Prevalence of a Positive Screen for PTSD Among OEF/OIF and OEF/OIF‐Era Veterans in a Large Population‐Based Cohort

Multiple studies have reported the prevalence of posttraumatic stress disorder (PTSD) in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans; however, these studies have been limited to populations who use the Department of Veterans Affairs (VA) for health care, specialty clinic populations, or veterans who deployed. The 3 aims of this study were to report weighted prevalence estimates of a positive screen for PTSD among OEF/OIF and nondeployed veterans, demographic subgroups, and VA health care system users and nonusers. The study analyzed data from the National Health Study for a New Generation of U.S. Veterans, a large population‐based cohort of OEF/OIF and OEF/OIF‐era veterans. The overall weighted prevalence of a positive screen for PTSD in the study population was 13.5%: 15.8% among OEF/OIF veterans and 10.9% in nondeployed veterans. Among OEF/OIF veterans, there was increased risk of a positive screen for PTSD among VA health care users (OR = 2.71), African Americans (OR = 1.61), those who served in the Army (OR = 2.67), and those on active duty (OR = 1.69). The same trend with decreased magnitude was observed in nondeployed veterans. PTSD is a significant public health problem in OEF/OIF‐era veterans, and should not be considered an outcome solely related to deployment.     

Sleep Variability in Military‐Related PTSD: A Comparison to Primary Insomnia and Healthy Controls

Sleep disturbances are prevalent in posttraumatic stress disorder (PTSD) and are associated with a number of adverse health consequences. Few studies have used comprehensive assessment methods to characterize sleep in Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn (OEF/OIF/OND) veterans with PTSD. OEF/OIF/OND veterans with PTSD and sleep disturbance (n = 45) were compared to patients with primary insomnia (n = 25) and healthy control subjects (n = 27). Participants were assessed using questionnaire‐based measures as well as daily subjective and objective measures of sleep. The 3 groups were compared with regard to (a) group means, (b) intraindividual (i.e., night‐to‐night) variability of sleep, and (c) interindividual (i.e., within‐group) variability of sleep. In terms of group means, only objective sleep efficiency was significantly worse with PTSD than with primary insomnia (d = 0.54). Those with PTSD differed from those with primary insomnia on measures of intraindividual as well as interindividual variability (d = 0.48–0.73). These results suggested sleep symptoms in OEF/OIF/OND veterans with PTSD are more variable across nights and less consistent across patients relative to sleep symptoms in insomnia patients without PTSD. These findings have implications for research, as well as for personalizing treatment for individuals with PTSD.     

A Preliminary Study of an Internet‐Based Intervention for OEF/OIF Veterans Presenting for VA Specialty PTSD Care

This preliminary study sought to evaluate the feasibility and potential effectiveness of a cognitive–behavioral, web‐based intervention for posttraumatic stress in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans who are not able to participate, or not eligible to participate, in evidence‐based posttraumatic stress disorder (PTSD) treatments. The study used an uncontrolled pre‐posttest design with a sample of 24 OEF/OIF veterans presenting to a VA PTSD specialty clinic. Participants used the afterdeployment.org, Post‐Traumatic Stress (PTS) Workshop, which was supplemented with brief weekly telephone calls. Half of the participants (n = 12) completed at least 5 of the 8 workshop sessions. At posttreatment, 40.0% of completers demonstrated reliable reductions on PTSD symptoms and overall d = 1.04. Treatment satisfaction and acceptability was generally positive based on Likert ratings. This web‐based intervention for PTS appears to be a feasible and potentially helpful intervention for veterans who may not otherwise receive psychosocial interventions. Given the minimal resources required and the potential reach, this web‐based intervention could be a viable addition to services provided to OEF/OIF veterans seeking PTSD specialty care. Efforts to further develop and more rigorously evaluate this approach are warranted.     

Feasibility and Desirability of Web‐Based Mental Health Screening and Individualized Education for Female OEF/OIF Reserve and National Guard War Veterans

Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Reserve and National Guard (RNG) service members have an increased risk for postdeployment mental health (MH) and readjustment problems, yet most do not access needed care. It is unknown if RNG servicewomen experiencing postdeployment readjustment symptoms are aware these may signify treatable MH concerns or if this knowledge activates care‐seeking. The aims of this proof‐of‐concept study were to determine the feasibility of web‐based MH screening for postdeployment MH symptoms to inform individualized psychoeducation, and to assess user perceptions about the online instrument and process, MH care access, and VA and other MH care. A midwestern sample (N = 131) of recently deployed (past 24 months) OEF/OIF RNG Army and Air Force servicewomen participated. High rates of combat experiences (95%) and military sexual trauma (50%) were reported. Positive screens for key symptoms of MH problems were prevalent. One third (31%) of satisfaction survey completers indicated online information reduced discomfort with seeking MH care; 42% reported they would subsequently seek MH assessment. Participants interviewed by telephone indicated that stigma and limited knowledge about women‐specific services were key reasons servicewomen do not use MH care. This study demonstrated web‐based screenings with individualized psychoeducation are implementable and favorable to RNG servicewomen.     

Traumatic Brain Injury and Suicidal Ideation Among U.S. Operation Enduring Freedom and Operation Iraqi Freedom Veterans

Traumatic brain injury (TBI) is associated with suicidal behavior among veterans, and gender differences in the strength of associations may exist. Almost all research has been limited to Veterans Health Administration (VHA) patients, and it is unclear if findings generalize to veterans who do not use VHA services. We examined gender‐ and VHA‐user‐specific associations between TBI related to deployment and postdeployment suicidal ideation in a U.S. national sample of 1,041 female and 880 male Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. Path analysis was used to estimate TBI and suicidal ideation association, and examine PTSD and depression symptomatology in these associations. TBI was associated with suicidal ideation among male VHA users, OR = 3.64, 95% CI [2.21, 6.01]; and male and female nonusers, OR = 2.24, 95% CI [1.14, 4.44] and OR = 2.65, 95% CI [1.26, 5.58], respectively, in unadjusted analyses. This association was explained by depression symptoms among male and female nonusers. Among male VHA users an association between TBI and suicidal ideation remained when accounting for depression symptoms, OR = 2.50, 95% CI [1.33, 4.71]. Our findings offered evidence of an association between TBI and suicidal ideation among male OEF/OIF VHA users.     

A Systematic Review of Dropout From Psychotherapy for Posttraumatic Stress Disorder Among Iraq and Afghanistan Combat Veterans

A significant number of veterans of the conflicts in Iraq and Afghanistan have posttraumatic stress disorder (PTSD), yet underutilization of mental health treatment remains a significant problem. The purpose of this review was to summarize rates of dropout from outpatient, psychosocial PTSD interventions provided to U.S. Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) veterans with combat‐related PTSD. There were 788 articles that were identified which yielded 20 studies involving 1,191 individuals eligible for the review. The dropout rates in individual studies ranged from 5.0% to 78.2%, and the overall pooled dropout rate was 36%, 95% CI [26.20, 43.90]. The dropout rate differed marginally by study type (routine clinical care settings had higher dropout rates than clinical trials) and treatment format (group treatment had higher dropout rates than individual treatment), but not by whether comorbid substance dependence was excluded, by treatment modality (telemedicine vs. in‐person treatment), or treatment type (exposure therapy vs. nonexposure therapy). Dropout is a critical aspect of the problem of underutilization of care among OEF/OIF/OND veterans with combat‐related PTSD. Innovative strategies to enhance treatment retention are needed.     

Deployment Risk and Resilience Inventory‐2 (DRRI‐2): An Updated Tool for Assessing Psychosocial Risk and Resilience Factors Among Service Members and Veterans

The Deployment Risk and Resilience Inventory (DRRI) is a widely used instrument for assessing deployment‐related risk and resilience factors among war veterans. A revision of this instrument was recently undertaken to enhance the DRRI's applicability across a variety of deployment‐related circumstances and military subgroups. The resulting suite of 17 distinct DRRI‐2 scales is the product of a multiyear psychometric endeavor that involved (a) focus groups with Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans to inform an assessment of the content validity of original DRRI measures, (b) examination of item and scale characteristics of revised scales in a national sample of 469 OEF/OIF veterans, and (c) administration of refined scales to a second national sample of 1,046 OEF/OIF veterans to confirm their psychometric quality. Both classical test theory and item response theory analytical strategies were applied to inform major revisions, which included updating the coverage of warfare‐related stressors, expanding the assessment of family factors throughout the deployment cycle, and shortening scales. Finalized DRRI‐2 scales demonstrated strong internal consistency reliability and criterion‐related validity. The DRRI‐2 can be applied to examine the role that psychosocial factors play in postdeployment health and inform interventions aimed at reducing risk and enhancing resilience among war veterans.     

Sexual Trauma and Combat During Deployment: Associations With Suicidal Ideation Among OEF/OIF/OND Veterans

Compelling evidence has emerged on the association between military sexual trauma and suicide attempt; however, research investigating how sexual trauma during deployment relates to suicidal ideation has received considerably less attention and has yielded mixed findings. Furthermore, such research has not accounted for other types of trauma that may occur during deployment. Our objectives were to examine whether sexual trauma during deployment was associated with recent suicidal ideation, adjusting for exposure to combat. Our sample included 199 Operation Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) veterans entering inpatient trauma‐focused treatment who completed the Beck Scale for Suicide Ideation (Beck & Steer, 1991) and the Deployment Risk and Resilience Inventory Sexual Harassment and Combat Experiences Scales (King, King, Vogt, Knight, & Samper, 2006). Deployment‐related sexual trauma was significantly associated with recent suicidal ideation, adjusting for age and gender (β = .18, η_p² = .03) and additionally for combat (β = .17, η_p² = .02). These findings underscore the importance of assessing for deployment‐related sexual trauma when assessing suicide risk in OEF/OIF/OND veterans in inpatient settings.     

Posttraumatic stress disorder, substance use disorders, and medical comorbidity among returning U.S. veterans

Evidence suggests that posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are associated with poorer physical health among U.S. veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). No research of which we are aware has examined the independent and interactive effects of PTSD and SUD on medical comorbidity among OEF/OIF veterans. This cross-sectional study examined medical record data of female and male OEF/OIF veterans with ≥ 2 Veterans Affairs primary care visits (N = 73,720). Gender-stratified logistic regression analyses, adjusted for sociodemographic factors, were used to examine the association of PTSD, SUD, and their interaction on the odds of medical diagnoses. PTSD was associated with increased odds of medical diagnoses in 9 of the 11 medical categories among both women and men, range of odds ratios (ORs) ranged from 1.07 to 2.29. Substance use disorders were associated with increased odds of 2 of the 11 medical categories among women and 3 of the 11 medical categories among men; ORs ranged from 1.20 to 1.74. No significant interactions between PTSD and SUD were detected for women or men. Overall, findings suggest that PTSD had a stronger association with medical comorbidity (in total and across various medical condition categories) than SUD among female and male OEF/OIF veterans.     

Structured Approach Therapy for Combat‐Related PTSD in Returning U.S. Veterans: Complementary Mediation by Changes in Emotion Functioning

To address the impact of combat‐related posttraumatic stress disorder (PTSD) on U.S. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans, the investigators developed a 12‐session manualized PTSD treatment for couples called structured approach therapy (SAT). A randomized controlled trial had shown that 29 OEF/OIF veterans with combat‐related PTSD who had participated in SAT showed significantly greater reductions in PTSD compared to 28 veterans receiving a 12‐session PTSD family education intervention (Sautter, Glynn, Cretu, Senturk, & Vaught, 2015). We conducted supplemental follow‐up and mediation analyses, which tested the hypothesis that changes in emotion functioning play a significant role in the decreases in PTSD symptoms primarily observed in veterans who had received SAT. Veterans assigned to the SAT condition showed significantly greater decreases than those assigned to PTSD family education in emotion regulation problems (p < .001, Cohen's f² = .18) and fear of intense emotions (p < .001, Cohen's f² = .152). Decreases in both emotion regulation problems (mediated effect:= .36), and fear of intense emotions (mediated effect: = .24) were found to be complementary mediators of reductions in PTSD symptoms greater with SAT. These findings suggest that SAT may aid veterans in improving their ability to regulate trauma‐related emotions.     

Barriers and Facilitators of Mental Health Treatment‐Seeking in U.S. Active Duty Soldiers With Sexual Assault Histories

Despite significant mental health needs among sexual assault (SA) victims in the military, little is known about treatment‐seeking patterns or factors associated with service use. This study examined service use behavior, barriers, and facilitators of mental health treatment‐seeking in an active duty sample of 927 U.S. Army soldiers with mental health problems. SA victims (n = 113) did not differ from non‐victims on barriers or facilitators after adjusting for demographic and mental health variables, with stigma rated as the largest barrier. Most SA victims (87.6%) had sought informal support and 59.3% had sought formal treatment. One third of treatment‐seekers had dropped out of treatment. Multivariate logistic regression analyses identified several correlates of treatment‐seeking among SA victims: Black race (OR = 7.57), SA during the military (OR = 4.34), positive treatment beliefs (OR = 2.22), social support for treatment (OR = 2.14), self‐reliance (OR = 0.47), and stigma towards treatment seekers (OR = 0.43). Mental health symptoms were not associated with treatment seeking. Findings suggested that treatment‐facilitating interventions should focus on improving recognition of mental health symptoms, altering perceptions related to self‐reliance, and reducing stigma. Interventions should also enlist support for treatment‐seeking from unit members, leaders, and significant others.     

Surveying Treatment Preferences in U.S. Iraq–Afghanistan Veterans With PTSD Symptoms: A Step Toward Veteran‐Centered Care

This study examined health care barriers and preferences among a self‐selected sample of returning U.S. veterans drawn from a representative, randomly selected frame surveyed about posttraumatic stress disorder (PTSD) symptomatology and mental health utilization in the prior year. Comparisons between treated (n = 160) and untreated (n = 119) veterans reporting PTSD symptoms were conducted for measures of barriers and preferences, along with logistic models regressing mental health utilization on clusters derived from these measures. Reported barriers corroborated prior research findings as negative beliefs about treatment and stigma were strongly endorsed, but only privacy concerns were associated with lower service utilization (B = ?0.408, SE = 0.142; p = .004). The most endorsed preference (91.0%) was for assistance with benefits, trailed by help for physical problems, and particular PTSD symptoms. Help‐seeking veterans reported stronger preferences for multiple interventions, and desire for services for families (B = 0.468, SE = 0.219; p = .033) and specific PTSD symptoms (B = 0.659, SE = 0.302; p = .029) were associated with increased utilization. Outcomes of the study suggested PTSD severity drove help‐seeking in this cohort. Results also support the integration of medical and mental health services, as well as coordination of health and benefits services. Finally, the study suggested that outreach about privacy protections and treatment options could well improve engagement in treatment.     

Deployment Experiences,Social Support,and Mental Health: Comparison of Black,White, and Hispanic U.S. Veterans Deployed to Afghanistan and Iraq

Compared to their White counterparts, Black and Hispanic Vietnam‐era, male, combat veterans in the United States have experienced discrimination and increased trauma exposure during deployment and exhibited higher rates of postdeployment mental health disorders. The present study examined differences in deployment experiences and postdeployment mental health among male and female Black, Hispanic, and White veterans deployed in support of Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom in Iraq. Data were drawn from a national survey of veterans (N = 924) who had returned from deployment within the last 2 years. Ethnoracial minority veterans were compared to White veterans of the same gender on deployment experiences and postdeployment mental health. The majority of comparisons did not show significant differences; however, several small group differences did emerge (.02 < η² < .04). Ethnoracial minority veterans reported greater perceived threat in the warzone and more family‐related concerns and stressors during deployment than White veterans of the same gender. Minority female veterans reported higher levels of postdeployment symptoms of anxiety than their White counterparts, which were accounted for by differences in deployment experience. These differences call for ongoing monitoring.     

Gender Differences in Posttraumatic Stress Symptoms Among OEF/OIF Veterans: An Item Response Theory Analysis

Establishing whether men and women tend to express different symptoms of posttraumatic stress in reaction to trauma is important for both etiological research and the design of assessment instruments. Use of item response theory (IRT) can reveal how symptom reporting varies by gender and help determine if estimates of symptom severity for men and women are equally reliable. We analyzed responses to the PTSD Checklist (PCL) from 2,341 U.S. military veterans (51% female) who completed deployments in support of operations in Afghanistan and Iraq (Operation Enduring Freedom/Operation Iraqi Freedom [OEF/OIF]), and tested for differential item functioning by gender with an IRT‐based approach. Among men and women with the same overall posttraumatic stress severity, women tended to report more frequent concentration difficulties and distress from reminders whereas men tended to report more frequent nightmares, emotional numbing, and hypervigilance. These item‐level gender differences were small (on average d = 0.05), however, and had little impact on PCL measurement precision or expected total scores. For practical purposes, men's and women's severity estimates had similar reliability. This provides evidence that men and women veterans demonstrate largely similar profiles of posttraumatic stress symptoms following exposure to military‐related stressors, and some theoretical perspectives suggest this may hold in other traumatized populations.     

Reported Barriers to Mental Health Care in Three Samples of U.S. Army National Guard Soldiers at Three Time Points

The military community and its partners have made vigorous efforts to address treatment barriers and increase appropriate mental health services use among returning National Guard soldiers. We assessed whether there were differences in reports of treatment barriers in 3 categories (stigma, logistics, or negative beliefs about treatment) in sequential cross‐sectional samples of U.S. soldiers from a Midwestern Army National Guard Organization who were returning from overseas deployments. Data were collected during 3 time periods: September 2007–August 2008 (n = 333), March 2009–March 2010 (n = 884), and August 2011–August 2012 (n = 737). In analyses using discretized time periods and in trend analyses, the percentages of soldiers endorsing negative beliefs about treatment declined significantly across the 3 sequential samples (19.1%, 13.9%, and 11.1%). The percentages endorsing stigma barriers (37.8%, 35.2%, 31.8%) decreased significantly only in trend analyses. Within the stigma category, endorsement of individual barriers regarding negative reactions to a soldier seeking treatment declined, but barriers related to concerns about career advancement did not. Negative treatment beliefs were associated with reduced services use (OR = 0.57; 95% CI [0.33, 0.97]).     

The Impact of Infidelity on Combat‐Exposed Service Members

This study examined relationships between combat‐exposed Operation Enduring Freedom/Operation Iraqi Freedom veterans’ experiences related to infidelity during deployment (i.e., indicating that a partner was unfaithful or reporting concern about potential infidelity) and postdeployment mental health, as well as the role of subsequent stress exposure and social support in these associations. The sample consisted of 571 individuals (338 men). There were 128 participants (22.2%) who indicated that their partners were unfaithful during their most recent deployment. Of the remaining 443 participants, 168 (37.8%) indicated that they were concerned that their partners might have been unfaithful. Individuals who indicated that their partners were unfaithful exhibited higher levels of posttraumatic stress symptomatology (β = .08; f²= .18) and depression symptom severity (β = .09; f² = .14), compared to individuals who did not indicate that their partners were unfaithful. For both men and women, reported infidelity was associated with mental health indirectly via postdeployment life stressors, whereas infidelity concerns were indirectly associated with mental health via postdeployment life stressors for men only. Findings suggested that infidelity can have a significant impact on combat‐exposed veterans’ mental health and highlight the need for additional research on this understudied topic within the military population.     

Mild Traumatic Brain Injury,PTSD, and Psychosocial Functioning Among Male and Female U.S. OEF/OIF Veterans

This study examined the unique and combined relationship between mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) with psychosocial functioning in a cohort of 1,312 U.S. male and female veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) enrolled in the Veterans After‐Discharge Longitudinal Registry (Project VALOR). We assessed mTBI with structured screening questions reflective of current TBI classification standards and PTSD via the SCID‐IV PTSD module; all other variables were assessed by self‐report questionnaires. We identified significant diagnostic group differences in psychosocial functioning for both sexes. Individuals with PTSD, with or without a history of mTBI, reported significantly worse psychosocial functioning than individuals with mTBI alone or neither mTBI nor PTSD (males, η²_p = .11, p < .001; females, η²_p = .14, p < .001), even after adjusting for demographics and severity of chronic pain. The results suggested that veterans experiencing PTSD, regardless of whether they had a history of mTBI, were at increased risk for long‐term psychosocial impairment. Further research examining possible benefits from improved access to resources and treatment to address these needs would be valuable.     

Stigma and Demographic Correlates of Help‐Seeking Intentions in Returning Service Members

Many U.S. Iraq/Afghanistan‐era veterans return from deployment with posttraumatic stress (PTS) symptoms, but few veterans seek psychological help. Research on barriers to care is growing, but the link between stigma and help‐seeking is understudied. The present study examined anticipated enacted stigma from military and nonmilitary sources, self‐stigma, PTS, perceived likelihood of deploying again, marital status, and history of mental health care engagement as correlates of help‐seeking intentions from a mental health professional or medical doctor/advance practice registered nurse (MD/APRN) in a sample of 165 combat veterans. Using structural equation modeling, results demonstrated that self‐stigma was negatively associated with help‐seeking intentions from a mental health professional and MD/APRN with small‐to‐medium effect sizes. Being married was positively associated with help‐seeking intentions from a mental health professional and MD/APRN with small effect sizes. History of previous mental health care engagement was positively associated with help‐seeking intentions from a mental health professional with a medium effect size, but unrelated to help‐seeking intentions from a MD/APRN. Anticipated enacted stigma from any source, PTS, and greater perceived likelihood of deploying again were unrelated to help‐seeking intentions from a mental health professional and MD/APRN. Implications for interventions aimed at decreasing self‐stigma and increasing intention to seek help are discussed.     

The Ending Self‐Stigma for Posttraumatic Stress Disorder (ESS‐P) Program: Results of a Pilot Randomized Trial

Experiences of and concerns about encountering stigma are common among veterans with posttraumatic stress disorder (PTSD). One common and serious consequence is self‐stigma, which is when an individual comes to believe that common negative stereotypes and assumptions about PTSD are true of oneself. The current study was a pilot randomized trial that evaluated the feasibility, acceptability, and preliminary outcomes of the Ending Self‐Stigma for PTSD (ESS‐P) program, a nine‐session group intervention that aims to assist veterans with PTSD learn tools and strategies to address stigma and self‐stigma. Veterans (N = 57) with a diagnosis of PTSD who were receiving treatment in U.S. Veterans Health Administration outpatient mental health programs were recruited. Participants were randomized to either ESS‐P or minimally enhanced treatment as usual and assessed at baseline and after treatment on clinical symptoms, self‐stigma, self‐efficacy, recovery, and sense of belonging. Information on mental health treatment utilization for the 3 months before and after group treatment was also collected. Compared to controls, there was a significant decrease in self‐stigma, d = ?0.77, and symptoms of depression, d = ?0.76, along with significant increases in general and social self‐efficacy, ds = 0.73 and 0.60, respectively, and psychological experience of belonging, d = 0.46, among ESS‐P participants. There were no differences regarding recovery status or changes in treatment utilization. The results of the pilot study suggest that participation in ESS‐P may help reduce self‐stigma and improve self‐efficacy and a sense of belonging in veterans with PTSD.