Posttraumatic stress disorder and quality of life: Extension of findings to veterans of
the wars in Iraq and Afghanistan
Paula P. Schnurra,b,⁎, Carole A. Lunneya, Michelle J. Bovinc,d, Brian P. Marxc,d,e
aNational Center for PTSD, Executive Division, United States
bDartmouth Medical School, United States
cNational Center for PTSD, Behavioral Science Division, United States
dVA Boston Healthcare System, United States
eBoston University School of Medicine, United States
a b s t r a c ta r t i c l e i n f o
Posttraumatic stress disorder
Quality of life
The wars in Iraq and Afghanistan—Operation Iraqi Freedom and Operation Enduring Freedom, or OEF/OIF—
have created unique conditions for promoting the development of psychological difficulties such as
posttraumatic stress disorder (PTSD). PTSD is an important outcome because it can affect quality of life,
impairing psychosocial and occupational functioning and overall well-being. The literature on PTSD and
quality of life in OEF/OIF Veterans is at an early stage, but the consistency of the evidence is striking. Our
review indicates that the findings on PTSD and quality of life in OEF/OIF veterans are comparable to findings
obtained from other war cohorts and from nonveterans as well. Even though the duration of PTSD in OEF/OIF
Veterans is much shorter than in Vietnam Veterans, for example, those with PTSD in both cohorts are likely
to experience poorer functioning and lower objective living conditions and satisfaction. The review ends
with discussion of the implications of the evidence for research and clinical practice.
Published by Elsevier Ltd
What is quality of life? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The impact of PTSD on the three components of quality of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1. PTSD and social–material conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.1.Findings in OEF/OIF Veterans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.PTSD and functioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.1.Studies in OEF/OIF Veterans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.PTSD and satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.1.Findings in OEF/OIF Veterans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.4. Longitudinal associations between PTSD and quality of life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.5.Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical implications for treating OEF/OIF Veterans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Knowledge gaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Servingin themilitarycan be a life-changingexperience.Apopular
advertising campaign launched in the 1980s capitalized on this fact,
telling potential recruits that joining the Army was a way to “be all
that you can be.” Military service can be a pathway to education, a
better job, and long-term economic benefits as well as personal
growth (e.g., Sampson & Laub, 1996; Schnurr, Rosenberg, & Friedman,
1993). However, military service, particularly in times of conflict, can
result in exposure to extremely dangerous and traumatic situations
that can cause physical and psychological injuries. In turn, these
injuries can adversely affect quality of life, which the World Health
Organization defines health as “a state of complete physical, mental
and social well-being and not merely the absence of disease or
infirmity” (1948, p. 1).
Clinical Psychology Review 29 (2009) 727–735
⁎ Corresponding author. National Center for PTSD, Executive Division, United States.
E-mail address: email@example.com (P.P. Schnurr).
0272-7358/$ – see front matter. Published by Elsevier Ltd
Contents lists available at ScienceDirect
Clinical Psychology Review
The wars in Iraq and Afghanistan—Operations Iraqi Freedom and
Enduring Freedom, or OEF/OIF—have created unique conditions for
promoting the development of posttraumatic psychological difficul-
ties. A report by the Rand Corporation notes that deployments are
longer and more frequent than in conflicts such as the Vietnam and
Persian Gulf Wars and there are now shorter intervals between
deployments (Tanelian & Jaycox, 2008). Advances in military
medicine have increased the rate of survival from battle wounds,
and blast injuries have caused a high rate of traumatic brain injury. As
a result, many service members are returning home to cope with
serious physical impairments along with the psychological conse-
quences of exposure. Furthermore, the demographics of the fighting
forces have changed, with a high proportion of National Guard and
Reserve troops serving in roles that many did not anticipate when
joining the military. These individuals are older than their active duty
counterparts, with established careers and families. Female service
members, represented in higher numbers than ever before, have a
high amount of exposure to direct combat and life-threatening
situations. This mix of factors—both the wars and the people fighting
them—increases the importance of understanding how posttraumatic
distress relates to quality of life in OEF/OIF personnel.
The wars in Iraq and Afghanistan also have permitted an
unprecedented opportunity to study the consequences of being
deployed to a warzone. Through this work we have gained much
greater understanding of the effects of traumatic military stressors on
mental health, including the development of posttraumatic stress
disorder (PTSD). Evidence is mounting that the prevalence of PTSD
among the men and women who served in Iraq and Afghanistan is
substantial. A recent study by the Rand Corporation estimated that 14%
of the men and women who served in OEF/OIF currently have PTSD
(Schell & Marshall, 2008). As a context for understanding these
numbers, consider that the current prevalence of PTSD in US adults is
4% (National Comorbidity Survey Replication, 2007). PTSD is an
important outcome because it can affect the whole person, impairing
psychosocial and occupational functioning and overall well-being (e.g.,
Kuhn, Blanchard, & Hickling, 2003; Schnurr, Hayes, Lunney, McFall, &
Uddo, 2006; Stein, Walker, Hazen, & Forde, 1997). Even simple tasks
such as going to a supermarket may be affected if an individual avoids
these activities because they trigger traumatic reminders.
In keeping with the focus of this special issue, we review the
literature on how PTSD relates to quality of life in OEF/OIF Veterans.
The literature provides a unique perspective on PTSD and quality of
life because so much of what is known about the topic comes from
cross-sectional, retrospective studies of chronic PTSD populations.
Studies of OEF/OIF Veterans soon after traumatic exposure offer the
opportunity to understand the effects of PTSD on quality of life before
the effects become chronic. In their comparison of OEF/OIF and
Persian Gulf War Veterans, Fontana and Rosenheck (2008) found that
contemporaneous comparisons showed relative adaptive advantages
of OEF/OIF Veterans in terms of “social assets” such as social support
and social integration. However non-contemporaneous comparisons
(comparing both groups at a similar timepoint after deployment)
suggested that these resources become depleted over time, which
could increase the risk of chronic problems such as PTSD.
The focus on OEF/OIF Veterans also is important because of the
substantial efforts by the Departments of Defense and Veterans Affairs
to identify and treat PTSD and other deployment-related mental
disorders, and to promote Veterans' successful reintegration into
society, improve their quality of life, and prevent disability (e.g., as
listed on www.oefoif.va.gov). Veterans of prior wars have not had
such concentrated programmatic support, nor have civilians, with the
exception of those exposed to recent large-scale traumas such as
Hurricane Katrina and the 9/11 attacks. Studies of OEF/OIF Veterans
thus offer an opportunity to look at what happens in a cohort that
might be expected to experience relatively minimal effects of PTSD on
quality of life.
We begin by discussing the construct of quality of life in order to
provide a context for our review. Next we briefly summarize what is
known about quality of life and PTSD from studies of both civilians
and Veterans of prior wars, and examine findings on OEF/OIF
Veterans. Our review is based a multicomponent model of quality of
life (Gladis, Gosch, Dishuk, & Crits-Christoph, 1999) that has not
previously been used to organize the findings on PTSD and quality of
life. We end by discussing implications of the evidence for clinical
practice and research.
1. What is quality of life?
Quality of life is defined as physical, mental, and social well-being
(WorldHealthOrganization, 1948). Overthepast fewdecades,quality
of life has gained recognition as an important component of health
(e.g., Gladis et al., 1999; Kaplan, 2003; Katschnig, 2006). In contrast
with the traditional biomedical model, the outcomes model of
healthcare places value not only on increasing life expectancy (or
quantity of life), but also helping patients to feel better about the
quality of their lives (e.g., Kaplan, 2003; Patrick & Erickson, 1993).
There has been a similar rise in recognition of how mental
disorders can affect quality of life. Since 2000, there have been no
fewer than 6 reviews of quality of life in anxiety disorders
(Mendlowicz & Stein, 2000; Mogotsi,Kaminer, & Stein, 2000; Olatunji,
Cisler, & Tolin, 2007; Quilty, Van Amerigen, Mancini, Oakman, &
Farvolden, 2003; Schneier & Pantol, 2006; Seedat, Lochner, Vythilin-
gum, & Stein, 2006). The studies reviewed reveal the diversity of
measures that fall under the umbrella of the term “quality of life.”
Some studies included objective measures, such as work status and
income, while others assessed self-reported occupational or social
role functioning using measures such as the Medical Outcomes Survey
Short Form-36 (SF-36; Ware & Sherbourne, 1992) or the Sheehan
Disability Scale (Sheehan, 1983). Although the SF-36 and its various
versions are often referred to as measures of “health-related quality of
life,” the physical and mental component scales include indicators of
physical and mental health symptoms in addition to functional
measures. Still other studies have used purely subjective measures
of well-being or life satisfaction, such as the Quality of Life Inventory
(QOLI; Frisch, 1994) or the Satisfaction with Life Scale (SWLS; Diener,
Emmons, Larsen, & Griffin, 1985).
Despite the variety of ways in which quality of life has been
assessed and the lack of an agreed-upon definition, there is some
central component of quality of life (e.g., Gladis et al., 1999;
Mendlowicz & Stein, 2000; Mogotsi et al., 2000). Yet Katschnig
(2006) argues that although subjective measures may be necessary to
assess the quality of life among individuals with mental disorders,
these measures may not be sufficient. For instance, he points out that
relying solely on measures of well-being or life satisfaction runs the
risk of distortions due to temporary psychological states, such as
mood, or psychological conditions such as depression or mania which
may color the way an individual perceives his or her living conditions
and role functioning.
For the purposes of this paper, we adopt a broader conceptuali-
zation of quality of life, as described by Gladis et al. (1999), according
to which quality of life consists of social–material conditions,
functioning (role performance), and satisfaction (well-being)
(Table 1). Katschnig (2006), Mogotsi et al. (2000), and Mendlowicz
and Stein (2000) have put forth similar conceptualizations. This
approach captures the breadth of the concept as articulated the World
Health Organization (WHOQOL Group, 1996, p. 5): “individuals'
perception of their position in life in the context of the culture and the
value system in which they live and in relation to their goals,
expectations, standards and concerns.” For example, work-related
quality of life could be captured by employment status and earnings
(social–material conditions), job performance and absenteeism
P.P. Schnurr et al. / Clinical Psychology Review 29 (2009) 727–735
(functioning), and satisfaction with work. These constructs can be
measured using self-report; social–material conditions and functioning
also can be measured using objective records, and functioning also can
be observer-rated, as in a supervisor's rating of an employee's work
performance. This example illustrates the value of understanding
quality of life from these multiple perspectives. Regardless of the
method of measurement, no single measure or even single component
fully reflects all aspects of the construct.
2. The impact of PTSD on the three components of quality of life
and nonveterans. A recent meta-analysis of quality of life in anxiety
disorders (Olatunji et al., 2007) found large effect sizes for PTSD across
multiple domains. In order to examine the effects of PTSD on quality of
life in OEF/OIF Veterans, we searched the Published International
Literature on Traumatic Stress database (PILOTS), anelectronic index of
literature on traumatic stress that indexes articles using a controlled
vocabulary of descriptors (DE), using the following search: DE =
DE = ((quality of life) or (occupational functioning) or (interpersonal
interaction)). We also searched PSYCINFO and MEDLINE using the
following keywords: “OIF,” “OEF,” “Iraq,” “Afghanistan,” “posttraumatic
stress disorder,” “SF-36,” “quality of life,” “functioning,” “functional
impairment,” “well-being,” and “satisfaction.” Additionally, we con-
ducted an Internet search for information about homelessness and
unemployment in OEF/OIF Veterans.
In each section below, we first illustrate the findings on
nonveterans and on Veterans who served prior to OEF/OIF. We then
review the existing findings on the OEF/OIF cohort, which are
summarized in Table 2.
2.1. PTSD and social–material conditions
Although there have been relatively few studies of objective
indicators of quality of life in PTSD, the existing studies paint a
consistent, negative picture. Studies of Veterans who served before
OEF/OIF show that PTSD is related to increased likelihood of
unemployment (Magruder et al., 2004; Savoca & Rosenheck, 2000;
Smith, Schnurr, & Rosenheck, 2005; Zatzick, Weiss et al., 1997;
Zatzick, Marmar et al., 1997). For example, in a sample of over 5000
Veterans enrolled in Compensated Work Therapy (less than 3% of
whom served in Iraq or Afghanistan), PTSD was associated with
decreased amount and likelihood of work at the end of therapy
(Resnick & Rosenheck, 2008). PTSD also is related to homelessness. A
study of formerly homeless Veterans found that PTSD was associated
with an 85% greater risk of becoming homeless again (O'Connell,
Kasprow, & Rosenheck, 2008). In addition, PTSD is related to marital
instability. The National Vietnam Veterans Readjustment Study
(Jordan et al., 1992; Kulka et al., 1990) found that divorce rates
were elevated among male and female Vietnam Veterans with PTSD.
Riggs, Byrne, Weathers, and Litz (1998) found that couples in which
the male Vietnam Veteran had PTSD were more likely to be consider-
ing separation or divorce.
The effect of PTSD on social–material conditions is not limited to
Veterans, however. In a nationally representative sample of US adults,
a diagnosis of PTSD was associated with a 150% increase in the like-
lihood being unemployed (Kessler, 2000). Data from Australia (Taylor
& Sharpe, 2008) show that the prevalence of PTSD is much higher in
the homeless (41%) than in the Australian general population (1.5%).
In 3 out of 5 cases, onset of PTSD occurred before the first episode of
homelessness, which suggests that PTSD was part of the circum-
stances leading to homelessness. Also, having PTSD symptoms also
was associated with a higher likelihood of divorce or separation in a
nonveteran community sample (Amaya-Jackson et al., 1999).
2.1.1. Findings in OEF/OIF Veterans
As shown in Table 2, we found only two studies of social–material
conditions and PTSD in OEF/OIF Veterans. A recent report by the
Healthcare for Homeless Veterans Program (HCHV, 2008) found that
the percentage of program participants with OEF/OIF service
increased from 1.4% in 2005 to 3.5% in 2008. Program participants
with OEF/OIF service were more likely to have a diagnosis of PTSD
(43.1%) than non-OEF/OIF participants (8.0%). Rona et al. (2009)
found that UK Armed Forces personnel who served in Iraq or were
serving in the military during that time were more likely to have
discussed divorce with their spouse in the past year if they had PTSD
than if they did not.
It is reasonable to expect that evidence about the negative
association between PTSD on social–material conditions will increase
given findings on the effects of deployment in the OEF/OIF cohort. For
example, starting in 2006, the Current Population Study, conducted
for the Bureau of Labor Statistics, has collected information about the
employment status of OEF/OIF-era Veterans (those who have served
since September 2001) separately from Veterans of other eras. In
2006, OEF/OIF-era Veterans between the ages of 18 and 54 had a
higher rate of unemployment (6.5%) than nonveterans (4.7%)
(Walker, 2008). The trend has continued. In 2008, the Bureau of
Labor Statistics estimated that the unemployment rate among OEF/
OIF-era Veterans was 7.3%, as compared with the overall jobless rate
of 4.6% for Veterans of all eras, and 5.6% for non-veterans (Bureau of
Labor Statistics, 2008). In light of the problems with unemployment
among OEF/OIF Veterans, it is no surprise that the Advisory
Committee on Homeless Veterans (2007, 2008) has noted an increase
in the numbers of OEF/OIF Veterans who are at risk for homelessness.
2.2. PTSD and functioning
There have been relatively more studies of how PTSD affects
functioning, which is often operationalized as self-reported difficul-
ties in role performance. PTSD is associated with problems across a
variety of domains, including social and interpersonal functioning
(e.g., Amaya-Jackson et al., 1999; Norman, Stein, & Davidson, 2007;
Stein et al., 1997), marital functioning (e.g., Dekel & Solomon, 2006;
Riggs et al., 1998), parental and family functioning (e.g., Cohen, Hien,
& Batchelder, 2008; Jordan et al., 1992), and occupational functioning
(e.g., Norman et al., 2007; Stein et al., 1997; Taylor, Wald, &
Asmundson, 2006). Some studies of occupational functioning in
nonveterans have operationalized functioning in more detail than
overall role performance. Stein, McQuaid, Pedrelli, Lenox, and McCa-
hill (2000) found that primary care patients with PTSD were more
likely to have missed work days or report reduced productivity due to
emotional problems relative to patients without an emotional
disorder. Similarly, Breslau, Lucia, and Davis (2004) found that PTSD
was associated with increased work loss and work cutback days.
Even individuals who do not meet full criteria for PTSD may
experience functional impairment (Breslau et al., 2004; Schnurr et al.,
2000; Stein et al., 1997). For example, using data from a community
The three components of quality of life.
SF-36 (Ware & Sherbourne, 1992)
Sheehan Disability Scale (Sheehan, 1983)
Quality of Life Inventory (Frisch, 1994)
Quality of Well-Being Scale
(Diener et al., 1985)
Note. For more details about the three components of quality of life, see Gladis et al.
P.P. Schnurr et al. / Clinical Psychology Review 29 (2009) 727–735
Summary of findings on quality of life in OEF/OIF Veterans.
Social–material conditions FunctioningSatisfaction
Engelhard et al. (2007)Relative to noncases, PTSD cases had more functional impairment at work,
home, or in interpersonal relationships
Erbes et al. (2007) Relative to noncases, PTSD cases reported more role limitations due to
physical and emotional problems, and poorer social functioning
Healthcare for Homeless Veterans (2008)Higher rates of PTSD in homeless OEF/OIF
Veterans than non-OEF/OIF Veterans
Hoge et al. (2007)PTSD cases more likely than noncases to have more sick calls or to have
missed work days in the past month
Hoge et al. (2008)PTSD and major depression mediated the relationship between missed
work days due to illness and mild TBI
Jakupcak et al. (2008)Higher PTSD symptoms associated with poorer physical function and role
functioning due to physical problems
Lapierre et al. (2007)Higher PTSD symptoms associated with lower
Nelson Goff et al. (2007) Higher PTSD symptoms associated with poorer relationship functioning
Ouimette et al. (2008) Higher PTSD symptoms associated with poorer mental (psychosocial) but
not physical functioning
Pietrzak et al. (in press)Higher PTSD symptoms associated with more psychosocial difficulties
Renshaw et al. (2008, 2009)Higher PTSD symptoms associated with lower
Rona et al. (2009)PTSD cases more likely than noncases to
have discussed divorce
PTSD caseness and higher PTSD symptoms associated with more social and
PTSD cases less satisfied than noncases with
Sayers et al. (2009)PTSD cases more likely than noncases to have at least one role-related
family adjustment problem
Vasterling et al. (2008) Higher PTSD symptoms associated with poorer physical function
P.P. Schnurr et al. / Clinical Psychology Review 29 (2009) 727–735
sample, Stein et al. (1997) found that full and partial PTSD groups had
significantly higher social and work impairment than a group of indi-
viduals who had trauma exposure only. Work or school impairment
was higher for the full PTSD group than the partial group, but the
groups did not differ in impairments in home and social functioning.
Researchers have begun to examine how PTSD symptoms or
symptom clusters affect different aspects of functioning. The
avoidance/numbing cluster, and in particular, emotional numbing
symptoms, are uniquely associated with reduced psychosocial
functioning (e.g., Riggs et al., 1998; Samper, Taft, King, & King,
2004; Tayloret al.,2006). Asuggestedexplanation forthese findingsis
that emotional numbing leads to withdrawal and difficulties expres-
sing emotion (Riggs et al., 1998; Samper et al., 2004). Some data
indicate that other symptom clusters are important as well (Norman
et al., 2007; Taylor et al., 2006), and Kuhn et al. (2003) found that
effects of different clusters varied according to sample characteristics;
hyperarousal symptoms were uniquely associated with poorer role
functioning in a treatment-seeking sample of accident survivors, but
avoidance and numbing were uniquely predictive in survivors with
lower PTSD severity.
2.2.1. Studies in OEF/OIF Veterans
In contrast with the few studies of objective indicators of quality of
life in OEF/OIF Veterans, there have been more studies of functioning
(see Table 2). All have found that PTSD is related to lower functioning.
Rona et al. (2009) found that work functioning (accomplishing less,
limited in type of work, and difficulty performing work) was more
impaired for UK Iraq War Veterans and Iraq-era Veterans with PTSD
than for those without PTSD; additionally, the odds of impairment
increased with symptom severity. Symptoms of avoidance and
numbing, followed by hyperarousal symptoms, were most strongly
and consistently associated with work impairment. Two studies
investigated productivity and absenteeism. Three to four months
post-deployment, OIF Veterans who had experienced an injury with
loss of consciousness were also more likely to have more than 2
missed workdays due to illness than those with other injuries, but
PTSD and depression mediated the relationship between injury and
work loss (Hoge et al., 2008). Such effects can persist. A year following
their return from Iraq, combat Veterans with PTSD had higher rates of
sick call visits, and were more likely to have missed two or more work
days in the past month, even when the effects of physical injury were
taken into account (Hoge, Terhakopian, Castro, Messer, & Engel,
A study of Dutch soldiers who served in Iraq found higher levels of
self-reported impairment in work, home, or interpersonal relation-
ships for those with PTSD than for those who did not have PTSD
(Engelhard et al., 2007). In a sample from the UK Armed Forces, 71% of
personnel with PTSD, versus only 15% of personnel without PTSD,
reported at least moderate impairment in social activities due to
physical or emotional problems (Rona et al., 2009). The odds of high
impairment were almost 4 times greater for those with high PTSD
severity relative to those with lower severity. Sayers, Farrow, Ross,
and Oslin (2009) found PTSD was associated with a higher likelihood
of impairment in family functioning in a sample of OEF/OIF Veterans.
Veteranswhoscreened positiveforPTSDwere morelikelyto have one
or more role-related family readjustment problems (e.g., feeling like a
guest at home, being unsure or having conflict about family
responsibilities). Two of these studies specifically examined the
effects of PTSD symptom clusters (Rona et al., 2009; Sayers et al.,
2009), finding that avoidance and numbing had the strongest
relationship with impaired functioning.
Two studies examined the relationship between functioning and
PTSD symptom severity (rather than PTSD diagnosis). Pietrzak et al.
(in press) found that severity was associated with psychosocial
difficulties at home, work, and school in a survey of Veterans who
served in the Connecticut National Guard. In a small sample of US
Soldiers, higher PTSD severity was correlated with poorer relationship
functioning (Nelson Goff, Crow, Reisbig, & Hamilton, 2007).
Several studies used the SF-36 to measure functioning. Erbes,
Westermeyer, Engdahl, and Johnsen (2007) studied OIF/OEF Veterans
approximately 6 months after return from deployment. Relative to
Veterans without PTSD, those with PTSD had poorer role functioning
due to emotional problems, rolefunctioningdue to physicalproblems,
and social functioning. When Erbes et al. controlled for symptoms of
depression, only social functioning was significantly lower in the
Veterans with PTSD. This suggests that depression mediated the
relationship between PTSD and role functioning. Ouimette et al.
(2008), in a small pilot study of National Guard Veterans, found that
PTSD severity was associated with lower scores on the mental
component, which taps psychosocial function but also includes
mental health symptoms; PTSD was not correlated with the physical
component score. Two other studies used the SF-36 to examine how
PTSD relates to physical functioning only. Vasterling et al. (2008)
found small but significant correlations between PTSD and physical
component scores both before and after deployment in a non-
treatment-seeking sample of OIF Soldiers. Jakupcak, Luterek, Hunt,
Conybeare, and McFall (2008) also found that PTSD symptom severity
was related to poorer physical function and role functioning due to
physical problems in a treatment-seeking sample that consisted
mostly of OEF/OIF Veterans who had served in the Army Reservists or
2.3. PTSD and satisfaction
PTSD is associated with lower life satisfaction and well-being (e.g.,
Gudmundsdottir, Beck, Coffey, Miller, & Palyo, 2004; Jordan et al.,
1992). One study found that almost 6 in 10 treatment-seeking
nonveterans with PTSD had clinically severe reductions in overall life
satisfaction, which was comparable to that of those with major
depression (Rapaport, Clary, Fayyad, & Endicott, 2005).
Studies that have examined satisfaction in specific domains show
thatPTSDis associatedwithlowersatisfactionwithrelationships (e.g.,
Gold et al., 2007; Koenen, Stellman, Sommer, & Stellman, 2008) and
parenting(e.g.,Gold etal., 2007; Ruscio,Weathers, King, & King, 2002;
Samper et al., 2004), for example. However, the effects of PTSD are
even broader. Rapaport et al. (2005) found that PTSD, like depression,
was related to a more general pattern of lower satisfaction with
multiple domains. A crosscultural validation study of a Swedish
versionofthe QOLI(Frisch, 1994), comparingcrime victimswithPTSD
to gender- and age-matched controls, found that the PTSD group had
lower importance-weighted satisfaction with 13 of the 16 items (all
except helping, relationships with children, and home) (Paunovic &
Findings on how PTSD symptom clusters are related to life satis-
faction show a somewhatclearer pattern than the findings on howthe
clusters relate to functioning. Reexperiencing seems unrelated, or less
strongly related, than the other symptoms, to satisfaction; avoidance
and numbing seem most strongly related (Lunney & Schnurr, 2007;
Paunovic & Öst, 2004; Ruscio et al., 2002; Samper et al., 2004; Schnurr
& Lunney, 2008). In the one exception to this pattern, Berz, Taft,
Watkins, and Monson (2008) found that although avoidance/numb-
ing and hyperarousal symptoms were correlated with lower parent-
ing satisfaction in female Vietnam Veterans, only hyperarousal had a
2.3.1. Findings in OEF/OIF Veterans
To our knowledge, there has been only a single published study of
overall life satisfaction in OEF/OIF Veterans (see Table 2). Lapierre,
Schwegler, and LaBauve (2007) assessed PTSD symptoms and life
satisfaction in a large sample of OEF/OIF Veterans who were parti-
cipating in a reintegration training program. Veterans with clinically
significant PTSD symptoms had lower life satisfaction, as measured by
P.P. Schnurr et al. / Clinical Psychology Review 29 (2009) 727–735
the Satisfaction With Life Scale (Diener et al., 1985). The symptomatic
group had average satisfaction scores that were at or slightly below
the midpoint of the scale, whereas a nonsymptomatic group had
average scores that were similar to those found in normative samples.
Both symptoms of depression and symptoms of PTSD were negatively
correlated with satisfaction.
Table 2 also show that marital function is the only specific domain
of life satisfaction that has been investigated in OEF/OIF Veterans.
Rona et al. (2009) found that UK Iraq war and era Veterans with PTSD
were less satisfied with their marriages than those without PTSD.
Renshaw, Rodrigues, and Jones (2008, 2009) found that marital
distress was relatively low in a group of National Guard Soldiers
(14%), similar to that of community samples. However, Soldiers'
marital satisfaction was negatively correlated with PTSD symptoms.
2.4. Longitudinal associations between PTSD and quality of life
One implication of the association between PTSD and quality of life
is that changes in one domain would result in corresponding changes
in the other. There is ample evidence from longitudinal studies
showing that PTSD (or acute stress disorder in samples assessed
within 30 days of traumatic exposure) predicts poor quality of life at
some later date (e.g., Golden-Kreuz et al., 2005; Koenen et al., 2008;
Solomon & Mikulincer, 2007). We identified only one such study in
OEF/OIF Veterans. Vasterling et al. (2008) examined PTSD and
physical function before and after deployment in a group of OIF
soldiers. Higher predeployment PTSD severity was correlated with
lower postdeployment physical functioning, but lower predeploy-
ment physical functioning also was correlated with higher post-
deployment PTSD severity. The correlations were almost identical:
r=−.12 versus r=−.13, respectively.
Although most longitudinal studies have used measures of total
PTSD severity, two studies examined how change in specific types of
symptoms relates to change in quality of life. Taylor et al. (2006)
found differential patterns of relationships between decreases in
symptoms and improvements in functioning. Decreased reexperien-
cing was related to improved occupational, social, and family
functioning. Avoidance was related only to social functioning, and
numbing and hyperarousal were related only to occupational
functioning. There also were differential patterns of relationships for
depression and PTSD, which suggests that the effects of PTSD on
functioning are not merely due to comorbid depression. Lunney and
Schnurr (2007) examined how change in PTSD symptom clusters was
related to change in satisfaction with domains of quality of life on the
QOLI (Frisch, 1994): achievement (e.g., work, money), self-expression
(e.g., play, creativity), relationships (e.g., friends, family), and
surroundings (e.g., neighborhood, home). Improvements in each
cluster were related to improvements in all domains, except change in
avoidance was unrelated to change in surroundings. However, only
numbing had unique effects on each domain.
Most of the evidence on temporal relationships between PTSD and
quality of life is grounded in a conceptualization in which impaired
quality of life is a consequence of PTSD, but both directions are
plausible and likely, as illustrated in the study by Vasterling et al.
(2008). Consider the case of an individual who develops PTSD and
then has difficulty at work due to irritability and impaired
concentration. Conflicts with supervisors and colleagues and poor
work performance could then result in the individual being
reprimanded or even being fired, and the stress of job loss and
economic difficulties could in turn exacerbate PTSD symptoms.
Two studies investigated how symptoms and quality of life
interact over time. Schnurr et al. (2006) examined synchronous and
lagged effects of change in PTSD symptoms on change in psychosocial
and physical health-related quality of life, using data from the clinical
trial for male Vietnam veterans mentioned above (Schnurr et al.,
2003). Synchronouseffectswere defined asoccurringwithinthe same
time period. Lagged effects were defined as change from one period to
a subsequent period. As symptoms improved, so did quality of life, but
the effects were synchronous and not lagged, with one exception.
Change in physical quality of life from 0 to 7 months predicted change
in PTSD symptoms from 7 to 12 months (beyond the change
explained by change in quality of life from 0 to 7 months). Ramchand,
Marshall, Schell, and Jaycox (2008) examined the relationship
between PTSD and physical health-related quality of life in injured
survivors of community violence who were assessed within 1 week of
injury, and then 3 and 12 months later. The direction of the
relationship between symptoms and quality of life changed over
time. Higher PTSD symptoms at 1 week predicted lower quality of life
at 3 months, but symptoms at 3 months did not predict quality of life
at 12 months. In contrast, quality of life (retrospectively-rated) prior
to injury did not predict PTSD symptoms at 3 months, but lower
quality of life at 3 months predicted higher symptoms at 12 months.
There have been relatively few studies of PTSD and quality of life in
OIF/OEF Veterans, especially of social–material conditions and life
satisfaction. Only two studies (Rona et al., 2009; Sayers et al., 2009),
both on functioning, examined whether there are differential patterns
of relationships between the symptom clusters of PTSD and quality of
life. Furthermore, there have been very few attempts to disentangle
the effects of PTSD from the effects of depression and other
comorbidities, and only one study that examined the longitudinal
association between PTSD and quality of life (Vasterling et al., 2008).
Nevertheless, the findings in this cohort mirror the findings obtained
from studies of civilians and other military cohorts. PTSD is associated
withreducedqualityoflife in OEF/OIFVeterans—despitetherelatively
new onset of PTSD due to deployment in Iraq or Afghanistan and
efforts by VA and DoD to identify and treat PTSD in returnees.
3. Clinical implications for treating OEF/OIF Veterans
The growing evidence showing that PTSD is related to impaired
quality of life in OEF/OIF Veterans has implications for clinical
practice. One question is whether treating PTSD can improve quality
of life. There have been no randomized clinical trials of treatment in
OEF/OIF Veterans, but evidence from other cohorts supports this
assumption. With few exceptions (Glynn et al., 1999; Schnurr et al.,
2003), studies have shown that both psychotherapy (e.g., Cloitre,
Koenen, Cohen, & Han, 2002; Ehlers et al., 2003; Foa et al., 2005) and
pharmacotherapy (e.g., Brady et al., 2000; Davidson et al., 2006;
Rapaport, Endicott, & Clary, 2002) can improve psychosocial quality of
life. Several studies have included measures of both psychosocial and
physical health-related quality of life; one found that treatment
improved psychosocial but not physical functioning (Malik et al.,
1999), another found the opposite (Mueser et al., 2008), and one
found no effect on either domain (Schnurr et al., 2003).
Another question concerns the effectiveness of interventions for
psychosocial and occupational problems in PTSD patients. There have
been few investigations of this question in any cohort, and the
evidence is inconclusive. Rosenheck, Stolar,and Fontana (2000) found
that Compensated Work Therapy not only improved employment
outcomes symptomsin a sample of Veterans with chronic war-related
PTSD, but also resulted in a reduction in PTSD symptoms. However,
these improvements did not differ from improvements in a
(propensity-score) matched sample receiving standard treatment
for PTSD. It may be especially difficult to address work-related
problems in Veterans with chronic PTSD. Resnick and Rosenheck
(2008) reported that Veterans with PTSD were 19% less likely than
other Veterans to work after receiving Compensated Work Therapy,
and that Vietnam Veterans with PTSD were even less likely to work.
Yet it is important to keep in mind that these results may not
P.P. Schnurr et al. / Clinical Psychology Review 29 (2009) 727–735
generalize to OEF/OIF Veterans, first of all, because their PTSD is so
much more recent, and second, because older Guard and Reserve
troops typically had long-established work histories before deploying.
This does not mean that these individuals can simply resume their
jobs—PTSD can cause difficulties even for previously successful men
and women—but it does at least indicate that there is a history of skill
and competence that a clinician can build upon in treatment.
Two treatment studies targeted relationship problems in PTSD
patients. Glynn and colleagues (1999) examined whether adding
Behavioral Family Therapy could enhance the effectiveness of
exposure therapy. Unfortunately, although Veterans who received
either exposure alone or exposure with family therapy had better
PTSD outcomes than Veterans assigned to a waiting list, none of the 3
groups differed in social adjustment after treatment, and in fact, did
not even improve from baseline levels. Monson, Stevens, and Schnurr
(2004) reported more encouraging results in an open trial of PTSD
treatment presented in couple's format, Cognitive-Behavioral Con-
joint Therapy. After treatment, Veterans had improved family and
couples functioning, although social functioning did not improve.
Monson, Fredman, and Adair (2008) illustrated the treatment in a
case presentation of a male OEF/OIF Veteran that highlights the issues
likely to be encountered when treating these Veterans. One is that
many tend to be married or living with a significant other and also
tend tohave children,whichmeans thatcliniciansare likely to needto
address family and interpersonal functioning problems.
Another question is how to use the evidence on PTSD and quality
of life to formulate a treatment plan. Careful psychosocial assessment
can provide a basis for determining the patient's needs and how to
addressthoseneeds in lightof thepatient's strengthsandweaknesses.
For many patients, adequately treating their PTSD symptoms may be
sufficient to resolve their functional problems. In patients for whom
functional difficulties are especially prominent, additional interven-
tion focused on these problems should be considered jointly with, or
after an adequate course of, treatment for PTSD. Family or couples
therapy may be indicated; at the very least, clinicians should consider
including family members in care to enhance the Veteran's function-
ing or to prevent future functional difficulties. When treating
functional problems in OEF/OIF Veterans, it is necessary to consider
the possible presence of traumatic brain injury (TBI). Depending upon
level of severity, TBI may be associated with difficulties that could
further impair functioning in individuals with PTSD. Clinicians may
need to work with a team that includes rehabilitation specialists,
social workers, and others and ensure that PTSD treatment is
delivered in coordination with the services delivered by these
professionals. Another potentially important clinical consideration is
that some returning Veterans may be redeployed to Iraq or
Afghanistan. The clinician may need to address the stress and tension
that such circumstances can create in relation to employment status
and interpersonal relationships.
4. Knowledge gaps
There is a need for more research on the relationship between
PTSD and quality of life in OEF/OIF Veterans. Most studies of quality of
life in this cohort have focused on functioning, so there is a particular
need for investigations of how PTSD relates to social–material
conditions and life satisfaction. Other priorities are longitudinal
studies and clinical trials to determine whether PTSD treatment
improves quality of life.
Population surveys can help us understand the breadth of the
impact of PTSD on quality of life (i.e., how many Veterans with PTSD
report moderate impairments in quality of life). Studies of treatment-
seeking samples or at-risk groups may give us a better sense of the
depth oftheproblem.Althoughtherehave beenseveralinvestigations
of risk and resilience factors associated with PTSD in OEF/OIF Veterans
(e.g., Iverson et al., 2008; Riddle, Sanders, Jones, & Webb, 2008), it is
not known whether the predictors of risk and resilience for quality of
life impairment the same as those for PTSD itself.
Given the demographic differences between OEF/OIF Veterans
relative to other conflicts in terms of gender, ethnicity, age, and
proportion of National Guard/Reservists, there is a unique opportu-
nity to examine how PTSD relates to quality of life in these different
subgroups of Veterans. For example, most of the research on OEF/OIF
Veterans up to this point has been focused on men; the possibility of
gender differences in the impact of PTSD on quality of life deserves
further investigation. Some past research has suggested that the effect
of PTSD on quality of life may be stronger for male than for female
Veterans (e.g., Zatzick, Marmar et al., 1997; Zatzick, Weiss et al., 1997)
but other research suggest no difference between male and female
Veterans (e.g., Magruder et al., 2004; Schnurr & Lunney, 2008).
More research is needed to understand how the unique pre-,
during, and post-deployment experiences affect the relationship
between PTSD and quality of life in National Guard and Reservists,
who are at elevated risk of negative outcomes (e.g., Browne et al.,
2007; Rundell, 2006). Upon return from deployment, National Guard
and Reservists must readjust to their civilian roles and responsibil-
ities, which may cause adjustment difficulties (Renshaw et al., 2009).
It also may be more difficult for National Guard and Reservists to
access VA or installation-based support programs and behavioral
health care (APA Presidential Task Force on Military Deployment
Services for Youth, Families and Service Members, 2007).
PTSD and depression are highly comorbid in OEF/OIF Veterans
(e.g., Grieger et al., 2006; Lapierre et al., 2007; Tanelian & Jaycox,
2008), and depression also can have negative effects on quality of life
(e.g., Rapaport et al., 2005). Untangling the unique effects of PTSD is
further complicated by the overlap in symptoms between the two
disorders. Some studies have found that the effect of PTSD is on
aspects of functioning is mediated by depression (Erbes et al., 2007;
Gudmundsdottir et al., 2004). Understanding the shared and unique
impacts of these two disorders on quality of life has important
implications for treatment planning.
There are assessment and methodological issues to consider if we
regard quality of life as an important outcome in understanding how
PTSD affects the lives of OEF/OIF Veterans. First, some instruments
used to assess quality of life, including the widely-used component
scales from the SF-36, also include measures of symptoms. Such
measures blur the distinction between a problem such as PTSD and its
relationship with quality of life. Second, it is important to look at the
impact of PTSD (and treatment of PTSD) on all three components of
quality of life (objective life circumstances, role functioning, and
subjective life satisfaction); few studies have assessed more than one
of the three components. Katschnig (2006) points out that the
different components of quality of life may have different rates of
change. In their modelof theconsequences of postdeployment mental
health, Karney et al. (2008) propose that resources and vulnerabilities
can influence the short-term effects of mental health conditions such
as PTSD. These short-term effects may in turn lead to negative long-
term outcomes. A similar framework could apply to quality of life
outcomes, as each component may interact mutually over time.
Quality of life indices might function as predisposing risk or resilience
factors, or as short- or long-term consequences of PTSD. For example,
being married might function as a resilience factor by buffering the
effects of warzone deployment, but PTSD might lead to poor
relationship functioning, and ultimately, to divorce. Finally, including
assessments of each component from multiple perspectives (e.g.,
spouses, co-workers) addresses not only the potential “psychopath-
ological fallacies” of relying solely on subjective satisfaction (Katsch-
nig, 2006), but also gives a broader picture of the indirect effect that
PTSD has on others.
Although many important research questions can be answered
with cross-sectional designs, there is a need for longitudinal research
to help us understand the dynamic interplay between PTSD and
P.P. Schnurr et al. / Clinical Psychology Review 29 (2009) 727–735
quality of life over time. This information is important to advance
scientific understanding and to support treatment. We need more
conclusive knowledge about how components of quality of life
respond to PTSD treatment and how to optimize treatment to ensure
that it results in improved quality of life. We also need to know how
treatment focused specifically on quality of life, such as work therapy
or couples therapy, affects PTSD.
Our review indicates that the findings on PTSD and quality of life in
OEF/OIF Veterans are comparable with findings obtained from other
war cohorts and from nonveterans. This literature on is at an early
stage, but the consistency of the evidence is striking. Even though the
duration of PTSD in OEF/OIF Veterans is much shorter than in Vietnam
Veterans, for example, those with PTSD in both cohorts are likely to
experience poorer functioning and lower objective living conditions
However, the similarity of findings on PTSD and quality of life
across cohorts and samples obscures an important consideration.
Because PTSD onset in many OEF/OIF Veterans has been relatively
recent, it may be possible to reverse or even prevent a downward
spiral of interaction between poor quality of life and PTSD by effec-
tively treating PTSD. But improved quality of life should be prioritized
Gladis et al. (1999) posed an important question: “Should clinicians
and their patients feel that the job is not done (or not done well) if
symptoms are alleviated but other areas of the patient's life are not
fully satisfying?” (p. 328). This question should guide the approach to
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