Military Psychiatry Branch, Walter Reed Army Institute of Research
Bereavement and Physical Health Outcomes in U.S. Soldiers Returning from Combat
LCDR Robin L. Toblin, Mr. Brian Kok, Dr. Lyndon A. Riviere, & COL Charles W. Hoge (ret.)
Military Psychiatry BranchCenter for Military Psychiatry and Neuroscience
Walter Reed Army Institute of ResearchJune 18, 2011
The views expressed here are those of the authors and do not represent the views of the Department of the Army or the Department of Defense.
Military Psychiatry Branch, Walter Reed Army Institute of Research
Post-War Physical Health
• Physical, cognitive, psychological symptoms, occupational/ social impairment reported after virtually every war
• Predictors of physical health outcomes for current wars focus on “signature injuries”– Concussion/mild traumatic brain injury (mTBI), post-
traumatic stress disorder (PTSD) • Few recent studies examine basic prevalence of post-
war physical health problems• Few studies examine risk factors except mTBI, PTSD
Military Psychiatry Branch, Walter Reed Army Institute of Research
Bereavement as Potential Risk Factor
• Bereavement predicts negative health outcomes– Includes physical health, functional impairment – Independent from PTSD, depression
• Direct exposure to trauma worsens grief • 80% of soldiers returning from Iraq knew someone
seriously injured or killed• Over 25% had buddy shot or hit near them• Losing team member in combat – like losing close family• Health impact of bereavement in current wars – virtually
no research
Military Psychiatry Branch, Walter Reed Army Institute of Research
Goals of the Study
• Identify the prevalence of post-deployment physical health concerns in Army soldiers after their return from combat duty in Iraq and Afghanistan
• Examine the unique contribution of difficulty coping with bereavement on physical health
Military Psychiatry Branch, Walter Reed Army Institute of Research
Study Population
• Part of a larger study of the impact of combat • Three U.S. infantry brigades • November, December 2008• Six months post- Iraq deployment• 50% available during recruitment phase• 86% response rate• 2064 soldiers completed the survey
– 1532 reported being deployed to Iraq or Afghanistan for at least one month
– 10 excluded for moderate or severe TBI to isolate specific contribution of mild TBI/concussion
• Final sample = 1522
Military Psychiatry Branch, Walter Reed Army Institute of Research
Measures – Exposure Variables
• Combat experiences– 34 items, dichotomized into “at least
once” / “never”, summed, divided into quartiles
• Injury – No injury, non-mTBI injury, mTBI with
alteration, but no loss of consciousness (AOC), mTBI with loss of consciousness (LOC)
• Adverse childhood experiences– Parent with alcohol problems, parent
with mental illness, emotional abuse, physical abuse (range: 0–4).
• Alcohol misuse – Two-Item Conjoint Screen (TICS):
Drank more than meant to; wanted to cut down
• Depression – Patient Health Questionnaire–9
(PHQ–9)
• PTSD – PTSD Checklist (PCL)
• Bereavement
Military Psychiatry Branch, Walter Reed Army Institute of Research
Measure for Bereavement
• “In the past month, how much have you experienced difficulty coping with grief over the death of someone close?”
• Responses: “not at all”, “a little bit”, “moderately”, “quite a bit”, “extreme”
• Any positive response categorized as having difficulty coping with bereavement
Military Psychiatry Branch, Walter Reed Army Institute of Research
Measure – Outcome Variables
• Physical/somatic symptoms (PHQ–15) in past month: “not bothered at all,” “bothered a little,” and “bothered a lot”– High score = ≥15
• Self-rated overall health: “excellent,” “very good,” “good,” “fair,” “poor”
• Missed work days in the past month• Medical utilization (i.e., # “sick call” visits) in past month• Physical impairment of important military requirements:
“not at all” to “extreme”– Difficulty carrying a heavy load – Difficulty performing physical training (PT)
Military Psychiatry Branch, Walter Reed Army Institute of Research
Analysis
• Examined prevalence of six main outcomes, physical health symptoms
• Prevalence rates, Kruskal-Wallis c2, c2 tests for trend – Association b/w bereavement severity, outcomes
• Multiple logistic regression – Examine unique contribution of bereavement to six
health outcomes– Control for demographics, combat experiences, injuries,
mental health factors
Military Psychiatry Branch, Walter Reed Army Institute of Research
Results- Demographics
• Male: 92% • Age < 30: 73% • Married: 56% • High school or less: 50% • Junior enlisted (E1-E4): 56%
Military Psychiatry Branch, Walter Reed Army Institute of Research
Prevalence of Physical Health Symptoms
• “Bothered a lot” by ≥ 1 symptom: 63.4%• Most common health symptoms– Sleep problems: 32.8%– Musculoskeletal pain: 32.7%– Fatigue: 32.3%– Back pain: 28.1%– Headaches: 16.2%
Military Psychiatry Branch, Walter Reed Army Institute of Research
Prevalence of Outcome Variables
• ≥2 medical visits/past month: 30.0%• Self-reported poor health: 28.1%• Difficulty performing PT: 26.7%• Difficulty carrying a heavy load: 24.1%• High symptom score on somatic scale: 9.7%• ≥2 days missed work/past month: 9.7%
Military Psychiatry Branch, Walter Reed Army Institute of Research
Prevalence of Difficulty Coping with Bereavement
Overall A little bit Moderate Quite a bit Extreme0
5
10
15
20
25
21.3
9.3
5.12.8
4.8
Bereavement Severity
Prev
alen
ce
Military Psychiatry Branch, Walter Reed Army Institute of Research
Prevalence of Symptoms for Soldiers Having Difficulty Coping with Grief
• Poor overall health: 49.7%– Irritability: 62.3%– Fatigue: 58.1%– Sleep problems: 55.4%– Musculoskeletal pain: 49.7%– Back pain: 41.3%
Military Psychiatry Branch, Walter Reed Army Institute of Research
High Score on Somatic Scale (PHQ-15) by Bereavement Severity
Not at all A little bit Moderate Quite a bit Extreme0
5
10
15
20
25
30
35
40
45
4.7
20.6
29.2
34.2
42.1
Bereavement Severity
Prev
alen
ce o
f hig
h PH
Q-1
5
Military Psychiatry Branch, Walter Reed Army Institute of Research
Self-Rated Poor Health by Bereavement Severity
Not at all A little bit Moderate Quite a bit Extreme0
10
20
30
40
50
60
70
22.3
44.3 45.9
58.5 60.7
Bereavement Severity
Prev
alen
ce o
f poo
r hea
lth
Military Psychiatry Branch, Walter Reed Army Institute of Research
Irritability by Bereavement Severity
Not at all A little bit Moderate Quite a bit Extreme0
102030405060708090
100
30.5
48.6
60.0
77.586.7
Bereavement Severity
Prev
alen
ce o
f Irr
itabi
lity
Military Psychiatry Branch, Walter Reed Army Institute of Research
Fatigue / Sleep Problems by Bereavement Severity
Not at all A little bit Moderate Quite a bit Extreme0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
24.8
47.8
57.3
70.075.0
26.3
45.353.3
62.5
76.7FatigueSleep Problems
Bereavement Severity
Prev
alen
ce o
f fati
gue
Military Psychiatry Branch, Walter Reed Army Institute of Research
Musculoskeletal Pain by Bereavement Severity
Not at all A little bit Moderate Quite a bit Extreme0
10
20
30
40
50
60
70
28.2
45.2 45.3
61.057.6
Bereavement Severity
Prev
alen
ce o
f mus
culo
skel
etal
pai
n
Military Psychiatry Branch, Walter Reed Army Institute of Research
Headaches by Bereavement Severity
Not at all A little bit Moderate Quite a bit Extreme0
10
20
30
40
50
60
11.8
24.1
30.736.6
52.5
Bereavement Severity
Prev
alen
ce o
f hea
dach
es
Military Psychiatry Branch, Walter Reed Army Institute of Research
Medical Visits by Bereavement Severity
Not at all A little bit Moderate Quite a bit Extreme0
10
20
30
40
50
60
25.7
34.4
51.456.1
53.6
Bereavement Severity
Prev
alen
ce o
f med
ical
vis
its
Military Psychiatry Branch, Walter Reed Army Institute of Research
Difficulty with PT by Bereavement Severity
Not at all A little bit Moderate Quite a bit Extreme0.0
10.0
20.0
30.0
40.0
50.0
60.0
22.528.0
48.6
55.050.0
Bereavement Severity
Prev
alen
ce o
f PT
diffi
culty
Military Psychiatry Branch, Walter Reed Army Institute of Research
Multiple Logistic Regression: DeterminingContribution of Bereavement to Health
Outcomes– Gender– Age– Education– Marital status– Rank– Combat experiences– Combat injury
(including mTBI)– Depression
– PTSD – Alcohol misuse– ACEs
Military Psychiatry Branch, Walter Reed Army Institute of Research
Independent Contribution of Bereavement to Health Outcomes
• High symptom score: AOR = 3.6 (95% CI: 2.1 – 6.2)
• Poor overall health: AOR= 2.0 (95% CI: 1.4 – 2.9)
• Missed work days: AOR = 1.7 (95% CI: 1.03 – 3.0)
• Medical visits: AOR = 1.5 (95% CI: 1.04 – 2.1)
• Carrying heavy load: AOR = 1.7 (95% CI: 1.2 – 2.4)
• Performing PT: AOR = 1.6 (95% CI: 1.1 – 2.3)
Military Psychiatry Branch, Walter Reed Army Institute of Research
Discussion: Prevalence of Physical Health Outcomes
• Health problems in current wars only in context of PTSD, mTBI
• Previous wars- strong association b/w deployment, symptoms found in this study
• Current wars – UK studies– Minimal differences in rates of physical symptoms
among those who deployed, non-deployers– However, deployed UK soldiers - lower rates of
combat experiences, mental health problems
Military Psychiatry Branch, Walter Reed Army Institute of Research
Discussion: Grief
• “Complicated grief” in civilian population: 9% – Our study: 21.3 - not based on a set of criteria
• Association of difficulty coping with grief, physical health outcomes consistent w/ civilian literature – Magnitude of differences in health outcomes
greater in our study• Grief independently predicts health outcomes
beyond PTSD, depression in civilian literature
Military Psychiatry Branch, Walter Reed Army Institute of Research
Limitations
• Difficulty coping with bereavement assessed with single item
• Unclear if deceased were unit buddies or family members/friends at home
• Could not determine duration of grief • Cross-sectional design • Self-reported data
Military Psychiatry Branch, Walter Reed Army Institute of Research
Conclusions
• Considerable post-war physical health burden• One in five soldiers - trouble with grief• Dose-response relationship between trouble
with grief, physical health symptoms/ occupational impairment
• Difficulty with bereavement independently contributes to physical health symptoms, occupational physical impairment
Military Psychiatry Branch, Walter Reed Army Institute of Research
Recommendations for Military, VA
• Research on bereavement• Availability of evidence-based clinical interventions for
complicated grief– Preventive interventions ineffective– Most will return to previous functioning w/o intervention– No research in military for treatment for “complicated” grief
• How unit training addresses bereavement– Caution: Easy to implement expedient interventions without
understanding empirical evidence and application to a military setting