Driving Difficulties Among Military Veterans: Clinical Needs and Current Intervention Status

REVIEW ARTICLES MILITARY MEDICINE, 179, 6:633, 2014 Driving Difficulties Among Military Veterans: Clinical Needs and Current Intervention Status Elizabeth Possis, PhD*; Thao Bui, PhD†; Margaret Gavian, PhD‡; Jennie Leskela, PhD*; Effie Linardatos, PhD§; Jennifer Loughlin, PhD∥; Thad Strom, PhD* ABSTRACT Military personnel deployed to Iraq and Afghanistan often develop mental health difficulties, which may manifest as problematic driving behavior. Veterans may be more likely to engage in risky driving and to subsequently be involved in motor vehicle accidents and fatalities. This article reviews literature on driving difficulties among military veterans and evaluates available research on the potential pathways that underlie risky driving behavior. Current interventions for problematic driving behaviors are considered, and the necessity of modifying these interventions to address the unique difficulties encountered by military veterans is highlighted. The review concludes with a discussion of clinical implications of these findings and identification of possible avenues for future research and intervention. INTRODUCTION Over the past decade, a significant segment of the U.S. armed forces has been involved in ongoing military operations in Iraq (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]). Several unique aspects of these conflicts are notable. For example, these deployments included greater numbers of individuals in the National Guard and Reserves who may not have received the same preparation and training of active duty service members and may have different psychosocial stressors, such as concern about absence from civilian work, impact on family, etc.1 Individuals serving in OEF/OIF operations are likely to encounter mortar attacks, improvised explosive devices (IEDs), and car bombings.2 Such experiences may result in specific mental health concerns, such as risky driving behavior, which need to be addressed in the treatment. This article reviews literature on driving difficulties among military veterans and evaluates research on the pathways that underlie this behavior as well as current interventions for risky driving. *Minneapolis Veterans Affairs Health Care System, One Veterans Drive (116A), Minneapolis, MN 55417. †VA Puget Sound Health Care System, 1660 South Columbian Way (116-MHC), Seattle, WA 98108. ‡North Memorial Medical Center, Psychiatric Partial Hospital Program, 3366 Oakdale Avenue, Suite 506, Robbinsdale, MN 55422. §Department of Psychiatry, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH 03756. kBarrow Neurological Institute, 222 West Thomas Road, Suite 401, Phoenix, AZ 85013. doi: 10.7205/MILMED-D-13-00327 SYSTEMATIC LITERATURE SEARCH Studies included in this review were identified from electronic searches of databases including CINAHL (1995–2013), PsychINFO (1995–2013), PsychARTICLES (1995–2013), and Psychology and Behavioral Sciences Collection (1995– 2013). Searches were conducted using keywords “veterans,” “military,” “driving,” “risky driving,” “driving anger,” “motor vehicle accident (MVA),” “motor vehicle crash,” “fear,” “anger,” “thrill seeking,” “sensation seeking,” “intervention,” “driving phobia,” and “PTSD.” Reference lists of relevant articles were also searched for additional sources. PHENOMENOLOGY OF DRIVING DIFFICULTIES Mental Health Difficulties in Returning Veterans Recent research suggests individuals deployed to Iraq and Afghanistan may develop mental health difficulties. Among combat veterans, 19% of those returning from Iraq and 11.3% of those returning from Afghanistan reported a mental health problem, and rates of Post-traumatic Stress Disorder (PTSD), depression, anxiety, and alcohol abuse increased substantially from pre- to postdeployment.3 Research suggests that 25% of OEF/OIF veterans meet criteria for a mental health diagnosis, with common diagnoses including PTSD, adjustment disorders, mood disorders, and substance use disorders.4 Veterans may struggle with anger, hostility, and aggression, and with pain, fatigue, and insomnia.5,6 These mental health problems create a significant occupational burden and negatively impact functioning and well-being.3 MILITARY MEDICINE, Vol. 179, June 2014 633 Driving Difficulties Among Military Veterans Reports of Risky Driving in Military Veterans Problematic driving behaviors have been the focus of considerable media attention and empirical investigation.7,8 Possible factors that underlie these behaviors have been hypothesized. Some authors suggest that traumatic brain injury, commonly seen among OEF/OIF veterans, may contribute to driving difficulties.9–11 The headaches, visual disturbances, dizziness, and attentional difficulties that accompany traumatic brain injuries may have detrimental effects on driving behavior.10 PTSD has also been cited as a factor that may contribute to risky driving as difficulties with hypervigilance, intrusive thoughts and memories, and affective dysregulation may detract from driving attention and performance.9,10 Alternatively, some propose that military training may contribute to driving difficulties. Training for driving in a combat zone may result in driving behavior patterns that are dangerous in noncombat driving situations.8–10 Because of situational threats and the likelihood of being attacked, military personnel on deployment may adopt offensive driving styles that involve speeding, keeping a great distance from other vehicles, driving in the middle of the road, and rapidly changing lanes. In recognition of the effect that such experiences may have on driving patterns, there has been an emphasis on helping veterans transition from a “battlemind” approach back into civilian life.12 Several empirical investigations have examined risky driving among military personnel. To illustrate, in a sample of 429 Army soldiers hospitalized for motor vehicle injuries, risky driving behaviors (e.g., driving under the influence of alcohol, speeding, less frequent use of seatbelts) were common and predictive of need for hospitalization following a motor vehicle crash.13 Among 474 veterans receiving residential treatment for PTSD, approximately 20% of the sample reported tailgating, cutting off, or chasing another driver during the past 4 months and two-thirds of the sample reported aggressive driving.8 Furthermore, risky driving behaviors were more common among veterans than among the general population. A large percentage (20%) of military armed forces from the United Kingdom can be classified as risky drivers, as defined by not wearing a seatbelt or speeding.14 Others have similarly found that among U.S. veterans receiving outpatient mental health and primary care services, a significant percentage of individuals reported racing cars (24%), sacrificing safety for speed (37%), and cutting off or chasing another driver (27%).15 In sum, considerable research suggests veterans struggle w (...truncated)