Predictors of Symptom Increase in Subsyndromal PTSD Among Previously Deployed Military Personnel.

INTRODUCTION: Subsyndromal PTSD (sub-PTSD) is associated with functional impairment and increased risk for full PTSD. This study examined factors associated with progression from sub-PTSD to full PTSD symptomatology among previously deployed military veterans. MATERIALS AND METHODS: Data were drawn from a longitudinal survey of Navy and Marine Corps personnel leaving military service between 2007 and 2010 administered immediately before separation (baseline) and ~1 year later (follow-up). Survey measures assessed PTSD symptoms at both times; the baseline survey also assessed potential predictors of symptom change over time. Logistic regression models were used to identify predictors of progression from sub-PTSD to full PTSD status. RESULTS: Compared to those with no or few PTSD symptoms at baseline, individuals with sub-PTSD were almost three times more likely to exhibit full PTSD symptomatology at follow-up. Risk factors for symptom increase among those with sub-PTSD included moderate or high levels of combat exposure and utilization of fewer positive coping behaviors. Use of prescribed psychotropic medication was protective against symptom increase. CONCLUSION: This study identified several predictors of symptom increase in military veterans with sub-PTSD. Interventions targeting modifiable risk factors for symptom escalation, including behavioral and pharmacological treatments, may reduce rates of new-onset PTSD in this population.

Blast Exposure and Risk of Recurrent Occupational Overpressure Exposure Predict Deployment TBIs.

INTRODUCTION: Traumatic brain injury (TBI) has been the leading cause of morbidity and mortality in recent military conflicts and deployment-related TBIs are most commonly caused by blast. However, knowledge of risk factors that increase susceptibility to TBI following an acute, high-level blast is limited. We hypothesized that recurrent occupational overpressure exposure (ROPE) may be one factor that increases susceptibility to mild TBI (mTBI) following blast. MATERIALS AND METHODS: Using military occupational specialty as a proxy, we examined the effects of high versus low ROPE on mTBI following blast exposure. Initial analyses included 111,641 active-duty-enlisted U.S. Marines who completed the 2003 or 2008 version of the Post-Deployment Health Assessment. Final analyses examined probable mTBI screens among Marines with at least one qualifying exposure as a function of whether the exposure was a blast and level of ROPE (N = 12,929). This study was approved by the Institutional Review Board at the Naval Health Research Center. RESULTS: Blast and ROPE were both independently and jointly associated with a probable mTBI. Marines who experienced a blast (vs other qualifying exposure) and those in high (vs low) risk occupations were 1.07 and 1.23 times more likely to sustain a probable mTBI, respectively. Furthermore, among those who experienced a blast during deployment, those in high-risk occupations were 1.45 times more likely than those in low-risk occupations to sustain a probable mTBI. CONCLUSIONS: Blast exposure and ROPE were independently associated with mTBIs, and Marines with both blast exposure during deployment and ROPE were especially likely to sustain an mTBI. This suggests that ROPE heightens the risk of mTBI following blast. Ongoing research is examining the severity, symptomology, and sequelae of TBIs as a function of ROPE.

Prevalence of Posttraumatic Stress Disorder and Psychological Comorbidities Among U.S. Active Duty Service Members, 2006-2013.

Among active duty service members, posttraumatic stress disorder (PTSD) diagnoses have increased dramatically since 2000. Because psychiatric comorbidity is more common for PTSD than for other mental health disorders, we examined the prevalence estimates of disorders comorbid or trimorbid with PTSD in this study. The medical records of 523,626 female and male active duty Sailors and Marines who entered the U.S. military between 2006 and 2013 were examined for diagnoses of PTSD and 14 potentially comorbid disorders. Results showed that 1.8% of military members had a PTSD diagnosis; among those with PTSD, 83.3% had a comorbid mental health disorder, and 62.2% had a third (i.e., trimorbid) disorder. Most frequently, PTSD co-occurred with depressive disorder (49.0%), adjustment disorder (37.0%), generalized anxiety disorder (36.1%), and alcohol use disorder (26.9%). All disorders we examined were significantly more likely to be diagnosed in service members with PTSD than in those without PTSD, odds ratios = 1.52-29.63. For service members with PTSD, comorbid mental health disorders are the rule rather than the exception. Consequently, it is important that clinicians also assess for other disorders and select treatment options that address both PTSD and comorbid conditions.

Etiology of depression comorbidity in combat-related PTSD: a review of the literature.

Posttraumatic stress disorder is often diagnosed with other mental health problems, particularly depression. Although PTSD comorbidity has been associated with more severe and chronic symptomology, relationships among commonly co-occurring disorders are not well understood. The purpose of this study was to review the literature regarding the development of depression comorbid with combat-related PTSD among military personnel. We summarize results of commonly tested hypotheses about the etiology of PTSD and depression comorbidity, including (1) causal hypotheses, (2) common factor hypotheses, and (3) potential confounds. Evidence suggests that PTSD may be a causal risk factor for subsequent depression; however, associations are likely complex, involving bidirectional causality, common risk factors, and common vulnerabilities. The unique nature of PTSD-depression comorbidity in the context of military deployment and combat exposure is emphasized. Implications of our results for clinical practice and future research are discussed.

Sex differences in cardiovascular and subjective stress reactions: prospective evidence in a realistic military setting.

Evidence points to heightened physiological arousal in response to acute stress exposure as both a prospective indicator and a core characteristic of posttraumatic stress disorder (PTSD). Because females may be at higher risk for PTSD development, it is important to evaluate sex differences in acute stress reactions. This study characterized sex differences in cardiovascular and subjective stress reactions among military survival trainees. One hundred and eighty-five military members (78% males) were studied before, during, and 24 h after stressful mock captivity. Cardiovascular (heart rate [HR], systolic blood pressure [SBP], diastolic blood pressure [DBP]) and dissociative states were measured at all three time points. Psychological impact of mock captivity was assessed during recovery. General linear modeling with repeated measures evaluated sex differences for each cardiovascular endpoint, and causal steps modeling was used to explore interrelationships among sex, cardiovascular reactions and psychological impact of mock captivity. Although females had lower SBP than males at all three time points, the difference was most pronounced at baseline and during stress. Accordingly, females showed greater residual elevation in SBP during recovery. Females had lower DBP at all three time points. In addition, females reported greater psychological impact of mock captivity than males. Exploratory causal steps modeling suggested that stress-induced HR may partially mediate the effect of sex on psychological impact of mock captivity. In conclusion, this study demonstrated sex-specific cardiovascular stress reactions in military personnel, along with greater psychological impact of stress exposure in females. This research may elucidate sex differences in PTSD development.

A prospective study of factors affecting recovery from musculoskeletal injuries.

PURPOSE: Research suggests the importance of psychosocial factors in recovery from musculoskeletal injuries. The objective of this study was to identify predictors of recovery among U.S. Marines who had musculoskeletal injuries of the back, knee, or shoulder. METHODS: A sample of 134 participants was assessed at baseline and followed for 1 year to determine outcome information. RESULTS: The strongest predictor of injury recovery at the 1-year follow-up was recovery expectations. In a multivariate logistic model with key demographic and psychosocial factors controlled, individuals who had high recovery expectations at baseline were over five times as likely to be recovered at follow-up as individuals who had low expectations (OR = 5.18, p\.01). CONCLUSIONS: This finding is consistent with a large body of research that has linked recovery expectations with better recovery outcomes in patients with musculoskeletal injuries as well as with research linking recovery expectations with better outcomes across a wide range of medical conditions.Applied to military populations, interventions designed to modify recovery expectations may have the potential to improve rates of return to duty and to reduce rates of disability discharge.

Implications of psychiatric comorbidity among combat veterans.

Limited research exists regarding the rates of and outcomes associated with psychiatric comorbidity among active duty military personnel. This study investigated the rates of comorbid psychiatric diagnoses among 81,720 U.S. Marines, and assessed the relationships between preexisting comorbid disorders and risk of psychiatric hospitalizations and attrition from service. The study used medical, deployment, and personnel records for all Marines who enlisted between 2002 and 2005. The baseline rate of comorbidity was 1.3% for Marines who deployed during the first term of service, and 6.3% for Marines who did not deploy. The most common baseline comorbidity among deployed Marines was mood disorders with anxiety disorders, and mood and adjustment disorders among nondeployed Marines. Logistic regression analyses revealed Marines with comorbid diagnoses before deployment were over three times more likely to attrite (odds ratio = 3.4, p < 0.001) and over five times more likely to be hospitalized for psychiatric symptoms (odds ratio = 5.1, p < 0.001) following deployment than those with no diagnoses. Similar patterns emerged among nondeployers. Outcomes associated with comorbid conditions were substantially worse than outcomes for single conditions. These findings demonstrate that Marines with a history of comorbid psychiatric diagnoses are at a much greater risk for adverse outcomes, specifically attrition from the military and psychiatric hospitalization.

Predictors of psychiatric disorders in combat veterans.

BACKGROUND: Most previous research that has examined mental health among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) combatants has relied on self-report measures to assess mental health outcomes; few studies have examined predictors of actual mental health diagnoses. The objective of this longitudinal investigation was to identify predictors of psychiatric disorders among Marines who deployed to combat in Iraq and Afghanistan. METHODS: The study sample consisted of 1113 Marines who had deployed to Iraq or Afghanistan. Demographic and psychosocial predictor variables from a survey that all Marines in the sample had completed were studied in relation to subsequent psychiatric diagnoses. Univariate and multivariate logistic regression were used to determine the influence of the predictors on the occurrence of psychiatric disorders. RESULTS: In a sample of Marines with no previous psychiatric disorder diagnoses, 18% were diagnosed with a new-onset psychiatric disorder. Adjusting for other variables, the strongest predictors of overall psychiatric disorders were female gender, mild traumatic brain injury symptoms, and satisfaction with leadership. Service members who expressed greater satisfaction with leadership were about half as likely to develop a mental disorder as those who were not satisfied. Unique predictors of specific types of mental disorders were also identified. CONCLUSIONS: Overall, the study's most relevant result was that two potentially modifiable factors, low satisfaction with leadership and low organizational commitment, predicted mental disorder diagnoses in a military sample. Additional research should aim to clarify the nature and impact of these factors on combatant mental health.

Substance abuse counselor and client reports of mental health screening and enhanced practices.

OBJECTIVE: The objective of this study was to examine mental health screening practices and attitudes from both counselor and client perspectives in the U.S. Marine Corps substance abuse program. METHOD: This study examined mental health screening practices and attitudes of 23 substance abuse counselors and 442 clients from six Marine Corps substance abuse counseling centers. RESULTS: After receiving training on screening and enhanced counseling practices, 76% of counselors reported that they almost always screened their clients for post-traumatic stress symptoms. Seventy-three percent of clients agreed that substance abuse counselors should ask about their clients' stress concerns. CONCLUSION: Overall, implementing screening for common mental disorders was feasible in this setting. Counselors may need further support to increase collaboration with mental health professionals and adapt treatment plans to address co-occurring mental health conditions.

Anxiety and depression in Marines sent to war in Iraq and Afghanistan.

Although the effects of combat deployment on posttraumatic stress disorder have been extensively studied, little is known about the effects of combat deployment on depression and anxiety. This study examined the factors associated with anxiety and depression in a sample of 1560 US Marines who were deployed to Iraq and Afghanistan. Eleven demographic and psychosocial factors were studied in relation to depression and anxiety. Five factors emerged as significant in relation to depression: deployment-related stressors, combat exposure, attitudes toward leadership, mild traumatic brain injury symptoms, and marital status. The same factors, with the exception of marital status, emerged as significant in relation to anxiety. Deployment-related stressors had a stronger association with both depression and anxiety than any other variable, including combat exposure. This finding is important because deployment-related stressors are potentially modifiable by the military.

Mental health and turnover following an initial term of military service.

OBJECTIVE: This study compared the rates of mental disorders between Marines who re-enlisted and Marines who separated after 1 term, distinguishing between Marines who were and were not recommended for re-enlistment. METHODS: Participants included 28,693 male Marines enlisting for 4-year terms between 2002 and 2003, including 9,338 who re-enlisted after 1 term, 18,177 who voluntarily separated after 1 term, and 1,184 who were not recommended for re-enlistment and separated after 1 term. RESULTS: Analysis revealed disproportionately high rates of mental disorders among Marines not recommended for re-enlistment (Odds Ratio = 8.5, 95% Confidence Interval 7.5-9.8) compared with Marines who re-enlisted. Mental disorder prevalence was also elevated among service members who voluntarily separated after 1 term (Odds Ratio = 1.2, 95% Confidence Interval 1.1-1.3). Several specific categories of disorders, including personality disorders, substance use disorders, and post-traumatic stress disorder, predicted re-enlistment status. CONCLUSIONS: These results suggest that mental disorders influence personnel retention in diverse ways, including heightened turnover, which could have a substantial impact on military manpower costs.

Postcombat outcomes among Marines with preexisting mental diagnoses.

Preexisting mental disorders are not always considered in mental health studies with military populations, even though prior diagnoses may be a risk factor for additional psychiatric harm stemming from combat exposure, as well as postdeployment behavioral problems. The objectives of this study were to investigate postcombat psychiatric and career outcomes among Marines with preexisting mental disorder diagnoses who deployed to combat in Iraq, Afghanistan, or Kuwait from 2002 to 2008. Marines with a preexisting diagnosis were 3.6 times (p < .001) more likely to have at least 1 postdeployment mental health disorder within 6 months postdeployment compared with Marines with no prior psychiatric diagnoses. Marines with a preexisting diagnosis were also 1.8 (p < .001) times more likely to receive a new-onset psychiatric diagnosis within 6 months postdeployment, indicating that postdeployment mental health concerns in this cohort extend beyond continuation of earlier disorders. Additionally, demotions and separation were significantly associated with having any preexisting mental health diagnoses (yielding odds ratios of 2.34 and 2.00, p < .001, respectively. Based on the current findings, it may be advisable to mandate a full medical and psychiatric record review during deployment health screening as part of new initiatives to address whether combat exposure has worsened preexisting conditions or compounded them with new-onset concerns.

Psychiatric diagnoses and punishment for misconduct: the effects of PTSD in combat-deployed Marines.

BACKGROUND: Research on Vietnam veterans suggests an association between psychological problems, including posttraumatic stress disorder (PTSD), and misconduct; however, this has rarely been studied in veterans of Operation Iraqi Freedom or Operation Enduring Freedom. The objective of this study was to investigate whether psychological problems were associated with three types of misconduct outcomes (demotions, drug-related discharges, and punitive discharges.) METHODS: A population-based study was conducted on all U.S. Marines who entered the military between October 1, 2001, and September 30, 2006, and deployed outside of the United States before the end of the study period, September 30, 2007. Demographic, psychiatric, deployment, and personnel information was collected from military records. Cox proportional hazards regression analysis was conducted to investigate associations between the independent variables and the three types of misconduct in war-deployed (n = 77,998) and non-war-deployed (n = 13,944) Marines. RESULTS: Marines in both the war-deployed and non-war-deployed cohorts with a non-PTSD psychiatric diagnosis had an elevated risk for all three misconduct outcomes (hazard ratios ranged from 3.93 to 5.65). PTSD was a significant predictor of drug-related discharges in both the war-deployed and non-war-deployed cohorts. In the war-deployed cohort only, a specific diagnosis of PTSD was associated with an increased risk for both demotions (hazard ratio, 8.60; 95% confidence interval, 6.95 to 10.64) and punitive discharges (HR, 11.06; 95% CI, 8.06 to 15.16). CONCLUSIONS: These results provide evidence of an association between PTSD and behavior problems in Marines deployed to war. Moreover, because misconduct can lead to disqualification for some Veterans Administration benefits, personnel with the most serious manifestations of PTSD may face additional barriers to care.

Factors associated with antisocial behavior in combat veterans.

The objective of this study was to identify factors associated with antisocial behavior in 1,543 Marines who deployed to combat zones in support of conflicts in Iraq and Afghanistan during 2002-2007. Five factors were associated with antisocial behavior in multivariate analyses: post-traumatic stress disorder (PTSD) symptoms, deployment-related stressors, combat exposure, younger age, and being divorced. PTSD symptoms had a stronger association with antisocial behavior than any other variable. A unique and important finding of this study was the association between deployment-related stressors and a higher incidence of antisocial behavior. Because deployment-related stressors are potentially modifiable, the military may be able to address them in concrete ways such as by shortening deployments and improving communication with home.

Psychosocial predictors of military misconduct.

The objective of this longitudinal study was to determine psychosocial predictors of military misconduct in a cohort of Marine Corps war veterans. The study included data from 20,746 male Marines who completed a life history questionnaire during initial basic training and were subsequently deployed to a combat zone. Associations between psychosocial variables, psychiatric diagnoses, and subsequent misconduct outcomes were analyzed using Cox proportional hazards regression. The strongest predictors of misconduct outcomes (bad conduct discharges and military demotions) were psychiatric diagnoses and young age at first combat deployment. The results indicate that combat-related psychological disorders may manifest in numerous harmful ways, including impulsive, disruptive, and antisocial behavior. We recommend that the association between misconduct and psychiatric disorders be more explicitly acknowledged in research and treatment efforts involving military war veterans and other trauma victims.

Correlates of posttraumatic stress disorder symptoms in Marines back from war.

The effect of combat and operational stress on the mental health of military personnel is a major concern. The objective of this study was to identify factors associated with possible posttraumatic stress disorder (PTSD). A questionnaire was completed by 1,569 Marines who deployed in support of conflicts in Iraq and Afghanistan (2002-2007). Using the PTSD Checklist with a cutoff score of 44, 17.1% of the sample screened positive for possible PTSD. Of 9 demographic and psychosocial factors examined in relation to PTSD, 4 were significant in a multivariate analysis: deployment-related stressors, combat exposure, marital status, and education. Deployment-related stressors had a stronger association with PTSD than any other variable. This is an important finding because deployment-related stressors are potentially modifiable.

Prospective analysis of psychiatric risk factors in marines sent to war.

The objective of this longitudinal study was to identify risk factors for combat-related psychiatric disorders. The sample consisted of 6442 enlisted U.S. Marines who completed a questionnaire during basic training, deployed to a combat zone with no prior psychiatric diagnoses, and completed a postdeployment assessment form. Cox proportional hazards regression was used to determine associations between predeployment and postdeployment self-reports and subsequent mental health outcomes. During the observation period, 6.8% of the sample were diagnosed with a psychiatric disorder. The strongest predictors of postdeployment psychiatric disorders were, in order of importance, low paygrade, hospitalization during deployment, low education, preservice smoking, and post-traumatic stress disorder symptoms at deployment's end. The impact of war zone variables was smaller than expected. It was recommended that the combat experience section of the military's postdeployment assessment form be expanded to enhance the military's ability to identify and refer personnel who may be at risk for psychiatric disorders.

Psychosocial predictors of return to duty among marine recruits with musculoskeletal injuries.

Psychosocial factors may have an important impact on injury recovery and return to work. To explore the influence of psychosocial factors in a cohort of injured military personnel, data were collected from 166 Marine Corps basic training recruits with musculoskeletal injuries. This sample was followed prospectively to determine whether they graduated from basic training or were discharged from the Marines. Demographic, injury-related, and psychosocial factors were analyzed to determine predictors of failure to graduate from basic training. The strongest risk factors for failing to graduate were not expecting to graduate, low or uncertain career intentions, lack of determination, psychological distress, and low organizational commitment. In the final multivariate logistics model, two predictors of failure to graduate emerged: not expecting to graduate and low or uncertain career intentions. The results suggest that interventions to reduce attrition in injured military populations should be designed to counter pessimistic expectations and emphasize career opportunities.

Psychiatric diagnoses in historic and contemporary military cohorts: combat deployment and the healthy warrior effect.

Research studies have identified heightened psychiatric problems among veterans of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). However, these studies have not compared incidence rates of psychiatric disorders across robust cohorts, nor have they documented psychiatric problems prior to combat exposure. The authors' objectives in this study were to determine incidence rates of diagnosed mental disorders in a cohort of Marines deployed to combat during OIF or OEF in 2001-2005 and to compare these with mental disorder rates in two historical and two contemporary military control groups. After exclusion of persons who had been deployed to a combat zone with a preexisting psychiatric diagnosis, the cumulative rate of post-OIF/-OEF mental disorders was 6.4%. All psychiatric conditions except post-traumatic stress disorder occurred at a lower rate in combat-deployed personnel than in personnel who were not deployed to a combat zone. The findings suggest that psychiatric disorders in Marines are diagnosed most frequently during the initial months of recruit training rather than after combat deployment. The disproportionate loss of psychologically unfit personnel early in training creates a "healthy warrior effect," because only those persons who have proven their resilience during training remain eligible for combat.