Helena K. Chandler

Effects of Repeated Deployment to Iraq and Afghanistan on the Health of New Jersey Army National Guard Troops: Implications for Military Readiness

OBJECTIVES We assessed the effects of prior military service in Iraq or Afghanistan on the health of New Jersey Army National Guard members preparing for deployment to Iraq. METHODS We analyzed anonymous, self-administered predeployment surveys from 2543 National Guard members deployed to Iraq in 2008. We used bivariate and multivariate analyses to measure the effects of prior service in Afghanistan (Operation Enduring Freedom [OEF]) or Iraq (Operation Iraqi Freedom [OIF]) on mental and physical health. RESULTS Nearly 25% of respondents reported at least 1 previous OEF or OIF deployment. Previously deployed soldiers were more than 3 times as likely as soldiers with no previous deployments to screen positive for posttraumatic stress disorder (adjusted odds ratio [AOR]=3.69; 95% confidence interval [CI]=2.59, 5.24) and major depression (AOR=3.07; 95% CI=1.81, 5.19), more than twice as likely to report chronic pain (AOR=2.20; 95% CI=1.78, 2.72) and more than 90% more likely to score below the general population norm on physical functioning (AOR=1.94; 95% CI=1.51, 2.48). CONCLUSIONS Repeated OEF and OIF deployments may adversely affect the military readiness of New Jersey National Guard combat soldiers.

Chronic Widespread Pain, Mental Health, and Physical Role Function in OEF/OIF Veterans

OBJECTIVE Describe the associations among pain, mental health concerns, and function in veterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). DESIGN Retrospective review of self-reported, standardized clinical intake surveys. SETTING A multidisciplinary deployment health clinic at a Veterans Affairs (VA) medical center. PATIENTS The first 429 veterans of OEF/OIF presenting for clinical evaluation at a deployment health clinic. OUTCOME MEASURES Function, measured with the Role Physical (RP) scale of the Veterans RAND (VR)-36 survey, was compared for veterans with and without chronic widespread pain (CWP). RESULTS After controlling for age, sex, and positive screens for depression and post-traumatic stress disorder (PTSD), the presence of CWP had a significant, clinically relevant, and independent effect on VR-36 RP (-6.2 points, DeltaR(2) = 0.052, P < 0.001). Mean VR-36 RP normed score was 43.3 (standard deviation 11.9). CWP was common (29%), as were positive mental health screens (PTSD 53%, depression 60%, alcohol misuse 63%). CONCLUSIONS In this sample of OEF/OIF veterans, the majority of whom reported good or better general health, CWP was common and related to poorer physical role function, independent of comorbid mental health concerns.

Rumination moderates the associations between PTSD and depressive symptoms and risky behaviors in U.S. veterans

Risky behaviors, including unsafe sex, aggression, rule breaking, self-injury, and dangerous substance use have become a growing issue for U.S. veterans returning from combat deployments. Evidence in nonveteran samples suggests that risky behaviors reflect efforts to cope with and alleviate depressive and/or anxious symptoms, particularly for individuals with poor emotion-regulation skills. These associations have not been studied in veterans. Rumination, or repeated thoughts about negative feelings and past events, is a coping strategy that is associated with several psychopathologies common in veterans. In this cross-sectional study, 91 recently returned veterans completed measures of trait rumination, self-reported risky behaviors, and symptoms of posttraumatic stress disorder (PTSD) and depression. Analyses revealed that veterans with more depressive and PTSD symptoms reported more risky behaviors. Moreover, rumination significantly interacted with PTSD symptoms and depressive symptoms (both β = .21, p < .05), such that psychiatric symptoms were associated with risky behaviors only for veterans with moderate to high levels of rumination. Although cross-sectional, these findings support theory that individuals with poor coping skills may be particularly likely to respond to negative mood states by engaging in risky behaviors. Implications include using rumination-focused interventions with veterans in order to prevent engagement in risky behaviors.

Illness trajectories in the chronic fatigue syndrome: a longitudinal study of improvers versus non-improvers.

The natural progression of chronic fatigue syndrome (CFS) in adults is not well established. The aims of this longitudinal study were to (a) compare CFS Improvers and Non-Improvers; (b) determine whether an initial diagnosis of fibromyalgia (FM) was associated with CFS nonimprovement; and (c) determine whether this effect could be explained by the presence of nonspecific physical symptoms. Consecutive referrals to a tertiary clinic that satisfied case criteria for CFS were invited to enroll in a longitudinal study. After an initial on-site physical examination and psychiatric interview, a total of 94 female care-seekers completed biannual telephone surveys, including the Short Form-36 physical functioning (PF) scale, over a period of 2½ years. There were very few differences between Improvers and Non-Improvers at baseline but at final assessment Improvers had less disability, less fatigue, lower levels of pain, fewer symptoms of depressed mood, and fewer nonspecific physical complaints. Participants with FM at baseline were 3.23 times (p < 0.05) more likely to become Non-Improvers than those without FM. Participants identified initially as Somatizers were 3.33 times (p < 0.05) more likely to become Non-Improvers. Patients with CFS who bear the added burden of FM are at greater risk of a negative outcome than patients with CFS alone. This effect could not be explained by the presence of multiple, nonspecific symptoms.

Hypocapnia is a biological marker for orthostatic intolerance in some patients with chronic fatigue syndrome

ContextPatients with chronic fatigue syndrome and those with orthostatic intolerance share many symptoms, yet questions exist as to whether CFS patients have physiological evidence of orthostatic intolerance.ObjectiveTo determine if some CFS patients have increased rates of orthostatic hypotension, hypertension, tachycardia, or hypocapnia relative to age-matched controls.DesignAssess blood pressure, heart rate, respiratory rate, end tidal CO2 and visual analog scales for orthostatic symptoms when supine and when standing for 8 minutes without moving legs.SettingReferral practice and research center.Participants60 women and 15 men with CFS and 36 women and 4 men serving as age matched controls with analyses confined to 62 patients and 35 controls showing either normal orthostatic testing or a physiological abnormal test.Main outcome measuresOrthostatic tachycardia; orthostatic hypotension; orthostatic hypertension; orthostatic hypocapnia or combinations thereof.ResultsCFS patients had higher rates of abnormal tests than controls (53% vs 20%, p < .002), but rates of orthostatic tachycardia, orthostatic hypotension, and orthostatic hypertension did not differ significantly between patients and controls (11.3% vs 5.7%, 6.5% vs 2.9%, 19.4% vs 11.4%, respectively). In contrast, rates of orthostatic hypocapnia were significantly higher in CFS than in controls (20.6% vs 2.9%, p < .02). This CFS group reported significantly more feelings of illness and shortness of breath than either controls or CFS patients with normal physiological tests.ConclusionA substantial number of CFS patients have orthostatic intolerance in the form of orthostatic hypocapnia. This allows subgrouping of patients with CFS and thus reduces patient pool heterogeneity engendered by use of a clinical case definition.

A Retrospective Cohort Study of U.S. Service Members Returning from Afghanistan and Iraq: Is Physical Health Worsening Over time?

BackgroundHigh rates of mental health disorders have been reported in veterans returning from deployment to Afghanistan (Operation Enduring Freedom: OEF) and Iraq (Operation Iraqi Freedom: OIF); however, less is known about physical health functioning and its temporal course post-deployment. Therefore, our goal is to study physical health functioning in OEF/OIF veterans after deployment.MethodsWe analyzed self-reported physical health functioning as physical component summary (PCS) scores on the Veterans version of the Short Form 36 health survey in 679 OEF/OIF veterans clinically evaluated at a post-deployment health clinic. Veterans were stratified into four groups based on time post-deployment: (1Yr) 0 – 365 days; (2Yr) 366 – 730 days; (3Yr) 731 – 1095 days; and (4Yr+) > 1095 days. To assess the possibility that our effect was specific to a treatment-seeking sample, we also analyzed PCS scores from a separate military community sample of 768 OEF/OIF veterans evaluated pre-deployment and up to one-year post-deployment.ResultsIn veterans evaluated at our clinic, we observed significantly lower PCS scores as time post-deployment increased (p = 0.018) after adjusting for probable post-traumatic stress disorder (PTSD). We similarly observed in our community sample that PCS scores were lower both immediately after and one year after return from deployment (p < 0.001) relative to pre-deployment PCS. Further, PCS scores obtained 1-year post-deployment were significantly lower than scores obtained immediately post-deployment (p = 0.02).ConclusionIn our clinical sample, the longer the duration between return from deployment and their visit to our clinic, the worse the Veteran’s physical health even after adjusting for PTSD. Additionally, a decline is also present in a military community sample of OEF/OIF veterans. These data suggest that, as time since deployment length increases, physical health may deteriorate for some veterans.

Medically unexplained illness in short- and long-term disability applicants: Prevalence and cost of salary reimbursement

Purpose. Compared to patients with explained illness, patients with medically unexplained illness (MUI) may be at elevated risk of applying for disability. Accordingly, patients with MUI may account for a disproportionate number of disability claims and for a disproportionate percentage of salary reimbursement costs. The study was conducted to determine: (a) The prevalence of MUI among disability insurance claimants; (b) the cost of salary reimbursement; and (c) the impact of psychiatric comorbidity on length and cost of disability. Method. An insurance database of 26,451 short-term disability (STD) recipients with long-term disability (LTD) coverage was analyzed to determine the prevalence and salary reimbursement costs of MUI. Applicants with medically explained and psychiatric illness were included for comparison. Results. The prevalence of MUI among STD recipients was lower than clinical and community rates. Rates of application and receipt of LTD benefits for MUI were similar to explained illness. When LTD payments were projected to retirement age, costs associated with unexplained back pain and fibromyalgia were comparable to those of explained illness. The length of disability and salary reimbursement costs were greater when comorbid psychiatric illness was present. Conclusions. Patients with MUI did not account for a disproportionate number of disability claims or amount of the money spent on salary reimbursement. Comorbid psychiatric illness increased the length and cost of disability.

Iraq and Afghanistan Veterans report symptoms consistent with chronic multisymptom illness one year after deployment

Many Veterans returning from service in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) experience chronic pain. What is not known is whether for some OIF/OEF Veterans this pain is part of a larger condition of diffuse multisystem symptoms consistent with chronic multisymptom illness (CMI). We use data from a prospective longitudinal study of OIF/OEF Veterans to determine the frequency of CMI. We found that 1 yr after deployment, 49.5% of OIF/OEF Veterans met criteria for mild to moderate CMI and 10.8% met criteria for severe CMI. Over 90% of Veterans with chronic pain met criteria for CMI. CMI was not completely accounted for either by posttraumatic stress disorder or by predeployment levels of physical symptoms. Veterans with symptoms consistent with CMI reported significantly worse physical health function than Veterans who did not report symptoms consistent with CMI. This study suggests that the presence of CMI should be considered in the evaluation of OIF/OEF Veterans. Further, it suggests the pain management for these Veterans may need to be tailored to take CMI into consideration.

A test of the symptom amplification hypothesis in patients with asthma.

The present study sought to measure the accuracy of symptom reporting in patients with asthma by calculating the difference between a subjective rating of illness severity and an objective test of lung function (forced expiratory volume in 1 second). At issue was the hypothesis that self-reported “symptom amplification” or sensory awareness accounts for differences in the accuracy of symptom reporting. Spirometric examination was performed, and psychological tests of symptom amplification, emotional distress, and neuroticism were administered. Participants consisted of 42 consecutive patients seeking medical treatment of asthma. The disparity between symptom perception (assessed by a Borg scale) and a corresponding measure of lung capacity allowed us to identify patients who overreported their symptoms (amplifiers) along with those who underreported them (minimizers). After controlling for the effects of sex and psychological distress, a self-report measure of symptom amplification explained 15% of the variability in reporting accuracy. Related constructs such as somatization and neuroticism could not explain differences in reporting ability.

Catastrophic appraisal of acute and chronic pain in a population sample of new jersey national guard troops.

ObjectivesCatastrophic appraisal has been implicated as a possible cause of psychiatric morbidity, psychological distress, and physical impairment in individuals with chronic pain. At issue in this study was whether catastrophizing was associated with psychiatric morbidity in a population sample of National Guard members. In addition, we sought to determine whether it could account for individual differences in psychological distress and impaired physical function in the presence of acute and chronic pain. MethodsWe performed a secondary analysis of an existing survey database. The original survey was designed to assess combat readiness in a population sample of 2995 National Guard troops about to deploy overseas. The database included screening instruments for psychiatric illness as well as continuous measures of psychological distress, pain perception, pain catastrophizing, and perceived physical function. ResultsAmong Guard members reporting a problem with pain, frequent catastrophizing was associated with higher rates of depression, posttraumatic stress, alcohol dependence, and somatization-like illness. Higher rates were also associated with chronic as opposed to acute pain (except for alcohol dependence). Pain-related catastrophizing accounted for substantial variance in measures of psychological distress and physical impairment regardless of pain duration. DiscussionAlthough catastrophizing beliefs are common in clinical settings, this study suggests that the phenomenon may be prevalent in the population at large and likely to influence the outcome of acute as well as chronic pain.