1. Melissa A. Polusny, PhD Minneapolis VA Health Care System Center for Chronic Disease Outcomes Research University of Minnesota Medical School April 16, 2015

2. Disclosure Information I have no financial relationships to disclose I will not discuss off label use and/or investigational use in my presentation Views expressed in this presentation are mine and do not reflect the position or policy of the VA or the US government

3. Collaborators Co-Principal Investigators: Christopher Erbes, PhD Paul Arbisi, PhD ABPP Co-Investigators: Paul Thuras, PhD David DeGarmo, PhD Abigail Gewirtz, PhD Dawne Vogt, PhD Mark Kramer, PhD (Project Manager) Military Collaborators: COL Michael Rath, MD LTC Barbara O’Reilly MAJ Aaron Krenz Special thank you to all of the MN ARNG Soldiers and Families for their participation in the RINGS Project.

4. Overview Background on National Guard/Reserve component troops in OEF/OIF/OND Lessons learned from the Readiness and Resilience in National Guard Soldiers (RINGS-1) Study New Research Findings from the RINGS-2 Family Study Discuss clinical implications and future directions

5. Background Nearly 2 million U.S. troops deployed to OEF/OIF High levels of combat exposure Elevated risk for mental health problems including posttraumatic stress disorder (PTSD)

7. Negative Outcomes Associated with Post-traumatic Stress Disorder (PTSD) High rates of psychiatric co-morbidity Physical health problems including chronic pain Impairments in occupational, interpersonal, and family functioning Poor quality of life Disability

8. National Guard/Reservists in OEF/OIF Unprecedented deployments of National Guard/Reserve troops to operations in Iraq and Afghanistan Nearly half National Guard/Reservists

9. National Guard/Reservists in OEF/OIF NG/R troops show greater increases in mental health distress over time than regular component troops

10. Milliken et al. (2007) DoD’s Post-Deployment Health Assessment/Re-Assessment Findings

11. Possible Explanations NG/R service members face unique challenges: Pre-deployment Demographics (older, married with children) Civilian roles (leaving jobs and careers behind) Training and expectations During deployment Deployment experiences Post-deployment Challenges returning to work/school Social reintegration Access to health care Unclear which factors are most important

12. Problems with Existing Research Vast majority of studies based on: Based on active duty personnel - findings may not generalize to NG/R service members Cross-sectional designs - provide only a snapshot in time Retrospective reports – may be biased by recall errors or current distress Traditional conceptualizations of trauma that focus on psychopathology, homogeneity of impact of trauma

13. Trauma and Resilience Resilience is “the ability of adults in otherwise normal circumstances who are exposed to an isolated and potentially highly disruptive event, such as a violent or life-threatening situation, to maintain relatively stable, healthy levels of psychological and physical functioning” (Bonnano, 2004)

14. Bonanno, G. A. (2004). Loss, Trauma, and Human Resilience: Have We Underestimated the Human Capacity to Thrive After Extremely Aversive Events? American Psychologist, 59 (1), 20-28. Prototypical Patterns of Disruption in Normal Functioning Across Time Following Potentially Traumatic Events

15. Why do we need prospective, longitudinal studies? Longitudinal designs allow us to identify varying courses of adjustment (trajectories) following trauma Prospective designs allow us to account for pre-existing problems or concerns and identify predictors of trajectory prior to trauma exposure Findings may inform interventions aimed at increasing resilience and recovery following trauma exposure

16. Readiness and Resilience in National Guard Soldiers (RINGS) Project Series of longitudinal studies conducted in collaboration with the MN Army National Guard Pre-deployment, in-theater, post-deployment data collection Identify risk and resilience factors predictive of National Guard Soldiers’ post-deployment mental health and reintegration

17. Samples and Data Collection RINGS-1 Study N=522 National Guard Soldiers Pre-deployment survey data collected at Camp Shelby, MS Follow-up data collected via mail, in person clinical interviews RINGS-2 Family Study Ns=2089 National Guard Soldiers and 1077 spouses/partners Pre-deployment survey data collected at NG training events (Family Preparation Academies) Follow-up data collection collected via mail and web-based survey (for Soldiers during deployment) Camp Shelby, MS

18. Deployment Experiences and Post- deployment Outcomes *Polusny et al 2011

19. Rates of Soldier Mental Health Problems Over Time RINGS-1 Participants (N=522)

20. Trajectories of PTSD Symptoms among National Guard Soldiers (76%) Polusny, Erbes, Arbisi, Thuras, DeGarmo, Kramer, Koffel, & Litz (under submission)

21. What factors predict these pathways? Predictors of Vulnerable-Risk Pathway: Soldiers’ perceptions prior to deployment of not being prepared Combat exposure Lower post-deployment social support Greater post-deployment life stressors Personality Predictors of Chronic Distress Pathway: Depression prior to deployment Worries about family, job, life disruption prior to deployment Combat exposure Personality

23. Lessons Learned from RINGS-1 Most Soldiers are resilient Social context plays important role in development of PTSD symptoms Family support and concerns about families influences Veterans’ PTSD symptoms before, during, and after deployment Role of subsequent life stressors Importance of longitudinal studies to examine change in well-being over time

24. Families and Deployment Well-being of military families is a top national priority

25. Families and Deployment Limited research in this area Most research on deployment and family functioning has focused on Service Members Elevated psychological distress in intimate partners Greater internalizing and externalizing behavioral problems in children Greater parenting stress Increased risk for child maltreatment Poorer couple relationship satisfaction

26. Families and Deployment Deployment as a “catastrophic” stressor (Peebles-Kleiger & Kleiger, 1994) Emotional Cycle of Deployment Model (Pinicus et al 2001) Posits that military families may become distressed as they face distinct emotional challenges and stressors across the deployment cycle Challenges/stressors erode family functioning  deplete availability of family support for Service Members Widely cited, but few studies have empirically tested model

27. Goals of the RINGS-2 Study Identify potentially distinct trajectories of family functioning Identify predictors of heterogeneity in family functioning Examine impact of family functioning on Soldiers’ post- deployment mental health

28. 12 Month Deployment to Iraq/Kuwait Time 1 Pre- Deployment Soldiers N=1973 Partners N=1020 Time 4 3 Months Post- Deployment Soldiers N=845 (43%) Partners N=608 (60%) RINGS-2 Study Design and Methods Time 2 Month 3 Partners N=750 (74%) Time 3 Month 8 Soldiers N=441 (22%) Partners N=707 (69%)

29. Demographics

30. Deployment Experiences and Post- deployment Outcomes *Polusny et al 2011

31. Partner Distress Resilience: 81.6% Vulnerable-Risk: 8.5% Anticipatory Distress: 5.3% Chronic distress: 4.6%

32. Pre-deployment Factors Predicting Partner Distress Vulnerable-Risk Distress vs. Resilience: Lower perceived social support by Soldier Greater stress reactivity reported by partner Lower perceived family readiness reported by partner Chronic Distress vs. Resilience: Greater stressors reported by Solider Partner personality (stress reactivity, low positive emotionality, impulsivity) Lower perceived social support by partner

33. Partner Alcohol Misuse Resilience: 91.3% Vulnerable-Risk: 5.4% Deployment Desistance: 3.3%

34. Pre-deployment Factors Predicting Partner Alcohol Misuse Vulnerable-Risk Distress vs. Resilience: Greater impulsivity reported by partner Lower perceived family readiness reported by partner Poorer relationship quality reported by partner Deployment Desistance vs. Resilience: Greater Solider alcohol use prior to deployment Partner personality (stress reactivity and impulsivity)

35. Soldiers’ Post-deployment Outcomes by Partner Distress Trajectory Soldier Post- Deployment Mental Health Outcome Class 1: Chronic Class2: Vul-Risk Class 3: Anticip Class 4: Resilient Pairwise n = 22n = 21n = 15n = 454 PTSD (PCL) 33.3 (15.72)37.1 (17.96)29.2 (10.23)29.2 (12.71) ns Depression (PHQ-8) 6.4 (5.35)5.0 (6.22)3.8 (3.49)4.4 (4.73) ns Alcohol Use (AUDIT) 5.8 (5.41)6.8 (5.64)4.2 (3.60)5.2 (4.16) ns ANCOVA Est M (SE) PTSD (PCL) 31.2 (2.19)36.2 (2.23)25.4 (2.74)29.6 (.49) 2>3**; 2>4**; 1>3 † Depression (PHQ-8) 5.3 (.84)4.7 (.85)3.6 (1.0)4.5 (.18)ns Alcohol Use (AUDIT) 5.5 (.85)6.5 (.89)4.2 (1.09)5.2 (.19)2>3 †

36. Soldiers’ Post-deployment Outcomes by Partner Alcohol Misuse Trajectory Soldier Post- Deployment Mental Health Outcome Class 1: Vul-Risk Class2: Desistance Class 3: Resilient Pairwise n = 12n = 17n = 492 PTSD (PCL) 36.6 (16.64)33.7 (14.56)29.4 (12.95) ns Depression (PHQ-8) 6.7 (6.79)6.1 (4.72)4.4 (4.78) ns Alcohol Use (AUDIT) 6.3 (6.03)7.6 (5.03)5.2 (4.22) ns ANCOVA Est M (SE) PTSD (PCL) 35.0 (2.84)32.5 (2.84)29.6 (.47)1>3 † Depression (PHQ-8) 6.4 (1.13)5.3 (.98)4.4 (1.77)1>3 † Alcohol Use (AUDIT) 5.9 (1.18)7.4 (1.02)5.2 (.18)2>3*

37. Soldiers’ Post-deployment PTSD by Partner Trajectory Classes

38. Soldiers’ Post-deployment Depression by Partner Trajectory Classes

39. Soldiers’ Post-deployment Alcohol Misuse by Partner Trajectory Classes

41. Conclusions/Limitations Most Soldiers and families are resilient over the cycle of deployment Those displaying difficulties vary in terms of both the course and domain of symptoms expressed Pre-deployment risk/protective factors uniquely predictive of distinct trajectories National Guard Soldiers report better post-deployment mental health when partners demonstrated a trajectory of resilience Limitations Self-report outcomes Generalizability to a ctive duty Service Members, deployments involving direct combat operations

42. Implications and Future Directions Practitioners can identify and monitor at-risk family members to ensure appropriate intervention efforts Interventions focused on reducing family risk factors may bolster Soldiers’ resilience How do we best help in need and at risk family members? Community/Organization, Unit, Family, and Individual levels of intervention Primary and secondary interventions Urgent need to empirically validate our intervention strategies

43. Acknowledgements This research was supported by:  Minneapolis VA Medical Center  Minnesota Medical Foundation  Minnesota Veterans Research Institute  University of Minnesota Press  Department of Defense Congressionally Directed Medical Research Program  VA Health Services Research & Development

45. Contact Information: melissa.polusny@va.gov