Mental Health Impact of Homecoming Experience Among 1730 Formerly Deployed Veterans From the Vietnam War to Current Conflicts: Results From the Veterans' Health Study

Emotional processing is not enough: relations among resilience, emotional approach coping, and posttraumatic stress symptoms among combat veterans

Combat soldiers are exposed to various potentially traumatic events and face high risk of developing military-related psychopathology, such as depression, posttraumatic stress and grief (PTSS). However, a strong body of research shows that resilience is the default in the aftermath of trauma and indeed, many veterans do not develop high symptomatic levels. To explicate this inconsistency, the current study examined the associations among PTSS, resilience, and patterns of emotional-approach coping. A sample of 595 male combat veterans filled out questionnaires on trauma exposure, PTSS, depressive symptoms, resilience, and emotional-approach coping. Their data were analyzed using structural equation modeling path analysis. Participants reported high exposure to potentially traumatic events during service. Mean scores were high for resilience and relatively low for PTSS and depressive symptoms; 13% had a clinical level of posttraumatic stress disorder. Structural equation modeling revealed that emotional-approach coping strategies mediated the relationship between resilience and PTSS. However, emotional expression was associated with lower PTSS levels, whereas emotional processing was associated with higher PTSS levels. These results suggest that although emotional-approach coping was related to higher resilience, emotional expression (an intrapersonal coping strategy) might have a more positive effect than self-oriented emotional coping strategies. Providing veterans with supportive opportunities and a wider repertoire of emotional coping skills might enhance their well-being, reduce postservice emotional distress while not harming veterans' resilience levels.

The Association between COVID-19-Related Discrimination and Probable Post-Traumatic Stress Disorder among Patients with COVID-19 in Sapporo, Japan

BackgroundDisasters such as earthquakes, terrorism, and pandemics have triggered post-traumatic stress disorder (PTSD), and discrimination against the affected individuals has been linked to the development of PTSD. However, there is limited evidence regarding the association between discrimination against coronavirus disease 2019 (COVID-19) patients and probable PTSD in Japan.MethodsWe conducted a cross-sectional study utilizing a web-based questionnaire targeting individuals who had contracted the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in Sapporo City. A total of 4247 individuals with laboratory-confirmed SARS-CoV-2 infection spanning from February 2020 to February 2022 completed the questionnaire (response rate: 15.9%). Probable PTSD was measured using the three-item Posttraumatic Diagnostic Scale. The stratified exact logistic regression was applied to calculate the odds ratios (OR) of probable PTSD for COVID-19-related discrimination with adjusted factors.ResultsThis study included 3626 patients who had a history of SARS-CoV-2 infection. Among them, 321 patients (8.9%) experienced COVID-19-related discrimination. The prevalence of probable PTSD was 19.6% (63/321) among the patients who experienced COVID-19-related discrimination, and 4.6% (152/3305) among those who had not encountered such discrimination. The adjusted OR of COVID-19-related discrimination for probable PTSD was 4.68 (95% confidence interval [95% CI], 3.36-6.53). The population attributable fraction of probable PTSD attributable to COVID-19-related discrimination among COVID-19 patients was estimated to be 23.4% (95% CI, 21.5-25.3).ConclusionThe comprehensive epidemiological survey of COVID-19 patients in Japan showed that COVID-19-related discrimination was associated with a higher prevalence of probable PTSD. Mitigating discrimination could be helpful to attenuate PTSD in future pandemics.

Disentangling effects of remote mild traumatic brain injury characteristics and posttraumatic stress on processing speed and executive function in veterans

Mild traumatic brain injury (mTBI) and posttraumatic stress are prevalent in military service members and share objective and subjective cognitive symptoms, complicating recovery. We investigated the effects of remote mTBI characteristics and current posttraumatic stress symptoms on neuropsychological performance in 152 veterans with a history of remote mTBI and current cognitive concerns. Participants completed clinical neuropsychological evaluations within a Veterans Affairs Level-II TBI/Polytrauma outpatient clinic (i.e. tertiary trauma care center for US military veterans outside of a research or teaching hospital setting). Archival data analysis of mTBI injury characteristics, clinical diagnoses, scores on the Posttraumatic Stress Disorder Checklist-Military Version (PCL-M) and performance on tests of processing speed, attention and executive function was conducted. Hierarchical linear regression demonstrated that elevated PCL-M scores were associated with slower performance on trail making test (TMT) Parts A and B (p < .016). PCL-M symptoms moderated the effect of alteration of consciousness (AOC) on TMT performance, with endorsement of AOC associated with better performance, but only when PCL-M scores were high (p < .005). Follow-up mediation analyses demonstrated that PCL-M score fully mediated the relationship between AOC and TMT-A performance and partially mediated the relationship between AOC and TMT-B performance. Post-hoc analyses meant to separate the impact of processing speed on TMT-B were all non-significant. Remote mTBI characteristics, specifically AOC, were not associated with decrements in cognitive performance. Posttraumatic symptoms were associated with worse processing speed, suggesting that psychological distress and psychopathology are contributing factors in understanding and treating persistent cognitive distress following remote mTBI.

Marital Quality and Loneliness Among Aging Vietnam-Era Combat Veterans: The Moderating Role of PTSD Symptom Severity

OBJECTIVES

We examined links between marital quality and loneliness among aging veterans and explored whether veterans' PTSD symptom severity moderated these associations.

METHODS

Data came from 269 Vietnam-Era combat veterans who had a spouse/partner (M age = 60.50). Utilizing two waves of data spanning six years, we estimated multiple regression models that included positive and negative marital quality, PTSD symptom severity, and loneliness in 2010 as predictors of loneliness in 2016.

RESULTS

Facets of positive (but not negative) marital quality were associated with veterans' loneliness. Companionship - spousal affection and understanding - was associated with lower subsequent loneliness among veterans with low/moderate - but not high - PTSD symptom severity. Conversely, sociability - the degree to which one's marriage promotes socializing with others - was associated with lower subsequent loneliness regardless of PTSD symptom severity.

CONCLUSIONS

Companionship and sociability were each associated with veterans' subsequent loneliness. Whereas benefits of companionship were attenuated at higher levels of PTSD symptom severity, benefits of sociability were not.

CLINICAL IMPLICATIONS

For veterans with higher PTSD symptoms, recommending mental health treatment to decrease symptom severity may help them to reap the benefits of close/intimate relationships. However, bolstering veterans' social participation more broadly may provide an additional means of reducing their loneliness.

Crisis due to war: anxiety, depression and stress in the population of 13 Latin American countries

Sustainability may be at risk in a population that has altered health, according to Sustainable Development Goal 3 (SDG 3): Health and well-being. The ongoing conflict between Russia and Ukraine could jeopardize SDG 3, specifically the mental health of the population. The present study sought to determine the association between severe anxiety, depression and stress in population of 13 Latin American countries according to fear about the war conflict. It was a cross-sectional, analytical and multicenter study. Anxiety, depression and stress were measured with the DASS-21 test (Cronbach's Alpha: 0.97) and fear due to an armed crisis with a questionnaire already validated in Latin America (Cronbach's Alpha: 0.92), which was also adjusted for sex, age, education level and country of residence. Descriptive and analytical statistics were obtained. Of the 2,626 respondents, the main fear was that weapons of mass destruction would be used. In the multivariate models, strong associations were found between fear of a possible world-scale armed conflict and having severe or very severe levels of anxiety (aPR: 1.97; 95% CI: 1.64-2.36; value of p <0.001), depression (aPR: 1.91; 95% CI: 1.54-2.36; value of p <0.001) or stress (aPR: 2.05; 95% CI: 1.63-2.57; value of p <0.001). Sustainability linked to SDG 3, specifically mental health, is affected by this type of significant events, given the possible global war crisis that could trigger major events, even more so if added to the deterioration already experienced by COVID-19 in the Latin American region, insecurity and constant political uncertainty.

Substance Use in U.S. Vietnam War Era Veterans and Nonveterans: Results from the Vietnam Era Health Retrospective Observational Study

Background: Substance use (SU) is associated with physical injury and mental health disorders in older persons, but recent research has scarcely examined SU in U.S. Vietnam-era veterans who are mostly in or near their eighth decade of life. Objectives: We compared the prevalence of self-reported lifetime and current SU and modeled current usage patterns in a nationally representative sample of veterans versus a matched nonveteran cohort. Methods: Cross-sectional, self-reported survey data were analyzed from the 2016-2017 Vietnam Era Health Retrospective Observational Study (VE-HEROeS) (n = 18,866 veterans, n = 4,530 nonveterans). We assessed lifetime and current alcohol and drug use disorders; lifetime and current use of cannabis, opioids, stimulants, sedatives, "other drugs" (psychedelics, prescription or over-the-counter drugs not prescribed/used as intended); and current SU patterns (alcohol-use-only, drug-use-only, dual-SU, no SU). Weighted descriptive, bivariable, and multivariable statistics were calculated. Covariates in multinomial modeling included sociodemographic characteristics, lifetime cigarette smoking, depression, potentially traumatic events (PTEs), and current pain (SF-8^TM). Results: Prevalence of lifetime opioid and sedative use (p ≤ .01), drug and alcohol use disorders (p < .001), and current "other drug" use (p < .001) were higher in veterans versus nonveterans. Current use of alcohol and cannabis was high in both cohorts. In veterans, very severe/severe pain, depression, and PTEs were highly associated with drug-use-only (p < .001) and dual-SU (p < .01), but these associations were fewer for nonveterans. Conclusion: This research confirmed existing concerns over substance misuse in older individuals. Vietnam-era veterans may be at particular risk due to service-related experiences and later-life tribulations. Era veterans' unique perceptions toward healthcare assistance for SU may need greater provider focus to maximize self-efficacy and treatment.

Paradoxical age-related improvement in mental health in U.S. military veterans: Results from the national health and resilience in veterans study

OBJECTIVE

To determine whether a seemingly "paradoxical" trend whereby mental health improves as a function of age despite declining physical and cognitive health occurs in U.S. military veterans, who are older, and have higher rates of trauma exposure and psychiatric morbidities relative to non-veterans.

METHODS

Using data from a nationally representative, cross-sectional sample of 4069 U.S. veterans, polynomial regression analyses were conducted to examine changes in self-reported physical, cognitive, and mental health of veterans representing the full age spectrum.

RESULTS

Physical health scores were consistently average and stable until around age 80 when they declined. In contrast, cognitive and mental health scores were markedly lower in young veterans and then increased linearly and positively well into late-life.

CONCLUSIONS

While greater age is associated with relative stability and late-life decline in physical health in U.S. veterans, mental and cognitive health steadily improve until much later in life. Results may help inform age-specific prevention and treatment efforts to promote healthy aging in this population.

Reculturation: A new perspective on military-civilian transition stress

Various forms of assistance are offered to help US Veterans achieve success in their post-military lives in recognition of their service. Despite the many successes, a significant number of Veterans continue to remain at risk for negative mental health outcomes, including suicidality and low levels of life satisfaction. These findings may be due to challenges arising from cultural identity dissonance. Problematic strategies used by Veterans to reduce this dissonance can result in a lack of belongingness, a key component in Joiner's Interpersonal Theory of Suicide. The authors suggest that research on the immigrant experience of acculturation may provide a new perspective to better understand issues of identity and sense of belonging in Veterans. Given that most Veterans return to the culture in which they grew up, the authors offer the term "reculturation." The authors propose clinical psychology focus on exploring the reculturation process of Veterans to support program engagement and suicide prevention.

Associations between changes in somatic and psychiatric symptoms and disability alterations in recent-era U.S. veterans

Cross-sectional work suggests that deployment-related posttraumatic sequelae are associated with increased disability in U.S. veterans deployed following the September 11, 2001 (9/11), terrorist attacks. However, few studies have examined the psychiatric and somatic variables associated with changes in functional disability over time. A total of 237 post-9/11 veterans completed comprehensive assessments of psychiatric and cognitive functioning, as well as a disability questionnaire, at baseline and 2-year follow-up. At baseline, higher levels of PTSD, depressive, and pain-related symptoms were associated with baseline global functional disability, semipartial r² = .036-.044. Changes in symptoms of PTSD, depression, pain, and sleep, but not anxiety or alcohol use, were independently associated with changes in functional disability, semipartial r² = .017-.068. Baseline symptoms of these conditions were unrelated to changes in disability, and cognitive performance was unrelated to disability at any assessment point. Together, this suggests that changes in psychiatric and somatic symptoms are tightly linked with changes in functional disability and should be frequently monitored, and even subclinical symptoms may be a target of intervention.

The mental health of Vietnam theater veterans-the lasting effects of the war: 2016-2017 Vietnam Era Health Retrospective Observational Study

Mental health data from the 2016-2017 Vietnam Era Health Retrospective Observational Study (VE-HEROeS) were analyzed by cohort, represented by United States Vietnam theater veterans (VTs) who served in Vietnam, Cambodia, and Laos; nontheater veterans (NTs) without theater service; and age- and sex-matched nonveterans (NVs) without military service. The exposure of interest was Vietnam theater service. Surveys mailed to random samples of veterans (n = 42,393) and nonveterans (n = 6,885) resulted in response rates of 45.0% for veterans (n = 6,735 VTs, M_age = 70.09, SE = 0.04; n = 12,131 NTs) and 67.0% for NVs (n = 4,530). We examined self-report data on four mental health outcomes: probable posttraumatic stress disorder (PTSD), depression, psychological distress, and overall mental health functioning. Weighted adjusted odds ratios (aORs) between each outcome and cohort were estimated, controlling for covariates in four models: cohort plus sociodemographic variables (Model 1), Model 1 plus physical health variables (Model 2), Model 2 plus potentially traumatic events (PTEs; Model 3), and Model 3 plus other military service variables (Model 4). Mental health outcome prevalence was highest for VTs versus other cohorts, with the largest aOR, 2.88, for PTSD, 95% CI [2.46, 3.37], p < .001 (Model 4, VT:NT). Physical health and PTEs contributed most to observed effects; other service variables contributed least to aORs overall. Mental health dysfunction persists among VTs years after the war's end. The present results reaffirm previous findings and highlight the need for continued mental health surveillance in VTs.

Mental Health Needs of Aging Veterans: Recent Evidence and Clinical Recommendations

Objectives: Large numbers of older Americans have a history of military service, which may be positively or negatively associated with mental health in late life. We reviewed literature with the aim of better understanding the mental health needs of older Veterans.Methods: Articles included those published in 2009-2018 and focused on prevalence/risk for mental illness and suicide among older Veterans; utilization of mental health services; effectiveness of evidence-based behavioral treatments; and pertinent care delivery models.Results: Older Veterans are generally resilient. A significant minority experience mental health concerns that are associated with poor outcomes including a substantial number of suicides. Most published research is based on the approximately one third of Veterans who use the Veterans Health Administration (VHA) for care. Older Veterans with mental health diagnoses are less likely to utilize mental health services compared to younger Veterans, but as likely to benefit once engaged. Integrated care models in primary and geriatric care settings are promising.Conclusions: Aging Veterans are a large subset of Americans whose mental health needs are complex and deserve attention.Clinical Implications: Clinicians should ask about history of military service (i.e., Veteran status) and utilize available resources when providing care for older Veterans.

Impact and Risk of Moral Injury Among Deployed Veterans: Implications for Veterans and Mental Health

The impact of "moral injury" (MI) among deployed veterans, defined as actions in combat that violate a veteran's moral beliefs and result in psychological distress, has increasingly become a significant clinical concern separate from other trauma- and stressor-related disorders. MI involves severe distress over violations of core beliefs often followed by feelings of guilt and conflict and is common among veterans with PTSD. While the psychological impact of PTSD is well-documented among veterans, this has been done less so with respect to MI. We studied MI among 1,032 deployed veterans who were outpatients in a large non-profit multi-hospital system in central Pennsylvania. The study included active duty and Guard/Reserve members, as well as veterans who were not Department of Veterans Affairs (VA) service users. Our hypothesis was that, controlling for other risk factors, veterans with high MI would have current mental disorders. Our secondary hypothesis was that MI would be associated with other psychopathologies, including chronic pain, sleep disorders, fear of death, anomie, and use of alcohol/drugs to cope post deployment. Most veterans studied were deployed to Vietnam (64.1%), while others were deployed to post-Vietnam conflicts in Iraq and Afghanistan and elsewhere. Altogether, 95.1% of the veterans were male and their mean age was 61.6 years (SD = 11.8). Among the veterans, 24.4% had high combat exposure, 10.9% had PTSD, 19.8% had major depressive disorder, and 11.7% had a history of suicidal thoughts. Based on the Moral Injury Events Scale (MIES), 25.8% had high MI post deployment, defined as a score above the 75th percentile. Results show that high MI among veterans was associated with current global mental health severity and recent mental health service use, but not suicidal thoughts. In addition, as hypothesized, MI was also associated with pain, sleep disorders, fear of death, anomie, use of alcohol/drugs to cope post-deployment, and poor unit support/morale during deployment. Deployed veterans with MI are more likely to have current mental health disorders and other psychological problems years after deployment. Further research is advised related to the screening, assessment, treatment, and prevention of MI among veterans and others after trauma exposures.

Resilience to Suicidal Ideation Among U.S. Military Veterans with Posttraumatic Stress: Results from the National Health and Resilience in Veterans Study

Veterans with combat exposure experience high rates of posttraumatic stress symptoms (PTSS) and associated suicidal ideation. The current study examined whether social support (i.e., social connectedness and social engagement) and protective psychological factors (i.e., resilience and altruism) moderated the relation between PTSS and suicidal ideation severity in a sample of 149 U.S. military combat veterans who served in the Vietnam War or Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND). Consistent with expectations, initial PTSS were positively associated with concurrent and three-year follow-up severity of suicidal ideation. Moderation analyses revealed the relation between initial PTSS and concurrent suicidal ideation severity was no longer significant at above average levels of social connectedness, social engagement, and psychological resilience. Further, the relation between initial PTSS and suicidal ideation severity three years later continued to be buffered by above average levels of social engagement. Results suggest social connectedness, psychological resilience, and social engagement help moderate initial severe thoughts of suicide linked to PTSS, while social engagement might be the strongest protective factor against severe suicidal ideation over time. Empirically-supported prevention and treatment efforts enhancing social engagement may help promote resilience to severe PTSS-related suicidal ideation among veterans from Vietnam and OEF/OIF/OND combat eras.

Genetic and Psychosocial Risk Factors Associated with Suicide Among Community Veterans: Implications for Screening, Treatment and Precision Medicine

Introduction

Since veteran suicide is a concern and our knowledge of predictive factors is still limited, our objective was to assess risk factors for suicide, including genetic factors, among deployed veterans.

Methods

For this study, we surveyed 1730 veterans who were outpatients in a multi-hospital system in Pennsylvania. Altogether, 1041 veterans (60%) provided a DNA sample. The genetic risk variants investigated were within loci previously associated with PTSD and substance misuse, including CRHR1, CHRNA5, RORA, and FKBP5 genetic variations, which were used to calculate a polygenic risk score (range=0–8, mean=3.6, SD=1.4).

Results

Most veterans (56.2%) were deployed to Vietnam while significant numbers were deployed to Iraq, Afghanistan, and other post-Vietnam conflicts. Overall, 95.1% of the veterans were male, their mean age was 56.2 (SD=12), and 95.6% were Caucasian. Among the veterans, 24% had high combat exposure. The prevalence of lifetime suicidal thoughts was 11.3%. Additionally, 5.7% ever developed a suicide plan or attempted suicide in their lifetimes. Among those with a history of a lifetime suicide attempt or suicide plan, the PTSD genetic risk score was significantly higher (OR=3.96 vs 3.55, p=0.033), but for suicidal thoughts, this association was not significant (p=0.717). In multivariable analysis (MVA) logistic regression, significant predictors of attempting suicide or having a suicide plan were history of depression (OR=5.04, p<0.001), PTSD genetic risk score (OR=1.25, p=0.036), history of childhood abuse/neglect (OR=2.24, p=0.009), and lifetime marijuana use (OR= 1.56, p=0.020). Conversely, rural residence was protective for suicide risk (OR=0.49; p=0.031). For suicidal thoughts, in the MVA genetic risk score was not significant (p=0.697), but history of child abuse/neglect (p<0.001), history of depression (p>0.001), low psychological resilience (p=0.004), and lifetime marijuana use (p=0.022) were significant.

Discussion

In this study, we identified genetic risk variants and other predictors for suicide among veterans that may have implications for future screening and clinical care. Further research is advised.

Psychological well-being and alcohol misuse among community-based veterans: results from the Veterans' Health Study

BACKGROUND

Maladaptive drinking is an increasing concern among military policy makers and healthcare providers. The goal of this study was to assess how social and psychological factors relate to alcohol problems among post-deployed US veterans and how problematic drinking is associated with well-being.

METHODS

Data were collected via a telephone survey from a random sample of veterans receiving their healthcare from a large non-VA hospital system in central Pennsylvania (N = 1730). Interviewers inquired about participants' current alcohol consumption, using the CAGE and AUDIT-C scales, and health-related outcomes (general psychological distress, major depression, and self-reported health status). Analyses included demographic, military and nonmilitary stressful events, use of alcohol or drugs to cope post-deployment, use of psychiatric services, and personality characteristics as independent variables. Our sample was 95% male, 96% White, and had a mean age of 59 years old (SD = 12 years).

RESULTS

Analyses included demographic, military and nonmilitary stressful events, use of alcohol or drugs to cope post-deployment, use of psychiatric services, and personality characteristics as independent variables. Our sample was 95% male, 96% White, and had a mean age of 59 years old (SD = 12 years). Analyses for our drinking measures show that those who used drugs or alcohol to cope post-deployment were more likely to be problematic drinkers, while positive personality characteristics such as agreeableness and conscientiousness were related to fewer drinking problems. Multivariate logistic regressions for our well-being measures found that alcohol misuse was not related to distress or depression, but that a positive score on the AUDIT-C was associated with a lower likelihood of poor self-rated health. Using alcohol or drugs to cope was related to higher distress.

DISCUSSION

We conclude that service providers might consider using post-deployment AUDIT-C and the drugs and alcohol coping questions when screening for possible alcohol and mental health problems among veterans.

The deadly gap: Understanding suicide among veterans transitioning out of the military

In the period following separation from the military, service members face the challenge of transitioning to a post-military civilian life. Some evidence suggests these transitioning Veterans are at higher risk for suicide compared with both the broader Veteran population and the United States public, yet they often do not receive adequate support and resources. In this review, we use the Three-Step Theory of suicide to outline characteristics of transitioning Veterans and the transition process that may affect suicide risk. We then highlight relevant services available to this specific subgroup of Veterans and make recommendations that address barriers to care. Cumulatively, this literature suggests transitioning Veterans fall within a "deadly gap" between the end of their military service and transition into civilian life. This "deadly gap" consists of limited psychiatric services and increased suicide risk factors which together may explain the increase in suicide during this transition period.

"That is Care That you Just can't fake!": Identifying Best Practices for the Care of Vietnam Veterans at End of Life

CONTEXT

We reviewed the Veterans Health Administration Bereaved Family Survey's open-ended responses to understand end-of-life (EOL) care best practices for Vietnam and pre-Vietnam Veterans.

OBJECTIVES

To identify 1) recommendations for improved EOL care enhancements for older Veterans, 2) a model of best practices in EOL care for Veterans, and 3) any relevant differences in best practices between Vietnam and prior war eras.

METHODS

We examined five years of Bereaved Family Survey data (n = 2784), collected between 2013 and 2017, from bereaved family members of Veterans focusing on 2 open-ended questions: 1) Is there anything else you would like to share about the Veteran's care during his last month of life? 2) Is there anything else you would like to share about how the care could have been improved for the Veteran? Applied thematic analysis identified successes and challenges in the experience of the bereaved of Vietnam and pre-Vietnam era Veterans.

RESULTS

Regardless of war era and death venue, a patient-centered approach to EOL care with readily available staff who could 1) provide ongoing support, comfort, honor, and validation; 2) routinely adjust to the patient's changing needs; 3) and provide clear, honest, timely, compassionate communication was important to the bereaved. Consideration of the uniqueness of Vietnam Veterans is beneficial.

CONCLUSIONS

Patient-centered EOL care should include assigning a point of contact that follows the patient, educates the family on expectations, ensures the patient's changing needs are met, ensures the family has appropriate support, and communicates updates to the family throughout the patient's care continuum.

The role of oxytocin signaling in depression and suicidality in returning war veterans

Many war veterans struggle with depression and suicidality, and separation from the military is a time of particularly high risk. Based on research in non-human animals, we hypothesized that reduced oxytocin signaling would mediate symptoms of depression and suicidality in war veterans recently separated from their close comrades. We also hypothesized that veterans with more frequent contact with comrades would have fewer symptoms of depression and suicidality. In this cross-sectional study, male veterans from the Iraq and Afghanistan wars (n = 86) provided blood and urine samples for measurement of peripheral oxytocin (OT) levels, as well as saliva samples for DNA extraction followed by genotyping of oxytocin receptor gene (OXTR) Single Nucleotide Polymorphisms, and CpG-methylation assessment. Participants also completed a series of mental health questionnaires and interviews. Veterans reported feeling very close to their comrades during war, and missing them greatly upon returning home. Neither peripheral OT levels nor OXTR genotypes were related to symptoms of depression or suicidality. On the other hand, methylation at OXTR CpG -924 was negatively correlated with depressive symptomology, after controlling for possible confounds. Veterans who socialized with comrades more frequently had higher levels of urinary, but not plasma OT, as well as less depressive symptomology. Social connectedness was a strong negative predictor of symptoms of both depression and suicidality, eclipsing the predictive power of other variables such as post-deployment social support, the degree to which participants reported missing their comrades, and the frequency with which they socialized with comrades. Our results suggest that veteran mental health is more impacted by lack of social connectedness than by separation from close comrades per se. While there is some evidence that OXTR methylation relates to depressive symptomology, decreased OT signaling does not appear to mediate the relationship between social disconnectedness and depression or suicidality. Sleep quality and anxiety disorders were also significantly associated with mental health symptoms, independent of social connectedness. Our findings suggest that efforts aimed at alleviating the burden of depression and suicidality in returning war veterans should focus on re-integrating veterans into society and establishing a feeling of social connectedness, as well as on treating anxiety disorders and sleep problems.

Risk and protective factors associated with mental health among female military veterans: results from the veterans' health study

Background

This study focuses on factors that may disproportionately affect female veterans’ mental health, compared to men, and is part of a larger study assessing the prevalence of mental health disorders and treatment seeking among formerly deployed US military service members.

Methods

We surveyed a random sample of 1,730 veterans who were patients in a large non-VA hospital system in the US. Based on previous research, women were hypothesized to be at higher risk for psychological problems. We adjusted our results for confounding factors, including history of trauma, childhood abuse, combat exposure, deployments, stressful life events, alcohol misuse, psychological resources, and social support.

Results

Among the veterans studied, 5% were female (n = 85), 96% were White (n = 1,161), 22.9% were Iraq/Afghanistan veterans (n = 398), and the mean age was 59 years old (SD = 12). Compared to males, female veterans were younger, unmarried, college graduates, had less combat exposure, but were more likely to have lifetime PTSD (29% vs. 12%.), depression (46% vs. 21%), suicidal ideation (27% vs. 11%), and lifetime mental health service use (67% vs. 47%). Females were also more likely to have low psychological resilience and to have used psychotropic medications in the past year. Using multivariate logistic regression analyses that controlled for risk and protective factors, female veterans had greater risk for lifetime PTSD, depression, suicidal thoughts, and for lifetime use of psychological services, compared to males. Since 95% of the population in this study were male and these results may have been statistically biased, we reran our analyses using propensity score matching. Results were consistent across these analyses.

Conclusion

Using a sample of post-deployment veterans receiving healthcare services from a large non-VA health system, we find that female veterans are at greater risk for lifetime psychological problems, compared to male veterans. We discuss these findings and their implications for service providers.

Social Embeddedness of Firefighters, Paramedics, Specialized Nurses, Police Officers, and Military Personnel: Systematic Review in Relation to the Risk of Traumatization

Background: Firefighters, paramedics, specialized nurses working in Intensive Care Units (ICUs), Operating Rooms (OR), and Emergency Rooms (ER), police officers and military personnel are more frequently exposed to potentially traumatic events than the general population; they are considered high-risk professionals. To reduce the risk of traumatization it is of great importance to be embedded in a social environment with supportive relationships. Methods: We performed a systematic review (based on the PRISMA-Guidelines) looking for social connections within the environment in which high-risk professionals are embedded (work, home, community), to obtain evidence on the impact of these connections on the risk of traumatization. Additionally, we aim to identify relevant supportive relationships in the professionals' environments. We identified the relevant scientific literature by searching, without time, and language restriction, five electronic bibliographic databases: MEDLINE, PsycINFO, Sociological Abstracts, CINAHL, and Web of Science. These databases were last searched in January 2019. Results: A qualitative analysis of the 89 eligible (out of 9,047 screened) studies shows that for firefighters, paramedics, and emergency nurses social connections in their work environment are predominantly supportive relationships and may protect them against traumatization. In other occupations (OR-nurses, ICU-nurses, police officers), however, social connections at work are not only a source of support but are also a source of stress. For military personnel study results are inconclusive as to whether their social connections at work or at home support them against traumatization. In so far as connections are supportive, their sources vary greatly from one occupational group to another; they differ between work vs. home as well as within work between peers vs. supervisor. Conclusions: Being embedded in a social environment, i.e., having social connections, is important but not always sufficient to protect high-risk professionals against traumatization. For, while these connections may be the antecedents of supportive relationships, they can also be the antecedents of damaging relationships. Additionally, the sources of supportive relationships differ among groups. This suggests that knowledge of how the social structures of the occupational groups differ may increase our understanding of the impact of social connections and relationships, including socialization, on the risk of traumatization of high-risk professionals.

Mental health status in veterans residing in rural versus non-rural areas: results from the veterans' health study

BACKGROUND

The majority of Veterans Affair (VA) hospitals are in urban areas. We examined whether veterans residing in rural areas have lower mental health service use and poorer mental health status.

METHODS

Veterans with at least 1 warzone deployment in central and northeastern Pennsylvania were randomly selected for an interview. Mental health status, including PTSD, major depression, alcohol abuse and mental health global severity, were assessed using structured interviews. Psychiatric service use was based on self-reported utilization in the past 12 months. Results were compared between veterans residing in rural and non-rural areas. Data were also analyzed using multivariate logistic regression to minimize the influence by confounding factors.

RESULTS

A total of 1730 subjects (55% of the eligible veterans) responded to the survey and 1692 of them had complete geocode information. Those that did not have this information (n = 38), were excluded from some analyses. Veterans residing in rural areas were older, more often of the white race, married, and experienced fewer stressful events. In comparison to those residing in non-rural areas, veterans residing in rural areas had lower global mental health severity scores; they also had fewer mental health visits. In multivariate logistic regression, rural residence was associated with lower service use, but not with PTSD, major depression, alcohol abuse, and global mental health severity score after adjusting confounding factors (e.g., age, gender, marital status and education).

CONCLUSIONS

Rural residence is associated with lower mental health service use, but not with poor mental health in veterans with former warzone deployment, suggesting rural residence is possibly protective.

Predictors of Current DSM-5 PTSD Diagnosis and Symptom Severity Among Deployed Veterans: Significance of Predisposition, Stress Exposure, and Genetics

BACKGROUND

Previously we reported a genetic risk score significantly improved PTSD prediction among a trauma-exposed civilian population. In the current study, we sought to assess this prediction among a trauma-exposed military population.

METHODS

We examined current PTSD diagnosis and PTSD symptom severity among a random sample of 1042 community-based US military veterans. Main effects and interaction effects were assessed for PTSD genetic risk by trauma exposure using cross-product terms for PTSD x trauma exposures, including combat, lifetime trauma, and adverse childhood exposures. The PTSD risk variants studied were within genetic loci previously associated with PTSD, including CRHR1, CHRNA5, RORA, and FKBP5 genetic variants, which were used to calculate a total PTSD genetic risk score (range=0-8, mean=3.6, SD=1.4).

RESULTS

Based on DSM-5 PTSD criteria, 7.1% of veterans (95% CI=5.6-8.8) met criteria for current PTSD. The PTSD genetic risk count was significantly higher among PTSD cases vs non-cases (3.92 vs 3.55, p=0.027). Since the PTSD genetic risk score was not significant in the PTSD diagnosis model, we assessed this association using PTSD symptom severity. Because these symptom data were skewed (mean=9.54, SD=12.71, range=0-76), we used negative binomial regression to assess this outcome. This symptom model included a PTSD genetic risk score, demographic factors, trauma exposures, current insomnia, current depression, concussion history, and attention-deficit disorder, expressed as incident rate ratios (IRR), which is an estimate of one-unit increase in PTSD severity, given other variables are held constant. Variables in the final model included age and sex (both p<0.001), PTSD genetic risk (IRR=1.02, p=0.028), warzone tours (IRR=0.94, p=0.003), childhood abuse (IRR=1.50, p<0.0001), current depression (IRR=1.89, p<0.0001), current insomnia (IRR=2.58, p<0.0001), low social support (IRR=1.19, p<0.0001), attention-deficit disorder (IRR=1.51, p<0.0001), agreeable personality (IRR=0.77, p<0.0001), and concussion (IRR=1.38, p<0.0001). Significant interactions were detected for combat and lifetime trauma exposure by PTSD genetic risk (both p<0.0001), suggesting that the impact of trauma exposures on PTSD severity was lower when the PTSD genetic risk was higher.

CONCLUSION

Both warzone and non-warzone factors predicted current PTSD symptoms among veterans, including a PTSD genetic risk score. Interaction effects were detected for combat exposure and lifetime trauma by genetic risk score for PTSD symptoms, suggesting that PTSD symptom manifestation was more dependent on PTSD risk variants than the level of trauma or combat exposure. This suggests that controlling for other factors, the absence of genetic risk variants may confer PTSD resilience. Further research is planned.

Grapheme-Color Synesthesia is Associated with PTSD Among Deployed Veterans: Confirmation of Previous Findings and Need for Additional Research

Post-traumatic stress disorder (PTSD) is related to alteration in neuropsychological functioning, including visual and other cognitive processes. Grapheme-color synesthesia is a phenomenon in which a letter or number elicits response of a concurrent image or color perception. Since we earlier reported an association between grapheme-color synesthesia and PTSD, our objective in the current study was to validate this association among a new study group and assess risk factors. For this, we surveyed 1,730 military veterans who have been outpatients in the Geisinger Clinic, a multi-hospital system in Pennsylvania, USA. All the study veterans served in a warzone deployment. The association between PTSD and Grapheme-color synesthesia was evaluated. The average age of veterans was 59.6 years among whom 95.1% were male. Current PTSD prevalence rate was observed to be 7.6% (95% C.I. = 6.5-9.0) and in 3.4% of veterans (95% C.I. = 2.7-4.4) grapheme-color synesthesia was found to be positive. Initial bivariate analyses suggested that synesthesia was associated with current PTSD [odds ratio (OR) = 3.3, p<0.001]. Multivariable stepwise logistic regression evaluating the age, sex, education, trauma exposure, current psychological stress, psychotropic medication use, combat exposure, history of concussion, and current depression, confirmed this association (OR = 2.33, p = 0.019). The present study corroborated that Grapheme-color synesthesia was linked to PTSD among a second cohort of deployed military veterans. Further research is recommended in order to validate this observation and to determine whether synesthesia is a risk factor for PTSD.