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Mental Health Problems, Use of Mental Health Services, and Attrition From Military Service After Returning From Deployment to Iraq or Afghanistan
Abstract
The US military has conducted population-level screening for mental health problems among all service members returning from deployment to Afghanistan, Iraq, and other locations. To date, no systematic analysis of this program has been conducted, and studies have not assessed the impact of these deployments on mental health care utilization after deployment.
To determine the relationship between combat deployment and mental health care use during the first year after return and to assess the lessons learned from the postdeployment mental health screening effort, particularly the correlation between the screening results, actual use of mental health services, and attrition from military service.
Population-based descriptive study of all Army soldiers and Marines who completed the routine postdeployment health assessment between May 1, 2003, and April 30, 2004, on return from deployment to Operation Enduring Freedom in Afghanistan (n = 16,318), Operation Iraqi Freedom (n = 222,620), and other locations (n = 64,967). Health care utilization and occupational outcomes were measured for 1 year after deployment or until leaving the service if this occurred sooner.
Screening positive for posttraumatic stress disorder, major depression, or other mental health problems; referral for a mental health reason; use of mental health care services after returning from deployment; and attrition from military service.
The prevalence of reporting a mental health problem was 19.1% among service members returning from Iraq compared with 11.3% after returning from Afghanistan and 8.5% after returning from other locations (P<.001). Mental health problems reported on the postdeployment assessment were significantly associated with combat experiences, mental health care referral and utilization, and attrition from military service. Thirty-five percent of Iraq war veterans accessed mental health services in the year after returning home; 12% per year were diagnosed with a mental health problem. More than 50% of those referred for a mental health reason were documented to receive follow-up care although less than 10% of all service members who received mental health treatment were referred through the screening program.
Combat duty in Iraq was associated with high utilization of mental health services and attrition from military service after deployment. The deployment mental health screening program provided another indicator of the mental health impact of deployment on a population level but had limited utility in predicting the level of mental health services that were needed after deployment. The high rate of using mental health services among Operation Iraqi Freedom veterans after deployment highlights challenges in ensuring that there are adequate resources to meet the mental health needs of returning veterans.
... 20 Some of the extant studies 21,22 in the literature have examined specific sedatives such as benzodiazepine and past-year use in national samples and excluded veteran status as a predictor. Conversely, many studies 16,[23][24][25][26][27][28][29] with veterans have largely based their analyses on participants recruited through government or VA-affiliated facilities despite the differences in patients' characteristics of veterans who used the VA facilities and those who did not 30 and the fact that many communitydwelling veterans receive their health treatment outside the VA system. 31 In the community, although 62% of veterans use the VA system, a substantial portion do not. ...
... This result was supported by past literature that veterans have a high prevalence of sedative use. 16,[40][41][42] The stress of regular deployments and exposure to combat are potential risk factors for mental health problems 26,[43][44][45] including anxiety, depression, insomnia, panic disorder, and PTSD. Veterans, faced with these diagnoses that often require sedative use, coupled with better access to health care and subsequent access to prescription sedatives, are at increased risk for sedative misuse. ...
... 2,3 As few as 40 to 50% of soldiers with BH problems use clinical services even after a clinical referral for care is made. [4][5][6] The proportion of SMs seeking care for BH disorders is particularly surprising in an institution with built-in medical leave policies and ready access to free or low-cost behavioral health care (BHC) services. 7 The perceived negative stigma associated with BH disorders may be one reason why more than half of the SMs with mental health problems do not seek BHC within the military health system. ...
... 3,11 Some concerns may be supported by the literature as studies have shown an association between BH diagnoses, BHC utilization, and increased military attrition rates. 5,12 This association appears to be moderated by early treatment seeking, self-referral, and the lack of command involvement. [12][13][14] Command involvement is a specific avenue for negative career-related impacts related to BHC seeking. ...
Introduction:
Less than half of service members with a behavioral health (BH) problem seek care. Soldiers may avoid seeking needed care because of concerns related to being placed on a duty-limiting profile and the related medical disclosures that follow.
Materials and methods:
This study used a retrospective population-based design to identify all new BH diagnoses across the U.S. Army. The relationship between diagnostic category, risk of being issued a duty limitation (profile), and time until return to full duty was also examined. Data were collected from a comprehensive data repository that includes medical and administrative records. Soldiers with a new BH diagnosis were identified from 2017 to 2018. All duty limitation profiles within 12 months of initial diagnosis were identified.
Results:
Records for 614,107 unique service members were reviewed. This cohort was mostly male, enlisted, unmarried, and White. The mean age was 27.13 years (SD = 8.05). Soldiers with a new BH diagnosis accounted for 16.7% (n = 102,440) of the population. The most common diagnostic category was adjustment disorder (55.7%). About a quarter (23.6%) of soldiers with a new diagnosis were issued a related profile. The mean length of these profiles was 98.55 days (SD = 56.91). Of those with a new diagnosis, sex and race failed to have an effect on the odds of being placed on a profile. Overall, enlisted, unmarried, or younger soldiers had greater odds of being placed on a profile.
Conclusion:
These data provide relevant information for both the service member who seeks care and command teams seeking readiness projections.
... Ряд досліджень, зокрема висновки Keane et al., свідчить, що військові часто зазнають психо-логічного стресу та травм під час служби в зоні конфлікту [20]. Це призводить до психічних порушень, таких як посттравматичний стресовий розлад (PTSD), а також фізичних проблем [16]. ...
Резюме. У сучасних умовах воєнного стану перед українським суспільством постає суттєвезавдання реабілітації учасників бойових дій, які можуть зіштовхнутися з посттравматичнимстресовим розладом (ПТСР), що істотно впливає на їхнє психологічне благополуччя, повсяк-денне життя, соціальну взаємодію та адаптацію до цивільного життя. Наукові дослідження угалузі освіти, науки, фізичної культури, спорту та психології вказують на негативний впливстресу на психоемоційний та фізичний стан військовослужбовців, підкреслюючи необхід-ність ефективних стратегій реабілітації. Мета. Дослідити проблему стрес-асоційованихстанів у військовослужбовців та запропонувати шляхи її вирішення. Довести доцільністьзастосування засобів кіберспорту для реабілітації учасників бойових дій. Методи. Аналіз тасинтез, систематизація та узагальнення. Результати. Стресові стани, асоційовані з військо-вою службою, включають посттравматичний стресовий розлад (ПТСР), відчуття самотностічерез віддаленість від родини та соціальну ізоляцію, а також внутрішні конфлікти, спричи-нені необхідністю виконання завдань, що суперечать особистим переконанням. Такі станивпливають на психічне здоров’я військовослужбовців, потребуючи професійного підходу доїх реабілітації та підтримки. ПТСР у військових часто проявляється через вторинні пере-живання травматичних подій, флешбеки, жахи та панічні атаки, що вимагає комплексногопідходу до лікування, включаючи когнітивно-поведінкову терапію, медикаментозну підтримкута психіатричну допомогу. Використання засобів кіберспорту демонструє значний потен-ціал у реабілітації та зниженні рівня стресу серед військових. Розроблено програму і мето-дику використання засобів кіберспорту в реабілітації військових. Рекомендації включаютьзастосування терапевтичних ігор, вправи на релаксацію та стрес-менеджмент, ініціативи,спрямовані на зміцнення соціальних зв’язків і фізичної активності через кіберспорт. Засто-сування віртуальної реальності для створення спеціалізованих терапевтичних середовищ єефективним засобом у зниженні рівня стресу та допомозі військовим та ветеранам бойовихдій подолати травматичні спогади. Розроблена програма реабілітації з використанням засо-бів кіберспорту базується на сучасних наукових дослідженнях і передбачає індивідуальнийпідхід до кожного учасника, враховуючи їхні особливості та потреби. Програма підкреслюєважливість постійного моніторингу та оцінки результатів для коригування та оптимізації реа-білітаційного процесу.Ключові слова: психологічний стрес, посттравматичний синдром, кіберспорт, реабілітація,військовослужбовці, терапія, комунікація, фізична активність, віртуальна реальність, моніто-ринг.
... • The establishment of institutions like the Veterans Administration (now the Department of Veterans Affairs) in the United States played a crucial role in providing comprehensive mental health services to veterans, including counseling, therapy, and rehabilitation programs (Hoge et al., 2008). ...
... It is important to test measures with diverse populations and the MCGM has not been evaluated in military veteran populations. US veterans represent a broad cross-section of diverse adults in the US and there is great public concern in the country about their well-being (Hoge et al., 2006;Tsai et al., 2021). Thus, US veterans represent an important population to examine gratitude and the MCGM has not been used in prior studies with veterans (McGuire et al., 2021). ...
The Multi-Component Gratitude Measure (MCGM) assesses one’s emotions, attitudes, and behaviors related to gratitude and has been used in numerous studies. This paper describes psychometric evaluation of the 29-item MCGM. Data from a nationally representative sample of 1,028 low-income veterans in the United States (US) collected 2022–2023 were analyzed. A content review of MCGM items followed by reliability analyses, factor analyses, and examination of construct validity were conducted. The MCGM scales showed good internal consistency as well as good convergent and discriminant validity in the veteran sample; these findings were successfully replicated with split subsamples. The MCGM scales were also tested with a supplementary general US population sample recruited through Amazon Mechanical Turk (n = 205) and internal consistency of the scales was found to be low, possibly due to negatively worded items. These findings support use of the MCGM among US veterans that may need further evaluation for use in the general population.
... Military spouses experience unique military-related stressors, including deployment separation, financial stress, and increased periods of operational tempo, that may ultimately influence familial support for the service member's military responsibilities. Unhealthy behaviors impose healthcare costs and productivity loss that reduce readiness; in contrast, positive lifestyles produce savings for the military health system [35,36]. In providing comprehensive healthcare to the military community, the DHA strives to assess and target modifiable health behaviors among beneficiary families, to support both individual and population-level health and readiness. ...
Background
Unhealthy behaviors impose costs on health-related quality of life (HRQOL) reducing productivity and readiness among military members (Hoge et al., JAMA 295:1023–32, 2006; Mansfield et al. 362:101–9, 2010). Among married personnel in particular, patterns of spouse health behaviors may play an interdependent role. As a result, the identification of military spouse health factors related to readiness may inform strategies to screen for and identify those in need of greater support and enhance readiness. This study explored behavioral and HRQOL predictors and potential mediators of military spouse readiness utilizing data from the Millennium Cohort Family Study.
Methods
The analytic sample comprised of 3257 spouses of active-duty, non-separated service members who responded to both waves 1 and 2 of the survey. Sample characteristics are described with respect to demographics (e.g., age, sex, race/ethnicity, etc.), readiness measures (i.e., military satisfaction, lost workdays, health care utilization, military-related stress, and satisfaction), health behaviors (i.e., exercise, sleep, smoking, and alcohol use) and HRQOL (Veterans RAND 12-Item Short Form Survey). We conducted multivariate mediation analyses to evaluate the role of mental and physical HRQOL as mediators between the baseline health behaviors and the health readiness outcomes at follow-up, while adjusting for spouse and service member demographics.
Results
HRQOL had direct effects for all five readiness outcomes examined. Multiple health behaviors (insomnia, smoking, binge drinking, and exercise) were further significantly associated with spouse readiness outcomes, although most effects were mediated through HRQOL, suggesting this may be a useful index of military spouse readiness. Insomnia was the specific health behavior most consistently associated with poorer readiness across outcomes, and effects were only partially mediated by physical and mental HRQOL.
Conclusions
The results show spouse health behaviors are directly and indirectly (through HRQOL) associated with readiness indicators. This suggests that assessments of modifiable health behaviors (e.g., insomnia symptoms) and mental and physical HRQOL are important indicators of readiness among military spouses and should be used to inform future programs designed to improve population health.
... Stress has both physical and behavioral manifestations. It can increase morbidity, particularly through immune system disorders (Adler et al., 2000;Hoge et al., 2004Hoge et al., , 2006. Neurobiological factors play a leading role in the ability to withstand trauma and stress (Wang et al., 2000;Сaspi et al., 2003). ...
Erectile dysfunction and the associated quality of life are a pressing social and medical problem for millions of people. The basis of the work was the results of a survey of 298 men injured as a result of combat operations (shrapnel and bullet wounds) using the questionnaires of the International Index of Erectile Function-5 (IIEF-5) and the SF-36 Health Status Survey (SF-36) questionnaire to characterize the quality of life. The research group was divided into two: men aged 20-39 years (group 1) and men aged 40-53 years (group 2). The control group consisted of 48 clinically healthy men without complaints of sexual dysfunction or cardiac, neurological or endocrinological pathology. It is shown that men aged 20-39 years have a mild form of ED where the total score is 19.57 ± 0.44. Men of the 2nd group aged 40-53 years also have a mild form of ED, but the total score is much lower and is 17.74 ± 0.41. Patients of both age groups affected by hostilities suffer from both mental and physical health components. Indicators such as general health, role functioning due to physical condition, and pain intensity have probably lower values compared to the contol group. Lower indicators of role functioning due to physical condition indicate limitations in everyday life due to unsatisfactory physical condition. The decrease in the physical functioning index has statistically significant differences only in patients of the 2nd observed group. Thus, a mild form of erectile dysfunction is observed in men injured as a result of hostilities. No significant differences in the severity of erectile dysfunction were found between male war victims of two age groups. All IIEF-5 domains were significantly reduced in men affected by combat operations. It has been proven that the physical and mental components of health suffer in victims of hostilities. Against the background of a decrease in all indicators on the scales of the physical component of health, general health and role functioning caused by physical condition lag behind the most. In the psychological domain, the most pronounced changes are recorded in such components as mental health, vital activity and social functioning. Сorrelation analysis revealed the significant correlation between physical functioning and role functioning caused by emotional state (r = +0.64; P < 0.05).
... Just like all military personnel, military police forces are exposed to various types of physical and psychological stress regardless of whether they are on a mission abroad or on duty in their home country [11]. They may be involved in combat action, witness atrocities, face threats to life and limb, and have the experience of killing, just to mention some sources of stress [13,16,22] while being deployed. ...
Leadership personnel in the German military police are often responsible for units that are frequently exposed to highly stressful situations due to their tasks and skills. As German military leaders are expected to take care of and support their subordinates, they need to know how resilience can be increased and trained. This article presents a resilience training concept for leaders in the German military police. The result is a 1-week resilience training course consisting of psychoeducational knowledge, practical training parts, and measures for sustainability. Subsequently, it was validated and scientifically evaluated with German military police officers (n= 19). The high degree of target group orientation was deemed necessary and expedient. Further objectives are to adapt the concept to the needs of other military target groups and to increase its sustainability.
... It affects an estimated 6.0% of adults and 5.0% of adolescents in the United States [1,2]. Because PTSD by de nition is related to an experienced traumatic event, populations with signi cant exposure to traumatic events such as veterans and the victims of sexual assault/intimate partner violence have a markedly increased risk of developing PTSD [3,4]. PTSD is associated with substantial comorbidities such as treatment resistant depression, substance abuse, suicidality, loss of quality of life and considerable societal burden through loss of productivity [5]. ...
Post-traumatic stress disorder (PTSD) affects ~ 6% of adolescents and adults in the US. Increased N-methyl-D-aspartate (NMDA) receptor activation leads to heightened intrusive memories and is associated with an increased risk of developing PTSD. Ketamine is an NMDA antagonist with ultra-rapid therapeutic action for treatment-resistant depression and suicide. In this meta-analysis, we assessed the effect of subanesthetic ketamine infusion on PTSD severity. Six databases were investigated according to PRISMA guidelines with quality assessments according to the NIH Quality Assessment tool. Eligible criteria included: 1) Randomized Control Trial (RCT) or cohort study 2) Used a single or multiple ketamine infusion(s) 3) Studies using another treatment for PTSD to which (2) is added 4) PTSD symptoms are measured at pre-infusion baseline and up to at least 40 minutes after infusion using a valid PTSD symptom measurement scale 5) Study included ≥ 5 patients. The primary outcome was the first measured value of PTSD symptoms after treatment completion. Meta-analysis using a random effects model was performed on pre-to-post changes in PTSD severity within ketamine treated patients and to compare ketamine to control outcomes. The search retrieved 526 articles. Nine articles met inclusion criteria: 5 RCTs and 4 cohort studies. Meta-analysis revealed that ketamine infusion reduced PTSD symptom severity (pre-post ketamine: standardized mean difference pre-to-post: 3.07, 95% confidence interval 1.54–4.60, P < 0.01). These results support ketamine infusions as an effective treatment modality for PTSD symptoms. Ketamine-assisted psychotherapy is shown to enhance ketamine effect and aid in prolonging remission. Further research is needed to provide effective and long-lasting PTSD treatment.
... While it could be argued that the rigidity of military masculinity is needed during military service to protect against the psychological stressors of combat (Fox & Pease, 2012), when these men transition to civilian life, the conditioning of military masculinity can be detrimental to mental health and render men silent in their suffering (Kivari, Oliffe, Borgen, & Westwood, 2018). This can amplify concealment of problems and reluctance to seek help for mental health concerns as self-protective strategies for preserving their military career and reputations (Britt et al., 2011;Hoge, Auchterlonie, & Milliken, 2006). Given the violent and traumatic events that accompany military deployments (Seal, Bertenthal, Miner, Sen, & Marmar, 2007;Wright, Huffman, Adler, & Castro, 2002), along with social pressures to embody military masculinity, male veterans are a population requiring targeted and tailored mental health promotion and suicide prevention efforts. ...
... Differences in psychopathology, gender, and age could explain the difference in findings between the studies. For instance, while Brown and colleagues found an effect of success autobiographical memories on problem solving regardless of PTSD status, combat veterans are likely to have more psychological difficulties than students (Ganly et al., 2017;Hoge et al., 2006). Psychological difficulties, particularly depression, have been associated with lower levels of open-ended problem-solving ability (Williams et al., 2007). ...
Why do we have autobiographical memory and how is it useful? Researchers have proposed a directive function; our experiences guide our behavior, particularly when faced with an open-ended problem. Two experiments (one between-participant and one mixed design) were therefore conducted to test whether success autobiographical memories – any experience when the participant felt successful and competent – are helpful for generating solutions to problem scenarios. One research aim was to experimentally test the directive function as current experimental evidence is limited and results are mixed. Consequently, it is unclear if and how autobiographical memory is helpful for open-ended problem solving. Another aim was to test whether self-efficacy is an important factor that supports open-ended problem solving and thus the directive function. Although success memories enhanced self-ratings of self-efficacy across both experiments, in samples of undergraduate students there was no experimental effect of success autobiographical memories on problem solving. Instead, some participants across the memory and control conditions in both experiments, even when not instructed, recalled autobiographical memories related to the problem scenarios presented in the problem-solving task, and these participants did better at problem solving than those who did not. This may hint to a directive function and is perhaps one reason why there is no experimental effect. Sample and experimental design differences are discussed as potential factors that may contribute to non-significant effects in this study but significant effects in others. Our results highlight the complexity of the directive function, and the difficulty of experimentally testing how autobiographical memory directs behavior.
... One national study found that of adults with past-year PTSD, only 30% had accessed a mental health specialist (Nobles et al., 2016). Similarly, fewer than half of service members with PTSD seek treatment and for those who receive a specialty care referral, less than half follow through (Edwards-Stewart et al., 2021;Hoge et al., 2006). Meta-analyses reveal the average PTSD treatment dropout rate was 18% in PTSD clinical trials (Imel et al., 2013) and 24.2% in military and veteran samples (Edwards-Stewart et al., 2021). ...
Objective: Posttraumatic stress disorder (PTSD) prevalence in the military is high and effective treatments are underutilized. Motivational enhancement therapy (MET) “check-ups” are brief interventions to elicit treatment uptake for those who are nontreatment seeking. The aim of the current study was to test the efficacy of a novel MET intervention designed to promote treatment engagement among active-duty U.S. military personnel with untreated PTSD. Method: One hundred and sixty-one active-duty service members who met the criteria for PTSD were randomized to MET or treatment as usual (TAU, treatment resource and referral). MET participants (n = 82) received up to three 30–90 min telephone sessions. TAU participants (n = 79) were mailed PTSD resources and referrals. Follow-up assessments were conducted 6-week, 3- and 6-month postbaseline. Results: Mixed effect model results indicated treatment uptake significantly increased over time but there were no significant differences between conditions or interactions. PTSD symptom severity significantly decreased for both conditions. There was also a significant three-way interaction with baseline readiness-to-change confidence. Those low in baseline readiness-to-change saw more favorable effects of MET (relative to TAU) at 6-month follow-up. Conclusions: Results suggest both MET and high-quality referral options have promise as a means of increasing evidence-based treatment uptake and decreasing PTSD for service members with PTSD. MET may be particularly useful for individuals with low confidence in their ability to address PTSD. Given the individual and societal costs of PTSD, there is a need for interventions facilitating treatment uptake.
... However, studies in the literature focused more on stigma associated with schizophrenia and depression, and were less discussed in the context of PTSD stigma, which is common in the military (Acosta 2014). Studies have reported that military personnel returning from conflicts and operations suffer from psychiatric disorders such as PTSD, major depression, and alcohol abuse (Hoge et al. 2004, Hoge et al. 2006, Zinzow et al. 2012, Ünlü 2014. . The second difference is that the private and business areas of the soldiers are closer than their counterparts in the civilian sector. ...
Due to its nature, the army is an environment with a high risk of mental illness. Research shows that mental health stigma is a common and serious barrier to early and effective treatment for mental disorders that result from the stress of military operations. Given the need for timely and effective mental health intervention, it is important to understand the barriers to seeking mental health help in a military context. Although there is stigma related to mental health in the studies and compilations carried out in the civil and military context in the national and international literature, there is no literature on mental health stigmatization in the military context, especially in the national literature. This study is a compilation research created by reviewing the national and international literature. In this article, it is aimed to present some innovative social work interventions in order to address the sources of stigma that hinders access to mental health care and the factors that reinforce them, in a military context, to potentially reduce stigma and to maximize the benefit of mental health care.
... We hypothesized that the previous year VA facility access and quality measures would be predictive of the following year enrollment. Given that post-9/11 Veterans have high rates of mental health (MH) conditions [15][16][17][18][19][20] and variable access to high-quality care, [21] it is especially important to understand how access to and quality of primary care (PC) and MH care affect VA enrollment. Results from this study are intended to inform VA leaders wanting to more proactively help recently separated Veterans enroll in VA to receive needed care, particularly for foundational services including PC and MH care. ...
Following recent policy changes, younger Veterans have particularly increased options for where to receive their health care. Although existing research provides some understanding of non-modifiable individual (e.g., age) and external community (e.g., non-VA provider supply) factors that influence VA enrollment, this study focused on modifiable facility access and quality factors that could influence Veterans' decisions to enroll in VA. In this cohort study, we examined enrollment in and use of VA services in the year following military separation as the binary outcome using mixed-effects logistic regressions, stratified by Active and Reserve Components. This study included 260,777 Active and 101,572 Reserve Component post-9/11 Veterans separated from the military in fiscal years 2016 to 2017. Independent variables included 4 access measures for timeliness of VA care and 3 VA quality measures, which are included in VA Medical Centers' performance plans. Eligible Veterans were more likely to enroll in VA when the closest VA had higher quality scores. After accounting for timeliness of VA care and non-modifiable characteristics, rating of primary care (PC) providers was associated with higher VA enrollment for Active Component (odds ratio [OR] = 1.014, 95% confidence interval [CI]: 1.007-1.020). Higher mental health (MH) continuity (OR = 1.039, 95% CI: 1.000-1.078) and rating of PC providers (OR = 1.009, 95% CI: 1.000-1.017) were associated with higher VA enrollment for Reserve Component. Improving facility-specific quality of care may be a way to increase VA enrollment. In a changing policy environment, study results will help VA leadership target changes they can make to manage enrollment of Veterans in VA and deliver needed foundational services.
... While a prior analysis examined barriers to BHC as a predictor of intention to leave military service 16 , our study links receipt of BHC care to the outcome of early service termination in a longitudinal manner. Other previous studies have looked at attrition from service following specific events, such as deployments 17,18 or particular BHC diagnoses 19 . These analyses, while not directly comparable, found much higher rates of attrition than we did in our examination. ...
Introduction: Behavioral health conditions (BHC) can reduce service member retention. This analysis sought to identify demographic and diagnostic factors among BHC care-seeking Active-Duty United States Coast Guard (ADCG) that were predictive of discharge before completion of obligated service.
Methods: A four-year retrospective cohort study of ADCG personnel was conducted. Five machine-learning (ML) algorithms and logistic regression were applied to data on ADCG who sought outpatient care for BHC in 2016. Covariates examined as possible mediators of early service termination included diagnosis group, gender, rank grouping, and race.
Results: Only 26.4 of every 1,000 members who sought BHC care did not complete their service obligation. Diagnosis group did not predict early service termination, whereas senior enlisted rank was associated with early termination. The ML algorithms best predictive of early discharge from service were bagging classifier and decision tree classifier. Logistic regression performed as well as the two leading algorithms.
Conclusions: Specific ML models can be used to identify personnel groups at risk for early separation, such as senior enlisted personnel. Traditional epidemiologic methods demonstrate value in predicting service member separation.
... Так, результати досліджень військових медиків з США, Великої Британії, Канади та Австралії свідчать, що поширеність невротичних розладів серед ВС, які приймали участь у бойових діях, становила у середньому 21,2%, при цьому найпоширенішими були такі розлади, як тривога (11,7%), погіршення настрою (8,0%), збільшення потреби щодо вживання психоактивних лікарських засобів з метою зменшення дії різноманітних психотравмуючих факторів (7,1%) [3,4]. В той же час, дослідження, проведені серед ВС США, які приймали участь у бойових діях в Афганістані та Ірані, показали, що поширеність ПТСР може становити 20 і навіть 30% [5,6]. ...
Вступ. В умовах відбиття збройної агресії РФ, що супроводжується значною інтенсивністю і напруженістю бойових дій, можна прогнозувати суттєве збільшення кількості військовослужбовців, які будуть мати невротичні розлади різного ступеня тяжкості, отже викликати потребу їх направлення для лікування у військово-медичні заклади. Дослідженням встановлена наявність незначної кількості наукової інформації щодо особливостей організації лікувально-діагностичного процесу при виникненні санітарних втрат неврологічного профілю. Семантичний аналіз доступних наукових джерел щодо організації проведення лікувально-діагностичного процесу і реабілітації військовослужбовців, у яких діагностовано порушення з боку центральної нервової системи, охоплює період повсякденної готовності Збройних Сил України і не враховує особливості воєнного стану. Виходячи з цього, з урахуванням загроз та викликів сьогодення, встановлено, що вирішення цієї проблеми неможливо без розробки і впровадження сучасних медичних технологій щодо організації діагностики, лікування і реабілітації військовослужбовців, що отримали невротичні розлади в умовах бойової обстановки з урахуванням сучасного досвіду військово-медичних служб передових країн світу. Мета дослідження полягає у визначені сучасних організаційних підходів щодо організації лікувально-діагностичного і реабілітаційного процесу військовослужбовців, які мають невротичні розлади, отримані в бойових умовах х. Матеріали та методи дослідження. Дослідження проводилось із використанням класичних соціально-гігієнічних методів: монографічного, семантичного, аналітичного, документального обліку та системного аналізу. Матеріалами дослідження слугували нормативно-правові документи з питань діагностики, лікування і реабілітації військовослужбовців з невротичними розладами. Результати. У статті наведені результати семантичного аналізу нормативно-правових документів щодо організації діагностики, лікування і реабілітації військовослужбовців з нервовими розладами та розроблений алгоритм організації лікувально-діагностичного процесу при цій патології з урахуванням досвіду військо-медичних служб передових країн світу. Висновки. Визначено, що в умовах відбиття Збройними силами України збройної агресії РФ і пов’язаної з цим потреби проведення мобілізаційних заходів без урахування психотипу і стресостійкості осіб, що вступають до лав Збройних Сил і інших військових формувань України, серед військовослужбовців можливе збільшення поширеності невротичних розладів. На основі аналізу наукової інформації з урахування власного досвіду розроблений алгоритм діагностики, лікування і реабілітації військовослужбовців з невротичними розладами, реалізація якого дозволить зменшити наслідки негативного впливу бойової обстановки на військовослужбовців і тим самим підвищити рівень їх боєздатності та працездатності, а також зменшити відсоток інвалідизації військовослужбовців з невротичними розладами.
... The Chilcot public inquiry on UK Iraq War veterans indicated PTSD among reservists at 6% among those who served in Iraq and 3% among those who did not (Greenberg, Bull and Wesseley, 2016). US rates suggest the overall rate may be as high as 30%, with 19.1% among those who served in Iraq and 11.3% among those who served in Afghanistan Hoge, Auchterlonie and Milliken, 2006;Tanielian, 2009;Tanielian, et al., 2008;Hoge, et al., 2004). Mental health problems tend to be higher among US military personnel and veterans compared to UK, Canada, Germany and Denmark (MacManus, et al., 2014). ...
Background: UK and US military veterans can face challenges navigating civilian society, along with specific mental health conditions such as Posttraumatic Stress Disorder (PTSD). In this study brief group dramatherapy with veterans with clinical and subclinical PTSD symptom levels were brought together to operationalise the teamwork of the Forces in creative exercises. The goal was to facilitate story sharing as a therapeutic practice and as chosen by participants. This intervention was then assessed for its impact on participant wellbeing, sense of belonging and transition.
Methods: Using a mixed methods approach, this study triangulated qualitative narrative inquiry with quantitative outcome measures (for PTSD [PCL5], Changes in Outlook [a posttraumatic growth measure], Sense of Belonging and Community Reintegration of Service Members) with data collected over 14 months including before and after the group dramatherapy series (8 weekly 90-minute sessions), and at 3- and 12-months after. The findings were based on 4 separate groups (2 UK; 2 US). This study included 19 participants and was grounded in their words to guard against appropriation of the embodied experience of military service that the researcher did not have. Co-creation (co-production) was a part of the dramatherapy approach.
Findings: Main themes of homecoming and sense of belonging arose in all group contexts suggesting common transition challenges across decades. Reframing veteran-life challenges occurred in the group contexts to foster the creation of a narrative of capacity but also inhibited the sharing of some types of stories that were shared only in post-group interviews. Story sharing over the life course revealed that early-life and veteran-life traumas impacted wellbeing. An intervention focused solely on military service stories would miss this breadth of wellbeing stories. Participation reduced PTSD symptoms for more than half of participants over the year of the study, with sense of belonging enhanced for some participants during the group but not sustained for most once the group concluded suggesting a lower sense of belonging particularly for veterans living in civilian communities. Benefits from participation were greater for veterans who lived in civilian communities as compared to veterans in veteran-only communities who exhibited lower PTSD symptoms and a higher sense of belonging before, during and after the study.
Conclusion: Findings suggest recurring challenges for veterans across decades with some UK and US similarities and differences. Findings also suggest reconsidering group therapy to address stress and transition challenges faced by veterans over the life course. Also, the value of an ongoing group, with veterans deciding when and how long to attend, was suggested by participants.
Key words: brief group dramatherapy, veterans, wellbeing, sense of belonging, transition, Posttraumatic Stress Disorder, experts by experience
... For instance, traumatic brain injury (TBI) rates are higher among those in the military than among civilians (Chapman and Diaz-Arrastia, 2014), and TBI has been associated with poor mental health conditions (Chin and Zeber, 2020 Jun 8). Deployments have been linked to service member substance abuse and mental health problems (Hoge et al., 2006 Mar 1;Larson et al., 2012 Jan 1), and are associated with elevated risks of behavioral and mental health problems, including substance abuse, among children (Acion et al., 2013 Aug;Gilreath et al., 2013 Feb;Gorman et al., 2010;Reed et al., 2011 Sep;Sullivan et al., 2015 Oct;Wadsworth et al., 2017) and spouses of service members (Mansfield et al., 2010 Jan 14). Frequent relocation, an aspect of military life that occurs at a higher rate than for civilians (Huebner, 2019), has also been correlated with behavioral health problems among children and can lead to difficulties with continuity of treatment for military populations more broadly (Tong et al., 2018). ...
Active duty service members and their families have unique behavioral health care service needs. The purpose of this study is to determine geographical access to specialized behavioral health programs tailored to active duty U.S. service members and military families from military installations. This study generated network distance measures between active duty military installations and licensed substance use disorder (SUD) treatment facilities and mental health treatment facilities for 2015-2018 using data from national surveys administered by the Substance Abuse and Mental Health Services Administration and coordinates for active duty military installations from the Defense Installation Spatial Data Infrastructure Program. Using regression analysis, we calculated the share of installations that are at-risk of being remote from behavioral healthcare services. Separately, we calculated the share of treatment facilities accepting military insurance that offer specialized programs for active duty service members and/or military families within a 30-minute drive to an installation. Three out of 10 installations were at-risk of being remote from a behavioral health treatment facility. About 25 percent of behavioral health treatment facilities accepting military insurance within a 30-minute drive to an installation offered a specialized treatment program for active duty military or military families. Lack of a specialized treatment programs could suggest facilities may not be equipped to manage stressors unique to being in the military, and as a consequence, could adversely impact the health and well-being of this population. Further research is necessary to understand what specialized treatment programs for military populations entail.
... Most research focuses on combatants showing that in low resource countries, there is poor availability of therapeutic health care [18,21,22]. Even in high resource countries like the United States, veterans from wars in Iraq and Afghanistan seeking health care are so abundant that they have overwhelmed the Veterans Health System with their serious health care needs, resulting in inadequate overall care [23,24]. Most healthfocused studies on war violence against civilians focus on framing, diagnosing, and describing the mental and psychosocial health of their study populations [10,12,[25][26][27]. ...
Experience of serious violations of International Humanitarian Law (IHL) results in complex physical disability and psychosocial trauma amplifying poverty and multi-generational trauma and impeding long-term recovery. We use data from a representative sample of victims in the case Prosecutor V. Dominic Ongwen brought before the International Criminal Court. Thirteen years after the 2004 massacre, the victims were significantly worse off than the general war-affected population that did not experience serious violations of IHL. The differences in health and wellbeing persisted for individuals and their households, including children born after the massacre. The victims have significantly lower availability of appropriate health services and medications, including significantly greater distance to travel to these services. These findings call attention to the needs of people having experienced IHL violations, for provision of physical and emotional trauma care to allow for recovery, and better understanding of the short- and long-term impacts of IHL violations.
... For example, trauma survivors face difficulties accessing essential features for survival, such as loss of assets, safe accommodations, food, and electricity (Nobakht et al., 2019). In addition, they required essential health care for effective treatment and financial support to maintain their livelihood (Hoge et al., 2006(Hoge et al., , 2007. Failure to meet these basic survival needs adversely affects their treatment process and outcomes, resulting in worsening PTSD symptoms (Grieger et al., 2003;Sareen et al., 2010). ...
Scholarly interest in the relationship between decent work and mental health based on the Psychology of Working Theory has recently increased. This study evaluated the indirect effects of survival, social contribution, and self-determination needs satisfaction on the relationship between decent work and trauma-related mental health among military personnel. We conducted a three-wave survey over 1 year. Results showed that decent work predicted satisfaction of the three basic needs. Additionally, survival needs directly predicted posttraumatic stress disorder symptoms, while social contribution and self-determination needs directly predicted posttraumatic growth. Finally, decent work had a significant indirect effect on posttraumatic stress disorder symptoms via survival needs, whereas decent work had significant indirect effects on posttraumatic growth via social contribution and self-determination needs. Our findings suggest that the more military personnel perceive their work as decent and feel that their three basic needs are fulfilled, the more posttraumatic stress disorder symptoms diminish, and posttraumatic growth increases. We discuss the implications and need for follow-up studies.
... Post-Deployment Health Assessments (PDHA) were used to verify that individuals in the non-concussion group did not screen-positive for concussion within 1-year post-injury. The PDHA is a questionnaire given to service members returning from deployment that queries the service member on a variety of health issues and allows providers to refer them for care [31]. In 2008, the PDHA was revised to include a concussion screening instrument. ...
Purpose
To examine the relationship between deployment-related concussion and long-term health-related quality of life (HRQoL) among injured US military personnel.
Methods
The study sample included 810 service members with deployment-related injuries between 2008 and 2012 who responded to a web-based longitudinal health survey. Participants were categorized into three injury groups: concussion with loss of consciousness (LOC; n = 247), concussion without LOC (n = 317), or no concussion (n = 246). HRQoL was measured using the 36-Item Short Form Health Survey physical and mental component summary (PCS and MCS) scores. Current post-traumatic stress disorder (PTSD) and depression symptoms were examined. Multivariable linear regression models assessed the effects of concussion on PCS and MCS scores, while controlling for covariates.
Results
A lower PCS score was observed in participants with concussion with LOC (B = − 2.65, p = 0.003) compared with those with no history of concussion. Symptoms of PTSD (PCS: B = − 4.84, p < 0.001; MCS: B = − 10.53, p < 0.001) and depression (PCS: B = − 2.85, p < 0.001; MCS: B = − 10.24, p < 0.001) were the strongest statistically significant predictors of lower HRQoL.
Conclusion
Concussion with LOC was significantly associated with lower HRQoL in the physical domain. These findings affirm that concussion management should integrate physical and psychological care to improve long-term HRQoL and warrant a more detailed examination of causal and mediating mechanisms. Future research should continue to incorporate patient-reported outcomes and long-term follow-up of military service members to further define the lifelong impact of deployment-related concussion.
Introduction
U.S. military women were at risk of combat exposure and injury from asymmetric warfare during the conflicts in Iraq and Afghanistan. Previous research has yielded mixed results when examining sex differences in PTSD following operational deployment. To date, no study has explored sex differences in PTSD after combat injury.
Materials and Methods
This retrospective study included U.S. military service men and women who experienced a combat injury in Iraq or Afghanistan (March 2003 to March 2013) and completed a Post-Deployment Health Assessment (PDHA) within 1 year of injury. The PDHA is administered at the end of deployment and includes the 4-item Primary Care PTSD Screen. The prevalence of screening positive for PTSD was evaluated by sex using a chi-square test. Multivariable logistic regression was used to assess the association between sex and PTSD while adjusting for covariates.
Results
The study sample included 16,215 injured military personnel (666 women and 15,549 men). The average time between injury and PDHA was 132 days (SD = 91.0). Overall, women had a higher prevalence of screening positive for PTSD than men (48.3% vs. 40.9%, P < .001). In multivariable regression, women had higher odds than men of screening positive for PTSD (odds ratio, 1.34; 95% confidence interval, 1.14-1.57). Psychiatric history was the strongest predictor of screening positive for PTSD regardless of sex (odds ratio, 1.59; 95% confidence interval, 1.45-1.74).
Conclusions
In this novel study of military service members, women were more likely to screen positive for PTSD than men after combat injury. Strategies to mitigate PTSD, enhance resiliency, and incorporate psychological care into injury rehabilitation programs for women may be needed for future U.S. military conflicts where they will play a larger role in combat operations.
Military careers demand unwavering dedication and sacrifice, with retirement marking a significant transition to civilian life. This dissertation explores coping strategies, resilience, and retirement preparedness among Indian military personnel nearing retirement. Drawing on the Transactional Model of Stress and Coping, it examines how stressors, coping, and adaptation intersect during retirement. A literature review underscores the challenges of military retirement and the importance of coping and resilience. Using a quantitative approach, the study assesses coping and resilience in military personnel aged 40 to 60 approaching retirement. Findings reveal insights into coping strategies, resilience levels, and retirement readiness, informing policies and interventions to support military retirees. This research advances understanding of the transition from military to civilian life, addressing the unique needs of retiring military personnel.
Deep neural networks (DNN) are increasingly being used in neuroimaging research for the diagnosis of brain disorders and understanding of human brain. Despite their impressive performance, their usage in medical applications will be limited unless there is more transparency on how these algorithms arrive at their decisions. We address this issue in the current report. A DNN classifier was trained to discriminate between healthy subjects and those with posttraumatic stress disorder (PTSD) using brain connectivity obtained from functional magnetic resonance imaging data. The classifier provided 90% accuracy. Brain connectivity features important for classification were generated for a pool of test subjects and permutation testing was used to identify significantly discriminative connections. Such heatmaps of significant paths were generated from 10 different interpretability algorithms based on variants of layer-wise relevance and gradient attribution methods. Since different interpretability algorithms make different assumptions about the data and model, their explanations had both commonalities and differences. Therefore, we developed a consensus across interpretability methods, which aligned well with the existing knowledge about brain alterations underlying PTSD. The confident identification of more than 20 regions, acknowledged for their relevance to PTSD in prior studies,was achieved with a voting score exceeding 8 and a family-wise correction threshold below 0.05. Our work illustrates how robustness and physiological plausibility of explanations can be achieved in interpreting classifications obtained from DNNs in diagnostic neuroimaging applications by evaluating convergence across methods. This will be crucial for trust in AI-based medical diagnostics in the future.
Purpose
The mental healthcare is experiencing an ever-growing surge in understanding the consumer (e.g., patient) engagement paradox, aiming to vouch for the quality of care. Despite this surge, scant attention has been given in academia to conceptualize and empirically investigate this particular aspect. Thus, drawing on the Stimulus-Organism-Response (S-O-R) paradigm, the study explores how patients engage with healthcare service providers and how they perceive the quality of the healthcare services.
Design/methodology/approach
Data were collected from 279 respondents, and the derived conceptual model was tested by using Smart PLS 3.2.7 and PROCESS. To complement the findings of partial least squares (PLS)-based structural equation modeling (SEM), the present study also applied fuzzy set qualitative comparative analysis (fsQCA) to identify the necessary and sufficient conditions to explore substitute conjunctive paths that emerge.
Findings
Findings show that patients’ perceived intimacy (PI), cohesion and privacy enhance the quality of mental healthcare service providers. The results also suggest that patients’ PI, cohesion and privacy have indirect effects on the perceived quality of care (PQC) by the service providers through consumer engagement. The fsQCA results derive that the relationship among conditions leading to patients’ perception of the quality of care in regard to mental healthcare service providers is complex and is best reflected as multiple and conjectural causation configurations.
Research limitations/implications
The findings from this research contribute to the advancement of studies on patients’ experiences by empirically examining the unique dynamics of interaction between consumers (patients) and mental healthcare service providers, thereby enriching both the literature on social interactions and the understanding of the consumer–provider relationship.
Practical implications
The results of this study provide practical implications for mental healthcare service providers on how to combine the study variables to enhance the quality of care and satisfy more patients.
Originality/value
A significant research gap has ascertained the inter-relationship between PI, cohesion, privacy, engagement and PQC from the perspective of mental healthcare service providers. This research is one of the primary studies from a managerial and methodological standpoint. The study contributes by combining symmetric and asymmetric statistical tools in service marketing and healthcare research. Furthermore, the application of fsQCA helps to understand the interactions that might not be immediately obvious through traditional symmetric methods.
The current study investigated the associations among probable posttraumatic stress disorder (PTSD), recent Veterans Health Administration (VHA) health care use, and care-seeking for PTSD in U.S. military veterans. Analyses were conducted among 19,691 active duty military personnel enrolled in the Millennium Cohort Study who separated from the military between 2000 and 2012 and were weighted to the 1,130,103 active duty personnel who separated across this time period. VHA utilization was identified from electronic medical records in the year before survey completion, and PTSD care-seeking and PTSD symptoms were assessed through self-report on the 2014-2016 survey; thus, the observation period regarding care-seeking and VHA use encompassed 2013-2016. Veterans with probable PTSD were more likely to use VHA services than those without probable PTSD, aOR = 1.12, 95% CI [1.01, 1.24], although the strongest association with recent VHA use was a depression diagnosis, aOR = 2.47, 95% CI [2.26, 2.70]. Among veterans with probable PTSD, the strongest predictor of care-seeking was recent VHA use compared to community care, aOR = 4.01, 95% CI [3.40, 4.74); reporting a diagnosis of depression was the second strongest predictor of PTSD care-seeking, OR = 2.99, 95% CI [2.53, 3.54]. However, the absolute number of veterans with probable PTSD who were not seeking care was approximately equivalent between veterans using VHA services and those not using VHA services. Additionally, certain groups were identified as being at risk of not seeking care, namely Air Force veterans and veterans with high physical and mental functioning despite substantial PTSD symptoms.
Background
Soldiers in military service are at risk of exposure to traumatic and stressful experiences, which can lead to symptoms of posttraumatic stress disorder (PTSD) and symptoms of depression. In the context of veterans’ PTSD and depression, social support has been shown to be a very significant resource. However, while general depression has been examined among veterans and although combat soldiers are often men, male depression has been rarely examined. Therefore, the present study aimed to examine the relationships between social support, PTSD symptoms, and male depression among veterans.
Methods
Five hundred and ninety-five male combat veterans completed a demographic questionnaire and measures of social support, PTSD, and male depression, including the specific symptoms of anger, substance use, social withdrawal, and restricted emotions.
Results
Structural-equation-model analyses showed that social support was negatively associated with both PTSD symptoms and depression symptoms. Specifically, social support showed lower trends of associations with substance use and anger; whereas there were higher associations with social withdrawal and restricted emotions. PTSD showed the strongest association with anger. Thus, we can see that social support is a key resource for coping with PTSD and different symptoms of male depression.
Conclusion
Greater attention to social support, PTSD, and aspects of male depression could assist the development of intervention and therapeutic programs and also help to prevent the misdiagnosis of depression among military veterans.
Objectives
Emergency departments (EDs) are a vital part of healthcare systems, at times acting as a gateway to community-based mental health (MH) services. This may be particularly true for veterans of the Royal Canadian Mounted Police who were released prior to 2013 and the Canadian Armed Forces, as these individuals transition from federal to provincial healthcare coverage on release and may use EDs because of delays in obtaining a primary care provider. We aimed to estimate the hazard ratio (HR) of MH-related ED visits between veterans and non-veterans residing in Ontario, Canada: (1) overall; and by (2) sex; and (3) length of service.
Methods
This retrospective cohort study used administrative healthcare data from 18,837 veterans and 75,348 age-, sex-, geography-, and income-matched non-veterans residing in Ontario, Canada between April 1, 2002, and March 31, 2020. Anderson–Gill regression models were used to estimate the HR of recurrent MH-related ED visits during the period of follow-up. Sex and length of service were used as stratification variables in the models.
Results
Veterans had a higher adjusted HR (aHR) of MH-related ED visits than non-veterans (aHR, 1.97, 95% CI, 1.70 to 2.29). A stronger effect was observed among females (aHR, 3.29; 95% CI, 1.96 to 5.53) than males (aHR, 1.78; 95% CI, 1.57 to 2.01). Veterans who served for 5–9 years had a higher rate of use than non-veterans (aHR, 3.76; 95% CI, 2.34 to 6.02) while veterans who served for 30+ years had a lower rate compared to non-veterans (aHR, 0.60; 95% CI, 0.42 à 0.84).
Conclusions
Rates of MH-related ED visits are higher among veterans overall compared to members of the Ontario general population, but usage is influenced by sex and length of service. These findings indicate that certain subpopulations of veterans, including females and those with fewer years of service, may have greater acute mental healthcare needs and/or reduced access to primary mental healthcare.
Aim
This study aims to examine the effects of social support and life satisfaction on post-traumatic growth in wounded veterans in Turkey.
Methods
1175 wounded veterans participated in the cross-sectional study. The sociodemographic questionnaire, the Post-Traumatic Growth Inventory, the Multidimensional Scale of Perceived Social Support, and the Satisfaction with Life Scale were used to collect data. Data were analyzed via SPSS.
Results
The results of the study show that the mean age is 43.04 ± 7.36. The participants are low in education and socioeconomic level. The mean of the Post-Traumatic Growth Inventory score is 43.44 ± 21.18, the mean of the Multidimensional Scale of Perceived Social Support score is 50.01 ± 15.23, and the mean of the Satisfaction With Life Scale score is 9.86 ± 4.04. The results of the study show that there is a positive relationship between social support and life satisfaction and post-traumatic growth.
Conclusion
It can be suggested to develop psychosocial intervention strategies and service delivery systems to promote the life satisfaction, social support mechanisms of wounded veterans.
Purpose of Review
This review summarizes empirical studies investigating the associations between moral injury and suicide-related outcomes.
Recent Findings
A total of 47 studies met inclusion criteria and were reviewed. Samples included military, veteran, and civilian populations. Overall, more exposure to potentially morally injurious events (PMIE) and greater morally injurious symptom severity were both related to increased risk for suicide-related outcomes, including suicidal ideation and suicide attempt[s], and composite suicide-related variables. The strength of the association depended on the population, assessments used to measure moral injury and suicide-related outcomes, and covariates included in the model. Mediators and moderators of the association were identified including depression, posttraumatic stress, hopelessness, guilt, shame, social support, and resilience.
Summary
Moral injury confers a unique risk for suicide-related outcomes even after accounting for formalized psychiatric diagnosis. Suicide prevention programs for military service members, veterans, and civilians working in high-stress environments may benefit from targeted interventions to address moral injury. While suicide-related outcomes have not been included in efficacy trials of moral injury interventions, mediators and moderators of the association between moral injury and suicide-related outcomes are potential targets for therapeutic change, including disclosure, self-forgiveness, and meaning-making.
Problematic alcohol use is a serious threat to the behavioral health of active-duty Service Members (ADSM), resulting in numerous calls from governmental agencies to better understand mechanistic factors contributing to alcohol misuse within the military. Alcohol use motives are reliable predictors of alcohol-related behaviors, and are considered malleable targets for prevention and interventions efforts. However, empirical research indicates that drinking motives vary across contextually-distinct populations. Although some research has been conducted among veteran and reservist populations, limited work has been specifically focused on ADSM and no research has evaluated motives and alcohol metrics among ADSM based on military rank. Participants for the current study included 682 ADSM recruited from a large military installation in the U.S. Structural equation modeling evaluated associations between four drinking motives (i.e., enhancement, social, conformity, coping) and three alcohol misuse metrics (i.e., alcohol frequency, binge frequency, alcohol problems). Three models were evaluated: one full (combined) model and two separate models based on military rank - junior enlisted (i.e., E1-E4) and non-commissioned officers (NCOs) (i.e., E5-E9). Results for junior enlisted ADSM indicated that coping and enhancement motives were most strongly associated with all alcohol misuse metrics. However, among NCOs, results indicated that alcohol problems were only associated with coping motives. Notably, results also indicated that alcohol use motives accounted for substantively more variance across all alcohol-related metrics among NCOs. Findings generally support extant military-related literature indicating use of alcohol for coping (e.g., with anxiety) as the motivation most consistently associated with increased alcohol misuse. However, novel findings highlight enhancement motives - using alcohol to attain some positive internal reward - as another, often stronger, motivation impacting alcohol use outcomes. Further, findings highlight notable distinctions between alcohol use motives (i.e., coping vs. enhancement) and the impact of alcohol use motives (i.e., effect size) on alcohol metrics between junior enlisted and NCOs.
Anger and aggression are common problems for military populations, particularly veterans with posttraumatic stress disorder (PTSD). Excessive anger is a key predictor of PTSD symptom severity and treatment outcomes. Dysregulated anger impacts other clinical factors, including interpersonal functioning, physical health problems, alcohol misuse, increased healthcare costs, and legal issues. Explanatory models to account for the strong relationship between anger and PTSD have been proposed in the research. PTSD‐related anger is posited to be distinct from other forms of problematic anger in terms of its causal and maintaining factors. Cognitive–behavioral treatment for anger management and trauma‐focused treatments, which include intervention strategies aligned with hypothesized anger regulation deficits, have been found to be effective in reducing anger symptoms. Clinical issues that it is important to address when treating veterans with anger problems include the assessment of risk for violence, common co‐occurring difficulties, treatment engagement, and ethnocultural and military cultural considerations.
This chapter reviews the array of interventions available for individuals who perpetrate intimate partner violence (IPV) that can be found in the clinical and research literature, from batterer intervention programs to individual‐ and family‐focused interventions that target specific subgroups of offenders. An overview of each intervention is provided along with the available evidence base. One‐size‐fits‐all approaches to IPV intervention have not been effective. Instead, assessment and selection of appropriate interventions or clinical treatments from a range of available options (which may include criminal justice intervention, psychoeducational groups, and individual clinical or family treatment) may be the most appropriate and successful way to reduce violence in the home. Specific treatments have been developed for individuals with co‐occurring violence and substance abuse, fatherhood and parenting concerns, and veteran populations with posttraumatic stress disorder that show promise and could be made available as intervention options for IPV offenders.
Metacognition, thinking about thinking, is disrupted in several clinical populations. One aspect of metacognition, global metacognitive bias (difference between objective and self-reported abilities), has shown to be particularly relevant to clinical functioning. However, previous studies of global metacognitive biases in clinical populations have not measured objective and self-reported abilities relative to normative samples, making quantification of the severity of biases difficult. Additionally, few studies have examined whether cognitive interventions can improve metacognitive biases and none have examined how this relates to depressive/PTSD symptoms. In 84 participants with mild traumatic brain injury (77% Veterans), a population whose self-reported cognitive deficits are often worse than their objective deficits, we assessed PTSD/depressive symptoms and self-reported and objective measures of global cognition. We used age-adjusted norm-based z-scores for cognition measures and calculated bias by subtracting objective from self-report scores. Participants then received 13 weeks of either targeted cognitive training or entertainment games training, with both conditions providing performance feedback. Participants were measured at baseline, immediately post-training, and 3 months post-training. We found large negative metacognitive biases in those with depression (z-score difference=-1.77), PTSD (-1.47), and depression+PTSD (-2.29). Notably, metacognitive bias improved after both targeted and entertainment training and was strongly associated with depressive and PTSD symptom improvements (r=.-41/-.42, respectively). These effects endured after 3-months of no contact. These findings show that depression/PTSD are associated with substantial negative global metacognition biases and provide initial evidence that cognitive training can improve biases and depressive/PTSD symptoms.
The course of posttraumatic stress disorder (PTSD) symptoms varies among veterans of war zones, but sources of variation in long-term symptom course remain poorly understood. Modeling of symptom growth trajectories facilitates the understanding of predictors of individual outcomes over time. Although growth mixture modeling (GMM) has been applied to military populations, few studies have incorporated both predeployment and follow-up measurements over an extended time. In this prospective study, 1,087 U.S. Army soldiers with varying military occupational specialties and geographic locations were assessed before and after deployment to the Iraq war zone, with long-term follow-up assessment occurring at least 5 years after return from deployment. The primary outcome variable was the PTSD Checklist-Civilian Version summary score. GMM yielded four latent profiles, characterized as primarily asymptomatic (n = 194, 17.8%); postdeployment worsening symptoms (n = 84, 7.7%); mild symptoms (n = 320, 29.4%); and preexisting, with a chronic postdeployment elevation of symptoms (n = 489, 45.0%). Regression models comparing the primarily asymptomatic class to the symptomatic classes revealed that chronic symptom classes were associated with higher degrees of stress exposure, less predeployment social support, military reservist or veteran status at the most recent assessment, and poorer predeployment visual memory, ORs = 0.98-2.90. PTSD symptom course varies considerably over time after military deployment and is associated with potentially modifiable biopsychosocial factors that occur early in its course in addition to exposures and military status.
Posttraumatic stress disorder (PTSD) is prevalent in military veterans. Although exposure to trauma is subsumed under the diagnostic criteria for PTSD, there is great variability in index traumatic events, and the clinical presentation of PTSD may vary in individuals depending on the type of event experienced. We examined the relationship between different index traumas and PTSD symptoms in 3507 trauma-exposed U.S. military veterans who participated in the National Health and Resilience in Veterans Study. Results showed that interpersonal violence and combat/captivity was associated with greater overall severity of PTSD symptoms relative to illness/injury and disaster/accident. Interpersonal violence and combat/captivity were also associated with greater severity of intrusive, avoidance, negative affect, anhedonia, externalizing behaviors, and anxious and dysphoric arousal symptoms, relative to the other two categories. Implications of these findings for tailoring treatment approaches for PTSD in veterans are discussed.
Background
Military services provide a unique opportunity for studying resilience, a dynamic process of successful adaptation (ie, doing well in terms of functioning and symptoms) in response to significant adversity. Despite the tremendous interest in positive adaptation among military service members, little is known about the processes underlying their resilience. Understanding the neurobiological, cognitive, and social mechanisms underlying adaptive functioning following military stressor exposure is essential for enhancing the resilience of military service members.
Objective
The primary objective of the Advancing Research on Mechanisms of Resilience (ARMOR) longitudinal study is to characterize the trajectories of positive adaptation among young military recruits in response to basic combat training (BCT), a well-defined, uniform, and 10-week period of intense stress (aim 1), and identify promotive and protective processes contributing to individual variations in resilience (aim 2). The secondary objective is to investigate the pathways by which neurobehavioral markers of self-regulation assessed using electroencephalography and magnetic resonance imaging contribute to adaptive trajectories (aim 3).
Methods
ARMOR is an ongoing, prospective longitudinal cohort study of young military recruits who recently joined the National Guard but have not yet shipped out for BCT. Participants (N=1201) are assessed at 5 time points over the initial >2 years of military service beginning before BCT (baseline) and followed up at 2 weeks and 6, 12, and 18 months after BCT. Participants complete web-based questionnaires assessing vulnerability and protective factors, mental health, and socioemotional functioning at each time point and a battery of neurocognitive tests at time 0. A subset of participants also complete structured diagnostic interviews and additional self-report measures and perform neurobehavioral tasks before and after BCT during electroencephalography sessions and before BCT only during magnetic resonance imaging sessions.
Results
This UG3/UH3 project was initially funded in August 2017, with the UG3 pilot work completed at the end of 2018. The UH3 phase of the project was funded in March 2019. Study enrollment for the UH3 phase began on April 14, 2019, and ended on October 16, 2021. A total of 1201 participants are enrolled in the study. Follow-up data collection for the UH3 phase is ongoing and projected to continue through February 2024. We will disseminate the findings through conferences, webinars, open access publications, and communications with participants and stakeholders.
Conclusions
The ARMOR study provides a rich data set to identify the predictors and mechanisms of resilient and nonresilient outcomes in the context of military stressors, which are intended to empirically inform the development of prevention and intervention strategies to enhance the resilience of military trainees and potentially other young people facing significant life challenges.
International Registered Report Identifier (IRRID)
DERR1-10.2196/51235
BACKGROUND
Military service provides a unique opportunity for studying resilience, a dynamic process of successful adaptation (i.e., doing well in terms of functioning and symptoms) in response to significant adversity. Despite tremendous interest in positive adaptation among military service members, little is known about the processes underlying their resilience. Understanding neurobiological, cognitive, and social mechanisms underlying adaptive functioning following military stressor exposure is essential to enhance the resilience of military service members.
OBJECTIVE
The primary objective of the Advancing Research on Mechanisms of Resilience (ARMOR) longitudinal study is to characterize trajectories of positive adaptation among young military recruits in response to Basic Combat Training (BCT), a well-defined, uniform, 10-week period of intense stress (Aim 1) and identify promotive and protective processes contributing to individual variations in resilience (Aim 2). The secondary objective is to investigate pathways by which neurobehavioral markers of self-regulation assessed by electroencephalography (EEG) and magnetic resonance imaging (MRI) contribute to adaptive trajectories (Aim 3).
METHODS
ARMOR is an ongoing, prospective longitudinal cohort study of young military recruits who recently joined the National Guard but have not yet shipped for BCT. Participants (N=1,201) are assessed at five timepoints over the initial 2+ years of military service beginning before BCT (baseline) and followed up at 2 weeks, 6, 12, and 18 months post-BCT. At each time point, participants complete online questionnaires assessing vulnerability and protective factors, mental health and social-emotional functioning, and, at Time 0 only, a battery of neurocognitive tests. A subset of participants also complete structured diagnostic interviews, additional self-report measures, and perform neurobehavioral tasks before and after BCT during EEG sessions, and, at pre-BCT only, during MRI sessions.
RESULTS
This UG3/UH3 project was initially funded in August 2017 with UG3 pilot work completed at the end of 2018. The UH3 phase of the project was funded in March 2019. Study enrollment for the UH3 phase began April 14, 2019 and ended in October 16, 2021. Follow-up data-collection for the UH3 phase is ongoing and projected to continue through March 2024. A total of 1,201 participants are enrolled in the study (68.9% male; mean age = 18.9, SD = 3.0). We will disseminate findings through conferences, webinars, open access publications, and communications with participants and stakeholders.
CONCLUSIONS
Results are expected to elucidate how young military recruits adapt to military stressors during the initial years of military service. Understanding positive adaptation of military recruits in the face of BCT has implications for developing prevention and intervention strategies to enhance resilience of military trainees and potentially other young people facing significant life challenges.
82% випадків біль стає хронічним. Одним із чинників, які можуть мати вплив на результати лікування болю, є обсяг пошкоджень і оперативних втручань. Мета роботи. Дослідити вплив обсягу пошкоджень і оперативних втручань на результати лікування болю у пацієнтів з вогнепальними та мінно-вибуховими пораненнями. Матеріали та методи. Результати лікування болю оцінювали за візуальною аналоговою шкалою. В дослідження взяли участь 1166 пацієнтів з вогнепальними та мінно-вибуховими пораненнями Для аналізу зв'язку ризиків отримання нега-тивного результату лікування з факторними ознаками було використано метод побудови однофакторних та багатофакторних моделей логістичної регресії. Якість моделей оцінювали за площею під Area under the ROC curve (AUC). Для кількісної оцінки ступеня впливу факторної ознаки розраховувався показник відношення шансів (ВШ). Результати дослідження. Вивчаючи вплив обсягу пошкоджень і оперативних втручань на результати лікування болю у пацієнтів з вогнепальними та мінно-вибуховими пораненнями було з'ясовано: 1) статистично значимого зв'язку ризи-ку хронізації болю з віком, зростом, масою тіла пацієнта, кількістю операцій, середньою тривалістю операцій немає (в усіх випадках p>0,05); 2) виявлений слабкий зв'язок (AUC=0,54, 95% довірчий інтервал (ДІ) 0,51-0,57) ризику хроні-зації болю з кількістю поранених анатомічних ділянок тіла; при кількості поранених більше 2 ділянок тіла, ризик зростає (ВШ 1,45, 95% ДІ 1,09-1,92, p=0,010) порівняно з пацієнтами, у яких поранення локалізовані у 1 або 2 ділянках тіла; 3) виявлено дві факторні ознаки, пов'язані із ризиком хронізації болю-кількість поранених анатомічних ділянок тіла та тип поранення (AUC=0,56, 95% ДІ 0,53-0,59). Висновки. З метою попередження хронізації болю, а також досягнення ефективнішого лікування гострого болю у пацієнтів із вогнепальними та мінно
The sharp differences between civilian culture and military culture, referred to as Dichotomous Cultures, turn the transition into the army and the transition out of the army to be extremely difficult. This is true especially for veterans who served in combat units, in which masculinity is the leading motive, who sometimes describe their transition to civilian life as “from hero to zero.” Moreover, veterans are often reluctant to seek help, due to their military conditioning, traditional masculine values, and stigma. The Veteran’s Transition Program (VTP) is a group-based program that has been shown to directly meet the transitional needs of veterans. Rather than being stigmatized as weakness, VTP reframes help seeking as a valid, courageous sign of strength that is a necessary prerequisite for helping others. Hence, by reducing the trauma-related effects of service, VTP helps veteran to effectively move back to a normal functioning life.KeywordsVeteranCivilian lifeMilitary culturePTSDTraumaHelp-seekingPersonal values
An imposed separation from a parent could frequently lead to feelings of trauma and to major effects on the child’s mental health and adjustment. In such cases, the child’s adjustment is highly dependent on the remaining parent’s attitude and behaviors in the new circumstances. Deployment is an example of parental separation and, based on the military family stress model, is conceptualized as a family stressor, especially when parents show PTSD symptoms. Studies show that, for both genders, parenting practices and marital adjustment mediated the relationship between parents’ PTSD symptoms and children’s behavioral and emotional symptoms. The After Deployment, Adaptive Parenting Tools (ADAPT) program is targeted at families with children between the ages of 4 and 12. The program aims to improve six main parenting practices: (1) family problem-solving, (2) effective discipline, (3) positive involvement, (4) skill encouragement, (5) monitoring, and (6) emotion socialization. The findings suggest that the ADAPT program benefits parenting practices, parental mental health, and child adjustment, with findings showing particular benefits for higher risk fathers. ADAPT is now available in online, telehealth, workshop, group, and individual formats.KeywordsSeparationDeploymentStressTraumaParenting practicesChild adjustment
In contrast with studies examining the incarceration experience in civil prisons, there is a lack of literature and theory focusing on the military prison incarceration experience. The present retrospective qualitative study explored the experience of 27 Ethiopian-Israelis, an overrepresented population in Israeli military prison, incarcerated during their military service due to desertion offenses. Two main themes developed from the interviews: (a) the military prison as a tool to achieve personal goals and (b) Self-perception as victims of the system. Findings suggest that military prison incarceration may be a different experience to that of civilian incarceration, at times lacking the negative psychological described in literature on civil incarceration. On a theoretical level, results suggest that the incarceration experience may not be universal but, rather, dependent on the social and cultural context and meaning of the incarceration for the individual involved.
While many aspects of military life can introduce stress into family systems, deployments are often described by military families as the most stressful. Since the start of the Global War on Terror in 2001, over 2.7 million service members have experienced more than 3.3 million wartime deployments. The impact of deployment on service members has been extensively researched; these may include physical injuries, mental health symptomatology, substance use, and suicidality, problems which may be exacerbated by barriers to seeking treatment. A smaller but growing body of evidence explores the impact that deployments have on the spouses, children, and families of service members. Findings from empirical research with this population suggest that the majority of families weather the stressors of deployment successfully, but a subset of families may be struggling and at risk of adverse outcomes. This chapter discusses the impact of deployment experiences on military-connected spouses, children, and families; this impact is considered distinct from the potential effects experienced during the reintegration period following deployment. While these are undoubtedly intertwined, deployment is time bound while reintegration is a subjective experience that can vary significantly in length depending on the adaptive capacities of the service member and their family.KeywordsMilitary familyMental healthDeploymentMilitary spouseParenting
Context
The Primary Care Evaluation of Mental Disorders (PRIME-MD) was developed
as a screening instrument but its administration time has limited its clinical
usefulness.Objective
To determine if the self-administered PRIME-MD Patient Health Questionnaire
(PHQ) has validity and utility for diagnosing mental disorders in primary
care comparable to the original clinician-administered PRIME-MD.Design
Criterion standard study undertaken between May 1997 and November 1998.Setting
Eight primary care clinics in the United States.Participants
Of a total of 3000 adult patients (selected by site-specific methods
to avoid sampling bias) assessed by 62 primary care physicians (21 general
internal medicine, 41 family practice), 585 patients had an interview with
a mental health professional within 48 hours of completing the PHQ.Main Outcome Measures
Patient Health Questionnaire diagnoses compared with independent diagnoses
made by mental health professionals; functional status measures; disability
days; health care use; and treatment/referral decisions.Results
A total of 825 (28%) of the 3000 individuals and 170 (29%) of the 585
had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those
of independent mental health professionals (for the diagnosis of any 1 or
more PHQ disorder, κ = 0.65; overall accuracy, 85%; sensitivity, 75%;
specificity, 90%), similar to the original PRIME-MD. Patients with PHQ diagnoses
had more functional impairment, disability days, and health care use than
did patients without PHQ diagnoses (for all group main effects, P<.001). The average time required of the physician to review the
PHQ was far less than to administer the original PRIME-MD (<3 minutes for
85% vs 16% of the cases). Although 80% of the physicians reported that routine
use of the PHQ would be useful, new management actions were initiated or planned
for only 117 (32%) of the 363 patients with 1 or more PHQ diagnoses not previously
recognized.Conclusion
Our study suggests that the PHQ has diagnostic validity comparable to
the original clinician-administered PRIME-MD, and is more efficient to use.
Figures in this Article
Mental disorders in primary care are common, disabling, costly, and
treatable.1- 5
However, they are frequently unrecognized and therefore not treated.2- 6
Although there have been many screening instruments developed,7- 8
PRIME-MD (Primary Care Evaluation of Mental Disorders)5
was the first instrument designed for use in primary care that actually diagnoses
specific disorders using diagnostic criteria from the Diagnostic
and Statistical Manual of Mental Disorders, Revised Third Edition9(DSM-III-R) and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition10(DSM-IV).
PRIME-MD is a 2-stage system in which the patient first completes a
26-item self-administered questionnaire that screens for 5 of the most common
groups of disorders in primary care: depressive, anxiety, alcohol, somatoform,
and eating disorders. In the original study,5
the average amount of time spent by the physician to administer the clinician
evaluation guide to patients who scored positively on the patient questionnaire
was 8.4 minutes. However, this is still a considerable amount of time in the
primary care setting, where most visits are 15 minutes or less.11
Therefore, although PRIME-MD has been widely used in clinical research,12- 28
its use in clinical settings has apparently been limited. This article describes
the development, validation, and utility of a fully self-administered version
of the original PRIME-MD, called the PRIME-MD Patient Health Questionnaire
(henceforth referred to as the PHQ).
DESCRIPTION OF PRIME-MD PHQ
ABSTRACT
|
DESCRIPTION OF PRIME-MD PHQ
|
STUDY PURPOSE
|
METHODS
|
RESULTS
|
COMMENT
|
REFERENCES
The 2 components of the original PRIME-MD, the patient questionnaire
and the clinician evaluation guide, were combined into a single, 3-page questionnaire
that can be entirely self-administered by the patient (it can also be read
to the patient, if necessary). The clinician scans the completed questionnaire,
verifies positive responses, and applies diagnostic algorithms that are abbreviated
at the bottom of each page. In this study, the data from the questionnaire
were entered into a computer program that applied the diagnostic algorithms
(written in SPSS 8.0 for Windows [SPSS Inc, Chicago, Ill]). The computer program
does not include the diagnosis of somatoform disorder, because this diagnosis
requires a clinical judgment regarding the adequacy of a biological explanation
for physical symptoms that the patient has noted.
A fourth page has been added to the PHQ that includes questions about
menstruation, pregnancy and childbirth, and recent psychosocial stressors.
This report covers only data from the diagnostic portion (first 3 pages) of
the PHQ. Users of the PHQ have the choice of using the entire 4-page instrument,
just the 3-page diagnostic portion, a 2-page version (Brief PHQ) that covers
mood and panic disorders and the nondiagnostic information described above,
or only the first page of the 2-page version (covering only mood and panic
disorders) (Figure 1).
Figure 1. First Page of Primary Care Evaluation
of Mental Disorders Brief Patient Health QuestionnaireGrahic Jump Location+View Large |
Save Figure |
Download Slide (.ppt)
|
View in Article ContextCopyright held by Pfizer Inc, but may be photocopied ad libitum.
For office coding, see the end of the article.
The original PRIME-MD assessed 18 current mental disorders. By grouping
several specific mood, anxiety, and somatoform categories into larger rubrics,
the PHQ greatly simplifies the differential diagnosis by assessing only 8
disorders. Like the original PRIME-MD, these disorders are divided into threshold
disorders (corresponding to specific DSM-IV diagnoses,
such as major depressive disorder, panic disorder, other anxiety disorder,
and bulimia nervosa) and subthreshold disorders (in which the criteria for
disorders encompass fewer symptoms than are required for any specific DSM-IV diagnoses: other depressive disorder, probable alcohol
abuse or dependence, and somatoform and binge eating disorders).
One important modification was made in the response categories for depressive
and somatoform symptoms that, in the original PRIME-MD, were dichotomous (yes/no).
In the PHQ, response categories are expanded. Patients indicate for each of
the 9 depressive symptoms whether, during the previous 2 weeks, the symptom
has bothered them "not at all," "several days," "more than half the days,"
or "nearly every day." This change allows the PHQ to be not only a diagnostic
instrument but also to yield a measure of depression severity that can be
of aid in initial treatment decisions as well as in monitoring outcomes over
time. Patients indicate for each of the 13 physical symptoms whether, during
the previous month, they have been "not bothered," "bothered a little," or
"bothered a lot" by the symptom. Because physical symptoms are so common in
primary care, the original PRIME-MD dichotomous-response categories often
led patients to endorse physical symptoms that were not clinically significant.
An item was added to the end of the diagnostic portion of the PHQ asking
the patient if he or she had checked off any problems on the questionnaire:
"How difficult have these problems made it for you to do your work, take care
of things at home, or get along with other people?" As with the original PRIME-MD,
before making a final diagnosis, the clinician is expected to rule out physical
causes of depression, anxiety and physical symptoms, and, in the case of depression,
normal bereavement and history of a manic episode.
STUDY PURPOSE
ABSTRACT
|
DESCRIPTION OF PRIME-MD PHQ
|
STUDY PURPOSE
|
METHODS
|
RESULTS
|
COMMENT
|
REFERENCES
Our major purpose was to test the validity and utility of the PHQ in
a multisite sample of family practice and general internal medicine patients
by answering the following questions:
Are diagnoses made by the PHQ as accurate as diagnoses
made by the original PRIME-MD, using independent diagnoses made by mental
health professionals (MHPs) as the criterion standard?Are the frequencies of mental disorders found by
the PHQ comparable to those obtained in other primary care studies?Is the construct validity of the PHQ comparable
to the original PRIME-MD in terms of functional impairment and health care
use?Is the PHQ as effective as the original PRIME-MD
in increasing the recognition of mental disorders in primary care patients?How valuable do primary care physicians find the
diagnostic information in the PHQ?How comfortable are patients in answering the questions
on the PHQ, and how often do they believe that their answers will be helpful
to their physicians in understanding and treating their problems?
Objective:
To assess the prevalence of self-reported symptoms and illnesses among military personnel deployed during the Persian Gulf War (PGW) and to compare the prevalence of these conditions with the prevalence among military personnel on active duty at the same time, but not deployed to the Persian Gulf (non-PGW).
Design:
Cross-sectional telephone interview survey of PGW and non-PGW military personnel. The study instrument consisted of validated questions, validated questionnaires, and investigator-derived questions designed to assess relevant medical and psychiatric conditions.
Setting:
Population-based sample of military personnel from Iowa.
Study participants:
A total of 4886 study subjects were randomly selected from 1 of 4 study domains (PGW regular military, PGW National Guard/Reserve, non-PGW regular military, and non-PGW National Guard/Reserve), stratifying for age, sex, race, rank, and branch of military service.
Main outcome measures:
Self-reported symptoms and symptoms of medical illnesses and psychiatric conditions.
Results:
Overall, 3695 eligible study subjects (76%) and 91% of the located subjects completed the telephone interview. Compared with non-PGW military personnel, PGW military personnel reported a significantly higher prevalence of symptoms of depression (17.0% vs 10.9%; Cochran-Mantel-Haenszel test statistic, P<.001), posttraumatic stress disorder (PTSD) (1.9% vs 0.8%, P=.007), chronic fatigue (1.3% vs 0.3%, P<.001), cognitive dysfunction (18.7% vs 7.6%, P<.001), bronchitis (3.7% vs 2.7%, P<.001), asthma (7.2% vs 4.1%, P=.004), fibromyalgia (19.2% vs 9.6%, P<.001), alcohol abuse (17.4% vs 12.6%, P=.02), anxiety (4.0% vs 1.8%, P<.001), and sexual discomfort (respondent, 1.5% vs 1.1%, P=.009; respondent's female partner, 5.1% vs 2.4%, P<.001). Assessment of health-related quality of life demonstrated diminished mental and physical functioning scores for PGW military personnel. In almost all cases, larger differences between PGW and non-PGW military personnel were observed in the National Guard/Reserve comparison. Within the PGW military study population, compared with veterans in the regular military, veterans in the National Guard/Reserve only reported more symptoms of chronic fatigue (2.9% vs 1.0%, P=.03) and alcohol abuse (19.4% vs 17.0%, P=.004).
Conclusions:
Military personnel who participated in the PGW have a higher self-reported prevalence of medical and psychiatric conditions than contemporary military personnel who were not deployed to the Persian Gulf. These findings establish the need to further investigate the potential etiologic, clinical, pathogenic, and public health implications of the increased prevalence of multiple medical and psychiatric conditions in populations of military personnel deployed to the Persian Gulf.
The current combat operations in Iraq and Afghanistan have involved US military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans.
We studied members of 4 US combat infantry units (3 Army units and a Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or 3 to 4 months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and posttraumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments.
Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6% to 17.1%) than after duty in Afghanistan (11.2%) or before deployment to Iraq (9.3%); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23% to 40% sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care.
This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care. The recent military operations in Iraq and Afghanistan, which have involved the first sustained ground combat undertaken by the United States since the war in Vietnam, raise important questions about the effect of the experience on the mental health of members of the military services who have been deployed there. Research conducted after other military conflicts has shown that deployment stressors and exposure to combat result in considerable risks of mental health problems, including posttraumatic stress disorder, major depression, substance abuse, impairment in social functioning and in the ability to work, and the increased use of healthcare services. One study that was conducted just before the military operations in Iraq and Afghanistan began found that at least 6% of all US military service members on active duty receive treatment for a mental disorder each year. Given the ongoing military operations in Iraq and Afghanistan, mental disorders are likely to remain an important healthcare concern among those serving there. Many gaps exist in the understanding of the full psychosocial effect of combat. The all-volunteer force deployed to Iraq and Afghanistan and the type of warfare conducted in these regions are very different from those involved in past wars, differences that highlight the need for studies of members of the armed services who are involved in the current operations. Most studies that have examined the effects of combat on mental health were conducted among veterans years after their military service had ended. A problem in the methods of such studies is the long recall period after exposure to combat. Very few studies have examined a broad range of mental health outcomes near to the time of subjects' deployment. Little of the existing research is useful in guiding policy with regard to how best to promote access to and the delivery of mental health care to members of the armed services. Although screening for mental health problems is now routine both before and after deployment and is encouraged in primary care settings, we are not aware of any studies that have assessed the use of mental health care, the perceived need for such care, and the perceived barriers to treatment among members of the military services before or after combat deployment. We studied the prevalence of mental health problems among members of the US armed services who were recruited from comparable combat units before or after their deployment to Iraq or Afghanistan. We identified the proportion of service members with mental health concerns who were not receiving care and the barriers they perceived to accessing and receiving such care.
To determine if Vietnam theater veterans were more likely than controls to have a specific psychiatric disorder other than posttraumatic stress disorder, the rates of specific psychiatric disorders were estimated using the Diagnostic Interview Schedule for national samples of veterans who served in Vietnam, other veterans of the Vietnam era, and matched civilian controls. Overall, there were few differences in rates of disorder between theater and other veterans; there were somewhat more differences between theater veterans and civilians. There were striking differences, however, in rates for most disorders, both lifetime and current, between male theater veterans with high levels of exposure to war zone stress and other male veterans or civilians. Female veterans exposed to high levels of war zone stress also had higher rates than other female respondents for several disorders.
Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated life-time prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode.
Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey.
The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years.
Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas.
Little is known about the risk and course of posttraumatic stress disorder (PTSD), and other forms of dysfunction, associated with combat trauma relative to other traumas. Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and Composite International Diagnostic Interview were administered to a representative national sample of 5,877 persons 15-54 years old in the part 2 subsample of the National Comorbidity Survey. Of the weighted subsample, 1,703 men reported a traumatic event. The risk of PTSD and other forms of dysfunction were compared for men who nominated combat as their worst trauma versus men nominating other traumas as worst, controlling for confounding influences. Men reporting combat as their worst trauma were more likely to have lifetime PTSD, delayed PTSD symptom onset, and unresolved PTSD symptoms, and to be unemployed, fired, divorced, and physically abusive to their spouses than men reporting other traumas as their worst experience.
This study determined the percentage of adverse outcomes in US men attributable to combat exposure.
Standardized psychiatric interviews (modified Diagnostic Interview Schedule and Composite International Diagnostic Interview assessments) were administered to a representative national sample of 2583 men aged 18 to 54 in the National Comorbidity Survey part II subsample.
Adjusted attributable fraction estimates indicated that the following were significantly attributable to combat exposure: 27.8% of 12-month posttraumatic stress disorder, 7.4% of 12-month major depressive disorder, 8% of 12-month substance abuse disorder, 11.7% of 12-month job loss, 8.9% of current unemployment, 7.8% of current divorce or separation, and 21% of current spouse or partner abuse.
Combat exposure results in substantial morbidity lasting decades and accounts for significant and multifarious forms of dysfunction at the national level.
The Defense Medical Surveillance System (DMSS) is the central repository of medical surveillance data for the US armed forces. The DMSS integrates data from sources worldwide in a continuouslyexpanding relational database that documents the military and medical experiences of servicemembers throughout their careers.
The Department of Defense Serum Repository (DoDSR) is a central archive of sera drawn from servicemembers for medical surveillance purposes.
Currently, the DMSS contains data relevant to more than 7 million individuals who have served in the armed forces since 1990, and the DoDSR contains more than 27 million specimens that are linkable to data in the DMSS. Recent applications of the DMSS and DoDSR provide glimpses of the capabilities and uses of comprehensive public health surveillance systems.
The authors estimated the prevalence of post-traumatic stress disorder (PTSD) and illness resembling chronic fatigue syndrome (CFS) in the entire population of Gulf War and non-Gulf-War veterans. They also evaluated the relation between the extent of deployment-related stress and the risk of either PTSD or CFS. In 1995-1997, the authors conducted a health survey in which these two symptom-based medical diagnoses in a population-based sample of 15,000 Gulf War veterans representing four military branches and three unit components (active, reserve, and National Guard) were compared with those of 15,000 non-Gulf veteran controls. Gulf War veterans, compared with non-Gulf veteran controls, reported significantly higher rates of PTSD (adjusted odds ratio = 3.1, 95% confidence interval: 2.7, 3.4) and CFS (adjusted odds ratio = 4.8, 95% confidence interval: 3.9, 5.9). The prevalence of PTSD increased monotonically across six levels of deployment-related stress intensity (test for trend: p < 0.01), while the prevalence of CFS rose only at the low end of the stress spectrum. While deployment-related stress could account for the higher risks of both PTSD and CFS, additional factor(s) unique to the Gulf environment may have contributed to the risk of CFS among Gulf War veterans.
A recent study showed that among U.S. military personnel, mental disorders were the leading medical correlate of separation from military service. The reasons for this association have not been determined. The purpose of this study was to characterize the risk and reasons for service separation for soldiers hospitalized with mental disorders compared with those hospitalized for other illnesses.
Population-based electronic health care data were linked with data on separations and disability. The authors constructed a cohort of 13,971 U.S. Army soldiers first hospitalized in 1998 and followed them for up to 2 years following this first hospitalization.
The rate of service separation 6 months after first hospitalization was 45% among personnel whose primary hospital discharge diagnosis was a mental disorder, 27% among those with a secondary mental disorder discharge diagnosis, and 11% among those hospitalized for all other medical conditions. Separation from military service due to medical disability, misconduct and other legal problems, unauthorized work absences, behavior related to personality disorders, and alcohol rehabilitation failure was significantly more common following hospitalization for a mental disorder than for other medical conditions. Mental disorders were also significantly associated with medical separations in which there was evidence that the condition existed prior to service.
In the military, the occupational impact of mental disorders compared with other medical conditions appears to be mediated not only by greater disease chronicity and severity but also by a variety of behavioral problems including misconduct, legal problems, unauthorized absences, and alcohol/drug-related problems. The study also points to the difficulties inherent in screening for mental disorders prior to entry into military service.
Many other perceived barriers to screening for psychological illness in the military have been recently reported.¹,14,19 In a British qualitative study, the central issue appeared to be lack of confidence in the military health care provision.¹⁹ The British personnel were so concerned with issues of confidentiality, stigmatization, and career prospects that some of them confided that they would not respond honestly to some items.¹⁹ US service members have sometimes expressed similar concerns and these views were more prevalent among those soldiers who met the criteria for a mental disorder than those who did not.¹ Soldiers who screened positive for psychological symptoms and did not accept a visit to their physician had a sense that seeing the physician would not serve any useful purpose. This attitude may reflect lack of confidence or, in a few individuals, may reflect the nature of their conditions. A perceived difficulty in the patient-physician relationship is the knowledge that military physicians are different from other occupational physicians, with a responsibility to the individual but also to the organization, and there is little doubt that military personnel are well aware of this.¹⁹
Objective:
To determine the validity of a two-question case-finding instrument for depression as compared with six previously validated instruments.
Design:
The test characteristics of a two-question case-finding instrument that asks about depressed mood and anhedonia were compared with six common case-finding instruments, using the Quick Diagnostic Interview Schedule as a criterion standard for the diagnosis of major depression.
Setting:
Urgent care clinic at the San Francisco Department of Veterans Affairs Medical Center.
Participants:
Five hundred thirty-six consecutive adult patients without mania or schizophrenia.
Measurements and main results:
Measurements were two questions from the Primary Care Evaluation of Mental Disorders patient questionnaire, both the long and short forms of the Center for Epidemiologic Studies Depression Scale, both the long and short forms of the Book Depression Inventory, the Symptom-Driven Diagnostic System for Primary Care, the Medical Outcomes Study depression measure, and the Quick Diagnostic Interview Schedule. The prevalence of depression, as determined by the standardized interview, was 18% (97 of 536). Overall, the case-finding instruments had sensitivities of 89% to 96% and specificities of 51% to 72% for diagnosing major depression. A positive response to the two-item instrument had a sensitivity of 96% (95% confidence interval [CI], 90-99%) and a specificity of 57% (95% CI 53-62%). Areas under the receiver operating characteristic curves were similar for all of the instruments, with a range of 0.82 to 0.89.
Conclusions:
The two-question case-finding instrument is a useful measure for detecting depression in primary care. It has similar test characteristics to other case-finding instruments and is less time-consuming.
There have been numerous studies of post-traumatic stress disorder in trauma victims, war veterans, and residents of communities exposed to disaster. Epidemiologic studies of this syndrome in the general population are rare but add an important perspective to our understanding of it. We report findings on the epidemiology of post-traumatic stress disorder in 2493 participants examined as part of a nationwide general-population survey of psychiatric disorders. The prevalence of a history of post-traumatic stress disorder was 1 percent in the total population, about 3.5 percent in civilians exposed to physical attack and in Vietnam veterans who were not wounded, and 20 percent in veterans wounded in Vietnam. Post-traumatic stress disorder was associated with a variety of other adult psychiatric disorders. Behavioral problems before the age of 15 predicted adult exposure to physical attack and (among Vietnam veterans) to combat, as well as the development of post-traumatic stress disorder among those so exposed. Although some symptoms of post-traumatic stress disorder, such as hyperalertness and sleep disturbances, occurred commonly in the general population, the full syndrome as defined by the Diagnostic and Statistical Manual of Mental Disorders, third edition, was common only among veterans wounded in Vietnam.
The purpose of the study was to determine predictors of missed appointments for psychiatric consultations among patients in a general medical clinic.
The charts of 180 patients consecutively referred for psychiatric consultations at a university-affiliated primary care clinic were reviewed. Ninety patients missed appointments for these consultations. Parametric and nonparametric tests were used to compare patients who missed and did not miss appointments on demographic and clinical variables, as well as measures related to patients' interactions with the clinic and the referring clinician.
Logistic regression analysis revealed three significant predictors of missed appointments. Patients with mild distress and those with significant resistance to seeing a psychiatrist were more likely to miss appointments, as were those who had to wait longer between the referral and the appointment date.
The results suggest that shortening the wait for a psychiatric consultation, reserving consultation for more severe cases, and working to reduce patients' resistance to consultation will reduce the number of missed appointments.
To assess the validity of the Department of Defense's Standard Inpatient Data Record (SIDR) for health services research and quality measurement.
Patients whose inpatient charts were abstracted through the Civilian External Peer Review Program's studies of acute myocardial infarction (N = 1,432) and 1993 review of the birth product line (N = 9,705).
Separate databases of professionally abstracted (the clinical data set) and hospital-reported (the administrative SIDR data set) diagnoses and procedures were compared for each patient, and the sensitivity and specificity of the SIDR for elements in the Civilian External Peer Review Program's clinical "gold standard" data set were calculated. Agreement beyond chance was examined with kappa statistics.
The clinical data set's principal procedure was found as a SIDR principal or secondary procedure in 92.5% of cases. Sensitivities of the SIDR data for common diagnoses in the clinical data ranged from 64% (viral infection) to 97% (diabetes), with kappa statistics ranging from 0.55 to 0.96. Procedural sensitivities ranged from 77% (echocardiography) to 99% (cesarean section), with kappa statistics ranging from 0.7 to 1.0.
Our analyses indicate that the Department of Defense's SIDR is a reliable source of administrative data that compares favorably with traditional civilian quality management and health services research data sources, such as those from the Health Care Financing Administration and large insurers.
Effects of Persian Gulf War (August 2, 1990-July 31, 1991) and Gulf War occupation on post-War hospitalization risk were evaluated through Cox proportional hazards modeling. Active-duty men (n = 1,775,236) and women (n = 209,760) in the Army, Air Force, Navy, and Marine Corps had 30,539 initial postwar hospitalizations for mental disorders between June 1, 1991 and September 30, 1993. Principal diagnoses in the Defense Manpower Data Center hospitalization database were grouped into 10 categories of ICD-9-CM codes. Gulf War service was associated with significantly greater risk for acute reactions to stress and lower risk for personality disorders and adjustment reactions among men. Personnel who served in ground war support occupations (men and women) were at greater risk for postwar drug-related disorders. Men who served in ground war combat occupations were at higher risk for alcohol-related disorders. Longitudinal studies of health, hospitalization, and exposure beginning at recruitment, are needed to better understand how exposure to combat affects the mental health of military personnel.
A number of self-administered questionnaires are available for assessing depression severity, including the 9-item Patient Health Questionnaire depression module (PHQ-9). Because even briefer measures might be desirable for use in busy clinical settings or as part of comprehensive health questionnaires, we evaluated a 2-item version of the PHQ depression module, the PHQ-2.
The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past 2 weeks, scoring each as 0 ("not at all") to 3 ("nearly every day"). The PHQ-2 was completed by 6000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.
As PHQ-2 depression severity increased from 0 to 6, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and healthcare utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-2 score > or =3 had a sensitivity of 83% and a specificity of 92% for major depression. Likelihood ratio and receiver operator characteristic analysis identified a PHQ-2 score of 3 as the optimal cutpoint for screening purposes. Results were similar in the primary care and obstetrics-gynecology samples.
The construct and criterion validity of the PHQ-2 make it an attractive measure for depression screening.
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