1. Resilience & Reintegration: What Can We Learn from Research? Karen Quigley, Ph.D. NJ WRIISC

2. Today’s Goals  Describe the prospective, longitudinal HEROES Project study  Discuss initial findings on predictors of non- specific physical symptoms after deployment  Discuss how these findings can inform clinical practice

3.  Healthy Resilience after Operational and Environmental Stressors  Longitudinal, prospective cohort study of 790 Army National Guard and Reserve Soldiers deploying to Iraq or Afghanistan

4. A Primary Study Aim: Understand what factors lead to increased physical symptoms in those returning from combat (and that can have important functional consequences)

5. Methods  Army National Guard and Reserve Soldiers volunteered at Fort Dix, NJ and Camp Shelby, MS  Informed Consent (both VA and DOD) Data Collection Timeline  Risk and Resilience survey measures PRE- DEPLOYMENT Surveys Lab Stressor with physiology I MMED. P OST - D EPLOYMENT Surveys Saliva samples (rest & first a.m.) 3 M ONTHS P OST Surveys mailed to home O NE Y EAR P OST Surveys mailed to home D EPLOYMENT

6. Risk and Resilience Measures RISKRESILIENCE Demographics: Age, gender, education, race/ethnicity, number of prior deployments Social Support Trait Negative EmotionalityUnit Cohesion Prior Life Stressors (including Trauma) Coping Style: Current Distress  Approach Absorption  Avoidance Alcohol Misuse Combat and Aftermath of Battle Experiences Social Desirability Injury

7. Outcome Measure - Non-Specific Physical Symptoms – Patient Health Questionnaire-15 (PHQ-15) Stomach painPain or problems during sexual intercourse Dizziness Back painChest painShortness of breath Pain in arms, legs, joints Trouble sleepingFainting spells HeadachesFeeling tired or having low energy Feeling heart pound or race Menstrual cramps or other problems w/periods (women) Nausea, gas or indigestion Constipation, loose bowels or diarrhea

8. Participants  790 Army Reserve and National Guard Soldiers deploying to Iraq and Afghanistan  Predominant unit types are Military Police, Infantry, Artillery, and Support

9. Current Study Status  Phase 1: N = 790  Phase 2: N = 430  Phase 3: N = 278  Phase 4: N = 260 *This analysis uses the first 320 Soldiers who have both Phase 1 and 2 data.

10. Our SampleArmy National Guard/Reserve Ages 18-57 years (Mean=28)Ages 18-60 years (ANG Mean approx. 33) 72% Army Nat’l Guard ANG) 27% Army Reserves (AR) 1% Other Deployed are 76% ANG & 24% Army Reserve (as a proportion of reserve component) Males 89% Females 11% Army NG female = 13% Army Reserve female = 23.6% Overall Army Res comp. = 16.8% Mean (& Median) Education is “Some college” (78% had some college) Army NG 99.8% and Army Reserve 99.3% were high school graduates or equivalent and 22% had some college White 74% Hispanic 10% Black 9% Asian 2% Other 5% White 67.8% Hispanic 9.5% Black 17.5% Asian 3.2% Other 4.6%

11. Number of Prior Deployments 56% 27% 11% 4% 3%

12. Participant Home State

13. Phase 1 HEROES sample Comparison samples or norms Current Distress 22.8 (7.5)23.2 (7.3)/25.0 (8.0) Pre-Deployment Life Events 6.0 (3.6)4.1 (4.6) NG/Reserves 4.8 (3.3) Active duty Alcohol MisuseQ1 = 39.6% Yes Q2 = 24.3% Yes No = 56.3% Before Q1 = 17% Yes Before Q2 = 12% Yes After Q1 = 24% Yes After Q2 = 18% Yes Negative Emotionality 9.6 (6.0)7.9 (5.1) MOS Social Support 73.6 (18.8)70.1 (24.2) healthcare Approach Coping 11.1 (2.9)8.8 men; 10.8 women Avoidance Coping 7.7 (3.3)3.4 men; 7.2 women Comparisons with other adult samples – Psychosocial Factors

14. Change in Symptoms from Pre- to Post-Deployment Minimal (1-4) Low (5-9) Medium (10-14) High (15-30) Pre-War (N=319) 163 51% 105 33% 43 14% 8 2% Post-War (N=318) 85 27% 126 39% 69 22% 38 12% primary care sample: Comparison data from 35% 20%10%

15. Demographic, Risk & Resilience Predictors of Non-Specific Symptoms ***Social support and avoidance coping become non-significant after deployment variables are added to the model. More Non- Specific Symptoms Immediately After War More Educated Female Less Social Support More Avoidance Coping

16. Deployment Predictors of Non- Specific Symptoms More Non- Specific Symptoms Immediately After War Less Unit Cohesion More Stressful Aftermath of Battle Experiences

17. Aftermath of Battle Experiences  I saw refugees who had lost their homes and belongings as a result of battle  I interacted with enemy soldiers who were taken as prisoners of war  I took care of injured or dying people  I was exposed to the sight, sound or smell of dying men and women

18. Unit Cohesion 1.The members of my unit are cooperative with each other. 2.The members of my unit know that they can depend on each other. 3.The members of my unit stand up for each other. Strongly Disagree – Neither Agree/Disagree – Strongly Agree 1 3 5

19. What Can We Do? More Non- Specific Symptoms Immediately After War YoungerFemale Less Social Support More Avoidance Coping More Stressful Aftermath of Battle Experiences Less Unit Cohesion

20. Limitations  No non-deployed control group  Sample only NG and Reserves, only Army & all volunteer  Physical symptoms immediately after deployment may be due to physical strain and there may be reluctance to report symptoms at homecoming  We do not know whether the same predictors will be important for later non-specific physical symptoms

21. Clinical Implications  Non-specific physical symptoms increase immediately after return from deployment  These may be due to physical strain, although the factors that predict who has more symptoms (after accounting for their pre-deployment symptoms) are not just physical factors  Increased physical symptoms are a common finding after a hazardous deployment

22. Clinical Implications (continued)  Suggests that we need to take into account the Veteran’s overall social network and experiences when assessing physical symptoms, not just their combat exposures  Physical or mental functioning is also frequently poorer when non-specific symptoms are increased

23. Functioning  Data from Kline et al.,2009 AJPH indicates that 15.5% of those who never deployed before and 24.4% of those who deployed before had physical function below the population mean before deployment

24. Functioning  In our sample, only 3.8% had physical function below the population norm before deploying and this was evenly split between those who had deployed previously and those who had not  However, at pre-deployment we do see lower mental function than physical function (in our preliminary data)

25. Functioning and Symptoms  Our hypothesis is that as symptoms increase and function declines, healthcare utilization will increase  We will explore these relationships once we have the full data set Need to be careful about assumptions For example, Deployment is NOT always the most common major stressor just before a deployment

27. Clinical Implications (continued)  Another assumption to be cautious about:  We have a tendency to assume that because we see the individuals who need care that all returning Veterans require care  Some Veterans recently back from a deployment may simply need support  Help them navigate the system by providing “institutional social support” – Individual VA staff can be part of the Veteran’s social support network.

28. Thanks to the Soldiers for their Participation!

29. Additional Thanks  Research Team:  Dr. Elizabeth D’Andrea  COL Charles Engel, MC, Deployment Health Clinical Center  Dr. Judith Lyons, Jackson, MS VA  Dr. Karen Raphael, NYU  Dr. Kathi Heffner, Univ. of Rochester  Robert DeMarco & Florence Chua  Research Assistants: Adam Ackerman, Heather Hamtil, Conway Yen, Benjamin Batorsky, Naci Powell, Isabella Rodrigues, Gladstone Reid, Michael Bergen & Sarah Lachiewicz

30. Funding/Support VA Health Services Research & Development Deployment Health Clinical Center, Dept of Defense VA New Jersey War Related Illness and Injury Study Center Center for Health Care Knowledge Management (New Jersey HSR&D REAP)