1. 1 KAPTUR COMBAT MENTAL HEALTH INITIATIVE KAPTUR COMBAT MENTAL HEALTH INITIATIVE “There is no greater priority than the mental health needs of our returning soldiers.” Adjutant General Wayt (2005) 1

2. Study Sites University Hospitals Case Medical Center Joseph Calabrese, MD Coordinating Principal Investigator Stephen Ganocy, PhD., Philip Chan, MS Edwin Shirley, PhD., Toyomi Goto, MA Renee Slembarski, BA University of Toledo Marijo Tamburrino, MD Co-Principal Investigator Thomas Fine, MA., Kimberly Wilson, MSW Daniel Rapport, MD

3. Columbia University Sandro Galea, MD, DrPH Co-Investigator Marta Prescott, MPH University of Michigan Israel Liberzon, MD, PhD Co-Investigator Anthony King, PhD Study Sites

4. 4 OUTLINE Background, Research Question & Design Overall Demographic Description Pre-deployment: Childhood Trauma, Stressors Deployment experiences, Trauma, Support PTSD, Depression, GAD findings Suicidal Thoughts

5. 5 Health in the military Studies have demonstrated that combat exposure and deployment stressors are linked to psychopathologies including posttraumatic stress disorder (PTSD), depression and anxiety 27% of WWI hospitalizations were due to neuropsychiatric problems 15% of Vietnam War Vets, 15 years after the war, showed symptoms of PTSD 2% - 12.2% of Persian Gulf War veterans have current symptoms of PTSD 4% - 21% of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans have current symptoms of PTSD Pols et al 2007; Kulka et al 1990; Kang et al 2003; Kang et al 2005; Pietrzak et al 2009; Hotopf et al 2006; Hoge et al 2006; Miliken 2007; Seal et al 2007 5

6. 6 National Guard in recent combat Army National Guard and Air National Guard are increasingly used in combat zones and overseas operations 18% of total force in Persian Gulf War Reserve forces have comprised ~ 40% of the total operating force in OIF and OEF Lakhani et al 1993; Vogt et al 2008, Iraq and Veterans Affairs, Ohio National Guard website dated 3-28-09 6

7. 7 Ohio National Guard (ONG) and Deployment From September 11, 2001 through March 2009, more than 13,000 Ohio Army National Guard and Ohio Air National Guard have been deployed for both national and international duty Unique factors about deployment today All volunteer force Multiple deployments Communication 11% deployed are women Ohio National Guard website dated 3-28-09 7

8. 8 National Guard in recent combat While studies have shown that National Guard members deployed overseas experience comparable combat and deployment stressors as active duty personnel, Guard members have different training and deployment conditions than active duty personnel. Traditionally train only one weekend a month and two weeks in the summer While in National Guard maintain civilian job Only 180 days of health care coverage upon deactivation as compared to 2 years for active duty personnel Vogt et al 2008, Hotopf et al 2006; La Bash 2007 8

9. 9 Kaptur CMHI Most other studies have NOT focused on: The ONG VA non-treatment seekers Anything other than screening assessments Genetics repository Longitudinal collection of stressors and life events both inside and outside of the military

10. 10 Overriding research question What are pre-, peri- and post-deployment factors associated with onset and course of psychopathology among the Ohio National Guard? Posttraumatic stress disorder, depression, generalized anxiety disorder Suicidal ideation Mental health services 10

11. http://www.101films.net/

12. 12 6,700 randomly sampled ONG personnel received Alert Letter 6,090 personnel do not opt-out of study 2616 ONG personnel participate in telephone interview 1,043 randomly selected for in-person interviews 2616 ONG personnel followed annually with telephone interviews 500 sub-sample followed annually with in-person interviews Kaptur CMHI ONG study design 10,778 Men and Women in the Ohio Army National Guard (ONG) as of July 2008 12 70% overall participation rates

13. 13 Domains assessed in telephone assessment Demographics Military History Deployment Preparedness, Stressors, Traumas, and Social Support: Deployment Risk and Resilience Inventory (DRRI) Lifetime Traumatic History: Life Events Checklist Posttraumatic Stress Disorder: PTSD Checklist Depression: Patient Health Questionnaire (PHQ-9) Generalized Anxiety Disorder: GAD-7

14. 14 In-Person Interview Domains Demographics Military History Deployment Preparedness, Stressors, Traumas, and Social Support: Deployment Risk and Resilience Inventory (DRRI) Lifetime Traumatic History: Life Events Checklist PTSD: Clinician-Administered PTSD Scale (CAPS) All DSM IV-TR Mood, Anxiety, Substance Use, Psychotic, Somatoform, Eating and Acute Stress Disorders: Structured Clinical Interview for DSM IV-TR (SCID-IV) Suicidal Thoughts: Mini-International Neuropsychiatric Interview (MINI-Plus) Childhood Trauma Questionnaire (CTQ)

15. 15 Who are these people and what are the stories of their lives? Demographics Childhood trauma Stressors and trauma outside of deployment Number of deployments

16. 16 Location of Kaptur CMHI Sample N=2616 16

17. . (Blue-Ed, Red-Toyomi, Green-Tom, Purple-Kim) Color of pushpins indicates different interviewers. (Blue-Ed, Red-Toyomi, Green-Tom, Purple-Kim) Location of In-person Sample N=500

18. Wave 1 sample is representative of the Ohio Army National Guard p-value <0.05. This is calculated from baseline sample (N≈2616). The calculation for race included an other category (Native American and Asian), the baseline sample had 123 individuals (4.7%) compared to 183 (1.7%) in the Ohio National Guard. Age distribution*Race distribution*Female distribution

19. Ohio Army National Guard

20. Men make up 85.2% of the sample MenWomen Calculated from baseline (N≈2616)

21. Majority of the sample is white (87.7%) WhiteNon-white Calculated from baseline (N≈2616)

22. Few are currently divorced, widowed or separated (9.6%) MarriedDivorced or separatedNever married Calculated from baseline (N≈2616 )

23. Soldiers reported facing trauma in childhood These values are from the Childhood Trauma Questionnaire (Bernstein et al. 1996) from the baseline sample of the in-person surveys (N≈500). Each variable is determined on a 4 –point scale from “none or minimal”, “low to moderate”, “moderate to severe” and “severe to extreme”. Presented are the percentages of those who reported “moderate to severe” and “severe to extreme” occurrences.

24. Childhood traumas are more frequent in women *p-value<0.05. These values are from the Childhood Trauma Questionnaire (Bernstein et al. 1996) from the baseline sample of the in-person surveys (N≈500). Each variable is determined on a 4 –point scale from “none or minimal”, “low to moderate”, “moderate to severe” and “severe to extreme”. Presented are the percentages of those who reported “moderate to severe” and “severe to extreme” occurrences.

25. Throughout lifetime, soldiers encounter stressful experiences that can impact deployment and mental health (n=2616) Wave 1 Telephone Survey. N≈2616 Mean number of type of stressors was 3.4 (min=0, max=12). These are the prevalence of occurrences ever reported in the baseline survey

26. 32% of the baseline sample had been deployed more than once Average number of deployments is 1.3 (min = 0, max = 24). This is the proportion of deployment experience from baseline sample (N≈2616)

27. 27 In addition to lifetime stressors, the guard experience trauma outside of deployment

28. Ninety-one percent have experienced a trauma at some time in their lives This was calculated within the baseline sample (N≈2616). Traumatic events include assaultive traumatic events as well as shocking events (e.g. car accident, natural disaster), learning about traumatic events to others, the sudden unexpected death of someone close and any other traumatic event the participant considered traumatic

29. 29 Summary of pre-deployment conditions In the baseline sample majority of soldiers had been deployed at least once and the majority of those who had been deployed more than once had prior combat experience. Only thirty-six percent soldiers have never been deployed. Overall, soldiers experience stressors, traumas as well as psychopathologies over their lifetime that can play a role in subsequent mental health consequences after deployment.

30. 30 What are deployment experiences? Have information from baseline on most recent deployment including war trauma, self-reported preparedness, unit and post-deployment support Measures were collected using the Deployment Risk and Resilience Inventory King, D.W., King, L.A., Vogt, D., Knight, J., Samper, R.E. (2006) Deployment Risk and Resilience Inventory: A collection of measures for studying deployment related experience among military personnel and veterans. Military Psychology; 18(2): 89 - 120

31. Ohio Army National Guard

32. Majority of sample (63%) have been deployed Never deployed Deployment experience Calculated from baseline sample (N≈2616)

33. Nearly one third have had their most recent deployment to a conflict zone Never deployed Non-conflict zoneConflict zone Calculated from baseline sample (N≈2616)

34. Trauma during deployment (n=1607)

35. http://www.101films.net/

36. 36 Feeling prepared on most recent deployment Answers were scaled from 1 (strongly disagree) to 5 (strongly agree) Had supplies and equipment needed to get my job done Equipment I was given functioned the way it was supposed to Received adequate training on how to use my equipment Accurately informed about what to expect from the enemy Accurately informed of what daily life would be like during my deployment Calculated from deployment risk and resilience inventory (DRRI) among those who were ever deployed at baseline (n=1607) King, D.W., King, L.A., Vogt, D., Knight, J, Samper, R.E. (2006) Deployment Risk and Resilience Inventory: A collection of measures for studying deployment related experience among military personnel and veterans. Military Psychology; 18(2): 89 - 120 Box plot of Preparedness scores X

37. Sense of camaraderie between myself and other soldiers in my unit Most people in my unit were trustworthy Could go to most people in my unit for help when I had a personal problem Commanding officers were interested in what I thought and how I felt about things Impressed by the quality of leadership in my unit My superiors made a real attempt to treat me as a person I felt like my efforts really counted to the military Calculated from deployment risk and resilience inventory (DRRI) among those who were ever deployed at baseline (n=1607).King, D.W., King, L.A., Vogt, D., Knight, J., Samper, R.E. (2006) Deployment Risk and Resilience Inventory: A collection of measures for studying deployment related experience among military personnel and veterans. Military Psychology; 18(2): 89 - 120 Unit support during most recent deployment Box plot of unit support score X

38. 38 Reception I received when I returned from my deployment made me feel appreciated for my efforts American people made me feel at home when I returned When I returned, people made me feel proud to have served my country in the Armed Forces People at home understand what I have been through while in the Armed Forces There are people to whom I can talk about my deployment experiences The people I work with respect the fact that I am a veteran Calculated from deployment risk and resilience inventory (DRRI) among those who were ever deployed at baseline (n=1607) King, D.W., King, L.A., Vogt, D., Knight, J., Samper, R.E. (2006) Deployment Risk and Resilience Inventory: A collection of measures for studying deployment related experience among military personnel and veterans. Military Psychology; 18(2): 89 - 120 Post-deployment support after most recent deployment Box plot of post-deployment score X

39. 39 Summary of experiences during deployment Most soldiers have deployment experience and many have faced multiple combat situations. While self-reports may vary, most reports of preparedness, unit support and post-deployment support were high.

40. 40 What are our Study Findings on Mental Health?

41. 41 Comparing…prevalence of psychopathologies found in the general population (GP) Kessler R et al. Arch Gen Psychiatry 2005;62:593-602 and 617-627. Lifetime %12-Month % GPONGGPONG PTSD6.8% 9.5% 3.5%7.2% MDD/Depr16.6%21.4%6.7%14% GAD5.7%12.4%3.1%9.3%

42. Majority of soldiers do not have a condition and only 8% have co-occurring conditions within the past year This was calculated from the baseline sample (N≈2616) using PTSD, depression and generalized anxiety disorder No conditions 79%

43. 43 ONG Gender Findings WomenMen PTSD past year 12.1% 6.9% Depression past year 20.4%12.8% GAD past year 12.6% 8.7%

44. 44 How family and social factors predict PTSD Demographic and Stressful factors Posttraumatic stress disorder * Female *+ Being married- High income- College education- Marital discord+ * Lost a job * + * p-value <0.05. High income is dichotomized by $60,000. Results are the direction of the odds ratios from multivariable logistic models. 44

45. 45 How deployment stressors predict PTSD High psychosocial support - * High levels of preparedness * - High levels of unit support + * Family concerns while deployed * + * High levels of post-deployment support * - * p-value <0.05. Preparedness, unit support, family concerns, perceived threat and postdeployment support were created by splitting each score from the median. Results are the direction of the odds ratios from multivariable logistic models. Effect of Self-reported factors Posttraumatic stress disorder

46. 46 How deployment stressors predict PTSD High psychosocial support - * High levels of preparedness * - High levels of unit support + * Family concerns while deployed * + * High levels of post-deployment support * - * p-value <0.05. Preparedness, unit support, family concerns, perceived threat and postdeployment support were created by splitting each score from the median. Results are the direction of the odds ratios from multivariable logistic models. Starred values represent significant findings. 46 Effect of Self-reported factors Posttraumatic stress disorder

47. 47 High levels of post-deployment support reduce the odds of developing PTSD. “People understand what I’ve been through” “There are people whom I can talk to about my experience” “When I returned, people made me feel proud to serve”

48. 48 Caregiving strains families of veterans with severe injuries – USATODAY.com

49. 49 Does deployment affect suicidal ideation?

50. Two percent of soldiers reported suicidal thoughts within the past 30 days Calculated within baseline sample (N≈2616). This is “thought (they) would be better off dead, or had thoughts of hurting (themselves)” from the Patient Health Questionnaire - 9. Kroenke K, Spitzer R. The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals 2002;32:1. Compared to general population with a prevalence of lifetime suicidal ideation between 4.8% and 18% (cdc.gov/ncipc/wisqars) 255/2508 47/2508

51. Stressors experienced over lifespan are associated with current suicidal ideation * Current income < 60,000 *p-value <0.05. n = 2,508. Calculated with in baseline sample that answered all questions * Low social support * Parents abused each other * Caregivers fought * Ever unemployed > 3 months * Serious financial problems

52. Deployment experience is not associated with current suicidal ideation Among those deployed N = 1,601 Not deployed in past 3 yrs Deployed in past 3 yrs

53. However, within those deployed, certain features of most recent deployment predict current suicidal ideation * High preparedness * High unit support * High family concerns * High post deployment support * High combat p-value <0.05. From the Deployment Risk and Resilience Inventory. High levels created by median split. Calculated from baseline sample those who have been deployed (N≈1607)

54. 54 Interim Conclusions from Kaptur CMHI Overall, the ONG appear resilient to the development of PTSD, Depression, GAD and suicidal ideation. However, highly vulnerable sub-groups exist within the ONG. Among deployed, preparedness and support predicted resilience, whereas family concerns and amount of combat predicted risk. Suicidal ideation does not appear to be associated with deployment. Suicidal ideation was associated with being unmarried, low income, low social support, physical/sexual abuse, unemployment and financial problems. 54