Social Information Processing in Anger Expression and Partner Violence in Returning U.S. Veterans.

We examined social information processing factors that could represent pathways through which posttraumatic stress disorder (PTSD) symptoms relate to anger expression and intimate partner violence (IPV) perpetration in returning U.S. veterans. The sample included 92 male Operation Enduring Freedom/Operation Iraqi Freedom veterans, primarily Caucasian (77.4%), with smaller numbers of African American, Asian, Hispanic or Latino, American Indian or Alaskan Native, and other minority participants (9.7%, 2.2%, 2.2%, 3.2%, and 5.3% respectively). The average age was 40.37 (SD = 9.63) years. Data were collected through self-report questionnaires (PTSD Checklist, State-Trait Anger Expression Scale, Revised Conflict Tactics Scales) and the Articulated Thoughts in Simulated Situations experimental protocol. Laboratory-based assessment of cognitive biases and hostile attributions were tested as mediators of associations between PTSD symptoms and anger expression and IPV. Among the PTSD symptom clusters, hyperarousal symptoms were most strongly associated with anger expression (r = .50) and IPV perpetration (r = .27). Cognitive biases mediated associations between PTSD total scores and 3 of 4 PTSD cluster scores as well as anger expression. Hostile attribution biases were also associated with IPV perpetration (r = .23). We discuss the implications of these findings for understanding social information processing mechanisms for the relationship between PTSD symptoms and aggression.

HealthViEWS: mortality study of female US Vietnam era veterans, 1965-2010.

We conducted a retrospective study among 4,734 women who served in the US military in Vietnam (Vietnam cohort), 2,062 women who served in countries near Vietnam (near-Vietnam cohort), and 5,313 nondeployed US military women (US cohort) to evaluate the associations of mortality outcomes with Vietnam War service. Veterans were identified from military records and followed for 40 years through December 31, 2010. Information on underlying causes of death was obtained from death certificates and the National Death Index. Based on 2,743 deaths, all 3 veteran cohorts had lower mortality risk from all causes combined and from several major causes, such as diabetes mellitus, heart disease, chronic obstructive pulmonary disease, and nervous system disease relative to comparable US women. However, excess deaths from motor vehicle accidents were observed in the Vietnam cohort (standardized mortality ratio = 3.67, 95% confidence interval (CI): 2.30, 5.56) and in the US cohort (standardized mortality ratio = 1.91, 95% CI: 1.02, 3.27). More than two-thirds of women in the study were military nurses. Nurses in the Vietnam cohort had a 2-fold higher risk of pancreatic cancer death (adjusted relative risk = 2.07, 95% CI: 1.00, 4.25) and an almost 5-fold higher risk of brain cancer death compared with nurses in the US cohort (adjusted relative risk = 4.61, 95% CI: 1.27, 16.83). Findings of all-cause and motor vehicle accident deaths among female Vietnam veterans were consistent with patterns of postwar mortality risk among other war veterans.

PTSD diagnoses among Iraq and Afghanistan veterans: comparison of administrative data to chart review.

To guide budgetary and policy-level decisions, the U.S. Department of Veterans Affairs (VA) produces quarterly reports that count the number of Iraq and Afghanistan veterans with International Classification of Diseases, 9(th) Revision, Clinical Modification (ICD-9-CM) codes for posttraumatic stress disorder (PTSD; 309.81) in their electronic medical record administrative data. We explored the accuracy of VA administrative data (i.e., diagnostic codes used for billing purposes), by comparing it to chart review evidence of PTSD (i.e., medical progress notes and all other clinical documentation contained in the entire VA medical record). We reviewed VA electronic medical records for a nationwide sample of 1,000 Iraq and Afghanistan veterans with at least one ICD-9-CM code for PTSD in their VA administrative data. Among veterans sampled, 99.9% had 2 or more ICD-9-CM codes for PTSD. Reviewing all VA electronic medical record notes for these 1,000 veterans for the full course of their VA health care history revealed that PTSD was diagnosed by a mental health provider for 89.6%, refuted for 5.6%, and PTSD was never evaluated by a mental health provider for 4.8%. VA treatment notes for the 12 months preceding chart review showed that 661 veterans sampled received a VA PTSD diagnosis during that 12-month timeframe, and of these 555 were diagnosed by a mental health provider (83.9%). Thus, the presence of an ICD-9-CM code for PTSD approximated diagnoses by VA mental health providers across time points (89.6% for entire treatment history and 83.9% for 12 months prior to chart review). Administrative data offer large-scale means to track diagnoses and treatment utilization; however, their limitations are many, including the inability to detect false-negatives.

Longitudinal health study of US 1991 Gulf War veterans: changes in health status at 10-year follow-up.

The authors assessed changes in the health status of US 1991 Gulf War-era veterans from a 1995 baseline survey to a 2005 follow-up survey, using repeated measurement data from 5,469 deployed Gulf War veterans and 3,353 nondeployed Gulf War-era veterans who participated in both surveys. Prevalence differences in health status between the 2 surveys were estimated for adverse health indices and chronic diseases for each veteran group. Persistence risk ratios and incidence risk ratios were calculated after adjustment for demographic and military service characteristics through Mantel-Haenszel stratified analysis. At 10-year follow-up, deployed veterans were more likely to report persistent poor health, as measured by the health indices (functional impairment, limitation of activities, repeated clinic visits, recurrent hospitalizations, perception of health as fair or poor, chronic fatigue syndrome-like illness, and posttraumatic stress disorder), than nondeployed veterans. Additionally, deployed veterans were more likely to experience new onset of adverse health (as measured by the indices) and certain chronic diseases than were nondeployed veterans. During the 10-year period from 1995 to 2005, the health of deployed veterans worsened in comparison with nondeployed veterans because of a higher rate of new onset of various health outcomes and greater persistence of previously reported adverse health on the indices.

Alcohol use and selected health conditions of 1991 Gulf War veterans: survey results, 2003-2005.

INTRODUCTION: A sizable literature has analyzed the frequency of alcohol consumption and patterns of drinking among veterans. However, few studies have examined patterns of alcohol use in veterans of the first Gulf War or factors associated with problem drinking in this population. We examined the frequency and patterns of alcohol use in male and female veterans who served in the 1991 Gulf War or during the same era and the relationships between alcohol use and selected health conditions. METHODS: We analyzed data from a follow-up survey of health information among population-based samples of 15,000 Gulf War and 15,000 Gulf Era veterans. Data had been collected from 9,970 respondents during 2003 through 2005 via a structured questionnaire or telephone survey. RESULTS: Posttraumatic stress disorder (PTSD), major depressive disorder (MDD), unexplained multisymptom illness (MSI), and chronic fatigue syndrome (CFS)-like illness were more frequent among veterans with problem drinking than those without problem drinking. Approximately 28% of Gulf War veterans with problem drinking had PTSD compared with 13% of Gulf War veterans without problem drinking. In multivariate analysis, problem drinking was positively associated with PTSD, MDD, unexplained MSI, and CFS-like illness after adjustment for age, sex, race/ethnicity, branch of service, rank, and Gulf status. Veterans who were problem drinkers were 2.7 times as likely to have PTSD as veterans who were not problem drinkers. CONCLUSION: These findings indicate that access to evidence-based treatment programs and systems of care should be provided for veterans who abuse alcohol and who have PTSD and other war-related health conditions and illnesses.

Neuropsychological functioning of U.S. Gulf War veterans 10 years after the war.

Many U.S. Gulf War-era veterans complained of poor cognition following the war. This study assessed neuropsychological functioning in veterans 10 years after the war through objective tests. 2189 Gulf War-era veterans (1061 deployed, 1128 non-deployed) were examined at 1 of 16 U.S. Veterans Affairs medical centers. Outcomes included neuropsychological domains derived from factor analysis and individual test scores. Deployed veterans performed significantly worse than non-deployed veterans on 2 of 8 factors (motor speed & sustained attention, analysis not corrected for multiple comparisons) and on 4 of 27 individual test variables (Trails A & B, California Verbal Learning Test-List B, and Continuous Performance Test sensitivity, with only Trails B surviving Bonferroni correction). Within deployed veterans, Khamisiyah exposure was negatively correlated with motor speed after controlling for emotional distress. Depressive symptoms and self-reported exposure to toxicants were independently and significantly associated with worse sustained attention. Other factors were also associated with self-reported exposures. The findings were not a result of differential effort across groups. Gulf War deployment is associated with subtle declines of motor speed and sustained attention, despite overall intact neuropsychological functioning. Evidence suggests that toxicant exposures influence both these functions, and depressive symptoms also influence attention.

Mortality follow-up of veterans who participated in military chemical and biological warfare agent testing between 1962 and 1972.

Between 1962 and 1972, several thousand U.S. Navy personnel participated in Project SHAD (Shipboard Hazard and Defense). These tests potentially exposed participants to either active chemical or biological warfare agents or their simulants. This study examined mortality risk associated with participating in SHAD tests by comparing the cause-specific mortality of 4927 SHAD veterans to that of 10,927 other Navy veterans. Compared to other Navy veterans, SHAD veterans had an increased risk of overall mortality, which was due primarily to heart disease deaths.

Neurological mortality among U.S. veterans of the Persian Gulf War: 13-year follow-up.

BACKGROUND: This study focuses on long-term mortality, specifically brain cancer, amyotrophic lateral sclerosis (ALS), Parkinson's disease, and multiple sclerosis (MS) of 621,902 veterans who served in the 1990-1991 Persian Gulf War (GW), and 746,248 non-GW veterans. METHODS: Follow-up began with the date the veteran left the GW theater or May 1, 1991 and ended with the date of death or December 31, 2004. Cox proportional hazard models were used for analyses. RESULTS: Adjusted mortality rate ratios (aRR) of GW veterans compared to non-GW veterans were not statistically significant for brain cancer (aRR = 0.90, 95% confidence interval (CI): 0.73, 1.11), MS (aRR = 0.61, 95% CI: 0.23, 1.63), Parkinson's disease (aRR = 0.71, 95% CI: 0.17, 2.99), or ALS (aRR = 0.96, 95% CI: 0.56, 1.62). GW veterans potentially exposed to nerve agents for 2 or more days and GW veterans exposed to oil well fire smoke were at increased risk for brain cancer mortality (aRR = 2.71, 95% CI: 1.25, 5.87; aRR = 1.81, 95% CI: 1.00, 3.27; respectively). CONCLUSIONS: The risk of death due to ALS, MS, Parkinson's disease, and brain cancer was not associated with 1991 GW service in general. However, GW veterans potentially exposed to nerve agents at Khamisiyah, Iraq, and to oil well fire smoke had an increased risk of mortality due to brain cancer.

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.

A cross-sectional study of military personnel following deployment to conflicts in Iraq or Afghanistan ascertained histories of combat theater injury mechanisms and mild traumatic brain injury (TBI) and current prevalence of posttraumatic stress disorder (PTSD) and postconcussive symptoms. Associations among injuries, PTSD, and postconcussive symptoms were explored. In February 2005, a postal survey was sent to Iraq/Afghanistan veterans who had left combat theaters by September 2004 and lived in Maryland; Washington, DC; northern Virginia; and eastern West Virginia. Immediate neurologic symptoms postinjury were used to identify mild TBI. Adjusted prevalence ratios and 95% confidence intervals were computed by using Poisson regression. About 12% of 2,235 respondents reported a history consistent with mild TBI, and 11% screened positive for PTSD. Mild TBI history was common among veterans injured by bullets/shrapnel, blasts, motor vehicle crashes, air/water transport, and falls. Factors associated with PTSD included reporting multiple injury mechanisms (prevalence ratio = 3.71 for three or more mechanisms, 95% confidence interval: 2.23, 6.19) and combat mild TBI (prevalence ratio = 2.37, 95% confidence interval: 1.72, 3.28). The strongest factor associated with postconcussive symptoms was PTSD, even after overlapping symptoms were removed from the PTSD score (prevalence ratio = 3.79, 95% confidence interval: 2.57, 5.59).

Preliminary findings from a clinical demonstration project for veterans returning from Iraq or Afghanistan.

Military veterans are at high risk for nicotine dependence. This clinical demonstration project used invitational letters, referral to the National Cancer Institute's Smoking Quitline, and local Veteran Affairs prescriptions for tobacco cessation to evaluate whether this low-cost method would potentially reduce smoking in separated veterans who served in Afghanistan and Iraq. Three cohorts (500 each) of recently separated veterans from Afghanistan and Iraq were contacted by survey letters. Interested veterans received follow-up telephone calls using standardized scripts. They were referred to the National Cancer Institute's Smoking Quitline (1-877-44U-QUIT) and offered local Veteran Affairs pharmacologic treatment for smoking cessation. Forty-three percent of respondents who were smokers were interested in the clinical program; of these, 77% participated. At 2 months follow-up, 38% of participants self-reported maintained smoking abstinence. Results suggested that the intervention was feasible and assisted the small number of veterans who participated.

Suicides, homicides, accidents, and undetermined deaths in the U.S. military: comparisons to the U.S. population and by military separation status.

PURPOSE: To compare rates of external causes of mortality among individuals who served in the military (before and after separation from the military) to the U.S. METHODS: This retrospective cohort study examined all 3.9 million service members who served from 2002 to 2007. External cause mortality data from 2002 to 2009 were used to calculate standardized mortality ratios. Negative binomial regression compared differences in the mortality rates for pre- and post-separation. RESULTS: Accident and suicide mortality rates were highest among cohort members under 30 years of age, and most of the accident and suicide rates for these younger individuals exceeded expectation given the U.S. population mortality rates. Military suicide rates began below the expected U.S. rate in 2002 but exceeded the U.S. rate by 2009. Accident, homicide, and undetermined mortality rates remained below the U.S. rates throughout the study period. Mortality rates for all external causes were significantly higher among separated individuals compared with those who did not separate. Mortality rates for individuals after separation from service decreased over time but remained higher than the rates for those who had not separated from service. CONCLUSIONS: Higher rates of death for all external causes of mortality after separation suggest prevention opportunities. Future research should examine how preseparation characteristics and experiences may predict postseparation adverse outcomes to inform transition programs.

Risk of motor vehicle accident death among 1.3 million veterans of the Iraq and Afghanistan wars.

OBJECTIVE: We conducted a cohort study of recent wartime veterans to determine the postservice mortality risk due to motor vehicle accidents (MVAs). METHODS: Veterans were identified from the Defense Manpower Data Center records. Deployment to te Iraq or Afghanistan war zone was determined from the Contingency Tracking System. Vital status of 317,581 deployed and 964,493 nondeployed veterans was followed from their discharge dates between 2001 to 2007 until earlier of date of death or December 31, 2009. Underlying causes of death were obtained from the National Death Index Plus. RESULTS: Based on 9,353 deaths (deployed, 1,650; nondeployed, 7,703), of which 779 were MVA deaths as drivers (166; 613), both cohorts had 25 to 24% lower mortality risk from all causes but had 44 to 45% higher risk of MVA deaths relative to the U.S. general population. The higher MVA mortality risk was not associated with deployment to the war zone. After controlling for age, sex, race, marital status, branch of service, and rank, the risk for deployed veterans was comparable to that of nondeployed veterans (hazard ratio = 0.91; 95% confidence interval, 0.77-1.09). CONCLUSIONS: Veterans exhibit significantly higher risk of MVA deaths compared to the U.S. general population. However, deployment to the Iraq or Afghanistan war was not associated with the excess risk.

Suicide Risk Among Wounded U.S. Service Members.

The association between suicide and combat injuries sustained during the wars in Iraq and Afghanistan was examined. A retrospective population-based cohort design was conducted using official military records to identify combat injuries (October 7, 2001, to December 31, 2007). Those who were injured during combat had higher crude suicide rates than those who deployed and were not injured (incidence rate ratio [IRR] = 1.50; confidence interval [CI] = 1.06, 2.12), or never deployed (IRR = 1.46; CI = 1.04, 2.06). After adjusting for demographics, these findings were no longer statistically significant. Although our data did not support an elevated suicide risk among wounded service members, additional research is needed to examine the impact of injury severity.

Risk of selected cardiovascular diseases and posttraumatic stress disorder among former World War II prisoners of war.

PURPOSE: American World War II (WWII) prisoners of war (POWs) suffered both mental and physical deprivation while interned. The long-term health consequences of the internment were studied for an increased risk of cardiovascular diseases and posttraumatic stress disorder (PTSD). METHODS: This study evaluated healthcare utilization data for 10 years (1991-2000) from Veterans Affairs (VA) and non-VA healthcare providers for 19,442 former WWII POWs and 9728 non-POW controls. The risk of diseases was approximated by odds ratios adjusted for race and age. RESULTS: Collectively, former POWs had statistically significant increased risk of PTSD, and those POWs with PTSD also had statistically significant increased risks of cardiovascular diseases including hypertension and chronic ischemic heart disease when compared to both non-POWs and POWs without PTSD. CONCLUSIONS: Among former WWII POWs, risk of cardiovascular disease is related to having PTSD.

Understanding the effect of deployment on the risk of fatal motor vehicle crashes: a nested case-control study of fatalities in Gulf War era veterans, 1991-1995.

Motor vehicle crashes (MVCs) are an important cause of morbidity and premature loss of life among military personnel during peacetime and particularly following combat. A nested case-control study of fatal MVC occurring between 1991 and 1995 was conducted in a cohort of Gulf War era veterans. Cases were validated MVC deaths in the Fatality Analysis Reporting System. Controls were selected using risk set sampling by gender and year of case ascertainment in a 10:1 ratio. Preliminary results, consistent with previous reports of increased fatal MVC risk among returning combat veterans, showed a crude odds ratio of 1.45 (95% confidence interval 1.27-1.65). Multivariable logistic regression modeling was used to identify important independent predictors, as well as to quantify the influence of deployment on a risk profile for fatal MVC. Because of significant interaction between deployment and inpatient diagnosis of substance abuse, the final model was stratified by deployment status. Results suggest that demographic, military, and behavioral characteristics of deployed healthy warriors are similar to the risk profile for fatal MVC. In addition to young, single, high school-educated, enlisted male personnel, those who served during times of ground combat, particularly in infantry, gun crews, or seamanship occupations, should be targeted for preventive interventions.

Gulf War veterans' health: medical evaluation of a U.S. cohort.

BACKGROUND: United States military personnel reported various symptoms after deployment to the Persian Gulf during the 1991 Gulf War. However, the symptoms' long-term prevalence and association with deployment remain controversial. OBJECTIVE: To assess and compare the prevalence of selected medical conditions in a national cohort of deployed and nondeployed Gulf War veterans who were evaluated by direct medical and teledermatologic examinations. DESIGN: A cross-sectional prevalence study performed 10 years after the 1991 Gulf War. SETTING: Veterans were examined at 1 of 16 Veterans Affairs medical centers. PARTICIPANTS: Deployed (n = 1061) and nondeployed (n = 1128) veterans of the 1991 Gulf War. MEASUREMENTS: Primary outcome measures included fibromyalgia, the chronic fatigue syndrome, dermatologic conditions, dyspepsia, physical health-related quality of life (Short Form-36 [SF-36]), hypertension, obstructive lung disease, arthralgias, and peripheral neuropathy. RESULTS: Of 12 conditions, only 4 conditions were more prevalent among deployed than nondeployed veterans: fibromyalgia (deployed, 2.0%; nondeployed, 1.2%; odds ratio, 2.32 [95% CI, 1.02 to 5.27]); the chronic fatigue syndrome (deployed, 1.6%; nondeployed 0.1%; odds ratio, 40.6 [CI, 10.2 to 161]); dermatologic conditions (deployed, 34.6%; nondeployed, 26.8%; odds ratio, 1.38 [CI, 1.06 to 1.80]), and dyspepsia (deployed, 9.1%; nondeployed, 6.0%; odds ratio, 1.87 [CI, 1.16 to 2.99]). The mean physical component summary score of the SF-36 for deployed and nondeployed veterans was 49.3 and 50.8, respectively. LIMITATIONS: Relatively low participation rates introduce potential participation bias, and deployment-related illnesses that resolved before the research examination could not, by design, be detected. CONCLUSIONS: Ten years after the Gulf War, the physical health of deployed and nondeployed veterans is similar. However, Gulf War deployment is associated with an increased risk for fibromyalgia, the chronic fatigue syndrome, skin conditions, dyspepsia, and a clinically insignificant decrease in the SF-36 physical component score.

Motor vehicle fatalities among Gulf War era veterans: characteristics, mechanisms, and circumstances.

OBJECTIVES: Our objective was to describe fatal motor vehicle crashes (MVC) among veterans of the 1991 Gulf War era and to compare the distribution of crash and individual characteristics between those deployed to the Gulf War (GWV) and those not deployed (NDV). METHODS: We compared individual characteristics, crash mechanisms, and crash circumstances between 765 GWV and 553 NDV who died from MVC within the first five years of the war, between May 1991 and December 1995. RESULTS: Overall, GWV and NDV who died from a MVC were more likely to be enlisted males (97%), 21-30 years old (72%), have a high school education or less (91%), drive a passenger car (52%), and not use restraints (60%). The overall annual rate of motor vehicle fatalities for GWV (23.6 per 100,000; 95% confidence interval: 21.9-25.3) was significantly greater than the rate for NDV (15.9, 95% CI: 14.6-17.3). GWV with the highest motor vehicle fatality rates include males (24.8, 95% CI: 23.0-26.6), 17-20 year olds (105.0, 95% CI: 78.2-138.1), and those not married (27.3, 95% CI: 25.1-30.1). Adjusting for differences in age distribution across GWV and NDV did not account for the difference in rates. Characteristics of MVC fatalities that were over-represented among GWV include serving as regular active duty (p = 0.001), having a high school education or less (p = 0.01), being involved in a single-vehicle crash (p = 0.008), and dying within the first hour following the crash (p = 0.004). Also, we identified a greater proportion of alcohol-related crashes among GWV during the late night and early morning hours. CONCLUSIONS: The highest rates of motor vehicle fatality among young, single males in the military mirror the experience of the general population. Further research is necessary to determine modifiable risk factors that can be targeted for specific interventions and whether the elevated late night alcohol-related crash rate among GWV is an effect of deployment or an inherent population bias among those selected for operational deployments.

Patterns of health care seeking of Gulf War registry members prior to deployment.

Following the Gulf War (GW), large numbers of individuals reported illness that they attributed to exposures encountered during the GW deployment. In response, the Department of Veterans Affairs and the Department of Defense established programs and registries for the evaluation and documentation of GW-related illness. We obtained registrants' medical records, which contained information on outpatient encounters during the 1-year period before their GW deployment, to determine whether registrants with multisymptom illness (cases) have patterns of predeployment health care seeking that are different from those of well registrants (controls). We found that subjects had significantly more predeployment outpatient visits than controls, but this varied by type of visit. Although the number of certain types of predeployment outpatient visits is significantly associated with subsequent multisymptom illness, these associations will have limited predictive value. These findings increase our understanding of multisymptom illness, especially its chronic nature, and justify doing additional studies.

The war-related illness and injury study centers: a resource for deployment-related health concerns.

Combat veterans often return from deployment having experienced a wide range of exposures, symptoms, and medical conditions. The Department of Veterans Affairs established war-related illness and injury study centers to serve combat veterans with unexplained illnesses. We report the exposures, clinical status, and utilization of 53 combat veterans who participated in the National Referral Program (NRP) from January 2002 until March 2004. Participants were primarily male (81%) and served in the Persian Gulf War (79%). Common diagnoses were chronic fatigue syndrome (n = 23, 43%), neurotic depression (n = 21, 40%), and post-traumatic stress disorder (n = 20, 38%). Self-reported exposures related to weaponry, disease prophylaxis, environmental hazards, stress, and poor hygiene. A small increase in mean SF-36V mental component scores (2.8 points, p = 0.009) and use of rehabilitation therapies (1.6 additional visits, p = 0.018) followed the NRP referral. The small gain in mental function suggests that the NRP may benefit combat veterans with long and complex medical histories.

Spouses of Persian Gulf War I veterans: medical evaluation of a U.S. cohort.

Ten years after the 1991 Persian Gulf War (GW I), a comprehensive evaluation of a national cohort of deployed veterans (DV) demonstrated a higher prevalence of several medical conditions, in comparison to a similarly identified cohort of nondeployed veterans (NDV). The present study determined the prevalence of medical conditions among nonveteran spouses of these GW I DV and NDV. A cohort of 490 spouses of GW I DV and 537 spouses of GW I NDV underwent comprehensive face-to-face examinations. No significant differences in health were detected except that spouses of DV were less likely to have one or more of a group of six common skin conditions. We conclude that, 10 years after GW I, the general physical health of spouses of GW I DV is similar to that of spouses of NDV.