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Capt. Karen-Nicole Napper wasn't in a combat unit. But as a signal officer with four tours of duty under her belt, she was shot at and mortared on a regular basis, flying from one forward operating base to another aboard CH-47 Chinook helicopters.
On her last deployment to Afghanistan, a fellow soldier was hit by a mortar two buildings away from hers and could be identified only by his dog tags, she recalled. Midway through that deployment, she began having trouble sleeping and developed anxiety problems.
She finally sought help, but it wasn't easy.
"I remember feeling pretty profoundly, as a woman being in command, not wanting to fall into the stereotype of, ‘We've got another sappy female breaking under pressure,'" she said.
Napper is among a growing number of female troops diagnosed with post-traumatic stress disorder at higher rates than their male counterparts, according to the annual Military Times Poll.
Of 85 active-duty women who responded to this year's poll, 22 percent said they have been diagnosed with PTSD. That represents a small but notable increase from 2009, when only 15 percent of female respondents said they had PTSD.
Over the same period, the percentage of active-duty men who say they've been diagnosed with PTSD rose from 9 percent to 14 percent.
The PTSD rate for women in the Military Times Poll tracks with the Veterans Affairs Department, which estimates the PTSD rates for female veterans of the Iraq and Afghanistan wars to be about 20 percent. Various studies of PTSD prevalence among male veterans of those wars has estimated the rate at anywhere from 10 percent to 18 percent. A Rand Corp. study in 2008 put it at 14 percent.
Elspeth Ritchie, a psychiatrist and retired Army colonel, said it's well-documented that civilian women have a higher rate of PTSD than civilian men, largely because of gender trends in such crimes as sexual and domestic violence. But there's considerably less specific research on PTSD gender differences among service members.
"One of the challenges, I think, is that many female soldiers are wanting more than anything else to be like the guys, and so they're not necessarily more likely than the guys to report," Ritchie said.
Napper said she saw male colleagues, including one of her noncommissioned officers, deal with the stigma of mental health problems, as well.
"He was very old-school Army — you don't talk about your problems, you don't cry," she said.
She said he resisted the idea of professional help, but "when it was just me and him … he would almost come to tears talking about his little boy at home, talking about how much he missed him."
The Military Times poll also found that women were more than twice as likely as men to have been prescribed a psychiatric medication. For both genders, the most common type of prescription drug was antidepressants — including brands like Paxil, Prozac and Zoloft, which are commonly used to treat PTSD — followed by sleep aids such as Ambien and Lunesta.
Napper said she was prescribed both types of medication. She had always been reluctant to take even aspirin, but a psychiatrist told her the stress-induced chemical changes in her brain weren't her fault, and she was desperate for relief from the anxiety.
Ritchie said women often are more receptive to taking meds than men, particularly the antidepressants known as selective serotonin re-uptake inhibitors or SSRIs, for two reasons: Men feel more pressure to appear tough, and are less inclined to accept the potential side effects, including reduced sexual performance.
Men also may be less likely to accept medication because they are in jobs that require deploying to the field more often than women. Defense Department rules prohibit troops from deploying within three months of starting a psychiatric medication.
Ritchie said the Pentagon needs to work on finding alternative treatments rather than pushing more pills.
"What we should be concerned about is, we don't know enough to make sense of this," she said. "We don't know what ‘right' looks like."