Download This article was downloaded by: [Angela Lamson] Publisher: Routledge

This article was downloaded by: [Angela Lamson]
On: 14 October 2013, At: 21:36
Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,
37-41 Mortimer Street, London W1T 3JH, UK
Military Behavioral Health
Publication details, including instructions for authors and subscription information:
http://www.tandfonline.com/loi/umbh20
Contextualizing Military Health and Trauma:
Recommendations for Integrated Care and CoupleCentered Interventions
a
b
b
Melissa Lewis , Angela Lamson , Mark White & Carmen Russoniello
a
University of Minnesota Medical School–Duluth , Duluth , Minnesota
b
East Carolina University , Greenville , North Carolina
b
To cite this article: Melissa Lewis , Angela Lamson , Mark White & Carmen Russoniello (2013) Contextualizing Military Health
and Trauma: Recommendations for Integrated Care and Couple-Centered Interventions, Military Behavioral Health, 1:2,
167-172, DOI: 10.1080/21635781.2013.839923
To link to this article: http://dx.doi.org/10.1080/21635781.2013.839923
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained
in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no
representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the
Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and
are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and
should be independently verified with primary sources of information. Taylor and Francis shall not be liable for
any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever
or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of
the Content.
This article may be used for research, teaching, and private study purposes. Any substantial or systematic
reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any
form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://
www.tandfonline.com/page/terms-and-conditions
MILITARY BEHAVIORAL HEALTH, 1: 167–172, 2013
C Taylor & Francis Group, LLC
Copyright ISSN: 2163-5781 / 2163-5803 online
DOI: 10.1080/21635781.2013.839923
Contextualizing Military Health and Trauma:
Recommendations for Integrated Care
and Couple-Centered Interventions
Melissa Lewis
University of Minnesota Medical School–Duluth, Duluth, Minnesota
Angela Lamson, Mark White, and Carmen Russoniello
Downloaded by [Angela Lamson] at 21:36 14 October 2013
East Carolina University, Greenville, North Carolina
Military personnel and their family members are currently facing risks to their health and
well-being, yet interventions such as prevention and treatment remain unsuccessful for many
families. For instance, almost one-quarter of a million returning troops have been diagnosed
with post-traumatic stress disorder (PTSD); however, the estimated prevalence of PTSD is
grossly underestimated due to ineffective assessment. Further, only half of military PTSD
sufferers are finding relief in their treatment. Through this literature review, assessment, prevention, and treatment recommendations to improve health outcomes for military personnel
are provided by expanding previous medical models and incorporating biopsychorelational
principles and data.
Keywords: Military couples, biopsychosocial, integrated care, PTSD
THE IMPLICATIONS OF POST-TRAUMATIC
STRESS DISORDER
The increased rates of post-traumatic stress disorder (PTSD)
for military members have staggering effects on service
personnel, families, and the health care system (Burnam,
Meredith, Tanielian, & Jaycox, 2009). Around 1.5 million
troops have been deployed to Operation Enduring Freedom
(OEF) and Operation Iraqi Freedom (OIF), and around
15% return home and screen positive for PTSD (Tanielian
& Jaycox, 2008). Of those 230,000 PTSD sufferers, only
around half of them will seek treatment. Further, the U.S.
health care system spends up to $1.5 billion treating just
combat-related PTSD (Tanielian & Jaycox, 2008), not to
mention noncombat-related PTSD. The U.S. Department of
Veterans Affairs estimates that it will be treating approximately 200,000 active and reserve military members in
the next 10 years, and researchers have estimated that the
cost to treat PTSD each year is around $5,000 per person
Address correspondence to Melissa Lewis, University of
Minnesota–Duluth, Department of Biobehavioral Health and Population Sciences, 1035 University Drive, Duluth, MN 55812-3031. E-mail:
[email protected]
(Tanielian & Jaycox, 2008). Unfortunately, less than half of
the PTSD patients find relief with the normative treatment
of medication and psychotherapy. Military researchers have
also noted this failure rate and have spent almost $300
million in the past five years to find new ways to treat or
even prevent the diagnosis of PTSD (Tanielian & Jaycox,
2008).
WHAT ARE WE MISSING? THE IMPLICATIONS
OF INDIVIDUALLY FOCUSED HEALTH CARE
Several components are missing in the treatment of military personnel and veterans, including (1) treatment in which
physical and mental health symptoms are treated simultaneously, (2) the inclusion of biopsychorelational assessments,
and (3) partners/family members present during medical visits. Although the effects for individuals suffering from PTSD
are profound and include persistent stressful thoughts and
nightmares (American Psychiatric Association, 2000), little attention is paid to the relationships in which PTSD
exists. Much of the literature suggests that supportive relationships reduce the risk and severity of the disease process (Taft, Walling, Howard, & Monson, 2011; Figley, 1988;
Mansfield et al., 2010), but rarely is the marital relationship
Downloaded by [Angela Lamson] at 21:36 14 October 2013
168
M. LEWIS ET AL.
thought of as a reciprocal conduit of positive or negative
health.
In fact, interpersonal relationships may suffer the most
following a PTSD diagnosis and also may hold the key
to recovery. Military-related experiences are linked to
decreased relational satisfaction, such as occupational
challenges (Faber, Willerton, Clymer, MacDermid, & Weiss,
2008; Hourani, Williams, & Kress, 2006), preparing for or
returning from deployment (McLeland, Sutton, & Schumm,
2008), and work-related separations (Orthner & Rose, 2009).
Traumatic military experiences seem to relate the strongest
to poor marital outcomes (Goff, Crow, Reisbig, & Hamilton,
2007): increased marital problems (Wood, Scarville, &
Gravino, 1995), intimate partner violence (Taft et al., 2011),
marital instability, and divorce (Hogan & Seifert, 2010).
When a member of a military marriage is diagnosed with
PTSD, he or she is less likely to have a satisfying relationship and more likely to experience poor marital functioning (Dirkzwager, Bramsen, Adèr, & Van der ploeg, 2005).
Compared to couples in which the military member has not
experienced combat stress, those who did experience combat stress reported increased marital conflict and less intimacy, commitment, support toward one another, and safe
feelings about their relationship (Rosen & Moghadam, 1991;
Solomon et al., 1992). Over time, the magnitude of the combat experience seems to erode marital functioning (Goff et al.,
2007). Specifically, at the time of marriage, the year before
war, the year after war, and six years after war, marital cohesion and satisfaction declined while marital conflict increased
for combat stress couples yet remained the same for noncombat couples. PTSD is a risk to marital satisfaction over time
and is also more strongly related to relational problems for
military couples than for civilian marriages (Taft et al., 2011).
While some think of PTSD as a psychological disease, the
strength of its effects on interpersonal relationships suggests
that it may be a disease of relationships.
THE RELATIONSHIP BETWEEN MARITAL
AND PHYSICAL HEALTH
PTSD in military and veteran populations not only is linked
to psychological problems such as depression (Hoge et al.,
2008) and alcohol abuse (Jakupcak et al., 2010; McFarlane
et al., 2009; Spera, Thomas, Barlas, Szoc, & Cambridge,
2011) but also poses a risk to physical functioning, such
as dermatologic, gastrointestinal, cardiovascular, and
musculoskeletal conditions even when other health risk
behaviors such as smoking and body mass index (BMI) are
controlled (Schnurr, Spiro, & Paris, 2000). While a PTSD
diagnosis has been found to be related to a worsening in
physical functioning, the exact mechanisms are unclear. An
unexplored yet probable route for some may exist via the
marital relationship.
The quality of a couple’s marriage appears to have significant implications for the physical health of the two in-
dividuals. It is hypothesized that conflictual marriages elicit
responses in the sympathetic nervous system resulting in
a stress response that may be related to negative implications in other health systems (Smith et al., 2011). For instance, members of happy marriages are more likely to have
good health, avoid illness and disease, and recover from illness more quickly (Kiecolt-Glaser & Newton, 2001), while
patients in conflictual or stressful marital relationships are
more likely to suffer from health risks in immune, autonomic
nervous system, endocrine, and cardiovascular functioning
(Graham, Christian, & Kiecolt-Glaser, 2006; Miller, Dopp,
Myers, Stevens, & Fahey, 1999; Smith, Gallo, Goble, Ngu, &
Stark, 1998). In addition, military experiences such as highstress job environments, long workdays, unpredictable absences from home and family members, combat training and
combat exposure, and separation from social networks are
risk factors to the well-being of military personnel and their
spouses and are events that military personnel have noted as
being sources of stress (Cooney, Segal, & De Angelis, 2009;
Hourani et al., 2006; Karney & Crown, 2007).
Military marriages tend to experience health risks coming
from both within and outside of the relationship. For instance,
in a large study investigating the source of stress and distress
for military members, those who met the minimum criteria
for anxiety or depression reported that both their work and
their home lives were highly stressful (Hourani et al., 2006).
Reporting stress in both domains was three times higher than
in those personnel who did not meet criteria for anxiety or
depression. The perpetual, severe, and unrelenting stresses
of military life combined with conflicted marriages are a
serious risk to health, and such situations need to be addressed
immediately for those experiencing them.
Marital relationships play a crucial role in the diagnosis
and treatment of PTSD for both military members and
spouses (Taft et al., 2011; Figley, 1988; Mansfield et al.,
2010). As the effects of PTSD work their way into a
marriage, many risks to individual and marital health
increase, including (1) lack of support for the military
member to cope with the disease (Tanielian & Jaycox,
2008), (2) development of PTSD symptoms in the partner
(Mansfield et al., 2010), and (3) increased marital conflict,
which is related to worsening physical functioning for both
individuals (Graham et al., 2006; Miller et al., 1999; Smith
et al., 2011). Thus, treatment must change in two very
specific ways: (1) treatment can no longer be conducted
in silos; distinct health systems must collaborate; and (2)
treatment for PTSD in the military should be done through
couple-centered care using a biopsychorelational lens.
TREATMENT IN SILOS
To increase the number of patients assessed and then treated
for mental health symptoms, medical health professionals
need to perform regular mental health assessments with
their patients. For instance, patients who speak to a health
Downloaded by [Angela Lamson] at 21:36 14 October 2013
CONTEXTUALIZING MILITARY HEALTH AND TRAUMA
professional about their mental health symptoms are more
likely to speak to a medical professional (6.4%) in comparison to a mental health specialist (5.9%) (Regier et al., 1993).
Therefore, if the medical arena is the location in which
patients feel most comfortable discussing their mental health
symptomatology, medical health professionals need to be
ready to assess, refer, and/or treat this population. Referral
to mental health counseling is also a problem for providers
who service military and veteran patients. However, when
medical providers do refer patients for behavioral health
services, only 44% of patients attend their first appointment,
compared to 76% when the provider introduces the patient
to the behavioral health specialist (e.g., colocation or with a
warm handoff) (Smeeding, Bradshaw, Kumpfer, Trevithick,
& Stoddard, 2011). Unfortunately, medical providers servicing military patients rarely collaborate with mental health
specialists when there is mental health symptomatology
(Apostoleris, 2000). Overall, about one-third of all soldiers
are in need of mental health assessments, but only 12.5%
receive that care (Burnam et al., 2009).
If a military member does decide to seek help for behavioral health symptoms, he or she will likely encounter
another obstacle. In a study of reservists in Indiana, many
returning soldiers found problems with access to behavioral
health care (Avery, 2011). The inability to find appropriate
behavioral health care providers was due to outdated lists
of providers (e.g., turnover with insurance panels), geography, high-utilization areas, long wait times, few providers
accepting new patients, and the sporadic needs of patient
due to deployment. Further, doctoral-level psychologists and
licensed mental health counselors are less likely to participate in TRICARE insurance than any other provider (Avery,
2011).
Once the military member gets inside the health clinic,
unfortunately, risk factors for inadequate treatment still persist. For example, PTSD has on-again-off-again symptoms
that are exacerbated by a number of triggers and, therefore,
should be assessed early after deployment (one month or
sooner) and at regular increments afterward to detect PTSD
symptoms (Avery & Wadsworth, 2011), which is generally
not the standard of care.
Further, many medical professionals are not trained, nor
do they typically assess for psychosocial difficulties, which is
strongly related to worsening PTSD symptoms. For instance,
lack of social support has consistent, negative effects for
military members (Milliken, Auchterlonie, & Hoge, 2007).
Interpersonal problems increased by four times from postdeployment return (3.5%) to six months postdeployment return
(14.0%). Marital relationships in which a military member
has PTSD are at risk for lowered marital satisfaction (Defense
Health Board Task Force on Mental Health, 2007). Further,
partners of military members with PTSD are more likely to
experience relational distress (Orthner & Rose, 2009), poorer
marital satisfaction, somatic and sleeping problems, and less
social supports (Riggs, Byrne, Weathers, & Litz, 1998), while
169
wives whose partners were deployed suffered from increased
prevalence of anxiety, depression, adjustment disorder, stress
reactions, and sleep problems (Gottman & Levenson, 1999).
INTEGRATED CARE AS AN ALTERNATIVE
TO THE MEDICAL MODEL
To more successfully address risks to physical health and
frequent users of the military medical system, a systemic
approach to medical assessment and treatment is necessary.
The integrated care model employs additional psychosocial
assessments, medical team collaboration, and mental health
treatment, if needed, all under one treatment plan (Blount,
2003). Inclusion of spouses/significant others and family
members as a part of treatment is endorsed in the primary
care setting for the following scenarios: (1) a new diagnosis, (2) a new developmental stage, (3) individual, marital,
or family crisis, (4) mild depression and anxiety, (5) grief
and stress reactions, and (6) behavioral problems (Granado
et al., 2009). Integrated care interventions are already validated and utilized at the national level. For example, the
Center for Integrated Health Solutions (CIHS) aims to
[i]ncrease the number of 1) Individuals trained in specific behavioral health related practices 2) Organizations using integrated health care service delivery approaches 3) Consumers
credentialed to provide behavioral health related practices 4)
Model curriculums developed for bidirectional primary and
behavioral health integrated practice and 5) Health providers
trained in the concepts of wellness and behavioral health
recovery. (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012, p.1)
The success that integrated care has received in the civilian
population is clear (Cummings, O’Donohue, & Ferguson,
2002; Katon, 1995; Phelps et al., 2009; Pratt, Lazorick, Lamson, Ivanescu, & Collier, 2013), especially in hard-to-reach
and comorbid populations, which makes the case for implementation in military medical settings. Specifically, in civilian populations, 90% of integrated care patients will complete their treatments, compared to less than half of patients
only referred to a behavioral health specialist by a medical
provider (Cummings et al., 2002; Katon, 1995). Given the
biopsychosocial implications of PTSD, integrated care may
have the added benefit of allowing PTSD sufferers to receive physical and behavioral health care to address all their
symptoms.
COUPLE-CENTERED CARE
Further, couple/family therapy (grounded in systems theory)
may be related to a significant decrease in health care utilization for patients and family members. While it is difficult
170
M. LEWIS ET AL.
Downloaded by [Angela Lamson] at 21:36 14 October 2013
to accurately assess cost offset for partners (Crane, 2011),
in a study investigating the difference between health care
utilization for patients seeking either individual or family
therapy, researchers discovered that high health care utilizers
who received family therapy reduced health care utilization
in urgent care by 78%, health screening by 68%, and illness
visits by 38% (Crane & Christenson, 2008). It appears a systemic, couple-centered care perspective results in improved
behavioral and physical health outcomes by reverberating
positive change within patient, couple, and medical systems
(Gallagher, 2009; Jorgensen, 2009; Manne, Alfieri, Taylor,
& Dougherty, 1999). This further punctuates the need for
both an integrated care and couple-centered care approach to
treating military personnel and veterans, especially those at
risk or suffering from PTSD.
POLICY RECOMMENDATIONS
If medical facilities that service military members (active,
reserve, veteran) implemented the inclusion of couple and
family members as a part of treatment as the standard of care,
many opportunities to address the health needs of military
families would be possible, as well as to reduce health care
costs. In the White House’s strategic plan to address the needs
of service personnel, the well-being and psychological health
of military families was identified as the number-one priority
(Whisman, Uebelacker, & Settles, 2010). With this goal in
mind as well as an awareness of the link between physical
and emotional health, the following recommendations are
presented:
1. Mental health assessments, especially those centered
on trauma, loss, and family functioning, should be
completed early and often after deployment to avoid
undiagnosed psychosocial conditions (Milliken et al.,
2007) and subsequent medical health risks.
2. Military medical centers should encourage patients to
bring their spouses to medical visits given the positive
effects for both the individual and the family member
(see Lewis, Lamson, & Lesueur, 2012; Defense Health
Board Task Force on Mental Health, 2007).
3. Mental health assessments of spouses of PTSD victims
should be mandated, given the reciprocal and shared
relationship between PTSD and marital health (Figley,
1988; Lewis et al., 2012; Riggs et al., 1998).
4. Medical care for service personnel should always include interviews/assessments in the biological, psychological, and social (BPS) domains (Engel, 1977).
5. Research testing both the effectiveness and efficacy
of implementing care with the inclusion of spouses
or family members in military medical settings is imperative. Successful interventions include those that
reduce/prevent patient and spouse BPS symptoms, offset health care costs, and reduce provider burnout (see
Cummings et al., 2002; Katon, 1995; Lewis et al.,
2012).
See appendix for additional resources for integrated care
and family-focused health care for military members and
veterans.
IMPLICATIONS FOR A NEW MODEL
Generally, primary care contexts assess and treat using a
physical-biological viewpoint with an individualized treatment plan, as opposed to couple-centered care using a biopsychorelational treatment plan whereby medical and mental
health is treated simultaneously.
Medical care requires both tracking patient symptomatology and using a series of tests and logic models to assess
and treat symptoms. Rarely do providers interview patients
about psychosocial health. However, with the policy recommendations as a guide, fewer mental health issues would
go unassessed, underdiagnosed, and undertreated, which has
significant implications for military members and their families. For instance, the medical patient’s support system could
have considerable effects on disease prevention, recovery,
and treatment implications (Barth, Schneider, & Von Känel,
2010; Wang, Wu, & Liu, 2003). Further, most people prefer
to have their family members involved with their health care
visits and treatment decisions; around half of patients actively
involve a family member in their health care decisions. The
majority of military behavioral health patients would rather
their family be involved in their care compared to going
through treatment alone (McDaniel, Campbell, Hepworth, &
Lorenz, 2005). Therefore, treating a patient in isolation (i.e.,
without consideration of integrated care) or without involving their partner is not patient centered or considerate of the
obvious influences of biopsychorelational well-being.
A further reasons to implement couple-centered care models is that marital and family support is related to increased
treatment plan adherence (Khaylis, Polusny, Erbes, Gewirtz,
& Rath, 2011), which is also related to improved cost management (DiMatteo, 2004). With the systemic perspective in
mind (i.e., that change in one area of a family system resounds throughout), when a patient and his or her partner
attend a medical visit together, the accompanying spouse is
less likely (21%) to present health symptomatology just by
attending the medical visit with their partner (DeSimone,
2000). Overall, medical visits by couples are related to reduced physical and mental health care symptoms for both
members of the couple along with reduced medical visits
overall (Law & Crane, 2000), punctuating the assets of using
integrated care and couple-centered care.
Military medical contexts that engage in couple-centered
care are an answer to providing patient-centered (Khaylis
et al., 2011), cost-effective (Law & Crane, 2000), and
evidence-based care (DiMatteo, 2004). The support of family members is related to (1) a reduction in pathological
CONTEXTUALIZING MILITARY HEALTH AND TRAUMA
symptom development, (2) an increased rate of recovery
(DeSimone, 2000), and (3) an increased adherence to the
treatment plan (i.e., taking medications when prescribed,
completing treatment recommendations), all three of which
are ultimately related to better health and cost management
outcomes (DeSimone, 2000). Couple-centered care has the
potential to have significant outcomes on the way health care
is delivered to service personnel, costs associated with care,
and health outcomes for military members, their spouses, and
families receiving services that are financed by the TRICARE
and Veterans Affairs systems.
Downloaded by [Angela Lamson] at 21:36 14 October 2013
REFERENCES
Apostoleris, N. H. (2000). Integrating psychological services into primary
care in an underserved community: Examining the referral process for
on-site mental health services. Paper presented at the Northeast Regional
Conference of the Society of Teachers of Family Medicine, Philadelphia,
PA.
Avery, G. H., & MacDermid Wadsworth, S. M. (2011). Access to mental
health services for active duty and national guard TRICARE enrollees in
Indiana. Military Medicine, 176(3), 261–264.
Avery, G. H., & Wadsworth, S. M. M. (2011). Access to mental health
services for active duty and national guard TRICARE enrollees in Indiana.
Military Medicine, 176(3), 261–264.
Barth, J., Schneider, S., & Von Känel, R. (2010). Lack of social support
in the etiology and the prognosis of coronary heart disease: A systematic review and meta-analysis. Psychosomatic Medicine, 72(3), 229–
238.
Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems, and Health, 21(2), 121–133.
Burnam, M. A., Meredith, L. S., Tanielian, T., & Jaycox, L. H. (2009).
Mental health care for Iraq and Afghanistan war veterans. Health Affairs
(Project Hope), 28(3), 771–782.
Cooney, R., Segal, M., & De Angelis, K. (2009, August). Moving with the
military: Race, class, and gender differences in the employment consequences of tied migration. Paper presented at the American Sociological
Association Annual Meeting, San Francisco, CA.
Crane, D. (2011). Does family therapy reduce health care costs for more
than the identified patient? Clinical Child Psychology and Psychiatry, 16,
3–4.
Crane, D., & Christenson, J. (2008). The medical offset effect: Patterns in outpatient services reduction for high utilizers of health care.
Contemporary Family Therapy: An International Journal, 30(2), 127–
138.
Cummings, N. A., O’Donohue, W. T., & Ferguson, K. E. (2002). In Ferguson
K. E. (Ed.), The impact of medical cost offset on practice and research:
Making it work for you: A report of the first reno conference on medical
cost offset. Reno, NV: Context Press.
Defense Health Board Task Force on Mental Health. (2007, June). An
achievable vision: Report of the Department of Defense task force on
mental health. Falls Church, VA: Defense Health Board. Retrieved from
http://www.health.mil/dhb/mhtf/mhtf-report-final.pdf
DeSimone, K. L. (2000). Is a single oral dose of amiodarone safe and
effective in converting new-onset atrial fibrillation (AF) to sinus rhythm?
Journal of Family Practice, 49(6), 493–494.
DiMatteo, M. (2004). Social support and patient adherence to medical treatment: A meta analysis. Health Psychology, 23(2), 207–
218.
Dirkzwager, A. J. E., Bramsen, I., Adèr, H., & Van der ploeg, H. M. (2005).
Secondary traumatization in partners and parents of Dutch peacekeeping
soldiers. Journal of Family Psychology, 19(2), 217–226.
171
Engel, G. L. (1977). The need for a new medical model: A challenge for
biomedicine. Science, 196(4286), 129–136.
Faber, A. J., Willerton, E., Clymer, S. R., MacDermid, S. M., & Weiss,
H. M. (2008). Ambiguous absence, ambiguous presence: A qualitative
study of military reserve families in wartime. Journal of Family Psychology, 22(2), 222–230.
Figley, C. R. (1988). A five-phase treatment of post-traumatic stress disorder
in families. Journal of Traumatic Stress, 1(1), 127–141.
Gallagher, R. M. (2009). Biopsychosocial pain research in America: The
veterans health system leads the way. Pain Medicine, 10(7), 1165–
1166.
Goff, B. S. N., Crow, J. R., Reisbig, A. M. J., & Hamilton, S. (2007). The impact of individual trauma symptoms of deployed soldiers on relationship
satisfaction. Journal of Family Psychology, 21(3), 344–353.
Gottman, J. M., & Levenson, R. W. (1999). What predicts change in marital
interaction over time? A study of alternative medicine. Family Process,
38(2), 143–158.
Graham, J. E., Christian, L. M., & Kiecolt-Glaser, J. (2006). Stress, age,
and immune function: Toward a lifespan approach. Journal of Behavioral
Medicine, 29(4), 389–400.
Granado, N. S., Smith, T. C., Swanson, G. M., Harris, R. B., Shahar, E.,
Smith, B., . . . Ryan, M. A. (2009). Newly reported hypertension after military combat deployment in a large population-based study. Hypertension,
54(5), 966–973.
Hogan, P. F., & Seifert, R. F. (2010). Marriage and the military: Evidence
that those who serve marry earlier and divorce earlier. Armed Forces and
Society, 36(3), 420–438.
Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I.,
& Koffman, R. L. (2008). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. United States Army Medical
Department Journal, July–September, 7–17.
Hourani, L. L., Williams, T. V., & Kress, A. M. (2006). Stress, mental health,
and job performance among active duty military personnel: Findings
from the 2002 Department of Defense Health Related Behaviors Survey.
Military Medicine, 171(9), 849–856.
Jakupcak, M., Tull, M. T., McDermott, M. J., Kaysen, D., Hunt, S., &
Simpson, T. (2010). PTSD symptom clusters in relationship to alcohol misuse among Iraq and Afghanistan war veterans seeking postdeployment VA health care. Addictive Behaviors, 35(9), 840–843.
Jorgensen, R. S. (2009). Newly reported hypertension after military combat
deployment: Research implications from a biopsychosocial perspective.
Hypertension, 54(5), 956–957.
Karney, B. R., & Crown, J. S. (2007). Families under stress: An assessment
of data, theory, and research on marriage and divorce in the military.
Santa Monica, CA: RAND.
Katon, W. (1995). Collaborative care: Patient satisfaction, outcomes, and
medical cost-offset. Family Systems Medicine 13(3–4), 351.
Khaylis, A., Polusny, M. A., Erbes, C. R., Gewirtz, A., & Rath, M. (2011).
Posttraumatic stress, family adjustment, and treatment preferences among
national guard soldiers deployed to OEF/OIF. Military Medicine, 176(2),
126–131.
Kiecolt-Glaser, J., & Newton, T. L. (2001). Marriage and health: His and
hers. Psychological Bulletin, 127(4), 472–503.
Law, D. D., & Crane, D. R. (2000). The influence of marital and family
therapy on health care utilization in a health-maintenance organization.
Journal of Marital and Family Therapy, 26(3), 281–291.
Lewis, M. E., Lamson, A. L., & Lesueur, B. (2012). Health dynamics of military and veteran couples: A biopsychorelational overview. Contemporary
Family Therapy.
Manne, S. L., Alfieri, T., Taylor, K. L., & Dougherty, J. (1999). Spousal
negative responses to cancer patients: The role of social restriction, spouse
mood, and relationship satisfaction. Journal of Consulting and Clinical
Psychology, 67(3), 352–361.
Mansfield, A. J., Kaufman, J. S., Marshall, S. W., Gaynes, B. N., Morrissey,
J. P., & Engel, C. C. (2010). Deployment and the use of mental health
Downloaded by [Angela Lamson] at 21:36 14 October 2013
172
M. LEWIS ET AL.
services among U.S. army wives. The New England Journal of Medicine,
362(2), 101–109.
McDaniel, S. H., Campbell, T. L., Hepworth, J., & Lorenz, A. (2005).
Family-oriented primary care (2nd ed.). New York, NY: Springer.
McFarlane, A. C., Browne, D., Bryant, R. A., O’Donnell, M., Silove, D.,
Creamer, M., & Horsley, K. (2009). A longitudinal analysis of alcohol
consumption and the risk of posttraumatic symptoms. Journal of Affective
Disorders, 118(1–3), 166–172.
McLeland, K. C., Sutton, G. W., & Schumm, W. R. (2008). Marital satisfaction before and after deployments associated with the global war on
terror. Psychological Reports, 103(3), 836–844.
Miller, G. E., Dopp, J. M., Myers, H. F., Stevens, S. Y., & Fahey, J. L.
(1999). Psychosocial predictors of natural killer cell mobilization during
marital conflict. Health Psychology, 18(3), 262–271.
Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component
soldiers returning from the Iraq war. Journal of the American Medical
Association, 298(18), 2141–2148.
Orthner, D. K., & Rose, R. (2009). Work separation demands and spouse
psychological well-being. Family Relations, 58(4), 392–403.
Phelps, K. W., Howell, C. D., Hill, S. G., Seemann, T. S., Lamson,
A. L., Hodgson, J. L., & Smith, D. A. (2009). A collaborative care model
for patients with type-2 diabetes. Families, Systems, and Health, 27(2),
131–140.
Pratt, K. J., Lazorick, S., Lamson, A., Ivanescu, A., Collier, D. N. (2013).
Quality of life and BMI changes in youth participating in an integrated
pediatric obesity treatment program. Health & Quality of Life Outcomes,
11(1), 116–125.
Regier, D. A., Narrow, W. E., Rae, D. S., Manderscheid, R. W., Locke,
B. Z., & Goodwin, F. K. (1993). The de facto U.S. mental and addictive disorders service system: Epidemiologic catchment area prospective
1-year prevalence rates of disorders and services. Archives of General
Psychiatry, 50(2), 85–94.
Riggs, D. S., Byrne, C. A., Weathers, F. W., & Litz, B. T. (1998). The
quality of the intimate relationships of male Vietnam veterans: Problems
associated with posttraumatic stress disorder. Journal of Traumatic Stress,
11(1), 87–101.
Rosen, L. N., & Moghadam, L. Z. (1991). Predictors of general well being
among Army wives. Military Medicine, 156(7), 357–361.
Schnurr, P. P., Spiro, A., III, & Paris, A. H. (2000). Physician-diagnosed
medical disorders in relation to PTSD symptoms in older male military
veterans. Health Psychology, 19(1), 91–97.
Smeeding, S. J. W., Bradshaw, D. H., Kumpfer, K. L., Trevithick, S., &
Stoddard, G. J. (2011). Outcome evaluation of the veterans affairs Salt
Lake City integrative health clinic for chronic nonmalignant pain. Clinical
Journal of Pain, 27(2), 146–155.
Smith, T. W., Cribbet, M. R., Nealey-Moore, J., Uchino, B. N., Williams,
P. G., MacKenzie, J., & Thayer, J. F. (2011). Matters of the variable heart:
Respiratory sinus arrhythmia response to marital interaction and associa-
tions with marital quality. Journal of Personality and Social Psychology,
100(1), 103–119.
Smith, T. W., Gallo, L. C., Goble, L., Ngu, L. Q., & Stark, K. A. (1998).
Agency, communion, and cardiovascular reactivity during marital interaction. Health Psychology, 17(6), 537–545.
Solomon, Z., Waysman, M., Belkin, R., Levy, G., Mikulincer, M., & Enoch,
D. (1992). Marital relations and combat stress reaction: The wives’ perspective. Journal of Marriage and the Family, 54(2), 316–326.
Spera, C., Thomas, R. K., Barlas, F., Szoc, R., & Cambridge, M. H. (2011).
Relationship of military deployment recency, frequency, duration, and
combat exposure to alcohol use in the air force. Journal of Studies on
Alcohol and Drugs, 72(1), 5–14.
Substance Abuse and Mental Health Services Administration. (2012).
SAMHSA-HRSA center for integrated health solutions: About us.
Retrieved from http://www.integration.samhsa.gov/
Taft, C. T., Walling, S. M., Howard, J. M., & Monson, C. (2011). Trauma,
PTSD, and partner violence in military families. In D. Riggs (Ed.), Risk
and resilience in U.S. military families (pp. 195–212). New York, NY:
Springer Science.
Tanielian, T. & Jaycox, L.H. (2008). Invisible wounds of war: Psychological
and cognitive injuries, their consequences, and services to assist recovery.
Santa Monica, CA: RAND.
Wang, H., Wu, S., & Liu, Y. (2003). Association between social support
and health outcomes: A meta-analysis. Kaohsiung Journal of Medical
Sciences, 19(7), 345–351.
Whisman, M. A., Uebelacker, L. A., & Settles, T. D. (2010). Marital distress
and the metabolic syndrome: Linking social functioning with physical
health. Journal of Family Psychology, 24(3), 367–370.
Wood, S., Scarville, J., & Gravino, K. S. (1995). Waiting wives: Separation and reunion among Army wives. Armed Forces and Society, 21(2),
217–236.
APPENDIX: RECOMMENDED RESOURCES
The Alliance of Military and Veteran Family Behavioral
Health Providers, http://www.ecu.edu/che/alliance/
Collaborative Family
www.cfha.net/
Healthcare
Association,
http://
SAMHSA-HRSA Center for Integrated Health Solutions,
Integrated care models, http://www.integration.samhsa.
gov/integrated-care-models
Naval Center for Combat and Operational Stress Control, http://www.med.navy.mil/sites/nmcsd/nccosc/Pages/wel
come.aspx