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.     

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.     

Deployment stressors, gender, and mental health outcomes among Gulf War I veterans

Findings indicate that war-zone exposure has negative implications for the postdeployment adjustment of veterans; however, most studies have relied on limited conceptualizations of war-zone exposure and focused on male samples. In this study, an array of deployment stressors that were content valid for both female and male Gulf War I military personnel was examined to elucidate gender differences in war-zone exposure and identify gender-based differential associations between stressors and mental health outcomes. While women and men were exposed to both mission-related and interpersonal stressors and both stressor categories were associated with mental health outcomes, women reported more interpersonal stressors and these stressors generally had a stronger impact on women's than on men's mental health. Exceptions are described, and implications are discussed.     

Deployment stressors, gender, and mental health outcomes among Gulf War I veterans

Findings indicate that war-zone exposure has negative implications for the postdeployment adjustment of veterans; however, most studies have relied on limited conceptualizations of war-zone exposure and focused on male samples. In this study, an array of deployment stressors that were content valid for both female and male Gulf War I military personnel was examined to elucidate gender differences in war-zone exposure and identify gender-based differential associations between stressors and mental health outcomes. While women and men were exposed to both mission-related and interpersonal stressors and both stressor categories were associated with mental health outcomes, women reported more interpersonal stressors and these stressors generally had a stronger impact on women's than on men's mental health. Exceptions are described, and implications are discussed.     

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.     

Trauma‐Related Correlates of Alcohol Use in Recently Deployed OEF/OIF Veterans

The co‐occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorders (AUDs) is well documented. Little is known about the factors that contribute to alcohol use and the development of AUDs among military personnel following deployment. The primary aim of this study was to examine trauma‐related correlates of alcohol use in recently deployed Operation Enduring Freedom/Operation Iraqi Freedom veterans. Members of the Rhode Island National Guard and Army Reserves (N = 238) completed an in‐person, initial assessment an average of 6 months postdeployment. Multiple regression analyses examined predictors of drinking outcomes (combat exposure, total PTSD symptoms, and PTSD symptom clusters) after accounting for gender, age, and history of AUD. Results indicated that total PTSD symptoms, but not combat exposure, significantly predicted alcohol use at the initial assessment. When PTSD symptom clusters were considered separately, reexperiencing symptoms (Cluster B) were the strongest predictor of total alcohol use (B = 3.58, p = .002) and heavy drinking episodes (B = 0.31, p = .005). Implications for these findings include early identification of risk factors that could lead to the development of AUDs, and the importance of integrated treatment approaches for co‐occurring PTSD and AUD among veterans postdeployment.     

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.     

Gender differences in mental health outcomes among Afghanistan veterans exposed to war zone trauma

Research has sought to identify whether women have an increased risk of developing mental health problems following military trauma compared to men, but the results are mixed. This study examined gender differences in a range of mental health outcomes within three levels of war zone trauma exposure and investigated gender differences in risk and protective factors associated with clinical mental health problems. Using data from a cross-sectional, postdeployment survey, a sample of Norwegian veterans of recent military operations in Afghanistan (N = 6,205, 8.3% women) were sorted according to reported war zone trauma exposure level (low, medium, high), then assessed for symptoms of posttraumatic stress disorder (PTSD), posttraumatic distress, anxiety, depression, insomnia, and alcohol problems. The findings revealed that men who reported low war zone exposure had lower levels of posttraumatic distress symptoms than women, d = -0.20, p = .040, but were more likely to report symptoms of alcohol problems within the low, d = 0.33, p < .001; medium, d = 0.39, p < .001; and high, d = 0.37, p = .049, exposure groups; however, these differences disappeared when all symptom variables were combined into one clinical mental health problem variable. Women with a clinical mental health problem were less likely to report war zone exposure than men, OR = 0.93, 95% CI [0.90, 0.97], p = .001. Findings suggest that although gender differences in mental health symptoms exist, male and female veterans with mental health problems may share more similarities than previously recognized.     

Combat-Related Posttraumatic Stress Disorder and Comorbid Major Depression in U.S. Veterans: The Role of Deployment Cycle Adversity and Social Support

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) commonly co-occur in combat veterans, and this comorbidity has been associated with higher levels of distress and more social and economic costs compared to one disorder alone. In a secondary analysis of a multisite randomized controlled trial of a sample of veterans with combat-related PTSD, we examined the associations among pre-, peri-, and postdeployment adversity, social support, and clinician-diagnosed comorbid MDD. Participants completed the Deployment Risk and Resilience Inventory and the Beck Depression Inventory–II as well as structured clinical interviews for diagnostic status. Among 223 U.S. veterans of the military operations in Iraq and Afghanistan (86.9% male) with primary combat-related PTSD, 69.5% had current comorbid MDD. After adjustment for sex, a linear regression model indicated that more concerns about family disruptions during deployment, f² = 0.065; more harassment during deployment, f² = 0.020; and lower ratings of postdeployment social support, f² = 0.154, were associated with more severe self-reported depression symptoms. Interventions that enhance social support as well as societal efforts to foster successful postdeployment reintegration are critical for reducing the mental health burden associated with this highly prevalent comorbidity in veterans with combat-related PTSD.     

Mental Health Beliefs and Their Relationship With Treatment Seeking Among U.S. OEF/OIF Veterans

Many veterans who would benefit from mental health care do not seek treatment. The current study provided an in‐depth examination of mental health‐related beliefs and their relationship with mental health and substance abuse service use in a national sample of 640 U.S. Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans. Both concerns about mental health stigma from others and personal beliefs about mental illness and mental health treatment were examined. Data were weighted to adjust for oversampling of women and nonresponse bias. Results revealed substantial variation in the nature of OEF/OIF veterans’ mental health beliefs, with greater anticipated stigma in the workplace (M = 23.74) than from loved ones (M = 19.30), and stronger endorsement of negative beliefs related to mental health treatment‐seeking (M = 21.78) than either mental illness (M = 18.56) or mental health treatment (M = 20.34). As expected, individuals with probable mental health problems reported more negative mental health‐related beliefs than those without these conditions. Scales addressing negative personal beliefs were related to lower likelihood of seeking care (ORs = 0.80–0.93), whereas scales addressing anticipated stigma were not associated with service use. Findings can be applied to address factors that impede treatment seeking.     

Stress, coping, and mental health-seeking behaviors: gender differences in OEF/OIF health care providers

Health care providers (HCPs) are often placed in positions of heightened stress when serving in military operations. As military HCPs have a large number of female providers, there is a concern that gender may influence both risk and resiliency within the health care provider subgroup. The purpose of this secondary analysis of the 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel (data collected April through August 2005) is to describe stress, coping, and health-seeking behaviors of Operation Enduring Freedom and Operation Iraqi Freedom deployed military health care providers and the role gender may have for both health care officers and specialists. Female HCP responses indicate the lives of these women are significantly impacted by their family responsibilities. Reluctance of females to seek mental health care is concerning with perhaps more concern over career than personal well-being. Findings included (a) concern about performance, odds ratio (OR) = 1.86, 95% confidence interval (CI) [0.43, 8.12] for enlisted females, OR = 2.83, 95% CI [0.31, 25.66] for female officers; (b) problems with money, OR = 1.6 CI [0.69, 3.7] for enlisted females; (c) having a drink to cope, OR = 3.26, 95% CI [0.22, 48.68] for enlisted females; and (d) damage military career to seek mental health care, OR = 1.78, 95% CI [0.59, 5.39] for female officers. Results indicate needed provider awareness concerning mental health-seeking behavior and sensitivity toward gender differences that contribute to unique manifestations of operational stress outcomes.     

Race/ethnic differences in bone mineral density in men

Summary The epidemiology of osteoporosis in male and minority populations is understudied. We compared BMD in 1,209 Black, Hispanic, and White men. Black men exhibited higher BMD than Hispanic or White men. Age-related BMD decreases were greatest among Hispanic men. Results may help explain variation in hip fracture rates by race/ethnicity. Introduction The epidemiology of osteoporosis in male and minority populations is understudied. To address this concern, we conducted a study of skeletal health in a diverse population of adult males. Methods A total of 367 Black, 401 Hispanic, and 451 White men aged 30–79 years were randomly sampled from Boston, MA. Bone densitometry (bone area (BA), bone mineral content (BMC), and bone mineral density (BMD)) at the whole body, hip, lumbar spine, and forearm was performed. Multiple regression analyses on 1,209 men with available data were used to describe race/ethnic group-specific means (height- and age-adjusted) and age trends (height-adjusted) in BMC, BA, and BMD. Results were weighted to represent the Boston male population aged 30–79 years. Results Black men had greater BMC and BMD than Hispanic or White men. Femoral neck BMD was 5.6% and 13.3% higher in Black men than in Hispanic and White men, respectively. Differences between Hispanic and White subjects were restricted to the hip. Age-related declines in BMC and BMD were significantly steeper among Hispanic than Black or White men. Conclusions Differences in BMC and BMD could explain variation in fracture rates among Black, Hispanic, and White men. The steeper age-related BMD decline in Hispanic men is of particular concern. The BACH/Bone study was supported by grant AG 20727 from the National Institute on Aging (NIA). The parent study (BACH) was supported by grant DK 56842 from the National Institute of Diabetes and Digestive and Kidney Diseases. Additional support from MO RR00533.     

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.     

Multiple Deployments and Combat Trauma: Do Homefront Stressors Increase the Risk for Posttraumatic Stress Symptoms?

Multiple deployments are common among military personnel who served in Operation Enduring Freedom and Operation Iraqi Freedom and are associated with greater posttraumatic stress symptoms (PTSS). Homefront stressors (i.e., family, occupational problems) resulting from deployments may increase the risk of PTSS. Moreover, with multiple deployments, a new deployment may occur while still experiencing homefront stressors from previous tours. This prospective study assessed whether homefront stressors from a previous tour increased the risk of PTSS after a new deployment. It also examined the effects of homefront stressors at postdeployment. Survey data were obtained from U.S. National Guard soldiers with previous deployments prior to (Wave 1) and after (Wave 2) a new deployment to Iraq (N = 196). Homefront stressors reported at Wave 1 (β = .154, p = .015) and Wave 2 (β = .214, p = .002) were both significantly predictive of PTSS at postdeployment, even after adjusting for warzone stressors, predeployment PTSS, and other variables. A pattern of chronic homefront stressors (i.e., homefront stressors at pre‐ and postdeployment) was associated with higher levels of PTSS at postdeployment (β = .220, p = .002). Service members with multiple deployments are at greater risk for PTSS if deployed with homefront stressors from previous tours and/or face these stressors at postdeployment.     

Work stressors,sleep quality,and alcohol‐related problems across deployment: A parallel process latent growth modeling approach among Navy members

This study examined how work stressors were associated with sleep quality and alcohol‐related problems among U.S. Navy members over the course of deployment. Participants were 101 U.S. Navy members assigned to an Arleigh Burke‐class destroyer who experienced an 8‐month deployment after Operational Enduring Freedom/Operation Iraqi Freedom. Approximately 6 weeks prior to deployment, 6 weeks after deployment, and 6 months reintegration, participants completed measures that assessed work stressors, sleep quality, and alcohol‐related problems. A piecewise latent growth model was conducted in which the structural paths assessed if work stressors influenced sleep quality or its growth over time, and in turn if sleep quality influenced alcohol‐related problems intercepts or growth over time. A significant indirect effect was found such that increases in work stressors from pre‐ to postdeployment predicted decreases in sleep quality, which in turn were associated with increases in alcohol‐related problems from pre‐ to postdeployment. These effects were maintained from postdeployment through the 6‐month reintegration. Findings suggest that work stressors may have important implications for sleep quality and alcohol‐related problems. Positive methods of addressing stress and techniques to improve sleep quality are needed as both may be associated with alcohol‐related problems among current Navy members.     

Social Information Processing in Anger Expression and Partner Violence in Returning U.S. Veterans

We examined social information processing factors that could represent pathways through which posttraumatic stress disorder (PTSD) symptoms relate to anger expression and intimate partner violence (IPV) perpetration in returning U.S. veterans. The sample included 92 male Operation Enduring Freedom/Operation Iraqi Freedom veterans, primarily Caucasian (77.4%), with smaller numbers of African American, Asian, Hispanic or Latino, American Indian or Alaskan Native, and other minority participants (9.7%, 2.2%, 2.2%, 3.2%, and 5.3% respectively). The average age was 40.37 (SD = 9.63) years. Data were collected through self‐report questionnaires (PTSD Checklist, State‐Trait Anger Expression Scale, Revised Conflict Tactics Scales) and the Articulated Thoughts in Simulated Situations experimental protocol. Laboratory‐based assessment of cognitive biases and hostile attributions were tested as mediators of associations between PTSD symptoms and anger expression and IPV. Among the PTSD symptom clusters, hyperarousal symptoms were most strongly associated with anger expression (r = .50) and IPV perpetration (r = .27). Cognitive biases mediated associations between PTSD total scores and 3 of 4 PTSD cluster scores as well as anger expression. Hostile attribution biases were also associated with IPV perpetration (r = .23). We discuss the implications of these findings for understanding social information processing mechanisms for the relationship between PTSD symptoms and aggression.     

Disparities in preventative diabetic foot examination

The objective of this study was to assess the overall differences in the standard of preventive foot care for patients at risk of diabetic foot ulceration and to identify specific demographic factors affecting these health care practices, including race and ethnicity. The National Health and Nutrition Examination Survey data for 2011 to 2018 were analyzed. Participants (20 years and older) with diabetes were categorized as White, Black, Hispanic, Asian, and others (including multiracial participants) based on self-reported race and ethnicity. The primary outcome was foot examination over the past year administered by a medical professional. Logistic regression was performed to examine the effects of race and ethnicity on the annual diabetic foot examination, controlling for age (65 years and older), gender, and health insurance status. Among the 2,836 participants included in the study (weighted percentage: 61.1% were White, 13.9% were Black, 15.1% were Hispanic, 5.4% were Asian, and 4.5% were other), 2,018 (weighted percentage: 71.6%) received annual diabetic foot examination over the past year. Hispanic participants (adjusted odds ratio [aOR] = 0.685; 95% CI, 0.52–0.90) were significantly less likely than White participants to receive an annual foot examination (Black participants: aOR = 1.11; 95% CI, 0.83–1.49; Asian participants: aOR = 0.80; 95% CI, 0.60–1.07; other participants: aOR = 0.66; 95% CI, 0.40–1.10). Factors associated with receipt of foot examination were age 65 years or older (aOR = 1.42; 95% CI, 1.05–1.92) and having health insurance (aOR = 3.02; 95% CI, 2.27–4.03). Our findings suggest that Hispanic adults with diabetes are receiving disproportionately lower rates of preventive foot care compared with their White counterparts. This significant variation in the standard of care for individuals with diabetes reflects the need to further identify factors driving the disparities in preventive foot care services among racial and ethnic minority groups.     

The influence of combat and interpersonal trauma on PTSD, depression, and alcohol misuse in U.S. Gulf War and OEF/OIF women veterans

The present study evaluated the impact of combat and interpersonal trauma exposure in a sample of 115 U.S. women veterans from Gulf War I and the Iraq and Afghanistan wars on 3 postdeployment trauma-related mental health outcomes: posttraumatic stress disorder symptoms (PSS), depressive symptom severity (DSS), and alcohol misuse. Patients presenting for healthcare services at a Veterans Affairs postdeployment health specialty clinic completed screening questionnaires that assessed combat exposure, lifetime interpersonal trauma history of childhood neglect, physical, or sexual abuse, and adult sexual and physical assault. In a regression model, combat exposure was the only significant independent variable associated with PSS, DSS, and alcohol misuse (β = .42, .27 and B = 1.58, respectively) even after adding lifetime interpersonal assault exposure to the model. Results highlight the negative effects of combat exposure on treatment-seeking women veterans' postdeployment mental health. Incorporating combat exposure into routine screening procedures for Gulf War and Iraq and Afghanistan war women veterans can aid in mental health treatment planning.     

Ethnic differences in symptoms among female veterans diagnosed with PTSD

Among U.S. male Vietnam veterans, Hispanics have been shown to have higher rates of posttraumatic stress disorder (PTSD) than African Americans and non-Hispanic Whites (Kulka et al., 1990). In terms of gender, Tolin and Foa's (2006) meta-analysis suggested women experience higher rates of PTSD than men. This study examined ethnic differences in PTSD and other symptomatology among 398 female veterans (63% non-Hispanic White, 28% Hispanic, 9% African American) seeking treatment for PTSD from 1995 to 2009 at a Veterans Administration (VA) behavioral health clinic. The following symptom clusters were examined: anxiety/PTSD, depression, anger/hostility, and psychotic/dissociative symptoms. Few differences were found among the groups, suggesting the 3 ethnic groups studied were more similar than different. African American female veterans, however, scored higher on measuring ideas of persecution/paranoia, although this may reflect an adaptive response to racism. These findings warrant further investigation to elucidate this relationship.     

War-related posttraumatic stress disorder in Black, Hispanic, and majority White Vietnam veterans: the roles of exposure and vulnerability

Elevated prevalence rates of chronic posttraumatic stress disorder (PTSD) have been reported for Black and Hispanic Vietnam veterans. There has been no comprehensive explanation of these group differences. Moreover, previous research has relied on retrospective reports of war-zone stress and on PTSD assessments that fail to distinguish between prevalence and incidence. These limitations are addressed by use of record-based exposure measures and clinical diagnoses of a subsample of veterans from the National Vietnam Veterans Readjustment Study (NVVRS). Compared with Majority White, the Black elevation is explained by Blacks' greater exposure; the Hispanic elevation, by Hispanics' greater exposure, younger age, lesser education, and lower Armed Forces Qualification Test scores. The PTSD elevation in Hispanics versus Blacks is accounted for mainly by Hispanics' younger age.