Post-Deployment Health Assessment Research Articles

Sex Differences in Screening Positive for Post-Traumatic Stress Disorder After Combat Injury.

U.S. military women were at risk of combat exposure and injury from asymmetric warfare during the conflicts in Iraq and Afghanistan. Previous research has yielded mixed results when examining sex differences in PTSD following operational deployment. To date, no study has explored sex differences in PTSD after combat injury. This retrospective study included U.S. military service men and women who experienced a combat injury in Iraq or Afghanistan (March 2003 to March 2013) and completed a Post-Deployment Health Assessment (PDHA) within 1 year of injury. The PDHA is administered at the end of deployment and includes the 4-item Primary Care PTSD Screen. The prevalence of screening positive for PTSD was evaluated by sex using a chi-square test. Multivariable logistic regression was used to assess the association between sex and PTSD while adjusting for covariates. The study sample included 16,215 injured military personnel (666 women and 15,549 men). The average time between injury and PDHA was 132 days (SD = 91.0). Overall, women had a higher prevalence of screening positive for PTSD than men (48.3% vs. 40.9%, P < .001). In multivariable regression, women had higher odds than men of screening positive for PTSD (odds ratio, 1.34; 95% confidence interval, 1.14-1.57). Psychiatric history was the strongest predictor of screening positive for PTSD regardless of sex (odds ratio, 1.59; 95% confidence interval, 1.45-1.74). In this novel study of military service members, women were more likely to screen positive for PTSD than men after combat injury. Strategies to mitigate PTSD, enhance resiliency, and incorporate psychological care into injury rehabilitation programs for women may be needed for future U.S. military conflicts where they will play a larger role in combat operations.

Increased Risk of Monoclonal Gammopathy of Undetermined Significance in US Military Service Members: A Case-Control Study of 1,068 Service Members Deployed to Either Europe or Iraq, with or without Reported Burn Pit and Toxic Smoke Exposure

Background:Monoclonal Gammopathy of Undetermined Significance (MGUS) is a plasma cell disorder which may lead to and in all cases precedes multiple myeloma (MM). Although, the etiology of MGUS is unknown, multiple studies have shown an association between MGUS and pesticide exposure (Kachuri et al, Int. J. Cancer 2013). Furthermore, soldiers and First Responders may be at higher risk of developing MGUS as evidenced by a 2.4-fold increased risk for MGUS in Vietnam Veterans exposed to Agent Orange (Landgren et al, JAMA Oncol. 2015) and a 1.8-fold higher risk in World Trade Center (9/11 attacks)-exposed fire fighters compared to reference populations (Landgren et al, JAMA Oncol. 2018). US Service Members deployed to the Southwest Asia theater of military operations (e.g., Iraq and Afghanistan) may have been exposed to various airborne hazards including smoke and fumes from open burn pits (chemical, paint, munitions, petroleum, plastic, rubber, medical, human, and food waste), oil well fires, and aircraft fuel/exhaust. Researchers are currently investigating the long-term consequences from these exposures. We were motivated to determine whether US Service Members deployed to Iraq were at increased risk of developing MGUS. Methods: Serum samples and clinical data (N=1,068) were attained from the Armed Forces Health Surveillance Division (AFHSD), the central epidemiologic health registry and biorepository for the US Military after IRB exemptions were granted. A total of 534 US Service Members who deployed to Iraq between January 1, 2005 and June 30, 2007 and reported burn pit exposure, smoke, burning trash, etc. on their post-deployment health assessment form (exposed cases) were matched 1:1 to 534 Members deployed to Germany (matched controls) who were never deployed to Southwest Asia and denied toxic exposure. All cases were deployed ≥ 6 months, were ≥ 35 years old at time of deployment, remained in the military ≥ 10 years and had serum available in the AFHSD repository 10 years after deployment. Matched criteria included deployment year (+/- 10 years), age (+/- 3 years), sex, service branch, military rank, and occupation category. The 10-year post-deployment samples underwent laboratory testing to screen for monoclonal protein by immunofixation (IFE) using pentavalent antisera with positive samples confirmed and typed using IFE gels (Sebia) and for serum free light chains (sFLC; Sebia) performed on the DYNEX Agility platform. IFE-positive samples underwent serum protein electrophoresis (SPEP) quantification by capillary electrophoresis (Sebia). Results:The median age of exposed Service Members was 37 years (range: 35-52) and 37 years (range: 35-55) for controls (Table 1). In both cohorts, the frequency of White (64.8%), Black (18.7%), Hispanic (7.5%), and male (89%) patients were the same as was the distribution of military occupation, rank, and service branch. The median number of days deployed for exposed vs controls was 243 and 852, respectively. There was no statistically significant difference between burn pit exposed and controls in the combined prevalence of MGUS (IFE+ monoclonal protein) and light chain (LC) MGUS (abnormal sFLC ratio), 6.7% (95% Confidence Interval (CI): 4.8-9.2%) vs 5.4% (95% CI: 3.7-7.7%), respectively (p=0.22). Similarly, there was no difference in prevalence when assessing IFE+ or sFLC+ cases separately (Table 2). The prevalence of MGUS or LC-MGUS for all 1,068 Service Members was 6.1% (95% CI: 4.7-7.7%). Conclusion:In our cohort of 534 Service Members deployed to Iraq and exposed to burn pits and other airborne toxic hazards (cases) there was no statistically significant difference in the prevalence of MGUS compared to 534 deployed to Germany (matched controls). Interestingly, the overall prevalence of MGUS/LC-MGUS in this combined deployed population was 6.1%. When taking into account that the median age at deployment was 37 years and samples were attained 10 years later (approximately at an age of 47 years), the observed prevalence is 3-fold higher than that reported in the Icelandic iStopMM study (2% in the 41-50 -year age group). Future studies are needed to further elucidate causes for the increased prevalence of MGUS/LC-MGUS in deployed US Military Service Members. This contents is the sole responsibility of the authors and do not necessarily reflect the views, opinions or policies of the US Government nor endorsement of commercial products mentioned.

Long Term Cancer Risk of U.S. Service Members Exposed to Burn Pits during Military Deployment to Iraq from 2006-2008: A Retrospective Cohort Study

Introduction: Burn pits have known individual carcinogenic byproducts, including polyaromatic hydrocarbons and volatile organic compounds, which have a presumptive link between deployment exposure and tumorigenesis. However, there are a dearth of epidemiologic data describing the long-term cancer incidence in U.S. service members who were exposed to burn pits during deployment to Iraq. A retrospective cohort study was carried out with the goal of assessing long-term cancer risk in service members who deployed to Iraq and reported exposure to burn pits. Methods: Data were collected from the Armed Forces Health Surveillance Division. Inclusion criteria were any service member who deployed to Iraq (Joint Base Balad or Camp Taji) between January 1st, 2005 to June 30th, 2007, whose deployment lasted at least 180 days, who reported burn pit exposure on their post-deployment health assessment form, who were at least 35 years old at the time of their deployment, who remained in the military for at least 10 years post-deployment, and who had post-deployment serum available in the DoD Serum Repository. Controls were individually matched to the research cohort by age (+/- 3 years), sex, branch of service, rank, and occupation category. To minimize confounding from the “healthy deployer effect”, controls were also required to have deployed to Germany for at least 180 days, and to have been at least 35 years old at the time of their deployment. Controls could not have ever deployed to Southwest Asia or reported burn pit exposure. Cancer incidence was captured via ICD-9 and -10 codes of 140-209 and C00-C96, respectively. Primary endpoint was assessment of serum monoclonal gammopathy in deployed, exposed personnel vs. non- deployed controls. The secondary endpoint was assessment of long-term neoplasia development via ICD-code, which is reported here. A Fisher test was used for comparison of post- deployment malignancies between deployed/exposed service members and controls. This study was exempt from full IRB review and funded by Murtha Cancer Center Research Program. Results: 534 deployed/exposed service members and 534 matched controls met inclusion criteria. Median age at deployment was 37 (range: 35-55). Most service members were white enlisted males in the Army. Mean follow up from the end of deployment was 14 years for deployed/exposed members and 10 years for controls. In each cohort, 39 service members (7%) developed malignancy post-deployment (p=1.0), of which solid tumors were exceedingly more common as shown in Table 1. Only two hematologic malignancies were diagnosed, both in the deployed/exposed cohort, consisting of multiple myeloma and a lymphoid malignancy. There were no differences in the number of service members with multiple primary tumor types between the exposed and unexposed groups. There were also no differences in the number of service members with anemia, hypercalcemia or kidney disease; however, exposed personnel were more likely to develop obesity after their deployment (n=171 vs. 159, p=0.002). Serum monoclonal gammopathy results will be reported separately. Conclusions: Service members who deployed to Iraq between 2006-2008 for at least 180 days, who reported burn pit exposure, and who were followed for an average of 14 years post deployment did not have higher rates of plasma cell disorders or any other malignancy than matched controls who deployed to Germany. Limitations of epidemiologic studies on service members include response bias on post-deployment health assessment forms, inability to capture service members who leave the military, and lack of details on Veterans seeking healthcare through the VA system or civilian healthcare system. It is possible that with a more expansive patient cohort that includes Veterans and longer follow up, that a difference in cancer incidence could emerge. Further research is needed to better understand cancer risk factors in service members. Disclaimer: The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of Uniformed Services University of the Health Sciences (USUHS), The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the Department of Defense (DoD) or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.

The Effect ofConcussion Mechanism ofInjury onSleep Problems inActive Duty Service Members Following Deployment.

Sleep disruption is pervasive in the military and is generally exacerbated during deployment, partially due to increases in operational tempo and exposure to stressors and/or trauma. In particular, sleep disruption is a commonly reported symptom following deployment-related traumatic brain injury (TBI), though less is known about the prevalence of sleep disturbance as a function of whether the TBI was induced by high-level blast (HLB) or direct impact to the head. TBI assessment, treatment, and prognosis are further complicated by comorbidity with posttraumatic stress disorder (PTSD), depression, and alcohol misuse. Here, we examine whether concussion mechanism of injury is associated with differences in the prevalence of self-reported sleep disturbance following deployment in a large sample of U.S. Marines while accounting for probable PTSD, depression, and alcohol misuse. This was a retrospective cohort study of active duty enlisted Marines with a probable concussion (N = 5757) who completed the Post-Deployment Health Assessment between 2008 and 2012. Probable concussion was defined as endorsement of a potentially concussive event with corresponding loss or alteration of consciousness. The presence of concussion-related sleep problems was assessed with a dichotomous item. Probable PTSD, depression, and alcohol misuse were assessed using the Primary Care PTSD Screen, the Patient Health Questionnaire-2, and the Alcohol Use Identification Test-Concise, respectively. Logistic regression models investigated the effects of mechanism of injury (HLB vs. impact), PTSD, depression, and alcohol misuse on the presence of sleep problems, adjusting for sex and pay grade. The study was approved by the Naval Health Research Center Institutional Review Board. Approximately 41% of individuals with a probable deployment-related concussion reported sleep problems following the event; 79% of concussed individuals reporting both HLB and probable PTSD reported sleep problems. All main effects were significantly associated with sleep disturbance in adjusted models. PTSD showed the strongest association with sleep disturbance (adjusted odds ratio [AOR] = 2.84), followed by depression (AOR = 2.43), HLB exposure (AOR = 2.00), female sex (AOR = 1.63), alcohol misuse (AOR = 1.14), and pay grade (AOR = 1.10). A significant HLB × PTSD interaction emerged (AOR = 1.58), which suggests that sleep disturbance was elevated among those with both HLB-induced (vs. impact-induced) concussions and presence (vs. absence) of PTSD. No other significant interactions emerged. To our knowledge, this is the first study to examine the prevalence of concussion-related sleep complaints following deployment as a function of the mechanism of injury in individuals with and without probable PTSD and depression. Individuals with HLB-induced concussion were twice as likely to report sleep problems as those with an impact-induced concussion. Future work should examine these effects longitudinally with validated measures that assess greater precision of exposure and outcome assessment (e.g., blast intensity and type of sleep disturbance).

Self-Reported Symptoms in U.S. Marines Following Blast- and Impact-Related Concussion.

Recent research on traumatic brain injury (TBI) has suggested that the mechanism of injury (i.e., whether the TBI was caused by high-level blast [HLB] vs. direct physical impact to the head) may be an important factor in injury severity, symptomology, and recovery because of differences in physiological effects of each type of injury on the brain. However, differences in self-reported symptomology resulting from HLB- vs. impact-related TBIs have not been thoroughly examined. This study tested the hypothesis that HLB- and impact-related concussions result in different self-reported symptoms in an enlisted Marine Corps population. All records of 2008 and 2012 Post-Deployment Health Assessment (PDHA) forms completed by enlisted active duty Marines between January 2008 and January 2017 were examined for self-reported concussion, mechanism of injury, and self-reported symptoms experienced during deployment. Concussion events were categorized as either blast- or impact-related; individual symptoms were categorized as neurological, musculoskeletal, or immunological. A series of logistic regressions were performed to examine associations between self-reported symptoms experienced by healthy controls and Marines who endorsed (1) any concussion (mTBI), (2) a probable blast-related concussion (mbTBI), and (3) a probable impact-related concussion (miTBI); analyses were also stratified by PTSD. To determine if there were significant differences between odds ratios (ORs) for mbTBIs vs. miTBIs, 95% CIs were examined for overlap. Marines with a probable concussion, regardless of the mechanism of injury, were significantly more likely to report all symptoms (OR range: 1.7-19.3). Overall, mbTBIs, compared with miTBIs, resulted in higher odds of symptom reporting for eight symptoms on the 2008 PDHA (tinnitus, trouble hearing, headache, memory problems, dizziness, dim vision, trouble concentrating, and vomiting) and six symptoms on the 2012 PDHA (tinnitus, trouble hearing, headaches, memory problems, balance problems, and increased irritability), all of which were in the neurological symptom category. Conversely, odds of symptom reporting were higher for Marines experiencing miTBIs (vs. mbTBIs) for seven symptoms on the 2008 PDHA (skin diseases or rashes, chest pain, trouble breathing, persistent cough, red eyes, fever, and other) and one symptom on the 2012 PDHA (skin rash and/or lesion), all of which were in the immunological symptoms category. mbTBI (vs. miTBI) was consistently associated with greater odds of reporting tinnitus, trouble hearing, and memory problems, regardless of PTSD status. These findings support recent research suggesting that the mechanism of injury may play an important role in symptom reporting and/or physiological changes to the brain after concussion. The results of this epidemiological investigation should be used to guide further research on the physiological effects of concussion, diagnostic criteria for neurological injuries, and treatment modalities for various concussion-related symptoms.

The Persistence of Blast- Versus Impact-Induced Concussion Symptomology Following Deployment.

To examine the persistence of concussion-related symptoms following injury as a function of mechanism of injury (high-level blast [HLB] vs impact) and low-level blast (LLB) exposure among Marines. Upon return from deployment and approximately 6 months later, respectively, Marines completed the Post-Deployment Health Assessment and Post-Deployment Health Re-Assessment in an operational or clinic setting. Data from active duty enlisted Marines who completed both assessments (n = 102 075) and who reported a potentially mild traumatic brain injury (mTBI)-inducing event and completed an mTBI screen (n = 8106) were analyzed. This was a retrospective cohort study of Marines deployed between 2008 and 2012. Marines were categorized into groups with relatively high versus low risk for occupational risk of LLB exposure. A mixed model analysis of variance was used to examine the number of symptoms Marines reported experiencing during deployment as a function of probable concussion, HLB exposure, occupational risk, type of symptom, and time of measurement. Self-reported deployment exposures including HLB, probable mTBIs, and occupational risk of LLB exposure were identified. Outcomes included the proportion of neurological, musculoskeletal, and immunological symptoms for which Marines reported seeking care during and following deployment were analyzed. Probable HLB-induced mTBIs (vs impact-induced) were associated with significantly more neurological symptoms at return from deployment and approximately 6 months later. Although symptom reporting decreased at statistically equivalent rates regardless of mechanism of injury, those with a probable HLB-induced concussion continued to report elevated symptomology post-deployment. Additionally, Marines with probable concussion working in occupations with LLB exposure reported elevated levels of persistent neurological symptoms. Both HLB and LLB exposure were associated with neurological symptoms that persisted following deployment. These findings suggest that blast-induced brain injuries may be fundamentally different from impact-induced injuries, and that additional screening and symptomatic treatment for blast-exposed patients may be warranted.

Time Since Injury as a Factor in Post-Concussion Symptom Reporting among Military Service Members with Blast-Related Concussion.

Over the last decade, much research has been devoted to concussion among military personnel. Post-concussion symptoms after blast-related concussion are common, but it is unknown whether symptom reporting differs over time. This study's objective was to assess the relationship between time since injury and post-concussion symptom reporting. We conducted a retrospective review of existing records to identify service members who experienced blast-related concussion during deployment between 2007 and 2012 and who responded to a Post-Deployment Health Assessment (PDHA). The study population included 3690 military personnel grouped by time between injury and PDHA completion: 1-90 days (45.3%, n = 1,673), 91-180 days (33.0%, n = 1,216), or 181-365 days (21.7%, n = 801). Post-concussion symptoms assessed on the PDHA included headache, tinnitus, memory problems, concentration problems, difficulty making decisions, irritability, dizziness, and sleep problems. All post-concussion symptoms were higher for 91-180 days and 181-365 days after injury relative to 1-90 days, with the exception of dizziness. After adjustment for loss of consciousness, mental health comorbidity, and other covariates, the odds of reporting three or more post-concussion symptoms were significantly higher in those who completed the PDHA 91-180 days (odds ratio: 1.29; 95% confidence interval: 1.09-1.51) or 181-365 days after injury (odds ratio: 1.33; 95% confidence interval: 1.09-1.61), compared with the 1-90 days group. These findings suggest that refinements to in-theater medical care may be needed to reduce post-concussion symptom burden and improve the prospect of concussion recovery.

Symptom profiles following combat injury and long-term quality of life: a latent class analysis.

The purpose of this study was to identify symptom profiles among U.S. military personnel within 1year after combat injury and assess the relationship between the symptom profiles and long-term quality of life (QoL). The study sample consisted of 885 military personnel from the Expeditionary Medical Encounter Database who completed (1) a Post-Deployment Health Assessment (PDHA) within 1year following combat injury in Iraq or Afghanistan, and (2) a survey for the Wounded Warrior Recovery Project (WWRP), a longitudinal study tracking patient-reported outcomes (e.g., QoL) in injured military personnel. Fifteen self-reported symptoms from the PDHA were assessed using latent class analysis to develop symptom profiles. Multivariable linear regression assessed the predictive effect of symptom profiles on QoL using the physical (PCS) and mental (MCS) component summary scores from the 36-Item Short Form Survey included in the WWRP. Time between PDHA and WWRP survey ranged from 4.3 to 10.5years (M = 6.6, SD = 1.3). Five distinct symptom profiles were identified: low morbidity (50.4%), multimorbidity (15.6%), musculoskeletal (14.0%), psycho-cognitive (11.1%), and auditory (8.9%). Relative to low morbidity, the multimorbidity (β = - 5.45, p < 0.001) and musculoskeletal (β = - 4.23, p < 0.001) profiles were associated with lower PCS, while the multimorbidity (β = - 4.25, p = 0.002) and psycho-cognitive (β = - 3.02, p = 0.042) profiles were associated with lower MCS. Multimorbidity, musculoskeletal, and psycho-cognitive symptom profiles were the strongest predictors of lower QoL. These profiles can be employed during screening to identify at-risk service members and assist with long-term clinical planning, while factoring in patient-specific impairments and preferences.

Headache complexity (number of symptom features) differentiates post-traumatic from non-traumatic headaches.

Post-traumatic headaches are a common sequela of mild traumatic brain injury (concussion). It is unclear whether or how these headaches differ phenotypically from primary headaches. Determine whether there is an overarching unobserved latent trait that drives the expression of observed features of post-traumatic headache and other headaches. Data from this post-hoc analysis come from the Warrior Strong Cohort Study conducted from 2010 through 2015. Approximately 25,000 soldiers were screened for concussion history at routine post-deployment health assessments. A random sample was invited to participate, enrolling 1567. Twelve observed headache phenotypic features were used to measure "headache complexity", the latent trait of clinical interest, using single factor confirmatory factor analysis. We compared headache complexity between groups and determined whether headache complexity predicted accessing medical care for headache. Of 1094 soldiers with headaches, 198 were classified as having post-traumatic headache. These headaches were compared to those in the other soldiers (647 without concussion history and 249 with concussion history). Soldiers with post-traumatic headache had greater endorsement of all 12 headache features compared to the soldiers with non-concussive headaches. The confirmatory factor analysis showed good model fit (χ2 (51) = 95.59, p = 0.0002, RMSEA = 0.03, comparative fit index = 0.99, and Tucker-Lewis index = 0.99), providing empirical support for the headache complexity construct. Soldier groups differed in their mean headache complexity level (p < 0.001) such that post-traumatic headache soldiers had greater headache complexity compared to non-concussed soldiers (standardized mean difference = 0.91, 95% confidence interval: 0.72-1.09, p < 0.001 and to concussed soldiers with coincidental headaches standardized mean difference = 0.75, 95% confidence interval: 0.53-0.96, p < 0.001). Increasing headache complexity predicted medical encounters for headache (odds ratio = 1.87, 95% confidence interval: 1.49-2.35, p < 0.001) and migraine (odds ratio = 3.74, 95% confidence interval: 2.33-5.98, p < 0.001) during the year following deployment.Conclusions and relevance: The current study provided support for a single latent trait, characterized by observed headache symptoms, that differentiates between concussive and non-concussive headaches and predicts use of medical care for headache. The single trait confirmatory factor analysis suggests that post-traumatic headaches differ from non-concussive headaches by severity more than kind, based on the symptoms assessed.ClinicalTrials.gov identifier NCT01847040.

Prevalence of Tinnitus and Association with Self-Rated Health among Military Personnel Injured on Combat Deployment.

Tinnitus is an auditory problem frequently reported by military personnel and is currently responsible for 1 billion dollars annually in disability compensation. Recent military conflicts in Iraq and Afghanistan saw high levels of combat exposure coupled with a surge in blast weaponry, both of which can adversely affect hearing. The present study explored the prevalence of tinnitus and the association with self-rated health among military personnel injured during combat deployment. A total of 1,026 U.S. military personnel who sustained an injury during operations (592 battle blast, 73 battle nonblast, 361 nonbattle) in Iraq were identified from clinical records. Post-Deployment Health Assessments administered at two separate points in time were used to identify self-reported tinnitus symptoms and self-rated health within 1 year of injury. Those with a battle blast injury had the highest prevalence of tinnitus with 19.1% and 31.3% on the first and second health assessments, respectively. In a multivariate model adjusting for combat exposure, concussion, posttraumatic stress disorder, and other covariates, tinnitus was associated with lower self-rated health for both the first (odds ratio [OR]=3.31, 95% confidence interval [CI]=2.07-5.30, P<0.001) and second assessments (OR=2.52, 95% CI=1.76-3.61, P<0.001). Tinnitus is a common source of impairment among military personnel injured during combat deployment and is associated with poorer self-rated health. Future research should determine whether timing of assessment is linked to symptom recognition or reporting, and what interventions are best suited for ameliorating the negative impact of tinnitus.

Self-Reported Concussion Symptomology during Deployment: Differences as a Function of Injury Mechanism and Low-Level Blast Exposure.

Traumatic brain injury (TBI), which can result from either direct impact to the head or blast exposure, has been the leading cause of morbidity and mortality in recent military conflicts. However, little research has compared mTBIs by mechanism of injury. The present research addressed two research questions: (1) Are blast-related mTBIs (mbTBIs) associated with significantly more symptoms than impact-related mTBIs (miTBIs), and (2) are mTBIs associated with more self-reported symptoms among service members with higher (vs. lower) risk of low-level blast (LLB) exposure. We obtained data from 181,423 active duty enlisted United States Marines deployed between 2003 and 2012, who completed the Post-Deployment Health Assessment. We examined the self-reported symptoms of Marines who completed an mTBI screen and could be classified as at high or low risk for LLB exposure, using their military occupation as a proxy (n = 12,013). Symptoms were compared as a function of blast exposure (blast vs. impact), probable mTBI (yes vs. no), occupational risk of LLB (high vs. low), and symptom type (neurological vs. musculoskeletal vs. immunological). Overall, musculoskeletal symptoms were reported more frequently than neurological and immunological symptoms. However, Marines with probable mTBIs (regardless of mechanism of injury) and those with probable mbTBIs specifically reported more neurological symptoms, which rose to the level of musculoskeletal symptom reporting. Among Marines with probable mTBI, those with high risk of LLB exposure also reported significantly more neurological symptoms. Our results indicate that mbTBIs and miTBIs may be fundamentally different, and that LLB may increase susceptibility to injury.

Testing the effects of using a behavioral health provider to deliver a routine post-deployment assessment for soldiers returning from combat.

Studies indicate that changes in postdeployment behavioral health care delivery are necessary to improve symptom-reporting and treatment-seeking. The present study compared two behavioral health strategies implemented during the Post-Deployment Health Assessment (PDHA) with soldiers within the first months of returning from a combat deployment. A quasi-experimental, longitudinal study compared soldiers (N = 1,612) interviewed by a behavioral health (BH) provider and soldiers (N = 1,326) interviewed by a primary care provider using the standard PDHA procedure. Surveys pre- and post-PDHA and four months later assessed treatment-seeking attitudes; PDHA data and BH clinic use were compiled and compared by each interview strategy. Soldiers interviewed by a BH provider rated interview usefulness, quality, and comfort reporting BH concerns more positively than soldiers interviewed by a primary care provider using the standard procedure. However, there were no differences in treatment-seeking attitudes, provider referral rates, or use of BH services in the 4 months after the PDHA. Although there were initial positive reports of the interview with the BH Provider, there was no evidence BH provider interviews resulted in any lasting improvements in treatment-seeking or long-term treatment attitudes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Characterization of lifetime TBIs in a cohort of recently deployed soldiers: The warrior strong study.

To describe and characterize the lifetime history of traumatic brain injury (TBI) among active duty soldiers returning from deployment to Afghanistan or Iraq. Data were extracted from a larger parent study that was conducted at two large United States Army bases between 2009 and 2014 during Post-Deployment Health Assessment. The sample included 1,060 soldiers who sustained at least one TBI during their lifetime. The Ohio State University TBI-Identification Method interview was administered to characterize individuals' total lifetime history of TBI. Soldiers reported sustaining a median of 2 lifetime TBIs. Slightly more than half of the sample without a most recent deployment-related TBI still reported a history of a lifetime TBI (some of which occurred during previous deployments). Most lifetime injuries reported were of mild severity; however, 6% of individuals reported a history of moderate/severe TBI. Blast was the most frequent mechanism associated with recent deployment-related mild TBIs. Findings suggest that soldiers who screened positive, as well as those who screened negative, for a history of TBI during their recent deployment still endorsed a lifetime history of TBI. Future research is needed to explore the functional impact of multiple TBIs over one's lifetime to help inform screening, assessment, and treatment among military personnel. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Blast Exposure and Risk of Recurrent Occupational Overpressure Exposure Predict Deployment TBIs.

Traumatic brain injury (TBI) has been the leading cause of morbidity and mortality in recent military conflicts and deployment-related TBIs are most commonly caused by blast. However, knowledge of risk factors that increase susceptibility to TBI following an acute, high-level blast is limited. We hypothesized that recurrent occupational overpressure exposure (ROPE) may be one factor that increases susceptibility to mild TBI (mTBI) following blast. Using military occupational specialty as a proxy, we examined the effects of high versus low ROPE on mTBI following blast exposure. Initial analyses included 111,641 active-duty-enlisted U.S. Marines who completed the 2003 or 2008 version of the Post-Deployment Health Assessment. Final analyses examined probable mTBI screens among Marines with at least one qualifying exposure as a function of whether the exposure was a blast and level of ROPE (N=12,929). This study was approved by the Institutional Review Board at the Naval Health Research Center. Blast and ROPE were both independently and jointly associated with a probable mTBI. Marines who experienced a blast (vs other qualifying exposure) and those in high (vs low) risk occupations were 1.07 and 1.23 times more likely to sustain a probable mTBI, respectively. Furthermore, among those who experienced a blast during deployment, those in high-risk occupations were 1.45 times more likely than those in low-risk occupations to sustain a probable mTBI. Blast exposure and ROPE were independently associated with mTBIs, and Marines with both blast exposure during deployment and ROPE were especially likely to sustain an mTBI. This suggests that ROPE heightens the risk of mTBI following blast. Ongoing research is examining the severity, symptomology, and sequelae of TBIs as a function of ROPE.

Post-traumatic stress disorder and hypertensive disorders of pregnancy among military women.

Women are more likely to develop post-traumatic stress disorder (PTSD) than men. Limited research exists evaluating the risk of hypertensive disorders of pregnancy (HDP) among military women with PTSD. We conducted a retrospective cohort study using US Department of Defense (DoD) data comprised of all active-duty women giving birth to their first, liveborn singleton infant using DoD-sponsored health insurance from 1 January 2004 to 31 December 2008 (n=34176). Birth hospitalisation records, maternal mental health visits, and Post-Deployment Health Assessment (PDHA) and Reassessment (PDHRA) screenings were included. The HDP outcome (yes vs no) was defined using ICD-9-CM codes in the maternal birth hospitalisation record. Women fit into one of four PTSD exposure categories (confirmed, probable, possible, none). Confirmed cases had a PTSD ICD-9-CM diagnosis code. Probable/possible cases were classified using PDHA screening items. We used multiple log-linear regression to assess PTSD (confirmed, any vs none) and the risk of HDP overall, and then explored effect modification by military service and demographic variables. We assessed the risk of HDP among deployed mothers with PTSD (confirmed, probable/possible vs none) who completed a PDHA, and explored effect modification by race/ethnicity. We also assessed risk of HDP with differing PTSD lead times. Overall, PTSD was not associated with HDP except among mothers whose PTSD was diagnosed ≥1year prior to conception (RR1.42, 95% CI 1.06, 1.90). Post-traumatic stress disorder preceding conception by at least a year appeared to confer an increased risk of HDP, but further research is needed using more thorough PTSD assessment.

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

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. Population-based data of US Marines returning from deployment between 2004 and 2013 were analyzed, using the Post-Deployment Health Assessment. 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%. 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.

Race/Ethnicity and Traumatic Brain Injury: Are There Disparities in Positive Screenings and Diagnoses Among Service Members Returning From Afghanistan and Iraq?

The authors examine racial/ethnic differences in screening positive for traumatic brain injury (TBI) and in diagnosis among service members upon returning from war in Afghanistan and Iraq. Using data from the Post-Deployment Health Assessment and Re-Assessment, and military health-care encounters from 2008 to 2009, they estimate logistic regressions in a sample of 46,488 service members. Hispanic and Asian service members do not differ from White service members in screening positive for TBI but have 19% and 33% lower odds of diagnosis, respectively. Compared to White service members, Black service members are less likely to screen positive for TBI immediately after deployment and about as likely 3–6 months later, yet have 27% lower odds of diagnosis. Further, racial/ethnic minority service members have a lower probability of TBI diagnosis than White service members at all self-reported symptom levels, suggesting there is a discrepancy between symptoms and diagnosis related to race/ethnicity.

Role of Department of Defense Policies in Identifying Traumatic Brain Injuries Among Deployed US Service Members, 2001-2016.

To examine the role of Department of Defense policies in identifying theater-sustained traumatic brain injuries (TBIs). We conducted a retrospective study of 48 172 US military service members who sustained their first lifetime TBIs between 2001 and 2016 while deployed to Afghanistan or Iraq. We used multivariable negative binomial models to examine the changes in TBI incidence rates following the introduction of Department of Defense policies. Two Army policies encouraging TBI reporting were associated with an increase of 251% and 97% in TBIs identified following their implementation, respectively. Among airmen, the introduction of TBI-specific screening questions to the Post-Deployment Health Assessment was associated with a 78% increase in reported TBIs. The 2010 Department of Defense Directive Type Memorandum 09-033 was associated with another increase of 80% in the likelihood of being identified with a TBI among soldiers, a 51% increase among sailors, and a 124% increase among Marines. Department of Defense and service-specific policies introduced between 2006 and 2013 significantly increased the number of battlefield TBIs identified, successfully improving the longstanding problem of underreporting of TBIs.

Defense and Veterans Brain Injury Center: The First 25 Years

Defense and Veterans Brain Injury Center: The First 25 Years

Assessment of Deployment-Related Exposures on Risk of Incident Mental Health Diagnoses Among Air Force Medical Service Personnel: Nested Case-Control Study.

Recent military conflicts in Iraq (Operation Iraqi Freedom), Afghanistan (Operation Enduring Freedom), and elsewhere have been associated with psychological impacts among military personnel. However, relatively little is known about the relationship between those conflicts and psychological health of military health care professionals. Previous work has shown certain demographic factors associated with diagnosed mental health conditions after deployment. However, unique exposures in the deployed environment may be present that are also associated. Understanding the relationship between the demographic factors, exposures, and post-deployment mental health (PDMH) conditions has not been investigated. The purpose of this study was to determine the association between occupational and/or environmental exposures and incident PDMH conditions in a defined population of United States Air Force health care personnel returning from the deployed environment (i.e., deployment-related exposures). A nested case-control study compared cohort members with (N = 4,114) and without (N = 14,073) a PDMH condition in terms of deployment-related occupational and/or environmental exposures. PDMH conditions were identified using the electronic health record and exposures were determined using post-deployment health assessments. Demographic-adjusted multivariable logistic regression models were used to compute odds ratios (ORs). The final regression model comprised five exposure and 12 demographic variables. Reported exposures were not strongly associated with incident PDMH conditions (OR ranged from 1.22 to 1.38) and were lower than some demographic factors. Demographic characteristics with relatively large effect sizes (ORs less than 0.5 or greater than 1.5) included the protective factors of Air Force Guardsman (OR: 0.45), reservists (OR: 0.34), and surgeons (OR: 0.32), as well as the risk factor of nurses (OR: 1.51). All model parameters had a p-value less than 0.0001 and the area under the receiver operating characteristic curve was 0.668. Given the low area under the receiver operating characteristic, the final statistical model had only marginal performance in its ability to correctly identify cases. Thus, other factors should be studied to identify additional predictors for PDMH conditions.