Posttraumatic Stress, Family Adjustment, and Treatment Preferences Among National Guard Soldiers Deployed to OEF/OIF

Transcription

1 ORIGINAL ARTICLES Authors alone are responsible for opinions expressed in the contribution and for its clearance through their federal health agency, if required. MILITARY MEDICINE, 176, 2:126, 2011 Posttraumatic Stress, Family Adjustment, and Treatment Preferences Among National Guard Soldiers Deployed to OEF/OIF Anna Khaylis, PhD * ; Melissa A. Polusny, PhD * ; Christopher R. Erbes, PhD * ; Abigail Gewirtz, PhD ; COL Michael Rath ABSTRACT We used an anonymous self-reported questionnaire to assess posttraumatic stress disorder symptoms, relationship concerns, and treatment preferences including interest in family-focused interventions among 100 National Guard Soldiers who were recently redeployed from Iraq or Afghanistan. We found that the majority of married or partnered soldiers were concerned about getting along with their partners, while the majority of parents were concerned about their child-rearing practices. Posttraumatic stress disorder symptoms were significantly associated with the degree of relationship concerns. Soldiers showed a striking preference for family-based interventions over individual treatment, highlighting the importance of developing family-based interventions tailored to address post-deployment mental health and co-occurring family problems. * Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN Center for Chronic Disease Outcomes Research, One Veterans Drive, Minneapolis, MN University of Minnesota Medical School, 420 Delaware Street SE, Minneapolis, MN Department of Family Social Science and Institute of Child Development, University of Minnesota, 290 McNeal Hall, 1985 Buford Avenue, St. Paul, MN Minnesota Army National Guard, 445 North Minnesota Street, St. Paul, MN The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of Veterans Affairs, Department of the Army, or Department of Defense. None of the authors report current or future competing interests or disclosures of financial interests and relationships. INTRODUCTION As conflicts in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) continue, the Departments of Defense and Veterans Affairs (VA) face the challenge of meeting the deployment-related mental health needs of a growing number of military service personnel returning from combat duty. To date, over 1.8 million troops have served in OEF or OIF, with nearly half of these troops activated from the National Guard and Reserve (NGR) component. With the historically unprecedented deployment of NGR troops who tend to be older and more likely to be married with families, over 2.7 million family members have been affected by their service members deployments to OEF or OIF. 1 All OEF or OIF veterans, including those from NGR, are eligible to receive military service related VA health care at no cost for 5 years following separation from active duty. 1 In light of the negative influence of combat-related posttraumatic stress disorder (PTSD) on family relationships and the potential for families to provide an important source of social support for combat veterans, there is a pressing need for the VA to address the family concerns of this newest generation of combat veterans. However, there are relatively few empirically validated interventions for addressing the combination of family functioning and individual posttraumatic distress within veteran populations. Moreover, less research has examined whether family-based interventions may be more acceptable or preferable to OEF or OIF combat veterans over individual interventions. This study begins to address this gap in the literature. As with previous eras of combat veterans, OEF or OIF veterans seeking VA health care frequently report post-deployment mental health concerns. Analysis of VA administrative data from over 100,000 OEF or OIF veterans shows that PTSD was the most common mental health diagnosis among those 126 MILITARY MEDICINE, Vol. 176, February 2011

2 veterans seeking help at VA health care facilities. 2 Specifically, 26% of OEF or OIF veterans treated at VA were diagnosed with mental disorders, with PTSD diagnosed in 10% of treated veterans.3 Compared with OEF or OIF veterans from the active duty component, NGR troops report higher rates of PTSD and other mental health problems initially after returning from deployment. These problems appear to escalate further during the months of reintegration following deployment. 4 At the same time, a significant number of OEF or OIF veterans may not readily seek needed mental health treatment because of concerns about stigma and other barriers to care. 5,6 Moreover, rates of drop-out from PTSD treatments are twice as high among OEF or OIF veterans as among combat veterans from the Vietnam War. 7 Without effective treatment, chronic PTSD can be disabling, with high rates of co-morbidity, 8 unemployment, and social impairments. 9 In particular, the negative influence of PTSD symptoms on romantic partner and parent child relationships has been well documented and may lead to poor outcomes for both the family and the individual with PTSD. 10 Research has shown that PTSD symptoms among veterans are associated with greater marital distress, 11 higher rates of intimate partner violence, 12 and higher rates of divorce. 9 Veterans with PTSD and their partners report significantly more relationship distress, difficulties with intimacy, and relationship problems. Additionally, veterans symptoms of emotional numbing are particularly associated with relationship distress. 11 A related line of research has shown that increased PTSD symptoms in veterans are also related to higher rates of psychological difficulties and marital distress among their partners. 13 A recent study found that wives of recently returned OEF or OIF National Guard Soldiers exhibited elevated levels of depression and PTSD compared with community samples. 14 Interestingly, spousal symptoms of depression and PTSD correlated much more strongly with spouses perception of soldiers symptoms than with soldiers self-reported symptoms. Moreover, marital satisfaction was negatively related to soldiers self-reported symptoms only when spouses perceived low levels of combat exposure in their soldier husbands, highlighting the importance of communication, attribution of symptoms, and marital functioning among veteran couples. 14 PTSD symptoms in veterans also have a significant negative influence on their children and parenting styles. Children of veterans with PTSD tend to experience greater rates of behavioral problems, academic difficulties, and social impairment.15,16 In addition, research has suggested that veterans with PTSD symptoms experience difficulties with parenting satisfaction and a decreased quality of parent child relationships.17,18 Several studies have shown that severity of PTSD and emotional numbing symptoms are associated with various aspects of the father child relationship and poorer satisfaction with parenting. 17,18 Symptoms of PTSD in veterans may lead to greater disruptions in their family relationships, which may in turn worsen the PTSD symptoms through the mechanism of social support, a posttrauma factor that may play a significant role in the trajectory of PTSD symptoms. A high level of social support post-deployment can serve as a crucial protective factor against worsening of PTSD symptoms A primary source of social support for veterans is marital and family relationships 24,25 and, if lacking, may contribute to worsening of PTSD symptoms. It is also possible that conflict within families, either between partners or with children, may serve as a source of stress for veterans with PTSD, leading to greater withdrawal or otherwise increased symptoms. To stabilize social support and minimize symptoms, it is crucial to address relationship functioning in the context of PTSD treatment. Veterans with PTSD and their families face an array of challenges, with implications for the veterans, their partners, and their children. Efforts to provide treatment that bolsters family functioning for veterans with PTSD and simultaneously addresses the symptoms of PTSD are relatively new and under-studied. 26,27 As such treatments are developed, investigated, and implemented, it is also important to consider the willingness of OEF or OIF veterans to engage in familybased interventions. One anonymous survey of 114 veterans receiving treatment from a specialized PTSD clinic found that nearly 80% of veterans reported interest in increasing family involvement in their VA treatment. 28 However, given the brevity of the survey, the combat era of veterans (e.g., Vietnam War, OEF or OIF) was not assessed, limiting the utility of findings to understanding the treatment preferences of OEF or OIF veterans. Although there is clearly a need for familybased interventions for combat veterans, it is unclear whether or not recently returned OEF or OIF veterans perceive such need or express interest in family-based interventions. Given the high drop-out rate among OEF or OIF veterans, 7 it may be necessary to tailor services for the specific needs and interests of this generation of veterans. This study examines the needs and interests of a sample of OEF and OIF deployed Army National Guard Soldiers pertaining to their relationship functioning and family-based interventions. METHODS Procedures One hundred National Guard Soldiers were invited to participate in a paper-and-pencil survey conducted during a postdeployment Soldier Readiness Program over 2 weekends of consecutive months. Soldiers received a cover letter and a self-report questionnaire (response rate = 97%). The cover letter detailed the purpose of the study and described the risks and benefits of participating. Written informed consent was waived, returning a completed survey-implied consent. The 5-page survey assessed demographics, PTSD symptoms, relationship satisfaction, concerns about relationships and mental health care, and likeliness of accessing various types of mental health care services. This study was approved by the human MILITARY MEDICINE, Vol. 176, February

3 subjects research review committees of the Minneapolis VA Medical Center, and all study procedures were approved by National Guard command. Per military regulations, no incentives were provided for participation. Participation was voluntary and anonymous. We assessed PTSD symptoms using the Primary Care- PTSD Screen (PC-PTSD), 29 a 4-item screening questionnaire designed for use in primary care and other medical settings. The measure cues respondents to a traumatic event and asks if they have had nightmares or intrusive thoughts about the event, avoided reminders or thoughts about the event, were hypervigilant or easily startled, and felt numb or detached. Prior research has established a cutoff score of 2 or more positive responses as a positive screen for PTSD symptoms, yielding a sensitivity of 0.91 and a specificity of 0.72 compared with the Clinician-Administered Scale for PTSD 30 for diagnosing PTSD. 29 We assessed relationship satisfaction using the global item from the Dyadic Adjustment Scale. 31 Respondents rated their degree of happiness with their marriage or primary relationship (1 = extremely unhappy, 2 = fairly unhappy, 3 = a little unhappy, 4 = happy, 5 = very happy, and 6 = extremely happy ). Research has shown that this item correlates highly with the total Dyadic Adjustment Scale score. 32 We also asked participants in a marital or romantic relationship to rate how concerned they were about their family adjustment in terms of getting along well or communicating with their partner (1 = not at all concerned, 2 = mildly concerned, 3 = concerned, and 4 = very concerned ). We asked parents to rate how concerned they were about childrearing or getting along well with their children (1 = not at all concerned, 2 = mildly concerned, 3 = concerned, and 4 = very concerned ). We also asked them to rate if parenting was more stressful after returning from deployment (1 = strongly disagree, 2 = somewhat disagree, 3 = neither agree nor disagree, 4 = somewhat agree, and 5 = strongly agree ). Finally, we asked all participants about the extent to which they would consider accessing various forms of mental health treatment, such as individual, group, or couple/family therapy (1 = would not use, 2 = might consider using, 3 = would strongly consider using, and 4 = would definitely use ). Participants Participants were 97 (90 male and 7 female) Army National Guard Soldiers who had been previously deployed to OEF or OIF. They were recruited to participate in the survey as part of a Soldier Readiness Training Program. As illustrated in Table I, the majority of participants were identified as Caucasians, which is consistent with the National Guard population of the state. Most participants reported completing at least some college degree. Less than half were married or living with a romantic partner, and over one-third reported being parents or caregivers of children. Mean age of the participants was 28.5 years (SD = 6.3). Participants on average reported 1 deployment to OEF or OIF (SD = 1). TABLE I. Demographic Characteristics ( N = 97) Variables n Percentage (%) Gender (% Male) Race White/Caucasian Black/African-American Hispanic/Latino Pacific Islander/Asian-American American Indian/Alaska Natives Others Education High School Diploma/General Educational Development (GED) Diploma Some College/Associate of Arts (AA) Degree 4-year College Degree Graduate Degree Employment Full-time Part-time Unemployed Marital Status (% Married/Co-habitating) Parental Status (% Parents of Children) RESULTS Frequencies of soldiers reports of PTSD symptoms and other post-deployment mental health concerns are shown in Table II. Overall, nearly half of the sample screened positive for PTSD symptoms based on the recommended cutoff score of 2 or more on the PC-PTSD. Over one-quarter reported experiencing nightmares or intrusive thoughts, avoiding trauma-related thoughts and situations, and almost half reported feeling numb and/or emotionally detached and being on guard, watchful, or easily startled. A substantial number of soldiers reported feeling that it was difficult to move on with life as usual after deployment, and the majority was concerned about their ability to manage emotions and reactions in the past year. Among the subsample of participants ( n = 42) who reported being married or living with a romantic partner, more than half screened positive for PTSD, agreed that it was difficult to move on with life as usual after deployment, and were concerned about their perceived ability to manage emotions and reactions in the past year. A quarter of partnered soldiers reported that they were unhappy in their relationship, and over three-fourths of partnered soldiers reported that they were concerned about getting along well with and communicating with their romantic partner. Relationship satisfaction was significantly associated with PTSD symptoms, with those soldiers reporting greater relationship dissatisfaction endorsing more PTSD symptoms (Spearman s rho = 0.31, p < 0.05). The percentage of partnered soldiers willing to consider couple counseling (76%) was significantly greater than the percentage willing to consider individual counseling (64%), χ 2 (1, n = 41) = 0.13; p < MILITARY MEDICINE, Vol. 176, February 2011

4 TABLE II. Frequencies of PTSD and Post-deployment Mental Health Symptoms ( N = 97) Variables n % n % n % Screened Positive for Symptoms of PTSD Trauma-related Re-experiencing Symptoms Trauma-related Avoidance Symptoms Emotional Numbing/Detachment Symptoms Hyperarousal Symptoms Difficulty in Moving on With Life After Deployment Difficulty in Managing Emotions and Reactions Unhappy With Romantic Relationship Concerns About Getting Along With Spouse/Partner Concerns About Child-Rearing and Getting Along With Children Parenting More Stressful After Deployment Of the subsample of participants ( n = 36) who reported being parents of children, the majority reported that they were concerned about child rearing and getting along well with their children and over half felt parenting was more stressful after deployment. Among soldiers who were parents, it was found that there was a strong interest and significantly greater preference for family counseling over individual treatment. Eighty percent of this subsample reported that they would consider seeking family counseling if it were available to them, while 75% reported that they would consider seeking individual counseling, χ 2 (1, n = 36) = 4.78; p < Overall ( N = 97) Married/Co-habiting Subsample ( n = 42) Parent Subsample ( n = 36) DISCUSSION Findings from this study demonstrate that National Guard Soldiers deployed to OEF or OIF report a high level of concern about family functioning. Although a quarter of the sample participants reported being unhappy in their relationship, most of the participants in relationships reported concern regarding getting along with their spouse or partner. Moreover, as soldiers endorsed a greater number of PTSD symptoms, they also reported more dissatisfaction with their romantic relationships. Similarly, a majority of parents or caregivers reported concerns about their child-rearing practices and found parenting to be more stressful after deployment. This concern of parents is generally consistent with previous research, which has established that combat veterans with PTSD tend to experience a variety of family-related stressors. 9,11 Similarly, studies have also suggested that veterans with PTSD tend to experience difficulties with parenting satisfaction and a decreased quality of parent child relationships. 17,18 Of note, our study found a high rate of positive screens for PTSD symptoms, consistent with other studies utilizing similar PTSD screening procedures. 4,33,34 Research has shown that rates of PTSD vary widely depending on the methodologies and samples. 35 In this study, we surveyed National Guard Soldiers who had recently returned from combat deployment. Furthermore, the survey was anonymous, and the PC-PTSD screen with a cutoff of 2 was used, all of which may have contributed to the high rate of positive PTSD screens found in this sample. 4,33,34 To our knowledge, this study is the first to examine OEF or OIF veterans interest in and preference for various treatment approaches for post-deployment reintegration concerns. Previous work has found that veterans receiving specialized PTSD treatment report significant interest in involving their families in their VA care. 28 Our study extends previous work by showing that recently returned National Guard Soldiers reported a greater preference for family-based interventions over individual therapy following combat deployment. Specifically, a greater percentage of soldiers in intimate relationships reported interest in couple therapy than individual therapy, and similarly a greater percentage of parents or caregivers were interested in family counseling over individual treatment. Our findings support the importance of developing family-based interventions that are tailored to address both post-deployment mental health and co-occurring family problems and suggest that such approaches may be preferred by OEF or OIF veterans experiencing the challenges of reintegration following combat deployment. In spite of the urgent need for family-based interventions for returning OEF or OIF veterans, there has been limited treatment development and evaluation in this area. Although the efficacy of behavioral couple therapies in improving marital functioning has been well documented, 36,37 there is a dearth of evidence-based couple therapy approaches for PTSD in general and for OEF and OIF veterans in particular. A promising approach based on individual cognitive therapy for PTSD is Cognitive-Based Couple Therapy, which has been shown to reduce PTSD symptoms and improve partner ratings of relationship satisfaction in a small number of Vietnam combat veterans.27,38 There has also been work on adapting other therapies for treating PTSD and couple distress in returning OEF or OIF veterans. Erbes et al 26 utilized principles of Integrative Behavioral Couple Therapy to treat both couple distress and PTSD by addressing experiential avoidance that maintains PTSD and erodes couple functioning. MILITARY MEDICINE, Vol. 176, February

5 Studies have documented the relationship between PTSD and other post-deployment problems, such as alcohol use and aggression, which may lead to discord in relationship. 39,40 Recent reports have indicated that NGR personnel are at an increased risk of maladaptive alcohol use, 41 which may disrupt healthy relationship functioning. Couple-based treatments may provide an appropriate context for reducing alcohol abuse experienced by OEF or OIF deployed military personnel and improving relationship functioning, which would in turn buffer against PTSD. In light of the interest expressed in couple therapy reported by National Guard Soldiers in this sample of participants, there is a need for more research on the efficacy of couple therapy as a primary treatment for relationship distress, PTSD, and related post-deployment problems. Participants in our study who had children ( n = 36) also reported significant concerns about impairments in parenting and expressed high levels of interest in family therapy over individual therapy. An evidence-based parenting intervention, the Oregon Model of Parent Management Training (PMTO), is showing promise in strengthening parenting practices among parents affected by traumatic events. 42 Applying a social interaction learning perspective, 43 research has shown that PMTO increases positive parenting and reduces coercive parenting practices that are prevalent among highly stressed families. This model s approach coaches parents on affect regulation while providing them positive parenting tools to provide a warm and structured family environment in the face of family stress. 42 Efforts are currently underway to tailor PMTO to the needs of military personnel returning from combat deployment. 44 This study has several limitations. First, the small convenience sample of Army National Guard Soldiers may limit the generalizability of findings to soldiers from other regions and military branches. Thus, findings should be considered preliminary, and future research should examine the relationship concerns among larger samples of OEF or OIF veterans who served in both active duty and NGR components. Second, PTSD symptoms and relationship satisfaction were assessed using brief screens, and future studies should use more comprehensive assessments in examining relationship concerns because of PTSD. Despite these limitations, the relationship concerns and their association with PTSD symptoms among returning veterans were noteworthy. Perhaps even more striking was the high level of interest of veterans in family-based interventions over individual approaches. Our findings suggest a pressing need to develop and test couple therapies for veterans with PTSD and co-occurring relationship distress and tailor evidence-based parenting interventions to the needs of returning veterans. Although recently returned OEF and OIF veterans are presenting with high rates of mental health difficulties, particularly PTSD, mental health utilization is limited and treatment drop-out rates are alarming among this population. 7,45 One of the priorities of VA is to match services with the needs of veterans. Findings from this study suggest that OEF and OIF veterans express both a need for and an interest in family-based interventions, and an increased focus on this area in treatment may significantly improve outcomes for our newest generation of veterans suffering from PTSD. ACKNOWLEDGMENTS This article is the result of work supported with resources and the use of facilities at the Minneapolis VA Health Care System, Minneapolis, MN. We acknowledge Kari Fletcher for her assistance in this study. REFERENCES 1. Veterans Health Administration : Analysis of VA Health Care Utilization Among US Global War on Terrorism (GWOT) Veterans. Government Report. Washington DC, August Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C : Bringing the war back home: mental health disorders among US veterans returning from Iraq and Afghanistan seen at Department of Veteran Affairs facilities. Arch Intern Med 2007 ; 167: Kang HK, Hyams KC : Mental health care needs among recent war veterans. New Engl J Med 2005 ; 352: Milliken CS, Auchterlonie JS, Hoge CW : Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA 2007 ; 298: Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RI : Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New Engl J Med 2004 ; 351: Kehle SM, Polusny MA, Murdoch M, et al : Early mental health treatment-seeking among National Guard soldiers deployed to Iraq. J Trauma Stress 2010 ; 23: Erbes CE, Curry KT, Leskela J : Treatment presentation and adherence of Iraq/Afghanistan era veterans in outpatient care of posttraumatic stress disorder. Psychol Serv 2009 ; 6: Brady KT, Killeen TK, Brewerton T, Lucerini S : Comorbidity of psychiatric disorders and posttraumatic stress disorder. J Clin Psychiatry 2000 ; 61: Prigerson HG, Maciejewski PK, Rosenheck RA : Combat trauma: trauma with highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men. J Nerv Ment Dis 2001 ; 189: Galovski T, Lyons JA : Psychological sequelae of combat violence: a review of the impact of PTSD on the veteran s family and possible interventions. Aggress Violent Behav 2004 ; 9: Riggs DS, Byrne CA, Weathers FW, Litz BT : The quality of the intimate relationships of male Vietnam veterans: problems associated with posttraumatic stress disorder. J Trauma Stress 1998 ; 11: Taft CT, Street AE, Marshall AD, Dowdall JD, Riggs DS : Posttraumatic stress disorder, anger, and partner abuse among Vietnam combat veterans. J Fam Psychol 2007 ; 21: Evans L, McHugh T, Hopwood M, Watt C : Chronic posttraumatic stress disorder and family functioning of Vietnam veterans and their partners. Aust N Z J Psychiatry 2003 ; 37: Renshaw KD, Rodrigues CS, Jones DH : Psychological symptoms and marital satisfaction in spouses of Operation Iraqi Freedom veterans: relationship with spouses perception of veterans experiences and symptoms. J Fam Psychol 2008 ; 22: Harkness LL : The effect of combat-related PTSD on children. National Center for PTSD Clinical Newsletter 1991 ; 2: Jordan BK, Marmar CR, Fairbank JA, et al : Problems in families of male Vietnam veterans with posttraumatic stress disorder. J Consult Clin Psychol 1992 ; 60: MILITARY MEDICINE, Vol. 176, February 2011

6 17. Ruscio AM, Weathers FW, King LA, King DW : Male war-zone veterans perceived relationships with their children: the importance of emotional numbing. J Trauma Stress 2002 ; 15: Samper RE, Taft CT, King DW, King LA : Posttraumatic stress disorder symptoms and parenting satisfaction among a national sample of male Vietnam samples. J Trauma Stress 2004 ; 17: Brewin CR, Andrews B, Valentine JD : Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol 2000 ; 68: Ozer EJ, Best SR, Lipsey TW, Weiss DS : Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull 2003 ; 129: Jankowski MK, Schnurr PP, Adams GA, Green BL, Ford JD, Friedman MJ : A meditational model of PTSD in Word War II veterans exposed to mustard gas. J Trauma Stress 2004 ; 17: Barret TW, Mizes JS : Combat level and social support in the development of posttraumatic stress disorder in Vietnam veterans. Behav Modif 1988 ; 12: Schnurr PP, Lunney CA, Sengupta A : Risk factors for the development versus maintenance of posttraumatic stress disorder. J Trauma Stress 2004 ; 17: Beach SR, Martin JK, Blum TC, Roman PM : Effects of marital and coworker relationships on negative affect: testing the central role of marriage. Am J Fam Ther 1993 ; 21: McLeod JD, Kessler RC, Landis KR : Speed of recovery from major depressive episodes in a community sample of married men and women. J Abnorm Psychol 1992 ; 101: Erbes CE, Polusny MA, MacDermid S, Compton JS : Couple therapy with combat veterans and their partners. J Clin Psychol 2008 ; 64: Monson CM, Schnurr PP, Stevens SP, Guthrie KA : Cognitive-behavioral couples treatment for posttraumatic stress disorder: initial findings. J Trauma Stress 2004 ; 17: Batten SV, Drapalski AL, Decker ML, et al : Veteran interest in family involvement in PTSD treatment. Psychol Serv 2009 ; 6: Prins A, Ouimette P, Kimmerling R, et al : The primary care PTSD screen (PC-PTSD): development and operating characteristics. Int J Psychiatry Clin Pract 2004 ; 9: Blake DD, Weathers FW, Nagy LM, et al : The development of a clinician-administered PTSD scale. J Trauma Stress 1995 ; 8: Spanier GB : Measuring dyadic adjustment: new scales for assessing the quality of marriage and similar dyads. J Marriage Fam 1976 ; 38: Goodwin R : Overall, just how happy are you? The magical Question 31 of the Spanier Dyadic Adjustment Scale. Fam Ther 1992 ; 19: Bliese PD, Wright KM, Adler AB, Thomas JL, Hoge CW : Timing of postcombat mental health assessments. Psychol Serv 2007 ; 4: Bliese PD, Wright KM, Adler AB, Cabrera O, Castro CA, Hoge CW : Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat. J Consult Clin Psychol 2008 ; 76: Sundin J, Fear NT, Iversen A, Rona RJ, Wessely S : PTSD after deployment to Iraq: conflicting rates, conflicting claims. Psychol Med 2009 ; 12: Christensen A, Atkins DC, Bern S, Wheeler J, Baucom DH, Simpson LE : Traditional versus integrative behavioral couple therapy for significantly and chronically distressed married couples. J Consult Clin Psychol 2004 ; 72: Carr A : The effectiveness of family therapy and systemic interventions for adult-focused problems. J Fam Ther 2009 ; 31: Monson CM, Guthrie KA, Stevens S : Cognitive-behavioral couples treatment for posttraumatic stress disorder. Behav Ther 2003 ; 26: Taft CT, Kaloupek G, Marshall AD, et al : Posttraumatic stress disorder symptoms, physiological reactivity, alcohol problems, and aggression among military veterans. J Abnorm Psychol 2007 ; 116: Vasterling JJ, Schumm J, Proctor SP, Gentry E, King DW, King LA : Posttraumatic stress disorder and health functioning in a non-treatmentseeking sample of Iraq war veterans: a prospective analysis. J Rehabil Res Dev 2008 ; 45: Jacobson IG, Ryan MA, Hooper TI, et al : Alcohol use and alcoholrelated problems before and after military combat deployment. JAMA ; 300: Gewirtz A, Forgatch M, Wieling E : Parenting practices as potential mechanisms for child adjustment following mass trauma. J Marital Fam Ther 2008 ; 34: Patterson GR : The next generation of PMTO models. Behav Ther 2005 ; 28: Gewirtz A, Erbes CR, Polusny MA, DeGarmo D, Forgatch M : Helping families through the deployment process: strategies to support parenting. Professional Psychology: Research & Practice (in press). 45. Erbes CE, Westermeyer J, Engdahl B, Johnsen E : Posttraumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan. Mil Med 2007 ; 172: MILITARY MEDICINE, Vol. 176, February