Relationships among predeployment risk factors, warzone-threat appraisal, and postdeployment PTSD symptoms

Adversity Interpreted: A Scoping Review of Adversity Appraisal Measurement

Although evidence suggests that individuals' appraisals (i.e., subjective interpretations) of adverse or traumatic life events may serve as a mechanism accounting for differences in adversity exposure and psychological adjustment, understanding this mechanism is contingent on our ability to reliably and consistently measure appraisals. However, measures have varied widely between studies, making conclusions about how best to measure appraisal a challenge for the field. To address this issue, the present study reviewed 88 articles from three research databases, assessing adults' appraisals of adversity. To be included in the scoping review, articles had to meet the following criteria: (1) published no earlier than 1999, (2) available in English, (3) published as a primary source manuscript, and (4) included a measure assessing for adults' (over the age of 18) subjective primary and/or secondary interpretations of adversity. Each article was thoroughly reviewed and coded based on the following information: study demographics, appraisal measurement tool(s), category of appraisal, appraisal dimensions (e.g., self-blame, impact, and threat), and the tool's reliability and validity. Further, information was coded according to the type of adversity appraised, the time in which the appraised event occurred, and which outcomes were assessed in relation to appraisal. Results highlight the importance of continued examination of adversity appraisals and reveal which appraisal tools, categories, and dimensions are most commonly assessed for. These results provide guidance to researchers in how to examine adversity appraisals and what gaps among the measurement of adversity appraisal which need to be addressed in the future research.

Sex Differences in US Army Suicide Attempts During the Wars in Iraq and Afghanistan

OBJECTIVE

To examine sex differences in risk for administratively documented suicide attempt (SA) among US Army soldiers during the Iraq/Afghanistan wars.

METHOD

Using administrative person-month records of Regular Army enlisted soldiers from 2004 to 2009, we identified 9650 person-months with a first documented SA and an equal-probability control sample (n=153,528 person-months). Person-months were weighted to the population and pooled over time. After examining the association of sex with SA in a logistic regression analysis, predictors were examined separately among women and men.

RESULTS

Women (an estimated 13.7% of the population) accounted for 25.2% of SAs and were more likely than men to attempt suicide after adjusting for sociodemographic, service-related, and mental health diagnosis (MHDx) variables (odds ratio=1.6; 95% confidence interval, 1.5-1.7). Women with increased odds of SA in a given person-month were younger, non-Hispanic White, less educated, in their first term of enlistment, never or previously deployed (vs. currently deployed), and previously received a MHDx. The same variables predicted SA among men. Interactions indicated significant but generally small differences between women and men on 6 of the 8 predictors, the most pronounced being time in service, deployment status, and MHDx. Discrete-time survival models examining risk by time in service demonstrated that patterns for women and men were similar, and that women's initially higher risk diminished as time in service increased.

CONCLUSIONS

Predictors of documented SAs are similar for US Army women and men. Differences associated with time in service, deployment status, and MHDx require additional research. Future research should consider stressors that disproportionately affect women.

Parental Wartime Deployment and Socioemotional Adjustment in Early Childhood: The Critical Role of Military Parents' Perceived Threat During Deployment

Infants, toddlers, and preschool-aged children have unique developmental needs that render them vulnerable to challenges associated with parental military service. We used a sample of military-connected families with 3-6-year-old children (N = 104) to examine associations among children's socioemotional development and fathers' trauma-related deployment experiences, including perceived threat during deployment and exposure to combat and the aftermath of battle. Of these potential stressors, only paternal perceived threat during deployment was significantly associated with measures of mother-reported child adjustment. Fathers' perceived threat during deployment was associated with child behavior problems even after accounting for demographic variables and current paternal symptoms of posttraumatic stress, depression, and anxiety, β = .36, p = .007. The association between fathers' perceived threat during deployment and child behavior problems was mediated by several family processes related to emotion socialization, including father-reported sensitive parenting, indirect effect (IE) B = 0.106, 95% CI [0.009, 0.236]; parent-child dysfunctional interaction, IE B = 0.119, 95% CI [0.014, 0.252]; and mother-reported family emotional responsiveness, IE B = 0.119, 95% CI [0.011, 0.258]. Implications for future research on the intergenerational transmission of traumatic stress as well as prevention and intervention efforts for military-connected families with young children are discussed.

Early First Deployment and Risk of Suicide Attempt Among First-term Enlisted Soldiers in the U.S. Army

OBJECTIVE

We examined early first deployment and subsequent suicide attempt among U.S. Army soldiers.

METHOD

Using 2004-2009 administrative data and person-month records of first-term, Regular Army, enlisted soldiers with one deployment (89.2% male), we identified 1,704 soldiers with a documented suicide attempt during or after first deployment and an equal-probability control sample (n = 25,861 person-months).

RESULTS

Logistic regression analyses indicated soldiers deployed within the first 12 months of service were more likely than later deployers to attempt suicide (OR = 1.7 [95% CI = 1.5-1.8]). Adjusting for sociodemographic characteristics, service-related characteristics, and previous mental health diagnosis slightly attenuated this association (OR = 1.6 [95% CI = 1.5-1.8]). Results were not modified by gender, deployment status, military occupation, or mental health diagnosis. The population-attributable risk proportion for deploying within the first 12 months of service was 17.8%. Linear spline models indicated similar risk patterns over time for early and later deployers, peaking at month 9 during deployment and month 5 postdeployment; however, monthly suicide attempt rates were consistently higher for early deployers.

CONCLUSIONS

Enlisted soldiers deployed within the first 12 months of service have elevated risk of suicide attempt during and after first deployment. Improved understanding of why early deployment increases risk can inform the development of policies and intervention programs.

How trauma influences cardiovascular responses to stress: contributions of posttraumatic stress and cognitive appraisals

Mechanisms for the association between posttraumatic stress disorder (PTSD) symptoms and cardiovascular diseases remain poorly understood. The present study examined associations among PTSD symptoms, appraisals of a current stressor, baseline cardiovascular indices, and cardiovascular responses to the stressor, including appraisals as a potential mediator of PTSD symptoms and cardiovascular responses. A sample of 125 undergraduates provided information about demographics, physical health, trauma history, and PTSD symptoms. Weight, height, blood pressure (BP), and heart rate (HR) measurements were obtained. During a modified Trier Social Stress Task, appraisals of the stressor were assessed and BP and HR were measured again. Findings suggest that PTSD symptoms are associated with current physical health (resting BP and HR) and more negative appraisals of the stressor; in turn, more negative appraisals were associated with increases in cardiovascular response. In particular, threat appraisal mediated the relationship between PTSD symptoms and increases in systolic BP response.

Coping strategies of Dutch servicemembers after deployment

BACKGROUND

This study examines the relationship between coping strategies and symptoms of anxiety or depression among Dutch servicemembers deployed to Afghanistan.

METHODS

Coping strategies were assessed in 33 battlefield casualties (BCs) and the control group (CTRLs) of 33 uninjured servicemembers from the same combat units using the Cognitive Emotion Regulation Questionnaire. A factor analysis was performed, and two clusters of coping strategies were derived, namely, adaptive and maladaptive coping. Symptoms of anxiety and depression were evaluated using the depression and anxiety subscales of the Symptom Checklist-90-Revised. Correlations between coping and symptoms of anxiety and between coping and symptoms of depression were calculated, and a logistic regression was performed.

RESULTS

A moderate correlation was observed between maladaptive coping and symptoms of anxiety in the BC group (r = 0.42) and among the CTRLs (r = 0.56). A moderate correlation was observed between maladaptive coping and symptoms of depression in both groups (r = 0.55). The statistical analysis for the total sample (BCs and CTRLs) demonstrated no association between coping and symptoms of anxiety or depression.

CONCLUSIONS

A correlation but no association was observed between maladaptive coping and mental health disorders in deployed Dutch servicemembers. Further research should focus on constructing cluster profiles of coping strategies and associating them with mental health outcomes and reintegration into society.

Predictors of Posttraumatic Stress Disorder, Anxiety Disorders, Depressive Disorders, and Any Mental Health Condition Among U.S. Soldiers and Marines, 2001-2011

Understanding mental health disorder diagnosis and treatment seeking among active-duty military personnel is a topic with both clinical and policy implications. It has been well documented in military populations that individual-level military experience, including deployment history and combat exposure, influences mental health outcomes, but the impact of unit-level factors is less well understood. In the current study, we used administrative longitudinal data to examine a comprehensive set of unit- and individual-level predictors of posttraumatic stress disorder (PTSD), non-PTSD anxiety disorders, depressive disorders, and overall mental health diagnoses among Army and Marines Corps personnel. Using Cox survival models for time-dependent variables, we analyzed time from military accession (between January 1, 2001 and December 31, 2011) until first mental health diagnosis for 773,359 soldiers and 332,093 Marines. Prior diagnosis of a substance abuse disorder during one's military career, hazard ratios (HRs) = 1.68-3.10, and cumulative time spent deployed, HRs = 1.11-2.04, were the most predictive risk factors for all outcomes. Male sex, HRs = 0.35-0.57, and officer rank, HRs = 0.13-0.23, were the most protective factors. Unit-level rate of high deployment stress was a small but significant predictor of all outcomes after controlling for individual-level deployment history and other predictors, HRs = 1.01-1.05. Findings suggest both unit- and individual-level risk and protective factors of mental health diagnoses associated with treatment seeking. Clinical, including mental health assessment and management, and policy implications related to the military environment and the individual as it relates to mental health disorders are discussed.

Associations of Time-Related Deployment Variables With Risk of Suicide Attempt Among Soldiers: Results From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

Importance

There has been limited systematic examination of whether risk of suicide attempt (SA) among US Army soldiers is associated with time-related deployment variables, such as time in service before first deployment, duration of first deployment, and dwell time (DT) (ie, length of time between deployments).

Objective

To examine the associations of time-related deployment variables with subsequent SA among soldiers who had deployed twice.

Design, Setting, and Participants

Using administrative data from January 1, 2004, through December 31, 2009, this longitudinal, retrospective cohort study identified person-month records of active-duty Regular Army enlisted soldiers who had served continuously in the US Army for at least 2 years and deployed exactly twice. The dates of analysis were March 1 to December 1, 2017. There were 593 soldiers with a medically documented SA during or after their second deployment. An equal-probability sample of control person-months was selected from other soldiers with exactly 2 deployments (n = 19 034). Logistic regression analyses examined the associations of time in service before first deployment, duration of first deployment, and DT with subsequent SA.

Main Outcomes and Measures

Suicide attempts during or after second deployment were identified using US Department of Defense Suicide Event Report records and International Classification of Diseases, Ninth Revision, Clinical Modification E950 to E958 diagnostic codes. Independent variables were constructed from US Army personnel records.

Results

Among 593 SA cases, most were male (513 [86.5%]), white non-Hispanic (392 [66.1%]), at least high school educated (477 [80.4%]), currently married (398 [67.1%]), and younger than 21 years when they entered the US Army (384 [64.8%]). In multivariable models adjusting for sociodemographics, service-related characteristics, and previous mental health diagnosis, odds of SA during or after second deployment were higher among soldiers whose first deployment occurred within the first 12 months of service vs after 12 months (odds ratio, 2.0; 95% CI, 1.6-2.4) and among those with a DT of 6 months or less vs longer than 6 months (odds ratio, 1.6; 95% CI, 1.2-2.0). Duration of first deployment was not associated with subsequent SA. Analysis of 2-way interactions indicated that the associations of early deployment and DT with SA risk were not modified by other characteristics. Multivariable population-attributable risk proportions were 14.2% for deployment within the first 12 months of service and 4.0% for DT of 6 months or less.

Conclusions and Relevance

Time in service before first deployment and DT are modifiable risk factors for SA risk among soldiers.

Frequency of Improvised Explosive Devices and Suicide Attempts in the U.S. Army

BACKGROUND

Improvised explosive devices (IEDs) were a prominent and initially new threat in the Iraq and Afghanistan war which raised concerns and anticipatory fear in and out of theater. This study examined the association of monthly IED rates with risk of soldier suicide attempt among those deployed and nondeployed.

METHODS

Person-month records for all active duty Regular Army suicide attempters from 2004 through 2009 (n = 9,791) and an equal-probability sample of control person-months (n = 183,826) were identified. Logistic regression analyses examined soldiers' risk of attempting suicide as a function of monthly IED frequency, controlling for sociodemographics, service-related characteristics, rate of deployment/redeployment, and combat deaths and injuries. The association of IED frequency with suicide attempt was examined overall and by time in service and deployment status.

FINDINGS

Soldiers' risk of suicide attempt increased with increasing numbers of IEDs. Suicide attempt was 26% more likely for each 1,000 IED increase in monthly frequency (odds ratio [OR] = 1.26, 95% confidence interval [CI] = 1.22-1.30). The association of IED frequency with suicide attempt was greater for soldiers in their first 2 years of service (OR = 1.30, 95% CI = 1.25-1.36) than for those with 3 or more years of service (OR = 1.18, 95% CI = 1.12-1.24). Among soldiers in their first 2 years of service, the association was constant, regardless of deployment status (χ₂² = 3.89, p = 0.14). Among soldiers with 3 or more years of service, the association was higher for those never deployed (OR = 1.12, 95% CI = 1.01-1.24) and currently deployed (OR = 1.14, 95% CI = 1.05-1.23) than for those previously deployed.

DISCUSSION

To our knowledge, this is the first study to examine and demonstrate an association between the aggregate frequency of IEDs and risk of suicide attempts among U.S. Army soldiers. This association was observed across deployment status and time in service, and for early-career soldiers in particular. The findings suggest that the threat of new weapons may increase stress burden among soldiers. Targeting risk perception and perceived preparedness, particularly early in a soldier's career, may improve psychological resilience and reduce suicide risk.

Amputation: Not a failure for severe lower extremity combat injury

INTRODUCTION

The use of improvised explosive devices is a frequent method of insurgents to inflict harm on deployed military personnel. Consequently, lower extremity injuries make up the majority of combat related trauma. The wounding pattern of an explosion is not often encountered in a civilian population and can lead to substantial disability. It is therefore important to study the impact of these lower extremity injuries and their treatment (limb salvage versus amputation) on functional outcome and quality of life.

PATIENTS AND METHODS

All Dutch repatriated service members receiving treatment for wounds on the lower extremity sustained in the Afghan theater between august 2005 and August 2014, were invited to participate in this observational cohort study. We conducted a survey regarding their physical and mental health using the Short Form health survey 36, EuroQoL 6 dimensions and Lower Extremity Functional Scale questionnaires. Results were collated in a specifically designed electronic database combined with epidemiology and hospital statistics gathered from the archive of the Central Military Hospital. Statistical analyses were performed to identify differences between combat and non-combat related injuries and between limb salvage treatment and amputation.

RESULTS

In comparison with non-battle injury patients, battle casualties were significantly younger of age, sustained more severe injuries, needed more frequent operations and clinical rehabilitation. Their long-term outcome scores in areas concerning well-being, social and cognitive functioning, were significantly lower. Regarding treatment, amputees experienced higher physical well-being and less pain compared to those treated with limb salvage surgery.

CONCLUSION

Sustaining a combat injury to the lower extremity can lead to partial or permanent dysfunction. However, wounded service members, amputees included, are able to achieve high levels of activity and participation in society, proving a remarkable resilience. These long-term results demonstrate that amputation is not a failure for casualty and surgeon, and strengthen a life before limb (damage control surgery) mindset in the initial phase. For future research, we recommend the use of adequate coding and injury scoring systems to predict outcome and give insight in the attributes that are supportive for the resilience that is needed to cope with a serious battle injury.

Exploring Reliability and Validity of the Deployment Risk and Resilience Inventory-2 Among a Nonclinical Sample of Discharged Soldiers Following Mandatory Military Service

The Deployment Risk and Resilience Inventory (DRRI) is a widely used questionnaire assessing deployment-related risk and resilience factors among war veterans. Its successor, the DRRI-2, has only been validated and used among veterans deployed for overseas military missions, but because many countries still enforce compulsory military service, validating it among nonclinical samples of healthy discharged soldiers following mandatory service is also a necessity. In the current study, a sample of 101 discharged Israeli soldiers (39 males, 62 females; mean time since discharge 13.92, SD = 9.09 years) completed the DRRI-2. There were 52 participants who completed the questionnaire at a second time point (mean time between assessments 19.02, SD = 6.21 days). Both physical and mental health status were examined, as well as symptomatology of depression, anxiety, and posttraumatic stress disorder. Cronbach's αs for all latent variables in the inventory ranged from .47 to .95. The DRRI-2 risk factors were negatively associated with psychological functioning, whereas resilience factors were positively associated with better self-reported mental health. Test-retest reliability coefficients were generally high (Pearson correlations were .61 to .94, all p values < .01). Our study provides evidence for the reliability and validity of the DRRI-2 in assessing salient deployment experiences among a nonclinical sample following mandatory military service.

The experience of traumatic events disrupts the measurement invariance of a posttraumatic stress scale

Studies that include multiple assessments of a particular instrument within the same population are based on the presumption that this instrument measures the same construct over time. But what if the meaning of the construct changes over time due to one's experiences? For example, the experience of a traumatic event can influence one's view of the world, others, and self, and may disrupt the stability of a questionnaire measuring posttraumatic stress symptoms (i.e., it may affect the interpretation of items). Nevertheless, assessments before and after such a traumatic event are crucial to study longitudinal development of posttraumatic stress symptoms. In this study, we examined measurement invariance of posttraumatic stress symptoms in a sample of Dutch soldiers before and after they went on deployment to Afghanistan (N = 249). Results showed that the underlying measurement model before deployment was different from the measurement model after deployment due to invariant item thresholds. These results were replicated in a sample of soldiers deployed to Iraq (N = 305). Since the lack of measurement invariance was due to instability of the majority of the items, it seems reasonable to conclude that the underlying construct of PSS is unstable over time if war-zone related traumatic events occur in between measurements. From a statistical point of view, the scores over time cannot be compared when there is a lack of measurement invariance. The main message of this paper is that researchers working with posttraumatic stress questionnaires in longitudinal studies should not take measurement invariance for granted, but should use pre- and post-symptom scores as different constructs for each time point in the analysis.

The relationship between glucocorticoid receptor polymorphisms, stressful life events, social support, and post-traumatic stress disorder

BACKGROUND

It is debatable whether or not glucocorticoid receptor (GR) polymorphisms moderate susceptibility to PTSD. Our objective was to examine the effects of stressful life events, social support, GR genotypes, and gene-environment interactions on the etiology of PTSD.

METHODS

Three tag single nucleotide polymorphisms, trauma events, stressful life events, and social support were assessed in 460 patients with PTSD and 1158 control subjects from a Chinese Han population. Gene-environment interactions were analyzed by generalized multifactor dimensionality reduction (GMDR).

RESULTS

Variation in GR at rs41423247 and rs258747, stressful life events, social support, and the number of traumatic events were each separately associated with the risk for PTSD. A gene-environment interaction among the polymorphisms, rs41423247 and rs258747, the number of traumatic events, stressful life events, and social support resulted in an increased risk for PTSD. High-risk individuals (a large number of traumatic events, G allele of rs258747 and rs41423247, high level stressful life events, and low social support) had a 3.26-fold increased risk of developing PTSD compared to low-risk individuals. The association was statistically significant in the sub-groups with and without childhood trauma.

CONCLUSIONS

Our data support the notion that stressful life events, the number of trauma events, and social support may play a contributing role in the risk for PTSD by interacting with GR gene polymorphisms.

Epigenetics in posttraumatic stress disorder

Reported exposure to traumatic event is relatively common within the general population (40-90%), but only a fraction of individuals will develop posttraumatic stress disorder (PTSD). Indeed, the lifetime prevalence of PTSD is estimated to range between 7% and 12%. The factors influencing risk or resilience to PTSD after exposure to traumatic events are likely both environmental, such as type, timing, and extent of trauma, and genetic. Recently, epigenetic mechanisms have been implicated in mediating altered risk for PTSD as they can reflect both genetic and environmental influences. In this chapter, we describe the accumulating evidences for epigenetic factors in PTSD highlighting the importance of sensitive periods as well as methodological aspects such as tissue availabilities for such studies. We describe studies using a candidate gene approach focusing mainly on key players in the stress hormone regulation that show epigenetic alterations both in humans and in animal models for PTSD. We also summarize the results of epigenome-wide studies reporting associations with PTSD. For the above, we focus on one epigenetic mechanism, DNA methylation, as it is so far the best studied for this disorder. Finally, we describe how epigenetic mechanisms could be responsible for the long-lasting effects of gene-environment interactions observed in PTSD.