Gender differences in mental health outcomes among Afghanistan veterans exposed to war zone trauma.

Research has sought to identify whether women have an increased risk of developing mental health problems following military trauma compared to men, but the results are mixed. This study examined gender differences in a range of mental health outcomes within three levels of war zone trauma exposure and investigated gender differences in risk and protective factors associated with clinical mental health problems. Using data from a cross-sectional, postdeployment survey, a sample of Norwegian veterans of recent military operations in Afghanistan (N = 6,205, 8.3% women) were sorted according to reported war zone trauma exposure level (low, medium, high), then assessed for symptoms of posttraumatic stress disorder (PTSD), posttraumatic distress, anxiety, depression, insomnia, and alcohol problems. The findings revealed that men who reported low war zone exposure had lower levels of posttraumatic distress symptoms than women, d = -0.20, p = .040, but were more likely to report symptoms of alcohol problems within the low, d = 0.33, p < .001; medium, d = 0.39, p < .001; and high, d = 0.37, p = .049, exposure groups; however, these differences disappeared when all symptom variables were combined into one clinical mental health problem variable. Women with a clinical mental health problem were less likely to report war zone exposure than men, OR = 0.93, 95% CI [0.90, 0.97], p = .001. Findings suggest that although gender differences in mental health symptoms exist, male and female veterans with mental health problems may share more similarities than previously recognized.

Differences in resilience profiles between military veterans and the general population: An exploratory latent profile analysis using the HUNT-4 survey.

Using latent profile analyses, the current work investigated levels of adverse childhood experiences, symptoms of anxiety and depression and 3 dimensions of relational promotive factors) to identify resilience profiles in a large general population sample (N = 161,622, mean age = 53.02; SD = 17.80; 56.1% females). We then used the same method to identify the resilience profiles of military veterans (N = 386, mean age = 43.47; SD = 10.08; 9.8% females), all of whom had served in Afghanistan. A four-profile-solution was the best fitting for the general population (High resilient 30%, Moderate resilient 13%, Low resilient 53%, Work/social-based resilience 4%), while a three-profile-solution had the best fit in the veteran cohort (Family-based resilience 28%, Work/social-based resilience 62%, Hardy loners 10%). To ground the identified profiles in occupational function, we also checked how they predicted reports of sleep difficulties, job demand and job control. Despite both samples inhabiting a geographic region known for high socioeconomic similarity among residents, we found marked differences in profile-solutions between the military veterans and the general population. Our findings suggests that resilience profiles are highly influenced by cohort characteristics and the specific resources needed to manage a given stressor load. Accordingly, the generalisability of specific protective factors may be low across distinct cohorts, and reliable findings need to be obtained in specific populations as defined by stressor context, sample characteristics, and relevant outcomes.

Cause-Specific Mortality Among Norwegian Veterans Deployed to Afghanistan Between 2001 and 2019.

INTRODUCTION: Norwegian military forces participated in the military campaign Operation Enduring Freedom in Afghanistan starting in 2001. Military personnel often show a "healthy soldier effect" in terms of lowered all-cause mortality when compared to the general population. However, military service in conflict areas is associated with an increased risk of death from external causes such as transport accidents and suicide after discharge. We aimed to investigate cause-specific mortality in a cohort of 9,192 Norwegian (7.5% women) veterans deployed to Afghanistan between 2001 and 2019. MATERIALS AND METHODS: We followed cohort members from their first day of service in Afghanistan through 2019. We computed standardized mortality ratios (SMRs) with 95% CIs by comparing the observed number of deaths in our cohort with the expected number of deaths in the general population. Standardized mortality ratios were calculated for the full follow-up period among men and women separately, and among men only for two time periods: during deployment and after discharge from service in Afghanistan. RESULTS: We observed 77 deaths (3 women and 74 men), 10 of which occurred during deployment (war casualties, 1 woman and 9 men); all others occurred after discharge. All-cause mortality in women did not differ from that in the general population (SMR = 0.52, 95% CI 0.11-1.53). For men, the observed all-cause mortality was lower than the expected rate for the full follow-up period (SMR = 0.55, 95% CI 0.43-0.69), during deployment, and after discharge, while deaths because of transport accidents after discharge (13 cases) were more than twice as high as expected rates (SMR = 2.36, 95% CI 1.26-4.04). The 11 observed suicides gave a nonstatistically significant, lower suicide risk compared to the expected rates (SMR = 0.66, 95% CI 0.33-1.18). CONCLUSION: In accordance with the "healthy soldier effect," military service in Afghanistan was generally associated with a lower than expected risk of death both during deployment and after discharge. The risk of death from transport accidents was higher than expected after discharge, while the observed incidence of suicide did not differ from the expected rate in the general population.

Caring for Coronavirus Healthcare Workers: Lessons Learned From Long-Term Monitoring of Military Peacekeepers.

BACKGROUND: The current outbreak of the coronavirus disease (COVID-19) is of unprecedented proportions in several regards. Recent reports suggest that many frontline healthcare workers (HCWs) suffer from mental health problems, including posttraumatic stress symptoms (PTSS). Previous studies have identified several key factors associated with short-term PTSS in pandemic HCWs, yet limited data is available on factors associated with long-term PTSS. Understanding the psychological impact of the pandemic on HCWs is important in planning for future outbreaks of emerging infectious diseases. In the current study, we look to findings from a highly relevant subsection of the trauma field, the military domain. OBJECTIVE: Pandemic HCWs and military peacekeepers may experience similar stressors in the line of duty. This study investigated whether factors linked to short-term PTSS in pandemic HCWs were also associated with long-term PTSS in military peacekeepers. MATERIALS AND METHODS: Peacekeepers who reported pandemic-relevant stressors during deployment to a UN peacekeeping mission were included in the study (N = 1,627). PTSS was self-reported using the Posttraumatic Stress Disorder Checklist - Military Version. Descriptive instruments were used to assess possible factors associated with PTSS. A multiple linear regression analysis was performed to explore associations between these factors and PTSS. RESULTS: Our model accounted for 50% of the variance in PTSS, F(1503,11) = 139.00, p < 0.001. Age, relationship and employment status, preparedness, working environment, social support after deployment, barriers to disclose, recognition, and loneliness were all significantly associated with PTSS on average 30 years after deployment. The most important risk factors of long-term PTSS were personal barriers to disclose one's experiences and current unemployment. CONCLUSION: Several factors linked to short-term PTSS in pandemic HCWs were associated with long-term PTSS in peacekeepers. We discuss how these findings may be used to prevent long-term PTSS in HCWs involved in the current COVID-19 outbreak.

Prevalence and Correlates of Mental Health Problems in Norwegian Peacekeepers 18-38 Years Postdeployment.

Peacekeeping missions involve experiences that may impact the mental health of participating soldiers. However, research on the long-term mental health consequences of peacekeeping is sparse. The present study aimed to find the prevalence of mental health problems (MHPs), possible MHP predictors, and associations between predictors and MHPs in Norwegian peacekeepers 18-38 years after deployment to a United Nations peacekeeping mission. We used data from a cross-sectional, postdeployment survey of Norwegian peacekeepers who served in Lebanon between 1978 and 1998 (N = 10,605). Participants were assessed for posttraumatic stress disorder (PTSD); anxiety; depression; insomnia; alcohol misuse; drug misuse; and exposure to pre-, peri-, and postdeployment stressors. Logistic regressions were executed to explore key variables associated with MHPs. Total MHP prevalence was 15.1%, 95% CI [14.4, 15.8]. The estimates for specific disorders were 0.1% for drug misuse, 3.4% for alcohol misuse, 4.0% for depression, 6.2% for PTSD, 6.4% for anxiety, and 9.3% for insomnia. Postdeployment stressors, OR = 1.91, 95% CI [1.79, 2.04]; employment status, OR = 1.41, 95% CI [1.33, 1.48]; and traumatic exposure during deployment, OR = 1.11, 95% CI [1.09, 1.12], were positively related to PTSD, χ2(17, N = 8,568) = 1,791.299, p < .001. Similar patterns were found for the other MHPs. Considering that most participants (84.9%) reported low symptom levels, our findings challenge the widespread public perception that most peacekeepers have MHPs. Moreover, our results indicate that future peacekeepers should be prepared for challenges they may face not only during deployment but also in the years following their homecoming.

Danger- and non-danger-based stressors and their relations to posttraumatic deprecation or growth in Norwegian veterans deployed to Afghanistan.

Objective: This study aimed to explore how exposure to danger-based and non-danger-based stressors may influence personal changes in veterans (N = 4053) after deployment to Afghanistan. Method: Twelve war zone related traumatic events were used to form two stressor categories. The non-danger-based category included two stressor types: Moral Challenges and Witnessing, and the danger-based category included one type: Personal Threat. Thus, three stressor types were explored in relation to self-reported personal changes after war zone stressor exposure, e.g. negative changes labelled posttraumatic deprecation, positive changes labelled posttraumatic growth or no major change. Furthermore, the relationship between the stressor types and reported levels of distress were explored. Results: The two non-danger-based stressor types, Moral Challenges (p < .001) and Witnessing (p < .001), were both significantly more associated with deprecation rather than growth, when compared to Personal Threat. Moreover, the non-danger-based stressors were significantly associated with a rise in posttraumatic stress symptoms, as well as a rise in symptoms of depression, anxiety and insomnia (p < .001). In contrast, exposure to the danger-based stressor was only significantly associated with a rise in the posttraumatic stress symptoms in the current model (p < .001). Reports of no-change were significantly associated with low degrees of exposure to all the three stressor types (p < .001). Conclusion: The current study highlights the special adverse effects of non-danger-based stressors. Our findings show that they are more associated with posttraumatic deprecation rather than with growth. This underscores the heterogeneity of responses to traumatic events and adds to the current knowledge about the impact of various stressor types.

Objetivo: El objetivo del estudio fue explorar cómo la exposición a estresores basados en peligro y a estresores no basados en peligro puede influenciar cambios personales en veteranos (N = 4053) luego de ser desplazados a Afganistán.Métodos: Doce eventos traumáticos relacionados a zonas de guerra se usaron para elaborar dos categorías de estresores. La categoría de estresores no basados en peligro incluyó a dos tipos: Desafíos Morales y Ser Testigo. La categoría de estresores basados en peligro incluyó un tipo: Amenaza Personal. Consecuentemente, se exploró la relación de tres tipos de estresores con los cambios personales auto reportados luego de la exposición a estresores de zona de guerra; así, los cambios negativos fueron etiquetados como 'declive postraumático', y los cambios positivos como 'crecimiento postraumático' o como 'sin cambio significativo'. Adicionalmente, se exploró la relación entre los tipos de estresores y los niveles reportados de sufrimiento.Resultados: Los dos tipos de estresores no basados en peligro, Desafíos Morales (p < .001) y Ser Testigo (p < .001) estuvieron significativamente más asociados a declive que a crecimiento, cuando fueron comparados con Amenaza Personal. Asimismo, los estresores no basados en peligro estuvieron significativamente asociados a un incremento en síntomas de estrés postraumático, así como a un incremento en síntomas de depresión, ansiedad e insomnio (p < .001). En contraste, la exposición a estresores basados en peligro estuvo únicamente asociada de manera significativa a un incremento de síntomas de estrés postraumático según el modelo actual (p < .001). Los reportes de no haber experimentado un cambio estuvieron asociados significativamente a bajos niveles de exposición a los tres tipos de estresores (p < .001).Conclusiones: El presente estudio resalta los efectos adversos particulares de los estresores no basados en peligro; nuestros hallazgos muestran que están más asociados con declive postraumático que con crecimiento postraumático. Esto enfatiza la heterogeneidad de las repuestas ante eventos traumáticos y añade información sobre el impacto de los diferentes tipos de estresores al conocimiento actual.

Measuring psychological change after trauma: Psychometric properties of a new bi-directional scale.

OBJECTIVE: The current scientific measures of posttraumatic changes in the wake of major stressors have mostly been unidirectional. This study is an attempt to develop a scale that will capture the continuum of positive to negative psychological changes after trauma. METHOD: Forty-five statements were presented to a veteran sample (N = 4,053) with the request to report for each item their experiences of negative, positive, or no posttraumatic changes as a result of their deployment to Afghanistan. RESULTS: Principal component analysis brought out 4 dimensions; 26 nonoverlapping items that had correlations above .40 were selected for the final version of the scale. The 4 dimensions were given the following designations: Self-Confidence, Interpersonal Involvement, Awareness, and Social Adaptability. Most veterans reported positive changes (36.8-80.8%) whereas a minority reported negative changes (4.5-22.0%). The total scale score correlated negatively with measures of depression, anxiety, sleep disorders, and posttraumatic stress symptoms. CONCLUSION: The posttraumatic change scale (PTCS) demonstrated acceptable psychometric properties and captured the range from negative to positive posttraumatic changes after major stress. Contrary to several previous studies, positive posttraumatic change, as measured by the PTCS, was not associated with increased symptoms of psychopathology. This underscores the heterogeneity of psychological responses to traumatic events. (PsycINFO Database Record

Sick Leave and Disability Across Three Decades After a Major Disaster.

Extended functional impairment characterized by sick leave and disability after a single disaster has not been documented before. This prospective, longitudinal, case-control study applied growth mixture modeling to predict trajectories of functional impairment in oil rig workers, survivors (n = 68) and a matched comparison group (n = 84), over 27 years after the 1980 North Sea oil rig disaster. In the initial 12 years post-disaster, survivors displayed higher rates of functional impairment than the comparison group. A minor group of survivors (n = 8, 11.8%) demonstrated persistent functional impairment from the start and remained unable to work during the subsequent three decades. Long-term sick leave and disability were related to perceived peritraumatic death threat and a propensity towards social withdrawal. Most survivors (n = 60) revealed no major functional impairment. The study indicates that functional impairment should be counteracted in the early support after a single disaster.

The benefits of being mindful: trait mindfulness predicts less stress reactivity to suppression.

BACKGROUND AND OBJECTIVES: There has been a recent proliferation of research evaluating the efficacy of mindfulness as a clinical intervention. However, there is still little known about trait mindfulness, or how trait mindfulness interacts with maladaptive emotion regulation strategies. The current study further explores the effect of trait mindfulness on emotion regulation, as well as whether specific factors of trait mindfulness are uniquely associated with subjective and autonomic reactivity to stress. METHODS: Forty-eight healthy male participants were trained in the use of the suppression strategy and then instructed to suppress their responses to the inhalation of a 15% CO2-enriched air mixture for 90 s while their subjective distress and heart rate were recorded. RESULTS: After controlling for anxiety-related variables, the ability to provide descriptions of observed experiences predicted less heart rate reactivity to CO2 inhalation, while skillfulness at restricting attention to the present moment was uniquely predictive of less subjective distress. The tendency to attend to bodily or sensory stimuli predicted greater distress during CO2 inhalation. LIMITATIONS: The inclusion of only healthy males limits the generalizability of study findings. Also, the sample size was relatively small. CONCLUSIONS: These findings suggest that factors associated with trait mindfulness predict less stress reactivity and distress while engaging in suppression above and beyond other variables that have been shown to predict anxious responding. The implications for emotion and clinical research are discussed.

Sudden gains during psychological treatments of anxiety and depression: a meta-analysis.

OBJECTIVE: The present study quantitatively reviewed the literature on sudden gains in psychological treatments for anxiety and depression. The authors examined the short- and long-term effects of sudden gains on treatment outcome as well as moderators of these effects. METHOD: The authors conducted a literature search using PubMed, PsycINFO, the Cochrane Library, and manual searches. The meta-analysis was based on 16 studies and included 1,104 participants receiving psychological treatment for major depressive disorder or an anxiety disorder. RESULTS: Effect size estimates suggest that sudden gains had a moderate effect on primary outcome measures at posttreatment (Hedges's g = 0.62) and follow-up (Hedges's g = 0.56). These effect sizes were robust and unrelated to publication year or number of treatment sessions. The effect size of sudden gains in cognitive-behavioral therapy was higher (Hedges's g = 0.75) than in other treatments (Hedges's g = 0.23). CONCLUSIONS: These results suggest that sudden gains are associated with short-term and long-term improvements in depression and anxiety, especially in cognitive-behavioral therapy.

Disaster survivors in their third decade: trajectories of initial stress responses and long-term course of mental health.

This study analyzed trajectories of initial stress and long-term mental health after the 1980 North Sea oil rig disaster. A growth-mixture model of the survivors' stress manifestations in the first 8 weeks (Posttraumatic Stress Scale, [PTSS-10]) and general mental health in 1980, 1981, 1985, and 2007 (General Health Questionnaire, [GHQ-20]) was estimated. Survivors' GHQ-scores in 1985 and 2007 were contrasted to those of a comparison group. Four trajectories were identified among survivors. The resilient (n = 43) displayed initially moderate stress that rapidly declined. The recovery (n = 10), chronic (n = 8), and relapse (n = 9) showed initially stable high stress scores, but the long-term mental health differed. Early screening may identify those at long-term risk.

Mental health outcomes and predictors of chronic disorders after the North Sea oil rig disaster: 27-year longitudinal follow-up study.

The present study examined long-term mental health outcomes following a major disaster, including the relative risks (RR) of developing psychiatric disorders. Trauma exposure and predisaster vulnerability factors were examined as predictors of chronic psychopathology. Standardized questionnaires measuring psychological distress were completed 5½ months, 14 months, 5 years, and 27 years after the disaster. Twenty seven years after the disaster, 48 (79%) survivors and a matched comparison group of 62 (78%) nondisaster-exposed controls were assessed using the Structured Clinical Interview for DSM-IV, axis I Disorders. The prevalence of posttraumatic stress disorder among the survivors was 6.1%, and the risk of having a psychiatric disorder was more than 3 times higher than in the comparison group (RR = 3.44, 95% confidence interval = 1.6-7.6). Disaster exposure and general neurotic personality predicted chronic psychopathology, which was reported by 20.9% of the participants. Findings from this study suggest that increased risk of psychopathology persists 27 years after disaster. Both disaster exposure and vulnerable personality are important predictors of chronic psychopathology.

Long-term perspectives on posttraumatic growth in disaster survivors.

Findings on posttraumatic growth (PTG) and distress have not been consistent. This study examines the relationship in a very long-term perspective. The Posttraumatic Growth Inventory was completed by 46 survivors from a single disaster 27 years posttrauma. Posttraumatic stress was measured by the Impact of Event Scale (IES) immediately after the event, and after 1, 5, and 27 years. In the final follow-up, general mental health was also assessed. Strong positive associations were found between PTG and concurrent posttraumatic stress. Although weaker associations were found for the past, concurrent problems in general mental health clearly coexisted with PTG decades after a disaster, yet mediated by IES.

Reactivation of posttraumatic stress in male disaster survivors: the role of residual symptoms.

The aim of this study was to establish the relative distribution of resilient, remitted, chronic and reactivated posttraumatic stress disorder (PTSD) in a population of survivors from a major civilian disaster. Residual PTSD symptoms were explored to identify predictors of future reactivation. Symptoms were measured by the Impact of Event Scale (IES) 5.5 months, 14 months and 5 years after the disaster. Forty-eight survivors (79%) were interviewed after 27 years. PTSD status was determined by using the Structural Clinical Interview for DSM-IV axis I Disorders (SCID-I). The distributions were: 58.3% resilient, 14.6% remitted, 8.3% chronic, and 18.8% reactivated PTSD. Number of residual symptoms from intrusion and avoidance 14 months and 5 years past trauma predicted later reactivation. Intrusion symptoms in general, and sleep related intrusions in particular, were the most consistent predictors deserving special attention.

Initial stress responses in relation to outcome after three decades.

The present study aimed at predicting posttraumatic stress 5 and 27 years after the North Sea oil rig disaster. The predictions were based on the initial levels of stress responses and the early recovery as reported in 1980. The Posttraumatic Stress Scale (PTSS) was used at 3 measure points. From 1980, data from 69 survivors were used in latent growth modeling. Follow-up studies included 65 survivors and 85 matched unexposed oil-rig workers in 1985; and 47 and 62 in 2007. In 1985, the survivors had higher total PTSS scores and more frequent endorsements on most single PTSS-items than the comparison group. In 2007, a few single items remained different. The initial levels of stress responses and the early recovery rate predicted the long-term outcomes after 5 and 27 years. Initial screenings may be helpful in the early detection of posttraumatic stress in the very long-term perspective.