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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
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 â¤ 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 â¤ 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 veteransâ 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-
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 veteranâs 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.
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 husbandâs 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 âhoneymoonâ 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
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): â¢ 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. â¢ The use, attempted use, or threatened use of physical force, violence, a deadly weapon, sexual assault, or the intentional destruction of property. â¢ 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
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
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 veteranâs parents, relationship variables (marital adjustment, family adaptability, family cohesion), and war-zone variables (combat
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 âhoneymoon period,â 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 âneverâ or ârarelyâ 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
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 (Ï2 = 9.4, p = 0.002, and Ï2 = 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 (Ï2 = 6.0, p = 0.01), increased aggressiveness (Ï2 = 5.7, p = 0.02), and greater PTSD severity (Ï2 = 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
292 GULF WAR AND HEALTH separation from a parent or may be caused by the parentâs PTSD symptoms of avoidance or hyperarousal. In general, boys and younger children appear to be more vulnerable to symptoms of depression related to the parentâs 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 childrenâs reactions to their parentsâ 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 childrenâs or parentâs 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 Childrenâs Depression Inventory than those with nondeployed parents (8.06 vs 5.33), but there were no other significant differences in reports of the childrenâs anxiety level or behavior. Boys had more dysfunction than girls, regardless of the girlâs parentâs 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 parentsâ reports of depression for those with and without a deployed spouse were again found after control for level of depression before deployment (p â¤ 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 parentsâ levels of depression or stress, that is related to the caregiving parentsâ increase in stress and depression during their spousesâ 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 childrenâs 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 parentsâ reactions to the responses of 1601 children to questions about their other parentsâ 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 childâs 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.
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 fathersâ 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 studyâs 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. Veteransâ reports of PTSD symptoms were associated with reports of hostility and violence towards their children. Veteransâ violent behavior was also correlated with their childrenâs 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.
294 GULF WAR AND HEALTH Six studies explored the associations between deployment and adverse psychosocial outcomes in children of veterans. The one primary study, by Jensen et al. (1996), found that children who had a parent who had been deployed to the Gulf War had more behavioral dysfunction and that boys were at greater risk for depression associated with their parentsâ deployment than were girls; a secondary study found similar results. Three secondary studies also support an association between deployment to war zone and veteransâ violent behavior toward their children, particularly if the veterans have PTSD. One secondary study found that children of veterans who had PTSD and were physically abusive also exhibited violent behavior even 15-20 years after their fathers had returned from the Vietnam War. There is an extensive literature on the effect of deployment on the perpetration of intimate partner violence by veterans against spouses and partners. One large primary study conducted in the early 1990s found an association between deployment and heightened intimate partner violence perpetrated by active-duty soldiers and found that the aggression increased with the length of deployment. Three other studies, all of which used data from a survey of spouses and partners of Vietnam veterans who participated in the NVVRS, found an association between combat-related PTSD and increased intimate partner violence. Four secondary studies lend additional support to the findings of primary studies. Virtually all the studies of veterans and intimate partner violence have been conducted in Vietnam veterans. In particular, veterans with PTSD score higher on various indexes of anger and, given the link between anger and aggression, are therefore more likely to engage in intimate partner violence. Although most of the studies have focused on intimate partner violence, other studies have shown that deployed veterans have more interpersonal violence outside intimate partner violence than nondeployed veterans. The committee therefore based it conclusions on the association between deployment and heightened marital and family conflict, including increased intimate partner violence. There also appears to be more depression in children of deployed veterans and more aggression against children perpetrated by veterans. Of the 7 primary studies, 5 showed a positive association and 2 no association; of the 18 secondary studies, 15 showed a positive association and 3 no association. The association was particularly strong for veterans with PTSD, almost all of whom were Vietnam-combat veterans. The committee concludes that there is sufficient evidence of an association between deployment to a war zone and later marital and family conflict, including intimate partner violence. The association is especially strong when a veteran has a diagnosis of PTSD.
TABLE 7-1 Marital and Family Conflict Reference Study Design Population Outcomes Results Adjustments Comments Jordan et al. Cross-sectional 871 male Vietnam Marital and family- Men with PTSD are more likely to None Strengths: 1992 survey, NSVG theater veterans adjustment patterns report: marital or relationship -nationally without PTSD vs associated with PTSD problems; higher levels of representative 319 with PTSD from prevalence parenting problems; higher levels population (Derived from the NSVG of family violence -deployed vs NVVRS) Measures included nondeployed 252 spouses or -Mississippi Scale for Partners and spouses of theater status partners of veterans Combat-Related PTSD, veterans with PTSD were -plethora of without PTSD vs DIS-PTSD module, and significantly more likely to report measures and 122 spouses of detailed assessment of lower levels of happiness and life interview veterans with PTSD exposure to traumatic satisfaction and to have higher -long-term events demoralization scores than effects -Parental Problems Index spouses or partners of theater -Level of Functioning veterans without PTSD Limitations: Index -study was -Family-Violence subscale Children of veterans with PTSD conducted 15 of CTS were substantially more likely to years after -Index of Subjective Well- have a problem score in the Vietnam War Being clinical range than children of ended -PERI Demoralization veterans without PTSD -no adjustments Scale -Social Isolation Index -alcohol problems -nervous breakdown -Child Behavior Checklist McCarroll et Cross-sectional Randomized sample Probability of spousal Probability of severe aggression in Age, race, sex, Causal al. 2000 survey in 1990- of 11,541 GW- aggression in association preceding year significantly rank, and number relationship 1994 deployed vs 15,294 with deployment greater in deployed (4.25%- of children living between nondeployed 4.95%) vs nondeployed soldiers with respondent deployment and married active-duty CTS to measure self- (3.67%) spousal Army men and reports of behaviors aggression women (95% men, exhibited in marital Probability of severe aggression cannot be 5% women) conflict increased with length of determined deployment from 15.8% (< 3 months) to 34.9% (6-12 months) 295
TABLE 7-1 Marital and Family Conflict 296 Reference Study Design Population Outcomes Results Adjustments Comments Orcutt et al. Cross-sectional 376 Vietnam Association of trauma PTSD symptom severity highly Family Possible recall 2003 survey veterans and their exposure in war zone and associated with increased IPV dysfunction, and response spouses or partners spousal violence relationship with bias (Derived from based on NSVG Combat exposure associated with mother and NVVRS) Measures included decreased IPV father, childhood Inability to -four measures of family antisocial determine dysfunction behavior, causality -DIS perceived threat -Mississippi Scale for Other possible Combat-Related PTSD risk factors not -CTS controlled for Taft et al. Cross-sectional 109 male Vietnam Association between PTSD Men with PTSD and history of Childhood abuse, Relatively small 2005 survey veterans and their and various war-zone IPV report more atrocity exposure interparental sample spouses or partners exposures (combat than men without PTSD but with violence, (Derived from from NSVG exposure, atrocity history of IPV and more than men antisocial Possible recall NVVRS) exposure) and IPV with PTSD but without history of personality bias IPV (p < 0.05) disorder, major depressive Inability to episode, alcohol determine dependence, drug causality dependence Call and Cohort; Career 2,901 white men Association between Young men in military service Education, birth, Limited Teachman Development who graduated from combat service and marital during Vietnam War were most military life- generalizability 1991 Study Washington state status likely to marry history data high schools in 1966 and 1967, 627 Original data collected by No long-term evidence of Vietnam combat questionnaire in 1965-1966 destructive effect of combat veterans, 586 in high schools; in 1979- service on life-course sequencing noncombat Vietnam 1980, telephone interview or veteransâ first marriages veterans, 1688 yielded event history data civilians on 88.8 % of original 1966 panel members
TABLE 7-1 Marital and Family Conflict Reference Study Design Population Outcomes Results Adjustments Comments Call and Cohort Part 1: 2857 white Association between Marriages initiated Age at first Limited Teachman males who military service and marital during military service in Vietnam marriage, marital generalizability 1996 graduated from status did not have a significant adverse conception of Washington state effect on long-term marital first child, high schools in 1966 Part I questionnaire and stability education level and 1967 Part II telephone interview about school, family Marrying for first time after Part 2: subsample of military and work military service increased marital 2369 men who experiences in Pacific stability married by age of 30 Northwest years Gimbel and Cross-sectional 2101 Vietnam Military service in Vietnam Combat exposure has statistically Age, intelligence, Limited Booth 1994 survey veterans who served and marital difficulties significant relationship with race, early generalizability in Army in 1965- marital adversity (including emotional 1971 divorce, separation, abuse, and problems Possible recall Measures include scales to infidelity) bias assess marital adversity, combat, premilitary Combat itself does not have direct Inability to problems relationship with marital quality determine and stability; instead, combat causality creates stress and antisocial behavior, but only antisocial behavior has direct effect on marital adversity Combat directly increases violent and unlawful (antisocial) behavior and stress, which then affect marital stability and quality 297
TABLE 7-1 Marital and Family Conflict 298 Reference Study Design Population Outcomes Results Adjustments Comments Jensen et al. Cross-sectional 383 children and Association of childrenâs Children of deployed personnel Sex, age No control for 1996 survey remaining mental health status and experienced increased self- other factors, caretaking parent, parental deployment reported symptoms of depression, including halo drawn from random as did their parents effects, pre- sample of 480 Parents: Child Behavior existing parental families living on Checklist, CES Depression Families of deployed personnel characteristics military post near Scale, Dyadic Adjustment reported significantly more predisposing Washington, DC, Scale, Live Events Record, intervening stressors than children them toward with at least one Social Assets Scale and families of nondeployed deployment child 4-17 years old; personnel almost all parents Children: Childrenâs Limited were married Inventory, Revised Deployment itself rarely provoked generalizability (94.4%) Childrenâs Manifest pathologic symptoms in otherwise Anxiety Scale healthy children Inability to determine causality NOTE: CES = Combat Exposure Scale, CTS = Conflict Tactics Scale, DIS = Diagnostic Interview Schedule, GW = Gulf War, IPV = intimate partner violence, NSVG = National Survey of the Vietnam Generation, NVVRS = National Vietnam Veterans Readjustment Study, PTSD = posttraumatic stress disorder.
PSYCHOSOCIAL EFFECTS 299 HOMELESSNESS For some, homelessness is a temporary condition; but for others, homelessness is a more permanent situation. The National Law Center on Homelessness and Poverty estimates that about 1% of the U.S. population experiences homelessness in any year. Homeless people may be living on the streets, in shelters, or with relatives or friends. Most homeless people live in urban areas. VA reports that about one-third of the adult homeless population in the United States served in the armed forces at some point. That means that on any given day, 200,000 men (and women) veterans are in need of shelter, food, medical care, and other essentials. Many homeless veterans are Vietnam-era veterans, although veterans of other periods are also homeless or at risk of being homeless. It is estimated that almost half the homeless veterans have some form of mental disorder, almost 70% have a substance-use disorder, and over half are black or Hispanic (VHA 2006). The committee reviewed 10 studies regarding deployment and homelessness. Three were designated as primary and seven secondary. The primary studies are summarized in Table 7-2. Primary Studies The three studies that were designated as primary used data from the NVVRS (Rosenheck and Fontana 1994) or from community surveys (Gamache et al. 2001; Rosenheck et al. 1994). Subjects were viewed as more representative of U.S. veterans than subjects in the secondary studies. The secondary studiesâGamache et al. (2000, 2003), Mares and Rosenheck (2004), Rosenheck et al. (1991, 1992), Tessler et al. (2002), and Wenzel et al. (1993)ârelied primarily on homeless subjects who were mentally ill. Rosenheck and Fontana (1994) reanalyzed data from the NVVRS on 1460 male Vietnam veterans to model the risk of homelessness on the basis of premilitary personal experiences, exposure to war-zone stress, current PTSD, other psychiatric disorders, and substance abuse. Veterans surveyed in the NVVRS who had never been homeless served as a control group for comparison with the 8.4% of the sample who did report homelessness since the war. Structural- equation modeling was used to determine the influence of 18 hypothesized risk factors. Risk ratios ranged from a low of 1.0 (95% CI 0.7-1.4) for being a member of a minority racial or ethnic group to the three highest risk ratios: 5.0 (95% CI 3.5-7.2) for PTSD, 5.3 (95% CI 2.0- 14.2) for being in foster care when young, and 6.5 (95% CI 1.9-22.5) for having psychiatric treatment before age 18. The modeling showed that four postmilitary factorsâpsychiatric disorder other than PTSD, not being married, substance abuse, and low levels of supportâwere directly related to homelessness, but PTSD was not; its effect was mediated through other psychiatric disorders. Combat exposure and participation in atrocities were associated with increased risk of homelessnessârisk ratios were 2.1 (95% CI 1.5-3.0) and 2.7 (95% CI 1.9-3.8), respectivelyâbut their effects on homelessness were also mediated through psychiatric disorders. Social support during the year after discharge was the most important variable in risk of homelessness in the model. Rosenheck et al. (1994) used data from four community surveys to determine whether male veterans, in general, were disproportionately represented among homeless people or whether vulnerability to homelessness was peculiar to one age or race cohort of veterans. Secondary analyses were performed on data from the Urban Instituteâs 1987 national survey of homeless-service users (n = 1140) and from single-city surveys conducted in Los Angeles (n =
300 GULF WAR AND HEALTH 270), Baltimore (n = 295), and Chicago (n = 486) in 1985-1987. It assessed whether veterans were more likely to be homeless than men who were not veterans. Among homeless men, 41% reported military service, compared with 34% of men in the general U.S. population. Comparing veterans with nonveterans showed that those 35-44 years old (those who were most likely to have served in Vietnam) had an odds ratio (OR) for homelessness of 1.01 (95% CI 0.85-1.21). Among both white and black veterans, the cohorts 20-34 and 45-54 years old had a greater likelihood of homelessness (OR 3.95, 95% CI 3.39-4.58; and OR 1.75, 95% CI 1.45-2.15, respectively). The youngest veterans in the 1987 Third Survey of Veterans, a nationally representative sample of 9442 noninstitutionalized veterans, had served after Vietnam in the all- volunteer Army, and only 7% had seen combat. Most of the veterans 45-54 years old had served between the Korean War and the Vietnam War, and 17% of them had seen combat; among veterans who served during the Vietnam War era, 40% reported combat exposure. The much higher prevalence of psychiatric illness, substance abuse, and antisocial personality disorder among white veterans 20-34 years old seemed to be a more likely contributor to the greater vulnerability of this group than combat exposure. Homeless veterans in the most vulnerable groups were the least likely to have served during wartime or combat, and this reduces the role that could be attributed to combat stress in the genesis of homelessness among veterans. Gamache et al. (2001) conducted a followup of the study by Rosenheck et al. (1994) to determine whether the exceptionally high risk of homelessness among post-Vietnam-era, largely noncombat veterans first observed in 1987 was still evident one decade later. Data on 1841 current male clients of homeless assistance programs throughout the U.S. gathered by the 1996 National Survey of Homeless Assistance Providers were compared with information on the general population from the 1996 Current Population Survey. The homeless clients, who were interviewed face-to-face, came from the 28 largest metropolitan statistical areas (MSAs), 24 randomly chosen small and medium-sized MSAs, and 24 randomly chosen rural counties. The relative probability of homelessness for veteran vs nonveteran was determined for defined age and race groups. As of 1996, the proportion of veterans in the adult male homeless population had declined from 41% to 33%, although this proportion was still greater than the 28% in the general population. The especially high risk of homelessness among veterans of the immediate post-Vietnam era who had been aged 20-34 in 1987 was sustained 10 years later (OR 3.17, 95% CI 2.69-3.73), although the youngest cohort of veterans also showed a significant risk of homelessness (OR 2.04, 95% CI 1.59-2.64). Secondary Studies The secondary studies that were reviewed provided mixed findings as to whether deployment to a war zone increased the risk of homelessness. Winkleby and Fleshin (1993) compared three groups of homeless men residing in three California shelters: 173 combat-exposed veterans, 250 veterans without combat exposure, and 585 nonveterans. The prevalence of psychiatric hospitalizations and physical injuries before homelessness was approximately 1.5-2 times as high in combat veterans as in nonveterans or veterans who had not experienced combat. The time between military discharge and first being homeless was more than a decade for 76% of the homeless combat veterans. Rosenheck et al. (1991) compared data on 10,524 veterans participating in the VA Homeless Chronically Mentally III Veterans Program with veterans in the general population. Of the participating veterans, 50% had served in the military during the Vietnam War era, 45% had served in the Vietnam theater, and 41% had been exposed to combat. Only 29% of the total U.S.
PSYCHOSOCIAL EFFECTS 301 veteran population served during the Vietnam War era. However, because the proportion of homeless veterans who served in combat and served in the Vietnam theater was about the same for the veterans who were not homeless, the authors interpreted that finding to suggest that the risk of homelessness could be attributed more to ageâthat is, being 30-44 years old (an age of specific vulnerability of men to homelessness)âthan to combat exposure. Rosenheck et al. (1992), in a study of the relationship between combat stress and homelessness, compared data on 627 Vietnam veterans who were evaluated in a VA clinical program for homeless mentally-ill veterans with data on Vietnam veterans assessed in a national epidemiologic study. Some 43% of the 627 veterans in the VA program showed evidence of combat stress that was associated with more severe psychiatric and substance-abuse problems. Wenzel et al. (1993) assessed 343 homeless male veterans receiving treatment for physical, mental, or substance-abuse disorders and compared the long-term homeless (more than 12 months) with the short-term homeless (12 months or less). The long-term homeless were more likely to be white, to have symptoms of mental and substance-abuse disorders, and to have weaker social support. A 2001-2003 survey of 631 homeless veterans enrolled in a VA clinical demonstration project designed to evaluate a vocational rehabilitation model, found that 31% of the veterans thought that military service had increased their risk of being homeless (Mares and Rosenheck 2004). Among all the homeless veterans, 19% had received hostile or friendly fire in a combat zone. Only 15% of those who did not think that being in the military had increased their risk of homelessness had received such fire, compared with 25% of those who perceived being in the military as a risk factor. Logistic regression showed that each additional childhood problem reported before military life also almost doubled the likelihood of perceiving that military service increased the risk of homelessness. Gamache et al. (2000), in the only study of homeless women, estimated the proportions of veterans and nonveterans. Subjects were drawn primarily from a program for homeless persons with mental illness, but the results showed that the risk of homelessness overall was 2-4 times greater for veterans than for nonveterans. Although Vietnam-era women were at greatest risk for homelessness in this sample, the study did not distinguish between Vietnam-theater veterans and Vietnam-era veterans. Tessler et al. (2002) compared homeless veterans with homeless nonveterans; all were enrolled in an outreach program for persons suffering from serious mental illness. The introduction of an all-volunteer military force did not appear to have changed the composition of the adult male homeless population. Similar results had been obtained by Gamache et al. (2001). Summary and Conclusions The primary and secondary studies reviewed by the committee yielded mixed results with respect to the effect of deployment, particularly combat, on the risk of homelessness in veterans. Of the three primary studies, only one (Rosenheck and Fontana 1994) showed an association between combat exposure and homelessness in Vietnam veterans. The other two studies were equivocal. The secondary studies were also mixed and in general showed that homelessness was related more to the presence of psychiatric disorders than to combat exposure itself. Nevertheless, as the committee concluded in Chapter 6, deployment to a war zone does increase the risk of psychiatric disorders among veterans, so there may be an indirect effect on homelessness.
302 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 homelessness.
TABLE 7-2 Homelessness Reference Study Design Population Outcomes Results Adjustments Comments Rosenheck and Retrospective 1460 male DIS, High combat exposure: OR 2.1, Race, age, rank, year of Limited recall bias, Fontana 1994 cohort; NSVG Vietnam theater Mississippi Scale 95% CI 1.5-3.0 birth, childhood low and era veterans for Combat-Related poverty, parental generalizability (Derived from discharged from PTSD (collected in Participation in atrocities: OR 2.7, mental illness, NVVRS) military before NVVRS), 95% CI 1.9-3.8 childhood abuse, other 1979 Combat Exposure childhood trauma, adult Scale, nonmilitary trauma, association of social support, marital multiple risk factors status, substance abuse, and vulnerability to psychiatric disorders homelessness Rosenheck et al. Cross- Homeless men Prevalence of All ages: OR 1.38, 95% CI 1.05- Includes whites, blacks, 1994 sectional (four from Urban homelessness in 1.85 others surveys Institute survey (n male veteran vs administered = 1140), Baltimore general population Age 20-34: OR 3.95, 95% CI 3.39- in 1985-1987) (n = 295), Chicago 4.58 (n = 486), Los Angeles (n = 270) Age 35-44: OR 1.01, 95% CI 0.85- vs general 1.21 population (from 1987 CPS) Age 45-54: OR 1.75, 95% CI 1.45- 2.15 Gamache et al. Cross- 1841 homeless Prevalence of All ages: OR 1.25, 95% CI 1.13- Includes both white, 2001 sectional, males vs general homeless veterans 1.38 blacks, and others study population (data in each population (Followup of from 1996 CPS) Age 20-34: OR 2.04, 95% CI 1.59- Rosenheck et al. 2.64 1994) Age 35-44: OR 3.17, 95% CI 2.69- 3.73 Age 45-54: OR 1.39, 95% CI 1.14- 1.71 NOTE: CI = confidence interval, CPS = Current Population Survey, DIS = Diagnostic Interview Schedule, NSVG = National Survey of the Vietnam Generation, NVVRS = National Vietnam Veterans Readjustment Study, OR = odds ratio, PTSD = posttraumatic stress disorder. 303
304 GULF WAR AND HEALTH INCARCERATION As of 1998, over 225,000 veterans were in prison or jail in the United States, more than half for violent offenses. Of the incarcerated veterans, about 20% had served in combat duty in the Vietnam War or the Gulf War (Mumola 2000). The committee reviewed six studies regarding the relationship between deployment to a war zone and incarceration. Two (Black et al. 2005; Yager et al. 1984) met the criteria for primary studies, and the other four (Boivin 1987; Hiley-Young et al. 1995; Kulka et al. 1990; Shaw et al. 1987) were designated as secondary studies. The primary studies involved a population-based survey of military personnel who had listed Iowa as their place of residence at enlistment for the Gulf War (Black et al. 2005) and a national sample of men who were of military age during the Vietnam War (Yager et al. 1984). Three of the secondary studies did not have representative samples: Hiley-Young et al. (1995) studied only PTSD inpatients, Shaw et al. (1987) studied Vietnam veterans who had been incarcerated in the state prisons of Iowa, and Boivin (1987) studied a group of incarcerated Vietnam veterans in the maximum-security section of a state prison. Kulka et al. (1990) did not use a validated instrument to determine Vietnam veteransâ involvement with the criminal justice system. Because of the small number of studies considered for this psychosocial effect, primary and secondary studies are treated together here; the two primary studies are summarized in Table 7-3. Black et al. (2005) investigated the prevalence of incarceration and its association with deployment among veterans who had been on active duty during the Gulf War. The study covered military personnel residing in Iowa in 1995-1996 who had deployed to the gulf and a comparison sample of nondeployed military personnel. A total of 4886 subjects were randomly drawn from four study domains: Gulf War regular military (n = 985), Gulf War National Guard and reserve (n = 911), non-Gulf War regular military (n = 968), and non-Gulf War National Guard and reserve (n = 831). A structured telephone interview consisting of validated questions, validated instruments, and investigator-derived questions regarding relevant medical and psychiatric conditions was used. Instruments included the PRIME-MD, the PTSD Checklist, and the Marlowe-Crowne Social Desirability Scale. The sample included 3695 participants (76% of eligible subjects), and a valid telephone number was identified for 91% of them. Of the 3695, 22.9% (845) reported that they had been incarcerated at some point in their lives, 14.5% had been incarcerated at least once before their deployment, and 8.3% had been incarcerated only during or after their deployment. The prevalence of incarceration only after August 1990 for Gulf War veterans vs nondeployed veterans was 8.1% (SE 0.7) and 8.4% (0.8), respectively (OR 0.71, 95% CI 0.5-1.0). In a multivariate model adjusted for age, gender, race, branch of service, and military status, the association between combat experience and being incarcerated only after the Gulf War was significant (OR 1.6, 95% CI 1.0-2.5), suggesting that combat was modestly associated with subsequent incarceration. Yager et al. (1984) studied a sample of 1342 American men who were of draft-eligible age during the Vietnam War. Respondents were chosen on a stratified-probability basis at 10 sites, including big cities, small cities, and rural areas in various regions of the United States. The combined dataset included 629 nonveterans and 713 veterans, 350 of whom served in Vietnam. Subjects were interviewed 6-15 years after the veterans left the service (1977-1979). Respondents were asked whether they had ever been arrested, when it had occurred, what the charge had been, and whether they had been convicted. Vietnam-theater veterans who did not
PSYCHOSOCIAL EFFECTS 305 experience combat or participate in abusive violence had lower conviction rates than era controls. However, if the veteran experienced combat or abusive violence, the results showed impressive effects of heavy combat exposure on arrests and convictions. The arrest rate increased by an average of 2.32 percentage points and the conviction rate by 1.23 percentage points for every point increase on the Combat Exposure Scale. When preservice background factors were statistically controlled for, combat exposure continued to show an association with arrests and convictions (generally for nonviolent offenses). The authors concluded that arrests in the years after service, including arrests that led to conviction, increased sharply with exposure to combat. Of the Vietnam veterans with heavy combat exposure who were arrested after discharge, 19.6% had been arrested for nonviolent offenses and 4.9% for violent offenses, compared with 17.7% and 2.1%, respectively, of veterans with moderate combat exposure and 5.7% and 0.6% of those with light combat exposure. In the 1986-1987 NVVRS, Kulka et al. (1990) found that the 406 Vietnam theater veterans with high levels of war-zone stress were more likely to have been arrested or jailed than the 783 theater veterans with moderate-low war-zone stress (39.1% vs 27.7%) and were almost 3 times as likely (8.8% vs 2.8%) to have been convicted of a felony. Involvement with the criminal-justice system was based on self-reports of number of times arrested since the age of 18 years, nights spent in jail or prison (since the age of 18 years), and number of lifetime convictions for a felony offense and on whether the veteran was in jail or prison at the time of the interview. Of the 319 Vietnam theater veterans with current PTSD, 45.7% had been arrested or jailed more than once in their lives compared with 11.6% of the 871 theater veterans without PTSD; 11.5% of the veterans with PTSD had been convicted of a felony. 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 validated in a subsample of the veterans with the SCID. Black theater veterans were more likely to be involved in the criminal-justice system than whites or Hispanics, but black and Hispanic theater veterans with low war-zone stress were less likely to be involved in the criminal-justice system than black or Hispanic era veterans. In contrast, the other three secondary studies were less likely to attribute incarceration to deployment. In a small study of 61 Vietnam veterans (31 incarcerated and 30 not) in Iowa state prisons, Shaw et al. (1987) concluded that previous personal characteristics, such as a history of antisocial behavior, and not wartime experiences best explained incarceration. Combat stress was similar in both groups although high stress was associated with the development of PTSD. Incarcerated veterans were found to have a higher prevalence of antisocial personality disorder than the community sample (36% vs 7%) and a higher prevalence of alcohol and drug abuse. In the study by Hiley-Young et al. (1995) of 177 Vietnam combat veterans who were receiving treatment for PTSD as inpatients at a VA hospital, high levels of combat exposure were not found to predict criminal activities. A strength of this study is that the authors verified combat status with military records. Boivin (1987), studying incarcerated male Vietnam veterans in a maximum-security section of a Michigan state prison, found that incarcerated veterans (n = 46) were more likely to be black, to have come from a less supportive family background, to have been assigned to an Army infantry combat unit, and to have been injured in combat than incarcerated nonveterans at the same prison (n = 19), nonincarcerated Vietnam veterans from a Vietnam Veterans of America chapter (n = 28), and nonincarcerated non-Vietnam veterans from a National Guard group at a local college (n = 28). The incarcerated veterans were also more likely to have been
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.
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 Scale point increase on Combat Exposure Scale (p < 0.01) Incarceration prevalence Prevalence of being between Vietnam arrested after discharge: theater and era -heavy combat exposed, veterans 19.6% nonviolent offenses, 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
308 GULF WAR AND HEALTH EMPLOYMENT Closely related to the disabling effects of PTSD on a personâs 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 subjectsâ 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
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 â¤ 0.01), whereas for men with anxiety disorders, there was a 31% increase (p â¤ 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.
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.
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
312 GULF WAR AND HEALTH REFERENCES Beckham JC, Feldman ME, Kirby AC, Hertzberg MA, Moore SD. 1997. Interpersonal violence and its correlates in Vietnam veterans with chronic posttraumatic stress disorder. Journal of Clinical Psychology 53(8):859-869. Black DW, Carney CP, Peloso PM, Woolson RF, Letuchy E, Doebbeling BN. 2005. Incarceration and veterans of the first Gulf War. Military Medicine 170(7):612-618. Boivin MJ. 1987. Forgotten warriors: An evaluation of the emotional well-being of presently incarcerated Vietnam veterans. Genetic, Social, and General Psychology Monographs 113(1):109-125. Call VR, Teachman JD. 1991. Military service and stability in the family life course. Military Psychology 3(4):233-250. Call VR, Teachman JD. 1996. Life-course timing and sequencing of marriage and military service and their effects on marital stability. Journal of Marriage and the Family 58(1):219- 226. Clark JC, Messer SC, Castro CAE, Adler ABE, Britt TWE. 2006. Intimate partner violence in the U.S. military: Rates, risks, and responses. Military Life: The Psychology of Serving in Peace and Combat 3:193-219. DoD (Department of Defense). 2004. Task Force Report on Care for Victims of Sexual Assault. Washington, DC. Evans L, McHugh T, Hopwood M, Watt C. 2003. Chronic posttraumatic stress disorder and family functioning of Vietnam veterans and their partners. Australian and New Zealand Journal of Psychiatry 37(6):765-772. Gamache G, Rosenheck R, Tessler R. 2000. Military discharge status of homeless veterans with mental illness. Military Medicine 165(11):803-808. Gamache G, Rosenheck R, Tessler R. 2001. The proportion of veterans among homeless men: A decade later. Social Psychiatry and Psychiatric Epidemiology 36(10):481-485. Gamache G, Rosenheck R, Tessler R. 2003. Overrepresentation of women veterans among homeless women. American Journal of Public Health 93(7):1132-1136. Gimbel C, Booth A. 1994. Why does military combat experience adversely affect marital relations? Journal of Marriage and the Family 56(3):691-703. Glenn DM, Beckham JC, Feldman ME, Kirby AC, Hertzberg MA, Moore SD. 2002. Violence and hostility among families of Vietnam veterans with combat-related posttraumatic stress disorder. Violence and Victims 17(4):473-489. Heyman RE, Neidig PH. 1999. A comparison of spousal aggression prevalence rates in U.S. Army and civilian representative samples. Journal of Consulting and Clinical Psychology 67(2):239-242. Hiley-Young B, Blake DD, Abueg FR, Rozynko V, Gusman FD. 1995. Warzone violence in Vietnam: An examination of premilitary, military, and postmilitary factors in PTSD in- patients. Journal of Traumatic Stress 8(1):125-141.
PSYCHOSOCIAL EFFECTS 313 Jensen PS, Martin D, Watanabe H. 1996. Childrenâs response to parental separation during operation desert storm. Journal of the American Academy of Child and Adolescent Psychiatry 35(4):433-441. Jordan BK, Marmar CR, Fairbank JA, Schlenger WE, Kulka RA, Hough RL, Weiss DS. 1992. Problems in families of male Vietnam veterans with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology 60(6):916-926. Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, Marmar CR, Weiss DS. 1990. Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel Publishers. Mares AS, Rosenheck RA. 2004. Perceived relationship between military service and homelessness among homeless veterans with mental illness. Journal of Nervous and Mental Disease 192(10):715-719. McCarroll JE, Ursano RJ, Liu X, Thayer LE, Newby JH, Norwood AE, Fullerton CS. 2000. Deployment and the probability of spousal aggression by U.S. Army soldiers. Military Medicine 165(1):41-44. McCarroll JE, Ursano RJ, Newby JH, Liu X, Fullerton CS, Norwood AE, Osuch EA. 2003. Domestic violence and deployment in U.S. Army soldiers. Journal of Nervous and Mental Disease 191(1):3-9. McFall M, Fontana A, Raskind M, Rosenheck R. 1999. Analysis of violent behavior in Vietnam combat veteran psychiatric inpatients with posttraumatic stress disorder. Journal of Traumatic Stress. 12(3):501-517. MHAT (Mental Health Advisory Team). 2006. Mental Health Advisory Team (MHAT) IV Operation Iraqi Freedom 05-07: Final Report. [Washington, DC]: Office of the Surgeon Multinational Force-Iraq and Office of the Surgeon General United States Army Medical Command. 17 November 2006. [Online]. Available: http://www.armymedicine.army.mil/news/mhat/mhat_iv/MHAT_IV_Report_17NOV06.pdf. Mumola CJ. 2000. Veterans in Prison or Jail. [Online]. Available: http://www.ojp.usdoj.gov/bjs/pub/ascii/vpj.txt [accessed July 31, 2007]. Newby JH, McCarroll JE, Ursano RJ, Fan Z, Shigemura J, Tucker-Harris Y. 2005. Positive and negative consequences of a military deployment. Military Medicine 170(10):815-819. Orcutt HK, King LA, King DW. 2003. Male-perpetrated violence among Vietnam veteran couples: Relationships with veteranâs early life characteristics, trauma history, and PTSD symptomatology. Journal of Traumatic Stress 16(4):381-390. Prigerson HG, Maciejewski PK, Rosenheck RA. 2001. Combat trauma: Trauma with highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men. Journal of Nervous and Mental Disease 189(2):99-108. Prigerson HG, Maciejewski PK, Rosenheck RA. 2002. Population attributable fractions of psychiatric disorders and behavioral outcomes associated with combat exposure among U.S. men. American Journal of Public Health 92(1):59-63. Rentz ED, Marshall SW, Loomis D, Casteel C, Martin SL, Gibbs DA. 2007. Effect of deployment on the occurrence of child maltreatment in military and nonmilitary families. American Journal of Epidemiology 165(10):1199-1206.
314 GULF WAR AND HEALTH Rosen LN, Teitelbaum JM, Westhuis DJ. 1993. Childrenâs reactions to the Desert Storm deployment: Initial findings from a survey of Army families. Military Medicine 158(7):465- 469. Rosenheck R, Fontana A. 1994. A model of homelessness among male veterans of the Vietnam War generation. American Journal of Psychiatry 151(3):421-427. Rosenheck R, Fontana A. 1998. Transgenerational effects of abusive violence on the children of Vietnam combat veterans. Journal of Traumatic Stress 11(4):731-742. Rosenheck R, Gallup P, Leda CA. 1991. Vietnam era and Vietnam combat veterans among the homeless. American Journal of Public Health 81(5):643-646. Rosenheck R, Leda C, Gallup P. 1992. Combat stress, psychosocial adjustment, and service use among homeless Vietnam veterans. Hospital and Community Psychiatry 43(2):145-149. Rosenheck R, Frisman L, Chung AM. 1994. The proportion of veterans among homeless men. American Journal of Public Health 84(3):466-469. Samper RE, Taft CT, King DW, King LA. 2004. Posttraumatic stress disorder symptoms and parenting satisfaction among a national sample of male Vietnam veterans. Journal of Traumatic Stress 17(4):311-315. Savarese VW, Suvak MK, King LA, King DW. 2001. Relationships among alcohol use, hyperarousal, and marital abuse and violence in Vietnam veterans. Journal of Traumatic Stress 14(4):717-732. Savoca E, Rosenheck R. 2000. The civilian labor market experiences of Vietnam-era veterans: The influence of psychiatric disorders. Journal of Mental Health Policy and Economics 3(4):199-207. Schumm WR, Bell DB, Knott B, Rice RE. 1996a. The perceived effect of stressors on marital satisfaction among civilian wives of enlisted soldiers deployed to Somalia for Operation Restore Hope. Military Medicine 161(10):601-606. Schumm WR, Hemesath K, Bell D, Palmer-Johnson C, Elig TW. 1996b. Did Desert Storm reduce marital satisfaction among Army enlisted personnel? Psychological Reports 78(3 Pt 2):1241-1242. Shaw DM, Churchill CM, Noyes R Jr, Loeffelholz PL. 1987. Criminal behavior and post- traumatic stress disorder in Vietnam veterans. Comprehensive Psychiatry 28(5):403-411. Smith MW, Schnurr PP, Rosenheck RA. 2005. Employment outcomes and PTSD symptom severity. Mental Health Services Research 7(2):89-101. Taft CT, Pless AP, Stalans LJ, Koenen KC, King LA, King DW. 2005. Risk factors for partner violence among a national sample of combat veterans. Journal of Consulting and Clinical Psychology 73(1):151-159. Tessler R, Rosenheck R, Gamache G. 2002. Comparison of homeless veterans with other homeless men in a large clinical outreach program. Psychiatric Quarterly 73(2):109-119. VHA (Veterans Health Administration). 2006. Overview of Homelessness. [Online]. Available: http://www1.va.gov/homeless/page.cfm?pg=1 [accessed August 14, 2007]. Wenzel SL, Gelberg L, Bakhtiar L, Caskey N, Hardie E, Redford C, Sadler N. 1993. Indicators of chronic homelessness among veterans. Hospital and Community Psychiatry 44(12):1172- 1176.
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.