Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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Impact of Combat on the Mental Health and Well-Being of Soldiers and Marines

7 Things I Think I Know

Colonel Carl A. CastroDirector, Military Operational Medicine

Research Program

Smith College School for Social WorkCombat Stress: Understanding the Challenges,

Preparing for the Return Northampton, New Hampshire

26-28 June 2008

Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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• Born in Kansas City, Missouri• Enlisted as an infantryman in the U.S. Army at the age of 17• Obtain BA from Wichita State University and MA and PhD from the University of Colorado (major psychology)• Entered active duty as a psychologist in 1989• Served on deployments to Bosnia (1998), Kosovo (2000, 2002), and Iraq (2003, 2006)• Authored, co-authored around 100 publications• Promoted to colonel in FEB 2007• Serves on several NATO, TTCP panels• Just started a new job as Director of Military Operational Medicine, Fort Detrick, Maryland• Areas of research interest include:

- Impact of combat and operations on mental health and well-being of Soldiers and Families- Development of validated mental health training instrument and procedures to facilitate effective adaptation and growth- Junior Leader development and their role in facilitating mental health and well-being in subordinates

Biography of Colonel Castro

Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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1. Combat impacts the mental health and well-being of Soldiers and Marines.

Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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Prevalence of PTSD

% PTSD

5.0

14.6

02468

1012141618

Pre-OIF Post-OIF (3 months)n = 2,414 n = 3,781

• There is a 3-fold increase for U.S. Soldiers screening positive for PTSD when assessed 3 months after returning from a year in Iraq.

Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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% PTSD

18.8

29.7

19.9 17.7

7.8 9.7 8.1 9.5

05

10152025303540

Firefights High Combat Perceiveddanger

Dissociation

Yes vs. No

Firefights, high combat, high perceived danger, & dissociative experiences increased PTSD risk.

Combat-related Risk Factors & PTSD

Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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Anger and Aggressive Behaviors

Got angry with someone and kicked or smashed something, slammed the door, punched the wall, etc.

Got into a fight with someone and hit the person

Percent one or more times

Got angry with someone and yelled or shouted at them

Threatened someone with physical violence

22

40

46

81

19

36

42

77

11

31

37

75

0 20 40 60 80 100

pre-OIF

3 mth PostOIF12 mth PostOIF

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2. Not all Soldiers are at equal risk for mental health problems.

Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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Combat Experiences: Combat vs. Support

9%

6%

15%

53%

57%

57%

68%

21%

21%

42%

80%

90%

87%

87%

0% 20% 40% 60% 80% 100%Happened At Least Once

CombatCS/CSS

Hand-to-hand fighting

Got shot at

Was attacked or ambushed

Saw dead bodies

Knew somebody injured/killed

Killed enemy combatants

IED exploded nearby

• Soldiers in combat units experienced more combat-related events than Soldiers in combat support (CS) and combat service support (CSS).

Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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Mental Health Status By Unit Types

Any Behavioral Health Problem (PTSD, Depression or Anxiety)

14.49.9

7.5 6.7

16.8 16.7

6.1

13.4

0

10

20

30

40

Combat Arm

s

ENG/EODMP/M

I

Signal

Civil A

ffairs

Transp

ortatio

n

Support

Medica

l

Perc

ent S

cree

ning

Pos

itive

• Soldiers were more likely to screen positive for a mental health problem if they were in a combat arms unit, engineer, transportation, or support unit than Soldiers in other types of units.

Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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The Frontline in Iraq

• Soldiers were divided into low, medium and high combat based on frequency of combat events during the deployment.• Soldiers with higher levels of combat were more likely to screen positive for anxiety, depression, or PTSD, indicating that all Soldiers are NOT at the same level of risk for a mental health problem.

5 58

118 8

1417

12

2830

13

0

5

10

15

20

25

30

35

Anxiety Depression PTSD Any Mental HealthProblem

Perc

ent S

cree

ning

Pos

itive

Low Combat Medium Combat High Combat

Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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3. Leadership is important for maintaining Soldier mental health.

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Leadership and Mental Health

Adjusted R Square = .15 and the Chi Square is significant at the .01 level

• Soldiers with high perceptions of Leadership were less likely to screen positive for a mental problem (PTSD, Depression or Anxiety) compared to those Soldiers with low perceptions of leadership.

28

11

0

10

20

30

40

50

LowLeadership

HighLeadership

Percent Screened Positive for any mental health problem

20

5

36

17

0

10

20

30

40

50Low Combat/Low LeadershipLow Combat/High LeadershipHigh Combat/Low LeadershipHigh Combat/High Leadership

Percent Screened Positive for any mental health problem

Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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Battlemind Training as an Example

• Battlemind Training is mental health training focused on the development of skills, involving self-aid, buddy aid, and leadership.

• Battlemind Training involves:– Evidence-based: Built on findings from the Land Combat

Study. Validated through research.– Experience-Based: Uses examples that Soldiers can relate to.– Strengths-based: Builds on existing Soldier strengths and

skills – rejects a deficit or illness model.– Training: Focuses on skill development – not education.– Explanatory: Highlights conflicted/misunderstood reactions.– Team-based: Self awareness through helping buddy.– Action-Focused: Discusses specific actions to guide Soldier

behavior.

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4. Mental health training works.

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Soldier Attitudes: Training Utility

• Battlemind Training had high ratings.

50.559.4

48

35.745.5

33.623.4

29.1 26.6

0

20

40

60

80

100

The discussion mademe realize that I had

learned a lot from mydeploymentexperiences

The discussion wasuseful because I

realized my reactions tothe deployment were

normal

It was helpful to hearwhat others have to sayabout their experiences

in Iraq

% A

gree

Small BMTLarge BMTStress Ed

Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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Battlemind Training: PTSD & Depression

-4

-1

2

5

8

11

14

17

20

23

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Combat Exposure: Events Experienced

PC

L C

hang

e S

core

Small BMT Stress Ed Large BMT

• Soldiers who received Battlemind Training (BMT) (p < .01) reported fewer PTSD symptoms at 3 months post-deployment compared to Soldiers who received the standard stress education training.

• Depression symptoms for Soldiers who received BMT were only marginally significantly lower than for Soldiers who received stress education (p < .10).

-2.0

0.0

2.0

4.0

6.0

8.0

10.0

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Combat Exposure: Events Experienced

Dep

ress

ion

Cha

nge

Sco

re

BMT Stress Ed

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Battlemind Training: Stigma & Sleep

2.00

2.20

2.40

2.60

2.80

3.00

3.20

3.40

3.60

3.80

4.00

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Combat Exposure: Events Experienced

Stig

ma

BMT Stress Ed

• Soldiers who received Battlemind training reported less psychological stigma at 3 months post-deployment compared to Soldiers who received the standard stress education training (p < .01).

• Soldiers who received Battlemind training also reported fewer sleep problems than Soldiers who received the standard stress education training (p < .01).

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Combat Exposure: Events Experienced

Pro

babi

lity

of S

leep

P

robl

ems

BMT Stress Ed

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Battlemind Training System: Deployment Cycle

AlertTransition to Post-Conflict

Battlemind AARPsychological Debriefing

Continuing the Transition Home

Battlemind Training II

PDHRA BattlemindBrief and DVD

Transitioning from Combat to Home

Post-Deployment Battlemind

Battlemind AARPsychological Debriefing

Pre-Deployment Battlemind For:LeadersJunior EnlistedHelping Professionals

Spouse/Couples Pre-Deployment Battlemind

Tough Facts about Combat

and what leaders can do to mitigate risk and build confidence

Battlemind Training ISpouse/Couples Post-Deployment Battlemind

Preparing for a Military Deployment

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5. Mental health “re-setting” following a year-long combat tour takes more than 12 months.

Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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High Performing Soldiers with Mental Health Symptoms Returning to Iraq

6.45.0

9.37.9 7.9

12.9

17.1

12.0

17.0

23.2

6.3

11.5

0

5

10

15

20

25

30

Depression Anxiety PTSD Any MHProblem

Perc

ent

pre-OIF3 mth Post OIF12 mth Post OIF

(Castro & Hoge, 2005)

• Soldiers’ mental health status does not “re-set” after 12 months following return from a combat tour.

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6. Longer and multiple deployments are likely to lead to more mental health issues.

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Soldier Multiple Deployments

• Soldiers deployed to Iraq more than once were more likely to screen positive for a mental health problem than first-time deployers.

15 1724 27

0

10

20

30

40

50

Acute Stress (PTSD scale) Any Mental Health Problem

Per

cent

Scr

eeni

ng P

ositi

ve

OIF First time DeployersOIF Multiple Deployers

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Soldier Deployment Length

• Soldiers deployed longer than 6 months were more likely to screen positive for a mental health problem than those deployed for 6 months or less.

12 1519 22

0

10

20

30

40

50

Acute Stress Any Mental Health Problem

Per

cent

Scr

eeni

ng P

ositi

ve Deployed 6 months or lessDeployed more than 6 months

Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel

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7. Every combat Soldier (and Marine) will face moral and ethical challenges.

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Torture should be allowed in order to gather important info about insurgents

Torture should be allowed if it will save the life of a Soldier/Marine

All non-combatants should be treated as insurgents

• Treatment of non-combatants and views on torture

24

39

44

17

38

25

36

41

17

47

0 20 40 60 80 100

Percent Agree/Strongly Agree

2006 OIFSoldiers

2006 OIFMarines

I would risk my own safety to help a non-combatant in danger

All non-combatants should be treated with dignity and respect

Battlefield Ethics: Attitudes

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Physically hit / kicked non-combatant when it was not necessary

Damaged / destroyed Iraqi property when it was not necessary

Insulted/cursed at non-combatants in their presence

Members of unit ignore ROEs in order to accomplish the mission

• Treatment of Noncombatants and ROEs

7

9

7

12

30

5

8

4

9

28

0 20 40 60 80 100

Percent Reporting One or More Times

2006 OIFSoldiers

2006 OIFMarinesMembers of unit modify ROEs in order to

accomplish the mission

Battlefield Ethics: Behaviors

Soldiers and Marines who report better officer leadership are more likely to follow the ROE.

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unnecessarily destroying private property

injuring or killing an innocent non-combatant

mistreatment of a non-combatant

violating ROEs

30

34

35

32

33

40

43

47

46

46

50

55

0 50 100

Percent Agree or Strongly Agree

2006 OIFSoldiers

2006 OIFMarines

stealing from a non-combatant

I would report a unit member for:

not following general orders

Battlefield Ethics: Reporting

“We prefer to handle things within the unit; would only turn someone in if it put the safety of unit members in jeopardy.”

---Junior NCO

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Received training that made it clear how I should behave toward non-combatants.

Training in proper treatment of non-combatants was adequate.

Received training in the proper treatment of non-combatants.

31

67

81

83

87

28

71

78

82

86

0 20 40 60 80 100Percent Agree or Strongly Agree

2006 OIFSoldiers

2006 OIFMarines

Encountered ethical situations in Iraq in which I did not know how to respond.

• Although Soldiers and Marines reported receiving adequate battlefield ethics training, over one quarter reported encountering situations in which they didn’t know how to respond.

NCOs and Officers in my unit made it clear not to mistreat non-combatants

Battlefield Ethics: Training

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• Soldiers who screened positive for a mental health problem or who had high levels of anger were twice as likely to engage in unethical behavior on the battlefield compared to those Soldiers who screened negative or who had low levels of anger.

• Soldiers with high levels of combat were more likely to engage in unethical behaviors than Soldiers with low levels of combat.

Physically hit / kicked non-combatant when it was not necessary

Insulted/cursed at non-combatants in their presence

7

16

40

3

7

25

0 20 40 60 80 100

Percent Reporting One or More Times

ScreenedNegative

ScreenedPositive

• The relationship between mental health and unethical behavior holds even when controlling for anger.

• These findings indicate the need to include Battlefield Ethics awareness in all mental health counseling and anger management courses.

Damaged and/or destroyed Iraqi private property when it was not necessary

Soldier Mental Health, Combat and Ethics

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Point of Contact

COL Carl CastroDirector, Military Operational Medicine Research

Program, Fort Detrick, MDcarl.castro@us.army.mil