Military Psychiatry Branch, Walter Reed Army Institute of Research

Bereavement and Physical Health Outcomes in U.S. Soldiers Returning from Combat

LCDR Robin L. Toblin, Mr. Brian Kok, Dr. Lyndon A. Riviere, & COL Charles W. Hoge (ret.)

Military Psychiatry BranchCenter for Military Psychiatry and Neuroscience

Walter Reed Army Institute of ResearchJune 18, 2011

The views expressed here are those of the authors and do not represent the views of the Department of the Army or the Department of Defense.

Military Psychiatry Branch, Walter Reed Army Institute of Research

Post-War Physical Health

• Physical, cognitive, psychological symptoms, occupational/ social impairment reported after virtually every war

• Predictors of physical health outcomes for current wars focus on “signature injuries”– Concussion/mild traumatic brain injury (mTBI), post-

traumatic stress disorder (PTSD) • Few recent studies examine basic prevalence of post-

war physical health problems• Few studies examine risk factors except mTBI, PTSD

Military Psychiatry Branch, Walter Reed Army Institute of Research

Bereavement as Potential Risk Factor

• Bereavement predicts negative health outcomes– Includes physical health, functional impairment – Independent from PTSD, depression

• Direct exposure to trauma worsens grief • 80% of soldiers returning from Iraq knew someone

seriously injured or killed• Over 25% had buddy shot or hit near them• Losing team member in combat – like losing close family• Health impact of bereavement in current wars – virtually

no research

Military Psychiatry Branch, Walter Reed Army Institute of Research

Goals of the Study

• Identify the prevalence of post-deployment physical health concerns in Army soldiers after their return from combat duty in Iraq and Afghanistan

• Examine the unique contribution of difficulty coping with bereavement on physical health

Military Psychiatry Branch, Walter Reed Army Institute of Research

Study Population

• Part of a larger study of the impact of combat • Three U.S. infantry brigades • November, December 2008• Six months post- Iraq deployment• 50% available during recruitment phase• 86% response rate• 2064 soldiers completed the survey

– 1532 reported being deployed to Iraq or Afghanistan for at least one month

– 10 excluded for moderate or severe TBI to isolate specific contribution of mild TBI/concussion

• Final sample = 1522

Military Psychiatry Branch, Walter Reed Army Institute of Research

Measures – Exposure Variables

• Combat experiences– 34 items, dichotomized into “at least

once” / “never”, summed, divided into quartiles

• Injury – No injury, non-mTBI injury, mTBI with

alteration, but no loss of consciousness (AOC), mTBI with loss of consciousness (LOC)

• Adverse childhood experiences– Parent with alcohol problems, parent

with mental illness, emotional abuse, physical abuse (range: 0–4).

• Alcohol misuse – Two-Item Conjoint Screen (TICS):

Drank more than meant to; wanted to cut down

• Depression – Patient Health Questionnaire–9

(PHQ–9)

• PTSD – PTSD Checklist (PCL)

• Bereavement

Military Psychiatry Branch, Walter Reed Army Institute of Research

Measure for Bereavement

• “In the past month, how much have you experienced difficulty coping with grief over the death of someone close?”

• Responses: “not at all”, “a little bit”, “moderately”, “quite a bit”, “extreme”

• Any positive response categorized as having difficulty coping with bereavement

Military Psychiatry Branch, Walter Reed Army Institute of Research

Measure – Outcome Variables

• Physical/somatic symptoms (PHQ–15) in past month: “not bothered at all,” “bothered a little,” and “bothered a lot”– High score = ≥15

• Self-rated overall health: “excellent,” “very good,” “good,” “fair,” “poor”

• Missed work days in the past month• Medical utilization (i.e., # “sick call” visits) in past month• Physical impairment of important military requirements:

“not at all” to “extreme”– Difficulty carrying a heavy load – Difficulty performing physical training (PT)

Military Psychiatry Branch, Walter Reed Army Institute of Research

Analysis

• Examined prevalence of six main outcomes, physical health symptoms

• Prevalence rates, Kruskal-Wallis c2, c2 tests for trend – Association b/w bereavement severity, outcomes

• Multiple logistic regression – Examine unique contribution of bereavement to six

health outcomes– Control for demographics, combat experiences,

injuries, mental health factors

Military Psychiatry Branch, Walter Reed Army Institute of Research

Results- Demographics

• Male: 92% • Age < 30: 73% • Married: 56% • High school or less: 50% • Junior enlisted (E1-E4): 56%

Military Psychiatry Branch, Walter Reed Army Institute of Research

Prevalence of Physical Health Symptoms

• “Bothered a lot” by ≥ 1 symptom: 63.4%• Most common health symptoms– Sleep problems: 32.8%– Musculoskeletal pain: 32.7%– Fatigue: 32.3%– Back pain: 28.1%– Headaches: 16.2%

Military Psychiatry Branch, Walter Reed Army Institute of Research

Prevalence of Outcome Variables

• ≥2 medical visits/past month: 30.0%• Self-reported poor health: 28.1%• Difficulty performing PT: 26.7%• Difficulty carrying a heavy load: 24.1%• High symptom score on somatic scale: 9.7%• ≥2 days missed work/past month: 9.7%

Military Psychiatry Branch, Walter Reed Army Institute of Research

Prevalence of Difficulty Coping with Bereavement

Overall A little bit Moderate Quite a bit Extreme0

5

10

15

20

25

21.3

9.3

5.12.8

4.8

Bereavement Severity

Prev

alen

ce

Military Psychiatry Branch, Walter Reed Army Institute of Research

Prevalence of Symptoms for Soldiers Having Difficulty Coping with Grief

• Poor overall health: 49.7%– Irritability: 62.3%– Fatigue: 58.1%– Sleep problems: 55.4%– Musculoskeletal pain: 49.7%– Back pain: 41.3%

Military Psychiatry Branch, Walter Reed Army Institute of Research

High Score on Somatic Scale (PHQ-15) by Bereavement Severity

Not at all A little bit Moderate Quite a bit Extreme0

5

10

15

20

25

30

35

40

45

4.7

20.6

29.2

34.2

42.1

Bereavement Severity

Prev

alen

ce o

f hig

h PH

Q-1

5

Military Psychiatry Branch, Walter Reed Army Institute of Research

Self-Rated Poor Health by Bereavement Severity

Not at all A little bit Moderate Quite a bit Extreme0

10

20

30

40

50

60

70

22.3

44.3 45.9

58.5 60.7

Bereavement Severity

Prev

alen

ce o

f poo

r hea

lth

Military Psychiatry Branch, Walter Reed Army Institute of Research

Irritability by Bereavement Severity

Not at all A little bit Moderate Quite a bit Extreme0

10

20

30

40

50

60

70

80

90

100

30.5

48.6

60.0

77.586.7

Bereavement Severity

Prev

alen

ce o

f Irr

itabi

lity

Military Psychiatry Branch, Walter Reed Army Institute of Research

Fatigue / Sleep Problems by Bereavement Severity

Not at all A little bit Moderate Quite a bit Extreme0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

24.8

47.8

57.3

70.075.0

26.3

45.353.3

62.5

76.7FatigueSleep Problems

Bereavement Severity

Prev

alen

ce o

f fati

gue

Military Psychiatry Branch, Walter Reed Army Institute of Research

Musculoskeletal Pain by Bereavement Severity

Not at all A little bit Moderate Quite a bit Extreme0

10

20

30

40

50

60

70

28.2

45.2 45.3

61.057.6

Bereavement Severity

Prev

alen

ce o

f mus

culo

skel

etal

pai

n

Military Psychiatry Branch, Walter Reed Army Institute of Research

Headaches by Bereavement Severity

Not at all A little bit Moderate Quite a bit Extreme0

10

20

30

40

50

60

11.8

24.1

30.736.6

52.5

Bereavement Severity

Prev

alen

ce o

f hea

dach

es

Military Psychiatry Branch, Walter Reed Army Institute of Research

Medical Visits by Bereavement Severity

Not at all A little bit Moderate Quite a bit Extreme0

10

20

30

40

50

60

25.7

34.4

51.456.1

53.6

Bereavement Severity

Prev

alen

ce o

f med

ical

vis

its

Military Psychiatry Branch, Walter Reed Army Institute of Research

Difficulty with PT by Bereavement Severity

Not at all A little bit Moderate Quite a bit Extreme0.0

10.0

20.0

30.0

40.0

50.0

60.0

22.528.0

48.6

55.050.0

Bereavement Severity

Prev

alen

ce o

f PT

diffi

culty

Military Psychiatry Branch, Walter Reed Army Institute of Research

Multiple Logistic Regression: DeterminingContribution of Bereavement to Health

Outcomes– Gender– Age– Education– Marital status– Rank– Combat experiences– Combat injury

(including mTBI)– Depression

– PTSD – Alcohol misuse– ACEs

Military Psychiatry Branch, Walter Reed Army Institute of Research

Independent Contribution of Bereavement to Health Outcomes

• High symptom score: AOR = 3.6 (95% CI: 2.1 – 6.2)

• Poor overall health: AOR= 2.0 (95% CI: 1.4 – 2.9)

• Missed work days: AOR = 1.7 (95% CI: 1.03 – 3.0)

• Medical visits: AOR = 1.5 (95% CI: 1.04 – 2.1)

• Carrying heavy load: AOR = 1.7 (95% CI: 1.2 – 2.4)

• Performing PT: AOR = 1.6 (95% CI: 1.1 – 2.3)

Military Psychiatry Branch, Walter Reed Army Institute of Research

Discussion: Prevalence of Physical Health Outcomes

• Health problems in current wars only in context of PTSD, mTBI

• Previous wars- strong association b/w deployment, symptoms found in this study

• Current wars – UK studies– Minimal differences in rates of physical symptoms

among those who deployed, non-deployers– However, deployed UK soldiers - lower rates of

combat experiences, mental health problems

Military Psychiatry Branch, Walter Reed Army Institute of Research

Discussion: Grief

• “Complicated grief” in civilian population: 9% – Our study: 21.3 - not based on a set of criteria

• Association of difficulty coping with grief, physical health outcomes consistent w/ civilian literature – Magnitude of differences in health outcomes

greater in our study• Grief independently predicts health outcomes

beyond PTSD, depression in civilian literature

Military Psychiatry Branch, Walter Reed Army Institute of Research

Limitations

• Difficulty coping with bereavement assessed with single item

• Unclear if deceased were unit buddies or family members/friends at home

• Could not determine duration of grief • Cross-sectional design • Self-reported data

Military Psychiatry Branch, Walter Reed Army Institute of Research

Conclusions

• Considerable post-war physical health burden• One in five soldiers - trouble with grief• Dose-response relationship between trouble

with grief, physical health symptoms/ occupational impairment

• Difficulty with bereavement independently contributes to physical health symptoms, occupational physical impairment

Military Psychiatry Branch, Walter Reed Army Institute of Research

Recommendations for Military, VA

• Research on bereavement• Availability of evidence-based clinical interventions for

complicated grief– Preventive interventions ineffective– Most will return to previous functioning w/o intervention– No research in military for treatment for “complicated”

grief• How unit training addresses bereavement

– Caution: Easy to implement expedient interventions without understanding empirical evidence and application to a military setting