Thomas A. Grieger

Posttraumatic stress disorder and depression in battle-injured soldiers.

OBJECTIVE This study examined rates, predictors, and course of probable posttraumatic stress disorder (PTSD) and depression among seriously injured soldiers during and following hospitalization. METHOD The patients were 613 U.S. soldiers hospitalized following serious combat injury. Standardized screening instruments were administered 1, 4, and 7 months following injury; 243 soldiers completed all three assessments. Cross-sectional and longitudinal analyses of risk factors were performed. PTSD was assessed with the PTSD Checklist; depression was assessed with the Patient Health Questionnaire. Combat exposure, deployment length, and severity of physical problems were also assessed. RESULTS At 1 month, 4.2% of the soldiers had probable PTSD and 4.4% had depression; at 4 months, 12.2% had PTSD and 8.9% had depression; at 7 months, 12.0% had PTSD and 9.3% had depression. In the longitudinal cohort, 78.8% of those positive for PTSD or depression at 7 months screened negative for both conditions at 1 month. High levels of physical problems at 1 month were significantly predictive of PTSD (odds ratio=9.1) and depression at 7 months (odds ratio=5.7) when the analysis controlled for demographic variables, combat exposure, and duration of deployment. Physical problem severity at 1 month was also associated with PTSD and depression severity at 7 months after control for 1-month PTSD and depression severity, demographic variables, combat exposure, and deployment length. CONCLUSIONS Early severity of physical problems was strongly associated with later PTSD or depression. The majority of soldiers with PTSD or depression at 7 months did not meet criteria for either condition at 1 month.

Post-Traumatic Stress Disorder and Depression in Health Care Providers Returning from Deployment to Iraq and Afghanistan

OBJECTIVE This study examines risk factors for post-traumatic stress disorder (PTSD), depression, and mental health care use among health care workers deployed to combat settings. METHODS Anonymous surveys were administered to previously deployed workers at a military hospital. PTSD and depression were assessed by using the PTSD Checklist and the Patient Health Questionnaire depression scale, respectively. Deployment exposures and perceived threats during deployment were also assessed. RESULTS There were 102 respondents (36% response rate). Nine percent (n=9) met the criteria for PTSD and 5% (n=5) met the criteria for depression. Direct and perceived threats of personal harm were risk factors for PTSD; exposure to wounded or dead patients did not increase risk. Those who met the criteria for PTSD were more likely to seek mental health care after but not before their deployment. CONCLUSIONS For health care workers returning from a warfare environment, threat of personal harm may be the most predictive factor in determining those with subsequent PTSD.

Acute stress disorder, subsequent posttraumatic stress disorder and depression after a series of typhoons

From August to November 1992, five typhoons struck the U.S. Pacific island territory of Guam. Three hundred and twenty subjects exposed to all five typhoons participated in a population survey measuring their acute stress symptoms and subsequent diagnoses of posttraumatic stress disorder (PTSD) and depression. A 23-item scale approximating the new DSM-IV diagnosis of acute stress disorder (ASD) was used to classify subjects into three groups based on their symptoms one week after the first typhoon: (1) probable ASD, (2) an early traumatic stress response (ETSR) of fear, intrusion, avoidance, and arousal, without dissociation, and (3) no acute diagnosis. A multi-dimensional measure of PTSD and the Zung Self-Rating Depression Scale were used to assess PTSD and depression 8 months after the first storm. The point prevalence of ASD at one week was 7.2%. An additional 15% of subjects had ETSR. Subjects with probable ASD at one week had significantly increased rates of PTSD and somewhat higher rates of depression at 8 months than those without ASD. In contrast, subjects with ETSR at one week did not have a poorer outcome than those with no acute diagnosis. These findings suggest that ASD is prognostically important, but also indicate that all acute stress symptoms do not have the same discriminative value. In this study, the acute dissociative symptoms of emotional numbing and derealization differentiated highly symptomatic subjects at risk for subsequent psychopathology (ASD) from others who were highly symptomatic at one week, but then had a more benign, posttraumatic course (ETSR).

Psychological Effects of Deployments on Military Families

FULL DISCLOSURE POLICY In accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support, all CME providers are required to disclose to the activity audience the relevant financial relationships of the planners, teachers, and authors involved in the development of CME content. An individual has a relevant financial relationship if he or she has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the CME activity content over which the individual has control. Relationship information appears at the beginning of each CME-accredited article in this issue.

Soldier Attitudes toward Mental Health Screening and Seeking Care upon Return from Combat

OBJECTIVE This study examined soldier attitudes about postdeployment mental health screening, treatment, barriers to care, strategies for overcoming barriers, and settings, personnel and timing for conducting postdeployment mental health screening. METHODS Deploying soldiers participated in a voluntary anonymous survey. RESULTS Of 3,294 soldiers, 2,678 (81.3%) responded to the survey. When the three most endorsed perceived barriers to mental health care (negative perception by unit members, negative perception by leaders, and being viewed as weak) were examined, approximately 15% fewer soldiers endorsed the perceptions, compared with a previous study conducted at the beginning of the war. Receipt of training focused on managing psychological problems associated with increased agreement to seek treatment. Participants endorsed surveys, interviews, and unit providers as preferred instruments and providers for postdeployment screening. Soldiers endorsed encouragement from family members and friends as the preferred approach to reducing barriers to mental health care. CONCLUSION Extensive educational programs seemed to have reduced the stigma related to receiving mental health care. Programs that focus on friend and family member encouragement of soldiers to seek mental health assistance should continue. Postdeployment screening should be conducted under conditions in which soldiers are most likely to report problems honestly.

Division Mental Health in the New Brigade Combat Team Structure: Part II. Redeployment and Postdeployment

OBJECTIVE Recent Army transformation has led to significant changes in roles and demands for division mental health staff members. This article focuses on redeployment and postdeployment. METHODS The postdeployment health assessment behavioral health screening and referral process and redeployment plan are reviewed, and data on postdeployment rates of negative events are reported. RESULTS All soldiers and many of their families participated in an aggressive education program. Of the 19,500 soldiers screened, 2,170 (11.1%) were referred for behavioral health consultation; of those referred, 219 (10.1%) were found to be at moderate or high risk for mental health issues (1.1% of total screened). Of the moderate/highrisk soldiers, 146 (71.9%) accepted follow-up mental health treatment upon return to home station. Fewer cases of driving under the influence, positive drug screens, suicidal gestures/ attempts, crimes, and acts of domestic violence were seen, in comparison with rates seen after an earlier deployment of this unit to Iraq. CONCLUSIONS A formalized approach with command support and coordination can have a positive impact on successful referral and treatment and reduce negative postdeployment events.

On-the-record screenings versus anonymous surveys in reporting PTSD.

ajp.psychiatryonline.org order to get him back on the road. In addition, he was generally very punctual but seemed to exhibit a new disregard for time. For example, he typically awakened early to take his son to school, but 2 days prior to admission he overslept, displaying an uncharacteristic apathy about getting his son to school on time. Upon psychiatric admission, prazosin was discontinued. After 30 hours, Mr. A’s odd behavior and dissociative symptoms resolved, and he was discharged from the hospital while still being treated with all previous medications except prazosin. Six months later, he has not experienced recurrence of these behavioral symptoms.

Acute Stress Disorder, Depression, and Tobacco Use in Disaster Workers Following 9/11

Early posttraumatic psychiatric disorders have not been well studied in disaster workers. This study examined the rates of probable acute stress disorder (ASD), probable depression, increased tobacco use, and their associated risk factors in 9/11 World Trade Center disaster workers. Surveys were obtained from 90 disaster workers (e.g., medical personnel, police, firefighters, search and rescue) 2-3 weeks after 9/11. Nearly 15% of disaster workers had probable ASD and 26% had probable depression. Probable ASD and depression were highly related to functional impairment. The risk for ASD was increased for those with 9/11-specific disaster exposures, more pre-9/11 trauma exposures, and the peritraumatic dissociative symptom of altered sense of time. Disaster workers who were younger, non-White, or who had increasing numbers of peritraumatic dissociative symptoms were more likely to have probable depression. More than half of tobacco users increased their tobacco use after 9/11. Additionally, all tobacco users with probable ASD and almost all tobacco users with probable depression increased tobacco use. Rapid mobilization of resources for early screening and intervention and health promotion campaigns aimed at improving adverse health-related behaviors may be helpful for this high-risk group.

Disordered Eating in Entry-Level Military Personnel

OBJECTIVE The goal was to determine the prevalence of and risk factors for disordered eating in an entry-level U.S. Army population. METHODS A cross-sectional survey of advanced individual training U.S. Army soldiers at Aberdeen Proving Ground, Maryland, was performed with an anonymous self-report survey containing demographic factors, history (including abuse and psychiatric treatment), and Eating Attitudes Test-26. RESULTS Of 1,184 advanced individual training soldiers approached, 1090 participated. The response rate was 91.2% (955 men and 135 women). Forty percent were overweight (body mass index of > or =25), 11% reported a psychiatric history, 26% reported a history of abuse, and 9.8% endorsed disordered eating (male, 7.0%; female, 29.6%), as defined by Eating Attitudes Test-26. Factors that placed soldiers at higher risk for disordered eating were female gender (odds ratio, 5.63; 95% confidence interval, 3.32-9.57; p < 0.00005), overweight (odds ratio, 3.06; 95% confidence interval, 1.92-4.89; p < 0.00005), previous psychiatric treatment (odds ratio, 1.87; 95% confidence interval, 1.04-3.36; p = 0.035), and history of verbal abuse (odds ratio, 2.02; 95% confidence interval, 1.16-3.51; p = 0.014). CONCLUSIONS Our study shows a higher than expected rate of disordered eating in advanced individual training soldiers with identifiable risk factors. This indicates an important need for further study, effective screening, preventive counseling, and early intervention for treatment.

Suicide Prevention in a Deployed Military Unit

Objective: Military suicide and parasuicidal behaviors have been increasing over the last several years, with rates highest in the deployed environment. This article presents a deployment cycle-specific suicide prevention plan utilized during one U.S. Army division’s 15-month deployment to Iraq. Methods: Education, identification, and intervention programs were implemented at each phase of the deployment cycle based on the specific unit activities and predicted stressors. Results: During the deployment, there was an annual suicide rate of 16/100,000 within the trial cohort, compared to a theater rate of 24/100,000. Peaks in suicidal ideation and behaviors occurred during months two, six, and twelve of deployment. Conclusions: A deployment cycle prevention program may decrease rates of suicide in the combat environment. This program may serve as a model for other suicide prevention programs.