1. 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 Branch Center for Military Psychiatry and Neuroscience Walter Reed Army Institute of Research June 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.

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. Military Psychiatry Branch, Walter Reed Army Institute of Research Analysis Examined prevalence of six main outcomes, physical health symptoms Prevalence rates, Kruskal-Wallis  2,  2 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

10. 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%

11. 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%

12. 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%

13. Military Psychiatry Branch, Walter Reed Army Institute of Research Prevalence of Difficulty Coping with Bereavement

14. 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%

15. Military Psychiatry Branch, Walter Reed Army Institute of Research High Score on Somatic Scale (PHQ-15) by Bereavement Severity

16. Military Psychiatry Branch, Walter Reed Army Institute of Research Self-Rated Poor Health by Bereavement Severity

17. Military Psychiatry Branch, Walter Reed Army Institute of Research Irritability by Bereavement Severity

18. Military Psychiatry Branch, Walter Reed Army Institute of Research Fatigue / Sleep Problems by Bereavement Severity

19. Military Psychiatry Branch, Walter Reed Army Institute of Research Musculoskeletal Pain by Bereavement Severity

20. Military Psychiatry Branch, Walter Reed Army Institute of Research Headaches by Bereavement Severity

21. Military Psychiatry Branch, Walter Reed Army Institute of Research Medical Visits by Bereavement Severity

22. Military Psychiatry Branch, Walter Reed Army Institute of Research Difficulty with PT by Bereavement Severity

23. Military Psychiatry Branch, Walter Reed Army Institute of Research Multiple Logistic Regression: Determining Contribution of Bereavement to Health Outcomes – Gender – Age – Education – Marital status – Rank – Combat experiences – Combat injury (including mTBI) – Depression – PTSD – Alcohol misuse – ACEs

24. 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)

25. 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

26. 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

27. 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

28. 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

29. 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