ORIGINAL ARTICLES Authors alone are responsible for opinions expressed in the contribution and for its clearance through their federal health agency, if required.

MILITARY MEDICINE, 179, 1:19, 2014

Mental Health in Deployed and Nondeployed Veteran Men and Women in Comparison With Their Civilian Counterparts [[/lark W. Hoglund, EdD*; Rebecca M. Schwartz, PhDf ABSTRACT Objective; We investigated the tnental health of deployed and nondeployed veterans cornpared with civilians, exploring gender differences. Methods; We sampled 41,903 respondents from the Behavioral Risk Factor Surveillance System survey. Respondents self-reported how many of the previous 30 days mental health was not good; 14 days or more indicated adverse mental health. Results: Women exhibited greater prevalence of adverse mental health than men among civilians (odds ratio [OR] = 1.783 (1.653, 1.924),/>< 0.001), deployed veterans [OR = 1.879 (1.019, 3.467), p = 0.043], and nondeployed veterans [OR = 2.621 (1.796, 3.825), p < 0.001]. Compared with civilian status, deployed status was associated with adverse mental health formen [OR =1.361 (1.055, 1.755),p = 0.018J and possibly women [OR = 1.521 (0.930, 2.487), p = 0.095]. Compared with civilian status, nondeployed status was associated with adverse mental health for women [OR = 1.525 (1.152, 2.018), p = 0.003], but not for rnen [OR = 1.169 (0.943, 1.448). p = 0.155]. We controlled for age, general health, employment status, marital status, education, race/ethnicity, and state of residence. Conclusions; Adverse mental health affects male and female combat veterans, as well as women in noncombat military occupations.

INTRODUCTION Many recent accounts of the mental health effects of military service in men and women are grounded in the experience of war. Concentration of attention in this area is understandable. The United States has been at war in Afghanistan since October 2001 and also waged war in Iraq from March 2003 to Decetnber 2011. A substantial proportion of individuals who served in the.se wars suffered mental health consequences.' Furthermore, the adverse mental health effects of war are prolonged.""** Studies of military personnel deployed in theaters of war (deployed veterans) have investigated gender differences in the association between combat exposure and/or war zone deployment and the risk of depression or post-traumatic stress disorder (PTSD).''* '" The preponderance of evidence in these studies suggests that deployed women have greater risk of *Department of Family Medicine, SUNY Downstate Medical Center, Box 67, 450 Clarkson Avenue, Brooklyn, NY 11203. tDepartment of Population Health, North Shore-LIJ Health System, Hofstra North Shore-LIJ School of Medicine, 175 Community Drive, 2nd Floor, Great Neck. NY 11021. doi: 10.7205/MILMED-D-13-00235

MILITARY MEDICINE, Vol. 179, January 2014

depression than deployed men. • Men may have greater risk of PTSD than women,'^"** though sotue studies obtained different results."*'^'° However, gender differences in mental health outcomes of deployment may be small in magnitude.'"" Some studies of deployed veterans have po.stulated associations between combat exposure and mental health conditions by demonstrating associations between PTSD and factors such as serving in the Army rather than other military branches, being enlisted rather than being an officer, and being deployed more than once, all of which arguably increase combat exposure.'** Seeing dead bodies, witnessing killing, and involvement in killing have also been associated with mental health disorders such as depression and PTSD.** These results are supported and augmented by studies whose samples included deployed veterans as well as military personnel who had not served in a war theater (nondeployed veterans) and which illuminated associations between war zone deployment/combat exposure and mental health outcomes for men and women in separate analyses.' '^"^ Service in a war zone and/or exposure to combat predicted greater odds of PTSD and depression among both men""'"* and women,'''""' though not all analyses involving women found significant associations.' '''"*

19

Mental Health in Deployed and Nondeployed Veteran Men and Women

Still, a framework that includes individuals who have never served in the active duty military (civilians) is needed for a more comprehensive understanding of associations between military service and mental health conditions in men and women. We found two studies that included the civilian population in the consideration of gender-specific mental health effects of military service.'^'** Both studies utilized data from the Behavioral Risk Factor Surveillance System (BRFSS) survey, and both studies focused exclusively on women.'^•'** Shen and Sambamoorthi'^ found that women veterans showed 75% greater likelihood to report a high number of poor mental health days than nonveteran women. Lehavot et al"^ reported that, compared to civilian women, mental health was better for current active duty military women, but worse for women who have left military service. However, neither study distinguished between deployed veteran status and nondeployed veteran status as risk factors for mental health conditions, and neither study addressed the mental health effects of military service on men. Our study begins to fill these gaps by investigating the mental health status of both deployed veterans and nondeployed veterans in comparison with the mental health status of civilians, and by extending the investigation to men as well as to women. We hypothesized that deployed, nondeployed, and civilian women would report higher levels of poor mental health days than their male counterparts. We also hypothesized that, for men and women in separate analyses, both deployed veterans and nondeployed veterans would manifest greater prevalence of adverse mental health symptoms in comparison with civilians. METHODS This study was approved by the Institutional Review Board of SUNY Downstate Medical Center.

Participants The sample for this study was drawn from the 2010, 2011, and 2012 databases of the BRFSS survey. Each year, the BRFSS survey, which is administered jointly by the Centers for Disease Control and Prevention (CDC) and the various states and territories of the United States, solicits information via telephone interview from a sample of U.S. adults (ages 18 and older) regarding practices and behaviors that may be either beneficial or harmful with respect to the risk of injury and disease. The survey includes core questions used in all states and territories, as well as optional modules, which states may incorporate if they choose; states may also add questions of their own. Historically, respondents were contacted exclusively via landline telephones, and this remained true in 2010. In 2011 and 2012, some respondents were recruited via cell phones as well. Fuller descriptions of the BRFSS survey may be found in the 2010 BRFSS Overview,''•* the 2011 BRFSS Overview,-" and the 2012 BRFSS Overview,-' which can be found on the BRFSS website.

20

TABLE I.

Total Number of Respondents From States That

Utilized the Optional Veteran's Health Module in the BRFSS Survey in One or More Years During 2010-2012

State

Survey Year(s)

Total Number of Respondents 2010-2012

Alaska Kansas Louisiana Maine Montana Nebraska Nevada New Jersey North Carolina Tennessee Totals

2011 2011", 2012° 2011 2011" 2012 2010, 2011", 2012" 2011 2011", 2012" 2011 2010,2011,2012 —

1,776 5,024 4.068 1,594 2,583 10,353 1,772 4,149 4,290 6,294 41,903

"Only a subset of the total state sample was surveyed on Veteran's Health.

This Study uses 2010-2012 data from states that utilized the optional module, "Veteran's Health." In 2010, only Nebraska and Tennessee included this module in their survey. In 2011, nine states utilized this optional module: Alaska, Kansas, Louisiana, Maine, Nebraska, Nevada, New Jersey, North Carolina, and Tennessee. In 2012, however, only five states used the Veteran's Health module: Kansas, Montana. Nebraska, New Jersey, and Tennessee. It should be noted that, in 2011 and 2012, some states elected to administer the Veteran's Health module to a subset of respondents rather than to all respondents. In addition, all data utilized in this study came from BRFSS landline databases. See Table I for a list of all the states that utilized the Veteran's Health module during 2010-2012, including the years of participation and the total number of respondents for each state. We deliberately excluded all respondents who would have been age 18 or older in 1973, which was the year that the Vietnam War officially ended. In view of the considerable time that has elapsed since the Vietnam War, we suspected that the results of any current study of Vietnam veterans could be confounded by "survivor bias." Therefore, we limited our investigation to individuals who came of age after the Vietnam War ended. Responses from 44,110 individuals were retained for analysis. A total of 2,207 individuals (5.0%) were eliminated as a result of missing data. Our final study sample, therefore, comprised 41,903 respondents, of whom 2,528 individuals (6.0%) reported active duty military experience.

Outcome Variabie All participants were asked how many days (during the 30 days before answering the BRFSS survey) their mental health was not good. A dichotomous variable was created to distinguish individuals who reported 14 or more poor mental health days from individuals who reported 13 or fewer poor mental health days. This cut point was identified by the CDC in 1998 based on thresholds for diagnosing clinical

MILITARY MEDICINE, Vol. 179, January 2014

Mental Health in Deployed and Nondeployed Veteran Men and Women

depression or anxiety disorders employed by practitioners and researchers.^^

Exposures of Interest Relating to military experience, there were two principal exposures of interest: (1) history of active duty military service that included service in a combat or war zone (deployed veteran status), and (2) history of active duty military service that did not include service in a combat or war zone (nondeployed veteran status). For each year, 2010-2012, the BRFSS Questionnaire included this question: "Have you ever served on active duty in the U.S. Armed Forces, either in the regular military or in a National Guard or military reserve i23-25 unit?" However, the response choices changed after 2010. The 2010 questionnaire asked respondents with active duty military experience to identify themselves as currently active, previously active within the past 12 months, or previously active but not within the past 12 months.^"' The 2011 and 2012 questionnaires asked only for a "yes" or "no" response.''*"""' To make the 2010 data consistent with the 2011-2012 data, we transformed the 2010 responses to this question in the following manner: 2010 responses indicating current or previous active duty service were scored as "yes"; responses indicating neither present nor past active duty military service were scored as "no." This transformation enabled us to utilize a uniform dichotomous variable to distinguish veteran status from civilian status for all 3 years of survey data. (It should be noted that the BRFSS definition of active duty military service excluded training in the Reserves or National Guard unless called up for active duty.^''""'') In all 3 years from 2010 to 2012, the Veteran's Health optional module also included an item which asked whether the respondent had ever "served in a combat or war zone" (yes or no).^"*"^^ This dichotomous variable was utilized to distinguish deployed veteran status from nondeployed veteran status in our analysis. The other primary exposure of interest was gender. We were especially interested to leam whether effects of military service may be manifested differently in women than in men.

Covariates In addition to gender, the literature in this area identified age, race/ethnicity, and education level as potentially significant demographic factors in investigating associations among war zone/combat service, gender, and mental health status. Age was treated as a continuous variable. Dichotomous variables were created for race/ethnicity (nonwhite and/or Hispanic versus white non-Hispanic) and education (high school or less education versus some college or more education). Dichotomous variables were also derived to test for effects of marital status (married/partnered versus single/separated/ divorced/widowed), employment status (out of work/ unable to work versus employed/homemaker/student/retired), and

MILITARY MEDICINE, Vol. 179, January 2014

general health (fair/poor versus good/very good/excellent). In addition, dummy variables were created and utilized to control for differences in mental health status based on state of residence.

Data Analyses We employed x analyses to compute unadjusted relative odds of adverse mental health for each categorical variable; the unadjusted odds ratio (OR) for an association between mental health status and age (a continuous variable) was computed using logistic regression. Multiple logistic regression was utilized to compute adjusted ORs. These statistical tests were applied first to estimate the effects of gender on the mental health status of individuals in each of the three categories of interest: deployed veterans, nondeployed veterans, and civilians. We then stratified our data by gender and performed these statistical tests to estimate the effects of deployed military service and nondeployed military service on men and women in separate analyses. Statistical analyses were conducted using IBM SPSS Statistics, version 21 (IBM Corporation, Chicago, Illinois). RESULTS

Participant Characteristics Our study sample cotnprised 41,903 individuals, including 26,206 women and 15,697 men. Participant characteristics are presented in Table II. Across all categories, a greater proportion of women than men were college educated (especially among deployed and nondeployed veterans) and reported poor mental health. A higher percentage of women than men were also nonwhite; this gender disparity was especially pronounced among deployed veterans. Among deployed and nondeployed veterans, a greater percentage of women than men were unattached, though this was not the case for civilians.

Gender Differences in Mental Health Status Adjusted analyses (Table III) indicated that women had greater odds of adverse mental health than men among civilians [0R= 1.783 (1.653, 1.924), p < 0.001], among deployed veterans [OR = 1.879 (1.019, 3.467), p = 0.043], and especially among nondeployed veterans [OR = 2.621 (1.796, 3.825),/7< 0.001].

Gender-Stratified Analyses of Active Duty Military Experience and Mental Health Status Cornparing deployed veterans with civilians (Table IV), adjusted analyses revealed greater odds of adverse mental health for men [OR = 1.361 (1.055, 1.755), p = 0.018] and possibly for women [OR = 1.521 (0.930, 2.487), p = 0.095], although the results for women lacked significance at p < 0.05. In contrast, comparing nondeployed veterans with

21

Mental Health in Deployed and Nondeployed Veteran Men and Women

* * #

*

— — in r-1 ^ rj o rf o ^

o

Q

rj O N 0 rJ —\ fN

in 00 _: ^' in

-c r-' — ON

(19 3%) (80 7%)

(23 (76 (42 2%) (57 8%) (18 (81 (18 5%) (81



o



s

*

'S

O

O ';t

o o. (D

in

*

oo

o

ON O N in -^

O

OO

o

ON

ra

ON OC

oc oc Os

—•

in

n-i

0

ON

oc

ON

oc

\D

m —

—'

133,2.07 U5, 10.2 710, 10.9 ,534 ,459 ,901

fN

ri



— —



p
.

•u

"o

ra -G

*

m

¿

o .^— .. ^

0

ri

¿ ° (2 Ö

OJ o s

*



fN

0

2



— * *

(-,

S * * *

d' od O N d"

r Less

i *— 'S

G

f



V

Q '^ .2

*

in in

0

ses a!

^

CL

y jjusted

ra

/ilii Ö V

T3 C CO

oc' ON

d

*

ON ["~~

q

E o

—' 0 ^' ON ml 0 ON

Ä

c

•s *

,836:

0 •J:

* * *

u

,762.(1.656, ,439 (5.086, .959 (6.504,

:rat ified Edu

r-

*

0

•S*

in

-){•

* -xoc

•0

,129.(2.001,

—' r t oo' in' oo' r j —' —' —' —'

o p

ri in 0 r-



U

ON

fN

—;

,924;

u



* * -v-

d

_:

;(Ci

r~^r*^fNooocr^iOO in d ON — oo ir-, — oc — oc 00 NC — o ^ r J o o o o o c r ^ — l/", i/"- r i o r~- r^. m, r-- o "^

* *

fN



(1. (0.

tio

E

V —

,232: .048; ,708;

c

"D.

00

oc m in

d

d d

T3 0

z

¿¿ è d * * *

(1.

c a. u 0 T3

_o ivil

q —

704,3.11

:3 C

1 c"

;5

V

ON

,537:

oo

d

\o'" 00' in >n

(1.

in

in

s

* * *

0

0 —

169. 2.76 J89, 1.02

S mm

oo

NO '?.

'S. •o 'S

Mental health in deployed and nondeployed veteran men and women in comparison with their civilian counterparts.

We investigated the mental health of deployed and nondeployed veterans compared with civilians, exploring gender differences...
8MB Sizes 0 Downloads 0 Views