background The current combat operations in Iraq and Afghanistan have involved U.S. military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans. methods We studied members of four U.S. combat infantry units (three Army units and one Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or three to four months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and post-traumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments. results Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care. conclusions This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care.

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Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.

25. Multiple Imputation for Nonresponse in Surveys. By D. B. Rubin. ISBN 0 471 08705 X. Wiley, Chichester, 1987. 258 pp. £30.25.

Multiple Imputation for Nonresponse in Surveys

The Posttraumatic Stress Disorder Checklist (PCL) is a widely used DSM-correspondent self-report measure of PTSD symptoms. The PCL was recently revised to reflect DSM-5 changes to the PTSD criteria. In this article, the authors describe the development and initial psychometric evaluation of the PCL for DSM-5 (PCL-5). Psychometric properties of the PCL-5 were examined in 2 studies involving trauma-exposed college students. In Study 1 (N = 278), PCL-5 scores exhibited strong internal consistency (α = .94), test-retest reliability (r = .82), and convergent (rs = .74 to .85) and discriminant (rs = .31 to .60) validity. In addition, confirmatory factor analyses indicated adequate fit with the DSM-5 4-factor model, χ2 (164) = 455.83, p < .001, standardized root mean square residual (SRMR) = .07, root mean squared error of approximation (RMSEA) = .08, comparative fit index (CFI) = .86, and Tucker-Lewis index (TLI) = .84, and superior fit with recently proposed 6-factor, χ2 (164) = 318.37, p < .001, SRMR = .05, RMSEA = .06, CFI = .92, and TLI = .90, and 7-factor, χ2 (164) = 291.32, p < .001, SRMR = .05, RMSEA = .06, CFI = .93, and TLI = .91, models. In Study 2 (N = 558), PCL-5 scores demonstrated similarly strong reliability and validity. Overall, results indicate that the PCL-5 is a psychometrically sound measure of PTSD symptoms. Implications for use of the PCL-5 in a variety of assessment contexts are discussed.

The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation.

The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review.

Of 2525 soldiers, 124 (4.9%) reported injuries with loss of consciousness, 260 (10.3%) reported injuries with altered mental status, and 435 (17.2%) reported other injuries during deployment. Of those reporting loss of consciousness, 43.9% met criteria for post-traumatic stress disorder (PTSD), as compared with 27.3% of those reporting altered mental status, 16.2% with other injuries, and 9.1% with no injury. Soldiers with mild traumatic brain injury, primarily those who had loss of consciousness, were significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somatic and postconcussive symptoms than were soldiers with other injuries. However, after adjustment for PTSD and depression, mild traumatic brain injury was no longer significantly associated with these physical health outcomes or symptoms, except for headache. Conclusions Mild traumatic brain injury (i.e., concussion) occurring among soldiers deployed in Iraq is strongly associated with PTSD and physical health problems 3 to 4 months after the soldiers return home. PTSD and depression are important mediators of the relationship between mild traumatic brain injury and physical health problems.

/pdf/mild-traumatic-brain-injury-in-u-s-soldiers-returning-from-48oxdlt2hs.pdf

Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq

Background The current study examines the unique and interactive effects of posttraumatic stress disorder (PTSD) symptoms and days using alcohol, opioids, and marijuana on PTSD symptoms, suicidal ideation, and suicidal behavior up to 1 year, later in a high-risk sample of military personnel not active in mental health treatment. Methods Current and former military personnel at risk for suicide (N = 545; M age = 31.91 years, standard deviation = 7.27; 88.2% male) completed self-report measures of PTSD symptoms, past 30 days heavy alcohol use, opioid use, marijuana use, and current suicidal ideation via telephone at baseline and 1, 3, 6, and 12 months later. PTSD symptoms and the substance use variables (and relevant covariates) were entered as predictors of changes in PTSD symptoms, the likelihood of suicidal ideation, suicidal ideation severity, and the likelihood of suicidal behavior during the 11-month follow-up period. Results PTSD symptoms predicted PTSD symptoms 1 month later. PTSD symptoms and marijuana use predicted the likelihood of suicidal ideation 1 month later and suicidal behavior during the 11-month follow-up period. The interaction between PTSD symptoms and marijuana use significantly predicted increased PTSD symptoms over time and suicidal behavior. At high, but not low levels of PTSD symptoms, more days using marijuana predicted increased PTSD symptoms over time and the likelihood of suicidal behavior. Conclusions Results suggest marijuana, especially for military personnel experiencing elevated PTSD symptoms may negatively impact suicidal thoughts and behavior. These results are relevant to suggestions that medical marijuana could be used in treating or augmenting treatment for PTSD.

Interactive effects of PTSD and substance use on suicidal ideation and behavior in military personnel: Increased risk from marijuana use.

Indirect associations of combat exposure with post-deployment physical symptoms in U.S. soldiers: Roles of post-traumatic stress disorder, depression and insomnia

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=jama&articleId=917029&pdfFileName=jlt0802-3-3.pdf

Mental Health After Deployment to Iraq or Afghanistan—Reply

Screening for Psychological Illness in the Military

During the past decade, unprecedented clinical and research resources have been directed toward addressing 2 conditions considered “silent” and “signature injuries” of the Iraq and Afghanistan wars, namely, posttraumatic stress disorder (PTSD) and concussion (m i l d t r auma t i c b r a i n injury). This investment is increasingly paying dividends in knowledge and interventions that are changing the standards of clinical practice. Notable examples include emerging trauma-focused psychotherapies and the antihypertensive prazosin hydrochloride for PTSD.1 However, along with these successes have also come seemingly promising interventions that in due course are shown to lack efficacy when tested in clinical trials such as the multicenter trial of risperidone augmentation for PTSD.1 This issue of JAMA Internal Medicine publishes results of a clinical trial that illuminates the challenges in designing effective interventions for silentwar-related injuries.2While the sample size was modest, this unique well-designed 3-arm double-blindstudyofhyperbaricoxygen (HBO) treatmentprovides compelling results with broad implications. Seventytwo service members who experienced concussions (including at least 1 concussion during war-zone deployment) and werehavingpersistentpostconcussionsymptoms (≥4months’ duration) were randomized to receive 40 HBO treatments (100%oxygenat1.5atmospheresabsolute for60minutes5days per week), a sham procedure (40 equivalent sessions involving slightly pressurized room air, sufficient to induce a feeling of inner ear pressure), or routine postconcussion care. Results showed that both the HBO and sham procedures were associated with significant improvements in postconcussion symptoms and secondary outcomes, including PTSD (which most participants had), depression, sleep quality, satisfactionwith life, andphysical, cognitive, andmental health functioning. However, there were no significant differences betweenHBOand the shamprocedure, and change scores for all secondary outcomes favored sham. Although this trialwas technically apilot investigationdesigned to produce data necessary for a pivotal study and will not likely end debate on this topic (given tenacious advocacy byHBOproponents3), these results are consistentwith 2other sham-controlledclinical trialsamongservicemembersandveterans involving a range ofHBOdoses.2 Given the outstanding methods, consistency in results, and lack of dose response across thesestudies, it is increasinglyhard toargue thataphase 3 trial of HBO for the treatment of postconcussion symptoms (or PTSD) is warranted. This conclusion is disappointing for servicemembers and veterans experiencing war-related symptoms but offers important lessons and anopportunity to engage in reneweddialogue concerning the priorities for future interventions. This dialogue requires us to begin by acknowledging that no new treatments for persistent blast or impact–related postconcussion symptomshavebeen identified, despite the extensive investment to date. The evidence remains weak and inconsistent for both pharmacological (eg, stimulant or cholinergic augmentation) and nonpharmacological (eg, cognitive rehabilitation) interventions.4,5 The only evidence-based treatment shown to be effective in attenuating persistent symptoms after concussion, based on clinical trials in civilian populations, is cognitive education to promote expectations of recovery.4,5However,despite thisbeingemphasizedasacornerstone of treatment guidelines,4 research is lacking to replicate or refine educational interventions in military or veteranpopulations.Furthermore, concernshavebeenraised that current screening approaches, combined with a specialtydriven structure of concussion care in the Veterans Health Administration and Department of Defense, may inadvertently promote negative, rather than positive, recovery expectations.5,6 ThisHBOclinical trial highlights a principal barrier to successful concussion-related interventions,namely, the fact that the condition of persistent postconcussion symptoms is such an elusive target for treatment that effective interventions will likely not be identified until this condition is reconceptualized.4-6 Postconcussion symptoms typically involve headaches, fatigue, cognitive and memory problems, sleep disturbance, irritability, dizziness and balance problems, andothers.However, these symptoms areubiquitous in general medical practice, they are associated with numerous different conditions, and no validated clinical case definition exists, oneofmany reasonswhy thisHBOpilot studywas conducted. Multiple studies amongmilitary and veteran populationshave shown thatpersistent cognitive andphysical symptoms attributed to concussion in the postdeployment period are much more likely to be associated with conditions other than concussion, including PTSD, depression, grief, nonconcussive injuries, or associated comorbidities (eg, chronic pain andsleepdysfunction).5-7Underlyingneuroendocrineandautonomic nervous system dysregulation likely mediates these multisymptom trauma-spectrum responses.1,5 Two-thirdsof servicemembers in thisHBOstudyhadadiagnosis ofPTSD (basedonstructuredclinical interviews), 44% were taking daily pain medication, and the mean depression scores were in the depressed range (with more than half takRelated article page 43 Hyperbaric Oxygen in Postconcussion Service Members Original Investigation Research

Charles W. Hoge

Papers

Interactive effects of PTSD and substance use on suicidal ideation and behavior in military personnel: Increased risk from marijuana use.

Indirect associations of combat exposure with post-deployment physical symptoms in U.S. soldiers: Roles of post-traumatic stress disorder, depression and insomnia

Mental Health After Deployment to Iraq or Afghanistan—Reply

Screening for Psychological Illness in the Military

The ritual of hyperbaric oxygen and lessons for the treatment of persistent postconcussion symptoms in military personnel.