Combat-related Mental Health Symptoms and Correlates through the

Deployment Cycle

MAJ Jeffrey L. Thomas, Ph.D.Chief, Military Psychiatry Branch

Center for Military Psychiatry and Neuroscience

Walter Reed Army Institute of Research

The views expressed in this presentation are those of the author and do not represent the official policy or position of the U.S. Army Medical command or the Department of Defense.

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WRAIR Psychological Research and Health Program

• WRAIR’s Psychological Research and Health Program is focused on:• Benchmarking the effects of combat• Moderating the negative effects of combat• Promoting resilience in Soldiers and Families

• Main Studies:• Land Combat Study (epi)• Mental Health Advisory Teams (MHATs) (epi)• Interventions

• Epidemiological Studies• Mental Health Advisory Team (MHAT) data

• Behavioral health symptoms during deployment

• Prescription drug use

• Risk factors

• Land Combat Studies data• Behavioral health symptoms following deployment

• Rates of alcohol misuse

• Risk behaviors

• The Army Alcohol Pilot: CATEP (Confidential Alcohol Treatment & Education Program)

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Outline

• Mental Health Advisory Teams

• Mission:• Assess Soldier behavioral health

• Examine the delivery of theater behavioral health care

• Provide recommendations to command

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MHAT Mission

• Estimated rates of mental health problems (MHAT V Report)

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MHAT Data: Mental Health Symptom Rates

19.2%16.5%

19.1%17.9%

20.7%

14.5%

17.9%20.4% 19.6%

13.0%

0%

5%

10%

15%

20%

25%

30%

35%

2003 2004 2005 2006 2007

Figure 5: Any Mental Health Problem Over TimeAdjusted Percents are for Male, E1-E4 BCT Soldiers

Per

cent

Sco

ring

Pos

itive

Any Problem (Unadjusted)Any Problem (Adjusted)

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MHAT Data: Combat Exposure Rates

Combat Exposure: Adjusted Percents for Male, E1-E4 Soldiers in Theater 6 Months or Longer.

  PercentCombat Experiences (OEF) 2005 2007 2009

During this deployment did you experience being attacked or ambushed 49.9% 74.3% 83.3%

During this deployment did you experience receiving small arms fire 48.5% 68.6% 74.1%

During this deployment did you experience witnessing violence within the local population or between ethnic groups

44.9% 48.4% 53.8%

During this deployment did you experience seeing dead or seriously injured Americans 49.1% 63.5% 62.2%

During this deployment did you experience knowing someone seriously injured or killed 70.4% 87.1% 82.9%

During this deployment did you experience being in threatening situations where you were unable to respond because of rules of engagement

33.1% 48.2% 58.2%

During this deployment did you experience shooting or directing fire at the enemy 36.0% 58.8% 74.8%

During this deployment did you experience calling in fire on the enemy 17.0% 30.6% 44.1%

During this deployment did you experience receiving incoming artillery rocket or mortar fire 75.2% 91.0% 92.9%

During this deployment did you experience being directly responsible for the death of an enemy combatant

12.9% 30.9% 51.6%

During this deployment did you experience having a member of your own unit become a casualty

56.4% 75.0% 77.1%

During this deployment did you experience a close call dud landed near you 19.6% 38.7% 39.2%

During this deployment did you experience a close call equipment shot off your body 3.0% 16.1% 11.5%

During this deployment did you experience a close call was shot or hit but protective gear saved you 2.5% 11.9% 11.0%

During this deployment did you experience having a buddy shot or hit who was near you 8.8% 24.1% 36.4%

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MHAT: Combat Exposure & Acute Stress (PTSD Symptoms)

20

25

30

35

40

45

50

55

60

Number of Combat Exposures

Acu

te S

tre

ss S

core

OEF 2009 Maneuver

• Medication use for a mental health, combat stress, or sleep problem• 14% of MHAT III Soldiers in 2005 (Overall Sample N = 1,124)

• 13% of MHAT IV Soldiers in 2006 (Overall Sample N = 1,320)

• 12% of MHAT V Soldiers in 2007 (Overall Sample N = 2,279)

• Medications for sleep and combat stress (Iraq & Afghanistan 2009)• Combat Stress:

• 4.8% of maneuver units Soldiers reported using medications for a mental health problem; 5.1% rate for Support units

• 2.9% of maneuver units Soldiers reported using medications for a mental health problem; 6.4% rate for Support units

• Sleep: • 8.1% of maneuver unit soldiers reported using sleep medications; 13.5%

rate for support units• 9.2% of maneuver unit soldiers reported using sleep medications; 13.5%

rate for support units

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MHAT: Medication Use—Iraq 2009

• Olfson and Marcus (2009) report rates of antidepressant medications use from nationally representative probability samples collected in 1996 and 2005• Antidepressant use for (a) 21-34 year old (b) males who were (c)

employed with (d) health insurance was 2.28% in 1996 and 4.59% in 2005 (Olfson and Marcus: personal communication, 31 AUG 2010)

• MHAT VI from 2009 Data (repeated for reference)• Iraq: 4.8% of maneuver units Soldiers reported using medications for a

mental health problem; 5.1% rate for Support units

• Afghanistan: 2.9% of maneuver units Soldiers reported using medications for a mental health problem; 6.4% rate for Support units

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Interpreting MHAT Medication Use

• In 2009,(Afghanistan) multiple deployments and medication use• No significant effect for sleep medications

• Significant increase for mental health medications by the third deployment

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MHAT: Multiple Deployments & Meds

4.5%

9.8%

12.9%12.0%

9.0%

3.5%

0%

5%

10%

15%

20%

1st Deployment 2nd Deployment 3+ Deployments

% R

epor

ting

Sleep Medication Medication for MH Problem

• Non-random sampling procedure used prior to 2009 provided more anonymity to participants• Illicit Drug Use

• 1.6% of MHAT IV Soldiers in 2006 (Overall Sample N = 1,320)

• 1.4% of MHAT V Soldiers in 2007 (Overall Sample N = 2,279)

• In-Theater Alcohol Use:• 6.8% in MHAT IV

• 8.0% in MHAT V

• Because of refinement in sampling (cluster-sampling by platoon), these items are no longer asked in current MHAT assessments

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MHAT: Illicit Drug / Alcohol Use

• Continue to identify correlates of medication use• Collect information on use of prescription pain

medications• Limited ability to collect information about abuse in

current MHAT process• Human use protection of participants in context where platoons

are randomly selected (thus identified)

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MHAT: Future Directions

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Land Combat Studies

• Land Combat Studies (LCS)• Focused on Brigade Combat Teams—infantry units• Large intact unit assessments• Majority of data collected in post-deployment time frame• LCS I (2003-2008)

• Initial study to assess the effects of combat in OIF and OEF (n ~ 70,000)

• LCS II (2008-2013)• Examines broader range of outcomes and moderating variables (n ~ 13,000)

• Publications stemming from LCS• Hoge et al., NEJM, 2004, 2008

• Thomas et al., Arch Gen Psych, 2010

• Wilk et al., Drug & Alcohol Dependence, 2010

• Kim et al., Psych Services, 2010

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Land Combat Studies: Post-Deployment Mental Health Symptom Rates

Thomas et al., Archives of General Psychiatry (2010)

• Alcohol misuse and aggression• Common among veterans of OIF / OEF

• ~50% of Soldiers with mental health problems and functional impairment reported alcohol misuse or aggression problems

• From 3 to 12 months post-deployment:• Active Duty Soldiers symptoms generally persisted

• Active Duty Soldiers PTSD symptoms typically increased

• Despite similar combat exposure levels and unit type, National Guard BCT Soldiers symptoms across all measures increased

• National Guard BCT Soldiers rates may be higher due to:• Lack of peer support during post-mobilization

• Readjustment problems (military to civilian)

• Access to care (TRICARE benefits expire after 6 months)

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Land Combat Studies: Mental Health Problems & Comorbidities

Thomas et al., Archives of General Psychiatry (2010)

• 10 ~ 25% screen positive for alcohol misuse at post-deployment (source: PDHRA screening data, anonymous surveys)

• Combat Experience factors associated with alcohol problems post-deployment• Threat to oneself

• Witnessing atrocities

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Combat Experiences & Alcohol Misuse

Wilk et al., Drug and Alcohol Dependence (2010)

• Aside from mandatory and random drug testing…• DOD health assessment with alcohol screening

• Periodic Health Assessment (PHA)

• Post-Deployment Health Assessment (PDHA)

• Post-Deployment Health Re-Assessment (PDHRA)

• Modified Two-Item Conjoint Screen (TICS) has used to screen for alcohol misuse (Brown et al., 2001)

• “In the past 4 weeks, have you used alcohol more than you meant to?”

• “In the past 4 weeks, have you felt you wanted or needed to cut down on your drinking?”

• Validated in primary and military settings.

• AUDIT-C

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Alcohol Screening in US Army

Alcohol and Risk Behaviors

Alcohol-Related BehaviorTICS

Positive(%)

TICSNegative

(%)

Adjusted Odds Ratio3 (95% CI)

Drinking and Driving 36 10 4.99 4.31 – 5.76

Riding w/ Drunk Driver 31 7 5.87 4.99 – 6.91

Late or Missed Work 11 1 9.24 6.73 – 12.68

Illicit Drug Use 9 2 4.97 3.68 – 6.71

Referral to Rehab Program 7 1 7.15 4.84 – 10.58

DUI 4 1 4.84 3.04 – 7.68

Any Alcohol-Related Behavior 51 15 5.63 4.94 – 6.41

3 Results of logistic regression, adjusting for gender, race, rank, and status in the reserves or active duty. For all adjusted odds ratios, calculated Wald statistics yielded p <0.001 with 1 degree of freedom. Hosmer and Lemeshow tests showed no significant deviation from fit with 7 degrees of freedom.

Santiago et al., Psychiatric Services (2010)

• Active Component Post-OIF PDHRA from Milliken et al, JAMA 2007

• Extremely low referral rates• Why? What’s going on? What needs to be improved?

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Abuse Prevention: Facilitate Care

56350

6669

134 290

10000

20000

30000

40000

50000

60000

70000

Total Positive Responses Referrals to ASAP Referred and Seen in 90 Days

Nu

mb

er o

f Se

rvic

e

Me

mb

ers

Scr

een

ed

2.0%0.4%

Figure from Milliken et al., JAMA (2007)

• ASAP is a Command program. Command involvement is NOT optional

• Active participation is mandatory for all Soldiers enrolled in ASAP treatment

• Until recently, Soldiers enrolled in ASAP treatment were automatically subject to negative personnel actions (barred, flagged, etc.)

• Soldiers who fail to comply with or respond successfully to ASAP treatment will be processed for administrative separation from military service

• Subsequent problems also deemed ‘rehab failures’ and AR requires processing for separation

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Current ASAP Policy

• Number of soldiers enrolled in ASAP treatment falls far short of number of soldiers in need of ASAP treatment• Senior NCOs & Officers are dramatically under-represented & under-

served among ASAP patients

• Majority of ASAP referrals are not self-referrals

• Majority of ASAP patients are junior enlisted Soldiers with little to no career investment in military service

• NCOs & Officers present to ASAP with alcohol problems only rarely & under duress with career on the line

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Current ASAP Policy (cont.)

• Reduce stigma of substance abuse treatment• Improve access to ASAP treatment for ALL Soldiers • Encourage career-minded Soldiers to obtain care• Provide earlier interventions for Soldiers in need BEFORE problem

adversely impacts functioning:• finances

• health

• relationships & social functioning

• occupational performance

• military career

• fitness for duty

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How can we do better?...

• The Army Alcohol Pilot: CATEP (Confidential Alcohol Treatment & Education Program)—POC: COL Charles Milliken, MC (WRAIR)

• Authority: Secretary of Army• Scope: Pilot for Soldiers who self-refer to the ASAP with alcohol

problems before they have an incident, without consequent compromise to military career

• Purpose: Test feasibility of trial policy changes to improve Soldiers’ access to alcohol treatment earlier in the course of their illness

• Pilot Sites: • Schofield Barracks, Hawaii 06 July 09

• Fort Richardson, Alaska 17 Aug 09

• Fort Lewis, Washington 24 Aug 09

• Expanded to include Ft Riley, Ft Carson, Ft Leonard Wood

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Army Alcohol Pilot Study

• Command involvement in ASAP treatment is OPTIONAL (but encouraged)

• Active participation in ASAP treatment is VOLUNTARY

• Soldiers in ASAP treatment are NOT SUBJECT to NEGATIVE PERSONNEL ACTIONS (barred, flagged, etc.)

• Soldiers who fail ASAP treatment WILL NOT BE automatically ADMINISTRATIVELY SEPARATED from military service• Enrollment in CATEP treatment will not count toward the number of

trials of rehabilitation allowed per military career

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Trial Policy Changes

• All Soldiers who present to the ASAP clinic as anything but a mandatory command-referral will be screened for eligibility to participate in the ASAP Pilot

• All Soldiers who present as self-referrals to ASAP for alcohol problems are eligible for Pilot participation if they:• have not had an alcohol or drug-related incident that merits

mandatory command-referral• are not being formally referred by their Commander for an

alcohol- or drug-related incident that merits mandatory ASAP referral

• A Soldier will be removed from Pilot care and back in ASAP if they:• have a significant alcohol-related incident, use illegal substances

or abuse prescription medication

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Pilot Eligibility

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Rank Distribution of Standard ASAP vs. ASAP Pilot cases

• Quantitative data• Referral rates from PDHRA and medical referral sources have

increased

• Increased numbers of senior NCOs and Officers are accessing care

• Qualitative data• Soldiers, Commanders, & ASAP clinicians give the Pilot 2 thumbs up

• Alcohol dependence is safely treated under CATEP

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Summary of Initial ASAP Pilot Findings

• Mental Health Advisory Team data• Land Combat Study data• The Army Alcohol Pilot: CATEP

(Confidential Alcohol Treatment & Education Program)

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Summary

MAJ Jeffrey L. Thomas, Ph.D.

Chief, Military Psychiatry Branch

Walter Reed Army Institute of Research

503 Robert Grant Avenue

Silver Spring, MD 20910

(301) 319-7577

jeffrey.l.thomas@us.army.mil

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Points of Contact