PTSD and TBI Comorbities - Relationships of Suicide for Returned Combat Veterans

Running head: PTSD AND TBI COMORBIDITIES 1

PTSD and TBI Comorbidities:

Understanding the Relationship Between These Disorders and the Suicide Rate Amongst

Returned Combat Veterans

Charles Mayer

University of San Francisco

PTSD AND TBI COMORBIDITIES 2

Throughout the past twelve years in America's involvement in conflicts across the globe,

troubling new problems are being faced by the soldiers who return home from deployments.

With the advancement in body armor, many of the injuries that would have been considered fatal

in the past are now saving more lives than ever. However, this advancement in armor and rapid

trauma treatment on the battlefields are leading to a new generation of disorders. Of these

disorders, there are two common diagnoses wounded soldiers return with: Post Traumatic Stress

Disorder (PTSD) and Traumatic Brain Injury (TBI). PTSD and TBI have been clinically

diagnosed more than any other disorder since 2001. Since these are relatively new diagnoses due

to the nature of modern warfare trauma, little is known as to accurate measuring instruments,

correlations with suicidal ideations, and other neurological disorders. The concussive blasts

from roadside bombs and suicide bombers are now being absorbed in the areas not protected by

the body armor, the limbs, and the head. The head trauma and emotional injuries that may be

associated with being involved in violent combat have now been categorized into two distinct

diagnoses. Some level of a TBI is often associated with neurological symptoms, such as

anterograde or retrograde amnesia. TBI is defined by the Diagnostic and Statistical Manual for

Mental Disorders DSM-IV-TR (2000) 4th ed., text rev. as an injury which causes specific

impairments in the ability to concentrate, processing speed, impulsivity, and mood swings. A

TBI is a history of head trauma that stems from a concussion. It is important to note that a TBI

has different levels of severity, with a mild Traumatic Brain Injury (mTBI) being the least

affected and most common diagnosis, and a severe Traumatic Brain Injury (sTBI) being the most

affected and least diagnosed trauma wound. According to the DSM-IV-TR (2000) 4th ed., text

rev., Post Traumatic Stress Disorder (PTSD) is a disorder which manifests in different severities

of mental processing: extreme alertness, nightmares, flashbacks of wartime scenarios, and other


psychological manifestations. PTSD results from exposure to "an extreme traumatic stressor

involving direct personal experience of an event that involves actual or threatened death or

serious injury". Being diagnosed with one of these disorders, or a combination of the two, may

greatly increase the risk of suicide and suicidal ideations among returning soldiers. The impacts

of these disorders are everywhere, as over 2,000,000 American soldiers have served in combat

the past decade. The majority of these diagnoses have occurred within the past decade,

coinciding with American conflicts in Iraq and Afghanistan (Morisette et al., 2001, p. 340).

These disorders can affect quality of life greatly, such that many turn to suicide to quiet the

emotional distress that is commonly associated with a TBI and/or PTSD. This review intends to

gather accurate diagnostic rates of these two disorders. Ultimately, with a better understanding

of these disorders, efforts can be made to diagnose these disorders to provide quicker treatment.

It is important to note that these studies all attempt to determine diagnoses of mental disorders

and suicide in a nonexperimental setting. The history of military personnel being subjected to

experimental research has been long and dubious, therefore no experimental research into

determining mental disorders and suicide are conducted with soldiers for the purpose of

determining the relationship between PTSD, TBI, and suicide.

The DSM-IV-TR (2000) 4th ed., text rev. defines PTSD as having numerous symptom

criterion. These symptoms include initially having "a stressor, intrusive recollection,

avoiding/numbing, hyper-arousal, duration, and functional significance." It only takes a

diagnosis of having several of these categories to be fully diagnosed with PTSD. According to

the DSM-IV-TR (2000) 4th ed., text rev., a TBI is a history of head trauma directly relating from

a concussive blast absorbed in combat. It is important to note that not all cases of PTSD and TBI

are directly related to military service, but the majority of these cases in the past decade are from


soldiers returning home from a war zone. Having a diagnosis of one, or both, dramatically

increased the risk of depression, and in the most severe cases, suicide. Since the majority of

people in the armed forces are male, the majority of the subjects in research are predominantly

male as well. There are difficulties, however, in determining the rates of soldiers with TBI, since

the nature of TBI is made more difficult to discern because of the nonspecific nature of post-

concussive symptoms (PCS) (Morisette et al., 2011, p. 340).

Research conducted by Hoge et al. (2008) directly looked at the relationship in a mTBI

within returning soldiers from combat. Since this is a nonexperimental study, it is important to

note the aim of this study. The purpose was to determine statistical significance between soldiers

who were diagnosed with PTSD and TBI. A total of 2,525 soldiers were surveyed 3-4 months

directly after a one-year long deployment to Iraq. A total of 124 (4.9%) were diagnosed with

loss of conscious (LOC) injuries, 260 (10.3%) with altered mental status, and 435 (17.2%) with

other injuries during deployment (Hoge et al., 2008, p. 453). A large percentage of these

soldiers, 43.9%, met the clinical criteria to be diagnosed with PTSD as well. The results indicate

that there is a very strong association between mTBI and PTSD in soldiers three to four months

post-deployment, since there were many overlapping symptoms. Initially, 2,714 soldiers

properly completed the questionnaire developed by the Walter Reed Army Institute of Research.

The dependent variable was measured in symptoms of post-concussive symptoms or PTSD that

were measured by the nine-question depression-assessment module of the Patient Health

Questionnaire (Hoge et al., 2011, p. 455). The independent variables were the life stressors and

experiences each individual underwent during military service, amount of time spent overseas,

and more specifically amount of combat exposure. The PTSD subjects had to meet the DSM-IV-

TR (2000) criteria, which is a mixture of testing positive for avoidance, arousal, and avoidance


symptoms. Statistical multivariate analysis tests were utilized with the use of multiple logistic

regression, as it was deemed to be the most effective to properly measure validity. Chi-Squared

testing and Analysis of Variance (ANOVA) were also conducted, and it is the aggregate of these

measures which make the research conducted by Hoge et al. (2008) a landmark study. Ninety-

five percent of the subjects were male, since an Infantry Brigade was assessed (at the time of the

study, Infantry was an all-male military occupational speciality). Of these, the majority were

Caucasian. This may be a possible area of bias, since infantry units tend to have more Caucasian

soldiers (Hoge et al., 2008, p. 455). Overall, 43.9% of soldiers who experiences a LOC also met

PTSD criteria (p<001). The two major factors for PTSD diagnosis was level of combat intensity,

and loss of consciousness. Injuries that were diagnosed as having an altered mental state and

high level of combat intensity were statistically significantly associated with PTSD (p=.002) but

not depression (Hoge et al., 2008, p. 458). One of the more difficult areas of research lies within

determining if certain factors are causes or correlations, and although research has not proved a

causal relationship, the correlations between the two are not disputed. Some potential areas of

bias in this study were similar to other studies. It was found very difficult due to the nature of

military movement to keep track of the soldiers at different time intervals. Also, soldiers who

were away for training on a survey day or at medical appointments were not assessed. It is these

soldiers who are at medical appointments that may need to be more thoroughly researched, since

PTSD and TBI have a direct impact on physical symptoms, including back pain, sleep

disturbance, memory problems, and emotional distress (Hoge et al., 2008, p. 460-461). As with

almost all large scale military trials, the main limitation is relying on the accuracy of self-

reported data, where recall bias may be an issue. This limitation occurs in nearly every large-

scale clinical trial.


Recent research has been conducted to more properly determine the relationships

between PTSD, TBI, and suicidal ideations. In a smaller-scale experimental study conducted by

Morisette et al. (2011), 213 veterans who had recently returned home from combat overseas were

tested to assess the relationships between PTSD, TBI, and Post-Concussive Symptoms (PCS).

Participants were given questionnaires, and were divided into either one or two different clinical

studies. Excluding factors for this process were soldiers who were diagnosed as being bipolar,

currently at risk to themselves or others, or started taking medications for their symptoms during

the previous three months (Morisette et al., 2011, p. 344). There is possible bias on relying

solely on questionnaires, but due to the nature of the military work schedule there is no other

effective way. The study determined that 47.0% of the first group screened positive for TBI and

44.4% screened positive in the second group, so determining the validity of the screenings both

groups were collapsed into one large group. Eighty seven percent of the population group was

male, which can be attributed to the nature of the military being male dominant.

These veterans were tested for a possible TBI or PTSD disorder using the Brief

Traumatic Brain Injury Screen (BTBIS), the PTSD Checklist-Military Version (PCL-M), or two

other similar and known measures to ensure validity. These test measures are the dependent

variables. This study was unique in that it had a more controlled access of the soldiers than most

larger-scale studies. Partial disaggregation was utilized to ensure the accuracy of these models

was most appropriate for a smaller sample size (Morisette et al., 2011, pp. 368-369). The scores

of the PTSD subjects were remarkably similar to the TBI subjects, and often overlapped. This

overlapping of symptoms is now associated with depression and suicidal ideations amongst war

veterans, as well as other physical symptoms.


In an attempt to view current data in a different way, research by Brenner et al. (2008)

utilizes data known about PTSD and TBI and qualitatively assessed these in relation to suicidal

ideations and suicides in the military. A total of 65.1% of OIF soldiers and 46% of OEF soldiers

reported a positive history of association with combat (Brenner et al., 2008, p. 212; Hoge et al.,

2008, pp. 456-457) up to the year 2008. In this study, three aspects of questioning were

involved. These constructs were perceived burdensomeness by the soldiers, reaction to acute or

chronic pain, and a feeling of a failure to belong and reintegrate (Brenner et al., 2008, p. 213).

This relatively small scale study is included to offer a qualitative construct of suicide in veterans

and how PTSD and TBI affects emotional stability. A sample of 16 OIF/OEF veterans were

chosen who had significant combat experience, with the majority coming from the Army (12).

All were either diagnosed with PTSD, TBI, or a combination. Nine were aged 18-24, and six

were 40 or older. The questions that were posited to the soldiers all revolved around the three

themes listed above. After the initial interviews were taken, four other team members

independently reviewed and coded each transcript to track universal themes and ideas. After a

further in-depth examination of the interviews, the researchers concluded that the point of

saturation had been reached and that no new ideas were being shown. The independent variable

was each individual experience unique to the soldier in regards to suicidal ideation. Common

themes were those of the perceived notion that "in the military I was always told to 'man up'...so

I really try to shut it out or not to let them see me" (Brenner et al., 2008, p. 217). Similarly, a

notion of being desensitized to emotional experiences of combat has made it particularly difficult

to adapt back into society, causing emotional distancing. A feeling of normalcy was not felt, as

typical reactions would be that they are not living, just existing. Additional burdens were placed

on the soldiers when they exited the military, as many felt that they had lost their identity, and


now had no way to support their family and felt like a failure. This was especially exacerbated

when the soldiers were involuntarily discharged due to medical reasons (Brenner et al., 2008, p.

218). Lastly, the theme of failed belongingness is explored. Many of the veterans stated that

post military, they had no one to share their common bond with. There is a strong theme of

connectivity and emotional health. This can also be stated as a fundamental failure to

emotionally connect with others outside the military after time served, and lacking a shared

experience that is so common to positive mental health. According to the modules determined

by Brenner et al. (2008), suicide risks are the highest when there is a conjunction of the two

groups of burdensomeness and failed belonging.

As a result of this study, certain coping strategies were theorized to combat each one of

the three modules. Mindfulness based therapy is attempting to teach people how to feel their

thoughts in a way which is analytical, cognitive, and nonjudgmental. In regards to

burdensomeness, it is stressed that certain veterans may need to receive vocational support, to

help create their identity. The perceived therapy for the feeling of failed belongingness is a

socially appropriate interaction therapy, such as couples counseling, Battle-minded Training

offered by Walter Reed (which specifically is aimed at the transition from service-member to

civilian), and other mixes of civilian-military therapy. It is stated that if tests were available to

accurately neurologically test for PTSD and TBI, therapeutic intervention could be given much

sooner and save potential lives (Brenner et al., 2008, p. 223). The researchers individually

checked the data for thoroughness, and multiple times with a random team member. The

qualitative measure was based on the Interpersonal-Psychology Theory of Suicide Risk, which is

a common and valid measurement for analysis in this field. Such flaws in this research study

would be the small sample-size used. Since the saturation point had been reached, the validity


measure was not affected. These same themes are being currently researched to help prevent

suicide in military members who suffer from one or more disorders.

There is also the issue of barriers to healthcare, especially the stigma of asking for help in

the military. Combined with a lack of proper diagnosis, stigma and perceived malingering can

lead soldiers to not ask for help. New research into the area of perceived stigma and other

barriers to healthcare were conducted by Wright et al. (2009). A sample size of 680 soldiers

from differing units were chosen three months after their return from overseas combat. The main

initiative of this research was to determine perceptions of leader behaviors and unit cohesion,

and the perceived stigma to access healthcare (Wright et al., 2009, p. 108). Data was collected

to determine the soldiers perception of unit cohesion in predicting barriers to care. As this is

another study relying on nonexperimental methods, the aim of this research must be understood.

Using standardized testing methods, the relationship between perceived stigma to receive mental

health was looked at in a leadership context. Specifically, the Patient Health Questionnaire

(PHQ) was utilized as well as the 13-item Depression and Anxiety Scale (Wright et al., 2009, p.

112). Also utilized was the 17-item PCL, which is clinically valid. The majority of the subjects

(431) had been in the military five years or less, were between the ages of 20-24 (39.2%), male

(82.6%), and Caucasian (56.1%). This is typical with other demographics coming from a

combined arms unit in the military (Hoge et al., 2008; Morisette et al., 2011). Reliability

analyses were carried out periodically throughout each different criteria in this experiment,

ranging from twelve different factors. It was determined that officer leadership is appropriate for

determining adequate reliability within individual units, as with each unit there is a different and

unique style of leadership (Wright et al., 2009, p. 114). In accordance with the correlations

among the main variables (N=591), four different predictors of stigma were tested. Ratings of


unit leadership, perception on combat cohesion, interaction between soldiers and leaders, and

mental health analyses were tested (Wright et al., 2009, p. 115). The interactions show that the

lowest scores of stigma and barriers to care were the unit where the officer participation was the

highest and perceived unit cohesion was the best (p<.01). It is the inverse relationship between

perceived leadership qualities and the stigma of receiving care that needs to be understood and

acted upon by the military. The results of this study were consistent with at least six other

similar studies conducted between 2001 and 2007 (Wright et al., 2009, p. 127).

Recent research has been conducted that also examines risk factors of suicides or suicide

attempts in the Army from 2001-2009 (Black, Gallaway, Bell, & Ritchie, 2011). The aim of this

study was to examine the soldiers already at risk to inversely determine what relationships

certain diagnoses maintained with suicide and suicidal ideations. The list of stressors for suicide

include socio-cultural and military risk factors, psychological risk factors, suicide event

characteristics, and stress load (Black et al., 2011, pp. 436-437). A total number of 874 Army

suicide cases were analyzed from information selected from the Army Behavioral Health

Integrated Data Environment (ABHIDE) from 2001-2009. Each individual stress factors was

identified individually, such as looking at the diagnosis of mental health disorders and examining

the levels of combat exposed to the soldiers. From the year 2001 to 2009, suicide rates have

more than doubled to a level of 22 per 100,000 (Black et al., 2011, p. 437). In 2001, there were

52 Army suicides, and in 2009 there were 162. This trend existed in all components of the

Army, including National Guard and Reserve forces. As of 2008, U.S. military deaths have

increased at a much higher rate than civilian deaths. Civilian suicide rates have maintained

relative stability in the past decade, fluctuating from 18.0 to 18.5 deaths per 100,000 per year. It

is noted that with the current operations tempo the U.S. Army has sustained, often this means


individual soldiers will deploy overseas to combat two or three times in a period of five years.

This is a commonly held belief as to why the suicide numbers have exponentially increased

(Black et al., 2011, p. 438).

It is important to note that although other stressors were examined in detail, for the

purpose of this review only the psychological factors will be reported. Fifty four percent of

suicides did not have any diagnosis of mental disorders, whereas 46% had received one mental

health diagnosis, and 31% had received multiple diagnoses. These results are remarkably

consistent with Hoge et al. (2008). Deployment histories almost doubled the risk of suicide,

from 35.6% (non-deployed) to 64.4% (one or more deployments). In summation, risk factors for

soldiers diagnosed with a mental health disorder were up to 4.7 times higher than soldiers

without a diagnosis. Twenty five percent of all Army suicides had previously been diagnosed

with an adjustment disorder. This term is somewhat lacking since it is sometimes used by

clinicians as a safety diagnosis when they know something is wrong, but do not know what

(Black et al., 2011, p. 442). Reduction of mental healthcare stigma is noted as being a major

obstacle to accessing healthcare. This study was non-experimental, as it looked through

ABHIDE records at suicide rate in the Army alone. A major limitation of this study was that

there were no non-suicide control groups available to be analyzed. Therefore, only correlations

could be inferred. It was the intent of this review to examine the preeminent studies in each

factor, and compare them.

Brenner et al. (2011) conducted follow-up research to contextualize their previous

qualitative studies with a more in-depth quantitative study. This article is considered along with

Hoge et al. (2008), to be the most relied upon research method for determining PTSD, TBI, and

suicidal behaviors. The results show that PTSD, and subsequently a history with TBI was


associated with increased risk for suicide attempt (OR=2.8; 95% Cl: 1.5, 5.1) (Brenner et al.,

2011, p. 417). Examined for the first time were previous generational diagnoses of PTSD and

suicide rates among those veterans. Among Vietnam veterans, soldiers with PTSD were fifteen

times more likely to attempt suicide than those not diagnosed with the disorder. Soldiers

returning from Iraq and Afghanistan were over four times as likely to have suicidal ideations

than soldiers without diagnosed PTSD (Brenner et al., 2011, p. 417). Out of necessity this study

only concentrated on a military population, which examined 81 veterans with a history of suicide

attempts. Of these 81 soldiers who had received VA healthcare between 2004 and 2006, two

control patients were matched for each individual patient, stratified for age and gender

demographics. Medical records were looked over to ensure a lack of bias, to thoroughly show

that each veteran had attempted suicide and was involved in the healthcare system at the time. A

final reliability check of patient medical charts, including neurologic conditions and suicidal

ideations, was conducted by a final member of the research team.

Key words were entered for four separate disorders and symptoms. These four disorders

were PTSD, TBI, suicide, and neurologic disease. Included in the neurologic disease categories

were key words such as: Huntingtons, Parkinsons, and stroke. The overall methodologies

utilized were varied, as either Fisher's Exact or Chi-Squared tests were used where appropriate.

Patients who had been diagnosed with PTSD were 64% in the case group, and 42% in the control

group (Chi-Squared p=.001). These percentages are consistent with the previous Hoge et al.

(2008) study. The relationship between diagnosed TBI was not clear. Thirty percent of the case

group were diagnosed with a TBI, along with 29% of the control group (Chi-Squared p=.97).

Furthermore, dual-diagnosis of these two disorders was 22% in the case group and 16% of the

control group (Chi-Squared p=.21). Eighty three percent of the overall patients were male, as is


consistent with military service. It must be noted that TBI and neurologic disorders were not

individually significant to be associated with suicide attempts. Unlike the other disorders, PTSD

is a significant predictor of suicide attempts (p=.0008) (Brenner et al., 2011 p. 421). When TBI

and PTSD were examined together, PTSD was deemed significant whereas TBI was not.

Overall, patients diagnosed with PTSD were 2.8 times the odds of a suicide attempt versus

patients not diagnosed with PTSD. The odds of a dual-diagnosis of PTSD and TBI rose from 2.8

times (PTSD only) to 3.3 times as likely to attempt suicide as with those diagnosed with TBI

only.

Limitations of this study shared a similar theme as with most studies regarding veterans

(Brenner et al., 2011; Hoge et al., 2008). A major limitation involving all of the studies is the

reliance on retrospective data. This data is received often directly from the patient may change

from time, thereby affecting the reliability. Another major limitation that is common is the lack

of medical data to determine PTSD, TBI, and other related disorders. Too often clinicians

diagnose these disorders based off one thirty minute session with a patient. Since the diagnosis

is unique to each clinician, exact data has been difficult to ascertain.

The main strengths of these studies has been the increased awareness of mental disorders

in the past decade. Whereas little data had previously been collected targeting PTSD, TBI and

suicide, now there is an abundance. Still, this matters little unless the data is reliable and valid.

Studies conducted by Brenner et al. (2011) and Hoge et al., (2008) has helped ascertain reliable

data and information regarding these correlations. One of the major challenges with studying

suicide in veterans has been the retrospective nature of the disorders themselves. The diagnosis

now is made based upon medical records and cognitive behavioral health analysis of the

individual veteran. Of all the numerous data collected by researchers, studies conducted by


Brenner et al., (2011) and Hoge et al. (2008) are considered to be landmark studies based on their

validity and reliability. There are immediate practical applications that can be based upon

current research. Most importantly, now that more reliable data has been gathered to show

percentages of soldiers with PTSD or a TBI, these must be matched with some sort of reliable

biomarker. Whether these imaging techniques include an fMRI, CT scan, PET scan, or MEG

imaging, the data collected must be reliably applied to information gathered (Brenner et al.,

2011).

Another important practical application is lessoning the stigma of receiving mental

healthcare in the military. Now that there are statistics that draw strong correlations between unit

cohesion and leadership effectiveness, there needs to be a more intensive effort starting from the

top down in de-stigmatizing receiving mental healthcare (Wright et al., 2009, p. 127). Examples

of this are specifically diagnosing concussive blasts while on the battlefield instead of shrugging

it off, and seeking behavioral healthcare during and after redeployment. The perception that

seeking help for emotional trauma is associated with malingering must be redefined. With a

more intensive program that holds senior leaders accountable, many suicides can be prevented.

Areas of future research that should be addressed are the instrumentations of veterans studies

themselves. Instead of gathering retrospective data which relies upon possibly brain damaged

individuals to denote psychological or physical symptoms, there should be a larger scale

database share within the military which is more streamlined and universal (similar to the

ABHIDE but a result of cohesive confluence between all armed forces sectors). This

achievement concurrent with the existence of a reliable biomarker for mental disorders would

allow for these disorders to be diagnosed at the earliest stage, allowing therapeutic benefit to be

the greatest. The scale of the previous military program testing body armor designed to protect


physical characteristics must be applied now to protect mental disorders as well. The ultimate

goal of this area of research is to diagnose as early as possible, and with treatment, improve

quality of life. In an era where the United States loses more soldiers each year to suicide than to

enemy combat, this is more than an essential task. Perhaps with the emergence of more refined

neuroimaging techniques and with a dramatic de-stigmatization of mental health treatment in the

military, countless lives will be saved.


References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders

(4th ed., text rev.). doi:10.1176.appi.books.9780890423349

Black, S., Gallaway, M., Bell, M., & Ritchie, E. (2011). Prevalence and risk factors associated

with suicides of Army soldiers 2001-2009. Military Psychology, 23(4), 433-451.

doi:10.1037/h0094766

Brenner, L., Betthauser, L., Homaifar, B., Villarreal, E., Harwood, J., Staves, P., & Huggins, J.

(2011). Posttraumatic stress disorder, traumatic brain injury, and suicide attempt history

among veterans receiving mental health services. Suicide and Life-Threatening Behavior,

41(1), 416-423. doi:10.1111/j.1943-278X.2011.00041.x

Brenner, L., Gutierrez, P., Cornette, M., Betthauser, L., Bahraini, N., & Staves, P. (2008). A

Qualitative study of potential suicide risk factors in returning combat veterans. Journal

of Mental Health Counseling, 30(3), 211-225.

Hoge, C., McGurk, D., Thomas, J., Cox, A., Engel, C., & Castro, C. (2008). Mild traumatic brain

injury in U.S. soldiers returning from Iraq. The New England Journal of Medicine,

358(5), 453-463. doi:10.1056/NEJMoa072972

Morisette, S., Woodward, M., Kimbrel, N., Meyer, M., Dolan, S., & Gulliver, B. (2011).

Deployment-related TBI, persistent postconcussive symptoms, PTSD, and depression in

OEF/OIF veterans. American Journal of Rehabilitation Psychology, 56(4), 340-350.

doi:10.1037/a0025462


Wright, K., Cabrera, O., Bliese, P., Adler, A., Hoge, C., & Castro, C. (2009). Stigma and barriers

to care in soldiers postcombat. Psychological Services, 6(2), 108-124.

doi:10.1037/a0012620

PTSD and TBI Comorbities - Relationships of Suicide for Returned Combat Veterans

Documents

Transcript of PTSD and TBI Comorbities - Relationships of Suicide for Returned Combat Veterans