Invisible Wounds of War: Invisible Wounds of War: PTSD and Depression Over TimePTSD and Depression Over Time

Terry Schell(with Grant Marshall, Terri Tanielian, Lisa Jaycox & Jeremy Miles)

2 10/2012

Sampling MethodsSampling Methods

Data collection was sponsored by California Data collection was sponsored by California Community Foundation; NIH has funded secondary Community Foundation; NIH has funded secondary analyses of these data (R01MH087657)analyses of these data (R01MH087657)

Was conducted independent of the DoD and VAWas conducted independent of the DoD and VA

Respondents were sampled using Random Digit Respondents were sampled using Random Digit Dialing within 24 geographic regionsDialing within 24 geographic regions

Residences were screened for individuals who had Residences were screened for individuals who had deployed for OEF/OIFdeployed for OEF/OIF

Respondents were given incentives to participateRespondents were given incentives to participate

Baseline data collection occurred in Late 2007 and Baseline data collection occurred in Late 2007 and early 2008early 2008

3 10/2012

Analytic WeightsAnalytic Weights

Final baseline sample of 2120 service members Final baseline sample of 2120 service members previously deployed to OEF/OIFpreviously deployed to OEF/OIF

TheThe Invisible Wounds of War Invisible Wounds of War RAND report was based RAND report was based on a preliminary data set from this study that had on a preliminary data set from this study that had approximately 200 fewer respondentsapproximately 200 fewer respondents

The analytic sample is weighted to be representative The analytic sample is weighted to be representative of the total previously-deployed force on branch of of the total previously-deployed force on branch of service, and within each branch on age, gender, service, and within each branch on age, gender, marital status, rank, separation status, and reserve marital status, rank, separation status, and reserve component. component.

4 10/2012

Follow-up SampleFollow-up Sample

Surveys conducted about 18 months after first wave Surveys conducted about 18 months after first wave

Follow up sample N = 1010Follow up sample N = 1010

Re-interviewed 88% of those who could be contacted Re-interviewed 88% of those who could be contacted at the baseline number, but the majority of at the baseline number, but the majority of participants had moved in the intervalparticipants had moved in the interval

Unweighted follow-up sample is highly representative Unweighted follow-up sample is highly representative of the baseline sampleof the baseline sample

Attrition weights create a close match to the weighted Attrition weights create a close match to the weighted baseline sample on almost all variables, including baseline sample on almost all variables, including rates of PTSD, Depression, TBI, and trauma exposure rates of PTSD, Depression, TBI, and trauma exposure

31% of respondents deployed in between the two 31% of respondents deployed in between the two surveyssurveys

5 10/2012

Approximately 1 in 6 Had a Approximately 1 in 6 Had a Current Probable Diagnosis at Wave 1Current Probable Diagnosis at Wave 1

No mental health No mental health conditioncondition

83.5%83.5%

11stst Wave Wave

Depression OnlyDepression Only 3.7 %3.7 %

PTSD OnlyPTSD Only 4.0 %4.0 %

BothBoth 8.8 %8.8 %

16.5%16.5%

6 10/2012

Who Develops Post-Deployment Mental Who Develops Post-Deployment Mental Health Problems?Health Problems?

The mental health outcomes were very well predicted by the The mental health outcomes were very well predicted by the available variablesavailable variables

Multivariate regression models found several subgroups at Multivariate regression models found several subgroups at high risk:high risk:

Army, Separated, Enlisted, Hispanic Ethnicity, Female, Army, Separated, Enlisted, Hispanic Ethnicity, Female, Trauma ExposedTrauma Exposed

Very similar partial relative risk ratios observed when Very similar partial relative risk ratios observed when predicting PTSD and Depression outcomespredicting PTSD and Depression outcomes

Several factors often assumed to be important were not Several factors often assumed to be important were not significant in the multivariate models: significant in the multivariate models:

number of deployments, length of deployments, total number of deployments, length of deployments, total deployment time, time since deploymentdeployment time, time since deployment

7 10/2012

Trauma Exposure Was Trauma Exposure Was Common During DeploymentCommon During Deployment

The study assessed deployment trauma with a 0-11 scale The study assessed deployment trauma with a 0-11 scale counting the different types of traumatic events that occurred counting the different types of traumatic events that occurred during any prior deployment, e.g.,:during any prior deployment, e.g.,:

Friend was seriously wounded or killed 50%

Witnessing serious accident 44%

Seeing dead/injured non-combatants 44%

Smelling decomposing bodies 36%

Injured not requiring hospitalization 23%

Being physically moved by an explosion 22%

Having a bump or blow to the head 17%

Injured requiring hospitalization 10%

Killing a civilian 5%

8 10/2012

Trauma Exposure is the Primary Risk FactorTrauma Exposure is the Primary Risk Factor

The range of covariate-adjusted, relative risk between the The range of covariate-adjusted, relative risk between the highest and lowest trauma exposure categories is very large.highest and lowest trauma exposure categories is very large.

25-fold increase in risk for PTSD, 25-fold increase in risk for PTSD,

23-fold increase in risk for Depression23-fold increase in risk for Depression

Prevalence among individuals reporting none of the 11 Prevalence among individuals reporting none of the 11 deployment traumas were at or below the rates found in the deployment traumas were at or below the rates found in the general US population. general US population.

RRR’s for deployment trauma are virtually unchanged in RRR’s for deployment trauma are virtually unchanged in bivariate and multivariate modelsbivariate and multivariate models

9 10/2012

Prevalence of Mental Health Problems by Prevalence of Mental Health Problems by Prior Deployment Trauma ExposurePrior Deployment Trauma Exposure

Trauma CategoryProbable

PTSDProbably

MDDEither

No Reported Trauma (N= 537) 1% 3% 4%

Medium Trauma (N=1115) 8% 8% 13%

High Trauma (N= 468) 38% 33% 40%

Medium Trauma = experienced 1 - 4 trauma typesHigh Trauma = experienced 5 - 11 trauma types

10 10/2012

Trauma Exposure Shows a Regular Dose-Trauma Exposure Shows a Regular Dose-Response Relationship with MH SymptomsResponse Relationship with MH Symptoms

Model: SX = b(covariates) + bModel: SX = b(covariates) + b11ff11 + + bb22ff22 + … + … ++ bbnnffnn

where Q is estimated at .30. where Q is estimated at .30.

QQ Q

11 10/2012

Implications of Deployment TraumaImplications of Deployment Trauma

The substantial majority of PTSD and Major The substantial majority of PTSD and Major Depression cases in this population can be Depression cases in this population can be attributed to deployment traumaattributed to deployment trauma

The was no significant evidence that general The was no significant evidence that general deployment stressors (time deployed, number deployment stressors (time deployed, number of cycles) play a significant role in the etiology of cycles) play a significant role in the etiology of either disorder controlling for traumaof either disorder controlling for trauma

Initial exposure to a given deployment trauma Initial exposure to a given deployment trauma type poses the greatest incremental risk for type poses the greatest incremental risk for mental health symptomsmental health symptoms

12 10/2012

How Do Military Mental How Do Military Mental Health Problems Change Over Time?Health Problems Change Over Time?

Most longitudinal civilian studies show gradual Most longitudinal civilian studies show gradual improvement of PTSD symptoms following improvement of PTSD symptoms following traumatrauma

Studies of Vietnam era veterans have shown Studies of Vietnam era veterans have shown relatively stable rates over time, with minimal relatively stable rates over time, with minimal aggregate improvementaggregate improvement

In contrast, two published longitudinal studies In contrast, two published longitudinal studies on service members deployed to OEF/OIF have on service members deployed to OEF/OIF have shown increases in symptoms over timeshown increases in symptoms over time

13 10/2012

Approximately 1 in 5 Had a Approximately 1 in 5 Had a Current Mental Health Condition at Wave 2Current Mental Health Condition at Wave 2

No mental health No mental health conditioncondition

83.5%83.5%

No mental health No mental health conditioncondition

80%80%

11stst Wave Wave 22ndnd Wave Wave

Depression OnlyDepression Only 3.7 %3.7 % 5.6 %5.6 %

PTSD OnlyPTSD Only 4.0 %4.0 % 5.5 %5.5 %

BothBoth 8.8 %8.8 % 8.9 %8.9 %

16.5%16.5% 20.0%20.0%

14 10/2012

Probable Diagnoses Are Probable Diagnoses Are Relatively Stable Over TimeRelatively Stable Over Time

Probable DiagnosesProbable Diagnoses T1T1 T2 T2 Either Either

T1 or T2T1 or T2

Any PTSDAny PTSD 12.8%12.8% 14.4%14.4% 19.0%19.0%

Any MDDAny MDD 12.5%12.5% 14.5%14.5% 19.8%19.8%

Either PTSD or MDDEither PTSD or MDD 16.5%16.5% 20.0%20.0% 24.8%24.8%

Of those with some probable diagnosis at T1, Of those with some probable diagnosis at T1, 71% continued with some diagnosis at T271% continued with some diagnosis at T2

Of those without any probable diagnosis at T1, Of those without any probable diagnosis at T1, 10% developed a new diagnoses10% developed a new diagnoses

About 41% of T2 cases are “new”About 41% of T2 cases are “new”

15 10/2012

Mental Health Problems Increase Over TimeMental Health Problems Increase Over Time

The odds of having a probable mental health problem The odds of having a probable mental health problem increased over time, Odds Ratio = 1.25 [1.03, 1.50 ] per year increased over time, Odds Ratio = 1.25 [1.03, 1.50 ] per year

The increase was not significantly associated with:The increase was not significantly associated with:

Whether individual deployed between surveysWhether individual deployed between surveys

Length of time they were home since last deploymentLength of time they were home since last deployment

This pattern is slightly different than found in other studiesThis pattern is slightly different than found in other studies

Civilian traumatized samples usually show declines in Civilian traumatized samples usually show declines in symptoms over time symptoms over time

The rate of increase is considerably smaller than was The rate of increase is considerably smaller than was found when comparing PDHA and PDHRA datafound when comparing PDHA and PDHRA data

16 10/2012

Service Members Prefer Talk TherapiesService Members Prefer Talk Therapies

About half of those with a probably diagnosis sought help in About half of those with a probably diagnosis sought help in the last yearthe last year

About half of those who sought help received some sort of About half of those who sought help received some sort of treatmenttreatment

Service members were about 3x more likely to seek care from Service members were about 3x more likely to seek care from a mental health specialist (MHS) than from a primary care a mental health specialist (MHS) than from a primary care physician (PCP), 14% vs 5% of the sample.physician (PCP), 14% vs 5% of the sample.

Visit length and frequency is consistent with the view that Visit length and frequency is consistent with the view that MHS are delivering talk therapies and PCPs pharmacotherapyMHS are delivering talk therapies and PCPs pharmacotherapy

Among those who sought help, care received from mental Among those who sought help, care received from mental health specialist was rated as more helpful than either care health specialist was rated as more helpful than either care from PCPs or pharmacotherapy.from PCPs or pharmacotherapy.

17 10/2012

Overall ConclusionsOverall Conclusions

Cross sectional studies are likely to underestimate the Cross sectional studies are likely to underestimate the number of individuals who will have mental health number of individuals who will have mental health problems subsequent to combat exposureproblems subsequent to combat exposure

Mental health problems, including Depression, appear to Mental health problems, including Depression, appear to be trauma-related and service-connected rather than a be trauma-related and service-connected rather than a product of pre-existing problemsproduct of pre-existing problems

The peak demand for mental health services in this The peak demand for mental health services in this population may be several years in the futurepopulation may be several years in the future

Meeting this demand may require a substantial expansion Meeting this demand may require a substantial expansion of our capacity to deliver evidence-based talk therapiesof our capacity to deliver evidence-based talk therapies

18 10/2012