Spotlight: Post-Deployment Health Research
September 2014
Since 2001, nearly 2.5 million U.S. troops have been deployed to Iraq and Afghanistan. Many have been deployed repeatedly, and some deployments have lasted longer than 12 months. While many Veterans return from those deployments without physical or mental health concerns and experience a straightforward reintegration into civilian life, others face a complex array physical or mental health conditions and community reintegration challenges, post-deployment.
According to the 2013 Institute of Medicine (IOM) report, Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Veterans (and those remaining on active duty) require an array of services to address post-deployment health concerns. The IOM report also suggests that all services "be guided by implementation research and validated by outcomes research." Investigators within VA's Health Services Research & Development Service (VA HSR&D) are contributing to that body of research through studies that address a variety of post-deployment health issues, including:
- outcomes of short-term rehabilitation
- adjustments and reintegration into civilian life
- risks for, and resilience to, post-deployment mental health issues
- screening instruments for early problem identification
- access to care
- studies related to combat-related neurotrauma (including spinal cord injury and sensory loss)
In addition to the studies covered within VA HSR&D's post-deployment health portfolio, the Polytrauma and Blast-Related Injuries Quality Enhancement Research Initiative (PT/BRI-QUERI) works to promote the successful rehabilitation, psychological adjustment and community reintegration of Veterans who have polytrauma (multiple traumatic injuries) and blast-related injuries.
The following VA HSR&D-funded studies are just a few of the ongoing and recently completed investigations focused on post-deployment health.
- Soldier to Civilian: RCT of an Intervention to Promote Post-Deployment Reintegration. Expressive writing—a simple, resource-efficient intervention that can be widely implemented online—is a promising strategy for improving health and functioning among Veterans who experience post-deployment reintegration challenges. In this study, investigators sought to determine if a brief, highly scalable online intervention—writing expressively about transitioning to civilian life—improved symptoms and functioning for Veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). The study consisted of a three-group (factual writing, expressive writing, no writing), randomized controlled trial of 1,292 OEF/OIF Veterans with self-reported reintegration difficulty. Study procedures were implemented online from July 2011 through April 2013 and included follow-up assessments at 3- and 6-months.
Results showed Veterans who wrote expressively experienced significantly greater reductions in PTSD symptoms, distress, hostility, physical complaints, and reintegration difficulty compared with Veterans assigned to the non-writing group. Compared with Veterans in the factual writing group, participants in the expressive writing group experienced greater reductions in physical complaints hostility, and distress. Effect sizes were small to medium. Relative to control conditions, expressive writing did not lead to improved social support or life satisfaction but did increase the odds of employment.
Researchers suggest that since there is a need for accessible, non-stigmatizing interventions to improve mental health and reintegration among new Veterans, online-based expressive writing methods may help people cope with past trauma and major life transitions.
Publications resulting from this study include a review that argues for a comprehensive approach to reintegration that includes partnership between the government, private sector, and the public; and an assessment of perceived reintegration difficulty in users of VA vs. non-VA care.
- Prospective Predictors of Veteran and Family Post-Deployment Mental Health.For many Veterans, families act as a primary source of support, which is often critical for those reintegrating into civilian life. However, families can also often face significant stress, both during and after deployments. These deployment-related family stressors can sometimes erode the support available to Veterans or active-duty service members. In this study, scheduled to conclude in October 2014, researchers sought to understand how families are affected by combat deployments, and how family well-being, in turn, affects the mental health of returning Veterans.
A total of 2,089 National Guard soldiers and 1,020 spouses/partners were enrolled in the study and completed the pre-deployment survey. During deployment, two rounds of data were collected from spouses/partners, with a subset of 440 soldiers completing a web-based survey during deployment. Post-deployment data were collected from 845 soldiers and Veterans, and 608 spouses/partners. In preliminary analyses, investigators compared single vs. partnered soldiers on measures of pre-deployment well-being (post-traumatic stress symptoms, depression symptoms, and alcohol use disorder.)
Early results showed that prior to deployment, partnered soldiers had higher PTSD and depression symptoms than single soldiers, while single soldiers reported greater alcohol use disorders than partnered soldiers.
- Combat Deployments Associated with New-Onset Coronary Heart Disease among Young U.S. Service Members and Veterans.
Stress is a contributing factor for coronary heart disease (CHD) and is present during combat; however, the role of specific deployment experiences and PTSD on the incidence of newly reported CHD is not well-defined, especially among service members returning from deployments in Iraq and Afghanistan. Because the number of combat-exposed Veterans continues to increase, along with increasing symptoms of PTSD, understanding the impact of these experiences on CHD is important. This study sought to determine whether specific deployment experiences and PTSD symptoms are associated with newly reported CHD among a young cohort (n=60,025; mean age = 34 years at baseline) of U.S. military personnel (active duty) from all service branches who had participated in the Millennium Cohort Study during 2001-2008.
Results indicated that combat deployments were associated with new-onset CHD among young U.S. service members and Veterans. Deployed service members who reported combat experiences had nearly twice the odds of having a diagnosis code for new-onset CHD than deployed service members wthout combat exposure. Screening positive for PTSD was associated with self-reported CHD as well. This finding was no longer significant when adjusting for depression and anxiety. These findings suggest that experiences of intense stress may increase the risk for CHD over a relatively short period among young adults.
Crum-Cianflone N, Bagnell M, Schaller E, Boyko E, Smith B, Maynard C, Ulmer C, Vernalis M, and Smith T. Impact of combat deployment and post-traumatic stress disorder on newly reported coronary heart disease among U.S. active duty and reserve forces. Circulation. May 2014;129(18):1813-1820.
- The Polytrauma Clinical Triad and Suicide-Related Behavior among US Veterans Who Served in Iraq and Afghanistan. Suicide rates among both OEF/OIF service members and younger Veterans have been on the rise. PTSD and traumatic brain injury (TBI) are prevalent conditions among these Veterans, and studies also have identified high rates of chronic pain in this population. Affecting as many as 42% of Veterans receiving polytrauma care, the co-occurrence of PTSD, TBI, and chronic pain is known as the "Polytrauma Clinical Triad" (PCT). This retrospective cohort study examined the association of these conditions, independently and in interaction with other conditions, with the risk of suicide-related behavior (SRB) among OEF/OIF Veterans. Using VA data (inpatient and outpatient), investigators identified 211,652 Veterans who received VA healthcare in FY09-FY11. Measured outcomes included suicidal ideation, attempted suicide, and both ideation and suicide attempt in each of the three study years. Investigators also examined patient demographics and clinical characteristics, including conditions that are part of the PCT, as well as prior suicidal behavior, insomnia, and other mental health diagnoses (i.e., depression, anxiety, bipolar, substance abuse).
Results indicated that the PCT was a moderate predictor of suicide-related behavior, but did not appear to increase risk for SRB above that associated with PTSD, depression, or substance abuse alone. Moreover, PTSD comorbid with either depression or substance abuse significantly increased risk for suicidal ideation. Additional findings showed that Veterans with a diagnosis of bipolar disorder, anxiety, substance abuse, depression, or PTSD were significantly more likely to be diagnosed with all three categories of SRB. Further, female Veterans were less likely than male Veterans to exhibit suicidal ideation, which contradicts prior research and may suggest that females are less comfortable reporting ideation within VA.
Finley E, Pugh M, Bollinger M, et al. A National Cohort Study of the Association between the Polytrauma Clinical Triad and Suicide-Related Behavior among US Veterans Who Served in Iraq and Afghanistan. American Journal of Public Health. July 17, 2014;e-pub ahead of print.
