Resilience & Reintegration: What Can We Learn from Research? Karen Quigley, Ph.D. NJ WRIISC

1. Resilience & Reintegration: What Can We Learn from Research?Karen Quigley, Ph.D.NJ WRIISC

2. Today’s Goals • Describe the prospective, longitudinal HEROES Project study  • Discuss initial findings on predictors of non-specific physical symptoms after deployment • Discuss how these findings can inform clinical practice

3. Healthy Resilience after Operational and Environmental Stressors • Longitudinal, prospective cohort study of 790 Army National Guard and Reserve Soldiers deploying to Iraq or Afghanistan

4. A Primary Study Aim: Understand what factors lead to increased physical symptoms in those returning from combat (and that can have important functional consequences)

5. Methods • Army National Guard and Reserve Soldiers volunteered at Fort Dix, NJ and Camp Shelby, MS • Informed Consent (both VA and DOD) Data Collection Timeline • Risk and Resilience survey measures Deployment • PRE-DEPLOYMENT • Surveys • Lab Stressor with physiology • Immed. Post-Deployment • Surveys • Saliva samples (rest & first a.m.) • 3 Months Post • Surveys mailed to home • One Year Post • Surveys mailed to home

6. Risk and Resilience Measures

7. Outcome Measure - Non-Specific Physical Symptoms – Patient Health Questionnaire-15 (PHQ-15)

8. Participants • 790 Army Reserve and National Guard Soldiers deploying to Iraq and Afghanistan • Predominant unit types are Military Police, Infantry, Artillery, and Support

9. Current Study Status • Phase 1: N = 790 • Phase 2: N = 430 • Phase 3: N = 278 • Phase 4: N = 260 *This analysis uses the first 320 Soldiers who have both Phase 1 and 2 data.

11. Number of Prior Deployments 3% 4% 11% 56% 27%

12. Participant Home State

13. Comparisons with other adult samples – Psychosocial Factors

14. Change in Symptoms from Pre- to Post-Deployment Comparison data from 35% 35% 20% 10% primary care sample:

15. Demographic, Risk & Resilience Predictors of Non-Specific Symptoms ***Social support and avoidance coping become non-significant after deployment variables are added to the model.

16. Deployment Predictors of Non-Specific Symptoms

17. Aftermath of Battle Experiences • I saw refugees who had lost their homes and belongings as a result of battle • I interacted with enemy soldiers who were taken as prisoners of war • I took care of injured or dying people • I was exposed to the sight, sound or smell of dying men and women

18. Unit Cohesion • The members of my unit are cooperative with each other. • The members of my unit know that they can depend on each other. • The members of my unit stand up for each other. 1 3 5 Strongly Disagree – Neither Agree/Disagree – Strongly Agree

19. What Can We Do?

20. Limitations • No non-deployed control group • Sample only NG and Reserves, only Army & all volunteer • Physical symptoms immediately after deployment may be due to physical strain and there may be reluctance to report symptoms at homecoming • We do not know whether the same predictors will be important for later non-specific physical symptoms

21. Clinical Implications • Non-specific physical symptoms increase immediately after return from deployment • These may be due to physical strain, although the factors that predict who has more symptoms (after accounting for their pre-deployment symptoms) are not just physical factors • Increased physical symptoms are a common finding after a hazardous deployment

22. Clinical Implications (continued) • Suggests that we need to take into account the Veteran’s overall social network and experiences when assessing physical symptoms, not just their combat exposures • Physical or mental functioning is also frequently poorer when non-specific symptoms are increased

23. Functioning • Data from Kline et al.,2009 AJPH indicates that 15.5% of those who never deployed before and 24.4% of those who deployed before had physical function below the population mean before deployment

24. Functioning • In our sample, only 3.8% had physical function below the population norm before deploying and this was evenly split between those who had deployed previously and those who had not • However, at pre-deployment we do see lower mental function than physical function (in our preliminary data)

25. Functioning and Symptoms • Our hypothesis is that as symptoms increase and function declines, healthcare utilization will increase • We will explore these relationships once we have the full data set • Need to be careful about assumptions • For example, Deployment is NOT always the most common major stressor just before a deployment

27. Clinical Implications (continued) • Another assumption to be cautious about: • We have a tendency to assume that because we see the individuals who need care that all returning Veterans require care • Some Veterans recently back from a deployment may simply need support • Help them navigate the system by providing “institutional social support” – Individual VA staff can be part of the Veteran’s social support network.

28. Thanks to the Soldiers for their Participation!

29. Additional Thanks • Research Team: • Dr. Elizabeth D’Andrea • COL Charles Engel, MC, Deployment Health Clinical Center • Dr. Judith Lyons, Jackson, MS VA • Dr. Karen Raphael, NYU • Dr. Kathi Heffner, Univ. of Rochester • Robert DeMarco & Florence Chua • Research Assistants: Adam Ackerman, Heather Hamtil, Conway Yen, Benjamin Batorsky, Naci Powell, Isabella Rodrigues, Gladstone Reid, Michael Bergen & Sarah Lachiewicz

30. Funding/Support Center for Health Care Knowledge Management (New Jersey HSR&D REAP) VA Health Services Research & Development Deployment Health Clinical Center, Dept of Defense VA New Jersey War Related Illness and Injury Study Center