Multiple deployments and combat trauma: do homefront stressors increase the risk for posttraumatic stress symptoms?

Is inflammatory change associated with psychological risk and resilience in high-risk military personnel?

INTRODUCTION

In military populations, the potential for under-reporting of Post-traumatic Stress Disorder (PTSD) symptoms and challenges in recognising early changes can make it difficult to detect an emerging disorder. However, early identification of PTSD symptoms would improve opportunities for intervention, and potentially reduce the likelihood of chronic mental health problems.

METHOD

This study explored if changes in levels of inflammation, measured by C reactive protein (CRP) and interleukin 6 (IL-6), were associated with the onset of psychological symptoms associated with PTSD. It also examined if changes in inflammation over time contributed to psychological risk and resilience, which was defined by psychological reactivity to deployment-related combat exposures. Participants were special forces personnel who completed psychological self-report questionnaires and had measures of CRP and IL-6 taken pre and post deployment. Regression analysis was used to examine how psychological symptoms predicted change in inflammation, and Analysis of Variance (ANOVA) were used to examine differences between identified subgroups.

RESULTS

Results identify this population as having high levels of combat and trauma exposures, with low-level psychological symptoms. The results also identified a decrease in CRP and an increase in IL-6 over time. A significant difference in inflammation was identified between subgroups (p<0.05). An association between inflammatory markers and subthreshold symptoms related to anger (p<0.01) and sleep (p<0.05) was also identified.

CONCLUSION

These preliminary findings suggest inflammatory markers may help to identify adaptive responses post deployment. In addition, low-level increases in inflammatory markers may be associated with subthreshold PTSD symptoms. These findings offer potential insights for prevention, early identification and treatment in military and veteran populations.

Functional significance of posttraumatic growth in U.S. military veterans

BACKGROUND

Although many studies indicate that individuals who have experienced a traumatic event can experience posttraumatic growth (PTG), some researchers have questioned the significance of PTG in associations with functioning. The role of PTG in functioning following trauma may be better elucidated by accounting for its joint effects with posttraumatic stress disorder (PTSD) symptoms.

METHODS

Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 3847 trauma-exposed U.S. veterans. Participants completed assessments of potentially traumatic events, PTSD symptoms, and PTG, as well as a broad range of sociodemographic, military, trauma, health, personality, and psychosocial characteristics.

RESULTS

PTG was independently and moderately associated with higher mental, cognitive, and psychosocial functioning, but not physical functioning. Results showed a similar pattern of findings when examining relations between subdomains of PTG and these aspects of functioning. Additionally, among veterans who screened positive for PTSD, those who endorsed PTG reported higher levels of mental, cognitive, and/or psychosocial functioning than those who did not endorse PTG.

LIMITATIONS

Findings may be limited by the use of a cross-sectional design, retrospective self-reports of PTG, and a predominantly older white male veteran sample.

CONCLUSION

Results provide support for the functional significance of PTG and highlight the importance of considering PTSD symptoms to better understand the role of PTG in functioning. Clinical interventions to foster PTG may help promote post-trauma functioning.

The Marcus Institute for Brain Health: an integrated practice unit for the care of traumatic brain injury in military veterans

PRIMARY OBJECTIVE

Traumatic brain injury (TBI) is a signature wound of recent Unites States military conflicts. The National Intrepid Center of Excellence (NICoE) has demonstrated that interdisciplinary care is effective for active-duty military personnel with TBI and related psychological health conditions. This paper details how the Marcus Institute for Brain Health (MIBH), established in 2017 as an Integrated Practice Unit (IPU), is founded on the NICoE model and is dedicated to interdisciplinary care for Veterans with persistent symptoms due to TBI and psychological comorbidities.

RESEARCH DESIGN

A highly integrated group of clinicians from diverse disciplines combine their expertise to offer comprehensive evaluation, intensive outpatient treatment, and program outcomes evaluation.

METHODS AND PROCEDURES

The role of each discipline in the provision of care, and the regular interaction of all clinicians, are delineated. A strong connection to academic medicine is maintained so that clinical research and education complement patient care.

MAIN OUTCOMES AND RESULTS

Over three hundred veterans and family members have received treatment at the MIBH. Program evaluation is underway.

CONCLUSIONS

As the understanding of TBI and related psychological conditions continues its rapid evolution, the expert interdisciplinary care at the MIBH has great promise as a Veteran counterpart of the NICoE.

Exploring Health Outcomes for U.S. Veterans Compared to Non-Veterans from 2003 to 2019

The physical demands on U.S. service members have increased significantly over the past several decades as the number of military operations requiring overseas deployment have expanded in frequency, duration, and intensity. These elevated demands from military operations placed upon a small subset of the population may be resulting in a group of individuals more at-risk for a variety of debilitating health conditions. To better understand how the U.S Veterans health outcomes compared to non-Veterans, this study utilized the U.S. Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS) dataset to examine 10 different self-reported morbidities. Yearly age-adjusted, population estimates from 2003 to 2019 were used for Veteran vs. non-Veteran. Complex weights were used to evaluate the panel series for each morbidity overweight/obesity, heart disease, stroke, skin cancer, cancer, COPD, arthritis, mental health, kidney disease, and diabetes. General linear models (GLM’s) were created using 2019 data only to investigate any possible explanatory variables associated with these morbidities. The time series analysis showed that Veterans have disproportionately higher self-reported rates of each morbidity with the exception of mental health issues and heart disease. The GLM showed that when taking into account all the variables, Veterans disproportionately self-reported a higher amount of every morbidity with the exception of mental health. These data present an overall poor state of the health of the average U.S. Veteran. Our study findings suggest that when taken as a whole, these morbidities among Veterans could prompt the U.S. Department of Veteran Affairs (VA) to help develop more effective health interventions aimed at improving the overall health of the Veterans.

Risk factors for mental ill health in UK Army personnel: an overview

Women in the UK military are more commonly diagnosed with a mental health disorder than men, but the reasons for this difference are not fully understood. This literature review identifies the risk factors for mental ill health in military personnel before serving, during service and as a veteran. The interaction of risk factors is complex and, in some cases, may be synergistic, such as experiencing adverse events in childhood and exposure to combat. Identification of risk factors allows further research to better understand differences between men and women, and the impact of these risk factors on army personnel. In turn this will inform better preventive strategies, which could be targeted at the primary, secondary or tertiary levels.

Personal Resources and Spiritual Change among Participants’ Hostilities in Ukraine: The Mediating Role of Posttraumatic Stress Disorder and Turn to Religion

The theory of conservation of resources (COR) can be used for searching mechanisms which explain spiritual changes caused by trauma. The aim of this paper was to analyze the relationship between distribution of personal resources and spiritual change, as well as the mediating role of posttraumatic stress disorder (PTSD) and turn to religion (stress coping strategy) in this relationship among participants’ hostilities in Ukraine. A total of 314 adults—74 women and 235 men—participated in the study. The mean age was 72.59. Polish adaptation of Hobfoll’s Conservation of Resources-Evaluation (COR-E), the Posttraumatic Stress Disorder (PTSD) Checklist—Civilian Version (PCL-C), the Inventory for Measuring Coping with Stress (MINI-COPE), and The Posttraumatic Growth Inventory (PTGI) were employed in the research. The mediating role of posttraumatic stress disorder and turn to religion in relationship between personal resources loss and spiritual change was confirmed. The turn to religion plays the role of mediator in relationship between personal resources gain/assigning value to personal resources and spiritual change. The results justify the postulate of conducting further research in the field of testing models which take into account the relationship between posttraumatic stress disorder, religious coping stress, and posttraumatic spiritual change. The conducted analyses should include the assumptions of the COR theory as well as psychological, social, and situational factors that could generate spiritual change.

Rates of Behavioral Health Conditions and Health Risk Behaviors in Operators and Support Personnel in U.S. Special Operations Forces

Objective: Rates of behavioral health disorders and potential protective factors in U.S. Special Operations Forces (SOF) have not been well studied, including differences between Operators and Support personnel, despite very high levels of combat exposure in these military personnel. The present study examined the prevalence of endorsed behavioral health problems and protective factors within a large sample of SOF personnel. Method: Anonymized data from 16,284 active duty SOF Service members from the 2016 Preservation of the Force and Family (POTFF) needs survey were analyzed. Results: Overall, the prevalence of PTSD (7.6%), depression (8.4%), alcohol misuse (12.8%), and nicotine use (28%) were comparable or lower than reported in conventional military populations. There were significant differences between Operators and Support personnel in a number of demographic and service-related variables. Operators also endorsed more direct combat exposure and scored higher on resilience and social support, and reported better quality and quantity of sleep. There were no significant group differences in rates of PTSD and depression, except lower odds (adjusted OR = 0.81) for alcohol problems in Support personnel (11.6%) compared to Operators (14.0%), p <.001, 95% CI [0.72, 0.91]. Conclusions: SOF personnel experience considerably higher exposure to combat deployments than conventional forces, yet the data from this study showed comparable or lower levels of behavioral health conditions. Although Operators were somewhat more likely than Support personnel to experience alcohol problems, they showed enhanced resilience, social support, and sleep health. Alcohol misuse is one potential target for preventive health efforts.

Five-Year Impacts of Family Stressors and Combat Threat on the Mental Health of Afghanistan and Iraq War Veterans

It has been well established that warfare-related stress puts service members at risk for a range of mental health problems after they return from deployment. Less is known about service members' experience of family stressors during deployment. The aims of this study were to (a) evaluate whether family stressors would contribute unique variance to posttraumatic stress disorder (PTSD) and depressive symptoms above and beyond combat threat during deployment and (b) examine whether family stressors would amplify the negative effects of combat threat on postmilitary mental health 5 years postdischarge. Study participants reported their experience of objective and subjective family stressors and combat threat during deployment. Objective family stressors demonstrated unique associations with PTSD and depression symptoms and remained significant after accounting for ongoing family stressors reported at follow-up. A significant interaction was found between objective family stressors and combat threat on PTSD symptoms, r = -.10. Although the association between combat threat and PTSD was significant for participants who reported high, B = 0.04; and low, B = 0.09, exposure to family stressors, the steeper slope for those exposed to fewer family stressors indicates a stronger effect of combat threat. Follow-up analyses revealed that veterans who experienced high amounts of family stress and high levels of combat threat reported significantly worse PTSD symptoms than those who reported low family stress, t(256) = 3.98, p < .001. Findings underscore the importance of attending to the role that family stressors experienced during deployment play in service members' postmilitary mental health.

PTSD and the influence of context: The self as a social mirror

The principal accepted models of posttraumatic stress disorder (PTSD) are based on both memory processing and biological/brain changes occurring when one's life or well-being is threatened. It is our thesis that these models would be greatly informed by community studies indicating that PTSD is predicted to a greater extent by earlier life experience and experiences that occur distant from the threatening event. These findings suggest posttraumatic responding is best conceptualized through the lens of the self-in-context, as opposed to imprinting that results from a given event at a given time. Moreover, studies of non-Western populations often do not express trauma as PTSD, or at least not primarily as PTSD, which argues against specific neural or memory encoding processes, but rather for a more plastic neural process that is shaped by experience and how the self develops in its cultural context, as a product of a broad array of experiences. We posit that fear and emotional conditioning as well as the ways traumas are encoded in memory are only partial explanatory mechanisms for trauma responding, and that issues of safety and harm, which are long term and developmental, are the common and principal underpinnings of the occurrence of posttraumatic distress, including PTSD.

A Review of Military Health Research Using a Social–Ecological Framework

Objective:

We aim to contextualize the growing body of research on the sequelae of military service in the wars in Afghanistan and Iraq. We employ a social–ecological (SE) framework for the taxonomy of military health research and classify risk as arising from the individual, family, community, and the institutional levels. We intend for this review to inform enhanced health promotion efforts in military communities.

Data Source:

Articles reviewed were extracted from Web of Science, PubMed, and Scopus.

Inclusion and Exclusion Criteria:

Research focused on somatic and psychological sequelae of combat deployment published from 2001—the year the war in Afghanistan began—through the end of 2014. We excluded studies of non-US military personnel, other systematic reviews, meta-analyses, book chapters, and theoretical papers.

Data Extraction:

We examined and summarized the aims, participants, methods, study design, SE framework tier, risk factors, and health outcomes.

Data Synthesis:

Studies were categorized according to SE tier, whether they focused on somatic, behavioral, or psychological outcomes, and by risk factor.

Results:

Of the 352 peer-reviewed papers, 84% focused on war’s sequelae on the index military personnel, and 75% focused on mental or behavioral health outcomes—mostly on post-traumatic stress disorder. We find comparatively little research focusing on the family, community, or institutional tiers.

Conclusions:

We know relatively little about how family and community respond to the return of personnel from combat deployment; how family resources affect the health of returning military personnel; and how a war’s persistence presents challenges for federal, state, and local agencies to meet military health-care needs. Such work is especially salient as US troops return home from war—particularly in communities where there are substantial military populations.

Randomized controlled trial of a brief Internet-based intervention for families of Veterans with posttraumatic stress disorder

Veterans with posttraumatic stress disorder (PTSD) and their families require resources to cope with postdeployment readjustment. Responding to this need, the current study examined a brief Internet-based intervention that provided Veterans' families with psychoeducation on postdeployment readjustment. Participants were 103 dyads of Veterans with probable PTSD and a designated family member/partner. Dyads were randomized to an intervention group, in which the family member completed the intervention, or to a control group with no intervention. Each member of the dyad completed surveys at baseline and 2 mo follow-up. Family member surveys focused on perceived empowerment, efficacy to provide support, and communication (perceived criticism and reactivity to criticism). Veteran surveys assessed perceived family support and communication. Results showed that Veterans in the intervention group reported decreases in reactivity to criticism but also decreased perceived family support. No significant differences were observed in outcomes reported by family members. This preliminary study provides an early understanding of this novel outreach program, as well as the challenges inherent with a very brief intervention. Future research can build on the current study by more closely evaluating the communication changes that occur with this form of intervention and whether greater intervention intensity is needed.

CLINICAL TRIAL REGISTRATION

Clinical Trials Identifier: NCT01554839.

Perceptions of Individual and Family Functioning Among Deployed Female National Guard Members

Females currently make up 15% of U.S. military service members. Minimal attention has been paid to families of female National Guard members who have been deployed and their subsequent reintegration challenges. This cross-sectional Internet-based survey of female members of four National Guard units compared those who were and were not deployed. Instruments, guided by the variables of the Family Resilience Model, measured individual, family, and deployment-related factors. Bivariate analysis and ordinal logistic regression were done to assess differences between the groups. Of the 239 National Guard members surveyed, deployed women (n = 164) had significantly higher levels of posttraumatic stress disorder (PTSD; p < .001) and lower coping skills (p = .003) than non-deployed women (n = 75). Perceptions of overall family functioning were higher among deployed when compared with never deployed women. Results indicate community interventions that focus on strengthening coping skills of female Guard members would be useful for this population.

MORBID THOUGHTS AND SUICIDAL IDEATION IN IRAQ WAR VETERANS: THE ROLE OF DIRECT AND INDIRECT KILLING IN COMBAT

BACKGROUND

Although research has identified numerous risk factors for military suicide, the contribution of combat exposure to suicide risk has not been clearly established. Previous studies finding no association of suicidality with combat exposure have employed overgeneral measures of exposure, which do not differentiate among the varieties of combat experiences. This study disaggregated the forms of combat exposure to assess the contribution of combat-related killing to morbid thoughts and suicidal ideation (MTSI) in National Guard troops deployed to Iraq.

METHODS

We conducted parallel analyses of two related samples: a cross-sectional sample (n = 1,665) having postdeployment interview data only and a longitudinal subsample (n = 922) having pre- and postdeployment data. We used multiple logistic regression to examine the role of killing-related exposures, after controlling for general combat and other suicide risks, and examined interactions between killing and other suicide vulnerability factors.

RESULTS

Killing-related exposure approximately doubled the risk of MTSI in the cross-sectional multivariate model (Adjusted Odds Ratio [AOR] = 1.87; CI = 1.26-2.78) and the longitudinal model (AOR = 2.02; CI = 1.06-3.85), which also controlled for predeployment risks. Killing exposures further increased the MTSI risk associated with other suicide vulnerability factors, including depression (AOR = 14.89 for depression and killing vs. AOR = 9.92 for depression alone), alcohol dependence (AOR = 5.63 for alcohol and killing vs. 1.91 for alcohol alone), and readjustment stress (AOR = 4.90 for stress and killing vs. 1.48 for stress alone). General combat exposure had no comparable effects.

CONCLUSIONS

The findings underscore a need for assessment and treatment protocols that address the psychological effects of killing-related and other potentially "morally injurious" experiences among combat soldiers.