9.5

5.3

0

5

10

15

PBES

Table 3. Correlations and Predictors for Patients with Primary Depression

Psychological Health Pathways: A Best-Practice Program for Military Health Care

The views expressed in this article are those of the authors and

do not necessarily reflect the official policy or position of the

Department of the Navy, the Department of Defense or the U.S.

Government.

ABSTRACT Introduction: The military is heavily invested in better understanding factors related to common war-related psychological health injuries. Several studies have been conducted or are currently under way to identify potential causes of PTSD and depression. However, little research has been done to explore these factors in military service members seeking treatment for mental health. Aim: To compare demographic and mental health risk factors between posttraumatic stress disorder (PTSD) and depression for deployed service members presenting for mental health care. Method: Retrospectively analyze self-report data of military service members who entered the Psychological Health Pathways (PHP) Program between March 1, 2009, and February 29, 2012. Results: Deployed services members presenting for mental healthcare reported higher rates of depression than PTSD. Those presenting primarily with depression were significantly different (younger, lower ranking, never married and not attributing visit to deployment reasons) from those with primarily PTSD. The Post-Battle Experiences Scale (PBES) predicted outcomes of PTSD and depression, although with differing relational directions. Conclusion: Depression in deployed service members warrants ongoing consideration and further study to enhance the understanding of this complex population with unique mental health care needs.

INTRODUCTION

METHODS

RESULTS RESULTS

CONCLUSIONS

• A retrospective study analyzing self-report data collected between March 2009 and February 2012. • Data included are from deployed service members presenting to mental health at NHCP and NMCSD. • Patients were grouped according to the primary presenting diagnosis: PTSD (n=166) or depression (n=202). • PTSD was assessed with the PTSD Checklist-Military (PCL-M) and depression was assessed with the Patient Health Questionnaire- 9 (PHQ-9).

• Psychological Health Pathways (PHP), a BUMED initiative, was developed by NCCOSC to implement a psychological health treatment and care management system. • One of the tenants of the PHP program is innovative and coordinated data capture. PHP uses a standard assessment process to routinely collect patient demographics, self- report questionnaires and clinical treatment reviews for service members in mental health treatment. • Centralized PHP data inform treatment planning and progress, program evaluation and resource allocation.

• Identifying more service members who presented primarily with depression versus PTSD suggests that depression is a common issue in mental health for deployed service members. • Significantly different demographic and treatment-seeking attributions in patients presenting primarily with depression may reflect symptom manifestation or a willingness to report various symptoms when seeking mental healthcare. • For patients with primarily PTSD, higher PHQ-9 scores correlated with modifiable life stressors (finance, housing) provided an opportunity for symptom reduction with stabilization. Further, the lack of a relationship with these stressors in the group presenting primarily with depression highlights the uniqueness of these two samples. • Divergent war-related exposures, even aside from combat, account for distinct symptom presentation that necessitates further research as an important risk factor for mental health consequences post deployment. • Of note, these data are comprised of 10% of the mental health population at two military treatment facilities, not randomly sampled, and, as such, may not be representative. • Ongoing comprehensive screening and centralized data capture through PHP should allow for a further understanding of the complex needs of the relatively new and growing population of deployed service members in need of mental healthcare. Ultimately, this could improve not only identification but treatment, and possibly prevention, of stress injuries in military personnel.

Factor Primary

PTSD Primary

Depression p-value Age 0.050

18-24 33.1% 46.0% 25-29 33.7% 30.7% 30-39 24.1% 18.3% ≥40 9.0% 5.0%

Gender 0.560 Male 93.0% 91.3%

Marital Status 0.008 Married 54.9% 48.4% Divorced 12.8% 6.8% Separated 12.2% 9.4% Widowed 0.6% 0.0% Never Married 19.5% 35.4%

Children 0.054 Yes 57.0% 46.4%

Factor Primary

PTSD Primary

Depression p-value Service Branch 0.064

Air Force 0.0% 0.5% Army 5.0% 2.0% Marines 63.8% 74.9% Navy 31.3% 22.6%

Rank 0.008 E1-E3 14.5% 29.9% E4-E6 74.1% 65.0% E7-E9 9.0% 3.5% W1-W5 0.6% 0.5% O1-O3 1.2% 0.5% O4-O10 0.6% 0.5%

Visit Deployment Related <0.001 Yes 91.6% 58.4%

Table 1. Demographics

Graph 1. Severity Measure Outcomes for Patients with Primary PTSD or Primary Depression

10.8

16.6

0

9

18

27

PHQ-9

59.0

40.9

17

34

51

68

85

PCL-M

Primary PTSD

Primary Depression

p<0.001 p<0.001 p<0.001

A. Significant Correlations with PCL-M

Factor r p-value Any Tx for Medical Conditions 0.20 0.003 Limited Duty 0.18 0.006 Post-Battle Experiences Scale 0.16 0.017

C. Significant Correlations with PHQ-9

Factor r p-value Housing Stressor 0.19 0.009 Finance Stressor 0.19 0.009 Physical Health Stressor 0.14 0.018

Table 2. Correlations and Predictors for Patients with Primary PTSD B. Significant Predictors of PCL-M

Factor Beta p-value Limited Duty 0.18 0.046 Post-Battle Experiences Scale 0.22 0.005

D. Significant Predictors of PHQ-9

Factor Beta p-value None Found

A. Significant Correlations with PCL-M

Factor r p-value Visit Deployment Related 0.21 0.001 Limited Duty 0.18 0.005 Post-Battle Experiences Scale 0.25 <0.001

C. Significant Correlations with PHQ-9

Factor r p-value Visit Deployment Related -0.15 0.017 Post-Battle Experiences Scale -0.17 0.008

B. Significant Predictors of PCL-M

Factor Beta p-value Visit Deployment Related 0.15 0.024 Post-Battle Experiences Scale 0.17 0.001

D. Significant Predictors of PHQ-9

Factor Beta p-value Post-Battle Experiences Scale -0.15 0.014

• More service members met criteria for depression than PTSD. • Compared to patients presenting primarily with PTSD, those presenting with depression were, on average, significantly younger, lower ranking, had never been married and didn’t attribute their mental health visit to deployment reasons. • In patients presenting primarily with PTSD, various stressors (housing, finance and physical health) were identified as correlates with depression. • The Post-Battle Experiences Scale (PBES), significantly predicted PTSD and depression. However, the direction of the relationship differed: A higher score on the PBES predicted a higher PTSD score for the primarily PTSD group; a lower score on the PBES predicted a higher depression score for the primarily depressed group.

Capt. Scott L. Johnston, MSC, USN, Jennifer A. Webb-Murphy, PhD, Ines Pandzic, MA, Susan F. Fesperman, MPH, Scott C. Roesch, PhD, Elizabeth A. Vishnyak, MA, Amela Ahmetovic, BA, Steven K. Gerard, BA, Bonnie J. Nebeker, AA, Stephanie C. Raducha, BA

Naval Center for Combat & Operational Stress Control, US Navy Bureau of Medicine and Surgery