Abstract
Objectives
Combat experiences predict PTSD and depression in U.S. military veterans. However, few studies have investigated associations between mindfulness and these constructs. We examined main, direct, and indirect effects for mindfulness and combat experiences on veterans’ PTSD and depressive symptoms and investigated the explanatory value of mindfulness on outcome variance in these models.
Methods
A total of 485 post-9/11 era military veterans with previous combat deployments residing in four major US cities completed online surveys asking about their combat experiences, mindfulness, and mental health. Two multivariable ordinary least squares regression models were specified to investigate main effects of mindfulness and combat experiences on veterans’ PTSD and depressive symptoms. Path models examined direct and indirect effects of combat experiences and mindfulness on these outcomes.
Results
There were significant associations for mindfulness (β = − 0.68, p < 0.001), (β = − 0.67, p < 0.001) and combat experiences (β = 0.12, p < 0.001), (β = 0.09, p < 0.001) with PTSD and depression respectively. In both models, the addition of the mindfulness parameter significantly increased model R2. Path analysis demonstrated significant direct effects for mindfulness and combat experiences and indirect effects for combat experiences on PTSD and depressive symptoms through the mindfulness pathway.
Conclusions
The associations of mindfulness with PTSD and depressive symptoms were greater in magnitude than the associations for combat experiences, and mindfulness explained a large and significant proportion of the variance in outcomes. Additional longitudinal research investigating how mindfulness skills and strategies may buffer against risk for PTSD and depression posed by combat experience is warranted in this high risk population.
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References
Adler, A. B., Vaitkus, M. A., & Martin, J. A. (1996). Combat exposure and posttraumatic stress symptomatology among U. S. Soldiers Deployed to the Gulf War. Military Psychology, 8(1), 1–14. https://doi.org/10.1207/s15327876mp0801_1.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Barr, N. U., Sullivan, K., Kintzle, S., & Castro, C. A. (2016). PTSD symptoms, suicidality and non-suicidal risk to life behavior in a mixed sample of pre- and post-9/11 veterans. Social Work in Mental Health, 14(5), 465–473. https://doi.org/10.1080/15332985.2015.1081666.
Batten, S. V., Orsillo, S. M., & Walser, R. D. (2007). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety (pp. 241–269). Boston, MA: Springer US. https://doi.org/10.1007/0-387-25989-9_10.
Bhatnagar, R., Phelps, L., Rietz, K., Juergens, T., Russell, D., Miller, N., & Ahearn, E. (2013). The effects of mindfulness training on post-traumatic stress disorder symptoms and heart rate variability in combat veterans. The Journal of Alternative and Complementary Medicine, 19(11), 860–861. https://doi.org/10.1089/acm.2012.0602.
Briere, J., Scott, C., & Weathers, F. (2005). Peritraumatic and persistent dissociation in the presumed etiology of PTSD. American Journal of Psychiatry, 162(12), 2295–2301. https://doi.org/10.1176/appi.ajp.162.12.2295.
Brown, K. W. & Ryan, R. M.(2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), 822-848.
Bruce, M. L. (2010). Suicide risk and prevention in veteran populations. Annals of the New York Academy of Sciences, 1208(1), 98–103. https://doi.org/10.1111/j.1749-6632.2010.05697.x.
Call, D., Pitcock, J., & Pyne, J. (2015). Longitudinal evaluation of the relationship between mindfulness, general distress, anxiety, and PTSD in a recently deployed National Guard sample. Mindfulness, 6(6), 1303–1312. https://doi.org/10.1007/s12671-015-0400-0.
Castro, C. A., & Kintzle, S. (2017). The state of the American veteran: the San Francisco veterans’ study. Los Angeles: University of Southern California, Center for Innovation and Research on Veterans & Military Families.
Castro, C. A., & McGurk, D. (2007). The intensity of combat and behavioral health status. Traumatology, 13(4), 6–23. https://doi.org/10.1177/1534765607309950.
Castro, C. A., Kintzle, S., & Hassan, A. (2014). The state of the American veteran: The Los Angeles County veterans’ study. Los Angeles: University of Southern California, Center for Innovation and Research on Veterans & Military Families.
Castro, C. A., Kintzle, S., & Hassan, A. (2015a). The state of the American veteran: the Orange County veterans’ study. Los Angeles: University of Southern California, Center for Innovation and Research on Veterans & Military Families.
Castro, C. A., Kintzle, S., & Hassan, A. M. (2015b). The combat veteran paradox: paradoxes and dilemmas encountered with reintegrating combat veterans and the agencies that support them. Traumatology, 21(4), 299–310. https://doi.org/10.1037/trm0000049.
Chiesa, A., Calati, R., & Serretti, A. (2011). Does mindfulness training improve cognitive abilities? A systematic review of neuropsychological findings. Clinical Psychology Review, 31(3), 449–464. https://doi.org/10.1016/j.cpr.2010.11.003.
Credé, M., Tynan, M. C., & Harms, P. D. (2017). Much ado about grit: a meta-analytic synthesis of the grit literature. Journal of Personality and Social Psychology. https://doi.org/10.1037/pspp0000102.
Davis, L. L., Whetsell, C., Hamner, M. B., Carmody, J., Rothbaum, B. O., Allen, R. S., … Bremner, J. D. (2018). A multisite randomized controlled trial of mindfulness-based stress reduction in the treatment of posttraumatic stress disorder Psychiatric Research and Clinical Practice, appi.Prcp.20180. https://doi.org/10.1176/appi.prcp.20180002.
de Abreu Costa, M., D’Alò de Oliveira, G. S., Tatton-Ramos, T., Manfro, G. G., & Salum, G. A. (2019). Anxiety and stress-related disorders and mindfulness-based interventions: a systematic review and multilevel meta-analysis and meta-regression of multiple outcomes. Mindfulness, 10(6), 996–1005. https://doi.org/10.1007/s12671-018-1058-1.
Dedert, E. A., Green, K. T., Calhoun, P. S., Yoash-Gantz, R., Taber, K. H., Mumford, M. M., … Beckham, J. C. (2009). Association of trauma exposure with psychiatric morbidity in military veterans who have served since September 11, 2001. Journal of Psychiatric Research, 43(9), 830–836. https://doi.org/10.1016/j.jpsychires.2009.01.004.
Department of Veterans’ Affairs, Veterans Health Administration, Office of Mental Health and Suicide Prevention. (2016). Veteran Suicide Data Report, 2005–2016. Retrieved from: https://www.mentalhealth.va.gov/docs/data-sheets/OMHSP_National_Suicide_Data_Report_2005-2016_508-compliant.pdf.
Dohrenwend, B. P., Turner, J. B., Turse, N. A., Lewis-Fernandez, R., & Yager, T. J. (2008). War-related posttraumatic stress disorder in Black, Hispanic, and majority White Vietnam veterans: the roles of exposure and vulnerability. Journal of Traumatic Stress, 21(2), 133–141. https://doi.org/10.1002/jts.20327.
Foa, E. B., Steketee, G., & Rothbaum, B. O. (1989). Behavioral/cognitive conceptualizations of post-traumatic stress disorder. Behavior Therapy, 20(2), 155–176. https://doi.org/10.1016/S0005-7894(89)80067-X.
Gil, S. (2005). Coping style in predicting posttraumatic stress disorder among Israeli students. Anxiety, Stress, and Coping, 18(4), 351–359. https://doi.org/10.1080/10615800500392732.
Guyker, W. M., Donnelly, K., Donnelly, J. P., Dunnam, M., Warner, G. C., Kittleson, J., … Meier, S. T. (2013). Dimensionality, reliability, and validity of the combat experiences scale. Military Medicine, 178(4), 377–384. https://doi.org/10.7205/MILMED-D-12-00223.
Haagen, J. F. G., Smid, G. E., Knipscheer, J. W., & Kleber, R. J. (2015). The efficacy of recommended treatments for veterans with PTSD: A metaregression analysis. Clinical Psychology Review, 40, 184–194. https://doi.org/10.1016/j.cpr.2015.06.008.
Harding, K., Simpson, T., & Kearney, D. J. (2018). Reduced symptoms of post-traumatic stress disorder and irritable bowel syndrome following mindfulness-based stress reduction among veterans. The Journal of Alternative and Complementary Medicine, 24(12), 1159–1165. https://doi.org/10.1089/acm.2018.0135.
Hayes, A. F., & Cai, L. (2007). Using heteroskedasticity-consistent standard error estimators in OLS regression: An introduction and software implementation. Behavior research methods, 39(4), 709–722.
Henning, K. R., & Frueh, B. C. (1997). Combat guilt and its relationship to PTSD symptoms. Journal of Clinical Psychology, 53(8), 801–808. https://doi.org/10.1002/(SICI)1097-4679(199712)53:8<801::AID-JCLP3>3.0.CO;2-I.
Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13–22. https://doi.org/10.1056/NEJMoa040603.
Hopwood, T. L., & Schutte, N. S. (2017). A meta-analytic investigation of the impact of mindfulness-based interventions on post traumatic stress. Clinical Psychology Review, 57, 12–20. https://doi.org/10.1016/j.cpr.2017.08.002.
International Society for Traumatic Stress Studies. (2019). Posttraumatic stress disorder prevention and treatment guidelines: methodology and recommendations. Oakbrook Terrace: ISTSS Retrieved from: http://www.istss.org/getattachment/Treating-Trauma/New-ISTSS-Prevention-and-Treatment-Guidelines/ISTSS_PreventionTreatmentGuidelines_FNL-March-19-2019.pdf.aspx.
Jha, A. P., Krompinger, J., & Baime, M. J. (2007). Mindfulness training modifies subsystems of attention. Cognitive, Affective, & Behavioral Neuroscience, 7(2), 109–119. https://doi.org/10.3758/CABN.7.2.109.
Jha, A. P., Morrison, A. B., Parker, S. C., & Stanley, E. A. (2017). Practice is protective: mindfulness training promotes cognitive resilience in high-stress cohorts. Mindfulness, 8(1), 46–58. https://doi.org/10.1007/s12671-015-0465-9.
Johnson, D. C., Thom, N. J., Stanley, E. A., Haase, L., Simmons, A. N., Shih, P. B., … Paulus, M. P. (2014). Modifying resilience mechanisms in at-risk individuals: a controlled study of mindfulness training in marines preparing for deployment. American Journal of Psychiatry, 171(8), 844–853. https://doi.org/10.1176/appi.ajp.2014.13040502.
Kabat-Zinn, J. (1990). Full catastrophe living: using the wisdom of your mind and body to face stress, pain, and illness. New York: Delacorte.
Kang, H. K., & Bullman, T. A. (2009). Is there an epidemic of suicides among current and former U.S. Military Personnel? Annals of Epidemiology, 19(10), 757–760. https://doi.org/10.1016/j.annepidem.2009.05.004.
Kang, H. K., Bullman, T. A., Smolenski, D. J., Skopp, N. A., Gahm, G. A., & Reger, M. A. (2015). Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars. Annals of Epidemiology. https://doi.org/10.1016/j.annepidem.2014.11.020.
Kaplan, J. B., Bergman, A. L., Christopher, M., Bowen, S., & Hunsinger, M. (2017). Role of resilience in mindfulness training for first responders. Mindfulness, 8(5), 1373–1380. https://doi.org/10.1007/s12671-017-0713-2.
Kearney, D. J., McDermott, K., Malte, C., Martinez, M., & Simpson, T. L. (2012). Association of participation in a mindfulness program with measures of PTSD, depression and quality of life in a veteran sample. Journal of Clinical Psychology, 68(1), 101–116. https://doi.org/10.1002/jclp.20853.
Killgore, W. D. S., Stetz, M. C., Castro, C. A., & Hoge, C. W. (2006). The effects of prior combat experience on the expression of somatic and affective symptoms in deploying soldiers. Journal of Psychosomatic Research, 60(4), 379–385. https://doi.org/10.1016/j.jpsychores.2006.02.012.
Killgore, W. D. S., Cotting, D. I., Thomas, J. L., Cox, A. L., McGurk, D., Vo, A. H., … Hoge, C. W. (2008). Post-combat invincibility: violent combat experiences are associated with increased risk-taking propensity following deployment. Journal of Psychiatric Research, 42(13), 1112–1121. https://doi.org/10.1016/j.jpsychires.2008.01.001.
King, A. P., Erickson, T. M., Giardino, N. D., Favorite, T., Rauch, S. A. M., Robinson, E., … Liberzon, I. (2013). A pilot study of group mindfulness-based cognitive therapy (MBCT) for combat veterans with posttraumatic stress disorder (PTSD). Depression and Anxiety, 30(7), 638–645. https://doi.org/10.1002/da.22104.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9.Journal of General Internal Medicine, 16 (9), 606-613.
LeardMann, C. A., Powell, T. M., Smith, T. C., Bell, M. R., Smith, B., Boyko, E. J., … Hoge, C. W. (2013). Risk factors associated with suicide in current and former US military personnel. JAMA, 310(5), 496. https://doi.org/10.1001/jama.2013.65164.
Linehan, M. M. (2018). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.
Management of Posttraumatic Stress Working Group (2017). VA/DoD clinical practice guideline for the management of posttraumatic stress Retrieved from: https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf.
Marlatt, G. A., & Kristeller, J. L. (1999). Mindfulness and meditation. In W. R. Miller (Ed.), Integrating spirituality into treatment: Resources for practitioners (pp. 67–84). Washington, DC: American Psychological Association. https://doi.org/10.1037/10327-004.
McCaslin, S. E., Inslicht, S. S., Metzler, T. J., Henn-Haase, C., Maguen, S., Neylan, T. C., … Marmar, C. R. (2008). Trait dissociation predicts posttraumatic stress disorder symptoms in a prospective study of urban police officers. The Journal of Nervous and Mental Disease, 196(12), 912–918. https://doi.org/10.1097/NMD.0b013e31818ec95d.
McFall, M. E., & Cook, J. W. (2006). PTSD and health risk behavior. PTSD Research Quarterly, 17(4), 1–7 Retrieved from: https://search.proquest.com/docview/42459314?accountid=28179.
Morina, N., Stangier, U., & Risch, A. K. (2008). Experiential avoidance in civilian war survivors with current versus recovered posttraumatic stress disorder: a pilot study. Behaviour Change, 25(1), 15–22. https://doi.org/10.1375/bech.25.1.15.
Polusny, M. A., Erbes, C. R., Thuras, P., Moran, A., Lamberty, G. J., Collins, R. C., … Lim, K. O. (2015). Mindfulness-based stress reduction for posttraumatic stress disorder among veterans. JAMA, 314(5), 456. https://doi.org/10.1001/jama.2015.8361.
Ramchand, R., Rudavsky, R., Grant, S., Tanielian, T., & Jaycox, L. (2015). Prevalence of, risk factors for, and consequences of posttraumatic stress disorder and other mental health problems in military populations deployed to Iraq and Afghanistan. Current Psychiatry Reports, 17(5), 37. https://doi.org/10.1007/s11920-015-0575-z.
Schlenger, W. E., Kulka, R. A., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1992). The prevalence of post-traumatic stress disorder in the Vietnam generation: a multimethod, multisource assessment of psychiatric disorder. Journal of Traumatic Stress, 5(3), 333–363. https://doi.org/10.1007/BF00977233.
Schultz, M., Glickman, M. E., & Eisen, S. V. (2014). Predictors of decline in overall mental health, PTSD and alcohol use in OEF/OIF veterans. Comprehensive Psychiatry, 55(7), 1654–1664. https://doi.org/10.1016/j.comppsych.2014.06.003.
Seal, K. H., Metzler, T. J., Gima, K. S., Bertenthal, D., Maguen, S., & Marmar, C. R. (2009). Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs Health Care, 2002–2008. American Journal of Public Health, 99(9), 1651–1658. https://doi.org/10.2105/AJPH.2008.150284.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression. New York: Guilford Press.
Silver, R. C. (2002). Nationwide longitudinal study of psychological responses to September 11. JAMA, 288(10), 1235. https://doi.org/10.1001/jama.288.10.1235.
Stanley, E. A., Schaldach, J. M., Kiyonaga, A., & Jha, A. P. (2011). Mindfulness-based mind fitness training: a case study of a high-stress predeployment military cohort. Cognitive and Behavioral Practice, 18(4), 566–576. https://doi.org/10.1016/j.cbpra.2010.08.002.
StataCorp. (2019). Stata statistical software: release 16. College Station: StataCorp LLC.
Steenkamp, M. M., Litz, B. T., Hoge, C. W., & Marmar, C. R. (2015). Psychotherapy for Military-Related PTSD. JAMA, 314(5), 489. https://doi.org/10.1001/jama.2015.8370.
Stephenson, K. R., Simpson, T. L., Martinez, M. E., & Kearney, D. J. (2017). Changes in mindfulness and posttraumatic stress disorder symptoms among veterans enrolled in mindfulness-based stress reduction. Journal of Clinical Psychology, 73(3), 201–217. https://doi.org/10.1002/jclp.22323.
Stretch, R. H., Marlowe, D. H., Wright, K. M., Bliese, P. D., Knudson, K. H., & Hoover, C. H. (1996). Post-traumatic stress disorder symptoms among gulf war veterans. Military Medicine, 161(7), 407–410. https://doi.org/10.1093/milmed/161.7.407.
Tang, Y.-Y., Hölzel, B. K., & Posner, M. I. (2015). The neuroscience of mindfulness meditation. Nature Reviews Neuroscience, 16(4), 213–225. https://doi.org/10.1038/nrn3916.
Thompson, R. W., Arnkoff, D. B., & Glass, C. R. (2011). Conceptualizing mindfulness and acceptance as components of psychological resilience to trauma. Trauma, Violence & Abuse, 12(4), 220–235. https://doi.org/10.1177/1524838011416375.
Tull, M. T., Gratz, K. L., Salters, K., & Roemer, L. (2004). The role of experiential avoidance in posttraumatic stress symptoms and symptoms of depression, anxiety, and somatization. The Journal of Nervous and Mental Disease, 192(11), 754–761. https://doi.org/10.1097/01.nmd.0000144694.30121.89.
Vasterling, J. J., Proctor, S. P., Friedman, M. J., Hoge, C. W., Heeren, T., King, L. A., & King, D. W. (2010). PTSD symptom increases in Iraq-deployed soldiers: comparison with nondeployed soldiers and associations with baseline symptoms, deployment experiences, and postdeployment stress. Journal of Traumatic Stress, 23(1), 41–51. https://doi.org/10.1002/jts.20487.
Vaughan, C. A., Schell, T. L., Tanielian, T., Jaycox, L. H., & Marshall, G. N.(2014) Prevalence of mental health problems among Iraq and Afghanistan veterans who have and have not received VA services. Psychiatric Services, 65(6), 833-835.
Vogt, D. S., Pless, A. P., King, L. A., & King, D. W. (2005). Deployment stressors, gender, and mental health outcomes among Gulf War I veterans. Journal of Traumatic Stress, 18(2), 115–127. https://doi.org/10.1002/jts.20018.
Vujanovic, A. A., Niles, B., Pietrefesa, A., Schmertz, S. K., & Potter, C. M. (2011). Mindfulness in the treatment of posttraumatic stress disorder among military veterans. Professional Psychology: Research and Practice, 42(1), 24–31. https://doi.org/10.1037/a0022272.
Walser, R. D., & Westrup, D. (2007). Acceptance & commitment therapy for the treatment of post-traumatic stress disorder & trauma-related problems: a practitioner’s guide to using mindfulness & acceptance strategies. Oakland: New Harbinger.
Weathers, F.W., Litz, B.T., Keane, T.M., Palmieri, P.A., Marx, B.P., & Schnurr, P.P. (2013). The PTSD Checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD at https://www.ptsd.va.gov.
Xue, C., Ge, Y., Tang, B., Liu, Y., Kang, P., Wang, M., & Zhang, L. (2015). A meta-analysis of risk factors for combat-related PTSD among military personnel and veterans. PLoS One, 10(3), e0120270. https://doi.org/10.1371/journal.pone.0120270.
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This study was funded with two pilot grants from the Military Research Cluster at the University of Southern California Suzanne Dworak-Peck School of Social Work.
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NB designed and executed the study, conducted data analysis, and wrote the manuscript. MK collaborated on the study design and writing of the study. CAC collaborated in study conceptualization, writing, and editing of the final manuscript. All authors approved the final version of the manuscript for submission.
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Barr, N., Keeling, M. & Castro, C. Associations Between Mindfulness, PTSD, and Depression in Combat Deployed Post-9/11 Military Veterans. Mindfulness 10, 2403–2414 (2019). https://doi.org/10.1007/s12671-019-01212-9
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DOI: https://doi.org/10.1007/s12671-019-01212-9