An examination of the broader effects of warzone experiences on returning Iraq/Afghanistan veterans' psychiatric health

The effect of combat deployments on veteran opioid abuse

Grim national statistics about the U.S. opioid crisis are increasingly well known to the American public. Far less well known is that U.S. servicemembers are at ground zero of the epidemic, with veterans facing an overdose death rate of up to twice that of civilians. Exploiting a quasi-experiment in overseas deployment assignment, this study estimates the causal impact of combat exposure among the deployed in the Global War on Terrorism on opioid abuse. We find that exposure to war theater substantially increased the risk of prescription painkiller abuse and illicit heroin use among active duty servicemen. The magnitudes of our estimates imply lower-bound combat exposure-induced healthcare costs of $1.04 billion per year for prescription painkiller abuse and $470 million per year for heroin use.

Obsessive-compulsive symptoms, perceived burdensomeness, and thwarted belongingness: Associations and implications among US veterans

OBJECTIVE

Obsessive-compulsive disorder (OCD) is among the most debilitating psychiatric disorders worldwide, but has gone relatively unnoticed within the US veteran population. Simultaneously, suicide rates continue to remain high within this population despite the high volume of veterans who receive psychiatric care. With recent research demonstrating OCD's unique relationship with suicidality, it is imperative to explore this association and factors that may explain this association within veterans.

METHODS

The present study investigated OCD symptoms and their relationship with two known risk factors of suicide, perceived burdensomeness (PB) and thwarted belongingness (TB), in two samples of veterans.

RESULTS

In the first study (N = 100), OCD symptoms were found to be uniquely related to both PB and TB even after covarying for demographics, trauma exposure, and probable depression. In the second study (N = 99), these relationships were replicated longitudinally. OCD symptoms at baseline were found to be indirectly related to suicidal ideation severity at a 1-month follow-up via PB and TB at post-treatment.

CONCLUSION

This study highlights the importance of assessing and addressing OCD symptoms within veterans due to the unique relationship these symptoms have with suicidal constructs. A deeper understanding of the impact of OCD within the veteran population will inform future prevention and intervention efforts.

Gender differences in direct and indirect associations of trauma types with disordered eating in a national U.S. veteran sample

OBJECTIVE

Disordered eating (DE) in military veterans has been linked to trauma exposure, but the mechanisms underlying this association remain unclear. The current study documented the direct associations of DE with multiple trauma types in a gender-balanced sample of veterans and examined indirect associations of trauma and DE via self-reported PTSD symptoms and concerns about shape and weight.

METHOD

Participants included 1,187 veterans (50% women, 46% men, 4% another) from multiple service eras. Sampling weights were applied to enhance representativeness to the national veteran population.

RESULTS

Gender-stratified, weighted models revealed associations of premilitary, warfare, and postseparation trauma with DE in men and associations of premilitary, military sexual (MST), and postseparation trauma with DE in women. Monte Carlo estimation of indirect effects showed support for indirect associations of premilitary, warfare, and postseparation-related trauma/stressor exposure with DE via PTSD symptoms among men; postseparation stressors were also indirectly associated with DE via shape and weight concerns. Among women, each trauma type was indirectly associated with DE via shape and weight concerns but not PTSD symptoms. When trauma exposures were examined concurrently, MST and postseparation trauma exposure were uniquely associated with DE via shape and weight concerns among women. Only the indirect association of postseparation trauma/stressor exposure with DE via shape and weight concerns was significant among men.

CONCLUSIONS

Findings support the need for gender-specific interventions that target different mechanisms contributing to DE symptoms among veterans. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

COVID-19 and Lifetime Experiences of Trauma, Moral Injury, and Institutional Betrayal Among Healthcare Providers

OBJECTIVE

The aim of the study is to increase understanding regarding healthcare provider experiences with psychological trauma, moral injury, and institutional betrayal, both over the lifetime and during the COVID-19 pandemic.

METHODS

The study employed a cross-sectional design to understand traumatic experiences, moral injury, and institutional betrayal among medical and mental health providers. Participants were asked to identify an index trauma, and experiences were coded qualitatively using categories for traumatic events, moral injury, and institutional betrayal.

RESULTS

Results revealed that experiences of trauma, moral injury, and institutional betrayal were common in relation to the pandemic, as were prepandemic histories of traumatic exposures. Findings indicate that trauma exposure was a work hazard for healthcare providers during the pandemic, which could result in negative long-term mental health outcomes.

CONCLUSIONS

Future research is needed to explore potential long-term negative outcomes among healthcare providers.

Complementary/integrative healthcare utilization in US Gulf-War era veterans: Descriptive analyses based on deployment history, combat exposure, and Gulf War Illness

Complementary and integrative health (CIH) approaches have gained empirical support and are increasingly being utilized among veterans to treat a myriad of conditions. A cluster of medically unexplained chronic symptoms including fatigue, headaches, joint pain, indigestion, insomnia, dizziness, respiratory disorders, and memory problems, often referred to as Gulf War Illness (GWI) prominently affect US Gulf War era (GWE) veterans, yet little is known about CIH use within this population. Using data collected as part of a larger study (n = 1153), we examined the influence of demographic characteristics, military experiences, and symptom severity on CIH utilization, and utilization differences between GWE veterans with and without GWI. Over half of the sample (58.5%) used at least one CIH modality in the past six months. Women veterans, white veterans, and veterans with higher levels of education were more likely to use CIH. GWE veterans with a GWI diagnosis and higher GWI symptom severity were more likely to use at least one CIH treatment in the past six months. Over three quarters (82.7%) of veterans who endorsed using CIH to treat GWI symptoms reported that it was helpful for their symptoms. Almost three quarters (71.5%) of veterans indicated that they would use at least one CIH approach if it was available at VA. Results provide a deeper understanding of the likelihood and characteristics of veterans utilizing CIH to treat health and GWI symptoms and may inform expansion of CIH modalities for GWE veterans, particularly those with GWI.

Correlates and clinical associations of military sexual assault in Gulf War era U.S. veterans: Findings from a national sample

Military sexual assault (MSA) is a prevalent issue among military personnel that can have direct implications on postmilitary mental health. Gulf War era U.S. veterans represent the first cohort in which women veterans were integrated into most aspects of military service except for combat. The present study sought to build on prior studies by identifying characteristics associated with the occurrence of MSA and clinical correlates of MSA and examining how these differ between men and women. This study analyzed cross-sectional survey data from a national sample of treatment-seeking Gulf War era veterans. Participants (N = 1,153) reported demographic information, clinical outcomes, military background, and history of MSA. MSA was more common among female veterans (n = 100, 41.3%) than male veterans (n = 32, 3.6%). The odds of experiencing MSA were approximately 19 times higher for female veterans relative to their male peers, OR = 18.92, p < .001. Moreover, as expected, MSA was robustly associated with probable current posttraumatic stress disorder, probable current depression, and past-year suicidal ideation in female veterans, whereas combat exposure was robustly associated with these sequelae in male veterans. The present findings confirm that a large proportion of female veterans from the Gulf War era experienced MSA and highlight the deleterious correlates of MSA on veterans' mental health. Sex differences of correlates of MSA and subsequent clinical associations are highlighted.

Experiential avoidance is associated with medical and mental health diagnoses in a national sample of deployed Gulf War veterans

A substantial minority of deployed Gulf War veterans developed posttraumatic stress disorder (PTSD), depression, and several chronic illnesses. Although military combat and exposure to certain nuclear, biological, and chemical agents (NBCs) increase risk for post-deployment health problems, they do not fully explain many Gulf War veteran health diagnoses and are not viable treatment targets. Experiential avoidance (EA; one's unwillingness to remain in contact with unpleasant internal experiences) is a modifiable psychosocial risk factor associated with PTSD and depression in veterans as well as pain and gastrointestinal diseases in the general population. In this study, we recruited a national sample of deployed Gulf War veterans (N = 454) to test the hypothesis that greater EA would be significantly associated with higher lifetime odds of PTSD, depression, "Gulf War Illness" (GWI/CMI), and other chronic illnesses common in this veteran cohort. Participants completed a self-report battery assessing demographic, military-related, and health-related information. Multivariate analyses showed that after adjusting for age, sex, race, combat exposure, and NBC exposure, worse EA was associated with higher lifetime odds of PTSD, depression GWI/CMI, gastrointestinal problems, irritable bowel syndrome, arthritis, fibromyalgia, and chronic fatigue syndrome (ORs ranged 1.25 to 2.89; effect sizes ranged small to large), but not asthma or chronic obstructive pulmonary disease. Our findings suggest medical and mental health providers alike should assess for EA and potentially target EA as part of a comprehensive, biopsychosocial approach to improving Gulf War veterans' health and wellbeing. Study limitations and future research directions are also discussed.

The effects of posttraumatic stress disorder symptoms on educational functioning in student veterans

Posttraumatic stress disorder (PTSD) occurs at high rates among student veterans and is known to negatively impact educational functioning; however, the unique effects of PTSD are less clear, given that PTSD is highly comorbid with many other conditions that could potentially affect educational functioning. The present study had two objectives: (a) to determine the impact of PTSD symptom severity on educational functioning after accounting for demographic variables, traumatic brain injury, and commonly co-occurring mental health conditions; and (b) to identify which symptom clusters of PTSD have the greatest impact on educational functioning. Educational functioning and other commonly occurring mental health conditions were assessed cross-sectionally among 90 student veterans. Traumatic brain injury and major depressive disorder (MDD) were initially associated with impaired educational functioning; however, after adding PTSD into the final model, only PTSD (β = .44, p < .001) and MDD (β = .31, p = .001) remained associated with educational impairment. Follow-up analyses indicated that the reexperiencing symptom cluster was most strongly associated with impaired educational functioning (β = .28, p = .031). Overall, these results suggest that PTSD symptoms-especially reexperiencing symptoms-may be a driving force behind impaired educational impairment, even after accounting for other commonly co-occurring mental health conditions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Cannabis Use Disorder and Post-Deployment Suicide Attempts in Iraq/Afghanistan-Era Veterans

The objective of the present study was to use retrospective data to test the hypothesis that cannabis dependence would be associated with an increased rate of post-deployment suicide attempts. Participants included 319 veterans who had deployed to either Iraq or Afghanistan. Study procedures involved completion of a structured clinical interview and a battery of self-report questionnaires. As expected, lifetime cannabis dependence was significantly associated with post-deployment suicide attempts, AOR = 7.963, p = .014, even after controlling for the effects of pre-deployment suicide attempts, posttraumatic stress disorder, depression, pain, non-cannabis substance use disorder, and gender. Although preliminary, our findings provide the first evidence to date that heavy cannabis use may be a unique risk factor for post-deployment suicide attempts among veterans.

A genome-wide association study of suicide attempts and suicidal ideation in U.S. military veterans

Death by suicide and suicidal behavior are major concerns among U.S. military veterans; however, no genome-wide association studies (GWAS) studies of suicidal behavior have been conducted among U.S. military veterans to date, despite the elevated rate of suicidal behavior observed within this population. Accordingly, the primary objective of the present research was to conduct the first GWAS of suicide attempts and suicidal ideation in a large and well-characterized sample of U.S. military veterans. The gene most significantly associated (p = 9.28 × 10^-7) with suicide attempts was the Potassium Calcium-Activated Channel Subfamily M Regulatory Beta Subunit 2 (KCNMB2) gene, which plays a key role in neuronal excitability. In addition, replication analyses provided additional support for the potential role of the ABI Family Member 3 Binding Protein (ABI3BP) gene in the pathogenesis of suicidal behavior, as numerous nominal associations were found between this gene and both suicide attempts and suicidal ideation. Additional work aimed at replicating and extending these findings is needed.

Examination of the indirect effects of combat exposure on suicidal behavior in veterans

BACKGROUND

Researchers have theorized that increased rates of suicide in the military are associated with combat exposure; however, this hypothesis has received inconsistent support in the literature, potentially because combat exposure may be indirectly related to suicide risk through its influence on posttraumatic stress disorder (PTSD) and depressive symptoms. The current study tested the hypothesis that combat exposure has a significant indirect effect on suicidal behavior among Iraq/Afghanistan-era veterans through its effects on PTSD-depressive symptomatology.

METHODS

Iraq/Afghanistan-era veterans (N = 3,238) participated in a cross-sectional, multi-site study of post-deployment mental health consisting of clinical interviews and self-report questionnaires. Structural equation modeling (SEM) was used to examine direct and indirect relationships between three latent variables: combat exposure, PTSD-depression, and suicidal behavior (past attempts and current ideation, intent, and preparation).

RESULTS

A partial mediation model was the best-fitting model for the data. Combat exposure was significantly associated with PTSD-depression (β = 0.50, p < .001), which was in turn associated with suicidal behavior (β = 0.62, p < .001). As expected, the indirect effect between combat exposure and suicidal behavior was statistically significant, β = 0.31, p < .001.

LIMITATIONS

Data were cross-sectional, and suicidal behavior was measured via self-report.

CONCLUSIONS

Results indicated that combat exposure was indirectly related to suicidal behavior via PTSD-depressive symptomatology. Findings lend support for a higher-order combined PTSD-depression latent factor and suggest that Iraq/Afghanistan-era veterans with high levels of PTSD-depressive symptoms are at increased risk for suicidal behavior.

Does Deployment-Related Military Sexual Assault Interact with Combat Exposure to Predict Posttraumatic Stress Disorder in Female Veterans?

The objective of the present research was to expand upon previous findings indicating that military sexual trauma interacts with combat exposure to predict PTSD among female Iraq/Afghanistan-era veterans. Three hundred and thirty female veterans completed self-report measures of combat experiences, military sexual assault (MSA) experiences, and PTSD symptoms as well as structured diagnostic interviews for PTSD. A significant strength of the present research was the use of PTSD diagnosis as an outcome measure. Consistent with prior research, both combat exposure and MSA were significant predictors of PTSD symptoms (linear regression) and PTSD diagnoses (logistic regression). Specifically, participants who experienced deployment-related MSA had approximately six times the odds of developing PTSD compared to those who had not experienced deployment-related MSA, over and above the effects of combat exposure. Contrary to expectations, the hypothesized interaction between MSA and combat exposure was not significant in any of the models. The low base rate of MSA may have limited power to find a significant interaction; however, these findings are also consistent with other recent studies that have failed to find support for the hypothesized interaction. Thus, whereas the majority of available evidence indicates that MSA increases risk for PTSD among veterans over and above the effects of combat, there is presently only limited support for the hypothesized MSA x combat interaction. These findings highlight the continued need for prevention and treatment of MSA in order to improve veterans' long-term mental health and well-being.

Clinical Profile Associated with Adverse Childhood Experiences: The Advent of Nervous System Dysregulation

Background: We report the prevalence of children with multiple medical symptoms in a pediatric neurology clinic, describe their symptom profiles, and explore their association with adverse childhood experiences (ACEs). Methods: We retrospectively reviewed 100 consecutive patients from an outpatient pediatric neurology clinic. Patients were included if they were ≥5 years old and reported ≥4 symptoms that were unexplained for ≥3-months. Symptom profiles across six functional domains were recorded: (1) executive dysfunction, (2) sleep disturbances, (3) autonomic dysregulation, (4) somatization, (5) digestive symptoms, and (6) emotional dysregulation. ACEs were scored for all patients. Results: Seventeen patients reported ≥4 medical symptoms. Somatization, sleep disturbances, and emotional dysregulation occurred in 100% patients, with executive dysfunction (94%), autonomic dysregulation (76%), and digestive problems (71%) in the majority. Forty-two children reported ≥1 ACE, but children with ≥4 symptoms were more likely to report ACEs compared to other children (88% vs. 33%; p < 0.0001) and had a higher median total ACE score (3 vs. 1; p < 0.001). Conclusions: Children with multiple medical symptoms should be screened for potential exposure to ACEs. A clinical profile of symptoms across multiple functional domains suggests putative neurobiological mechanisms involving stress and nervous system dysregulation that require further study.

Mental health among Iranian combat veterans with ankle-foot neuromusculoskeletal injuries

BACKGROUND

Veterans with purely physical disorders, such as ankle-foot neuromusculoskeletal disorders, are often neglected in psychological assessments because mental health evaluations are usually focused on those with a psychological disturbance or with a high percentage of injury. The purpose of this study was to evaluate the psychological condition of veterans with ankle-foot neuromusculoskeletal disorders.

METHODS

A cross-sectional study was performed between 2014 and 2016 on veterans with war-related ankle-foot injuries living in two provinces of Iran. An information form for demographic data and injury-related factors was used. Additionally, the previously validated Persian version of the Symptom Checklist-90-Revision (SCL-90-R) questionnaire was used for data collection.

RESULTS

The respondents were 215 male veterans with a mean age of 51.7 ± 7.5 years. The most common mental health problems were observed for the somatization (24.7%), obsessions-compulsions (14.4%), and anxiety (12.6%). Based on the Global Severity Index (GSI), 48.6% of individuals had a possible psychiatric/psychological illness. According to the multivariate regression analysis, GSI scores were significantly higher among veterans who were older than 27 years at the time of injury (P = 0.005), had an associated injury (P = 0.002), and had a history of hospitalization within the past 12 months for reasons other than their injury (P = 0.035).

CONCLUSIONS

Approximately half of the combat veterans with ankle-foot neuromusculoskeletal disorders likely had psychological problems. The evaluation of the patterns and predicting factors of psychological conditions may inform strategic planning efforts and decision-making, which, in turn, may provide a better quality of life for veterans. Further studies that utilize longitudinal designs are needed to evaluate and compare the psychological status of different groups of veterans and other groups in the general population.

Deployment characteristics and long-term PTSD symptoms

OBJECTIVE

The impact of number, length, and time between (i.e., "dwell time") deployments on long-term Diagnostic and Statistical Manual of Mental Disorders Fourth Edition posttraumatic stress disorder (PTSD) symptoms was examined in post-9/11 U.S. veterans.

METHOD

This cross-sectional design includes data from 278 veterans participating in a larger longitudinal research program of postdeployment recovery. Measures included self-report questionnaires and the Clinician Administered PTSD Scale.

RESULTS

Hierarchical regression was used to evaluate the independent contributions of deployment characteristics on long-term PTSD symptoms after controlling for demographics and combat exposure. As expected, dwell time was a significant predictor of long-term PTSD symptoms (β = - 0.17, p = .042; F_5,108  = 8.21, ∆R²  = 0.03, p < .001). Follow-up analyses indicated that dwell time of less than 12 months was associated with significantly greater long-term PTSD symptoms than those deployed once or with dwell time greater than 12 months.

CONCLUSION

In addition to combat exposure, time between deployments warrants clinical attention as an important deployment characteristic for predicting long-term PTSD symptoms.

Nonsuicidal self-injury and suicide attempts in Iraq/Afghanistan war veterans

The present study examined the association between history of nonsuicidal self-injury (NSSI) and history of suicide attempts (SA) among 292 Iraq/Afghanistan veterans, half of whom carried a lifetime diagnosis of posttraumatic stress disorder (PTSD). Consistent with hypotheses, veterans who reported a history of NSSI were significantly more likely to report a history of SA than veterans without a history of NSSI. In addition, logistic regression demonstrated that NSSI remained a significant predictor of SA even after a wide range of covariates (i.e., combat exposure, traumatic brain injury, PTSD, depression, alcohol dependence) were considered. Taken together, these findings suggest that clinicians working with veterans should include NSSI history as part of their standard risk assessment battery.

Reinforcement Sensitivity and Social Anxiety in Combat Veterans

OBJECTIVE

The present study tested the hypothesis that low behavioral approach system (BAS) sensitivity is associated with social anxiety in combat veterans.

METHOD

Self-report measures of reinforcement sensitivity, combat exposure, social interaction anxiety, and social observation anxiety were administered to 197 Iraq/Afghanistan combat veterans.

RESULTS

As expected, combat exposure, behavioral inhibition system (BIS) sensitivity, and fight-flight-freeze system (FFFS) sensitivity were positively associated with both social interaction anxiety and social observation anxiety. In contrast, BAS sensitivity was negatively associated with social interaction anxiety only. An analysis of the BAS subscales revealed that the Reward Responsiveness subscale was the only BAS subscale associated with social interaction anxiety. BAS-Reward Responsiveness was also associated with social observation anxiety.

CONCLUSION

The findings from the present research provide further evidence that low BAS sensitivity may be associated with social anxiety over and above the effects of BIS and FFFS sensitivity.

Self-Compassion as a prospective predictor of PTSD symptom severity among trauma-exposed U.S. Iraq and Afghanistan war veterans

U.S. combat veterans of the Iraq and Afghanistan wars have elevated rates of posttraumatic stress disorder (PTSD) compared to the general population. Self-compassion, characterized by self-kindness, a sense of common humanity when faced with suffering, and mindful awareness of suffering, is a potentially modifiable factor implicated in the development and maintenance of PTSD. We examined the concurrent and prospective relationship between self-compassion and PTSD symptom severity after accounting for level of combat exposure and baseline PTSD severity in 115 Iraq and Afghanistan war veterans exposed to 1 or more traumatic events during deployment. PTSD symptoms were assessed using the Clinician Administered PTSD Scale for DSM-IV (CAPS-IV) at baseline and 12 months (n =101). Self-compassion and combat exposure were assessed at baseline via self-report. Self-compassion was associated with baseline PTSD symptoms after accounting for combat exposure (β = -.59; p < .001; ΔR(2) = .34; f(2) = .67; large effect) and predicted 12-month PTSD symptom severity after accounting for combat exposure and baseline PTSD severity (β = -.24; p = .008; ΔR(2) = .03; f(2) = .08; small effect). Findings suggest that interventions that increase self-compassion may be beneficial for treating chronic PTSD symptoms among some Iraq and Afghanistan war veterans.