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Operational Stress in Detainee
Operations at Joint Task Force
Guantanamo Bay Cuba
Naval Center for Combat & Operational Stress Control
Bureau of Medicine and Surgery
Disclaimer • The views expressed in this article are those of the author and do
not necessarily reflect the official policy or position of the
Department of the Navy, Department of Defense, nor the U.S.
Government.
• I am a military service member (or employee of the U.S.
Government).
This work was prepared as part of my official duties. Title 17, USC,
§105 provides that ‘Copyright protection under this title is not
available for any work of the U.S.Government.’ Title 17, USC, §101
defines a U.S. Government work as a work prepared by a military
service member or employee of the U.S. Government as part of that
person’s official duties.
Introduction • Combat tours vs. GTMO deployment
• Guards vs. Medical Staff
• Aim1-Methods & Full Sample Results
• Aim2-Comparisons Within & Outside
of Sample
• Aim3-Predicting Depression & PTSD
Symptoms
Life at GTMO • History
– Camp X-Ray
• Safe, humane, legal and transparent care
• Spotlight of the world
• Tropical paradise
AIM #1
Methods & Full Sample Results
Methods
• N = 368
• Guards & Medical Staff
• Mid-deployment
• Data collected between
August 2009 –
November 2009
• Retrospective review of
anonymous self report
surveys
The majority of participants were
18 – 24 years old
39.2%
28.1% 26.4%
6.4%
18-24 25-29 30-39 40 plus
Age Groups
Participants were predominantly
male
80% 20%
Most of the participants’ ranks were
E4 - 6
23.7%
63.0%
6.4% 5.0% 1.9%
E1-3 E4-6 E7-9 O1-3 O4-8
Rank
Participants were predominantly
Navy
27% 73%
Measures • PTSD Checklist – Military (PCL-M)
• Patient Health Questionnaire- 9 Item (PHQ-9)
• Perceived Stress Scale (PSS)
• Response to Stressful Experiences Scale (RSES)
• Beliefs about Psychotherapy (BP)
– Referral Questions
• NEO-Neuroticism (NEO-N)
• Substance Abuse Screener: Cut Down, Annoyed, Guilty,
Eye Opener (CAGE)
Measure Results: Full Sample
N = 340
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
PSS PHQ-9 PCL-M RSES BMH NEO-N
0.00
0.20
0.40
0.60
0.80
1.00
1.20
CAGE
Mean
BP
Measure Results: Full Sample
• High perceived stress
• 13% met criteria for PTSD
• 10% met criteria for depression
• Average resilience
Referral Questions
• Asked two questions:
– If you believed you had a mental health problem,
would you ask for professional help?
– If you believed you had a trooper under your
leadership that had a mental health problem, would
you refer them for professional help?
66%
28%
0% 6%
Refer Self & Refer Trooper Not Refer Self & Refer Trooper
Refer Self & Not Refer Trooper Not Refer Self & Not Refer Trooper
* Based on two referral
questions: 1) If you
believed you had a
mental health problem,
would you ask for
professional help? 2) If
you believed you had a
trooper under your
leadership that had a
mental health
problem, would you
refer them for
professional help?
Willingness to Refer for Professional Help
Willingness to Refer
With or Without PTSD
*Will Refer Self,
Won’t Refer Trooper;
Won’t Refer Self,
Won’t Refer Trooper
are not reported. 0
10
20
30
40
50
60
70
80
PTSD No PTSD
Perc
en
tag
e (
%)
Refer Self &
Refer Trooper
Not Refer
Self & Refer
Trooper
Willingness to Refer
With and Without Depression
0
10
20
30
40
50
60
70
80
Depression No Depression
Perc
en
tag
e (
%)
Refer Self &
Refer Trooper
Not Refer
Self & Refer
Trooper
*Will Refer Self,
Won’t Refer Trooper;
Won’t Refer Self,
Won’t Refer Trooper
are not reported.
Aim #1 Conclusions
• Majority of sample was 18-24 years old,
male, E4-6 and in the Navy
• Overall detainee operations staff have on
average elevated levels of perceived
stress, PTSD and depression
• Evidence of stigma
• Those who need help the most are the
least likely to seek help
AIM #2
Comparisons Within &
Outside of Sample
Army vs. Navy Differences
0
10
20
30
40
50
60
70
PSS PHQ-9 PCL-M RSES BP NEO-N
Mean
Sco
re
Measure
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
CAGE
Measure
Army
Navy
*All reported
results are
statistically
significant
(p<.05).
Guard (JDG) vs. Medical (JMG) Differences
JDG
JMG
*All reported
results are
statistically
significant
(p<.05). 0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
CAGE
Measure
0
10
20
30
40
50
60
70
PSS PHQ-9 PCL-M RSES BP NEO-N
Mean
Sco
re
Measure
Guard (JDG) Medical (JMG)
Were results due to disproportionate
representation of Army personnel?
Branch Representation within Command
68%
32%
93%
7%
Guard (JDG) vs. Medical (JMG) Differences
Navy Personnel Only
0
10
20
30
40
50
60
70
PSS PHQ-9 PCL-M RSES BP NEO-N
Mean
Sco
re
Measure
0.0
0.1
0.2
0.3
0.4
0.5
0.6
CAGE
Measure
JDG
JMG
*All reported
results
except
RSES are
statistically
significant
(p<.05).
Plans to Stay in the Military
0
5
10
15
20
25
30
35
40
JDG JMG
Perc
en
tag
e (
%)
Resp
on
ded
No
Groups
Reported result was not statistically significant at (p<.05)
Summary
• Statistical differences were found on
mental health scales
• Army had elevated scores compared to
Navy personnel
• Guards had elevated score on majority of
measures compared to the medical staff
• Subsequent analyses focused on the
Guards
Joint Detention Group
(Guards)
0
5
10
15
20
25
30
35
40
45
50
GTMO Guards OIF Soldiers*
Mean
PC
L-M
Sco
re
Groups
*Operation Iraqi Freedom National Guard Soldiers with moderate combat
exposure who served from 2005 to 2006. (Renshaw et al., 2008).
PTSD Symptoms for GTMO Population
vs. Combat Population
MHAT Background
• Mental Health Advisory Team for OIF
• Chartered by U.S. Army Surgeon General
• Mission: To assess mental health of
Soldiers and provide recommendations to
medical and line commands
• MHAT I-VI have been released
MHAT Comparison
0
2
4
6
8
10
12
14
GTMO Population OIF-I OIF-II OIF 04-06
Perc
en
t M
eeti
ng
Dep
ressio
n C
rite
ria
Groups
GTMO Population
MHAT
Population
*U.S. Department of the
Army, Office of the
Surgeon General, Mental
Health Advisory Team
(MHAT-III) Report, 2006.
Depression criteria based
on PHQ-9 endorsement
of at least 5 items with a
score >2 where Q1 or 2
were one of the 5items.
• Increased Risk for Depression
– Psychological vs. kinetic warfare
– Constriction vs. small unit autonomy
Aim #2 Conclusions
• Army endorsed more mental health
symptoms than Navy
• Guards reported more mental health
symptoms than medical staff
• Guards had comparable rates of PTSD
and higher rates of depression compared
to other combat personnel samples
AIM #3
Predicting Depression
& PTSD Symptoms
• Potential Predictors
– Working within one’s rate
– Number of previous deployments
– Other mental health symptoms
Working Within One’s Rate
• Rate = job
• 48% of Guards
worked within their
regular job
0
5
10
15
20
25
30
35
Depression PTSD Alcohol
Mean
Sco
re
Measure
*All reported results are
statistically significant (p<.05).
Depression – Patient Health
Questionnaire (PHQ-9); PTSD -
PTSD Checklist – Military (PCL-
M); Alcohol - CAGE Alcohol –
primary care alcohol screener.
Working Within vs. Outside Rate
Within Rate
Outside Rate
Working Within Rate
• 4% of the variance in depression scores was attributable
to working within one’s rate
• Though it does not have a lot of prediction power,
working within one’s rate has some impact
• A separate analysis showed the same results for PTSD
symptoms (4%)
Number of Previous Deployments
• Other studies show a connection between number of
deployments and increased depression and PTSD
symptoms
• Number of previous deployments did not explain a
significant proportion of variance in depression scores or
PTSD scores
• Perhaps, traumatic experiences during previous
deployments may be a stronger factor than just the
number of previous deployments itself
Predicting: Depression/PTSD
• Working Within Rate
• Number of Previous Deployments
Good
Predictors
Poor
Predictors
Predicting: Depression
• Perceived Stress (PSS)
• PTSD (PCL-M)
• Alcohol Use (CAGE)
• Neuroticism (NEO-N)
• Beliefs about Psychotherapy
Good
Predictors
Poor
Predictors
Aim #3 Conclusions • There was a protective quality for guards that worked
outside of their rate
• Number of previous deployments did not appear to
impact depression or PTSD
• The Guard population may benefit from:
– Operational Stress Control Training
– Alcohol Use Education
– Treatment plans taking into consideration comorbid
conditions such as the presence of depression and
PTSD
Overall Conclusions • Detainee operations are stressful
– Guards experience as much PTSD and even more
depression than combat soldiers
– Guards are more stressed than medical staff
• Stigma is present
– More likely to refer other then self
– Those at risk are less likely to seek treatment
• Protective quality of working outside rate
• Continue to identify and study the stress and symptom
levels of this population to develop prevention programs
and effective treatment
Questions
CAPT Scott Johnston
www.nccosc.navy.mil
