for WIZARD KIM: Review Paper—Topic Proposal & Reference Page

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Soldiers returning from combatoften face a postdeployment pe-riod in which there is an in- creased risk of readjustment stres- sors, such as problems with family, marriage, or employment. This peri-

od can also be marked by the onset of posttraumatic stress disorder (PTSD). Coping with the additional burden of PTSD likely complicates soldiers’ ability to cope during the readjust- ment period. Accordingly, research

has documented a relationship be- tween PTSD and greater readjust- ment stress among soldiers serving in recent conflicts (1) or in previous ones (2,3).

Many soldiers with a mental health need do not seek care within the first year of their readjustment period. An estimated 23%–44% of returning sol- diers with PTSD or other mental health problems receive treatment within the first year (4,5). Linking re- turning soldiers who have PTSD with treatment is a national priority be- cause effective treatments for PTSD are available (6,7) and PTSD suffer- ers who seek treatment experience symptom relief more quickly than those who do not (8). Therefore, re- search is needed to better understand the process by which returning sol- diers with PTSD seek treatment.

Readjustment stressors may be a key motivator for treatment seeking. Veterans returning from Operation Enduring Freedom or Operation Iraqi Freedom (OIF) often seek help for fi- nancial, occupational, and other read- justment concerns. A qualitative study suggested that returning sol- diers are most likely to seek mental health treatment when problems emerge within family and occupa- tional roles (9). Accordingly, one study showed that combat veterans seeking care from the U.S. Depart- ment of Veterans Affairs (VA) ex- pressed most interest for services re- lated to veterans’ benefits (83%) and schooling, employment, or job train- ing (80%) (1). Also, at least one study

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Dr. Interian, Dr. Kline, and Dr. Losonczy are affiliated with the Department of Psychia- try, UMDNJ–Robert Wood Johnson Medical School, 671 Hoes Lane, D306, Piscataway, NJ 08854-5635 (e-mail: [email protected]). They are also with the Veterans Af- fairs New Jersey Healthcare System, Mental Health and Behavioral Sciences, Lyons, New Jersey. Ms. Callahan is with the Bloustein Center for Survey Research, Rutgers Univer- sity, Piscataway.

Objectives: Readjustment stressors are commonly encountered by vet- erans returning from combat operations and may help motivate treat- ment seeking for posttraumatic stress disorder (PTSD). The study ex- amined rates of readjustment stressors (marital, family, and employ- ment) and their relationship to early mental health treatment seeking among returning National Guard soldiers with PTSD. Methods: Partici- pants were 157 soldiers who were surveyed approximately three months after returning from combat operations in Iraq and scored positive on the PTSD Checklist (PCL). The survey asked soldiers about their expe- rience with nine readjustment stressors as well as their use of mental health care in the three months after returning. Results: Many read- justment stressors were common in this cohort, and most soldiers expe- rienced at least one stressor (72%). Univariate analyses showed that readjustment stressors were related to higher rates of treatment seek- ing. These findings remained significant after multivariate analyses ad- justed for depression and PTSD severity but were no longer significant after adjustment for age and marital status. Conclusions: Readjustment stressors are common among soldiers returning from duty with PTSD and may be more predictive than PTSD symptom levels in treatment seeking. These effects appeared to be at least partially accounted for by demographic variables and the role of greater familial and occupation- al responsibilities among older veterans. Treatment seeking may be mo- tivated by social encouragement or social interference and less by symp- tom severity. (Psychiatric Services 63:855–861, 2012; doi: 10.1176/appi. ps.201100337)

has found a positive association be- tween mental health treatment seek- ing and readjustment stress (5). How- ever, because the study examined the effect of readjustment stressors in a sample with and without mental dis- orders, it may be that readjustment stressors are more common among veterans with a mental disorder. Less clear is whether these stressors differ- entiate PTSD sufferers who go on to seek treatment from those who do not.

Therefore, research is needed that further establishes the role of read- justment stressors in treatment seek- ing among PTSD sufferers, especially given that those suffering from this disorder may be more likely to be af- fected by readjustment stress (1). Such information can be valuable in policy and program development. Consistent with this aim, this study examined the role of readjustment stress as a predictor of mental health care seeking among returning sol- diers with likely PTSD. We hypothe- sized that readjustment stressors are significantly related to seeking mental health care. This study built on the existing literature by using survey re- sponses obtained from members of the New Jersey National Guard (NJNG) during reintegration events after a one-year deployment to Iraq. The survey collected information from veterans who did and did not seek mental health care, both within the Veterans Health Administration and from community-based provi- ders. Also, our analyses considered only veterans who met criteria for likely PTSD, in order to identify fac- tors associated with help seeking, giv- en the need for PTSD treatment. With this sample, we describe the prevalence of readjustment stressors, their relationship to depressive and PTSD symptoms, and their associa- tion with early mental health treat- ment seeking.

Methods Participants With support from the New Jersey Department of Military and Veterans Affairs, we collected data anony- mously in September 2009 from 1,665 of 1,723 NJNG soldiers who were attending postdeployment rein-

tegration events three months after returning from a 12-month tour in Iraq. Twenty-nine attendees at the reintegration did not complete the survey, and an additional 29 were ex- cluded because of poor data quality as judged by three independent raters, yielding a response rate of 97%. The sample was surveyed as part of a larger, longitudinal study as- sessing the mental and physical health effects of serving in the NJNG. This study focused on the 179 NJNG soldiers who met criteria, based on self-report, for PTSD at three months postdeployment.

Data collection Anonymous and self-administered surveys were distributed to all NJNG members attending the reintegration events, which were held on four days over two consecutive weekends. The surveys were administered to soldiers in groups of approximately 45–75. Participation was voluntary, and NJNG leadership was not aware of soldiers’ survey completion status. Soldiers received no monetary incen- tive for participation. All research procedures were approved by the Rutgers University and VA New Jer- sey Healthcare System Institutional Review Boards.

Measures PTSD was assessed with the PTSD Checklist (PCL), which is a 17-item self-report scale (10,11). This study focused on respondents who pro- duced a positive PTSD score (≥50). This criterion has been used fre- quently in PTSD research, including studies with veterans (11,12), and has been shown to have adequate sensi- tivity and specificity with a PTSD di- agnosis based on a structured psychi- atric interview (13). We measured PTSD severity as a continuous vari- able based on the PCL score.

Depression was assessed with the commonly used nine-item Patient Health Questionnaire (PHQ-9) (14) and analyzed as a continuous variable. Readjustment stressors were assessed with a nine-item scale that inquired, using the following stem, whether a number of stressors occurred: “Did any of the following things trouble you during your deployment to Iraq

or after you returned home?” Items inquired about marriage, financial, and family problems. The items for this measure were developed on the basis of qualitative interviews that elicited common readjustment expe- riences among New Jersey National Guardsmen. Participants indicated yes or no to each stressor, yielding a score of 0–9, with acceptable internal consistency (Cronbach’s α=.76).

Utilization of mental health care Questions about mental health serv- ice use inquired about visits that oc- curred since returning home (post- deployment). We first asked whether participants had a visit with a “men- tal health professional” for a “mental health problem.” Respondents were provided with examples of mental health professionals, such as psy- chologists, psychiatrists, social work- ers, and counselors. Responses were used to code for any mental health visit postdeployment. Second, par- ticipants were asked whether they received a “doctor’s prescription” for antidepressants, anxiolytics, mood stabilizers, or sedatives. A response of yes concerning any of these med- ications was used to code “pre- scribed a psychotropic postdeploy- ment.” Given that pharmacotherapy is often provided by non–mental health physicians (that is, primary care physicians), we defined any mental health visit postdeployment as either having a mental health visit postdeployment or receiving a pre- scription for a psychotropic postde- ployment. This was the study’s key outcome.

Analyses All analyses were completed with SPSS, version 16.0. Because of a 17% missing value rate for the variables pertaining to mental health visits, a missing value analysis assessed whether the missing values were re- lated to age, gender, race-ethnicity, and marital status and produced a nonsignificant value of Little’s miss- ing completely at random test. This signified that the values were missing randomly, and 22 cases with missing values therefore were not analyzed.

Analyses first described rates of mental health visits that had been

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made within three months postde- ployment. Next, chi square analyses examined whether demographic vari- ables were significantly different among those with or without any mental health visit postdeployment. Significant variables were later used as covariates in the multivariate analyses. Chi square analyses then compared whether those having a visit differed according to individual readjustment stressors, as well as cat- egories of cumulative number of stressors reported. Correlations were then generated to examine the rela- tionship between readjustment stres- sors with the PCL score (Spearman rho), where PCL scores were catego- rized into tertiles because of nonnor- mal score distributions. Also, a Pear- son correlation was generated be- tween readjustment stress and PHQ- 9 scores. The final analysis used hier- archical logistic regression to exam- ine the association between readjust- ment stress and any mental health visit after controlling for the relevant mental health and demographic characteristics. The independent variables were entered into the mod- el in three blocks. Block 1 included readjustment stress only. In block 2, we added the mental health variables PTSD and depression. Block 3 in- cluded all of the above variables plus the statistically significant demo- graphic variables.

Results A total of 179 (11%) respondents scored positive for PTSD, and our analyses focused on the 157 who did not have missing utilization data. The rates for several types of mental health visits are summarized in Table 1. Rates of treatment contact ranged from 23% to 36% for the three- month postdeployment period, de- pending on the type of contact. Most visits occurred with a mental health professional, and the medications most commonly prescribed were an- tidepressants and sedatives.

Table 2 summarizes the rates of having any mental health visit post- deployment, according to demo- graphic characteristics. Having a mental health visit significantly dif- fered by age and marital status. Pair- wise comparisons showed that Na-

tional Guard soldiers who had any mental health visit postdeployment were more likely to be married or liv- ing with a partner (χ2=10.5, df=1, p< .001) and separated, divorced, or widowed (χ2=11.5, df=1, p<.001), compared with those who were sin- gle. Having a visit was also more like- ly among soldiers ages 26–39 (χ2=4.1, df=1, p<.05) and 40–70 (χ2=8.3, df= 1, p<.01), compared with those who were ages 17–25.

Table 3 shows the relationship be- tween any mental health visit postde- ployment and PTSD severity, depres- sion, and each of the individual read- justment stressors. First, PTSD symptom severity was not significant- ly related to utilization of mental health services. In contrast, having a visit was associated with a higher PHQ-9 depression score (greater de- pression). Table 3 also shows that sig- nificant negative life events were not

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TTaabbllee 11

Mental health care utilization by 157 National Guard veterans within three months postdeploymenta

Care used postdeployment N %

Mental health visit 51 34 Prescribed a psychotropic 41 23 Any mental health visit (for psychotherapy or prescription) 57 36 Type of medication prescribedb

Antidepressant 25 14 Mood stabilizer 9 5 Anxiolytic 13 7 Sedative 29 16

a Some denominators are below 157 because of missing values. b Soldiers may have received a prescription for more than one psychotropic.

TTaabbllee 22

Demographic characteristics of 157 National Guard veterans who did or did not have a mental health visit within three months postdeploymenta

Any mental health visit postdeployment

No Yes All veterans

Characteristic N % N % N % p

Age .02 17–25 40 40 11 19 51 33 26–39 37 38 24 43 61 40 40–70 21 21 21 38 42 27

Race or ethnicityb White 36 36 24 42 60 38 .50 Black 28 28 12 22 40 26 .34 Hispanic 27 27 16 28 43 27 .89 Other 9 9 5 9 14 9 .96

Gender .42 Male 77 77 47 83 124 79 Female 23 23 10 18 33 21

Marital status Married or living as married 32 32 28 50 60 39 <.001 Never married 56 57 14 25 70 45 Divorced, separated, or

widowed 11 11 14 25 25 16 Education .77

High school or less 37 38 18 32 55 36 Some college 44 44 28 50 72 47 Bachelor’s degree or higher 18 18 10 18 28 18

a Some totals are below 157 because of missing values. b Analyses compared one racial or ethnic group with all others combined.

uncommon in this group. Events as serious as job or business loss and marital separation or divorce were re- ported by 20% and 26% of the sam- ple, respectively. Illustrating a cumu- lative effect, higher levels of these readjustment stressors were signifi- cantly associated with having any mental health visit postdeployment (χ2=8.7, df=2, p≤.05) (Figure 1). In total, most soldiers experienced a readjustment stressor, with only 28% experiencing no stressors. Next, re- sults showed a significant number of readjustment stressors and a signifi- cant correlation between them and PCL score (analyzed in tertile cate-

gories; rs=.21, p≤.05) and PHQ-9 score (r=.26, p≤.001).

Finally, Table 4 presents the results of multivariate models examining the prediction of any mental health visit postdeployment by level of readjust- ment stressors. Model 1 shows that National Guard soldiers with the highest accumulation of readjustment stressors were more likely to have any mental health visit postdeployment. Model 2 adjusted for the effects of PTSD symptom severity and depres- sion and found a mostly undimin- ished, statistically significant effect for readjustment stressors. This step shows that depression was also relat- ed to having a mental health visit.

PTSD severity was not statistically significant. In model 3, which added age and marital status variables, read- justment stressors were no longer sig- nificant but depression was.

Discussion Key findings The findings of this study, showing relatively low rates of early treatment seeking among returning soldiers, are consistent with previous literature (15). We found that only 34% of Na- tional Guard veterans who scored positive for PTSD had made a post- deployment mental health visit and that psychotropic medication had been prescribed to only 23%. The rates of medication usage in this study were slightly lower than those report- ed by Kehle and colleagues (16), in which 30% of OIF National Guard soldiers with PTSD received psy- chotropic treatment. The rate differ- ences between this study and those reported by Kehle and colleagues may be accounted for by the length of time in which utilization was as- sessed, which varied across the stud- ies (three months versus up to six months, respectively). The 11% of re- spondents in our sample who scored positive for PTSD was also compara- ble with that found in the Kehle and colleagues study.

Results were mixed in terms of meeting the treatment needs of OIF soldiers with PTSD. It is estimated that 7% of the U.S. population with PTSD seeks care within the first year of onset, and our results show that more OIF National Guard soldiers were engaging with early mental health care compared with their civil- ian counterparts (17). This finding provides some support for recent policies, such as five-year access to Veterans Health Administration care among soldiers serving in Iraq or Afghanistan, increased education and awareness of combat-related stress, and routine assessment of mental health conditions (18,19). However, the treatment utilization rate report- ed for National Guard soldiers with PTSD means that approximately two- thirds were without any early mental health treatment contact. Thus addi- tional policies and strategies for screening and referral should be con-

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TTaabbllee 33

Posttraumatic stress disorder (PTSD) symptom severity and readjustment stressors among 157 National Guard veterans with and without any postdeployment mental health visit

Any mental health visit postdeployment

No Yes All veterans

Readjustment stressor N % N % N %

Marital problemsa 28 30 31 59 59 40 Decision to divorce or separate 20 21 18 34 38 26 Problems with childrenb 15 16 18 34 33 22 Job status worsened 28 29 21 40 49 33 Lost job or businessb 14 15 16 31 30 20 Serious financial problemsb 29 31 27 50 56 38 Problems paying mortgage 12 13 13 25 25 17 Bank began foreclosureb 2 2 6 12 8 6 Family member or loved one became

ill or passed awayb 25 26 23 43 48 32 PCL score (M±SD)c 58.9±8.7 60.6±7.3 59.5±8.2 PHQ-9 depression score (M±SD)b,d 20.6±5.9 23.7±6.4 21.7±6.2

a p<.001 for comparison between soldiers with and without any mental health visit postdeployment b p<.05 for comparison between soldiers with and without any mental health visit postdeployment c PTSD severity was derived from the PTSD Checklist (PCL). Possible scores range from 17 to 85,

with a score above 50 indicating PTSD. d Depression score derived from the nine-item Patient Health Questionnaire. Possible scores range

from 0 to 27, with higher scores indicating greater depression.

FFiigguurree 11

Relationship between readjustment stressors and postdeployment mental health visits among 157 National Guard veterans

0

10

20

30

40

50

60

P e rc

e n ta

g e o

f sa

m p

le

No visit ≥1 visit

No stressors 1–2 stressors ≥3 stressors

sidered for improving treatment par- ticipation rates.

In terms of this study’s key objec- tive, we found that readjustment stressors played a significant role in early treatment seeking. Six out of nine readjustment stressors were in- dividually associated with having any mental health visit in the univariate analyses (Table 3). This effect was cu- mulative, with higher numbers of stressors being associated with higher rates of service utilization. The associ- ation between readjustment stressors and mental health service use was in- dependent of the severity of PTSD or depression symptoms. As noted, this relationship diminished considerably on adjustment for age and marital sta- tus. Also, depression levels remained a significant predictor of service use, even after adjustment for age and marital status. The finding that de- pression was a significant variable as- sociated with help seeking is consis- tent with previous research (5,20).

The loss of significance of readjust- ment stress after analyses adjusted for demographic characteristics is likely due to our sample characteristics and the relationship of readjustment stress with age and with marital sta- tus. Researchers have suggested that readjustment stressors may be more relevant for National Guard soldiers, who tend to be older and have more

developed familial and occupational roles than members of the active mil- itary components (5).

The results of this study, along with previous research, provide some sup- port for this interpretation. First, our sample of National Guard soldiers ap- peared to be older compared with samples from active-duty compo- nents studied by Hoge and colleagues (15) and others (21). Second, in our somewhat older sample, individual readjustment stressors were reported at high levels, with each often report- ed by more than 20% of the partici- pants. For example, 20% had lost their job or business, which compares with an unemployment rate of 9.8% in New Jersey during the period when these data were collected (Sep- tember 2009) (22). A similar rate (28%) of job loss was found in a pre- vious study with reserve-duty soldiers with PTSD (23). Third, a previous study using the same data set found that readjustment stressors were more common among National Guard soldiers who were older and either married or previously married (24). Combined with our finding that readjustment stressors were no longer significant after analyses ad- justed for age and marital status, these observations lend support to the view that National Guard soldiers tend to be older and more susceptible

to the type of readjustment stressors assessed in this study. This is because they will likely have more involved family and occupational roles that can be affected by their symptoms.

Limitations To interpret the loss of significance of readjustment stress after adjustment for demographic variables, one should consider the types of readjust- ment stressors captured by our scale. Its items tap stressors that pertain more to veterans who are or who have been married. Note, however, that the scale used in this study was based on qualitative interviews with New Jersey National Guardsmen and was designed to capture the readjustment stressors that were most salient to this sample. Nevertheless, it is important to interpret these findings in terms of the specific readjustment stressors that were assessed (marital problems and job problems). Unmarried sol- diers may experience stress in areas that were not captured in our survey of readjustment stressors, which mainly inquired about marital, child, and occupational difficulties. Future studies should examine a broader ar- ray of readjustment stressors to better sort out their relationship to help seeking among soldiers varying in age range and marital status. A recently published scale may improve our abil-

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TTaabbllee 44

Multivariate analysis of predictors of postdeployment mental health visits among 157 National Guard soldiers

Model 1 Model 2a Model 3b

Measure OR 95% CI OR 95% CI OR 95% CI

Readjustment stress (reference: none)c 1.29∗∗ 1.10–1.50 1.24∗ 1.05–1.47 1.17 .98–1.41 Axis I disorder

PTSD symptomsd — — 1.00 .95–1.01 1.00 .95–1.06 Depressive symptomse — — 1.10∗ 1.03–1.05 1.10∗ 1.02 –1.18

Age (reference: 17–25) 26–39 — — — — 2.05 .76–5.54 ≥40 — — — — 2.72 .94–7.93

Marital status (reference: married or living as married)

Never married — — — — .59 .23–1.49 Divorced, separated, or widowed — — — — 1.50 .52–4.36

a Adjusted for effects of posttraumatic stress disorder (PTSD) severity and depression b Adjusted for same variables as model 2, plus age and marital status c Participants answered yes or no to nine potential stressors. d PTSD severity was derived from the PTSD Checklist. e Depression severity was derived from the Patient Health Questionnaire–9. ∗p<.05

∗∗p<.01

ity to study this issue, given its broad- er range of stressors assessed (25).

The significance of readjustment stressors in the rate of early treatment seeking has useful implications for services designed to treat PTSD among soldiers. PTSD service deliv- ery models may consider meaningful- ly integrating interventions that help with marital and family functioning, as well as case management support for addressing financial and occupa- tional stressors. Also, motivation for treatment can be built by linking the goals of treatment to better function- ing with family and occupation. Given that PTSD treatment may be charac- terized by considerable attrition, ad- dressing these issues may improve treatment retention rates by aligning services with key motivators for seek- ing treatment (20,26). Also, outreach and awareness efforts can utilize readjustment stressors as a point of engagement, which would increase the numbers of veterans who visit with a professional and would be more likely to be screened and re- ferred to treatment. Future studies can build on this research by examin- ing the degree to which returning sol- diers cite readjustment stressors as their reason for seeking care. Future studies can also examine the role that family members play in encouraging care seeking.

There are other limitations worth noting. First, although the use of a three-month postdeployment win- dow was advantageous for studying early treatment contact, it provided a very limited window for examining treatment continuity. Second, it is critical that engagement occur within a context of optimal treatment quali- ty. Given the importance of treatment quality, we caution that our data could not describe involvement with empirically supported psychothera- pies for PTSD or other care quality indicators, such as wait times (6,7,27). We also did not have the data to de- scribe the type of mental health visit utilized or the type of professional that was contacted (psychotherapy or pharmacotherapy background, psy- chologist, psychiatrist, or informal source of care). Third, the data lacked information on the soldiers’ perspec- tives regarding PTSD and its treat-

ment. Such data are critical for un- derstanding participants’ own reasons for seeking care. Thus future studies should clarify whether soldiers report readjustment stressors as reasons for seeking care. Fourth, it is likely that a portion of soldiers with PTSD symp- toms at postdeployment will recover on their own. Our cross-sectional de- sign did not allow for an estimate of early mental health care seeking that accounts for those who may have a natural recovery (28). Yet it is impor- tant to note that our PCL cutoff of ≥50 likely identified a cohort of vet- erans with more severe PTSD symp- toms that are less likely to naturally remit. Still, future research can build on the results of this study by incor- porating a longitudinal design that can describe the natural remission among those who do not seek early mental health care.

Conclusions Readjustment stressors among re- turning National Guard soldiers were fairly common, with many soldiers re- porting multiple occupational, finan- cial, and family stressors. Readjust- ment stressors generally were associ- ated with having an early mental health visit, and these effects ap- peared to be accounted for by older age and marital status. Most return- ing soldiers with PTSD do not seek early treatment, but rates of having a mental health visit were more favor- able in this population than in the general population.

Acknowledgments and disclosures

This work was supported by a grant from the New Jersey Department of Military and Veter- ans Affairs.

The authors report no competing interests.

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PSYCHIATRIC SERVICES � ps.psychiatryonline.org � September 2012 Vol. 63 No. 9 886611

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Submissions to the journal’s Datapoints column are invited. Datapoints encour- ages the rapid dissemination of relevant and timely findings related to clinical and policy issues in psychiatry. National data are preferred. Areas of interest in- clude diagnosis and practice patterns, treatment modalities, treatment sites, pa- tient characteristics, and payment sources. The analyses should be straightfor- ward, so that the figure or figures tell the story. The text should follow the stan- dard research format to include a brief introduction, description of the methods and data set, description of the results, and comments on the implications or meanings of the findings.

Datapoints columns, which have a one-page format, are typically 350 to 400 words of text with one or two figures. Because of space constraints, submissions with multiple authors are discouraged; submissions with more than four authors should include justification for additional authors.

Inquiries or submissions should be directed to column editors Amy M. Kil- bourne, Ph.D., M.P.H. ([email protected]), or Tami L. Mark, Ph.D. (tami. [email protected]).

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