Biopsychosocial Health of Military Couples

1. Session # H2a October 11, 20131:30pm-2:00pm Biopsychosocial Health of Military Couples Angela Lamson, PhD East Carolina University Melissa Lewis, PhD University of Minnesota-Duluth Meghan Lacks, MS East Carolina University Amelia Muse, MS Texas Tech University Lisa Buchner, MS University of Minnesota Collaborative Family Healthcare Association 15thAnnual Conference October 10-13, 2013 Bolder, CO U.S.A.

2. Faculty Disclosure • “This research and development project was conducted by East Carolina University and is made possible by a cooperative agreement that was awarded and administered by the U.S. Army Medical Research & Materiel Command (USAMRMC) and the Telemedicine & Advanced Technology Research Center (TATRC), at Fort Detrick, MD, under Contract Number: W81XWH1120221.” • “The views, opinions and/or findings contained in this presentation are those of the author(s)/East Carolina University and do not necessarily reflect the views of the Department of Defense and should not be construed as an official DoD/Army position, policy or decision unless so designated by other documentation.  No official endorsement should be made.”

3. Need/Practice Gap & Supporting Resources Most mental health concerns are seen in a physical healthcare context. Therefore, mental health screenings should be a mandatory part of treatment within healthcare systems that treat service personnel and veterans AND spouse. Mental health problems are more likely to occur at the 3 month assessment versus the later 6 month assessment. However at 6 months, cases that were missed at 3 months were identified.Therefore, we should assess the mental health of service personnel EVERY 3 months after deployment (at least 9-12 months).

4. Abstract • This presentation will be comprised of 1) a review of the biopsychosocial health of military couples, 2) results of the research that has been conducted with 100 military couples and 3) assessment and intervention recommendations for clinicians and researchers. The first section will be a review of current literature of the biopsychosocial state of military couples today. This information will familiarize the participants with the strengths and risks to the health of military couples, whereby both partners were involved in the research. Section two is a presentation of study results. Data collection, methodology and statistics will be briefly presented. Next, the presenters will discuss study results and implications for military couples with an emphasis on the systemic and dynamic health trends (i.e., depression, substance use, PTSD, BMI, blood pressure, stress response, relational quality) in military marriages. The third section will focus on implications for future practice or research. Finally, some time will be left at the end for audience members to ask questions and complete their evaluation forms.

5. Learning Objectives

6. Military Marriages • Risks to marriage are higher in military couples • 3.6% of officers sought divorce in 2009. • Probability of divorce greater for those who have served 2 or more years in active duty • Those who marry early have higher rates of divorce than civilians Department of Defense. (2010). Demographics 2009: Profile of the military community.Washington, D.C.: Department of Defense. Hogan, P. F., & Seifert, R. F. (2010). Marriage and the military: Evidence that those who serve marry earlier and divorce earlier. Armed Forces & Society (0095327X), 36, 420-438.

7. Military Marriages • Military couple life is complex • Regular relocation • Challenges to both partners’ emotional health • Trauma and secondary-trauma • Apart on significant occasions • Interpersonal violence and abuse by partner or on duty • Divorce Eran-Jona, M. (2011) Married to the military: Military-family relations in the Israel defense forces. Armed Forces and Society, 37, 19-41. doi 10.1177/0095327X10379729 Figley, C. R. (1988). A five-phase treatment of post-traumatic stress disorder in families. Journal of Traumatic Stress, 1, 127-141. doi:10.1002/jts.2490010109 Goff, B. S. N., Crow, J. R., Reisbig, A. M. J., & Hamilton, S. (2007). The impact of individual trauma symptoms of deployed soldiers on relationship satisfaction. Journal of Family Psychology, 21, 344-353. doi:10.1037/0893-3200.21.3.344 Hogan, P. F., & Seifert, R. F. (2010). Marriage and the military: Evidence that those who serve marry earlier and divorce earlier. Armed Forces & Society (0095327X), 36, 420-438. Mansfield, A. J., Kaufman, J. S., Marshall, S. W., Gaynes, B. N., Morrissey, J. P., & Engel, C. C. (2010). Deployment and the use of mental health services among U.S. army wives. The New England Journal of Medicine, 362(2), 101-109. Renshaw, K. D., Rodrigues, C. S., & Jones, D. H. (2008). Psychological symptoms and marital satisfaction in spouses of operation Iraqi freedom veterans: Relationships with spouses’ perceptions of veterans’ experiences and symptoms. Journal of Family Psychology, 22, 586-594. doi:10.1037/0893-3200.22.3.586 Sayers, S. L., Farrows, V. A., Ross, J., & Oslin, D. W. (2009). Family problems among recently returned military veterans referred for a mental health evaluation. Journal of Clinical Psychiatry,70, 163-170. doi:10.4088/JCP.07m03863 Warner, C. H., Appenzeller, G. N., Warner, C. M., Grieger, T. (2009). Psychological effects of deployments on military families. Psychiatric Annals, 39, 56-63. doi:10.3928/00485713-20090201-11

8. Military Marriages • Military couple life is complex (Continued) • Division of labor and roles • Marital strengths and challenges • Unpredictability of deployment • Exposure to combat and secondary trauma Allen, E. S., Rhoades, G. K., Stanley, S. M., & Markman, H. J. (2010). Hitting home: Relationships between recent deployment, posttraumatic stress symptoms, and marital functioning for army couples. Journal of Family Psychology, 24, 280-288. doi:10.1037/a0019405 Eran-Jona, M. (2011) Married to the military: Military-family relations in the Israel defense forces. Armed Forces and Society, 37, 19-41. doi 10.1177/0095327X10379729 Mattson, R. E., Paldino, D., & Johnson, M. D. (2007). The increased construct validity and clinical utility of assessing relationship quality using separate positive and negative dimensions. Journal of Psychological Assessment, 19, 146-151. doi:10.1037/1040-3590.19.1.146 Sayers, S. L., Farrows, V. A., Ross, J., & Oslin, D. W. (2009). Family problems among recently returned military veterans referred for a mental health evaluation. Journal of Clinical Psychiatry,70, 163-170. doi:10.4088/JCP.07m03863

9. Health risks for military personnel AFHSC. (2010). Mental health issue. Medical Surveillance Monthly Report, 17(1), 1-32. Associated Press. (2007). Military divorce rates studied. Retrieved March 5, 2010 http://www.military.com. Bobo, W. V., Hoge, C. W., Messina, M. A., Pavlovcic, F., Levandowski, D., & Grieger, T. (2004). Characteristics of repeat users of an Inpatient psychiatry service at a large military tertiarycare hospital. Military Medicine, 169(8), 648-653. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=14080893&site=ehost-live -See Reference page for full list

10. Deployment & Mental Health • 19% of military personal who returned for deployment reported a mental health problem • Only 35% of these accessed mental health services within a year of returning home • Diagnoses of depression was significantly higher 120 days after returning from deployment than directly after returning home • Complex presentations may complicate depression • Marital distress • Alcohol abuse • Family problems Bliese, P. D., Wright, K. M., Adler, A. B., Thomas, J. L., & Hoge, C. W. (2007). Timing of postcombat mental health assessments. Journal of Psychological Services, 4, 141-148. doi:10.1037/1541-1559.4.3.141 Felker, B., Hawkins, E., Dobie, D., Gutierrez, J., & McFall, M. (2008). Characteristics of deployed operation Iraqi freedom military personnel who seek mental health care. Military Medicine, 173, 155-158. Iverson, A. C., Staden, L. V., Hughes, J. H., Browne, T., Hull, L., Hall, J., Greenberg, N., Rona, R. J., Hotopf, M., Wessely, S., & Fear, N. T. (2009). The prevalence of common medical disorders and PTSD in the UK military: Using data from a clinical interview-based study. Journal of BMC Psychiatry, 9, 1-2. doi:10.1186/1471-244X-9-68 Renshaw, K. D., Rodrigues, C. S., & Jones, D. H. (2008). Psychological symptoms and marital satisfaction in spouses of Operation Iraqi Freedom veterans: Relationships with spouses' perceptions of veterans' experiences and symptoms. Journal of Family Psychology, 22(4), 586-594. doi:10.1037/0893-3200.22.3.586 Sayers, S. L., Farrows, V. A., Ross, J., & Oslin, D. W. (2009). Family problems among recently returned military veterans referred for a mental health evaluation. Journal of Clinical Psychiatry,70, 163-170. doi:10.4088/JCP.07m03863 Verdeli, H., Baily, C., Vousoura, Belser, A., E., Singla, D., & Manos, G. (2011). The case for treating depression in military spouses. American Psychological Association, 25, 488-496. doi: 10.1037/a0024525

11. Military Wives’ Emotional Health • Military wives have been shown to struggle with physical and emotional health concerns: • Physiological distress • Depression • Caregiver burden • Psychological distress Allen, E. S., Rhoades, G. K., Stanley, S. M., & Markman, H. J. (2010). Hitting home: Relationships between recent deployment, posttraumatic stress symptoms, and marital functioning for army couples. Journal of Family Psychology, 24, 280-288. doi:10.1037/a0019405 Eaton, K. M., Hoge, C. W., Messer, S. C., Whitt, A. A., & Cabrora, O. A. (2008). Prevalence of mental health problems, treatment needed, and barriers to care among primary care-seeking spouses of military service members involved in Iraq and Afghanistan deployments. Journal of Military Medicine, 173, 1051-1056 Smith, T. W., Cribbet, M. R., Nealey-Moore, J., Uchino, B. N., Williams, P. G., MacKenzie, J., & Thayer, J. F. (2011). Matters of the variable heart: Respiratory sinus arrhythmia response to marital interaction and associations with marital quality. Journal of Personality and Social Psychology, 100(1), 103-119. doi:10.1037/a0021136 Warner, C. H., Appenzeller, G. N., Warner, C. M., Grieger, T. (2009). Psychological effects of deployments on military families. Psychiatric Annals, 39, 56-63. doi:10.3928/00485713-20090201-11

12. Physiological Arousal & Marital Quality • Physiological arousal is related to marital quality. • Wives experience changes in physiology when discussing problem areas • These physiological changes are related to women’s judgments' of the negativity of their marriages • Thus, arousal might impact how wives think about their marriages when interacting with their husbands Menchaca, D., & Dehle, C. (2005). Marital quality and physiological arousal: How do I love thee? Let my heartbeat count the ways. The American Journal of Family Therapy, 33, 117-130. doi:10.1080/01926180590915897

13. Research questions • What is the state of dyadic data collection in research on military couples? • What is the state of dyadic analysis in research on military couples? • How do researchers employ methodology in an effort to gather data from both members of a dyad? • Which dyadic interventions are effective in treating military couples? Lewis, M. E., Lamson, A. L., & White, M. B. A systematic review of interventions for military couples. Under review by Family Process.

14. Constructing a BPR study with Couples

16. How is stress measured? Boysen, A., Lewin, M. A., Hecker, W., Leichter, H. E., & Uhlemann, F. (2007). Autonomic function testing in children and adolescents with diabetes mellitus. Pediatric Diabetes, 8(5), 261-264. Cohen, H., Benjamin, J., Geva, A. B., Matar, M. A., Kaplan, Z., & Kotler, M. (2000). Autonomic dysregulation in panic disorder and in post-traumatic stress disorder: Application of power spectrum analysis of heart rate variability at rest and in response to recollection of trauma or panic attacks. Psychiatry Research, 96(1), 1-13. Smith, T. W., Cribbet, M. R., Nealey-Moore, J., Uchino, B. N., Williams, P. G., MacKenzie, J., & Thayer, J. F. (2011). Matters of the variable heart: Respiratory sinus arrhythmia response to marital interaction and associations with marital quality. Journal of Personality and Social Psychology, 100(1), 103-119. doi:10.1037/a0021136 Thayer, J. F., & Lane, R. D. (2007). The role of vagal function in the risk for cardiovascular disease and mortality. Biological Psychology, 74(2), 224-242. doi:10.1016/j.biopsycho.2005.11.013 In order to quantify stress, psychophysiological or biological markers can be used to measure the amount of stress that someone is experiencing (i.e., increased respiration, blood pressure, sweat, brain wave activity, etc.). Heart Rate Variability (HRV) is a measure of the autonomic nervous system that assesses sympathetic and parasympathetic responses (relaxation and stress response). HRV has been used to detect biopsychorelational health concerns including cardiovascular disease, diabetes, PTSD, as well as marital quality.

17. Physiological Reactivity and PTSD Beckham, J. C., Taft, C. T., Vrana, S. R., Feldman, M. E., Barefoot, J. C., Moore, S. D., . . . Calhoun, P. S. (2003). Ambulatory monitoring and physical health report in Vietnam veterans with and without chronic posttraumatic stress disorder. Journal of Traumatic Stress, 16(4), 329-335. doi:10.1023/A:1024457700599 Schnurr, P. P., & Jankowski, M. K. (1999). Physical health and post-traumatic stress disorder: Review and synthesis. Seminars in Clinical Neuropsychiatry, 4(4), 295-304. Schnurr, P. P., Spiro,Avron, I.,II, & Paris, A. H. (2000). Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military veterans. Health Psychology, 19(1), 91-97. doi:10.1037/0278-6133.19.1.91 • For those persons who have experienced traumatic events, those diagnosed with PTSD had worse physical outcomes than those who did not have PTSD • The ‘active ingredient’ is not just the PTSD diagnosis but the actual sympathetic nervous system activity which is associated with worsening biopsychosocial health • PTSD is usually accompanied by other physical symptoms

18. Summary of Outcomes • Lewis, Lamson, et al. 2012, 2013 • Buchner, Lamson et al 2013 • Lacks, Lamson et al. 2013 • Lamson, Meadorset al 2013 • Muse, Lamson et al. 2013

19. Policy Recommendation 1 Bowen, G. L., & Orthner, D. K. (Eds.). (1989). Organization family: Work & family linkages in the U.S. military. Organization Family: Work & Family Linkages in the U.S. Military. Ipswich, MA: Praeger Publishers. Dirkzwager, A. J. E., Bramsen, I., Adèr, H., & van derploeg, H. M. (2005). Secondary traumatization in partners and parents of Dutch peacekeeping soldiers. Journal of Family Psychology, 19(2), 217-226. doi:10.1037/0893-3200.19.2.217 Faber, A. J., Willerton, E., Clymer, S. R., MacDermid, S. M., & Weiss, H. M. (2008). Ambiguous absence, ambiguous presence: A qualitative study of military reserve families in wartime. Journal of Family Psychology, 22(2), 222-230. doi:10.1037/0893-3200.22.2.222 Figley, C. R. (1988). A five-phase treatment of post-traumatic stress disorder in families. Journal of Traumatic Stress, 1(1), 127-141. doi:10.1002/jts.2490010109 Hourani, L. L., Williams, T. V., & Kress, A. M. (2006). Stress, mental health, and job performance among active duty military personnel: Findings from the 2002 department of defense health-related behaviors survey. Military Medicine, 171(9), 849-856. Lewis, M., Lamson, A., & Leseuer, B. (2012). Health Dynamics of Military and Veteran Couples: A Biopsychorelational Overview. Contemporary Family Therapy: An International Journal, 34(2), 259-276. doi:10.1007/s10591-012-9193-7 Mansfield, A. J., Kaufman, J. S., Marshall, S. W., Gaynes, B. N., Morrissey, J. P., & Engel, C. C. (2010). Deployment and the use of mental health services among U.S. Army wives. The New England Journal of Medicine, 362(2), 101-109. Orthner, D. K., & Rose, R. (2009). Work separation demands and spouse psychological well-being.Family Relations, 58(4), 392-403. doi:10.1111/j.1741-3729.2009.00561.x Riggs, D. S., Byrne, C. A., Weathers, F. W., & Litz, B. T. (1998). The quality of the intimate relationships of male Vietnam veterans: Problems associated with posttraumatic stress disorder. Journal of Traumatic Stress, 11(1), 87-101. doi:10.1023/A:1024409200155 Romanoff, M. R. (2006). Assessing military veterans for posttraumatic stress disorder: A guide for primary care clinicians. Journal of the American Academy of Nurse Practitioners, 18(9), 409-413. doi:10.1111/j.1745-7599.2006.00147.x • Ask about partners and encourage clients/patients to bring their spouse to healthcare visits • Military experiences such as occupational stress, deployment, and PTSD can pose serious threats to marital relationships, yet medical professionals do not routinely assess both members of a couple during medical visits. • The most common mental health concern for returning military personnel with PTSD is marital disruption • Mental health assessments of spouses of PTSD victims are also necessary due to the reciprocal and shared relationship of PTSD for couples.

20. Recommendation #2 Conceptualize PTSD relationally, as opposed to individually. PTSD severity is moderated by the social system of the sufferer and those closest to the victim of PTSD are equally at risk for health concerns

21. More support for familial intervention… DiMatteo, M. (2004). Social support and patient adherence to medical treatment: A meta-analysis. Health Psychology, 23(2), 207-218. doi:10.1037/0278-6133.23.2.207 DeSimone, K. L. (2000). Is a single oral dose of amiodarone safe and effective in converting new-onset atrial fibrillation (AF) to sinus rhythm? The Journal of Family Practice, 49(6), 493-494. Khaylis, A., Polusny, M. A., Erbes, C. R., Gewirtz, A., & Rath, M. (2011). Posttraumatic stress, family adjustment, and treatment preferences among national guard soldiers deployed to OEF/OIF. Military Medicine, 176(2), 126-131. Law, D. D., & Crane, D. R. (2000). The influence of marital and family therapy on health care utilization in a health-maintenance organization. Journal of Marital & Family Therapy, 26(3), 281-291. Sayers, S. L., White, T., Zubritsky, C., & Oslin, D. W. (2006). Family involvement in the care of healthy medical outpatients. Family Practice, 23(3), 317-324. doi:10.1093/fampra/cmi114 • Family Support with healthcare decisions should be encouraged • The support system of a patient has numerous positive effects on the patient’s health outcomes provide and provide needed support with recovery that results in better symptom and cost management than when receiving care alone. • Many people prefer to involve family in their healthcare needs • The majority of all military personnel prefer family-focused interventions to treat mental health needs. • The presence of a spouse at a medical visit has been found to decrease partner symptomology by 21% and relate to reduced medical visits by both partners. • Further, marital status and familial support are related to higher incidence of adherence to the medical treatment plan.

22. Resources • The Alliance of Military and Veteran Family Behavioral Health Providers: http://www.ecu.edu/che/alliance/ • Integrated Care Models: http://www.integration.samhsa.gov/integrated-care-models • Collaborative Family Healthcare Association: http://www.cfha.net/ • Naval Center for Combat & Operational Stress Control: http://www.med.navy.mil/sites/nmcsd/nccosc/Pages/welcome.aspx • SAMHSA Military Families: http://www.samhsa.gov/MilitaryFamilies/ • Database for Veteran and Military Health (Medline Plus): • http://www.nlm.nih.gov/medlineplus/veteransandmilitaryhealth.html

23. Contact Information Angela Lamson, PhD, LMFT, CFLE 112 Redditt House Greenville, NC 27858 East Carolina University (252)737-2042 lamsona@ecu.edu Melissa Lewis, PhD University of Minnesota Medical School - Duluth Dept of Biobehavioral Health & Population Sciences 1035 University Drive Duluth, MN 55812-3031 218-726-6569 218-726-7559 (fax) melewis@d.umn.edu

24. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!