Transcript What are deployment experiences? - NASW

KAPTUR COMBAT
MENTAL HEALTH INITIATIVE
“There is no greater priority than the mental health needs of our returning soldiers.”
Adjutant General Wayt (2005)
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Study Sites
University Hospitals Case Medical Center
Joseph Calabrese, MD
Coordinating Principal Investigator
Stephen Ganocy, PhD., Philip Chan, MS
Edwin Shirley, PhD., Toyomi Goto, MA
Renee Slembarski, BA
University of Toledo
Marijo Tamburrino, MD
Co-Principal Investigator
Thomas Fine, MA., Kimberly Wilson, MSW
Daniel Rapport, MD
Study Sites
Columbia University
Sandro Galea, MD, DrPH
Co-Investigator
Marta Prescott, MPH
University of Michigan
Israel Liberzon, MD, PhD
Co-Investigator
Anthony King, PhD
OUTLINE
• Background, Research Question & Design
• Overall Demographic Description
• Pre-deployment: Childhood Trauma, Stressors
• Deployment experiences, Trauma, Support
• PTSD, Depression, GAD findings
• Suicidal Thoughts
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Health in the military
Studies have demonstrated that combat exposure and
deployment stressors are linked to psychopathologies including
posttraumatic stress disorder (PTSD), depression and anxiety
• 27% of WWI hospitalizations were due to neuropsychiatric
problems
• 15% of Vietnam War Vets, 15 years after the war, showed
symptoms of PTSD
• 2% - 12.2% of Persian Gulf War veterans have current
symptoms of PTSD
• 4% - 21% of Operation Iraqi Freedom (OIF) and Operation
Enduring Freedom (OEF) veterans have current symptoms of
PTSD
Pols et al 2007; Kulka et al 1990; Kang et al 2003; Kang et al 2005; Pietrzak et al 2009; Hotopf et al 2006;
Hoge et al 2006; Miliken 2007; Seal et al 2007
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National Guard in recent combat
Army National Guard and Air National Guard are increasingly
used in combat zones and overseas operations
• 18% of total force in Persian Gulf War
• Reserve forces have comprised ~ 40% of the total operating
force in OIF and OEF
Lakhani et al 1993; Vogt et al 2008, Iraq and Veterans Affairs, Ohio National Guard website dated 3-28-09
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Ohio National Guard (ONG) and Deployment
From September 11, 2001 through March 2009, more than
13,000 Ohio Army National Guard and Ohio Air National
Guard have been deployed for both national and international
duty
Unique factors about deployment today
• All volunteer force
• Multiple deployments
• Communication
• 11% deployed are women
Ohio National Guard website dated 3-28-09
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National Guard in recent combat
While studies have shown that National Guard members
deployed overseas experience comparable combat and
deployment stressors as active duty personnel, Guard
members have different training and deployment conditions
than active duty personnel.
• Traditionally train only one weekend a month and two
weeks in the summer
• While in National Guard maintain civilian job
• Only 180 days of health care coverage upon deactivation as
compared to 2 years for active duty personnel
Vogt et al 2008, Hotopf et al 2006; La Bash 2007
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Kaptur CMHI
Most other studies have NOT focused on:
• The ONG
• VA non-treatment seekers
• Anything other than screening assessments
• Genetics repository
• Longitudinal collection of stressors and life events both inside
and outside of the military
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Overriding research question
What are pre-, peri- and post-deployment factors
associated with onset and course of psychopathology
among the Ohio National Guard?
• Posttraumatic stress disorder, depression, generalized
anxiety disorder
• Suicidal ideation
• Mental health services
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http://www.101films.net/
Kaptur CMHI ONG study design
10,778 Men and Women in the Ohio Army
National Guard (ONG) as of July 2008
6,700 randomly sampled ONG personnel
received Alert Letter
6,090 personnel do not opt-out of study
2616 ONG personnel participate in telephone
interview
2616 ONG personnel followed annually with
telephone interviews
70% overall participation rates
1,043 randomly selected for in-person
interviews
500 sub-sample followed annually
with in-person interviews
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Domains assessed in telephone assessment
• Demographics
• Military History
• Deployment Preparedness, Stressors, Traumas, and
Social Support: Deployment Risk and Resilience
Inventory (DRRI)
• Lifetime Traumatic History: Life Events Checklist
• Posttraumatic Stress Disorder: PTSD Checklist
• Depression: Patient Health Questionnaire (PHQ-9)
• Generalized Anxiety Disorder: GAD-7
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In-Person Interview Domains
• Demographics
• Military History
• Deployment Preparedness, Stressors, Traumas, and Social
Support: Deployment Risk and Resilience Inventory (DRRI)
• Lifetime Traumatic History: Life Events Checklist
• PTSD: Clinician-Administered PTSD Scale (CAPS)
• All DSM IV-TR Mood, Anxiety, Substance Use, Psychotic,
Somatoform, Eating and Acute Stress Disorders:
Structured Clinical Interview for DSM IV-TR (SCID-IV)
• Suicidal Thoughts: Mini-International Neuropsychiatric
Interview (MINI-Plus)
• Childhood Trauma Questionnaire (CTQ)
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Who are these people and
what are the stories of their lives?
• Demographics
• Childhood trauma
• Stressors and trauma outside of deployment
• Number of deployments
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Location of Kaptur CMHI Sample N=2616
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Location of In-person Sample N=500
Color of pushpins indicates different interviewers. (Blue-Ed, Red-Toyomi, Green-Tom, Purple-Kim)
Wave 1 sample is representative of the
Ohio Army National Guard
ONG sample
Ohio National Guard 2008
100
90
87.788.3
85.286.2
80
Proportion
70
60
50
37.5
33.6
40
34.8
32.4
30
24.2
19.9
20
14.813.8
9.6
10
7.8
7.5
10.0
0
Male
Female
Female distribution
17-24
25-34
35-44
Age distribution*
45+
White
Black
Race distribution*
•p-value <0.05. This is calculated from baseline sample (N≈2616). The calculation for race included an other category
(Native American and Asian), the baseline sample had 123 individuals (4.7%) compared to 183 (1.7%) in the Ohio National Guard.
Ohio Army National Guard
Men make up 85.2% of the sample
Men
Women
Calculated from baseline (N≈2616)
Majority of the sample is white (87.7%)
White
Non-white
Calculated from baseline (N≈2616)
Few are currently divorced,
widowed or separated (9.6%)
Married
Calculated from baseline (N≈2616)
Divorced or separated
Never married
Soldiers reported facing trauma in childhood
Percent of in-person sample who reported "moderate to severe" or "severe to
extreme"
25
20
15
10
5
0
Physical Abuse
Emotional Abuse
Physical Neglect
Sexual Abuse
Emotional Neglect
These values are from the Childhood Trauma Questionnaire (Bernstein et al. 1996) from the baseline sample of the in-person surveys (N≈500).
Each variable is determined on a 4 –point scale from “none or minimal”, “low to moderate”, “moderate to severe” and “severe to extreme”.
Presented are the percentages of those who reported “moderate to severe” and “severe to extreme” occurrences.
Childhood traumas are more frequent in women
Men
Women
Percent within subgroups of in-person sample who report "moderate to severe" or
"severe to extreme" type of abuse
40
35
30
25
20
15
10
5
0
Physical Abuse*
Emotional Abuse
Physical Neglect
Sexual Abuse*
Emotional Neglect
*p-value<0.05. These values are from the Childhood Trauma Questionnaire (Bernstein et al. 1996) from the baseline sample of the in-person
surveys (N≈500). Each variable is determined on a 4 –point scale from “none or minimal”, “low to moderate”, “moderate to severe” and “severe
to extreme”. Presented are the percentages of those who reported “moderate to severe” and “severe to extreme” occurrences.
Throughout lifetime, soldiers encounter stressful experiences
that can impact deployment and mental health (n=2616)
Family member (other than parent) had drug or alcohol problems
Been through divorce or breakup
Seen or heard physical fighting between parents or caregivers
Mental illness personally or someone close to them had mental illness
Been unemployed for at least 3 months
Lost their job
Had serious financial problems
Been robbed or home was broken into
Ever been emotionally mistreated
Parent with problem with drugs or alcohol
Experienced stressful legal problems
Had problems getting adequate healthcare
0
5
10
15
20
25
30
35
40
45
Percent of baseline sample that reported ever having experience
Wave 1 Telephone Survey. N≈2616
Mean number of type of stressors was 3.4 (min=0, max=12). These are the prevalence of occurrences ever reported in the baseline survey
32% of the baseline sample had been
deployed more than once
Average number of deployments is 1.3 (min = 0, max = 24). This is the proportion of deployment experience from baseline sample
(N≈2616)
In addition to lifetime stressors, the guard
experience trauma outside of deployment
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Ninety-one percent have experienced a
trauma at some time in their lives
This was calculated within the baseline sample (N≈2616). Traumatic events include assaultive traumatic events as well as shocking events
(e.g. car accident, natural disaster), learning about traumatic events to others, the sudden unexpected death of someone close and any other
traumatic event the participant considered traumatic
Summary of pre-deployment conditions
• In the baseline sample majority of soldiers had been deployed
at least once and the majority of those who had been
deployed more than once had prior combat experience.
• Only thirty-six percent soldiers have never been deployed.
• Overall, soldiers experience stressors, traumas as well as
psychopathologies over their lifetime that can play a role in
subsequent mental health consequences after deployment.
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What are deployment experiences?
• Have information from baseline on most recent deployment
including war trauma, self-reported preparedness, unit and
post-deployment support
• Measures were collected using the Deployment Risk and
Resilience Inventory
King, D.W., King, L.A., Vogt, D., Knight, J., Samper, R.E. (2006) Deployment Risk and Resilience Inventory: A collection of measures for
studying deployment related experience among military personnel and veterans. Military Psychology; 18(2): 89 - 120
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Ohio Army National Guard
Majority of sample (63%) have been deployed
Never deployed
Deployment experience
Calculated from baseline sample (N≈2616)
Nearly one third have had their most recent
deployment to a conflict zone
Never deployed
Calculated from baseline sample (N≈2616)
Non-conflict zone
Conflict zone
Received hostile incoming fire
Attacked by terrorists, insurgents, or civilians
Encountered land or water mines or booby traps
In a vehicle that was under fire
Saw Americans or allies after they were severely wounded or disfigured in combat
Trauma during
deployment
(n=1607)
Saw civilians after they were severely wounded or disfigured
Saw enemy soldiers after they were severely wounded or disfigured in combat
Saw the bodies of dead enemy soldiers
Fired your weapon at the enemy
Saw soldiers from enemy troops being seriously wounded or killed
Saw someone from your unit or an ally unit being seriously wounded or killed
Saw the bodies of dead civilians
Engaged in battle in which your unit suffered casualties
Saw the bodies of dead Americans or allies
Killed or thought you killed someone in combat
Received "friendly" incoming fire
Injured or wounded during combat
0
10
20
30
40
50
Percent of those who had been ever been deployed at baseline that reported
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http://www.101films.net/
Feeling prepared on most recent deployment
• Answers were scaled from 1 (strongly
disagree) to 5 (strongly agree)
Box plot of Preparedness scores
• Had supplies and equipment needed to
get my job done
• Equipment I was given functioned the
way it was supposed to
X
• Received adequate training on how to
use my equipment
• Accurately informed about what to
expect from the enemy
• Accurately informed of what daily life
would be like during my deployment
Calculated from deployment risk and resilience inventory (DRRI) among those who were ever deployed at baseline (n=1607) King, D.W.,
King, L.A., Vogt, D., Knight, J , Samper, R.E. (2006) Deployment Risk and Resilience Inventory: A collection of measures for studying
deployment related experience among military personnel and veterans. Military Psychology; 18(2): 89 - 120
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Unit support during most recent deployment
• Sense of camaraderie between myself
and other soldiers in my unit
Box plot of unit support score
• Most people in my unit were trustworthy
• Could go to most people in my unit for
help when I had a personal problem
X
• Commanding officers were interested in
what I thought and how I felt about things
• Impressed by the quality of leadership in
my unit
• My superiors made a real attempt to
treat me as a person
• I felt like my efforts really counted to the
military
Calculated from deployment risk and resilience inventory (DRRI) among those who were ever deployed at baseline (n=1607).King, D.W.,
King, L.A., Vogt, D., Knight, J., Samper, R.E. (2006) Deployment Risk and Resilience Inventory: A collection of measures for studying
deployment related experience among military personnel and veterans. Military Psychology; 18(2): 89 - 120
Post-deployment support after most recent deployment
• Reception I received when I returned
from my deployment made me feel
appreciated for my efforts
• American people made me feel at home
when I returned
Box plot of post-deployment score
X
• When I returned, people made me feel
proud to have served my country in the
Armed Forces
• People at home understand what I have
been through while in the Armed Forces
• There are people to whom I can talk
about my deployment experiences
• The people I work with respect the fact
that I am a veteran
Calculated from deployment risk and resilience inventory (DRRI) among those who were ever deployed at baseline (n=1607) King, D.W.,
King, L.A., Vogt, D., Knight, J., Samper, R.E. (2006) Deployment Risk and Resilience Inventory: A collection of measures for studying
deployment related experience among military personnel and veterans. Military Psychology; 18(2): 89 - 120
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Summary of experiences
during deployment
• Most soldiers have deployment experience and many have
faced multiple combat situations.
• While self-reports may vary, most reports of preparedness,
unit support and post-deployment support were high.
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What are our Study Findings
on Mental Health?
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Comparing…prevalence of psychopathologies
found in the general population (GP)
Lifetime %
12-Month %
GP
ONG
GP
ONG
PTSD
6.8%
9.5%
3.5%
7.2%
MDD/Depr
16.6%
21.4%
6.7%
14%
GAD
5.7%
12.4%
3.1%
9.3%
Kessler R et al. Arch Gen Psychiatry 2005;62:593-602 and 617-627.
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Majority of soldiers do not have a condition and only 8%
have co-occurring conditions within the past year
One condtion
13%
Two conditions
6%
Three conditions
2%
Noconditions
conditions
No
79%
79%
This was calculated from the baseline sample (N≈2616) using PTSD, depression and generalized anxiety disorder
ONG Gender Findings
Women
Men
PTSD past year
12.1%
6.9%
Depression past year
20.4%
12.8%
GAD past year
12.6%
8.7%
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How family and social factors predict PTSD
Demographic and
Stressful factors
Female*
Being married
High income
College education
Marital discord
Lost a job*
Posttraumatic
stress disorder
+
+
+
* p-value <0.05. High income is dichotomized by $60,000. Results are the direction of the odds ratios from multivariable logistic
models.
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How deployment stressors predict PTSD
Effect of
Self-reported factors
Posttraumatic
stress disorder
High psychosocial support
-
High levels of preparedness*
-
High levels of unit support
+
Family concerns while deployed*
+
High levels of post-deployment
support*
-
* p-value <0.05. Preparedness, unit support, family concerns, perceived threat and postdeployment support were created by splitting each
score from the median. Results are the direction of the odds ratios from multivariable logistic models.
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How deployment stressors predict PTSD
Effect of
Self-reported factors
Posttraumatic
stress disorder
High psychosocial support
-
High levels of preparedness*
-
High levels of unit support
+
Family concerns while deployed*
+
High levels of post-deployment
support*
-
* p-value <0.05. Preparedness, unit support, family concerns, perceived threat and postdeployment support were created by splitting each
score from the median. Results are the direction of the odds ratios from multivariable logistic models. Starred values represent significant
findings.
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High levels of post-deployment support reduce
the odds of developing PTSD.
“People understand what I’ve been through”
“There are people whom I can talk to about my experience”
“When I returned, people made me feel proud to serve”
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Caregiving strains families of veterans with severe injuries – USATODAY.com
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Does deployment affect
suicidal ideation?
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Two percent of soldiers reported suicidal thoughts
within the past 30 days
12
255/2508
Prevalence within baseline sample
10
8
6
4
47/2508
2
0
Lifetime suicidal Ideation
Suicidal Ideation within past 30 days
Calculated within baseline sample (N≈2616). This is “thought (they) would be better off dead, or had thoughts of hurting (themselves)” from the Patient
Health Questionnaire - 9. Kroenke K, Spitzer R. The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals 2002;32:1. Compared to
general population with a prevalence of lifetime suicidal ideation between 4.8% and 18% (cdc.gov/ncipc/wisqars)
Stressors experienced over lifespan are
associated with current suicidal ideation
5.0
4.5
Prevalence within past 30 days
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
No
Yes
* Current
income < 60,000
No
Yes
* Low social
support
No
Yes
* Parents abused
each other
*p-value <0.05. n = 2,508. Calculated with in baseline sample that answered all questions
No
Yes
* Caregivers
fought
No
Yes
* Ever unemployed
> 3 months
No
Yes
* Serious financial
problems
Deployment experience is not associated
with current suicidal ideation
Prevalence within wave 1 subgroups within the past 30
days
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Never deployed
Have been deployed
deployed
in past
3
NotNot
deployed
in past
3 yrs
years
Deployedininpast
past33yrs
Deployed
years
Among those deployed
N = 1,601
However, within those deployed, certain features of most
recent deployment predict current suicidal ideation
Prevalence of suicidal ideation within wave 1 subgroups
within the past 30 days
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
No
Yes
* High preparedness
No
Yes
* High unit support
No
Yes
* High family concerns
No
Yes
* High post deployment
support
•p-value <0.05. From the Deployment Risk and Resilience Inventory. High levels created by median split.
Calculated from baseline sample those who have been deployed (N≈1607)
No
Yes
* High combat
Interim Conclusions from Kaptur CMHI
• Overall, the ONG appear resilient to the development of
PTSD, Depression, GAD and suicidal ideation.
• However, highly vulnerable sub-groups exist within the ONG.
• Among deployed, preparedness and support predicted
resilience, whereas family concerns and amount of combat
predicted risk.
• Suicidal ideation does not appear to be associated with
deployment.
• Suicidal ideation was associated with being unmarried, low
income, low social support, physical/sexual abuse,
unemployment and financial problems.
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