Trends in mental health outcomes and combat exposure among US marines returning from Iraq, Afghanistan or other deployments, 2004–13

Trends in mental health outcomes and combat exposure among US marines returning from Iraq,... Abstract Background As of 2015, more than 2.7 million US military Veterans have served in support of the Global War on Terror. The negative sequelae associated with deployment stressors and related traumas are well-documented. Although data on mental health issues are routinely collected from service members returning from deployment, these data have not been made publicly available, leaving researchers and clinicians to rely on convenience samples, outdated studies and small sample sizes. Methods Population-based data of US Marines returning from deployment between 2004 and 2013 were analyzed, using the Post-Deployment Health Assessment. Results Rates of Marines returning from Iraq who screened positive for depression ranged from 19.31 to 30.02%; suicidal ideation ranged from 0 to 1.44%. Marines screening positive for PTSD ranged from 3.00 to 12.41%; combat exposure ranged from 15.58 to 55.12%. Depression was indicated for between 12.54 and 30.04% of Marines returning from Afghanistan, while suicidal ideation ranged from 0 to 5.33%. PTSD percentages ranged from 6.64 to 18.18%; combat exposure ranged between 42.92 and 75%. Conclusion Our results support the heterogeneity of experiences and mental health sequelae of service members returning from deployments. Outcomes for Afghanistan and Iraq Veterans fluctuate with changes in OPTEMPO across theaters over time. The Department of Defense (DOD) Defense Manpower Data Center (DMDC) Contingency Tracking System (CTS) reports that as of 2015 more than 2.7 million US military Veterans have served in Afghanistan and/or Iraq in support of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) as part of the Global War on Terror, and over half of them have been deployed more than once. The negative sequelae associated with deployment stressors and related traumas are well-documented, and include post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), depression, substance abuse and suicidal ideation.1 Behavioral health issues are among the leading causes of disability worldwide, making them a significant burden on public health.2 To date, however, there have been few large-scale studies that have examined mental health issues of contemporary service members following deployment, and the existing literature is now nearly 10 years old. Although data are routinely collected from service members upon return from deployment, these data have not been made publicly available, leaving researchers and clinicians to rely on convenience samples, outdated studies and small sample sizes. The provision of a more accurate assessment of the prevalence of mental health issues is the crux of psychiatric epidemiology; using the public health model, this study aims to assess the prevalence of mental health issues immediately post-deployment in the military community and begin to identify risk factors.3 This stage of research lays the foundation for the design and evaluation of prevention interventions3 and guides efforts to improve outcomes for Veterans. There are several issues that make estimating prevalence of mental health issues among military Veterans, and generalizing those findings, difficult. The main issue is that there is substantial variation in exposure to adversity based on many factors, including service branch, deployment location, and operations tempo (OPTEMPO). OPTEMPO is ‘the rate of US forces involvement in all military activities’ and is ‘often used to describe only the pace of contingency deployments.’4(p16) As the Global War on Terror has required US military involvement in several theaters simultaneously, overall OPTEMPO has remained high, but the intensity of engagement has shifted across regions. As shown in Fig. 1, the USA reached peak involvement in Iraq in late 2007, just 2 months after the Iraq troop reduction announcement was made. Beginning in early 2009, more troops were sent to Afghanistan, shortly before the Iraq withdrawal began. As Fig. 1 shows, the number of troops in Afghanistan did not exceed the number of troops in Iraq until 2010. These shifts in deployment trends make any single cross-sectional study of military post-deployment mental health incomplete and problematic. This limitation notwithstanding, two large-scale studies have been conducted to provide estimates of post-deployment mental health among post-9/11 Veterans. Fig. 1 View largeDownload slide Timeline of troops deployed and key dates in United States military operations 2001–12. Fig. 1 View largeDownload slide Timeline of troops deployed and key dates in United States military operations 2001–12. One population-based study of mental health issues combined Army Soldiers and Marines returning from deployment between May 2003 and April 2004 and found substantial heterogeneity among Veterans deployed to different combat zones.5 Namely, within the study timeframe, those returning from Iraq were more likely to screen positive for PTSD than those returning from Afghanistan (9.8 versus 4.7%); the same trend was found for depression (6.1 versus 3.5%).5 As a follow-up to this study, the authors examined a sample of returning Veterans longitudinally and found increases in mental health issues from the Post-Deployment Health Assessment (PDHA) (immediately upon return from deployment) to the Post-Deployment Health Re-Assessment (PDHRA) (between 3 and 6 months later).6 In another study conducted from April 2007 to January 2008, Tanielian and Jaycox7 collected data from 1965 Veterans using a telephone survey to estimate the prevalence of mental health issues and found that 14% of OEF/OIF Veterans self-reported clinical levels of PTSD and 14% reported symptom levels indicative of depression; this study included participants from the Army, Marines, Navy and Air Force, and those who were separated from the military as well as still active. Almost two-thirds of the participants had experienced their last deployment more than a year and a half before the survey, with one-third having experienced their last deployment more than 3 years prior.7 Although these studies were methodologically sound, the continued reliance on these estimates by researchers and practitioners may not adequately represent all service members; given the changes in OPTEMPO and conflict climate over time, suggesting the need for the analysis of more recent data spanning longer periods of time. A few other notable studies have been conducted more recently in smaller samples (N < 900). For instance, a longitudinal study found that 10.5% of US Army Soldiers returning from an Iraq War deployment met criteria for PTSD, and that percentage increased to 24.7% at a follow-up roughly 8 years later.8 Additionally, the effects of deployment on mental health symptoms and diagnoses seem to depend largely on the amount of combat exposure the service member experiences; in Marines returning from Afghanistan, only those experiencing high trauma deployments saw an increase in PTSD symptoms upon their return.9 Other studies have examined Soldiers’ mental health issues following deployment, but these have been limited by the use of convenience or volunteer samples10,11 or restricted timeframes;12 others, such as government reports, lack the rigor associated with the peer-review process.7 Given the lack of recent large-scale studies, the present study seeks to fill this gap by providing a comprehensive description of trends in behavioral health among US Marines returning from deployment between 2004 and 2013. Methods Subjects and data source The Post-Deployment Health Assessment (PDHA; DD Form 279613) is administered to all American military service members returning from deployment, with the primary purpose of assessing the service member’s health in order to provide information to healthcare providers who then offer medical, dental, and behavioral referrals, as necessary. The PDHA assesses a variety of exposures related to deployment, including combat and other occupational and environmental exposures, as well as physical and mental health issues and psychosocial concerns.14 Since its inception, the PDHA has become more extensive and thorough in its screening; the first version was issued in April 2003, the second version in January 2008, and the third version in September 2012. The data analyzed herein are population-based data of US Marines returning from deployment between 2004 and 2013 (N = 335 327), using three versions of the PDHA. From 2004 to 2008, the first version of the PDHA (V1) was administered to 80 918 unique Marines (2728 in 2004; 5972 in 2005; 25 135 in 2006; 38 457 in 2007; 8626 in 2008). The second version of the PDHA (V2) was administered to 243 541 Marines from 2007 to 2012 (1166 in 2007; 43 639 in 2008; 63 938 in 2009; 44 537 in 2010; 48 284 in 2011; 41 977 in 2012). In 2012 and 2013, the third version of the PDHA (V3) was administered to 10 868 Marines (2162 in 2012; 8706 in 2013). The first version of the PDHA was completed either electronically or using paper-and-pencil, while the subsequent versions were administered electronically only. Measures Service members fill out the PDHA within 30 days of return from a deployment, so all screening assessments are measured contemporaneously, although screening items have various reference periods. Over the course of its administration, the PDHA has been modified across versions; Table 1 offers a comparison of the measures of depression and suicidal ideation, which varied substantially. Table 1 Reference period, response options, and mode of administration changes across PDHA versions Construct  Reference period  Response options  Administration mode  Depression         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  not at all, few or several days, more than half the days or nearly every day  Self   V3  Last 2 weeks  not at all, few or several days, more than half the days or nearly every day  Self  Suicidal ideation         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  yes or no  Healthcare provider   V3  Past month  yes or no  Healthcare provider  Construct  Reference period  Response options  Administration mode  Depression         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  not at all, few or several days, more than half the days or nearly every day  Self   V3  Last 2 weeks  not at all, few or several days, more than half the days or nearly every day  Self  Suicidal ideation         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  yes or no  Healthcare provider   V3  Past month  yes or no  Healthcare provider  Table 1 Reference period, response options, and mode of administration changes across PDHA versions Construct  Reference period  Response options  Administration mode  Depression         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  not at all, few or several days, more than half the days or nearly every day  Self   V3  Last 2 weeks  not at all, few or several days, more than half the days or nearly every day  Self  Suicidal ideation         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  yes or no  Healthcare provider   V3  Past month  yes or no  Healthcare provider  Construct  Reference period  Response options  Administration mode  Depression         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  not at all, few or several days, more than half the days or nearly every day  Self   V3  Last 2 weeks  not at all, few or several days, more than half the days or nearly every day  Self  Suicidal ideation         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  yes or no  Healthcare provider   V3  Past month  yes or no  Healthcare provider  Military and deployment-related factors The PDHA assessed the location and name of the operation to which the service member deployed, as well as dates of arrival in, and departure from, theater. For the purposes of these analyses, deployment locations were divided into three groups: Afghanistan, Iraq and Other (e.g. Bahrain or Haiti). Depression The PDHA included a modified version of the 2-item Patient Health Questionnaire15–17 to assess how often respondents had been bothered by anhedonia (‘little interest or pleasure in doing things’) and depressed mood (‘feeling down, depressed, or hopeless’). The service member was considered at risk for depression if he or she answered ‘some or a lot’ on either question in V1 or ‘more than half the days or nearly every day’ on V2 and V3 (Table 1). Suicidal ideation Suicidal ideation was assessed using a modified question from the PHQ-9,18 ‘Over the last 2 weeks, how often have you been bothered by any of the following problems? Thoughts that you would be better off dead or hurting yourself in some way.’ Response options changed across versions (Table 1). Responses of some or a lot on V1 and ‘yes’ on V2 were considered indicative of suicidal ideation. Post-traumatic stress disorder PTSD was assessed using the Primary Care PTSD Screen (PC-PTSD), a 4-item screening tool that was developed by the National Center for PTSD.19 The question asks, ‘Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you…’ Each item of the assessment then corresponds to a symptom cluster of PTSD: re-experiencing, numbing, avoidance and hyperarousal, and positive responses to two or more are considered a positive screen on the PDHA by the military healthcare providers.19 Combat exposure Service members reported whether they had experienced various combat exposures over the course of the deployment from which they were returning, including ‘see[ing] anyone wounded, killed or dead’, ‘engag[ing] in direct combat where you discharged your weapon’ or ‘ever feel[ing] that you were in great danger of being killed.’ Statistical analysis All analyses were run using SAS version 9.4 software (SAS Institute Inc, Cary, NC). Due to the population-based nature of these data, significance levels are not calculated, as differences are reflective of the entire population and therefore significant. Results Subject characteristics Most of the population was male (96.18%) with an average age of 25.42 years (SD = 5.38). Respondents were 98.54% Active Duty and 1.46% National Guard and Reserve. Prevalence of mental health issues and exposures reported on the PDHA Percentages of Marines reporting mental health issues and combat exposure immediately post-deployment varied significantly across deployment locations and years. Across the 10 years included in this study, 106,755 Marines reported exposure to combat; 85 001 Marines screened positive for depression; PTSD was indicated in 21 726 Marines; and 1316 Marines reported suicidal ideation (across V1 and V2 alone). Below we highlight results by deployment locations (i.e. Iraq, Afghanistan and Other) and report ranges of percentages for depression, suicidal ideation, PTSD and combat exposure. Returning from Iraq Overall, the highest percentages of depression and suicidal ideation followed trends for combat exposure, with the highest being in 2006. For PTSD, however, the highest percentages were in 2011 and 2012. Rates of Marines returning from Iraq who screened positive for depression ranged from 19.31 to 30.02% and suicidal ideation ranged from a low of 0 to a high of 1.44%. The percentage of Marines screening positive for PTSD fluctuated more, ranging from 3.00 to 12.41%. The percentage of Marines reporting any kind of combat exposure ranged from 15.58 to 55.12%. Detailed results are reported in Supplemental Tables S2–S4 and trends are displayed in Fig. 2. Fig. 2 View largeDownload slide Behavioral health and exposures among Marines returning from Iraq, Afghanistan and Other Locations, 2004–13. Fig. 2 View largeDownload slide Behavioral health and exposures among Marines returning from Iraq, Afghanistan and Other Locations, 2004–13. Returning from Afghanistan The highest percentages screening positive for PTSD and combat exposure for Marines returning from Afghanistan were in 2008. Depression was indicated for between 12.54 and 30.04% of respondents, while suicidal ideation ranged from 0 to 5.33%. PTSD percentages ranged from 6.64 to 18.18% and the percentage of Marines reporting any kind of combat exposure ranged between 42.92 and 75% (Fig. 2). Returning from other locations Percentages of mental health issues and exposures were substantially lower among Marines returning from deployments to locations other than Iraq and Afghanistan. The highest prevalence of depression and of combat exposure were reported in 2007. Depression prevalence ranged from 13.51 to 21.92% and suicidal ideation ranged from 0 to 0.94%. Percentages of Marines screening positive for PTSD ranged from 1.11 to 5.41% and any combat exposure was reported by 0.59–13.41% (Fig. 2). Discussion Main finding of the study This study provides population-based assessments of the prevalence of mental health issues among returning post-9/11 Veterans and highlights the incredible burden that deployment-related stressors have on public health. These findings also identify salient risk factors, and therefore contribute to improving recommendations for practice. Consistent with our expectations, trends in mental health symptoms and combat exposure varied significantly by deployment location and year. Our results indicate that the highest percentages of mental health concerns and combat exposure for Marines returning from Iraq were reported in 2006, although PTSD percentages were highest in the last 2 study years, 2011 and 2012. However, for those returning from Afghanistan, PTSD and combat exposure were highest in 2008. Prevalence of depression for both Iraq and Afghanistan Veterans reached more than 30% at some point during the study years. While 2007 was the highest year for mental health issues and exposures among Marines returning from all other locations, percentages were substantially lower for all outcomes than for Marines returning from Iraq and Afghanistan (Fig. 3). Fig. 3 View largeDownload slide Comparison of percentages of mental health issues over time by theater. Fig. 3 View largeDownload slide Comparison of percentages of mental health issues over time by theater. What is already known on this topic and what this study adds Our results support the heterogeneity of the experiences and mental health sequelae of service members returning from deployments, as was previously reported by Hoge and colleagues.5 Our findings differ, however, in that for the year on which Hoge et al.5 reported, poor mental health outcomes following deployment to Iraq were consistently higher than those following deployment to Afghanistan. Instead, the present study, which utilizes 10 years of data, shows that outcomes for Afghanistan Veterans are worse than Iraq Veterans for some years, and better in others, as there were changes in OPTEMPO across theaters over time. To contextualize these trends historically, it appears that the increases in Marines reporting combat exposure and screening positive for depression and suicidal ideation after Iraq deployments occurred slightly before the peak involvement of US troops in Iraq (2006 versus 2007). Interestingly, the percentage of Marines screening positive for PTSD was highest in the final 2 years for which data are available. Given the decrease in OPTEMPO over the same time, there are a few possible explanations. One possibility is that these increases are due to the cumulative effects of trauma, and that this was not the first or only deployment for these Marines. Another plausible explanation is that the missions for, and combat specialties of, Marines still deploying to Iraq in 2011 and 2012 are essentially different than missions at the height of the conflict. The results for Afghanistan followed similar trends, with percentages of reported behavioral health concerns spiking prior to the influx of troops to the region. These results should also be compared to findings in the existing literature. While the 14% prevalence for both depression and PTSD reported by Tanielian and Jaycox7 are within the ranges we found in this study, they are on the lower end of the percentage of Marines screening positive for depression, which reached 30% at times; these differences are likely due to differences across service branches, as Marines are more likely to experience combat exposure and subsequent mental health issues than service members in the Air Force or the Navy.7 Our results are congruent, however, with recent percentages published for Army Soldiers returning from Iraq, and these percentages went on to more than double over the following 8 years.8 Lastly, these findings offer support for prior studies that found a strong predictive nature of combat exposures on mental health outcomes,9 as trends in this study show that these constructs tended to shift together with changes in OPTEMPO. Finally, it is worth noting that, although ‘other’ deployment locations resulted in fewer behavioral health issues and less combat exposure, a substantial number of service members still reported seeing people who were wounded, dead, or dying. Additionally, there is likely greater variation across the experiences of this subsample based on the location and nature of their deployment. For instance, deployments in support of humanitarian efforts are likely qualitatively different from those in support of combat operations, but no less traumatic. In 2010, following the devastating earthquake, more than 2300 Marines in this sample deployed to Haiti. Others were deployed to places like Bahrain or Kuwait in support of OEF/OIF and may still have been exposed to dangers related to combat deployments. Future research should examine this understudied group of Veterans deployed to locations other than Afghanistan and Iraq. Limitations of this study This study is limited by its reliance on self-report of both behavioral outcomes and experiences or exposures. Our prior research on the Post-Deployment Health Re-Assessment (PDHRA)20 has shown that service members drastically under-report behavioral health issues on these mandated screenings, either due to stigma associated with these concerns, or fear of effect on their military career; indeed, the two most under-reported issues were related to risk of violence and self-harm.21 Future research should examine the validity of the PDHA as a screening tool for these sensitive outcomes. As mentioned previously, screening for PTSD immediately post-deployment, while necessary, is still likely mistimed, and may be artificially lowering the percentages of those identified.6 While a screen immediately post-deployment, when combined with a pre-deployment screen would be good for capturing the incidence of PTSD, we also know that symptoms of PTSD often take longer to manifest than would be validly captured on a screen so closely tied to the conclusion of one’s most recent deployment.8 It should also be noted that the rigor with which the Marine Corps and/or individual commands complied with administering the PDHA has also changed since its inception, with completion rates being lower when the screening was first introduced,5 and more emphasis placed on adherence over time. Additionally, future work should examine the impact of multiple deployments on mental health outcomes, not only in terms of number of deployments, but also in relation to cumulative time deployed, length of deployments and dwell time. These limitations notwithstanding, this study benefits from a large, population-based sample, and a decade worth of data, furthering our understanding of the clinical implications of deployment, and highlighting the need for researchers, clinicians, and policymakers to remain cognizant of the variation in, and dynamic nature of, mental health issues following deployment. Conclusions The largest contribution of this study is a more complete picture of mental health in the Marine Corps. These numbers go beyond the typical combat deployment and can assist researchers, military officials, clinicians and those that care for these service members after separation (e.g. Department of Veteran’s Affairs) to better plan and provide for Marine’s mental health needs. Additionally, while much of the research examining mental health in post-9/11 service members focuses on Iraq and Afghanistan, the prevalence found in this study suggest that deployments to other countries (e.g. South Korea, Bahrain, Haiti) reported similar rates of depression. With this in mind, if a ‘deploy-or-get-out’ policy22 is implemented in the military, it is highly likely that the rates of mental health problems will increase regardless of active combat operations. Finally, politicians and DoD leadership must consider the effects that such a policy has on our service members’ mental health and commit the necessary resources to research and manage the mental health needs of these service members after separation from the military. Supplementary data Supplementary data are available at the Journal of Public Health online. Funding Grant number (W81XWH-12-2-0095) from the US Army Medical Research and Materiel Command. The sponsor had no role in study design; in the collection, analysis and interpretation of data; in the writing of the article; or in the decision to submit the article for publication. The views expressed in this article are those of the authors and do not necessarily represent the views of the Departments of Department of Defense, Veterans Affairs, or any US government agency. References 1 Committee on the Assessment of the Readjustment Needs of Military Personnel, Veterans, and Their Families; Board on the Health of Select Populations; Institute of Medicine. Returning Home From Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families . Washington, DC: National Academies Press (USA), 2013. https://www.ncbi.nlm.nih.gov/books/NBK206861/. (27 April 2017, date last accessed). 2 Whiteford HA, Degenhardt L, Rehm J et al.  . Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet Lond Engl  2013; 382( 9904): 1575– 86. doi:10.1016/S0140-6736(13)61611-6. Google Scholar CrossRef Search ADS   3 DeAngelis T. A successful marriage of psychology and public health. Monit Psychol  2001; 32( 3): 40. 4 National Defense Fellow, Foreign Affairs and National Defense Division. Military Readiness, Operations Tempo (OPTEMPO) and Personnel Tempo (PERSTEMPO): Are U.S. Forces Doing Too Much? Congressional Research Service, The Library of Congress; 1998. 5 Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. J Am Med Assoc  2006; 295( 9): 1023– 32. Google Scholar CrossRef Search ADS   6 Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA  2007; 298( 18): 2141– 8. doi:10.1001/jama.298.18.2141. Google Scholar CrossRef Search ADS PubMed  7 Tanielian T, Jaycox LH. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery . Santa Monica, CA: RAND Corporation, 2008. 8 Vasterling JJ, Aslan M, Proctor SP et al.  . Longitudinal examination of posttraumatic stress disorder as a long-term outcome of Iraq war deployment. Am J Epidemiol  2016; 184( 11): 796– 805. doi:10.1093/aje/kww151. Google Scholar CrossRef Search ADS PubMed  9 Moore TM, Risbrough VB, Baker DG et al.  . Effects of military service and deployment on clinical symptomatology: The role of trauma exposure and social support. J Psychiatr Res  2017; 95: 121– 8. doi:10.1016/j.jpsychires.2017.08.013. Google Scholar CrossRef Search ADS PubMed  10 Hoge CW, Terhakopian A, Castro CA et al.  . Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. Am J Psychiatry  2007; 164( 1): 150– 3. doi:https://doi.org/10.1176/ajp.2007.164.1.150. Google Scholar CrossRef Search ADS PubMed  11 Lapierre CB, Schwegler AF, Labauve BJ. Posttraumatic stress and depression symptoms in soldiers returning from combat operations in Iraq and Afghanistan. J Trauma Stress  2007; 20( 6): 933– 43. doi:10.1002/jts.20278. Google Scholar CrossRef Search ADS PubMed  12 Martin CB. Routine screening and referrals for PTSD after returning from Operation Iraqi Freedom in 2005, U.S. Armed Forces. MSMR Med Surveill Mon Rep  2007; 14( 6): 2– 7. 13 Department of Defense. Post-Deployment Health Assessment DD Form 2796. www.dtic.mil/whs/directives/forms/eforms/dd2796.pdf. 14 DoD Deployment Health Clinical Center. Post-Deployment Health Assessment. http://www.pdhealth.mil/treatment-guidance/deployment-health-assessments/post-deployment-health-assessment. Published 2017. (13 August 2017, date last accessed). 15 Kroenke K, Spitzer RL, Williams JBW. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care  2003; 41( 11): 1284– 92. doi:10.1097/01.MLR.0000093487.78664.3C. Google Scholar CrossRef Search ADS PubMed  16 Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. J Am Med Assoc  1999; 282( 18): 1737– 44. Google Scholar CrossRef Search ADS   17 Whooley MA, Avins AL, Miranda J et al.  . Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med  1997; 12( 7): 439– 45. Google Scholar CrossRef Search ADS PubMed  18 Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med  2001; 16( 9): 606– 13. doi:https://doi.org/10.1046/j.1525-1497.2001.016009606.x. Google Scholar CrossRef Search ADS PubMed  19 Prins A, Ouimette P, Kimerling R et al.  . The Primary Care PTSD Screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatry  2004; 9( 1): 9– 14. doi:10.1185/135525703125002360. Google Scholar CrossRef Search ADS   20 Department of Defense. Post-Deployment Health Re-Assessment DD Form 2900. www.dtic.mil/whs/directives/forms/eforms/dd2796.pdf. 21 Hourani L, Bender R, Weimer B et al.  . Comparative analysis of mandated versus voluntary administrations of post-deployment health assessments among Marines. Mil Med  2012; 177( 6): 643– 8. Google Scholar CrossRef Search ADS PubMed  22 Wilkie RL. DoD Retention Policy for Non-Deployable Service Members . Washington, DC: Office of the Under Secretary of Defense for Personnel and Readiness, Department of Defense, 2018. https://www.defense.gov/Portals/1/Documents/pubs/DoD-Universal-Retention-Policy.PDF. © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. 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Trends in mental health outcomes and combat exposure among US marines returning from Iraq, Afghanistan or other deployments, 2004–13

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Abstract

Abstract Background As of 2015, more than 2.7 million US military Veterans have served in support of the Global War on Terror. The negative sequelae associated with deployment stressors and related traumas are well-documented. Although data on mental health issues are routinely collected from service members returning from deployment, these data have not been made publicly available, leaving researchers and clinicians to rely on convenience samples, outdated studies and small sample sizes. Methods Population-based data of US Marines returning from deployment between 2004 and 2013 were analyzed, using the Post-Deployment Health Assessment. Results Rates of Marines returning from Iraq who screened positive for depression ranged from 19.31 to 30.02%; suicidal ideation ranged from 0 to 1.44%. Marines screening positive for PTSD ranged from 3.00 to 12.41%; combat exposure ranged from 15.58 to 55.12%. Depression was indicated for between 12.54 and 30.04% of Marines returning from Afghanistan, while suicidal ideation ranged from 0 to 5.33%. PTSD percentages ranged from 6.64 to 18.18%; combat exposure ranged between 42.92 and 75%. Conclusion Our results support the heterogeneity of experiences and mental health sequelae of service members returning from deployments. Outcomes for Afghanistan and Iraq Veterans fluctuate with changes in OPTEMPO across theaters over time. The Department of Defense (DOD) Defense Manpower Data Center (DMDC) Contingency Tracking System (CTS) reports that as of 2015 more than 2.7 million US military Veterans have served in Afghanistan and/or Iraq in support of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) as part of the Global War on Terror, and over half of them have been deployed more than once. The negative sequelae associated with deployment stressors and related traumas are well-documented, and include post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), depression, substance abuse and suicidal ideation.1 Behavioral health issues are among the leading causes of disability worldwide, making them a significant burden on public health.2 To date, however, there have been few large-scale studies that have examined mental health issues of contemporary service members following deployment, and the existing literature is now nearly 10 years old. Although data are routinely collected from service members upon return from deployment, these data have not been made publicly available, leaving researchers and clinicians to rely on convenience samples, outdated studies and small sample sizes. The provision of a more accurate assessment of the prevalence of mental health issues is the crux of psychiatric epidemiology; using the public health model, this study aims to assess the prevalence of mental health issues immediately post-deployment in the military community and begin to identify risk factors.3 This stage of research lays the foundation for the design and evaluation of prevention interventions3 and guides efforts to improve outcomes for Veterans. There are several issues that make estimating prevalence of mental health issues among military Veterans, and generalizing those findings, difficult. The main issue is that there is substantial variation in exposure to adversity based on many factors, including service branch, deployment location, and operations tempo (OPTEMPO). OPTEMPO is ‘the rate of US forces involvement in all military activities’ and is ‘often used to describe only the pace of contingency deployments.’4(p16) As the Global War on Terror has required US military involvement in several theaters simultaneously, overall OPTEMPO has remained high, but the intensity of engagement has shifted across regions. As shown in Fig. 1, the USA reached peak involvement in Iraq in late 2007, just 2 months after the Iraq troop reduction announcement was made. Beginning in early 2009, more troops were sent to Afghanistan, shortly before the Iraq withdrawal began. As Fig. 1 shows, the number of troops in Afghanistan did not exceed the number of troops in Iraq until 2010. These shifts in deployment trends make any single cross-sectional study of military post-deployment mental health incomplete and problematic. This limitation notwithstanding, two large-scale studies have been conducted to provide estimates of post-deployment mental health among post-9/11 Veterans. Fig. 1 View largeDownload slide Timeline of troops deployed and key dates in United States military operations 2001–12. Fig. 1 View largeDownload slide Timeline of troops deployed and key dates in United States military operations 2001–12. One population-based study of mental health issues combined Army Soldiers and Marines returning from deployment between May 2003 and April 2004 and found substantial heterogeneity among Veterans deployed to different combat zones.5 Namely, within the study timeframe, those returning from Iraq were more likely to screen positive for PTSD than those returning from Afghanistan (9.8 versus 4.7%); the same trend was found for depression (6.1 versus 3.5%).5 As a follow-up to this study, the authors examined a sample of returning Veterans longitudinally and found increases in mental health issues from the Post-Deployment Health Assessment (PDHA) (immediately upon return from deployment) to the Post-Deployment Health Re-Assessment (PDHRA) (between 3 and 6 months later).6 In another study conducted from April 2007 to January 2008, Tanielian and Jaycox7 collected data from 1965 Veterans using a telephone survey to estimate the prevalence of mental health issues and found that 14% of OEF/OIF Veterans self-reported clinical levels of PTSD and 14% reported symptom levels indicative of depression; this study included participants from the Army, Marines, Navy and Air Force, and those who were separated from the military as well as still active. Almost two-thirds of the participants had experienced their last deployment more than a year and a half before the survey, with one-third having experienced their last deployment more than 3 years prior.7 Although these studies were methodologically sound, the continued reliance on these estimates by researchers and practitioners may not adequately represent all service members; given the changes in OPTEMPO and conflict climate over time, suggesting the need for the analysis of more recent data spanning longer periods of time. A few other notable studies have been conducted more recently in smaller samples (N < 900). For instance, a longitudinal study found that 10.5% of US Army Soldiers returning from an Iraq War deployment met criteria for PTSD, and that percentage increased to 24.7% at a follow-up roughly 8 years later.8 Additionally, the effects of deployment on mental health symptoms and diagnoses seem to depend largely on the amount of combat exposure the service member experiences; in Marines returning from Afghanistan, only those experiencing high trauma deployments saw an increase in PTSD symptoms upon their return.9 Other studies have examined Soldiers’ mental health issues following deployment, but these have been limited by the use of convenience or volunteer samples10,11 or restricted timeframes;12 others, such as government reports, lack the rigor associated with the peer-review process.7 Given the lack of recent large-scale studies, the present study seeks to fill this gap by providing a comprehensive description of trends in behavioral health among US Marines returning from deployment between 2004 and 2013. Methods Subjects and data source The Post-Deployment Health Assessment (PDHA; DD Form 279613) is administered to all American military service members returning from deployment, with the primary purpose of assessing the service member’s health in order to provide information to healthcare providers who then offer medical, dental, and behavioral referrals, as necessary. The PDHA assesses a variety of exposures related to deployment, including combat and other occupational and environmental exposures, as well as physical and mental health issues and psychosocial concerns.14 Since its inception, the PDHA has become more extensive and thorough in its screening; the first version was issued in April 2003, the second version in January 2008, and the third version in September 2012. The data analyzed herein are population-based data of US Marines returning from deployment between 2004 and 2013 (N = 335 327), using three versions of the PDHA. From 2004 to 2008, the first version of the PDHA (V1) was administered to 80 918 unique Marines (2728 in 2004; 5972 in 2005; 25 135 in 2006; 38 457 in 2007; 8626 in 2008). The second version of the PDHA (V2) was administered to 243 541 Marines from 2007 to 2012 (1166 in 2007; 43 639 in 2008; 63 938 in 2009; 44 537 in 2010; 48 284 in 2011; 41 977 in 2012). In 2012 and 2013, the third version of the PDHA (V3) was administered to 10 868 Marines (2162 in 2012; 8706 in 2013). The first version of the PDHA was completed either electronically or using paper-and-pencil, while the subsequent versions were administered electronically only. Measures Service members fill out the PDHA within 30 days of return from a deployment, so all screening assessments are measured contemporaneously, although screening items have various reference periods. Over the course of its administration, the PDHA has been modified across versions; Table 1 offers a comparison of the measures of depression and suicidal ideation, which varied substantially. Table 1 Reference period, response options, and mode of administration changes across PDHA versions Construct  Reference period  Response options  Administration mode  Depression         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  not at all, few or several days, more than half the days or nearly every day  Self   V3  Last 2 weeks  not at all, few or several days, more than half the days or nearly every day  Self  Suicidal ideation         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  yes or no  Healthcare provider   V3  Past month  yes or no  Healthcare provider  Construct  Reference period  Response options  Administration mode  Depression         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  not at all, few or several days, more than half the days or nearly every day  Self   V3  Last 2 weeks  not at all, few or several days, more than half the days or nearly every day  Self  Suicidal ideation         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  yes or no  Healthcare provider   V3  Past month  yes or no  Healthcare provider  Table 1 Reference period, response options, and mode of administration changes across PDHA versions Construct  Reference period  Response options  Administration mode  Depression         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  not at all, few or several days, more than half the days or nearly every day  Self   V3  Last 2 weeks  not at all, few or several days, more than half the days or nearly every day  Self  Suicidal ideation         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  yes or no  Healthcare provider   V3  Past month  yes or no  Healthcare provider  Construct  Reference period  Response options  Administration mode  Depression         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  not at all, few or several days, more than half the days or nearly every day  Self   V3  Last 2 weeks  not at all, few or several days, more than half the days or nearly every day  Self  Suicidal ideation         V1  Last 2 weeks  none, some or a lot  Self   V2  Past month  yes or no  Healthcare provider   V3  Past month  yes or no  Healthcare provider  Military and deployment-related factors The PDHA assessed the location and name of the operation to which the service member deployed, as well as dates of arrival in, and departure from, theater. For the purposes of these analyses, deployment locations were divided into three groups: Afghanistan, Iraq and Other (e.g. Bahrain or Haiti). Depression The PDHA included a modified version of the 2-item Patient Health Questionnaire15–17 to assess how often respondents had been bothered by anhedonia (‘little interest or pleasure in doing things’) and depressed mood (‘feeling down, depressed, or hopeless’). The service member was considered at risk for depression if he or she answered ‘some or a lot’ on either question in V1 or ‘more than half the days or nearly every day’ on V2 and V3 (Table 1). Suicidal ideation Suicidal ideation was assessed using a modified question from the PHQ-9,18 ‘Over the last 2 weeks, how often have you been bothered by any of the following problems? Thoughts that you would be better off dead or hurting yourself in some way.’ Response options changed across versions (Table 1). Responses of some or a lot on V1 and ‘yes’ on V2 were considered indicative of suicidal ideation. Post-traumatic stress disorder PTSD was assessed using the Primary Care PTSD Screen (PC-PTSD), a 4-item screening tool that was developed by the National Center for PTSD.19 The question asks, ‘Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you…’ Each item of the assessment then corresponds to a symptom cluster of PTSD: re-experiencing, numbing, avoidance and hyperarousal, and positive responses to two or more are considered a positive screen on the PDHA by the military healthcare providers.19 Combat exposure Service members reported whether they had experienced various combat exposures over the course of the deployment from which they were returning, including ‘see[ing] anyone wounded, killed or dead’, ‘engag[ing] in direct combat where you discharged your weapon’ or ‘ever feel[ing] that you were in great danger of being killed.’ Statistical analysis All analyses were run using SAS version 9.4 software (SAS Institute Inc, Cary, NC). Due to the population-based nature of these data, significance levels are not calculated, as differences are reflective of the entire population and therefore significant. Results Subject characteristics Most of the population was male (96.18%) with an average age of 25.42 years (SD = 5.38). Respondents were 98.54% Active Duty and 1.46% National Guard and Reserve. Prevalence of mental health issues and exposures reported on the PDHA Percentages of Marines reporting mental health issues and combat exposure immediately post-deployment varied significantly across deployment locations and years. Across the 10 years included in this study, 106,755 Marines reported exposure to combat; 85 001 Marines screened positive for depression; PTSD was indicated in 21 726 Marines; and 1316 Marines reported suicidal ideation (across V1 and V2 alone). Below we highlight results by deployment locations (i.e. Iraq, Afghanistan and Other) and report ranges of percentages for depression, suicidal ideation, PTSD and combat exposure. Returning from Iraq Overall, the highest percentages of depression and suicidal ideation followed trends for combat exposure, with the highest being in 2006. For PTSD, however, the highest percentages were in 2011 and 2012. Rates of Marines returning from Iraq who screened positive for depression ranged from 19.31 to 30.02% and suicidal ideation ranged from a low of 0 to a high of 1.44%. The percentage of Marines screening positive for PTSD fluctuated more, ranging from 3.00 to 12.41%. The percentage of Marines reporting any kind of combat exposure ranged from 15.58 to 55.12%. Detailed results are reported in Supplemental Tables S2–S4 and trends are displayed in Fig. 2. Fig. 2 View largeDownload slide Behavioral health and exposures among Marines returning from Iraq, Afghanistan and Other Locations, 2004–13. Fig. 2 View largeDownload slide Behavioral health and exposures among Marines returning from Iraq, Afghanistan and Other Locations, 2004–13. Returning from Afghanistan The highest percentages screening positive for PTSD and combat exposure for Marines returning from Afghanistan were in 2008. Depression was indicated for between 12.54 and 30.04% of respondents, while suicidal ideation ranged from 0 to 5.33%. PTSD percentages ranged from 6.64 to 18.18% and the percentage of Marines reporting any kind of combat exposure ranged between 42.92 and 75% (Fig. 2). Returning from other locations Percentages of mental health issues and exposures were substantially lower among Marines returning from deployments to locations other than Iraq and Afghanistan. The highest prevalence of depression and of combat exposure were reported in 2007. Depression prevalence ranged from 13.51 to 21.92% and suicidal ideation ranged from 0 to 0.94%. Percentages of Marines screening positive for PTSD ranged from 1.11 to 5.41% and any combat exposure was reported by 0.59–13.41% (Fig. 2). Discussion Main finding of the study This study provides population-based assessments of the prevalence of mental health issues among returning post-9/11 Veterans and highlights the incredible burden that deployment-related stressors have on public health. These findings also identify salient risk factors, and therefore contribute to improving recommendations for practice. Consistent with our expectations, trends in mental health symptoms and combat exposure varied significantly by deployment location and year. Our results indicate that the highest percentages of mental health concerns and combat exposure for Marines returning from Iraq were reported in 2006, although PTSD percentages were highest in the last 2 study years, 2011 and 2012. However, for those returning from Afghanistan, PTSD and combat exposure were highest in 2008. Prevalence of depression for both Iraq and Afghanistan Veterans reached more than 30% at some point during the study years. While 2007 was the highest year for mental health issues and exposures among Marines returning from all other locations, percentages were substantially lower for all outcomes than for Marines returning from Iraq and Afghanistan (Fig. 3). Fig. 3 View largeDownload slide Comparison of percentages of mental health issues over time by theater. Fig. 3 View largeDownload slide Comparison of percentages of mental health issues over time by theater. What is already known on this topic and what this study adds Our results support the heterogeneity of the experiences and mental health sequelae of service members returning from deployments, as was previously reported by Hoge and colleagues.5 Our findings differ, however, in that for the year on which Hoge et al.5 reported, poor mental health outcomes following deployment to Iraq were consistently higher than those following deployment to Afghanistan. Instead, the present study, which utilizes 10 years of data, shows that outcomes for Afghanistan Veterans are worse than Iraq Veterans for some years, and better in others, as there were changes in OPTEMPO across theaters over time. To contextualize these trends historically, it appears that the increases in Marines reporting combat exposure and screening positive for depression and suicidal ideation after Iraq deployments occurred slightly before the peak involvement of US troops in Iraq (2006 versus 2007). Interestingly, the percentage of Marines screening positive for PTSD was highest in the final 2 years for which data are available. Given the decrease in OPTEMPO over the same time, there are a few possible explanations. One possibility is that these increases are due to the cumulative effects of trauma, and that this was not the first or only deployment for these Marines. Another plausible explanation is that the missions for, and combat specialties of, Marines still deploying to Iraq in 2011 and 2012 are essentially different than missions at the height of the conflict. The results for Afghanistan followed similar trends, with percentages of reported behavioral health concerns spiking prior to the influx of troops to the region. These results should also be compared to findings in the existing literature. While the 14% prevalence for both depression and PTSD reported by Tanielian and Jaycox7 are within the ranges we found in this study, they are on the lower end of the percentage of Marines screening positive for depression, which reached 30% at times; these differences are likely due to differences across service branches, as Marines are more likely to experience combat exposure and subsequent mental health issues than service members in the Air Force or the Navy.7 Our results are congruent, however, with recent percentages published for Army Soldiers returning from Iraq, and these percentages went on to more than double over the following 8 years.8 Lastly, these findings offer support for prior studies that found a strong predictive nature of combat exposures on mental health outcomes,9 as trends in this study show that these constructs tended to shift together with changes in OPTEMPO. Finally, it is worth noting that, although ‘other’ deployment locations resulted in fewer behavioral health issues and less combat exposure, a substantial number of service members still reported seeing people who were wounded, dead, or dying. Additionally, there is likely greater variation across the experiences of this subsample based on the location and nature of their deployment. For instance, deployments in support of humanitarian efforts are likely qualitatively different from those in support of combat operations, but no less traumatic. In 2010, following the devastating earthquake, more than 2300 Marines in this sample deployed to Haiti. Others were deployed to places like Bahrain or Kuwait in support of OEF/OIF and may still have been exposed to dangers related to combat deployments. Future research should examine this understudied group of Veterans deployed to locations other than Afghanistan and Iraq. Limitations of this study This study is limited by its reliance on self-report of both behavioral outcomes and experiences or exposures. Our prior research on the Post-Deployment Health Re-Assessment (PDHRA)20 has shown that service members drastically under-report behavioral health issues on these mandated screenings, either due to stigma associated with these concerns, or fear of effect on their military career; indeed, the two most under-reported issues were related to risk of violence and self-harm.21 Future research should examine the validity of the PDHA as a screening tool for these sensitive outcomes. As mentioned previously, screening for PTSD immediately post-deployment, while necessary, is still likely mistimed, and may be artificially lowering the percentages of those identified.6 While a screen immediately post-deployment, when combined with a pre-deployment screen would be good for capturing the incidence of PTSD, we also know that symptoms of PTSD often take longer to manifest than would be validly captured on a screen so closely tied to the conclusion of one’s most recent deployment.8 It should also be noted that the rigor with which the Marine Corps and/or individual commands complied with administering the PDHA has also changed since its inception, with completion rates being lower when the screening was first introduced,5 and more emphasis placed on adherence over time. Additionally, future work should examine the impact of multiple deployments on mental health outcomes, not only in terms of number of deployments, but also in relation to cumulative time deployed, length of deployments and dwell time. These limitations notwithstanding, this study benefits from a large, population-based sample, and a decade worth of data, furthering our understanding of the clinical implications of deployment, and highlighting the need for researchers, clinicians, and policymakers to remain cognizant of the variation in, and dynamic nature of, mental health issues following deployment. Conclusions The largest contribution of this study is a more complete picture of mental health in the Marine Corps. These numbers go beyond the typical combat deployment and can assist researchers, military officials, clinicians and those that care for these service members after separation (e.g. Department of Veteran’s Affairs) to better plan and provide for Marine’s mental health needs. Additionally, while much of the research examining mental health in post-9/11 service members focuses on Iraq and Afghanistan, the prevalence found in this study suggest that deployments to other countries (e.g. South Korea, Bahrain, Haiti) reported similar rates of depression. With this in mind, if a ‘deploy-or-get-out’ policy22 is implemented in the military, it is highly likely that the rates of mental health problems will increase regardless of active combat operations. Finally, politicians and DoD leadership must consider the effects that such a policy has on our service members’ mental health and commit the necessary resources to research and manage the mental health needs of these service members after separation from the military. Supplementary data Supplementary data are available at the Journal of Public Health online. Funding Grant number (W81XWH-12-2-0095) from the US Army Medical Research and Materiel Command. The sponsor had no role in study design; in the collection, analysis and interpretation of data; in the writing of the article; or in the decision to submit the article for publication. The views expressed in this article are those of the authors and do not necessarily represent the views of the Departments of Department of Defense, Veterans Affairs, or any US government agency. References 1 Committee on the Assessment of the Readjustment Needs of Military Personnel, Veterans, and Their Families; Board on the Health of Select Populations; Institute of Medicine. Returning Home From Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families . Washington, DC: National Academies Press (USA), 2013. https://www.ncbi.nlm.nih.gov/books/NBK206861/. (27 April 2017, date last accessed). 2 Whiteford HA, Degenhardt L, Rehm J et al.  . Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet Lond Engl  2013; 382( 9904): 1575– 86. doi:10.1016/S0140-6736(13)61611-6. Google Scholar CrossRef Search ADS   3 DeAngelis T. A successful marriage of psychology and public health. Monit Psychol  2001; 32( 3): 40. 4 National Defense Fellow, Foreign Affairs and National Defense Division. Military Readiness, Operations Tempo (OPTEMPO) and Personnel Tempo (PERSTEMPO): Are U.S. Forces Doing Too Much? Congressional Research Service, The Library of Congress; 1998. 5 Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. J Am Med Assoc  2006; 295( 9): 1023– 32. Google Scholar CrossRef Search ADS   6 Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA  2007; 298( 18): 2141– 8. doi:10.1001/jama.298.18.2141. Google Scholar CrossRef Search ADS PubMed  7 Tanielian T, Jaycox LH. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery . Santa Monica, CA: RAND Corporation, 2008. 8 Vasterling JJ, Aslan M, Proctor SP et al.  . Longitudinal examination of posttraumatic stress disorder as a long-term outcome of Iraq war deployment. Am J Epidemiol  2016; 184( 11): 796– 805. doi:10.1093/aje/kww151. Google Scholar CrossRef Search ADS PubMed  9 Moore TM, Risbrough VB, Baker DG et al.  . Effects of military service and deployment on clinical symptomatology: The role of trauma exposure and social support. J Psychiatr Res  2017; 95: 121– 8. doi:10.1016/j.jpsychires.2017.08.013. Google Scholar CrossRef Search ADS PubMed  10 Hoge CW, Terhakopian A, Castro CA et al.  . Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. Am J Psychiatry  2007; 164( 1): 150– 3. doi:https://doi.org/10.1176/ajp.2007.164.1.150. Google Scholar CrossRef Search ADS PubMed  11 Lapierre CB, Schwegler AF, Labauve BJ. Posttraumatic stress and depression symptoms in soldiers returning from combat operations in Iraq and Afghanistan. J Trauma Stress  2007; 20( 6): 933– 43. doi:10.1002/jts.20278. Google Scholar CrossRef Search ADS PubMed  12 Martin CB. Routine screening and referrals for PTSD after returning from Operation Iraqi Freedom in 2005, U.S. Armed Forces. MSMR Med Surveill Mon Rep  2007; 14( 6): 2– 7. 13 Department of Defense. Post-Deployment Health Assessment DD Form 2796. www.dtic.mil/whs/directives/forms/eforms/dd2796.pdf. 14 DoD Deployment Health Clinical Center. Post-Deployment Health Assessment. http://www.pdhealth.mil/treatment-guidance/deployment-health-assessments/post-deployment-health-assessment. Published 2017. (13 August 2017, date last accessed). 15 Kroenke K, Spitzer RL, Williams JBW. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care  2003; 41( 11): 1284– 92. doi:10.1097/01.MLR.0000093487.78664.3C. Google Scholar CrossRef Search ADS PubMed  16 Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. J Am Med Assoc  1999; 282( 18): 1737– 44. Google Scholar CrossRef Search ADS   17 Whooley MA, Avins AL, Miranda J et al.  . Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med  1997; 12( 7): 439– 45. Google Scholar CrossRef Search ADS PubMed  18 Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med  2001; 16( 9): 606– 13. doi:https://doi.org/10.1046/j.1525-1497.2001.016009606.x. Google Scholar CrossRef Search ADS PubMed  19 Prins A, Ouimette P, Kimerling R et al.  . The Primary Care PTSD Screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatry  2004; 9( 1): 9– 14. doi:10.1185/135525703125002360. Google Scholar CrossRef Search ADS   20 Department of Defense. Post-Deployment Health Re-Assessment DD Form 2900. www.dtic.mil/whs/directives/forms/eforms/dd2796.pdf. 21 Hourani L, Bender R, Weimer B et al.  . Comparative analysis of mandated versus voluntary administrations of post-deployment health assessments among Marines. Mil Med  2012; 177( 6): 643– 8. Google Scholar CrossRef Search ADS PubMed  22 Wilkie RL. DoD Retention Policy for Non-Deployable Service Members . Washington, DC: Office of the Under Secretary of Defense for Personnel and Readiness, Department of Defense, 2018. https://www.defense.gov/Portals/1/Documents/pubs/DoD-Universal-Retention-Policy.PDF. © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Journal of Public HealthOxford University Press

Published: May 4, 2018

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