A higher severity of an injury during war – and of a post-traumatic stress disorder diagnosis later – could more than double the risk for high blood pressure, according to a new study of service members wounded in Iraq and Afghanistan.

The study, published Monday in the journal Hypertension, included 3,846 soldiers wounded from 2002 to 2011. Those who had one to 15 “PTSD diagnosis encounters” with a doctor had nearly double the risk of developing high blood pressure in the four years of follow-up compared to those who never had a diagnosis of PTSD. Vets with more than 15 such visits had well more than double the risk.

“Our service members get the finest medical care in the history of warfare, bar none, and people are surviving injuries who would not have survived 10, 20, 30 or 40 years ago,” said Major Ian J. Stewart, a doctor who saw some of that care firsthand when he was deployed to Afghanistan. “The question I had is, how do these patients do in the long term?”

Stewart, who led the study and is a researcher at David Grant Medical Center at California’s Travis Air Force Base, authored his first study on the topic in 2015. It suggested the severity of combat injuries increased the risk of developing a wide array of chronic diseases, including high blood pressure. This latest study, he said, was intended to look deeper into why.

“Even after we considered how severely injured the patients was, the presence of PTSD beyond that increased the risk of hypertension,” he said. “So, improving the long-term outcomes in these casualties of the recent wars … requires a wholistic approach that encompasses both medical and mental health treatment.”

That’s exactly the kind of care Wounded Warrior Project is aiming to see for all veterans. The nonprofit founded in 2003 by military veterans and their families, connects injured soldiers with more than 20 programs and services. Alex Balbir, a Navy reservist who directs the group’s Warrior Care Network, said the study results affirm its approach of working with veterans on mental, physical, economic and social issues – all of which can impact the long-term health of a soldier.

“This is a chronic disorder but there are treatments for it,” Balbir said. The Warrior Care Network is a partnership with four university-centered hospitals providing two to three weeks of intensive therapy for vets with PTSD and traumatic brain injury. “I think if we have good interventions early on, we can mitigate the downstream consequences of post-traumatic stress disorder.”

Stewart hopes the study results will lead to increased screenings for high-risk patients in active service and for those no longer active and in the care of federal Veterans Affairs hospitals. The next step, examining the link between PTSD and hypertension, will need more research. Stewart suggests inflammation and stress-related hormones have a role.

The study estimates 23,000 U.S. service members have been hospitalized with injuries from combat in Afghanistan and Iraq – and that as many as 9,800 of them already could have PTSD and 3,200 could have high blood pressure. The annual cost to treat these vets with PTSD and high blood pressure could add up to $42.4 million, the study says.

The recognition and treatment of PTSD, which used to be called shell shock or battle fatigue, has grown by leaps and bounds, Stewart said. The overall prevalence of PTSD among the study group of injured soldiers was 42 percent, almost twice as high as 2009 estimates for the general population of veterans who served in Iraq and Afghanistan.

“We suspect it’s been this way all along, and it’s because of an increased awareness of providers and less of a social stigma of having these symptoms that it appears the prevalence is going up,” Stewart said. “People are people. I don’t think anything has really changed in our baseline physiology or mental state. It’s simply because we as a medical profession have recognized it and people are more likely to tell us.”

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