Symptoms Affecting Reintegration in OEF/Oif/Ond Veterans

Background:

Veterans of wars in Iraq and Afghanistan returned home after deployments and experienced challenges reintegrating in civilian, social and civic activities.  Difficulty with reintegration has been attributed to PTSD and TBI, the characteristic injuries of these wars, but our previous work does not support this association. In multivariate analyses, depression and affective cluster of symptoms were associated with low reintegration scores.  In this analysis, we test which affective symptoms are associated with poor reintegration. 

Methods:

This was a retrospective analysis of 78 Veterans who completed a TBI evaluation and reintegration measure (Community Reintegration for Service Members (CRIS)).  The CRIS does not have a composite score but three sub scores including extent of participation, satisfaction with participation and perceived limitations to participation.  Other instruments include: alcohol use (AUDIT), pain (BPI), depression (CES-D), environmental barriers to function (CHIEF), testing effort (WMT) and post-concussive symptoms (NSI).  NSI (Neurobehavioral Symptom Inventory) measures symptoms in three clusters; somatic/sensory, affective and cognitive.  Hierarchical linear regressions were performed with each CRIS subscale as a dependent variable.  The four models were entered in the following manner; demographics including WMT, TBI vs No TBI, NSI Cognitive and Somatic-Sensory and individual NSI Affective Symptoms. 

Results:

The mTBI and non-TBI groups did not differ regarding age, ethnicity, marital status, years of education, or number of deployments (all p>0.05), although the mTBI group had higher comorbidity and symptom ratings than the non-TBI group.  Our analyses of affective symptoms demonstrated that irritability (-0.429 (0.015) was associated with extent of participation while fatigue was associated with all three subscales of CRIS; extent of participation (-0.398 (0.007)), limitation of participation (-0.383 (0.009)) and satisfaction of participation (-0.378 (0.009)), all p< 0.05. 

Conclusion:

This study has demonstrated that fatigue was associated with lower reintegration scores.  While fatigue is a cardinal symptom of depression, it may not always be a focus of treatment and management. Our results suggest fatigue may be a good target for treatment but further research is needed to examine fatigue’s relationship on reintegration to determine causation and etiology.

From a patient centered care perspective, addressing individual symptoms above and beyond mere diagnostic labels may be an innovative approach to these Veterans.  Social workers are trained to incorporate symptom management in their clinical practice and are in the unique position to address fatigue in this context.

As the VA implements the Transition and Care Management Program, it is important to optimize allocation of case management services to veterans who are in the greatest need.  Systematic use of the CRIS and identification of symptoms could be an effective approach in this effort.