The role of stress sensitization in progression of posttraumatic distress following deployment

Childhood unpredictability is associated with increased risk for long- and short-term depression and anhedonia symptoms following combat deployment

High unpredictability has emerged as a dimension of early-life adversity that may contribute to a host of deleterious consequences later in life. Early-life unpredictability affects development of limbic and reward circuits in both rodents and humans, with a potential to increase sensitivity to stressors and mood symptoms later in life. Here, we examined the extent to which unpredictability during childhood was associated with changes in mood symptoms (anhedonia and general depression) after two adult life stressors, combat deployment and civilian reintegration, which were assessed ten years apart. We also examined how perceived stress and social support mediated and /or moderated links between childhood unpredictability and mood symptoms. To test these hypotheses, we leveraged the Marine Resiliency Study, a prospective longitudinal study of the effects of combat deployment on mental health in Active-Duty Marines and Navy Corpsman. Participants (N = 273) were assessed for depression and anhedonia before (pre-deployment) and 3-6 months after (acute post-deployment) a combat deployment. Additional assessment of depression and childhood unpredictability were collected 10 years post-deployment (chronic post-deployment). Higher childhood unpredictability was associated with higher anhedonia and general depression at both acute and chronic post-deployment timepoints (βs ≥ 0.16, ps ≤.007). The relationship between childhood unpredictability and subsequent depression at acute post-deployment was partially mediated by lower social support (b = 0.07, 95% CI [0.03, 0.15]) while depression at chronic post-deployment was fully mediated by a combination of lower social support (b = 0.14, 95% CI [0.07, 0.23]) and higher perceived stress (b = 0.09, 95% CI [0.05, 0.15]). These findings implicate childhood unpredictability as a potential risk factor for depression in adulthood and suggest that increasing the structure and predictability of childhood routines and developing social support interventions after life stressors could be helpful for preventing adult depression.

Effects of prior deployments and perceived resilience on anger trajectories of combat-deployed soldiers

BACKGROUND

Problematic anger is frequently reported by soldiers who have deployed to combat zones. However, evidence is lacking with respect to how anger changes over a deployment cycle, and which factors prospectively influence change in anger among combat-deployed soldiers.

METHODS

Reports of problematic anger were obtained from 7298 US Army soldiers who deployed to Afghanistan in 2012. A series of mixed-effects growth models estimated linear trajectories of anger over a period of 1-2 months before deployment to 9 months post-deployment, and evaluated the effects of pre-deployment factors (prior deployments and perceived resilience) on average levels and growth of problematic anger.

RESULTS

A model with random intercepts and slopes provided the best fit, indicating heterogeneity in soldiers' levels and trajectories of anger. First-time deployers reported the lowest anger overall, but the most growth in anger over time. Soldiers with multiple prior deployments displayed the highest anger overall, which remained relatively stable over time. Higher pre-deployment resilience was associated with lower reports of anger, but its protective effect diminished over time. First- and second-time deployers reporting low resilience displayed different anger trajectories (stable v. decreasing, respectively).

CONCLUSIONS

Change in anger from pre- to post-deployment varies based on pre-deployment factors. The observed differences in anger trajectories suggest that efforts to detect and reduce problematic anger should be tailored for first-time v. repeat deployers. Ongoing screening is needed even for soldiers reporting high resilience before deployment, as the protective effect of pre-deployment resilience on anger erodes over time.

Problem drinking recognition among UK military personnel: prevalence and associations

PURPOSE

Despite the higher prevalence of problem drinking in the UK military compared to the general population, problem recognition appears to be low, and little is known about which groups are more likely to recognise a problem. This study examined prevalence of problem drinking recognition and its associations.

METHODS

We analysed data from 6400 regular serving and ex-serving personnel, collected in phase 3 (2014-2016) of the King's Centre for Military Health Research cohort study.

MEASUREMENTS

Participants provided sociodemographic, military, health and impairment, life experiences, problem drinking, and problem recognition information. Problem drinking was categorised as scores ≥ 16 in the AUDIT questionnaire. Associations with problem recognition were examined with weighted logistic regressions.

FINDINGS

Among personnel meeting criteria for problem drinking, 49% recognised the problem. Recognition was most strongly associated (ORs ≥ 2.50) with experiencing probable PTSD (AOR = 2.86, 95% CI = 1.64-5.07), social impairment due to physical or mental health problems (AOR = 2.69, 95% CI = 1.51-4.79), adverse life events (AOR = 2.84, 95% CI = 1.70-4.75), ever being arrested (AOR = 2.99, CI = 1.43-6.25) and reporting symptoms of alcohol dependence (AOR = 3.68, 95% CI = 2.33-5.82). To a lesser extent, recognition was also statistically significantly associated with experiencing psychosomatic symptoms, feeling less healthy, probable common mental health disorders, and increased scores on the AUDIT.

CONCLUSION

Half of UK military personnel experiencing problem drinking does not self-report their drinking behaviour as problematic. Greater problem drinking severity, poorer mental or physical health, and negative life experiences facilitate problem recognition.

Pre-pandemic resilience to trauma and mental health outcomes during COVID-19

PURPOSE

The stress-sensitization hypothesis posits that individuals with prior trauma are at elevated risk for poor mental health when faced with subsequent stressors. Little work has examined whether those who have demonstrated psychological resilience to prior trauma would show either increased resilience or vulnerability to subsequent stressors. We examined pre-pandemic psychological resilience to lifetime trauma in relation to mental health outcomes amid the coronavirus disease 2019 (COVID-19) pandemic, a major societal stressor.

METHODS

The sample included 16,900 trauma-exposed women from the Nurses' Health Study II. Pre-pandemic resilience was defined by psychological health in 2017-2019 (characterized by levels of both distress and positive emotional well-being) relative to lifetime trauma. Resilience was defined categorically by cross-classifying unfavorable, adequate, and favorable psychological health by higher versus lower trauma burden, and continuously as the residual difference in predicted versus actual psychological health regressed on trauma burden. Mental health outcomes as of May-August 2020 included psychological distress symptoms and overall positive emotional well-being. Associations were assessed using covariate-adjusted regression models.

RESULTS

Pre-pandemic resilience was associated with lower distress and higher well-being early in the COVID-19 pandemic. Relative to the women showing highest resilience (favorable psychological health despite higher trauma), only those with lower trauma and favorable prior psychological health had significantly lower distress and higher positive emotional well-being during the pandemic. Higher continuous pre-pandemic resilience was also significantly associated with lower distress and higher positive emotional well-being during the pandemic.

CONCLUSION

Preventing mental health problems following trauma may contribute to protecting population well-being amid major stressors.

Post-traumatic growth among UK military personnel deployed to Iraq or Afghanistan: data from phase 3 of a military cohort study

BACKGROUND

Post-traumatic growth (PTG) refers to beneficial psychological change following trauma.

AIMS

This study explores the sociodemographic, health and deployment-related factors associated with PTG in serving/ex-serving UK armed forces personnel deployed to military operations in Iraq or Afghanistan.

METHOD

Multinomial logistic regression analyses were applied to retrospective questionnaire data collected 2014-2016, stratified by gender. PTG scores were split into tertiles of no/very low PTG, low PTG and moderate/large PTG.

RESULTS

A total of 1447/4610 male personnel (30.8%) and 198/570 female personnel (34.8%) reported moderate/large PTG. Male personnel were more likely to report moderate/large PTG compared with no/very low PTG if they reported a greater belief of being in serious danger (relative risk ratio (RRR) 2.47, 95% CI 1.68-3.64), were a reservist (RRR 2.37, 95% CI 1.80-3.11), reported good/excellent general health (fair/poor general health: RRR 0.33, 95% CI 0.24-0.46), a greater number of combat experiences, less alcohol use, better mental health, were of lower rank or were younger. Female personnel were more likely to report moderate/large PTG if they were single (in a relationship: RRR 0.40, 95% CI 0.22-0.74), had left military service (RRR 2.34, 95% CI 1.31-4.17), reported better mental health (common mental disorder: RRR 0.37, 95% CI 0.17-0.84), were a reservist, reported a greater number of combat experiences or were younger. Post-traumatic stress disorder had a curvilinear relationship with PTG.

CONCLUSIONS

A moderate/large degree of PTG among the UK armed forces is associated with mostly positive health experiences, except for post-traumatic stress disorder.

Association of polygenic risk scores, traumatic life events and coping strategies with war-related PTSD diagnosis and symptom severity in the South Eastern Europe (SEE)-PTSD cohort

OBJECTIVES

Posttraumatic stress disorder (PTSD) is triggered by extremely stressful environmental events and characterized by high emotional distress, re-experiencing of trauma, avoidance and hypervigilance. The present study uses polygenic risk scores (PRS) derived from the UK Biobank (UKBB) mega-cohort analysis as part of the PGC PTSD GWAS effort to determine the heritable basis of PTSD in the South Eastern Europe (SEE)-PTSD cohort. We further analyzed the relation between PRS and additional disease-related variables, such as number and intensity of life events, coping, sex and age at war on PTSD and CAPS as outcome variables.

METHODS

Association of PRS, number and intensity of life events, coping, sex and age on PTSD were calculated using logistic regression in a total of 321 subjects with current and remitted PTSD and 337 controls previously subjected to traumatic events but not having PTSD. In addition, PRS and other disease-related variables were tested for association with PTSD symptom severity, measured by the Clinician Administrated PTSD Scale (CAPS) by liner regression. To assess the relationship between the main outcomes PTSD diagnosis and symptom severity, each of the examined variables was adjusted for all other PTSD related variables.

RESULTS

The categorical analysis showed significant polygenic risk in patients with remitted PTSD and the total sample, whereas no effects were found on symptom severity. Intensity of life events as well as the individual coping style were significantly associated with PTSD diagnosis in both current and remitted cases. The dimensional analyses showed as association of war-related frequency of trauma with symptom severity, whereas the intensity of trauma yielded significant results independently of trauma timing in current PTSD.

CONCLUSIONS

The present PRS application in the SEE-PTSD cohort confirms modest but significant polygenic risk for PTSD diagnosis. Environmental factors, mainly the intensity of traumatic life events and negative coping strategies, yielded associations with PTSD both categorically and dimensionally with more significant p-values. This suggests that, at least in the present cohort of war-related trauma, the association of environmental factors and current individual coping strategies with PTSD psychopathology was stronger than the polygenic risk.

Time course of symptoms in posttraumatic stress disorder with delayed expression: A systematic review

OBJECTIVE

To examine the hypothesis that PTSD with delayed expression in some cases occurs without subthreshold PTSD symptoms above background levels bridging the gap between the traumatic exposure(s) and the clinical diagnosis.

METHODS

We performed systematic searches of peer-reviewed papers in English referenced in Pubmed, Embase, or PsycINFO and ascertained 34 prospective studies of PTSD symptom trajectories identified by latent class growth statistical modeling. Studies with delayed and low-stable trajectories provided appropriate data for this study. We computed the difference between the delayed trajectory PTSD symptom sumscore and the low-stable PTSD sumscore at the observed points in time after the traumatic event(s).

RESULTS

In 29 study populations, the latent class growth analyses displayed delayed trajectories, and in these, we identified 110 data points (% PTSD sumscore difference/months since traumatic exposure). The median PTSD symptom sumscore was 25% higher during the initial 6 months among individuals in the delayed trajectory compared to those in low-stable trajectory. From this level, the difference widened and reached a plateau of 40-50% higher. The variation was large, and the baseline participation rate and loss to follow-up were exceeding 25% in the majority of the studies. Heterogeneity of populations, measures, and analyses precluded formal meta-analysis.

CONCLUSION

Delayed PTSD is preceded by PTSD symptoms during the first year in most cases. Still, few individuals may experience an asymptomatic delay. The results underpin the rationale for monitoring PTSD symptoms and may inform forensic assessments in that delayed PTSD without symptoms bridging the traumatic event is rare.

A prospective cohort study of the psychological consequences of the COVID-19 pandemic on frontline healthcare workers in New York City

Objectives

We sought to describe the course and correlates of psychological distress in frontline healthcare workers (FHCWs) during the COVID-19 pandemic in New York City (NYC).

Methods

A prospective cohort study of FHCWs at the Mount Sinai Hospital was conducted during the initial 2020 surge (T1) and 7 months later (T2). Psychological distress [i.e., positive screen for pandemic-related post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and/or generalized anxiety disorder (GAD)], occupational and personal exposures to COVID-19, coping strategies, and psychosocial characteristics were assessed. Four courses of psychological distress response were identified: no/minimal, remitted, persistent, and new-onset. Multinomial logistic regression and relative importance analyses were conducted to identify factors associated with courses of distress.

Results

Of 786 FHCWs, 126 (16.0%) FHCWs had persistent distress; 150 (19.1%) remitted distress; 35 (4.5%) new-onset distress; and 475 (60.4%) no/minimal distress. Relative to FHCWs with no/minimal distress, those with persistent distress reported greater relationship worries [19.8% relative variance explained (RVE)], pre-pandemic burnout (18.7% RVE), lower dispositional optimism (9.8% RVE), less emotional support (8.6% RVE), and feeling less valued by hospital leadership (8.4% RVE). Relative to FHCWs with remitted symptoms, those with persistent distress reported less emotional support (29.7% RVE), fewer years in practice (28.3% RVE), and psychiatric history (23.6% RVE).

Conclusions

One-fifth of FHCWs in our study experienced psychological distress 7 months following the COVID-19 surge in NYC. Pandemic-related worries, pre-pandemic burnout, emotional support, and feeling valued by leaders were linked to persistent distress. Implications for prevention, treatment, and organizational efforts to mitigate distress in FHCWs are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-022-01832-0.

The relevance of post-traumatic stress disorder as a moderator of the relationship between experience of violent or sexual assault and opioid use in adulthood

BACKGROUND

Past research has indicated that individuals suffering from post-traumatic stress disorder (PTSD) may demonstrate increased sensitivity to stress exposure following onset of the disorder. Thus, having PTSD may amplify the effects of subsequent stressors. This has been found to be relevant in some forms of substance use but relationships between PTSD, new stress and opioid use specifically has not been examined.

AIMS

To explore interactions between PTSD, new victimisation and opioid use and test the hypothesis that PTSD will moderate any victimisation-opioid use relationship.

METHODS

The pathways to desistance data were used in analyses. A series of logistic regression models were used to test both direct effects of victimisation and PTSD on opioid use and interactions between them.

RESULTS

The sample was comprised of a male majority (male N = 1,170; female N = 184). Results indicated that neither PTSD nor victimisation were significant predictors of opioid use. PTSD was found to moderate the relationship between victimisation and opioid use in the hypothesised manner.

CONCLUSIONS

There may be clinical implications of these results relating to both inpatient and outpatient treatment. Regular trauma screening, additional victims' services and trauma-informed care may help to reduce the risk of opioid use among individuals suffering from PTSD.

Social Interaction Within a Trauma-Exposed Population During the Early Phase of COVID-19

The novel coronavirus (COVID-19) has led to significant stressors and shifts in social life, yet social interactions experienced by people with trauma exposure during the COVID pandemic is largely unknown. This study assessed frequency of interactions, social support given and received, and prosocial behavior using online survey methods (N=1049). We examined differences in experiences across three groups: no trauma exposure, trauma-exposed with low PTSD symptoms, and trauma-exposed with high PTSD symptoms. We also explored correlations between social interactions and PTSD symptom clusters. Results indicated significant differences across groups and the high PTSD group reported stronger associations between social interaction variables and symptom clusters, on average.

Individual Stress Prevention through Qigong

Owing to work intensification and an accelerated pace of life in general, individuals in many Western countries are often overactivated and find it difficult to switch off. However, recovery from physiological and mental activation is critical to prevent stress symptoms and maintain one’s physiological and mental well-being. Extensive research evidence indicates that Qigong, a traditional Chinese movement practice for promoting health, provides an effective means to recover from work and off-work demands. The main objective of this paper is to offer a comprehensive, narrative review of the effects of Qigong and its core components. Attention is first paid to the outcomes of work and off-work demands and stress, and the role of recovery for individuals’ well-being. Then, Qigong and its components are explained, followed by the results of scientific research. Finally, limitations and implications for research and practiced are discussed.

A framework of meaning attribution following loss

The loss of a loved one causes the world and the place of the bereaved survivor in it to change irreversibly. A key aspect of the grieving process is the integration of the loss in the bereaved survivor's life story, identity change, and a new future orientation through meaning attribution. Meaning attribution can have favourable or unfavourable effects on the grieving process and hence determines the extent to which a loss disrupts the bereaved survivor's functioning. A framework of meaning attribution after loss is presented, comprising 17 determinants that fall into five categories: event-related, cultural, social, individual and relational determinants. Each determinant may lead to both positive and negative meanings, thereby facilitating or complicating the grieving process. The framework of meaning attribution highlights the importance of an integrated network for mental health care, spiritual care, and end-of-life care in the prevention and treatment of traumatic grief. It also emphasizes the support from relatives, collective rituals, cultural views, legal settlements, and other societal factors that may foster or impede adaptation to loss. The framework of meaning attribution informs research across a range of research themes, including specialist care for traumatic grief, a culturally sensitive care network for traumatic grief, and improving care for ambiguous loss in a global context.

PTSD as a Risk Factor Predicting Polydrug Use: A Dual Systems of Self-Control Mediation Model

Post-traumatic stress disorder (PTSD) is associated with increased risk for polydrug use. Low self-control is a key characteristic of the disorder and is predictive of polydrug use. However, there is a dearth of research focused on the relevance of a dual systems model delineation of self-control into the constructs of risk-seeking and impulsivity as it pertains to polydrug use and PTSD. This study tested dual systems mediation of this relationship. Generalized structural equation modeling was used to test for mediation effects. Results indicated that more PTSD symptoms predicted increased drug use variety (coefficient = 0.024; confidence interval [CI] = [0.001, 0.046]). Inclusion of dual systems constructs fully attenuated this relationship. The total indirect effect achieved marginal significance (coefficient = 0.005; CI = [>−0.001, 0.009]). Sensitivity analyses of the specific indirect effect of impulsivity as the sole mediator indicated significant mediation. These results provide some indication that impulsivity-based programming may help to treat polydrug use among those with severe PTSD.

The Impact of PTSD-Linked Strain Sensitivity on Violent Offending: Differences in Effects During Adolescence Versus Early Adulthood

OBJECTIVES

Investigate the relevance of post-traumatic stress disorder (PTSD)-linked strain sensitivity associated with exposure to violence for predicting violence outcomes among juvenile offenders during adolescence and early adulthood.

METHODS

This study uses the Pathways to Desistance data and to test relevant relationships. Two series of negative binomial regression models were estimated to test hypotheses, one corresponding to each period of the life course.

RESULTS

Results indicated that witnessed violence interacted with PTSD status in adolescence, indicating that individuals afflicted with PTSD demonstrated heightened sensitivity to this strain, manifested in increased violent offending.

CONCLUSIONS

Results indicate that witnessed violence may act as a trigger during adolescence, resulting in juvenile offenders with PTSD responding with violence. This may have treatment implications for individuals suffering from PTSD.

Severity profiles of posttraumatic stress, depression, anxiety, and somatization symptoms in treatment seeking traumatized refugees

BACKGROUND

Western countries are facing many challenges hosting refugees from several regions in the world. Many of them are severely traumatized and suffer from a variety of mental health symptoms, which complicates the identification and treatment of refugees at risk. This study examined subgroups based on a broad range of psychopathology, and several predictors, including trauma characteristics and gender.

METHODS

Participants were 1147 treatment-seeking, traumatized refugees. Latent profile analysis was conducted to identify different subgroups based on levels of posttraumatic stress disorder (PTSD), depression, anxiety, and somatic symptoms. Multinomial logistic regression was used to identify predictors of subgroup membership.

RESULTS

Three distinct subgroups were identified, reflecting Moderate (10.2%), Severe (43.0%), and Highly Severe (45.9%) symptom severity levels, respectively. Symptom severity of all psychopathology dimensions was distributed equally between the subgroups. Participants in the Severe and Highly Severe Symptoms subgroups reported more types of traumatic events compared to the Moderate subgroup. In particular, traumatic events associated with human right abuses, lack of human needs and separation from others predicted subgroup membership, as did gender.

LIMITATIONS

The results are confined to treatment-seeking, traumatized refugee populations.

CONCLUSIONS

Distinguishable symptom severity profiles of PTSD, depression, anxiety and somatic complaints could be identified in this large treatment-seeking refugee population, without qualitative differences in symptom distribution. Instead of focusing on specific mental disorders, classification based on overall symptom severity is of interest in severely traumatized patients. This knowledge will help to identify individuals at risk and to enhance existing treatment programs for specific patient groups.

Early Life Poly-Victimization and Differential Development of Anxiety as Risk Factors for the Continuity of Substance Dependence in Adulthood

Background: Abuse of psychoactive substances may lead to physical and/or physiological dependence on said substances. While a great deal of research has focused on risk factors predicting onset, there has been little research focused on risk factors influencing continued dependence on substances in adulthood following onset early in life. Purpose/Objectives: The present study examined poly-victimization and developmental patterns of anxiety as predictors of continued substance dependence problems. Methods: The Pathways to Desistance data were used in the present study. A subset of this sample was used in analyses comprising 261 juvenile offenders who reported lifetime drug and/or alcohol dependence at baseline. Firth logistic regression was used to estimate the impact that covariates had on the odds that individuals in this subsample had continued substance dependence in adulthood. Results: Results indicated that increased poly-victimization score pertaining to direct victimization at baseline was associated with increased odds of continued substance dependence problems in adulthood. Further, presentation of high and chronic anxiety symptomatology during adolescence was associated with increased risk for continued dependence. Conclusions/Importance: Drug dependent adolescents who demonstrate chronic anxiety and/or have experienced polyvictimization are at-risk for continuity of dependent in adulthood. Youth should be screened for these issues and targeted with treatment.

Military Veteran Status and Posttraumatic Stress Disorder Symptomatology Among Urban Firefighters: The Moderating Role of Emotion Regulation Difficulties

A significant portion of firefighters are military veterans, and both populations experience high rates of trauma and posttraumatic stress disorder (PTSD) symptomatology. We investigated main and interactive effects of military veteran status (MVS) and emotion regulation difficulties (ERD) with regard to PTSD symptom severity in firefighters. Covariates included trauma load, number of years in the fire department, and depressive symptom severity. The sample was composed of 839 (93.9% men; mean age = 38.4, SD = 8.5) trauma-exposed firefighters who completed a web-based questionnaire battery. Structural equation modeling was used. ERD were significantly, positively associated with PTSD symptom severity (β = 0.30, confidence interval [CI] = 0.20-0.41, p < 0.001). A significant interactive effect was noted (β = 0.07, CI = 0.01-0.14, p = 0.020); firefighters who endorsed MVS and greater ERD had the highest levels of PTSD symptom severity. It is vital that future work examine associations between MVS and relevant cognitive mechanisms for the purposes of informing effective screening, intervention, and prevention programs.

Symptom severity in PTSD and comorbid psychopathology: A latent profile analysis among traumatized veterans

Individuals diagnosed with posttraumatic stress disorder (PTSD) show remarkably different symptom presentations. Identification of diagnostic profiles of PTSD may contribute to knowledge about treatment modifications to enhance treatment effectiveness. The present study aimed to identify symptom severity classes among 236 Dutch veterans based on a broad range of psychopathology outcomes, including PTSD, using Latent Profile Analysis (LPA). Moreover, multinomial logistic regression was used to test whether class membership could be predicted by the number and characteristics of traumatic event types, coping and personality dimensions. LPA identified three classes of individuals, defined as average, severe, and highly severe symptom severity classes, respectively. No qualitative differences in the symptom dimensions emerged between classes. Veterans with higher amounts of traumatic experiences and specifically with regard to lack of basic human needs, as well as those using more avoidant and problem-focused coping strategies and with more dysfunctional personality characteristics regarding neuroticism and agreeableness were significantly more often in the severe and/or highly severe symptom classes. In conclusion, general symptom severity was found to be an important diagnostic characteristic in this population. Integrated treatments targeting the broad spectrum of mental health problems may be of importance in treating patients that show low therapeutic recovery.

Loss of loved ones or home due to a disaster: Effects over time on distress in immigrant ethnic minorities

Exposure to mass trauma may bring about increased sensitivity to new or ongoing stressors. It is unclear whether sensitivity to stress associated with ethnic minority/immigrant status may be affected by severe exposure to mass trauma. We examined whether the loss of loved ones or home due to a disaster is associated with more persistent disaster-related distress in ethnic minorities compared with Dutch natives in the Netherlands. In residents affected by a fireworks disaster ( N = 1029), we assessed disaster-related distress after 3 weeks, 18 months, and 4 years. The effects of loss of loved ones or home and ethnic minority/immigrant status on distress were analyzed using latent growth modeling. After controlling for age, gender, education, employment, and post-disaster stressful life events, the loss of loved ones was associated with more persistent disaster-related distress in ethnic minorities compared with natives at 18 months, and the loss of home was associated with more persistent disaster-related distress in ethnic minorities compared with natives between 18 months and 4 years. Our results suggest that the loss of loved ones may increase sensitivity to stress associated with ethnic minority/immigrant status during the early phase of adaptation to a disaster. Loss of home may lead to further resource loss and thereby increase sensitivity to stress associated with ethnic minority/immigrant status in the long term. Efforts to prevent stress-related psychopathology following mass trauma should specifically target ethnic minority groups, notably refugees and asylum seekers, who often experienced multiple losses of loved ones as well as their homes.

Understanding mental health among military veterans in the fire service

Firefighters who have previously served in the military may be at potentially higher risk for worsened mental health outcomes. This investigation examined the mental health of military veterans, as compared to non-veterans, in the fire service. We hypothesized that firefighters who endorsed military veteran status would have higher rates of mental health symptoms, in comparison to firefighters who did not endorse prior service in the military. Age, gender, and race/ethnicity were used as covariates. The sample was comprised of 910 career firefighters, 209 (23.0%) of whom endorsed military veteran status. One-way analyses of covariance were employed. The military veteran subsample reported significantly higher levels of sleep disturbance, depression, and posttraumatic stress symptom severity in comparison to the non-veteran subsample; however, effect sizes were small indicating that between group differences are actually negligible. Results highlight the need to improve our understanding of risk and resilience factors for firefighters who have served in the military, as this line of inquiry has potentially important mental health intervention implications for this exceptionally understudied population.

Gene expression associated with PTSD in World Trade Center responders: An RNA sequencing study

The gene expression approach has provided promising insights into the pathophysiology of posttraumatic stress disorder (PTSD). However, few studies used hypothesis-free transcriptome-wide approach to comprehensively understand gene expression underpinning PTSD. A transcriptome-wide expression study using RNA sequencing of whole blood was conducted in 324 World Trade Center responders (201 with never, 81 current, 42 past PTSD). Samples from current and never PTSD reponders were randomly split to form discovery (N = 195) and replication (N = 87) cohorts. Differentially expressed genes were used in pathway analysis and to create a polygenic expression score. There were 448 differentially expressed genes in the discovery cohort, of which 99 remained significant in the replication cohort, including FKBP5, which was found to be up-regulated in current PTSD regardless of the genotypes. Several enriched biological pathways were found, including glucocorticoid receptor signaling and immunity-related pathways, but these pathways did not survive FDR correction. The polygenic expression score computed by aggregating 30 differentially expressed genes using the elastic net algorithm achieved sensitivity/specificity of 0.917/0.508, respectively for identifying current PTSD in the replication cohort. Polygenic scores were similar in current and past PTSD, with both groups scoring higher than trauma-exposed controls without any history of PTSD. Together with the pathway analysis results, these findings point to HPA-axis and immune dysregulation as key biological processes underpinning PTSD. A novel polygenic expression aggregate that differentiates PTSD patients from trauma-exposed controls might be a useful screening tool for research and clinical practice, if replicated in other populations.

The impact of antecedent trauma exposure and mental health symptoms on the post-deployment mental health of Afghanistan-deployed Australian troops

BACKGROUND

Both traumatic deployment experiences and antecedent traumas increase personnel's risk of developing PTSD and depression. However, only cross-sectional studies have assessed whether antecedent trauma moderates stress reactions to deployment experiences. This study prospectively examines whether antecedent trauma moderates the association between deployment trauma and post-deployment PTSD and depressive symptoms after accounting for antecedent mental health problems, in a large Australian Defence Force (ADF) sample.

METHODS

In the ADF Middle East Area of Operations Prospective Study, currently-serving military personnel deployed to Afghanistan across 2010-2012 (n = 1122) completed self-reported measures at pre-deployment and post-deployment.

RESULTS

Within multivariable regressions, associations between deployment trauma and PTSD and depressive symptoms at post-deployment were stronger for personnel with greater antecedent trauma. However, once adjusting for antecedent mental health problems, these significant interaction effects disappeared. Instead, deployment-related trauma and antecedent mental health problems showed direct associations with post-deployment mental health problems. Antecedent trauma was also indirectly associated with post-deployment mental health problems through antecedent mental health problems. Similar associations were seen with prior combat exposure as a moderator.

LIMITATIONS

Antecedent and deployment trauma were reported retrospectively. Self-reports may also suffer from social desirability bias, especially at pre-deployment.

CONCLUSIONS

Our main effects results support the pervasive and cumulative negative effect of trauma on military personnel, regardless of its source. While antecedent trauma does not amplify personnel's psychological response to deployment trauma, it is indirectly associated with increased post-deployment mental health problems. Antecedent mental health should be considered within pre-deployment prevention programs, and deployment-trauma within post-operational screening.

Gender and Age Differences in Trauma and PTSD Among Dutch Treatment-Seeking Police Officers

Little is known about how age and gender are associated with posttraumatic stress disorder (PTSD) symptoms and traumatic experiences in treatment-seeking police offers. In this study, we examined 967 diagnostic files of police officers seeking treatment for PTSD. Six hundred twelve (63%) of the referred police officers were diagnosed with PTSD (n = 560) or partial PTSD (n = 52). Police officers reported on average 19.5 different types of traumatic events (range 1-43). Those who experienced a greater variety of traumatic events suffered from more PTSD symptoms. Also, women reported more often direct life-threatening or private events as their index trauma than men and suffered from more PTSD symptoms than their male colleagues. Results indicate that police officers experience a considerable number of different traumatic events, which is significantly associated with PTSD symptoms. The results highlight the importance of early detection of PTSD symptoms in the police force.

The Need to Take a Staging Approach to the Biological Mechanisms of PTSD and its Treatment

Despite the substantial body of neurobiological research, no specific drug target has been developed to treat PTSD and there are substantial limitations with the available interventions. We propose that advances are likely to depend on the development of better classification of the heterogeneity of PTSD using a staging approach of disease. A primary rationale for staging is to highlight the probability that distinct therapeutic approaches need to be utilised according to the degree of biological progression of the disorder. Prospective studies, particularly of military populations, provide substantial evidence about the emerging biological abnormalities that precede the full-blown disorder. These need to be targeted with tailored interventions to prevent disease progression. Equally, the neurobiology of chronic unremitting PTSD needs to be differentiated from the acute disorder which emerges across a spectrum of severity, and this range of presentations correspondingly needs to be addressed with differing therapeutic strategies. The staging approach also needs to take account of the range of somatic pathological outcomes that are being identified as a consequence of traumatic stress exposure. PTSD should be conceptualised as a systemic disorder underpinned a range of biological dysregulation, including metabolic and altered immune function, reflected in the increased rates of cardiovascular and autoimmune disease. The effectiveness of novel treatments needs to be judged across their effectiveness in addressing the spectrum of trauma-related pathology.

Day patient treatment for traumatic grief: preliminary evaluation of a one-year treatment programme for patients with multiple and traumatic losses

Background: Bereaved individuals who have lost a loved one under traumatic circumstances can develop symptoms of Persistent Complex Bereavement Disorder (PCBD) and/or Posttraumatic Stress Disorder (PTSD). This is particularly common in refugees, as they frequently have been confronted with multiple traumatic losses. For patients with severe PTSD and traumatic grief a treatment programme was developed, embedding individual traumatic grief focused therapy in a group-based multidisciplinary day patient treatment programme. The day patient treatment comprised a weekly five-hour programme consisting of three phases with a duration of four months each. Objective: To evaluate the feasibility and potential effectiveness of the treatment programme. Method: Data were analyzed from 16 participants treated between October 2013 and March 2014. PTSD severity and PTSD/PCBD diagnoses were measured during the initial and final phases of treatment using the Clinician-Administered PTSD Scale for DSM-IV (CAPS) and the Traumatic Grief Inventory Self Report (TGI-SR). One clinical case is presented in more detail. Treatment attendance was also registered and therapist satisfaction was evaluated in a focus group. Results: Thirteen patients (81%) completed the treatment. Each day of the treatment programme was attended by a mean of 76% of the participants. In the focus group, therapists noted symptom reduction in their patients and they therefore regarded Brief Eclectic Psychotherapy for Traumatic Grief (BEP-TG) as an effective therapy for their patients. During treatment, significant decreases in PTSD severity as well as diagnosable PTSD and PCBD were observed. Conclusions: Results support the feasibility and potential effectiveness of the day patient treatment programme for traumatic grief. The programme appears to be particularly suitable for refugees with severe PTSD and PCBD psychopathology, who may not benefit enough from usual care.

Latent typologies of posttraumatic stress disorder in World Trade Center responders

Posttraumatic stress disorder (PTSD) is a debilitating and often chronic psychiatric disorder. Following the 9/11/2001 World Trade Center (WTC) attacks, thousands of individuals were involved in rescue, recovery and clean-up efforts. While a growing body of literature has documented the prevalence and correlates of PTSD in WTC responders, no study has evaluated predominant typologies of PTSD in this population. Participants were 4352 WTC responders with probable WTC-related DSM-IV PTSD. Latent class analyses were conducted to identify predominant typologies of PTSD symptoms and associated correlates. A 3-class solution provided the optimal representation of latent PTSD symptom typologies. The first class, labeled "High-Symptom (n = 1,973, 45.3%)," was characterized by high probabilities of all PTSD symptoms. The second class, "Dysphoric (n = 1,371, 31.5%)," exhibited relatively high probabilities of emotional numbing and dysphoric arousal (e.g., sleep disturbance). The third class, "Threat (n = 1,008, 23.2%)," was characterized by high probabilities of re-experiencing, avoidance and anxious arousal (e.g., hypervigilance). Compared to the Threat class, the Dysphoric class reported a greater number of life stressors after 9/11/2001 (OR = 1.06). The High-Symptom class was more likely than the Threat class to have a positive psychiatric history before 9/11/2001 (OR = 1.7) and reported a greater number of life stressors after 9/11/2001 (OR = 1.1). The High-Symptom class was more likely than the Dysphoric class, which was more likely than the Threat class, to screen positive for depression (83% > 74% > 53%, respectively), and to report greater functional impairment (High-Symptom > Dysphoric [Cohen d = 0.19], Dysphoric > Threat [Cohen d = 0.24]). These results may help inform assessment, risk stratification, and treatment approaches for PTSD in WTC and disaster responders.

Risk, coping and PTSD symptom trajectories in World Trade Center responders

Trajectories of disaster-related posttraumatic stress disorder (PTSD) symptoms are often heterogeneous, and associated with common and unique risk factors, yet little is known about potentially modifiable psychosocial characteristics associated with low-symptom and recovering trajectories in disaster responders. A total of 4487 rescue and recovery workers (1874 police and 2613 non-traditional responders) involved during and in the aftermath of the unprecedented World Trade Center (WTC) attacks, were assessed an average of 3, 6, 8, and 12 years post-9/11/2001. Among police responders, WTC-related PTSD symptoms were characterized by four trajectories, including no/low-symptom (76.1%), worsening (12.1%), improving (7.5%), and chronic (4.4%) trajectories. In non-traditional responders, a five-trajectory solution was optimal, with fewer responders in a no/low-symptom trajectory (55.5%), and the remainder in subtly worsening (19.3%), chronic (10.8%), improving (8.5%), and steeply worsening (5.9%) trajectories. Consistent factors associated with symptomatic PTSD trajectories across responder groups included Hispanic ethnicity, pre-9/11 psychiatric history, greater WTC exposure, greater medical illness burden, life stressors and post-9/11 traumas, and maladaptive coping (e.g., substance use, avoidance coping). Higher perceived preparedness, greater sense of purpose in life, and positive emotion-focused coping (e.g., positive reframing, acceptance) were negatively associated with symptomatic trajectories. Findings in this unique cohort indicate considerable heterogeneity in WTC-related PTSD symptom trajectories over 12 years post-9/11/2001, with lower rates of elevated PTSD symptoms in police than in non-traditional responders. They further provide a comprehensive risk prediction model of PTSD symptom trajectories, which can inform prevention, monitoring, and treatment efforts in WTC and other disaster responders.

Test of the stress sensitization model in adolescents following the pipeline explosion

PURPOSE

The stress sensitization model states that early traumatic experiences increase vulnerability to the adverse effects of subsequent stressful life events. This study examined the effect of stress sensitization on development of posttraumatic stress disorder (PTSD) symptoms in Chinese adolescents who experienced the pipeline explosion.

METHODS

A total of 670 participants completed self-administered questionnaires on demographic characteristics and degree of explosion exposure, the Childhood Trauma Questionnaire (CTQ), and the Posttraumatic Stress Disorder Checklist-Civilian Version (PCL-C). Associations among the variables were explored using MANOVA, and main effects and interactions were analyzed.

RESULTS

Overall MANOVA tests with the PCL-C indicated significant differences for gender (F=6.86, p=.000), emotional abuse (F=6.79, p=.000), and explosion exposure (F=22.40, p=.000). There were significant interactions between emotional abuse and explosion exposure (F=3.98, p=.008) and gender and explosion exposure (F=2.93, p=.033).

CONCLUSIONS

Being female, childhood emotional abuse, and a high explosion exposure were associated with high PTSD symptom levels. Childhood emotional abuse moderated the effect of explosion exposure on PTSD symptoms. Thus, stress sensitization influenced the development of PTSD symptoms in Chinese adolescents who experienced the pipeline explosion as predicted by the model.

A Life-span Perspective on Combat Exposure and PTSD Symptoms in Later Life: Findings From the VA Normative Aging Study

PURPOSE OF THE STUDY

We tested a life-span model of combat exposure on posttraumatic stress disorder (PTSD) symptoms in later life, examining the direct and indirect effects of prewar, warzone, and postwar factors.

DESIGN AND METHODS

The sample included 947 male World War II and Korean War veterans from the VA Normative Aging Study (Mage = 65, SD = 7). They completed mail surveys on childhood family environment, military service and postwar experience, stressful life events, and PTSD symptoms (response rates > 80%).

RESULTS

We constructed an initial path model testing cumulative advantage and disadvantage pathways. Although all hypothesized relationships were significant, the model was not a good fit to the data. Subsequent models showed that all three life-span periods had both direct and indirect effects on PTSD symptoms and that there were interesting cross-links between the two sets of pathways.

IMPLICATIONS

The life-span perspective provides a useful heuristic to model various developmental effects on later-life outcomes. A supportive childhood family environment can have lifelong protective effects, whereas a conflictual one can set up lifelong patterns of pessimistic appraisals.

The efficacy of recommended treatments for veterans with PTSD: A metaregression analysis

Soldiers and veterans diagnosed with PTSD benefit less from psychotherapy than non-military populations. The current meta-analysis identified treatment predictors for traumatised soldiers and veterans, using data from studies examining guideline recommended interventions, namely: EMDR, exposure, cognitive, cognitive restructuring, cognitive processing, trauma-focused cognitive behavioural, and stress management therapies. A systematic search identified 57 eligible studies reporting on 69 treated samples. Exposure therapy and cognitive processing therapy were more effective than EMDR and stress management therapy. Group-only therapy formats performed worse compared with individual-only formats, or a combination of both formats. After controlling for study design variables, EMDR no longer negatively predicted treatment outcome. The number of trauma-focused sessions, unlike the total number of psychotherapy sessions, positively predicted treatment outcome. We found a relationship between PTSD pretreatment severity levels and treatment outcome, indicating lower treatment gains at low and high PTSD severity levels compared with moderate severity levels. Demographic variables did not influence treatment outcome. Consequently, soldiers and veterans are best served using exposure interventions to target PTSD. Our results did not support a group-only therapy format. Recommended interventions appear less effective at relatively low and high patient PTSD severity levels. Future high-quality studies are needed to determine the efficacy of EMDR.

Cytokine production as a putative biological mechanism underlying stress sensitization in high combat exposed soldiers

OBJECTIVE

Combat stress exposed soldiers may respond to post-deployment stressful life events (SLE) with increases in symptoms of posttraumatic stress disorder (PTSD), consistent with a model of stress sensitization. Several lines of research point to sensitization as a model to describe the relations between exposure to traumatic events, subsequent SLE, and symptoms of PTSD. Based on previous findings we hypothesized that immune activation, measured as a high in vitro capacity of leukocytes to produce cytokines upon stimulation, underlies stress sensitization.

METHODS

We assessed mitogen-induced cytokine production at 1 month, SLE at 1 year, and PTSD symptoms from 1 month up to 2 years post-deployment in soldiers returned from deployment to Afghanistan (N=693). Exploratory structural equation modeling as well as latent growth models were applied.

RESULTS

The data demonstrated significant three-way interaction effects of combat stress exposure, cytokine production, and post-deployment SLE on linear change in PTSD symptoms over the first 2 years following return from deployment. In soldiers reporting high combat stress exposure, both high mitogen-stimulated T-cell cytokine production and high innate cytokine production were associated with increases in PTSD symptoms in response to post-deployment SLE. In low combat stress exposed soldiers as well as those with low cytokine production, post-deployment SLE were not associated with increases in PTSD symptoms.

CONCLUSION

High stimulated T-cell and innate cytokine production may contribute to stress sensitization in recently deployed, high combat stress exposed soldiers. These findings suggest that detecting and eventually normalizing immune activation may potentially complement future strategies to prevent progression of PTSD symptoms following return from deployment.

Prevalence of mental health symptoms in Dutch military personnel returning from deployment to Afghanistan: a 2-year longitudinal analysis

OBJECTIVE

Recent studies in troops deployed to Iraq and Afghanistan have shown that combat exposure and exposure to deployment-related stressors increase the risk for the development of mental health symptoms. The aim of this study is to assess the prevalence of mental health symptoms in a cohort of Dutch military personnel prior to and at multiple time-points after deployment.

METHODS

Military personnel (n=994) completed various questionnaires at 5 time-points; starting prior to deployment and following the same cohort at 1 and 6 months and 1 and 2 years after their return from Afghanistan.

RESULTS

The prevalence of symptoms of fatigue, PTSD, hostility, depression and anxiety was found to significantly increase after deployment compared with pre-deployment rates. As opposed to depressive symptoms and fatigue, the prevalence of PTSD was found to decrease after the 6-month assessment. The prevalence of sleeping problems and hostility remained relatively stable.

CONCLUSIONS

The prevalence of mental health symptoms in military personnel increases after deployment, however, symptoms progression over time appears to be specific for various mental health symptoms. Comprehensive screening and monitoring for a wide range of mental health symptoms at multiple time-points after deployment is essential for early detection and to provide opportunities for intervention.

DECLARATION OF INTEREST

This project was funded by the Dutch Ministry of Defence.

Deployment-related mental health support: comparative analysis of NATO and allied ISAF partners

BACKGROUND

For years there has been a tremendous gap in our understanding of the mental health effects of deployment and the efforts by military forces at trying to minimize or mitigate these. Many military forces have recently systematized the mental support that is provided to support operational deployments. However, the rationale for doing so and the consequential allocation of resources are felt to vary considerably across North Atlantic Treaty Organisation (NATO) International Security Assistance (ISAF) partners. This review aims to compare the organization and practice of mental support by five partnering countries in the recent deployment in Afghanistan in order to identify and compare the key methods and structures for delivering mental health support, describe bottlenecks and illustrate new developments.

METHOD

Information was collected through document analysis and semi-structured interviews with key military mental healthcare stakeholders. The review resulted from close collaboration between key military mental healthcare professionals within the Australian Defense Forces (ADF), Canadian Armed Forces (CAF), United Kingdom Armed Forces (UK), Netherlands Armed Forces (NLD), and the United States Army (US). Key stakeholders were interviewed about the mental health support provided during a serviceperson's military career. The main items discussed were training, prevention, early identification, intervention, and aftercare in the field of mental health.

RESULTS

All forces reported that much attention was paid to mental health during the individual's military career, including deployment. In doing so there was much overlap between the rationale and applied methods. The main method of providing support was through training and education. The educative focus was to strengthen the mental resilience of individual soldiers while providing a range of mental healthcare services. All forces had abandoned standard psychological debriefing after critical incidents. Instead, by default, mental healthcare professionals acted to support the leader and peer led "after action" reviews. All countries provided professional mental support close to the front line, aimed at early detection and early return to normal activities within the unit. All countries deployed a mental health support team that consisted of a range of mental health staff including psychiatrists, psychologists, social workers, mental health nurses, and chaplains. There was no overall consensus in the allocation of mental health disciplines in theatre. All countries (except the US) provided troops with a third location decompression (TLD) stop after deployment, which aimed to recognize what the deployed units had been through and to prepare them for transition home. The US conducted in-garrison 'decompression', or 'reintegration training' in the US, with a similiar focus to TLD. All had a reasonably comparable infrastructure in the field of mental healthcare. Shared bottlenecks across countries included perceived stigma and barriers to care around mental health problems as well as the need for improving the awareness and recognition of mental health problems among service members.

CONCLUSION

This analysis demonstrated that in all five partners state-of-the-art preventative mental healthcare was included in the last deployment in Afghanistan, including a positive approach towards strengthening the mental resilience, a focus on self-regulatory skills and self-empowerment, and several initiatives that were well-integrated in a military context. These initiatives were partly/completely implemented by the military/colleagues/supervisors and applicable during several phases of the deployment cycle. Important new developments in operational mental health support are recognition of the role of social leadership and enhancement of operational peer support. This requires awareness of mental problems that will contribute to reduction of the barriers to care in case of problems. Finally, comparing mental health support services across countries can contribute to optimal preparation for the challenges of military deployment.

Repeated fear-induced diurnal rhythm disruptions predict PTSD-like sensitized physiological acute stress responses in F344 rats

AIM

To identify objective factors that can predict future sensitized stress responses, thus allowing for effective intervention prior to developing sensitization and subsequent stress-related disorders, including post-traumatic stress disorder (PTSD).

METHODS

Adult male F344 rats implanted with biotelemetry devices were exposed to repeated conditioned fear or control conditions for 22 days followed by exposure to either no, mild or severe acute stress on day 23. Diurnal rhythms of locomotor activity (LA), heart rate (HR) and core body temperature (CBT) were biotelemetrically monitored throughout the study. In a subset of rat not implanted, corticosterone and indices of chronic stress were measured immediately following stress.

RESULTS

Rats exposed to repeated fear had fear-evoked increases in behavioural freezing and HR/CBT during exposure to the fear environment and displayed indices of chronic stress. Repeated fear produced flattening of diurnal rhythms in LA, HR and CBT. Repeated fear did not sensitize the corticosterone response to acute stress, but produced sensitized HR/CBT responses following acute stress, relative to the effect of acute stress in the absence of a history of repeated fear. Greater diurnal rhythm disruptions during repeated fear predicted sensitized acute stress-induced physiological responses. Rats exposed to repeated fear also displayed flattened diurnal LA and basal increases in HR.

CONCLUSIONS

Exposure to repeated fear produces outcomes consistent with those observed in PTSD. The results suggest that diurnal rhythm disruptions during chronic stressors may help predict sensitized physiological stress responses following traumatic events. Monitoring diurnal disruptions during repeated stress may thus help predict susceptibility to PTSD.

Do soldiers seek more mental health care after deployment? Analysis of mental health consultations in the Netherlands Armed Forces following deployment to Afghanistan

BACKGROUND

Military deployment to combat zones puts military personnel to a number of physical and mental challenges that may adversely affect mental health. Until now, few studies have been performed in Europe on mental health utilization after military deployment.

OBJECTIVE

We compared the incidence of mental health consultations with the Military Mental Health Service (MMHS) of military deployed to Afghanistan to that of non-deployed military personnel.

METHOD

We assessed utilization of the MMHS by the full cohort of the Netherlands Armed Forces enlisted between 2008 and 2010 through linkage of mental health and human resource information systems.

RESULTS

The total population consisted of 50,508 military (18,233 deployed, 32,275 non-deployed), who accounted for 1,906 new consultations with the MMHS. The follow-up was limited to the first 2 years following deployment. We observed higher mental health care utilization in deployed vs. non-deployed military personnel; hazard ratio (HR), adjusted for sex, military branch and time in service, 1.84 [95% CI 1.61-2.11] in the first and 1.28 [1.09-1.49] in the second year after deployment. An increased risk of adjustment disorders (HR 2.59 [2.02-3.32] and 1.74 [1.30-2.32]) and of anxiety disorders (2.22 [1.52-3.25] and 2.28 [1.50-3.45]) including posttraumatic stress disorder (5.15 [2.55-10.40] and 5.28 [2.42-11.50]), but not of mood disorders (1.33 [0.90-1.97] and 1.11 [0.68-1.82]), was observed in deployed personnel in the first- and second-year post-deployment, respectively. Military personnel deployed in a unit with a higher risk of confrontation with potentially traumatic events had a higher HR (2.13 [1.84-2.47] and 1.40 [1.18-1.67]).

CONCLUSIONS

Though absolute risk was low, in the first and second year following deployment to Afghanistan there was an 80 and 30% higher risk for mental health problems resulting in a consultation with the Dutch MMHS compared to military never deployed to Afghanistan. These observations underscore the need for an adequate mental health infrastructure for those returning from deployment.