary care settings, given the high burden of comorbid medical conditions and a nearly 20 percent mortality noted within the cohort. Third, the study highlights the importance of addressing stressors associated with aging—retirement, chronic illness, declining social supports, and cognitive changes—that can complicate management of intrusive memories and PTSD symptoms. Lastly, the authors note that lessons from the Vietnam cohort should inform planning and services for veterans of more recent conflicts.
Editorial commentary: An accompanying editorial by Charles W. Hoge, M.D., of the Walter Reed Army Institute of Research describes the NVVLS as a methodologically rigorous follow-up that provides a rare, long-term perspective on the psychiatric health of combat veterans. The editorial emphasizes that the study’s findings illuminate both the experiences of the Vietnam generation and the broader, lifelong impact of combat exposure across generations.
Funding: The National Vietnam Veterans Longitudinal Study was funded and contracted by the Department of Veterans Affairs.
Research summary (Abstract)
Importance: The long-term course of readjustment problems after military service has not been assessed in a representative national sample over multiple decades. The NVVLS provides a congressionally mandated reassessment of veterans who participated in the original NVVRS.
Objective: To determine the prevalence, course, and comorbidities of war-zone PTSD over a 25-year interval, using follow-up data collected approximately 40 years after the end of the Vietnam War.
Design, Setting, and Participants: NVVLS included a self-report health questionnaire (n = 1,409), a computer-assisted telephone interview (n = 1,279), and a telephone clinical interview (n = 400) conducted from July 3, 2012, through May 17, 2013. Of 2,348 original NVVRS participants, 1,920 were alive at the outset of NVVLS; after accounting for deaths during recruitment, 1,839 were eligible and 1,450 participated in at least one phase (78.8%). Analysis was performed from May 18, 2013, through January 9, 2015, with further analyses through April 13, 2015.
Main Outcomes and Measures: Instruments included the Mississippi Scale for Combat-Related PTSD, a combined PTSD Checklist for DSM-IV and DSM-5 items (PCL-5+), the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), and the Structured Clinical Interview for DSM-IV, Nonpatient Version.
Key Results: Estimated prevalence among male theater veterans was 4.5% for current PTSD by CAPS-5, 10.8% when including subthreshold cases, and 11.2% by PCL-5+. Among female veterans, estimates were 6.1%, 8.7%, and 6.6%, respectively. Comorbid major depression occurred in 36.7% of veterans with current war-zone PTSD. Regarding symptom course, 16.0% reported notable symptom increases while 7.6% reported notable decreases on the Mississippi Scale.
Conclusions and Relevance: Approximately 271,000 Vietnam theater veterans continue to experience full or subthreshold war-zone PTSD, and about one-third of these veterans have current major depressive disorder, four decades after the conflict. The findings highlight the enduring need for access to mental health services for veterans with PTSD symptoms.
“Course of Posttraumatic Stress Disorder 40 Years After the Vietnam War: Findings From the National Vietnam Veterans Longitudinal Study” by Charles R. Marmar, MD, and colleagues was published online July 22, 2015 in JAMA Psychiatry (doi:10.1001/jamapsychiatry.2015.0803).