Mild Traumatic Brain Injury (Concussion), Posttraumatic Stress Disorder, and Depression in U.S. Soldiers Involved in Combat Deployments
Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command, Silver Spring, Maryland 20910, USA. Psychosomatic Medicine
(Impact Factor: 3.47).
02/2012; 74(3):249-57. DOI: 10.1097/PSY.0b013e318244c604
Several studies have examined the relationship between concussion/mild traumatic brain injury (mTBI), posttraumatic stress disorder (PTSD), depression, and postdeployment symptoms. These studies indicate that the multiple factors involved in postdeployment symptoms are not accounted for in the screening processes of the Department of Defense/Veteran's Affairs months after concussion injuries. This study examined the associations of single and multiple deployment-related mTBIs on postdeployment health.
A total of 1502 U.S. Army soldiers were administered anonymous surveys 4 to 6 months after returning from deployment to Iraq or Afghanistan assessing history of deployment-related concussions, current PTSD, depression, and presence of postdeployment physical and neurocognitive symptoms.
Of these soldiers, 17% reported an mTBI during their previous deployment. Of these, 59% reported having more than one. After adjustment for PTSD, depression, and other factors, loss of consciousness was significantly associated with three postconcussive symptoms, including headaches (odds ratio [OR] = 1.5, 95% confidence interval [CI] = 1.1-2.3). However, these symptoms were more strongly associated with PTSD and depression than with a history of mTBI. Multiple mTBIs with loss of consciousness increased the risk of headache (OR = 4.0, 95% CI = 2.4-6.8) compared with a single occurrence, although depression (OR = 4.2, 95% CI = 2.6-6.8) remained as strong a predictor.
These data indicate that current screening tools for mTBI being used by the Department of Defense/Veteran's Affairs do not optimally distinguish persistent postdeployment symptoms attributed to mTBI from other causes such as PTSD and depression. Accumulating evidence strongly supports the need for multidisciplinary collaborative care models of treatment in primary care to collectively address the full spectrum of postwar physical and neurocognitive health concerns.
Available from: Danielle R. Miller
- "By contrast, loss of consciousness (LOC) may be a reliable indicator of the presence and severity of concussion as it is more likely to be noticed and reported by witnesses than other alterations in consciousness. LOC has been shown to be an important predictor of brain volume loss over time (MacKenzie et al., 2002), postconcussive symptoms (Wilk et al., 2012) and psychosocial limitations, even after adjusting for psychological symptoms (Verfaellie et al., 2013). Two recent studies also suggest that LOC may be associated with greater white matter abnormalities, but these studies did not measure spatial heterogeneity (Matthews et al., 2012; Sorg et al., 2014). "
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ABSTRACT: Blast-related traumatic brain injury (TBI) has been a common injury among returning troops due to the widespread use of improvised explosive devices in the Iraq and Afghanistan Wars. As most of the TBIs sustained are in the mild range, brain changes may not be detected by standard clinical imaging techniques such as CT. Furthermore, the functional significance of these types of injuries is currently being debated. However, accumulating evidence suggests that diffusion tensor imaging (DTI) is sensitive to subtle white matter abnormalities and may be especially useful in detecting mild TBI (mTBI). The primary aim of this study was to use DTI to characterize the nature of white matter abnormalities following blast-related mTBI, and in particular, examine the extent to which mTBI-related white matter abnormalities are region-specific or spatially heterogeneous. In addition, we examined whether mTBI with loss of consciousness (LOC) was associated with more extensive white matter abnormality than mTBI without LOC, as well as the potential moderating effect of number of blast exposures. A second aim was to examine the relationship between white matter integrity and neurocognitive function. Finally, a third aim was to examine the contribution of PTSD symptom severity to observed white matter alterations. One hundred fourteen OEF/OIF Veterans underwent DTI and neuropsychological examination and were divided into three groups including a control group, blast-related mTBI without LOC (mTBI-LOC) group, and blast-related mTBI with LOC (mTBI + LOC) group. Hierarchical regression models were used to examine the extent to which mTBI and PTSD predicted white matter abnormalities using two approaches: 1) a region-specific analysis and 2) a measure of spatial heterogeneity. Neurocognitive composite scores were calculated for executive functions, attention, memory, and psychomotor speed. Results showed that blast-related mTBI + LOC was associated with greater odds of having spatially heterogeneous white matter abnormalities. Region-specific reduction in fractional anisotropy (FA) in the left retrolenticular part of the internal capsule was observed in the mTBI + LOC group as the number of blast exposures increased. A mediation analysis revealed that mTBI + LOC indirectly influenced verbal memory performance through its effect on white matter integrity. PTSD was not associated with spatially heterogeneous white matter abnormalities. However, there was a suggestion that at higher levels of PTSD symptom severity, LOC was associated with reduced FA in the left retrolenticular part of the internal capsule. These results support postmortem reports of diffuse axonal injury following mTBI and suggest that injuries with LOC involvement may be particularly detrimental to white matter integrity. Furthermore, these results suggest that LOC-associated white matter abnormalities in turn influence neurocognitive function.
Available from: Hyunhwa Lee
- "There is often an inability to restore sleep quality upon return from deployment, resulting in the diagnosis of insomnia . Sleep disturbance in military personnel is associated with high rates ofpost-traumatic stress disorder (PTSD) and depression  , and these diagnoses are likely to perpetuate sleep disturbance symptoms . We and others have reported higher levels of inflammation, as assessed by the concentrations of interleukin 6 (IL-6), in participants with PTSD, depression, and insomnia, with the highest levels in those with the greatest severity of these comorbidites . "
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Deployed military personnel are vulnerable to chronic sleep disturbance, which is highly comorbid with post-traumatic stress disorder (PTSD) and depression, as well as declines in health-related quality of life (HRQOL). Inflammation is associated with HRQOL declines and sleep-related comorbidities; however, the impact of sleep changes on comorbid symptoms and inflammation in this population is unknown.
In this observational study, we examined the relationship between reported sleep changes and concentrations of inflammatory biomarkers, interleukin 6 (IL-6) and C-reactive protein (CRP), in peripheral blood. The sample was dichotomized into two groups: (1) decrease in Pittsburgh Sleep Quality Index (PSQI; restorative sleep) and (2) no change or increase in PSQI (no change). Mixed between-within subjects analysis of variance tests were used to determine group differences on changes of inflammation and comorbid symptoms.
In our sample of 66 recently deployed military personnel with insomnia, 34 participants reported restorative sleep whereas 32 reported no sleep changes. The two groups did not differ on demographic or clinical characteristics, with the exception of PTSD at baseline. The restorative sleep group had significant reductions in CRP concentrations and depression symptoms, as well as reduced fatigue and improvements in emotional well-being, social functioning, and physical functioning at follow-up.
Military personnel who report sleep restoration after deployment have reduced concentrations of CRP, decreased severity of depression, and improved HRQOL. These findings suggest that treatment for sleep disturbances may be associated with improvements in mental and physical health, thereby supporting continued study in this line of research.
Available from: Alexander Mcfarlane
- "There is high overlap with symptoms of PTSD, which contributed to strong debates about diagnosis (Creamer, O'Donnell, & Pattison, 2005; Ruff, Riechers, & Ruff, 2010; Vanderploeg, Belanger, & Curtiss, 2009), symptom trajectory (Bryant, O'Donnell, Creamer, McFarlane, & Silove, 2013), and optimal treatment (Davis, Walter, Chard, Parkinson, & Houston, 2013). In our review material, there was an increased focus across partners on proper detection and treatment of soldiers having obtained (m)TBI due to blasts of IEDs during their deployment and recognition for multidisciplinary collaborative care models of treatment in primary care to collectively address the full spectrum of postwar physical and neurocognitive health concerns (Wilk, Herrell, Wynn, Riviere, & Hoge, 2012). This was accomplished through a combination of research, educational programs, and policy development. "
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For years there has been a tremendous gap in our understanding of the mental health effects of deployment and the efforts by military forces at trying to minimize or mitigate these. Many military forces have recently systematized the mental support that is provided to support operational deployments. However, the rationale for doing so and the consequential allocation of resources are felt to vary considerably across North Atlantic Treaty Organisation (NATO) International Security Assistance (ISAF) partners. This review aims to compare the organization and practice of mental support by five partnering countries in the recent deployment in Afghanistan in order to identify and compare the key methods and structures for delivering mental health support, describe bottlenecks and illustrate new developments.
Information was collected through document analysis and semi-structured interviews with key military mental healthcare stakeholders. The review resulted from close collaboration between key military mental healthcare professionals within the Australian Defense Forces (ADF), Canadian Armed Forces (CAF), United Kingdom Armed Forces (UK), Netherlands Armed Forces (NLD), and the United States Army (US). Key stakeholders were interviewed about the mental health support provided during a serviceperson's military career. The main items discussed were training, prevention, early identification, intervention, and aftercare in the field of mental health.
All forces reported that much attention was paid to mental health during the individual's military career, including deployment. In doing so there was much overlap between the rationale and applied methods. The main method of providing support was through training and education. The educative focus was to strengthen the mental resilience of individual soldiers while providing a range of mental healthcare services. All forces had abandoned standard psychological debriefing after critical incidents. Instead, by default, mental healthcare professionals acted to support the leader and peer led “after action” reviews. All countries provided professional mental support close to the front line, aimed at early detection and early return to normal activities within the unit. All countries deployed a mental health support team that consisted of a range of mental health staff including psychiatrists, psychologists, social workers, mental health nurses, and chaplains. There was no overall consensus in the allocation of mental health disciplines in theatre. All countries (except the US) provided troops with a third location decompression (TLD) stop after deployment, which aimed to recognize what the deployed units had been through and to prepare them for transition home. The US conducted in-garrison ‘decompression’, or ‘reintegration training’ in the US, with a similiar focus to TLD. All had a reasonably comparable infrastructure in the field of mental healthcare. Shared bottlenecks across countries included perceived stigma and barriers to care around mental health problems as well as the need for improving the awareness and recognition of mental health problems among service members.
This analysis demonstrated that in all five partners state-of-the-art preventative mental healthcare was included in the last deployment in Afghanistan, including a positive approach towards strengthening the mental resilience, a focus on self-regulatory skills and self-empowerment, and several initiatives that were well-integrated in a military context. These initiatives were partly/completely implemented by the military/colleagues/supervisors and applicable during several phases of the deployment cycle. Important new developments in operational mental health support are recognition of the role of social leadership and enhancement of operational peer support. This requires awareness of mental problems that will contribute to reduction of the barriers to care in case of problems. Finally, comparing mental health support services across countries can contribute to optimal preparation for the challenges of military deployment.
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