By Stephen Spotswood
SAN FRANCISCO – One of the most important realizations by VA physician researchers in the past decade has been that mental illnesses such as post-traumatic stress disorder (PTSD) and depression can be linked, sometimes very strongly, to various physical illnesses. The tally of those physical ailments is rising, and researchers continue to find surprising links.
One connection that might not occur to physicians treating recently returned veterans, and for which evidence is accumulating rapidly, is between mental illness and lower urinary tract symptoms (LUTS). These include problems with urinary frequency, urgency and nocturnal urination, which are relatively common in older men.
The medical literature suggests, however, that these symptoms can occur in younger people, particularly when there’s a corresponding mental illness.
An examination of existing data on VA patients reinforced this, suggesting a strong corollary between Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans with PTSD and depression and these symptoms. The study results have encouraged researchers to look more closely at the link, and ways in which military service can lead to LUT dysfunction.
This research is being led by Benjamin Breyer, MD, a urologic surgeon at the University of California, San Francisco Medical Center and Karen Seal, MD, a staff physician at the San Francisco VAMC and codirector of the facility’s OEF/OIF Integrated Care Clinic, which provides one-stop primary care, mental health and social services to returning veterans.
When the two physician-researchers teamed up several years ago, they came at the issue from very different vantage points — Seal from a history of research into veterans with PTSD, Brayer from that of a surgeon focusing on one specific area of health. Both were seeing the same phenomenon: younger patients, especially those with mental-health issues, complaining of LUTS.
“I was seeing returning Iraq and Afghanistan veterans, who have a median age of 31, and I was pretty surprised that a significant minority were reporting symptoms similar to some of my patients 60 years and older,” Seal said. “That included urgent incontinence — the feeling of not being able to go and then a tremendous need to urinate. And while I only work with men in my integrated OEF/OIF clinic, I’ve heard similar things from colleagues working with women.”
Patients with these kinds of symptoms also find themselves more at risk to develop urinary tract infections — another relative rarity for younger men.
“A lot of these patients who had these complaints appeared to have PTSD,” Seal said.
As a VA researcher, Seal had done extensive work using VA’s national database. With that access, she and Breyer were able to look at a large snapshot of veterans returning form OEF/OIF who had enrolled in VA and sought care.
“We were able to look at a number of different outcomes, including what mental-health resources the patient used, whether they saw urologists, whether they had been prescribed medications for LUTS and if they had any procedures associated with LUTS,” Breyer said.
They found that having a mental-health diagnosis increased the risk of being diagnosed and treated for lower urinary tract dysfunction about twofold.
Those findings were presented at the 2012 Annual Scientific Meeting of the American Urological Association.
Moving forward, Breyer and Seal are considering a survey of VA patients that would allow them to get a much more detailed view of mental health and urinary tract symptoms.
“We want to get long-term data on fewer patients, but more granular data,” Breyer said. “We want to look at the relationship between mental health problems and LUTS and see how that all plays out.”
They also will make a point of asking about the physical hardships of military service to better understand how those could impact urinary function later on.
“In some patients, this could simply be due to the physical factors of deployment where they couldn’t urinate properly,” Seal said.
She said the problem could be even more common in female servicemembers, for whom opportunities to urinate discreetly are more difficult to come by.
The research is currently in early planning stages.
While Breyer and Seal hope to eventually use the results to inform treatment options for both LUTS and mental illnesses, in the meantime, their data might mean it is time for VA physicians working with OEF/OIF veterans to take notice.
“We have screens for PTSD and depression, but they don’t include LUTS,” Seal said. “In a quick 20-minute primary care appointment, we don’t always have time to ask about this. And it’s something that younger men tend to not volunteer. So it’s important to send this message out that it’s something your patient might be suffering from and that you might want to ask about.”
Legislation that would streamline VA’s community care programs into one program and expand VA’s caregiver program to veterans of all eras was signed into law earlier this month..
The good news from a recent consultant study is that, overall, the VA healthcare system is generally equal or better than others when inpatient and outpatient quality is measured.