Lyndon A. Riviere

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.

Stigma, Negative Attitudes About Treatment, and Utilization of Mental Health Care Among Soldiers

Stigma and organizational barriers have been identified as factors for why a small proportion of soldiers with psychological problems seek professional help. In this article, we examine the impact of negative attitudes toward treatment on treatment seeking among soldiers previously deployed to Afghanistan or Iraq (n = 2,623). We asked soldiers with psychological problems questions about stigma, organizational barriers, negative attitudes toward treatment, and whether they sought treatment for their psychological problems. We found that negative attitudes about treatment inversely predicted treatment seeking. These results provide a more comprehensive examination of reasons that soldiers do not seek needed treatment and highlight the need for policy aimed at reducing negative attitudes toward mental health treatment.

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

Mental health outcomes in US and UK military personnel returning from Iraq

BACKGROUND Research of military personnel who deployed to the conflicts in Iraq or Afghanistan has suggested that there are differences in mental health outcomes between UK and US military personnel. AIMS To compare the prevalence of post-traumatic stress disorder (PTSD), hazardous alcohol consumption, aggressive behaviour and multiple physical symptoms in US and UK military personnel deployed to Iraq. METHOD Data were from one US (n = 1560) and one UK (n = 313) study of post-deployment military health of army personnel who had deployed to Iraq during 2007-2008. Analyses were stratified by high- and low-combat exposure. RESULTS Significant differences in combat exposure and sociodemographics were observed between US and UK personnel; controlling for these variables accounted for the difference in prevalence of PTSD, but not in the total symptom level scores. Levels of hazardous alcohol consumption (low-combat exposure: odds ratio (OR) = 0.13, 95% CI 0.07-0.21; high-combat exposure: OR = 0.23, 95% CI 0.14-0.39) and aggression (low-combat exposure: OR = 0.36, 95% CI 0.19-0.68) were significantly lower in US compared with UK personnel. There was no difference in multiple physical symptoms. CONCLUSIONS Differences in self-reported combat exposures explain most of the differences in reported prevalence of PTSD. Adjusting for self-reported combat exposures and sociodemographics did not explain differences in hazardous alcohol consumption or aggression.

Coming home may hurt: risk factors for mental ill health in US reservists after deployment in Iraq

BACKGROUND Little research has been conducted on the factors that may explain the higher rates of mental health problems in United States National Guard soldiers who have deployed to the Iraq War. AIMS To examine whether financial hardship, job loss, employer support and the effect of deployment absence on co-workers were associated with depression and post-traumatic stress disorder (PTSD). METHOD Cross-sectional data were obtained from 4034 National Guard soldiers at two time points. All measures were assessed by self-report. RESULTS The four factors were associated with depression and PTSD, with variability based on outcome and time point. For example, job loss increased the odds of meeting criteria for depression at 3 and 12 months and for PTSD at 12 months; the negative effect of deployment absence on co-workers increased the likelihood of meeting criteria for PTSD, but not depression, at both time points. CONCLUSIONS The findings demonstrate that National Guard soldiers have unique post-deployment social and material concerns that impair their mental health.

Grief and physical health outcomes in U.S. soldiers returning from combat

BACKGROUND Few studies have measured the burden of physical health problems after Iraq/Afghanistan deployment, except in association with post-traumatic stress disorder (PTSD) or mild traumatic brain injury (mTBI). Grief, a correlate of health problems in the general population, has not been systematically examined. We aimed to identify the prevalence of post-deployment physical health problems and their association with difficulty coping with grief. METHODS Infantry soldiers (n=1522) completed anonymous surveys using validated instruments six months following deployment in November-December 2008. Multiple logistic regression was used to assess the association of difficulty coping with grief and physical health. RESULTS The most frequent physical health symptoms reported were: sleep problems (32.8%), musculoskeletal pain (32.7%), fatigue (32.3%), and back pain (28.1%). Difficulty coping with grief over the death of someone close affected 21.3%. There was a dose-response relationship between level of difficulty coping with grief and principal physical health outcomes (ps<.002). Controlling for demographics, combat experiences, injuries, PTSD, depression, and other factors, grief significantly and uniquely contributed to a high somatic symptom score (adjusted odds ratio (AOR)=3.6), poor general health (AOR=2.0), missed work (AOR=1.7), medical utilization (AOR=1.5), difficulty carrying a heavy load (AOR=1.7), and difficulty performing physical training (AOR=1.6; all 95% confidence intervals>1). LIMITATIONS Data are cross-sectional and grief was measured with one item. CONCLUSIONS Over 20% of soldiers reported difficulty coping with grief. This difficulty was significantly associated with physical health outcomes and occupational impairment. Clinicians should be aware of the unique role grief plays in post-deployment physical health when treating patients.

Chronic Pain and Opioid Use in US Soldiers After Combat Deployment

Chronic Pain and Opioid Use in US Soldiers After Combat Deployment Chronic pain affects a quarter of people seeking primary health care.1,2 Opioid medications are prescribed for chronic pain, but recently, rates of opioid use and misuse have ballooned, leading to significant numbers of overdose-related hospitalizations and deaths.3 The prevalence of chronic pain and opioid use assoc iated w ith deployment is not well known, despite large numbers of wounded service members. To our knowledge, this is the first study to assess chronic pain prevalence and opioid use in a non– treatment-seeking, active duty infantry population following deployment.