interpersonal relationships, and interest in receiving care. The PDHA also included three questions about combat experiences, including whether the solider had seen anyone wounded, killed, or dead; had engaged in direct combat and discharged a weapon; or felt in great danger of being killed. The investigators did not assess for prior trauma. Of the veterans returning from Iraq (n = 222,620), Afghanistan (n = 16,318), or deployment elsewhere (Bosnia, Turkey, Uzbekistan, Kosovo, on a ship, or other; n = 64,967), 19.1%, 11.3%, and 8.5%, respectively, met the risk criteria for a mental-health problem. The 8.5% for the deployed-elsewhere soldiers was similar to the prevalence of mental-health problems reported by soldiers prior to their first deployment to OIF or OEF. The OR for OIF veterans compared to those deployed elsewhere was 2.72 (95% CI 2.63-2.80, p < 0.001). Mental-health problems were associated with combat exposure. Almost 10% of the OIF veterans, 4.7% of the OEF veterans, and 2.1% of those deployed elsewhere screened positive for PTSD.

Erickson et al. (2001) surveyed a cohort of 2949 Army veterans from Fort Devens, Massachusetts, immediately after their return from the Gulf War (time 1) and then 18-24 months later (time 2) to examine the temporal relationship between depression and PTSD. The Mississippi Scale for Combat-Related PTSD and the Brief Symptom Inventory were administered to all participants, and results were analyzed at time 2. A latent-variable, cross-lag panel model found evidence of a reciprocal relationship between PTSD and depression, which means the best-fit model includes both the progression from PTSD to depression and from depression to PTSD. Essentially, it provides some support for Kessler’s notion that each outcome could be antecedent to the other (Kessler et al. 1995). The committee notes that the use of latent variables required that an index be developed both for the measurement of PTSD and for the measurement of depression; thus, the results are not tied strictly to diagnosis, but rather to separate symptom clusters. Moreover, after adjustment for military and demographic characteristics, the results suggest that the reciprocal relationship only held up on followup at time 2 for re-experiencing and avoidance-numbing symptoms.

Grieger et al. (2006) examined the influence of battle injury on combat-related PTSD or of depression on PTSD in 243 soldiers hospitalized after serious combat injury, including life-threatening or seriously disfiguring injuries (n = 613). The longitudinal cohort was evaluated at 1, 4, and 7 months with the PTSD Checklist; depression was assessed with the Patient Health Questionnaire. Soldiers who did not meet the criteria for PTSD or depression at 1 month but who did at 7 months were compared with soldiers who remained below the diagnostic threshold for PTSD or depression at 7 months. The investigators noted that most of the soldiers with PTSD or depression at 7 months did not meet criteria for either condition at 1 month. Moreover, at 1 month, 4.2% of the soldiers had probable PTSD and 4.4% had depression; at 4 months, 12.2% had PTSD and 8.9% had depression; and at 7 months, 12.0% had PTSD and 9.3% had depression. After controlling for demographic characteristics (age, marital status, and sex), early severity of physical problems was strongly associated with later PTSD or depression. Of those contacted, fewer than 0.5% refused to participate. The investigators note that there were no differences at 1 month in the rates of probable depression, probable PTSD, or either condition between soldiers who completed all three assessments and those who did not complete the followup assessments.

Suicide ideation was not included in this section as a psychiatric outcome itself, but, as in depression, there are consistent reports that ideation is greater in deployed veterans than in nondeployed veterans (Fontana and Rosenheck 1995a; Fu et al. 2002; Gray et al. 2002). Suicide ideation is also briefly discussed in the section “Suicide and Accidental Death.”

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