Behavioral Health of Combat Veterans

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Behavioral Health of Combat Veterans (BHCV) Contributors

Stephanie McWhorter, M.A.

Shiloh E. Beckerley, M.A.

Ryan S. Darby, M.A.

Jennifer McAnany, B.S.

LCDR Katharine Shobe, Ph.D.

Cynthia J. Thomsen, Ph.D.

Gerald E. Larson, Ph.D.

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BHCV Project:

– Funded by BuMED through the Wounded, Ill, and Injured (WII) and Psychological Health/Traumatic Brain Injury (PH/TBI) programs.

– Housed at the Naval Health Research Center (NHRC), San Diego, CA.

BHCV’s Unique Capabilities1. Data relevant to behavioral health concerns exist, but in many cases have not been thoroughly analyzed. Using existing data sources will reduce the survey burden of military personnel.

2. New analyses of existing data sets, individually or in combination, can shed light on:

− Risk and protective factors for specific outcomes; − Whether particular subpopulations are differentially at risk;− Whether different factors predict outcomes across

subpopulations.

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BHCV Objectives1. Create a comprehensive electronic library of existing databases.

2. Using existing databases (individually or in combination), conduct original statistical analyses.

3. Prepare Behavioral Health Quarterly (BHQ) reports.

BHCV Objective 1Create a comprehensive electronic library of existing databases:

― Identify relevant restricted-use and public-use data sources;

― Establish data-sharing agreements with external ownership agencies;

― Obtain IRB approval and follow approved protocols for each data resource.

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Public-use data, including data from:– Service Safety Centers– Medical Surveillance Monthly Reports– Bureau of Justice Statistics– Bureau of Labor Statistics– Current Population Survey– US Census Bureau– Naval Postgraduate School

Objective 1: Databases Procured to Date

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Status of Forces Surveys from DMDC:– Active-Duty Members – Reserve Component Members – Spouses of Active-Duty Members– Spouses of Reserve Component Members– Workplace and Gender Relations– Workplace and Equal Opportunity

Databases Procured to Date, cont.

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Databases Procured to Date, cont.– 2008 DoD Survey of Health Related Behaviors

(HRB) among Active-Duty Military Personnel– Career History Archival Medical and Personnel

System (CHAMPS) – Military Deployment Records– Veterans Mortality Data, including:

1. CA and FL state death certificate data

2. National Center for Health Statistics (NCHS) multiple cause of death files

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BHCV Objective 2Using existing databases (individually or in combination), conduct original statistical analyses to:

– Examine effects of combat deployment on current service members, veterans, and their families;

– Focus on potentially sensitive outcomes.

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BHCV Objective 3Prepare Behavioral Health Quarterly (BHQ) reports:

− Review relevant research, with particular emphasis on OIF/OEF-era findings;

− Present results of new analyses of existing datasets, conducted by BHCV;

− Provide summaries of findings to date, their implications for policy and practice, and directions for future research.

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Objective 3: BHQ ReportsTo Date:

– Vol. 1, No. 1, “National Guard/Reserves: Weekend Warriors No More”

– Vol. 1, No. 2 & 3, “Women at War: A New Generation of Citizen-Soldiers”

Upcoming reports may focus on:Junior enlisted Spouses and children

NCOs Mortality

BHCV Original Analyses

Sample results from the current BHQ report, focusing on gender differences/female service members. Topics include:

– Military satisfaction and performance– Mental health– Injuries– Aggressive behavior

Trauma Experienced During Any Deployment:• I was sent outside the wire on combat patrols, convoys, or sorties.• I, or members of my unit, received incoming fire from small arms, artillery, rockets, or

mortars.• I, or members of my unit, encountered mines, booby traps, or IEDs (improvised explosive devices).• I worked with landmines or other unexploded ordinances.• My unit fired on the enemy.• I personally fired my weapon at the enemy.• I engaged in hand-to-hand combat.• I was responsible for the death or serious injury of an enemy.• I witnessed members of my unit or an ally unit being seriously wounded or killed.• My unit suffered casualties.• I saw dead bodies or human remains.• I handled, uncovered, or removed dead bodies or human remains.• Someone I knew well was killed in combat.• I took care of injured or dying people.• I interacted with enemy prisoners of war.• I witnessed or engaged in acts of cruelty, excessive force, or acts violating rules of

engagement.• I was wounded in combat.

Military and Mental Health Outcomes: Associations with Gender and Deployment

Jennifer McAnany

Military outcomes examined:

Satisfaction with military

Military productivity

Negative career events

Military satisfaction by gender, past 12 months

BHCV, 2008 SOF/AN=31,210

Controlled demographics: marital status, dependents, pay grade, race, service, education. *p<.05, **p<.01, ***p<.001

0% 10% 20% 30% 40% 50% 60% 70% 80%

MenWomen

***

***

***

***

Quality of supervisor

Quality of coworkers

Promotion opportunities

Type of work

Total compensation

Overall military way of life

BHCV, 2008 HRBN=22,767

Productivity loss by gender & combat deployment, past 12 months

Controlled demographics: marital status, dependents, pay grade, race, service, education, dual military marriage. *p<.05, **p<.01, ***p<.001

0%

10%

20%

30%

40%

50%Men Women***

******

***

NoEver combat deployed? No NoYes Yes Yes

Late for work,30 min or more

Left work early Worked below normal performance level

Negative career events by gender, past 12 months

Controlled demographics: marital status, dependents, pay grade, race, service, education, dual military marriage. *p<.05, **p<.01, ***p<.001

BHCV, 2008 HRBN=24,123

***

***

Mental health outcomes examined:Depression, anxiety, & distress

Substance use

Family problems, anger & stress management

Suicidality

Mental health concerns of members seeking care, past 12 months

BHCV, 2008 HRBN=22,946

Controlled demographics: marital status, pay grade, race, service, education, dual military marriage, age. *p<.05, **p<.01, ***p<.001

0% 4% 8% 12% 16%

MenWomen

***

***

***

***

***

***

Depression

Anxiety

Family problems

Anger management

Substance use

Stress management

Attempted suicide

Considered suicide

Mental health concerns of women seeking care by deployment trauma, past 12 months

Controlled demographics: marital status, pay grade, race, service, education, dual military marriage, age. *p<.05, **p<.01, ***p<.001

BHCV, 2008 HRBN=6,107

0% 5% 10% 15% 20% 25%

NoneLowHigh

***

**

*

***

***

***

*

Depression

Anxiety

Family problems

Anger management

Substance use

Stress management

Attempted suicide

Considered suicide

Women’s mental health issues by unwanted sexual contact

BHCV, 2008 HRBN=6,402

Controlled demographics: marital status, pay grade, race, service, education, dual military marriage, age. *p<.05, **p<.01, ***p<.001

0%

10%

20%

30%

40%

50%

None (N=3,823)

Premilitary only (N=1,742)

Military only (N=578)

Both premilitary and military (N=259)

Someone made or pressured you to have unwanted sexual contact.

******

******

PTSD symptoms(past 30 days)

Depression(past week)

Psychological distress(past 12 months)

Hazardous alcohol use(past 12 months)

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ConclusionsMilitary Life

― Women and all members who have been combat deployed are less satisfied with the military.

― Women report more lost productivity but fewer negative career events.

Mental Health― Women seek more mental health care.― Women with deployment trauma seek more mental

health care and report more suicidal ideation/attempts.― Women who experienced unwanted sexual contact

(versus not) report more mental health concerns.

Issues addressed:Impact of injuries on military readinessInjury rates by gender and service branchRecommendations for reducing injuries

Combat Deployment and Injury among Military Women

Shiloh Elizabeth Beckerley, M.A.

Controlled demographics: gender***, race, rank***, service**, education, marital status, dependents***.***p<.001, for all contrasts except contrast between the middle two categories.

BHCV, 2008 HRB N=21,096

44%

33%

32%

22%

0% 10% 20% 30% 40% 50%

Injured 3 times

Injured 2 times

Injured 1 time

Never injured

***

Percent of female AD members unable to deploy by self-reported injuries, past 12 months

14%

14%

11%

11%

31%

24%

20%

19%

0% 10% 20% 30% 40% 50%

Injured 3 times

Injured 2 times

Injured 1 time

Never injured

Unlikely Very unlikely

Controlled demographics: gender**,race***, rank***, service**, education***, marital status***, dependents***. **p<.01, ***p<.001

BHCV, 2008 HRB N=21,096

**

Percent of female AD members unlikely to stay on AD service by injuries, past 12 months

Male Female Male Female Male Female Male FemaleNavy . Air Force . Army . USMC

0%

10%

20%

30%

40%

50%

60%

22% 23% 21% 24% 24% 25% 25%29%

6%7%

6%6%

10%14%

9%

12%

5%7%

5%

7%

11%

14%

7%

14%

3 serious injuries2 serious injuries1 serious injury

Injuries by gender & service, past 12 months

Controlled demographics: gender**,race***, rank***, service***, education***, marital status*, dependents***. *p<.05, **p<.01, ***p<.001 for all service contrasts except Navy vs. Air Force.

BHCV, 2008 HRB N=24,690

***

*** ***

****

Female AD members’ injuries by service & injury cause, past 12 months

Controlled demographics, other injury/unit training injury: gender -/**,race, rank**/**, service***/***, education-/**, marital status-/***, dependents. **p<.01, ***p<.001

BHCV, 2008 HRB N=24,690

13%

13%

14%

14%

16%

21%

16%

23%

3%

4%

3%

4%

4%

9%

4%

9%

2%

3%

1%

3%

3%

8%

3%

8%

0% 10% 20% 30% 40% 50%

Other injury

Unit training injury

Other injury

Unit training injury

Other injury

Unit training injury

Other injury

Unit training injury

Na

vyW

om

en

.

Air

Fo

rce

Wo

me

n.

Arm

yW

om

en

.U

SM

CW

om

en

1 injury 2 injuries 3+ injuries

***

***

***

***

***

19%

18%

15%

13%

26%

23%

29%

32%

10%

13%

11%

13%

7%

12%

12%

10%

0% 10% 20% 30% 40% 50%

AD

NG/R

AD

NG/R

AD

NG/R

AD

NG/R

Nav

yW

omen

Air

For

ceW

omen

Arm

yW

omen

US

MC

Wom

en

On-duty injury

Off-duty injury

***

Female AD members’ use of medical care by on- versus off-duty injuries, past 12 months

Controlled demographics: gender**,race***, rank***, service***, education, marital status, dependents***, component***. ***p<.001. NG/R > AD; USMC & Army > Navy & USAF. Service contrasts in when injury occurred, all contrast significant at p<.001 except USMC vs. Army.

BHCV, 2008 SOF/A&R N=27,265

Controlled demographics: gender**,race*, rank***, service**, education***, marital status***, dependents***. *p<.05, **p<.01, ***p<.001 for all service contrasts except USMC vs. Army

BHCV, 2008 HRB N=24,482

2.7 2.93.8

3.3

1.72.0

2.8

2.5

0

1

2

3

4

5

6

7

Navy Air Force Army USMC

Vigorous exercise

Moderate exercise

***

Female AD members’ average hours of exercise per week, past 12 months

Type of Injury– Primary cause of injury: running/jogging

outdoors:– Reported by 41% of men, 55% of women– Typically occurred during unit physical training

– 65% of women’s injuries were to lower extremities (most commonly, knee injury).

– Majority of injuries result from overuse, typically due to volume overload.

BHCV, 2008 SOF/A N=2,393

15%

25%

35%

Less than 1 hr 1-2 hrs 2-3 hrs 3-5 hrs Over 5 hrs

Controlled demographics (unit training/other): gender*/***,race, rank***/***, service***/***, education***/*, marital status***/-, dependents***/-. *p<.05, ***p<.001

BHCV, 2008 HRB N=24,480

*** Unit training injury

*** Other injury

Hours of vigorous exercise per week

Percent of female AD members injured 1+ times by average weekly exercise & injury cause, past 12 months

% in

jure

d at

lea

st 1

tim

e

Recommendations– Reduce high mileage running volume, particularly

for those who are the least fit.

– Gradually increase running distance.

– Structure PT so that it accommodates all fitness levels, e.g., run for time rather than distance.

– Replace some distance runs with interval running.

– Allow adequate recovery time.

Gender, Deployment, and Aggressive Behavior

Ryan Darby, M.A.

Rates of self-reported physical aggression byDeployment traumaGender of service memberTarget of aggression (spouse, child, other)

I hit my spouse, live-in fiancé, boyfriend or girlfriend, or the person I date.

Controlled demographics: race***, rank***, service, education***, marital status, dependents. *p<.05, **p<.01, ***p<.001

No Trauma Some Trauma High Trauma0%

1%

2%

3%

4%

5%

6%

FemaleMale

******

***

BHCV, 2008 HRBN=22,148

Deployment trauma & intimate partner violence

I hit my child(ren) for a reason other than discipline (spanking).

Controlled demographics: race***, rank***, service, education**, marital status. *p<.05, **p<.01, ***p<.001

No Trauma Some Trauma High Trauma0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

FemaleMale***

***

BHCV, 2008 HRBN=22,266

Deployment trauma & child abuse

I hit someone other than a member of my family.

BHCV, 2008 HRBN=22,130

Controlled demographics: race***, rank***, branch**, education***, marital status***, dependents***. *p<.05, **p<.01, ***p<.001

No Trauma Some Trauma High Trauma0%

2%

4%

6%

8%

10%

12%

FemaleMale

***

******

**

Deployment trauma & general violence

No

inte

ract

ion

Inte

ract

ed

No

inte

ract

ion

Inte

ract

ed

No

inte

ract

ion

Inte

ract

ed

Hit Spouse Hit Child Hit Other

-5%

0%

5%

10%

15%Female Male

Aggression by interaction with enemy POWs

Controlled demographics: marital status, dependents, pay grade, race, service, education, dual-military marriage. *p<.05, **p<.01, ***p<.001

BHCV, 2008 HRBN’s=7,747 -14,768

I interacted with enemy prisoners of war during deployment.

***

***

***

******

***

***

Gender, deployment, & aggressive behaviors: Conclusions Gender differences:

– Women are more likely to report intimate partner violence.

– Men are more likely to report extra-familial aggression.

Deployment trauma:– Associated with increases in all types of

violence.– May have greater effects on child abuse and

intimate partner violence for women than men.

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BHCV’s Ongoing Work

Applications for use of additional data resources, including:

1. Defense Incident-Based Reporting System (DIBRS)

2. CDC programs, e.g., Behavioral Risk Factor Surveillance System (BRFSS)

Analysis of associations between military personnel actions, deployment history, medical inpatient and outpatient records.

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– Creation of veterans’ mortality database.– Examination of veterans mortality data

using recently acquired CA and FL data.– Preparation of reports expanding on

selected BHQ results for possible publication.

– Pursuing possible collaborations with other groups.

BHCV’s Ongoing Work, cont.

Questions or comments?