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KAPTUR COMBAT
MENTAL HEALTH INITIATIVE
“There is no greater priority than the mental health needs of our returning soldiers.” Adjutant General Wayt (2005)
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Study SitesUniversity Hospitals Case Medical Center
Joseph Calabrese, MDCoordinating Principal Investigator
Stephen Ganocy, PhD., Philip Chan, MS Edwin Shirley, PhD., Toyomi Goto, MA
Renee Slembarski, BA
University of ToledoMarijo Tamburrino, MDCo-Principal Investigator
Thomas Fine, MA., Kimberly Wilson, MSW Daniel Rapport, MD
Columbia UniversitySandro Galea, MD, DrPH
Co-InvestigatorMarta Prescott, MPH
University of MichiganIsrael Liberzon, MD, PhD
Co-InvestigatorAnthony King, PhD
Study Sites
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OUTLINE
• Background, Research Question & Design• Overall Demographic Description• Pre-deployment: Childhood Trauma, Stressors• Deployment experiences, Trauma, Support• PTSD, Depression, GAD findings• Suicidal Thoughts
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Health in the militaryStudies have demonstrated that combat exposure and deployment stressors are linked to psychopathologies including posttraumatic stress disorder (PTSD), depression and anxiety
• 27% of WWI hospitalizations were due to neuropsychiatric problems
• 15% of Vietnam War Vets, 15 years after the war, showed symptoms of PTSD
• 2% - 12.2% of Persian Gulf War veterans have current symptoms of PTSD
• 4% - 21% of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans have current symptoms of PTSD
Pols et al 2007; Kulka et al 1990; Kang et al 2003; Kang et al 2005; Pietrzak et al 2009; Hotopf et al 2006; Hoge et al 2006; Miliken 2007; Seal et al 2007
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National Guard in recent combat
Army National Guard and Air National Guard are increasingly used in combat zones and overseas operations
• 18% of total force in Persian Gulf War• Reserve forces have comprised ~ 40% of the total operating force
in OIF and OEF
Lakhani et al 1993; Vogt et al 2008, Iraq and Veterans Affairs, Ohio National Guard website dated 3-28-09
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Ohio National Guard (ONG) and Deployment
From September 11, 2001 through March 2009, more than 13,000 Ohio Army National Guard and Ohio Air National Guard have been deployed for both national and international dutyUnique factors about deployment today• All volunteer force• Multiple deployments• Communication• 11% deployed are women
Ohio National Guard website dated 3-28-09
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National Guard in recent combatWhile studies have shown that National Guard members deployed overseas experience comparable combat and deployment stressors as active duty personnel, Guard members have different training and deployment conditions than active duty personnel.
• Traditionally train only one weekend a month and two weeks in the summer
• While in National Guard maintain civilian job• Only 180 days of health care coverage upon deactivation as
compared to 2 years for active duty personnel
Vogt et al 2008, Hotopf et al 2006; La Bash 2007 8
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Kaptur CMHIMost other studies have NOT focused on:
• The ONG• VA non-treatment seekers• Anything other than screening assessments• Genetics repository • Longitudinal collection of stressors and life events both inside and
outside of the military
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Overriding research question
What are pre-, peri- and post-deployment factors associated with onset and course of psychopathology among the Ohio National Guard?
• Posttraumatic stress disorder, depression, generalized anxiety disorder
• Suicidal ideation• Mental health services
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6,700 randomly sampled ONG personnel received Alert Letter
6,090 personnel do not opt-out of study
2616 ONG personnel participate in telephone interview
1,043 randomly selected for in-person interviews
2616 ONG personnel followed annually with telephone interviews
500 sub-sample followed annually with in-person interviews
Kaptur CMHI ONG study design10,778 Men and Women in the Ohio Army
National Guard (ONG) as of July 2008
1270% overall participation rates
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Domains assessed in telephone assessment
• Demographics• Military History• Deployment Preparedness, Stressors, Traumas, and
Social Support: Deployment Risk and Resilience Inventory (DRRI)
• Lifetime Traumatic History: Life Events Checklist• Posttraumatic Stress Disorder: PTSD Checklist• Depression: Patient Health Questionnaire (PHQ-9)• Generalized Anxiety Disorder: GAD-7
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In-Person Interview Domains• Demographics• Military History• Deployment Preparedness, Stressors, Traumas, and Social
Support: Deployment Risk and Resilience Inventory (DRRI)• Lifetime Traumatic History: Life Events Checklist• PTSD: Clinician-Administered PTSD Scale (CAPS)• All DSM IV-TR Mood, Anxiety, Substance Use, Psychotic,
Somatoform, Eating and Acute Stress Disorders:Structured Clinical Interview for DSM IV-TR (SCID-IV)
• Suicidal Thoughts: Mini-International Neuropsychiatric Interview (MINI-Plus)
• Childhood Trauma Questionnaire (CTQ)
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Who are these people and what are the stories of their lives?
• Demographics• Childhood trauma• Stressors and trauma outside of deployment• Number of deployments
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Location of Kaptur CMHI Sample N=2616
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Color of pushpins indicates different interviewers. (Blue-Ed, Red-Toyomi, Green-Tom, Purple-Kim)
Location of In-person Sample N=500
Wave 1 sample is representative of the Ohio Army National Guard
• p-value <0.05. This is calculated from baseline sample (N≈2616). The calculation for race included an other category (Native American and Asian), the baseline sample had 123 individuals (4.7%) compared to 183 (1.7%) in the Ohio National Guard.
Age distribution* Race distribution*Female distribution
Male Female 17-24 25-34 35-44 45+ White Black0
10
20
30
40
50
60
70
80
90
100
85.2
14.8
33.6 32.4
24.2
9.6
87.7
7.5
86.2
13.8
37.534.8
19.9
7.8
88.3
10.0
ONG sampleOhio National Guard 2008
Pro
po
rtio
n
Ohio Army National Guard
Men make up 85.2% of the sample
Men Women Calculated from baseline (N≈2616)
Majority of the sample is white (87.7%)
White Non-whiteCalculated from baseline (N≈2616)
Few are currently divorced, widowed or separated (9.6%)
Married Divorced or separated Never marriedCalculated from baseline (N≈2616)
Soldiers reported facing trauma in childhood
Physical Abuse Emotional Abuse Physical Neglect Sexual Abuse Emotional Neglect0
5
10
15
20
25
Perc
ent o
f in-
pers
on s
ampl
e w
ho re
port
ed "
mod
erat
e to
sev
ere"
or "
seve
re to
ex-
trem
e"
These values are from the Childhood Trauma Questionnaire (Bernstein et al. 1996) from the baseline sample of the in-person surveys (N≈500). Each variable is determined on a 4 –point scale from “none or minimal”, “low to moderate”, “moderate to severe” and “severe to extreme”. Presented are the percentages of those who reported “moderate to severe” and “severe to extreme” occurrences.
Childhood traumas are more frequent in women
*p-value<0.05. These values are from the Childhood Trauma Questionnaire (Bernstein et al. 1996) from the baseline sample of the in-person surveys (N≈500). Each variable is determined on a 4 –point scale from “none or minimal”, “low to moderate”, “moderate to severe” and “severe to extreme”. Presented are the percentages of those who reported “moderate to severe” and “severe to extreme” occurrences.
Physical Abuse* Emotional Abuse Physical Neglect Sexual Abuse* Emotional Neglect0
5
10
15
20
25
30
35
40 Men
Women
Perc
ent w
ithin
sub
grou
ps o
f in-
pers
on s
ampl
e w
ho re
port
"m
oder
ate
to s
ever
e" o
r "s
ever
e to
ext
rem
e" ty
pe o
f abu
se
Throughout lifetime, soldiers encounter stressful experiences that can impact deployment and mental health (n=2616)
Wave 1 Telephone Survey. N≈2616Mean number of type of stressors was 3.4 (min=0, max=12). These are the prevalence of occurrences ever reported in the baseline survey
Family member (other than parent) had drug or alcohol problems
Been through divorce or breakup
Seen or heard physical fighting between parents or caregivers
Mental illness personally or someone close to them had mental illness
Been unemployed for at least 3 months
Lost their job
Had serious financial problems
Been robbed or home was broken into
Ever been emotionally mistreated
Parent with problem with drugs or alcohol
Experienced stressful legal problems
Had problems getting adequate healthcare
0 5 10 15 20 25 30 35 40 45
Percent of baseline sample that reported ever having experience
32% of the baseline sample had been deployed more than once
Average number of deployments is 1.3 (min = 0, max = 24). This is the proportion of deployment experience from baseline sample (N≈2616)
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In addition to lifetime stressors, the guard experience trauma outside of deployment
Ninety-one percent have experienced a trauma at some time in their lives
This was calculated within the baseline sample (N≈2616). Traumatic events include assaultive traumatic events as well as shocking events (e.g. car accident, natural disaster), learning about traumatic events to others, the sudden unexpected death of someone close and any other traumatic event the participant considered traumatic
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Summary of pre-deployment conditions
• In the baseline sample majority of soldiers had been deployed at least once and the majority of those who had been deployed more than once had prior combat experience.
• Only thirty-six percent soldiers have never been deployed.• Overall, soldiers experience stressors, traumas as well as
psychopathologies over their lifetime that can play a role in subsequent mental health consequences after deployment.
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What are deployment experiences?• Have information from baseline on most recent deployment
including war trauma, self-reported preparedness, unit and post-deployment support
• Measures were collected using the Deployment Risk and Resilience Inventory
King, D.W., King, L.A., Vogt, D., Knight, J., Samper, R.E. (2006) Deployment Risk and Resilience Inventory: A collection of measures for studying deployment related experience among military personnel and veterans. Military Psychology; 18(2): 89 - 120
Ohio Army National Guard
Majority of sample (63%) have been deployed
Never deployed Deployment experienceCalculated from baseline sample (N≈2616)
Nearly one third have had their most recent deployment to a conflict zone
Never deployed Non-conflict zone Conflict zoneCalculated from baseline sample (N≈2616)
Received hostile incoming fire
Attacked by terrorists, insurgents, or civilians
Encountered land or water mines or booby traps
In a vehicle that was under fire
Saw Americans or allies after they were severely wounded or disfigured in combat
Saw civilians after they were severely wounded or disfigured
Saw enemy soldiers after they were severely wounded or disfigured in combat
Saw the bodies of dead enemy soldiers
Fired your weapon at the enemy
Saw soldiers from enemy troops being seriously wounded or killed
Saw someone from your unit or an ally unit being seriously wounded or killed
Saw the bodies of dead civilians
Engaged in battle in which your unit suffered casualties
Saw the bodies of dead Americans or allies
Killed or thought you killed someone in combat
Received "friendly" incoming fire
Injured or wounded during combat
0 10 20 30 40 50 60
Percent of those who had been ever been deployed at baseline that reported
Trauma during deployment
(n=1607)
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Feeling prepared on most recent deployment
• Answers were scaled from 1 (strongly disagree) to 5 (strongly agree)• Had supplies and equipment needed to get my job done• Equipment I was given functioned the way it was supposed to• Received adequate training on how to use my equipment• Accurately informed about what to expect from the enemy• Accurately informed of what daily life would be like during my deployment
Calculated from deployment risk and resilience inventory (DRRI) among those who were ever deployed at baseline (n=1607) King, D.W., King, L.A., Vogt, D., Knight, J , Samper, R.E. (2006) Deployment Risk and Resilience Inventory: A collection of measures for studying deployment related experience among military personnel and veterans. Military Psychology; 18(2): 89 - 120
Box plot of Preparedness scores
X
• Sense of camaraderie between myself and other soldiers in my unit• Most people in my unit were trustworthy• Could go to most people in my unit for help when I had a personal problem• Commanding officers were interested in what I thought and how I felt about things• Impressed by the quality of leadership in my unit• My superiors made a real attempt to treat me as a person• I felt like my efforts really counted to the military
Calculated from deployment risk and resilience inventory (DRRI) among those who were ever deployed at baseline (n=1607).King, D.W., King, L.A., Vogt, D., Knight, J., Samper, R.E. (2006) Deployment Risk and Resilience Inventory: A collection of measures for studying deployment related experience among military personnel and veterans. Military Psychology; 18(2): 89 - 120
Unit support during most recent deployment
Box plot of unit support score
X
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• Reception I received when I returned from my deployment made me feel appreciated for my efforts • American people made me feel at home when I returned • When I returned, people made me feel proud to have served my country in the Armed Forces • People at home understand what I have been through while in the Armed Forces• There are people to whom I can talk about my deployment experiences • The people I work with respect the fact that I am a veteran
Calculated from deployment risk and resilience inventory (DRRI) among those who were ever deployed at baseline (n=1607) King, D.W., King, L.A., Vogt, D., Knight, J., Samper, R.E. (2006) Deployment Risk and Resilience Inventory: A collection of measures for studying deployment related experience among military personnel and veterans. Military Psychology; 18(2): 89 - 120
Post-deployment support after most recent deployment
Box plot of post-deployment score
X
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Summary of experiences during deployment
• Most soldiers have deployment experience and many have faced multiple combat situations.
• While self-reports may vary, most reports of preparedness, unit support and post-deployment support were high.
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What are our Study Findings on Mental Health?
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Comparing…prevalence of psychopathologies found in the general population (GP)
Kessler R et al. Arch Gen Psychiatry 2005;62:593-602 and 617-627.
Lifetime % 12-Month %
GP ONG GP ONG
PTSD 6.8% 9.5% 3.5% 7.2%
MDD/Depr 16.6% 21.4% 6.7% 14%
GAD 5.7% 12.4% 3.1% 9.3%
Majority of soldiers do not have a condition and only 8% have co-occurring conditions within the past year
One condtion13%
Two conditions6%
Three conditions2%
No conditions80%
This was calculated from the baseline sample (N≈2616) using PTSD, depression and generalized anxiety disorder
No conditions79%
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ONG Gender Findings
Women Men
PTSD past year 12.1% 6.9% Depression past year 20.4% 12.8%GAD past year 12.6% 8.7%
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How family and social factors predict PTSD
Demographic and Stressful factors
Posttraumatic stress disorder
Female* +Being married -High income -College education -Marital discord +Lost a job* +
* p-value <0.05. High income is dichotomized by $60,000. Results are the direction of the odds ratios from multivariable logistic models.
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How deployment stressors predict PTSD
High psychosocial support -
High levels of preparedness*-
High levels of unit support +
Family concerns while deployed*+
High levels of post-deployment support*
-
* p-value <0.05. Preparedness, unit support, family concerns, perceived threat and postdeployment support were created by splitting each score from the median. Results are the direction of the odds ratios from multivariable logistic models.
Effect of Self-reported factors
Posttraumatic stress disorder
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How deployment stressors predict PTSD
High psychosocial support -
High levels of preparedness*-
High levels of unit support +
Family concerns while deployed*+
High levels of post-deployment support*
-
* p-value <0.05. Preparedness, unit support, family concerns, perceived threat and postdeployment support were created by splitting each score from the median. Results are the direction of the odds ratios from multivariable logistic models. Starred values represent significant findings.
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Effect of Self-reported factors
Posttraumatic stress disorder
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High levels of post-deployment support reduce the odds of developing PTSD.
“People understand what I’ve been through”
“There are people whom I can talk to about my experience”
“When I returned, people made me feel proud to serve”
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Caregiving strains families of veterans with severe injuries – USATODAY.com
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Does deployment affect suicidal ideation?
Two percent of soldiers reported suicidal thoughts within the past 30 days
Lifetime suicidal Ideation Suicidal Ideation within past 30 days0
2
4
6
8
10
12
Prev
alen
ce w
ithin
bas
elin
e sa
mpl
e
Calculated within baseline sample (N≈2616). This is “thought (they) would be better off dead, or had thoughts of hurting (themselves)” from the Patient Health Questionnaire - 9. Kroenke K, Spitzer R. The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals 2002;32:1. Compared to general population with a prevalence of lifetime suicidal ideation between 4.8% and 18% (cdc.gov/ncipc/wisqars)
255/2508
47/2508
Stressors experienced over lifespan are associated with current suicidal ideation
* Current income < 60,000
*p-value <0.05. n = 2,508. Calculated with in baseline sample that answered all questions
* Low social support
* Parents abused each other
* Caregivers fought
* Ever unemployed > 3 months
* Serious financial problems
No Yes No Yes No Yes No Yes No Yes No Yes0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Prev
alen
ce w
ithin
pas
t 30
days
Deployment experience is not associated with current suicidal ideation
Never deployed Have been deployed Not deployed in past 3 years
Deployed in past 3 years
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Prev
alen
ce w
ithin
wav
e 1
subg
roup
s w
ithin
the
past
30
days
Among those deployedN = 1,601
Not deployed in past 3 yrs Deployed in past 3 yrs
However, within those deployed, certain features of most recent deployment predict current suicidal ideation
No Yes No Yes No Yes No Yes No Yes0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Prev
alen
ce o
f sui
cida
l ide
ation
with
in w
ave
1 su
bgro
ups
with
in th
e pa
st 3
0 da
ys
* High preparedness * High unit support * High family concerns * High post deployment support
* High combat
• p-value <0.05. From the Deployment Risk and Resilience Inventory. High levels created by median split. Calculated from baseline sample those who have been deployed (N≈1607)
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Interim Conclusions from Kaptur CMHI
• Overall, the ONG appear resilient to the development of PTSD, Depression, GAD and suicidal ideation.
• However, highly vulnerable sub-groups exist within the ONG. • Among deployed, preparedness and support predicted
resilience, whereas family concerns and amount of combat predicted risk.
• Suicidal ideation does not appear to be associated with deployment.
• Suicidal ideation was associated with being unmarried, low income, low social support, physical/sexual abuse, unemployment and financial problems.
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