Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq

CONTEXT

A growing body of literature has demonstrated the association of combat in Iraq and Afghanistan with postdeployment mental health problems, particularly posttraumatic stress disorder (PTSD) and depression. However, studies have shown varying prevalence rates of these disorders based on different case definitions and have not assessed functional impairment, alcohol misuse, or aggressive behavior as comorbid factors occurring with PTSD and depression.

OBJECTIVES

To (1) examine the prevalence rates of depression and PTSD using several case definitions including functional impairment, (2) determine the comorbidity of alcohol misuse or aggressive behaviors with depression or PTSD, and (3) compare rates between Active Component and National Guard soldiers at the 3- and 12-month time points following their deployment to Iraq.

DESIGN

Population-based, cross-sectional study.

SETTING

United States Army posts and National Guard armories.

PARTICIPANTS

A total of 18 305 US Army soldiers from 4 Active Component and 2 National Guard infantry brigade combat teams.

INTERVENTIONS

Between 2004 and 2007, anonymous mental health surveys were collected at 3 and 12 months following deployment.

MAIN OUTCOME MEASURES

Current PTSD, depression, functional impairment, alcohol misuse, and aggressive behavior.

RESULTS

Prevalence rates for PTSD or depression with serious functional impairment ranged between 8.5% and 14.0%, with some impairment between 23.2% and 31.1%. Alcohol misuse or aggressive behavior comorbidity was present in approximately half of the cases. Rates remained stable for the Active Component soldiers but increased across all case definitions from the 3- to 12-month time point for National Guard soldiers.

CONCLUSIONS

The prevalence rates of PTSD and depression after returning from combat ranged from 9% to 31% depending on the level of functional impairment reported. The high comorbidity with alcohol misuse and aggression highlights the need for comprehensive postdeployment screening. Persistent or increased prevalence rates at 12 months compared with 3 months postdeployment illustrate the persistent effects of war zone service and provide important data to guide postdeployment care.

Stigma, barriers to care, and use of mental health services among active duty and National Guard soldiers after combat

OBJECTIVE

This study examined rates of utilization of mental health care among active duty and National Guard soldiers with mental health problems three and 12 months after they returned from combat in Iraq. Stigma and barriers to care were also reported for each component (active duty and National Guard).

METHODS

Cross-sectional, anonymous surveys were administered to 10,386 soldiers across both time points and components. Mean scores from 11 items measuring stigma and barriers to care were computed. Service utilization was assessed by asking soldiers whether they had received services for a mental health problem from a mental health professional, a medical doctor, or the Department of Veterans Affairs in the past month. Risk of mental problems was measured using the Patient Health Questionnaire, the PTSD Checklist, and items asking about aggressive behaviors and "stress, emotional, alcohol, or family" problems within the past month.

RESULTS

A higher proportion of active duty soldiers than National Guard soldiers reported at least one type of mental health problem at both three months (45% versus 33%) and 12 months (44% versus 35%) postdeployment. Among soldiers with mental health problems, National Guard soldiers reported significantly higher rates of mental health care utilization 12 months after deployment, compared with active duty soldiers (27% versus 13%). Mean stigma scores were higher among active duty soldiers than among National Guard soldiers.

CONCLUSIONS

Active duty soldiers with a mental health problem had significantly lower rates of service utilization than National Guard soldiers and significantly higher endorsements of stigma. Current and future efforts to improve care for veterans should work toward reducing the stigma of receiving mental health care.

Screening for alcohol misuse and alcohol-related behaviors among combat veterans

OBJECTIVE

The U.S. military conducts health screenings of service members three to six months after they return from combat deployments. This population health program includes a modified version of the Two-Item Conjoint Screen (TICS), which is widely used in primary care to screen for alcohol misuse. Rates of referral in the military for alcohol treatment are very low, and the utility of these screening questions in predicting serious alcohol-related behaviors is unknown.

METHODS

Anonymous surveys were collected from 6,527 U.S. Army soldiers who were screened three to four months after returning from deployment to Iraq. Positive responses on the TICS alcohol screen were correlated with alcohol-related behaviors. Odds ratios (ORs) were calculated using logistic regression, after adjusting for gender, rank, race, and military component (active or reserve).

RESULTS

Twenty-seven percent of soldiers screened positive for alcohol misuse. Compared with soldiers who screened negative, those who screened positive were more likely to have recently engaged in the following behaviors: drinking and driving (OR=4.99, 95% confidence interval [CI]=4.31-5.76), riding with a driver who had been drinking (OR=5.87, CI=4.99-6.91), reporting late or missing work because of a hangover (OR=9.24, CI=6.73-12.68), using illicit drugs (OR=4.97, CI=3.68-6.71), being referred to alcohol rehabilitation (OR=7.15, CI=4.84-10.58), and being convicted of driving under the influence (OR=4.84, CI=3.04-7.67).

CONCLUSIONS

Positive responses to a two-item alcohol screening tool were strongly associated with serious alcohol-related behaviors. This study highlights the need to improve screening and access to care for alcohol-related problems among service members returning from combat deployments.

Prevalence of mental health problems, treatment need, and barriers to care among primary care-seeking spouses of military service members involved in Iraq and Afghanistan deployments

Military spouses must contend with unique issues such as a mobile lifestyle, rules and regulations of military life, and frequent family separations including peacekeeping and combat deployments. These issues may have an adverse effect on the health of military spouses. This study examined the mental health status, rates of care utilization, source of care, as well as barriers and stigma of mental health care utilization among military spouses who were seeking care in military primary care clinics. The data show spouses have similar rates of mental health problems compared to soldiers. Spouses were more likely to seek care for their mental health problems and were less concerned with the stigma of mental health care than were soldiers. Services were most often received from primary care physicians, rather than specialty mental health professionals, which may relate to the lack of availability of mental health services for spouses on military installations.

Post-combat invincibility: violent combat experiences are associated with increased risk-taking propensity following deployment

Combat exposure is associated with increased rates of mental health problems such as post-traumatic stress disorder, depression, and anxiety when Soldiers return home. Another important health consequence of combat exposure involves the potential for increased risk-taking propensity and unsafe behavior among returning service members. Survey responses regarding 37 different combat experiences were collected from 1252 US Army Soldiers immediately upon return home from combat deployment during Operation Iraqi Freedom. A second survey that included the Evaluation of Risks Scale (EVAR) and questions about recent risky behavior was administered to these same Soldiers 3 months after the initial post-deployment survey. Combat experiences were reduced to seven factors using principal components analysis and used to predict post-deployment risk-propensity scores. Although effect sizes were small, specific combat experiences, including greater exposure to violent combat, killing another person, and contact with high levels of human trauma, were predictive of greater risk-taking propensity after homecoming. Greater exposure to these combat experiences was also predictive of actual risk-related behaviors in the preceding month, including more frequent and greater quantities of alcohol use and increased verbal and physical aggression toward others. Exposure to violent combat, human trauma, and having direct responsibility for taking the life of another person may alter an individual's perceived threshold of invincibility and slightly increase the propensity to engage in risky behavior upon returning home after wartime deployment. Findings highlight the importance of education and counseling for returning service members to mitigate the public health consequences of elevated risk-propensity associated with combat exposure.

Combat duty in Iraq and Afghanistan, mental health problems and barriers to care

BACKGROUND

The current combat operations in Iraq and Afghanistan have involved US military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans.

METHODS

We studied members of 4 US combat infantry units (3 Army units and a Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or 3 to 4 months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and posttraumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments.

RESULTS

Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6% to 17.1%) than after duty in Afghanistan (11.2%) or before deployment to Iraq (9.3%); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23% to 40% sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care.

CONCLUSIONS

This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care. The recent military operations in Iraq and Afghanistan, which have involved the first sustained ground combat undertaken by the United States since the war in Vietnam, raise important questions about the effect of the experience on the mental health of members of the military services who have been deployed there. Research conducted after other military conflicts has shown that deployment stressors and exposure to combat result in considerable risks of mental health problems, including posttraumatic stress disorder, major depression, substance abuse, impairment in social functioning and in the ability to work, and the increased use of healthcare services. One study that was conducted just before the military operations in Iraq and Afghanistan began found that at least 6% of all US military service members on active duty receive treatment for a mental disorder each year. Given the ongoing military operations in Iraq and Afghanistan, mental disorders are likely to remain an important healthcare concern among those serving there. Many gaps exist in the understanding of the full psychosocial effect of combat. The all-volunteer force deployed to Iraq and Afghanistan and the type of warfare conducted in these regions are very different from those involved in past wars, differences that highlight the need for studies of members of the armed services who are involved in the current operations. Most studies that have examined the effects of combat on mental health were conducted among veterans years after their military service had ended. A problem in the methods of such studies is the long recall period after exposure to combat. Very few studies have examined a broad range of mental health outcomes near to the time of subjects' deployment. Little of the existing research is useful in guiding policy with regard to how best to promote access to and the delivery of mental health care to members of the armed services. Although screening for mental health problems is now routine both before and after deployment and is encouraged in primary care settings, we are not aware of any studies that have assessed the use of mental health care, the perceived need for such care, and the perceived barriers to treatment among members of the military services before or after combat deployment. We studied the prevalence of mental health problems among members of the US armed services who were recruited from comparable combat units before or after their deployment to Iraq or Afghanistan. We identified the proportion of service members with mental health concerns who were not receiving care and the barriers they perceived to accessing and receiving such care.

Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat

The purpose of the research was to assess the diagnostic efficiency of the Primary Care Posttraumatic Stress Disorder Screen (PC-PTSD) and the Posttraumatic Stress Disorder Checklist (PCL) as clinical screening tools for active duty soldiers recently returned from a combat deployment. A secondary goal was to examine the item-level characteristics of both the PC-PTSD and the PCL. A validation study conducted with a sample of 352 service members showed that both the PC-PTSD and PCL had good diagnostic efficiency. The overall diagnostic efficiency assessed by the area under the curve (AUC) was virtually the same for both the PC-PTSD and PCL. The most efficient cutoff values for the PC-PTSD were either 2 or 3 "yes" responses with the latter favoring specificity. For the PCL, the most efficient cutoff values were between 30 and 34, mirroring recommended PCL cutoff values from some studies in primary care settings. The examination of item characteristics suggested a 4-item PCL with an AUC virtually identical to that of the full PCL. Item analyses also identified that the most discriminate item in both scales pertained to symptoms of avoidance. Implications and limitations are discussed.

Mild traumatic brain injury in U.S. Soldiers returning from Iraq

BACKGROUND

An important medical concern of the Iraq war is the potential long-term effect of mild traumatic brain injury, or concussion, particularly from blast explosions. However, the epidemiology of combat-related mild traumatic brain injury is poorly understood.

METHODS

We surveyed 2525 U.S. Army infantry soldiers 3 to 4 months after their return from a year-long deployment to Iraq. Validated clinical instruments were used to compare soldiers reporting mild traumatic brain injury, defined as an injury with loss of consciousness or altered mental status (e.g., dazed or confused), with soldiers who reported other injuries.

RESULTS

Of 2525 soldiers, 124 (4.9%) reported injuries with loss of consciousness, 260 (10.3%) reported injuries with altered mental status, and 435 (17.2%) reported other injuries during deployment. Of those reporting loss of consciousness, 43.9% met criteria for post-traumatic stress disorder (PTSD), as compared with 27.3% of those reporting altered mental status, 16.2% with other injuries, and 9.1% with no injury. Soldiers with mild traumatic brain injury, primarily those who had loss of consciousness, were significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somatic and postconcussive symptoms than were soldiers with other injuries. However, after adjustment for PTSD and depression, mild traumatic brain injury was no longer significantly associated with these physical health outcomes or symptoms, except for headache.

CONCLUSIONS

Mild traumatic brain injury (i.e., concussion) occurring among soldiers deployed in Iraq is strongly associated with PTSD and physical health problems 3 to 4 months after the soldiers return home. PTSD and depression are important mediators of the relationship between mild traumatic brain injury and physical health problems.

The impact of deactivation uncertainty, workload, and organizational constraints on reservists' psychological well-being and turnover intentions

This study assessed the impact of the activation of U.S. Army reservists after terrorists attacked the United States on September 11, 2001. A total of 263 soldiers completed a survey and participated in focus groups. The model's stressors were deactivation uncertainty, workload, and organizational constraints. The outcomes were well-being and turnover intentions. In general, most stressors did predict the proposed outcomes. That is, with high deactivation uncertainty, workload, or organizational constraints, reservists reported low psychological well-being and high turnover intentions. Commanders and policymakers can use our findings when addressing ways to improve reservists' psychological health and to decrease turnover intentions. Specifically, reservists need more predictability and the needed organizational conditions (i.e., proper workload levels and equipment) while activated and deployed to protect our country.

Childhood adversity and combat as predictors of depression and post-traumatic stress in deployed troops

BACKGROUND

Previous studies have shown a relationship between childhood adversity and health outcomes in adulthood. The military represents a segment of the young working population that faces unique hazards that may be worsened by previous adverse life experiences. To date, no comprehensive studies of childhood adversity have been conducted with military samples that have included combat troops before and after a combat deployment.

METHODS

Surveys were administered in 2003 to 4529 male soldiers who had not deployed to Iraq, and in 2004 to a separate group of 2392 male soldiers 3 months after returning from Iraq. The main predictor was adverse childhood experiences, an aggregated construct representing incremental exposure to six types of traumatic childhood experiences. This construct correlated with depression and post-traumatic stress disorder rates, as well as symptom scores. For the post-Iraq sample, analyses were conducted to assess whether individuals with childhood trauma were affected differently by exposure to combat.

RESULTS

The likelihood of screening positive for depression and post-traumatic stress disorder was significantly higher for individuals reporting exposure to two or more categories of childhood adversity. Core analyses showed that adverse childhood experiences were a significant predictor of mental health symptoms, beyond the expected contribution of combat.

CONCLUSIONS

This study confirms the high prevalence of adverse childhood experiences and the association of these experiences with key mental health outcomes. In addition, the results highlight the importance of considering pre-enlistment childhood traumatic experiences as well as the level of combat exposure in the treatment of military personnel returning from combat operations.

Non-linear function model of voice pitch dependency on physical and mental load

The present work describes that under increasing physical load the voice fundamental frequency (voice pitch) remains on a given level as long as the physical load is well tolerated by the subject, whereas heart rate and blood pressure continuously increase during increasing physical load. This voice pitch level was compared to voice pitch levels under mental load. Using a word recognition system, 11 well trained, young male subjects had to solve 2 moderate mental load tasks. Before, during and after each task, there were structured relaxation phases. The physical load protocol was a standard bicycle stress test. In each protocol phase the subjects had to count from 1 to 10 in order to provide a standardized speech sample. Heart rate and blood pressure were recorded in all phases. Voice frequency was at average 106 +/- 5.2 Hz in the relaxation phases ('rest level') and was increased under mental load (115.9 +/- 5.7 Hz, Pillais-P = 0.037). During physical stress testing, voice pitch remained unchanged ('tolerated load level') between 100 and 200 W (117.4 +/- 4.8 Hz) and increased shortly before physical exhaustion ('exhaustion level', 275-350 W, 142.9 +/- 5.6 Hz, Pillais-P = 0.007). In contrast, heart rate and blood pressure increased continuously with the physical load. Three voice pitch levels could be verified also individually for each subject. For the practical monitoring of emotional stress the individual anchor frequencies for these levels must be assessed. These data indicate that the relationship between both types of load and voice pitch is non-linear with multiple plateaus and transition functions between them.

Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans

OBJECTIVE

Studies of soldiers from prior wars conducted many years after combat have shown associations between combat-related posttraumatic stress disorder (PTSD) and physical health problems. The current Iraq war has posed a considerable PTSD risk, but the association with physical health has not been well studied.

METHOD

The authors studied 2,863 soldiers using standardized self-administered screening instruments 1 year after their return from combat duty in Iraq.

RESULTS

Among all participants, 16.6% met screening criteria for PTSD. PTSD was significantly associated with lower ratings of general health, more sick call visits, more missed workdays, more physical symptoms, and high somatic symptom severity. These results remained significant after control for being wounded or injured.

CONCLUSIONS

The high prevalence of PTSD and its strong association with physical health problems among Iraq war veterans have important implications for delivery of medical services. The medical burden of PTSD includes physical health problems; combat veterans with serious somatic concerns should be evaluated for PTSD.

Correlates and consequences of morale versus depression under stressful conditions

The role of morale as a positive psychological construct distinct from the construct of depression was examined using data from a longitudinal study of 1,685 U.S. soldiers on a peacekeeping mission to Kosovo. Structural equation modeling analyses revealed morale was best predicted by indices of engagement in meaningful work and confidence in unit functioning and leadership, whereas depression was best predicted by deployment stressors and negative events. Morale assessed during the deployment was related to perceiving benefits from deploying six months later, whereas depression was related to posttraumatic stress disorder and negative perceptions of deploying. The relationship between morale and benefits was a function of engagement in meaningful work. Discussion focuses on the importance of longitudinal research in specifying the antecedents of positive and negative outcomes of a stressful work environment.

Assessing risk propensity in American soldiers: preliminary reliability and validity of the Evaluation of Risks (EVAR) scale--English version

Risk-taking propensity is a critical component of judgment and decision-making in military operations. The Evaluation of Risks scale (EVAR) was recently developed to measure state and trait aspects of risk proneness. The scale, however, was psychometrically normed in French and no data are available for the English translation. We administered the English version of the EVAR to 165 U.S. soldiers to obtain reliability, validity, and normative data for English-speaking respondents. Confirmatory factor analysis suggested that the factor structure of the English EVAR differs from that obtained in the French studies. Instead, a three-factor solution, including recklessness/impulsivity, self-confidence, and need for control, emerged. Internal consistency was comparable to the French version. EVAR scores correlated with age, military rank, and years of service, and discriminated soldiers with histories of high-risk behavior. The data support the reliability and validity of the English version of the EVAR for evaluating risk propensity in U.S. soldiers.

The effects of prior combat experience on the expression of somatic and affective symptoms in deploying soldiers

OBJECTIVE

Deployment to a combat zone is undoubtedly an extremely stressful experience. It was hypothesized that, when faced with an impending wartime deployment, soldiers with prior combat experience would report minimal emotional problems accompanied by high rates of somatic complaints compared with combat-naive soldiers.

METHODS

Self-reports of posttraumatic stress disorder (PTSD) and affective and somatic complaints were collected from 2068 U.S. soldiers just prior to combat deployment during Operation Iraqi Freedom.

RESULTS

Although the percentage of soldiers scoring positive for PTSD was nearly identical for the experienced and inexperienced groups, scores on the Affective and Somatic scales differed as a function of prior combat history. Previous combat experience was associated with lower affective and greater somatic complaints relative to combat-naive soldiers.

CONCLUSIONS

Consistent with theories of stress reaction, repression, and somatic amplification, combat-experienced soldiers reported limited affective complaints but greater somatic complaints relative to soldiers without combat experience.

The impact of National Guard activation for homeland defense: employers' perspective

Data gathered from a study of reserve component (RC) soldiers who were activated during the spring of 2002, following the terrorist attacks of September 11, 2001, suggested that they were concerned about how the effects of their activation affected their civilian employment. Therefore, the purpose of this study was to obtain this information from the civilian employers of these RC soldiers. Most civilian employers who participated in this study (N = 28) were male (89%) and working in law enforcement (39%). Fifty-six percent of employers gave consent to be interviewed by telephone. Although supervisors reported difficulties in several areas of operation and aspects of the RC activation, they still supported the activation of their RC employees and their military mission. This study is a significant start to illuminating the important roles that both RC employees and their civilian employers play in homeland defense.