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PSYCHOSOCIAL BUFFERS OF TRAUMATIC STRESS, DEPRESSIVE SYMPTOMS, ANDPSYCHOSOCIAL DIFFICULTIES IN VETERANS OF OPERATIONS ENDURING FREEDOMAND IRAQI FREEDOM: : T HE ROLE OF RESILIENCE, UNIT SUPPORT,AND POSTDEPLOYMENT SOCIAL SUPPORTRobert H. Pietrzak a,b,* , Douglas C. Johnson c , Marc B. Goldstein d , James C. Malley e ,Alison J. Rivers a,b , Charles A. Morgan a,b , Steven M. Southwick a,bPreviously published in the Journal of Affective Disorders, (2009), doi:10.1016/j.jad.2009.04.015. Permission granted to republishin the JSOM.ABSTRACTBackground: Little research has examined the role of protective factors such as psychological resilience, unit support, andpostdeployment social support in buffering against PTSD and depressive symptoms, and psychosocial difficulties in veteransof Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF). Materials and methods: A total of 272 OEF/OIF veteranscompleted a survey containing PTSD and depression screening measures, and questionnaires assessing resilience,social support, and psychosocial functioning. Results: Lower unit support and postdeployment social support were associatedwith increased PTSD and depressive symptoms, and decreased resilience and psychosocial functioning. Path analysessuggested that resilience fully mediated the association between unit support and PTSD and depressive symptoms, and thatpostdeployment social support partially mediated the association between PTSD and depressive symptoms and psychosocialfunctioning. Limitations: Generalizability of results is limited by the relatively low response rate and predominantly olderand reserve/National Guard sample. Conclusions: These results suggest that interventions designed to bolster unit support,resilience, and postdeployment support may help protect against traumatic stress and depressive symptoms, and improvepsychosocial functioning in veterans.1.INTRODUCTIONEpidemiologic surveys of Operation Iraqi Freedom(OIF)and Operation Enduring Freedom (OEF) veteranshave found high rates of posttraumatic stress disorder(PTSD), depression, and related conditions (Tanielian andJaycox, 2008). While it is well known that these conditionsmay negatively affect psychosocial functioning and quality oflife in this population (e.g., Milliken et al., 2007), little researchhas examined the role of protective factors such aspsychological resilience, unit support, and postdeploymentsocial support in buffering against PTSD and depressivesymptoms, and psychosocial difficulties.Psychological resilience, which refers to an individual’scapacity to successfully adapt or change in the face ofadversity, protects against the development of combat-relatedPTSD in Vietnam veterans (King et al., 1998;Waysman et al.,2001) and Army Reserve Soldiers (Bartone, 1999). Aspectsof resilience such as positive emotions, cognitive flexibility,meaning making, and active coping also protect against thedeleterious effects of depression (Southwick et al., 2005).Social support also protects against depression(Paykel, 1994; Southwick et al., 2005), and PTSD, withmeta-analyses suggesting that it is among the strongest negativepredictors of PTSD (Oliver et al., 1999; Brewin et al.,2000; Ozer et al., 2008). Higher perceived social support hasalso been linked to increased resilience (Bonanno et al.,2007) and lower risk of PTSD in Vietnam veterans (King etal., 1998), prisoners of war (Engdahl et al., 1997) and UnitedNations soldiers (Kaspersen et al., 2003). An understandingof associations between resilience, social support, PTSD anddepressive symptoms, and functioning in OEF/OIF veteransis important, as it may help guide the development of interventionsto enhance resilience and support, and promote successfulreadjustment to civilian life after deployment.This study examined associations between resilience,unit support, postdeployment social support, traumaticstress and depressive symptoms, and psychosocialfunctioning two years following return from deployment ina sample of OEF/OIF veterans. Path analyses tested the hypothesesthat unit support may help enhance psychologicalresilience (Bartone, 2006; Oliver et al., 1999), which in turnreduces PTSD and depressive symptom severity, and thatpostdeployment social support may mediate the relationshipbetween PTSD and depressive symptoms and psychosocialdifficulties (Oxman and Hull, 2001; Zatzick et al., 1997). Wehypothesized that resilience would mediate the relationshipbetween unit support and PTSD and depressive symptoms,and that postdeployment social support would mediate therelationship between PTSD and depressive symptoms andpsychosocial difficulties.2. METHODS2.1. SampleParticipants (N=272) completed the ConnecticutOEF/OIF Veterans Needs Assessment Survey. OEF/OIF veteranswere identified alphabetically from a review of copiesof discharge papers (DD-214s) by the Connecticut Departmentof Veterans’Affairs until names and addresses of 1000potential respondents were obtained. To maintain confidentiality,surveys were addressed and mailed by the ConnecticutDepartment of Veterans’Affairs. No personal identifyinginformation was made available to the authors. The surveywas mailed in October 2007 to a sample of 1000 veteranswho had served between 1/1/03 and 3/1/07; as of 2/08, 285surveys were returned for an overall return rate of 28.5%.Respondents were older than non-respondents in the samplingframe (33.4 vs. 31.3 years, t(998)=2.87, p =.004). On74Journal of Special Operations Medicine Volume 9, Edition 3 / Summer 09
average, time between return from deployment to OEF/OIFand survey completion was 26.9±.7 months.2.2. Assessment instrumentsThe Unit Support Scale (USS) is a self-report measurefrom the Deployment Risk and Resilience Inventory(DRRI; King et al., 2006) that assesses the quality of relationshipsand degree of cohesion between a Soldier andhis/her unit. Cronbach’s α=.93.The Postdeployment Social Support Scale is a selfreportmeasure from the DRRI that assesses the extent towhich family, friends, coworkers, employers, and communityprovide postdeployment emotional support and instrumentalassistance. Cronbach’s α=.82.The Connor–Davidson Resilience Scale (Connor andDavidson, 2003) is a self-report measure of psychological resilience.Higher scores reflect greater resilience. Cronbach’sα=.94.The Combat Experiences Scale (CES) is a self-reportinstrument from the DRRI that assesses exposure tocombat (e.g., firing a weapon, witnessing injury and death).Higher scores reflect more combat exposure. Cronbach’sα=.93.The Posttraumatic Stress Disorder Checklist-MilitaryVersion (PCL-M; Weathers et al., 1991) is a 17-item instrumentbased on DSM-IV criteria for PTSD. Higher scoresindicate greater posttraumatic stress symptoms. Cronbach’sα=.96.The Patient Health Questionnaire-9 (Kroenke andSpitzer, 2002) is a 9-item self-report screening instrument fordepression derived from the clinician-administered PrimaryCare Evaluation of Mental Disorders. Higher scores indicategreater depressive symptoms. Cronbach’s α=.92.The Psychosocial Difficulties Scale (PDS) is a 23-item questionnaire developed by two of the authors (M.B.G.,J.C.M.) that assesses psychosocial functioning in family andpeer relationships (e.g., “have difficulty connecting emotionallywith family and/or friends”), and work, school, andfinancial functioning (e.g., “have difficulty finding employment”;“have difficulty paying bills”). Ratings are “Not aconcern”, “A slight concern”, “A moderate concern”, and “Amajor concern”. Higher scores indicate greater psychosocialdifficulties. Cronbach’s α=.89.2.3. Data analysisNon-normally distributed data (e.g., PCL-M scores)were transformed using logarithmic base 10 transformations.Pearson correlations were computed between measures of socialsupport and resilience, PTSD and depressive symptoms,and psychosocial difficulties. Path analyses were conductedto test the hypotheses that resilience mediates the relationshipbetween unit support and PTSD and depressive symptoms;and that postdeployment social support mediates therelationship between PTSD and depressive symptoms andpsychosocial difficulties. Data from all respondents were includedin these analyses, including those with and withoutpositive screens for PTSD and depression. Model fit wasevaluated using a number of fit statistics, including χ2, rootmean square error of approximation (RMSEA), comparativefit index (CFI), and Tucker–Lewis Index (TLI). By convention,lower, non-significant χ2 values, RMSEA values ≤.08,and CFI and TLI values ≥.90 indicate acceptable model fit(Kline, 2005). Path coefficients are presented as standardizedregression weights (β).3. RESULTSThe mean age of the total sample was 34.9±.4 years,89% were white, 82% completed at least some college education,the majority (72%) were in the National Guard or reservesand 28% were on active duty; 87% were in the Army,9% Marines, 2% Air Force, and 2% multiple branches.Table 1 shows mean scores and standard errors, andcorrelations between all measures. Unit support scores correlatedwith scores on all other variables except combat exposureand psychosocial difficulties. Postdeployment socialsupport scores correlated positively with resilience scores andnegatively with scores on all other variables. Resiliencescores correlated negatively with measures of PTSD and depressivesymptoms, and psychosocial difficulties, but theywere not associated with combat exposure. Combat exposurescores correlated negatively with postdeployment socialsupport scores and positively with measures of PTSD and depressivesymptoms, and psychosocial difficulties. PTSD anddepressive symptoms correlated positively with scores on ameasure of psychosocial difficulties.Previously Published 75
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Field Evaluation and Management of
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REFERENCES1. James L. Jones, “A b
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Figure 4 : A Special Forces medic c
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exposure. Conversely, the customary
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7. Ted Westmoreland. (2006). Attrib
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Page 91 and 92: Peter J. Benson, MDCOL, USACommand
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LABORATORYClinical Lab Science Reso
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A 11 year old boy whose tibia conti
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Meet Your JSOM StaffEXECUTIVE EDITO
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Special Forces Aidman's PledgeAs a
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