7
PSYCHOSOCIAL EFFECTS

Evidence from World War II, the Vietnam War, the 1991 Gulf War, and now Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq suggests that many military personnel deployed to war zones suffer not only long-term health effects (see Chapter 6) but also adverse psychosocial effects. According to the Oxford English Dictionary, one definition of psychosocial refers to the interrelationship of behavior and social factors (http://dictionary.oed.com). Veterans on return from deployment, especially those suffering from posttraumatic stress disorder (PTSD), anxiety, and depression, might find reintegration into family, social, and occupational settings difficult.

Given the complexity of the psychosocial factors in the lives of veterans and their families, the committee addresses the following issues in this chapter: connections between deployment to a war zone and marital and family conflict, including intimate partner violence and adverse effects on children; employment; incarceration; and homelessness. As in Chapter 6, the committee describes the epidemiologic literature that compares deployed veterans from the Gulf War and other wars with their nondeployed counterparts.

MARITAL AND FAMILY CONFLICT

Marital and family conflict includes divorce, separation, infidelity, and abuse. Abuse is considered in the section on interpersonal violence. In this section, the committee evaluates the evidence on marital and family conflict and deployment. The potential influence of deployment on rates of divorce is also discussed.

Gimbel and Booth (1994), in a historical overview of how the experiences encountered by soldiers in combat adversely affect marital relations, noted that typically each war in the last century was followed by an increase in the divorce rate. The most recent report issued by the Department of Defense (DoD) Mental Health Advisory Team of the Office of the Surgeon Multinational Force-Iraq and the Office of the Surgeon General U.S. Army Medical Command (MHAT 2006) noted that marital satisfaction, in general, was high among soldiers and Marines deployed to Iraq although there had been a downward trend during 2006. The number of deployed soldiers experiencing severe stress or emotional, alcohol, or family concerns increased from 7% in 2003 to 13% in 2006. During this time, the proportion of soldiers reporting a good marriage dropped from 81% to 71%, the proportion planning a divorce or separation rose from 11% to 20%, problems with infidelity rose from 4% to 15%, and marital problems more than doubled, from 12% to 27%.



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7 PSYCHOSOCIAL EFFECTS Evidence from World War II, the Vietnam War, the 1991 Gulf War, and now Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq suggests that many military personnel deployed to war zones suffer not only long-term health effects (see Chapter 6) but also adverse psychosocial effects. According to the Oxford English Dictionary, one definition of psychosocial refers to the interrelationship of behavior and social factors (http://dictionary.oed.com). Veterans on return from deployment, especially those suffering from posttraumatic stress disorder (PTSD), anxiety, and depression, might find reintegration into family, social, and occupational settings difficult. Given the complexity of the psychosocial factors in the lives of veterans and their families, the committee addresses the following issues in this chapter: connections between deployment to a war zone and marital and family conflict, including intimate partner violence and adverse effects on children; employment; incarceration; and homelessness. As in Chapter 6, the committee describes the epidemiologic literature that compares deployed veterans from the Gulf War and other wars with their nondeployed counterparts. MARITAL AND FAMILY CONFLICT Marital and family conflict includes divorce, separation, infidelity, and abuse. Abuse is considered in the section on interpersonal violence. In this section, the committee evaluates the evidence on marital and family conflict and deployment. The potential influence of deployment on rates of divorce is also discussed. Gimbel and Booth (1994), in a historical overview of how the experiences encountered by soldiers in combat adversely affect marital relations, noted that typically each war in the last century was followed by an increase in the divorce rate. The most recent report issued by the Department of Defense (DoD) Mental Health Advisory Team of the Office of the Surgeon Multinational Force-Iraq and the Office of the Surgeon General U.S. Army Medical Command (MHAT 2006) noted that marital satisfaction, in general, was high among soldiers and Marines deployed to Iraq although there had been a downward trend during 2006. The number of deployed soldiers experiencing severe stress or emotional, alcohol, or family concerns increased from 7% in 2003 to 13% in 2006. During this time, the proportion of soldiers reporting a good marriage dropped from 81% to 71%, the proportion planning a divorce or separation rose from 11% to 20%, problems with infidelity rose from 4% to 15%, and marital problems more than doubled, from 12% to 27%. 283

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284 GULF WAR AND HEALTH The committee identified four primary papers and several secondary papers that assessed marital conflict and deployment. The committee also considered additional papers on the effects of parental deployment on children. Several of the studies considered the effects of deployment on marital stability of veterans with and without PTSD, and these are included in the discussions of both primary and secondary studies. The primary studies for marital conflict are summarized in Table 7-1. Primary Studies Gimbel and Booth (1994) assessed the degree of marital adversity, combat exposure, and premilitary factors in a sample of 2101 Vietnam veterans who had participated in the Vietnam Experience Study (VES) conducted by the Centers for Disease Control and Prevention. The VES was conducted in two stages: first, a random sample of 17,867 Vietnam-era veterans was interviewed by telephone, of these veterans, 7748 were randomly selected for in-person testing and medical examinations. Of those selected, 4462 participated in the examinations which were conducted in 1985-1965. The 2101 veterans were selected from the ever-married examination participants who had served in the Vietnam theater; all the men were of enlisted rank and had only served one tour of duty in Vietnam. Combat exposure was found to be moderately related (standardized regression coefficient 0.109, p ≤ 0.01) with marital adversity (divorce, separation, abuse, or infidelity). Premilitary characteristics, such as early emotional problems and problems in school, when factored into the model, reduced the impact of combat by about one-third (standardized regression coefficient 0.073, p ≤ 0.01). The impact of combat on marital adversity was also mediated by two postmilitary factors: posttraumatic stress symptoms and antisocial behavior. When both those postmilitary factors were in the model, the impact of combat itself became insignificant and did not have a direct relationship with marital quality and stability. Furthermore, it appeared that the influence of postmilitary stress symptoms was mediated by antisocial behavior, as was the effect of combat stress. Thus, the authors concluded that combat exposure creates stress that leads to postcombat antisocial behavior and ultimately to adversity in marriage. Although the low participation rate (60%) in the VES and the retrospective nature of the early-life experience data represent limitations in this cross-sectional study, the representativeness of the sample and thoroughness of the data analysis lend credence to the conclusions. The National Survey of the Vietnam Generation (NSVG) and the Spouse/Partner Interview (also called the Family Interview) components of the National Vietnam Veterans Readjustment Study (NVVRS) have been used by several researchers assessing impact of serving in Vietnam on the veterans’ marital and family status and intimate partner violence. In the NVVRS, male Vietnam-theater veterans with PTSD were compared with theater veterans without PTSD. In the NSVG, 1200 Vietnam-theater veterans were randomly selected from all military personnel who had served in the Vietnam theater between August 1964 and May 1975; 432 female Vietnam-theater veterans, and 412 male and 304 female era veterans were also included in the study. Most male veterans were middle-aged and married at the time of the interview; over 50% had some college education. About 17% of veterans were of black or Hispanic backgrounds. PTSD symptom level at the time of the interview was assessed with the Mississippi Scale for Combat-Related PTSD; a study cutoff score of 94 was used as a threshold for an assessment of current PTSD. A diagnosis of PTSD was confirmed in a subset of the veterans using the Structured Clinical Interview for DSM-III (SCID). Psychiatric comorbidity was diagnosed with the Diagnostic Interview Schedule (DIS). The veterans participated in face-

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PSYCHOSOCIAL EFFECTS 285 to-face interviews and medical examinations in 1986-1988. The response rate for the NSVG was 83% for Vietnam-theater veterans. Of the 1200 theater veterans who were interviewed, 862 were selected for followup on the basis of PTSD classification. The followup group also contained an oversampling of veterans without PTSD who indicated they had had high combat exposure or high levels of nonspecific psychological distress. Of these veterans, 585 were living with a female spouse or partner at the time of the survey and 376 of these women were selected to participate in the 1-hour Spouse/Partner Interview; the response rate was 80%. PTSD in the veterans was determined based on the DIS and the Mississippi Scale for Combat-Related PTSD; the clinical examination portion of the NVVRS also included the SCID and the Minnesota Multiphasic Personality Inventory (MMPI) PTSD Scale. The PTSD cases for the following studies were identified based on the Mississippi Scale and adjusted for the bias relative to the clinical interview assessments. Based on responses to the NSVG, Jordan et al. (1992) selected all households of theater veterans who appeared to have PTSD, and the households of a subset of veterans who did not appear to have PTSD, to determine the effects of PTSD on family adjustment and marital conflict. The 1200 Vietnam veterans and 376 of their spouses or partners completed the Marital Problems Index (MPI), the Parental Problems Index (PPI), the Family Adjustment Index, the Level of Functioning Index, the Social Isolation Index, the Child Behavior Checklist, and the Index of Subjective Well-Being. Of the veterans who were married or cohabitating at the time of the survey, the 231 veterans with PTSD, compared with the 736 veterans without PTSD, reported significantly (p < 0.001) more marital and relationship problems (mean MPI score 2.54 vs 1.74), more parenting problems (mean PPI score 2.61 vs 1.93), and poorer family adjustment (54.8% vs 19.3% reporting extreme problems). Veterans with PTSD were six times as likely to have the most martial and relationship problems (that is to score in the high range on the MPI) (48.9% vs 8.7%), three times as likely to fall in the highest category on the PPI (54.7% vs 17.3%), and two times as likely to report extreme family adjustment issues (49.2% vs 21.9%) as veterans without PTSD. The 122 partners and spouses of veterans with PTSD were significantly more likely to report lower levels of happiness and life satisfaction (11.2% vs 1.9%), and higher demoralization scores (42.7% vs 15.4%) than the 252 spouses or partners of veterans without PTSD. Along similar lines, children of veterans with PTSD were substantially more likely to have a behavior problem than those of veterans without PTSD (20.5% vs 12.0%). The authors suggest that a veteran’s PTSD is a major source of family dysfunction. Two studies (Call and Teachman 1991, 1996) used data from the Career Development Study (CDS). In the CDS, a stratified sample of 6729 young men and women in public high schools in the state of Washington who completed a questionnaire in 1965-1966 (time 1) were contacted again in 1979-1980 (time 2) by telephone to gather information on life experiences since high school. The response rate at the followup was 90.6%. Call and Teachman (1991) classified the CDS cohort of 2901 men responding at time 2 into 627 Vietnam-combat veterans, 586 Vietnam-era veterans, and 1688 nonveterans. The men were about 30-31 years old at time 2. As of 1980, 87.2%, 82.1%, and 79.9%, of the men, respectively, had been married. The authors used multivariate analysis to determine the probability of divorce and the influence of combat service on marital stability. The authors found that being in combat in Vietnam vs serving in the military but not in Vietnam, had no impact on the probability of being divorced. They also found that combat service had a positive impact on marriage duration.

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286 GULF WAR AND HEALTH Using a subsample of 2369 men from the CDS who had married by the age of 30 years, Call and Teachman (1996) embarked on a study of 610 Vietnam-combat veterans, 581 Vietnam- era veterans, and 1666 nonveterans. The study assessed the rates and timing of marriage and the association between deployment and marital stability. A multivariate analysis was used to account for variation in the duration of martial disruption, specifically divorce. By 1980, the prevalence of divorce was 28% in nonveterans, 34% in veterans (both theater and era) who married before military service (less then 10% of the sample), 28% in veterans who married during service, and 21% in veterans who married after service. Combat exposure had no significant effect on the likelihood of being divorced. Marrying for the first time after military service increased marital stability. Although both those CDS studies provided complex multivariate analyses with comparisons between deployed and nondeployed veterans, they had some methodologic limitations. The sample consisted only of white men whose families had slightly higher socioeconomic status and higher educational achievement than other such studies and there were no minorities in the sample, so the studies lacked representativeness. Secondary Studies Several secondary studies have reported an association between deployment and marital conflict and dissatisfaction. Several studies that assessed the relationship between PTSD and marital conflict in veteran populations are also briefly discussed. Finally, the committee reviewed four additional secondary studies that reported positive findings that specifically address the role of deployment-related marital and family conflict in psychosocial effects on children. Two studies that yielded negative findings regarding the association between deployment and marital functioning were published in 1996. The survey by Schumm et al. (1996b) of 806 married active-duty soldiers inquired about marital satisfaction at the time of the survey in 1991- 1992, and in 1990 before the invasion of Kuwait. Soldiers who had deployed in the Gulf War showed no significant overall changes with respect to marital satisfaction; this suggested that the effect of deployment was neutral for couples who remained married for 18 months after the conflict, regardless of their predeployment marital satisfaction. Limitations of the study included lack of presentation of results, the absence of a comparison nondeployed group, and the retrospective nature of the predeployment marriage assessment. The second study was conducted by Schumm et al. (1996a) in August 1993. They examined the perceived effects of stressors on marital satisfaction in civilian wives of enlisted soldiers deployed to Somalia for 6 months from December 1992 to July 1993. Marital stability was a strong predictor of marital satisfaction. The results suggest that being stressed during a husband’s deployment by being pregnant, experiencing loneliness or missing the spouse, having problems in communication with the spouse, or having a close friend or family member die did not result in more marital dissatisfaction a month after the return of the spouse. However, those results must be interpreted with caution because the survey was conducted during the “honeymoon” period (that is, the first 3 months after return), the deployments were relatively short and uneventful, and many of the soldiers and spouses were familiar with the deployment experience. Prigerson et al. (2001) conducted a cross-sectional survey of a subsample of the 1990- 1992 National Comorbidity Study to explore the risk factors for veterans with PTSD symptoms. Of the sample of 1703 men who indicated that they had experienced a trauma, 96 reported

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PSYCHOSOCIAL EFFECTS 287 combat as their most traumatic experience, and 42% of the 96 met the criteria for PTSD at some time in their lives. PTSD was diagnosed with the DIS or Composite International Diagnostic Interview (CIDI). Following combat, the trauma next-most likely to result in PTSD was ever having been raped or sexually molested. Men with combat trauma were the most likely to be divorced (39%) or to be physically abusive to their spouses (15%). The association between PTSD and parenting satisfaction was explored by Samper et al. (2004), who assessed a sample of 250 male Vietnam veterans, part of the NVVRS cohort, for depression, intimate partner violence, PTSD, and parenting satisfaction. Results indicated that the PTSD severity and symptoms of numbness and avoidance were significantly negatively associated with parenting satisfaction. Reports on a clinical sample of 270 Australian Vietnam veterans suffering with chronic PTSD showed the influences of PTSD-related symptoms on family functioning (Evans et al. 2003). In particular, PTSD symptoms of avoidance, affect dysregulation, and heightened anger led to more dissension in families of veterans with PTSD. Veterans reported that their avoidance behavior contributed to poor family functioning, and the arousal symptoms of PTSD were associated with angry reactions that also adversely affected family functioning. The perceptions of 951 U.S. Army male and female peacekeepers deployed to Bosnia were queried by Newby et al. (2005). Although most of the soldiers (77%) reported favorable consequences of their deployment, married soldiers were more than twice as likely as single soldiers to report adverse consequences, primarily being away from family and missing important events. Intimate Partner Violence To define intimate partner violence, the committee considered the definition developed by the DoD Task Force on Domestic Violence (DoD 2004): • A pattern of behavior resulting in emotional or psychologic abuse, economic control, and/or interference with personal liberty and that is directed toward a current or former spouse, a person with whom the abuser shares a child in common; or a current or former intimate partner. • The use, attempted use, or threatened use of physical force, violence, a deadly weapon, sexual assault, or the intentional destruction of property. • Behavior that has the intent or impact of placing a victim in fear of physical injury. Most intimate partner violence involves perpetration of violence by men against women. Findings of past-year prevalence in the general U.S. population vary from 0.5% in the 2001 National Crime Victimization Survey to 11.6% in the 1985 National Family Violence Re- Survey; the prevalence of severe violence was estimated to be 3.4% in the latter survey. Surveys that are based on crime statistics and criminal-offense records tend to yield a lower prevalence of intimate partner violence because the report of offenses is voluntary, whereas national surveys of randomly selected couples are generally more accurate and yield a higher prevalence if such instruments as the Conflict Tactics Scale (CTS) are used (Clark et al. 2006). The CTS is an 18- item self-report inventory that assesses conflict tactics as functional (for example, calmly discussing a problem), verbally abusive, or physically abusive. Heyman and Neidig (1999) addressed the prevalence of intimate partner violence in the U.S. Army (n = 33,762) and the general population (n = 3044) and found a higher prevalence of severe husband-against-wife violence in the military population than in the general population

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288 GULF WAR AND HEALTH whether reported by men (2.5% vs 0.7%, respectively) or by women (4.4 % vs 2.0%, respectively). Rates of moderate violence committed by military men and women were higher (10.8% and 13.1%, respectively) than by civilian men and women (9.9% and 10.0%, respectively). The committee reviewed ten papers related to the associations between deployment and intimate partner violence. Two studies (Jordan et al. 1992; McCarroll et al. 2000) met the criteria for a primary study as described in Chapter 2. The Jordan et al. (1992) study focused on the effects of PTSD on intimate partner violence using data from the NVVRS. Studies by Orcutt et al. (2003) and by Taft et al. (2005) provided additional analyses of the Jordan data. The primary studies for intimate partner violence are summarized in Table 7-1. Primary Studies McCarroll et al. (2000) conducted a cross-sectional survey in 1990-1994 of a randomly chosen sample of about 15% of the married, active-duty Army men and women at each of 47 Army installations; civilian spouses were not included in the survey. A modified version of the CTS, a widely used self-report instrument, was used to assess aggression in the past year by the military spouse toward the nonmilitary spouse. Responses were categorized as no, moderate, or severe physical aggression. Of the 37,514 surveys received, 26,835 were deemed eligible: 25,520 from men and 1315 from women. Dual military couples were excluded from the survey, and an analysis of responders and nonresponders found no pattern of bias. During the year prior to the survey, 11,540 soldiers had been deployed: 6195 of them for less than 3 months, 3944 for between 3 and 6 months, and 1402 for between 6 and 12 months; 15,294 soldiers had not been deployed. The nature and location of the deployments was not provided. Using multinomial logistic modeling, the researchers found that the predicted probability of moderate and severe aggression increased with increasing length of deployment. For moderate aggression the probability was 0.1762 for nondeployed, 0.1776 for less than 3 month deployments, 0.1793 for 3-6 month deployments, and 0.1850 for 6-12 month deployments; the probabilities for severe aggression were 0.0367, 0.0425, 0.0464, and 0.0495, respectively. The model was controlled for deployment, age, race, sex, rank, and children living with the respondent. A comparison of the predicted probabilities for moderate and severe aggression with no aggression found that the ratios increased with deployment length, although only the difference in ratios for severe aggression were significant (p < 0.05). For severe aggression, ratios of no deployment vs deployment were: 1.1580 (deployed less than 3 months, 95% CI 1.1370-1.1791), 1.2643 (deployed 3-6 months, 95% CI 1.2415-1.2872); and 1.3488 (deployed 6-12 months, 95% CI 1.3245-1.3731). For moderate aggression the ratios were: 1.0079 (95% CI 0.8431-1.1728), 1.0176 (5% CI 0.8518-1.1834), and 1.0499 (95% CI 0.8808-1.2190), respectively. The researchers note that although the increases were significant for severe aggression the changes represented small absolute values of probability. Although there are limitations inherent in a cross-sectional design, this study demonstrates a clear association between deployment and increased spousal aggression. Intimate partner violence was studied by three research groups using information from the NVVRS discussed above. Based on responses to the NSVG, Jordan et al. (1992) selected all households of theater veterans who appeared to have PTSD and the households of a subset of veterans who did not appear to have PTSD to determine the effects of PTSD on family adjustment and marital conflict, including intimate partner violence. Of those without PTSD, the researchers oversampled for veterans who indicated they had had high combat exposure or high

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PSYCHOSOCIAL EFFECTS 289 levels of nonspecific psychological distress. Family violence in the past year was assessed with the Standard Family Violence Measure, an eight-item subscale of the CTS, and an Alternate Family Violence Measure, which is the total number of violent acts committed or threatened in the past year; scores were categorized as low, medium-low, medium-high, or high violence. Both measures were completed by the veteran as a self-report and by the spouse/partner of the veteran. Family violence, perpetrated by the veteran or by the spouse or partner, was significantly more prevalent in families of veterans with PTSD, with about a third of the veterans with PTSD having engaged in some level of family violence in the past year compared with 15% of those without PTSD. The mean score on the Standard Family Violence Index for the 736 veterans with PTSD was 2.08 vs 0.54 for the 231 veterans without PTSD (p = 0.002), scores for the spouses or partners were 1.57 and 0.51, respectively (p = 0.001). In all, 372 spouses or partners were interviewed. The 122 spouses or partners of veterans with PTSD reported up to four times as much medium-high to very-high family violence perpetrated by the veteran as did the 252 spouses or partners of veterans without PTSD (7-12% vs 3%, standard error 1.4-3.9, p < 0.01) on both the Standard Family Violence Index and the Alternate Family Violence Index. The mean number of violent acts committed or threatened by veterans in the past year was 4.86 for those with PTSD vs 1.32 for those without PTSD; for spouses or partners of the veterans the mean number of violent acts was 3.03 and 0.96, respectively. Over 9% of the veterans with PTSD had committed 13 or more acts of violence in the past year. The analyses were weighted to compensate for differences in selection probabilities so that the data provide unbiased national estimates for all male theater veterans with a spouse or partner. Age, sex, race or ethnicity, and nonresponse were used to stratify the weights. Strengths of this study are the reporting of family violence perpetrated by both the veteran and the spouse or partner and the use of a nationally representative sample of veterans. In a further analysis of the same 376 Vietnam veteran couples who had participated in NSVG, Orcutt et al. (2003) used structural-equation modeling to assess the influence of early-life stressors, war-zone stressors, and PTSD symptom severity on intimate partner severity. The modeling showed that there were four direct influences on intimate partner violence in male Vietnam veterans: a poor relationship with mother, combat exposure, perceived threat in the war zone, and PTSD symptom severity. All the influences resulted in more intimate partner violence except for combat exposure. Increasing combat exposure was related to less violence against a spouse or partner. The model also suggests that retrospective reports of a stressful early family- life and antisocial behavior during childhood acted indirectly on intimate partner violence via war-zone stressors and PTSD symptom severity. Taft et al. (2005) also assessed the NSVG subsample of the 376 veterans and spouses or partners who had participated in the family interview. Veterans with a lifetime history of physical violence toward their spouse or partner but with none reported for the past year were excluded. In all, 40 male veterans were classified as both PTSD-positive and partner violent (one or more episodes of partner violence in the past year), 41 were PTSD-negative but partner violent, and 28 were PTSD-positive but nonviolent. Data analysis showed that PTSD severity did not differ significantly between the two PTSD groups, nor did violence severity between the two partner-violent groups. The PTSD-positive and partner-violent group scored higher for all the following factors than did the PTSD-positive/nonviolent or PTSD-negative/partner-violent groups: psychiatric disorders (antisocial personality disorder, major depressive disorder, and alcohol and drug-use/dependence), violence between the veteran’s parents, relationship variables (marital adjustment, family adaptability, family cohesion), and war-zone variables (combat

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290 GULF WAR AND HEALTH exposure, perceived threat, atrocities exposure). However, the PTSD-positive/nonviolent group had the most childhood abuse (49%), over twice that of the other groups (21-23%). Both PTSD- positive groups both had more combat exposure than the PTSD-negative group; the PTSD- positive/partner-violent group had more exposure to combat and particularly to atrocities than the PTSD-positive/nonviolent group. Secondary Studies In addition to the primary studies that support the association between deployment and intimate partner violence after deployment, there are numerous supportive secondary studies. Studies that assess deployed vs nondeployed veterans are discussed first, followed by studies of intimate partner violence in veterans with and without PTSD. McCarroll et al. (2003) surveyed a group of 313 male U.S. Army soldiers assigned to peacekeeping functions in Bosnia for 6 months from September 1998 to April 1999 and compared them with 712 male soldiers who had not deployed. The research team used the CTS to explore the incidence of intimate partner violence at two times: prior to September 1998, and April-June 1999. There were no significant demographic differences between the two groups; all participants were married, and deployed soldiers had been home from deployment for 90-113 days at the time of the survey. The rates of predeployment intimate partner violence did not differ between deployed and nondeployed soldiers (11.5% vs 10.3%) and deployment was not a significant predictor of later moderate or severe domestic violence (6.7% deployed vs 7.4% nondeployed). The strongest predictor of postdeployment domestic violence was a previous history of domestic violence (OR 4.56, 95% CI 2.60-8.00); the next-strongest was living off post (OR 2.71, 95% CI 1.39-5.32), which was followed by being nonwhite (OR 1.69, 95% CI 1.03- 2.76). Although this study had a reasonably representative sample and deployment to a single area, behavior was assessed for the “honeymoon period,” which typically is not accompanied by heightened intimate partner violence, so the study may underestimate the degree of intimate partner violence that may later develop. Several other secondary studies highlight the association between PTSD and intimate partner violence after deployment. Several of the studies of veterans with PTSD and intimate partner violence involved treatment populations; all were of Vietnam veterans, and, like the studies discussed above, many used data from the NVVRS. Prigerson et al. (2002) used data from the 1990-1992 National Comorbidity Survey that sought to determine the prevalence of psychiatric disorders in a nationally representative sample of 2578 men 18-54 years old, of whom 1337 were currently married or cohabitating. Participants were asked about possible combat exposure and the CIDI was used to diagnose psychiatric disorders, except for PTSD, which was assessed for the previous 12 months with the DIS. The married or cohabiting men were asked about abuse of spouses or partners, and those who responded with “never” or “rarely” were counted as nonabusive. Combat exposure was associated with current spouse or partner abuse (relative risk [RR] 4.40, 95% CI 1.68-10.49, p = 0.004; adjusted for age, race, urbanicity, and low socioeconomic status in family of origin). Path analysis suggested that the effect of combat exposure on current spouse or partner abuse was indirect and mediated through PTSD. Savarese et al. (2001) also analyzed the NSVG data on the 376 male Vietnam veterans and their female partners discussed above (Jordan et al. 1992) to examine the joint effects of drinking frequency, drinking quantity, and the severity of the hyperarousal symptoms of PTSD on marital abuse and violence. Of the 376 men, 315 (84%) indicated that they had engaged in at

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PSYCHOSOCIAL EFFECTS 291 least one or more act of psychologic violence toward their partners in the preceding year, and 21% had engaged in physical violence; men who engaged in psychologic abuse are more likely also to engage in physical abuse. Both physical and psychologic abuse were associated with hyperarousal symptoms and this association was exacerbated when excessive alcohol was consumed on an occasion. However, frequent consumption of small quantities of alcohol, even during high hyperarousal conditions, does not increase, and may even mitigate, husband-to-wife violence. Beckham et al. (1997) conducted two studies to explore PTSD, intimate partner violence, and their correlates in Vietnam-combat veterans. The first study assessed 37 male outpatients at a VA medical center: 17 help-seeking combat veterans with PTSD and 20 combat veterans without PTSD recruited from all veterans who had attended the VA center within the past year. The second study involved 118 male Vietnam veterans who were also outpatients at the PTSD clinic. The SCID or Clinician-Administered PTSD Scale (CAPS) was used to diagnose PTSD. In the first study all veterans and a family member or friend completed the Standard Family Violence Index of the CTS; in the second study only the veterans completed the Standard Family Violence Index and they also completed the CAGE screening questionnaire for alcohol use. In the first study, veterans with PTSD reported significantly greater occurrences of violent behavior during the preceding year than veterans without PTSD (22 acts vs 0.2 acts of violence). Both PTSD and combat exposure had a significant main effect on interpersonal violence (χ2 = 9.4, p = 0.002, and χ2 = 4.2, p = 0.04, respectively). In the second study, risk factors for increased intimate partner violence, in order of importance, were lower socioeconomic status (χ2 = 6.0, p = 0.01), increased aggressiveness (χ2 = 5.7, p = 0.02), and greater PTSD severity (χ2 = 4.4, p = 0.04). Current problems with alcohol abuse were not associated with intimate partner violence. An association between PTSD in veterans and heightened violence was demonstrated in a study by McFall et al. (1999). They compared 228 Vietnam-combat veterans seeking inpatient treatment for PTSD at a VA medical center with 64 psychiatric inpatients without PTSD who had served during the Vietnam War but not served in a war zone. An additional comparison was with 273 community-dwelling Vietnam veterans with PTSD (assessed with the Mississippi Scale for Combat-Related PTSD), who had never been hospitalized for the disorder. PTSD was diagnosed with a standard clinical interview by a psychiatrist. The sample of community- dwelling PTSD veterans was derived from the NVVRS data set; veterans were selected to have a level of combat exposure comparable with that of the inpatient PTSD veterans. Data from the NVVRS, CTS, and clinician interviews were used to assess the level of violence engaged in by the veterans. PTSD inpatients were significantly more likely to report having engaged in one or more acts of violence in the preceding month than the psychiatric inpatients (OR 7.40, p < 0.001), particularly having destroyed property, threatened others with or without a weapon, or been involved in a physical fight. Comparison with the community sample of veterans who had PTSD yielded similar findings except that the community veterans were more likely than the PTSD inpatients to have destroyed property. Symptom severity and, to a lesser degree, substance abuse were correlated with violence among the PTSD inpatients. It should be noted that this study did not include intimate partner violence as a violence endpoint. Deployment Impacts on Families and Children Young families are at greatest risk for coping with children who are distressed by deployment of one of their parents. The distress may be related to anxieties or worries about

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292 GULF WAR AND HEALTH separation from a parent or may be caused by the parent’s PTSD symptoms of avoidance or hyperarousal. In general, boys and younger children appear to be more vulnerable to symptoms of depression related to the parent’s deployment. Results of several studies support an association between deployment and adverse psychosocial effects on children. Jensen et al. (1996) conducted a study of 480 families with children 4-17 years old, randomly selected from a sample of families living on a military base near Washington, DC; 383 families completed all or part of the survey. Although the study emphasized the children’s reactions to their parents’ deployment for Operation Desert Storm, it also considered the effect of deployment on the caretaker parents and the marriages. Almost all the parents were married (94.4%), and the racial distribution of the families was 52.5% non-Hispanic white, 30.9% black, and 9.0% Hispanic. Both of the parents and the children completed a wide array of surveys and questionnaires that assessed behavior, depression, anxiety, and social assets. Families were divided into those with a soldier-parent who was deployed to the Gulf War and those with a soldier-parent who was not deployed and remained on the military base. The researchers also compared the results of the assessments with an assessment of some of the same families a year earlier, before deployment. Prior to deployment of any parents, there were no meaningful differences in terms of the children’s or parent’s self-reported behaviors and parent or family functioning between families where a parent would deploy and those where no parent deployed. Children whose parents had deployed scored moderately higher on the Children’s Depression Inventory than those with nondeployed parents (8.06 vs 5.33), but there were no other significant differences in reports of the children’s anxiety level or behavior. Boys had more dysfunction than girls, regardless of the girl’s parent’s deployment status and boys with a deployed parent were more likely to have increased dysfunction than boys with a nondeployed parent. Deployment itself rarely provoked pathologic symptoms in otherwise healthy children. Parents with deployed spouses reported more depression and higher levels of life stressors than those parents whose spouses had not deployed. The same differences seen between caretaking parents’ reports of depression for those with and without a deployed spouse were again found after control for level of depression before deployment (p ≤ 0.001). Likewise, there continued to be significant predeployment and postdeployment differences in reported stress levels of the caretaking parent. There were no predeployment and postdeployment differences in marital adjustment, social supports, or coping. The data indicate that it is deployment itself, rather than pre-existing differences in the parents’ levels of depression or stress, that is related to the caregiving parents’ increase in stress and depression during their spouses’ deployment. The authors suggest that many young families have particular difficulty with even temporary-duty separations, perhaps because they also have less experience with a military lifestyle. The authors note that the findings do not suggest that the caretaking parents cause their children’s symptoms of depression; instead, the interrelationships between caretaking parent, child, and absent deployed parent contribute to a complex outcome. Rosen et al. (1993) explored caretaker parents’ reactions to the responses of 1601 children to questions about their other parents’ Gulf War deployment. Results were similar to those of Jensen et al. (1996). Although the children expressed sadness and had eating and sleeping problems, among other symptoms of distress, the most important predictor of a child’s symptoms was the expression of symptoms of distress by other members of the household. This study lacked direct input from the children themselves, but the findings support an association between deployment and adverse psychologic effects on children, which association seems to be mediated by its effect on the parent.

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PSYCHOSOCIAL EFFECTS 293 Family dysfunction was also found by Rosenheck and Fontana (1998), who explored the transgenerational effects of abusive violence on the children of Vietnam combat veterans in the NVVRS. Children of veterans who had participated in abusive violence or had high war-zone stress during the war, scored significantly higher (worse) on the Child Behavior Checklist than did children of other Vietnam veterans (p < 0.01). That study showed that children of veterans who exhibited abusive violence had more behavior problems themselves even 15-20 years after their fathers’ deployment. Rentz et al. (2007) examined the rate of child maltreatment in military families. The design involved a time-series analysis of Texas child-maltreatment data from the 2000-2003 National Child Abuse and Neglect Data System to examine changes in the occurrence of child maltreatment over time and the effect of recent increases in deployment. Substantiated child maltreatment in military families was twice as frequent between October 2002 (the 1-year anniversary of the September 11, 2001, attacks) and June 2003, than in the period between October 2002 and October 2001 (rate ratio 2.15, 95% CI 1.85-2.50). Between January 2000 and September 2002, the rate of child maltreatment in military families was 37% lower than in nonmilitary families (rate ratio 0.67, 95% CI 0.62-0.72) but after October 2002, the rate was 22% higher (rate ratio 1.22, 95% CI 1.10-1.36). After December 2002, child maltreatment was found to increase by about 30% for every 1% increase in the number of active-duty personnel who departed for or returned from operational deployments. The results suggest that both departures for, and returns from, deployment impose stress on military families and increase rates of child maltreatment. Maltreated children in military families were more likely to be non-Hispanic whites less than 4 years old. The study’s cross-sectional design has limitations, but its strengths include comparisons of deployed and nondeployed soldier-parents. One study focused on veteran populations who sought treatment for PTSD. For example, Glenn et al. (2002) assessed the degree of violence and hostility in 31 Vietnam veterans who had a diagnosis of PTSD (using the CAPS) and their spouses or partners and 29 of their older adolescent or adult children. The veterans, their spouses or partners, and their children reported a moderate to moderate-high level of violent behavior based on responses to the Childhood Physical Punishment Scale, Cook-Medley Hostility Scale, and the Violent Behavior Index. Veterans’ reports of PTSD symptoms were associated with reports of hostility and violence towards their children. Veterans’ violent behavior was also correlated with their children’s violent behavior. Although this study suffers from the absence of a representative sample, the findings highlight the disruptive effects of PTSD on all members of a family. Summary and Conclusions The collective findings of the primary and secondary studies of marital and family conflict, including intimate partner violence, indicate that many veterans and their families will experience significant stress after the return of the veterans from deployment. The impact of deployment on marital and family conflict is mixed. Two primary studies indicated that exposure to combat alone did not result in increased marital conflict, particularly divorce, for Vietnam theater veterans. The two secondary studies considered by the committee also found that exposure to combat alone did not increase postdeployment marital conflict for Gulf War veterans. However, the two primary and three secondary studies of Vietnam veterans with combat-related PTSD all found that marital conflict and family adjustment problems were significantly increased in these veterans and that the problems persisted for years after the war.

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306 GULF WAR AND HEALTH involved in killing enemy soldiers, prisoners, or civilians and to have flashbacks of those events. The author attributed their incarceration, however, to having been poor prospects with respect to their social, economic, and interpersonal well-being before being sent to Vietnam. Summary and Conclusions The two primary studies, one of Gulf War veterans and one of Vietnam veterans, found that exposure to heavy combat increased the likelihood of being incarcerated after release from military service. However, veterans who were deployed but did not experience heavy combat were less likely to be incarcerated than those exposed to heavy combat and were not any more likely to be incarcerated than nondeployed veterans. The secondary studies, conducted mainly with Vietnam veterans, were mixed and tended to show that having a psychiatric disorder increased the risk of a veteran being incarcerated. The committee concludes that there is limited but suggestive evidence of an association between deployment to a war zone and later incarceration.

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TABLE 7-3 Incarceration Reference Study Design Population Outcomes Results Adjustments Comments Black et al. 2005 Cross-sectional 985 Gulf War regular Structured Deployed vs nondeployed Age, sex, race, rank, Recall bias, survey conducted military, 911 Gulf War telephone veterans incarcerated after branch of service, limited in 1995-1996 National Guard or interview to August 1990: OR 0.71, military status generalizability, reserve, 968 nondeployed assess prevalence 95% CI 0.5-1.0; ever lack of specificity regular military, 831 of incarceration in incarcerated: OR 1.04, of details of nondeployed National Gulf War vs non- 95% CI 0.9-1.3 incarceration Guard or reserve veterans Gulf War veterans drawn as a random sample from 4886 Iowa-based veterans Yager et al. 1984 Cross-sectional 350 Vietnam-theater Interview about Arrest rate increased by Age, race, drug use, Recall bias, survey conducted veterans, 363 era war experience average of 2.32 percentage alcohol use limited 6-15 years after veterans, 629 nonveterans variable points and conviction rate generalizability leaving service by average of 1.23 (1977-1979) Combat Exposure percentage points for every point increase on Combat Scale Exposure Scale (p < 0.01) Incarceration Prevalence of being prevalence between Vietnam arrested after discharge: -heavy combat exposed, theater and era 19.6% nonviolent offenses, veterans 4.9% violent offenses -moderate combat exposure, 17.7% and 2.1%, respectively -light combat exposure, 5.7% and 0.6%, respectively NOTE: CI = confidence interval, OR = odds ratio. 307

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308 GULF WAR AND HEALTH EMPLOYMENT Closely related to the disabling effects of PTSD on a person’s ability to function is its effect on the ability to find and maintain employment. The committee reviewed five studies regarding the effect of deployment to a war zone on employment and earnings. The two that were designated as primary studies used data from the NVVRS, a nationally representative sample of male Vietnam veterans. Of the three secondary studies, two were based on data from the National Comorbidity Survey (NCS) and these were considered secondary because the subjects were selected nonrandomly and because there was no control or comparison group. The third secondary study had a nonrepresentative sample consisting only of veterans in treatment for PTSD. Primary studies are summarized in Table 7-4. Zatzick et al. (1997a,b) studied the relationship between PTSD and functioning and quality of life. One sample included male Vietnam veterans, and the other, female Vietnam veterans. The authors used archival data from the NVVRS NSVG, a study that was completed in 1988 and included a cohort of 1200 male and 432 female Vietnam-theater veterans, and 412 male and 304 female era veterans. Most male veterans were middle-aged and married at the time of the interview; over 50% had some college education. About 17% of veterans were of black or Hispanic backgrounds. PTSD symptom level at the time of the interview was assessed with the Mississippi Scale for Combat-Related PTSD; a study cutoff score of 94 and 89 was used to define current PTSD in the men and women, respectively. Psychiatric comorbidity was diagnosed with the DIS. A single question assessed the subjects’ ability to function in a particular role on the job, at home, or at school. Male veterans who were gainfully employed (n = 1033), active with schoolwork (n = 2), or engaged in housework (n = 2) were categorized as working. Logistic models were used to determine the association between PTSD and outcome; adjustment was made for demographic characteristics and comorbid psychiatric and other medical conditions. The results showed that veterans with PTSD (n = 242) were more likely not to be working at the time of the survey than veterans without PTSD (n = 948), for an OR of 3.3 (95% CI 1.5-7.6) adjusted for age, ethnicity, marital status, educational attainment, region of country, and comorbidity; 10 veterans did not complete the scale and were not included in the analyses. The study of 432 female Vietnam veterans also used archival data from the NVVRS (Zatzick et al. 1997b). Aside from the use of a cutoff of 89 for a PTSD diagnosis, the methods for this study were the same as for the study of male veterans. About 8.9% (37) women were estimated to have PTSD. Once again, logistic models were used to determine the association between PTSD and various outcomes, including employment. Adjusted for age, ethnicity, marital status, educational attainment, region of country, and comorbidity, PTSD was associated with approximately 10 times greater odds of not working (OR 10.4, 95% CI 1.8-61.9). This was the strongest association found between PTSD and the various outcomes, which also included subjective well-being and self-reported physical health status. A limitation of both Zatzick et al. studies is that they were cross-sectional, making it impossible to determine the extent to which PTSD may have caused this functional impairment. Savoca and Rosenheck (2000) also used data from the NVVRS NSVG to explore the influence of psychiatric disorders on the civilian labor-market experiences of 1417 Vietnam-era veterans. The authors used the NSVG lifetime diagnoses of major depression, anxiety disorders, substance abuse or dependence, constructed with the DIS and combat-related PTSD based on the

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PSYCHOSOCIAL EFFECTS 309 Mississippi Scale for Combat-Related PTSD. The employment probability equation was estimated by using a probit: hourly earnings and hour-worked were estimated via ordinary least squares conditioned on being employed. The comparison group was white veterans without a history of psychiatric disorder, who had served in the military, but not in Southeast Asia, for less than one year and had low levels of war-related stress. The presence of any of four psychiatric diagnoses had a statistically significant negative effect on the probability of being employed: anxiety disorder, -0.415 (p < 0.01); substance abuse or dependence, -0.233 (p < 0.01); major depression, -0.390 (p < 0.01); and PTSD -0.498 (p < 0.01). However, none of the psychiatric disorders had an effect on the usual number of hours worked per week. Veterans with lifetime PTSD were 8.6% less likely to be working and, if working, earned 16% less per hour than veterans without PTSD. Veterans with major depression or substance use or dependence, but not anxiety disorders, also had lower hourly wages, although the lower wages are not significant for those with substance abuse or dependence. For men with depression, there was as 45% decrease in hourly wages (p ≤ 0.01), whereas for men with anxiety disorders, there was a 31% increase (p ≤ 0.01). In summary, combat-related PTSD significantly lowered the likelihood of working and the hourly wage. The authors noted that PTSD had a greater effect on reducing the likelihood of working and on the hourly wage than did deployment to Vietnam itself. Similar results were seen by Jordan et al. (1992). Using data from the NVVRS, they found that Vietnam veterans with PTSD were five times more likely to be unemployed than veterans without PTSD (13.3% vs 2.5%). The three secondary studies (Prigerson et al. 2001, 2002; Smith et al. 2005) reported similar results. Prigerson et al. (2001) used a subsample of 1703 men from the 1990-1992 NCS who reported experiencing a traumatic event to assess the impact of combat exposure on employment. They found that the 96 men who reported combat as their worst trauma had the highest rates of unemployment (20%) or having been fired in the last year (13%) compared with the highest rates for men who reported one of eight other traumas as their worst (13.4% and 9.7%, respectively). Using a different subsample of 2248 men from NCS, 179 of whom reported combat exposure data, Prigerson et al. (2002) estimated that 11.7% of 12-month job loss (relative risk 2.90, 95% CI 1.70-4.70, p < 0.001) and 8.9% of current unemployment (relative risk 2.37, 95% CI 1.55-3.44, p < 0.001) could be attributed to combat exposure. Among 325 male Vietnam-era veterans being treated in 10 VA medical centers for severe or very severe PTSD symptoms, veterans with more severe PTSD symptoms (based on responses to the CAPS) were more likely to work part-time or not at all. A 10-point increase in CAPS score was associated with an almost 6% increase in the probability of not working, a 2% decrease in the likelihood of part-time work, and almost a 4% decrease in having full-time work (Smith et al. 2005). Summary and Conclusions Both primary studies considered by the committee indicated that veterans with PTSD are at greater risk for being unemployed and, if they are employed, are at risk for receiving lower wages than their counterparts without PTSD. However, the conclusions that can be drawn from the studies are limited in that they did not assess whether deployment itself had the same effect. Furthermore, all the primary studies were conducted in Vietnam veterans; none assessed the effect of Gulf War or other deployment on the later employment status of veterans. The secondary studies also indicated that veterans with combat exposure had poorer employment outcomes than those who experienced other or no traumas, particularly if they had PTSD.

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310 GULF WAR AND HEALTH The committee concludes that there is inadequate/insufficient evidence to determine whether an association exists between deployment to a war zone and adverse employment outcomes.

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TABLE 7-4 Adverse Employment Outcomes Reference Study Design Population Outcomes Results Adjustments Comments Zatzick et al. 1997a Cross-sectional 1200 male Vietnam- Not working vs OR 3.3, 95% CI Demographic Unable to determine survey; archival theater veterans; 242 working associated 1.5-7.6 characteristics, causality, (Derived from analysis of data veterans with PTSD with PTSD other medical employment status NVVRS) from NVVRS vs 948 without PTSD disorders determined with single question, possible recall bias due to self-reports Zatzick et al. 1997b Cross-sectional 432 female Vietnam Not working vs OR 10.4, 95% CI Demographic Unable to determine survey; archival theater veterans, working associated 1.8-61.9 characteristics, causality, (Derived from analysis of data mostly nurses; 37 with PTSD other medical employment status NVVRS) from NVVRS with PTSD disorders determined with single question, possible recall bias due to self-reports Savoca and Cross-sectional 1417 Vietnam-era Estimates of hourly Theater veteran: Demographic Unable to determine Rosenheck 2000 survey veterans wages and 60% higher chance characteristics, causality, probability of of employment (p length of service, comparison group is (Derived from Comparison group is employment < 0.01); 50% other psychiatric nonrepresentative NVVRS) white veterans with higher wages (NS) disorders, no history of difficulty of job psychiatric disorders PTSD: 50% lower and deployed chance of elsewhere employment; 16% lower wages NOTE: CI = confidence interval, NS = nonsignificant, NVVRS = National Vietnam Veterans Readjustment Study, OR = odds ratio, PTSD = posttraumatic stress disorder. 311

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PSYCHOSOCIAL EFFECTS 315 Winkleby MA, Fleshin D. 1993. Physical, addictive, and psychiatric disorders among homeless veterans and nonveterans. Public Health Reports 108(1):30-36. Yager T, Laufer R, Gallops M. 1984. Some problems associated with war experience in men of the Vietnam generation. Archives of General Psychiatry 41(4):327-333. Zatzick DF, Marmar CR, Weiss DS, Browner WS, Metzler TJ, Golding JM, Stewart A, Schlenger WE, Wells KB. 1997a. Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans. American Journal of Psychiatry 154(12):1690-1695. Zatzick DF, Weiss DS, Marmar CR, Metzler TJ, Wells K, Golding JM, Stewart A, Schlenger WE, Browner WS. 1997b. Post-traumatic stress disorder and functioning and quality of life outcomes in female Vietnam veterans. Military Medicine 162(10):661-665.

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