Posttraumatic stress disorder, Veterans Health Administration use, and care-seeking among recent-era U.S. veterans.

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.

Patterns of Smoking and Unhealthy Alcohol Use Following Sexual Trauma Among U.S. Service Members.

In the first known longitudinal study of the topic, we examined whether experiencing sexual assault or sexual harassment while in the military was associated with increased risk for subsequent unhealthy alcohol use and smoking among U.S. service members in the Millennium Cohort Study (2001-2012). Adjusted complementary log-log models were fit to estimate the relative risk of (a) smoking relapse among former smokers (men: n = 4,610; women: n = 1,453); (b) initiation of unhealthy alcohol use (problem drinking and/or drinking over recommended limits) among those with no known history of unhealthy alcohol use (men: n = 8,459; women: n = 4,816); and (c) relapse among those previously reporting unhealthy alcohol use (men: n = 3,487; women: n = 1,318). Men who reported experiencing sexual assault while in the military had sixfold higher risk for smoking relapse: relative risk (RR) = 6.62; 95% confidence interval (CI) [2.34, 18.73], than men who did not. Women who reported experiencing sexual assault while in the military had almost twice the risk for alcohol relapse: RR = 1.73; 95% CI [1.06, 2.83]. There were no other significant associations. These findings suggest that men and women may respond differently following sexual trauma, and support future concerted policy efforts by military leadership to prevent, detect, and intervene on sexual assault.

Longitudinal Investigation of Smoking Initiation and Relapse Among Younger and Older US Military Personnel.

OBJECTIVES: We examined whether military service, including deployment and combat experience, were related to smoking initiation and relapse. METHODS: We included older (panel 1) and younger (panel 2) participants in the Millennium Cohort Study. Never smokers were followed for 3 to 6 years for smoking initiation, and former smokers were followed for relapse. Complementary log-log regression models estimated the relative risk (RR) of initiation and relapse by military exposure while adjusting for demographic, health, and lifestyle factors. RESULTS: Deployment with combat experience predicted higher initiation rate (panel 1: RR = 1.44; 95% confidence interval [CI] = 1.28, 1.62; panel 2: RR = 1.26; 95% CI = 1.04, 1.54) and relapse rate (panel 1 only: RR = 1.48; 95% CI = 1.36, 1.62). Depending on the panel, previous mental health disorders, life stressors, and other military and nonmilitary characteristics independently predicted initiation and relapse. CONCLUSIONS: Deployment with combat experience and previous mental disorder may identify military service members in need of intervention to prevent smoking initiation and relapse.

Hearing loss associated with US military combat deployment.

The objective of this study was to define the risk of hearing loss among US military members in relation to their deployment experiences. Data were drawn from the Millennium Cohort Study. Self-reported data and objective military service data were used to assess exposures and outcomes. Among all 48,540 participants, 7.5% self-reported new-onset hearing loss. Self-reported hearing loss showed moderate to substantial agreement (k = 0.57-0.69) with objective audiometric measures. New-onset hearing loss was associated with combat deployment (adjusted odds ratio [AOR] = 1.63, 95% confidence interval [CI] = 1.49-1.77), as well as male sex and older age. Among deployers, new-onset hearing loss was also associated with proximity to improvised explosive devices (AOR = 2.10, 95% CI = 1.62-2.73) and with experiencing a combat-related head injury (AOR = 6.88, 95% CI = 3.77-12.54). These findings have implications for health care and disability planning, as well as for prevention programs.

Individual and Military Factors That Modify the Association Between Recent Sexual Trauma and Health Outcomes Among U.S. Service Members and Veterans.

Sexual trauma (ST), which includes both sexual harassment and sexual assault, is associated with a variety of adverse mental and physical health outcomes in military and civilian populations. However, little is known about whether certain individual or military attributes or prior experiences may modify the relationship between recent ST and mental or physical health outcomes. Data from a longitudinal cohort study of current and former military members were used to examine whether individual and military factors modify the association between recent ST and health outcomes (posttraumatic stress disorder, depression, multiple somatic symptoms, and insomnia). Results indicated that demographic (sex, sexual orientation, race/ethnicity) and military factors (service branch, service component, military separation) generally did not modify the main effect of ST on the outcomes examined. On the other hand, factors known to be protective (spirituality, social support) and risk factors (childhood trauma, combat deployment, and mental health status) did modify the effect of ST on multiple outcomes examined; notably, protective effects were diminished among those who experienced recent ST. Protective factors were associated with the lowest risk of adverse outcomes among those with no ST, while risk reduction was less among survivors of ST. Diminished impacts also were found for cumulative risk factors, with the influence of multiple individual risk factors associated with increased risk but in a subadditive manner. We conclude that the effect of recent ST on the outcomes examined was persistent in the presence of potential protective factors, but that it may be impacted by ceiling effects in combination with other risk factors.

Prospective evaluation of mental health and deployment experience among women in the US military.

Previous research has shown that military women often experience potentially severe health outcomes following deployment. Data from the Millennium Cohort Study, a 21-year longitudinal study examining the health effects of military service, were used to examine this issue. In longitudinal analyses (2001-2008) carried out among US military women (n = 17,481), the authors examined positive screens for depression, anxiety, panic, and posttraumatic stress disorder in relation to deployment in support of the operations in Iraq and Afghanistan, while adjusting for relevant baseline and time-varying covariates. Women who were deployed and reported combat-related exposures had greater odds than nondeployed women of reporting symptoms of a mental health condition (odds ratio = 1.91, 95% confidence interval: 1.65, 2.20), after adjustment for demographic, military, and behavioral covariates. In addition, higher stress, problem drinking, and a history of mental illness were significantly associated with increased risk of later mental health conditions. In contrast, women in the Reserves or National Guard and those with higher education were at decreased risk of mental health conditions (all P 's < 0.01). As the roles and responsibilities of women in the military expand and deployments continue, designing better prevention and recovery strategies specifically for women are critical for overall force health protection and readiness.

The Millennium Cohort Study: The first 20 years of research dedicated to understanding the long-term health of US Service Members and Veterans.

PURPOSE: The Millennium Cohort Study, the US Department of Defense's largest and longest running study, was conceived in 1999 to investigate the effects of military service on service member health and well-being by prospectively following active duty, Reserve, and National Guard personnel from all branches during and following military service. In commemoration of the Study's 20th anniversary, this paper provides a summary of its methods, key findings, and future directions. METHODS: Recruitment and enrollment of the first 5 panels occurred between 2001 and 2021. After completing a baseline survey, participants are requested to complete follow-up surveys every 3-5 years. RESULTS: Study research projects are categorized into 3 core portfolio areas (psychological health, physical health, and health-related behaviors) and several cross-cutting areas and have culminated in more than 120 publications to date. For example, some key Study findings include that specific military service-related factors (e.g., experiencing combat, serving in certain occupational subgroups) were associated with adverse health-related outcomes and that unhealthy behaviors and mental health issues may increase following the transition from military service to veteran status. CONCLUSIONS: The Study will continue to foster stakeholder relationships such that research findings inform and guide policy initiatives and health promotion efforts.

Sleep patterns before, during, and after deployment to Iraq and Afghanistan.

STUDY OBJECTIVES: To determine the associations between deployment in support of the wars in Iraq and Afghanistan and sleep quantity and quality. DESIGN: Longitudinal cohort study SETTING: The Millennium Cohort Study survey is administered via a secure website or US mail. PARTICIPANTS: Data were from 41,225 Millennium Cohort members who completed baseline (2001-2003) and follow-up (2004-2006) surveys. Participants were placed into 1 of 3 exposure groups based on their deployment status at follow-up: nondeployed, survey completed during deployment, or survey completed postdeployment. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Study outcomes were self-reported sleep duration and trouble sleeping, defined as having trouble falling asleep or staying asleep. Adjusted mean sleep duration was significantly shorter among those in the deployed and postdeployment groups compared with those who did not deploy. Additionally, male gender and greater stress were significantly associated with shorter sleep duration. Personnel who completed their survey during deployment or postdeployment were significantly more likely to have trouble sleeping than those who had not deployed. Lower self-reported general health, female gender, and reporting of mental health symptoms at baseline were also significantly associated with increased odds of trouble sleeping. CONCLUSIONS: Deployment significantly influenced sleep quality and quantity in this population though effect size was mediated with statistical modeling that included mental health symptoms. Personnel reporting combat exposures or mental health symptoms had increased odds of trouble sleeping. These findings merit further research to increase understanding of temporal relationships between sleep and mental health outcomes occurring during and after deployment.

Longitudinal Investigation of Military-specific Factors Associated With Continued Unhealthy Alcohol Use Among a Large US Military Cohort.

OBJECTIVE: To examine whether military separation (Veteran), service component (active duty, Reserve/National Guard), and combat deployment are prospectively associated with continuing unhealthy alcohol use among US military service members. METHODS: Millennium Cohort Study participants were evaluated for continued or chronic unhealthy alcohol use, defined by screening positive at baseline and the next consecutive follow-up survey for heavy episodic, heavy weekly, or problem drinking. Participants meeting criteria for chronic unhealthy alcohol use were followed for up to 12 years to determine continued unhealthy use. Multivariable regression models-adjusted for demographics, military service factors, and behavioral and mental health characteristics-assessed whether separation status, service component, or combat deployment were associated with continuation of 3 unhealthy drinking outcomes: heavy weekly (sample n = 2653), heavy episodic (sample n = 22,933), and problem drinking (sample n = 2671). RESULTS: In adjusted models, Veterans (compared with actively serving personnel) and Reserve/Guard (compared with active duty members) had a significantly higher likelihood of continued chronic use for heavy weekly, heavy episodic, and problem drinking (Veteran odds ratio [OR] range 1.17-1.47; Reserve/Guard OR range 1.25-1.29). Deployers without combat experience were less likely than nondeployers to continue heavy weekly drinking (OR 0.75, 95% confidence interval 0.61-0.91). CONCLUSIONS: The elevated likelihood of continued unhealthy alcohol use among Veterans and Reserve/Guard members suggests that strategies to reduce unhealthy drinking targeted to these populations may be warranted.

Limb- and Person-Level Risk Factors for Lower-Limb Amputation in the Prospective Seattle Diabetic Foot Study.

OBJECTIVE: Diabetes is the leading cause of nontraumatic lower-limb amputations in the U.S., but no research has prospectively examined associations between limb-specific measurements and amputation risk among patients without foot ulcer. We investigated amputation risk by limb in relation to the same limb- and person-level factors. RESEARCH DESIGN AND METHODS: We conducted a 22-year prospective study among 1,461 male patients with diabetes without foot ulcer (mean age 62.4 years), with 2,893 lower limbs among subjects recruited between 1990 and 2002 from one Department of Veterans Affairs general internal medicine clinic. The following information was collected: demographic, lifestyle, and diabetes characteristics; visual acuity; kidney function (estimated glomerular filtration rate [eGFR]); and lower-limb measurements including presence of Charcot deformity, sensory neuropathy by 10-g monofilament, dorsal foot transcutaneous oximetry (TcPO2) at 44°C, and ankle-brachial index (ABI). RESULTS: Over 25,735 limb-years, 136 amputations occurred. A multivariable Cox model identified multiple independent risk factors: sensory neuropathy (hazard ratio 3.09 [95% CI 2.02-4.74]), ABI ≤0.5 vs. >0.9 to <1.3 (3.98 [2.31-6.85]), ABI ≥1.3 vs. >0.9 to <1.3 (2.20 [1.18-4.09]), 1-SD decrease in eGFR (1.18 [1.00-1.38]), poor vision (1.70 [1.05-2.73]), body weight in 21.4-kg increments (0.78 [0.61-0.98]), and age >70 years vs. <57 years (0.13 [0.04-0.38]). Although TcPO2 was not significantly associated with amputation overall, TcPO2 <26 mmHg significantly predicted a higher risk in the ABI ≥1.3 category. CONCLUSIONS: Arterial disease and neuropathy emerged as the only limb-specific risk factors for amputation, but these and several person-level factors may be amenable to prevention or treatment interventions to potentially reduce diabetic amputation risk.

Smoking and drinking behaviors of military spouses: Findings from the Millennium Cohort Family Study.

INTRODUCTION: The associations between stressful military experiences and tobacco use and alcohol misuse among Service members are well documented. However, little is known about whether stressful military experiences are associated with tobacco use and alcohol misuse among military spouses. METHODS: Using 9872 Service member-spouse dyads enrolled in the Millennium Cohort Family Study, we employed logistic regression to estimate the odds of self-reported cigarette smoking, risky drinking, and problem drinking among spouses by Service member deployment status, communication regarding deployment, and stress associated with military-related experiences, while adjusting for demographic, mental health, military experiences, and Service member military characteristics. RESULTS: Current cigarette smoking, risky drinking, and problem drinking were reported by 17.2%, 36.3%, and 7.3% of military spouses, respectively. Current deployment was not found to be associated with spousal smoking or drinking behaviors. Communication about deployment experiences with spouses was associated with lower odds of smoking, but not with risky or problem drinking. Spouses bothered by communicated deployment experiences and those who reported feeling very stressed by a combat-related deployment or duty assignment had consistently higher odds of both risky and problem drinking. CONCLUSIONS: Our findings suggest that contextual characteristics about the deployment experience, as well as the perceived stress of those experiences, may be more impactful than the simple fact of Service member deployment itself. These results suggest that considering the impact of deployment experiences on military spouses reveals important dimensions of military community adaptation and risk.

Posttraumatic Stress Disorder Symptom Association With Subsequent Risky and Problem Drinking Initiation.

OBJECTIVES: Posttraumatic stress disorder (PTSD) and unhealthy alcohol use are commonly associated conditions. It is unknown whether specific symptoms of PTSD are associated with subsequent initiation of unhealthy alcohol use. METHODS: Data from the first 3 enrollment panels (n = 151,567) of the longitudinal Millennium Cohort Study of military personnel were analyzed (2001-2012). Complementary log-log models were fit to estimate whether specific PTSD symptoms and symptom clusters were associated with subsequent initiation of 2 domains of unhealthy alcohol use: risky and problem drinking (experience of 1 or more alcohol-related consequences). Models were adjusted for other PTSD symptoms and demographic, service, and health-related characteristics. RESULTS: Eligible study populations included those without risky (n = 31,026) and problem drinking (n = 67,087) at baseline. In adjusted analyses, only 1 PTSD symptom-irritability/anger-was associated with subsequent increased initiation of risky drinking (relative risk [RR] 1.05, 95% confidence interval [CI] 1.00-1.09) at least 3 years later. Two symptom clusters (dysphoric arousal [RR 1.17, 95% CI 1.11-1.23] and emotional numbing [RR 1.30, 95% CI 1.22-1.40]) and 5 symptoms (restricted affect [RR 1.13, 95% CI 1.08-1.19], sense of foreshortened future [RR 1.12, 95% CI 1.06-1.18], exaggerated startle response [RR 1.07, 95% CI 1.01-1.13], sleep disturbance [RR 1.11, 95% CI 1.07-1.15], and irritability/anger [RR 1.12, 95% CI 1.07-1.17]) were associated with subsequent initiation of problem drinking. CONCLUSIONS: Findings suggest that specific PTSD symptoms and symptom clusters are associated with subsequent initiation of unhealthy alcohol use.

Longitudinal Examination of the Influence of Individual Posttraumatic Stress Disorder Symptoms and Clusters of Symptoms on the Initiation of Cigarette Smoking.

OBJECTIVES: The aim of this study was to determine whether specific individual posttraumatic stress disorder (PTSD) symptoms or symptom clusters predict cigarette smoking initiation. METHODS: Longitudinal data from the Millennium Cohort Study were used to estimate the relative risk for smoking initiation associated with PTSD symptoms among 2 groups: (1) all individuals who initially indicated they were nonsmokers (n = 44,968, main sample) and (2) a subset of the main sample who screened positive for PTSD (n = 1622). Participants were military service members who completed triennial comprehensive surveys that included assessments of smoking and PTSD symptoms. Complementary log-log models were fit to estimate the relative risk for subsequent smoking initiation associated with each of the 17 symptoms that comprise the PTSD Checklist and 5 symptom clusters. Models were adjusted for demographics, military factors, comorbid conditions, and other PTSD symptoms or clusters. RESULTS: In the main sample, no individual symptoms or clusters predicted smoking initiation. However, in the subset with PTSD, the symptoms "feeling irritable or having angry outbursts" (relative risk [RR] 1.41, 95% confidence interval [CI] 1.13-1.76) and "feeling as though your future will somehow be cut short" (RR 1.19, 95% CI 1.02-1.40) were associated with increased risk for subsequent smoking initiation. CONCLUSIONS: Certain PTSD symptoms were associated with higher risk for smoking initiation among current and former service members with PTSD. These results may help identify individuals who might benefit from more intensive smoking prevention efforts included with PTSD treatment.

Risk Factors Associated with Miscarriage and Impaired Fecundity among United States Servicewomen during the Recent Conflicts in Iraq and Afghanistan.

BACKGROUND: Research on the reproductive health of U.S. servicewomen deployed in support of the recent operations in Iraq and Afghanistan is sparse. The objective of this study was to evaluate whether military experiences, including combat deployment, deployment length, and life stressors during the recent conflicts, were associated with increased odds for miscarriage or impaired fecundity among U.S. servicewomen. METHODS: We used data from the Millennium Cohort Study, a large longitudinal military study that began in 2001 and includes military personnel from all service branches, including active duty and Reserve/National Guard personnel. Participants for this study included women aged 18 to 45 years who had completed two questionnaires (2004-2006 and 2007-2008). Separate multivariable logistic regression models were performed to estimate the odds of reporting miscarriage and impaired fecundity by military experiences that adjusted for covariates. Subanalyses were conducted using International Classification of Diseases, Ninth Revision, Clinical Modification codes found in the Military Health System Data Repository for both outcomes among servicewomen on active duty. RESULTS: Overall, 31% and 11% of military servicewomen reported miscarriage and impaired fecundity, respectively, during the approximate 3-year follow-up period. After adjusting for demographic, behavioral, and military characteristics, deployment experiences and life stressors were not associated with miscarriage or perceived impaired fecundity. Subanalyses using medical record data confirmed these results. CONCLUSIONS: Overall, these results suggest that military deployments do not increase risk for miscarriage and impaired fecundity among U.S. servicewomen. However, because the point estimates for many of the exposures were elevated, more research is needed to better understand the potential risks associated with environmental exposures and specific types of combat exposures.

Sleep and Health Resilience Metrics in a Large Military Cohort.

STUDY OBJECTIVES: Examine the relationship between self-reported sleep parameters and indicators of resilience in a US military population (n = 55,021). METHODS: Longitudinal analyses (2001-2008) were conducted using subjective data collected from Millennium Cohort Study questionnaires and objective data from military records that included demographics, military health, and deployment information. Subjective sleep duration and insomnia symptoms were collected on the study questionnaire. Resilience metrics included lost work days, self-rated health, deployment, frequency and duration of health care utilization, and early discharge from the military. Generalized estimating equations and survival analyses were adjusted for demographic, military, behavioral, and health covariates in all models. RESULTS: The presence of insomnia symptoms was significantly associated with lower self-rated health, more lost work days, lower odds of deployment, higher odds of early discharge from military service early, and more health care utilization. Those self-reporting < 6 h (short sleepers) or > 8 h (long sleepers) of sleep per night had similar findings, except for the deployment outcome in which those with the shortest sleep were more likely to deploy. CONCLUSIONS: Poor sleep is a detriment to service members' health and readiness. Leadership should redouble efforts to emphasize the importance of healthy sleep among military service members, and future research should focus on the efficacy of interventions to promote healthy sleep and resilience in this population. COMMENTARY: A commentary on this article appears in this issue on page 963.

Risk factors for relapse to problem drinking among current and former US military personnel: a prospective study of the Millennium Cohort.

BACKGROUND: Military service members may be prone to relapse to problem drinking after remission, given a culture of alcohol use as a coping mechanism for stressful or traumatic events associated with military duties or exposures. However, the prevalence and correlates of relapse are unknown. We sought to identify socio-demographic, military, behavioral, and health characteristics associated with relapse among current and former military members with remittent problem drinking. METHODS: Participants in the longitudinal Millennium Cohort Study who reported problem drinking at baseline (2001-2003) and were remittent at first follow-up (2004-2006) were included (n=6909). Logistic regression models identified demographic, military service, behavioral, and health characteristics that predicted relapse (report of ≥1 past-year alcohol-related problem on the validated Patient Health Questionnaire) at the second follow-up (2007-2008). RESULTS: Sixteen percent of those with remittent problem drinking relapsed. Reserve/National Guard members compared with active-duty members (odds ratio [OR]=1.71, 95% confidence interval [CI]: 1.45-2.01), members separated from the military during follow-up (OR=1.46, 95% CI: 1.16-1.83), and deployers who reported combat exposure (OR=1.32, 95% CI: 1.07-1.62, relative to non-deployers) were significantly more likely to relapse. Those with multiple deployments were significantly less likely to relapse (OR=0.73, 95% CI: 0.58-0.92). Behavioral factors and mental health conditions also predicted relapse. CONCLUSION: Relapse was common and associated with military and non-military factors. Targeted intervention to prevent relapse may be indicated for military personnel in particular subgroups, such as Reservists, veterans, and those who deploy with combat exposure.

Deployment-related depression screening, 2001-2008: comparing clinical versus research surveys.

BACKGROUND: Potential adverse mental health effects of deployment, including depression, are an ongoing concern. Although a previous study assessed under-reporting of depression on post-deployment health assessments compared to anonymous surveys, those results were not examined at the individual level to identify demographic or military factors that may be associated with unwillingness to report depression symptoms. PURPOSE: To compare self-reported depression symptoms on post-deployment health assessments with responses to the same depression questions on a research survey. METHODS: This cross-sectional study analyzed depression screening responses from 2001 to 2008 from participants of the Millennium Cohort Study, a longitudinal military cohort study, who completed a post-deployment health assessment within 30 days of a research survey. Kappa statistics and percent positive and negative agreement were calculated. Demographic and military characteristics associated with discordant screening results were examined. Initial analyses were performed in 2011, with additional analyses in 2013. RESULTS: Moderate agreement (κ=0.464) was observed between paired survey responses. A higher proportion of active duty members, the unmarried, and new accessions into military service endorsed depression symptoms on the research survey but not the military-linked survey. In stratified analyses, agreement was higher in Reserve/National Guard members than active duty (κ=0.561 vs 0.409). New active duty accessions showed lower agreement (κ=0.388), as did unmarried active duty participants (κ=0.304). CONCLUSIONS: Deployment health surveys are important tools for identifying returning service members experiencing depression symptoms. However, these findings suggest that ongoing stigma and barriers to appropriate follow-up mental health care remain to be addressed in the military setting.

Sleep characteristics, mental health, and diabetes risk: a prospective study of U.S. military service members in the Millennium Cohort Study.

OBJECTIVE: Research has suggested that a higher risk of type 2 diabetes associated with sleep characteristics exists. However, studies have not thoroughly assessed the potential confounding effects of mental health conditions associated with alterations in sleep. RESEARCH DESIGN AND METHODS: We prospectively assessed the association between sleep characteristics and self-reported incident diabetes among Millennium Cohort Study participants prospectively followed over a 6-year time period. Surveys are administered approximately every 3 years and collect self-reported data on demographics, height, weight, lifestyle, features of military service, sleep, clinician-diagnosed diabetes, and mental health conditions assessed by the PRIME-MD Patient Health Questionnaire and the PTSD Checklist-Civilian Version. Statistical methods for longitudinal data were used for data analysis. RESULTS: We studied 47,093 participants (mean 34.9 years of age; mean BMI 26.0 kg/m2; 25.6% female). During 6 years of follow-up, 871 incident diabetes cases occurred (annual incidence 3.6/1,000 person-years). In univariate analyses, incident diabetes was significantly more likely among participants with self-reported trouble sleeping, sleep duration<6 h, and sleep apnea. Participants reporting incident diabetes were also significantly older, of nonwhite race, of higher BMI, less likely to have been deployed, and more likely to have reported baseline symptoms of panic, anxiety, posttraumatic stress disorder, and depression. After adjusting for covariates, trouble sleeping (odds ratio 1.21 [95% CI 1.03-1.42]) and sleep apnea (1.78 [1.39-2.28]) were significantly and independently related to incident diabetes. CONCLUSIONS: Trouble sleeping and sleep apnea predict diabetes risk independent of mental health conditions and other diabetes risk factors.

Predeployment Sleep Duration and Insomnia Symptoms as Risk Factors for New-Onset Mental Health Disorders Following Military Deployment.

STUDY OBJECTIVES: To evaluate predeployment sleep duration and insomnia symptoms in relation to the development of mental health symptoms. DESIGN: Longitudinal cohort study. SETTING: The Millennium Cohort Study survey is administered via a secure website or US mail. PARTICIPANTS: Data were from 15,204 participants who completed their first deployment between the submissions of 2 consecutive Millennium Cohort questionnaires (2001-2008). INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Using self-reported data from the Millennium Cohort Study we evaluated the association of predeployment sleep duration and insomnia symptoms on the development of new-onset mental disorders among deployers. Multivariable logistic regression was used to estimate the odds of developing posttraumatic stress disorder (PTSD), depression, and anxiety, while adjusting for relevant covariates including combat-related trauma. The study outcomes were assessed using validated instruments, including the PTSD checklist-civilian version, and the PRIME-MD Patient Health Questionnaire. We identified 522 people with new-onset PTSD, 151 with anxiety, and 303 with depression following deployment. In adjusted models, combat-related trauma and predeployment insomnia symptoms were significantly associated with higher odds of developing posttraumatic stress disorder, depression, and anxiety postdeployment. CONCLUSIONS: Sleep characteristics, especially insomnia symptoms, are related to the development of mental disorders following military deployments. Assessment of insomnia symptoms predeployment may help to better identify those at highest risk for subsequent adverse mental health outcomes. CITATION: Gehrman P; Seelig AD; Jacobson IG; Boyko EJ; Hooper TI; Gackstetter GD; Ulmer CS; Smith TC; for the Millennium Cohort Study Team. Predeployment sleep duration and insomnia symptoms as risk factors for new-onset mental health disorders following military deployment. SLEEP 2013;36(7):1009-1018.

Risk Factors for Lower Extremity Tendinopathies in Military Personnel.

BACKGROUND: Overuse injuries have a significant impact on United States military service members, but research to date has been limited in its ability to assess occupational and behavioral risk factors. HYPOTHESIS/PURPOSE: To prospectively identify risk factors for the development of lower extremity tendinopathy and plantar fasciitis in United States military personnel. STUDY DESIGN: Descriptive epidemiology study. METHODS: Baseline data from the Millennium Cohort Study, a long-term observational cohort of military personnel, were utilized. Service members were enrolled in the cohort in 2001, 2004, and 2007. A total of 80,106 active-duty personnel were followed over 1 year for the development of patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis. Regression analyses were used to estimate significant associations between each tendinopathy, plantar fasciitis, and demographic, behavioral, and occupational characteristics. RESULTS: Using medical records, 450 cases of Achilles tendinitis, 584 cases of patellar tendinopathy, and 1228 cases of plantar fasciitis were identified. Recent deployment was associated with an increased risk for developing plantar fasciitis (adjusted odds ratio [AOR], 1.27; 95% confidence interval [CI], 1.04-1.56). Moderate weekly alcohol consumption was marginally associated with an increased risk for Achilles tendinopathy (AOR, 1.33; 95% CI, 1.00-1.76). Overweight or obese individuals were more likely to develop Achilles tendinopathy and plantar fasciitis. CONCLUSION: Lower extremity tendinopathies and plantar fasciitis are common among military service members, and this study identified several modifiable risk factors for their occurrence. These potential risk factors could serve as the focus for future preventive and intervention studies.