ARTIGO SUPORTE BRUMS E MILITARES

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MILITARY MEDICINE, 178, 4:372, 2013
Clinical Utility of the Brunel Mood Scale in Screening for
Post-Traumatic Stress Risk in a Military Population
Charles H. van Wijk, PhD; Jarred H. Martin, M Soc Sci; Chesray Hans-Arendse, B Psych
ABSTRACT Measures of mood states and post-traumatic stress (PTS) symptoms are commonplace in many studies.
However, the conventional application of these measures conjointly raises questions whether they actually correlate,
and whether mood states have a meaningful role in predicting PTS symptoms. This study aimed to assess the degree
to which the Brunel Mood Scale (BRUMS) and the Impact of Event Scale—Revised (IES-R) would be useful in
detecting adverse psychological experiences (e.g., PTS). A sample of South African Navy sailors (N = 103) completed
the BRUMS during demobilization after a traumatic deployment, and 6 weeks later completed a repeat BRUMS and
the IES-R. Significant correlations were found between some BRUMS and IES-R subscales, but the lack of other
subscale correlations indicates that the two measures probably tap different expressions of psychological distress
following exposure to adverse events. Greater mood distress correlated with more severe PTS. A BRUMS total mood
distress score cutoff of ³24 gave a sensitivity of 100% and specificity of 79% for severe PTS 6 weeks later. Using
a BRUMS score of ³24 at demobilization to assess for possible elevated PTS response later could be useful in the
screening of large groups of people.
INTRODUCTION
Both mood state scales and post-traumatic stress (PTS) scales
have been extensively used in studies examining PTS expe-
riences.1 The Profile of Mood States (POMS) and Impact
of Events Scale—Revised (IES-R) are particularly popular
examples of such scales, and have been used in studies
exploring the trajectories of adjustment responses to,2 social
contexts dealing with,3 and effects of treatment after4 trau-
matic events, to name a few recent examples. From a review
of the literature, numerous studies using the POMS and IES-R
together in the past 5 years alone were found.2–10
Various studies using these scales2–10 have consistently
used them in parallel—as indicators of negative affectivity
or psychological distress—across a large number of con-
texts. The overall hypothesis guiding previous studies using
these measures proposed that they would indicate dif-
ferent expressions of psychological distress. Typically, the
scores on these measures are compared or correlated to other
markers or experimental conditions, such as sociodemo-
graphic variables or psychological interventions. Surpris-
ingly, in spite of their parallel use, correlations between
the two measures were never investigated. This study,
therefore, builds on previous literature by analyzing corre-
lational statistics between the shortened form of the
POMS—referred to as the Brunel Mood Scale (BRUMS)—
and IES-R. The aim here is to assess the degree to which
the BRUMS and IES-R are useful in detecting psycho-
logical distress, particularly in the operational environ-
ment, with reference to PTS. In addition to the above, this
research will also address the question of whether one mea-
sure can be used to more robustly predict the other after
traumatic incidents, if they are conducted at different times
to the same military sample.
At the present time, the South African Navy (SAN), a
part of the South African National Defence Force (SANDF),
is involved in antipiracy operations, in support of neigh-
bouring Southern African Development Community countries,
along the east coast of Africa. At times, these operations
involve traumatic exposure, and as it is known that such
exposure may affect indicators of psychological distress, as
measured by mood states,3,11 all personnel on ships that
return from such deployments complete the BRUMS during
their demobilization.
Recently, one SAN vessel returned after a particularly
difficult deployment, which included the trauma associated
with the loss of fellow sailors during antipiracy boarding
operations, which was the first such experience for most of
this crew. In response to the emergent stressors endured by
the crew during their deployment, a standard demobilization
of the crew, rendered by psychologists in the SANDF, took
place approximately 4 weeks after the death of their comrade.
As part of this, all the sailors completed the BRUMS as a
measure of current mood distress. Coincidentally, the same
vessel did their annual scheduled military health screening
approximately 6 weeks after their return, which presented an
opportunity to screen for PTS. At this time, they completed
another BRUMS, as well as the IES-R. This situation pro-
vided for a unique opportunity to examine possible correla-
tions between the measures of mood distress and PTS
symptoms. As the BRUMS is routinely administered in the
demobilization context for SAN sailors described, it also
provided an opportunity to examine whether it can be used
to predict PTS 6 weeks later.
The aim of the study is thus three-fold: First, this
study aimed to determine whether the BRUMS and IES-R
scores correlate, when both were administered approximately
Institute for Maritime Medicine, Naval Base Simon’s Town, Private
Bag X 1, Simon’s Town 7995, South Africa.
doi: 10.7205/MILMED-D-12-00422
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2 months post trauma. Second, this study aimed to determine
whether BRUMS scores during demobilization are useful in
predicting post-traumatic symptoms or experience 6 weeks
later. In this context, PTS is understood as a set of dystonic
psychological symptoms following adverse events. Third,
this study explored associations between repeated BRUMS
scores during demobilization and six weeks later, as well
as the relationship between scores on the IES-R and age
and gender.
METHOD
Participants
The sample consisted of 103 officers and sailors of the
SAN, which constituted all available sailors returning from
this deployment. All participants had been on an antipiracy
deployment with the SAN, and had been exposed to the
loss of a comrade during this deployment. The sample was
multicultural and came from a diverse range of South Africa’s
language groups. The language of the work-groups is English.
They gave written consent for the anonymous use of their
psychometric data for research. Age and gender distribution
can be found in Table I. Not all participants completed all
the scales, and there are thus different sample sizes (N) for
different calculations.
Instruments
BRUMS
The BRUMS12,13 is a shortened version of the POMS. Vali-
dation studies provided strong support for content, factorial,
and criterion validity equivalent to that of the original POMS
mood states.12,13 The BRUMS measures six identifiable
affective states through a 24-item self-report inventory, with
respondents rating a list of adjectives on a 5-point Likert
scale ranging from 0 (not at all) to 4 (extremely), based on
subjective feelings. The instructions refer to how participants
“have been feeling in the past week, including today”. Scores
from the six mood state subscales (Tension, Depression,
Anger, Vigor, Fatigue, and Confusion) can also be calculated
into a Total Mood Distress (TMD) index.
The BRUMS has proved a productive measure of current
mood states and their fluctuations in many diverse groups,12
with good concurrent and criterion validity reported inter-
nationally,12,13 and research on South African samples
shows acceptable internal consistency (between 0.66 and
0.89 across the mood states).14,15 Gender and age, but not
race, have been shown to influence scores in comparable
South African samples.15
The BRUMS is routinely used during demobilization and
is chosen because of its robust psychometric properties, ease
of completion,short time required, and availability of norms
for the study population.15 The six affective mood states
subscales are not diagnostic indicators, and thus have no
cutoff points to indicate clinical mood disturbance. Mood
states are generally presented as T-scores.
IES-R
The IES-R16 is one of the most often used self-report ques-
tionnaires for determining PTS symptoms following trauma.1
The 22-item scale consists of three subscales (Intrusion,
Avoidance, and Hyperarousal).16 Respondents rate each
item on a 5-point scale ranging from 0 (not at all) to
4 (extremely). Scores of 33 or greater indicate a high proba-
bility of a post-traumatic stress disorder (PTSD) diagnosis.17
Results from various studies investigating the psycho-
metric properties of the IES-R report acceptable internal
consistency that range between 0.85 and 0.95 for indi-
vidual subscales.18,19
It was chosen because of its robust psychometric proper-
ties and widespread use in similar studies. Meta-analysis
of various studies using the IES-R has concluded that cul-
tural differences were relatively insignificant in the develop-
ment of PTSD as measured by IES-R,20 and thus its use was
applicable in this study population. Although there are sug-
gestions that gender influences scores in certain samples,18
the effects of age and gender on IES-R responses has not
been clarified.19
The issues of using cutoff points to suggest PTSD has
received much attention in the literature. Although there are
different systems in use,21 it is the framework of Creamer
et al17 that is used most often. Creamer et al17 propose scores
of 0 to 11 as normal response, 12 to 32 as moderate symp-
toms, and 33 and more as PTSD. The Avoidance subscale
is considered less accurate for indicating clinical PTSD.19
Between 4% and 8% of international noncombat mili-
tary personnel with war exposure developed severe symp-
toms, as measured by the IES-R.22 As South African military
personnel are often exposed to multiple traumas outside their
work context,23 no reliable PTSD data is available for this
group. Given that exposure to trauma is widespread in South
Africa,24 the IES-R instructions were adjusted to exclude
previous traumatic experiences, so to focus participants’ self-
report on their recent deployment (e.g., death of a comrade).
Procedure
As noted, the first round of data, consisting of the BRUMS,
were collected from sailors on return from their deploy-
ment. This took place about 4 weeks after the death of
their shipmates. The second round of data were collected
6 weeks later, during their annual scheduled military health
screening, and consisted of a follow-up BRUMS and the
IES-R. Both the BRUMS and IES-R were administered in
TABLE I. Age Data for the Sample Per Gender
Gender N Mean SD Range
Women 21 26 5 20–44
Men 82 29.5 8 20–55
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pencil-and-paper format. Sailors spent the time between
2 rounds of data collection either on leave or while engaged
with ship’s maintenance. No further incidents of trauma
during this time were reported.
Ethics
Participants completed a written informed consent form,
agreeing that their anonymized results may be used for this
study. The study protocol was authorized by the Surgeon
General’s Ethics Committee for Health Research, which
permitted the use of anonymous data.
Data Analysis
All data were entered into a spreadsheet, and all identifying
information was removed. The anonymous dataset was used
for statistical analysis. The first aim was explored using
correlational statistics (BRUMS and IES-R data at 6 weeks).
The second aim also used correlational statistics, as well as
calculating sensitivity and specificity figures (BRUMS data
after return, and IES-R data from 6 weeks later). The third
aim compared BRUMS on return with BRUMS 6 weeks
later using t-tests and correlational statistics, and further
explored the relationship between age, gender, and the mea-
sures using correlational statistics and t-tests. Pearson’s r
was used, as it is a concise and widely used coefficient for
measuring linear dependence,25 in this case BRUMS and
IES-R. Given the possible role of demographic variables on
scores, the effects of age and gender were explored using
correlational statistics and t-tests. All analyses were done
using the STATISTICA 7 (for Windows [StatSoft, Tulsa, OK])
software package.
RESULTS
Do the BRUMS and IES-R Scores Correlate?
The scores on the BRUMS and IES-R (both administered at
6 weeks after demobilization) showed a remarkable degree
of correlation (Table II). In this regard, the BRUMS sub-
scales Tension, Fatigue, Confusion, and the TMD score
correlated significantly with the IES-R subscales Intrusion
and Hyperarousal and the Total score.
Do the BRUMS Scores Predict IES-R Scores
6 Weeks Later?
The scores on the BRUMS (completed on return) and IES-R
(6 weeks later) also showed a significant degree of correlation
(Table III). In this regard, the BRUMS subscale Depression
correlated significantly with the IES-R subscales Intrusion
and Hyperarousal and the Total score, with Tension and
Confusion also correlating significantly with Intrusion and
Total IES-R scores.
Greater mood distress correlates with more severe PTS
symptoms. To answer the question whether the BRUMS
TMD can predict this, an IES-R cutoff point of ³33 was
taken as reflecting severe PTS.17 This indicated that 4.5% of
the sample reported severe PTS symptoms.
When using a BRUMS TMD score cutoff of ³24 (com-
pleted on return from the deployment), it gave a sensitivity of
100% and specificity of 79% for PTS 6 weeks later. When a
cutoff of ³39 was used, it decreased sensitivity to 75% while
increasing specificity to 89% for PTS 6 weeks later.
When using t-tests for single measures to compare the
IES-R scores of sailors in this study with mean scores pub-
lished by Feinstein and Botes (2009),22 the sailors reported
significantly less symptom severity than security contractors
(t = −6.33, pStress
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Age played a significant role in the experience of PTS symp-
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