Prospective Analysis of Premilitary Mental Health, Somatic Symptoms, and Postdeployment Postconcussive Symptoms

Diet's Impact on Post-Traumatic Brain Injury Depression: Exploring Neurodegeneration, Chronic Blood-Brain Barrier Destruction, and Glutamate Neurotoxicity Mechanisms

Traumatic brain injury (TBI) has a profound impact on cognitive and mental functioning, leading to lifelong impairment and significantly diminishing the quality of life for affected individuals. A healthy blood-brain barrier (BBB) plays a crucial role in guarding the brain against elevated levels of blood glutamate, making its permeability a vital aspect of glutamate regulation within the brain. Studies have shown the efficacy of reducing excess glutamate in the brain as a treatment for post-TBI depression, anxiety, and aggression. The purpose of this article is to evaluate the involvement of dietary glutamate in the development of depression after TBI. We performed a literature search to examine the effects of diets abundant in glutamate, which are common in Asian populations, when compared to diets low in glutamate, which are prevalent in Europe and America. We specifically explored these effects in the context of chronic BBB damage after TBI, which may initiate neurodegeneration and subsequently have an impact on depression through the mechanism of chronic glutamate neurotoxicity. A glutamate-rich diet leads to increased blood glutamate levels when contrasted with a glutamate-poor diet. Within the context of chronic BBB disruption, elevated blood glutamate levels translate to heightened brain glutamate concentrations, thereby intensifying neurodegeneration due to glutamate neurotoxicity.

The importance of screening for functional neurological disorders in patients with persistent post-concussion symptoms

BACKGROUND

Functional neurological disorder (FND) may commonly co-occur with persistent symptoms following a psychological trauma or physical injury such as concussion.

OBJECTIVE

To explore the occurrence of FND in a population with persistent post-concussion symptoms (PPCS) and the associations between FND and depression as well as anxiety in participants with PPCS.

METHODS

Sixty-three individuals with PPCS presenting to a specialized brain injury clinic completed the following questionnaires: screening for somatoform disorder conversion disorder subscale (SOM-CD), Rivermead post-concussion symptom questionnaire (RPQ), patient health questionnaire-9 (PHQ-9), and generalized anxiety disorder questionnaire- 7 (GAD-7). Both multiple linear regression and logistic regression were conducted to evaluate the relationship between questionnaires and adjust for covariates.

RESULTS

We found that total RPQ score (βˆ= 0.27; 95% CI = [0.16, 0.38]), GAD-7 score (βˆ= 0.71; 95% CI = [0.50, 0.92]) and PHQ-9 score (βˆ= 0.54; 95% CI = [0.32, 0.76]) were positively associated with SOM-CD score individually, after consideration of other covariates. Participants meeting the criteria for severe FND symptoms were 4.87 times more likely to have high PPCS symptom burden (95% CI = [1.57, 22.84]), 8.95 times more likely to have severe anxiety (95% CI = [3.31, 35.03]) and 4.11 times more likely to have severe depression symptom burden (95% CI = [1.77, 11.53]).

CONCLUSION

The findings of this study indicate an association between FND and post-concussion symptoms as well as an association between FND and symptoms of depression and anxiety in patients with PPCS. Patients with PPCS should be screened for FND to provide a more targeted treatment approach that includes somatic-focused interventions.

"I Constantly Feel Worn Out": Mixed-methodology Approach to Seafarers' Sleep on Board

Although seafaring is one of the most important professions for trade in goods in the 21st century, the results of recent research indicate that seafarers face various sources of stress in their work, including high workload and long working hours. These stressors can be reflected in low job satisfaction and poor mental health, which can result in sleep problems, and consequently lead to various somatic symptoms. The main goal of this mixed method research was, therefore, to expand knowledge about seafarers' sleep on board, whereby a sequential explanatory design was used. Study 1 (N = 286 male seafarers from Croatia) examined whether the number of sleep hours on board has a mediating role in explaining the relationship between job satisfaction and mental health as predictors of somatic symptoms. The results of the path analysis showed that higher job satisfaction directly and indirectly through longer sleep on board reduces the number of somatic symptoms, while better mental health directly contributes to fewer somatic symptoms. Study 2 (N = 205 seafarers from Croatia) aimed to get a deeper insight into the sleep of seafarers on board, whereby 39% (N = 80) of the participants had difficulties related to sleep problems on board. The thematic analysis of their answers (N = 76) showed the sleeping difficulties experienced by seafarers on board and gave an insight into the consequences of sleeping difficulties and the coping strategies they use. The results of this research indicate the importance of developing healthy work environments for seafarers.

Health differences by entry stream among Canadian Armed Forces officer cadets

LAY SUMMARY

This study compared the baseline physical and mental health of officer candidates attending military college and officer training programs (i.e., non-direct-entry officer or non-DEO stream) with those of officers entering through a direct stream (direct-entry officer or DEO stream). Overall, DEO candidates had better health than non-DEO candidates. Female DEO and non-DEO candidates also reported more physical activity than male DEO and non-DEO candidates, and female non-DEO candidates had more symptoms of mental illness than male non-DEO candidates. A better understanding of these groups may lead to opportunities to customize health screening and supports depending on officer entry stream and sex; however, more research is needed to inform policy.

History of Functional Somatic Syndromes and Persistent Symptoms After Mild Traumatic Brain Injury

OBJECTIVE

Somatization is thought to underlie functional somatic syndromes (FSSs) and may also contribute to prolonged symptoms after mild traumatic brain injury (mTBI). The investigators evaluated the prevalence of FSSs in patients seeking specialty care after mTBI and whether a history of FSSs was associated with symptom persistence.

METHODS

A total of 142 patients with mTBI completed questionnaires regarding demographic information, injury characteristics, and medical history, including history of diagnosed FSSs at clinic intake (mean=41 days postinjury [SD=22.41]). Postconcussion symptoms were assessed at clinic intake and again 1 and 3 months later. A linear mixed-effects model was used to determine whether history of FSSs was related to persistent mTBI symptoms over time.

RESULTS

A history of at least one FSS was reported by 20.4% of patients. In the linear mixed model, postconcussion symptom scores were not significantly different over time among patients with a history of one or more FSSs or two or more FSSs from those with no FSSs. A history of one or more FSSs or two or more FSSs (versus no FSS) was not associated with increased odds of severe postconcussion symptoms at clinic intake (one or more FSSs: odds ratio=0.88, 95% CI=0.38-2.03; two or more FSSs: odds ratio=1.78, 95% CI=0.45-7.03), at the 1-month follow-up visit (one or more FSSs: odds ratio=0.57, 95% CI=0.22-1.45; two or more FSSs: odds ratio=0.57, 95% CI=0.14-2.37), or at the 3-month follow-up visit (one or more FSSs: odds ratio=0.97, 95% CI=0.36-2.63; two or more FSSs: odds ratio=1.27, 95% CI=0.29-5.65).

CONCLUSIONS

In this sample, the prevalence rates of FSSs were higher than rates previously reported for the general population. However, FSS history did not predict higher postconcussion symptom burden at clinic intake or persistence over the following 3 months. Further research is needed to clarify the potential role of somatization in poor mTBI outcome.

Unexpected symptoms after concussion: Potential links to functional neurological and somatic symptom disorders

OBJECTIVE

Reporting of unexpected symptoms after concussion might, in some people, reflect a Functional Neurological Disorder (FND), Somatic Symptom Disorder (SSD), or exaggeration (feigning). This study aimed to determine whether reporting unexpected symptoms after concussion was associated with risk factors for FND/SSD, exaggeration, or both.

METHOD

Adults with persistent symptoms following concussion (N = 77; 61% women) rated the presence and severity of unexpected neurological symptoms (from the Screening for Somatoform Symptoms scale, e.g., paralysis) and somatic symptoms (from the Patient Health Questionnaire-15, e.g., stomach pain) that did not overlap with post-concussion symptom scale items. The independent variables were risk factors for exaggeration (neuropsychological performance validity test failure and personal injury litigation) and predisposing and perpetuating factors for developing FND and/or SSD (e.g., fear avoidance behavior).

RESULTS

When adjusting for all covariates, fear avoidance behavior was most strongly related to unexpected neurological symptoms (B = 0.11, 95% confidence interval = 0.05-0.18, p < .001), while current anxiety scores were most strongly related to unexpected somatic symptoms (B = 0.34, 95% confidence interval = 0.15-0.52, p < .001). Performance validity test failure and litigation were not significant predictors in either model.

CONCLUSION

Unexpected neurological and other somatic symptoms after concussion should not be dismissed as exaggeration. Psychological factors thought to perpetuate FND and SSD (e.g., fear avoidance behavior) may contribute to unexpected symptoms following concussion. More research is needed at the intersection of FND, SSD, and persistent post-concussive symptoms.

Psychoeducation as Precision Health in Military-Related Mild Traumatic Brain Injury

A significant proportion of Service Members and Veterans (SMVs) experience at least 1 mild traumatic brain injury during military activities (mil-mTBI), which can result in enduring cognitive symptoms. Although multiple cognitive rehabilitation (CR) interventions have been developed for this population, patient psychoeducation focusing on biopsychosocial relationships and health behaviors is often cited as the first line of defense for mil-mTBI sequelae. However, theoretical and conceptual foundations of these psychoeducational techniques are not well articulated. This raises questions about the potency of attempts to boost health literacy in affected SMVs, who represent a highly heterogeneous patient population within a special cultural milieu. To elucidate the significance of this problem and identify opportunities for improvement, we view the psychoeducation of SMVs through the lens of educational principles described in serious mental illness, where "psychoeducation" was first formally defined, as well as contextual and phenomenological aspects of mil-mTBI that may complicate treatment efforts. To advance psychoeducation research and practice in mil-mTBI, we discuss how treatment theory, which seeks to link active treatment ingredients with specific therapeutic targets, and an associated conceptual framework for medical rehabilitation-the Rehabilitation Treatment Specification System-can be leveraged to personalize educational content, integrate it into multicomponent CR interventions, and evaluate its effectiveness.

Characterizing the Risk of Depression Following Mild Traumatic Brain Injury: A Meta-Analysis of the Literature Comparing Chronic mTBI to Non-mTBI Populations

Objective: Mild traumatic brain injury (mTBI) is associated with depressed mood acutely post-injury, but there is little evidence regarding long-term depression. The aim of this study was to determine the odds ratio (OR) of depression chronically following mTBI.

Methods: We searched Medline (PubMed), ProQuest, and Web of Science from date of database creation to January 23, 2019, for eligible studies examining depression at least 6 months post-injury in adult subjects with mTBI of any etiology, including civilians and military. Three authors independently reviewed titles and abstracts for study eligibility. Data were extracted and collated by two investigators. Risk of bias was assessed with the SIGN methodology. Study data were pooled using random-effects meta-analysis. The primary exposure was mTBI, and the primary outcome was depression. Secondary exploratory variables were time of assessment, age at injury, age at assessment, sex, and etiology.

Results: We included 47 cross-sectional studies (n = 25,103 mTBI and 29,982 control), 26 cohort studies (n = 70,119 mTBI, 262,034 control), four prospective observational studies (n = 1,058 mTBI and 733 control), two prospective longitudinal studies (n = 119 mTBI, 81 control), two case-control studies (n = 56 mTBI, 56 control), and one randomized controlled trial (n = 252 mTBI, 3,214 control). mTBI was associated with a 3.29-fold increased risk of depression (OR 3.29, 95% CI 2.68–4.03, I² = 96%). The OR for depression did not change when subjects were assessed at 6–12 months (OR 2.43, 1.45–4.07), years 1–2 (OR 4.12, 2.10–8.07); 2–10 (OR 3.28, 2.42–4.46), or 10+ (OR 3.42, 1.51–7.77). Similar risk of depression was sustained across different age at injury (<25: OR 2.26, 1.82–2.81; 25–35: OR 4.67, 3.06–7.14; >35: OR 2.69, 1.42–5.10) and different age at assessment (<40 years: OR 3.14, 2.48–3.99; >40 years: OR 4.57, 2.54–8.24). Female sex had a non-significant increase in OR (OR 19.97, 2.39–166.93) compared to male (OR 3.0, 2.33–3.86). mTBI etiology had no impact on depression.

Conclusions: Those experiencing mTBI are more than three times more likely to experience depression compared to those without a history of mTBI, and this risk remains decades beyond the mTBI event. Future longitudinal studies are needed to identify and mitigate this risk.

Atypical Somatic Symptoms in Adults With Prolonged Recovery From Mild Traumatic Brain Injury

Somatization may contribute to persistent symptoms after mild traumatic brain injury (mTBI). In two independently-recruited study samples, we characterized the extent to which symptoms atypical of mTBI but typical for patients suffering from somatization (e.g., gastrointestinal upset, musculoskeletal, and cardiorespiratory complaints) were present in adult patients with prolonged recovery following mTBI. The first sample was cross-sectional and consisted of mTBI patients recruited from the community who reported ongoing symptoms attributable to a previous mTBI (n = 16) along with a healthy control group (n = 15). The second sample consisted of patients with mTBI prospectively recruited from a Level 1 trauma center who had either good recovery (GOSE = 8; n = 32) or poor recovery (GOSE < 8; n = 29). In all participants, we evaluated atypical somatic symptoms using the Patient Health Questionnaire-15 and typical post-concussion symptoms with the Rivermead Post-Concussion Symptom Questionnaire. Participants with poor recovery from mTBI had significantly higher "atypical" somatic symptoms as compared to the healthy control group in Sample 1 (b = 4.308, p < 0.001) and to mTBI patients with good recovery in Sample 2 (b = 3.169, p < 0.001). As would be expected, participants with poor outcome in Sample 2 had a higher burden of typical rather than atypical symptoms [t ₍₂₈₎ = 4.750, p < 0.001, d = 0.88]. However, participants with poor recovery still reported atypical somatic symptoms that were significantly higher (1.4 standard deviations, on average) than those with good recovery. Our results suggest that although "typical" post-concussion symptoms predominate after mTBI, a broad range of somatic symptoms also frequently accompanies mTBI, and that somatization may represent an important, modifiable factor in mTBI recovery.

Prevention of post-concussion-like symptoms in patients presenting at the emergency room, early single eye movement desensitization, and reprocessing intervention versus usual care: study protocol for a two-center randomized controlled trial

Background

Recent data suggest that 10–20% of injury patients will suffer for several months after the event from diverse symptoms, generally referred to as post-concussion-like symptoms (PCLS), which will lead to a decline in quality of life. A preliminary randomized control trial suggested that this condition may be induced by the stress experienced during the event or emergency room (ER) stay and can be prevented in up to 75% of patients with a single, early, short eye movement desensitization and reprocessing (EMDR) psychotherapeutic session delivered in the ER.

The protocol of the SOFTER 3 study was designed to compare the impact on 3-month PCLS of early EMDR intervention and usual care in patients presenting at the ER. Secondary outcomes included 3-month post-traumatic stress disorder, 12-month PCLS, self-reported stress at the ER, self-assessed recovery expectation at discharge and 3 months, and self-reported chronic pain at discharge and 3 months.

Methods

This is a two-group, open-label, multicenter, comparative, randomized controlled trial with 3- and 12-month phone follow-up for reports of persisting symptoms (PCLS and post-traumatic stress disorder). Those eligible for inclusion were adults (≥18 years old) presenting at the ER departments of the University Hospital of Bordeaux and University Hospital of Lyon, assessed as being at high risk of PCLS using a three-item scoring rule. The intervention groups were a (1) EMDR Recent Traumatic Episode Protocol intervention performed by a trained psychologist during ER stay or (2) usual care. The number of patients to be enrolled in each group was 223 to evidence a 15% decrease in PCLS prevalence in the EMDR group.

Discussion

In 2012, the year of the last national survey in France, 10.6 million people attended the ER, some of whom did so several times since 18 million visits were recorded in the same year. The SOFTER 3 study therefore addresses a major public health challenge.

Trial registration

Clinical Trials. NCT03400813. Registered 17 January 2018 – retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2902-2) contains supplementary material, which is available to authorized users.

Emergency room intervention to prevent post concussion-like symptoms and post-traumatic stress disorder. A pilot randomized controlled study of a brief eye movement desensitization and reprocessing intervention versus reassurance or usual care

Up to 20% of patients presenting at an emergency room (ER) after a stressful event will for several months suffer from very diverse long-lasting symptoms and a potentially significant decline in quality of life, often described as post concussion-like symptoms (PCLS). The objectives of our randomized open-label single-center study were to assess the feasibility of psychologist-led interventions in the context of the ER and to compare the effect of eye movement desensitization and reprocessing (EMDR) with reassurance and usual care. Conducted in the ER of Bordeaux University Hospital, the study included patients with a high risk of PCLS randomized in three groups: a 15-min reassurance session, a 60-min session of EMDR, and usual care. Main outcomes were the proportion of interventions that could be carried out and the prevalence of PCSL and post-traumatic stress disorder (PTSD) three months after the ER visit. One hundred and thirty patients with a high risk of PCLS were randomized. No logistic problem or patient refusal was observed. In the EMDR, reassurance and control groups, proportions of patients with PCLS at three months were 18%, 37% and 65% and those with PTSD were 3%, 16% and 19% respectively. The risk ratio for PCLS adjusted for the type of event (injury, non-injury) for the comparison between EMDR and control was 0.36 [95% CI 0.20-0.66]. This is the first randomized controlled trial that shows that a short EMDR intervention is feasible and potentially effective in the context of the ER. The study was registered at ClinicalTrials.gov (NCT03194386).

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.

Risk of Epilepsy in Individuals With Posttraumatic Stress Disorder: A Nationwide Longitudinal Study

OBJECTIVE

Several cross-sectional studies have reported a relationship between posttraumatic stress disorder (PTSD) and epilepsy. However, the temporal association between PTSD and epilepsy has rarely been investigated. We hypothesized that the risk of developing epilepsy later in life would be higher in patients with PTSD than in those without PTSD.

METHODS

Using the Taiwan National Health Insurance Research Database, 6425 individuals with PTSD and 24,980 age-/sex-matched controls were enrolled between 2002 and 2009 in our study and followed up to the end of 2011. Those who developed epilepsy during the follow-up period were identified.

RESULTS

Individuals with PTSD had a higher incidence of developing epilepsy (2.65 versus 0.33 per 1000 person-years, p < .001), with an earlier onset of epilepsy (37.53 years [15.80 years] versus 48.11 years [23.97 years], p = .002) than did the controls. Individuals with PTSD had an elevated risk of developing epilepsy (hazard ratio [HR] = 3.72, 95% confidence interval [CI] = 2.27-6.11) during the follow-up after adjustment for demographic data and medical and psychiatric comorbidities. Sensitivity analyses after excluding the observation in the first year (HR = 2.53, 95% CI = 1.44-4.47) and the first 3 years (HR = 2.14, 95% CI = 1.15-4.01) revealed consistent results.

CONCLUSIONS

These results supported a temporal association between PTSD and the development of epilepsy. Further studies are warranted to investigate the underlying pathophysiological pathways that explain the longitudinal association of PTSD with subsequent epilepsy.

Longitudinal evaluation of ventricular volume changes associated with mild traumatic brain injury in military service members

PRIMARY OBJECTIVE

To investigate differences in longitudinal trajectories of ventricle-brain ratio (VBR), a general measure of brain atrophy, between Veterans with and without history of mild traumatic brain injury (mTBI).

RESEARCH DESIGN

Structural magnetic resonance imaging (MRI) was used to calculate VBR in 70 Veterans with a history of mTBI and 34 Veterans without such history at two time points approximately 3 and 8 years after a combat deployment.

MAIN OUTCOMES AND RESULTS

Both groups demonstrated a quadratic relationship between VBR and age that is consistent with normal developmental trajectories. Veterans with history of mTBI had larger total brain volume, but no interaction between mTBI and age was observed for brain volume, ventricular volume, or VBR.

CONCLUSIONS

In our longitudinal sample of deployed Veterans, mTBI was not associated with gross brain atrophy as reflected by abnormally high VBR or abnormal increases in VBR over time.

Resilience and Traumatic Brain Injury Among Iraq/Afghanistan War Veterans: Differential Patterns of Adjustment and Quality of Life

OBJECTIVE

We examined the degree to which a resilient personality prototype predicted adjustment among war Veterans with and without a traumatic brain injury (TBI) while covarying the level of combat exposure.

METHOD

A total of 127 war Veterans (107 men, 20 women; average age = 37 years) participated. Personality prototypes were derived from the Multidimensional Personality Questionnaire (Patrick, Curtain, & Tellegen, 2002). Measures were administered at baseline, and a subset was administered at 4- and 8-month follow-ups.

RESULTS

Veterans with resilient personalities reported less sleep disturbance, more health-promoting behaviors, psychological flexibility, and emotional distress tolerance than Veterans with undercontrolled or overcontrolled prototypes. Path models revealed that resilience significantly predicted posttraumatic stress disorder (PTSD), depression, quality of life, and social support over time. TBI had unique and consistent effects only on PTSD.

CONCLUSION

Personality characteristics influence distress and quality of life among war Veterans with and without TBI. Implications for assessment, interventions, and research are discussed.

The 2013 Canadian Forces Mental Health Survey: Background and Methods

OBJECTIVE

The 2013 Canadian Forces Mental Health Survey (CFMHS) collected detailed information on mental health problems, their impacts, occupational and nonoccupational determinants of mental health, and the use of mental health services from a random sample of 8200 serving personnel. The objective of this article is to provide a firm scientific foundation for understanding and interpreting the CFMHS findings.

METHODS

This narrative review first provides a snapshot of the Canadian Armed Forces (CAF), focusing on 2 key determinants of mental health: the deployment of more than 40,000 personnel in support of the mission in Afghanistan and the extensive renewal of the CAF mental health system. The findings of recent population-based CAF mental health research are reviewed, with a focus on findings from the very similar mental health survey done in 2002. Finally, key aspects of the methods of the 2013 CFMHS are presented.

RESULTS

The findings of 20 peer-reviewed publications using the 2002 mental health survey data are reviewed, along with those of 25 publications from other major CAF mental health research projects executed over the past decade.

CONCLUSIONS

More than a decade of population-based mental health research in the CAF has provided a detailed picture of its mental health and use of mental health services. This knowledge base and the homology of the 2013 survey with the 2002 CAF survey and general population surveys in 2002 and 2012 will provide an unusual opportunity to use the CFMHS to situate mental health in the CAF in a historical and societal perspective.