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Wars may end, but the mental health ramifications of stressful war-zone exposure can endure for many years for some military personnel and veterans. Identification of risk and resilience factors that differentiate the long-term course of posttraumatic stress disorder (PTSD) symptoms among war-zone veterans can potentially inform both post-exposure interventions and pre-exposure preventative measures. However, much remains to be learned about what underlies variation in the long-term course of PTSD, including sometimes overlooked factors such as early trauma exposure and pre-existing PTSD symptoms. 
In early 2003 at the outset of the Iraq War, we established a cohort of US Army soldiers with varying military occupational specialties and geographic locations to better understand the mental health and neuropsychological outcomes of war-zone deployment.  We assessed the cohort, known as the Neurocognition Deployment Health Study (NDHS), before and after they deployed to Iraq and at a long-term follow-up assessment conducted at least five years after their return from deployment as part of VA Cooperative Study Program 566 (CSP566). 
More recently, we modeled symptom growth trajectories in 1087 members of the NDHS/CSP566 cohort to better understand predictors of individual outcomes over time (results to be published in a forthcoming issue of the Journal of Traumatic Stress). Using growth mixture modeling, we found that PTSD symptom course indeed varied considerably over time. The pattern of symptoms fell into four categories, or “classes”:  (1) primarily asymptomatic (n = 194; 17.8%), (2) post-deployment worsening symptoms (n = 84; 7.7%), (3) mild symptoms (n = 320; 29.4%), and (4) pre-existing, with chronic post-deployment elevation of symptoms (n = 489; 45.0%).  
When we examined factors that potentially differentiated the four longitudinal courses of PTSD symptoms, we found that, compared with individuals in the primarily asymptomatic class, individuals in chronic symptom classes were more likely to report greater stress exposure, had less access to pre-deployment social support, were either military reservists or veterans (vs. regular active duty) at the most recent assessment, and performed less well on a visual memory task at the pre-deployment assessment. 
Although an unfortunately large number of study participants experienced elevated PTSD symptoms many years after their deployment to the Iraq War, we were encouraged to find that some risk factors (e.g., social support and even visual memory) are potentially modifiable. Among those factors that are not modifiable, we hope that identification of those at greater risk will facilitate outreach and clinical service provision efforts. 
We remain extremely grateful to the members of the NDHS/CSP566 cohort for both their military service and their commitment to helping fellow military service members and veterans via their sustained participation in this research.

Target Article

Vasterling, J. J.,  Franz, M. R.,  Lee, L. O.,  Kaiser, A. P.,  Proctor, S. P.,  Marx, B. P.,  Schnurr, P. P.,  Ko, J.,  Concato, J., &  Aslan, M. (2023).  Early predictors of chronic posttraumatic stress disorder symptom trajectories in U.S. Army soldiers deployed to the Iraq war zone. Journal of Traumatic Stress,  00,  1–13. https://doi.org/10.1002/jts.22964

Discussion Questions

  1. How can we best shape preventative efforts to minimize adverse mental health outcomes of war?
  2. We found that the integrity of a cognitive process (i.e., visual memory) may influence outcomes.  Are there ways we can better integrate knowledge from the field of cognition and emotion into preventative efforts?
  3. Given that both pre-deployment and deployment stressors created risk of poorer long-term outcomes and, relatedly the sizable number of participants reporting pre-deployment PTSD symptoms, can we better serve those with adverse early life experiences?
  4. Are there additional ways to better address early symptoms following deployment that will then minimize the risk of chronically elevated PTSD symptoms?

About the Authors

Jennifer J. Vasterling, PhD, is Chief of Psychology at VA Boston Healthcare System, an affiliated investigator in the Behavioral Science Division of the National Center for PTSD, Professor of Psychiatry at the Boston University Chobanian and Avedisian School of Medicine, and a Lecturer at Harvard Medical School. Trained as a clinical neuropsychologist, Dr. Vasterling’s long-standing interests focus on the interface of PTSD and neurocognitive processes. To address prior limitations in understanding of the  health consequences of war-zone participation due to a lack of pre-deployment health data, she and Dr. Proctor initiated the Neurocognition Deployment Health Study to prospectively assessment military personnel prior to Iraq War deployment.  Dr. Vasterling can be contacted at Jennifer.Vasterling@va.gov.
Molly Franz, PhD, is an Assistant Professor in the Department of Psychology at the University of Maryland Baltimore County. The overarching aims of Dr. Franz’s research are to (1) understand the effects of PTSD and trauma-related distress on survivors’ family relationships, and (2) identify and promote sources of strength and resilience among individuals coping with trauma-related distress. Dr. Franz can be contacted at mfranz@umbc.edu.
Lewina O. Lee, PhD, is a Psychologist and Staff Investigator at the Behavioral Science Division of the National Center for Posttraumatic Stress Disorder at VA Boston, and an Associate Professor of Psychiatry at the Boston University Chobanian & Avedisian School of Medicine. She completed her doctoral training in clinical psychology (aging) from the University of Southern California and a postdoctoral fellowship in Epidemiology at the Boston University School of Public Health. Her research examines the role of psychosocial stressor exposure in health from a lifespan developmental perspective; she also studies positive psychosocial factors which confer resilience against the effects of stressor exposure on health. Dr. Lee can be reached at lewina@bu.edu
Twitter handle: @DrLewina
Anica Pless Kaiser, PhD, is a clinical research psychologist in the Behavioral Science Division of the National Center for PTSD and is affiliated with the New England GRECC at VA Boston Healthcare System. She is a Research Assistant Professor of Psychiatry at Boston University Chobanian & Avedisian School of Medicine, a co-director of the Stress, Health, and Aging Research Program (SHARP) group, and part of the ORH-funded PTSD in late life group at VA Boston. Her research interests include understanding the effects of stress and trauma over the lifespan, PTSD symptom course over time, development of interventions for older Veterans, and the relationships among trauma exposure, PTSD, and physical function in older Veterans. Dr. Pless Kaiser may be contacted at: Anica.PlessKaiser@va.gov.
Susan P Proctor, DSc, MS, has spent her career focused on active military and veteran deployment and environmental health epidemiology research efforts, with the Boston University School of Public Health, US Department of Veterans Affairs, and the US Army Research Institute of Environmental Medicine. With Dr. Vasterling, she initiated the Neurocognition Deployment Health Study. Dr. Proctor has retired and can be contacted at spproctor@comcast.net.
Brian Marx, PhD, serves as the Deputy Director of Behavioral Science Division of the National Center for PTSD, Co-Director of VA’s Suicide Prevention Research Impact Network, and is a Professor of Psychiatry at the Boston University Chobanian and Avedisian School of Medicine. Dr. Marx’s research interests include the assessment and treatment of PTSD and improving means and methods of suicide prevention among military veterans and service members.

Paula P. Schnurr, PhD, is the Executive Director of the National Center for PTSD and a Professor of Psychiatry at the Geisel School of Medicine at Dartmouth.  She is a Past-President of ISTSS and formerly served as Editor-in-Chief of the Journal of Traumatic Stress and as a member of the ISTSS Board of Directors.  Her research focuses on the treatment of PTSD.

John Ko, MS, currently works at the VHA Medicare and Medicaid Analysis Center. He is a program analyst, managing CMS files permissions for operation DUA users.
John Concato, MD, FACP, MS, MPH, is an Associate Director in the Office of Medical Policy, Center for Drug Evaluation and Research (CDER), Food and Drug Administration. His responsibilities focus on FDA’s Real-World Evidence (RWE) Program, including internal agency processes, external stakeholder engagement, demonstration projects, guidance development, and serving as Chair of CDER’s RWE Subcommittee. Dr. Concato joined FDA in 2019 after a 27-year career at Yale School of Medicine and the U.S. Department of Veterans Affairs (VA), where he was Professor of Medicine, Director of the VA Clinical Epidemiology Research Center, and one of two founding principal investigators of the VA Million Veteran Program mega-biobank.
Mihaela Aslan, PhD, is the Director, West Haven VA Cooperative Studies Program Epidemiology Center, which has been the coordinating center for VA CSP566, and serves as a Research Scientist at Yale University School of Medicine. Dr. Aslan had additionally led or contributed to initiatives such as partnerships with the Biomedical Advanced Research and Development Authority and US Food and Drug Administration during the COVID pandemic and CSP’s IT/Informatics, Data, Epidemiology and Analytics for a Learning Healthcare System (IDEAL) initiative.