Post-Deployment Health Reassessment Research Articles

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.

The association of engagement in substance use treatment with negative separation from the military among soldiers with post-deployment alcohol use disorder

BackgroundAlcohol use disorder (AUD) reduces the health of soldiers and the readiness of the Armed Forces. It remains unknown if engagement in substance use treatment in the Military Health System improves retention in the military. MethodsThe sample consisted of active duty soldiers returning from an Afghanistan/Iraq deployment in fiscal years 2008–2010 who received an AUD diagnosis within 150 days of completing a post-deployment health re-assessment survey (n = 4,726). A Heckman probit procedure was used to examine predictors of substance use treatment initiation and engagement in accordance with Healthcare Effectiveness Data and Information Set (HEDIS) criteria. Cox proportional hazard modeling was used to examine the association between treatment engagement and retention, defined as a negative separation for a non-routine cause (e.g., separation due to misconduct, poor performance, disability) from the military in the two years following the index AUD diagnosis. Results40 % of soldiers meeting HEDIS AUD criteria initiated and 24 % engaged in substance use treatment. Among soldiers diagnosed with AUD, meeting criteria for treatment engagement was associated with a significantly higher hazard of having a negative separation compared to soldiers who did not engage in treatment. ConclusionsRates of initiation and engagement in substance use treatment for post-deployment AUD were relatively low. Soldiers with AUD who engaged in substance use treatment were more likely to have a negative separation from the military than soldiers with AUD who did not engage. Our findings imply that in the study cohort, treatment did not mitigate negative career consequences of AUD.

Postdeployment Behavioral Health Screens and Linkage to the Veterans Health Administration for Army Reserve Component Members.

Approximately three to six months after returning from deployment, military service members complete the Post-Deployment Health Reassessment (PDHRA), which includes screens for alcohol misuse, depression, and posttraumatic stress disorder (PTSD). To determine whether Army Reserve Component (RC) members (Army National Guard and Army Reserve) with positive screening scores on the PDHRA receive needed care, the investigators examined the association between positive scores and enrollment and utilization of care ("linkage") in the Veterans Health Administration (VHA), as well as rescreening scores, diagnosis, and behavioral treatment in VHA. Mixed-effects regression models were used to predict linkage to VHA within six months after RC members (N=73,164) completed the PDHRA, with alcohol misuse, depression, and PTSD screen scores as key independent variables. Regression models were stratified by gender and National Guard versus Reserve status. Among those who linked to VHA (N=25,168), screening scores and subsequent diagnosis and treatment in VHA were also examined. Army RC members with positive PTSD and depression screening scores were more likely than those with negative screens to link to VHA, and most (54%-84%) received VHA treatment once diagnosed. Positive screens for alcohol misuse were associated with linkage to VHA for men but not for women, and treatment rates for alcohol use disorders were relatively low (0%-25%) for both men and women diagnosed as having an alcohol use disorder. The finding that Army RC members with greater indications of behavioral health problems linked to VHA is encouraging. However, more outreach and treatment engagement strategies could be directed to those with alcohol use disorder, particularly women.

The Impact of the United States Air Force Deployment Transition Center on Postdeployment Mental Health Outcomes

The United States Air Force Deployment Transition Center (DTC) operates a 2-day third-location decompression program that commenced operations during the summer of 2010 in Ramstein, Germany, with the aim to assist Air Force service members (AFSMs) who are returning from deployment as they prepare to reintegrate back into their home lives and work stations. The present study evaluated the impact of DTC attendance on later mental health outcomes. Because participants are not randomly assigned to attend the DTC, propensity score weighting was used to compare DTC participants (N = 1,573) to a weighted control group of AFSMs (N = 1,570) in the same job specialties who returned from deployment during the same time period. Rates of endorsement to items on the Postdeployment Health Reassessment were examined and compared, as were rates of mental health diagnoses from AFSMs’ official medical records. Key findings indicate that DTC participants reported lower levels of depressive and posttraumatic stress symptoms and lower levels of relationship conflict following return from deployment, as compared to weighted control participants. Mental health diagnostic rates were comparable for the 2 groups during the first 6 months following return from deployment. These findings suggest that participation in the DTC program had notable benefits for redeploying AFSMs and support the continued use of the program.

Posttraumatic stress disorder after combat zone deployment among Navy and Marine Corps men and women.

As more women are deployed into combat environments, preliminary findings have been inconsistent regarding gender differences in symptoms of posttraumatic stress disorder (PTSD) following deployment. Very little is known about the experiences of Navy and Marine Corps personnel deployed to combat zones. The study population consisted of Navy and Marine Corps personnel who completed a Post-Deployment Health Assessment upon return from deployment to Iraq, Afghanistan, or Kuwait during 2008 and 2009 and a Post-Deployment Health Reassessment approximately 6 months later. These instruments included screening questions for PTSD. The final sample of 31,534 service members included 29,640 men and 1,894 women. Within occupation categories, women were overrepresented relative to men in the roles of functional support/administration and healthcare specialists, whereas men were overrepresented in the role of combat specialist. Screening rates were similar by gender, with a slightly higher percentage of women compared with men screening positive for PTSD (6.6% vs. 5.3%). These symptoms of PTSD among men and women in this sample could not be attributed to combat exposure or other deployment-related characteristics. Relative to men, women in this sample had a similar probability of screening positive for PTSD following deployment. These PTSD symptoms were not associated with deployment-related variables, suggesting that deployment to a combat zone does not affect women differently from men. This finding could have meaningful implications for policies surrounding women in the military.

Traumatic brain injury and PTSD screening efforts evaluated using latent class analysis.

To empirically identify latent classes of service members according to persistent postconcussive symptom patterns and to characterize the identified classes relative to other postdeployment variables including posttraumatic stress disorder (PTSD) and mild traumatic brain injury (TBI) screening results. Such comparisons may directly inform policy regarding these routine assessments and translate to improved treatment decisions. Self-report data were obtained for 12,581 combat-exposed male U.S. Navy and Marine Corps personnel who returned from deployment in 2008-2009 and completed a Post-Deployment Health Assessment (PDHA) and an associated Post-Deployment Health Reassessment (PDHRA). Persistent postconcussive symptoms indicated on the PDHRA were used as manifest variables in a latent class analysis yielding 4 distinct classes: systemic, cognitive/behavioral, comorbid, and nonpresenting. Although the nonpresenting class endorsed few or no postconcussive symptoms, the systemic and cognitive/behavioral classes displayed elevated likelihoods of neurological and mental health symptoms, respectively. Members of the comorbid class had an increased probability of reporting a wide range of symptoms across both domains. Characterization of identified classes suggested that class membership may indicate the presence or absence of persistent conditions resulting from head injury and/or mental health issues. Under this assumption, estimated class membership probabilities implied a rate of probable neurological injury among this sample to be 17.9%, whereas the standard assessments aimed at identifying repercussions of mild TBI reported a positive screening rate of only 13.1%. Findings suggest that the routinely administered PDHA and PDHRA appear to underestimate the true prevalence of service members experiencing postdeployment health problems. Supplemental items or an alternative screening algorithm incorporating persistent postconcussive symptoms may enable identification of additional cases requiring treatment following return from deployment.

Co-occurring mental health and alcohol misuse: Dual disorder symptoms in combat injured veterans

ObjectiveService members face difficulties during military deployment potentially resulting in morbidities such as posttraumatic stress disorder (PTSD), depression, and alcohol misuse. The co-occurrence of alcohol misuse and mental health disorders is termed dual disorder and has been associated with adverse outcomes. MethodsThe study included 812 high-risk (i.e., endorsing combat exposure with documented combat injury) male U.S. veterans of Operation Iraqi Freedom, injured between October 2004 and November 2007, identified from the Expeditionary Medical Encounter Database. ResultsPTSD and depression symptoms were significant correlates of alcohol misuse. Veterans with dual disorder symptoms reported a significantly higher mean number of health complaints on the Post-Deployment Health Reassessment compared with those endorsing only mental health symptoms. ConclusionsThese results highlight how mental health disorders among injured service members increases the odds of problem drinking and those with dual disorder have elevated health complaints.

An Examination of the Diagnostic Efficiency of Post‐Deployment Mental Health Screens

To conduct a blinded study to examine the diagnostic efficiency of the Department of Defense (DoD) Post-Deployment Health Reassessment (PDHRA) screens for major depressive disorder (MDD), posttraumatic stress disorder (PTSD), and alcohol abuse. Participants were 148 post-deployed soldiers who were completing the PDHRA protocol. Soldiers' mean age was 27.7 (standard deviation= 6.6) years, and 89.0% were male. Mental health professionals blinded to the PDHRA screening results administered the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition directly after the PDHRA assessment protocol. All screens exhibited excellent negative predictive power. Sensitivity metrics were lower, consistent with the relatively low base rates observed for MDD (10.1%), PTSD (8.8%), and alcohol abuse (5.4%). Metrics obtained for the PTSD screen were consistent with previous research with a similar base rate. A two-item screen containing PTSD reexperiencing and hyperarousal symptom items revealed excellent psychometric properties (sensitivity= .92; specificity= .79). The alcohol abuse screen yielded high sensitivity (.86), but very poor precision; these metrics were somewhat improved when the screen was reduced to a single item. The PDHRA MDD, PTSD, and alcohol abuse screens appear to be functioning well in accurately ruling out these diagnoses, consistent with a population-level screening program. Cross validation of the current results is indicated. Additional refinement may yield more sensitive screening measures within constraints imposed by the low base rates in a typically healthy population.

Comparative Analysis of Mandated Versus Voluntary Administrations of Post-Deployment Health Assessments Among Marines

Little empirical data exist regarding candidness of service members' responses on the mandated Post-Deployment Health Reassessment (PDHRA) administered 3 to 6 months postdeployment. This study reports on the agreement between responses from U.S. Marines on a subset of the military-administered mandatory PDHRA items and answers to the same subset of items embedded in confidential research surveys. Results show that personnel are clearly underreporting certain symptoms and conditions on the mandatory PDHRA. The most dramatic increases in reporting on the research study's PDHRA items, as indicated by the percentage ratio, were for self-harming ideation and concern about harming others, each of which has about 14 times the endorsement percentage on the survey as on the official PDHRA. Lack of agreement for some items may be the result of resolution or onset of more acute conditions, but disagreement on sensitive behavioral concerns suggests that mandated PDHRAs are not effective screens for those domains.

Use of the Air Force Post-Deployment Health Reassessment for the Identification of Depression and Posttraumatic Stress Disorder: Public Health Implications for Suicide Prevention

Military members are required to complete the Post-Deployment Health Assessment on return from deployment and the Post-Deployment Health Reassessment (PHDRA) 90 to 180 days later, and we assessed the PDHRA's sensitivity and specificity in identifying posttraumatic stress disorder (PTSD) and depression after a military deployment among US Air Force personnel. We computed the PDHRA's sensitivity and specificity for depression and PTSD and developed a structural model to suggest possible improvements to it. For depression, sensitivity and specificity were 0.704 and 0.651, respectively; for PTSD, they were 0.774 and 0.650, respectively. Several variables produced significant direct effects on depression and trauma, suggesting that modifications could increase its sensitivity and specificity. The PDHRA was moderately effective in identifying airmen with depression and PTSD. It identified behavioral health concerns in many airmen who did not develop a diagnostic mental health condition. Its low level of specificity may result in reduced barriers to care and increased support services, key components of a public health approach to suicide prevention, for airmen experiencing subacute levels of distress after deployment, which may, in part, account for lower suicide rates among airmen after deployment.

Screening for Alcohol Misuse and Alcohol-Related Behaviors Among Combat Veterans

Screening for Alcohol Misuse and Alcohol-Related Behaviors Among Combat Veterans

Structured Clinical Interview Guide for Postdeployment Psychological Screening Programs

Brief structured clinical interviews are a key component of the Department of Defense postdeployment health reassessment program. Such interviews are critical for recommending individuals for follow-up assessment and care. To standardize the interview process, U.S. Army Medical Research Unit-Europe developed a structured interview guide, designed in response to both clinical requirements and research findings. The guide includes sections on depression, suicidality, post-traumatic stress disorder, anger, relationship problems, alcohol problems, and sleep problems. In addition, there is an open-ended section on other problems and a section for case dispositions. Data from a 2005 blinded validation study with soldiers returning from a 1-year-long combat deployment are included to demonstrate the utility of the structured interview. Guidelines and implementation considerations for the use of the structured interview are discussed.

War's Impact May Not Appear Until Months After Return

War's Impact May Not Appear Until Months After Return

Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War

To promote early identification of mental health problems among combat veterans, the Department of Defense initiated population-wide screening at 2 time points, immediately on return from deployment and 3 to 6 months later. A previous article focusing only on the initial screening is likely to have underestimated the mental health burden. To measure the mental health needs among soldiers returning from Iraq and the association of screening with mental health care utilization. Population-based, longitudinal descriptive study of the initial large cohort of 88 235 US soldiers returning from Iraq who completed both a Post-Deployment Health Assessment (PDHA) and a Post-Deployment Health Re-Assessment (PDHRA) with a median of 6 months between the 2 assessments. Screening positive for posttraumatic stress disorder (PTSD), major depression, alcohol misuse, or other mental health problems; referral and use of mental health services. Soldiers reported more mental health concerns and were referred at significantly higher rates from the PDHRA than from the PDHA. Based on the combined screening, clinicians identified 20.3% of active and 42.4% of reserve component soldiers as requiring mental health treatment. Concerns about interpersonal conflict increased 4-fold. Soldiers frequently reported alcohol concerns, yet very few were referred to alcohol treatment. Most soldiers who used mental health services had not been referred, even though the majority accessed care within 30 days following the screening. Although soldiers were much more likely to report PTSD symptoms on the PDHRA than on the PDHA, 49% to 59% of those who had PTSD symptoms identified on the PDHA improved by the time they took the PDHRA. There was no direct relationship of referral or treatment with symptom improvement. Rescreening soldiers several months after their return from Iraq identified a large cohort missed on initial screening. The large clinical burden recently reported among veterans presenting to Veterans Affairs facilities seems to exist within months of returning home, highlighting the need to enhance military mental health care during this period. Increased relationship problems underscore shortcomings in services for family members. Reserve component soldiers who had returned to civilian status were referred at higher rates on the PDHRA, which could reflect their concerns about their ongoing health coverage. Lack of confidentiality may deter soldiers with alcohol problems from accessing treatment. In the context of an overburdened system of care, the effectiveness of population mental health screening was difficult to ascertain.

Bringing It All Back Home: Social Work and the Challenge of Returning Veterans

The June 2007 DOD Task Force on Mental Health report cited here suggests the current system of care is inadequate and unable to meet the needs of veterans now and into the future. This is so, not only because of a lack of human power, but also because of the underlying theoretical and methodological assumptions on which the system is based. The report states emphatically that the current system is not succeeding in providing successful care for those affected by the current Iraq war or in building resilience among the soldiers and their families as a whole. This report challenges the way that health and mental health care in the United States has been provided, not only to veterans and their families, but also to all of those affected by exposure to violence. In recent years, social workers, and others working in the formal health and mental health sector, have been required to apply a medical model that treats psychosocial issues as though they were diseases, to be managed through dosed therapies designed to reduce symptoms. This medical model is different from the biopsychosocial framework on which social work practice is built and the strengths perspective, which places each person as the subject rather than the object of his or her own life (Robbins, Chatterjee, & Canda, 2006). Therefore, the DOD critiques of the model of care for serving mental health needs of soldiers, veterans, and their families present social work with an important opportunity, if not an obligation. Namely, to bring its methods of inquiry to bear on the problems of reintegrating war veterans into society, as well as understanding and mitigating the effects of exposure to violence on soldiers and civilians alike. The need to build resilience and promote effective reintegration processes for active-duty soldiers, veterans, and their families is not a problem for practitioners alone. It is an issue that requires stringent intellectual inquiry to locate, test, and provide more successful models of intervention, and in so doing, shed light on the contemporary discourse regarding trauma and recovery, violence, and transformation. The task force report (DOD, 2007) provides a detailed account of the scope of the current problem facing the Departments of Defense and Veterans Affairs. According to the report, which uses data from the Post-Deployment Health Reassessment administered to service members from 90 to 120 days after returning from deployment, * 38 percent of soldiers and 31 percent of Marines report psychological symptoms. * 49 percent of returning National Guard members report psychological symptoms. * Hundreds of children have experienced the deployment of one or both parents. * Psychological concerns among family members have yet to be quantified. The report emphasizes the prevalence of co-occurring diagnoses, most frequently posttraumatic stress disorder (PTSD) and traumatic brain injury, sometimes complicated by physical injury and disability. The report states that such a range of injuries require a seamless continuum of biopsychosocial care (DOD, 2007) that is unavailable in the current system. One issue raised by the report is the emerging public health problem presented by a cohort of men and women returning from repeated deployments with untreated mental health and neuropsychological issues. Of greater concern is the loss to the nation of the enormous leadership potential that this returning cohort represents. Viewed through a strengths perspective lens (Scurfield, 2006), these men and women represent essential resources to address current and emerging social, economic, and developmental problems here at home. A BRIEF HISTORY Some history is useful to help us understand how work involving emotional and physical difficulties resulting from the effects of external real-world stressors was ceded to the medical model. The diagnosis of PTSD formally entered the nomenclature in 1980. …

Postdeployment Health Reassessment: A Sustainable Method for Brigade Combat Teams

The Postdeployment Health Reassessment (PDHRA) was mandated in 2006 and the 3rd Infantry Division was the first unit to perform a large-scale implementation. This article outlines a reproducible model for conducting PDHRA using only existing resources. The PDHRA (DD 2900) screening and referral processes are reviewed and data on positive screens are reported. Of the 12,817 soldiers who participated in the mass screening, 1,460 (11.4%) were referred for behavioral health, 815 (6.4%) for primary care, 71 (0.01%) for specialty services, and 9 (0.001%) for emergency services. Consult requests were higher in maneuver brigades than in support units (12.1% versus 8.6% for behavioral health and 6.9% versus 4.4% for primary care referrals). All (1,460, 100%) of the behavioral health consults were completed on-site and the unit incurred no additional financial cost in conducting this process. This method for performing a large-scale implementation of the PDHRA provides a flexible, efficient, and cost-effective process that could be implemented at the brigade combat team level without difficulty and in most locations without significant impact on other medical demands.