Shannon M. Kehle

Prevalence, assessment, and treatment of mild traumatic brain injury and posttraumatic stress disorder: a systematic review of the evidence.

Background:Iraq and Afghanistan war veterans are returning from combat having sustained traumatic brain injury, most commonly mild traumatic brain injury (mTBI), and experiencing posttraumatic stress disorder (PTSD). Clinical guidelines for mTBI and PTSD do not focus on the co-occurrence of these conditions (mTBI/PTSD). A synthesis of the evidence on prevalence, diagnostic accuracy, and treatment effectiveness for mTBI/PTSD would be of use to clinicians, researchers, and policymakers. Methods:We conducted a systematic review of studies identified through PubMed, PsycINFO, REHABDATA, Cochrane Library, pearling, and expert recommendations. Peer-reviewed English language studies published between 1980 and June, 2009 were included if they reported frequencies of traumatic brain injury and PTSD, or diagnostic accuracy or treatment effectiveness specific to mTBI/PTSD. Results:Thirty-four studies met inclusion criteria. None evaluated diagnostic accuracy or treatment effectiveness. Studies varied considerably in design. Frequency of mTBI/PTSD ranged from 0% to 89%. However, in 3 large studies evaluating Iraq and Afghanistan war veterans, frequencies of probable mTBI/PTSD were from 5% to 7%; among those with probable mTBI, frequencies of probable PTSD were from 33% to 39%. Discussion:The wide range of mTBI/PTSD frequency levels was likely due to variation across study parameters, including aims and assessment methods. Studies using consistent, validated methods to define and measure mTBI history and PTSD are needed.

Early Mental Health Treatment-Seeking Among U.S. National Guard Soldiers Deployed to Iraq

The authors examined rates of and factors associated with postdeployment treatment-seeking in a panel of 424 National Guard soldiers who spent 16 months in Iraq. Soldiers completed a self-report, mailed survey 3- to 6-months after returning home. Approximately one third of respondents reported postdeployment mental health treatment. Those who screened positive for mental health problems were more likely to indicate that they had received treatment compared to those who screened negative, but over one half of those who screened positive were not engaged with mental health treatment. Variables related to reported treatment receipt included positive attitudes about mental health therapies, having been injured in-theater, illness-based need, and having received mental health treatment while in-theater. Implications and future research directions are discussed.

Psychiatric diagnoses, comorbidity, and functioning in National Guard troops deployed to Iraq

OBJECTIVE Over 1.8 million troops have been deployed to Iraq (OIF) and Afghanistan. Estimates of mental health problems postdeployment have been based on screening instruments; no studies have examined the postdeployment mental health of troops returning from OIF using structured diagnostic interviews. The goal of the current study is to (a) report on rates of mental health diagnoses and comorbidity in soldiers after deployment to OIF using clinical interviews, and (b) examine the relationship between mental health diagnoses and overall functioning and quality of life. METHOD Participants were 348 National Guard soldiers drawn from the Readiness and Resilience in National Guard Soldiers (RINGS) study, a longitudinal study of mental health after deployment to OIF from March 2006 to July 2007. Participants completed clinical interviews, including the Clinician Administered PTSD Scale and the Structured Clinical Interview for the DSM-IV, and self-report measures of social adjustment and quality of life 6-12 months following deployment. RESULTS Most participants did not meet criteria for a mental health diagnosis. Non-PTSD anxiety disorders and depressive disorders were the most common. Mental health diagnoses were associated with poorer functioning and quality of life. PTSD had the strongest relationship with social functioning and quality of life. For those with PTSD, comorbid diagnoses were not associated with an incremental decrease in functioning or quality of life. CONCLUSIONS The findings highlight the significant rate and burden of mental health disorders among this population and suggest that while PTSD is relatively uncommon, it is a particularly deleterious disorder.

Relationship Adjustment, PTSD Symptoms, and Treatment Utilization Among Coupled National Guard Soldiers Deployed to Iraq

Although combat-related posttraumatic stress disorder (PTSD) is associated with considerable impairment in relationship adjustment, research has yet to investigate how PTSD symptoms and relationship distress uniquely and jointly predict utilization of a range of mental health services. The present study sought to examine these issues utilizing a longitudinal sample of National Guard soldiers surveyed 2-3 months following return from deployment to Iraq and again 12 months later (N = 223). Results indicated that PTSD symptom severity, but not relationship adjustment, uniquely predicted greater odds of utilizing individual-oriented mental health services. A significant interaction was found indicating associations between PTSD symptoms and the odds of using services were increased when soldiers reported greater relationship adjustment. For utilization of family-oriented care, greater relationship distress was significantly correlated with greater odds of using services, but associations with PTSD symptoms were nonsignificant. The association between relationship distress and utilization of family-oriented services did not vary significantly with severity of PTSD symptoms. Results suggest supportive intimate relationships facilitate mental health treatment utilization for soldiers with PTSD symptoms.

Predictors of postdeployment alcohol use disorders in National Guard soldiers deployed to Operation Iraqi Freedom.

Alcohol use in the military is a significant problem. The goal of this study was to examine the associations between personality, posttraumatic stress disorder (PTSD) symptoms, and postdeployment alcohol use disorders (AUDs) among a group of Operation Iraqi Freedom (OIF) deployed National Guard soldiers, with a focus on differentiating predeployment and postdeployment onset AUDs. Participants were 348 National Guard soldiers deployed to Iraq from March 2006 to July 2007 drawn from the Readiness and Resilience in National Guard Soldiers (RINGS) study. Participants completed self-report measures one month before deployment and 3 to 6 months postdeployment; current and lifetime history of AUDs were assessed 6 to 12 months postdeployment, using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (4th ed. text rev.; DSM-IV; American Psychiatric Association, 2000). Overall, 13% of the panel was diagnosed with a current AUD. Of those who met criteria for a current AUD, 38% had an AUD that developed following return from deployment (new onset AUD). The development of new onset AUDs was uniquely predicted by higher levels of PTSD symptom severity, higher levels of avoidance-specific PTSD symptoms, and lower levels of positive emotionality. AUDs with onset prior to deployment were predicted by higher levels of negative emotionality and disconstraint. Results of this study suggest that combat deployed soldiers with current AUDs are a heterogeneous group and point to the influence of combat-related PTSD symptoms in the development of AUDs following deployment.

Impact of Prior Operation Enduring Freedom/Operation Iraqi Freedom Combat Duty on Mental Health in a Predeployment Cohort of National Guard Soldiers

OBJECTIVES The goal was to examine the impact of prior Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat deployment on reported psychiatric and somatic symptoms among National Guard/Reserve (NGR) soldiers 1 month before deployment to Iraq. METHOD 522 NGR soldiers completed a survey assessing predeployment risk and resilience factors as well as current levels of PTSD, depressive, and somatic symptoms. RESULTS Overall, soldiers reported few psychiatric symptoms present before deployment to Iraq. However, compared to soldiers preparing for their first deployment to Iraq, soldiers previously deployed to OEF/OIF reported more PTSD, depressive, and somatic symptoms. Previously OEF/OIF deployed soldiers reported lower perceptions of unit social support, but reported no differences in perceptions of preparedness or concerns about family disruptions. Implications for interventions and training with military personnel before deployment as well as future longitudinal research directions are discussed.

Predictors of alcohol use prior to deployment in National Guard Soldiers

Frequent and heavy alcohol use is associated with negative mental and physical health consequences. Previous research has suggested that alcohol misuse is associated with demographic, personality, and mental health variables. This study examined the relative contribution of these factors in predicting drinking among National Guard soldiers prior to deployment to a combat zone. Members of a National Guard Brigade Combat Team (N=515) completed questionnaires assessing drinking behaviors in the past year (frequency, quantity, binge, and total drinking), as well as demographic, personality, and mental health variables. As a group, demographic and personality variables significantly predicted all drinking outcomes. Negative emotionality and disconstraint were independent predictors of all drinking variables. Younger age predicted higher quantity of drinking, while being unmarried predicted greater total drinking and higher frequency of binge drinking. Once the influence of personality variables were accounted for, mental health was not associated with any drinking variable. The results of this study illustrate the role of factors associated with problematic drinking in a sample of high-risk individuals.

Interventions to Improve Veterans’ Access to Care: A Systematic Review of the Literature

ObjectivesTo conduct a systematic review to address the following key questions: (1) what interventions have been successful in improving access for veterans with reduced health care access? (2) Have interventions that have improved health care access led to improvements in process and clinical outcomes?Data SourcesOVID MEDLINE, CINAHL, PsychINFO.Study Eligibility Criteria, Participants, and InterventionsEnglish language articles published in peer-reviewed journals from 1990 to June 2010. All interventions designed to improve access to health care for US veterans that reported the impact of the intervention on perceived (e.g., satisfaction with access) or objective (e.g., travel time, wait time) access were included.Appraisal and Synthesis MethodsInvestigators abstracted data on study design, study quality, intervention, and impact of the intervention on access, process outcomes, and clinical outcomes.ResultsNineteen articles (16 unique studies) met the inclusion criteria. While there were a small number of studies in support of any one intervention, all showed a positive impact on either perceived or objective measures of access. Implementation of Community Based Outpatient Clinics (n = 5 articles), use of Telemedicine (n = 5 articles), and Primary Care Mental Health Integration (n = 6 articles) improved access. All 16 unique studies reported process outcomes, most often satisfaction with care and utilization. Four studies reported clinical outcomes; three found no differences.LimitationsIncluded studies were largely of poor to fair methodological quality.Conclusions and Implications of Key FindingsInterventions can improve access to health care for veterans. Increased access was consistently linked to increased primary care utilization. There was a lack of data regarding the link between access and clinical outcomes; however, the limited data suggest that increased access may not improve clinical outcomes. Future research should focus on the quality and appropriateness of care and clinical outcomes.

Predeployment Gender Differences in Stressors and Mental Health Among U.S. National Guard Troops Poised for Operation Iraqi Freedom Deployment

Increased exposure of women soldiers to combat in current conflicts heightens interest in the question of whether risk and resilience factors differ for female and male military personnel prior to deployment. The authors examined this question in a panel of 522 National Guard soldiers (462 men and 60 women) poised for deployment to Iraq. Soldiers completed a battery of self-report measures, including the PTSD Checklist, Beck Depression Inventory-II, and scales from the Deployment Risk and Resilience Inventory. Modest differences were observed between women and men on predeployment risk factors and some risk-related correlations with PTSD and depression measures; however, gender did not moderate the associations between hypothesized risk/resilience factors and baseline mental health. Implications for interventions and future research are discussed.