The evolution of mental health outcomes across a combat deployment cycle: A longitudinal study of a Guam-based National Guard unit

Autoři: Dale W. Russell aff001;  Cristel Antonia Russell aff002
Působiště autorů: Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America aff001;  Department of Marketing, Pepperdine University, Graziadio Business School, Malibu, California, United States of America aff002
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0223855


Sustained overseas military operations over the last two decades have resulted in large numbers of United States and Allied servicemembers being faced with multiple unique occupational and environmental stressors, from serving in a combat zone, to having to be away from family and home for long periods of time. These stressors result in numerous negative health (physical and mental) and behavioral outcomes. Whereas there is a substantial amount of research focused on deployment-related health outcomes within active duty military populations, reserve forces are less understood. This study focuses on a United States Army National Guard combat unit before, during and after a deployment to Afghanistan. This prospective longitudinal study, conducted over the course of an operational deployment cycle (i.e., before, during and after), documents the trajectories of salient mental health outcomes (i.e., post-traumatic stress, depression, general anxiety, and aggression). The findings show that both combat (e.g., killing others) and non-combat (e.g., boredom) stressors negatively affect mental health outcomes, and the severity of these outcomes increases over the course of a deployment cycle. Of special note, the study reveals key gender differences in the evolution of PTSD, depression and anxiety across a deployment cycle: females report increased PTSD, depression and anxiety 6 months post-deployment whereas the levels reported by males stabilize at their mid-deployment levels. The findings offer insights for medical providers and policymakers in developing more targeted health promotion campaigns and interventions, especially during the post-deployment phase.

Klíčová slova:

Aggression – Depression – Longitudinal studies – Mental health and psychiatry – Post-traumatic stress disorder – Research assessment – Surveys – United States


1. DeBruyne NF, Leland A. American war and military operations casualties: Lists and statistics. Congressional Research Service Washington United States; 2015 Jan 2. Available from:

2. Ciarleglio MM, Aslan M, Proctor SP, Concato J, Ko J, Kaiser AP, et al. Associations of stress exposures and social support with long-term mental health outcomes among US Iraq War Veterans. Behav Ther. 2018 Sep 1;49(5):653–67. doi: 10.1016/j.beth.2018.01.002 30146134

3. Yang S, Wynn GH, Ursano RJ. A clinician’s guide to PTSD biomarkers and their potential future use. Focus. 2018 Apr 27;16(2):143–52.

4. Fink DS, Calabrese JR, Liberzon I, Tamburrino MB, Chan P, Cohen GH, et al. Retrospective age-of-onset and projected lifetime prevalence of psychiatric disorders among US Army National Guard soldiers. J Affect Disorders. 2016 Sep 15;202:171–7. doi: 10.1016/j.jad.2016.05.025 27262639

5. Russell DW, Kazman JB, Benedek DM, Ursano RJ, Russell CA. Domestic Civil Support Missions Can Aggravate Negative Mental Health Outcomes Among National Guardsmen: The Moderating Role of Economic Difficulties. J Trauma Stress. 2017 Apr;30(2):195–9. doi: 10.1002/jts.22164 28141895

6. Hofscher R, Bennett E, Crabtree M, Russell E, Isacco A. National Guard and Reserve: An Examination of Differences on Posttraumatic Stress Symptoms. Mil Behav Health. 2017 Apr 3;5(2):157–62.

7. Russell DW, Cohen GH, Gifford R, Fullerton CS, Ursano RJ, Galea S. Mental health among a nationally representative sample of United States Military Reserve Component Personnel. Soc Psychiatry Psychiatr Epidemiol. 2015 Apr 1;50(4):639–51. doi: 10.1007/s00127-014-0981-2 25421591

8. Russell DW, Benedek DM, Naifeh JA, Fullerton CS, Benevides N, Ursano RJ, et al. Social support and mental health outcomes among US Army Special Operations personnel. Mil Psychol. 2016 Oct 6;28(6):361–75.

9. Bennett EA, Crabtree M, Schaffer ME, Britt TW. Mental health status and perceived barriers to seeking treatment in rural reserve component veterans. JRSS. 2011 Sep 1;26(3):113.

10. Russell DW, Russell CA, Riviere LA, Thomas JL, Wilk JE, Bliese PD. Changes in alcohol use after traumatic experiences: The impact of combat on Army National Guardsmen. Drug Alcohol Depend. 2014 Jun 1;139:47–52. doi: 10.1016/j.drugalcdep.2014.03.004 24685562

11. Heavey SC, Homish DL, Goodell EA, Homish GG. US reserve soldiers' combat exposure and intimate partner violence: Not more common but it is more violent. Stress Health. 2017 Dec;33(5):617–23. doi: 10.1002/smi.2748 28198140

12. Hoopsick RA, Vest BM, Homish DL, Homish GG. Combat exposure, emotional and physical role limitations, and substance use among male United States Army Reserve and National Guard soldiers. Qual Life Res. 2018 Jan 1;27(1):137–47. doi: 10.1007/s11136-017-1706-2 28921407

13. Defense Health Agency. Mental health disorder prevalence among active duty service members in the military health system, fiscal years 2005–2016. Silver Spring, MD: Deployment Health Clinical Center, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Center. 2017.

14. Norman SB, Haller M, Hamblen JL, Southwick SM, Pietrzak RH. The burden of co-occurring alcohol use disorder and PTSD in US Military veterans: Comorbidities, functioning, and suicidality. Psychol Addict Behav. 2018 Mar;32(2):224. doi: 10.1037/adb0000348 29553778

15. Ramchand R, Rudavsky R, Grant S, Tanielian T, Jaycox L. Prevalence of, risk factors for, and consequences of posttraumatic stress disorder and other mental health problems in military populations deployed to Iraq and Afghanistan. Current psychiatry reports. 2015 May 1;17(5):37. doi: 10.1007/s11920-015-0575-z 25876141

16. Broekman BF, Olff M, Boer F. The genetic background to PTSD. Neurosci Biobehav Rev. 2007 Jan 1;31(3):348–62. doi: 10.1016/j.neubiorev.2006.10.001 17126903

17. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Eng J Med. 2004 Jul 1;351(1):13–22.

18. Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. Am J Psychiatry. 2007 Jan;164(1):150–3. doi: 10.1176/ajp.2007.164.1.150 17202557

19. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). American Psychiatric Pub; 2013 May 22.

20. Yehuda R. Advances in understanding neuroendocrine alterations in PTSD and their therapeutic implications. Ann N Y Acad Sci. 2006 Jul 1;1071(1):137–66.

21. Koenen KC, Saxe G, Purcell S, Smoller JW, Bartholomew D, Miller A, et al. Polymorphisms in FKBP5 are associated with peritraumatic dissociation in medically injured children. Mol Psychiatry. 2005 Aug 9;10(12):1058. doi: 10.1038/ 16088328

22. Koenen KC, Stellman SD, Sommer JF Jr, Stellman JM. Persisting posttraumatic stress disorder symptoms and their relationship to functioning in Vietnam veterans: a 14‐year follow‐up. J Trauma Stress. 2008 Feb;21(1):49–57. doi: 10.1002/jts.20304 18302174

23. Odani S, Agaku IT, Graffunder CM, Tynan MA, Armour BS. Tobacco product use among military veterans—United States, 2010–2015. MMWR. 2018 Jan 12;67(1):7. doi: 10.15585/mmwr.mm6701a2 29324732

24. Olenick M, Flowers M, Diaz VJ. US veterans and their unique issues: enhancing health care professional awareness. Adv Med Educ Pract. 2015;6:635. doi: 10.2147/AMEP.S89479 26664252

25. Breslau N, Davis GC, Peterson EL, Schultz LR. A second look at comorbidity in victims of trauma: The posttraumatic stress disorder–major depression connection. Biol Psychiatry. 2000 Nov 1;48(9):902–9. doi: 10.1016/s0006-3223(00)00933-1 11074228

26. McFarlane AC, Papay P. Multiple diagnoses in posttraumatic stress disorder in the victims of a natural disaster. J Nerv Ment Dis. 1992 Aug;180(8):498–504. doi: 10.1097/00005053-199208000-00004 1500931

27. Russell DW, Whalen RJ, Riviere LA, Clarke-Walper K, Bliese PD, Keller DD, et al. Embedded behavioral health providers: An assessment with the Army National Guard. Psychol Serv. 2014 Aug;11(3):265. doi: 10.1037/a0037005 24841511

28. Booth‐Kewley S, Larson GE, Highfill‐McRoy RM, Garland CF, Gaskin TA. Correlates of posttraumatic stress disorder symptoms in Marines back from war. J Trauma Stress. 2010 Feb;23(1):69–77. doi: 10.1002/jts.20485 20104587

29. Halverson RR, Bliese PD, Moore RE, Castro CA. Psychological Well-Being and Physical Health Symptoms of Soldiers Deployed for Operation Uphold Democracy. A Summary of Human Dimensions Research in Haiti (No. WRAIR/TR-95-0008). Washington DC: Walter Reed Army Inst of Research. 1995 May 25.

30. Mayeux R, Basham KK, Bromet EJ, Burke GL, Charney DS, Davis M, et al. Gulf War and Health. 2008;6. Available from:

31. Linley PA, Joseph S. Positive change following trauma and adversity: A review. J Trauma Stress. 2004 Feb;17(1):11–21. doi: 10.1023/B:JOTS.0000014671.27856.7e 15027788

32. Morden E, Oster M, O'Brien CP, editors. Substance use disorders in the US Armed Forces. National Academies Press; 2013 Mar 21.

33. Schaller EK, Woodall KA, Lemus H, Proctor SP, Russell DW, Crum-Cianflone NF. A longitudinal comparison of posttraumatic stress disorder and depression among military service components. Mil Psychol. 2014 Mar 1;26(2):77–87.

34. Kwan J, Jones M, Hull L, Wessely S, Fear N, MacManus D. Violent behavior among military reservists. Aggress Behav. 2017 May;43(3):273–80. doi: 10.1002/ab.21687 27775160

35. Polusny MA, Martyr MA, Erbes CR, Arbisi PA, Kramer M, Gibson E, et al. Prevalence and Risk Factors for Post-Traumatic Stress Disorder Symptoms among National Guard/Reserve Component Service Members Deployed to Iraq and Afghanistan. Comprehensive Guide to Post-Traumatic Stress Disorders. 2016 Jun:455–87.

36. Pietrzak E, Pullman S, Cotea C, Nasveld P. Effects of deployment on mental health in modern military forces: A review of longitudinal studies. J Mil Veterans Health. 2012 Aug;20(3):24.

37. Bliese PD, Wright KM, Adler AB, Thomas JL, Hoge CW. Timing of postcombat mental health assessments. Psychol Serv. 2007 Aug;4(3):141.

38. Thomas JL, Wilk JE, Riviere LA, McGurk D, Castro CA, Hoge CW. Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Arch Gen Psychiatry. 2010 Jun 1;67(6):614–23. doi: 10.1001/archgenpsychiatry.2010.54 20530011

39. Wilson AL, Hoge CW, McGurk D, Thomas JL, Clark JC, Castro CA. Application of a new method for linking anonymous survey data in a population of soldiers returning from Iraq. Ann Epidemiol. 2010 Dec 1;20(12):931–8. doi: 10.1016/j.annepidem.2010.08.008 21074108

40. Grube JW, Morgan M, Kearney KA. Using self-generated identification codes to match questionnaires in panel studies of adolescent substance use. Addict Behav. 1989 Jan 1;14(2):159–71. doi: 10.1016/0306-4603(89)90044-0 2786325

41. Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. San Antonio, TX: Annual convention of the international society for traumatic stress studies. 1993 Oct 24;462.

42. Spitzer RL, Kroenke K, Williams JB, Patient Health Questionnaire Primary Care Study Group. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA. 1999 Nov 10;282(18):1737–44. doi: 10.1001/jama.282.18.1737 10568646

43. Lang AJ, Laffaye C, Satz LE, Dresselhaus TR, Stein MB. Sensitivity and specificity of the PTSD checklist in detecting PTSD in female veterans in primary care. J Trauma Stress. 2003 Jun;16(3):257–64. doi: 10.1023/A:1023796007788 12816338

44. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092–7. doi: 10.1001/archinte.166.10.1092 16717171

45. Adler AB, Britt TW, Castro CA, McGurk D, Bliese PD. Effect of transition home from combat on risk‐taking and health‐related behaviors. J Trauma Stress. 2011 Aug;24(4):381–9. doi: 10.1002/jts.20665 21818784

46. Ehlers A, Mayou RA, Bryant B. Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents. J Abnorm Psychol. 1998 Aug;107(3):508. doi: 10.1037//0021-843x.107.3.508 9715585

47. Forbes D, Bennett N, Biddle D, Crompton D, McHugh T, Elliott P, et al. Clinical presentations and treatment outcomes of peacekeeper veterans with PTSD: Preliminary findings. Am J Psychiatry. 2005 Nov 1;162(11):2188–90. doi: 10.1176/appi.ajp.162.11.2188 16263866

48. McHugh T, Forbes D, Bates G, Hopwood M, Creamer M. Anger in PTSD: is there a need for a concept of PTSD-related posttraumatic anger?. Clin Psychol Rev. 2012 Mar 1;32(2):93–104. doi: 10.1016/j.cpr.2011.07.013 22236575

49. Wilk JE, Bliese PD, Thomas JL, Wood MD, McGurk D, Castro CA, et al. Unethical battlefield conduct reported by soldiers serving in the Iraq war. J Nerv Ment Dis. 2013 Apr 1;201(4):259–65. doi: 10.1097/NMD.0b013e318288d302 23538969

50. Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, Marmar CR, et al. Trauma and the Vietnam war generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel; 1990 Mar.

51. Boscarino JA. Diseases among men 20 years after exposure to severe stress: implications for clinical research and medical care. Psychosom Med. 1997 Nov 1;59(6):605–14. doi: 10.1097/00006842-199711000-00008 9407579

52. Wilk JE, Bliese PD, Kim PY, Thomas JL, McGurk D, Hoge CW. Relationship of combat experiences to alcohol misuse among US soldiers returning from the Iraq war. Drug Alcohol Depend. 2010 Apr 1;108(1–2):115–21. doi: 10.1016/j.drugalcdep.2009.12.003 20060237

53. Kim PY, Britt TW, Klocko RP, Riviere LA, Adler AB. Stigma, negative attitudes about treatment, and utilization of mental health care among soldiers. Mil Psychol. 2011 Jan 13. doi: 10.1080/08995605.2011.534407

54. Kim PY, Thomas JL, Wilk JE, Castro CA, Hoge CW. Stigma, barriers to care, and use of mental health services among active duty and National Guard soldiers after combat. Psychiatr Serv. 2010 Jun;61(6):582–8. doi: 10.1176/ps.2010.61.6.582 20513681

55. Anderson L, Campbell‐Sills L, Ursano RJ, Kessler RC, Sun X, Heeringa SG, et al. Prospective associations of perceived unit cohesion with postdeployment mental health outcomes. Depress Anxiety. 2019 Jan 29. Available from:

56. Kelley CL, Britt TW, Adler AB, Bliese PD. Perceived organizational support, posttraumatic stress disorder symptoms, and stigma in soldiers returning from combat. Psychol Serv. 2014 May;11(2):229. doi: 10.1037/a0034892 24364593

57. Ehrhart MG, Bliese PD, Thomas JL. Unit-level OCB and unit effectiveness: Examining the incremental effect of helping behavior. Hum Perform. 2006 Apr 1;19(2):159–73.

58. Wright KM, Cabrera OA, Bliese PD, Adler AB, Hoge CW, Castro CA. Stigma and barriers to care in soldiers postcombat. Psychol Serv. 2009 May;6(2):108.

59. Chen G, Bliese PD. The role of different levels of leadership in predicting self-and collective efficacy: Evidence for discontinuity. J Appl Psychol. 2002 Jun;87(3):549. doi: 10.1037/0021-9010.87.3.549 12090612

60. Thomas JL, Bliese PD, Jex SM. Interpersonal Conflict and Organizational Commitment: Examining Two Levels of Supervisory Support as Multilevel Moderators 1. J Appl Soc Psychol. 2005 Nov;35(11):2375–98.

61. Zinzow HM, Britt TW, Pury CL, Raymond MA, McFadden AC, Burnette CM. Barriers and facilitators of mental health treatment seeking among active-duty army personnel. Mil Psychol. 2013 Sep 30;25(5):514–35.

62. Sayer NA, Frazier P, Orazem RJ, Murdoch M, Gravely A, Carlson KF, et al. Military to civilian questionnaire: A measure of postdeployment community reintegration difficulty among veterans using Department of Veterans Affairs medical care. J Trauma Stress. 2011 Dec;24(6):660–70. doi: 10.1002/jts.20706 22162082

63. Blais AR, Thompson MM, McCreary DR. The development and validation of the army post-deployment reintegration scale. Mil Psychol. 2009 Jun 30;21(3):365–86.

64. Cohen GH, Sampson LA, Fink DS, Wang J, Russell D, Gifford R, et al. Gender, position of authority, and the risk of depression and posttraumatic stress disorder among a national sample of US Reserve component personnel. Women's Health Issues. 2016 May 1;26(3):268–77. doi: 10.1016/j.whi.2016.01.001 26899583

65. Wallace M, Saurel-Cubizolles MJ, EDEN Mother–Child Cohort Study Group. Returning to work one year after childbirth: data from the mother–child cohort EDEN. Matern Child Health J. 2013 Oct 1;17(8):1432–40. doi: 10.1007/s10995-012-1147-z 23054452

66. Ford JD. Complex PTSD: Research directions for nosology/assessment, treatment, and public health. Eur J Psychotraumatol. 2015 Dec 1;6(1):27584.

67. Hosek J, Kavanagh JE, Miller LL. How deployments affect service members. Santa Monica, CA: Rand Corporation; 2006 Feb 7.

Článek vyšel v časopise


2019 Číslo 10