When men and women join the military, they and their family members adapt to a new culture. They learn a different language steeped in acronyms and military slang. They participate in a community whose members are bound together by the core military value of service before self and by the missions they carry out. The chain of command that oversees almost every aspect of a military service member’s life also provides for the member’s basic needs, including regular employment, medical care, and housing. What challenges might military service members and their families face when they separate from the military and its unique culture and provisions?
Demers, A. (2011). When veterans return: The role of community in reintegration. Journal of Loss and Trauma: International Perspectives on Stress & Coping, 16(2), 160–179.
Ghahramanlou-Holloway, M., Cox, D. W., Fritz, E. C., & George, B. J. (2011). An evidence-informed guide for working with military women and veterans. Professional Psychology: Research and Practice, 42(1), 1–7.
Heflin, C. M., Wilmoth, J. M., & London, A. S. (2012). Veteran status and material hardship: The moderating influence of work-limiting disability. Social Service Review, 86(1), 119–142.
Sherman, M.D., Larsen, J., & Borden, L.M. (2015). Broadening the focus in supporting reintegrating Iraq and Afghanistan veterans: Six key domains of functioning. Professional Psychology, Research and Practice, 46(5), 355-366.
Laureate Education (Producer). (2013). Retirement and veterans’ needs [Video file].
Laureate Education (Producer). (2013). Separation from the military [Video file].
To prepare for this Discussion, review both Kristin Wilkinson and Michael Wilkinson Video this week’s resources.
· Describe the greatest challenge this individual is facing or had faced during reintegration and explain why this is/was the greatest challenge.
· Explain one recommendation you might make to improve or enhance this individual’s reintegration experience and to mitigate further challenges.
Be sure to support your post with specific references and Required Reading to the resources. If you are using additional articles, be sure to provide full APA-formatted citations for your references.
Broadening the Focus in Supporting Reintegrating Iraq and Afghanistan Veterans: Six Key Domains of Functioning
Michelle D. Sherman University of Minnesota
Jessica Larsen University of Oklahoma Health Sciences Center
Lynne M. Borden University of Minnesota
The major ground troop presence in the Middle East is reduced, it is time to reflect, maximize lessons learned, and look forward to what lies ahead for the nearly 2.6 million service members of the United States military who have deployed in support of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. A systematic review of the literature on post deployment functioning of Iraq and Afghanistan troops was conducted. Findings are described and contextualized in terms of service members’ ongoing strengths, needs, and challenges. The corpus of research on deployed personnel indicates that service members demonstrate resilience in the face of war-related stressors. However, post deployment impairment in 6 functional domains emerged in the literature review, including mental health, social and role functioning, relationship functioning and family life, spirituality, physical health, and financial well-being. Although risk factors and future trajectories vary across these domains, psychiatric difficulties are a consistent predictor of a worsened course. Implications for clinical practice are described based on the review findings. To promote wellbeing in the years ahead, it is important that service members are supported in their various roles (such as in the classroom, the workforce, and the family). In addition, routine assessment of functioning across domains is highly recommended for post deployment service members.
Keywords: reintegration, service member, veteran, community reintegration, PTSD
Beginning in 2001, the Global War on Terrorism has been the longest war in our nation’s history, drawing upon unprecedented numbers of National Guard and Reserve personnel, involving multiple, repeated deployments for many service members, and entailing a unique kind of warfare. According to the Defense Manpower Data Center, over 2.6 million members of the United States military have deployed in support of Operation Enduring Freedom, Operation Iraqi Freedom (OEF/OIF), and Operation New Dawn (Institute of Medicine, 2014). In recent years, the number of ground troops committed to combat operations has decreased considerably. The nation finds itself in uncharted waters, as millions of military veterans return home to new challenges. Thus, it is imperative for mental health providers, clinical educators, and administrators to anticipate the landscape for our nation’s veterans in the years ahead. The purpose of this article is to review the literature on OEF/OIF service members’ functioning during and after deployment to provide research-based implications for clinical practice. Although the term service member is used herein, many of the recommendations also apply to veterans.
Review of the Empirical Literature A systematic review of the literature was conducted identifying relevant articles and reports. PsycINFO, PubMed, and Google
Scholar were searched and inclusion criteria included peer reviewed journal article or Department of Defense (DoD) report (including both quantitative and qualitative studies); focus on service member/veteran functioning during or after deployment to Iraq or Afghanistan; published since 2001; and English language. Although research on service member postwar functioning exists for previous wars, the generalizability of these data to the current cohort of OEF/OIF service members is limited due to differences in wartime experiences (for a description of the unique features of these operations, see IOM, 2013). Thus, this review focused on data drawn from OEF/OIF samples. In all, 92 distinct sources met criteria for inclusion in this review. Six domains of post deployment functioning of OEF/OIF service members emerged in this literature review, including (a) mental health, (b) social/role functioning, (c) relationships/family life, (d) spirituality, (e) physical health, and (f) financial wellbeing.
Approximately half (n 47; 51%) of the articles included in this review addressed mental health issues, in particular posttraumatic stress disorder (PTSD), depression, and alcohol abuse. For example, data from the Armed Forces Surveillance Center found that rates of mental health conditions among active duty service members increased by 62% between 2001 and 2011 (incidence of PTSD increased 656% and anxiety 226%; Blakeley & Jansen, 2013). In this decade, almost one million service members or veterans were diagnosed with a psychological disorder either during or after deployment; almost half had more than one mental health disorder. Further, 40% of troops have deployed more than once in support of OEF/OIF(InstituteofMedicine,2014);research has documented higher rates of mental health problems among these service members than single deployers, both among active duty (Mental Health Advisory Team 5, 2008; Mental Health Advisory Team 9, 2013) and National Guard troops (Kline et al., 2010).
PTSD. Prevalence estimates of PTSD among service members returning from Iraq and Afghanistan vary, with most recent analyses suggesting 13–16% (Dursa, Reinhard, Barth, & Schneiderman, 2014; Kok, Herrell, Thomas, & Hoge, 2012). Prospective data from the Millennium Cohort Study found a threefold increase in new onset self-reported symptoms of PTSD among recently deployed military personnel who report combat exposure (Smith et al., 2008). PTSD can emerge from a variety of traumatic events beyond combat, such as military sexual trauma (Kimerling et al., 2010) and seeing dead bodies or human remains (Hoge et al., 2004).
Depression and grief. Although PTSD has been named one of the “signature injuries” of the wars in Iraq and Afghanistan, returning service members face an array of other mental health difficulties as well. Troops who experience combat have been found to be at an increased risk for depression compared to nondeployed service members (Shen, Arkes, & Williams, 2012; Wells et al., 2010). Estimates of the prevalence of major depression among service members vary, ranging from 5% to 37% (Institute of Medicine, 2014). Considerable numbers of OEF/OIF veterans entering the Veterans Administration (VA) health care system are experiencing depression; a study examining new enrollees from 2002–2008 found that almost one fifth of these veterans were diagnosed with depression (Seal et al., 2009). Grief is a relatively unexamined construct in the literature but may be a component of or contributor to depression. In one study of infantry soldiers six months after an OEF/OIF deployment, 21% reported difficulty coping with grief over the death of someone close to them. After controlling for possible confounds, grief significantly contributed to service members’ physical health problems, poor general health, and days of missed work (Toblin et al., 2012).
Sleep problems. Sleep problems may be a related or distinct problem from depression and PTSD for OEF/OIF service members. The 2013 Mental Health Assessment Team report (MHAT 9) found that nearly 25% of troops described sleep problems during deployment, with clear relationships between insufficient sleep and both mental health problems and having accidents on the job. Poor sleep hygiene and sleep difficulties can continue upon homecoming (Luxton et al., 2011; Seelig et al., 2010), exacerbating other reintegration difficulties. A recent examination of OEF/OIF veterans found that 89% were categorized as “poor sleepers” (Plumb, Peachey, & Zelman, 2014).
Suicide. A correlate of a range of mental health problems can be self-injurious behavior, including suicide. This issue has received a great deal of attention, both in the research and popular press, in part because of the recent growing rates of service member suicide, which increased by 60% from 2005 to 2011 (DoD, 2012b). OEF/OIF veterans have not been found to have significantly elevated rates of suicide compared to the general population; however, OEF/OIF veterans with psychiatric problems have been found to be at elevated risk for suicide in comparison to the general population (Kang & Bullman, 2008).
Alcohol use. Combat deployment may be related to an increased risk of alcohol problems upon homecoming (Shen et al., 2012), and considerable numbers of service members are abusing substances. Within the first 3 to 4 months after homecoming, approximately 1/4 to 1/3 of male and 1/6 of female OEF/OIF service members are reporting hazardous drinking or alcohol misuse (Blow et al., 2013; Scott et al., 2013; Wilk et al., 2010). Rates of alcohol misuse are higher among service members who had greater exposure to atrocities or the threat of death. Review of VA administrative data of diagnoses of OEF/OIF veterans who were first-time users of VA health care revealed that some people continue to abuse alcohol. In this analysis of 450,000 veterans’ records from 2001 to 2009, 10% received alcohol use diagnoses, 5% received drug use diagnoses, and 3% received both in that timespan (Seal et al., 2011); further, substance use diagnoses were 3–4.5 times more likely in veterans with PTSD and depression.
Review of VA administrative data of diagnoses of OEF/OIF veterans who were first-time users of VA health care revealed that some people continue to abuse alcohol. In this analysis of 450,000 veterans’ records from 2001 to 2009, 10% received alcohol use diagnoses, 5% received drug use diagnoses, and 3% received both in that timespan (Seal et al., 2011); further, substance use diagnoses were 3–4.5 times more likely in veterans with PTSD and depression.
Symptom trajectories. Research on symptom trajectories for OEF/OIF military personnel is limited by the recency of deployment(s) for many service members. However, several longitudinal studies have examined psychiatric symptoms after deployment, revealing large majorities of troops are resilient (i.e., do not demonstrate psychopathology; Dickstein, Suvak, Litz, & Adler, 2010). The Millennium Cohort Study analyzed PTSD symptom trajectories among OEF/OIF veterans over the course of pre deployment to two follow-up periods, each 3 years apart; in this sample, 83–85% were resilient or had low-stable posttraumatic stress symptoms, followed by those with moderate improvement (8–9%), and with
worsening chronic PTSD (5–7%; Bonanno et al., 2012). For some service members, however, difficulties continue and may even increase over time. Research has demonstrated enduring problems following deployment including anger and aggressive behavior, depression (Bliese, Wright, Adler, Thomas, & Hoge, 2007; Thomas et al., 2010), and interpersonal concerns (Milliken, Auchterlonie, & Hoge, 2007). Such deterioration in functioning is associated with low social support (Cigrang et al., 2014).
Although much of the research has focused on mental health outcomes, there is a growing recognition of the importance of a broad range of functional domains after deployment, including social/role functioning, a topic addressed by 11% (n 10) of the studies in this review. A national mail survey of OEF/OIF combat veterans using VA services assessed a range of reintegration problems, including difficulties in social functioning, productivity, community involvement, driving, and self-care domains (Sayer et al., 2010). Almost half of respondents reported difficulty with participating in community activities, belonging in “civilian” society, and enjoying free time. Veterans with probable PTSD reported more reintegration problems than those without. Relevant qualitative inquiry has termed this challenge one of “warring identities” (Smith & True, 2014), as service members struggle when transitioning out of wartime activity. Some service members do not feel understood by civilians and feel separated from their communities and culture of origin, which can result in some wanting to return to a combat zone because they feel they “belong” and are understood in that environment.
Upon returning from deployment, many service members navigate the process of changing occupational roles within the Armed Forces, while others exit the military. Research is beginning to document some challenges in transitioning to student and civilian employee roles. For example, qualitative research with OEF/OIF veterans returning to higher education revealed some transitional challenges, including role incongruities, altered relationships with schoolmates, and identity renegotiations (Rumann & Hamrick, 2010). Some student veterans reported challenges with socializing with peers, academic demands, and crowded, noisy school classrooms (DiRamio, Ackerman, & Mitchell, 2008), and some student veterans are experiencing elevated rates of psychological distress, alcohol misuse, and suicidal ideation compared to the general student population (Rudd, Goulding, & Bryan, 2011; Widome, Laska, Gulden, Fu, & Lust, 2011). College students with PTSD report higher levels of some health risk behaviors (e.g., physical fighting, high-risk driving) than those without the disorder (Widome, Kehle, et al., 2011). Regarding job functioning, research suggests that there is no direct negative impact of deployment on subsequent work functioning (Erbes, Kaler, Schult, Polusny, & Arbisi, 2011; Horton et al., 2013). Rather, mental health problems and combat exposure appear to be associated with later employment difficulties (Burnett-Zeigler et al., 2011; Erbes et al., 2011; Wells et al., 2014).
Relationship Functioning and Family Life
Marital functioning. One domain of post deployment functioning that has received specific attention is relationship functioning; 14% (n = 13) of our reviewed studies addressed intimate partnerships. Approximately 40–50% of suicides among active duty soldiers in recent years were precipitated by the ending of an intimate relationship, documenting the importance of close relationships to well-being (DoD, 2012b, 2013). Mental Health Assessment Team (MHAT) surveys conducted in theater found troops described marital problems, with longer deployments being related to increased reports of marital problems and concerns about infidelity (MHAT IV, 2006). Foran, Wright, and Wood (2013) found that 37% of soldiers who had recently returned from combat reported marital problems. Post deployment Health Reassessment data from a large sample of married Army troops recently returned from OEF/OIF revealed that 18% of respondents reported serious interpersonal conflict with spouses, family members, close friends, or coworkers; rates of interpersonal conflict were higher among those with PTSD, depression, and physical health problems (Gibbs, Clinton-Sherrod, & Johnson, 2012).
In addition, research has shown veterans reported difficulties in relating to others, including 44% struggling to make new friends, 45% having difficulty keeping up with nonmilitary friendships, 42% struggling with getting along with spouse/partner, and 35% reporting a divorce or separation since homecoming (Sayer et al., 2010). Another study of married, male recently returned combat deployers found that one fifth described “sexual frustration” as “very stressful” (Allen, Rhoades, Stanley, & Markman, 2011). Further, a study of OEF/OIF veterans referred for mental health services in a VA hospital revealed that 77% of the married/ cohabiting veterans had some family problems in the past week, with many struggling in their role as spouse/partner (Sayers, Farrow, Ross, & Oslin, 2009).
Thus, across settings, many service members describe relationship problems after deployment. Research on the association between deployment and marital functioning, however, is mixed. Some research has found that deployment is not associated with marital satisfaction and functioning (Allen, Rhoades, Stanley, & Markman, 2010). Other studies have reported decreased marital satisfaction and quality, increased rates of past-year infidelity, and increased intent to separate or divorce among service members after deployment (McLeland, Sutton, & Schumm, 2008; Riviere, Merrill, Thomas, Wilk, & Bliese, 2012). Regarding relationship stability, a recent review of military administrative databases found that deployment increased the risk of divorce among Army enlisted troops, and PTSD symptoms further increased the odds of divorce (Negrusa & Negrusa, 2014). Similarly, longitudinal research with OEF/OIF veterans has found that increases in veteran PTSD symptoms over time relate to poorer couple functioning (Gewirtz, Polusny, DeGarmo, Khaylis, & Erbes, 2010).
Violence. Although interpersonal violence is a considerable social concern, it has received relatively little research in this population (addressed by only 11% [n 10] of sources in this review). Research with OEF/OIF veterans who had been referred for a mental health evaluation at one VA hospital found that 60% of married or recently separated veterans reported some family violence in the home in the past 6 months, and 28% indicated that their partner was “afraid of them” (Sayers et al., 2009). Some research is documenting elevated rates of intimate partner aggression perpetration among both OEF/OIF veterans and their partners. For example, LaMotte and colleagues (2014) gathered data from 65 OEF/OIF veterans and their female partners in
Boston. Based on combined veteran/partner report, 28% of the veterans and 39% of the partners had perpetrated physical intimate partner aggression in the past year; 97% of the veterans and 95% of the partners had perpetrated psychological intimate partner aggression in that time period.
PTSD is a known risk factor for relationship violence (Taft, Watkins, Stafford, Street, & Monson, 2011), and emerging research is documenting an elevated risk among OEF/OIF veterans (Jakupcak et al., 2007), including for perpetration of sexual coercion against partners (Teten et al., 2009). In a study of veterans who had completed a PTSD screening at a VA hospital, male OEF/OIF veterans with PTSD were 1.9 to 3.1 times more likely to perpetrate psychological or physical aggression to their female partners than those without PTSD. Notably, these PTSD veterans were 1.6 to 6 times more likely to report experiencing aggression from their female partners than veterans without PTSD (Teten et al., 2010).
Veterans’ aggression may also impact nonfamilial relationships. Exposure to combat has been associated with increased rates of aggression upon homecoming (Thomas, Wilk, Riviere, McGurk, Castro, & Hoge, 2010). Longitudinal research of OEF/OIF veterans with PTSD found that 9% admitted to aggression toward a stranger in the previous year (Sullivan & Elbogen, 2014), and veteran students with PTSD have been found to have an elevated risk for fighting (Widome, Kehle, et al., 2011). Veterans with PTSD and negative affect (anger/irritability) may be at increased risk for criminal arrests (Elbogen et al., 2012).
Parenting. Another important domain of relationship functioning is the role of parent; however, little research has specifically addressed this topic among OEF/OIF personnel (5%, n = 5, of the articles in this review). Physical separation during deployment can strain parent–child relationships and create emotional distance. Service members with young children miss important milestones in their children’s lives during deployment(s), and reestablishing relationships takes time and commitment. Some service members cite difficulties with this process (Sayer et al., 2011; Sayers et al., 2009) and worry about the effects of deployment on their children (Allen et al., 2011). Contextually, it is important to note that service members may be reentering families that have endured considerable strain during deployment (Institute of Medicine, 2013), and research has documented some heightened risks among these children (Creech, Hadley, & Borsari, 2014). Preliminary evidence suggests that OEF/OIF veterans with combat-related PTSD appear to have unique challenges with parenting. In a longitudinal study from homecoming to one year after an OIF deployment, increases in PTSD symptoms were associated with poorer parenting practices among National Guard fathers (Gewirtz et al., 2010). Similarly, a study of 434 military couples found that PTSD was associated with decreased parental cooperation and communication (Allen, Rhoades, Stanley, & Markman, 2010). As parental PTSD is associated with child distress and behavioral problems (Lambert, Holzer, & Hasbun, 2014), it is important for therapists to provide support and resources for the entire family and help parents talk about these issues with their children (Sherman, Larsen, Straits-Troster, Erbes, & Tassey, in press).
Thus, across a variety of indicators, some service members returning from deployment struggle in their family relationships. Although the course of relationship functioning over time warrants continued evaluation, chronic relationship difficulties may decrease social support, exacerbate other reintegration difficulties, and worsen overall well-being.
Little has been written about the impact of OEF/OIF combat deployment on spiritual functioning; only 4% (n = 4) reviewed articles addressed this topic. The longitudinal trajectories of OEF/ OIF veterans’ spiritual health and wellbeing are unknown. However, consideration of the role of spiritual functioning for service members is an important research agenda as over half of Americans say that religion is “very important” in their lives (Gallup, 2014) and over 90% of Americans profess a belief in God (Newport, 2011). Religious beliefs have been associated with coping with life’s challenges (Park, 2005), and spirituality has been linked to an increased sense of meaning, purpose, resilience, satisfaction, and happiness (Pargament, Mahoney, Exline, Jones, & Shafranske, 2013). Long-term separation from family, hazardous living situations, living in dangerous situations, and trauma exposure have the potential to spark difficult spiritual challenges among deployed personnel.
A few relevant studies of spirituality among OEF/OIF personnel are noteworthy. Sayer and colleagues (2010) found that 42% of OEF/OIF veterans reported that they had “lost touch with their spirituality or religious life” following deployment. On the other hand, some military personnel seek out chaplains for support in coping with mental health issues. Elbogen, Wagner, Johnson, Kinneer, Kang, Vasterling, et al. (2013) found that 18% of OEF/ OIF service members had spoken with a chaplain/pastor in the past year; those with PTSD or depression talked to chaplains at higher rates than those without. Other preliminary research with OEF/OIF veterans has documented a majority of veterans reported some posttraumatic growth related to combat experiences, which may include spiritual growth (Pietrzak et al., 2010).
The construct of moral injury refers to situations when traumatic experiences force a person to question core moral or religious principles, often resulting in guilt, shame, anger, demoralization, impaired self-care, loss of meaning or sense of moral direction, impaired social functioning, and increased risk for psychiatric conditions including depression and PTSD (Drescher et al., 2011; Litz et al., 2009). Research linking spiritual distress with suicidal ideation among OIF veterans underscores the need for future research in this area (Maguen et al., 2011). Although consensus has not yet been reached on the precise nature of this phenomenon, some tools for assessing and addressing moral injury and broader spiritual
struggles among veterans are emerging (e.g., Currier, Holland, Drescher, & Foy, 2015; Litz et al., 2009; Sherman, Harris, & Erbes, 2015).
A growing research base has examined the physical health correlates of deployment; 14% (n 13) of the reviewed articles addressed this domain. Some studies document worsening course of symptoms over time after homecoming (Falvo et al., 2012; Haskell et al., 2012; Milliken et al., 2007). Research drawing solely on self-report data has revealed a range of physical health
concerns among OEF/OIF veterans after deployment, including musculoskeletal pain (33%), fatigue (32%), back pain (28%; Toblin et al., 2012), and chronic, widespread pain (Helmer et al., 2009). Longitudinal research with OEF/OIF troops undergoing deployment found clinically significant declines in both physical and mental health functioning following deployment as compared to baseline (McAndrew at al., 2013). Longitudinal research has documented associations between OEF/OIF deployment and both smoking initiation and smoking recidivism, especially among service members with multiple or prolonged deployments and combat experiences (Hermes et al., 2012; Smith et al., 2008). The Millennium Cohort Study has also specifically examined the role of combat exposure and physical health among service members. Deployers with combat experiences have been found to have an increased risk of hypertension and a new diagnosis of coronary heart disease than deployers without combat exposure (Crum-Cianflone et al., 2014; Granado et al., 2009). Relatedly, deployers who experienced combat had significantly higher odds of a new-onset headache diagnosis than nondeployers (Jankosky et al., 2011). Some research has specifically examined the contribution of PTSD to physical health problems among recent OEF/OIF returnees (e.g., Afari et al., 2009).
A review of VA records of OEF/OIF veterans who used primary care services found that PTSD was associated with both increased prevalence and an earlier onset of physical disease (hypertensive, circulatory, digestive, nervous, and musculoskeletal disease) within the first 5 years after military service compared to those without PTSD (Andersen, Wade, Possemato, & Ouimette, 2010). This research highlights the potential additive contribution of combat exposure and PTSD to the later development of physical health problems. Another issue faced by some OEF/OIF personnel that can have both physical and emotional correlates is traumatic brain injury, which has been described as one of the “signature wounds” of OEF/OIF in addition to PTSD (Tanielian & Jaycox, 2008). Between 1997 and 2007, the prevalence rate of physician-diagnosed mild traumatic brain injury among U.S. military personnel was estimated at 6.55 per 1,000 person years. The highest rates were during the later portion of the study reflecting increased exposure to improvised explosive device blasts among OEF/OIF veterans (Cameron, Marshall, Sturdivant, & Lincoln, 2012). In addition to problems associated directly to TBI, there is some evidence for the overlapping symptoms of TBI and PTSD (Hoge et al., 2004).
Little is known about the financial wellbeing of Iraq and Afghanistan service members; in fact, only five sources emerged in our literature review addressing this topic (5% of the total articles). Although service members are generally well compensated, some experience financial stress, especially those among the junior enlisted ranks (Hosek & Wadsworth, 2013). A large-scale survey collected within the DoD from Active duty members (Defense Manpower Data Center, 2014) revealed that approximately two thirds of families report feeling comfortable financially; this sample includes, but is not limited to, OEF/OIF personnel. Family economics are likely impacted by frequent geographic moves, which impact military spouses’ ability to achieve steady employment and academic/career trajectories. Concerns about money may have mounted during the service member’s OEF/OIF deployment. Although the additional deployment pay may increase the service member’s income during deployment, some individuals (especially those in the National Guard or Reserves) experience a reduction in income when away from well-paying jobs. Upon homecoming, adjusting to a decreased income and tighter budget can be challenging for some military personnel. Despite the protections in place for job security for National Guard members and Reservists, some face challenges in securing employment after deployment (Burnett-Zeigler et al., 2011). Thus, finances can change across the deployment cycle and beyond, placing additional stress on the service member and family.
Two studies have examined financial issues among OEF/OIF veterans including a 2012 mail survey of 922 Minneapolis VA medical center users. Approximately 27% of these OEF/OIF veterans were food insecure (unable to have consistent access to sufficient food for a healthy lifestyle), and 14.5% reported very low food security (Widome, Jensen, Bangerter, & Fu, 2015); these figures are almost double the rates of the general United States population in 2012 (Coleman-Jensen, Nord, & Singh, 2013). Second, data from the National Post-Deployment Adjustment Survey of OEF/OIF veterans revealed that 30% reported mismanaging money in the past year, such as forging or bouncing a check, going over credit limit, or falling victim to a money scam (Elbogen, Sullivan, Wolfe, Wagner, & Beckham, 2013).
Implications for Clinical Practice
A body of literature has emerged examining functioning of service members following deployment to Iraq and Afghanistan. Although outcomes and trajectories vary across the domains presented here, mental health difficulties are a consistent predictor of a worsened course. Based on this review, the following recommendations may be useful regarding clinical practice.
1.Broadenfromanarrowfocusonservicemembers’mental health to community reintegration. Conceptualizations of post deployment functioning should be expanded from focusing solely on symptom reduction to including positive community involvement. Scholars have begun to attend specifically to veterans’ participation in life roles (i.e., “community integration”) and a return to participation in life roles (i.e., “community reintegration”) following deployment (Resnik et al., 2012). Participation reflects functioning across a range of roles, including social, work, education, parental, spouse, spiritual/religious, leisure, domestic life, civic, self-care, and economic life. These roles echo the six domains reviewed here and highlight the multifaceted nature of function and dysfunction that may result following deployment to OEF/OIF. Practitioners are urged to provide interventions that address functioning across a range of domains when assisting veterans to reintegrate into their communities. Providers may also develop a network of referral sources that can assist service members in specific domains (e.g., job coaches, vocational rehabilitation specialists, clergy, academic advisors).
2. Build provider capacity to offer services that are responsive to military culture. An important component of outreach and treatment of service members is ensuring they are responsive
to military culture. Educating service providers about conditions with known elevated risks among returning service members will be important in ensuring screening and treatment protocols appropriately assess, monitor, and treat these domains. Numerous programs exist to educate community members, ranging from programs for mental health professionals (e.g., Center for Deployment Psychology; Indiana’s Star Behavioral Health Providers program; National Council for Behavioral Health’s Serving Our Veterans Behavioral Health Certification) to primary care providers (e.g., Citizen Soldier Support Program) to child-focused providers (e.g., Military Child Education Coalition). Despite these laudable initiatives, a recent RAND survey of mental health professionals found that very few felt they possessed the knowledge and skills necessary to provide culturally competent, evidence-based care to service members (Tanielian, Farris, et al., 2014); these findings highlight the importance of training civilian providers about military culture.
3. Coordinate a community response. Veterans present a complex, multifaceted range of strengths and issues to their communities, necessitating a thoughtful, coordinated response. Strategies for addressing needs will undoubtedly continue to be a broad effort, drawing upon resources from the federal, state, and local levels as well as community organizations, private sector health care systems, school systems and programs of higher education, faith-based communities, businesses, advocacy organizations, legal authorities, and others. Organizing and coordinating effective community responses are challenging yet very important tasks; some helpful models (e.g., Straits-Troster et al., 2011) and successful initiatives (e.g.,theGive an Hour Program, www.giveanhour .org) can provide opportunities and guidance to interested clinicians.
4. Provide a range of supports and services and monitor functioning over time. Early intervention may minimize the course of some difficulties described herein and potentially prevent them from becoming chronic, disabling conditions. To meet the diverse needs of the population, efforts will continue to span a range of modalities, including face-to-face services, online programs, mobile-phone applications, social networking, and phone-based coaching. Given the unknown course of OEF/OIF troops’ functioning over time, continued assessment across all domains (mental, social, relational, spiritual, physical, and financial) will be important. Interestingly, financial wellness among OEF/OIF veterans has received little empirical or clinical attention to date (addressed by only 5% of the studies in this review). However, over the coming years, potential reductions in force and the tightening DoD budget will likely exacerbate financial stress among service members. Financial concerns and problems may have ripple effects on wellbeing, role functioning, and relationships. As OEF/OIF service members transition out of the military, unprecedented numbers are receiving disability compensation. By 2012, 45% of OEF/OIF veterans applied for service-connected disability compensation for medical problems (both mental health and nonmental health), and 28% had secured it (Marchione, 2012). Disability income will likely have both short- and long-term consequences for OEF/OIF veterans’ families. Additional income may reduce financial stress; however, the uncertain duration of the income and the consequent (actual or feared) limitations on securing full-time employment may create other challenges (Rosen et al., 2014). Monitoring the financial wellbeing of OEF/OIF personnel as they transition out of the military will be important and may highlight benefits of financial education and planning.
5. Dedicate resources to evaluation of programs and services and longitudinal research. Numerous supports and infrastructures are already well established by the federal government and other organizations to prevent distress, promote resilience, and address difficulties of both service members and families following deployment. Arange of programs and services exist such as the Comprehensive Soldier Fitness Program, the Families Over Coming Under Stress (FOCUS) Project, and online assessments and resources. Some of these programs lack a strong empirical foundation; therefore, the selection, implementation, monitoring, and evaluation of evidence-based services will continue to be important in the years ahead (Institute of Medicine, 2014). Although more research has been conducted with service members deployed in support of OEF/OIF and their families than with any previous wars, a majority of this research is cross-sectional, and some domains (e.g., spiritual, financial, parenting) have received little attention. Some rigorous longitudinal studies are providing insights into changes in functioning over time, including the DoD’s Millennium Cohort Study (MCS; Crum-Cianflone, 2013), the Deployment Life Study (Tanielian, Karney, Chandra, & Meadows, 2014), and the National Health Study for a New Generation of U.S. Veterans (Eber et al., 2013). Clinicians and program administrators can gain insights about the challenges faced by military families over time from these important lines of research and incorporate this information in program development.
6. Attend to diverse populations. Similar to the broader United States population, considerable diversity exists within the military forces. Clinicians are urged to seek education about distinct segments of the OEF/OIF population, including but not limited to National Guard Reserve, females, wounded warriors, and sexual minorities, because of their unique experiences and subsequent needs.
National Guard and Reserve.
In light of the unprecedented utilization of National Guard and Reserve personnel in these wars and their distinct culture and background, an explicit focus on monitoring and supporting these troops as they reintegrate after a high-operational tempo is vital. Research has documented that the experiences of “civilian warriors” may differ from active duty personnel across deployment, reintegration, and longer-term functioning, and therefore warrant explicit attention (Werber et al., 2013). Clinicians working with Guard and Reserve personnel can seek guidance on understanding their distinct cultures and challenges.
According to the 2012 DoD Demographics Profile of the Military Community (DoD, 2012a), women currently comprise approximately 14% of active duty troops and 18% of the Reserves. Women have served in war-efforts throughout history, but their roles have changed dramatically in the past decade. Since 2001, over half of female troops have deployed; of these, over half have deployed multiple times (Defense Advisory Committee on Women in the Services, 2011). The Pentagon recently formalized the integration of women in direct ground combat positions by 2016 (Pellerin, 2013). However, women have already had a range of combat experiences; a national survey of OEF/OIF veterans revealed that 73% of women had experienced at least one combat event (Street, Gradus, Giasson, Vogt, & Resick, 2013).
Little is known about the unique experiences of deployed women to OEF/OIF, but they face challenges beyond the actual or perceived dangers common to all service members, including risks of gender-based violence (Shanks & Schull, 2000), including but not limited to military sexual trauma (Kimerling et al., 2010) and sexual harassment (LeardMann et al., 2013). Combat-exposed women may face increased risks of disordered eating after deployment (Jacobson et al., 2009). Clinicians are urged to develop and offer specific programming for female veterans that address their unique needs and experiences (Street et al., 2013).
Over 52,000 troops have sustained serious physical injury in OEF/OIF (http://www.defense.gov/news/ casualty.pdf), a large percentage of which are due to improvised explosive devices (Belmont, Schoenfeld, & Goodman, 2010). Because of advanced medical care and effective body armor, many more service members are surviving serious injuries than in previous wars, resulting in a cohort of veterans living with significant physical limitations (McNally & Frueh, 2013). The demands on caregivers of wounded, ill, and injured warriors can also be great (Ramchand et al., 2014). Further, estimates suggest approximately one fifth of deployed OEF/OIF troops experience mild traumatic brain injury, a condition that frequently co-occurs with both depression and PTSD (Institute of Medicine, 2014). Clinicians can focus attention on promoting functioning and quality of life issues for our wounded warriors.
Lesbian, gay, and bisexual (LGB) service members may also face distinct stressors upon return from deployment (Oswald & Sternberg, 2014). Although minimal research exists on their unique postdeployment experiences, LGB individuals may struggle to reconnect with intimate partners, particularly in those relationships they keep hidden from others. Furthermore, preliminary research has documented that some LGB veterans experience challenges in seeking care in the VA system, reporting fears surrounding disclosure and not feeling welcome in VA facilities (Sherman, Kauth, Shipherd, & Street, 2014).
7. Include family members in outreach and treatment services. Research has clearly documented that family members are also impacted by service member deployment, and these challenges can be exacerbated by short- and long-term reintegration problems with the service member (Creech et al., 2014; Institute of Medicine, 2013). Given the importance of social support broadly and family specifically, clinicians are urged to offer specific supports to family members and familiarize themselves with local referral options. Numerous programs exist to support families affected by deployment, such as a family education program titled Operation Enduring Families (www.ouhsc.edu/oef), the VA’s phone-based Coaching into Care Program for families concerned about their veteran’s mental health (http://www.mirecc.va.gov/ coaching/), the NAMI Homefront Program which provides peerled classes for family members (www.nami.org/homefront), and the American Red Cross’s Psychological First Aid for Military Families community-based courses (http://www.redcross.org/findhelp/military-families).
In summary, research has found that some OEF/OIF veterans’ experiences abroad are resulting in challenges across several domains of functioning. The mental health community is well situated to provide a collaborative, coordinated response to this increased need to help buffer the effects of more than a decade of war on our nation’s veterans.
Afari, N., Harder, L. H., Madra, N. J., Heppner, P. S., Moeller-Bertram, T., King, C., & Baker, D. G. (2009). PTSD, combat injury, and headache in Veterans Returning from Iraq/Afghanistan. Headache: The Journal of Head and Face Pain, 49, 1267–1276. http://dx.doi.org/10.1111/j.15264610.2009.01517.x
Allen, E. S., Rhoades, G. K., Stanley, S. M., & Markman, H. J. (2010). Hitting home: Relationships between recent deployment, posttraumatic stress symptoms, and marital functioning for Army couples. Journal of Family Psychology, 24, 280–288. http://dx.doi.org/10.1037/a0019405
Allen, E. S., Rhoades, G. K., Stanley, S. M., & Markman, H. J. (2011). On the home front: Stress for recently deployed Army couples. Family Process, 50, 235–247. http://dx.doi.org/10.1111/j.1545-5300.2011 .01357.x
Andersen, J., Wade, M., Possemato, K., & Ouimette, P. (2010). Association between posttraumatic stress disorder and primary care provider-diagnosed disease among Iraq and Afghanistan veterans. PsychosomaticMedicine,72, 498–504. http://dx.doi.org/10.1097/PSY.0b013e3181d969a1
Belmont, P. J., Schoenfeld, A. J., & Goodman, G. (2010). Epidemiology of combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom: Orthopaedic burden of disease. Journal of Surgical Orthopaedic Advances, 19, 2–7.
Blakeley, K., & Jansen, D. (2013). Post-traumatic stress disorder and other mental health problems in the military: Oversight issues for congress. Retrieved from http://www.fas.org/sgp/crs/natsec/R43175.pd
f Bliese, P., Wright, K., Adler, A., Thomas, J., & Hoge, C. (2007). Timing of postcombat mental health assessments. Psychological Services, 4, 141–148. http://dx.doi.org/10.1037/1541-15188.8.131.52
Blow, A. J., Gorman, L., Ganoczy, D., Kees, M., Kashy, D. A., Valenstein, M.,…Chermack,S.(2013).Hazardous drinking and family functioning in National Guard veterans and spouses postdeployment. Journal of Family Psychology, 27, 303–313. http://dx.doi.org/10.1037/a0031881
Bonanno, G. A., Mancini, A. D., Horton, J. L., Powell, T. M., Leardmann, C. A., Boyko, E. J., . . . The Millennium Cohort Study Team. (2012). Trajectories of trauma symptoms and resilience in deployed U.S. military service members: Prospective cohort study. The British Journal of Psychiatry, 200, 317–323. http://dx.doi.org/10.1192/bjp.bp.111.096552
Burnett-Zeigler, I., Valenstein, M., Ilgen, M., Blow, A. J., Gorman, L. A., & Zivin, K. (2011). Civilian employment among recently returning Afghanistan and Iraq National Guard veterans. Military Medicine, 176, 639–646. http://dx.doi.org/10.7205/MILMED-D-10-00450
Cameron, K. L., Marshall, S. W., Sturdivant, R. X., & Lincoln, A. E. (2012). Trends in the incidence of physician-diagnosed mild traumatic brain injury among active duty U.S. military personnel between 1997 and 2007. Journal of Neurotrauma, 29, 1313–1321. http://dx.doi.org/10.1089/neu.2011.2168
Cigrang, J. A., Talcott, G. W., Tatum, J., Baker, M., Cassidy, D., Sonnek, S., . . .Smith Slep, A. M. (2014). Impact of combat deployment on psychological and relationship health: A longitudinal study. Journal of Traumatic Stress, 27, 58–65. http://dx.doi.org/10.1002/jts.21890
Coleman-Jensen, A., Nord, M., & Singh, A. (2013). Household food security in the United States in 2012: Economic Research Report. No. 155. Washington, DC: US Department of Agriculture, Economic Research Service. Creech, S. K., Hadley, W., & Borsari, B. (2014). The impact of military deployment and reintegration on children and parenting: A systematic review. Professional Psychology: Research and Practice, 45, 452–464. http://dx.doi.org/10.1037/a0035055
Crum-Cianflone, N. (2013). The Millennium Cohort Study: Answering long-term health concerns of U.S. military service members by integrating longitudinal survey data with military health system records. In J. Amara & A. Hendricks (Eds.), Military health care: From pre deployment to postseparation (pp. 55–77). New York, NY: Routledge.
Crum-Cianflone, N. F., Bagnell, M. E., Schaller, E., Boyko, E. J., Smith, B., Maynard, C.,…Smith, T. C. (2014). Impact of combat deployment and posttraumatic stress disorder on newly reported coronary heart disease among US active duty and reserve forces. Circulation, 129, 1813–1820. http://dx.doi.org/10.1161/CIRCULATIONAHA.113 .005407
Currier, J. M., Holland, J. M., Drescher, K., & Foy, D. (2015). Initial psychometric evaluation of the Moral Injury Questionnaire—Military version. Clinical Psychology & Psychotherapy, 22, 54–63. http://dx.doi.org/10.1002/cpp.1866
Defense Advisory Committee on Women in the Services. (2011). 2011 report. Retrieved from http://dacowits.defense.gov
Defense Manpower Data Center. (2014). 2013 Quick compass of financial issues: Tabulation of responses (DMDC Report 2013–056). Arlington, VA:
Department of Defense. Department of Defense. (2012a). Demographics profile of the military community. Retrieved from http://www.militaryonesource.mil/12038/MOS/Reports/2012_Demographics_Report.pdf
Department of Defense. (2012b). Department of Defense suicide event report: Calendar year 2011 annual report. Retrieved from http://www.t2.health.mil/programs/dodser
Department of Defense. (2013). Department of Defense suicide event report: Calendar year 2012 annual report. Retrieved from http://www.suicideoutreach.org/Docs/Reports/2012_DoDSER_Annual_Report.pdf
Dickstein, B. D., Suvak, M., Litz, B. T., & Adler, A. B. (2010). Heterogeneity in the course of posttraumatic stress disorder: Trajectories of symptomatology. Journal of Traumatic Stress, 23, 331–339.
DiRamio, D., Ackerman, R., & Mitchell, R. L. (2008). From combat to campus: Voices of student-veterans. NASPA Journal, 45, 73–108. http://dx.doi.org/10.2202/0027-6014.1908
Drescher,K.,Foy,D.,Kelly,C.,Leshner,A.,Schutz,K.,&Litz,B.(2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17, 8–13. http://dx.doi.org/10.1177/1534765610395615
Dursa, E. K., Reinhard, M. J., Barth, S. K., & Schneiderman, A. I. (2014). Prevalence of a positive screen for PTSD among OEF/OIF and OEF/ OIF-era veterans in a large population-based cohort. Journal of Traumatic Stress, 27, 542–549. http://dx.doi.org/10.1002/jts.21956
Eber, S., Barth, S., Kang, H., Mahan, C., Dursa, E., & Schneiderman, A. (2013). The National Health Study for a New Generation of United States Veterans: Methods for a large-scale study on the health of recent veterans. Military Medicine, 178, 966–969. http://dx.doi.org/10.7205/MILMED-D-13-00175
Elbogen, E. B., Johnson, S. C., Newton, V. M., Straits-Troster, K., Vasterling, J. J., Wagner, H. R., & Beckham, J. C. (2012). Criminal justice involvement, trauma, and negative affect in Iraq and Afghanistan war era veterans. Journal of Consulting and Clinical Psychology, 80, 1097– 1102. http://dx.doi.org/10.1037/a0029967
Elbogen, E. B., Sullivan, C. P., Wolfe, J., Wagner, H. R., & Beckham, J. C. (2013). Homelessness and money mismanagement in Iraq and Afghanistan veterans. American Journal of Public Health, 103(Suppl 2), S248– S254. http://dx.doi.org/10.2105/AJPH.2013.30133
5 Elbogen, E. B., Wagner, H. R., Johnson, S. C., Kinneer, P., Kang, H., Vasterling, J. J.,…Beckham, J. C. (2013). Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey. Psychiatric Services, 64, 134–141. http://dx.doi.org/10.1176/appi.ps.004792011
Erbes, C. R., Kaler, M. E., Schult, T., Polusny, M. A., & Arbisi, P. A. (2011). Mental health diagnosis and occupational functioning in National Guard/Reserve veterans returning from Iraq. Journal of Rehabilitation Research and Development, 48, 1159–1170. http://dx.doi.org/10.1682/JRRD.2010.11.0212
Falvo, M. J., Serrador, J. M., McAndrew, L. M., Chandler, H. K., Lu, S. E., & Quigley, K. S. (2012). A retrospective cohort study of U.S. servicemembers returning from Afghanistan and Iraq: Is physical health worsening over time? BMC Public Health, 12, 1124–1131. http://dx.doi.org/10.1186/1471-2458-12-1124
Foran, H., Wright, K., & Wood, M. (2013). Do combat exposure and post-deployment mental health influence intent to divorce? Journal of Social and Clinical Psychology, 32, 917–938. http://dx.doi.org/10.1521/jscp.2013.32.9.917
Gallup.(2014).Religion. Retrieved from http://www.gallup.com/poll/1690/religion.aspx#1
Gewirtz, A. H., Polusny, M. A., DeGarmo, D. S., Khaylis, A., & Erbes, C. R. (2010). Posttraumatic stress symptoms among National Guard soldiers deployed to Iraq: Associations with parenting behaviors and couple adjustment. Journal of Consulting and Clinical Psychology, 78, 599–610. http://dx.doi.org/10.1037/a0020571
Gibbs, D. A., Clinton-Sherrod, A. M., & Johnson, R. E. (2012). Interpersonal conflict and referrals to counseling among married soldiers following return from deployment. Military Medicine, 177, 1178–1183. http://dx.doi.org/10.7205/MILMED-D-12-00008
Granado, N. S., Smith, T. C., Swanson, G. M., Harris, R. B., Shahar, E., Smith, B., . . . TheMillennium Cohort Study Team. (2009). Newly reported hypertension after military combat deployment in a large population-based study. Hypertension, 54, 966–973. http://dx.doi.org/10.1161/HYPERTENSIONAHA.109.132555
Haskell, S. G., Ning, Y., Krebs, E., Goulet, J., Mattocks, K., Kerns, R., & Brandt, C. (2012). Prevalence of painful musculoskeletal conditions in female and male veterans in 7 years after return from deployment in Operation Enduring Freedom/Operation Iraqi Freedom. The Clinical Journal of Pain, 28, 163–167. http://dx.doi.org/10.1097/AJP .0b013e318223d951
Helmer, D. A., Chandler, H. K., Quigley, K. S., Blatt, M., Teichman, R., & Lange, G. (2009). Chronic widespread pain, mental health, and physical role function in OEF/OIF veterans. Pain Medicine, 10, 1174– 1182. http://dx.doi.org/10.1111/j.1526-4637.2009.00723.x
Hermes, E. D., Wells, T. S., Smith, B., Boyko, E. J., Gackstetter, G. G., Miller, S. C., & Smith, T. C., & the Millennium Cohort Study Team. (2012). Smokeless tobacco use related to military deployment, cigarettes and mental health symptoms in a large, prospective cohort study among US service members. Addiction, 107, 983–994. http://dx.doi.org/ 10.1111/j.1360-0443.2011.03737.x
Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351, 13–22. http://dx.doi.org/10.1056/NEJMoa040603
Horton, J. L., Jacobson, I. G., Wong, C. A., Wells, T. S., Boyko, E. J., Smith, B., . . . TheMillennium Cohort Study Team. (2013). The impact of prior deployment experience on civilian employment after military service. Occupational and Environmental Medicine, 70, 408–417. http://dx.doi.org/10.1136/oemed-2012-101073
Hosek, J., & Wadsworth, S. M. (2013). Economic conditions of military families. The Future of Children, 23, 41–59. http://dx.doi.org/10.1353/foc.2013.000
Institute of Medicine. (2013). Returning home from Iraq and Afghanistan: Assessment of readjustment needs of veterans, service members, and their families. Retrieved from http://www.iom.edu/Reports/2013/Returning-Home-from-Iraq-and-Afghanistan.aspx
Institute of Medicine. (2014). Preventing psychological disorders in service members and their families: An assessment of programs. Retrieved from http://www.iom.edu/Reports/2014/Preventing-PsychologicalDisorders-in-Service-Members-and-Their-Families.aspx
Jacobson, I. G., Smith, T. C., Smith, B., Keel, P. K., Amoroso, P. J., Wells, T. S., . . . The Millennium Cohort Study Team. (2009). Disordered eating and weight changes after deployment: Longitudinal assessment of a large US military cohort. American Journal of Epidemiology, 169, 415–427. http://dx.doi.org/10.1093/aje/kwn366
Jakupcak, M., Conybeare, D., Phelps, L., Hunt, S., Holmes, H. A., Felker, B., . . .McFall, M. E. (2007). Anger, hostility, and aggression among Iraq and Afghanistan war veterans reporting PTSD and subthreshold PTSD. Journal of Traumatic Stress, 20(6), 945–954. http://dx.doi.org/10.1002/jts.20258
Jankosky, C. J., Hooper, T. I., Granado, N. S., Scher, A., Gackstetter, G. D., Boyko, E. J., . . . TheMillennium Cohort Study Team. (2011). Headache disorders in the millennium cohort: Epidemiology and relations with combat deployment. Headache: The Journal of Head and Face Pain, 51, 1098–1111. http://dx.doi.org/10.1111/j.1526-4610.2011 .01914.x
Kang, H. K., & Bullman, T. A. (2008). Risk of suicide among US veterans after returning from the Iraq and Afghanistan war zones. Journal of the American Medical Association, 300, 652–653.
Kimerling, R., Street, A. E., Pavao, J., Smith, M. W., Cronkite, R. C., Holmes, T. H., & Frayne, S. M. (2010). Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq. American Journal of Public Health, 100, 1409–1412. http://dx.doi.org/10.2105/AJPH.2009.171793
Kline, A., Falca-Dodson, M., Sussner, B., Ciccone, D. S., Chandler, H., Callahan, L., & Losonczy, M. (2010). Effects of repeated deployment to Iraq and Afghanistan on the health of New Jersey Army National Guard troops: Implications for military readiness. American Journal of Public Health, 100, 276–283. http://dx.doi.org/10.2105/AJPH.2009.16292
5 Kok, B. C., Herrell, R. K., Thomas, J. L., & Hoge, C. W. (2012). Posttraumatic stress disorder associated with combat service in Iraq or Afghanistan: Reconciling prevalence differences between studies. Journal of Nervous and Mental Disease, 200, 444–450. http://dx.doi.org/10.1097/NMD.0b013e3182532312
Lambert, J. E., Holzer, J., & Hasbun, A. (2014). Association between parents’ PTSD severity and children’s psychological distress: A metaanalysis. Journal of Traumatic Stress, 27, 9–17. http://dx.doi.org/10.1002/jts.21891
LaMotte, A. D., Taft, C. T., Weatherill, R. P., Scott, J. P., & Eckhardt, C. I. (2014). Examining intimate partner aggression assessment among returning veterans and their partners. Psychological Assessment, 26, 8–15. http://dx.doi.org/10.1037/a0034579
Leardmann, C. A., Pietrucha, A., Magruder, K. M., Smith, B., Murdoch, M., Jacobson, I. G., . . . TheMillennium Cohort Study Team. (2013). Combat deployment is associated with sexual harassment or sexual assault in a large, female military cohort. Women’s Health Issues, 23, e215–e223. http://dx.doi.org/10.1016/j.whi.2013.05.002
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695–706. http://dx.doi.org/10.1016/j.cpr.2009.07.003
Luxton, D. D., Greenburg, D., Ryan, J., Niven, A., Wheeler, G., & Mysliwiec, V. (2011). Prevalence and impact of short sleep duration in redeployed OIF soldiers. Sleep: Journal of Sleep and Sleep Disorders Research, 34, 1189–1195.
Maguen, S., Luxton, D. D., Skopp, N. A., Gahm, G. A., Reger, M. A., Metzler, T. J., & Marmar, C. R. (2011). Killing in combat, mental health symptoms, and suicidal ideation in Iraq war veterans. Journal of Anxiety Disorders, 25, 563–567. http://dx.doi.org/10.1016/j.janxdis.2011.01.003
Marchione, M. (2012). Almost half of new vets seek disability. Associated Press. Retrieved from http://news.yahoo.com/ap-impact-almost-halfvets-seek-disability-160656481.html
McAndrew, L. M., D’Andrea, E., Lu, S. E., Abbi, B., Yan, G. W., Engel, C., & Quigley, K. S. (2013). What pre-deployment and early post deployment factors predict health function after combat deployment?: A prospective longitudinal study of Operation Enduring Freedom (OEF)/ Operation Iraqi Freedom (OIF) soldiers. Health and Quality of Life Outcomes, 11, 73–82. http://dx.doi.org/10.1186/1477-7525-11-73
McLeland, K. C., Sutton, G. W., & Schumm, W. R. (2008). Marital satisfaction before and after deployments associated with the Global War on Terror. Psychological Reports, 103, 836–844. http://dx.doi.org/10.2466/pr0.103.3.836-844
McNally, R. J., & Frueh, B. C. (2013). Why are Iraq and Afghanistan War veterans seeking PTSD disability compensation at unprecedented rates? Journal of Anxiety Disorders, 27, 520–526. http://dx.doi.org/10.1016/j .janxdis.2013.07.002
Mental Health Advisory Team IV. (2006). Operation Iraqi Freedom 05– 07. Retrieved from www.combatreform.org/MHAT_IV_Report_ 17NOV06.pdf
Mental Health Advisory Team V. (2008). Operation Iraqi Freedom 06–08: Iraq; Operation Enduring Freedom 8. Afghanistan. Retrieved from http://armymedicine.mil/Documents/Redacted1MHATVFEB2008Overview.pdf
Mental Health Advisory Team 9. (2013). Operation Enduring Freedom (OEF) 2013 Afghanistan. Retrieved from http://armymedicine.mil/Documents/MHAT_9_OEF_Report.pdf
Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA: Journal of the American Medical Association, 298, 2141–2148. http://dx.doi.org/10.1001/jama.298.18.2141
Negrusa, B., & Negrusa, S. (2014). Home front: Post-deployment mental health and divorces. Demography, 51, 895–916. http://dx.doi.org/10.1007/s13524-014-0294-9
Newport, F. (2011, June 3). More than 9 in 10 Americans continue to believe in God: Professed belief is lower among younger Americans, Easterners, and liberals. Retrieved from http://www.gallup.com/poll/147887/americans-continue-believe-god.aspx
Oswald, R. F., & Sternberg, M. M. (2014). Lesbian, gay, and bisexual military families: Visible but legally marginalized. In S. MacDermid & D. Riggs (Eds.), Military deployment and its consequences for families (pp. 133–147). New York, NY: Springer. http://dx.doi.org/10.1007/9781-4614-8712-8_8
Pargament, K., Mahoney, A., Exline, J., Jones, J., & Shafranske, E. P. (2013). Envisioning an integrative paradigm for the psychology of religion and spirituality. In K. Pargament, J. Exline, & J. Jones (Eds.), APA handbook of psychology, religion, and spirituality (Vol. 1, pp. 3–19). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/14045-001
Park, C. (2005). Religion as a meaning-making framework in coping with life stress. Journal of Social Issues, 61, 707–729. http://dx.doi.org/ 10.1111/j.1540-4560.2005.00428.x
Pellerin, C. (2013, January 24). Allowing women in combat strengthens joint force. Washington, DC: U.S. Department of Defense. Retrieved from http://defense.gov/news/newsarticle.aspx?id119100
Pietrzak, R. H., Goldstein, M. B., Malley, J. C., Rivers, A. J., Johnson, D. C., Morgan, C. A., III, & Southwick, S. M. (2010). Posttraumatic growth in Veterans of Operations Enduring Freedom and Iraqi Freedom. Journal of Affective Disorders, 126, 230–235. http://dx.doi.org/10.1016/j.jad.2010.03.021
Plumb, T. R., Peachey, J. T., & Zelman, D. C. (2014). Sleep disturbance is common among servicemembers and veterans of Operations Enduring Freedom and Iraqi Freedom. Psychological Services, 11, 209–219. http://dx.doi.org/10.1037/a0034958
Ramchand, R., Tanielian, T., Fisher, M., Vaughan, C., Trail, T., & Epley, C., . . .Ghosh-Dastidar, B. (2014). Hidden heroes: America’s military caregivers (Document Number: RR-499-TEDF). Santa Monica, CA: RAND Corporation.
Resnik, L., Bradford, D. W., Glynn, S. M., Jette, A. M., Hernandez, C. J., & Wills, S. (2012). Issues in defining and measuring veteran community reintegration: Proceedings of the Working Group on Community Reintegration, VA Rehabilitation Outcomes Conference, Miami, FL. Journal of Rehabilitation Research and Development, 49, 87–100. http://dx.doi.org/10.1682/JRRD.2010.06.0107
Riviere, L. A., Merrill, J. C., Thomas, J. L., Wilk, J. E., & Bliese, P. D. (2012). 2003–2009 marital functioning trends among U.S. enlisted soldiers following combat deployments. Military Medicine, 177, 1169– 1177. http://dx.doi.org/10.7205/MILMED-D-12-00164
Rosen, M. I., Ablondi, K., Black, A. C., Mueller, L., Serowik, K. L., Martino, S.,…Rosenheck, R. A. (2014). Work outcomes after benefits counseling among veterans applying for service connection for a psychiatric condition. Psychiatric Services, 65, 1426–1432. http://dx.doi.org/10.1176/appi.ps.201300478
Rudd, M. D., Goulding, J., & Bryan, C. J. (2011). Student veterans: A national survey exploring psychological symptoms and suicide risk. Professional Psychology, Research and Practice, 42, 354–360. http://dx.doi.org/10.1037/a0025164
Rumann, C. B., & Hamrick, F. (2010). Student veterans in transition: Re-enrolling after war zone deployments. The Journal of Higher Education, 81, 431–458. http://dx.doi.org/10.1353/jhe.0.0103
Sayer, N. A., Frazier, P., Orazem, R. J., Murdoch, M., Gravely, A., Carlson, K. F.,…Noorbaloochi, S. (2011). Military to civilian questionnaire: A measure of post deployment community reintegration difficulty among veterans using Department of Veterans Affairs medical care. Journal of Traumatic Stress, 24, 660–670. http://dx.doi.org/10.1002/jts.20706
Sayer, N. A., Noorbaloochi, S., Frazier, P., Carlson, K., Gravely, A., & Murdoch, M. (2010). Reintegration problems and treatment interests among Iraq and Afghanistan combat veterans receiving VA medical care. Psychiatric Services, 61, 589–597. http://dx.doi.org/10.1176/ps 2010.61.6.589
Sayers, S. L., Farrow, V. A., Ross, J., & Oslin, D. W. (2009). Family problems among recently returned military veterans referred for a mental health evaluation. The Journal of Clinical Psychiatry, 70, 163–170. http://dx.doi.org/10.4088/JCP.07m03863
Scott, J. C., Pietrzak, R. H., Mattocks, K., Southwick, S. M., Brandt, C., & Haskell, S. (2013). Gender differences in the correlates of hazardous drinking among Iraq and Afghanistan veterans. Drug and Alcohol Dependence, 127(1–3), 15–22. http://dx.doi.org/10.1016/j.drugalcdep.2012.06.003
Seal, K. H., Cohen, G., Waldrop, A., Cohen, B. E., Maguen, S., & Ren, L. (2011). Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001–2010: Implications for screening, diagnosis and treatment. Drug and Alcohol Dependence, 116(1–3), 93–101. http://dx.doi.org/10.1016/j.drugalcdep.2010.11.027
Seal, K. H., Metzler, T. J., Gima, K. S., Bertenthal, D., Maguen, S., & Marmar, C. R. (2009). Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002–2008. American Journal of Public Health, 99, 1651–1658. http://dx.doi.org/10.2105/AJPH.2008.150284
Seelig, A. D., Jacobson, I. G., Smith, B., Hooper, T. I., Boyko, E. J., Gackstetter, G. D., . . . The Millennium Cohort Study Team. (2010). Sleep patterns before, during, and after deployment to Iraq and Afghanistan. Sleep: Journal of Sleep and Sleep Disorders Research, 33, 1615– 1622.
Shanks, L., & Schull, M. J. (2000). Rape in war: The humanitarian response. Canadian Medical Association Journal, 163, 1152–1156.
Shen, Y. C., Arkes, J., & Williams, T. V. (2012). Effects of Iraq/ Afghanistan deployments on major depression and substance use disorder: Analysis of active duty personnel in the US military. American Journal of Public Health, 102(Suppl 1), S80–S87. http://dx.doi.org/10.2105/AJPH.2011.300425
Sherman, M. D., Harris, J. I., & Erbes, C. (2015). Clinical approaches to addressing spiritual struggle in veterans with PTSD. Professional Psychology: Research and Practice, 46, 203–212. http://dx.doi.org/10.1037/pro0000020
Sherman, M. D., Kauth, M. R., Shipherd, J. C., & Street, R. L., Jr. (2014). Communication between VA providers and sexual and gender minority veterans: A pilot study. Psychological Services, 11, 235–242. http://dx.doi.org/10.1037/a0035840
Sherman, M. D., Larsen, J., Straits-Troster, K., Erbes, C., & Tassey, J. (in press). Veteran-child communication about parental PTSD: A mixed methods pilot study. Journal of Family Psychology. http://dx.doi.org/10.1037/fam0000124
Smith, R., & True, G. (2014). Warring identities: Identity conflict and the mental distress of American veterans of the wars in Iraq and Afghanistan. Society and Mental Health, 4, 147–161. http://dx.doi.org/10.1177/2156869313512212
Smith, T. C., Ryan, M. A., Wingard, D. L., Slymen, D. J., Sallis, J. F., Kritz-Silverstein, D., & The Millennium Cohort Study Team. (2008). New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: Prospective population based US military cohort study. BMJ: British Medical Journal, 336, 366–371. http://dx.doi.org/10.1136/bmj.39430.638241.AE
Straits-Tröster, K., Brancu, M., Goodale, B., Pacelli, S., Wilmer, C., Simmons, E., & Kudler, H. (2011). Developing community capacity to treat post-deployment mental health problems. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 283–291. http://dx.doi.org/10.1037/a0024645
Street, A. E., Gradus, J. L., Giasson, H. L., Vogt, D., & Resick, P. A. (2013). Gender differences among veterans deployed in support of the wars in Afghanistan and Iraq. Journal of General Internal Medicine, 28(2, Suppl 2), S556–S562. http://dx.doi.org/10.1007/s11606-0132333-4
Sullivan, C. P., & Elbogen, E. B. (2014). PTSD symptoms and family versus stranger violence in Iraq and Afghanistan veterans. Law and Human Behavior, 38, 1–9. http://dx.doi.org/10.1037/lhb0000035 Taft, C. T., Watkins, L. E., Stafford, J., Street, A. E., & Monson, C. M. (2011). Posttraumatic stress disorder and intimate relationship problems: A meta-analysis. Journal of Consulting and Clinical Psychology, 79, 22–33. http://dx.doi.org/10.1037/a0022196
Tanielian, T., Farris, F., Epley, C., Farmer, C., Robinson, E., Engel, C.,… Jaycox, L. (2014). Ready to serve: An assessment of community-based provider capacity to deliver competent, quality care to veterans and their families. Santa Monica, CA: RAND.
Tanielian, T., & Jaycox, L. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND.
Tanielian, T., Karney, B., Chandra, A., & Meadows, S. (2014). The deployment life study: Methodological overview and baseline sample description. Santa Monica, CA: RAND. Retrieved from http://www.rand.org/pubs/research_reports/RR209.html
Teten, A. L., Schumacher, J. A., Bailey, S. D., & Kent, T. A. (2009). Male-to-female sexual aggression among Iraq, Afghanistan, and Vietnam veterans: Co-occurring substance abuse and intimate partner aggression. Journal of Traumatic Stress, 22, 307–311. http://dx.doi.org/10.1002/jts.20422
Teten, A. L., Schumacher, J. A., Taft, C. T., Stanley, M. A., Kent, T. A., Bailey, S. D.,…White, D. L. (2010). Intimate partner aggression perpetrated and sustained by male Afghanistan, Iraq, and Vietnam veterans with and without posttraumatic stress disorder. Journal of Interpersonal Violence, 25, 1612–1630. http://dx.doi.org/10.1177/0886260509354583
Thomas, J. L., Wilk, J. E., Riviere, L. A., McGurk, D., Castro, C. A., & Hoge, C. W. (2010). Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3- and 12-months following combat in Iraq. Archives of General Psychiatry, 67, 614–623. http://dx.doi.org/10.1001/archgenpsychiatry.2010.54
Toblin, R. L., Riviere, L. A., Thomas, J. L., Adler, A. B., Kok, B. C., & Hoge, C. W. (2012). Grief and physical health outcomes in U.S. soldiers returning from combat. Journal of Affective Disorders, 136, 469–475. http://dx.doi.org/10.1016/j.jad.2011.10.048
Wells, T., Bagnell, M., Miller, S., Smith, T., Gackstetter, G., & Boyko, E. (2014). U.S. Naval and Marine Corps occupations, posttraumatic stress disorder, depression risk, and absenteeism. Journal of Workplace Behavioral Health, 29, 91–112. http://dx.doi.org/10.1080/15555240.2014.899187
\ Wells, T. S., Leardmann, C. A., Fortuna, S. O., Smith, B., Smith, T. C., Ryan, M. A., . . . The Millennium Cohort Study Team. (2010). A prospective study of depression following combat deployment in support of the wars in Iraq and Afghanistan. American Journal of Public Health, 100, 90–99. http://dx.doi.org/10.2105/AJPH.2008.155432
Werber, L., Schaefer, A., Osilla, K., Wilke, E., Wong, A., Breslau, J., & Kitchens, K. (2013). Support for the 21st century reserve force: Insights on facilitating successful reintegration for citizen warriors and their families. Santa Monica, CA: RAND.
Widome, R., Jensen, A., Bangerter, A., & Fu, S. S. (2015). Food insecurity among veterans of the US wars in Iraq and Afghanistan. Public Health Nutrition, 18, 844–849. http://dx.doi.org/10.1017/S136898001400072X
Widome, R., Kehle, S. M., Carlson, K. F., Laska, M. N., Gulden, A., & Lust, K. (2011). Post-traumatic stress disorder and health risk behaviors among Afghanistan and Iraq War veterans attending college. American Journal of Health Behavior, 35, 387–392. http://dx.doi.org/10.5993/AJHB.35.4.1
Widome, R., Laska, M. N., Gulden, A., Fu, S. S., & Lust, K. (2011). Health risk behaviors of Afghanistan and Iraq war veterans attending college. American Journal of Health Promotion, 26(2), 101–108. http://dx.doi.org/10.4278/ajhp.090826-QUAN-278
Wilk, J. E., Bliese, P. D., Kim, P. Y., Thomas, J. L., McGurk, D., & Hoge, C. W. (2010). Relationship of combat experiences to alcohol misuse among U.S. soldiers returning from the Iraq war. Drug and Alcohol Dependence, 108, 115–121. http://dx.doi.org/10.1016/j.drugalcdep.2009.12.003
Received December 28, 2014
Revision received April 29, 2015
Accepted July 7, 2015