Preventing Psychological Disorders in Service Members and Their Families An Assessment of Programs (2014) / Chapter Skim
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3 UNDERSTANDING PSYCHOLOGICAL HEALTH IN THE MILITARY
3 UNDERSTANDING PSYCHOLOGICAL HEALTH IN THE MILITARY
Pages 35-84
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From page 35... ...
, Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment (IOM, 2012) , and Substance Use Disorders in the U.S.
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The Marine Corps, the smallest branch, makes up 13.8 percent of the active force. In the reserve component, the Army National Guard is the largest branch (42.2 percent)
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d A dual-military marriage refers to an active-duty or reserve component member who is married to another active-duty or reserve component member. The Army National Guard does not report dual military marriages.
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Those in the National Guard and reserves had fewer multiple deployments than those in the active component. The average length of deployments was 7.7 months, with the average length in the various services ranging from 4.5 months in the Air Force to 9.4 months in the Army.
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From page 39... ...
Many of those who have served in OEF and OIF have readjusted with few difficulties, but others have had problems in returning home, reconnecting with family members, finding employment, and returning to school. Lingering health problems related to combat, including traumatic brain injury (TBI)
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. Based on the literature of psychological health disorders in OEF and OIF active-duty members and veterans, the 2013 IOM report Returning Home from Iraq and Afghanistan concluded that our understanding of the health consequences of service in Iraq and Afghanistan remains incomplete; even simple questions such as prevalence rates of physical and psychologic morbidity after military service in Iraq or Afghanistan continue to lack precision.
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The RAND Corporation completed a telephone survey of 1,938 soldiers to determine probable TBI and other psychological health outcomes. Probable TBI was assessed using the Brief Traumatic Brain Injury Screen.
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. The researchers used an adapted version of the Defense and Veterans Brain Injury Center screening tool to determine mild TBI in a large group of National Guardsmen.
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Posttraumatic Stress Disorder Although the 2009 IOM report found limited or suggestive evidence of an association between mild TBI and PTSD, the overlapping symptomology of TBI and PTSD complicates the relationship between the two conditions. Returning Home from Iraq and Afghanistan (IOM, 2013a)
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Specifically, the IOM (2013a) reported that being under age 25, being single, and being of junior rank are risk factors for PTSD in OEF and OIF service members and veterans (Lapierre et al., 2007; Phillips et al., 2010; Seal et al., 2009)
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found that certain deployment-related stressors (such as troubles at home, lack of privacy, and problems with leadership) , combat exposure, prior traumatic exposure, military sexual trauma, a history of psychological health conditions, and severe physical injury were all risk factors for PTSD.
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(2013a) examined the risk factors associated with sexual assault or harassment in a cohort of 13,262 active- and reserve-component women.
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Additional protective factors cited in Returning Home from Iraq and Afghanistan included positive appraisals of military service, having five or more close confidants, and longer dwell times (MacGregor et al., 2012; Phillips et al., 2010; Skopp et al., 2011)
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, unmarried, and with less than a college education increased the likelihood of depression. Other risk factors for depression reported in literature include military sexual trauma, childhood physical abuse, and other adverse childhood experience (Cabrera et al., 2007; Fritch et al., 2010; Kimerling et al., 2010; Suris and Lind, 2008)
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among service members ranged from 11.8 percent (active duty) to 15.0 percent (National Guard and reserve)
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, only 2 percent have been referred for further evaluation or treatment. Alcohol abuse is associated with several risk factors related to combat service, such as exposure to the threat of death or injury, witnessing atrocities, depression and PTSD symptoms, and a diagnosis of PTSD (Burnett-Zeigler et al., 2011; Department of the Army, 2012; Spera et al., 2011; Wilk et al., 2012)
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National Guardsmen frequently reported that stigma and concerns about their military careers were barriers to their seeking treatment. Looking at risk factors by deployment phase, Ferrier-Auerbach et al.
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Risk Factors Risk factors for suicidal ideation among active-duty male personnel in the Air Force include not being married, being non-Christian, being junior enlisted, being employed as medical personnel, having alcohol problems, working longer hours, having poor social support, being dissatisfied with relationships, having poor coping ability, having experienced interpersonal violence, and being dissatisfied with the Air Force way of life. Among Air Force women, risk factors include lower rank, financial stress, alcohol problems, relationship dissatisfaction, interpersonal violence, poor social support, and being non-Christian.
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At the individual level, depressive symptoms and alcohol problems were both risk factors for suicidal ideation. For mothers in the study population, however, alcohol problems actually decreased the risk of suicidal ideation.
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Protective Factors Protective factors that make suicide less likely are not as well studied as risk factors, and most of the research on them has been carried out in civilian populations. The most recognized protective factors are social support, including strong interpersonal bonds to family/unit members and responsibility to one's family; psychological factors, such as resilience, good impulse control, and good problem-solving skills; and psychological health treatment (Bryan and Hernandez, 2013; Nock et al., 2013; VA and DOD, 2013)
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Returning Home from Iraq and Afghanistan (IOM, 2013a) found in the limited existing research that spouses of service members expecting deployment reported substantially elevated stress levels and depressive symptoms, although baseline levels of these problems in this population are not well documented.
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(The specific resources available depend on whether the service member is in the active component, National Guard, or reserves.) On the other hand, military children may also have to cope with circumstances specific to military families, such as frequent relocations, parents leaving for and returning from deployments (which can be unexpected, prolonged, and repeated)
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This was true no matter which parent was deployed. During a parent's deployment, military children make more outpatient and well-child visits to TRICARE providers.
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. Family Violence This section addresses the problem of interpersonal violence within military families, which includes intimate partner violence and child maltreatment.
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found that deployment and substance use were risk factors for spousal aggression among activeduty military service members (Martin et al., 2010; Merrill et al., 2004)
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. Although it is less focused on psychological health, the Periodic Health Assessment is discussed at the end of this section.
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attention deficit disorder, developmental disorders, bipolar disorder, depressive disorder, speech disorders, obsessive-compulsive disorders, schizophrenic disorders, a history of suicidal behavior, eating disorders, alcohol or drug dependence or abuse, and other psychological disorders not mentioned that the examining clinician feels may interfere with satisfactory performance of military duties. The services have the authority to waive medical standards on a case-by-case basis (DOD, 2010)
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It is therefore plausible that psychological health disorders or other risk factors for suicide were present in some service members at enlistment. Regardless of when the risk factors arise, the authors suggest that the current DOD and VA prevention initiatives with the greatest potential to mitigate suicide risk are those "that address previous psychological health disorders and involve screening and facilitation of high-quality treatment for psychological and substance use disorders in primary care, specialty psychological health care, and postdeployment settings" (LeardMann et
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. These findings further support the suggestion that pre-military experiences can affect psychological health outcomes in individuals after they join the military, indicating that these experiences should be among the risk factors considered for screening and prevention.
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; psychiatric disorders (2.9 percent versus 13.2 percent; p<0.001) , suicidal ideation (0.4 percent versus 0.9 percent; p<0.001)
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Despite the PDHA using valid, evidence-based measures, the self-report nature of the assessment, the well-documented stigma of psychological health issues (Ben-Zeev et al., 2012; Caetano et al., 2013; Gould et al., 2007; Momen et al., 2012) , and the effects that negative psychological health outcomes may have on deployment may limit DOD's ability to identify individuals with risk factors for psychological health disorders or even to identify those individuals who have already developed full-blown psychological health disorders.
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The HRA does not include questions about PTSD, suicide, or any other psychological health conditions4 (Navy and Marine Corps Public Health Center, 2013) and health care providers are not required to ask follow-up questions about these conditions during the Periodic Health Assessment; however, health care providers are supposed to document any unresolved health concerns identified by previously completed Post-Deployment Health Assessments or Post-Deployment Health Reassessments (DOD, 2008)
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Embedded Mental Health Providers In theater there are no routine required psychological health screenings, although DOD is making an effort to identify service members who display signs of psychological stress during deployment and is improving access to psychological health care. Based on a recommendation from the DOD Task Force on Mental Health (2007)
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Self-Assessment Tools Military Pathways Military Pathways provides free, anonymous psychological health and alcohol selfassessments for family members and service personnel in all branches, including the National Guard and reserve (Military Pathways, 2013)
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. The VA/DOD guidelines addressing patients at risk for suicide are divided into four different modules: the assessment and determination of risk for suicide, including assessment of risk factors and protective factors; the initial management of the patient at risk for suicide, including determination of appropriate care setting and securing the patient's safety, especially through restriction of lethal means; the treatment of the patient at risk for suicide, including suicide-focused psychotherapy, psychotherapy for co-occurring psychological disorders, and pharmacotherapy; and follow-up and monitoring of the patient at risk for suicide, including adherence to treatment and follow-up care strategies and continuity of care.
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2. Gather data on warning signs, risk factors, and protective factors for suicide [ D ]
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restrictive setting of care that manages safety risks No appropriately 21 Patient at INTERMEDIATE ACUTE Manage High [F] RISK for suicide Acute Risk for Current suicidal ideation, no intent or Suicide plan, no suicidal preparatory behavior Continue on or suicide attempt Algorithm C 22 Discuss safety and restriction of access to lethal means Treat mental health and medical conditions Address psychosocial needs Encourage social support (family/unit members, friends, command and community resources)
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Known as TRICARE Reserve Select, the plan has monthly premiums and cost-sharing arrangements similar to those of civilian employer plans, although often at lower cost. Some members of Congress have called for having psychological health professionals embedded where National Guard and reserve troops train one weekend per month, but DOD opposes this policy as unnecessary and logistically difficult because of a shortage of psychological health providers (Zoroya, 2011)
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From page 73... ...
For example, there are different experiences and conditions associated with the societal environment to which members of the reserve component return as compared to the active component. Reserve component members must immediately reintegrate into civilian work places and neighborhoods, environments which may have little comprehension of the military member's deployment experience.
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2010. Correlates of posttraumatic stress disorder symptoms in Marines back from war.
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Washington, DC: National Center for Telehealth and Technology, Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury.
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2013d. TRICARE National Guard and Reserve Member Families.
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2009. Separating deployment-related traumatic brain injury and posttraumatic stress disorder in veterans: Preliminary findings from the Veterans Affairs traumatic brain injury screening program.
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2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment.
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2013b. Risk factors associated with suicide in current and former US military personnel.
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2012. Posttraumatic stress disorder, substance use disorders, and medical comorbidity among returning U.S.
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2011. Longitudinal effects of mild traumatic brain injury and posttraumatic stress disorder comorbidity on postdeployment outcomes in National Guard soldiers deployed to Iraq.
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2008. Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: Persistent postconcussive symptoms and posttraumatic stress disorder.
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2009. Intimate partner and general aggression perpetration among combat veterans presenting to a posttraumatic stress disorder clinic.
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, posttraumatic stress disorder, and depression in U.S. soldiers involved in combat deployments: Association with postdeployment symptoms.
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