Bereavement and Physical Health Outcomes in U.S. Soldiers Returning from Combat

1. 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. 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. 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. 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. 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. 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. 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. 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. Analysis • Examined prevalence of six main outcomes, physical health symptoms • Prevalence rates, Kruskal-Wallis c2, c2tests 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. Results- Demographics • Male: 92% • Age < 30: 73% • Married: 56% • High school or less: 50% • Junior enlisted (E1-E4): 56%

11. 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. 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. Prevalence of Difficulty Coping with Bereavement

14. 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. High Score on Somatic Scale (PHQ-15) by Bereavement Severity

16. Self-Rated Poor Health by Bereavement Severity

17. Irritability by Bereavement Severity

18. Fatigue / Sleep Problems by Bereavement Severity

19. Musculoskeletal Pain by Bereavement Severity

20. Headaches by Bereavement Severity

21. Medical Visits by Bereavement Severity

22. Difficulty with PT by Bereavement Severity

23. 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

24. 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. 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. 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. 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. 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. 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