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.

Effects of military service and deployment on clinical symptomatology: The role of trauma exposure and social support.

The Marine Resiliency Study-II examined changes in symptomatology across a deployment cycle to Afghanistan. U.S. Servicemembers (N = 1041) received clinical testing at two time points either bracketing a deployment (855) or not (186). Factor analyses were used to generate summary and change scores from Time 1 to Time 2. A between-subject design was used to examine changes across the deployment cycle with deployment (low-trauma, high-trauma, and non-deployed) and social support (low vs. high) as the grouping variables. Insomnia increased post-deployment regardless of deployment trauma (std. effect for high-trauma and low-trauma = 0.39 and 0.26, respectively). Only the high-trauma group showed increased PTSD symptoms and non-perspective-taking (std. effect = 0.40 and 0.30, respectively), while low-trauma showed decreased anxiety symptoms after deployment (std. effect = -0.17). These associations also depend on social support, with std. effects ranging from -0.22 to 0.51. When the groups were compared, the high-trauma deployed group showed significantly worse PTSD and non-perspective-taking than all other groups. Similar to studies in other military divisions, increased clinical symptoms were associated with high deployment stress in active duty Servicemembers, and social support shows promise as a moderator of said association.

A genetic risk factor for major depression and suicidal ideation is mitigated by physical activity.

We evaluated associations of five candidate polymorphisms (Bcl1 [rs41423247], -2C/G [rs2070951], COMT [rs737865], Val66Met [rs6265], and 5HTTLPR [biallelic and triallelic [5HTTLPR/rs25531]) with probable MDD and suicidal ideation (SI), the effects of physical activity on these endpoints, and whether physical activity attenuates genetic risk in military members (N=736). C carriers who were also less physically active were 3.3 times as likely to meet criteria for probable MDD and 9.6 times as likely to endorse SI as compared to physically active GG carriers. An adequate dose of physical activity diminishes risk of MDD and SI imposed by a genetic predisposition.

Treatment of Mental or Physical Health Problems in a Combat Zone: Comparisons of Postdeployment Mental Health and Early Separation From Service.

The primary aim of this study was to evaluate whether being treated for mental health or nonbattle physical injury during military combat deployment was associated with higher risk for postdeployment mental disorders and poorer career outcomes than seen in the general combat-deployed population. Service members treated in theater for mental health (n = 964) or noncombat injury (n = 853) were compared with randomly sampled personnel (n = 7,220) from the general deployed population on diagnosed mental disorders and early separation from service. Deployment, medical, and career information were obtained from Department of Defense archival databases. Over half of the personnel who received mental health treatment while deployed were diagnosed with 1 or more mental disorders postdeployment and/or were separated from service before completing their full-term enlistment. This was significantly higher than expected compared to the general deployed group, adjusting for demographic/military characteristics and mental health history (adjusted odds ratios [ORs] ranging 1.62 to 2.96). Frequencies of problems also were higher in the mental health-treated group than in the group treated for nonbattle physical injuries (significant adjusted ORs ranging 1.65 to 2.58). The documented higher risks for postdeployment adjustment problems suggested that especially those treated in theater by mental health providers might benefit from postdeployment risk-reduction programs.

Assessment of Sleep Disruption and Sleep Quality in Naval Special Warfare Operators.

Little is known about sleep in elite military populations who are exposed to higher operational demands, unpredictable training, deployment, and mission cycles. Twenty-nine Naval Special Warfare (NSW) Operators wore an actiwatch for an 8-day/7-night period for objective sleep assessment and completed a nightly sleep log. A total of 170 nights of actigraphically recorded sleep were collected. When comparing objectively versus subjectively recorded sleep parameter data, statistically significant differences were found. Compared with sleep log data, actigraphy data indicate NSW Operators took longer to fall asleep (an average of 25.82 minutes), spent more time awake after sleep onset (an average of 39.55 minutes), and demonstrated poorer sleep efficiency (83.88%) (ps < 0.05). Self-reported sleep quality during the study period was 6.47 (maximum score = 10). No relationships existed between the objectively derived sleep indices and the self-reported measure of sleep quality (rs = -0.29 to 0.09, all ps > 0.05). Strong inter-relationships existed among the subjectively derived sleep indices (e.g., between self-reported sleep quality and sleep efficiency; r = 0.61, p < 0.001). To our knowledge, this is the first study to objectively and subjectively quantify sleep among NSW Operators. These findings suggest sleep maintenance and sleep efficiency are impaired when compared to normative population data.

Prospective prediction of functional difficulties among recently separated veterans.

Reports of functional problems are common among Veterans who served post-9/11 (more than 25% report functional difficulties in at least one domain). However, little prospective work has examined the risk and protective factors for functional difficulties among Veterans. In a sample of recently separated Marines, we used stepwise logistic and multiple regressions to identify predictors of functional impairment, including work-related problems, financial problems, unlawful behavior, activity limitations due to mental health symptoms, and perceived difficulty reintegrating into civilian life. Posttraumatic stress disorder symptoms assessed both before and after military separation significantly predicted functional difficulties across all domains except unlawful behavior. Certain outcomes, such as unlawful behavior and activity limitations due to mental health symptoms, were predicted by other or additional predictors. Although several forms of functioning were examined, the list was not exhaustive. The results highlight a number of areas where targeted interventions may facilitate the reintegration of military servicemembers into civilian life.

Predictors of continued problem drinking and substance use following military discharge.

OBJECTIVE: The goals of the present study were to (a) examine change in rates of problem alcohol/substance use among a sample of veterans between their last year of military service and their first year following separation, (b) identify predictors of continued problem use in the first year after separation, and (c) evaluate the hypothesis that avoidant coping, posttraumatic stress disorder (PTSD) symptoms, and chronic stress place individuals at particularly high risk for continued problem use. METHOD: Participants (N = 1,599) completed self-report measures before and during the year following separation. Participants who endorsed either having used more than intended or wanting or needing to cut down during the past year were considered to have problem use. RESULTS: Of 742 participants reporting problem substance use at baseline, 42% reported continued problem substance use at follow-up ("persistors"). Persistors reported more trouble adjusting to civilian life, had a greater likelihood of driving while intoxicated, and had a greater likelihood of aggression. Multivariate analyses showed that avoidant coping score at baseline and higher PTSD symptom score and greater sensation seeking at follow up predicted continued problem use. CONCLUSIONS: Understanding risk factors for continued problem use is a prerequisite for targeted prevention of chronic problems and associated negative life consequences.

Genetic variants in serotonin and corticosteroid systems modulate neuroendocrine and cardiovascular responses to intense stress.

Common variants in serotonin and corticosteroid receptor genes influence human stress in laboratory settings. Little is known of their combined effects, especially in high stress environments. This study evaluated distinct and combined effects of polymorphisms in the serotonin transporter (5HTTLPRL/S), glucocorticoid receptor (Bcl1C/G), and mineralocorticoid (-2C/G) receptor genes on adrenocortical and cardiovascular responses to intense, realistic stress. One hundred and forty four healthy, active-duty military men were studied before, during, and 24h after a stressful 12-day survival course. Dependent variables were cortisol, heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP). 5HTTLPR SS carriers revealed higher overall cortisol concentrations than L carriers (p=.022). 5HTTLPR L carriers demonstrated higher stress-induced HR than non-carriers (SS) yet rebounded to a lower recovery value (p=.026), while Bcl1 G carriers showed higher mean stress-induced HR than non-carriers (CC) (p=.047). For DBP, 5HTTLPR S carriers showed higher overall values than non-carriers (LL) (p=.043), Bcl1 GG were higher than C carriers (p=.039), and -2C/G G carriers exceeded non-carriers (CC) (p=.028). A "high" composite genotype group revealed substantially higher overall cortisol concentrations than a "low" composite genotype group (p<.001), as was the case for DBP (p=.037). This study revealed a synergistic effect of common polymorphisms on the acute stress response in healthy men. Pending additional study, these findings may have implications for drug discovery, gene therapy, and stress inoculation strategies.

Salivary nerve growth factor response to intense stress: effect of sex and body mass index.

Ample evidence links stress to psychiatric and neurological disease. Although many studies examine stress hormone secretion and receptor activity, exciting new developments signify a shift in focus to neuromodulatory systems influencing neuronal development, survival, and neuroplasticity. The purpose of this study was to characterize salivary nerve growth factor (sNGF) responses to intense stress exposure in healthy military members undergoing survival training. A second purpose was to explore effects of age, sex, education, and body mass index (BMI). One hundred sixteen military members (80% male) were studied before, during, and 24 h after a stressful mock-captivity exercise. sNGF was measured at all three time points. Reactivity, recovery, and residual elevation of sNGF were computed. General linear modeling with repeated measures evaluated effect of stress exposure, as well as the roles of age, sex, education, and BMI. sNGF increased 137% from baseline to intense stress. During recovery, sNGF remained elevated an average of 67% above baseline (i.e., residual elevation). Men showed greater sNGF reactivity than women quantified by larger absolute T1-T2Δ (+148.1 pg/mL vs. +64.9 pg/mL, p<0.017). A noteworthy trend of higher sNGF concentrations in low BMI participants was observed (p=0.058). No effects of age or education were shown. This study shows substantial reactivity and residual elevation of sNGF in response to intense stress exposure in healthy humans. Further research is needed to refine the sNGF assay, fully characterize the sNGF stress response, delineate correlates and mechanisms, and validate therapeutic applications.

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.

Association between traumatic brain injury and risk of posttraumatic stress disorder in active-duty Marines.

IMPORTANCE: Whether traumatic brain injury (TBI) is a risk factor for posttraumatic stress disorder (PTSD) has been difficult to determine because of the prevalence of comorbid conditions, overlapping symptoms, and cross-sectional samples. OBJECTIVE: To examine the extent to which self-reported predeployment and deployment-related TBI confers increased risk of PTSD when accounting for combat intensity and predeployment mental health symptoms. DESIGN, SETTING, AND PARTICIPANTS: As part of the prospective, longitudinal Marine Resiliency Study (June 2008 to May 2012), structured clinical interviews and self-report assessments were administered approximately 1 month before a 7-month deployment to Iraq or Afghanistan and again 3 to 6 months after deployment. The study was conducted at training areas on a Marine Corps base in southern California or at Veterans Affairs San Diego Medical Center. Participants for the final analytic sample were 1648 active-duty Marine and Navy servicemen who completed predeployment and postdeployment assessments. Reasons for exclusions were nondeployment (n = 34), missing data (n = 181), and rank of noncommissioned and commissioned officers (n = 66). MAIN OUTCOMES AND MEASURES: The primary outcome was the total score on the Clinician-Administered PTSD Scale (CAPS) 3 months after deployment. RESULTS: At the predeployment assessment, 56.8% of the participants reported prior TBI; at postdeployment assessment, 19.8% reported sustaining TBI between predeployment and postdeployment assessments (ie, deployment-related TBI). Approximately 87.2% of deployment-related TBIs were mild; 250 of 287 participants (87.1%) who reported posttraumatic amnesia reported less than 24 hours of posttraumatic amnesia (37 reported ≥ 24 hours), and 111 of 117 of those who lost consciousness (94.9%) reported less than 30 minutes of unconsciousness. Predeployment CAPS score and combat intensity score raised predicted 3-month postdeployment CAPS scores by factors of 1.02 (P < .001; 95% CI, 1.02-1.02) and 1.02 (P < .001; 95% CI, 1.01-1.02) per unit increase, respectively. Deployment-related mild TBI raised predicted CAPS scores by a factor of 1.23 (P < .001; 95% CI, 1.11-1.36), and moderate/severe TBI raised predicted scores by a factor of 1.71 (P < .001; 95% CI, 1.37-2.12). Probability of PTSD was highest for participants with severe predeployment symptoms, high combat intensity, and deployment-related TBI. Traumatic brain injury doubled or nearly doubled the PTSD rates for participants with less severe predeployment PTSD symptoms. CONCLUSIONS AND RELEVANCE: Even when accounting for predeployment symptoms, prior TBI, and combat intensity, TBI during the most recent deployment is the strongest predictor of postdeployment PTSD symptoms.

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.

Depression and pain: independent and additive relationships to anger expression.

UNLABELLED: Anger and anger expression (ANGX) are concerns in the U.S. military population and have been linked to stress dysregulation, heart disease, and poor coping behaviors. OBJECTIVE: We examined associations between depression, pain, and anger expression among military veterans. METHOD: Subjects (N = 474) completed a depression scale, a measure of pain across the last 4 weeks, and an ANGX scale. A multiple regression model assessed the independent and additive relationships of depression and pain to ANGX. RESULTS: Almost 40% of subjects met the case definition for either major or minor depression. Subjects reported low-to-moderate levels of pain (mean = 6.3 of possible 20) and somewhat frequent episodes of ANGX. As expected, depression and pain were positively associated (r = 0.42, p < 0.001) and crossover effects of antidepressant and pain medication were shown. Specifically, frequency of antidepressant medication use was inversely associated with pain symptoms (r = -0.20, p < 0.001) and frequency of pain medication use was inversely linked to depressive symptoms (r = -0.21, p < 0.001). In a multiple regression model, depression (ß = 0.58, p < 0.001) and pain (ß = 0.21, p < 0.05) showed independent and additive relationships to ANGX (F = 41.5, p < 0.001, R(2)adj = 0.31). CONCLUSIONS: This study offers empirical support for depression-pain comorbidity and elucidates independent and additive contributions of depression and pain to ANGX.

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.

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.

Psychiatric diagnoses and treatment of U.S. military personnel while deployed to Iraq.

Military personnel deployed in support of combat operations are at significantly higher risk for mental health problems. However, much of what we know about combat-related mental health comes from postdeployment assessments. This study describes the mental health of 1,336 treatment-seeking deployed U.S. military personnel and interventions recommended by military mental health providers in Iraq from January 2006 to January 2007. Cases were primarily young enlisted men, most of whom were on their first combat deployment. Marines made up the majority of the cases (60%), but there were also large numbers of Army and Navy personnel. The most common psychiatric diagnoses were anxiety disorders (31%, including 11% with posttraumatic stress disorder), followed by adjustment (27%) and mood disorders (25%, including 22% with depression). Medication was the most commonly prescribed treatment for patients with psychiatric diagnoses but was often combined with recommendations for psychotherapy/counseling and/or behavioral modifications. The findings illustrate the distribution of mental health conditions seen among treatment-seeking troops while actively serving in a combat environment and the interventions recommended for them. Further examination of postdeployment health outcomes may help to facilitate the development of more effective acute intervention strategies in theater.

Predictors of risk and resilience for posttraumatic stress disorder among ground combat Marines: methods of the Marine Resiliency Study.

The Marine Resiliency Study (MRS) is a prospective study of factors predictive of posttraumatic stress disorder (PTSD) among approximately 2,600 Marines in 4 battalions deployed to Iraq or Afghanistan. We describe the MRS design and predeployment participant characteristics. Starting in 2008, our research team conducted structured clinical interviews on Marine bases and collected data 4 times: at predeployment and at 1 week, 3 months, and 6 months postdeployment. Integrated with these data are medical and career histories from the Career History Archival Medical and Personnel System (CHAMPS) database. The CHAMPS database showed that 7.4% of the Marines enrolled in MRS had at least 1 mental health diagnosis. Of enrolled Marines, approximately half (51.3%) had prior deployments. We found a moderate positive relationship between deployment history and PTSD prevalence in these baseline data.

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.

Theater Mental Health Encounter Data (TMHED): overview of study design and methods.

Research has documented higher risks for mental health problems among service members deployed to war zones, yet a research limitation has been that assessment has generally occurred often years after combat exposure. The Operational Stress Control and Readiness program integrated mental health practitioners with 1st Marine Division units serving in Iraq. This team documented mental health visits between January 2006 and January 2007 and developed the Theater Mental Health Encounter Database (TMHED). This report describes the TMHED study design, measures, and cases. Of 1336 patients (3180 patient visits), 10% were women, 75% were high school educated, 55% were mid-paygrade enlisted, and 63% were on their first combat deployment. Compared with the overall deployed population, patient percentages included higher percentages of Marines and Navy personnel but lower percentages of Army and Air Force personnel, more junior enlisted but fewer officers, and fewer college graduates. TMHED provides an unprecedented opportunity to study early psychiatric intervention in a combat zone and prospectively examines postdeployment health and career outcomes.