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Subgroups of US IRAQ and Afghanistan veterans: associations with traumatic brain injury and mental health conditions

  • Military/Veteran TBI
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Abstract

U. S. veterans of Iraq and Afghanistan are known to have a high prevalence of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and depression, which are often comorbid and share many symptoms. Attempts to describe this cohort by single diagnoses have limited our understanding of the complex nature of this population. The objective of this study was to identify subgroups of Iraq and Afghanistan veterans (IAVs) with distinct compositions of symptoms associated with TBI, PTSD, and depression. Our cross-sectional, observational study included 303,716 IAVs who received care in the Veterans Health Administration in 2010–2011. Symptoms and conditions were defined using International Classification of Diseases, Ninth Revision codes and symptom-clusters were identified using latent class analysis. We identified seven classes with distinct symptom compositions. One class had low probability of any condition and low health care utilization (HCU) (48 %). Other classes were characterized by high probabilities of mental health comorbidities (14 %); chronic pain and sleep disturbance (20 %); headaches and memory problems (6 %); and auditory problems (2.5 %). Another class had mental health comorbidities and chronic pain (7 %), and the last had high probabilities of most symptoms examined (3 %). These last two classes had the highest likelihood of TBI, PTSD, and depression and were identified as high healthcare utilizers. There are subgroups of IAVs with distinct clusters of symptom that are meaningfully associated with TBI, PTSD, depression, and HCU. Additional studies examining these veteran subgroups could improve our understanding of this complex comorbid patient population.

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References

  • Afari, N., Harder, L. H., Madra, N. J., Heppner, P. S., Moeller-Bertram, T., King, C., & Baker, D. G. (2009). PTSD, combat injury, and headache in Veterans Returning from Iraq/Afghanistan. Headache, 49(9), 1267–1276.

    Article  PubMed  Google Scholar 

  • Association, A. P. (2000). Diagnostic and statistical manual of mental disorders, 4th edition, Text revision (4th ed.). Washington: American Psychiatric Association.

    Book  Google Scholar 

  • Bandeen-Roche, K., Miglioretti, D. L., Zeger, S. L., & Rathouz, P. J. (1997). Latent variable regression for multiple discrete outcomes. Journal of the American Statistical Association, 92(440), 1375–1386.

    Article  Google Scholar 

  • Belanger, H. G., Curtiss, G., Demery, J. A., Lebowitz, B. K., & Vanderploeg, R. D. (2005). Factors moderating neuropsychological outcomes following mild traumatic brain injury: a meta-analysis. Journal of the International Neuropsychological Society: JINS, 11(3), 215–227.

    Article  PubMed  Google Scholar 

  • Belanger, H. G., Uomoto, J. M., & Vanderploeg, R. D. (2009). The Veterans Health Administration’s (VHA’s) Polytrauma System of Care for mild traumatic brain injury: costs, benefits, and controversies. The Journal of Head Trauma Rehabilitation, 24(1), 4–13.

    Article  PubMed  Google Scholar 

  • Belanger, H. G., Vanderploeg, R. D., Soble, J. R., Richardson, M., & Groer, S. (2012). Validity of the Veterans Health Administration’s traumatic brain injury screen.

  • Borzecki, A. M., Wong, A. T., Hickey, E. C., Ash, A. S., & Berlowitz, D. R. (2004). Identifying hypertension-related comorbidities from administrative data: what’s the optimal approach? American Journal of Medical Quality: The Official Journal of the American College of Medical Quality, 19(5), 201–206.

    Article  Google Scholar 

  • Boscarino, J. A. (2006). Posttraumatic stress disorder and mortality among U.S. Army veterans 30 years after military service. Annals of Epidemiology, 16(4), 248–256.

    Article  PubMed  Google Scholar 

  • Carlson, K. F., Nelson, D., Orazem, R. J., Nugent, S., Cifu, D. X., & Sayer, N. A. (2010). Psychiatric diagnoses among Iraq and Afghanistan war veterans screened for deployment-related traumatic brain injury. Journal of Traumatic Stress, 23(1), 17–24.

    PubMed  Google Scholar 

  • Carlson, K. F., Kehle, S. M., Meis, L. A., Greer, N., Macdonald, R., Rutks, I., et al. (2011). Prevalence, assessment, and treatment of mild traumatic brain injury and posttraumatic stress disorder: a systematic review of the evidence. The Journal of Head Trauma Rehabilitation, 26(2), 103–115.

    Article  PubMed  Google Scholar 

  • Cifu, D. X., Taylor, B. C., Carne, W. F., Bidelspach, D., Sayer, N. A., Scholten, J., & Campbell, E. H. (2014). Traumatic brain injury, posttraumatic stress disorder, and pain diagnoses in OIF/OEF/OND Veterans. Journal of Rehabilitation Research and Development, 50(9), 1169–1176.

    Article  Google Scholar 

  • Cohen, B. E., Marmar, C., Ren, L., Bertenthal, D., & Seal, K. H. (2009). ASsociation of cardiovascular risk factors with mental health diagnoses in Iraq and Afghanistan war veterans using VA health care. JAMA, 302(5), 489–492.

    Article  CAS  PubMed  Google Scholar 

  • DoD Worldwide Numbers for TBI | DVBIC. (n.d.). http://www.dvbic.org/dod-worldwide-numbers-tbi. Accessed 7 Aug 2014.

  • Elbogen, E. B., Wagner, H. R., Johnson, S. C., Kinneer, P., Kang, H., Vasterling, J. J., et al. (2013). Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey. Psychiatric Services, 64(2), 134–141.

    Article  PubMed Central  PubMed  Google Scholar 

  • Frayne, S. M., Chiu, V. Y., Iqbal, S., Berg, E. A., Laungani, K. J., Cronkite, R. C., et al. (2011). Medical care needs of returning veterans with PTSD: their other burden. Journal of General Internal Medicine, 26(1), 33–39.

    Article  PubMed Central  PubMed  Google Scholar 

  • Friedemann-Sánchez, G., Sayer, N. A., & Pickett, T. (2008). Provider perspectives on rehabilitation of patients with polytrauma. Archives of Physical Medicine and Rehabilitation, 89(1), 171–178.

    Article  PubMed  Google Scholar 

  • Gondusky, J. S. R., & Michael, P. (2005). Protecting military convoys in Iraq: an examination of battle injuries sustained by a mechanized battalion during operation Iraqi Freedom II. Military Medicine, 170(6), 546–549.

    Article  PubMed  Google Scholar 

  • Hart, T., Sherer, M., Whyte, J., Polansky, M., & Novack, T. A. (2004). Awareness of behavioral, cognitive, and physical deficits in acute traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 85(9), 1450–1456.

    Article  PubMed  Google Scholar 

  • Hebenstreit, C., Madden, E., & Maguen, S. (2014). Latent classes of PTSD symptoms in Iraq and Afghanistan female veterans. Journal of Affective Disorders, 166, 132–138.

    Article  PubMed  Google Scholar 

  • Hill, J. J., 3rd, Mobo, B. H. P., Jr., & Cullen, M. R. (2009). Separating deployment-related traumatic brain injury and posttraumatic stress disorder in veterans: preliminary findings from the Veterans Affairs traumatic brain injury screening program. American Journal of Physical Medicine & Rehabilitation / Association of Academic Physiatrists, 88(8), 605–614.

    Article  Google Scholar 

  • Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351(1), 13–22.

    Article  CAS  PubMed  Google Scholar 

  • Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA, the Journal of the American Medical Association, 295(9), 1023–1032.

    Article  CAS  PubMed  Google Scholar 

  • Hoge, C. W., McGurk, D., Thomas, J. L., Cox, A. L., Engel, C. C., & Castro, C. A. (2008). Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq. New England Journal of Medicine, 358(5), 453–463.

    Article  CAS  PubMed  Google Scholar 

  • Holowka, D. W., Marx, B. P., Gates, M. A., Litman, H. J., Ranganathan, G., Rosen, R. C., & Keane, T. M. (2014). Ptsd diagnostic validity in veterans affairs electronic records of iraq and afghanistan veterans. Journal of Consulting and Clinical Psychology, 82(4), 569–579.

    Article  PubMed  Google Scholar 

  • Iverson, G. L. (2005). Outcome from mild traumatic brain injury. Current Opinion in Psychiatry, 18(3), 301–317.

    Article  PubMed  Google Scholar 

  • Jacobsen, L. K., Southwick, S. M., & Kosten, T. R. (2001). Substance use disorders in patients with posttraumatic stress disorder: a review of the literature. The American Journal of Psychiatry, 158(8), 1184–1190.

    Article  CAS  PubMed  Google Scholar 

  • Kang, H. K., Natelson, B. H., Mahan, C. M., Lee, K. Y., & Murphy, F. M. (2003). Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: a population-based survey of 30,000 veterans. American Journal of Epidemiology, 157(2), 141–148.

    Article  PubMed  Google Scholar 

  • Landy, P. J. (1998). Neurological sequelae of minor head and neck injuries. Injury, 29(3), 199–206.

    Article  CAS  PubMed  Google Scholar 

  • Lanza, S. T., Bray, B. C., & Collins, L. M. (2012). An introduction to latent class and latent transition analysis. In J. A. Schinka, W. F. Velicer, & I. B. Weiner (Eds.), Handbook of psychology (2nd ed., Vol. 2, pp. 691–716). Hoboken, NJ: Wiley

  • Lew, H. L., Poole, J. H., Vanderploeg, R. D., Goodrich, G. L., Dekelboum, S., Guillory, S. B., et al. (2007). Program development and defining characteristics of returning military in a VA Polytrauma Network Site. Journal of Rehabilitation Research and Development, 44(7), 1027–1034.

    Article  PubMed  Google Scholar 

  • Lew, H. L., Otis, J. D., Tun, C., Kerns, R. D., Clark, M. E., & Cifu, D. X. (2009). Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad. Journal of Rehabilitation Research and Development, 46(6), 697–702.

    Article  PubMed  Google Scholar 

  • Maguen, S., Madden, E., Bosch, J., Galatzer-Levy, I., Knight, S. J., Litz, B. T., et al. (2013). Killing and latent classes of PTSD symptoms in Iraq and Afghanistan veterans. Journal of Affective Disorders, 145(3), 344–348.

    Article  PubMed  Google Scholar 

  • Management of Concussion/mTBI Working Group. (2009). VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury. Journal of Rehabilitation Research and Development, 46(6), CP1–CP68.

    Google Scholar 

  • McDevitt-Murphy, M. E., Williams, J. L., Bracken, K. L., Fields, J. A., Monahan, C. J., & Murphy, J. G. (2010). PTSD symptoms, hazardous drinking, and health functioning among U.S.OEF and OIF veterans presenting to primary care. Journal of Traumatic Stress, 23(1), 108–111.

    PubMed Central  PubMed  Google Scholar 

  • Murray, C. K., Reynolds, J. C., Schroeder, J. M., Harrison, M. B., Evans, O. M., & Hospenthal, D. R. (2005). Spectrum of care provided at an echelon II Medical Unit during Operation Iraqi Freedom. Military Medicine, 170(6), 516–520.

    Article  PubMed  Google Scholar 

  • Nampiaparampil, D. E. (2008). Prevalence of chronic pain after traumatic brain injury: a systematic review. JAMA, The Journal of the American Medical Association, 300(6), 711–719.

    Article  CAS  PubMed  Google Scholar 

  • Norman, R. S., Jaramillo, C. A., Amuan, M., Wells, M. A., Eapen, B. C., & Pugh, M. J. (2013). Traumatic brain injury in veterans of the wars in Iraq and Afghanistan: communication disorders stratified by severity of brain injury. Brain Injury: [BI], 27(13-14), 1623–1630.

    Article  Google Scholar 

  • Norrie, J., Heitger, M., Leathem, J., Anderson, T., Jones, R., & Flett, R. (2010). Mild traumatic brain injury and fatigue: a prospective longitudinal study. Brain Injury: [BI], 24(13–14), 1528–1538.

    Article  Google Scholar 

  • Possemato, K., Wade, M., Andersen, J., & Ouimette, P. (2010). The impact of PTSD, depression, and substance use disorders on disease burden and health care utilization among OEF/OIF veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 2(3), 218–223.

    Article  Google Scholar 

  • Pugh, M. J. V., Finley, E. P., Copeland, L. A., Wang, C.-P., Noel, P. H., Amuan, M. E., et al. (2014). Complex comorbidity clusters in OEF/OIF veterans: the polytrauma clinical triad and beyond. Medical Care, 52(2), 172–181.

    Article  PubMed  Google Scholar 

  • Romesser, J., Booth, J., Benge, J., Pastorek, N., & Helmer, D. (2012). Mild traumatic brain injury and pain in Operation Iraqi Freedom/Operation Enduring Freedom veterans. Journal of Rehabilitation Research and Development, 49(7), 1127–1136.

    Article  PubMed  Google Scholar 

  • Ruff, R. L. (2008). Headaches among Operation Iraqi Freedom/Operation Enduring Freedom veterans with mild traumatic brain injury associated with exposures to explosions. Journal of Rehabilitation Research and Development, 45(7), 941–952.

    Article  PubMed  Google Scholar 

  • Sayer, N. A., Rettmann, N. A., Carlson, K. F., Bernardy, N., Sigford, B. J., Hamblen, J. L., & Friedman, M. J. (2009). Veterans with history of mild traumatic brain injury and posttraumatic stress disorder: challenges from provider perspective. Journal of Rehabilitation Research and Development, 46(6), 703.

    Article  PubMed  Google Scholar 

  • Schneiderman, A. I., Braver, E. R., & Kang, H. K. (2008). Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: persistent postconcussive symptoms and posttraumatic stress disorder. American Journal of Epidemiology, 167(12), 1446–1452.

    Article  PubMed  Google Scholar 

  • Scholten, J. D., Sayer, N. A., Vanderploeg, R. D., Bidelspach, D. E., & Cifu, D. X. (2012). Analysis of US Veterans Health Administration comprehensive evaluations for traumatic brain injury in Operation Enduring Freedom and Operation Iraqi Freedom Veterans. Brain Injury, 26(10), 1177–1184.

    Article  PubMed  Google Scholar 

  • Seal, K. H., Bertenthal, D., Miner, C. R., Sen, S., & Marmar, C. (2007). Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine, 167(5), 476–482.

    Article  PubMed  Google Scholar 

  • Selim, A. J., Fincke, G., Ren, X. S., Lee, A., Rogers, W. H., Miller, D. R., et al. (2004). Comorbidity assessments based on patient report: results from the Veterans Health Study. The Journal of Ambulatory Care Management, 27(3), 281–295.

    Article  PubMed  Google Scholar 

  • Sigford, B. J. (2008). “To care for him who shall have borne the battle and for his widow and his orphan” (Abraham Lincoln): the Department of Veterans Affairs polytrauma system of care. Archives of Physical Medicine and Rehabilitation, 89(1), 160–162.

    Article  PubMed  Google Scholar 

  • Stroupe, K. T., Smith, B. M., Hogan, T. P., & St Andre, J. R. (2013). Healthcare utilization and costs of Veterans screened and assessed for traumatic brain injury. Journal of Rehabilitation Research and Development, 50(8), 1047–1068.

    Article  PubMed  Google Scholar 

  • Uomoto, J. M., & Esselman, P. C. (1993). Traumatic brain injury and chronic pain: differential types and rates by head injury severity. Archives of Physical Medicine and Rehabilitation, 74(1), 61–64.

    CAS  PubMed  Google Scholar 

  • Vanderploeg, R. D. C. (2007). Long-term morbidities following self-reported mild traumatic brain injury. Journal of Clinical and Experimental Neuropsychology, 29(6), 585–598.

    Article  PubMed  Google Scholar 

  • Vanderploeg, R. D., Belanger, H. G., Horner, R. D., Spehar, A. M., Powell-Cope, G., Luther, S. L., & Scott, S. G. (2012). Health outcomes associated with military deployment: mild traumatic brain injury, blast, trauma, and combat associations in the Florida National Guard. Archives of Physical Medicine and Rehabilitation, 93(11), 1887–1895.

    Article  PubMed  Google Scholar 

  • Walker, W. C., McDonald, S. D., Ketchum, J. M., Nichols, M., & Cifu, D. X. (2012). Identification of transient altered consciousness induced by military-related blast exposure and its relation to Postconcussion symptoms. The Journal of Head Trauma Rehabilitation, 38(4), 329–335.

    Google Scholar 

  • Warden, D. (2006). Military TBI during the Iraq and Afghanistan wars. Journal of Head Trauma Rehabilitation, 21(5), 398–402.

    Article  PubMed  Google Scholar 

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Conflict of interest

Dr. Jaramillo declares that he has no conflict of interest.

Dr. Cooper declares that he has no conflict of interest.

Dr. Wang declares that she has no conflict of interest.

Dr. Tate declares that he has no conflict of interest.

Dr. Eapen declares that he has no conflict of interest.

Dr. York declares that he has no conflict of interest.

Dr. Pugh declares that she has no conflict of interest.

Funding/Support

The study was funded by VA Health Services Research and Development (DHI 09–237).

Role of the sponsor

The content of this article is solely the responsibility of the authors and does not necessarily reflect the official views of the Veterans’ Health Administration. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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Authors and Affiliations

  1. Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System (ALMD), 7400 Merton Minter Blvd (11C6), San Antonio, TX, 78229-4404, USA

    Carlos A. Jaramillo & Blessen C. Eapen

  2. Defense and Veterans Brain Injury Center, San Antonio Military Medical Center, San Antonio, TX, USA

    Douglas B. Cooper, David F. Tate & Gerald E. York

  3. Research and Development, South Texas Veterans Health Care System, 7400 Merton Minter Blvd (11C6), San Antonio, TX, 78229-4404, USA

    Chen-Pin Wang & Mary Jo Pugh

  4. Department Of Epidemiology & Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA

    Chen-Pin Wang & Mary Jo Pugh

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  1. Carlos A. Jaramillo
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  2. Douglas B. Cooper
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  3. Chen-Pin Wang
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  4. David F. Tate
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  5. Blessen C. Eapen
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  6. Gerald E. York
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  7. Mary Jo Pugh
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Correspondence to Carlos A. Jaramillo.

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Jaramillo, C.A., Cooper, D.B., Wang, CP. et al. Subgroups of US IRAQ and Afghanistan veterans: associations with traumatic brain injury and mental health conditions. Brain Imaging and Behavior 9, 445–455 (2015). https://doi.org/10.1007/s11682-015-9402-8

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