The main goal of this study was to examine the associations between psychiatric diagnoses, PTSD, and misconduct outcomes among war-deployed and non-war-deployed Marines. The incidence rate of PTSD diagnoses in the war-deployed cohort was 3.0%, which is comparable with other studies among active duty personnel that use diagnoses as inclusion criteria (as opposed to PTSD symptom checklists.) [29
]. This study found that for both cohorts, Marines with a non-PTSD psychiatric diagnosis had an elevated risk for all three misconduct outcomes (demotions, drug-related discharges, and non-drug-related punitive discharges). A specific diagnosis of PTSD was also associated with an increased risk for all three misconduct outcomes, but only in the war-deployed cohort. In the non-war-deployed cohort, PTSD was a significant predictor in only one of the three misconduct outcomes (drug-related discharges).
The finding that PTSD increased the risk of drug-related discharges for all Marines is consistent with other literature, and a number of theories have been posited to explain the relationship, including the self-medication hypothesis, the sensation-seeking hypothesis, and the susceptibility hypothesis [25
]. Individuals with comorbid PTSD and substance abuse problems are at an increased risk for interpersonal violence, imprisonment, and homelessness [32
]. Therefore, our results provide more evidence for the importance of drug abuse screening and counseling among service members with PTSD.
Our study also revealed that PTSD increased the risk for demotions and punitive discharges in war deployers only. One possible explanation for this finding is that war deployers may have relatively higher levels of PTSD symptoms. This explanation would be consistent with a recent finding that military veterans with combat-related PTSD reported more severe symptoms on the Trauma Symptom Inventory than did crime victims with PTSD [35
]. Data from the National Vietnam Veterans Readjustment Study showed that specific types of combat exposure were associated with higher PTSD scores [36
]. For example, PTSD scores were significantly higher for those who said they had killed compared with those who had said they had not killed [36
Beckham et al
(1998) also found that exposure to atrocities was associated with higher PTSD symptom levels, even after controlling for combat exposure [26
]. Iversen et al
(2008) found that United Kingdom military personnel deployed to Iraq who felt their life had been threatened were significantly more likely to have high levels of PTSD symptoms compared with personnel who did not feel their life had been threatened [37
]. These findings suggest that psychological and behavioral responses to trauma may be specific to the type of trauma experienced. Compared with other types of traumas, the experience of combat has also been shown to be related to both distinct PTSD symptom profiles and increased aggressive behaviour [10
], both of which could explain the increased behavioral problems in the war-deployed cohort.
The finding of greatest concern in this study is that combat deployed Marines with a PTSD diagnosis were over 11 times more likely to engage in the most serious forms of misconduct than were combat deployed Marines without a psychiatric diagnosis. This finding is similar to results by Noonan and Mumola (2007), who found that compared with other prisoners, military veterans in prison were less likely to report mental health problems but were more likely to be incarcerated for violent offenses than were other prisoners [40
]. In another study of veterans who deployed to the first Gulf War (August 1990 to February 1991), Black et al
(2005) found that incarcerated veterans were 3.6 times more likely to report PTSD symptoms than were non-incarcerated veterans [20
]. Future research should examine the reasons that combat veterans with PTSD are at a higher risk for serious misconduct problems and develop interventions to reduce behavioral problems. Such research is critical, because serious misconduct may lead to disqualification for some Veterans Administration benefits. In addition, personnel with the most serious manifestations of PTSD may face additional barriers to care.
Some military studies examining Navy personnel have found that African Americans have higher rates of involvement in the military's discipline system compared to Caucasians [41
]. Our study replicated this finding and identified that African Americans in the war-deployed cohort were at an increased risk for all three outcomes compared with Caucasians. In addition, African Americans in the non-war-deployed cohort were also at an increased risk of two types of misconduct: punitive discharges and demotions. More research is required to explore possible factors that moderate this relationship, such as previous trauma exposure, socio-economic status, and military occupation.
The interpretation of these findings is limited by multiple factors. First, cases were identified from service utilization records and were restricted to treatment seeking individuals who had a psychiatric or PTSD diagnosis, and it is likely that additional personnel had symptoms without an official clinical diagnosis. Also, combat deployers are likely made aware of and encouraged to seek psychological care if they are experiencing symptoms at a higher rate than non-deployed personnel. Our study only included misconduct outcomes that were measurable in personnel records, so the relationship between PTSD and undocumented types of misconduct remains unclear. Only Marines were included in the study, so the findings may not generalize to other military populations. Also, subjects only contributed time to our study while they were on active duty. As a result, questions remain about misconduct in veterans who have left the service. Lastly, PTSD was a relatively uncommon event in the non-war-deployed cohort, and this may have made it more difficult to detect significant associations.