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Sarah L. Martindale is now at W.G. “Bill” Hefner Veterans Affairs Medical Center, and VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center. Sandra B. Morissette is now at University of Texas at San Antonio.
The present research tested the hypothesis that action- and emotion-focused coping strategies would mediate the relationship between neuropsychological functioning and quality of life among a sample of returning Iraq/Afghanistan veterans.
Veterans (N = 130) who served as part of the wars in Iraq and Afghanistan, completed a diagnostic assessment of PTSD, a battery of questionnaires assessing coping style, traumatic brain injury (TBI), and quality of life, and neuropsychological tests measuring attention, learning and memory, working memory, inhibition, executive control, and visual motor coordination.
Executive control, immediate and delayed verbal recall, and visual motor coordination were associated with quality of life. However, after controlling for the effects of combat exposure, PTSD, and probable TBI, no measure of neuropsychological functioning was directly associated with quality of life. Mediation analyses indicated that delayed verbal recall influenced quality of life through its effect on action-focused coping.
Although replication is needed, these findings indicate that delayed verbal recall may indirectly influence quality of life among Iraq/Afghanistan veterans through its association with action-focused coping strategies. Psychologists who are working with veterans that are experiencing memory difficulties and poor quality of life may consider focusing on improving coping skills prior to rehabilitation of memory deficits.
Quality of life is generally conceptualized as the overall level of satisfaction individuals have with different aspects of their lives, including material and physical well-being, relationships with others, social and community activities, personal development and fulfillment, and recreation (Burckhardt & Anderson, 2003; Flanagan, 1978; Stock et al., 2014). Poor quality of life may be indicative of problems within these areas, and treatments often measure quality of life to determine broader effects beyond symptom remission (Reid-Amdt, Hsieh, & Perry, 2010). Unfortunately, returning Iraq and Afghanistan veterans experience a range of psychological problems that can have a profound impact on their quality of life, particularly posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI; Dolan et al., 2012; Hoge et al., 2004; Morissette et al., 2011). These and other types of psychological disorders are also associated with a number of neuropsychological difficulties, such as attention and memory deficits (Campbell et al., 2009; Dolan et al., 2012; Gilbertson, Gurvits, Lasko, Orr, & Pitman, 2001; Shandera-Ochsner et al., 2013), which may further worsen returning veterans’ quality of life (Meneses, Pais-Ribeiro, da Silva, & Giovagnoli, 2009; Nys et al., 2006; Schnurr, Lunney, Bovin, & Marx, 2009; Wallin et al., 2009). Whereas it is clear that neuropsychological deficits have either direct or indirect effects on perceived quality of life (Halligan & Wade, 2005; Sohlberg & Mateer, 2001), there is a paucity of research available that directly examines the associations between specific neuropsychological functioning skills and indices of quality of life, particularly within a veteran sample.
Neuropsychological abilities, such as memory, can affect how someone learns, adopts, and ultimately utilizes different coping strategies (Krpan, Levine, Stuss, & Dawson, 2007). Coping strategies can be conceptually categorized into two types: action-focused (also referred to as active, problem-focused, and positive coping strategies), which includes active coping behaviors targeted at changing the source of a stressor; and emotion-focused (also sometimes referred to as avoidant coping or negative coping), that are used to regulate emotional responses to a stressor (Folkman & Lazarus, 1980). Although emotion-focused and avoidant coping are often used interchangeably, emotion-focused coping, defined as coping aimed at lessening emotional distress, has been adopted as a parent factor to avoidant coping, which is a type of emotion-focused coping expressed by actions that purposefully avoid confronting a stressor with the goal of indirectly reducing emotional distress (Billings & Moos, 1981). Evidence supports a positive association between good neuropsychological functioning and action-focused coping skills as well as between poor neuropsychological functioning and emotion-focused coping skills. For example, higher IQ scores are related to better quality of coping strategies in TBI patients (Wolters, Stapert, Brands, & Van Heugten, 2011). Patients with PTSD more frequently use less efficacious coping mechanisms, such as suppression, which is a type of avoidance, and less frequently use positive coping skills, such as seeking alternate solutions (Amir et al., 1997). Evidence from TBI patients indicates that patients with better executive functioning use more active, problem solving coping skills and less avoidant coping skills regardless of injury severity and intelligence (Krpan et al., 2007).
As with neuropsychological function, coping skills also impact quality of life. TBI patients who use action-focused coping strategies report better long-term quality of life than those who use emotion-focused coping strategies (Wolters, Stapert, Brands, & Van Heugten, 2010). It has been suggested that the adoption of emotion-focused coping strategies is positively associated with symptom development and severity of psychological distress, such as PTSD symptom severity, which then affects quality of life. One study found that patients with TBI who developed PTSD were more likely to have adopted an avoidant coping strategy, which positively influenced PTSD symptom severity (Bryant, Marosszeky, Crooks, Baguley, & Gurka, 2000). A similar pattern was also noted by Johnsen, Eid, Laberg, and Thayer (2002), which indicated that the adoption of emotion-focused coping did not improve symptom severity over time, when compared to other coping styles. In a similar vein, PTSD mediates the impact of coping skills on quality of life (Huijts, Kleijn, van Emmerik, Noordhof, & Smith, 2012). These studies suggest that it is important to study coping and quality of life in veterans who are at risk for PTSD, TBI, and other neuropsychological impairments that may negatively affect redeployment from the war zone. Veterans are a patient group that frequently present with symptoms of both PTSD and TBI, which are in turn associated with neuropsychological implications that can complicate treatment (Najavits, Highley, Dolan, & Fee, 2012; Vanderploeg, Curtiss, Luis, & Salazar, 2007). Although coping skills are already taught as part of evidence-based approaches to treatment for military personnel (Rosen, Chow, Finney, Greenbaum, Moos, Sheikh, & Yesavage, 2004), there is a paucity of literature that examines how different cognitive deficits, such as memory and attention, affect the ability of an individual to adopt and utilize these skills, and subsequently impact on quality of life. However, recent literature supports this relationship in patients with acquired brain injury (Wolters Gregório, Ponds, Smeets, Jonker, Pouwels, Verhey, & van Heugten, 2015), finding that executive functioning was related to greater use of passive coping, which was in turn related to lower quality of life. The current study investigated this relationship in veterans.
Taken together, these data suggest that not only may neuropsychological functioning and coping directly affect quality of life, but also that coping may act as an intervening mediator variable. That is, individuals with neuropsychological deficits may adopt less efficacious coping styles, leading to poor quality of life. Identifying modifiable mediators that explain the association between neuropsychological functioning and quality of life could have important implications for treatment intervention. It was hypothesized that attention, executive control, inhibition, immediate and delayed verbal recall, visual motor coordination, and working memory would be positively related to quality of life. In addition, it was hypothesized that action-focused coping would positively predict quality of life and emotion-focused coping would negatively predict quality of life. Our final hypothesis posited that action-focused coping and emotion-focused coping would mediate the association between neuropsychological functioning and quality of life.
Participants included 130 eligible veterans who served in support of the wars in Iraq and Afghanistan (Mage = 37.82 years, SD = 10.61, range 22-66), who were enrolled in a local Veterans Health Care System. Representative of military demographics, women comprised 14.6% of the sample. The sample was well educated (Med = 14.12 years, SD = 2.52). Participants deployed an average of 2.22 times (SD = 1.36, range 1-7) in support of the wars in Iraq and Afghanistan, with the last deployment occurring on average 41.70 months (SD = 25.40, range = 0 - 97.63) prior to participation. Table 1 lists sample demographics and military characteristics.
This study reflects secondary analyses of a parent longitudinal study that was conducted to identify predictors of PTSD, depression, alcohol/substance use disorders and their comorbidity. Participants included male and female, English-speaking veterans who were 18 years of age or older. To be eligible, veterans were required to: (a) have served in support of the wars in Iraq and Afghanistan; (b) be enrolled in the local VA system; (c) be able to complete the informed consent process and assessments.
Participants were excluded if they: (a) had plans to relocate out of the local VA catchment area within four months of protocol initiation (due to parent longitudinal study); (b) recently started psychiatric medications or therapy to ensure symptoms were not related to recent treatment changes; (c) had diagnoses of a psychotic disorder or bipolar disorder; or (d) were actively suicidal or homicidal at the level of warranting crisis intervention. Regarding medication and therapy stabilization, participants were deemed stable on psychotropic medications per the following: ≥3 months on a selective serotonin reuptake inhibitor or monoamine oxidase inhibitor; ≥1 month on an anxiolytic or beta-blocker; or ≥1 month medication discontinuation. Participants were deemed stable if they were engaged in psychotherapy for >3 months or 1-month psychotherapy discontinuation.
All procedures were reviewed and approved by the local Institutional Review Board. Participants were recruited using multiple strategies, including flyers posted in the local hospital, in-services to mental health and primary care staff, and mailings to veterans who served in support of the wars in Iraq and Afghanistan who were enrolled in the Central Texas Veterans Healthcare System. Participants were screened by telephone for inclusion/exclusion criteria after providing informed verbal consent. A total of 272 telephone screens were conducted, of which 224 were deemed eligible and scheduled for an initial assessment and 48 were deemed ineligible. Of those who were ineligible at the phone screen level, 19 were ruled out due to not being stabilized on psychiatric medications/psychotherapy, 10 were ruled out for bipolar disorder, seven who reported current hallucinations and delusions indicative of a psychotic disorder, four due to current suicidal/homicidal risk, two planning to relocate out of the area within 4 months, one who was not an OEF/OIF veteran, two who were not enrolled in the local VA system, and three other/unknown. Written consent was completed during an in-person assessment, after which final eligibility was determined using the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998; i.e., to exclude psychotic and bipolar disorders). A total of 145 veterans were enrolled to participate in a study evaluating post-deployment adjustment. Of those, 130 were deemed eligible to participate and completed the assessment battery. Of the 15 deemed ineligible after consent, eight were unable to complete the baseline assessment and seven had bipolar disorder.
Several neuropsychological measures were administered, including the Wide Range Achievement Test – Fourth Edition, word reading standard score (WRAT-4; Jastak & Jastak, 2006) as an estimate of pre-morbid intellectual functioning; California Verbal Learning Test, Second Edition (CVLT-II; Delis, Kramer, Kaplan, & Ober, 2000) for immediate verbal recall and delayed verbal recall raw scores for verbal learning and memory (CVLT-II raw scores were used in place of standardized z-scores to normalize the distribution); Wechsler Adult Intelligence Scale – Fourth Edition (WAIS-IV; Wechsler, 2008), Digit Span Forward (DSF) scaled score to measure attention, Digit Span Backward (DSB) scaled score to measure working memory, and Coding scaled score to measure visual-motor coordination; Trail Making Test – A and B ratio score (TMT; Reitan, 1958) for executive control; and the Stroop Color and Word Test interference T-score (SCWT; Golden, 1978; Stroop, 1935) to measure inhibition.
Coping was measured using the Brief COPE (B-COPE; Carver, 1997), a self-report inventory of 14 action-focused and emotion-focused coping strategies, including self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and self-blame. Higher scores indicate greater frequency of use. Cronbach's alpha in the current study was .73.
The Quality of Life Scale (QOLS; Burckhardt & Anderson, 2003) is a 16 item self-report inventory that assesses how satisfied people are in regards to 5 areas distinct from health status based on the domains of quality of life described by Flanagan (1978, 1982). Scores on the QOLS can range from 16-112, with higher scores indicative of better satisfaction with quality of life (M = 73.94, SD = 19.09). Cronbach's alpha in the current study was .94.
Combat exposure, diagnosis of PTSD, and diagnosis of TBI were included as covariates in mediation analyses. Combat exposure was measured using the total score of the combat exposure scale of the Deployment Risk and Resilience Inventory (DRRI; King, King, & Vogt, 2003). Cronbach's alpha in the current study was .88. PTSD diagnosis was assessed by trained assessors who were supervised by licensed clinical psychologists using the Clinician Administered PTSD Scale (CAPS; Blake et al., 1995). The CAPS was administered based on the worst event identified during their service in Iraq/Afghanistan, or if no DSM-IV criterion A event, in response to general deployment stress. This allowed for a continuous PTSD severity score to be derived for all participants. Exposure to a probable TBI was determined using the Brief Traumatic Brain Injury Screen (BTBIS; Schwab et al., 2006). The BTBIS has been used successfully in military populations as an early intervention and screening tool (Drake, Meyer, Cessante, Cheung, Cullen, McDonald, & Holland, 2010) and has shown to have good reporting consistency between other TBI questionnaires and interviews (Schwab et al., 2007). A positive TBI screen was based on report of a head injury during deployment (e.g., from a blast, vehicular accident, fall, bullet, fragment) that resulted in an alteration of consciousness (e.g., being disoriented, “dazed,” or confused, seeing “stars”), loss of consciousness, or posttraumatic amnesia.
To determine the second-order factor structure of the B-COPE, principal component analysis (PCA) with Promax rotation was used. Variables were created, based on the second-order factor structure, using unit weighting (Carver, Scheier, & Weintraub, 1989). The associations between neuropsychological functioning and quality of life as well as coping and quality of life were evaluated using linear regression. To determine whether action- and emotion-focused coping acted as mediators in the association between neuropsychological functioning, outcomes were assessed using a statistical mediation analysis, as described by Preacher and Hayes (2004). Indirect effects were tested using a nonparametric bootstrapping procedure, which has been developed into a macro for use in SPSS (Preacher & Hayes, 2008). Because the derived action- and emotion-focused coping variables were unrelated, mediation was used.
Covariates for linear regressions and mediation analysis included intensity of combat exposure, and PTSD diagnosis, and probable TBI. These covariates were chosen because of their high prevalence in veteran samples and because of their previously established effects on neuropsychological functioning (Vasterling et al., 2006) and quality of life (Anderson et al., 2011; Vasterling & Brailey, 2005). Age was not related to any neuropsychological function, coping style, or quality of life outcome, and therefore was not used as a covariate. Additionally, word reading (WRAT-4) was normally distributed (M = 99.24, SD = 12.59) and not significantly related to any measure of neuropsychological function, coping style, or quality of life outcome, and therefore not included as a covariate.
Cognitively, this sample was not significantly impaired, with the highest impairment rates ranging between 15.9-19.8% on verbal memory, and ranging between 0-7.8% on all other neuropsychological measures. Table 2 depicts means, standard deviations and impairment percentages (defined as greater than or equal to 1.5 SDs below the standardized mean) by neuropsychological measure.
Parallel analysis (O'Connor, 2000) indicated that two factors should be extracted from the PCA for the Brief COPE, which corresponded to theoretically derived action- (eigenvalue of 4.38) and emotion-focused (eigenvalue of 2.19) coping skills. The first component, which represented action-focused coping, included the positive reframing (.82), active coping (.76), planning (.75), emotional support (.68), instrumental support (.68), acceptance (.60), religion (.50), humor (.35), and self-distraction (.34) subscales of the B-COPE. The second component represented emotion-focused coping and included the behavioral disengagement (.67), self-blame (.62), venting (.59), denial (.53), and substance use (.31) subscales of the B-COPE. Unit weighting was used to create factor scores based on the factor score coefficients that were at least 33% as large as the largest factor score for each respective factor. Positive reframing, active coping, planning, emotional support, instrumental support, acceptance, religion, humor, and self-distraction were summed to create the action-focused coping factor. Behavioral disengagement, self-blame, venting, denial, and substance use were summed to create the emotion-focused coping factor. The unit-weighted action-focused coping and emotion-focused coping factors were not significantly related to one another, r = −.09, p = .30.
Attention, inhibition, and working memory were not significantly associated with QoL. Executive control, immediate and delayed verbal recall and visual motor coordination were associated with quality of life, but were no longer significant after controlling for combat exposure, PTSD diagnosis, and probable TBI status. Table 3 depicts the predictive associations between neuropsychological function and quality of life before and after accounting for combat exposure, PTSD diagnosis, and probable TBI status. In support of the second hypothesis, action-focused coping was positively associated with quality of life, β = .27, p < .001, f2 = .10, and emotion-focused coping was negatively associated with quality of life, β = −.44, p < .001, f2 = .27, after controlling for combat exposure, PTSD diagnosis, and probable TBI.
Finally, the hypothesis that action- and emotion-focused coping would mediate the association between neuropsychological functioning and quality of life was tested. Attention, executive control, inhibition, immediate verbal recall, visual motor coordination, and working memory were not significantly related to action- or emotion-focused coping, and therefore were not examined in the mediation analyses. Of note, delayed verbal recall was associated with action-focused coping, and PTSD diagnosis was positively associated with emotion-focused coping. The associations between neuropsychological functioning and action- and emotion-focused coping skills can be seen in Table 4. Mediation analysis indicated that delayed verbal recall influenced quality of life through its effects on action-focused coping, after accounting for the effects of combat exposure, β = −.06, p = .55, PTSD, β = −.42, p < .001, and probable TBI status, β = .02, p = .84. As can be seen in Figure 1, delayed verbal recall was positively associated with action-focused coping skills, a; β = .19, p = .04, which was, in turn, positively associated with quality of life, b; β = .27, p < .01. A 95% bias-corrected bootstrap confidence interval for the indirect effect, ab; β = .05, based on 10,000 bootstrap samples was above zero (.04 to .66).
Contrary to our first hypothesis and the existing literature, neuropsychological functioning did not directly affect quality of life after controlling for degree of combat exposure, PTSD diagnosis, and probable TBI. Many veterans who experience psychological problems also experience neuropsychological difficulties including attention and memory deficits (Dolan et al., 2012). In turn, these difficulties have the potential to impair quality of life. For example, if a veteran has difficulty remembering to complete a task his/her spouse has asked him/her to do, this could cause difficulties within their relationship. These findings may be due to the majority of neuropsychological tests in this sample indicating a less than 8% impairment rate, which suggests minimal overall impairment despite high rates of PTSD diagnosis and self-reported, TBI exposure.
PTSD diagnosis was the only variable positively associated with emotion-focused coping. This is congruent with previous studies that have indicated PTSD as a differential mediator for the relationship between avoidant coping and family functioning (Creech, Benzer, Liebsack, Proctor, & Taft, 2013). PTSD is associated with many neuropsychological deficits, including attention, learning, and memory, which may account for the increased use in emotion-focused coping style (Vasterling, Brailey, Constans, Borges, & Sutker, 1997; Vasterling, Duke, Brailey, Constans, Allain, & Sutker, 2002). For example, a veteran with memory deficits may not be able to readily recall or access action-focused coping alternatives and will instead rely on more habitual emotion-focused coping skills.
Consistent with previous literature, both action- and emotion-focused coping directly predicted quality of life in veterans. Action-focused coping skills were positively predictive of a higher quality of life score, whereas emotion-focused coping was negatively predictive of a low quality of life score. In practice, this suggests treatment strategies that emphasize healthy action-focused coping and curb emotion-focused coping styles could be beneficial to veterans’ quality of life.
Finally, action-focused coping mediated the association between delayed verbal recall and quality of life even after controlling for combat exposure, PTSD, and probable TBI. Interestingly, this indirect finding was specific to delayed verbal recall and not other neuropsychological deficits. It is possible that veterans who have difficulty with delayed recall also have difficulties accessing or remembering to use action-focused coping skills. These results were similar to a recent study by Wolters Gregório et al. (2015), which found TBI patients with self-reported executive functioning difficulties tended to use more passive coping strategies and ultimately reported lower quality of life. Of note, although significant, the magnitude of the relationship between delayed verbal recall and action-focused coping was small. This might be due to the generally low impairment rates in this sample, compared to other studies that have similarly reported that neuropsychological functioning affects coping skills (Krpan et al., 2007).
Teaching coping skills is already a focus of some evidence-based approaches to treatment for military personnel (Rosen et al., 2004). Coping skills training has been found to be effective in reducing anxiety and depression in active-duty members who deploy (Jones, Perkins, Cook, & Ong, 2008). However, no known study has investigated how neuropsychological deficits impact these coping skills, and in turn, a veteran's quality of life. Although this effect was small in magnitude, these findings are clinically relevant and have a variety of implications for treatment, care, and rehabilitation in a veteran population. Notably, neuropsychological rehabilitation requires specialized training and experience. However, teaching coping skills does not require as much training and experience and, therefore, could be more easily disseminated in treatment. This study suggests that concentrating on action-focused coping skills can be a point of intervention that can improve outcomes – particularly in veterans who are also experiencing difficulties with delayed verbal recall. Focusing on teaching veterans with memory difficulties to use more effective action-focused coping skills may not only help them to improve general coping with life stressors, but could also help to improve overall quality of life. Specifically, difficulties in delayed verbal recall may make it difficult for veterans to acquire new coping skills taught in treatment. It may benefit these veterans to present new action-focused coping skills in treatment multi-modally (e.g., in traditional auditory and additional visual formats) and to rehearse new coping skills in treatment so they may be encoded and stored more deeply, thus more able to be accessed and utilized outside of treatment.
A number of limitations should be considered when interpreting cross-sectional data from the current study. First, consistent with military demographics for the current war theatres, the sample was largely male, which limits generalizability. Second, participants were not asked if they had undergone previous neuropsychological testing, which could have introduced bias via practice effects. Third, after meeting initial treatment stabilization requirements, participants were allowed to take psychiatric medications or engage in psychotherapy, the latter of which could have included components of coping skills training. Fourth, it is possible that participants may have had co-morbid neurological conditions that were not assessed or ruled out. Finally, PTSD and probable TBI were used as covariates in regressions of neuropsychological functioning predicting quality of life. Because severity of current symptoms of both PTSD and probable TBI and time since head injury were not assessed, this could have confounded the overall interpretation of the effects of neuropsychological functioning on quality of life.
Future research is needed to examine the prospective influence of the proposed mediation model. A prospective study would account for the temporal nature of causality that a mediation model assumes. Also, certain types of action- (e.g., planning, acceptance) or emotion-focused coping (e.g., venting) skills may be more strongly related to quality of life. In addition to focusing on individual skills, larger studies are needed that explore the level, frequency, and efficacy of specific coping skills. Previous studies have also found coping skills to be more sensitive to self-reported executive functioning deficits (Wolters Gregório et al., 2015). Future research is needed to evaluate the impact of executive functioning measures in addition to intellectual and memory measures. Additionally, rates of substance use in military personnel are higher than in the general population, and the presence of co-occurring substance use disorders can complicate both treatment and quality of life. Including substance use as a covariate in future analyses exploring these hypotheses would help evaluate an additional spectrum of difficulties than can impact neuropsychological functioning, coping skills, and quality of life in veterans. Effect sizes were small, which indicates other factors impact quality of life. Future studies are needed to identify such other constructs, including, for example, distress tolerance, attributional bias, or social support. In addition, studies are needed that examine a wider array of neuropsychological functions (e.g., executive functioning and visual memory) and take into account other complicating problems that veterans experience, such as pain and co-occurring medical conditions. Finally, future studies are needed to determine whether findings are generalizable to other war theatres and within samples of women veterans and those in different age cohorts.
The current study provides evidence that action-focused coping mediates the association between long-term memory functioning and quality of life in returning veterans. Neuropsychological functioning impacts quality of life through coping skills. This suggests that focusing on action-focused coping skills could be valuable in improving quality of life for veterans with memory impairment. Additional research is clearly needed to determine whether teaching action-focused coping skills could serve as an intermediary solution to improving quality of life in veterans with delayed verbal recall deficits. However, because the magnitude of the indirect relationship established between delayed verbal recall and quality of life was small, it is likely that other components affect this association. Understanding the complex bidirectional relationships between neuropsychological functioning and quality of life is a critical step in developing empirically-informed recovery programs.
This research was supported by a Merit Award (I01RX000304) to Dr. Morissette from the Rehabilitation Research and Development Service of the Department of Veterans Affairs (VA) Office of Research and Development (ORD); a VISN 17 New Investigator Award to Dr. Meyer; a Career Development Award (IK2 CX000525) to Dr. Kimbrel from the Clinical Science Research and Development Service of VA ORD; the VA VISN 17 Center of Excellence for Research on Returning War Veterans; Central Texas Veterans Health Care System; and Baylor University Graduate School. We appreciate the contributions of veterans who participated in this study as well as numerous study staff who helped conduct the study. A complete list of publications from the project is available upon request from Dr. Morissette at ude.astu@ettessiroM.ardnaS. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.