Nancy A. Skopp

Gender differences in depression and PTSD symptoms following combat exposure

Background: This research examined gender as a moderator of the association between combat exposure (CE) and depression as well as CE and PTSD symptoms among a nonclinical sample of Soldiers following deployment in support of operations in Afghanistan and Iraq. Methods: Cases included 6,943 (516 women, 6,427 men) active duty Soldiers that were retrospectively analyzed from a pre‐ and post‐deployment screening database at a large Army installation. Results: Gender moderated the association between CE and depressive and PTSD symptoms such that higher levels of CE were more strongly associated with depression and PTSD symptoms in women compared to men. Female Soldiers also reported higher severity of depressive symptoms compared to male Soldiers, whereas men reported higher levels of CE and a greater number of previous deployments compared to women. Conclusions: CE was a stronger predictor of post‐deployment depression and PTSD symptoms for women compared to men. These results provide evidence for gender‐based differences in depression and PTSD risk. Screening for degree of CE in addition to symptoms associated with depression and PTSD can help with the care for service members who are returning from deployments to combat zones. Depression and Anxiety, 2010. Published 2010 Wiley‐Liss, Inc.

Gender differences in traumatic experiences and mental health in active duty soldiers redeployed from Iraq and Afghanistan

The purpose of this study was to examine gender differences in combat exposure, military sexual trauma (MST), and their associations with mental health screen results among military personnel deployed in support of the wars in Afghanistan and Iraq. Data were collected as part of a pre- and post-deployment screening program at a large Army medical treatment facility. Cases included 7251 active duty soldiers (6697 men and 554 women) who presented for their pre- and post-deployment screening from March 2006 to July 2009. Pre-deployment mental health symptoms were statistically controlled for in our analyses. We found significant gender differences in demographic variables, exposure to combat, and MST. Women reported greater exposure to MST than did men. Although men reported greater exposure to high-intensity combat experiences than women, results indicate that women are experiencing combat at higher rates than observed in prior cohorts. Men were more likely to report problem drinking, and women were more likely to report depression symptoms. There were no gender differences with respect to PTSD symptoms. Although we found few differences between women and men in the impact of combat stressors on mental health, there was a stronger association between injury and PTSD symptoms for women than for men. Our findings indicate that it would be useful for clinicians to be aware of this difference and assess for exposure to a full range of traumatic combat experiences, particularly injury, as not all types of combat experiences may be equally experienced by men and women returning from military deployments.

Killing in combat, mental health symptoms, and suicidal ideation in Iraq war veterans

This study examined combat and mental health as risk factors of suicidal ideation among 2854 U.S. soldiers returning from deployment in support of Operation Iraqi Freedom. Data were collected as part of a postdeployment screening program at a large Army medical facility. Overall, 2.8% of soldiers reported suicidal ideation. Postdeployment depression symptoms were associated with suicidal thoughts, while postdeployment PTSD symptoms were associated with current desire for self harm. Postdeployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while postdeployment PTSD symptoms mediated the association between killing in combat and desire for self harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning veterans.

Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars

PURPOSE We conducted a retrospective cohort mortality study to determine the postservice suicide risk of recent wartime veterans comparing them with the US general population as well as comparing deployed veterans to nondeployed veterans. METHODS Veterans were identified from the Defense Manpower Data Center records, and deployment to Iraq or Afghanistan war zone was determined from the Contingency Tracking System. Vital status of 317,581 deployed and 964,493 nondeployed veterans was followed from the time of discharge to December 31, 2009. Underlying causes of death were obtained from the National Death Index Plus. RESULTS Based on 9353 deaths (deployed, 1650; nondeployed, 7703), of which 1868 were suicide deaths (351; 1517), both veteran cohorts had 24% to 25% lower mortality risk from all causes combined but had 41% to 61% higher risk of suicide relative to the US general population. However, the suicide risk was not associated with a history of deployment to the war zone. After controlling for age, sex, race, marital status, branch of service, and rank, deployed veterans showed a lower risk of suicide compared with nondeployed veterans (hazard ratio, 0.84; 95% confidence interval, 0.75-0.95). Multiple deployments were not associated with the excess suicide risk among deployed veterans (hazard ratio, 1.00; 95% confidence interval, 0.79-1.28). CONCLUSIONS Veterans exhibit significantly higher suicide risk compared with the US general population. However, deployment to the Iraq or Afghanistan war, by itself, was not associated with the excess suicide risk.

Risk of suicide among US Military Service Members following Operation Enduring Freedom or Operation Iraqi Freedom deployment and separation from the US Military

IMPORTANCE A pressing question in military suicide prevention research is whether deployment in support of Operation Enduring Freedom or Operation Iraqi Freedom relates to suicide risk. Prior smaller studies report differing results and often have not included suicides that occurred after separation from military service. OBJECTIVE To examine the association between deployment and suicide among all 3.9 million US military personnel who served during Operation Enduring Freedom or Operation Iraqi Freedom, including suicides that occurred after separation. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort design used administrative data to identify dates of deployment for all service members (October 7, 2001, to December 31, 2007) and suicide data (October 7, 2001, to December 31, 2009) to estimate rates of suicide-specific mortality. Hazard ratios were estimated from time-dependent Cox proportional hazards regression models to compare deployed service members with those who did not deploy. MAIN OUTCOMES AND MEASURES Suicide mortality from the Department of Defense Medical Mortality Registry and the National Death Index. RESULTS Deployment was not associated with the rate of suicide (hazard ratio, 0.96; 99% CI, 0.87-1.05). There was an increased rate of suicide associated with separation from military service (hazard ratio, 1.63; 99% CI, 1.50-1.77), regardless of whether service members had deployed or not. Rates of suicide were also elevated for service members who separated with less than 4 years of military service or who did not separate with an honorable discharge. CONCLUSIONS AND RELEVANCE Findings do not support an association between deployment and suicide mortality in this cohort. Early military separation (<4 years) and discharge that is not honorable were suicide risk factors.

Virtual reality exposure therapy for the treatment of anxiety disorders: An evaluation of research quality

Randomized controlled trials (RCTs) support the effectiveness of virtual reality exposure therapy (VRET) for anxiety disorders; however, the overall quality of the VRET RCT literature base has yet to be evaluated. This study reviewed 27 VRET RCTs and the degree of adherence to 8 RCT research design criteria derived from existing standards. Adherence to the study quality criteria was generally low as the articles met an average 2.85 criteria (SD=1.56). None of the studies met more than six quality criteria. Study quality did not predict effect size; however, a reduction in effect size magnitude was observed for studies with larger sample sizes when comparing VRET to non-active control groups. VRET may be an effective method of treatment but caution should be exercised in interpreting the existing body of literature supporting VRET relative to existing standards of care. The need for well-designed VRET research is discussed.

The role of intimate relationships, appraisals of military service, and gender on the development of posttraumatic stress symptoms following Iraq deployment.

A retrospective cohort study was conducted to examine risk and protective factors for combat-related posttraumatic stress disorder (PTSD) symptoms reported by soldiers (n = 2,583) at postdeployment. Positive appraisals of military service related negatively, OR = 0.86, 95% CI [0.83, 0.89], to screening positive for presumed PTSD at postdeployment. Decreases in perceived intimate relationship strength from predeployment to postdeployment were positively associated with presumed PTSD at higher, but not lower, levels of combat exposure; this effect, OR = 1.91, 95% CI [1.08, 3.39], was found only for female soldiers. Overall risk for postdeployment presumed PTSD was found to be nearly 2.5 times greater for women, as compared to men. In addition, positive screening rates of anxiety, depression, hazardous alcohol use, and PTSD increased from predeployment to postdeployment, with the most prominent increase found for PTSD.

Behavioral screening measures delivered with a smartphone app: psychometric properties and user preference.

Abstract The smartphone is an increasingly widespread technological vehicle for general health and psychological health promotion, evaluation, education, and sometimes intervention. However, the psychometric performance of behavioral health screening measures has not been commonly evaluated for the new, small-format, touch-screen medium. Before mobile-based applications for behavioral health screening can be disseminated confidently, the reliability and the validity of measures administered by the smartphone must be evaluated. We compared psychometric properties (i.e., internal consistency and test-retest reliability) of seven behavioral health measures completed on paper, a computer, and an iPhone by 45 army soldiers. The results showed the internal consistencies of the smartphone-delivered measures to be equivalent and very high across all three modalities and the test-retest reliability of the iPhone measures also to be very high. Furthermore, completion of the behavioral screening measures by the iPhone was highly preferred over the other modalities and was reported to be easy and convenient. Our findings help corroborate the use of smartphones and other small mobile devices for behavioral health screening.

Suicides and Suicide Attempts in the U.S. Military, 2008-2010.

The Department of Defense Suicide Event Report Program collects extensive information on suicides and suicide attempts from the U.S. Air Force, Army, Marine Corps, and Navy. Data are compiled on demographics, suicide event details, behavioral health treatment history, military history, and information about other potential risk factors such as psychosocial stressors that were present at the time of the event. The ultimate goal of this standardized suicide surveillance program is to assist suicide prevention in the U.S. military. Descriptive data are presented on 816 suicides and 1,514 suicide attempts reported through the program between 2008 and 2010.

Characteristics of Suicides Among US Army Active Duty Personnel in 17 US States From 2005 to 2007

Suicides are increasing among active duty US Army soldiers. To help focus prevention strategies, we characterized 56 US Army suicides that occurred from 2005 to 2007 in 17 US states using 2 large-scale surveillance systems. We found that intimate partner problems and military-related stress, particularly job stress, were common among decedents. Many decedents were also identified as having suicidal ideation, a sad or depressed mood, or a recent crisis before death. Focusing efforts to prevent these forms of stress might reduce suicides among soldiers.