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RCD 06-042 – HSR&D Study

 
RCD 06-042
The Mental Health Impact of Exposure to Death and Dying in the Iraq War
Shira Maguen PhD
San Francisco VA Medical Center, San Francisco, CA
San Francisco, CA
Funding Period: April 2008 - March 2013

BACKGROUND/RATIONALE:
My long-term career goal was to establish a research program at the San Francisco VA Medical Center that aims to improve the care of Veterans with PTSD related to war-zone exposures. The focus of this CDA was to examine the relationship between killing in combat, PTSD, and other mental health sequelae in war Veterans. The skills and knowledge that I gained from this CDA were used to improve mental health services for returning Afghanistan and Iraq War Veterans.




OBJECTIVE(S):
1) Understand the role of killing in the war zone on mental health outcomes.

2) Develop a reliable and valid measure of the cognitions associated with killing in the war zone.

3) Design and test the efficacy of an intervention for the impact of taking another life in combat.

4) Conduct an open trial to pilot test and refine treatment module.

5) Conduct a randomized, controlled trial to test the intervention.

METHODS:
The first goal was to use existing databases from the Vietnam War, Gulf War I, and the Iraq War to understand the role of killing in combat on mental health outcomes. In each data set, we compared those who reported killing in combat to those who did not. Next, a preliminary measure was developed, indexing maladaptive killing-related cognitions, and we conducted focus groups with Veterans to evaluate and refine this measure. We administered the measure to 67 Veterans who had killed in war to assess its validity and reliability. Next, a 6-8 session individual therapy protocol was developed and pilot tested with eight Veterans. We are currently conducting a RCT with 50 Veterans and interviews with ten providers concerning acceptability, feasibility, and dissemination.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
The development of an empirically-sound measure that captures the cognitions associated with killing in combat and the development of a 6-8 week treatment module for these Veterans will contribute to a better level of care and ultimately change the delivery of care for Veterans who have killed in combat. We have received excellent feedback from Veterans who participated in the treatment and from providers who hope to use it in their clinical practice. After RCT completion, we plan to apply for subsequent funding that would address issues related to treatment dissemination.



External Links for this Project

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PUBLICATIONS:

Journal Articles

  1. Bennett S, Litz B, Maguen S, Ehrenreich J. An Exploratory Study of the Psychological Impact and Clinical Care of Perinatal Loss. Journal of loss & trauma. 2008 Nov 1; 13(6):485-510. [view]
  2. Seal KH, Shi Y, Cohen G, Cohen BE, Maguen S, Krebs EE, Neylan TC. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA. 2012 Mar 7; 307(9):940-7. [view]
  3. O'Donovan A, Epel E, Lin J, Wolkowitz O, Cohen B, Maguen S, Metzler T, Lenoci M, Blackburn E, Neylan TC. Childhood trauma associated with short leukocyte telomere length in posttraumatic stress disorder. Biological psychiatry. 2011 Sep 1; 70(5):465-71. [view]
  4. Maguen S, Papa A, Litz BT. Coping with the threat of terrorism: a review. Anxiety Stress Coping. 2008 Jan 1; 21(1):15-35. [view]
  5. Maguen S, Turcotte DM, Peterson AL, Dremsa TL, Garb HN, McNally RJ, Litz BT. Description of risk and resilience factors among military medical personnel before deployment to Iraq. Military medicine. 2008 Jan 1; 173(1):1-9. [view]
  6. Maguen S, Cohen B, Cohen G, Madden E, Bertenthal D, Seal K. Eating disorders and psychiatric comorbidity among Iraq and Afghanistan veterans. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2012 Jul 1; 22(4):e403-6. [view]
  7. Maguen S, Lau KM, Madden E, Seal K. Factors associated with completing comprehensive traumatic brain injury evaluation. Military medicine. 2012 Jul 1; 177(7):797-803. [view]
  8. Inslicht SS, McCaslin SE, Metzler TJ, Henn-Haase C, Hart SL, Maguen S, Neylan TC, Marmar CR. Family psychiatric history, peritraumatic reactivity, and posttraumatic stress symptoms: a prospective study of police. Journal of psychiatric research. 2010 Jan 1; 44(1):22-31. [view]
  9. Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, Friedman M, Gersons BP, de Jong JT, Layne CM, Maguen S, Neria Y, Norwood AE, Pynoos RS, Reissman D, Ruzek JI, Shalev AY, Solomon Z, Steinberg AM, Ursano RJ. Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry. 2007 Jan 1; 70(4):283-315; discussion 316-69. [view]
  10. Luxton DD, Skopp NA, Maguen S. Gender differences in depression and PTSD symptoms following combat exposure. Depression and anxiety. 2010 Nov 1; 27(11):1027-33. [view]
  11. Maguen S, Cohen B, Cohen G, Madden E, Bertenthal D, Seal K. Gender differences in health service utilization among Iraq and Afghanistan veterans with posttraumatic stress disorder. Journal of women's health (2002). 2012 Jun 1; 21(6):666-73. [view]
  12. Maguen S, Ren L, Bosch JO, Marmar CR, Seal KH. Gender differences in mental health diagnoses among Iraq and Afghanistan veterans enrolled in veterans affairs health care. American journal of public health. 2010 Dec 1; 100(12):2450-6. [view]
  13. Maguen S, Cohen B, Ren L, Bosch J, Kimerling R, Seal K. Gender differences in military sexual trauma and mental health diagnoses among Iraq and Afghanistan veterans with posttraumatic stress disorder. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2012 Jan 1; 22(1):e61-6. [view]
  14. Maguen S, Luxton DD, Skopp NA, Madden E. Gender differences in traumatic experiences and mental health in active duty soldiers redeployed from Iraq and Afghanistan. Journal of psychiatric research. 2012 Mar 1; 46(3):311-6. [view]
  15. Seal KH, Bertenthal D, Maguen S, Gima K, Chu A, Marmar CR. Getting beyond "Don't ask; don't tell": an evaluation of US Veterans Administration postdeployment mental health screening of veterans returning from Iraq and Afghanistan. American journal of public health. 2008 Apr 1; 98(4):714-20. [view]
  16. Suvak M, Maguen S, Litz BT, Silver RC, Holman EA. Indirect exposure to the September 11 terrorist attacks: does symptom structure resemble PTSD? Journal of traumatic stress. 2008 Feb 1; 21(1):30-9. [view]
  17. Somer E, Zrihan-Weitzman A, Fusé T, Parker H, Dickstein B, Maguen S, Litz BT. Israeli civilians under heavy bombardment: prediction of the severity of post-traumatic symptoms. Prehospital and Disaster Medicine. 2009 Sep 1; 24(5):389-94. [view]
  18. Maguen S, Metzler TJ, Bosch J, Marmar CR, Knight SJ, Neylan TC. Killing in combat may be independently associated with suicidal ideation. Depression and anxiety. 2012 Nov 1; 29(11):918-23. [view]
  19. Maguen S, Luxton DD, Skopp NA, Gahm GA, Reger MA, Metzler TJ, Marmar CR. Killing in combat, mental health symptoms, and suicidal ideation in Iraq war veterans. Journal of anxiety disorders. 2011 May 1; 25(4):563-7. [view]
  20. Somer E, Maguen S, Or-Chen K, Litz BT. Managing terror: differences between Jews and Arabs in Israel. International Journal of Psychology. 2009 Apr 1; 44(2):138-46. [view]
  21. Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, Maguen S. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clinical Psychology Review. 2009 Dec 1; 29(8):695-706. [view]
  22. Maguen S, Schumm JA, Norris R, Taft C, Litz BT, King LA, King DW. Predictors of Mental and Physical Health Service Utilization Among Vietnam Veterans. Psychological Services. 2007 Aug 1; 4(3):168-180. [view]
  23. Maguen S, Shipherd JC, Harris HN, Welch LP. Prevalence and Predictors of Disclosure of Transgender Identity. International journal of sexual health : official journal of the World Association for Sexual Health. 2008 Jan 1; 19(1):3-13. [view]
  24. Neria Y, Gross R, Litz B, Maguen S, Insel B, Seirmarco G, Rosenfeld H, Suh EJ, Kishon R, Cook J, Marshall RD. Prevalence and psychological correlates of complicated grief among bereaved adults 2.5-3.5 years after September 11th attacks. Journal of traumatic stress. 2007 Jun 1; 20(3):251-62. [view]
  25. Maguen S, Stalnaker M, McCaslin S, Litz BT. PTSD subclusters and functional impairment in Kosovo peacekeepers. Military medicine. 2009 Aug 1; 174(8):779-85. [view]
  26. Seal KH, Cohen G, Bertenthal D, Cohen BE, Maguen S, Daley A. Reducing barriers to mental health and social services for Iraq and Afghanistan veterans: outcomes of an integrated primary care clinic. Journal of general internal medicine. 2011 Oct 1; 26(10):1160-7. [view]
  27. Cohen BE, Maguen S, Bertenthal D, Shi Y, Jacoby V, Seal KH. Reproductive and other health outcomes in Iraq and Afghanistan women veterans using VA health care: association with mental health diagnoses. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2012 Sep 1; 22(5):e461-71. [view]
  28. Maguen S, Metzler TJ, McCaslin SE, Inslicht SS, Henn-Haase C, Neylan TC, Marmar CR. Routine work environment stress and PTSD symptoms in police officers. The Journal of nervous and mental disease. 2009 Oct 1; 197(10):754-60. [view]
  29. Seal KH, Cohen G, Waldrop A, Cohen BE, Maguen S, Ren L. Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001-2010: Implications for screening, diagnosis and treatment. Drug and Alcohol Dependence. 2011 Jul 1; 116(1-3):93-101. [view]
  30. Maguen S, Shipherd JC. Suicide risk among transgender individuals. Psychology & Sexuality. 2010 Jan 1; 1(1):34-43. [view]
  31. Barnes JB, Dickstein BD, Maguen S, Neria Y, Litz BT. The distinctiveness of prolonged grief and posttraumatic stress disorder in adults bereaved by the attacks of September 11th. Journal of affective disorders. 2012 Feb 1; 136(3):366-9. [view]
  32. Somer E, Maguen S, Moin V, Boehm A, Metzler TJ, Litz BT. The effects of perceived community cohesion on stress symptoms following a terrorist attack. Journal of Psychological Trauma. 2008 Jun 1; 7(2):73-90. [view]
  33. Maguen S, Madden E, Lau KM, Seal K. The impact of head injury mechanism on mental health symptoms in veterans: do number and type of exposures matter? Journal of traumatic stress. 2012 Feb 1; 25(1):3-9. [view]
  34. Komarovskaya I, Maguen S, McCaslin SE, Metzler TJ, Madan A, Brown AD, Galatzer-Levy IR, Henn-Haase C, Marmar CR. The impact of killing and injuring others on mental health symptoms among police officers. Journal of psychiatric research. 2011 Oct 1; 45(10):1332-6. [view]
  35. Maguen S, Metzler TJ, Litz BT, Seal KH, Knight SJ, Marmar CR. The impact of killing in war on mental health symptoms and related functioning. Journal of traumatic stress. 2009 Oct 1; 22(5):435-43. [view]
  36. Maguen S, Vogt DS, King LA, King DW, Litz BT, Knight SJ, Marmar CR. The impact of killing on mental health symptoms in Gulf War veterans. Psychological trauma : theory, research, practice and policy. 2011 Mar 18; 3(1):21-26. [view]
  37. Maguen S, Lucenko BA, Reger MA, Gahm GA, Litz BT, Seal KH, Knight SJ, Marmar CR. The impact of reported direct and indirect killing on mental health symptoms in Iraq war veterans. Journal of traumatic stress. 2010 Feb 1; 23(1):86-90. [view]
  38. Hassija CM, Jakupcak M, Maguen S, Shipherd JC. The influence of combat and interpersonal trauma on PTSD, depression, and alcohol misuse in U.S. Gulf War and OEF/OIF women veterans. Journal of traumatic stress. 2012 Apr 1; 25(2):216-9. [view]
  39. Maguen S, Seal KH, Cohen G, Cohen B, Lawhon GD, Marmar CR. The Role of Psychologists in the Care of Iraq and Afghanistan Veterans in Primary Care Settings. Professional Psychology, Research and Practice. 2010 Apr 21; 41(2):135-142. [view]
  40. McCaslin SE, Inslicht SS, Metzler TJ, Henn-Haase C, Maguen S, Neylan TC, Choucroun G, Marmar CR. Trait dissociation predicts posttraumatic stress disorder symptoms in a prospective study of urban police officers. The Journal of nervous and mental disease. 2008 Dec 1; 196(12):912-8. [view]
  41. Seal KH, Metzler TJ, Gima KS, Bertenthal D, Maguen S, Marmar CR. Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002-2008. American journal of public health. 2009 Sep 1; 99(9):1651-8. [view]
  42. Seal KH, Maguen S, Cohen B, Gima KS, Metzler TJ, Ren L, Bertenthal D, Marmar CR. VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. Journal of traumatic stress. 2010 Feb 1; 23(1):5-16. [view]
Book Chapters

  1. Maguen S, Neria Y, Conoscenti LM, Litz BT. Depression and prolonged grief in the wake of disasters. In: Neria Y, Galea S, Norris F, editors. Mental Health and Disasters. Cambridge: Cambridge University Press; 2009. Chapter 7. 116-130 p. [view]
  2. Litz B, Maguen S. Early intervention for trauma in adults and children. In: Friedman MT, Keane TM, Resick PA, editors. Handbook of PTSD: Science and Practice. New York, NY: The Guilford Press; 2007. Chapter 16. 306-329 p. [view]
  3. Ruzek J, Maguen S, Litz B. Evidence-Based Interventions for Survivors of Terrorism. In: Bongar B, Brown LM, Beutler LE, Breckenridge JN, Zimbardo PG, editors. Psychology of Terrorism. New York, NY: Oxford University Press; 2006. Chapter 18. 247-272 p. [view]
  4. Litz B, Maguen S. Peacekeeping. In: Fink G, editor. Encyclopedia of Stress. London, England: Academic Press; 2007. Chapter 24. 134-137 p. [view]
  5. Gray M, Maguen S, Litz B. Schema constructs and cognitive models of posttraumatic stress disorder. In: Riso LP, du Toit PL, Stein DJ, Young JE, editors. Cognitive Schemas and Core Beliefs in Psychological Problems: A Scientist-Practitioner Guide. Washington, DC: American Psychological Association; 2007. Chapter 4. 59-92 p. [view]
Conference Presentations

  1. Maguen S. Assessment and Treatment of PTSD: Theory and Practice. Paper presented at: Kaiser Oakland Mental Health Grand Rounds Monthly Assembly; 2010 Mar 19; Oakland, CA. [view]
  2. Maguen S, Ren L, Bosch J, Marmar CR, Seal KH. Gender differences in Iraq and Afghanistan veterans enrolled in VA healthcare. Paper presented at: Association for Psychological Science Annual Convention; 2009 May 23; San Francisco, CA. [view]
  3. Maguen S, Seal KH, Bosch J, Ren L, Marmar CR. Gender differences in Iraq and Afghanistan Veterans enrolled in VA healthcare. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2009 Nov 6; Atlanta, GA. [view]
  4. Maguen S, Cohen B, Ren L, Bosch J, Kimerling R, Seal K. Gender differences in military sexual trauma and mental health diagnoses among Iraq & Afghanistan Veterans with posttraumatic stress disorder. Paper presented at: VA Women's Health Research Conference; 2010 Jul 15; Arlington, VA. [view]
  5. Maguen S, Ren L, Cohen B, Bosch J, Kimerling R, Seal KH. Gender differences in military sexual trauma and mental health diagnoses among Iraq and Afghanistan Veterans with posttraumatic stress disorder. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2010 Nov 5; Montréal, Canada. [view]
  6. Seal KH, Cohen G, Shah R, Maguen S, Lawhon D, Marmar CR. Iraq Integrated co-located primary care and mental health services for Afghanistan Veterans. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2009 Nov 6; Atlanta, GA. [view]
  7. Maguen S, Luxton DD, Skopp NA, Gahm GA, Reger MA, Metzler TJ, Marmar CR. Killing in combat, mental health symptoms, and suicidal ideation in Iraq War Veterans. Paper presented at: VA HSR&D Career Development Annual Meeting; 2011 Feb 16; National Harbor, MD. [view]
  8. Drescher K, Litz BT, Maguen S, Nash W. Moral Injury: What clinicians and caregivers need to know. Presented at: U.S. Navy and Marine Corps Combat and Operational Stress Control Conference; 2010 May 18; San Diego, CA. [view]
  9. Drescher K, Litz BT, Maguen S, Nash W. Moral Injury: What leaders should know. Paper presented at: U.S. Navy and Marine Corps Combat and Operational Stress Control Conference; 2010 May 18; San Diego, CA. [view]
  10. Cohen B, Maguen S, Ren L, Seal KH. Post-deployment mental health disorders and physical health outcomes in returning Veterans. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2010 Nov 5; Montréal, Canada. [view]
  11. Maguen S, Seal KH, Chu A, Abrams G, Marmar C. Posttraumatic Stress Disorder and Traumatic Brain Injury in OIF/OEF Veterans. Paper presented at: VA VISN 21 Polytrauma Network Site Planning Meeting; 2008 Sep 8; Sacramento, CA. [view]
  12. Maguen S, Metzler TJ, McCaslin SE, Inslicht S, Henn-Haase C, Neylan TC, Marmar CR. Routine work environment stress and PTSD symptoms in police officers. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2007 Nov 17; Baltimore, MD. [view]
  13. Maguen S, Knight SJ, Seal KH. The impact of killing in veterans of war. Paper presented at: VA / DoD Resilience and Psychological Health Collaborative Meeting; 2009 May 29; San Francisco, CA. [view]
  14. Maguen S, Metzler TJ, Litz BT, Seal KH, Knight SJ, McCaslin S, Inslicht S, Marmar CR. The impact of killing in Vietnam Veterans. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2008 Nov 13; Chicago, IL. [view]
  15. Maguen S, Metzler TJ, Litz BT, Seal KH, Bosch J, Knight SJ, Marmar CR. The impact of killing in war on mental health symptoms and related functioning. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD. [view]
  16. Maguen S, Metzler TJ, Litz BT, Seal KH, Bosch J, Knight SJ, Marmar CR. The impact of killing in war on mental health symptoms and related functioning. Paper presented at: Hebrew University of Jerusalem Institute for Advanced Studies / Israel Science Foundation on: Future Directions in PTSD: Prevention, Diagnosis and Treatment Conference; 2009 Oct 19; Jerusalem, Israel. [view]
  17. Maguen S, Metzler TJ, Litz BT, Seal KH, Bosch J, Knight SJ, Marmar CR. The impact of killing in war on mental health symptoms and related functioning. Paper presented at: University of California San Francisco Department of Psychiatry Annual Research Retreat; 2009 Nov 16; San Francisco, CA. [view]
  18. Maguen S. The impact of killing on mental health symptoms and functioning in Iraq War Veterans. Paper presented at: VA Palo Alto VAMC Psychology Services Critical Issues Affecting OEF/OIF Veterans Workshop; 2010 Jun 3; Palo Alto, CA. [view]
  19. Maguen S. The impact of killing on mental health symptoms and functioning in Veterans of War. Presented at: New York University School of Medicine Grand Rounds; 2010 Dec 9; New York, NY. [view]
  20. Maguen S, Bosch J, Litz BT, Knight SJ. The impact of killing on mental health symptoms and functioning in Veterans of War. Paper presented at: Armed Forces Public Health Conference; 2011 Mar 23; Hampton, VA. [view]
  21. Maguen S, Lucenko BA, Reger MA, Gahm GA, Litz BT, Seal KH, Bosch J, Knight SJ, Marmar CR. The impact of killing on mental health symptoms in Iraq War Veterans. Paper presented at: VA HSR&D Career Development Annual Meeting; 2010 Feb 25; San Francisco, CA. [view]
  22. McCaslin S, Metzler T, Maguen S, Inslicht S, Marmar CR. The impact of line of duty killing/serious injury in urban police officers. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2008 Nov 13; Chicago, IL. [view]
  23. Inslicht S, Maguen S, Lucenko B, Reger M, Gahm G, Seal KH, McCaslin S, Marmar CR, Knight SJ. The impact of taking another life in Operation Iraqi Freedom (OIF) soldiers returning from deployment. Presented at: International Society for Traumatic Stress Studies Annual Meeting; 2008 Nov 13; Chicago, IL. [view]
  24. Lindner G, Maguen S, Neria Y, Litz BT, Gross R, Marshall RD. The role of avoidance in complicated grief among bereaved individuals after 9-11. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2007 Nov 17; Baltimore, MD. [view]
  25. Maguen S. The role of mental health in integrated post-combat clinic settings. Paper presented at: VA Integrated Post-Combat Care Conference; 2008 Aug 12; Seattle, WA. [view]
  26. Munroe J, Maguen S, Reeder K, Collins-Clark C, Proescher E. Transitioning war zone skills: A de-stigmatizing skills-based approach with returning Veterans. Presented at: International Society for Traumatic Stress Studies Annual Meeting; 2009 Nov 6; Atlanta, GA. [view]
  27. Maguen S. VA Career Development Award: Transforming Clinical Care Through Research. Paper presented at: VA Clinical and Translational Science Awards Annual Meeting; 2011 Apr 29; Washington, DC. [view]


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Epidemiology, Diagnosis, Treatment - Efficacy/Effectiveness Clinical Trial, Pathology
Keywords: PTSD
MeSH Terms: none

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