Extended military deployments to combat areas increase stress, anxiety and depression among families

Originally published in MedPage Today

by John Gever, MedPage Today Senior Editor

The longer that U.S. Army soldiers spent in Iraq and Afghanistan, the greater the likelihood that their wives would seek psychiatric treatment, researchers said.

The risk that a woman would receive a new mental illness diagnosis during her husband’s deployment was significantly higher when he was overseas for a year or more, compared with tours of duty of 11 months or less, according to Alyssa J. Mansfield, PhD, MPH, of RTI International in Research Triangle Park, N.C., and colleagues.

Some individual diagnoses were as much as tripled among wives of soldiers with long deployments, Mansfield and colleagues reported in the Jan. 14 issue of the New England Journal of Medicine.

The researchers also found that the number of outpatient mental health visits by Army wives correlated significantly with the length of their husbands’ deployments.

“Overall, our data suggest that the mental health effects of current operations are extending beyond soldiers and into their immediate families,” Mansfield and colleagues wrote.

The researchers based their findings on records for 250,626 wives of active-duty, regular Army personnel sent to Iraq and Afghanistan from 2003 to 2006.

Initially, Mansfield and colleagues had also included husbands of female personnel deployed to these areas, but the results “were highly unstable,” the researchers indicated.

“Without persuasive evidence that male spouses had a similar pattern of effects, it was not appropriate to generalize these results to husbands and wives. Therefore, we opted to be conservative and restrict our analyses to wives (approximately 95% of the complete sample); this limited the generalizability of our results accordingly,” Mansfield and colleagues wrote.

About 173,000 women in the sample had husbands deployed to the two combat areas; the others’ husbands were not deployed and they served as controls.

Among those whose spouses were not deployed, 30.5% received some mental health diagnosis. That percentage rose to 36.6% among those whose husbands were serving in the Middle East.

Among the specific disorders that appeared more common among those whose spouses were deployed were alcohol and drug use, depression, sleep problems, and stress disorders.

And the length of deployment increased the risk and apparent severity of psychiatric problems.

Compared with the nondeployed sample, the adjusted number of “excess” mental health diagnoses per 1,000 women was 41.3 (95% CI 35.6 to 47.1) for deployments lasting one to 11 months, compared with 60.7 (95% CI 53.8 t0 67.7) for deployments of one year or more.

Rates of excess cases, per 1,000 women, for certain specific diagnoses were as follows:

* Depression: 27.4 (95% CI 22.4 to 32.3) for short deployments, 39.3 (95% CI 33.2 to 45.4) for long deployments
* Drug use: 0.8 (95% CI -0.3 to 1.9) for short deployments, 2.6 (95% CI 1.2 to 4.0) for long deployments
* Sleep disorder: 11.6 (95% CI 8.3 to 14.8) for short deployments, 23.5 (95% CI 19.4 to 27.6) for long deployments

Other categories of diagnosis — specifically neurotic stress disorder, impulse control disorder, and personality disorder — showed nonsignificant trends toward increased frequency with long spousal deployments.

Mansfield and colleagues noted that a woman’s age and her husband’s total number of deployments also were correlated with increased risk of psychiatric illness. Those factors were included in the adjustments taken in calculating excess-case rates.

Use of mental health services was also more intense with longer deployments.

The researchers found that the average number of outpatient mental health visits was 19% greater (95% CI 15% to 22%) among wives of personnel deployed for one to 11 months, and 27% higher (95% CI 22% to 32%) among wives of troops with longer deployments — both relative to wives of nondeployed personnel.

In an accompanying editorial, Matthew J. Friedman, MD, PhD, of the VA Medical Center in White River Junction, Vt., noted that the researchers lacked data on the exact timing of the husbands’ deployments, leaving it unclear when the wives’ psychiatric problems emerged — before, during, or after the deployments.

“In other words, was the presence or absence of the soldier more likely to be associated with mental health problems in the wife?” Friedman asked rhetorically, noting that the likely causes would differ considerably.

He also indicated other factors that were unaddressed in the study including the possible roles of intensity of husbands’ combat experiences, presence of post-traumatic stress disorder or physical injury, or problems involving children.

Nevertheless, Friedman indicated that the study’s findings had public health implications.

“Besides the obvious importance of developing appropriate programs to fortify wellness and resilience among spouses and children, such programs might also be expected to prevent psychiatric morbidity among the troops themselves,” he wrote.

Mansfield and colleagues identified several limitations to the study, in addition to the exclusion of male spouses of female soldiers. They included the reliance on administrative records, the possibility that some wives received mental health treatment without a corresponding diagnostic code, and the exclusion of reserve and National Guard personnel.

The researchers said the impacts of deployments could be greater on spouses of reserve and Guard personnel.

“Spouses in our sample probably had at least five years of continuous Army life,” during which they would have had “substantial opportunities for networking, shared experience, and military services associated with life in and around most active-duty communities,” according to Mansfield and colleagues.

Such exposure, generally lacking for families of reserve and Guard personnel, might help wives of Army regulars cope more effectively with their husbands’ deployments, the researchers suggested.

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