Journal of Social and Clinical Psychology, Vol. 35, No. 9, 2016, pp.

705-721

STRESSORS AND MENTAL HEALTH IN VETERANS

SCHMIED ET AL.

RECIPROCAL RELATIONSHIPS BETWEEN

STRESSORS AND MENTAL HEALTH PROBLEMS
IN MILITARY VETERANS
EMILY A. SCHMIED
Naval Health Research Center, Health and Behavioral
Sciences Department, San Diego

GERALD E. LARSON
Naval Health Research Center, Warfighter Performance Department, San Diego

ROBYN M. HIGHFILL-MCROY AND CYNTHIA J. THOMSEN

Naval Health Research Center, Health and Behavioral
Sciences Department, San Diego

Growing research recognizes the reciprocal relationship between stressful life

events and psychiatric health, yet this topic has seldom been examined in military
populations. This study examined the reciprocal relationships between psycho-
logical symptoms and stressful life events over time among veterans of Operations
Iraqi Freedom and Enduring Freedom. Service members (N = 1,599) completed
surveys when separating from service and approximately one year later. Surveys
assessed demographic characteristics, impulsivity, combat exposure, noncombat-
related stressful life events, and symptoms of PTSD, depression, and substance

This work was supported by the Navy Bureau of Medicine and Surgery, Washington,
DC, under work unit 60812. The views expressed in this article are those of the
authors and do not represent the official policy or position of the Department of the
Navy, Department of Defense, or the U.S. Government. Approved for public release;
distribution is unlimited. Human subjects participated in this study after giving their
free and informed consent. This research has been conducted in compliance with all
applicable federal regulations governing the protection of human subjects in research
(protocol NHRC.2007.0011).
Address correspondence to Dr. Emily Schmied, Health and Behavioral Sciences,
Naval Health Research Center, 140 Sylvester Rd., San Diego, CA 92106; E-mail:
Emily.a.schmied.ctr@mail.mil.

2016 Guilford Publications, Inc.

705
706 SCHMIED ET AL.

abuse. Structural equation modeling showed that both depression and PTSD
symptoms predicted future stressful life events; this relationship was fully medi-
ated by substance abuse for depression, but not for PTSD symptoms. Consistent
with some previous research, noncombat stressors showed stronger and more
pervasive effects on mental health symptoms than did combat exposure. Impul-
sivity emerged as a shared vulnerability factor for depression, PTSD, substance
use, and stressful experiences. Prior to and following separation, service members
should receive interventions to improve their response to stressful life events, in-
cluding coping skills and substance abuse prevention training.

Keywords: veterans, depression, PTSD, stress, stress generation

Veterans of Operations Iraqi Freedom and Enduring Freedom

(OIF/OEF) are at risk for posttraumatic stress disorder (PTSD),
depression, and substance abuse disorders, which are associated
with high rates of symptom recurrence and other negative out-
comes including suicide (Cohen et al., 2010; Hoge, Auchterlonie,
& Milliken, 2006; LeardMann et al., 2013; Milliken, Auchterlonie,
& Hoge, 2007; Seal et al., 2009). Many studies of military person-
nel have documented associations between exposure to combat
and other stressors and the development of psychiatric condi-
tions among service members (Clancy et al., 2006; Dohwenrend
et al., 2006; Wilk et al., 2010). In accord with traditional theory
regarding the adverse effects of stress on health, these findings
typically have been interpreted as reflecting a causal impact of
stressors on mental health. However, this perspective provides a
truncated view of the cause and course of psychiatric problems
among veterans.
There is growing recognition of a reciprocal relationship be-
tween psychiatric health and stressful life events (Hammen,
2006; Liu & Alloy, 2010). This bidirectional model, known as the
stress generation model, posits that individuals with psychiatric
problems such as depression or anxiety play an active role in
generating stressful experiences (Hammen, 1991, 2006; Joiner &
Wingate, 2005; Liu & Alloy, 2010). Consistent with this model, a
number of civilian studies have found that compared to those
without psychiatric health concerns, individuals with preexist-
ing depression and/or anxiety are more likely to experience
future stressful life events, including divorce, assault, and acci-
dents (Hammen, 2006; Liu & Alloy, 2010).
STRESSORS AND MENTAL HEALTH IN VETERANS 707

To date, few studies have explored stress generation effects

among service members and veterans. A longitudinal study of
2,949 Gulf War veterans determined that veterans with preexist-
ing PTSD experienced higher rates of future traumatic events,
including assault and injury (Orcutt, Erickson, & Wolfe, 2002).
Similarly, a study of mortality among 15,000 Vietnam-era veter-
ans concluded that those with PTSD were more likely to die from
external causes, including poisoning, accidents, and homicides
(Boscarino, 2006). Thus, in contrast to the standard perspective
that trauma increases PTSD symptoms, it may be more appro-
priate to hypothesize a cycle in which trauma increases PTSD
symptoms, which in turn predispose individuals to additional
future traumas, and so on.
There are numerous limitations to the available research on
stress generation in military populations. First, stress generation
has not been examined in contemporary military cohorts. This
is an important consideration given the unique experiences of
post-9/11-era veterans who often serve multiple and extended
deployments in environments that differ from previous war
zones. Second, the majority of research on veterans has focused
exclusively on combat exposure, with no examination of more
general stressful life events. Although combat exposure clearly
increases the risk of psychiatric problems among veterans, it is
unlikely to be the only significant stressor experienced. While
data pertaining to general stressful life events in veterans are
scarce, recent research on deployed service members suggests
that noncombat stressors also influence mental health. For exam-
ple, survey data from OIF/OEF-deployed Marines revealed that
the strongest correlates of depression and anxiety were noncom-
bat stressors such as problems with superiors (Booth-Kewley,
Highfill-McRoy, Larson, Garland, Gaskin, 2012; Booth-Kewley
et al., 2013). Considering the breadth of stressors experienced by
veterans, it is important to examine the relative contributions of
general stressful life events as well as combat when assessing the
course of psychiatric disorders.
Another limitation of available research on veterans is a lack
of consideration of how the presence of multiple disorders may
708 SCHMIED ET AL.

contribute to stress generation. To date, research on stress gener-

ation among veterans has assessed only PTSD (Boscarino, 2006;
Orcutt et al., 2002). Because PTSD, depression, and substance
use are frequently comorbid, it is not possible to determine the
unique effects of each without controlling for the others. In ad-
dition, examining multiple types of disorders is desirable given
that numerous studies in civilian samples have found differen-
tial relationships between specific categories of psychiatric dis-
orders and risk of future stressful life events (Conway, Hammen,
Brennan, 2012; Joiner & Wingate, 2005; Liu & Alloy, 2010; Phil-
lips, Carroll, & Der, 2015).
A final limitation of the stress generation literature is that the
causal mechanisms remain unclear. A leading hypothesis is that
the characteristics that make individuals vulnerable to psychiat-
ric disorders (e.g., cognitive and coping styles, personality traits)
also may predispose them to generate situations in which they
may experience stressful life events, thereby perpetuating their
symptoms. This shared-vulnerability hypothesis is supported by
the finding that the stressful life events experienced by individu-
als with psychiatric disorders are often interpersonal in nature,
often referred to in the literature as dependent life events (e.g.,
getting divorced or fired; Hammen, 2006; Liu & Alloy, 2010).
In line with this hypothesis, impulsivity is one characteristic
worthy of exploration. Impulsivity, a heritable and stable per-
sonality trait (Klinteberg, Magnusson, & Schalling, 1989; Niv, Tu-
vblad, Raine, Wang, & Baker, 2012), has been found to indepen-
dently relate to incidence of PTSD and stressful life events (Weiss,
Tull, Viana, Anestis, & Gratz, 2012). Further, recent evidence sug-
gests impulsivity may warrant examination as an underlying
shared vulnerability factor in the stress generation model (Liu
& Kleiman, 2012). Substance abuse is another potential causal
factor in stress generation. Research suggests that many veterans
use substances as a form of self-medication for other psychiatric
symptoms; thus, substance abuse may be a mechanism by which
psychiatric problems are linked with future adversity (Jakupcak
et al., 2010).
A reciprocal relationship between mental health and future
stress among veterans may help explain the high rates of symp-
tom recurrence, yet this hypothesis remains largely unexplored in
STRESSORS AND MENTAL HEALTH IN VETERANS 709

FIGURE 1. Proposed path model examining the relationship between

posttraumatic stress disorder, depression, and substance abuse and
future stressful life events among 1,599 recently separated Navy and
Marine Corps personnel.

military samples. To address these issues, the present study used

longitudinal data from 1,599 OIF/OEF veterans to test a model
incorporating reciprocal relationships between psychiatric symp-
toms and stress exposure. The model, depicted in Figure 1, posits
that both combat exposure and other types of stressful life events
increase the likelihood of exposure to future stressful life events
at least in part due to the mediating factors of PTSD symptoms,
depression symptoms, and substance abuse. The model further
suggests that the impact of PTSD and depression symptoms on
future exposure to stressful events is partially mediated by sub-
stance abuse. Individual differences in impulsivity are predicted
to increase the likelihood of future stress exposure both directly
and via the impact of impulsivity on mental health symptoms.
Of particular interest are whether associations between mental
health and future stressor exposure vary for (a) PTSD versus de-
pression symptoms, and (b) dependent (i.e., interpersonal) ver-
sus independent (i.e., noninterpersonal) stressors.
710 SCHMIED ET AL.

METHODS
PARTICIPANTS

Baseline surveys were completed by 6,352 active-duty Navy and

Marine Corps personnel who were in the process of separating
from service under honorable conditions (e.g., retirement, end
of service term, or nonlife-threatening injuries that hindered sat-
isfactory completion of military duties). The final study sample
included 1,599 participants (852 Marines, 747 sailors) who also
completed a 1-year follow-up survey (i.e., 25.2% follow-up rate).

PARTICIPANT CHARACTERISTICS

The average participant was 29.9 years old (Standard deviation

[SD] = 8.9), male (86%), non-Hispanic White (66%), and married
or cohabitating (56%). Preliminary analyses examined whether
participants who completed the follow-up survey (N = 1,599)
differed from those who did not (N = 4,753) (data not shown).
Sailors were significantly more likely than Marines to complete
the follow-up survey (32% vs. 21%; p < .001) and participants
who completed both surveys were significantly older (M = 29.91,
SD = 8.9) than those who competed only the baseline survey (M
= 28.1, SD = 7.4; p < .001). Participants completing both surveys
were more likely to be married or cohabitating (56.0% vs. 50.6%;
p < .001). Follow-up nonresponders had significantly higher lev-
els of both PTSD symptoms (M = 35.7, SD = 16.3 vs. M = 33.2, SD
= 15.4; p < .001) and depression symptoms (M = 16.86, SD = 11.78
vs. M = 14.59, SD = 10.98; p < .001).

MEASURES

Demographic and Service Characteristics. Characteristics assessed

included age, sex, race/ethnicity, and marital status.
Impulsivity. Impulsivity was assessed at follow-up with Cherpi-
tels (1993) five-item scale (e.g., I often act on the spur of the mo-
ment without stopping to think). Participants were asked how
well each statement described them, with response options rang-
STRESSORS AND MENTAL HEALTH IN VETERANS 711

ing from 0 (not at all) to 3 (quite a lot). Responses were summed

to obtain a total score (range = 015; = .88).
Posttraumatic Stress Disorder. PTSD symptoms were assessed
at baseline using the 17-item PTSD ChecklistCivilian Version
(PCL-C; Weathers, Litz, Huska, & Keane, 1994). Participants re-
port the degree to which they were bothered by each symptom
(e.g., repeated, disturbing memories, thoughts or images of a
stressful experience) in the past month, 1 (not at all) to 5 (ex-
tremely). Item responses were summed to create a total scale
score (range = 1785; = .95).
Depression. Depression symptoms were measured at baseline
using the 20-item Center for Epidemiologic Studies Depression
Scale (Radloff, 1977). Participants reported the frequency with
which they experienced specific symptoms (e.g., I felt depressed,
I felt like everything I did was an effort) during the previous
week using a scale from 0 (none of the time) to 3 (all of the time).
Item responses were summed to derive a total scale score (range
= 060; = .91).
Substance Abuse. Substance abuse was assessed at baseline and
at follow-up with the Two-Item Conjoint Screen (TICS; Brown,
Leonard, Saunders, & Papasouliotis, 2001). These yes/no items
assess substance abuse problems in the past year (drug or alco-
hol). Responses were summed to obtain a total substance abuse
score that ranged from 0 to 2.
Combat Exposure. Combat exposure was measured at baseline
with a 17-item scale adapted from previous measures (Hoge et
al., 2004; Keane et al., 1989; Maguen, Litz, Wang, & Cook, 2004).
The scale assessed combat experiences during participants most
recent deployment (e.g., I was wounded in combat). Response
options ranged from 1 (never) to 5 (51 times or more). Item re-
sponses were summed to create a total score ranging from 17 to
85 ( = .92). Participants reporting no combat deployments were
assigned a 0 value on this scale.
Stressful Life Events. Stressful life events other than combat ex-
posure were measured at both baseline and follow-up with 11
yes/no items drawn from the prior stressors scale of the Deploy-
ment Risk and Resilience Inventory (King, King, Vogt, Knight, &
712 SCHMIED ET AL.

Samper, 2006). Sample items included, experienced unwanted

sexual activity as a result of threat of harm, force, or manipu-
lation, and witnessed someone being violently assaulted or
killed. At baseline, participants were asked whether they had
experienced each event during the previous year. At follow-up,
participants were asked if they had experienced each event since
they separated from service.
As in previous research (Hammen, 1991, 2006; Liu & Alloy,
2010) each noncombat stressful life event was classified as de-
pendent or independent based on the judgments of 3 indepen-
dent raters. Interrater reliability was high (intraclass correla-
tion coefficient = .75), with all 3 raters agreeing on 8/11 items.
A fourth rater was consulted on the 3 items on which the initial
raters had disagreed. In the end, 5 events were classified as in-
dependent, and 6 as dependent. Total scores indicate the num-
ber of dependent and independent stressors experienced during
the reference period. Internal consistencies for these scales were
somewhat low: at baseline, dependent = .49 and independent
= .40; at follow-up, dependent = .33 and independent =
.33. This finding is consistent with the published literature and
is reasonable given the diverse types of stressful life events as-
sessed for each index (Kim, Conger, Elder, & Lorenz, 2003; King
et al., 2006; Netland, 2001; Vogt, King, & King, 2004).

PROCEDURES

Data were derived from a longitudinal study designed to assess

the reintegration experiences of Navy and Marine Corps person-
nel as they transitioned from active duty to civilian life. Baseline
data collection took place from September 2007 to April 2010.
Participants were recruited from seven Navy and six Marine
Corps installations while attending mandatory Transition Assis-
tance Program workshops immediately prior to separating from
service. After providing written consent, respondents completed
the baseline questionnaire. Approximately 12 months later, they
were invited to complete the follow-up survey. Contact was at-
tempted via both postal mail and email, and the survey was of-
fered in both hard-copy and web-based formats.
STRESSORS AND MENTAL HEALTH IN VETERANS 713

ANALYSIS

To test the hypothesized model (see Figure 1), path analyses were
performed using AMOS, version 19.0 (IBM, Armonk, NY). To
simplify the figure, several paths included in the model are not
depicted. These include demographic controls (paths from age,
sex, marital status, ethnicity to each type of stressful life event
at follow-up), intercorrelations among exogenous variables (i.e.,
impulsivity, baseline stressful life events, combat exposure, and
demographic covariates), and a correlation between depression
and PTSD symptoms. To achieve a parsimonious model, the ini-
tial model was revised using an iterative process in which the
nonsignificant paths were sequentially removed, beginning with
the least significant and continuing until all remaining paths
were significant. At each step, changes in fit were examined us-
ing the chi-square goodness-of-fit test as well as several fit indi-
ces: the comparative fit index (CFI), root-mean-square error of
approximation (RMSEA), and parsimonious comparative fit in-
dex (PCFI). Acceptable cutoffs are .95 for CFI and .08 for RM-
SEA (Schreiber, Stage, King, Nora, & Barlow, 2006). There is no
consensus regarding acceptable cutoffs for the PCFI, but higher
scores on this index indicate better fit (Schreiber, Stage, King,
Nora, & Barlow, 2006).

RESULTS
DESCRIPTIVE STATISTICS

Table 1 presents bivariate Pearson correlations between model

variables, as well as descriptive statistics for each variable. The
strongest correlation was between PTSD and depression symp-
toms; correlations between psychiatric symptoms and stressful
life events at both baseline and follow-up were small to moder-
ate in magnitude. Individual differences in impulsivity showed
small-to-moderate positive associations with both stress expo-
sure and psychiatric symptoms.
714 SCHMIED ET AL.

TABLE 1. Correlations and Descriptive Statistics for Model Variables

1 2 3 4 5 6 7 8 9 10
1. Impulsivity
2. Combat exposure .26
3. Dependent life events .14 .12
(baseline)
4. Independent life events .25 .40 .32
(baseline)
5. Depression symptoms .27 .18 .38 .29
6. PTSD symptoms .33 .30 .41 .39 .80
7. Substance abuse (baseline) .25 .12 .20 .18 .22 .25
8. Substance abuse (follow-up) .32 .13 .12 .16 .21 .20 .38
9. Dependent life events .21 .14 .33 .24 .26 .28 .08 .18
(follow-up)
10. Independent life events .21 .15 .19 .22 .18 .22 .05a .10 .38
(follow-up)
M (SD)
4.06 5.47 0.41 1.01 14.58 35.37 0.69 0.40 0.28 0.64
(3.72) (8.97) (0.73) (1.14) (10.99) (16.67) (0.80) (0.69) (0.60) (0.92)
Note. PTSD = posttraumatic stress disorder. aNot significant; all other correlations were statistically
significant (p < .001).

PATH ANALYSIS

The initial path analysis of the theoretical model depicted in Fig-

ure 1 indicated relatively good fit, but low parsimony, c2 (df = 19)
= 289.19, p < .001, CFI = .94, RMSEA = .09, PCFI = .17. Through
the iterative process described previously, thirteen nonsignifi-
cant paths were ultimately removed from the initial model, in-
cluding paths from ethnicity, age, and gender to independent life
events (covariates not shown). The final reduced model resulting
from this process is depicted in Figure 2. The chi-square good-
ness-of-fit test for the more parsimonious reduced model, c2 (df =
28) = 303.50, p < .001, was not significantly worse than the fit of
the original model c2 (df = 9) = 14.31, p = .112. Moreover, a com-
parison of the fit indices suggested that the revised model (CFI
= .93, RMSEA = .08, PCFI = .29) fit as well as the original model.
As can be seen in Figure 2, the only direct effect of combat expo-
sure was on PTSD symptoms; PTSD symptoms fully accounted
for the effects of combat exposure on later exposure to both in-
dependent and dependent stressful life experiences. In contrast,
STRESSORS AND MENTAL HEALTH IN VETERANS 715

FIGURE 2. Theoretical model of bidirectional associations between

stressful life events and mental health symptoms.
*p < .05; **p < .01; ***p < .001; PTSD = posttraumatic stress disorder.

impulsivity and baseline stressful life events (both independent

and dependent) had direct effects on all three types of symptoms
(PTSD, depression, and substance abuse) and on both types of
stressful life events at follow-up. This indicates that the effects
of impulsivity and baseline stressful life events on later stressful
life events were only partially mediated by mental health symp-
toms.
Although all three types of mental health symptoms played a
role in mediation, patterns were somewhat different for predict-
ing the occurrence of dependent and independent life events.
First, effects of baseline depression on subsequent exposure to
dependent life events were fully mediated by substance abuse at
follow-up, and depression symptoms were not related to subse-
quent exposure to independent life events. In contrast, baseline
PTSD was directly associated with increased likelihood of both
independent and dependent stressful events at follow-up, and
these associations were not mediated by substance abuse. Inter-
estingly, baseline substance abuse was inversely associated with
both dependent and independent stressors at follow-up, which
716 SCHMIED ET AL.

suggests the operation of suppressor effects (MacKinnon, Krull,

& Lockwood, 2000). However, baseline substance use also had
a significant indirect positive effect on the likelihood of depen-
dent stressors at follow-up (mediated through substance abuse
at follow-up).
In addition to these theoretically specified paths, the final
model included two significant paths involving demographic
covariates (not shown): age was inversely related to dependent
life events (b = 0.060, p < .05), and female sex was positively re-
lated to dependent life events (b = 0.062, p < .01); race/ethnicity
and marital status were not related to dependent life events, and
none of the demographic factors were related to the occurrence
of independent life events. Together, combat exposure, baseline
(independent and dependent) life events, and impulsivity ex-
plained sizeable variance in PTSD (30%), depression (21%), and
baseline substance abuse (10%). These factors, in combination
with follow-up substance abuse, accounted for nearly 20% of
the variance in dependent stressors at follow-up and 10% of the
variance in independent stressors at follow-up.

DISCUSSION

Using the theory of stress generation as a guide, this study ap-

plied a unique approach to investigate bidirectional relation-
ships between stress exposure and mental health among mili-
tary personnel. Consistent with the studys proposed model, the
results indicate a causal chain in which exposure to stressors in-
crease mental health problems, namely symptoms of depression,
PTSD, and substance abuse, and in turn, mental health problems
increase the likelihood of future stress exposure. These findings
may help to explain the chronicity of depression and PTSD be-
cause continuous exposure to stress may perpetuate psychiatric
symptoms.
The majority of research in veteran populations has exam-
ined the effects of combat exposure on psychiatric health, yet
emerging evidence suggests lower level stressors may actually
be a stronger predictor of psychiatric problems (Booth-Kewley
et al., 2012). Accordingly, in this study baseline dependent and
independent stressful life events predicted higher levels of PTSD
STRESSORS AND MENTAL HEALTH IN VETERANS 717

symptoms, depression symptoms, and substance use, whereas

combat exposure predicted only PTSD. Combat exposure also
differed from other types of stressors in that its effects on like-
lihood of future exposure to stressors were fully mediated by
PTSD symptoms. Conversely, the effects of dependent and inde-
pendent stressors on future stressor exposure were only partially
mediated by PTSD symptoms, and were also partially mediated
by depression and substance abuse. These results suggest that
compared with combat exposure, noncombat-related stress-
ful life events (e.g., assault, injury, divorce) were more strongly
related to depression, substance use, and follow-up life events.
Though more research is needed, this finding has important im-
plications because, due to stigma, veterans may be more willing
to participate in training or treatment targeting general stress
management than in psychotherapy targeting psychiatric symp-
toms stemming from combat experiences.
This studys model included depression, PTSD, and substance
abuse as baseline predictors of future stress based on literature
suggesting each may generate stress (Boscarino, 2006; Conway et
al., 2012; Jakupcak et al., 2010; Orcutt et al., 2002). To our knowl-
edge, no prior study has explored the mediating role of sub-
stance use in the context of stress generation, though it has been
frequently suggested that veterans use substances as a form of
self-medication for psychiatric symptoms (Jakupcak et al., 2010).
In this study each factor uniquely contributed to explaining fu-
ture stressors, even when controlling for the effects of the others.
The relationship between depression and future stress exposure
was mediated by follow-up substance abuse, whereas the rela-
tionship between PTSD symptoms and future stress exposure
was not. The novel finding that substance abuse may play an
important role in stress generation merits further exploration.
The significant role of impulsivity in stress generation was a
key finding of this study. Impulsivity was directly related to el-
evated levels of PTSD, depression, and substance abuse at base-
line, all of which contributed to future stress exposure. In ad-
dition, impulsivity directly affected future exposure to stressful
events, even after controlling for these mediating effects. These
findings not only support the hypothesis that personality plays
a role in stress generation, but suggest that the personality char-
718 SCHMIED ET AL.

acteristic of impulsivity may play a significant role in psychiatric

health outcomes.
Prior stress generation literature has repeatedly found that
psychiatric disorders are most likely to generate dependent,
or interpersonal, life events (Hammen, 1991, 2006; Liu & Alloy,
2010). The results of this study are largely consistent with the
existing body of research. Depression symptoms were signifi-
cantly predictive of increases in dependent stressful life events
(via substance abuse), but they were not significantly related
to future exposure to independent stressors. In contrast, PTSD
symptoms were predictive of increases in both types of future
stressors. These findings further support the notion that an in-
dividuals psychological symptoms should be more strongly
linked to subsequent stressors that are to some degree instigated
by the individuals behavior (i.e., dependent events) than stress-
ors that are not (i.e., independent events).
Several limitations must be considered when interpreting the
results of this study. First, self-reported measures may be subject
to recall and social desirability bias. Further, service members of-
ten underreport symptoms of mental health problems because of
stigma associated with psychiatric issues in the military (Nevin,
2009). Second, the follow-up response rate was somewhat low
(25.2%) and significant differences were noted in the characteris-
tics of responders and nonresponders. Therefore, these findings
may not be generalizable to all separating veterans. Third, most
OIF/OEF veterans deployed more than once, yet this survey as-
sessed combat exposure only for the most recent deployment;
this could cause overall combat exposure to be underestimated.
Strengths of this study are the longitudinal design; large sample
size; strong theoretical model; simultaneous consideration of
PTSD, depression, and substance abuse; and inclusion of both
combat- and noncombat-related stressors.
The present findings suggest that service members who suffer
from symptoms of depression, PTSD, or substance abuse at the
time of separation may be more likely to continue to abuse sub-
stances and to experience stressful events in the future. In turn,
this stress exposure may reinforce and exacerbate the underlying
mental health problems, resulting in a self-perpetuating cycle.
The results of this study suggest that prior to and even follow-
STRESSORS AND MENTAL HEALTH IN VETERANS 719

ing separation, service members should receive interventions

designed to improve their response to stressful life events, such
as coping or interpersonal skills training, as well as targeted sub-
stance use prevention training. By providing new veterans with
the skills to deal with life stress, this type of program may im-
prove the transition from active duty to civilian life and reduce
the burden of psychiatric illness within the veteran population.

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