Mental health problems and military discharge in U.S. combat veterans

Nursing Research, Enlisted Soldiers

Mental Health Problems in Serving Soldiers and Subsequent Discharge from the U.S. Army: Nursing Study Outline

It is recognized that serving on the frontline in military conflict may have lasting mental health consequences for U.S. armed forces personnel. As a result, the U.S. military has conducted population-level screening on all service members returning from deployment, with a particular focus on those returning from Iraq and Afghanistan (Hoge et al., 2006). Hoge et al. (2004) found that screening criteria for major depression, generalized anxiety or PTSD had an incidence of up to 17.1% in infantry who had served in Iraq, and 11.2% in those who had served in Afghanistan. This was in contrast to 9.3% of the general infantry population. In a subsequent study, Hoge et al. (2006) found that mental health problems had a prevalence of 19.1% in those returning from Iraq, and that in the general population of army and marine personnel the rate was 8.5%. Seal et al. (2007) reported that the prevalence of mental health diagnoses may be as high as 25% in serving personnel, with over half of sufferers having two or more distinct diagnoses. This is indicative that there are significant problems with mental health issues in the U.S. army as a result of the current conflicts in which it is involved. Research from the UK suggests that mental health screening prior to deployment would not significantly reduce morbidity of mental health subsequent to serving (Rona et al., 2006). This therefore indicates that the increased incidence of mental health problems in returning soldiers is a direct result of their involvement in frontline operations. This indicates that the mental health consequences of serving in these areas needs to be an issue which is seriously considered by army health services and the government.

Despite the apparently increased prevalence of mental health diagnoses in those returning from combat, current mental health support strategies may not be sufficient to provide help to all those affected. Hoge et al. (2004) found that only between 23 and 40% of those soldiers who screened positively for a mental disorder subsequent to serving in Iraq and Afghanistan sought health care. Responses suggested that this poor level of help-seeking behavior was a result of stigmatization of mental health care. It is therefore possible that there may be many returning soldiers who do not seek help and therefore suffer further adverse consequences. There is however little information available as to how mental health issues may be affecting our soldiers in the long-term. It is however crucial to gain an understanding of these long-term effects if those at risk of future adverse implications are to be successfully identified and preventatively managed.

II. Specific Aim with Research Question/Hypothesis

The aim of this study is to assess the link between adjustment disorder and discharge or separation from the army for mental health reasons. It is hypothesized that those who return from combat in Iraq and Afghanistan have higher levels of adjustment disorder than the general army population. It is also hypothesized that there will be no significant difference in the incidence of discharge for mental health reasons in those who seek help for this condition than for the general army population. It is however hypothesized that those returning from frontline combat who do not seek help for psychiatric disorders may have higher rates of discharge from the army on the grounds of mental health.

III. Theoretical/Conceptual Framework

The conceptual framework for this study is based on previous work which has been done into the psychological impacts of serving on the frontline in combat situations. It has been shown that adjustment disorder (AD) is one of the primary psychiatric symptoms which is suffered by those returning from the frontline in Iraq (Turner et al., 2005) and other areas of frontline combat (Kang & Hyams, 2005). It is usually characterized by one or more elements of mild depressive symptoms, anxiety symptoms and traumatic stress syndrome (Bisson, 2006). AD is a response which is mounted by the body in response to stress, and is often also associated specifically with avoiding reminders of the stress which occurred and failure to adapt to subsequent life (Maercker et al., 2008).

Although often a self-righting condition, up to half of all those with AD will go on to develop a more serious psychiatric condition within 5 years (Bisson, 2006). For example adjustment disorder has been linked to suicidal behavior, particularly when depressive symptoms are also present (Portzky et al., 2005). Certain types of crime have also been shown to be associated with diagnosis of AD (Elonheimo et al., 2007) which indicates that there may be adverse behavioral effects of AD which should be considered in those returning from combat. This is therefore indicative that those who suffer from AD may be at increased risk of behavior which will result in them being discharged from the army.

The theoretical basis of the study is rooted in theory relating to stress and the human stress response. According to the cognitive activation of stress (CATS) theory which is presented by Ursin and Eriksen (2004) there are four components to stress, which are the stress stimuli, the stress experience, the stress response, and the feedback from the stress response. According to this model, the stress actually occurs when there is a discrepancy between what is expected, or considered normal, and what is actually occurring. It is more likely that the stress stimulus and experience are present for those serving on the frontline than those whose operations remain in the U.S. Or other non-combat situations. This therefore indicates that those on the frontline would be at greater risk of the stress response. According to this model, expectations of a positive outcome are the elements which are mostly associated with moderation of the coping mechanism. This would therefore indicate that receiving support which increases these positive expectations would reduce the stress effect, and therefore prevent the psycho-biological impacts which may be associated with a prolonged stress response (Brosschot et al., 2005).

IV. Study Design longitudinal cohort study will be used. Comparison will be made between those who had served in frontline operations and had been admitted to the psychiatric nursing unit with DSM-IV AD and those without DSM-IV AD. Comparisons will also be made with the general population of army personnel who had served in frontline operations but had not sought psychiatric help.

V. Subjects

A. Sampling Criteria

The study sample will consist of those who meet the following criteria:

1. Have returned from frontline duties in Iraq or Afghanistan since 2001

2. Have subsequently been admitted to the psychiatric nursing unit as inpatients

This sample will further be split into two groups, based on the following criteria:

3. Diagnosis of DSM-IV adjustment disorder

Therefore a stratified sampling technique will be used to create a sample which contains equal numbers of those admitted with and without AD.

A control group sample will be taken of the general population of army personnel who have returned from frontline duties in Iraq or Afghanistan but have not been admitted to the psychiatric nursing unit as an inpatient. This will include all personnel, past and present, who served in Iraq or Afghanistan since 2001.

B. Dependent Variables

The dependent variable of interest in the study is whether the individual was discharged from the army on grounds of mental health. This information will be obtained through analysis of records where possible, or through self-reporting by study participants.

C. Mediating Variables

It is expected that the presence of AD in the population and discharge from the army on grounds of mental health may be mediated by the presence of pre-existing mental health issues or health issues other than AD.

D. Confounding Variables

It is also possible that the mediating variables may act as confounding variables. Therefore information on previous mental health history will be sought from patients. An assessment of the presence of other mental health issues at the present time will also be conducted to allow for incorporation of this data into analysis.

VII. Statistical Issues

A. Sample Size

To detect an effect with a power of 0.95 at a 0.05 level of significance, given the size of the study population, a sample size of 385 participants would be required. Given the sampling techniques which were discussed earlier the study will therefore aim to sample at least 250 past or present inpatients of the psychiatric unit and 250 control participants. This will account for rejection of participation by 25% of those approached to participate.

B. Approach to Analysis

Chi-squared tests will be used to determine whether there are different rates of discharge for mental health between the different groups identified. Chi-squared testing and other non-parametric tests will also be used to test whether other demographic and health factors have any impact on discharge differences between the sample and control groups.