Enduring Freedom Veterans Research Articles

A qualitative analysis of meaning-making and mental health among OIF/OEF veterans.

After combat, veterans may experience mental health symptomology and attempt to make meaning from their experiences. The present study qualitatively examined the mental health effects of deployment and meaning-making among Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) veterans. OIF/OEF veterans who were exposed to combat (N = 14) participated in semi-structured interviews to assess how their perspectives had changed post-deployment. Most participants (86%) were male, with a mean age of 30. Veterans described issues post-combat that caused psychological distress or promoted distancing from others. Veterans also discussed factors that could promote or hinder meaning-making, including perceptions of growth, changed global beliefs, and disillusionment. Finally, veterans described psychological reactions to death, which could be related to moral injury. Mental health concerns, meaning-making, and consideration of mortality appear to characterize veterans' experiences post-deployment. These constructs may be important for clinicians to consider when working with OIF/OEF veterans.

Morally Injurious Events, Moral Injury, and Suicidality among Recent-Era Veterans: The Moderating Effects of Rumination and Mindfulness

The present study used mediation analysis to examine the associations among morally injurious events (MIEs), moral injury, and suicidality in a sample of 285 Operation Enduring Freedom and Operation Iraqi Freedom veterans. Additionally, moderated mediation analysis was used to examine rumination and mindfulness as potential moderators of the MIE, moral injury, suicidality associations. Participants were largely male (n = 174, 61.1%), White (n = 197, 69.1%), and reported a mean age of 32.01 years (SD = 6.90 years). The most represented branch of the military was the Army (n = 136, 47.7%), followed by the Navy (n = 87, 30.5%) and participants on average reported completing 3.05 (SD = 1.38) deployments in support of OIF and 3.15 (SD = 1.42) deployments in support of OEF. Moral injury mediated the association between MIEs and suicidality, such that higher levels of exposure to potential MIEs were associated with higher levels of moral injury; which in turn was associated with higher suicidality. Our moderated mediation models revealed that this indirect effect was attenuated among individuals with higher mindfulness (i.e., the nonjudging of experience and acting with awareness dimensions of mindfulness) and strengthened among those who reported higher rumination. Results point to the potential utility of mindfulness-based therapies among service members who serve in combat and who report moral injury.

A-66 Wechsler Test of Adult Reading is a More Useful Indicator of Premorbid Cognitive Functioning than the Reynolds Intellectual Screening Test in Blast Exposed Veterans

Abstract Objective The primary objective of this study was to compare the utility of the Wechsler Test of Adult Reading (WTAR) with the Reynolds Intellectual Screening Test (RIST) as a measure of premorbid cognitive functioning among blast-exposed Veterans. Method Sixty-nine Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans enrolled at the VA Portland Health Center who passed the Test of Memory Malingering (TOMM) were given the WTAR, RIST, and the Neuropsychological Assessment Battery (NAB). Data was analyzed using bi-variate correlational analyses and linear regressions. Results Scores on the WTAR were correlated significantly ( p < .05) with RIST, academic achievement, executive functioning (phonemic fluency), and multiple measures of attention, verbal learning and memory, and visuospatial skills. The WTAR was more consistently and strongly associated with those cognitive outcomes than the RIST. A stepwise linear regression was conducted to examine which of these cognitive domains loaded the highest on the WTAR. The overall attention index was the single most significant contributor to WTAR score, F(1,67) = 23.23, p < .001. Phonemic fluency added a significant proportion to the variance in WTAR scores Δr2 = .10, F (2, 66) = 18.30, p < .001. Conclusions The utility of word reading measures as indicators of premorbid functioning across multiple domains has been recently questioned. The current data suggests that for blast-exposed Veterans, the WTAR is indeed associated with cognitive functioning in attention, learning/memory, and executive functioning, even more so than the RIST. In particular, the WTAR appears related to attention.

Relationships and Evidence-Based Theoretical Perspectives on Persisting Symptoms and Functional Impairment Among Mild Traumatic Brain Injury and Behavioral Health Conditions.

The purpose of this study is to characterize and describe the relationships between symptoms and functional impairment following mild traumatic brain injury (mTBI) and behavioral health conditions (BHCs) in order to inform evidence-based theories on why symptoms and functional impairments persist in some individuals but not others. This is a retrospective, multi-site, cross-sectional study utilizing data collected from a total of 289 Operation Iraqi Freedom/Operation Enduring Freedom Veterans who were classified into diagnostic groups using the symptom attribution and classification algorithm and the VA clinical reminder and comprehensive traumatic brain injury evaluation. The Neurobehavioral Symptom Inventory was used to assess mTBI symptom number and severity. The World Health Organization Disability Assessment Schedule 2.0 was used to assess functional impairment. Symptom profiles differed between diagnostic groups irrespective of symptom attribution method used. Veterans with both mTBI and BHCs and those with BHCs alone had consistently greater number of symptoms and more severe symptoms relative to no symptom and symptoms resolved groups. Symptom number and severity were significantly associated with functional impairment. Both symptom number and functional impairment were significantly associated with the number of mTBI exposures. Together, these results informed evidence-based theories on understanding why symptoms and functional impairment persist among some OEF/OIF Veterans.

Curriculum Implications for Collaborative Practice From Veterans Health Care Sector Social Workers Serving OIF/OEF Veterans

ABSTRACTThis study examined veterans health care social workers’ perceptions of collaboration and practice with Operation Iraqi Freedom and Enduring Freedom veterans with the purpose of developing curriculum implications for social work education. Using a mixed-methods design, including surveys (n=21) and interviews (n=13), associations between serving this veterans cohort and the occurrence of collaboration were assessed. Surveys revealed that reflection on collaborative processes increased when serving this cohort. Interviews identified frequent high acuity in behavioral health conditions and emotionally overwhelmed veterans as contributors to this finding. Curriculum recommendations include infusing content on interprofessional collaboration in practice courses, improved instruction on intervening with colleagues to promote effective client processes and outcomes, and education on developing positive interprofessional climates.

A Rasch analysis of the Neurobehavioral Symptom Inventory in a national cohort of Operation Enduring and Iraqi Freedom veterans with mild traumatic brain injury.

This study investigated the dimensionality and measurement properties of the Neurobehavioral Symptom Inventory (NSI), a 22-item questionnaire of postconcussive symptoms, in a national sample of 9,679 Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans with mild traumatic brain injury. Dimensionality of the NSI was examined using exploratory factor analysis (EFA) and Rasch analysis. Rasch measurement properties, including overall fit, unidimensionality, item level statistics, and category functioning were examined for individual NSI symptom domains identified through EFA. Differential item functioning (DIF) analyses of subgroups based on gender and Posttraumatic Stress Disorder (PTSD) diagnosis were also conducted. Results showed that the NSI items are multidimensional and responses can be differentiated into 3 unidimensional domains reflecting Cognitive, Mood-Behavioral, and Vestibular-Sensory symptoms. All items in each of the 3 subscales demonstrated adequate fit to the Rasch model. In each domain, the item hierarchy was consistent with expectations regarding the theoretical ordering of symptoms. Some problems were observed regarding test targeting for all 3 subscales, such that items were generally concentrated around the mean ability level of the population. As such there were fewer items that differentiated between those at the upper and lower extremes of the scale. Differential item functioning (DIF) based on gender was noted for hearing difficulty. This item on average reflected a higher degree of severity for women than for men. There was no DIF based on PTSD status. Implications for using the NSI as an outcome measure are discussed. (PsycINFO Database Record

Feasibility of a Skills-Based Group Reintegration Workshop for OEF/OIF Veterans: STEP-Home.

To evaluate the feasibility of a newly developed reintegration workshop for Operation Iraqi Freedom/Operation Enduring Freedom (OEF/OIF) Veterans that is based on an evidence-based rehabilitation program shown to be effective in treating mild traumatic brain injury-related symptoms in civilians. Underutilization and resistance to mental health treatment remain a significant problem for OEF/OIF Veterans. Innovative, integrative, transdiagnostic, and acceptable interventions are needed, particularly for this heterogeneous group. Eighty-four OEF/OIF/Operation New Dawn Veterans (74 male and 10 female)-mean age = 35; standard deviation = 7.4. VA Healthcare System. A 12-week, 2-hour/wk, group skills-based workshop with individual skill building to assist all OEF/OIF Veterans (with and without psychiatric and/or traumatic brain injury) in reintegration after military service. Primary outcomes were feasibility measures including treatment fidelity, acceptability, tolerability/adherence, and treatment-related skill acquisition. Secondary outcomes were interest and engagement in future treatment and reintegration status. Veterans' enrollment, adherence, and attrition data indicated that Short-Term Executive Plus adapted for Veteran civilian reintegration (STEP-Home) was acceptable and tolerable. Pre-/postintervention differences in attention, problem-solving, and emotional regulation skills demonstrated treatment-related skills acquisition. Secondary outcome data demonstrated Veterans who were hesitant to participate in mental health treatments before enrollment were more open to treatment engagement after STEP-Home, and reintegration status improved. This study demonstrated that the STEP-Home workshop is feasible in OEF/OIF Veterans and changes in treatment-related skill acquisition and reintegration status were observed. STEP-Home has potential to facilitate readjustment and serves as a gateway to additional, critically needed Veterans Administration services.

Personality Factors and Their Impact on PTSD and Post-traumatic Growth is Mediated by Coping Style Among OIF/OEF Veterans.

Traumatic experiences can trigger negative effects such as post-traumatic stress disorder (PTSD). However, some individuals may also experience positive changes following trauma exposure. These changes are known as post-traumatic growth (PTG). Dispositional and situational factors are likely at play in determining both severity of PTSD symptoms and whether and to what degree an individual experiences PTG. This study examined how coping style and personality traits interact to influence PTSD and PTG. Two hundred and seventy-one Operation Iraqi Freedom/Operation Enduring Freedom veterans not engaged in mental health treatment completed self-report measures of trauma exposure, personality traits, coping styles, PTSD symptoms, and PTG. The study was approved by the Minneapolis VAHCS Institutional Review Board. Adaptive coping and positive personality traits such as openness were positively correlated with PTG. Maladaptive coping and neuroticism were positively correlated with PTSD symptoms. Regression analyses indicated that an inverted-U (quadratic) curve characterized the relationship between PTSD symptoms and PTG; veterans who reported moderate PTSD levels reported the most PTG. Mediation analyses revealed that adaptive coping partially mediated the relationship between openness and PTG. Maladaptive coping partially mediated the relationship between neuroticism and PTSD symptoms. This study demonstrated that coping style mediated relationships between personality traits and post-trauma outcomes. Our findings are subject to the limitations of the self-report and cross-sectional nature of the data. Longitudinal studies, preferably incorporating coping-oriented interventions, could convincingly demonstrate the impact of coping style on PTSD and PTG. As coping styles can be modified, our findings nonetheless suggest that coping-oriented clinical intervention has potential to reduce PTSD symptoms and promote positive growth following trauma exposure.

A Dyadic Analysis of PTSD and Psychological Partner Aggression Among U.S. Iraq and Afghanistan Veterans: The Impact of Gender and Dual-Veteran Couple Status.

Posttraumatic stress disorder (PTSD) symptoms have been repeatedly linked to intimate partner aggression (IPA), and previous research has suggested that this association may be stronger among veterans and men. However, few studies have examined veteran status and gender as moderators of the association between PTSD and psychological IPA, taking both partners' perspectives into account (i.e., within a dyadic framework). The current study aimed to address this limitation by using dyadic multilevel modeling to examine the association between PTSD symptoms and psychological IPA perpetration among a sample of 159 Operation Iraqi Freedom and Operation Enduring Freedom veterans and their partners (N = 318 participants). Findings revealed that both one's own and one's partner's PTSD symptoms were positively associated with greater psychological IPA. In addition, the effects of partner PTSD symptoms on psychological IPA perpetration differed across gender and veteran status. Results suggested that the association of partner PTSD and IPA perpetration may be stronger for male veterans than for female veterans. Findings from the current study are consistent with previous research showing associations between PTSD and IPA, and have clinical implications for treatment of PTSD and IPA among Operation Iraqi Freedom and Operation Enduring Freedom veterans.

Diagnostic Accuracy of the Veteran Affairs' Traumatic Brain Injury Screen

ObjectiveTo comprehensively estimate the diagnostic accuracy and reliability of the Department of Veterans Affairs (VA) Traumatic Brain Injury (TBI) Clinical Reminder Screen (TCRS). DesignCross-sectional, prospective, observational study using the Standards for Reporting of Diagnostic Accuracy criteria. SettingThree VA Polytrauma Network Sites. ParticipantsOperation Iraqi Freedom, Operation Enduring Freedom veterans (N=433). Main Outcome MeasuresTCRS, Comprehensive TBI Evaluation, Structured TBI Diagnostic Interview, Symptom Attribution and Classification Algorithm, and Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale. ResultsForty-five percent of veterans screened positive on the TCRS for TBI. For detecting occurrence of historical TBI, the TCRS had a sensitivity of .56 to .74, a specificity of .63 to .93, a positive predictive value (PPV) of 25% to 45%, a negative predictive value (NPV) of 91% to 94%, and a diagnostic odds ratio (DOR) of 4 to 13. For accuracy of attributing active symptoms to the TBI, the TCRS had a sensitivity of .64 to .87, a specificity of .59 to .89, a PPV of 26% to 32%, an NPV of 92% to 95%, and a DOR of 6 to 9. The sensitivity was higher for veterans with PTSD (.80–.86) relative to veterans without PTSD (.57–.82). The specificity, however, was higher among veterans without PTSD (.75–.81) relative to veterans with PTSD (.36–.49). All indices of diagnostic accuracy changed when participants with questionably valid (QV) test profiles were eliminated from analyses. ConclusionsThe utility of the TCRS to screen for mild TBI (mTBI) depends on the stringency of the diagnostic reference standard to which it is being compared, the presence/absence of PTSD, and QV test profiles. Further development, validation, and use of reproducible diagnostic algorithms for symptom attribution after possible mTBI would improve diagnostic accuracy.

Supplemental Material for A Rasch Analysis of the Neurobehavioral Symptom Inventory in a National Cohort of Operation Enduring and Iraqi Freedom Veterans With Mild Traumatic Brain Injury

Supplemental Material for A Rasch Analysis of the Neurobehavioral Symptom Inventory in a National Cohort of Operation Enduring and Iraqi Freedom Veterans With Mild Traumatic Brain Injury

POWER-A Telehealth Rehabilitation Program for Veterans: Feasibility and Preliminary Efficacy

Combat veterans experience high rates of traumatic brain injury (TBI) and related comorbidities. In addition to the deficits arising from the injury, veterans often experience a myriad of psychosocial impairments including post-traumatic stress symptoms (PTSS) and depression; however, utilization of mental health services or cognitive rehabilitation can be limited given the unique needs of the Operation Iraqi and Operation Enduring Freedom (OEF/OIF) veterans, most notably, family and work constraints. Results of this study support the feasibility of utilizing telehealth for cognitive rehabilitation in a group of veterans with a diagnosis of mild traumatic brain injury. Veterans reported high levels of satisfaction and perceived self-efficacy because they were able to stick with the program. Outcome measures including the Test of Memory and Learning (TOMAL-2nd Edition) and the Behavior Rating of Executive Function-Adult version (BRIEF-A) yielded moderate improvements in memory and some aspects of self-repo...

Self-Stigma and Veteran Culture.

Self-stigma is a salient concept in mental health care. Consequences of self-stigma include increased morbidity and decreased engagement with the health care system. Cultural factors may affect self-stigma and its consequences. This article utilizes the Giger and Davidhizar transcultural assessment model to explore veteran culture and self-stigma. Veterans have their own cultural values that can affect nursing care. Operation Iraqi Freedom and Operation Enduring Freedom veterans are seeking care in community settings more often than within the VA system; therefore, all nurses should be aware of the cultural needs of veterans including the impact of self-stigma.

Posttraumatic stress disorder and somatic complaints: Contrasting Vietnam and OIF/OEF Veterans' experiences

ObjectiveTo replicate and expand upon the relationship of somatic symptoms and posttraumatic stress disorder (PTSD) by comparing symptoms among service eras in US Veterans. MethodData were collected from 226 Vietnam and 132 Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans who were referred to a Veterans Affairs (VA) hospital PTSD outpatient clinic between 2005 and 2013. Veterans were administered self-report inventories and a clinical interview to measure somatic symptoms and PTSD severity. A subset of Veterans (n=185) screening positive for PTSD were administered the Clinician Administered PTSD Scale (CAPS) to measure PTSD severity. Multiple moderated linear regressions were used to examine the influence of service era on the relationship between somatic and PTSD symptoms. ResultsThere were no significant differences between service eras in pain severity, pain interference, and total somatic symptoms reported. Vietnam Veterans were more likely to report limb/join pain (p<.05), fainting (p<.01), and shortness of breath (p<.001), whereas OIF/OEF Veterans were more likely to complain of headaches (p<.001). A significant interaction effect occurred between service era and dizziness (p<.05) and chest pain (p<.01), with OIF/OEF Veterans reporting higher levels of these symptoms significantly more likely than Vietnam Veterans to also experience more severe PTSD. ConclusionFindings are consistent with previous research demonstrating the relationship of somatic symptoms and PTSD across service eras but provide additional data concerning similarities and differences of somatic symptoms between eras. Potential explanations for observed service era differences in somatic symptoms are discussed.

Postconcussive symptom overreporting in Iraq/Afghanistan Veterans with mild traumatic brain injury.

A comprehensive evaluation, including the assessment of neurobehavioral symptoms, has been instituted at the Department of Veterans Affairs (VA) healthcare system to address the large number of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans returning with mild traumatic brain injuries (mTBIs). The Validity-10 is measure of symptom overreporting embedded within the Neurobehavioral Symptom Inventory, a component of the comprehensive evaluation that assesses postconcussive symptom severity. The Validity-10 is composed of 10 unlikely/low-frequency items and a validated cutoff score to identify postconcussive symptom overreporting. We examined the items and cutoff used in the initial development and validation study of the Validity-10 through retrospective chart reviews of 331 treatment-seeking Veterans who sustained an mTBI. The Validity-10 exhibited significant relationships with psychiatric variables, VA service connection, and neuropsychological performance validity (all p < 0.01), but nonsignificant relationships with demographic and injury variables (all p > 0.05). Furthermore, the Validity-10 modestly predicted neuropsychological performance validity test failure over and above psychiatric comorbidities and VA service connection. The present study supports the use of the Validity-10 to assess symptom validity in treatment-seeking OIF/OEF Veterans with a history of mTBI.

Posttraumatic Stress Disorder Symptoms, Traumatic Reminders, and Partner Aggressive Tendencies Among Veterans

This study examined whether laboratory exposure to traumatic reminders potentiated the relationship between veterans’ posttraumatic stress disorder (PTSD) symptoms and intimate partner aggression (IPA) articulations elicited during an anger-induction task. The sample included 82 male Operation Iraqi Freedom/Operation Enduring Freedom veterans. The Articulated Thoughts in Simulated Situations (ATSS) procedure was used to assess physical IPA articulations (i.e., expressions of physically aggressive intentions toward the partner) and verbal IPA articulations (i.e., statements intended to insult or demean the partner) made during “relationship anger” provoking scenarios. Participants were administered versions of the ATSS both with and without trauma cue presentation. Results indicated that trauma cue exposure potentiated the relationship between veterans’ PTSD symptoms and physical IPA articulations, but did not strengthen the significant relationship between PTSD symptoms and verbal IPA articulations. Findings contribute to the literature on veterans’ PTSD symptoms and IPA perpetration by highlighting the influence of traumatic reminders.

Psychiatric comorbidity effects on compensatory cognitive training outcomes for veterans with traumatic brain injuries.

To investigate the influence of posttraumatic stress disorder (PTSD) diagnosis, and PTSD and depression severity, on the postconcussive symptom trajectory over the course of a 1-year study period. Secondary analysis of a randomized controlled trial comparing veterans who received supported employment combined with compensatory cognitive training to those who received supported employment only. Assessments were conducted at baseline, 3- (postintervention), 6-, and 12-months. Participants were 50 Operation Enduring and Iraqi Freedom (OEF/OIF) veterans with a history of mild to moderate traumatic brain injury (TBI) who were unemployed, seeking work, and who had neuropsychological impairment. Of all participants, 74% met diagnostic criteria for PTSD. All participants received supported employment and half of the sample also received Cognitive Symptom Management and Rehabilitation Therapy (CogSMART), a 12-session, manualized compensatory cognitive training intervention. Veterans with PTSD and greater depression severity endorsed significantly more severe postconcussive symptomatology at all assessment time points. However, the rate of CogSMART-associated improvement in postconcussive symptoms did not differ as a result of psychiatric symptomatology. Study results suggest that for veterans with a history of mild to moderate TBI, presence of comorbid PTSD or depressive symptoms should not preclude participation in cognitive rehabilitation interventions.

Auricular Acupuncture for Sleep Disturbance in Veterans With Post-Traumatic Stress Disorder: A Feasibility Study

The purpose of this study was to examine the feasibility and acceptability of an auricular acupuncture (AA) insomnia regimen among Operation Iraqi Freedom and Operation Enduring Freedom veterans with post-traumatic stress disorder and sleep disturbance. Secondarily, this study examined the effect of an AA insomnia regimen on objective sleep times by wrist actigraphy, subjective sleep times by sleep diary, and sleep quality ratings utilizing the Pittsburg Sleep Quality Index. Veterans (n = 30) were randomized to receive a 3-week AA insomnia regimen. Veterans receiving the AA insomnia regimen reported it as a more acceptable treatment for sleep disturbance than subjects in the control group (AA group median = 5 vs. control group median = 3, p = 0.004). Significant differences between groups were found on the sleep quality and daytime dysfunction components of the Pittsburgh Sleep Quality Index (p = 0.003, p = 0.004). No other significant differences between groups were found for objective and subjective sleep measures. These results suggest that an AA insomnia regimen may improve sleep quality and daytime dysfunction among veterans with post-traumatic stress disorder. Future, large-scale, prospective clinical trials are needed to examine AA effects on sleep.

E-mental health preferences of Veterans with and without probable posttraumatic stress disorder.

Mental health care practices supported by electronic communication, referred to as e-mental health, offer ways to increase access to mental health resources. In recent years, e-mental health interventions using clinical video teleconferencing, Internet-based interventions, social networking sites, and telephones have emerged as viable, cost-effective methods to augment traditional service delivery. Whereas some research evaluates attitudes about e-mental health, few studies have assessed interest in using these approaches in a contemporary sample of U.S. Veterans. This study sought to understand willingness to use e-mental health in a diverse group of Veterans residing in Hawaii. Mailed surveys were completed by 600 Operation Iraqi Freedom/Operation Enduring Freedom Veterans and National Guard members. Results suggest that overall willingness to use e-mental health ranged from 32.2% to 56.7% depending on modality type. Importantly, Veterans who screened positive for posttraumatic stress disorder (PTSD) were significantly less likely to report willingness to use each e-mental health modality than their peers without PTSD, despite their greater desire for mental health services. These results suggest that despite solutions to logistical barriers afforded via e-mental health services, certain barriers to mental health care may persist, especially among Veterans who screen positive for PTSD.

Correlates of Intimate Partner Violence Perpetrated by Female Partners of Operation Iraqi Freedom and Operation Enduring Freedom Veterans

The problem of intimate partner violence (IPV) is increasingly being studied among military populations, although there is a dearth of research examining IPV perpetrated against male veterans by their female partners. Returning veterans and their partners face several unique difficulties, including psychological and relationship distress, which may be important factors related to the partners’ perpetration of IPV. This study investigates correlates of psychological and physical IPV perpetrated by female partners of male Operation Iraqi Freedom and Operation Enduring Freedom (OEF) veterans. Specifically, the correlates examined include female partners’ relationship satisfaction, depressive symptoms, and posttraumatic stress disorder (PTSD) symptoms as well as veterans’ relationship satisfaction, PTSD symptoms, and psychological and physical IPV perpetration. Results indicated several significant correlates of female partners’ psychological and physical IPV perpetration, including veterans’ psychological and physical IPV, veterans’ and partners’ relationship satisfaction, and veterans’ PTSD symptoms. In regression analyses, veterans’ psychological IPV was the only unique predictor of female partners’ psychological IPV, and veterans’ physical IPV was the only unique predictor of female partners’ physical IPV. Findings emphasize the role of veteran factors in their partners’ IPV perpetration.