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Combat-related Mental Health Symptoms and Correlates through the Deployment Cycle

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Title: Combat-related Mental Health Symptoms and Correlates through the Deployment Cycle


1
Combat-related Mental Health Symptoms and
Correlates through the Deployment Cycle
  • MAJ Jeffrey L. Thomas, Ph.D.
  • Chief, Military Psychiatry Branch
  • Center for Military Psychiatry and Neuroscience
  • Walter Reed Army Institute of Research

The views expressed in this presentation are
those of the author and do not represent the
official policy or position of the U.S. Army
Medical command or the Department of Defense.
2
WRAIR Psychological Research
and Health Program
  • WRAIRs Psychological Research and Health Program
    is focused on
  • Benchmarking the effects of combat
  • Moderating the negative effects of combat
  • Promoting resilience in Soldiers and Families
  • Main Studies
  • Land Combat Study (epi)
  • Mental Health Advisory Teams (MHATs) (epi)
  • Interventions

3
Outline
  • Epidemiological Studies
  • Mental Health Advisory Team (MHAT) data
  • Behavioral health symptoms during deployment
  • Prescription drug use
  • Risk factors
  • Land Combat Studies data
  • Behavioral health symptoms following deployment
  • Rates of alcohol misuse
  • Risk behaviors
  • The Army Alcohol Pilot CATEP
    (Confidential Alcohol
    Treatment Education Program)

4
MHAT Mission
  • Mental Health Advisory Teams
  • Mission
  • Assess Soldier behavioral health
  • Examine the delivery of theater behavioral health
    care
  • Provide recommendations to command

5
MHAT Data Mental Health Symptom Rates
  • Estimated rates of mental health problems (MHAT V
    Report)

6
MHAT Data Combat Exposure Rates
Combat Exposure Adjusted Percents for Male, E1-E4 Soldiers in Theater 6 Months or Longer. Combat Exposure Adjusted Percents for Male, E1-E4 Soldiers in Theater 6 Months or Longer. Combat Exposure Adjusted Percents for Male, E1-E4 Soldiers in Theater 6 Months or Longer. Combat Exposure Adjusted Percents for Male, E1-E4 Soldiers in Theater 6 Months or Longer.
  Percent Percent Percent
Combat Experiences (OEF) 2005 2007 2009
During this deployment did you experience being attacked or ambushed 49.9 74.3 83.3
During this deployment did you experience receiving small arms fire 48.5 68.6 74.1
During this deployment did you experience witnessing violence within the local population or between ethnic groups 44.9 48.4 53.8
During this deployment did you experience seeing dead or seriously injured Americans 49.1 63.5 62.2
During this deployment did you experience knowing someone seriously injured or killed 70.4 87.1 82.9
During this deployment did you experience being in threatening situations where you were unable to respond because of rules of engagement 33.1 48.2 58.2
During this deployment did you experience shooting or directing fire at the enemy 36.0 58.8 74.8
During this deployment did you experience calling in fire on the enemy 17.0 30.6 44.1
During this deployment did you experience receiving incoming artillery rocket or mortar fire 75.2 91.0 92.9
During this deployment did you experience being directly responsible for the death of an enemy combatant 12.9 30.9 51.6
During this deployment did you experience having a member of your own unit become a casualty 56.4 75.0 77.1
During this deployment did you experience a close call dud landed near you 19.6 38.7 39.2
During this deployment did you experience a close call equipment shot off your body 3.0 16.1 11.5
During this deployment did you experience a close call was shot or hit but protective gear saved you 2.5 11.9 11.0
During this deployment did you experience having a buddy shot or hit who was near you 8.8 24.1 36.4
7
MHAT Combat Exposure
Acute Stress (PTSD Symptoms)
8
MHAT Medication UseIraq 2009
  • Medication use for a mental health, combat
    stress, or sleep problem
  • 14 of MHAT III Soldiers in 2005 (Overall Sample
    N 1,124)
  • 13 of MHAT IV Soldiers in 2006 (Overall Sample N
    1,320)
  • 12 of MHAT V Soldiers in 2007 (Overall Sample N
    2,279)
  • Medications for sleep and combat stress (Iraq
    Afghanistan 2009)
  • Combat Stress
  • 4.8 of maneuver units Soldiers reported using
    medications for a mental health problem 5.1
    rate for Support units
  • 2.9 of maneuver units Soldiers reported using
    medications for a mental health problem 6.4
    rate for Support units
  • Sleep
  • 8.1 of maneuver unit soldiers reported using
    sleep medications 13.5 rate for support units
  • 9.2 of maneuver unit soldiers reported using
    sleep medications 13.5 rate for support units

9
Interpreting MHAT Medication Use
  • Olfson and Marcus (2009) report rates of
    antidepressant medications use from nationally
    representative probability samples collected in
    1996 and 2005
  • Antidepressant use for (a) 21-34 year old (b)
    males who were (c) employed with (d) health
    insurance was 2.28 in 1996 and 4.59 in 2005
    (Olfson and Marcus personal communication, 31
    AUG 2010)
  • MHAT VI from 2009 Data (repeated for reference)
  • Iraq 4.8 of maneuver units Soldiers reported
    using medications for a mental health problem
    5.1 rate for Support units
  • Afghanistan 2.9 of maneuver units Soldiers
    reported using medications for a mental health
    problem 6.4 rate for Support units

10
MHAT Multiple Deployments Meds
  • In 2009,(Afghanistan) multiple deployments and
    medication use
  • No significant effect for sleep medications
  • Significant increase for mental health
    medications by the third deployment

11
MHAT Illicit Drug / Alcohol Use
  • Non-random sampling procedure used prior to 2009
    provided more anonymity to participants
  • Illicit Drug Use
  • 1.6 of MHAT IV Soldiers in 2006 (Overall Sample
    N 1,320)
  • 1.4 of MHAT V Soldiers in 2007 (Overall Sample N
    2,279)
  • In-Theater Alcohol Use
  • 6.8 in MHAT IV
  • 8.0 in MHAT V
  • Because of refinement in sampling
    (cluster-sampling by platoon), these items are no
    longer asked in current MHAT assessments

12
MHAT Future Directions
  • Continue to identify correlates of medication use
  • Collect information on use of prescription pain
    medications
  • Limited ability to collect information about
    abuse in current MHAT process
  • Human use protection of participants in context
    where platoons are randomly selected (thus
    identified)

13
Land Combat Studies
  • Land Combat Studies (LCS)
  • Focused on Brigade Combat Teamsinfantry units
  • Large intact unit assessments
  • Majority of data collected in post-deployment
    time frame
  • LCS I (2003-2008)
  • Initial study to assess the effects of combat in
    OIF and OEF (n 70,000)
  • LCS II (2008-2013)
  • Examines broader range of outcomes and moderating
    variables (n 13,000)
  • Publications stemming from LCS
  • Hoge et al., NEJM, 2004, 2008
  • Thomas et al., Arch Gen Psych, 2010
  • Wilk et al., Drug Alcohol Dependence, 2010
  • Kim et al., Psych Services, 2010

14
Land Combat Studies Post-Deployment Mental
Health Symptom Rates
Thomas et al., Archives of General Psychiatry
(2010)
15
Land Combat Studies Mental Health Problems
Comorbidities
  • Alcohol misuse and aggression
  • Common among veterans of OIF / OEF
  • 50 of Soldiers with mental health problems and
    functional impairment reported alcohol misuse or
    aggression problems
  • From 3 to 12 months post-deployment
  • Active Duty Soldiers symptoms generally persisted
  • Active Duty Soldiers PTSD symptoms typically
    increased
  • Despite similar combat exposure levels and unit
    type, National Guard BCT Soldiers symptoms across
    all measures increased
  • National Guard BCT Soldiers rates may be higher
    due to
  • Lack of peer support during post-mobilization
  • Readjustment problems (military to civilian)
  • Access to care (TRICARE benefits expire after 6
    months)

Thomas et al., Archives of General Psychiatry
(2010)
16
Combat Experiences Alcohol Misuse
  • 10 25 screen positive for alcohol misuse at
    post-deployment (source PDHRA screening data,
    anonymous surveys)
  • Combat Experience factors associated with alcohol
    problems post-deployment
  • Threat to oneself
  • Witnessing atrocities

Wilk et al., Drug and Alcohol Dependence (2010)
17
Alcohol Screening in US Army
  • Aside from mandatory and random drug testing
  • DOD health assessment with alcohol screening
  • Periodic Health Assessment (PHA)
  • Post-Deployment Health Assessment (PDHA)
  • Post-Deployment Health Re-Assessment (PDHRA)
  • Modified Two-Item Conjoint Screen (TICS) has used
    to screen for alcohol misuse (Brown et al., 2001)
  • In the past 4 weeks, have you used alcohol more
    than you meant to?
  • In the past 4 weeks, have you felt you wanted or
    needed to cut down on your drinking?
  • Validated in primary and military settings.
  • AUDIT-C

18
Alcohol and Risk Behaviors
Alcohol-Related Behavior TICS Positive () TICS Negative () Adjusted Odds Ratio3 (95 CI)
Drinking and Driving 36 10 4.99 4.31 5.76
Riding w/ Drunk Driver 31 7 5.87 4.99 6.91
Late or Missed Work 11 1 9.24 6.73 12.68
Illicit Drug Use 9 2 4.97 3.68 6.71
Referral to Rehab Program 7 1 7.15 4.84 10.58
DUI 4 1 4.84 3.04 7.68
Any Alcohol-Related Behavior 51 15 5.63 4.94 6.41
3 Results of logistic regression, adjusting for
gender, race, rank, and status in the reserves or
active duty. For all adjusted odds ratios,
calculated Wald statistics yielded p lt0.001 with
1 degree of freedom. Hosmer and Lemeshow tests
showed no significant deviation from fit with 7
degrees of freedom.
Santiago et al., Psychiatric Services (2010)
19
Abuse Prevention Facilitate Care
  • Active Component Post-OIF PDHRA from Milliken et
    al, JAMA 2007
  • Extremely low referral rates
  • Why? Whats going on? What needs to be improved?

0.4
2.0
Figure from Milliken et al., JAMA (2007)
20
Current ASAP Policy
  • ASAP is a Command program. Command involvement is
    NOT optional
  • Active participation is mandatory for all
    Soldiers enrolled in ASAP treatment
  • Until recently, Soldiers enrolled in ASAP
    treatment were automatically subject to negative
    personnel actions (barred, flagged, etc.)
  • Soldiers who fail to comply with or respond
    successfully to ASAP treatment will be processed
    for administrative separation from military
    service
  • Subsequent problems also deemed rehab failures
    and AR requires processing for separation

21
Current ASAP Policy (cont.)
  • Number of soldiers enrolled in ASAP treatment
    falls far short of number of soldiers in need of
    ASAP treatment
  • Senior NCOs Officers are dramatically
    under-represented under-served among ASAP
    patients
  • Majority of ASAP referrals are not self-referrals
  • Majority of ASAP patients are junior enlisted
    Soldiers with little to no career investment in
    military service
  • NCOs Officers present to ASAP with alcohol
    problems only rarely under duress with career
    on the line

22
How can we do better?...
  • Reduce stigma of substance abuse treatment
  • Improve access to ASAP treatment for ALL Soldiers
  • Encourage career-minded Soldiers to obtain care
  • Provide earlier interventions for Soldiers in
    need BEFORE problem adversely impacts
    functioning
  • finances
  • health
  • relationships social functioning
  • occupational performance
  • military career
  • fitness for duty

23
Army Alcohol Pilot Study
  • The Army Alcohol Pilot CATEP (Confidential
    Alcohol Treatment Education Program)POC COL
    Charles Milliken, MC (WRAIR)
  • Authority Secretary of Army
  • Scope Pilot for Soldiers who self-refer to the
    ASAP with alcohol problems before they have an
    incident, without consequent compromise to
    military career
  • Purpose Test feasibility of trial policy changes
    to improve Soldiers access to alcohol treatment
    earlier in the course of their illness
  • Pilot Sites
  • Schofield Barracks, Hawaii 06 July 09
  • Fort Richardson, Alaska 17 Aug 09
  • Fort Lewis, Washington 24 Aug 09
  • Expanded to include Ft Riley, Ft Carson, Ft
    Leonard Wood

24
Trial Policy Changes
  • Command involvement in ASAP treatment is OPTIONAL
    (but encouraged)
  • Active participation in ASAP treatment is
    VOLUNTARY
  • Soldiers in ASAP treatment are NOT SUBJECT to
    NEGATIVE PERSONNEL ACTIONS (barred, flagged,
    etc.)
  • Soldiers who fail ASAP treatment WILL NOT BE
    automatically ADMINISTRATIVELY SEPARATED from
    military service
  • Enrollment in CATEP treatment will not count
    toward the number of trials of rehabilitation
    allowed per military career

25
Pilot Eligibility
  • All Soldiers who present to the ASAP clinic as
    anything but a mandatory command-referral will be
    screened for eligibility to participate in the
    ASAP Pilot
  • All Soldiers who present as self-referrals to
    ASAP for alcohol problems are eligible for Pilot
    participation if they
  • have not had an alcohol or drug-related incident
    that merits mandatory command-referral
  • are not being formally referred by their
    Commander for an alcohol- or drug-related
    incident that merits mandatory ASAP referral
  • A Soldier will be removed from Pilot care and
    back in ASAP if they
  • have a significant alcohol-related incident, use
    illegal substances or abuse prescription
    medication

26
Rank Distribution of Standard ASAP vs. ASAP
Pilot cases

27
Summary of Initial ASAP Pilot Findings
  • Quantitative data
  • Referral rates from PDHRA and medical referral
    sources have increased
  • Increased numbers of senior NCOs and Officers are
    accessing care
  • Qualitative data
  • Soldiers, Commanders, ASAP clinicians give the
    Pilot 2 thumbs up
  • Alcohol dependence is safely treated under CATEP

28
Summary
  • Mental Health Advisory Team data
  • Land Combat Study data
  • The Army Alcohol Pilot CATEP (Confidential
    Alcohol Treatment Education Program)

29
Points of Contact
  • MAJ Jeffrey L. Thomas, Ph.D.
  • Chief, Military Psychiatry Branch
  • Walter Reed Army Institute of Research
  • 503 Robert Grant Avenue
  • Silver Spring, MD 20910
  • (301) 319-7577
  • jeffrey.l.thomas_at_us.army.mil
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