Invisible Wounds of War: Invisible Wounds of War: PTSD and Depression Over TimePTSD and Depression Over Time
Terry Schell(with Grant Marshall, Terri Tanielian, Lisa Jaycox & Jeremy Miles)
2 10/2012
Sampling MethodsSampling Methods
Data collection was sponsored by California Data collection was sponsored by California Community Foundation; NIH has funded secondary Community Foundation; NIH has funded secondary analyses of these data (R01MH087657)analyses of these data (R01MH087657)
Was conducted independent of the DoD and VAWas conducted independent of the DoD and VA
Respondents were sampled using Random Digit Respondents were sampled using Random Digit Dialing within 24 geographic regionsDialing within 24 geographic regions
Residences were screened for individuals who had Residences were screened for individuals who had deployed for OEF/OIFdeployed for OEF/OIF
Respondents were given incentives to participateRespondents were given incentives to participate
Baseline data collection occurred in Late 2007 and Baseline data collection occurred in Late 2007 and early 2008early 2008
3 10/2012
Analytic WeightsAnalytic Weights
Final baseline sample of 2120 service members Final baseline sample of 2120 service members previously deployed to OEF/OIFpreviously deployed to OEF/OIF
TheThe Invisible Wounds of War Invisible Wounds of War RAND report was based RAND report was based on a preliminary data set from this study that had on a preliminary data set from this study that had approximately 200 fewer respondentsapproximately 200 fewer respondents
The analytic sample is weighted to be representative The analytic sample is weighted to be representative of the total previously-deployed force on branch of of the total previously-deployed force on branch of service, and within each branch on age, gender, service, and within each branch on age, gender, marital status, rank, separation status, and reserve marital status, rank, separation status, and reserve component. component.
4 10/2012
Follow-up SampleFollow-up Sample
Surveys conducted about 18 months after first wave Surveys conducted about 18 months after first wave
Follow up sample N = 1010Follow up sample N = 1010
Re-interviewed 88% of those who could be contacted Re-interviewed 88% of those who could be contacted at the baseline number, but the majority of at the baseline number, but the majority of participants had moved in the intervalparticipants had moved in the interval
Unweighted follow-up sample is highly representative Unweighted follow-up sample is highly representative of the baseline sampleof the baseline sample
Attrition weights create a close match to the weighted Attrition weights create a close match to the weighted baseline sample on almost all variables, including baseline sample on almost all variables, including rates of PTSD, Depression, TBI, and trauma exposure rates of PTSD, Depression, TBI, and trauma exposure
31% of respondents deployed in between the two 31% of respondents deployed in between the two surveyssurveys
5 10/2012
Approximately 1 in 6 Had a Approximately 1 in 6 Had a Current Probable Diagnosis at Wave 1Current Probable Diagnosis at Wave 1
No mental health No mental health conditioncondition
83.5%83.5%
11stst Wave Wave
Depression OnlyDepression Only 3.7 %3.7 %
PTSD OnlyPTSD Only 4.0 %4.0 %
BothBoth 8.8 %8.8 %
16.5%16.5%
6 10/2012
Who Develops Post-Deployment Mental Who Develops Post-Deployment Mental Health Problems?Health Problems?
The mental health outcomes were very well predicted by the The mental health outcomes were very well predicted by the available variablesavailable variables
Multivariate regression models found several subgroups at Multivariate regression models found several subgroups at high risk:high risk:
Army, Separated, Enlisted, Hispanic Ethnicity, Female, Army, Separated, Enlisted, Hispanic Ethnicity, Female, Trauma ExposedTrauma Exposed
Very similar partial relative risk ratios observed when Very similar partial relative risk ratios observed when predicting PTSD and Depression outcomespredicting PTSD and Depression outcomes
Several factors often assumed to be important were not Several factors often assumed to be important were not significant in the multivariate models: significant in the multivariate models:
number of deployments, length of deployments, total number of deployments, length of deployments, total deployment time, time since deploymentdeployment time, time since deployment
7 10/2012
Trauma Exposure Was Trauma Exposure Was Common During DeploymentCommon During Deployment
The study assessed deployment trauma with a 0-11 scale The study assessed deployment trauma with a 0-11 scale counting the different types of traumatic events that occurred counting the different types of traumatic events that occurred during any prior deployment, e.g.,:during any prior deployment, e.g.,:
Friend was seriously wounded or killed 50%
Witnessing serious accident 44%
Seeing dead/injured non-combatants 44%
Smelling decomposing bodies 36%
Injured not requiring hospitalization 23%
Being physically moved by an explosion 22%
Having a bump or blow to the head 17%
Injured requiring hospitalization 10%
Killing a civilian 5%
8 10/2012
Trauma Exposure is the Primary Risk FactorTrauma Exposure is the Primary Risk Factor
The range of covariate-adjusted, relative risk between the The range of covariate-adjusted, relative risk between the highest and lowest trauma exposure categories is very large.highest and lowest trauma exposure categories is very large.
25-fold increase in risk for PTSD, 25-fold increase in risk for PTSD,
23-fold increase in risk for Depression23-fold increase in risk for Depression
Prevalence among individuals reporting none of the 11 Prevalence among individuals reporting none of the 11 deployment traumas were at or below the rates found in the deployment traumas were at or below the rates found in the general US population. general US population.
RRR’s for deployment trauma are virtually unchanged in RRR’s for deployment trauma are virtually unchanged in bivariate and multivariate modelsbivariate and multivariate models
9 10/2012
Prevalence of Mental Health Problems by Prevalence of Mental Health Problems by Prior Deployment Trauma ExposurePrior Deployment Trauma Exposure
Trauma CategoryProbable
PTSDProbably
MDDEither
No Reported Trauma (N= 537) 1% 3% 4%
Medium Trauma (N=1115) 8% 8% 13%
High Trauma (N= 468) 38% 33% 40%
Medium Trauma = experienced 1 - 4 trauma typesHigh Trauma = experienced 5 - 11 trauma types
10 10/2012
Trauma Exposure Shows a Regular Dose-Trauma Exposure Shows a Regular Dose-Response Relationship with MH SymptomsResponse Relationship with MH Symptoms
Model: SX = b(covariates) + bModel: SX = b(covariates) + b11ff11 + + bb22ff22 + … + … ++ bbnnffnn
where Q is estimated at .30. where Q is estimated at .30.
QQ Q
11 10/2012
Implications of Deployment TraumaImplications of Deployment Trauma
The substantial majority of PTSD and Major The substantial majority of PTSD and Major Depression cases in this population can be Depression cases in this population can be attributed to deployment traumaattributed to deployment trauma
The was no significant evidence that general The was no significant evidence that general deployment stressors (time deployed, number deployment stressors (time deployed, number of cycles) play a significant role in the etiology of cycles) play a significant role in the etiology of either disorder controlling for traumaof either disorder controlling for trauma
Initial exposure to a given deployment trauma Initial exposure to a given deployment trauma type poses the greatest incremental risk for type poses the greatest incremental risk for mental health symptomsmental health symptoms
12 10/2012
How Do Military Mental How Do Military Mental Health Problems Change Over Time?Health Problems Change Over Time?
Most longitudinal civilian studies show gradual Most longitudinal civilian studies show gradual improvement of PTSD symptoms following improvement of PTSD symptoms following traumatrauma
Studies of Vietnam era veterans have shown Studies of Vietnam era veterans have shown relatively stable rates over time, with minimal relatively stable rates over time, with minimal aggregate improvementaggregate improvement
In contrast, two published longitudinal studies In contrast, two published longitudinal studies on service members deployed to OEF/OIF have on service members deployed to OEF/OIF have shown increases in symptoms over timeshown increases in symptoms over time
13 10/2012
Approximately 1 in 5 Had a Approximately 1 in 5 Had a Current Mental Health Condition at Wave 2Current Mental Health Condition at Wave 2
No mental health No mental health conditioncondition
83.5%83.5%
No mental health No mental health conditioncondition
80%80%
11stst Wave Wave 22ndnd Wave Wave
Depression OnlyDepression Only 3.7 %3.7 % 5.6 %5.6 %
PTSD OnlyPTSD Only 4.0 %4.0 % 5.5 %5.5 %
BothBoth 8.8 %8.8 % 8.9 %8.9 %
16.5%16.5% 20.0%20.0%
14 10/2012
Probable Diagnoses Are Probable Diagnoses Are Relatively Stable Over TimeRelatively Stable Over Time
Probable DiagnosesProbable Diagnoses T1T1 T2 T2 Either Either
T1 or T2T1 or T2
Any PTSDAny PTSD 12.8%12.8% 14.4%14.4% 19.0%19.0%
Any MDDAny MDD 12.5%12.5% 14.5%14.5% 19.8%19.8%
Either PTSD or MDDEither PTSD or MDD 16.5%16.5% 20.0%20.0% 24.8%24.8%
Of those with some probable diagnosis at T1, Of those with some probable diagnosis at T1, 71% continued with some diagnosis at T271% continued with some diagnosis at T2
Of those without any probable diagnosis at T1, Of those without any probable diagnosis at T1, 10% developed a new diagnoses10% developed a new diagnoses
About 41% of T2 cases are “new”About 41% of T2 cases are “new”
15 10/2012
Mental Health Problems Increase Over TimeMental Health Problems Increase Over Time
The odds of having a probable mental health problem The odds of having a probable mental health problem increased over time, Odds Ratio = 1.25 [1.03, 1.50 ] per year increased over time, Odds Ratio = 1.25 [1.03, 1.50 ] per year
The increase was not significantly associated with:The increase was not significantly associated with:
Whether individual deployed between surveysWhether individual deployed between surveys
Length of time they were home since last deploymentLength of time they were home since last deployment
This pattern is slightly different than found in other studiesThis pattern is slightly different than found in other studies
Civilian traumatized samples usually show declines in Civilian traumatized samples usually show declines in symptoms over time symptoms over time
The rate of increase is considerably smaller than was The rate of increase is considerably smaller than was found when comparing PDHA and PDHRA datafound when comparing PDHA and PDHRA data
16 10/2012
Service Members Prefer Talk TherapiesService Members Prefer Talk Therapies
About half of those with a probably diagnosis sought help in About half of those with a probably diagnosis sought help in the last yearthe last year
About half of those who sought help received some sort of About half of those who sought help received some sort of treatmenttreatment
Service members were about 3x more likely to seek care from Service members were about 3x more likely to seek care from a mental health specialist (MHS) than from a primary care a mental health specialist (MHS) than from a primary care physician (PCP), 14% vs 5% of the sample.physician (PCP), 14% vs 5% of the sample.
Visit length and frequency is consistent with the view that Visit length and frequency is consistent with the view that MHS are delivering talk therapies and PCPs pharmacotherapyMHS are delivering talk therapies and PCPs pharmacotherapy
Among those who sought help, care received from mental Among those who sought help, care received from mental health specialist was rated as more helpful than either care health specialist was rated as more helpful than either care from PCPs or pharmacotherapy.from PCPs or pharmacotherapy.
17 10/2012
Overall ConclusionsOverall Conclusions
Cross sectional studies are likely to underestimate the Cross sectional studies are likely to underestimate the number of individuals who will have mental health number of individuals who will have mental health problems subsequent to combat exposureproblems subsequent to combat exposure
Mental health problems, including Depression, appear to Mental health problems, including Depression, appear to be trauma-related and service-connected rather than a be trauma-related and service-connected rather than a product of pre-existing problemsproduct of pre-existing problems
The peak demand for mental health services in this The peak demand for mental health services in this population may be several years in the futurepopulation may be several years in the future
Meeting this demand may require a substantial expansion Meeting this demand may require a substantial expansion of our capacity to deliver evidence-based talk therapiesof our capacity to deliver evidence-based talk therapies
18 10/2012