Psychiatric Symptoms and Quality of Life in Military Personnel Deployed Abroad

Abstract

Background: Military personnel deployed abroad could be exposed to more risk factors that adversely affect quality of life. In this study, we examined psychiatric symptoms and quality of life in Turkish Armed Forces deployed to Afghanistan. Method: A total of 289 Turkish military personnel working in Afghanistan enrolled in this study. They completed two surveys containing questions about socio-demographic characteristics. Data were collected and analyzed from 258 of the participants. Results: The general symptom scores (GSI) were above 1 in 20.8% (n=54) of the participants. The lowest SF -36 scores by the sub -groups were mental health (59.14 18.56) and vitality (59.25 21.17). The highest score was in the physical function subscale (84.42 19.53). All Quality of Life Questionnaire Short Form (SF-36)subscale scores were lower in the GSI above 1 group than the GSI below I group. In the GSI above I group: education level and depression affected SF -36 physical functioning; paranoid ideation and somatization affected SF -36 role limitations due to physical health; age and somatization affected SF -36 pain; age affected SF -36 general health; phobic anxiety affected SF -36 vitality; age, tenure of occupation, tenure abroad; and phobic anxiety affected SF-36 mental health. Conclusions: The negative effects of psychiatric symptoms on the quality of life were similar to those in the general population and in specific disease groups. These results should be considered when evaluating the mental health of military personnel deployed abroad.

Full text

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Isr J Psychiatry Relat Sci - Vol. 52 - No 3 (2015)
Address for Correspondence: Süleyman Akarsu, MD, Aksaz Military Hospital, Dept. of Psychiatry, Marmaris, Muğla, Turkey.
drakarsus@hotmail.com
INTRODUCTION
Performing tasks abroad is challenging for military
personnel because of certain conditions, like limited
resources, increased risk of illness, life-threatening situ-
ations, separation from the family, dierent climate, dif-
ferent cultural. ese extreme conditions strain military
personnel involved in multinational forces equipped for
I have obtained permission from all persons named in the acknowledgement. No financial support from any company or institution has been received and the
authors do not have any commercial relationship. This manuscript has not been published elsewhere or submied for publication elsewhere.
Psychiatric Symptoms and Quality of Life in
Military Personnel Deployed Abroad
Taner Öznur, MD,1 Süleyman Akarsu, MD,2 Murat Erdem, MD,3 Murat Durusu, MD,4 Mehmet Toygar, MD,5
Yavuz Poyrazoglu, MD,6 Ümit Kaldirim, MD,4 Mehmet Eryilmaz, MD,4 and Kamil Nahit Ozmenler, MD1
1 Gülhane Military Medical Academy, Dept. of Psychiatry, Dept. of Military Psychology and Combat Psychiatry, Ankara, Turkey
2 Aksaz Military Hospital, Dept. of Psychiatry, Marmaris, Muğla, Turkey
3 Gülhane Military Medical Academy, Dept. of Psychiatry, Ankara, Turkey
4 Gülhane Military Medical Academy, Dept. of Emergency, Ankara, Turkey
5 Gülhane Military Medical Academy, Dept. of Forensic Medicine, Ankara, Turkey
6 Mevki Military Hospital, Dept. of General Surgery, Elazığ, Turkey
dierent purposes. Besides separation from familiar fam-
ily, social and occupational environments, personnel are
faced with the process of physically and psychologically
adapting to performing a task in a new environment.
e absence of a private and sexual life, the diculty
of ensuring hygienic conditions, and a variety of chal-
lenging weather conditions and geographic features are
signicant diculties that interfere with this process.
ABSTRACT
Background: Military personnel deployed abroad could be
exposed to more risk factors that adversely affect quality
of life. In this study, we examined psychiatric symptoms
and quality of life in Turkish Armed Forces deployed to
Afghanistan.
Method: A total of 289 Turkish military personnel working
in Afghanistan enrolled in this study. They completed two
surveys containing questions about socio-demographic
characteristics. Data were collected and analyzed from 258
of the participants.
Results: The general symptom scores (GSI) were above
1 in 20.8% (n=54) of the participants. The lowest SF-36
scores by the sub-groups were mental health (59.14 ± 18.56)
and vitality (59.25 ± 21.17). The highest score was in the
physical function subscale (84.42 ± 19.53). All Quality of Life
Questionnaire Short Form (SF-36)subscale scores were
lower in the GSI above 1 group than the GSI below 1 group.
In the GSI above 1 group: education level and depression
affected SF-36 physical functioning; paranoid ideation
and somatization affected SF-36 role limitations due to
physical health; age and somatization affected SF-36 pain;
age affected SF-36 general health; phobic anxiety affected
SF-36 vitality; age, tenure of occupation, tenure abroad; and
phobic anxiety affected SF-36 mental health.
Conclusions: The negative effects of psychiatric symptoms
on the quality of life were similar to those in the general
population and in specific disease groups. These results
should be considered when evaluating the mental health
of military personnel deployed abroad.

61
TANER ÖZNUR ET AL.
Additionally, occupational challenges are another source
of stress (1). e emergence of psychiatric symptoms
associated with this process adversely aects the quality
of life of the individual.
e World Health Organization denes quality of life as
“perception of the conditions of people within the entirety
of their culture and values in connection with objectives,
expectations, standards and concerns.” Quality of life can
also be dened as “a concept that reects the individual
reactions to the diseases, physical, psychological, social
eects of daily life and aecting the level of personal
satisfaction that can be achieved in the context of life”
(2). Many factors have an eect on health-related quality
of life. Biological and physiological variables, functional
status, and general health perception have been included
in this concept by Wilson and Cleary (3). Yıldırım has
discussed individuals’ physical, functional and emotional
satisfaction levels in the context of social health-related
quality of life (4). Studies have revealed an intermediate
or advanced relationship between the health-related qual-
ity of life and feeling disabled, which is dependent on a
person’s age, income, type of chronic disease, and use of
health care services (5). Mental health is an important
part of health-related quality of life. Individuals who
have a psychiatric disorder have a lower quality of life
score compared to those who do not (6). Similar quality
of life scores have been reported in patients with major
depression and in patients with physical illness (7).
According to the other international task groups
(e.g., civil society aid organizations), military personnel
deployed abroad could be exposed to more risk factors
related to the properties of “being a soldier,” such as
wearing uniforms and carrying weapons. Studies evaluat-
ing the psychiatric symptoms and quality of life of the
military personnel deployed abroad are oen performed
aer the end of the task and in the post-traumatic stress
disorder (PTSD) samples. In the studies researching
soldiers involved in the Vietnam, Afghanistan and Iraq
wars, the association between PTSD and impaired quality
of life was determined (8, 9).
In this study, our aim was to identify psychiatric symp-
toms and how these symptoms aect the quality of life
in the military personnel deployed to a foreign country
to maintain international peace.
METHODS
Military personnel who served at least three months with
the International Security Assistance Force (ISAF), and
who voluntarily agreed to participate, were enrolled in
the study. ISAF has been serving in Afghanistan and its
sta changes every six months. ISAF consists of ranking
personnel and soldiers. eir duties focus on humanitar-
ian purposes. ere are no casualties.
e Brief Symptom Inventory (BSI), Quality of Life
Questionnaire Short Form (SF-36) and a data form
containing questions about socio-demographic char-
acteristics such as age, marital status, rank, tenure of
occupation, and tenure abroad were administered to the
participants. Of the 289 participants, 258 lled out the
forms properly and the data from these 258 were evalu-
ated. Ethical approval was obtained from the university
hospital research ethics committee from the hospital
where the study was conducted. Written consent was
obtained from all participants aer being informed about
the research.
MATERIALS
THE BRIEF SYMPTOM INVENTORY
e BSI is a 53 item Likert-type scale derived from the
acronym Symptom Check List-90 and is used for scan
-
ning for a wide variety of psychological symptoms (10).
A Turkish adaptation and a reliability and validity study
were made by Sahin et al. (11). Items are rated using
values between 0–4. is scale consists of nine sub-
scales, three global indices, and additional ingredients.
e subscales are somatization, obsessive-compulsive,
interpersonal sensitivity, depression, anxiety, hostility,
phobic anxiety, paranoid ideation, and psychoticism.
e global indices are called the general symptom index,
the sum of signs index, and the symptom severity index.
In this study, general symptom index (GSI) scores were
used for the overall assessment of psychopathology.
QUALITY OF LIFE QUESTIONNAIRE-SHORT FORM
e SF-36 is a self-administered, generic measure of
health status, containing 36 items. A Turkish reliability
and validity study was made Kocyigit et al. (12). Scores
are transformed to a scale of 0–100, where higher scores
represent higher function. Using content analysis, the
items are assigned to eight subscales: physical func-
tioning, role limitations due to physical health, pain,
general health, vitality, social functioning, role limita-
tions due to emotional problems, and mental health. e
most obvious advantage of the scale is that it measures
physical function and related skills. A limitation of this

62
PSYCHIATRIC SYMPTOMS AND QUALITY OF LIFE IN MILITARY PERSONNEL DEPLOYED ABROAD
questionnaire is that it did not to include questions to
assess sexual function.
STATISTICAL ANALYSIS
e data are presented in the form of numbers and per-
centages for categorical variables and in the form of
mean plus or minus standard deviation for continuous
variables. Because the parametric conditions were not
met, the Mann-Whitney U test was used when compar-
ing the participants whose GSI was above 1 with those
whose GSI was under 1.
A backward linear regression analysis was done to
determine the eect of the BSI subscales, and the age,
education level, tenure of occupation, and tenure abroad
of each participant, on the SF-36 subscale scores. We
evaluated all eight subscales of the SF-36 as dependent
variables. We evaluated the nine subscales of the BSI, as
well as age, education level, tenure of occupation and ten-
ure abroad, as independent variables. e rened models
results are presented. A p-value of 0.05 was considered
statistically signicant.
RESULTS
e GSI scores were above in 20.8% (n=54) of the par-
ticipants. A comparison of age, education level, marital
status, rank, tenure of occupation, and tenure abroad in
the participants whose GSI was above 1 to those with a
GSI under 1 is shown in Table 1. ere are no dierences
between these two groups with regard to these features.
A comparison of the SF-36 subscale scores in the
participants whose GSI was above 1 to those with a GSI
below 1 is shown in Table 2. All of the SF-36 subscale
scores were lower in the GSI above 1 group than of those
in the GSI below 1 group. Factors aecting the SF-36
subscale scores of the GSI above 1 group are shown
in Table 3. In the group having psychopathology (GSI
above 1), BSI depression subscale score was found to
have a positive eect on the SF-36 physical functioning
subscale score, but education level was found to have a
negative eect. e BSI paranoid ideation subscale score
had a positive eect on the SF-36 role limitations due
to physical health subscale score, but the somatization
subscale score had a negative eect. e BSI somatization
subscale score had a negative eect on the SF-36 pain
subscale score, and the BSI phobic anxiety subscale score
had a negative eect on the SF-36 vitality and mental
health subscale scores.
On the other hand, the age of participants was found
to have a negative eect on the SF-36 pain, general health,
and mental health subscale scores in the GSI above 1
group. Also, tenure of occupation had a positive eect
on the SF-36 mental health subscale score, but tenure
abroad had a negative eect.
e BSI anxiety, obsessive compulsive, hostility, inter-
personal sensitivity, and psychoticism subscale scores
had no eect on quality of life in the GSI above 1 group.
Table 1: Comparison of two groups according to age,
tenure of occupation, tenure abroad, education level,
marital status and rank
Variable GSI<1 (n=205) GSI >1 (n=54) Z/X2, p
Age 25.42 ± 6.12 24.63±5.24 0.87, 0.38
Tenure of occupation
(years) 1.77 ± 1.14 1.75±0.89 0.12, 0.90
Tenure abroad
(months) 3.38 ± 1.00 3.48±0.99
0.56, 0.58
Education level
(years) 11.22 ± 0.68 11.15±0.76 0.62, 0.53
Marital status (n, %)
Married
Single 47(22.9)
158(77.1) 11(20.4)
43(79.6) 0.16, 0.69
Rank
Officer-Pey officer
Expert lance corporal
Private-Ranker
20(9.8)
34(16.6)
151(73.7)
2(3.7)
8(14.8)
44(81.5)
2.27, 0.32
GSI: General Symptom Index. Z: Mann-Whitney U test value.
X2:Chi-square test value.
Table 2: Comparison of SF-36 subscale scores in the participants
whose BSI general symptom index above 1 or under 1
SF-36 Subscale
GSI<1 (n=205)
(Mean ± sd)
GSI >1 (n=54)
(Mean ± sd) Z p
Physical
functioning 87.29 ± 17.89 73.52 ± 21.69 5.23 < 0.001
Role limitations
due to
physical health 70.73 ± 33.07 50.00 ± 34.00 4.06 < 0.001
Pain 69.38 ± 24.90 46.85 ± 21.78 5.68 < 0.001
General health
perception 69.46 ± 17.87 45.19 ± 22.73 6.79 < 0.001
Vitality 63.98 ± 19.02 41.30 ± 19.33 6.62 < 0.001
Social
functioning 72.56 ± 24.98 45.85 ± 26.41 6.17 < 0.001
Role limitations
due to emotional
problems
71.49 ± 30.18 49.39 ± 31.67 4.65 < 0.001
Mental health 64.41 ± 15.76 39.11 ± 14.30 8.58 < 0.001
GSI: General Symptom Index. Z: Mann Whitney U test value.
SF-36 subscale scores of the group with GSI score below 1 found to be
higher than the group with GSI score above 1 (p< 0.001).

63
TANER ÖZNUR ET AL.
DISCUSSION
Psychological morbidity was determined in 20.8% of
the study sample. is ratio is similar to the general
population (9–26%) (13–23). In a prior study, the total
percentage of depression, generalized anxiety, PTSD and
alcohol abuse was found to be 24.5% in U.S. soldiers who
served in Afghanistan (24). is result indicates that
personnel had substantially adapted to the task even
though they were in service abroad. Despite the many
diculties brought about by performing a task abroad,
this study’s detection of a similar rate of psychological
morbidity to that in the general population indicates that
personnel had substantially adapted to the task and that
coping attitudes, with moral and motivational factors,
were sucient to manage the challenges.
In this study, the lowest SF-36 scores by the sub-
groups were mental health (59.14 ± 18.56) and vitality
(59.25 ± 21.17). e highest score was in the physi-
cal function subscale (84.42 ± 19.53). Similar to our
ndings, the quality of life for U.S. soldiers who par-
ticipated in the Iraq and Afghanistan wars was found
to be impaired for those with psychiatric diagnosis,
especially for PTSD (1). e results of other studies,
not involving soldiers, were similar (25–27).
ese results show that personnel serving abroad, with
high levels of psychiatric symptoms, had an adversely
aected quality of life. e multiple linear regression
analysis showed that one or more psychiatric symptom
clusters aected some aspects of quality of life. It was
noteworthy that most of symptom groups (except for
paranoid ideation and depression) had a negative eect
on the quality of life.
Educational level had a negative eect, but BSI depres-
sion subscale score had a positive eect on the SF-36
physical functioning subscale score. is result suggests
that low educational level adversely aected the physical
functionality in tasks abroad. Also, in GSI above 1 group,
the presence of subthreshold depressive symptoms had
a positive eect on physical functionality. Contrary to
this nding, depressive disorders (major depression,
minor depression, etc.) were found to be associated with
deterioration in physical functioning in the Cuijpers et
al. study (28). Age, nancial status and moral motivation
for tasks were evaluated to prevent the reduction in the
level of physical functioning in our study.
e BSI somatization subscale score had a negative
eect on the SF-36 role limitations due to physical health
subscale score, but the BSI paranoid ideation subscale
score had a positive eect. is relationship suggests that
high levels of somatization may cause role limitations and
physical problems. In a similar study, somatization was
found to cause role limitations and great deterioration
in business life and social activities (29).
e positive eect of paranoid ideation on role limita-
tions due to physical health was considered to be associ-
ated with the shortness of the task period of the sampling
group and the presence of occupational and nancial
motivational factors. Similar to this result, individuals
who have paranoid ideation characteristic of paranoid
personality disorder have been found to not lose function
in the elds of physical health and role limitations (30).
Age and the BSI somatization subscale score had a
negative eect on the SF-36 pain subscale score in the
group with possible psychopathology. Physical pain
increased with an increase in age, and this was con-
sidered a negative impact on quality of life. Contrary
to this nding, Sun et al. determined that the physical
dimension of quality of life, including physical pain,
negatively correlated with age (31).
A negative correlation has been found between age
and physical pain in a population-based study (32). is
dierence seems to be associated with the low-mean
Table 3: Factors affecting the SF-36 subscale scores of the
GSI above 1 group
Beta t p
%95
Confidence
Interval
Physical functioning
Education level -0.48 -2.88 0.009 -11.50- (-1.85)
Depression 0.38 2.27 0.034 0.64–14.53
Role limitations due to physical health
Somatization -0.42 -2.47 0.022 -43.97- (-3.80)
Paranoid ideation 0.68 3.97 0.001 16.49–52.76
Pain
Age -0.42 -2.31 0.031 -2.91-(-0.15)
Somatization -0.39 -2.17 0.041 -24.97-(-0.55)
General Health Perception
Age -0.52 -2.82 0.01 -3.58- (-0.55)
Vitality
Phobic Anxiety -0.47 -2.49 0.021 -26.89-(-2.45)
Mental Health
Age -1.32 -2.92 0.009 -4.97-(-0.82)
Tenure of Occupation 1.25 2.78 0.012 3.82–27.17
Tenure Abroad -0.69 -3.06 0.006 -13.37-(2.51)
Phobic Anxiety -0.50 -2.24 0.037 -22.63-(-0.76)

64
PSYCHIATRIC SYMPTOMS AND QUALITY OF LIFE IN MILITARY PERSONNEL DEPLOYED ABROAD
age of the sample. e mean age of participants with a
GSI above 1 was 24.63±5.24 in our study and the mean
ages in the other studies were 73.2 ± 5.8 and 47 ± 13,
respectively (31, 32). e nding that the negative eect
of the somatization on physical pain in the GSI above 1
group in our study is compatible with the results of the
study (33) indicating the negative eect of the somatiza-
tion on physical dimension of quality of life, including
physical pain.
Age had a negative eect on the SF-36 general health
subscale score in the GSI above 1 group in our study. is
nding is consistent with the ndings of Sun et al. that
general health perception in male participants decreases
with the age (31).
Phobic anxiety had a negative eect on the SF-36
vitality subscale score in the GSI above 1 group. is
nding suggests that the phobic thoughts level of par-
ticipants reduce energy (vitality) levels. In other stud-
ies, vitality has been found to be negatively aected
by the panic-agoraphobia levels in the patients with
social phobia (34), dental fears (35), and rheumatoid
arthritis (36).
e nding of a negative eect of age on mental health
does not coincide with the nding of McAndrew et al.
that young age is associated with poorer mental health
function (37). On the other hand, Sun et al. found that
age has a negative eect on a mental component summary
score that contains the mental health subscale score (31).
e negative eect of tenure abroad on the mental
health is considered to be associated with the lack of
family and social support systems and the burden created
by the challenging task conditions. In a related study, the
deployment length was found to inuence psychological
health levels of male soldiers in a peacekeeping deploy-
ment (38).
e negative eect of phobic anxiety on mental health
was detected in the participants. Mental health has been
shown to be negatively aected in patients with social
phobia (34). In relation to phobic anxiety, psychological
well-being has been found to be negatively aected in
patients with dental fear (35). Also, panic-agoraphobic
symptoms have been found to adversely aect the mental
health of patients with rheumatoid arthritis (36).
e positive eect of tenure of occupation on mental
health suggests the positive inuence of the experience
of dealing with occupational challenges. Occupational
experience had been shown to increase familiarity and
competence in dealing with occupational challenges in
studies carried out in dierent occupational groups (39, 40).
CONCLUSION
In this study, the negative eects of the psychiatric
symptoms on quality of life in many areas was deter-
mined to be similar to the general population and to
specic disease groups, although not to evaluation axis
I psychiatric diagnoses such as PTSD was a limitation.
Another limitation of this study is absence of a control
group. is is a cross-sectional study. A follow up study
is needed that includes a control group. Also, there is a
need for further research examining the interpretation
of psychological problems and coping styles in relation
to the cultural structure of participants.
e literature shows that studies of international mili-
tary tasks were conducted aer soldiers return to their
country (37, 41, 42). We believe that the assessment
of psychiatric symptoms associated with deployment
and quality of life while the task is not yet nished is a
better methodology, one that would give more accurate
results. is study demonstrates the eects of psychiatric
symptoms arising in the soldiers during deployment on
quality of life. Rigorous planning and implementation
of training before the task in order to prevent the occur-
rence of psychiatric symptoms is considered necessary.
Conflict of interest
The authors declared that they have no conflict of interest.
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