The purpose of the present study was to assess the occurrence of visual dysfunctions and associated symptoms in active duty warfighters during the subacute stage of blast-induced mild traumatic brain injury (mTBI). A comprehensive visual and oculomotor function evaluation was performed on 40 U.S. military personnel, 20 with blast-induced mTBI and 20 without. In addition, a comprehensive symptom questionnaire was used to assess the frequency of visual, vestibular, and neuropsychiatric-associated symptoms. The most common mTBI-induced visual dysfunctions were associated with near oculomotor deficits, particularly large exophoria, decreased fusion ranges, receded near point of convergence, defective pursuit and saccadic eye movements, decreased amplitude of accommodation, and monocular accommodative facility. These were associated with reduced reading speed and comprehension and an increased Convergence Insufficiency Symptom Survey score. Photosensitivity was a common visual dysfunction along with hearing, balance, and neuropsychiatric symptoms. The oculomotor testing for warfighters suspected of blast-induced mTBI should include, at a minimum, the assessment of near lateral and vertical phorias, positive fusional vergence, stereoacuity, near point of convergence, amplitude of accommodation, monocular accommodative facility, saccades, and pursuit eye movements. A reading test should be included in all routine exams as a functional assessment of the integration of oculomotor functions.

We surveyed 700 veterans who were outpatients in a non–Veterans Affairs (VA) multihospital system. Our objective was to assess the prevalence of mental disorders and service use among these veterans. The majority were Vietnam veterans (72.0%), and male (95.9%), and 40.4% reported recently using the VA for care. The prevalence of lifetime post-traumatic stress disorder (PTSD) was 9.6%, lifetime depression 18.4%, and lifetime mental health service use 50.1%. In multivariate analyses, significant factors associated with PTSD, depression, and mental health service use were low self-esteem, use of alcohol/drugs to cope, history of childhood adversity, high combat exposure, and low psychological resilience. VA service use was associated with greater mental health service use and combat exposure. With the exception of alcohol misuse, the mental health status of veterans seen in non-VA facilities appeared to be better than reported in past studies. Because most veterans have access to both VA and non-VA services, these findings have implications for veterans and outcomes research.

We examined the effects of homecoming support on current mental health among 1,730 deployed veterans from Vietnam, Iraq/Afghanistan, Persian Gulf, and other conflicts. The prevalence of current PTSD was 5.4%, current depression was 8.3%, and 5.4% had suicidal thoughts in the past month. Overall, 26% of veterans had low homecoming support, which was more prevalent among Vietnam veterans (44.3%, p<0.001). In multivariable logistic regressions, controlling for demographics, combat exposure, number of deployments, trauma history, and operational theater, low post-deployment support was associated with PTSD (OR=2.2, p=0.027) and suicidality (2.10, p<0.018), but not depression. For suicidality, an interaction was detected for homecoming by theater status, whereby Iraq/Afghanistan veterans with lower homecoming support had a higher probability of suicidal thoughts (p=0.002). Thus, years after deployment, lower homecoming support was associated with current PTSD and suicidality, regardless of theater and warzone exposures. For suicidality, lower support had a greater impact on Iraq/Afghanistan veterans.

Using a stress process model, the authors examined social and psychological resources to better understand mental health outcomes among veterans. For this study, we surveyed 700 U.S. veterans who were outpatients in the Geisinger Health System. Independent variables included demographic factors, stressful and traumatic events, social support measures, and psychosocial factors. Using logistic regression, the authors examined 4 types of social connections: social support, help-seeking support, social capital, and other mental health support to predict mental health outcomes, including posttraumatic stress disorder, depression, suicide ideation, alcohol misuse, mental health service use, and Veterans Affairs service use. Results suggested that help-seeking support since deployment was a risk factor for 5 adverse outcomes, whereas social support was protective for 1 outcome. We concluded that high levels of help-seeking support since deployment among veterans was associated with a higher prevalence of mental health problems. These findings were unexpected and suggest the need for additional social support-related research among veterans.

Background: Previously we reported a genetic risk score significantly improved PTSD prediction among a trauma-exposed civilian population. In the current study, we sought to assess this prediction among a trauma-exposed military population. Methods: We examined current PTSD diagnosis and PTSD symptom severity among a random sample of 1042 community-based US military veterans. Main effects and interaction effects were assessed for PTSD genetic risk by trauma exposure using cross-product terms for PTSD x trauma exposures, including combat, lifetime trauma, and adverse childhood exposures. The PTSD risk variants studied were within genetic loci previously associated with PTSD, including CRHR1, CHRNA5, RORA, and FKBP5 genetic variants, which were used to calculate a total PTSD genetic risk score (range=0-8, mean=3.6, SD=1.4). Results: Based on DSM-5 PTSD criteria, 7.1% of veterans (95% CI=5.6-8.8) met criteria for current PTSD. The PTSD genetic risk count was significantly higher among PTSD cases vs noncases (3.92 vs 3.55, p=0.027). Since the PTSD genetic risk score was not significant in the PTSD diagnosis model, we assessed this association using PTSD symptom severity. Because these symptom data were skewed (mean=9.54, SD=12.71, range=0-76), we used negative binomial regression to assess this outcome. This symptom model included a PTSD genetic risk score, demographic factors, trauma exposures, current insomnia, current depression, concussion history, and attention-deficit disorder, expressed as incident rate ratios (IRR), which is an estimate of oneunit increase in PTSD severity, given other variables are held constant. Variables in the final model included age and sex (both p<0.001), PTSD genetic risk (IRR=1.02, p=0.028), warzone tours (IRR=0.94, p=0.003), childhood abuse (IRR=1.50, p<0.0001), current depression (IRR=1.89, p<0.0001), current insomnia (IRR=2.58, p<0.0001), low social support (IRR=1.19, p<0.0001), attention-deficit disorder (IRR=1.51, p<0.0001), agreeable personality (IRR=0.77, p<0.0001), and concussion (IRR=1.38, p<0.0001). Significant interactions were detected for combat and lifetime trauma exposure by PTSD genetic risk (both p<0.0001), suggesting that the impact of trauma exposures on PTSD severity was lower when the PTSD genetic risk was higher. Conclusion: Both warzone and non-warzone factors predicted current PTSD symptoms among veterans, including a PTSD genetic risk score. Interaction effects were detected for combat exposure and lifetime trauma by genetic risk score for PTSD symptoms, suggesting that PTSD symptom manifestation was more dependent on PTSD risk variants than the level of trauma or combat exposure. This suggests that controlling for other factors, the absence of genetic risk variants may confer PTSD resilience. Further research is planned.

Background The majority of Veterans Affair (VA) hospitals are in urban areas. We examined whether veterans residing in rural areas have lower mental health service use and poorer mental health status. Methods Veterans with at least 1 warzone deployment in central and northeastern Pennsylvania were randomly selected for an interview. Mental health status, including PTSD, major depression, alcohol abuse and mental health global severity, were assessed using structured interviews. Psychiatric service use was based on self-reported utilization in the past 12 months. Results were compared between veterans residing in rural and non-rural areas. Data were also analyzed using multivariate logistic regression to minimize the influence by confounding factors. Results A total of 1730 subjects (55% of the eligible veterans) responded to the survey and 1692 of them had complete geocode information. Those that did not have this information (n = 38), were excluded from some analyses. Veterans residing in rural areas were older, more often of the white race, married, and experienced fewer stressful events. In comparison to those residing in non-rural areas, veterans residing in rural areas had lower global mental health severity scores; they also had fewer mental health visits. In multivariate logistic regression, rural residence was associated with lower service use, but not with PTSD, major depression, alcohol abuse, and global mental health severity score after adjusting confounding factors (e.g., age, gender, marital status and education). Conclusions Rural residence is associated with lower mental health service use, but not with poor mental health in veterans with former warzone deployment, suggesting rural residence is possibly protective.

Abstract-The prevalence of oculomotor dysfunctions associated with blast-induced mild traumatic brain injury (mTBI) in warfighters has increased as a consequence of recent conflicts. This study evaluated the effectiveness of computerized oculomotor vision screening (COVS) in a military population. Oculomotor functions were assessed with COVS and by conventional methods in 20 U.S. military personnel with and 20 without mTBI. The validity of COVS was determined by Pearson correlation and Bland-Altman method or the kappa coefficient. The repeatability of the COVS was assessed with the coefficient of repeatability or the kappa coefficient. The results showed that COVS had high sensitivity and specificity for screening near oculomotor functions. Overall, the COVS showed excellent validity and repeatability for assessing near lateral and vertical phorias, Worth 4 Dot, and fixation, as well as pursuit and saccadic eye movements. Despite the strong Pearson correlation, the Bland-Altman analysis identified minor to moderate discrepancies for both positive and negative fusional vergence and their associated recovery as well as for the monocular accommodative facility measurements. This study demonstrated that non-eye-care professionals may be able to use the COVS as a tool to efficiently screen oculomotor functions in a military population with or without mTBI.

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