Jeane Bosch

Gender Differences in Mental Health Diagnoses Among Iraq and Afghanistan Veterans Enrolled in Veterans Affairs Health Care

OBJECTIVES We examined gender differences in sociodemographic, military service, and mental health characteristics among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. We evaluated associations between these sociodemographic and service characteristics and depression and posttraumatic stress disorder (PTSD) diagnoses. METHODS In a retrospective, cross-sectional study, we used univariate descriptive statistics and log binominal regression analyses of Department of Veterans Affairs (VA) administrative data on 329 049 OEF and OIF veterans seeking VA health care from April 1, 2002, through March 31, 2008. RESULTS Female veterans were younger and more likely to be Black and to receive depression diagnoses than were male veterans, who were more frequently diagnosed with PTSD and alcohol use disorders. Older age was associated with a higher prevalence of PTSD and depression diagnoses among women but not among men. CONCLUSIONS Consideration of gender differences among OEF and OIF veterans seeking health care at the VA will facilitate more targeted prevention and treatment services for these newly returning veterans.

Gender differences in military sexual trauma and mental health diagnoses among Iraq and Afghanistan veterans with posttraumatic stress disorder.

OBJECTIVE We examined correlates of posttraumatic stress disorder (PTSD), including military sexual trauma (MST), in Iraq and Afghanistan veterans. We also compared mental health comorbidities by gender among veterans with PTSD, with and without MST. METHODS Retrospective data analyses were conducted using Department of Veterans Affairs (VA) administrative data from 213,803 Iraq and Afghanistan veterans and the subset diagnosed with PTSD from April 1, 2002, to October 1, 2008. We used descriptive statistics and multivariate logistic regression compared by gender to investigate independent correlates and mental health comorbidities associated with PTSD, with and without MST. RESULTS Among women with PTSD, 31% screened positive for MST; 1% of men with PTSD screened positive for MST. Among those with PTSD, veterans with MST had more comorbid mental health diagnoses than those without MST. Women with PTSD and MST were more likely to receive comorbid depression, anxiety, and eating disorder diagnoses, and men were more likely to receive comorbid substance use disorder diagnoses. CONCLUSIONS MST is associated with an increased prevalence of mental health disorders comorbid with PTSD. Better understanding comorbidity patterns will allow for targeted evaluation and treatment of returning veterans with MST.

Killing in combat may be independently associated with suicidal ideation.

The United States military has lost more troops to suicide than to combat for the second year in a row and better understanding combat‐related risk factors for suicide is critical. We examined the association of killing and suicide among war veterans after accounting for PTSD, depression, and substance use disorders.

Killing and latent classes of PTSD symptoms in Iraq and Afghanistan veterans

BACKGROUND Our goal was to better understand distinct PTSD symptom presentations in Iraq and Afghanistan Veterans (N=227) and to determine whether those who killed in war were at risk for being in the most symptomatic class. METHODS We used latent class analysis of responses to the PTSD checklist and logistic regression of most symptomatic class. RESULTS We found that a four-class solution best fit the data, with the following profiles emerging: High Symptom (34% of participants), Intermediate Symptom (41%), Intermediate Symptom with Low Emotional Numbing (10%), and Low Symptom (15%). The largest group of individuals who reported killing (45%) was in the High Symptom class, and those who killed had twice the odds of being in the most symptomatic PTSD class, compared to those who did not kill. Those who endorsed killing a non-combatant (OR=4.56, 95% CI [1.77, 11.7], p<0.01) or killing in the context of anger or revenge (OR=4.63, 95% CI=[1.89, 11.4], p<0.001) were more likely to belong to the most symptomatic PTSD class, compared to those who did not kill. LIMITATIONS The study was retrospective and cross-sectional. The results may not generalize to veterans of other wars. CONCLUSIONS Killing in war may be an important indicator of risk for developing frequent and severe PTSD symptoms. This has implications for the mental healthcare of veterans, providing evidence that a comprehensive evaluation of returning veterans should include an assessment of killing experiences and reactions to killing.

The Impact of Intimate Partner Violence on Women’s Physical Health Findings From the Missouri Behavioral Risk Factor Surveillance System

Intimate partner violence (IPV) is a significant public health problem. It has far reaching consequences such as social and economic costs, as well as a negative impact on women’s health outcomes. This study assessed the relationship between IPV and health risk factors, health behaviors, and poor mental health in Missouri women utilizing 2005 Missouri Behavioral Risk Factor Surveillance System (BRFSS) data (n = 3,110). Moderators (demographic indicators) of the relationship between IPV and health risk factors (high blood pressure, high cholesterol, and obesity) and health behaviors (physical inactivity, smoking, and binge drinking) were also examined. Women with a history of IPV were more likely to engage in health-compromising behaviors such as smoking and binge drinking, be obese, and report more poor mental health days compared with women without a history of IPV. Demographic variables moderated the relationship between IPV, obesity, smoking, high blood pressure, and high cholesterol. These findings underscore the importance that clinics, community, or other health care settings can play in identifying women who are victims of or have a history of IPV and provide them with appropriate resources as well as targeted interventions to reduce morbidity in this population.

Impact of Killing in War: A Randomized, Controlled Pilot Trial

OBJECTIVE The purpose of this pilot study was to test the effectiveness of Impact of Killing (IOK), a novel, cognitive-behavioral treatment (CBT) aimed at reducing mental health symptoms and functional impairment. METHOD Participants were 33 combat Veterans with a posttraumatic stress disorder (PTSD) diagnosis who had completed trauma-focused psychotherapy and reported distress regarding killing or feeling responsible for the deaths of others in war. Veterans were randomized to either IOK treatment or a 6-week waitlist condition, after which Veterans could receive IOK. IOK is a 6- to 8-session, weekly, individual, CBT, lasting 60-90 minutes, and focused on key themes, including physiology of killing responses, moral injury, self-forgiveness, spirituality, making amends, and improved functioning. RESULTS We found that compared to controls (N = 16), the IOK group (N = 17) experienced a significant improvement in PTSD symptoms, general psychiatric symptoms, and quality of life functional measures. Veterans who received IOK reported that the treatment was acceptable and feasible. CONCLUSION These results provide preliminary evidence that Veterans can benefit from a treatment focused on the impact of killing after initial trauma therapy.

Veterans’ Perspectives on the Psychosocial Impact of Killing in War

Based on focus group and individual interviews with 26 combat veterans, this qualitative thematic analysis examines the psychosocial and interpersonal consequences of killing in war. It describes the consequences that veterans identify as most relevant in their lives, including postwar changes in emotions, cognitions, relationships, and identity. Furthermore, it illustrates the linked psychological and social dimensions of those consequences—namely, how the impact of killing in war is rooted in the unique perspectives, actions, and experiences of individual veterans, as well as the social worlds they confront upon returning from war. We found that, for many veterans, killing provokes a moral conflict with a lasting impact on their sense of self, spirituality, and relationships with others. In working with combat veterans, mental health professionals should be sensitive to the complexities of discussing killing and attuned to the psychosocial challenges veterans may face after taking a life in war.

Assessing posttraumatic stress related impairment and well-being: The Posttraumatic Stress Related Functioning Inventory (PRFI)

Posttraumatic stress symptoms are associated with poorer social and occupational functioning and quality of life. However, general assessments of functioning do not determine the extent to which these difficulties are directly related to PTSD symptoms. This study examines the psychometric properties of a self-report measure, the 27-item Posttraumatic Stress Related Functioning Inventory (PRFI), which was developed to provide a self-report tool for clinicians and researchers to better understand the perceived impact of PTSD symptoms on functioning. The psychometric properties of the PRFI were examined utilizing data collected within a larger study examining quality of life and functioning in 251 veterans who had served in OEF/OIF/OND and endorsed the presence of subsyndromal or greater levels of PTSD symptoms at screening. One-year test-retest reliability of the measure was examined in a subset of the baseline sample who received a second administration of the PRFI (n = 109). Higher levels of PTSD symptoms were associated with poorer functioning in all domains. The PRFI demonstrated convergent validity with a measure of PTSD symptoms and was less correlated with measures of alcohol and drug use, good internal consistency and test-retest reliability from baseline to one-year follow-up. The PRFI provides self-report information regarding several domains of functioning. This initial examination of psychometric properties of the scale indicated that it may be useful for efficiently eliciting information about the ways in which PTSD symptoms in veterans impact everyday functioning.

Residual Injury, Appearance-Related Concerns, Symptoms of Post-Traumatic Stress Disorder, and Depression Within a Treatment-Seeking Veteran Sample

This study explored the associations among injury-related appearance changes experienced during deployment/combat, symptom severity of post-traumatic stress disorder and depression, and body image distress within a treatment-seeking veteran population (n = 91). Thirty-three percent of the sample reported having an appearance-related residual injury experienced during combat or deployment (n = 30). A subsample, who completed the body image distress measure (n = 69), was divided into two groups: those with an appearance-related residual injury (n = 22) and those without an appearance-related residual injury (n = 47). Correlational analyses revealed significant, positive correlations between body image distress and depression symptom severity. Results also showed a trend relationship between body image distress and post-traumatic stress disorder symptom severity for those with an appearance-related residual injury although correlations were nonsignificant among these constructs for those without an appearance-related residual injury. Multiple regression analyses revealed that body image distress was a unique predictor of depression symptom severity, controlling for residual injury status. Implications of these findings for exploring the psychological impact of residual injury were discussed.

Sources of moral injury among war veterans: A qualitative evaluation

OBJECTIVE Service members deployed to war are at risk for moral injury, but the potential sources of moral injury are poorly understood. The aim of this qualitative study was to explore the types of events that veterans perceive as morally injurious and to use those events to develop a categorization scheme for combat-related morally injurious events. METHOD Six focus groups with US war veterans were conducted. RESULTS Analysis based on Grounded Theory yielded two categories (and eight subcategories) of events that putatively cause moral injury. The two categories were defined by the focal attribution of responsibility for the event: Personal Responsibility (veterans reported distress is related to his own behavior) versus Responsibility of Others (veterans distress is related to actions taken by others). Examples of each type of morally injurious event are provided. CONCLUSIONS Implications for the further development of the moral injury construct and treatment are discussed.