Gender Differences in Service Utilization among OEF/OIF Veterans with Posttraumatic Stress Disorder after a Brief Cognitive–Behavioral Intervention to Increase Treatment Engagement: A Mixed Methods Study

PurposeWomen veterans who served in Iraq and Afghanistan (Operation Enduring Freedom and Operation Iraqi Freedom [OEF/OIF]) have a moderately higher risk of developing posttraumatic stress disorder (PTSD) than male veterans. However, gender disparities in treatment engagement may prevent women veterans from initiating the care they need. Understanding gender differences in predictors of and barriers to treatment is essential to improving engagement and mental health outcomes. The purpose of this study was to examine gender differences in treatment utilization after a brief, cognitive–behavioral therapy (CBT) intervention among male and female OEF/OIF veterans.MethodsParticipants were assigned randomly to either the intervention or control conditions. Intervention participants received the telephone-based CBT intervention. Participants were 35 female and 238 male OEF/OIF veterans who screened positive for PTSD and had never initiated PTSD treatment. Participants were asked about treatment utilization, beliefs about PTSD treatment, and symptoms at months 1, 3, and 6 months subsequent to the baseline telephone assessment. The PTSD Checklist—Military Version was used to assess PTSD and the Patient's Health Questionnaire was used to assess symptoms of depression.FindingsFemale veterans who received an intervention were significantly more likely to have attended treatment over the 6-month follow-up period than male veterans who received an intervention (χ² = 7.91; df = 3; odds ratio, 3.93; p = .04).ConclusionsThe CBT intervention may be a critical mechanism to engage female veterans in treatment. Further research is needed to understand how to engage male veterans with PTSD in treatment.     

Post-traumatic stress disorder, depression, and health-related quality of life in OEF/OIF veterans

Purpose  

Comorbid post-traumatic stress disorder (PTSD) and depression are often associated with negative physical and mental health outcomes in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat veterans. The current study examines the individual contributions of these two disorders on health-related quality of life (HRQoL) in an OEF/OIF cohort. The study hypothesizes that PTSD and depression will each significantly predict lower physical and mental HRQoL even when controlling for overlapping symptoms: anhedonia, concentration, and insomnia.     

Comparison of outpatient health care utilization among returning women and men Veterans from Afghanistan and Iraq

Background  

The number of women serving in the United States military increased during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), leading to a subsequent surge in new women Veterans seeking health care services from the Veterans Administration (VA). The objective of this study was to examine gender differences among OEF/OIF Veterans in utilization of VA outpatient health care services.     

Gender Differences in Response to Acceptance and Commitment Therapy Among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans

BackgroundMost of our knowledge base regarding treatment response among veterans comes from predominantly male samples. Evidence suggests, however, that women and men use different coping strategies, which may impact how effective treatments are for people of different genders. The purpose of this investigation was to examine gender differences in response to acceptance and commitment therapy, an empirically supported transdiagnostic psychotherapy.MethodsData were drawn from a multisite, randomized, controlled trial of acceptance and commitment therapy as compared with a psychotherapy control, namely, present-centered therapy (PCT), in veterans with emotional distress who served in Operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND). Although the original trial did not find a difference between acceptance and commitment therapy and present-centered therapy, we were interested in examining whether gender differences may have been obscured in the original analyses. This secondary analysis included 117 participants for whom at least one post-baseline data point was available and examined the role of gender in treatment response.ResultsGender differences were not observed on the primary outcome of general distress, but were observed in post-traumatic stress disorder symptoms (p < .01).ConclusionsThese preliminary results suggest the possibility of gender differences in psychotherapy response and should motivate additional study of gender-specific care.     

Characterization and Comparison of Physical and Mental Health Profiles and Department of Veterans Affairs Health Care Utilization Patterns among Operation Iraqi Freedom/Operation Enduring Freedom Women Veterans in Puerto Rico versus the United States

BackgroundResearch on the physical and mental health profiles and patterns of health care use among women veterans receiving health care from the Department of Veterans Affairs (VA) on the island of Puerto Rico is lacking.MethodsThis cross-sectional study examines differences in physical and mental health conditions, and patterns of VA health care use, between women veterans of the Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) era who were using VA facilities in Puerto Rico (n = 897) and those using U.S.-based VA facilities (n = 117,216) from 2002 to 2015.ResultsResults of fully adjusted logistic regression models revealed that OIF/OEF women in Puerto Rico had heightened risk for global pain-related disorders (i.e., any pain) (adjusted odds ratio [AOR], 1.45; 95% confidence interval [CI], 1.22–1.71), back pain (AOR, 1.83; 95% CI, 1.56–2.14), diabetes (AOR, 1.42; 95% CI, 1.03–1.95), hyperlipidemia (AOR, 3.34; 95% CI, 2.80–3.98), major depression (AOR, 1.78; 95% CI, 1.53–2.06), and bipolar depression (AOR, 1.66; 95% CI, 1.34–2.04). They also evidenced greater risk for a host of reproductive health conditions and had higher average annual use of VA health care than their U.S. counterparts.ConclusionsOIF/OEF women receiving VA health care in Puerto Rico evidenced a greater burden of physical illness, depression, and heightened use of VA health care services relative to their U.S. counterparts. Providers’ increased awareness of the physical and mental health care needs of this population is warranted. Research efforts that help to identify efficient and effective strategies to provide culturally tailored and/or personalized health care for this population could also be useful.     

Health risk behaviors of Afghanistan and Iraq war veterans attending college

PURPOSE. The population of military veterans attending college is rapidly growing as veterans return from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). We sought to describe patterns of student veterans' health-related behaviors and how they might differ from their nonveteran peers. DESIGN. We analyzed data from the 2008 Boynton College Student Health Survey (CSHS). SETTING. CSHS participants completed an anonymous online survey. SUBJECTS. The CSHS sampled students (n = 8651) attending public, private, 2-year, and 4-year postsecondary educational institutions in Minnesota. MEASURES. The CSHS included items on substance use (including alcohol and tobacco), safety, nutrition, and physical activity. ANALYSIS. We described demographics of OEF/OIF veteran, non-OEF/OIF veteran, and nonveteran students and used Poisson regression to compute adjusted relative risks (ARRs) with 95% confidence intervals (CIs) to characterize associations between veteran status and health behaviors. RESULTS. After controlling for demographics, veteran students reported more safety-, tobacco-, and alcohol-related risk behaviors compared to nonveteran students. For instance, compared to the nonveteran reference group, the ARR for past year smokeless tobacco use and physical fighting among for OEF/OIF veterans was 1.76 (95% CI = 1.31-2.35) and 1.48 (95% CI = 1.22-1.79) respectively. Veteran and nonveteran students display similar weight-related behaviors, though OEF/OIF veteran students were more likely to engage in strengthening exercises. CONCLUSIONS. There are specific health risk behaviors that are particularly relevant for veterans attending postsecondary institutions. As veterans enroll in postsecondary education, there is a unique window of opportunity for health promotion in this population.     

Women at war: understanding how women veterans cope with combat and military sexual trauma

The wars in Iraq (Operation Iraqi Freedom, OIF) and Afghanistan (Operation Enduring Freedom, OEF) have engendered a growing population of US female veterans, with women now comprising 15% of active US duty military personnel. Women serving in the military come under direct fire and experience combat-related injuries and trauma, and are also often subject to in-service sexual assaults and sexual harassment. However, little is known regarding how women veterans cope with these combat and military sexual trauma experiences once they return from deployment. To better understand their experiences, we conducted semi-structured interviews with nineteen OEF/OIF women veterans between January-November 2009. Women veterans identified stressful military experiences and post-deployment reintegration problems as major stressors. Stressful military experiences included combat experiences, military sexual trauma, and separation from family. Women had varying abilities to address and manage stressors, and employed various cognitive and behavioral coping resources and processes to manage their stress.     

Sociodemographic and substance use characteristics associated with typologies and composition of social support networks among youth experiencing homelessness in Los Angeles,USA

Youth experiencing homelessness are a vulnerable population with increased behavioural health risks. Social networks are a consistent correlate of youths’ substance use behaviours. However, less is known about the reciprocal relationships among these constructs. This study classified youth experiencing homelessness according to their social support network type (e.g. instrumental, emotional, service) and composition (e.g. family, peers, service staff) and linked their membership in these social network classes to sociodemographic and substance use characteristics. Four waves of cross‐sectional data were collected between October 2011 and June 2013 from youth experiencing homelessness, ages 14–29, at three drop‐in centres in Los Angeles, CA (N = 1,046). This study employed latent class analysis to identify subgroups of youth experiencing homelessness according to the type and composition of their social support networks. Multinomial logistic regression analyses were then conducted to identify the sociodemographic and substance use characteristics associated with social support network class membership. Five latent classes of youths’ social support networks were identified: (a) high staff emotional and service support; (b) high home‐based peer and family emotional, service and instrumental support; (c) moderate street‐ and home‐based peer emotional support; (d) low or no support and (e) high home‐based peer and family emotional and instrumental support. Multinomial logistic regression models indicated that race/ethnicity, gender, sexual orientation, literal homelessness, former foster care experience, depression, heroin and marijuana use were significant correlates of social support network class membership. Results indicate distinct classes of social support networks among youth experiencing homelessness, with certain sociodemographic and substance use characteristics implicated in youths’ social networks.     

Social Support During Pregnancy Modifies the Association Between Maternal Adverse Childhood Experiences and Infant Birth Size

Introduction Adverse childhood experiences (ACEs) can deleteriously affect health, including pregnancy and birth outcomes occurring later in life. Identification of modifiable factors during pregnancy that buffer the ill effects of adversity is warranted. Social support during pregnancy can promote better birth outcomes, yet it is unknown whether it could also mitigate perinatal risks stemming from ACEs. Thus, this study considers multiple forms of social support in pregnancy as modifiers of an ACEs and fetal growth association. Methods Data were collected from mother and infant pairs from an ongoing prospective birth cohort. Women enrolled around 27 weeks gestation and completed gold-standard assessments of ACEs and social support. Infant cephalization index scores [(head circumference /birthweight)?×?100; a marker of asymmetric fetal growth] were derived. Multivariable regression models tested main effects and interaction between ACEs and social support in relation to infant cephalization. Results Higher levels of ACEs were associated with higher cephalization scores (β?=?0.01, SE?=?0.01, p?<?0.05) whereas higher social support was associated with lower cephalization scores (β?=???0.03, SE?=?0.01, p?<?0.05). A significant interaction was observed showing a protective effect of social support among those with low (0 events) and moderate (1–3 events) ACEs but not among those with high ACEs (4?+?events; p?<?0.05). Tangible and emotional support, but not information support, contributed to the associations. Discussion Maternal ACEs can deleteriously affect birth size, yet social support during pregnancy provides some buffer from its enduring effects. Interventions designed to enhance pregnancy social support may not only improve maternal wellbeing, but may also safeguard infant health.

     

Psychiatric diagnoses in historic and contemporary military cohorts: combat deployment and the healthy warrior effect

Research studies have identified heightened psychiatric problems among veterans of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). However, these studies have not compared incidence rates of psychiatric disorders across robust cohorts, nor have they documented psychiatric problems prior to combat exposure. The authors' objectives in this study were to determine incidence rates of diagnosed mental disorders in a cohort of Marines deployed to combat during OIF or OEF in 2001-2005 and to compare these with mental disorder rates in two historical and two contemporary military control groups. After exclusion of persons who had been deployed to a combat zone with a preexisting psychiatric diagnosis, the cumulative rate of post-OIF/-OEF mental disorders was 6.4%. All psychiatric conditions except post-traumatic stress disorder occurred at a lower rate in combat-deployed personnel than in personnel who were not deployed to a combat zone. The findings suggest that psychiatric disorders in Marines are diagnosed most frequently during the initial months of recruit training rather than after combat deployment. The disproportionate loss of psychologically unfit personnel early in training creates a "healthy warrior effect," because only those persons who have proven their resilience during training remain eligible for combat.     

Partnering with communities to address the mental health needs of rural veterans

Purpose: Many veterans who face mental illness and live in rural areas never obtain the mental health care they need. To address these needs, it is important to reach out to community stakeholders who are likely to have frequent interactions with veterans, particularly those returning from Operations Enduring and Iraqi Freedom (OEF/OIF). Methods: Three community stakeholder groups—clergy, postsecondary educators, and criminal justice personnel—are of particular importance for OEF/OIF veterans living in rural areas and may be more likely to come into contact with rural veterans struggling with mental illness or substance abuse than the formal health care system. This article briefly describes the conceptualization, development, initial implementation, and early evaluation of a Veterans Affairs (VA) medical center‐based program designed to improve engagement in, and access to, mental health care for veterans returning to rural areas. Findings: One year since initial funding, 90 stakeholders have attended formal training workshops (criminal justice personnel = 36; educators = 31; clergy = 23). Two training formats (a 2‐hour workshop and an intensive 2.5‐day workshop) have been developed and provided to clergy in 1 rural county with another county scheduled for training. A veteran outreach initiative, which has received 32 referrals for various student services, has been established on 4 rural college campuses. A Veterans Treatment Court also has been established with 16 referrals for eligibility assessments. Conclusions: While this pilot program is in the early stages of evaluation, its success to date has encouraged program and VA clinical leadership to expand beyond the original sites.     

No one leaves unchanged: insights for civilian mental health care professionals into the military experience and culture

This article aims to elucidate an understanding of military culture and experience, so as to better frame the services offered by civilian clinicians. Service members indoctrinated into such an influential culture can experience adjustment problems upon reentry into the larger society, and thus professional counselors and social workers must be ready to address the reintegration process with veteran clients. Furthermore, this article highlights a few of the major mental health concerns that are prevalent in combat veterans, especially for those returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), and presents a brief overview of treatment modalities implemented both within and outside of the military. Practical therapeutic suggestions for clinicians with little or no knowledge of the military are discussed. The objective is to educate and prepare civilian mental health practitioners to administer culturally sensitive prevention and intervention services to meet the unique needs of this population.     

Small airways disease in an Operation Desert Storm Deployer: Case report and review of the literature on respiratory health and inhalational exposures from Gulf War I

Constrictive Bronchiolitis (CB) has been reported in US Operation Iraqi Freedom/Enduring Freedom (OIF/OEF) deployers but not in those from prior US conflicts. A 62‐year old presented with progressive dyspnea 13 years after deployment to the Persian Gulf in 1991‐1992, where he was exposed to burning oil well fire emissions, dust storms, and other potential airborne hazards. In 2014, after a chest computed tomography (CT) scan demonstrated diffuse mosaic attenuation, he underwent surgical lung biopsy, which revealed CB. Deployers from both GWI and OIF/OEF share many exposures. As respiratory symptoms are a feature associated with Gulf War medically unexplained illness, there may be a role for renewed interest in evaluating GWI Veterans with unexplained respiratory symptoms for conditions such as CB, which may result from exposures relevant to deployers from both conflicts.

     

Effects of Repeated Deployment to Iraq and Afghanistan on the Health of New Jersey Army National Guard Troops: Implications for Military Readiness

Objectives. We assessed the effects of prior military service in Iraq or Afghanistan on the health of New Jersey Army National Guard members preparing for deployment to Iraq.Methods. We analyzed anonymous, self-administered predeployment surveys from 2543 National Guard members deployed to Iraq in 2008. We used bivariate and multivariate analyses to measure the effects of prior service in Afghanistan (Operation Enduring Freedom [OEF]) or Iraq (Operation Iraqi Freedom [OIF]) on mental and physical health.Results. Nearly 25% of respondents reported at least 1 previous OEF or OIF deployment. Previously deployed soldiers were more than 3 times as likely as soldiers with no previous deployments to screen positive for posttraumatic stress disorder (adjusted odds ratio [AOR] = 3.69; 95% confidence interval [CI] = 2.59, 5.24) and major depression (AOR = 3.07; 95% CI = 1.81, 5.19), more than twice as likely to report chronic pain (AOR = 2.20; 95% CI = 1.78, 2.72) and more than 90% more likely to score below the general population norm on physical functioning (AOR = 1.94; 95% CI = 1.51, 2.48).Conclusions. Repeated OEF and OIF deployments may adversely affect the military readiness of New Jersey National Guard combat soldiers.The mental and physical health consequences of service in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) have been well documented. Studies report rates of posttraumatic stress disorder (PTSD) among returning soldiers ranging from 4%¹ to 31%² and rates of depression ranging from 3%³ to 25%,⁴ with rates varying by diagnostic criteria, military population, deployment location, and time since deployment. Traumatic brain injury has been identified in 19% of returning troops.⁵ Those experiencing multiple deployments are most at risk, with the Office of the US Army Surgeon General⁶ reporting mental health problems in 11.9% of those with 1 deployment, 18.5% with 2 deployments, and 27.2% with 3 or 4 deployments. National Guard and Reserve troops are more vulnerable than active-duty troops, with 35.5% of Guard and Reserve troops at mental health risk 6 months after deployment compared with 27.1% of active-duty soldiers.⁷ With respect to physical health, the OEF and OIF conflicts have produced the highest ratio of wounded to killed of any previous military operation (approximately 7:1), with over 33 170 wounded in action as of October 2008.⁸ Orthopedic injuries are the most common class of injury⁹ and pain one of the most frequently reported symptoms.^10,11Although the adverse health consequences of service in OEF and OIF have focused public attention on the medical needs of returning veterans, concern has also centered on the military readiness of our fighting force, given the unprecedented pattern of repeat deployments unique to this particular conflict. Of all soldiers deployed to Iraq since 2003, approximately 38% have been deployed more than once and 10% have been deployed 3 times or more.¹² The Department of Defense and state National Guard authorities conduct extensive pre- and postdeployment screenings to ensure that only “healthy and medically prepared”¹³ soldiers are deployed to combat. However, because most studies of veterans of OEF and OIF to date have focused on postdeployment populations, we have little information about the effectiveness of military programs in screening seriously impaired soldiers out of the eligibility pool for future deployment. Postdeployment studies, moreover, are likely to include many medically compromised soldiers who were subsequently disqualified from, or voluntarily left, active military service before being recalled to duty. In the absence of large-scale predeployment health studies, we have no information on the effect of multiple deployments on the fitness of soldiers returning to combat. The 1 published study identified by the authors to date that examined predeployment health status⁷ included a small sample of combat veterans (n = 173) with mixed histories of previous service: some had served in Afghanistan, some in conflicts other than OEF and OIF, but none in Iraq, even though, until recently, Iraq war veterans experienced substantially greater combat stress than veterans from Afghanistan.¹⁴We explored the effects of multiple deployments on the mental and physical health of New Jersey Army National Guard troops preparing for deployment to Iraq. Specifically, we (1) compared the health status of soldiers with previous OEF and OIF deployments with that of soldiers experiencing their first deployment, (2) examined associations between deployment status and health after controlling for possible confounding factors, and (3) compared the present survey with New Jersey''s predeployment health assessment on identification rates of key mental health problems.     

Utilization and Intensity of Outpatient Care Related to Military Sexual Trauma for Veterans from Afghanistan and Iraq

Little research has examined factors associated with the utilization of outpatient health care services related to sexual assault experiences. The Veterans Health Administration provides free outpatient treatment services to veterans who report military sexual trauma (MST); this system provides a unique opportunity to examine factors related to the utilization of mental health and non-mental health outpatient services by patients with sexual trauma. The current study examined sociodemographic, military service factors, and primary diagnoses related to utilization and utilization intensity of MST-related care among 4,458 Operation Enduring Freedom/Operation Iraqi Freedom Veterans in a 1-year period after reporting an experience of MST. Of the veterans who reported MST, 75.9% received MST-related care. The most notable factor that influenced receipt and intensity of MST-related care was gender, where male veterans used less care than female veterans. These results have important treatment implications for both veteran and civilian sexual trauma survivors.