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.

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

A DECADE OF CONFLICT IN AFGHANISTAN AND IRAQ has caused a substantial mental health burden for war veterans and their families, particularly posttraumatic stress disorder (PTSD). (The term veterans in this article includes personnel still remaining in service.) The postdeployment PTSD prevalence in US infantry personnel has averaged 10% to 20%, often coexisting with depression, substance misuse, and other concerns. In response, the US Departments of Defense and Veterans Affairs (VA) have implemented numerous programs in the areas of population screening, education (eg, stigma reduction), and clinical care. The VA has mandated that all veterans treated for PTSD have access to either prolonged exposure therapy or cognitive processing therapy (CPT). However, veterans remain reluctant to seek care, with half of those in need not utilizing mental health services. Among veterans who begin PTSD treatment with psychotherapy or medication, a high percentage drop out, commonly 20% to 40% in randomized clinical trials (RCTs) but considerably higher in routine practice. The rate of recovery of 60% to 80% among treatment completers declines to around 40% when noncompleters are accounted for (using intentionto-treat analyses). With only 50% of veterans seeking care and a 40% recovery rate, current strategies will effectively reach no more than 20% of all veterans needing PTSD treatment. Thus, interventions that will have the greatest potential for improving care on a population level are those focused on enhancing the reach of treatment (eg, engagement, adherence, and acceptability). Enhancing treatment reach requires moving beyond screening and other stigma-reduction approaches. Postdeployment screening has never been demonstrated to be effective in improving mental health (one program evaluation found paradoxical opposite associations), and new research among veterans found negative perceptions of mental health care more important than stigma in predicting low service utilization. Examples of such perceptions include lack of trust in mental health professionals, thinking less of others who seek care, or considering treatment ineffective, unhealthy, or a “last resort.” Therefore, a high priority is to understand the reasons for these perceptions and meet veterans where they are. Veterans frequently report dissatisfaction with care and disconnect between their experiences as warriors and perspectives they encounter trying to obtain the help they need. Conceptualizing PTSD within an occupational context that is much broader than the clinical definition can help bridge the gap. Military personnel are members of professional workgroups, similar to police and other first responders, trained to respond to multiple traumatic events; they do not normally perceive themselves as victims, nor their reactions as pathological. The paradox of war-related PTSD is that reactions labeled “symptoms” upon return home can be highly adaptive in combat, fostered through rigorous training and experience. For example, hyperarousal; hypervigilance; and the ability to channel anger, shut down (numb) other emotions even in the face of casualties, replay or rehearse responses to dangerous scenarios, and function on limited sleep are adaptive in war. Improving evidence-based treatments, therefore, must be paired with education in military cultural competency to help clinicians foster rapport and continued engagement with professional warriors. This includes sensitivity and knowledge in attending to difficult topics, such as grief and survivor’s guilt stemming from loss of team members, ethical dilemmas in combat, or situations associated with feelings of betrayal (eg, poor leadership, rape by fellow team member). Strict fidelity to treatment protocols may not always support these goals, and clinicians must know how to apply evidence-based techniques in a patient-centered manner. Fundamentally, all psychotherapies with an A-level recommendation for PTSD (good evidence that benefits outweigh harm by US Preventive Services Task Force criteria) involve 5 core components: (1) narration, (2) cognitive restructuring, (3) in vivo exposure, (4) stress inoculation (eg, relaxation) skills, and (5) psychoeducation. Evidence indicates that as long as these components are applied, how

Interventions for war-related posttraumatic stress disorder: meeting veterans where they are.

Stigma and barriers to care in soldiers postcombat.

Chronic Pain and Opioid Use in US Soldiers After Combat Deployment Chronic pain affects a quarter of people seeking primary health care.1,2 Opioid medications are prescribed for chronic pain, but recently, rates of opioid use and misuse have ballooned, leading to significant numbers of overdose-related hospitalizations and deaths.3 The prevalence of chronic pain and opioid use assoc iated w ith deployment is not well known, despite large numbers of wounded service members. To our knowledge, this is the first study to assess chronic pain prevalence and opioid use in a non– treatment-seeking, active duty infantry population following deployment.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/1885986/ild140025.pdf

Chronic pain and opioid use in US soldiers after combat deployment.

Background:
The US military is currently involved in large, lengthy, and complex combat operations around the world. Effective military operations require optimal health of deployed service members, and both mental and physical health can be affected by military operations.

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The physical and mental health of a large military cohort: baseline functional health status of the Millennium Cohort

BEFORE THE WARS IN IRAQ AND AFGHANISTAN, THE INcidence of suicide in active duty US service members was consistently 25% lower than that in civilians, attributable to “healthy-worker” effects from career selection factors and universal access to health care. Between 2005 and 2009, the incidence of suicide in Army and Marine personnel nearly doubled. From 2009 through the first half of 2012, the incidence of suicide among Army soldiers remained elevated (22 per 100 000 per year), with the number dying of suicide each year exceeding the number killed in action. High rates of suicide have also been reported for US veterans, although incidence studies in veteran populations have drawn conflicting conclusions. The pressing question is why suicides increased so markedly in soldiers and Marines, but not in Navy or Air Force personnel (or in civilians). An obvious answer would be repeated ground combat tours. However, to date no study has definitively confirmed an independent association with deployment variables. This may be due to confounding factors such as higher service attrition for personnel with deployment-related mental health problems (contributing to healthy-worker effects). The optimal way to study militaryspecific risk factors is to follow individuals longitudinally beyond the time of their service, an endeavor few research groups are able to undertake. Although longitudinal studies may eventually establish deployment associations, current evidence suggests that such associations are likely to be weak and not independent of well-established risk factors, especially underlying mental health problems. A logical explanation for the high suicide rates in soldiers and Marines is the cumulative strain from the protracted war effort, across both deployed and garrison environments, causing higher population prevalences of mental disorders. If this explanation is accurate, the most effective medical intervention strategies are those that facilitate access to effective treatment. Determining the value of intervention strategies requires reliable effectiveness measures. However, military and veteran suicide research is hampered by problems with determination of “veteran” status on surveillance records; misclassifications of the manner of death; lack of integration of data from the US Department of Defense (DOD), Department of Veterans Affairs (VA), and National Death Index; and wide rate variability in population subgroups. Pressures exist to rapidly implement multicomponent prevention programs. However, apparent program successes based on observational evidence (eg, Air Force effort in the 1990s) cannot be replicated without knowing which components contributed to effectiveness. As the war effort in Afghanistan draws down, caution is advised in attributing future reductions in suicide rates to specific programs. Attention must stay focused on the most promising suicide intervention strategies within the broad categories of screening, education, and treatment, considering also potential iatrogenic effects.

https://jamanetwork.com/journals/jama/articlepdf/1346202/jvp120052_671_672.pdf

Charles W. Hoge

Papers

Interventions for war-related posttraumatic stress disorder: meeting veterans where they are.

Stigma and barriers to care in soldiers postcombat.

Chronic pain and opioid use in US soldiers after combat deployment.

The physical and mental health of a large military cohort: baseline functional health status of the Millennium Cohort

Preventing Suicides in US Service Members and Veterans: Concerns After a Decade of War