Impact and Risk of Moral Injury Among Deployed Veterans: Implications for Veterans and Mental Health.

The impact of "moral injury" (MI) among deployed veterans, defined as actions in combat that violate a veteran's moral beliefs and result in psychological distress, has increasingly become a significant clinical concern separate from other trauma- and stressor-related disorders. MI involves severe distress over violations of core beliefs often followed by feelings of guilt and conflict and is common among veterans with PTSD. While the psychological impact of PTSD is well-documented among veterans, this has been done less so with respect to MI. We studied MI among 1,032 deployed veterans who were outpatients in a large non-profit multi-hospital system in central Pennsylvania. The study included active duty and Guard/Reserve members, as well as veterans who were not Department of Veterans Affairs (VA) service users. Our hypothesis was that, controlling for other risk factors, veterans with high MI would have current mental disorders. Our secondary hypothesis was that MI would be associated with other psychopathologies, including chronic pain, sleep disorders, fear of death, anomie, and use of alcohol/drugs to cope post deployment. Most veterans studied were deployed to Vietnam (64.1%), while others were deployed to post-Vietnam conflicts in Iraq and Afghanistan and elsewhere. Altogether, 95.1% of the veterans were male and their mean age was 61.6 years (SD = 11.8). Among the veterans, 24.4% had high combat exposure, 10.9% had PTSD, 19.8% had major depressive disorder, and 11.7% had a history of suicidal thoughts. Based on the Moral Injury Events Scale (MIES), 25.8% had high MI post deployment, defined as a score above the 75th percentile. Results show that high MI among veterans was associated with current global mental health severity and recent mental health service use, but not suicidal thoughts. In addition, as hypothesized, MI was also associated with pain, sleep disorders, fear of death, anomie, use of alcohol/drugs to cope post-deployment, and poor unit support/morale during deployment. Deployed veterans with MI are more likely to have current mental health disorders and other psychological problems years after deployment. Further research is advised related to the screening, assessment, treatment, and prevention of MI among veterans and others after trauma exposures.

Genetic and Psychosocial Risk Factors Associated with Suicide Among Community Veterans: Implications for Screening, Treatment and Precision Medicine.

INTRODUCTION: Since veteran suicide is a concern and our knowledge of predictive factors is still limited, our objective was to assess risk factors for suicide, including genetic factors, among deployed veterans. METHODS: For this study, we surveyed 1730 veterans who were outpatients in a multi-hospital system in Pennsylvania. Altogether, 1041 veterans (60%) provided a DNA sample. The genetic risk variants investigated were within loci previously associated with PTSD and substance misuse, including CRHR1, CHRNA5, RORA, and FKBP5 genetic variations, which were used to calculate a polygenic risk score (range=0-8, mean=3.6, SD=1.4). RESULTS: Most veterans (56.2%) were deployed to Vietnam while significant numbers were deployed to Iraq, Afghanistan, and other post-Vietnam conflicts. Overall, 95.1% of the veterans were male, their mean age was 56.2 (SD=12), and 95.6% were Caucasian. Among the veterans, 24% had high combat exposure. The prevalence of lifetime suicidal thoughts was 11.3%. Additionally, 5.7% ever developed a suicide plan or attempted suicide in their lifetimes. Among those with a history of a lifetime suicide attempt or suicide plan, the PTSD genetic risk score was significantly higher (OR=3.96 vs 3.55, p=0.033), but for suicidal thoughts, this association was not significant (p=0.717). In multivariable analysis (MVA) logistic regression, significant predictors of attempting suicide or having a suicide plan were history of depression (OR=5.04, p<0.001), PTSD genetic risk score (OR=1.25, p=0.036), history of childhood abuse/neglect (OR=2.24, p=0.009), and lifetime marijuana use (OR= 1.56, p=0.020). Conversely, rural residence was protective for suicide risk (OR=0.49; p=0.031). For suicidal thoughts, in the MVA genetic risk score was not significant (p=0.697), but history of child abuse/neglect (p<0.001), history of depression (p>0.001), low psychological resilience (p=0.004), and lifetime marijuana use (p=0.022) were significant. DISCUSSION: In this study, we identified genetic risk variants and other predictors for suicide among veterans that may have implications for future screening and clinical care. Further research is advised.

Psychological well-being and alcohol misuse among community-based veterans: results from the Veterans' Health Study.

BACKGROUND: Maladaptive drinking is an increasing concern among military policy makers and healthcare providers. The goal of this study was to assess how social and psychological factors relate to alcohol problems among post-deployed US veterans and how problematic drinking is associated with well-being. METHODS: Data were collected via a telephone survey from a random sample of veterans receiving their healthcare from a large non-VA hospital system in central Pennsylvania (N = 1730). Interviewers inquired about participants' current alcohol consumption, using the CAGE and AUDIT-C scales, and health-related outcomes (general psychological distress, major depression, and self-reported health status). Analyses included demographic, military and nonmilitary stressful events, use of alcohol or drugs to cope post-deployment, use of psychiatric services, and personality characteristics as independent variables. Our sample was 95% male, 96% White, and had a mean age of 59 years old (SD = 12 years). RESULTS: Analyses included demographic, military and nonmilitary stressful events, use of alcohol or drugs to cope post-deployment, use of psychiatric services, and personality characteristics as independent variables. Our sample was 95% male, 96% White, and had a mean age of 59 years old (SD = 12 years). Analyses for our drinking measures show that those who used drugs or alcohol to cope post-deployment were more likely to be problematic drinkers, while positive personality characteristics such as agreeableness and conscientiousness were related to fewer drinking problems. Multivariate logistic regressions for our well-being measures found that alcohol misuse was not related to distress or depression, but that a positive score on the AUDIT-C was associated with a lower likelihood of poor self-rated health. Using alcohol or drugs to cope was related to higher distress. DISCUSSION: We conclude that service providers might consider using post-deployment AUDIT-C and the drugs and alcohol coping questions when screening for possible alcohol and mental health problems among veterans.

Risk and protective factors associated with mental health among female military veterans: results from the veterans' health study.

BACKGROUND: This study focuses on factors that may disproportionately affect female veterans' mental health, compared to men, and is part of a larger study assessing the prevalence of mental health disorders and treatment seeking among formerly deployed US military service members. METHODS: We surveyed a random sample of 1,730 veterans who were patients in a large non-VA hospital system in the US. Based on previous research, women were hypothesized to be at higher risk for psychological problems. We adjusted our results for confounding factors, including history of trauma, childhood abuse, combat exposure, deployments, stressful life events, alcohol misuse, psychological resources, and social support. RESULTS: Among the veterans studied, 5% were female (n = 85), 96% were White (n = 1,161), 22.9% were Iraq/Afghanistan veterans (n = 398), and the mean age was 59 years old (SD = 12). Compared to males, female veterans were younger, unmarried, college graduates, had less combat exposure, but were more likely to have lifetime PTSD (29% vs. 12%.), depression (46% vs. 21%), suicidal ideation (27% vs. 11%), and lifetime mental health service use (67% vs. 47%). Females were also more likely to have low psychological resilience and to have used psychotropic medications in the past year. Using multivariate logistic regression analyses that controlled for risk and protective factors, female veterans had greater risk for lifetime PTSD, depression, suicidal thoughts, and for lifetime use of psychological services, compared to males. Since 95% of the population in this study were male and these results may have been statistically biased, we reran our analyses using propensity score matching. Results were consistent across these analyses. CONCLUSION: Using a sample of post-deployment veterans receiving healthcare services from a large non-VA health system, we find that female veterans are at greater risk for lifetime psychological problems, compared to male veterans. We discuss these findings and their implications for service providers.

Mental health status in veterans residing in rural versus non-rural areas: results from the veterans' health study.

BACKGROUND: The majority of Veterans Affair (VA) hospitals are in urban areas. We examined whether veterans residing in rural areas have lower mental health service use and poorer mental health status. METHODS: Veterans with at least 1 warzone deployment in central and northeastern Pennsylvania were randomly selected for an interview. Mental health status, including PTSD, major depression, alcohol abuse and mental health global severity, were assessed using structured interviews. Psychiatric service use was based on self-reported utilization in the past 12 months. Results were compared between veterans residing in rural and non-rural areas. Data were also analyzed using multivariate logistic regression to minimize the influence by confounding factors. RESULTS: A total of 1730 subjects (55% of the eligible veterans) responded to the survey and 1692 of them had complete geocode information. Those that did not have this information (n = 38), were excluded from some analyses. Veterans residing in rural areas were older, more often of the white race, married, and experienced fewer stressful events. In comparison to those residing in non-rural areas, veterans residing in rural areas had lower global mental health severity scores; they also had fewer mental health visits. In multivariate logistic regression, rural residence was associated with lower service use, but not with PTSD, major depression, alcohol abuse, and global mental health severity score after adjusting confounding factors (e.g., age, gender, marital status and education). CONCLUSIONS: Rural residence is associated with lower mental health service use, but not with poor mental health in veterans with former warzone deployment, suggesting rural residence is possibly protective.

Predictors of Current DSM-5 PTSD Diagnosis and Symptom Severity Among Deployed Veterans: Significance of Predisposition, Stress Exposure, and Genetics.

BACKGROUND: Previously we reported a genetic risk score significantly improved PTSD prediction among a trauma-exposed civilian population. In the current study, we sought to assess this prediction among a trauma-exposed military population. METHODS: We examined current PTSD diagnosis and PTSD symptom severity among a random sample of 1042 community-based US military veterans. Main effects and interaction effects were assessed for PTSD genetic risk by trauma exposure using cross-product terms for PTSD x trauma exposures, including combat, lifetime trauma, and adverse childhood exposures. The PTSD risk variants studied were within genetic loci previously associated with PTSD, including CRHR1, CHRNA5, RORA, and FKBP5 genetic variants, which were used to calculate a total PTSD genetic risk score (range=0-8, mean=3.6, SD=1.4). RESULTS: Based on DSM-5 PTSD criteria, 7.1% of veterans (95% CI=5.6-8.8) met criteria for current PTSD. The PTSD genetic risk count was significantly higher among PTSD cases vs non-cases (3.92 vs 3.55, p=0.027). Since the PTSD genetic risk score was not significant in the PTSD diagnosis model, we assessed this association using PTSD symptom severity. Because these symptom data were skewed (mean=9.54, SD=12.71, range=0-76), we used negative binomial regression to assess this outcome. This symptom model included a PTSD genetic risk score, demographic factors, trauma exposures, current insomnia, current depression, concussion history, and attention-deficit disorder, expressed as incident rate ratios (IRR), which is an estimate of one-unit increase in PTSD severity, given other variables are held constant. Variables in the final model included age and sex (both p<0.001), PTSD genetic risk (IRR=1.02, p=0.028), warzone tours (IRR=0.94, p=0.003), childhood abuse (IRR=1.50, p<0.0001), current depression (IRR=1.89, p<0.0001), current insomnia (IRR=2.58, p<0.0001), low social support (IRR=1.19, p<0.0001), attention-deficit disorder (IRR=1.51, p<0.0001), agreeable personality (IRR=0.77, p<0.0001), and concussion (IRR=1.38, p<0.0001). Significant interactions were detected for combat and lifetime trauma exposure by PTSD genetic risk (both p<0.0001), suggesting that the impact of trauma exposures on PTSD severity was lower when the PTSD genetic risk was higher. CONCLUSION: Both warzone and non-warzone factors predicted current PTSD symptoms among veterans, including a PTSD genetic risk score. Interaction effects were detected for combat exposure and lifetime trauma by genetic risk score for PTSD symptoms, suggesting that PTSD symptom manifestation was more dependent on PTSD risk variants than the level of trauma or combat exposure. This suggests that controlling for other factors, the absence of genetic risk variants may confer PTSD resilience. Further research is planned.

Social and Psychological Risk and Protective Factors for Veteran Well-Being: The Role of Veteran Identity and Its Implications for Intervention.

Social psychological theory hypothesizes that one's identity, self-definitions, and meanings used for a particular social role fosters individual purpose in life and affects behavior in specific social situations. As such, it can be protective against the onset of psychological disorders. We examined this hypothesis with data collected from 1,730 military veterans recruited to study the health effects of warzone deployments. The sample was primarily male, older, and White. Our key independent variable was a Likert scale rating the prominence of a respondent's veteran identity: how important it is to the person. Outcome variables included posttraumatic stress disorder (PTSD), suicide ideation, depression, alcohol misuse, and use of VA services. Bivariate analysis suggested that veterans with a prominent veteran identity are older, noncollege graduates, have less income, and had their first deployment to Vietnam. In multivariate analyses, study participants with a prominent veteran identity were less likely to exhibit suicide ideation, but more likely to misuse alcohol and use VA services. We found no differences for PTSD, self-rated health, or depression by veteran identity. Veterans who scored higher on the veteran identity scale appeared to be protected from suicidal thoughts, although they had an elevated risk for alcohol misuse.

Grapheme-Color Synesthesia is Associated with PTSD Among Deployed Veterans: Confirmation of Previous Findings and Need for Additional Research.

Post-traumatic stress disorder (PTSD) is related to alteration in neuropsychological functioning, including visual and other cognitive processes. Grapheme-color synesthesia is a phenomenon in which a letter or number elicits response of a concurrent image or color perception. Since we earlier reported an association between grapheme-color synesthesia and PTSD, our objective in the current study was to validate this association among a new study group and assess risk factors. For this, we surveyed 1,730 military veterans who have been outpatients in the Geisinger Clinic, a multi-hospital system in Pennsylvania, USA. All the study veterans served in a warzone deployment. The association between PTSD and Grapheme-color synesthesia was evaluated. The average age of veterans was 59.6 years among whom 95.1% were male. Current PTSD prevalence rate was observed to be 7.6% (95% C.I. = 6.5-9.0) and in 3.4% of veterans (95% C.I. = 2.7-4.4) grapheme-color synesthesia was found to be positive. Initial bivariate analyses suggested that synesthesia was associated with current PTSD [odds ratio (OR) = 3.3, p<0.001]. Multivariable stepwise logistic regression evaluating the age, sex, education, trauma exposure, current psychological stress, psychotropic medication use, combat exposure, history of concussion, and current depression, confirmed this association (OR = 2.33, p = 0.019). The present study corroborated that Grapheme-color synesthesia was linked to PTSD among a second cohort of deployed military veterans. Further research is recommended in order to validate this observation and to determine whether synesthesia is a risk factor for PTSD.

Mental Health Impact of Homecoming Experience Among 1730 Formerly Deployed Veterans From the Vietnam War to Current Conflicts: Results From the Veterans' Health Study.

We examined the effects of homecoming support on current mental health among 1730 deployed veterans from Vietnam, Iraq/Afghanistan, Persian Gulf, and other conflicts. The prevalence of current posttraumatic stress disorder (PTSD) was 5.4%, current depression was 8.3%, and 5.4% had suicidal thoughts in the past month. Overall, 26% of veterans had low homecoming support, which was more prevalent among Vietnam veterans (44.3%, p < 0.001). In multivariable logistic regressions, controlling for demographics, combat exposure, number of deployments, trauma history, and operational theater, low postdeployment support was associated with PTSD (odds ratio, 2.13; p = 0.032) and suicidality (odds ratio, 1.91; p < 0.030), but not depression. For suicidality, an interaction was detected for homecoming by theater status, whereby Iraq/Afghanistan veterans with lower homecoming support had a higher probability of suicidal thoughts (p = 0.002). Thus, years after deployment, lower homecoming support was associated with current PTSD and suicidality, regardless of theater and warzone exposures. For suicidality, lower support had a greater impact on Iraq/Afghanistan veterans.

Visual Dysfunction and Associated Co-morbidities as Predictors of Mild Traumatic Brain Injury Seen Among Veterans in Non-VA Facilities: Implications for Clinical Practice.

Introduction: Traumatic brain injury (TBI) and post-traumatic stress disorder are considered the signature injuries of the Iraq and Afghanistan conflicts. With the extensive use of improvised explosive devices by the enemy, the concussive effects from blast have a greater potential to cause mild TBI (mTBI) in military Service Members. These mTBI can be associated with other physical and psychological health problems, including mTBI-induced visual processing and eye movement dysfunctions. Our study assessed if any visual dysfunctions existed in those surveyed in non-Veterans Administration (VA) facilities who had suffered mTBI (concussive effect), in addition to the presence of concussion-related co-morbidities. Materials and Methods: As part of a larger study involving veterans from different service eras, we surveyed 235 Veterans who had served during the Iraq and/or Afghanistan conflict era. Data for the study were collected using diagnostic telephone interviews of these veterans who were outpatients of the Geisinger Health System. We assess visual dysfunction in this sample and compare visual dysfunctions of those who had suffered a mTBI (concussive effect), as well as co-morbidities, with those in the cohort who had not suffered concussion effects. Results: Of those veterans who experienced visual dysfunctions, our results reflected that the visual symptoms were significant for concussion with the subjects surveyed, even though all had experienced a mTBI event greater than five years ago. Although we did find an association with concussion and visual symptoms, the association for concussion was strongest with the finding of greater than or equal to three current TBI symptoms, therefore we found this to be the best predictor of previous concussion among the veterans. Conclusions: Veterans from the Iraq/Afghanistan era who had suffered concussive blast effects (mTBI) can present with covert visual dysfunction as well as additional physical and psychological health problems. The primary eye care providers, especially those in a non-military/VA facility, who encounter these veterans need to be aware of the predictors of mTBI, with the aim of uncovering visual dysfunctions and other associated co-morbidities.

Social Support, Help-Seeking, and Mental Health Outcomes Among Veterans in Non-VA Facilities: Results from the Veterans' Health Study.

Using a stress process model, the authors examined social and psychological resources to better understand mental health outcomes among veterans. For this study, we surveyed 700 U.S. veterans who were outpatients in the Geisinger Health System. Independent variables included demographic factors, stressful and traumatic events, social support measures, and psychosocial factors. Using logistic regression, the authors examined 4 types of social connections: social support, help-seeking support, social capital, and other mental health support to predict mental health outcomes, including posttraumatic stress disorder, depression, suicide ideation, alcohol misuse, mental health service use, and Veterans Affairs service use. Results suggested that help-seeking support since deployment was a risk factor for 5 adverse outcomes, whereas social support was protective for 1 outcome. We concluded that high levels of help-seeking support since deployment among veterans was associated with a higher prevalence of mental health problems. These findings were unexpected and suggest the need for additional social support-related research among veterans.

Attitudes about Future Genetic Testing for Posttraumatic Stress Disorder and Addiction among Community-Based Veterans.

This study explored attitudes toward hypothetical genetic testing for posttraumatic stress disorder (PTSD) and addiction among veterans. We surveyed a random sample of community-based veterans (n = 700) by telephone. One year later, we asked the veterans to provide a DNA sample for analysis and 41.9% of them returned the DNA samples. Overall, most veterans were not interested in genetic testing neither for PTSD (61.7%) nor for addiction (68.7%). However, bivariate analyses suggested there was an association between having the condition of interest and the likelihood of genetic testing on a 5-point scale (p < 0.001 for PTSD; p = 0.001 for alcohol dependence). While ordinal regressions confirmed these associations, the models with the best statistical fit were bivariate models of whether the veteran would likely test or not. Using logistic regressions, significant predictors for PTSD testing were receiving recent mental health treatment, history of a concussion, younger age, having PTSD, having alcohol dependence, currently taking opioids for pain, and returning the DNA sample during the follow-up. For addiction testing, significant predictors were history of concussion, younger age, psychotropic medication use, having alcohol dependence, and currently taking opioids for pain. Altogether, 25.9% of veterans reported that they would have liked to have known their genetic results before deployment, 15.6% reported after deployment, and 58.6% reported they did not want to know neither before nor after deployment. As advancements in genetic testing continue to evolve, our study suggests that consumer attitudes toward genetic testing for mental disorders are complex and better understanding of these attitudes and beliefs will be crucial to successfully promote utilization.

Mental Health Disorders and Treatment Seeking Among Veterans in Non-VA Facilities: Results and Implications from the Veterans' Health Study.

We surveyed 700 veterans who were outpatients in a non-Veterans Affairs (VA) multihospital system. Our objective was to assess the prevalence of mental disorders and service use among these veterans. The majority were Vietnam veterans (72.0%), and male (95.9%), and 40.4% reported recently using the VA for care. The prevalence of lifetime post-traumatic stress disorder (PTSD) was 9.6%, lifetime depression 18.4%, and lifetime mental health service use 50.1%. In multivariate analyses, significant factors associated with PTSD, depression, and mental health service use were low self-esteem, use of alcohol/drugs to cope, history of childhood adversity, high combat exposure, and low psychological resilience. VA service use was associated with greater mental health service use and combat exposure. With the exception of alcohol misuse, the mental health status of veterans seen in non-VA facilities appeared to be better than reported in past studies. Because most veterans have access to both VA and non-VA services, these findings have implications for veterans and outcomes research.

Military aircrew eyewear survey: operational issues.

BACKGROUND: Army aircrew are required to operate under stressful conditions within a degraded visual environment. To gain an understanding of current eyewear mission needs, we surveyed aircrew regarding operational issues associated with the current U.S. Army-issue aircrew eyewear. METHODS: An anonymous online survey was completed by 976 U.S. Army aircrew personnel recruited through an invitational e-mail. RESULTS: Of the respondents, 34% reported wearing corrective lenses. Nearly 50% of them reported dissatisfaction with the HGU-4/P Aviator spectacles. The leading problems reported were discomfort (15%), "hot spots" around the ears (13%), and break of the earcup seal (11%). Nearly 41% of the respondents wore multifocal lenses and, of those, 16% reported that the HGU-4/P's restricted field of view (FOV) adversely affected duty performance. Of those who wore Modified HGU-4/P Apache spectacles, 79% had an unacceptable FOV with the helmet display unit. A similar number of aircrew modified the Apache eyewear to increase the FOV. In addition, wind and dust created eye discomfort or affected the vision of 46% of all respondents when performing flight duties. Over 82% expressed the need for an improved aircrew spectacles and 73% desired aviation-compatible protective eyewear. DISCUSSION: The current Army HGU-4/P Aviator and the Modified HGU-4/P Apache spectacles have significant operational deficiencies and compatibility issues. Such deficiencies have led to poor wear compliance and unauthorized modification of the Army-issue Aviator eyewear, posing readiness and safety issues. The results of this survey formally identify the need for military combat eye protection that is compatible with flight systems.

Visual dysfunctions and symptoms during the subacute stage of blast-induced mild traumatic brain injury.

The purpose of the present study was to assess the occurrence of visual dysfunctions and associated symptoms in active duty warfighters during the subacute stage of blast-induced mild traumatic brain injury (mTBI). A comprehensive visual and oculomotor function evaluation was performed on 40 U.S. military personnel, 20 with blast-induced mTBI and 20 without. In addition, a comprehensive symptom questionnaire was used to assess the frequency of visual, vestibular, and neuropsychiatric-associated symptoms. The most common mTBI-induced visual dysfunctions were associated with near oculomotor deficits, particularly large exophoria, decreased fusion ranges, receded near point of convergence, defective pursuit and saccadic eye movements, decreased amplitude of accommodation, and monocular accommodative facility. These were associated with reduced reading speed and comprehension and an increased Convergence Insufficiency Symptom Survey score. Photosensitivity was a common visual dysfunction along with hearing, balance, and neuropsychiatric symptoms. The oculomotor testing for warfighters suspected of blast-induced mTBI should include, at a minimum, the assessment of near lateral and vertical phorias, positive fusional vergence, stereoacuity, near point of convergence, amplitude of accommodation, monocular accommodative facility, saccades, and pursuit eye movements. A reading test should be included in all routine exams as a functional assessment of the integration of oculomotor functions.

Effectiveness of computerized oculomotor vision screening in a military population: pilot study.

The prevalence of oculomotor dysfunctions associated with blast-induced mild traumatic brain injury (mTBI) in warfighters has increased as a consequence of recent conflicts. This study evaluated the effectiveness of computerized oculomotor vision screening (COVS) in a military population. Oculomotor functions were assessed with COVS and by conventional methods in 20 U.S. military personnel with and 20 without mTBI. The validity of COVS was determined by Pearson correlation and Bland-Altman method or the kappa coefficient. The repeatability of the COVS was assessed with the coefficient of repeatability or the kappa coefficient. The results showed that COVS had high sensitivity and specificity for screening near oculomotor functions. Overall, the COVS showed excellent validity and repeatability for assessing near lateral and vertical phorias, Worth 4 Dot, and fixation, as well as pursuit and saccadic eye movements. Despite the strong Pearson correlation, the Bland-Altman analysis identified minor to moderate discrepancies for both positive and negative fusional vergence and their associated recovery as well as for the monocular accommodative facility measurements. This study demonstrated that non-eye-care professionals may be able to use the COVS as a tool to efficiently screen oculomotor functions in a military population with or without mTBI.