A Meta-Analysis of Risk Factors for Combat-Related PTSD among Military Personnel and Veterans

Post-traumatic stress disorder (PTSD), a complex and chronic disorder caused by exposure to a traumatic event, is a common psychological result of current military operations. It causes substantial distress and interferes with personal and social functioning. Consequently, identifying the risk factors that make military personnel and veterans more likely to experience PTSD is of academic, clinical, and social importance. Four electronic databases (PubMed, Embase, Web of Science, and PsycINFO) were used to search for observational studies (cross-sectional, retrospective, and cohort studies) about PTSD after deployment to combat areas. The literature search, study selection, and data extraction were conducted by two of the authors independently. Thirty-two articles were included in this study. Summary estimates were obtained using random-effects models. Subgroup analyses, sensitivity analyses, and publication bias tests were performed. The prevalence of combat-related PTSD ranged from 1.09% to 34.84%. A total of 18 significant predictors of PTSD among military personnel and veterans were found. Risk factors stemming from before the trauma include female gender, ethnic minority status, low education, non-officer ranks, army service, combat specialization, high numbers of deployments, longer cumulative length of deployments, more adverse life events, prior trauma exposure, and prior psychological problems. Various aspects of the trauma period also constituted risk factors. These include increased combat exposure, discharging a weapon, witnessing someone being wounded or killed, severe trauma, and deployment-related stressors. Lastly, lack of post-deployment support during the post-trauma period also increased the risk of PTSD. The current analysis provides evidence of risk factors for combat-related PTSD in military personnel and veterans. More research is needed to determine how these variables interact and how to best protect against susceptibility to PTSD.     

Mortality experience of US veterans following service as international peacekeepers in Bosnia/Kosovo theater, 1996–2002

BackgroundBeginning in 1996 US military personnel served as peacekeeping forces in Bosnia/Kosovo. No studies have assessed the long-term post-deployment health of this US cohort. Based on the health concerns raised in studies of military personnel from other countries, this study focused on mortality due to Leukemia, respiratory disease, respiratory cancer, and heart disease.MethodsThis study compared the post-war cause-specific mortality of 53,320 veterans who deployed to Bosnia/Kosovo between 1996–2002 to that of 117,267 veterans who also served in the military between 1996–2002, but were not deployed to Bosnia/Kosovo. Expressed as standardized mortality ratios (SMR)s the cause-specific mortality for both deployed and non-deployed were compared separately to that of the US general population. Cause-specific mortality risks among Bosnia/Kosovo veterans relative to that of non-deployed veterans were assessed using Hazard Ratios (HR)s generated by Cox proportional-hazards models.ResultsThe overall mortality of both deployed and non-deployed veterans was almost half that of the US population, SMR = 0.59, 95%, C.I., 0.55–0.62 and SMR = 0.66, 95%, C.I., 0.64–0.68, respectively. Neither group of veterans had any excess of disease related mortality compared to that of the US population. Compared to non-deployed, deployed veterans did not experience any increased risks for any of the diseases of a priori interest.ConclusionIt does not appear that US military deployed to Bosnia/Kosovo have any increased risks of disease related mortality. However, this study would not have been able to detect increased risk of cancers with latency periods that exceeded the 18 years of follow-up available in this study.     

The effect of combat exposure on sexually transmitted diseases

Traumatic exposures can affect beliefs and behaviors related to the spread of sexually transmitted diseases (STDs), a persistent public health problem. I leverage a natural experiment created by variation in US military deployment location assignments to estimate how combat exposure changes a surviving deployed male veteran’s probability of acquiring a sexually transmitted disease. I analyze longitudinal data from 1994 to 2008 on 485 deployed veterans with information theoretic methods to reduce the sensitivity of estimates to small samples, an infrequently observed outcome, and highly correlated covariates. For veterans assigned to a combat zone, I estimate combat exposure results in a 5.4 percentage point increase in the probability of acquiring an STD. Additional estimations provide evidence suggesting risky behaviors involving substance use or multiple sexual partners may serve as pathways from combat exposure to STDs. My results are relevant to discussions regarding STD screening and care needs for trauma exposed individuals.     

Mental Health Status of Sri Lanka Navy Personnel Three Years after End of Combat Operations: A Follow Up Study

The main aim of this study was to assess the mental health status of the Navy Special Forces and regular forces three and a half years after the end of combat operations in mid 2009, and compare it with the findings in 2009. This cross sectional study was carried out in the Sri Lanka Navy (SLN), three and a half years after the end of combat operations. Representative samples of SLN Special Forces and regular forces deployed in combat areas were selected using simple random sampling. Only personnel who had served continuously in combat areas during the one year period prior to the end of combat operations were included in the study. The sample consisted of 220 Special Forces and 275 regular forces personnel. Compared to regular forces a significantly higher number of Special Forces personnel had experienced potentially traumatic events. Compared to the period immediately after end of combat operations, in the Special Forces, prevalence of psychological distress and fatigue showed a marginal increase while hazardous drinking and multiple physical symptoms showed a marginal decrease. In the regular forces, the prevalence of psychological distress, fatigue and multiple somatic symptoms declined and prevalence of hazardous drinking increased from 16.5% to 25.7%. During the same period prevalence of smoking doubled in both Special Forces and regular forces. Prevalence of PTSD reduced from 1.9% in Special Forces to 0.9% and in the regular forces from 2.07% to 1.1%. Three and a half years after the end of combat operations mental health problems have declined among SLN regular forces while there was no significant change among Special Forces. Hazardous drinking among regular forces and smoking among both Special Forces and regular forces have increased.     

Residential Treatment for Combat-Related Posttraumatic Stress Disorder: Identifying Trajectories of Change and Predictors of Treatment Response

Background

Combat-related posttraumatic stress disorder (PTSD) can be a difficult condition to treat and has been associated with serious medical and economic issues among U.S. military veterans. Distinguishing between treatment responders vs. non-responders in this population has become an important public health priority. This study was conducted to identify pre-treatment characteristics of U.S. veterans with combat-related PTSD that might contribute to favorable and unfavorable responses to high value treatments for this condition.

Method

This study focused on 805 patients who completed a VHA PTSD residential program between 2000 and 2007. These patients completed the PTSD Clinical Checklist at pre-treatment, post-treatment, and a four-month follow-up assessment. Latent growth curve analysis (LCGA) was incorporated to determine trajectories of changes in PTSD across these assessments and whether several key clinical concerns for this population were associated with their treatment responses.

Study Findings

LCGA indicated three distinct trajectories in PTSD outcomes and identified several clinical factors that were prospectively linked with changes in veterans'' posttraumatic symptomatology. When compared to a group with high PTSD symptom severity that decreased over the program but relapsed at follow-up (41%), the near half (48.8%) of the sample with an improving trajectory had less combat exposure and superior physical/mental health. However, when compared to a minority (10.2%) with relatively low symptomatology that also remained somewhat stable, patients in the improving group were younger and also reported greater combat exposure, poorer physical/mental health status, and more problems with substance abuse before the start of treatment.

Conclusions

Findings suggest that veterans are most likely to benefit from residential treatment in an intermediate range of symptoms and risk factors, including PTSD symptom severity, history of combat exposure, and comorbid issues with physical/mental health. Addressing these factors in an integrative manner could help to optimize the effectiveness of treatments of combat-related PTSD in many cases.     

Social support and posttraumatic stress disorder in combat veterans in Croatia

Recent studies have shown that greater social support after combat stress is associated with better psychological posttraumatic outcomes. By comparison of a group of veterans (n = 71) who sought psychiatric help and were diagnosed with PTSD (clinical group) and a group of veterans (n = 43) without PTSD (control group) we examined various components of structural and functional social support in war veterans in Croatia. The measures of social support were assessed for two time periods: a) immediately after the war, and b) at the present time. Results of two-way analysis of variance indicate that veterans without PTSD tend to report significantly higher number of persons who provide them different forms of social support than veterans with PTSD. Perceived family and friends support is higher in veterans without PTSD than in veterans with PTSD. Support received from friends and fellow soldiers decreases over time in both groups, whereas for the clinical group support of friends decreases significantly more.     

New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study

Objective To describe new onset and persistence of self reported post-traumatic stress disorder symptoms in a large population based military cohort, many of whom were deployed in support of the wars in Iraq and Afghanistan.Design Prospective cohort analysis.Setting and participants Survey enrolment data from the millennium cohort (July 2001 to June 2003) obtained before the wars in Iraq and Afghanistan. Follow-up (June 2004 to February 2006) data on health outcomes collected from 50 184 participants.Main outcome measures Self reported post-traumatic stress disorder as measured by the posttraumatic stress disorder checklist—civilian version using Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria.Results More than 40% of the cohort were deployed between 2001 and 2006; between baseline and follow-up, 24% deployed for the first time in support of the wars in Iraq and Afghanistan. New incidence rates of 10-13 cases of post-traumatic stress disorder per 1000 person years occurred in the millennium cohort. New onset self reported post-traumatic stress disorder symptoms or diagnosis were identified in 7.6-8.7% of deployers who reported combat exposures, 1.4-2.1% of deployers who did not report combat exposures, and 2.3-3.0% of non-deployers. Among those with self reported symptoms of post-traumatic stress disorder at baseline, deployment did not affect persistence of symptoms.Conclusions After adjustment for baseline characteristics, these prospective data indicate a threefold increase in new onset self reported post-traumatic stress disorder symptoms or diagnosis among deployed military personnel who reported combat exposures. The findings define the importance of post-traumatic stress disorder in this population and emphasise that specific combat exposures, rather than deployment itself, significantly affect the onset of symptoms of post-traumatic stress disorder after deployment.     

The economics of clinical genetics services. II. A time analysis of a medical genetics clinic.

In a time-and-reimbursement analysis of our clinical genetics service, we documented (1) the time spent by professionals and staff in serving families before, during, and after the clinic visit; (2) the charges and reimbursement for the services provided; and (3) the relationship between income from clinical practice and the personnel costs of the clinic. We found that newly referred and returning families required 7.1 and 4.0 h, respectively. Average collections for professional services were +135 (+19/h) for new families and +49 (+12/h) for returning families. Income from clinical practice covered 37% of the clinical portion of personnel costs. These results indicate that cognitive clinical genetics services are labor intensive, yield low payments per service hour, and are not financially self-supporting. To improve the economic status of genetics clinics, administrators might consider rendering services more efficiently; increasing charges for services; billing for all services provided to all family members; billing for all genetics professionals, including counselors and social workers; and requesting payment at the time of service.     

A high risk twin study of combat-related PTSD comorbidity.

Combat-related posttraumatic stress disorder (PTSD) is highly comorbid with other mental disorders. However, the nature of the relationship between PTSD and other mental disorders remains unclear. A discordant high-risk twin design was used on data from a sub-sample of the male-male twin pair members of the Vietnam Era Twin Registry to examine whether patterns of comorbidity are consistent with a psychopathological response to combat exposure or reflect familial vulnerability to psychopathology. Mental disorders were assessed via the Mental Health Diagnostic Interview Schedule Version III - Revised. Discordant monozygotic within-pair comparisons revealed that PTSD probands had higher symptom counts and diagnostic prevalences of mood and anxiety disorders than their non-combat exposed co-twins. Monozygotic co-twins of PTSD probands had significantly more mood disorder symptoms than monozygotic co-twins of combat controls or dizygotic co-twins of veterans with PTSD. These findings suggest that a) major depression, generalized anxiety disorder and panic disorder are part of a post-combat response syndrome; b) a shared familial vulnerability also contributes to the association between PTSD and major depression, PTSD and dysthymia, and c) this shared vulnerability is mediated by genetic factors.     

Analysis of Post-Deployment Cognitive Performance and Symptom Recovery in U.S. Marines

Background

Computerized neurocognitive testing (NCAT) has been proposed to be useful as a screening tool for post-deployment cognitive deficits in the setting of mild traumatic brain injury (mTBI). We assessed the clinical utility of post-injury/post-deployment Automated Neurocognitive Assessment Metric (ANAM) testing, using a longitudinal design to compare baseline ANAM tests with two post-deployment ANAM tests in a group of Marines who experienced combat during deployment.

Methods and Findings

Post-deployment cognitive performance and symptom recovery were compared in a subsample of 1324 U.S. Marines with high rates of combat exposure during deployment. Of the sample, 169 Marines had available baseline and twice repeated post-deployment ANAM results. A retrospective analysis of the ANAM data, which consisted of a self-report questionnaire about deployment-related blast exposure, recent history of mTBI, current clinical symptoms, and cognitive performance. Self-reported concussion sustained anytime during deployment was associated with a decrease in cognitive performance measured between 2–8 weeks post-deployment. At the second post-deployment test conducted on average eight months later, performance on the second simple reaction time test, in particular, remained impaired and was the most consistent and sensitive indicator of the cognitive decrements. Additionally, post-concussive symptoms were shown to persist in injured Marines with a self-reported history of concussion for an additional five months after most cognitive deficits resolved. Results of this study showed a measurable deployment effect on cognitive performance, although this effect appears to resolve without lasting clinical sequelae in those without history of deployment-related concussion.

Conclusions

These results highlight the need for a detailed clinical examination for service members with history of concussion and persistent clinical symptoms. Reliance solely upon computerized neurocognitive testing as a method for identifying service members requiring clinical follow-up post-concussion is not recommended, as cognitive functioning only slowly returned to baseline levels in the setting of persistent clinical symptoms.     

Cancer incidence in Dutch Balkan veterans

Suspicion has been raised about an increased cancer risk among Balkan veterans because of alleged exposure to depleted uranium. The authors conducted a historical cohort study to examine cancer incidence among Dutch Balkan veterans. Male military personnel (n = 18,175, median follow-up 11 years) of the Army and Military Police who had been deployed to the Balkan region (1993–2001) was compared with their peers not deployed to the Balkans (n = 135,355, median follow-up 15 years) and with the general Dutch population of comparable age and sex. The incidence of all cancers and 4 main cancer subgroups was studied in the period 1993–2008. The cancer incidence rate among Balkan deployed military men was 17% lower than among non-Balkan deployed military men (hazard ratio 0.83 (95% confidence interval 0.69, 1.00)). For the 4 main cancer subgroups, hazard ratios were statistically non-significantly below 1. Also compared to the general population cancer rates were lower in Balkan deployed personnel (standardised incidence rate ratio (SIR) 0.85 (0.73, 0.99). The SIR for leukaemia was 0.63 (0.20, 1.46). The authors conclude that earlier suggestions of increased cancer risks among veterans are not supported by empirical data. The lower risk of cancer might be explained by the ‘healthy warrior effect’.     

Military Veterans and Service Dogs: A Qualitative Inquiry Using Interpretive Phenomenological Analysis

There are over 18.8 million veterans of the United States of America's Armed Forces. After military service veterans may find it difficult transitioning back to civilian life. Veterans reintegrating may experience physical and psychological challenges related to their military service. For many, a successful role change takes considerable time and determination. In order to ease their transition, veterans are using the assistance of service dogs to aid in symptom management and assist with positive reintegration into civilian life. Service dogs are highly trained animals that help individuals perform life tasks to assist with physical and psychological challenges. The purpose of this qualitative study was to give voice to the experiential viewpoints of veterans who utilize service dogs. Guided by the theoretically informed method of interpretation— interpretive phenomenological analysis (IPA)—the researchers uncovered the veterans’ perspectives, which provided meaningful insight into their lives with a service dog. Semi-structured interviews were conducted with veterans (n = 21) who utilized a service dog. The interviews lasted approximately one hour and were video or audio recorded. The most salient themes that emerged from the interviews were grouped into four superordinate themes: Procurement, psychosocial functioning, value, and detriments. Results suggest that service dogs improved veterans’ physical and psychological health, provided a coping resource and a form of social support, and supported sustaining their independence. Veterans’ right to privacy and the public's lack of knowledge and understanding of legal accommodation requirements via the Americans with Disabilities Act (ADA) were perceptible. Implications for policy, practice, and research, are discussed.     

Quality of life in families of Croatian veterans 15 years after the war

Exposure to war trauma with its consequences such as post traumatic stress disorder (PTSD) and disability due to combat injuries poses a significant problem for modern Croatian society. However, this is also a public health problem requiring continuous study of effective treatment strategies to achieve an increase in quality of life of most war-affected groups. Aim of this study was to examine the quality of life of population most affected by war - families of Croatian veterans. Present study included 126 female participants, who agreed to complete physical and psychiatric examination organized by the Ministry of Family, War Veterans and Intergenerational Solidarity. Included were participants with status of either wife of war veteran suffering from PTSD, wife who lost her husband in war circumstances or wife of war veteran with physical disabilities resulting from war activities. All three groups were asked to fill out the World Health Organization Quality of Life Questionnaire - short form (WHOQOL-BREF). Results indicate that assumed intensity of secondary trauma is not associated with quality of life. Namely, the highest level of satisfaction was found in wives of the most seriously affected invalids of war (M=3.77; sd=0.741), folowed by the wives of deceased soldiers (M=3.5; sd= 0.697), while the lowest quality of life results were found in wives of veterans suffering from PTSD (M=3.12; sd=0.608). Our results confirm that, nearly 15 years after the war, wives of disabled or killed Croatian soldiers have a (comparatively) satisfactory quality of their everyday lives, compared to the wives of veterans suffering from PTSD.     

Use of a Portable Biofeedback Device to Improve Insomnia in a Combat Zone,a Case Report

Insomnia is a common problem in situations of stress. Some forms of stress, however, may contraindicate the use of traditional, pharmacological interventions. Working in a combat zone is such a situation. Alternative means of improving sleep are clearly needed for Service Members. We report a case involving a medical provider who was serving in a military, emergency-services facility in Iraq, and who presented with anxiety, depressed mood, and insomnia. Symptoms were sub-threshold for major depressive disorder or acute stress disorder. Mood and anxiety symptoms responded to traditional therapy techniques, but problems with insomnia remained. The patient was given a portable biofeedback device that employs an infrared sensor photoplethysmograph to measure heart rate variability (HRV) from peripheral finger pulse. One week later, sleep was significantly improved. Symptom improvement lasted to at least 6 weeks while in theater. One year later, a check-in with the patient revealed that after returning home, he had been diagnosed with post traumatic stress disorder (PTSD). PTSD symptoms had resolved after 6 months of psychopharmacology and cognitive behavioral therapy. These results indicate that biofeedback may be a useful means of improving sleep in a combat zone, but that such improvements may not necessarily prevent the development of more serious symptoms later. No clear causality can be inferred from a single case, and further study is needed to determine if this finding have wider applicability.     

Hypodensity of platelet serotonin uptake sites in posttraumatic stress disorder: Associated clinical features

We have previously reported that binding to blood platelets of paroxetine, a selective serotonin (5-HT) reuptake inhibitor which binds to 5-HT uptake sites, is decreased in patients with posttraumatic stress disorder (PTSD). Specifically, we found a lower number of platelet ³H-paroxetine binding sites (B_max) and a lower dissociation constant (K_d) for ³H-paroxetine binding in combat veterans with PTSD compared to normal control subjects. In the current study we assessed the relationship of platelet ³H-paroxetine binding to clinical features in 41 Vietnam combat veterans with SCID-diagnosed PTSD. The results indicated that B_max of platelet ³H-paroxetine binding was negatively correlated with both state and trait anxiety, as well as with depressive and overall PTSD symptoms. However, there was no evidence that platelet ³H-paroxetine binding differed as a function of comorbid psychiatric diagnoses including major depression, other anxiety disorders and substance abuse in these patients.     

Managing future Gulf War Syndromes: international lessons and new models of care

After the 1991 Gulf War, veterans of the conflict from the United States, United Kingdom, Canada, Australia and other nations described chronic idiopathic symptoms that became popularly known as 'Gulf War Syndrome'. Nearly 15 years later, some 250 million dollars in United States medical research has failed to confirm a novel war-related syndrome and controversy over the existence and causes of idiopathic physical symptoms has persisted. Wartime exposures implicated as possible causes of subsequent symptoms include oil well fire smoke, infectious diseases, vaccines, chemical and biological warfare agents, depleted uranium munitions and post-traumatic stress disorder. Recent historical analyses have identified controversial idiopathic symptom syndromes associated with nearly every modern war, suggesting that war typically sets into motion interrelated physical, emotional and fiscal consequences for veterans and for society. We anticipate future controversial war syndromes and maintain that a population-based approach to care can mitigate their impact. This paper delineates essential features of the model, describes its public health and scientific underpinnings and details how several countries are trying to implement it. With troops returning from combat in Afghanistan, Iraq and elsewhere, the model is already getting put to the test.     

Effects of Pharmacotherapy on Combat-Related PTSD,Anxiety, and Depression: A Systematic Review and Meta-Regression Analysis

ObjectivesTo estimate the effect of pharmacotherapy on PTSD, anxiety, and depression among combat veterans; to determine whether the effects varied according to patient and intervention characteristics; and to examine differential effects of pharmacotherapy on outcomes.ResultsPharmacotherapy significantly reduced (Δ, 95%CI) PTSD (0.38, 0.23-0.52), anxiety (0.42, 0.30-0.54), and depressive symptoms (0.52, 0.35-0.70). The effects of SSRIs and tricyclic antidepressants on PTSD were greater than other medications independent of treatment duration. The effect of SSRIs and tricyclic antidepressants were greater than other medications up to 5.2 and 13.6 weeks for anxiety and depression, respectively. The magnitude of the effect of pharmacotherapy on concurrently-measured PTSD, anxiety, and depression did not significantly differ.ConclusionsPharmacotherapy reduced PTSD, anxiety, and depressive symptoms in combat veterans. The effects of SSRIs and tricyclic antidepressants were greater for PTSD and occurred quicker for anxiety and depression than other medications.     

A Systematic Review of PTSD Prevalence and Trajectories in DSM-5 Defined Trauma Exposed Populations: Intentional and Non-Intentional Traumatic Events

Objective

We conducted a systematic review of the literature to explore the longitudinal course of PTSD in DSM-5-defined trauma exposed populations to identify the course of illness and recovery for individuals and populations experiencing PTSD.

Methods

We reviewed the published literature from January 1, 1998 to December 31, 2010 for longitudinal studies of directly exposed trauma populations in order to: (1) review rates of PTSD in the first year after a traumatic event; (2) examine potential types of proposed DSM-5 direct trauma exposure (intentional and non-intentional); and (3) identify the clinical course of PTSD (early onset, later onset, chronicity, remission, and resilience). Of the 2537 identified articles, 58 articles representing 35 unique subject populations met the proposed DSM-5 criteria for experiencing a traumatic event, and assessed PTSD at two or more time points within 12 months of the traumatic event.

Results

The mean prevalence of PTSD across all studies decreases from 28.8% (range  = 3.1–87.5%) at 1 month to 17.0% (range  = 0.6–43.8%) at 12 months. However, when traumatic events are classified into intentional and non-intentional, the median prevalences trend down for the non-intentional trauma exposed populations, while the median prevalences in the intentional trauma category steadily increase from 11.8% to 23.3%. Across five studies with sufficient data, 37.1% of those exposed to intentional trauma develop PTSD. Among those with PTSD, about one third (34.8%) remit after 3 months. Nearly 40% of those with PTSD (39.1%) have a chronic course, and only a very small fraction (3.5%) of new PTSD cases appears after three months.

Conclusions

Understanding the trajectories of PTSD over time, and how it may vary by type of traumatic event (intentional vs. non-intentional) will assist public health planning and treatment.     

“Nudging Them Back to Reality”: Toward a Growing Public Acceptance of the Role Dogs Fulfill in Ameliorating Contemporary Veterans' PTSD Symptoms

ABSTRACT

There is a long history of service dog usage to assist people with physical disabilities (e. g., dogs for the blind, deaf, and disabled). In comparison, however, relatively little empirical research has been conducted into the use of service or emotional support dogs for people with psychiatric disabilities (e. g., PTSD, bipolar disorder, anxiety disorder and schizophrenia). Given this research shortfall, the present study sought to provide insights into the post-war dog ownership experiences of contemporary veterans from the Iraq and Afghanistan fields of engagement, particularly in relation to the differences adopted dogs have made to the veterans' readjustment back into society. In this regard, reporters' media accounts of the experiences of veterans with PTSD and the general public's social media response comments were subjected to a triangulated three-phase content analysis to explore the role dogs seemingly play in helping contemporary veterans to readjust to civilian life. The core theme to emerge from the study was one of: “‘Nudging them back to reality’: Toward a growing public acceptance of the role dogs fulfill in ameliorating contemporary veterans' PTSD symptoms.” In light of the difficulties of interpreting the accounts of veterans through the filter of media coverage and social commentary, this core finding may prove to provide insights into how contemporary veterans diagnosed with PTSD utilize the assistance of dogs to help deal with their fundamental human needs for safety, affiliation, and succourance. Finally, the difficulties associated with dogs as therapeutic agents are discussed.