Impact of Combat on the Mental Health
and Well-Being of Soldiers and Marines
7 Things I Think I Know
Colonel Carl A. Castro
Director, Military Operational Medicine
Research Program
Smith College School for Social Work
Combat Stress: Understanding the Challenges,
Preparing for the Return
Northampton, New Hampshire
26-28 June 2008
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
1
Biography of Colonel Castro
• Born in Kansas City, Missouri
• Enlisted as an infantryman in the U.S. Army at the age of 17
• Obtain BA from Wichita State University and MA and PhD from the
University of Colorado (major psychology)
• Entered active duty as a psychologist in 1989
• Served on deployments to Bosnia (1998), Kosovo (2000, 2002), and Iraq
(2003, 2006)
• Authored, co-authored around 100 publications
• Promoted to colonel in FEB 2007
• Serves on several NATO, TTCP panels
• Just started a new job as Director of Military Operational Medicine, Fort
Detrick, Maryland
• Areas of research interest include:
- Impact of combat and operations on mental health and well-being of
Soldiers and Families
- Development of validated mental health training instrument and
procedures to facilitate effective adaptation and growth
- Junior Leader development and their role in facilitating mental health
and well-being in subordinates
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
2
1. Combat impacts the mental health
and well-being of Soldiers and Marines.
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
3
Prevalence of PTSD
• There is a 3-fold increase for U.S. Soldiers screening
positive for PTSD when assessed 3 months after returning
from a year in Iraq.
18
16
14
12
10
8
6
4
2
0
% PTSD
14.6
5.0
Pre-OIF
n = 2,414
Post-OIF (3 months)
n = 3,781
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
4
Combat-related Risk Factors & PTSD
 Firefights, high combat, high perceived danger, &
dissociative experiences increased PTSD risk.
40
35
30
25
20
15
10
5
0
% PTSD
29.7
19.9
18.8
7.8
Firefights
9.7
High Combat
17.7
9.5
8.1
Perceived
danger
Dissociation
Yes vs. No
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
5
Anger and Aggressive Behaviors
75
77
81
Got angry with someone and yelled or
shouted at them
Got angry with someone and kicked or
smashed something, slammed the door,
punched the wall, etc.
pre-OIF
37
42
46
3 mth Post
OIF
12 mth Post
OIF
31
36
40
Threatened someone with physical
violence
11
Got into a fight with someone and hit
the person
19
22
0
20
40
60
80
100
Percent one or more times
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
6
2. Not all Soldiers are at equal risk for
mental health problems.
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
7
Combat Experiences: Combat vs. Support
• Soldiers in combat units experienced more combat-related
events than Soldiers in combat support (CS) and combat service
support (CSS).
Saw dead bodies
Got shot at
87%
53%
Killed enemy combatants
0%
80%
57%
Was attacked or ambushed
IED exploded nearby
90%
57%
Knew somebody injured/killed
Hand-to-hand fighting
87%
68%
15%
42%
21%
6%
9%
Combat
CS/CSS
21%
20%
40%
60%
80%
100%
Happened At Least Once
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
8
Mental Health Status By Unit Types
• Soldiers were more likely to screen positive for a mental health
problem if they were in a combat arms unit, engineer,
transportation, or support unit than Soldiers in other types of units.
Percent Screening Positive
40
Any Behavioral Health Problem
(PTSD, Depression or Anxiety)
30
20
13.4
16.8
14.4
9.9
10
7.5
6.7
16.7
6.1
0
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
9
The Frontline in Iraq
• Soldiers were divided into low, medium and high combat based
on frequency of combat events during the deployment.
• Soldiers with higher levels of combat were more likely to screen
positive for anxiety, depression, or PTSD, indicating that all
Soldiers are NOT at the same level of risk for a mental health
problem.
Percent Screening Positive
35
30
28
30
Low Combat
Medium Combat
High Combat
25
20
17
13
15
8
10
5
14
12
8
11
8
5
5
0
Anxiety
Depression
PTSD
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
Any Mental Health
Problem
10
3. Leadership is important for
maintaining Soldier mental health.
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
11
Leadership and Mental Health
• Soldiers with high perceptions of Leadership were less likely to
screen positive for a mental problem (PTSD, Depression or
Anxiety) compared to those Soldiers with low perceptions of
leadership.
50
50
Low
Leadership
40
Percent
Screened
Positive 30
for any
mental 20
health
problem
10
0
Low Combat/Low Leadership
Low Combat/High Leadership
High Combat/Low Leadership
High Combat/High Leadership
28
High
Leadership
11
40
Percent
Screened
Positive
for any
mental
health
problem
36
30
20
20
10
17
5
0
Adjusted R Square = .15 and the Chi Square is significant at the .01 level
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
12
Battlemind Training as an Example
• Battlemind Training is mental health training focused on
the development of skills, involving self-aid, buddy aid,
and leadership.
• Battlemind Training involves:
– Evidence-based: Built on findings from the Land Combat
Study. Validated through research.
– Experience-Based: Uses examples that Soldiers can relate to.
– Strengths-based: Builds on existing Soldier strengths and
skills – rejects a deficit or illness model.
– Training: Focuses on skill development – not education.
– Explanatory: Highlights conflicted/misunderstood reactions.
– Team-based: Self awareness through helping buddy.
– Action-Focused: Discusses specific actions to guide Soldier
behavior.
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
13
4. Mental health training works.
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
14
Soldier Attitudes: Training Utility
• Battlemind Training had high ratings.
Small BMT
Large BMT
Stress Ed
100
% Agree
80
60
40
59.4
50.5
48
45.5
35.7
23.4
29.1
33.6
26.6
20
0
The discussion made
me realize that I had
learned a lot from my
deployment
experiences
The discussion was
It was helpful to hear
useful because I
what others have to say
realized my reactions to about their experiences
the deployment were
in Iraq
normal
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
15
Battlemind Training: PTSD & Depression
• Soldiers who received Battlemind Training (BMT) (p < .01) reported
fewer PTSD symptoms at 3 months post-deployment compared to
Soldiers who received the standard stress education training.
• Depression symptoms for Soldiers who received BMT were only
marginally significantly lower than for Soldiers who received stress
education (p < .10).
10.0
Stress Ed
BMT
Large BMT
Depression Change
Score
Small BMT
20
17
14
11
8
5
2
-1
Stress Ed
8.0
6.0
4.0
2.0
0.0
-2.0
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
-4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
PCL Change Score
23
Combat Exposure: Events Experienced
Combat Exposure: Events Experienced
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
16
Battlemind Training: Stigma & Sleep
• Soldiers who received Battlemind training reported less
psychological stigma at 3 months post-deployment compared to
Soldiers who received the standard stress education training (p < .01).
• Soldiers who received Battlemind training also reported fewer sleep
problems than Soldiers who received the standard stress education
training (p < .01).
1.00
4.00
BMT
Stress Ed
3.60
3.20
3.00
2.80
2.60
2.40
Stress Ed
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
2.00
0.00
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
2.20
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Stigma
3.40
BMT
0.90
Probability of Sleep
Problems
3.80
Combat Exposure: Events Experienced
Combat Exposure: Events Experienced
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
17
Battlemind Training System: Deployment Cycle
Tough Facts about Combat
Battlemind AAR
Psychological Debriefing
and what leaders can do to
mitigate risk and build confidence
Pre-Deployment Battlemind For:
Alert
Transition to
Post-Conflict
Leaders
Junior Enlisted
Helping Professionals
Spouse/Couples PreDeployment Battlemind
Battlemind AAR
Psychological Debriefing
Preparing for a Military Deployment
Post-Deployment Battlemind
PDHRA Battlemind
Brief and DVD
Battlemind Training II
Continuing the
Transition Home
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
Battlemind Training I
Spouse/Couples PostDeployment Battlemind
Transitioning from
Combat to Home
18
5. Mental health “re-setting” following a
year-long combat tour takes more than
12 months.
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
19
High Performing Soldiers with Mental Health
Symptoms Returning to Iraq
• Soldiers’ mental health status does not “re-set” after
12 months following return from a combat tour.
30
pre-OIF
3 mth Post OIF
12 mth Post OIF
25
Percent
20
23.2
17.1
17.0
15
12.0
10
7.9
6.3
12.9
11.5
6.4
9.3
7.9
5.0
5
0
Depression
Anxiety
PTSD
(Castro & Hoge, 2005)
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
Any MH
Problem
20
6. Longer and multiple deployments are
likely to lead to more mental health
issues.
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
21
Soldier Multiple Deployments
Soldiers deployed to Iraq more than once were more likely to
screen positive for a mental health problem than first-time
deployers.
50
Percent Screening Positive
•
OIF First time Deployers
OIF Multiple Deployers
40
30
20
27
24
17
15
10
0
Acute Stress (PTSD scale)
Any Mental Health Problem
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
22
Soldier Deployment Length
• Soldiers deployed longer than 6 months were more likely to
screen positive for a mental health problem than those deployed
for 6 months or less.
Percent Screening Positive
50
Deployed 6 months or less
Deployed more than 6 months
40
30
20
19
12
22
15
10
0
Acute Stress
Any Mental Health Problem
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
23
7. Every combat Soldier (and Marine) will
face moral and ethical challenges.
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
24
Battlefield Ethics: Attitudes
• Treatment of non-combatants and views on torture
All non-combatants should be treated with
dignity and respect
47
38
All non-combatants should be treated as
insurgents
17
17
Torture should be allowed if it will save the life
of a Soldier/Marine
2006 OIF
Soldiers
41
44
Torture should be allowed in order to gather
important info about insurgents
2006 OIF
Marines
36
39
I would risk my own safety to help a noncombatant in danger
25
24
0
20
40
60
80
100
Percent Agree/Strongly Agree
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
25
Battlefield Ethics: Behaviors
• Treatment of Noncombatants and ROEs
Insulted/cursed at non-combatants in their
presence
28
30
Damaged / destroyed Iraqi property when it was
not necessary
9
12
Physically hit / kicked non-combatant when it was
not necessary
4
7
Members of unit modify ROEs in order to
accomplish the mission
2006 OIF
Marines
8
9
Members of unit ignore ROEs in order to
accomplish the mission
Soldiers and Marines who report
better officer leadership are more
likely to follow the ROE.
2006 OIF
Soldiers
5
7
0
20
40
60
80
100
Percent Reporting One or More Times
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
26
Battlefield Ethics: Reporting
I would report a unit member for:
55
injuring or killing an innocent non-combatant
40
50
stealing from a non-combatant
33
mistreatment of a non-combatant
32
not following general orders
35
violating ROEs
34
46
2006 OIF
Soldiers
46
2006 OIF
Marines
47
43
unnecessarily destroying private property
“We prefer to handle things within the unit;
would only turn someone in if it put the
safety of unit members in jeopardy.”
30
0
50
100
Percent Agree or Strongly Agree
---Junior NCO
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
27
Battlefield Ethics: Training
• Although Soldiers and Marines reported receiving adequate battlefield
ethics training, over one quarter reported encountering situations in
which they didn’t know how to respond.
Received training that made it clear how I should
behave toward non-combatants.
86
87
Received training in the proper treatment of noncombatants.
82
83
Training in proper treatment of non-combatants
was adequate.
78
81
NCOs and Officers in my unit made it clear not to
mistreat non-combatants
71
67
Encountered ethical situations in Iraq in which I did
not know how to respond.
2006 OIF
Soldiers
2006 OIF
Marines
28
31
0
20
40
60
80
100
Percent Agree or Strongly Agree
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
28
Soldier Mental Health, Combat and Ethics
•
•
Soldiers who screened positive for a mental health problem or who had
high levels of anger were twice as likely to engage in unethical behavior on
the battlefield compared to those Soldiers who screened negative or who
had low levels of anger.
Soldiers with high levels of combat were more likely to engage in unethical
behaviors than Soldiers with low levels of combat.
• The relationship
between mental health
and unethical behavior
holds even when
controlling for anger.
• These findings indicate
the need to include
Battlefield Ethics
awareness in all mental
health counseling and
anger management
courses.
Insulted/cursed at non-combatants in their
presence
25
40
Screened
Negative
7
Damaged and/or destroyed Iraqi private
property when it was not necessary
16
Screened
Positive
3
7
Physically hit / kicked non-combatant
when it was not necessary
0
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
20
40
60
80
100
Percent Reporting One or More Times
29
Point of Contact
COL Carl Castro
Director, Military Operational Medicine Research
Program, Fort Detrick, MD
carl.castro@us.army.mil
Walter Reed Army Institute of Research,
U.S. Army Medical Research and Materiel Command
30