Joshua E. Wilk

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

CONTEXT A 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. OBJECTIVES To (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. DESIGN Population-based, cross-sectional study. SETTING United States Army posts and National Guard armories. PARTICIPANTS A total of 18 305 US Army soldiers from 4 Active Component and 2 National Guard infantry brigade combat teams. INTERVENTIONS Between 2004 and 2007, anonymous mental health surveys were collected at 3 and 12 months following deployment. MAIN OUTCOME MEASURES Current PTSD, depression, functional impairment, alcohol misuse, and aggressive behavior. RESULTS Prevalence 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. CONCLUSIONS The 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.

Relationship of combat experiences to alcohol misuse among U.S. soldiers returning from the Iraq war

OBJECTIVE Studies have shown a relationship between combat experiences and alcohol misuse in military personnel; it is not known if there are specific combat experiences that confer a greater risk. The current study examined the association of specific types of combat experiences with a positive screen for alcohol misuse. METHODS 1120 U.S. soldiers who were members of brigade combat infantry teams were surveyed anonymously 3-4 months after returning from deployment to Iraq regarding their experiences in combat and their physical and mental health. Combat items were independently rated and placed into the following categories: (1) Fighting; (2) Killing; (3) Threat to oneself; (4) Death/injury of others; (5) Atrocities; and, (6) Positive experiences. Alcohol misuse was measured using a 2-item alcohol screen combined with alcohol-related behavioral items. RESULTS Of the soldiers sampled, 25% (N=275) screened positive for alcohol misuse 3-4 months post-deployment; 12% (N=125) screened positive and exhibited alcohol-related behavioral problems. Most combat exposure factors were significantly related to alcohol misuse individually. When factors were analyzed simultaneously, soldiers who had higher rates of exposure to the threat of death/injury were significantly more likely to screen positive for alcohol misuse; exposure to atrocities predicted misuse of alcohol with alcohol-related behavioral problems. CONCLUSIONS High exposure to threatening situations and atrocities was associated with a positive screen for alcohol misuse. Clinicians treating combat veterans should be aware of the potential association of alcohol misuse with specific types of experiences and closely follow those soldiers upon their return home.

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.

The prevalence of post-traumatic stress disorder (PTSD) in US combat soldiers: a head-to-head comparison of DSM-5 versus DSM-IV-TR symptom criteria with the PTSD checklist

BACKGROUND The definition of post-traumatic stress disorder (PTSD) underwent substantial changes in the 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). How this will affect estimates of prevalence, whether clinical utility has been improved, and how many individuals who meet symptom criteria according to the previous definition will not meet new criteria is unknown. Updated screening instruments, including the PTSD checklist (PCL), have not been compared with previously validated methods through head-to-head comparisons. METHODS We compared the new 20-item PCL, mapped to DSM-5 (PCL-5), with the original validated 17-item specific stressor version (PCL-S) in 1822 US infantry soldiers, including 946 soldiers who had been deployed to Iraq or Afghanistan. Surveys were administered in November, 2013. Soldiers alternately received either of two surveys that were identical except for the order of the two PCL versions (911 per group). Standardised scales measured major depression, generalised anxiety, alcohol misuse, and functional impairment. RESULTS In analysis of all soldiers, 224 (13%) screened positive for PTSD by DSM-IV-TR criteria and 216 (12%) screened positive by DSM-5 criteria (κ 0·67). In soldiers exposed to combat, 177 (19%) screened positive by DSM-IV-TR and 165 (18%) screened positive by DSM-5 criteria (0·66). However, of 221 soldiers with complete data who met DSM-IV-TR criteria, 67 (30%) did not meet DSM-5 criteria, and 59 additional soldiers met only DSM-5 criteria. PCL-5 scores from 15-38 performed similarly to PCL-S scores of 30-50; a PCL-5 score of 38 gave optimum agreement with a PCL-S of 50. The two definitions showed nearly identical association with other psychiatric disorders and functional impairment. CONCLUSIONS Our findings showed the PCL-5 to be equivalent to the validated PCL-S. However, the new PTSD symptom criteria do not seem to have greater clinical utility, and a high percentage of soldiers who met criteria by one definition did not meet the other criteria. Clinicians need to consider how to manage discordant outcomes, particularly for service members and veterans with PTSD who no longer meet criteria under DSM-5. FUNDING US Army Military Operational Medicine Research Program (MOMRP), Fort Detrick, MD.

PTSD treatment for soldiers after combat deployment: low utilization of mental health care and reasons for dropout.

OBJECTIVE Limited data exist on the adequacy of treatment for posttraumatic stress disorder (PTSD) after combat deployment. This study assessed the percentage of soldiers in need of PTSD treatment, the percentage receiving minimally adequate care, and reasons for dropping out of care. METHODS Data came from two sources: a population-based cohort of 45,462 soldiers who completed the Post-Deployment Health Assessment and a cross-sectional survey of 2,420 infantry soldiers after returning from Afghanistan (75% response rate). RESULTS Of 4,674 cohort soldiers referred to mental health care at a military treatment facility, 75% followed up with this referral. However, of 2,230 soldiers who received a PTSD diagnosis within 90 days of return from Afghanistan, 22% had only one mental health care visit and 41% received minimally adequate care (eight or more encounters in 12 months). Of 229 surveyed soldiers who screened positive for PTSD (PTSD Checklist score ≥50), 48% reported receiving mental health treatment in the prior six months at any health care facility. Of those receiving treatment, the median number of visits in six months was four; 22% had only one visit, 52% received minimally adequate care (four or more visits in six months), and 24% dropped out of care. Reported reasons for dropout included soldiers feeling they could handle problems on their own, work interference, insufficient time with the mental health professional, stigma, treatment ineffectiveness, confidentiality concerns, or discomfort with how the professional interacted. CONCLUSIONS Treatment reach for PTSD after deployment remains low to moderate, with a high percentage of soldiers not accessing care or not receiving adequate treatment. This study represents a call to action to validate interventions to improve treatment engagement and retention.

Mild Traumatic Brain Injury (Concussion), Posttraumatic Stress Disorder, and Depression in U.S. Soldiers Involved in Combat Deployments: Association With Postdeployment Symptoms

Objectives Several studies have examined the relationship between concussion/mild traumatic brain injury (mTBI), posttraumatic stress disorder (PTSD), depression, and postdeployment symptoms. These studies indicate that the multiple factors involved in postdeployment symptoms are not accounted for in the screening processes of the Department of Defense/Veteran’s Affairs months after concussion injuries. This study examined the associations of single and multiple deployment-related mTBIs on postdeployment health. Methods A total of 1502 U.S. Army soldiers were administered anonymous surveys 4 to 6 months after returning from deployment to Iraq or Afghanistan assessing history of deployment-related concussions, current PTSD, depression, and presence of postdeployment physical and neurocognitive symptoms. Results Of these soldiers, 17% reported an mTBI during their previous deployment. Of these, 59% reported having more than one. After adjustment for PTSD, depression, and other factors, loss of consciousness was significantly associated with three postconcussive symptoms, including headaches (odds ratio [OR] = 1.5, 95% confidence interval [CI] = 1.1–2.3). However, these symptoms were more strongly associated with PTSD and depression than with a history of mTBI. Multiple mTBIs with loss of consciousness increased the risk of headache (OR = 4.0, 95% CI = 2.4–6.8) compared with a single occurrence, although depression (OR = 4.2, 95% CI = 2.6–6.8) remained as strong a predictor. Conclusions These data indicate that current screening tools for mTBI being used by the Department of Defense/Veteran’s Affairs do not optimally distinguish persistent postdeployment symptoms attributed to mTBI from other causes such as PTSD and depression. Accumulating evidence strongly supports the need for multidisciplinary collaborative care models of treatment in primary care to collectively address the full spectrum of postwar physical and neurocognitive health concerns. Abbreviations TBI = traumatic brain injury; mTBI = mild traumatic brain injury; LOC = loss of consciousness; AOC = alteration of consciousness; DOD = U.S. Department of Defense; VA = U.S. Department of Veterans Affairs; PTSD = posttraumatic stress disorder; PCS = postconcussive symptom(s); PHQ-15 = 15-item Patient Health Questionnaire; PCL = PTSD Checklist; CES = Combat Exposure Scale

Screening for Alcohol Misuse and Alcohol-Related Behaviors Among Combat Veterans

OBJECTIVE The U.S. military conducts health screenings of service members three to six months after they return from combat deployments. This population health program includes a modified version of the Two-Item Conjoint Screen (TICS), which is widely used in primary care to screen for alcohol misuse. Rates of referral in the military for alcohol treatment are very low, and the utility of these screening questions in predicting serious alcohol-related behaviors is unknown. METHODS Anonymous surveys were collected from 6,527 U.S. Army soldiers who were screened three to four months after returning from deployment to Iraq. Positive responses on the TICS alcohol screen were correlated with alcohol-related behaviors. Odds ratios (ORs) were calculated using logistic regression, after adjusting for gender, rank, race, and military component (active or reserve). RESULTS Twenty-seven percent of soldiers screened positive for alcohol misuse. Compared with soldiers who screened negative, those who screened positive were more likely to have recently engaged in the following behaviors: drinking and driving (OR=4.99, 95% confidence interval [CI]=4.31-5.76), riding with a driver who had been drinking (OR=5.87, CI=4.99-6.91), reporting late or missing work because of a hangover (OR=9.24, CI=6.73-12.68), using illicit drugs (OR=4.97, CI=3.68-6.71), being referred to alcohol rehabilitation (OR=7.15, CI=4.84-10.58), and being convicted of driving under the influence (OR=4.84, CI=3.04-7.67). CONCLUSIONS Positive responses to a two-item alcohol screening tool were strongly associated with serious alcohol-related behaviors. This study highlights the need to improve screening and access to care for alcohol-related problems among service members returning from combat deployments.

Trends in Mental Health Services Utilization and Stigma in US Soldiers From 2002 to 2011

OBJECTIVES We characterized trends in mental health services utilization and stigma over the course of the Afghanistan and Iraq wars among active-component US soldiers. METHODS We evaluated trends in mental health services utilization and stigma using US Army data from the Health-Related Behavior (HRB) surveys from 2002, 2005, and 2008 (n = 12,835) and the Land Combat Study (LCS) surveys administered to soldiers annually from 2003 to 2009 and again in 2011 (n = 22,627). RESULTS HRB and LCS data suggested increased mental health services utilization and decreased stigma in US soldiers between 2002 and 2011. These trends were evident in soldiers with and without posttraumatic stress disorder (PTSD), major depressive disorder (MDD), or PTSD and MDD. Despite the improving trends, more than half of soldiers with mental health problems did not report seeking care. CONCLUSIONS Mental health services utilization increased and stigma decreased over the course of the wars in Iraq and Afghanistan. Although promising, these findings indicate that a significant proportion of US soldiers meeting criteria for PTSD or MDD do not utilize mental health services, and stigma remains a pervasive problem requiring further attention.

Use of Evidence-Based Treatment for Posttraumatic Stress Disorder in Army Behavioral Healthcare

Objective: To identify the extent to which evidence-based psychotherapy (EBP) and psychopharmacologic treatments for posttraumatic stress disorder (PTSD) are provided to U.S. service members in routine practice, and the degree to which they are consistent with evidence-based treatment guidelines. Method: We surveyed the majority of Army behavioral health providers (n = 2,310); surveys were obtained from 543 (26%). These clinicians reported clinical data on a total sample of 399 service member patients. Of these patients, 110 (28%) had a reported PTSD diagnosis. Data were weighted to account for sampling design and nonresponses. Results: Army providers reported 86% of patients with PTSD received evidence-based psychotherapy (EBP) for PTSD. As formal training hours in EBPs increased, reported use of EBPs significantly increased. Although EBPs for PTSD were reported to be widely used, clinicians who deliver EBP frequently reported not adhering to all core procedures recommended in treatment manuals; less than half reported using all the manualized core EBP techniques. Conclusions: Further research is necessary to understand why clinicians modify EBP treatments, and what impact this has on treatment outcomes. More data regarding the implications for treatment effectiveness and the role of clinical context, patient preferences, and clinical decision-making in adapting EBPs could help inform training efforts and the ways that these treatments may be better adapted for the military.

2003-2009 marital functioning trends among U.S. enlisted soldiers following combat deployments

OBJECTIVE This study examined 2003-2009 trends in three marital functioning indicators: marital quality, infidelity, and separation/divorce intent, and in marital dissolution rates among U.S. soldiers. METHODS Marital functioning trends were examined with cross-sectional postdeployment sample data collected under the Land Combat Study from married, male, enlisted soldiers who had deployed to Iraq or Afghanistan (n = 5,928). Marital dissolution rates were examined with population data (n = 1,895,571). The relationships between time (measured by year) and all study variables were analyzed with chi2 tests of association, analysis of variance, and logistic regression analyses adjusting for combat exposure, mental and physical health, and demographic variables. RESULTS Marital quality has declined, and reports of past-year infidelity and separation/divorce intent have increased between 2003 and 2009. However, no increases were observed in marital dissolution rates. CONCLUSIONS The results indicate that more proximal indicators of marital functioning such as decreased marital quality, infidelity, and separation/divorce intent may better illustrate the strain that increased deployment tempo exerts on marital relationships. The findings provide a better understanding of how Army marriages have been affected by the wars, and suggest that further inquiry is needed on military marriages.