1. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 1 Impact of Combat on the Mental Health and Well-Being of Soldiers and Marines 7 Things I Think I Know Colonel Carl A. Castro Director, Military Operational Medicine Research Program Smith College School for Social Work Combat Stress: Understanding the Challenges, Preparing for the Return Northampton, New Hampshire 26-28 June 2008

2. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 2 Born in Kansas City, Missouri Enlisted as an infantryman in the U.S. Army at the age of 17 Obtain BA from Wichita State University and MA and PhD from the University of Colorado (major psychology) Entered active duty as a psychologist in 1989 Served on deployments to Bosnia (1998), Kosovo (2000, 2002), and Iraq (2003, 2006) Authored, co-authored around 100 publications Promoted to colonel in FEB 2007 Serves on several NATO, TTCP panels Just started a new job as Director of Military Operational Medicine, Fort Detrick, Maryland Areas of research interest include: - Impact of combat and operations on mental health and well-being of Soldiers and Families - Development of validated mental health training instrument and procedures to facilitate effective adaptation and growth - Junior Leader development and their role in facilitating mental health and well-being in subordinates Biography of Colonel Castro

3. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 3 1. Combat impacts the mental health and well-being of Soldiers and Marines.

4. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 4 Prevalence of PTSD n = 2,414 n = 3,781 There is a 3-fold increase for U.S. Soldiers screening positive for PTSD when assessed 3 months after returning from a year in Iraq.

5. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 5  Firefights, high combat, high perceived danger, & dissociative experiences increased PTSD risk. Combat-related Risk Factors & PTSD

6. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 6 Anger and Aggressive Behaviors Got angry with someone and kicked or smashed something, slammed the door, punched the wall, etc. Got into a fight with someone and hit the person Percent one or more times Got angry with someone and yelled or shouted at them Threatened someone with physical violence

7. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 7 2. Not all Soldiers are at equal risk for mental health problems.

8. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 8 Combat Experiences: Combat vs. Support Hand-to-hand fighting Got shot at Was attacked or ambushed Saw dead bodies Knew somebody injured/killed Killed enemy combatants IED exploded nearby Soldiers in combat units experienced more combat-related events than Soldiers in combat support (CS) and combat service support (CSS).

9. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 9 Mental Health Status By Unit Types Any Behavioral Health Problem (PTSD, Depression or Anxiety) 14.4 9.9 7.5 6.7 16.8 16.7 6.1 13.4 0 10 20 30 40 Combat Arms ENG/EOD MP/MI Signal Civil Affairs Transportation Support Medical Percent Screening Positive Soldiers were more likely to screen positive for a mental health problem if they were in a combat arms unit, engineer, transportation, or support unit than Soldiers in other types of units.

10. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 10 The Frontline in Iraq Soldiers were divided into low, medium and high combat based on frequency of combat events during the deployment. Soldiers with higher levels of combat were more likely to screen positive for anxiety, depression, or PTSD, indicating that all Soldiers are NOT at the same level of risk for a mental health problem.

11. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 11 3. Leadership is important for maintaining Soldier mental health.

12. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 12 Leadership and Mental Health Adjusted R Square =.15 and the Chi Square is significant at the.01 level Soldiers with high perceptions of Leadership were less likely to screen positive for a mental problem (PTSD, Depression or Anxiety) compared to those Soldiers with low perceptions of leadership. Percent Screened Positive for any mental health problem

13. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 13 Battlemind Training as an Example Battlemind Training is mental health training focused on the development of skills, involving self-aid, buddy aid, and leadership. Battlemind Training involves: –Evidence-based: Built on findings from the Land Combat Study. Validated through research. –Experience-Based: Uses examples that Soldiers can relate to. –Strengths-based: Builds on existing Soldier strengths and skills – rejects a deficit or illness model. –Training: Focuses on skill development – not education. –Explanatory: Highlights conflicted/misunderstood reactions. –Team-based: Self awareness through helping buddy. –Action-Focused: Discusses specific actions to guide Soldier behavior.

14. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 14 4. Mental health training works.

15. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 15 Soldier Attitudes: Training Utility Battlemind Training had high ratings.

16. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 16 Battlemind Training: PTSD & Depression Soldiers who received Battlemind Training (BMT) (p <.01) reported fewer PTSD symptoms at 3 months post-deployment compared to Soldiers who received the standard stress education training. Depression symptoms for Soldiers who received BMT were only marginally significantly lower than for Soldiers who received stress education (p <.10).

17. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 17 Battlemind Training: Stigma & Sleep Soldiers who received Battlemind training reported less psychological stigma at 3 months post-deployment compared to Soldiers who received the standard stress education training (p <.01). Soldiers who received Battlemind training also reported fewer sleep problems than Soldiers who received the standard stress education training (p <.01).

18. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 18 Battlemind Training System: Deployment Cycle Alert Transition to Post-Conflict Battlemind AAR Psychological Debriefing Continuing the Transition Home Battlemind Training II PDHRA Battlemind Brief and DVD Transitioning from Combat to Home Post-Deployment Battlemind Battlemind AAR Psychological Debriefing Pre-Deployment Battlemind For: Leaders Junior Enlisted Helping Professionals Spouse/Couples Pre- Deployment Battlemind Tough Facts about Combat and what leaders can do to mitigate risk and build confidence Battlemind Training I Spouse/Couples Post- Deployment Battlemind Preparing for a Military Deployment

19. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 19 5. Mental health “re-setting” following a year-long combat tour takes more than 12 months.

20. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 20 High Performing Soldiers with Mental Health Symptoms Returning to Iraq (Castro & Hoge, 2005) Soldiers’ mental health status does not “re-set” after 12 months following return from a combat tour.

21. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 21 6. Longer and multiple deployments are likely to lead to more mental health issues.

22. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 22 Soldier Multiple Deployments Soldiers deployed to Iraq more than once were more likely to screen positive for a mental health problem than first-time deployers.

23. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 23 Soldier Deployment Length Soldiers deployed longer than 6 months were more likely to screen positive for a mental health problem than those deployed for 6 months or less.

24. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 24 7. Every combat Soldier (and Marine) will face moral and ethical challenges.

25. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 25 Torture should be allowed in order to gather important info about insurgents Torture should be allowed if it will save the life of a Soldier/Marine All non-combatants should be treated as insurgents Treatment of non-combatants and views on torture I would risk my own safety to help a non- combatant in danger All non-combatants should be treated with dignity and respect Battlefield Ethics: Attitudes

26. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 26 Physically hit / kicked non-combatant when it was not necessary Damaged / destroyed Iraqi property when it was not necessary Insulted/cursed at non-combatants in their presence Members of unit ignore ROEs in order to accomplish the mission Treatment of Noncombatants and ROEs Members of unit modify ROEs in order to accomplish the mission Battlefield Ethics: Behaviors Soldiers and Marines who report better officer leadership are more likely to follow the ROE.

27. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 27 unnecessarily destroying private property injuring or killing an innocent non-combatant mistreatment of a non-combatant violating ROEs stealing from a non-combatant I would report a unit member for: not following general orders Battlefield Ethics: Reporting “We prefer to handle things within the unit; would only turn someone in if it put the safety of unit members in jeopardy.” ---Junior NCO

28. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 28 Received training that made it clear how I should behave toward non-combatants. Training in proper treatment of non-combatants was adequate. Received training in the proper treatment of non- combatants. Encountered ethical situations in Iraq in which I did not know how to respond. Although Soldiers and Marines reported receiving adequate battlefield ethics training, over one quarter reported encountering situations in which they didn’t know how to respond. NCOs and Officers in my unit made it clear not to mistreat non-combatants Battlefield Ethics: Training

29. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 29 Soldiers who screened positive for a mental health problem or who had high levels of anger were twice as likely to engage in unethical behavior on the battlefield compared to those Soldiers who screened negative or who had low levels of anger. Soldiers with high levels of combat were more likely to engage in unethical behaviors than Soldiers with low levels of combat. Physically hit / kicked non-combatant when it was not necessary Insulted/cursed at non-combatants in their presence The relationship between mental health and unethical behavior holds even when controlling for anger. These findings indicate the need to include Battlefield Ethics awareness in all mental health counseling and anger management courses. Damaged and/or destroyed Iraqi private property when it was not necessary Soldier Mental Health, Combat and Ethics

30. Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command 30 Point of Contact COL Carl Castro Director, Military Operational Medicine Research Program, Fort Detrick, MD carl.castro@us.army.mil