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Address correspondence to:, Peter M. Wayne, PhD, Osher Center for Integrative Medicine, Division of Preventive Medicine, Harvard Medical School and Brigham and Women's Hospital, 900 Commonwealth Avenue, 3rd Floor, Boston, MA 02215E-mail:pwayne@partners.org
Editor's Note: War has a long and devastating tail of human cost. While the burden of the Middle East wars is orders of magnitude higher in the countries where the wars were (and in some cases still are) being fought, the toll on U.S. soldiers is brought home almost daily through veterans' health issues, family challenges, and the horrifying number of suicides. From the 1990–1991 Gulf Wars alone, an estimated 25%–32% of the 700,000 who served “continue to have health problems that are not easily diagnosed” (USA Department of Defense Congressionally Directed Research Programs). As we have moved from neatly defining these individuals as “shell-shocked” to humanizing and fitting our responses to the multiple insidious invasions wrought on the survivors of modern war, mind–body methods are increasingly being explored and welcomed as beneficial.
In these three reviews of recent research, the Osher team explores the potential from mind–body intervention in three distinct milieus. These run, sequentially, from a focus on the basic science of the impact on telomere length, to a group-based clinical intervention, and third, to an app developed to help veterans heal relationships with their partners as they return to their homes. One net effect of reading these is to make one wish useful mind–body tools were available to wounded warriors from all nations. —John Weeks, Editor-in-Chief, JACM
Citation: USA Department of Defense Congressionally Directed Research Programs. Gulf War Illness. Online document at: http://cdmrp.army.mil/gwirp/default (accessed May 7, 2017).
Peter M. Wayne, PhD, Director of Research, Osher Center for Integrative Medicine, Division of Preventive Medicine, Associate Professor of Medicine, Harvard Medical School and Brigham and Women's Hospital
According to the RAND Center for Military Health Policy Research, 20% of the veterans who served in either Iraq or Afghanistan suffer from either major depression or post-traumatic stress disorder (PTSD). These are in addition to multiple physical morbidities.
A growing body of research in nonveteran populations suggests that exposures to psychological, physical, and environmental stresses, at any developmental time period within the entire human lifespan, may be correlated with shortening of telomeres. Shortening of telomeres—the DNA and protein complexes located at the end of chromosomes essential for DNA replication and chromosome stability—is predictive of accelerated aging and the onset of several diseases. Among these are hypertension, atherosclerosis, type 2 diabetes mellitus, cardiovascular disease, and cognitive decline and dementia. However, to date, little research has evaluated the impact of combat exposure on telomere length in veterans.
An international research team led by Francesco Bersani conducted an innovative cross-sectional study to explore the association between various dimensions of psychopathology, independent of psychiatric diagnosis, and telomere length (TL) in veterans. Seventy-six combat-exposed male veterans were recruited for this study. A battery of careful screening and diagnostic procedures determined that 41 participants were psychiatrically healthy, 18 had PTSD, and 17 exhibited concomitant PTSD and major depressive disorder (MDD). TL was assayed in granulocytes isolated from peripherally drawn blood samples, using sound and well-described methods.
Results revealed that across all subjects, TL was negatively correlated with early trauma (p < 0.001), global psychopathological severity (p = 0.044) and perceived stress (p = 0.019), and positively correlated with positive affect (p = 0.026). In contrast, TL was not significantly correlated with symptom severity of PTSD, depression, or negative affect.
Although this is an observational, relatively small cross-sectional study limited to male combat-exposed veterans, the results provide important preliminary evidence regarding potential negative epigenetic impacts of combat exposure, as well as the developmental and psychosocial factors that may mediate or moderate such impacts. Specifically, the findings suggest that early trauma, severity of perceived stress, and general psychopathological symptoms are more closely associated with shorter TL than is the severity of core diagnostic symptoms of PTSD or MDD. Interestingly, while positive affect is associated with longer TL, negative affect did not have a reciprocal shortening of TL. Future larger-scale studies in veteran with varying amounts and types of combat exposure should assess TL associated with specific psychological dimensions, apart from only categorical psychiatric diagnoses, to develop a more nuanced understanding of the epigenetic impact of military service.
Recent studies support that mind–body therapies may buffer the negative impact of psychosocial stress on TL. Findings from future research could be used to inform how to optimize the use of mind–body therapies for enhancing resilience to the negative epigenetic impact of combat exposure.
Citation: Bersani FS, Lindqvis D, Mellod SH, Epel ES, et al. Zen meditation, length of telomeres, and the role of experiential avoidance and compassion. Mindfulness 2016;7:651–659.
Darshan Mehta, MD, MPH, Medical Director, Benson-Henry Institute for Mindy Body Medicine, Massachusetts General Hospital, Associate Director of Education, Osher Center for Integrative Medicine, Harvard Medical School and Brigham and Women's Hospital
The 1991 Gulf War was fought by a multinational coalition that formed to oppose Iraq's invasion of Kuwait in 1990, which included nearly 700,000 U.S. troops. It was comprised of Operation Desert Shield and Operation Desert Storm, which included a 6-week air campaign and 4 days of ground fighting before a ceasefire was declared on February 28, 1991. While there were few casualties, this conflict was remarkable for the number of chemical exposures experienced by troops. Sources were multiple and varied: the low-level chemical warfare agents released by the destruction of Iraqi facilities, extensive spraying and use of pesticides, medications given prophylactically to protect troops against hazardous exposures, and hundreds of oil well fires set by the Iraqi troops as they withdrew from Kuwait.
Gulf War Illness (GWI) is usually defined by one or more symptoms that have been ongoing for at least 6 months in two of three categories: (1) musculoskeletal pain (joint pain, joint stiffness, muscle pain); (2) mood–cognition changes (feeling depressed, feeling moody, feeling anxious, trouble sleeping, difficulty remembering or concentrating, trouble with word finding); and (3) fatigue. While post-traumatic stress disorder (PTSD) only affects 3%–6% of this population, it is estimated that anywhere between 25% and 32% of individuals suffer from this condition. Presently, there are very few treatment options for this condition, and “usual care” is not quite clear.
In this pilot randomized controlled study by Kearney et al. (2016) conducted at the VA Puget Sound Health Care System, 55 patients with GWI were randomized to mindfulness-based stress reduction (MBSR) with usual care, versus usual care alone. The primary outcomes of the study were standardized measures of pain, fatigue, and cognitive failures. Secondary outcomes included measures of PTSD, depression, and mindfulness. There were no baseline differences in participant characteristics in this study, including exposure to biological, chemical, and nuclear agents.
The MBSR intervention was standard, with eight weekly 2.5-h sessions and a 7-h session between weeks 6 and 7. It does not appear that any adaptations were made to the curriculum. Of note, completers were defined as those that attended more than four sessions.
While differences were not necessarily seen immediately after the intervention, there were significant differences seen at 6 months among all primary outcomes, with moderate-to-large effect sizes seen in both intention-to-treat and completer analyses. In addition, significant differences were seen at 6 months in secondary outcome analyses as well.
While this was a small pilot study, these findings provide credibility for a nonpharmacological therapeutic option in the management of a condition that has few therapeutic options. Future studies would benefit from analyses in medication changes, as the mainstay of treatment in GWI is often pharmacological symptom management. Nonetheless, for a large affected population, providing this type of group-based approach may allow for inexpensive and efficient treatment delivery. Perhaps, a modified curriculum that is tailored to veterans with GWI may provide to be even more fruitful. For example, how might a loving-kindness meditation be taught to a veteran who was programmed/trained to take somebody's life? Or, how is a body scan adjusted to accommodate for the wounds of combat?
Citation: Kearney DJ et al. Mindfulness-based stress reduction in addition to usual care is associated with improvements in pain, fatigue, and cognitive failures among veterans with gulf war illness. Am J Med129:204–214.
Gloria Yeh, MD, MPH, Director, Research Fellowship in Integrative Medicine, Director of Mind–Body Research, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School
Over the last 15 years, more than 2 million men and women in the U.S. military have been deployed to the Global War on Terror. Unfortunately, the rates of individuals that return from war with conditions such as post-traumatic stress, chronic pain, and traumatic brain injury are extremely high. The increased awareness of these comorbidities in postdeployment veterans and the myriad of mental and emotional distresses inherent in these conditions have coincided with an increased attention and openness to use of mind–body and integrative therapies in the veteran population. This randomized controlled study by Kahn et al. evaluates an innovative, multidimensional, web-based application of mind–body strategies on mental health and well-being in post-911 veterans and their partners.
The authors provide good rationale for extending mind–body strategies to a self-directed, web-based intervention. The majority of veterans do not seek treatment for postdeployment mental and emotional conditions. They cite barriers such as concerns for negative career repercussions, access issues (e.g., long wait times and limited availability of providers), and potential side effects of medications. Thus, a nonpharmacological, self-directed approach delivered through the web may increase access and perhaps patient sense of control and autonomy.
The authors also provide convincing rationale for adopting a partner approach. Emerging literature highlights the critical importance of interpersonal support in protecting against long-term mental health problems and the significant impact of deployment on not only the veteran, but also the partner, and the partner relationship. Military health organizations have called for couple-focused interventions. Existing programs such as the Department of Defense's Prevention and Relationship Enhancement Program (PREP) for Strong Bonds, a weekend residential program delivered by military chaplains, only reaches up to 18% of those eligible. Clearly, there is a gap to be filled.
In this study, investigators recruited combat veterans and their partners (N = 160 dyads; 320 participants) through the Iraq and Afghanistan Veterans of America organization. They focused on four metropolitan areas: San Diego (CA), Dallas (TX), Fayetteville (NC), and New York City (NY). Participant/partner dyads were randomized to one of four groups: (1) Intervention (called Mission Reconnect [MR]), (2) PREP (active comparator), (3) MR+PREP, (4) Waitlist control. The MR web-based program included written, video, and audio content with three main components: (1) connecting with yourself (positive psychology with morning gratitude and mirror greeting, relaxation, and body awareness exercises), (2) connecting with quiet (centering/mindfulness meditation, meditative movement, progressive relaxation, and yoga nidra meditation), and (3) connecting with others (guided contemplative exercise for recognizing the other, partner massage). Participants completed weekly web reports over the first 8 weeks, and then at 16 weeks follow-up with continuous access to the MR web content during this time.
At 8 weeks, those in MR reported significant improvements in capacity to respond to stress and sleep quality when compared with either waitlist or to PREP. Stress resiliency was sustained at 16 weeks with additional benefits seen with MR in self-compassion and decreased pain. Interestingly, adding MR to PREP improved outcomes in several domains over PREP alone; however, MR alone still appeared to do better. In the subgroup of veterans with PTSD (N = 53), all three active groups showed significant reductions in PTSD symptoms, although the magnitude of change was greatest for those in MR alone. User adherence and satisfaction in MR groups was very high.
This study highlights the potential for multidimensional mind–body strategies to improve a range of patient-centered outcomes within the complexities of mental, emotional comorbidities in postdeployment veterans. In particular, the study recognized key strategies in a holistic, mind–body–spirit model of health. Engaging partners in a meaningful way leveraged the importance of interpersonal communication, support, and shared journeys in the healing process. In addition, the self-directed web approach may have enhanced patient autonomy. While one obvious benefit of using a web app may be expansion of the intervention's reach, perhaps just as important is that use of a modern, familiar platform, can help to place self-care back in the hands of the patient. The ability to explicitly share this tool and training with a partner might further enhance transformation and healing.
Citation: Kahn JR, Collinge W, Soltysik R. Post-9/11 veterans and their partners improve mental health outcomes with a self-directed mobile and web-based wellness training program: A randomized controlled trial. J Med Internet Res 2016;18:e255.
