Carl A. Castro

Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq

BACKGROUNDnAn 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.nnnMETHODSnWe 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.nnnRESULTSnOf 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.nnnCONCLUSIONSnMild 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.

Prevalence of Mental Health Problems and Functional Impairment Among Active Component and National Guard Soldiers 3 and 12 Months Following Combat in Iraq

CONTEXTnA 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.nnnOBJECTIVESnTo (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.nnnDESIGNnPopulation-based, cross-sectional study.nnnSETTINGnUnited States Army posts and National Guard armories.nnnPARTICIPANTSnA total of 18 305 US Army soldiers from 4 Active Component and 2 National Guard infantry brigade combat teams.nnnINTERVENTIONSnBetween 2004 and 2007, anonymous mental health surveys were collected at 3 and 12 months following deployment.nnnMAIN OUTCOME MEASURESnCurrent PTSD, depression, functional impairment, alcohol misuse, and aggressive behavior.nnnRESULTSnPrevalence 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.nnnCONCLUSIONSnThe 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.

Association of Posttraumatic Stress Disorder With Somatic Symptoms, Health Care Visits, and Absenteeism Among Iraq War Veterans

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

Battlemind Debriefing and Battlemind Training as Early Interventions With Soldiers Returning From Iraq: Randomization by Platoon

Researchers have found that there is an increase in mental heath problems as a result of military-related traumatic events, and such problems increase in the months following return from combat. Nevertheless, researchers have not assessed the impact of early intervention efforts with this at-risk population. In the present study, the authors compared different early interventions with 2,297 U.S. soldiers following a year-long deployment to Iraq. Platoons were randomly assigned to standard postdeployment stress education, Battlemind debriefing, and small and large group Battlemind training. Results from a 4-month follow-up with 1,060 participants showed those with high levels of combat exposure who received Battlemind debriefing reported fewer posttraumatic stress symptoms, depression symptoms, and sleep problems than those in stress education. Small group Battlemind training participants with high combat exposure reported fewer posttraumatic stress symptoms and sleep problems than stress education participants. Compared to stress education participants, large group Battlemind training participants with high combat exposure reported fewer posttraumatic stress symptoms and lower levels of stigma and, regardless of combat exposure, reported fewer depression symptoms. Findings demonstrate that brief early interventions have the potential to be effective with at-risk occupational groups.

Care of war veterans with mild traumatic brain injury--flawed perspectives.

Researchers estimate that more than 300,000 U.S. veterans of the wars in Iraq and Afghanistan have sustained a mild traumatic brain injury. Dr. Charles Hoge, Herb Goldberg, and Carl Castro write that the clinical definition of “concussion/mild TBI” adopted by the Department of Defense and the VA is inadequate for achieving the objectives of their well-intentioned initiatives.

Stigma, Barriers to Care, and Use of Mental Health Services Among Active Duty and National Guard Soldiers After Combat

OBJECTIVEnThis 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).nnnMETHODSnCross-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.nnnRESULTSnA 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.nnnCONCLUSIONSnActive 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.

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.

Mild traumatic brain injury (concussion) during combat: lack of association of blast mechanism with persistent postconcussive symptoms.

ObjectiveTo determine whether screening for a blast mechanism of concussion identifies individuals at higher risk of persistent postconcussive symptoms (PCS). SettingUnited States Army post. Participants3952 US Army infantry soldiers were administered anonymous surveys 3 to 6 months after returning from a yearlong deployment to Iraq. Main Outcome MeasuresSelf-reported concussion (defined as an injury that resulted in being “dazed, confused, or ‘seeing stars’”; “not remembering the injury”; or “losing consciousness [knocked out]): Patient Health Questionnaire 15-item scale for physical symptoms and PCS; Posttraumatic Stress Disorder Checklist; and Patient Health Questionnaire depression module. ResultsOf the 587 soldiers (14.9% of the total sample) who met criteria for concussion, 201 (34.2%) reported loss of consciousness, and 373 (63.5%) reported only an alteration of consciousness without loss of consciousness; 424 (72.2%) reported a blast mechanism, and 150 (25.6%) reported a nonblast mechanism. Among soldiers who lost consciousness, blast mechanism was significantly associated with headaches and tinnitus 3 to 6 months postdeployment compared with a nonblast mechanism. However, among the larger group of soldiers reporting concussions without loss of consciousness, blast was not associated with adverse health outcomes. ConclusionsBlast mechanism of concussion was inconsistently associated with PCS, depending on the definition of concussion utilized. A self-reported history of blast mechanism was not associated with persistent PCS for the majority of US soldiers with concussions.

Self-Engagement, Stressors, and Health: A Longitudinal Study

The authors examined whether engagement in a performance domain could buffer or exacerbate the consequences of different stressors. Soldiers completed measures of engagement in work, work demands (days training, work hours, and subjective work overload), and symptoms at two time periods. Engagement in work interacted with days training and work hours at Time 1 to predict health symptoms at Time 2 (after controlling Time 1 outcomes). Soldiers highly engaged in their jobs were less likely to report negative consequences under high levels of training/work hours in comparison to soldiers disengaged from their jobs. However, engagement in work interacted with work overload in the opposite manner, with high levels of engagement potentiating the relationship between overload and reports of health symptoms. Engagement in a domain appears to buffer individuals from stressors that do not undermine performance but may exacerbate the impact of stressors that compromise performing well in the domain.

How Leaders Can Influence the Impact That Stressors Have on Soldiers.

The present review addresses the importance of leader behaviors in influencing the extent to which various stressors soldiers experience (e.g., high workload and lack of sleep) are related to different types of strains (e.g., psychological health, poor job satisfaction, and low morale). Research conducted by the Walter Reed Army Institute of Research (WRAIR) in the area of leadership is reviewed. Researchers at the WRAIR have examined the role of leadership as a predictor of stress, as a buffer against the negative effects of stress, and as a variable that predicts or enables variables that have been found to decrease the adverse effects of stress (e.g., role clarity, self-efficacy, and job engagement). A key strength of the WRAIR program of research is the use of multilevel modeling to examine how perceptions of leadership at the unit level are related to unit and individual soldier well-being and motivation.