Impact of combat and non-military trauma exposure on symptom reduction following treatment for veterans with posttraumatic stress disorder

A Scoping Review of Interventions Targeting the Mental Health of Australian Veterans

Serving in the military can have significant impacts on the mental health of veterans and their families. Military personnel can be exposed to a range of physical stressors, psychological trauma, risky lifestyle factors, a regimented military culture, and inadequate support when transitioning out of service. This article reviews research on interventions designed to improve the mental health of Australian military veterans in order to synthesise current knowledge and identify gaps in the literature. Our scoping review followed PRISMA recommendations and comprised peer-reviewed literature published since 2000. The review demonstrates a dominance of psychologically driven research paradigms and interventions and a neglect of the importance of social factors in shaping veteran mental health. There is a wide range of interventions available; however, the literature is narrow and limited. We found little evidence that the lived experience of veterans had been harnessed in program design or delivery. We argue the need for a holistic approach that moves beyond psychological and biological understandings of health and wellbeing to incorporate social and cultural determinants. Future research could adopt a stronger multidisciplinary approach, increased socio-cultural understanding, and greater consideration of the lived experience of veterans and their families.

Does Prior Civilian Trauma Moderate the Relationship Between Combat Trauma and Post-deployment Mental Health Symptoms?

In addition to combat trauma, childhood and adult non-military, interpersonal trauma exposures have been linked to a range of psychiatric symptoms (e.g., alcohol use problems, posttraumatic stress disorder [PTSD], depression symptoms) in veterans. However, few studies simultaneously explore the associations between these civilian and combat trauma types and mental health outcomes. Using a sample of combat-exposed veterans who were previously deployed to Iraq and Afghanistan (N = 302), this study sought to (a) understand the independent associations of civilian interpersonal trauma (i.e., childhood trauma and non-military adult trauma) and combat-related trauma with post-deployment alcohol use, PTSD symptoms, and depressive symptoms, respectively and (b) to examine the interactive effects of trauma type to test whether childhood and non-military adult trauma moderate the association of combat trauma with these outcomes. A path analytic framework was used to allow for the simultaneous prediction of these associations. In the final model non-military adult trauma and combat trauma were found to be significantly associated with PTSD symptoms and depression symptoms, but not average amount of drinks consumed per drinking day. Childhood trauma was not associated with any outcomes (i.e., PTSD symptoms, depression symptoms, average amount of drinks consumed per day). Only combat trauma was significantly associated with average amount of drinks consumed per day. Results underscore the importance of assessing multiple trauma types and considering trauma as a non-specific risk factor, as different trauma types may differentially predict various mental health outcomes other than PTSD. Further, results highlight the noteworthiness of considering co-occurring outcomes within the veteran community. Limitations, future directions, and implications of diversity are discussed.

Deployment of personnel to military operations: impact on mental health and social functioning

This Campbell systematic review examines the effects of deployment on mental health. The review summarizes evidence from 185 studies. All studies used observational data to quantify the effect of deployment. This review includes studies that evaluate the effects of deployment on mental health. A total of 185 studies were identified. However, only 40 of these were assessed to be of sufficient methodological quality to be included in the final analysis. The studies spanned the period from 1993 to 2017 and were mostly carried out in the USA, UK and Australia. The studies all had some important methodological weaknesses. None of the included studies used experimental designs (random assignment). Deployment to military operations negatively affects the mental health functioning of deployed military personnel. For assessments taken more than 24 months since exposure, we consistently found adverse effects of deployment on all mental health domains (PTSD, depression, substance abuse/dependence, and common mental disorders), particularly on PTSD. For assessments taken less than 24 months (or a variable number of months since exposure) the evidence was less consistent and in many instances inconclusive.

Plain language summary

Deployment to military operations negatively affects the mental health functioning of deployed military personnel: While additional research is needed, the current evidence strongly supports the notion that deployment negatively affects mental health functioning of deployed military personnel.What is this review about?: When military personnel are deployed to military operations abroad they face an increased risk of physical harm, and an increased risk of adverse shocks to their mental health.The primary condition under consideration is deployment to an international military operation. Deployment to a military operation is not a uniform condition; rather, it covers a range of scenarios. Military deployment is defined as performing military service in an operation at a location outside the home country for a limited time period, pursuant to orders.The review included studies that reported outcomes for individuals who had been deployed. This review looked at the effect of deployment on mental health outcomes. The mental health outcomes are: post-traumatic stress disorder (PTSD), major depressive disorder (MDD), common mental disorders (depression, anxiety and somatisation disorders) and substance-related disorders.By identifying the major effects of deployment on mental health and quantifying these effects, the review can inform policy development on deployment and military activity as well as post-deployment support for veterans. In this way the review enables decision-makers to prioritise key areas.What are the main findings of this review?: What studies are included?: This review includes studies that evaluate the effects of deployment on mental health. A total of 185 studies were identified. However, only 40 of these were assessed to be of sufficient methodological quality to be included in the final analysis. The studies spanned the period from 1993 to 2017 and were mostly carried out in the USA, UK and Australia. The studies all had some important methodological weaknesses. None of the included studies used experimental designs (random assignment).Does deployment have an effect on mental health?: Deployment to military operations negatively affects the mental health functioning of deployed military personnel. For assessments taken more than 24 months since exposure, we consistently found adverse effects of deployment on all mental health domains (PTSD, depression, substance abuse/dependence, and common mental disorders), particularly on PTSD. For assessments taken less than 24 months (or a variable number of months since exposure) the evidence was less consistent and in many instances inconclusive.What do the findings of this review mean?: The odds of screening positive for PTSD and depression were consistently high in the longer term. This suggests that efforts should be increased to detect and treat mental disorders, as effects may be long-lasting.Overall the risk of bias in the majority of included studies was high. While it is difficult to imagine a randomised study design to understand how deployment affects mental health, other matters such as changes to personnel policy, or unanticipated shocks to the demand for military personnel, could potentially be a rich source of quasi-experimental variation.How up-to-date is this review?: The review authors searched for studies up to 2017. This Campbell systematic review was published in March 2018.

Executive summary

BACKGROUND: When military personnel are deployed to military operations abroad they face an increased risk of physical harm, and an increased risk of adverse shocks to their mental health. Research suggests that the increased risk to mental health is mainly due to the hazards of war, combat exposure: firing weapons, road side bombs, seeing fellow soldiers, friends, civilians, and enemies being injured, maimed or killed. These experiences may lead to severe mental stress. The adverse impact on mental health is the psychological cost of war, and it is of interest to policymakers to learn the magnitude of these effects. This review sets out to synthesise available evidence about the consequences of deployment for deployed military personnel in the mental health and social functioning domains.OBJECTIVES: The objective of this review isto synthesise the consequences of deployment to military operation on the mental health and social functioning of deployed military personnel.SEARCH METHODS: We searched electronic databases, grey literature, and references from primary studies and related reviews. No language or date restrictions were applied to the searches. We searched the following electronic databases: Academic Search Elite, Cochrane Library, EMBASE, ERIC, MEDLINE, PsycINFO, Science Citation Index, Social Science Citation Index, SocINDEX, as well as the Nordic platforms: bibliotek.dk, BIBSYS, and LIBRIS. The conclusions of this review are based on the most recent searches performed. The last search was performed in April 2017.SELECTION CRITERIA: Primary studies had to meet the following inclusion criteria: Participants: The participants should be military personnel.Intervention: The condition should be deployment to a military operation.Comparison: The relevant comparisons were either comparing a) deployed military personnel to non-deployed military personnel, b) deployed military personnel to military personnel deployed elsewhere, for example personnel deployed to non-combat operations, c) military personnel deployed to the same operation but stratified by combat exposure.Outcomes: The study should report on one or more mental health outcomes, and/or social functioning for the deployed participants. In particular studies should report on one or more of the following mental health outcomes: PTSD, major depression, substance abuse or dependence (including alcohol), and common mental disorders (depression and anxiety disorders). The following social functioning outcomes were relevant: employment, and homelessness.Study Designs: Both experimental and quasi-experimental designs with a comparison group were eligible for inclusion in the review. Studies were excluded if they: Reported on deployments taking place before 1989.Used a within group pre-post study design.Did not report on at least one of the mental health or social functioning outcomes. DATA COLLECTION AND ANALYSIS: The total number of potentially relevant studies constituted31,049records. A total of 185 studies met the inclusion criteria and were critically appraised by the review authors. The final selection of 185 studies was from 13 different countries.Forty eight of the 185 studies did not report effect estimates or provide data that would allow the calculation of an effect size and standard error. Fifty four studies were excluded because of overlapping samples. The majority of those studies were from USA but the main reason for not using studies from USA in the synthesis was lack of information to calculate an effect size. Nearly half the studies from the UK could not be used in the synthesis due to overlap of data samples. Forty three studies were judged to have a very high risk of bias (5 on the scale) and, in accordance with the protocol, we excluded these from the data synthesis on the basis that they would be more likely to mislead than inform., Thus a total of 40 studies, from five different countries, were included in the data synthesis.Random effects models were used to pool data across the studies. We used the odds ratio. Pooled estimates were weighted with inverse variance methods, and 95% confidence intervals were calculated. The meta-analyses were carried out by time since exposure (short, medium, long, and other time since exposure) and by type of comparison (deployed versus non-deployed, all deployed but stratified by either combat operations versus non-combat operations, or stratified by combat exposure). We performed single factor subgroup analysis. The assessment of any difference between subgroups was based on 95% confidence intervals. Funnel plots were used to assess the possibility of publication bias. Sensitivity analysis was used to evaluate whether the pooled effect sizes were robust across components of methodological quality.MAIN RESULTS: The findings were mixed, depending on the outcome, the time since exposure and the approach (deployed versus non-deployed termed absolute or stratified by extent of combat termed relative) used to investigate the effect. It was not possible to analyse the outcomes homelessness and employment. All studies that could be used in the data synthesis reported on the impact of deployment on mental health; PTSD, depression, substance use or common mental disorder.For assessments taken less than 24 months since exposure the evidence was inconclusive either because too few studies reported results in the short and medium term and/or the degree of heterogeneity between studies was large.For assessments taken at other time points (a variable number of months since exposure) the evidence was inconclusive for the relative comparisons due to either too few studies or a substantial degree of heterogeneity between studies. For the absolute comparison the analysis of common mental disorder was inconclusive, whereas the average effects of PTSD and depression were positive and statistically significant (PTSD odds ratio (OR) was 1.91 (95% confidence interval (CI): 1.28 to 2.85) and OR=1.98 (95% CI: 1.05 to 3.70) for depression). The analysis concerning substance use indicated that deployed participants did not have higher odds of screening positive for substance use compared to non-deployed participants (OR=1.15 (95% CI: 0.98 to 1.36)).For assessments taken more than 24 months post exposure, meta-analyses indicated that the odds of screening positive for PTSD, depression, substance use and common mental disorder were higher for participants in the deployed group compared to participants in the group that were not deployed (PTSD OR=3.31 (95% CI: 2.69 to 4.07), OR=2.19 (95% CI: 1.58 to 3.03) for depression, OR=1.27 (95% CI: 1.15 to 1.39) for substance use, and OR=1.64 (95% CI: 1.38 to 1.96) for common mental disorder). Likewise, participants reporting high combat exposure had higher odds of screening positive for PTSD and depression than participants reporting lower exposure for long term assessments (PTSD OR=3.05 (95% CI: 1.94 to 4.80) and OR=1.81 (95% CI: 1.28 to 2.56) for depression). The analyses of substance use and common mental disorder were inconclusive due to too few studies.On the basis of the prevalence of mental health problems in pre-deployed or non-deployed population based comparison sampleswe would therefore expect the long term prevalence of PTSD in post-deployed samples to be in the range 6.1 - 14.9%, the long term prevalence of depression to be in the range from 7.6% to 18%, the long term prevalence of substance use to be in the range from 2.4% to 17.5% and the prevalence of common mental disorder to be in the range from 10% to 23%.Sensitivity analyses resulted in no appreciable change in effect size, suggesting that the results are robust.It was only possible to assess the impact of two types of personnel characteristics (branch of service and duty/enlistment status) on the mental health outcomes. We found no evidence to suggest that the effect of deployment on any outcomes differ between these two types of personnel characteristics.AUTHORS' CONCLUSIONS: Deployment to military operations negatively affects the mental health functioning of deployed military personnel. We focused on the effect of deployment on PTSD (post-traumatic stress disorder), depression, substance abuse/dependence, and common mental disorders (depression and anxiety disorders). For assessments taken less than 24 months (or a variable number of months since exposure) the evidence was less consistent and in many instances inconclusive. For assessments taken more than 24 months since exposure, we consistently found adverse effects of deployment on all domains, particularly on PTSD. There is increased political awareness of the need to address post deployment mental health problems. The odds of screening positive for PTSD and depression were consistently high in the longer term. This suggests that efforts should be increased to detect and treat mental disorders, as effects may be long lasting. Mental illness is of particular concern in the military for operational reasons, but they may be hard to detect in the military setting because a military career is intimately linked with mental and physical strength.It was not possible to examine a number of factors which we had reason to expect would impact on the magnitude of the effect. This would have been particularly relevant from a policy perspective because these are direct parameters that one could use to optimally "organize" deployment in order to minimize impacts on mental health functioning.While additional research is needed, the current evidence strongly supports the notion that deployment negatively affects mental health functioning of deployed military personnel. The next step is to begin to examine preventive measures and policies for organizing deployment, in order to minimize the effects on mental health.

Combat exposure and pain in male and female Afghanistan and Iraq veterans: The role of mediators and moderators

Veterans experience physical health problems associated with disability and poor quality of life following combat exposure (CE). Understanding the CE-physical health relationship, specifically pain intensity and somatic pain, may inform etiological models and interventions. This study examined the CE-pain relationship, associated mediators, and gender as a moderator. 2381 veterans at the VA San Diego Healthcare System completed paper or electronic self-report measures of pain intensity and somatic pain. Analyses examined associations of pain with CE and posttraumatic stress disorder (PTSD), depression, and resilience as mediators of the CE-pain association. Moderated mediation models explored gender as a moderator of significant mediated pathways. Controlling for age, veterans with CE had significantly higher pain intensity and somatic pain, and PTSD and depression scores significantly mediated the CE-pain relationships. Gender significantly moderated the CE-pain intensity association through depression scores such that the indirect effect was stronger for female veterans relative to male veterans. CE is associated with pain intensity and somatic pain, with greater levels of PTSD and depression mediating the CE-pain link and gender moderating the depression mediated CE-pain association. Future studies should examine gender differences and mediators in the CE-pain relationships using longitudinal designs to inform etiological models and targeted pain interventions.

The impact of potentially traumatic events on the mental health of males who have served in the military: Findings from the Australian National Survey of Mental Health and Wellbeing

OBJECTIVE

The study investigated the impact of potentially traumatic events on mental health outcomes among males who had ever served in the Australian Defence Force.

METHOD

Data from a nationally representative household survey of Australian residents, the 2007 National Survey of Mental Health and Wellbeing, were used for this study.

RESULTS

Compared with community members, Australian Defence Force males were significantly more likely to have experienced not only deployment and other war-like events but also accidents or other unexpected events, and trauma to someone close. For non-deployed males, Australian Defence Force members were at increased risk of accidents or other unexpected events compared to community members. After controlling for the effect of potentially traumatic events that were more prevalent among all Australian Defence Force members, the increased risk of mental disorders among Australian Defence Force members was no longer evident. For non-deployed males, Australian Defence Force and community members were at comparable risk of poor mental health outcomes. A significant minority of Australian Defence Force members had onset of a mental disorder prior to their first deployment.

CONCLUSIONS

Deployment and other potentially traumatic events among Australian Defence Force members can help to explain their increased vulnerability to mental disorders compared with community members. Providers should routinely enquire about a range of potentially traumatic events among serving and ex-serving military personnel.

Treatment-refractory posttraumatic stress disorder (TRPTSD): a review and framework for the future

Post-traumatic stress disorder (PTSD) is a serious psychiatric consequence of trauma that occurs in a proportion of individuals exposed to life-threatening events. Trauma-focused psychotherapy is often recommended as first choice for those who do not recover spontaneously. But many individuals require medications. In the US, only paroxetine (PRX) and sertraline (SRT) are FDA approved for PTSD. But response and remission rates with these medications are low, so numerous other pharmacologic interventions have been tried. To date, there has not been a systematic review of the data on what are the best next-step pharmacologic strategies for individuals who fail standard treatments. To that end, we review 168 published trials of medications other than PRX or SRT and provide a detailed analysis of the 88/168 studies that describe alternative pharmacologic interventions in patients refractory to other treatment. We also review clinical factors relevant to treatment-refractory PTSD; the neurobiology of extinction, as well as evidence-based psychotherapy and neuromodulation strategies for this condition.

A service evaluation of self-referral to military mental health teams

BACKGROUND

The UK military runs a comprehensive mental health service ordinarily accessed via primary care referrals.

AIMS

To evaluate the feasibility of self-referral to mental health services within a military environment.

METHODS

Three pilot sites were identified; one from each service (Royal Navy, Army, Air Force). Socio-demographic information included age, rank, service and career duration. Clinical data included prior contact with general practitioner (GP), provisional diagnosis and assessment outcome.

RESULTS

Of the 57 self-referrals, 69% (n = 39) had not previously accessed primary care for their current difficulties. After their mental health assessment, 47 (82%) were found to have a formal mental health problem and 41 (72%) were offered a further mental health clinician appointment. The data compared favourably with a large military mental health department that reported 87% of primary care referrals had a formal mental health condition.

CONCLUSIONS

The majority of self-referrals had formal mental health conditions for which they had not previously sought help from primary care; most were offered further clinical input. This supports the view that self-referral may be a useful option to encourage military personnel to seek professional care over and above the usual route of accessing care through their GP.

PTSD detection and symptom presentation: Racial/ethnic differences by gender among veterans with PTSD returning from Iraq and Afghanistan

BACKGROUND

To determine differences in positive PTSD screenings and symptom presentation by race/ethnicity and gender for Iraq and Afghanistan veterans diagnosed with PTSD.

METHOD

We conducted a retrospective analysis using existing records from Iraq and Afghanistan veterans who enrolled in VA care, received a post-deployment PTSD diagnosis, initiated mental health outpatient treatment between 10/01/07 and 12/31/11, and had a PTSD screen result at the start of treatment (N=79,938). PTSD outcomes were measured using the PC-PTSD and PCL.

RESULTS

At treatment initiation, differences in race/ethnicity and gender were found for PTSD screens and PTSD symptoms. Compared to their white counterparts, Asian/Pacific Islander (A/PI) women and black men were more likely to screen positive for PTSD (adjusted ORs=1.42 and 1.17, ps=.04 and <.0001, respectively) and endorse all measured symptoms (adjusted ORs=1.09 to 1.66, ps≤.000-.04) except avoidance for A/PI women and hyperarousal for black men; A/PI men were less likely to endorse hyperarousal (adjusted OR=.88, p=.04) and did not differ otherwise; and black women did not differ from their white counterparts. Additional differences in PTSD symptom presentation by race/ethnicity and gender were found.

LIMITATIONS

The current study utilized administrative data and was cross-sectional. The results may not be generalizable to veterans from other service eras.

CONCLUSIONS

PTSD screens differ by race/ethnicity and gender, and further by PTSD symptoms, which can influence initiation and planning of PTSD treatment. Awareness of such differences may aid in detecting PTSD to provide care for diverse veterans.

Race/ethnicity and gender differences in mental health diagnoses among Iraq and Afghanistan veterans

Veterans who served in Operation Enduring Freedom (OEF; predominantly in Afghanistan) and Operations Iraqi Freedom and New Dawn (OIF and OND; predominantly in Iraq) and are enrolled in the VA are comprised of a growing cohort of women and higher proportions of racial/ethnic minorities than civilians. To compare rates of mental health disorders by race/ethnicity and gender for this diverse cohort, we conducted a retrospective analysis of existing records from OEF/OIF/OND veterans who were seen at the VA 10/7/01-8/1/2013 (N=792,663). We found that race/ethnicity was related to diagnoses of mental health disorders. Asian/Pacific Islanders (A/PIs) were diagnosed with all disorders at lower rates than whites, and American Indian/Alaska Native (AI/AN) males were diagnosed with most disorders at higher rates than white males. Research is needed to identify contributing factors to differential rates of diagnoses based on race/ethnicity and gender. A/PIs and AI/ANs have unique patterns of mental health diagnoses indicating they should be considered separately to present a comprehensive picture of veteran mental health.