Abstract
Rates of suicidal thoughts and behaviors (STBs) in US soldiers have increased sharply since the terrorist attacks on September 11, 2001, and postdeployment posttraumatic stress disorder (PTSD) remains a concern. Studies show that soldiers with greater combat exposure are at an increased risk for adverse mental health outcomes, but little research has been conducted on the specific exposure of responsibility for the death of others. To examine the association between responsibility for the death of others in combat and mental health outcomes among active-duty US Army personnel at 2 to 3 months and 8 to 9 months postdeployment. This cohort study obtained data from a prospective 4-wave survey study of 3 US Army brigade combat teams that deployed to Afghanistan in 2012. The sample was restricted to soldiers with data at all 4 waves (1-2 months predeployment, and 2-3 weeks, 2-3 months, and 8-9 months postdeployment). Data analysis was performed from December 12, 2020, to April 23, 2021. Primary outcomes were past-30-day PTSD, major depressive episode, STBs, and functional impairment at 2 to 3 vs 8 to 9 months postdeployment. Combat exposures were assessed using a combat stress scale. The association of responsibility for the death of others during combat was tested using separate multivariable logistic regression models per outcome adjusted for age, sex, race and ethnicity, marital status, brigade combat team, predeployment lifetime internalizing and externalizing disorders, and combat stress severity. A total of 4645 US soldiers (mean [SD] age, 26.27 [6.07] years; 4358 men [94.0%]) were included in this study. After returning from Afghanistan, 22.8% of soldiers (n = 1057) reported responsibility for the death of others in combat. This responsibility was not associated with any outcome at 2 to 3 months postdeployment (PTSD odds ratio [OR]: 1.23 [95% CI, 0.93-1.63]; P = .14; STB OR: 1.19 [95% CI, 0.84-1.68]; P = .33; major depressive episode OR: 1.03 [95% CI, 0.73-1.45]; P = .87; and functional impairment OR: 1.12 [95% CI, 0.94-1.34]; P = .19). However, responsibility was associated with increased risk for PTSD (OR, 1.42; 95% CI, 1.09-1.86; P = .01) and STBs (OR, 1.55; 95% CI, 1.03-2.33; P = .04) at 8 to 9 months postdeployment. Responsibility was not associated with major depressive episode (OR, 1.30; 95% CI, 0.93-1.81; P = .13) or functional impairment (OR, 1.13; 95% CI, 0.94-1.36; P = .19). When examining enemy combatant death only, the pattern of results was unchanged for PTSD (OR, 1.44; 95 CI%, 1.10-1.90; P = .009) and attenuated for STBs (OR, 1.46; 95 CI%, 0.97- 2.20; P = .07). This cohort study found an association between being responsible for the death of others in combat and PTSD and STB at 8 to 9 months, but not 2 to 3 months, postdeployment in active-duty soldiers. The results suggest that delivering early intervention to those who report such responsibility may mitigate the subsequent occurrence of PTSD and STBs.
Highlights
After returning from Afghanistan, 22.8% of soldiers (n = 1057) reported responsibility for the death of others in combat. This responsibility was not associated with any outcome at 2 to 3 months postdeployment (PTSD odds ratio [OR]: 1.23 [95% CI, 0.93-1.63]; P = .14; suicidal thoughts and behaviors (STBs) OR: 1.19 [95% CI, 0.84-1.68]; P = .33; major depressive episode OR: 1.03 [95% CI, 0.73-1.45]; P = .87; and functional impairment OR: 1.12 [95% CI, 0.94-1.34]; P = .19)
This cohort study found an association between being responsible for the death of others in combat and posttraumatic stress disorder (PTSD) and STB at 8 to 9 months, but not 2 to 3
We examined the association between responsibility for the death of others in combat and postdeployment mental health outcomes among active-duty US Army personnel
Summary
The association between deployment experiences and postdeployment mental health outcomes in military personnel has been extensively studied.[1,2,3] Combat exposure is associated with postdeployment posttraumatic stress disorder (PTSD), depression, and suicidal thoughts and behaviors (STBs).[4,5,6,7,8,9] Consistent with fear-based conceptualizations of trauma response,[10] most studies examining combat have focused on the impact of threats to one’s life (eg, taking enemy fire) or witnessing harm done to others.[11,12,13,14,15,16] evidence has shown that other specific combat experiences may confer greater risk.[6,17,18,19]In studies of combat-deployed military personnel, many soldiers report being responsible for death and violence, but little attention has been paid to the long-term outcomes of such a traumatic event.[2,20,21,22] The current diagnosis of PTSD does not explicitly identify participation in harming or killing others as meeting criterion A of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) PTSD diagnosis.[20,22,23] despite soldiers’ preparation and training to use violence, being responsible for someone else’s death may adversely affect their mental health, in which case screenings and interventions could be developed to mitigate these outcomes.[20,21,24,25] Most evidence of mental health sequelae is found in studies of veterans. Across multiple war eras (Vietnam, Gulf, and Iraq/Afghanistan), being responsible for the death of others has been associated with a PTSD diagnosis and the most severe PTSD symptoms.[21,26,27,28,29] this association persists after adjusting for other combat exposures. Being responsible for the death of others during combat has been associated with STBs, demonstrating large effect sizes compared with other types of combat experiences.[17,18,28,30] whether these findings extend to active-duty soldiers in the post–September 11, 2001 era,[31,32,33] a group whose suicide rates have increased substantially over the past decade, remains relatively unexplored.[34,35]
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