Alterations in the Topology of Functional Connectomes Are Associated with Post-Traumatic Stress Disorder and Blast-Related Mild Traumatic Brain Injury in Combat Veterans.

Post-traumatic stress disorder (PTSD) is a common condition in post-deployment service members (SM). SMs of the conflicts in Iraq and Afghanistan also frequently experience traumatic brain injury (TBI) and exposure to blasts during deployments. This study evaluated the effect of these conditions and experiences on functional brain connectomes in post-deployment, combat-exposed veterans. Functional brain connectomes were created using 5-min resting-state magnetoencephalography data. Well-established clinical interviews determined current PTSD diagnosis, as well as deployment-acquired mild TBI and history of exposure to blast. Linear regression examined the effect of these conditions on functional brain connectomes beyond covariates. There were significant interactions between blast-related mild TBI and PTSD after correction for multiple comparisons including number of nodes (non-standardized parameter estimate [PE] = -12.47), average degree (PE = 0.05), and connection strength (PE = 0.05). A main effect of blast-related mild TBI was observed on the threshold level. These results demonstrate a distinct functional connectome presentation associated with the presence of both blast-related mild TBI and PTSD. These findings suggest the possibility that blast-related mild TBI alterations in functional brain connectomes affect the presentation or progression of recovery from PTSD. The current results offer mixed support for hyper-connectivity in the chronic phase of deployment TBI.

Deployed Military Medical Personnel: Impact of Combat and Healthcare Trauma Exposure.

Introduction: Limited research has been conducted on the impact of deployment-related trauma exposure on post-traumatic stress symptoms in military medical personnel. This study evaluated the association between exposure to both combat experiences and medical duty stressors and post-traumatic stress symptoms in deployed military medical personnel. Materials and Methods: U.S. military medical personnel (N = 1,138; 51% male) deployed to Iraq between 2004 and 2011 were surveyed about their exposure to combat stressors, healthcare stressors, and symptoms of post-traumatic stress disorder (PTSD). All participants were volunteers, and the surveys were completed anonymously approximately halfway into their deployment. The Combat Experiences Scale was used as a measure of exposure to and impact of various combat-related stressors such as being attacked or ambushed, being shot at, and knowing someone seriously injured or killed. The Military Healthcare Stressor Scale (MHSS) was modeled after the Combat Experiences Scale and developed for this study to assess the impact of combat-related healthcare stressors such as exposure to patients with traumatic amputations, gaping wounds, and severe burns. The Post-traumatic Stress Disorder Checklist-Military Version (PCL-M) was used to measure the symptoms of PTSD. Results: Eighteen percent of the military medical personnel reported exposure to combat experiences that had a significant impact on them. In contrast, more than three times as many medical personnel (67%) reported exposure to medical-specific stressors that had a significant impact on them. Statistically significant differences were found in self-reported exposure to healthcare stressors based on military grade, education level, and gender. Approximately 10% of the deployed medical personnel screened positive for PTSD. Approximately 5% of the sample were positive for PTSD according to a stringent definition of caseness (at least moderate scores on requisite Diagnostic and Statistical Manual for Mental Disorders criteria and a total PCL-M score ≥ 50). Both the MHSS scores (r(1,127) = 0.49, p < 0.0001) and the Combat Experiences Scale scores (r(1,127) = 0.34, p < 0.0001) were significantly associated with PCL-M scores. However, the MHSS scores had statistically larger associations with PCL-M scores than the Combat Experiences Scale scores (z = 5.57, p < 0.0001). The same was true for both the minimum criteria for scoring positive for PTSD (z = 3.83, p < 0.0001) and the strict criteria PTSD (z = 1.95, p = 0.05). Conclusions: The U.S. military has provided significant investments for the funding of research on the prevention and treatment of combat-related PTSD, and military medical personnel may benefit from many of these treatment programs. Although exposure to combat stressors places all service members at risk of developing PTSD, military medical personnel are also exposed to many significant, high-magnitude medical stressors. The present study shows that medical stressors appear to be more impactful on military medical personnel than combat stressors, with approximately 5-10% of deployed medical personnel appearing to be at risk for clinically significant levels of PTSD.

Autonomic Symptoms in Gulf War Veterans Evaluated at the War Related Illness and Injury Study Center.

INTRODUCTION: We characterized the presence of autonomic symptoms in a sample of Veterans with Gulf War Illness (GWI) using the Composite Autonomic Symptom Scale (COMPASS-31). In addition, we examined the report of autonomic symptoms across comorbid mental health conditions in this sample. MATERIALS AND METHODS: Case-series follow-up of Gulf War veterans evaluated by the War Related Illness and Injury Study Center (WRIISC) between 2011 and 2016 (n = 153). Phone-based interview consisted of questionnaires designed to investigate autonomic symptoms, physical symptoms, mental health conditions, and GWI. Sixty-One Veterans agreed to participate in this follow-up arm of the study. We restricted our analysis to only those Veterans meeting CDC and/or Kansas criteria for GWI, leaving us with a sample of 56 Veterans. RESULTS: Veterans in our sample were, male (n = 55, 98%), 49 (±6.8) years old and used 8 (±6.6) medications. The mean COMPASS-31 score for our sample was 45.6 (±18.3). There were no differences in reports of autonomic symptoms between participants who screened positive or negative for depression or post-traumatic stress disorder, but COMPASS-31 scores were higher among those who screened positive for anxiety (49.6 (±16.0)) compared with those who screened negative (29.3 (±18.9)) (p < 0.001). CONCLUSIONS: The elevated COMPASS-31 scores suggest that there may be autonomic dysfunction present in our sample of Veterans with GWI, consistent with other published reports. Additionally, we believe that the high scores on the anxiety measure may reflect assessment of physiological symptoms that are not specific to anxiety, and may reflect GWI symptoms. Objective physiological tests of the autonomic nervous system are warranted to better characterize autonomic function and the clinical relevance of COMPASS-31 in this population.

Sources of moral injury among war veterans: A qualitative evaluation.

OBJECTIVE: Service members deployed to war are at risk for moral injury, but the potential sources of moral injury are poorly understood. The aim of this qualitative study was to explore the types of events that veterans perceive as morally injurious and to use those events to develop a categorization scheme for combat-related morally injurious events. METHOD: Six focus groups with US war veterans were conducted. RESULTS: Analysis based on Grounded Theory yielded two categories (and eight subcategories) of events that putatively cause moral injury. The two categories were defined by the focal attribution of responsibility for the event: Personal Responsibility (veteran's reported distress is related to his own behavior) versus Responsibility of Others (veteran's distress is related to actions taken by others). Examples of each type of morally injurious event are provided. CONCLUSIONS: Implications for the further development of the moral injury construct and treatment are discussed.

New-Onset Asthma and Combat Deployment: Findings From the Millennium Cohort Study.

Recent reports suggest US military service members who deployed in support of the recent conflicts in Iraq and Afghanistan have higher rates of new-onset asthma than those who did not deploy. However, it is unknown whether combat experiences, in addition to deployment, contribute to new-onset asthma risk. This study aimed to longitudinally determine the risk factors for developing asthma, including combat deployment (categorized as deployed with combat experience, deployed without combat experience, or nondeployed), among participants in the Millennium Cohort Study from 2001 to 2013. A total of 75,770 participants completed a baseline survey and at least 1 triennial follow-up survey on deployment experiences, lifestyle characteristics, and health outcomes. Complementary log-log models stratified by sex were used to estimate the relative risk of developing asthma among participants who reported no history of asthma at baseline. In models with adjustments, those who deployed with combat experience were 24%-30% more likely to develop asthma than those who did not deploy. Deployed personnel without combat experience were not at a higher risk for new-onset asthma compared with nondeployers. Further research is needed to identify specific features of combat that are associated with greater asthma risk to inform prevention strategies.

Indirect Relations Between Transgressive Acts and General Combat Exposure and Moral Injury.

INTRODUCTION: Moral injury describes the deleterious effects of acts of commission (e.g., killing noncombatants), omission (e.g., failing to prevent a massacre), or betrayal (i.e., by a trusted authority figure) during military service that transgress accepted behavioral boundaries and norms. Transgressive acts are proposed to lead to a guilt- and shame-based syndrome consisting of post-traumatic stress disorder (PTSD) symptoms, demoralization, self-handicapping, and self-injury. In this study, we tested a frequently cited model of moral injury and assessed the associations between potentially transgressive acts, moral injury outcomes, and guilt and fear. Additionally, we sought to clarify the relative contribution of transgressive and nontransgressive/general combat exposure to moral injury. On the basis of previous research and theory, we anticipated that the transgressive acts would be related to outcomes through guilt and that nontransgressive combat exposure would be related to outcomes through fear. MATERIALS AND METHODS: Secondary analysis was conducted on data from a sample of combat-exposed male veterans at a Midwestern Veterans Affairs (VA) medical center (N = 190) who participated in a larger parent study on postdeployment readjustment. Structural equation modeling was used to test the pathways from transgressive and nontransgressive combat exposure to PTSD symptoms and suicidality through combat-related guilt and combat-related fear. The institutional review boards of the Midwestern VA medical center and the university of the affiliated researchers approved the study. RESULTS: In total, 38% (n = 72) of the sample reported a potentially transgressive act as one of their three worst traumatic events. The most common potentially transgressive act was killing an enemy combatant (17%; n = 32). In structural equation modeling analyses. potentially transgressive acts were indirectly related to both suicidality (ß = 0.09, p < 0.01) and PTSD symptoms (ß = 0.06, p < 0.05) through guilt. General combat exposure was indirectly related to PTSD through fear, ß = 0.19, p < 0.01. Combat exposure was not directly or indirectly related to suicidality. CONCLUSION: Overall, these findings suggest that veterans with a history of potentially transgressive acts may present to the VA with a constellation of symptoms that are associated with combat-related guilt. Transgressive acts were identified using a qualitative approach, allowing a broader sampling of this domain. Results were limited by the use of self-report data and by gathering data from participants who were Veterans seeking compensation and pension evaluations for PTSD. The clinical implications suggest that focusing on fear-related outcomes and ignoring guilt- and shame-based reactions may lead to an incomplete case conceptualization. Clinicians working with veterans with moral injury are encouraged to prepare themselves for the discomfiting therapeutic experiences of bearing witness to and empathizing with clients' memories of their actions, which may include atrocities. Effective and empathic treatments that address the guilt and shame associated with transgressive acts are needed to adequately care for returning veterans.

Effects of military service and deployment on clinical symptomatology: The role of trauma exposure and social support.

The Marine Resiliency Study-II examined changes in symptomatology across a deployment cycle to Afghanistan. U.S. Servicemembers (N = 1041) received clinical testing at two time points either bracketing a deployment (855) or not (186). Factor analyses were used to generate summary and change scores from Time 1 to Time 2. A between-subject design was used to examine changes across the deployment cycle with deployment (low-trauma, high-trauma, and non-deployed) and social support (low vs. high) as the grouping variables. Insomnia increased post-deployment regardless of deployment trauma (std. effect for high-trauma and low-trauma = 0.39 and 0.26, respectively). Only the high-trauma group showed increased PTSD symptoms and non-perspective-taking (std. effect = 0.40 and 0.30, respectively), while low-trauma showed decreased anxiety symptoms after deployment (std. effect = -0.17). These associations also depend on social support, with std. effects ranging from -0.22 to 0.51. When the groups were compared, the high-trauma deployed group showed significantly worse PTSD and non-perspective-taking than all other groups. Similar to studies in other military divisions, increased clinical symptoms were associated with high deployment stress in active duty Servicemembers, and social support shows promise as a moderator of said association.

The Impact of Trauma Type or Number of Traumatic Events on PTSD Diagnosis and Symptom Severity in Treatment Seeking Veterans.

Trauma history and increased exposure to combat and sexual trauma may account for heightened rates of PTSD among military populations. This study assessed trauma type and exposure history, diagnostic impressions, and PTSD severity in a large clinical dataset (n = 2463) of veterans presenting for PTSD evaluation at a Midwestern VA Medical Center between the years 2006 and 2013. The degree of lifetime trauma exposure was pronounced, with approximately 76% of the sample reporting exposure to at least four traumatic events. Higher numbers of lifetime trauma and higher levels of combat exposure were associated with more severe PTSD symptoms. Sexual trauma and combat trauma were more predictive of PTSD than other trauma types. Sexual trauma was associated with more severe PTSD than combat and other trauma.

Distinguishing war-related PTSD resulting from perpetration- and betrayal-based morally injurious events.

OBJECTIVE: We investigated whether potentially morally injurious events (PMIEs) during a combat deployment may lead to PTSD through distinct pathways from danger-based events. We also examined the prevalence of perpetration-based PMIEs, during which service members behaved in ways that violated their own moral values, and betrayal-based PMIEs, during which personal moral expectations were violated by trusted others. METHOD: Using a sample of 867 active duty Marines from a single infantry battalion that engaged in heavy ground combat while deployed to Afghanistan, a structural equation model was built to examine the relationships between perpetration- and betrayal-based PMIEs, combat experiences, and peritraumatic dissociation reported at 1 month postdeployment, and guilt/shame, anger, and PTSD symptoms reported at 8 months postdeployment. RESULTS: The relationship between betrayal-based PMIEs and PTSD was mediated by anger (ß = .14). There was marginal evidence of mediation of the relationship between perpetration-based PMIEs and PTSD by shame and guilt (ß = .09), and of the relationship between danger-based combat events and PTSD by peritraumatic dissociation (ß = .08). No significant direct relationships were found between any of these 3 types of events and subsequent PTSD. Perceived perpetration and betrayal accounted for PTSD symptoms above and beyond combat exposure. Over a third of the sample reported experiencing perpetration- or betrayal-based PMIEs. CONCLUSIONS: The associations of perpetration and betrayal with PTSD, controlling for danger-based combat events, highlight the limitations of conceptualizations and treatments of PTSD based on fear or helplessness as sole etiologic factors. (PsycINFO Database Record

Female Service Members and Symptom Reporting after Combat and Non-Combat-Related Mild Traumatic Brain Injury.

Females are often excluded from military-related mild traumatic brain injury (mTBI) research because of its relatively low prevalence in this population. The purpose of this study was to focus on outcome from mTBI in female service members, compared with males. Participants were 172 United States military service members selected from a larger sample that had sustained an mTBI, and were evaluated within 24 months of injury (Age: mean = 28.9, SD = 8.1) at one of six military medical centers. Eighty-six women were matched to 86 men on nine key variables: TBI severity, mechanism of injury, bodily injury severity, days post-injury, age, number of deployments, theater where wounded, branch of service, and rank. Participants completed the Neurobehavioral Symptom Inventory (NSI) and the Posttraumatic Stress Disorder Checklist (PCL-C). There were no meaningful gender differences across all demographic and injury-related variables (p > 0.05). There were significant group differences and medium effect sizes for the NSI total score and all four NSI cluster scores. Symptoms most affected related to nausea, sensitivity to light, change in taste/smell, change in appetite, fatigue, and poor sleep. There were significant group differences and small-medium effect sizes for the PCL-C total score and two of the three PCL-C cluster scores. Symptoms most affected related to poor concentration, trouble remembering a stressful event, and disturbing memories/thoughts/images. Females consistently experienced more symptoms than males. As females become more active in combat-related deployments, it is critical that future studies place more emphasis on this important military population.

[The dynamics of formation of psychic disordersof combatants and pensioners of the ministry of internal affairs.]

Retrospective analysis of the dynamics of formation and nosological structure of mental disorders among the pensioners of the Ministry of internal Affairs (MIA) with the retirement on superannuation of mental disorder impeding further passage of service. All respondents were divided into two groups according to the criterion of participation in hostilities. It is shown that the ex-combatants, pensioners of MIA in the clinic dominated by organic disorder associated with the consequences of closed traumatic brain injury mine blast etiology, despite the rendered medical aid, the formation of personality disorders that violate social functioning and lead to disability. Pensioners of MIA, who was not involved in pain action, revealed the presence of severe neurotic with a decline in socialization and the formation of chemical dependency and the subsequent development of organic disorders of the Central nervous system predominantly alcoholic etiology, resulting in poor social functioning and to disability. The data obtained indicate certain weaknesses in the organization of psychiatric care to this population: the limited psycho-prophylactic and correctional activities, late diagnosis of borderline mental disorders. To reduce the risk of the formation of personality disorders and chemical dependency have retired police officers it is necessary to improve the organizational and methodological approaches to carrying out annual medical examination of personnel of the interior MIA.

A Dynamic Model of Post-Traumatic Stress Disorder for Military Personnel and Veterans.

Post-traumatic stress disorder (PTSD) stands out as a major mental illness; however, little is known about effective policies for mitigating the problem. The importance and complexity of PTSD raise critical questions: What are the trends in the population of PTSD patients among military personnel and veterans in the postwar era? What policies can help mitigate PTSD? To address these questions, we developed a system dynamics simulation model of the population of military personnel and veterans affected by PTSD. The model includes both military personnel and veterans in a "system of systems." This is a novel aspect of our model, since many policies implemented at the military level will potentially influence (and may have side effects on) veterans and the Department of Veterans Affairs. The model is first validated by replicating the historical data on PTSD prevalence among military personnel and veterans from 2000 to 2014 (datasets from the Department of Defense, the Institute of Medicine, the Department of Veterans Affairs, and other sources). The model is then used for health policy analysis. Our results show that, in an optimistic scenario based on the status quo of deployment to intense/combat zones, estimated PTSD prevalence among veterans will be at least 10% during the next decade. The model postulates that during wars, resiliency-related policies are the most effective for decreasing PTSD. In a postwar period, current health policy interventions (e.g., screening and treatment) have marginal effects on mitigating the problem of PTSD, that is, the current screening and treatment policies must be revolutionized to have any noticeable effect. Furthermore, the simulation results show that it takes a long time, on the order of 40 years, to mitigate the psychiatric consequences of a war. Policy and financial implications of the findings are discussed.

Tackling Shell Shock in Great War Oxford: Thomas Saxty Good, William McDougall, and James Arthur Hadfield.

Shell shock was an important object of diagnostic and therapeutic concern in Oxford during the Great War. The efforts of three Oxford physicians--Thomas Saxty Good, William McDougall, and James Arthur Hadfield--are of particular significance to our story. All worked on the problem at various sites throughout the city. They often collaborated. All were committed to employing innovative techniques such as psychotherapy and hypnosis. Each rose, to differing extents, to prominence in the field of psychological medicine during the succeeding decades. Yet all have been neglected in the current historiography. I argue that a close examination of their practices reveals a curious combination of therapeutic pragmatism and psychoanalytically informed techniques that later helped inform clinical psychology's challenge to psychiatry's dominance over the concept and care of mental disorder.

Course and Predictors of Postdeployment Fatigue: A Prospective Cohort Study in the Dutch Armed Forces.

OBJECTIVE: The purpose of this study was to examine course and predictors of fatigue in military personnel deployed to Afghanistan. METHODS: A total of 906 soldiers in the Dutch Armed Forces who participated in a 4-month mission to Afghanistan were included in this study. Assessment took place prior to and 1, 6, 12, and 24 months after deployment. Data were collected between 2005 and 2011. The fatigue severity subscale of the Checklist Individual Strength was used to indicate the level of fatigue during the previous 2 weeks. Mixed models and logistic regression analysis were used to predict course and prevalence of fatigue after deployment. Predictors of postdeployment fatigue were assessed prior to deployment. RESULTS: The mean level of fatigue increased significantly following deployment (B = 0.58, P = .007). In total, 274 soldiers (30.2%) were severely fatigued at least once after deployment and 130 (14.3%) soldiers had recurrent levels of severe fatigue. Only a minority of the veterans with severe fatigue could be classified as having posttraumatic stress disorder (PTSD, per DSM-IV-TR criteria) or potential medical problems. Significant predeployment predictors of less favorable courses of fatigue after deployment were higher levels of fatigue (B = 0.46, P ≤ .001), emotional abuse during childhood (B = 0.99, P ≤ .001), and harm avoidance (B = 0.27, P = .012). These predeployment factors also predicted severe fatigue after deployment. CONCLUSIONS: Severe fatigue is a substantial problem in Afghanistan War veterans that does not seem to resolve over time. In a majority of cases, the symptoms cannot be attributed to medical problems or PTSD, whereas predeployment differences in psychosocial factors partially explain course and prevalence of postdeployment fatigue. These findings support assumptions that a complex interplay of various factors might be responsible for the symptoms.

Post-Traumatic Stress Disorder among French Armed Forces Members in Afghanistan: A New Approach.

During the 20th century, the management of war-related psychological trauma shifted from neurology to psychiatry. After September 11, 2001, the French forces participated in a multinational force deployed in Afghanistan to fight against terrorism. Post-traumatic stress disorder (PTSD) became a priority. We report the daily work of the psychiatrists involved in this mission and the organization developed to psychologically support wounded military personnel. The doctrine of early intervention psychiatrization and the technique of collective debriefing are the key points of this procedure. The psychiatrist is also responsible for the healthcare community, particularly vulnerable when confronted with severe ballistic injuries. One aim of this organization is also to screen PTSD in soldiers returning from Afghanistan. The military general practitioner is a pivotal point of this procedure built to detect PTSD, anxiety, depressive reaction and behavioral problems. The French health service has developed a genuine care strategy aimed at identifying patients, accompanying them in the formalities for recognition and compensation, and offering them treatment locally by arranging clinical psychology consultations near their home.

German Emergency Care in Neurosurgery and Military Neurology during World War II, 1939-1945.

A critical analysis of the historical involvement of neurology and neurosurgery in military emergency care services enables us to better contextualize and appreciate the development of modern neurology at large. Wartime neurosurgery and civil brain science during the German Nazi period tightly coalesced in examining the specific injury types, which military neurosurgeons such as Wilhelm Toennis, Klaus Joachim Zuelch, and Georg Merrem encountered and treated based on their neurophysiological understanding gained from earlier peacetime research. Collaborative associations with Dr. Toennis in particular proved to be highly beneficial to other military neurologists and neurosurgeons during World War II and beyond. This article also discusses the prewar developments and considers the fate of German neurosurgeons and military neurologists after the war. The envisaged dynamic concepts of fast action, reaction, and recycling, which contemporary physicians had intensively studied in the preceding scientific experiments in their neurophysiological laboratories, had already been introduced into neurological surgery during the interwar period. In retrospect, World War II emergency rescue units greatly strengthened military operations through an active process of 'recycling' indispensable army personnel. Neurosurgical emergency chains thereby introduced another decisive step in the modernization of warfare, in that they increased the momentum of military mobility in the field. Notwithstanding the violence of warfare and the often inhumane ways in which such knowledge in the field of emergency neurology was gained, the protagonists among the group of experts in military neurology and neurosurgery strongly contributed to the postwar clinical neuroscience community in Germany. In differing political pretexts, this became visible in both East Germany and West Germany after the war, while the specific military and political conditions under which this knowledge of emergency medicine was obtained have largely been forgotten.

Gender Differences in Posttraumatic Stress Disorder and Help Seeking in the U.S. Army.

BACKGROUND: Inconsistent findings between studies of gender differences in mental health outcomes in military samples have left open questions of differential prevalence in posttraumatic stress disorder (PTSD) among all United States Army soldiers and in differential psychosocial and comorbid risk and protective factor profiles and their association with receipt of treatment. METHODS: This study assesses the prevalence and risk factors of screening positive for PTSD for men and women based on two large, population-based Army samples obtained as part of the 2005 and 2008 U.S. Department of Defense Surveys of Health Related Behaviors among Active Duty Military Personnel. RESULTS: The study showed that overall rates of PTSD, as measured by several cutoffs of the PTSD Checklist, are similar between active duty men and women, with rates increasing in both men and women between the two study time points. Depression and problem alcohol use were strongly associated with a positive PTSD screen in both genders, and combat exposure was significantly associated with a positive PTSD screen in men. Overall, active duty men and women who met criteria for PTSD were equally likely to receive mental health counseling or treatment, though gender differences in treatment receipt varied by age, race, social support (presence of spouse at duty station), history of sexual abuse, illness, depression, alcohol use, and combat exposure. CONCLUSIONS: The study demonstrates that the prevalence of PTSD as well as the overall utilization of mental health services is similar for active duty men compared with women. However, there are significant gender differences in predictors of positive PTSD screens and receipt of PTSD treatment.

International military operations and mental health--A review.

BACKGROUND: Volunteering in international military missions has been scrutinized for its effects on mental health. Different kinds of exposures to traumatic events are associated with a variety of mental disorders, mainly heightened rates of post-traumatic stress disorder (PTSD) and alcohol abuse. AIMS: Based on the literature we discuss risk and protective factors concerning the psychological well-being of soldiers attending to international military operations. METHODS: A systematic literature search was carried out using relevant search terms to identify the articles for this review. RESULTS AND CONCLUSIONS: The ability to recognize and treat acute stress reactions during deployments is important. Post-deployment psychosocial support and services have a role in lowering barriers to care, diminishing stigma and also in recognizing individuals who suffer from psychological distress or psychiatric symptoms, to connect them with appropriate care. Further investigation of gender differences and the role of stigmatization is warranted. Most of those participating in international military operations are repatriated without problems, but repeated exposure to combat situations and other stressors may affect mental health in various ways. Stigmatization is still a barrier to care.

Aggressive and violent behavior among military personnel deployed to Iraq and Afghanistan: prevalence and link with deployment and combat exposure.

A systematic review and meta-analyses were conducted on studies of the prevalence of aggressive and violent behavior, as well as of violent offenses and convictions, among military personnel following deployment to Iraq and/or Afghanistan; the relationship with deployment and combat exposure; and the role that mental health problems, such as post-traumatic stress disorder (PTSD), have on the pathway between deployment and combat to violence. Seventeen studies published between January 1, 2001, and February 12, 2014, in the United States and the United Kingdom met the inclusion criteria. Despite methodological differences across studies, aggressive behavior was found to be prevalent among serving and formerly serving personnel, with pooled estimates of 10% (95% confidence interval (CI): 1, 20) for physical assault and 29% (95% CI: 25, 36) for all types of physical aggression in the last month, and worthy of further exploration. In both countries, rates were increased among combat-exposed, formerly serving personnel. The majority of studies suggested a small-to-moderate association between combat exposure and postdeployment physical aggression and violence, with a pooled estimate of the weighted odds ratio = 3.24 (95% CI: 2.75, 3.82), with several studies finding that violence increased with intensity and frequency of exposure to combat traumas. The review's findings support the mediating role of PTSD between combat and postdeployment violence and the importance of alcohol, especially if comorbid with PTSD.