The associations of opioid and benzodiazepine prescriptions with injuries among US military service members.

ABSTRACT: Given the high rates of physical trauma and pain among service members, opioid-prescribing practices and use patterns have significant implications for the well-being of service members and can affect military medicine and personnel readiness. This study measured the association between prescribed opioid and benzodiazepine medications and subsequently reported injuries (accidental, alcohol and drug related, self-inflicted, and violence related) among active duty military members. Participants were service members who entered the military between January 1, 2005, and June 30, 2010. In a nested case-control design, we compared individuals with injuries to individuals without injuries with respect to their opioid and benzodiazepine prescriptions in the 30 days before the injury of an index case. We used a multiintercept, logistic regression model to compare coefficient estimates by injury type. Overall, approximately 17% of individuals with an injury and 4% of individuals without an injury had a recorded opioid prescription. Individuals with an injury of any type had greater odds of prior exposure to opioid prescriptions than controls. Although a dose-response effect was observed for all injury types, it reached a plateau sooner for natural or environmental accidents and self-inflicted injuries relative to alcohol-related and drug-related injuries, violence-related injuries, vehicle accidents, accidental falls, and other accidents. Benzodiazepine prescriptions were found in 3.5% of individuals with an injury and 0.5% of individuals without an injury. The association between benzodiazepine prescriptions and injuries was strongest for natural and environmental accidents.

Evidence-based telehealth interventions for posttraumatic stress disorder, depression, and anxiety: A systematic review and meta-analysis.

INTRODUCTION: The goal of this systematic review was to examine the efficacy of behavioral health care treatments for posttraumatic stress disorder (PTSD), depression, and anxiety delivered via telehealth. METHODS: We searched a combination of keywords related to telehealth, relevant mental health disorders, and evidence-based psychotherapies in three databases (PubMed, PsycInfo, and Embase) from database inception to April 2022. We included randomized controlled trials published in English wherein at least one arm received an evidence-based psychotherapy via telehealth. To be included, studies also had to enroll an adult population with symptoms or diagnosis of PTSD, depressive disorder, or anxiety disorder. RESULTS: Moderate quality of evidence was consistent with only small differences, if any, in efficacy between video teleconferencing (VTC) and in-person delivery for patients with PTSD (d = 0.06, 95% CI -0.17, 0.28). However, for those with depression, in-person delivery was associated with better outcomes compared to VTC (d = 0.28, 95% CI 0.03, 0.54; low quality of evidence). We also found that evidence-based treatments delivered over telephone were more efficacious for depression compared to treatment as usual (d = -0.47, 95% CI -0.66, -0.28; very low quality of evidence). Very low quality of evidence supported the use of telehealth versus waitlist for anxiety (d = -0.48, 95% CI -0.89, -0.09). CONCLUSIONS: A synthesis across 29 studies indicates that the efficacy of telehealth for delivery of evidence-based behavioral health interventions varies by target diagnosis and telehealth modality. More research is needed on the efficacy of telehealth treatments for depression and anxiety.

Diagnostic and functional outcomes of adjustment disorder in U.S. active duty service members.

BACKGROUND: Adjustment disorder (AD) is a commonly diagnosed psychiatric disorder. However, little is known about its course, predictors of its diagnostic outcomes, or its association with functional impairment. Our primary aim was to examine diagnostic transitions of service members with an incident AD diagnosis (IADx) to one of three states: 1) another psychiatric diagnosis, 2) chronic AD, or 3) no psychiatric diagnosis. Secondary outcomes included predictors of diagnostic course and functional outcomes associated with follow-up diagnoses. METHODS: Health records of a random sample of 10,720 service members with an IADx were analyzed using multinomial logit regression and hazard rate model with competing risks. RESULTS: IADx transitions were 24.3 % to another psychiatric diagnosis, 8.9 % with chronic AD, and 43.7 % without a diagnosis. Nearly a quarter (23.1 %) separated from service. Deployment was the strongest predictor of transitioning to another diagnosis. Those who transitioned to another diagnosis separated at an increased rate and with more adverse outcomes. LIMITATIONS: Diagnostic findings are based on data in the electronic health record, and we could not specifically identify the stressor that precipitated an AD diagnosis. These findings describe the course of AD in military personnel and may not generalize to civilians. CONCLUSIONS: AD, as initially diagnosed, represents a heterogeneous disorder with an enduring impact across the military career for a considerable proportion of service members. As an early indicator of more severe psychiatric outcomes, an IADx may signal an opportunity for early intervention and screening, particularly in service members with a history of deployment.

In-Theater Mental Health Disorders Among U.S. Soldiers Deployed Between 2008 and 2013.

Deployed service members regularly undergo demanding and stressful experiences that can contribute to mental health difficulties; however, there is a scarcity of studies examining rates of mental health disorders in-theater. The current study examined case rates of mental health disorders among deployed U.S. Army Soldiers using diagnostic encounter data from the Theater Medical Data Store. Case rates were calculated across 12 categories of mental health disorders. While in theater, soldiers' highest rates were for stress reactions and adjustment disorders, depression, anxiety, and sleep disorders. The lowest rates in theater were for psychosis, bipolar, somatic, and eating disorders. Notably, female soldiers had higher rates than their male counterparts for disorders in each of the 12 diagnostic categories. Results provide crucial information to aid in decision making about necessary interventions and provider competencies in deployed settings. Knowledge gained from these data may improve force readiness, help lessen disease burden, and inform military policy and prevention efforts.

Adjustment disorders: A research gaps analysis.

Adjustment disorders are among the most commonly diagnosed mental health disorders in both civilian and military clinical settings. Despite their high prevalence, adjustment disorders have received little research attention. The many gaps in our understanding of this group of disorders hinder the development of adequate, evidence-based treatment protocols. This study utilizes a systematic methodology to identify and prioritize research gaps in adjustment disorders. We used authoritative source reports to identify gaps in research domains from foundational science to services research. Subject-matter experts conducted literature searches to substantiate and refine research gaps, and stakeholders assessed the importance and impact of this work for researchers and policy-makers. We identified 254 possible research-needs statements, which were ultimately reduced to 11 final, prioritized research gaps. Two gaps addressed prevention and screening and three addressed treatment and services research. Six gaps addressed foundational science, epidemiology, and etiology research domains, highlighting the need for basic research. Until some of the basic science questions are resolved (e.g., diagnostic clarity, valid screening, and assessment measures) about adjustment disorders, we may not be able to develop adequate evidence-based interventions for the disorders, and it will be difficult to understand the trajectory of these disorders throughout treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Demographic, Behavioral, and Proximal Risk Factors for Gambling Disorder in the US Military.

BACKGROUND AND OBJECTIVES: To estimate the diagnostic prevalence and incidence of gambling disorder among United States service members and to identify associated risk factors, including demographics, history of mental illness or substance misuse, and proximity to legalized gambling vicinities. METHODS: Gambling disorder cases comprised active component Service members who received a pathological or problem gambling diagnosis between October 1, 2005 and September 30, 2015. There were 901 cases (392 incidents) during the study period. Controls were matched on the case military entrance date (N = 43,564). Geospatial distance between gambling venue and military treatment facilities were calculated, then multivariable logistic regression and survival analyses were conducted. RESULTS: The 10-year prevalence of gambling disorder was 6.6 per 100,000. Men were 3.5 times more likely than women to receive a gambling disorder diagnosis. Other risk factors included age over 24, Asian or Black race, formerly married, and enlisted rank. The odds of gambling disorder increased with duration and proximity to gambling venues, ranging from 2.0 to 3.9. Service members with prior substance misuse or mental health conditions were 3.9 times and 6.3 times more likely to receive a disordered gambling diagnosis than those without substance misuse or mental illness history, respectively. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: The results of this study reveal that proximity to gambling venues and slot machines on bases, as well as a history of substance misuse or mental disorders, are important risk factors for gambling disorder in the US military. Department of Defense screening policies that focus on high-risk populations are appropriate. (Am J Addict 2021;00:00-00).

Explosive ordnance disposal personnel in the U.S. military have higher risk of insomnia and post-traumatic stress disorder: a large retrospective cohort study.

PURPOSE: We examined the risk of post-traumatic stress disorder (PTSD), affective disorders, alcohol/substance-related disorders, traumatic brain injury (TBI) and insomnia, among explosive ordnance disposal (EOD) technicians compared to the general population of active-duty non-EOD personnel in the U.S. military. METHODS: We conducted a retrospective cohort study using administrative and healthcare utilization data from fiscal year 2004 (FY2004) to FY2015 for this comparison. We used propensity score matching to balance baseline covariates, and discrete-time hazard models to compare the odds of occurrence of the outcomes. RESULTS: EOD personnel had higher odds of having a new diagnosis of insomnia (odds ratio [OR] = 1.33; 95% confidence interval [CI]:1.22-1.45) and PTSD (OR = 1.23; 95% CI:1.08-1.41) than did non-EOD personnel. EOD technicians had lower odds of having a new diagnosis of affective disorders (OR = 0.83; 95% CI:0.79-0.87) and alcohol/substance-related disorders (OR = 0.59; 95% CI:0.54-0.64) than did non-EOD personnel. There was little evidence of a difference in the odds of a TBI diagnosis (OR = 1.07; 95% CI:0.99-1.16). CONCLUSIONS: As reliance on EOD forces continues, ongoing vigilance of the stressors, health sequelae and disincentives to access mental health care among this military occupation should be monitored and mitigated wherever possible.

Longitudinal Relationship of Combat Exposure With Mental Health Diagnoses in the Military Health System.

INTRODUCTION: Combat deployment is associated with mental and physical health disorders and functional impairment. Mental health (MH) diagnoses such as adjustment and anxiety disorders have received little research attention but may reflect important postdeployment sequelae. The purpose of this study was to investigate the association of combat exposure with the acquisition of a wide range of mental health diagnoses over 2 years. MATERIALS AND METHODS: This retrospective longitudinal study utilized multiple administrative Military Health System datasets compiled for all individuals who entered active duty in the U.S. Army from FY2005 to FY2011. A total eligible cohort of 289,922 Service members was stratified into three mutually exclusive groups according to their deployment status after 2 years in service: Deployed, Combat-Exposed; Deployed, Not-Combat-Exposed; and Not Deployed. Outcomes of interest were new mental health diagnoses grouped into six categories-posttraumatic stress disorder, anxiety, adjustment, mood, substance use disorders, and any MH diagnosis. Survival analyses over 2 years were conducted and adjusted hazard ratios were calculated. RESULTS: Combat exposure in the first 2 years of military service was associated with significantly higher rates of a wide range of mental health diagnoses over a two-year follow-up period, compared with deployment with no combat exposure and no deployment. Adjusted cumulative failure proportions demonstrated that approximately a third of the Combat-Exposed group, a quarter of the Not-Combat-Exposed, and a fifth of the Not Deployed groups received a MH diagnosis over 2 years. For all groups, cumulative failure proportions and incidence rates were highest for adjustment disorder and lowest for posttraumatic stress disorder diagnoses. CONCLUSIONS: Researchers and providers should be alerted to the impact of combat exposure and the wide range of MH conditions and diagnoses that may represent important postdeployment sequelae.

Women in combat: The effects of combat exposure and gender on the incidence and persistence of posttraumatic stress disorder diagnosis.

Recent expansions in the roles of women in combat have prompted increased interest in the psychological toll combat exposure may have on female service members as compared to males. This study examined the interactive effects of gender and combat exposure on transitions in posttraumatic stress disorder (PTSD) diagnostic status (presence or absence of PTSD diagnosis). We used administrative data of 20,000 U.S. Army soldiers whose combat exposure was assessed after return from deployment between January 1, 2008 and June 30, 2014; soldiers' PTSD diagnostic status was determined using International Classification of Diseases-9 diagnoses at four time points separated by 12 months. We used a mixed-effects logit transition model to examine the effects of combat and gender on incidence, persistence, and prevalence of PTSD diagnosis. Incidence and prevalence of PTSD diagnosis were higher among women, but persistence of PTSD diagnosis was higher in men. Higher rates of new PTSD diagnosis among women were not dependent on combat exposure, suggesting that other types of trauma may be responsible for increased rates among women. Gender differences in prevalence and persistence of PTSD diagnosis were greater among combat-exposed soldiers than among those not exposed to combat. Men maintained a PTSD diagnosis over longer periods of time than women suggesting greater PTSD persistence, and this pattern was particularly pronounced among soldiers exposed to combat. These results have implications for the recent policy changes and gender-based prevention strategies, and suggest that women in combat roles may be no more vulnerable to PTSD than are their male counterparts. Though the gender differences were small, they are indicative of healthcare utilization patterns that may be important for prevention and that warrant further exploration.

A systematic review evaluating screening instruments for gambling disorder finds lack of adequate evidence.

OBJECTIVES: To date, no research has systematically evaluated screening instruments for gambling disorder to assess their accuracy and the quality of the research. This systematic review evaluated screening instruments for gambling disorder to inform decision makers about choices for population-level screening. STUDY DESIGN AND SETTING: On May 22, 2017 and January 4, 2019, we searched PubMed, PsycInfo, EMBASE, and Cochrane for studies that evaluated screening instruments for gambling disorder. Studies were included if (1) the screening instrument was in English, (2) the screening instrument was compared to a reference standard semistructured interview based on Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases diagnoses of gambling disorder, and (3) data were reported on psychometric properties of the instrument. RESULTS: We identified 31 different screening instruments from 60 studies. Only three instruments from three separate studies were eligible for inclusion in the systematic review. CONCLUSION: Few screening instruments for gambling disorder have been validated with sufficient methodological quality to be recommended for use across a large health system.

Typologies of Combat Exposure and Their Effects on Posttraumatic Stress Disorder and Depression Symptoms.

The present study identified distinct classes of U.S. military service members based on their combat experiences and examined mental health outcomes and longitudinal growth curves of posttraumatic stress disorder (PTSD) and depression symptoms associated with each class. Participants were 551 active duty service members who screened positive for PTSD and/or depression based on DSM-IV-TR criteria. All participants completed the Combat Experiences Scale at baseline as well as PTSD and depression measures at baseline and at 3-, 6-, and 12-month follow-ups. A latent class analysis identified four classes of service members based on their combat experiences: limited exposure, medical exposure, unit exposure, and personal exposure. Service members in the personal exposure class were characterized by a distinct mental health profile: They reported a higher level of PTSD symptoms at baseline and a higher prevalence of traumatic brain injury and PTSD diagnoses during the course of the study. The limited exposure class was more likely to receive diagnoses of depression and adjustment disorders. All classes except the medical exposure class demonstrated a slight decrease in PTSD and depression symptoms over time. However, participants in the limited exposure class had a larger decrease in PTSD and depression symptoms earlier in care but did not demonstrate superior long-term symptom improvements at 12 months compared to the other groups. These results inform PTSD development models and have implications for the screening and clinical management of combat-exposed service members.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Tipologías de Exposición a Combate y sus Efectos en el Trastorno de Estrés Postraumático y Síntomas Depresivos. EXPERIENCIAS TRAUMÁTICAS DE COMBATE, TEPT Y DEPRESIÓN El presente estudio identificó clases distintivas de miembros del servicio militar de los EEUU basados en sus experiencias de combate y examinó los resultados en salud mental y las curvas de crecimiento longitudinal del Trastorno de Estrés Postraumático (TEPT) y síntomas depresivos asociados con cada clase. Los participantes fueron 551 miembros en servicio activo que resultaron positivo para TEPT y/o depresión basado en los criterios DSM-IV-R. Todos los participantes completaron la Escala de Experiencias de Combate así como también medidas de TEPT y Depresión, al inicio y a los 3, 6 y 12 meses de seguimiento. Un análisis de grupos latente identificó cuatro clases de miembros del servicio basados en sus experiencias de combate: exposición limitada, exposición médica, exposición de la unidad, y exposición personal. Los miembros del servicio en el grupo de exposición personal se caracterizaron por un perfil distintivo de salud mental: Ellos reportaron, al inicio, niveles más altos de síntomas de TEPT y prevalencias más altas de diagnósticos de lesión traumática cerebral y TEPT durante el curso del estudio. El grupo de exposición limitada tuvo mayor probabilidad de recibir los diagnósticos de depresión y trastorno de adaptación. Todos los grupos, excepto el grupo de exposición médica, demostraron una leve disminución en los síntomas de TEPT y depresión con el tiempo. Sin embargo, los participantes en el grupo de exposición limitada tuvieron una disminución mayor en síntomas de TEPT y depresión al inicio de la atención, pero no demostraron una mejoría mayor de los síntomas a largo plazo a los 12 meses en comparación con los otros grupos. Estos resultados sirven de base para los modelos de desarrollo de TEPT y tienen implicaciones para la detección y manejo clínico de los miembros en servicio expuestos a combate.

Establishing an Evidence Synthesis Capability For Psychological Health Topics in the Military Health System.

BACKGROUND: To promote evidence-based health care, clinical providers and decision makers rely on scientific evidence to inform best practices. Evidence synthesis (ES) is a key component of this process that serves to inform health care decisions by integrating and contextualizing research findings across studies. OBJECTIVE: This paper describes the process of establishing an ES capability in the Military Health System dedicated to psychological health topics. RESEARCH DESIGNS: The goal of establishing the current ES capability was to facilitate evidence-based decision-making among clinicians, clinic managers, research funders, and policymakers, through the production and dissemination of trustworthy ES reports. We describe how we developed this capability, provide an overview of the types of evidence syntheses products we use to respond to different stakeholders, and detail the procedures established for selecting and prioritizing synthesis topics. RESULTS: We report on the productivity, acceptability, and impact of our efforts. Our reports were used by a variety of stakeholders and working groups, briefed to major committees, included in official reports and policies, and cited in clinical practice guidelines and the peer-reviewed literature. CONCLUSIONS: Our experiences thus far suggest that the current ES capability offers a needed service within our health system. Our framework may help inform other agencies interested in developing or sponsoring a similar capability.

Evaluating measures of combat deployment for U.S. Army personnel using various sources of administrative data.

PURPOSE: This study's purpose is to inform future research decisions about optimal measures for identifying combat deployments. We aim to evaluate four commonly utilized measures available in population-level administrative data to identify combat deployments in recent military operations among active duty Army personnel. METHODS: We compare these measures in three ways: (1) agreement (assessing the extent to which soldiers were differentially identified as combat deployed via each measure); (2) validity (calculating the sensitivity of each measure against a criterion measure); and (3) corroboration (examining how each measure predicted subsequent incidence of traumatic brain injury and post-traumatic stress disorder). RESULTS: We found that using personnel records to identify deployments to Iraq, Afghanistan, and/or Kuwait captured over 98% of combat-related deployments identified via self-reported measures. The addition of Kuwait allowed for detection of nearly 100% of battle injuries, improving sensitivity from 94.5% to 99.8%. However, self-reported combat exposure measures showed the largest differential in subsequent incidence of traumatic brain injury and post-traumatic stress disorder. Completeness and accuracy of different combat deployment measures varied significantly. CONCLUSIONS: Using personnel records to identify deployment to Iraq, Afghanistan, and/or Kuwait was the most valid and comprehensive measure of combat deployment. However, self-reported combat exposure measures were more predictive of combat-related outcomes.

Impact of financial reimbursement on retention rates in military clinical trial research: A natural experiment within a multi-site randomized effectiveness trial with active duty service members.

INTRODUCTION: Achieving adequate retention rates in clinical trials is essential to ensuring meaningful results. Although financial reimbursement is an effective strategy to increase participant retention, current policies restrict the use of federal funds to reimburse U.S. active duty Service members for research participation. It is unknown whether permitting financial reimbursement among this population would improve trial retention rates. A recent randomized effectiveness trial received approval to provide reimbursement to Service member participants several months after recruitment began, creating a natural experiment to study the effects of financial reimbursement on retention. MATERIALS AND METHODS: Active duty Service members recruited from six U.S. military treatment facilities (N = 666) were enrolled in a collaborative care study and completed assessments at baseline, three-, six-, and 12-months. Data on study assessment completion rates at three- and six-months were analyzed using the mixed-effects binary logit model to determine the probabilities of completing assessments based on reimbursement status. RESULTS: Participants who received reimbursement were significantly more likely to complete study assessments at both time-points than participants who did not receive reimbursement (p < 0.01). Survey completion was 5% and 4% greater among participants offered reimbursement at three- and six-month time-points, respectively. CONCLUSION: Results suggest that providing Service members with reimbursement for research participation is associated with modest increases in retention rates in clinical trials. Findings provide useful insight for researchers, funding agencies, and policy-makers in considering retention strategies to maximize the value and impact of military research.

Prediction Models for Suicide Attempts and Deaths: A Systematic Review and Simulation.

Importance: Suicide prediction models have the potential to improve the identification of patients at heightened suicide risk by using predictive algorithms on large-scale data sources. Suicide prediction models are being developed for use across enterprise-level health care systems including the US Department of Defense, US Department of Veterans Affairs, and Kaiser Permanente. Objectives: To evaluate the diagnostic accuracy of suicide prediction models in predicting suicide and suicide attempts and to simulate the effects of implementing suicide prediction models using population-level estimates of suicide rates. Evidence Review: A systematic literature search was conducted in MEDLINE, PsycINFO, Embase, and the Cochrane Library to identify research evaluating the predictive accuracy of suicide prediction models in identifying patients at high risk for a suicide attempt or death by suicide. Each database was searched from inception to August 21, 2018. The search strategy included search terms for suicidal behavior, risk prediction, and predictive modeling. Reference lists of included studies were also screened. Two reviewers independently screened and evaluated eligible studies. Findings: From a total of 7306 abstracts reviewed, 17 cohort studies met the inclusion criteria, representing 64 unique prediction models across 5 countries with more than 14 million participants. The research quality of the included studies was generally high. Global classification accuracy was good (≥0.80 in most models), while the predictive validity associated with a positive result for suicide mortality was extremely low (≤0.01 in most models). Simulations of the results suggest very low positive predictive values across a variety of population assessment characteristics. Conclusions and Relevance: To date, suicide prediction models produce accurate overall classification models, but their accuracy of predicting a future event is near 0. Several critical concerns remain unaddressed, precluding their readiness for clinical applications across health systems.

Discrepancies in diagnostic records of military service members with self-reported PTSD: Healthcare use and longitudinal symptom outcomes.

OBJECTIVE: The study compared healthcare utilization and posttraumatic stress disorder (PTSD) symptom trajectories of active duty service members (ADSM) with self-reported PTSD based on whether they had a PTSD diagnosis in the electronic health record (EHR). METHODS: ADSM meeting study criteria for self-reported PTSD (N = 470) were grouped according to EHR-PTSD diagnostic status. Participants completed PTSD symptom assessments over a 12 month period. We used log binomial regression and linear mixed model to examine predictors of receiving an EHR-PTSD diagnosis and to analyze healthcare utilization and symptom trajectories based on diagnostic status. RESULTS: Thirty percent of ADSM with study-identified PTSD had an EHR-PTSD diagnosis. Combat exposure and PTSD severity predicted EHR-PTSD diagnosis. ADSM without the diagnosis were more likely to have an adjustment disorder diagnosis. Participants with an EHR-PTSD diagnosis utilized more healthcare and reported worse PTSD symptoms over 12 months. CONCLUSIONS: Findings suggest providers are more likely to record PTSD diagnoses for more severe, complex cases. While less severe cases may be less likely to receive a PTSD diagnosis, they may still access and benefit from care. Findings have implications for use of EHRs to describe health patterns and inform practices and policy in the Military Health System.

Identifying research gaps in substance use disorder: A systematic methodology and prioritized list.

Background: This paper presents a new methodology for identifying and prioritizing research gaps, contributing to the nascent literature on systematic ways to identify research gaps. Objectives: The goal of this paper is to report on a gaps analysis of substance use disorder (SUD) research. Based on input from Military Health System stakeholders, we selected the following subtopics as priorities: alcohol use disorder (AUD) and comorbid conditions, prescription opioids, and novel synthetic drugs (NSDs), including synthetic cannabinoids, synthetic cathinones, novel synthetic opioids, and e-cigarette use. Methods: Statements of research needs were extracted from authoritative source reports. A work group of 13 subject matter experts then supplemented, consolidated, and refined the statements. Support for each statement was rated based on predetermined metrics to produce a list of high-priority potential research gaps. Work group members searched both published and ongoing research literature to determine whether these potential gaps were sufficiently addressed in the literature. Finally, to prioritize the gaps, work group members rated them on a set of metrics. Results: The work group reduced 175 statements of research needs to a list of 18 final prioritized gaps: nine for AUD, four for prescription opioids, and five for NSDs. For each topic, we present a prioritized list of gaps. Conclusions: This paper describes a method to identify and prioritize research gaps relevant to military and civilian research and presents the prioritized SUD gaps. Our methodology and findings can inform policy makers, researchers, and funding agencies as they consider investments in future research.

Development of Longitudinal Data Analysis in Mental Health Research For Military Service Members.

INTRODUCTION: Since the 1991 Gulf War, mental health conditions of military Service members have received increasing public attention and are a major focus for the U.S. government. A substantial proportion of military health research has been devoted to examining the pattern of change over time in mental health symptoms and diagnostic status among Service members. Unfortunately, many researchers continue to use somewhat obsolete methods to analyze trends and transitions in mental health, despite advances in statistical methodology that permit attention to the unique features inherent in longitudinal data. MATERIALS AND METHODS: This article defines and describes data features and structures, and basic specifications of longitudinal data analysis to military health researchers. In particular, we highlight the respective impacts of missing data and intra-individual correlation on longitudinal data analysis. Based on the descriptions of the basic features in longitudinal data, we introduce several popular techniques to analyze a variety of longitudinal data types. RESULTS: We demonstrate that traditional analytic techniques do not properly account for missing data and intra-individual correlation inherent in longitudinal data. Failure to use correct, appropriate models and methods can result in major bias in analytic results and mental health predictions. CONCLUSIONS: Failure to use correct, appropriate models and methods in longitudinal data analysis can have unfortunate repercussions on a military health system that needs accurate findings to support valid policy decisions. By applying adequate models and methods, military health researchers will be able to better understand the complex interactions of biological, psychological, and social factors on mental health trends and transitions among military Service members.

A randomized controlled trial of a manual-only treatment for reduction and cessation of problematic caffeine use.

BACKGROUND: Caffeine Use Disorder was added to DSM-5 as a diagnosis for further research, but few studies have been conducted to identify effective treatments. This randomized, controlled clinical trial examined the efficacy of a manual-only treatment program for caffeine cessation and reduction among individuals seeking treatment for problematic caffeine use. METHODS: Individuals meeting at least two proposed DSM-5 diagnostic criteria for Caffeine Use Disorder were randomly assigned to receive either immediate treatment or treatment delayed by 7 weeks. The treatment consisted of a manual containing information about caffeine and instructions for gradually reducing caffeine consumption over a period of 6 weeks, with no counseling or additional support. Caffeine consumption and caffeine-related distress were assessed before treatment, 7 weeks after receiving the treatment manual (end-of-treatment), and 20 weeks post-treatment. RESULTS: The manual-only treatment resulted in significant reductions in participants' self-reported caffeine consumption and caffeine-related distress at end-of-treatment that were sustained at 20-weeks post-treatment. Salivary caffeine levels and community observers corroborated the self-reported reductions in caffeine consumption. Comparisons between the immediate and delayed treatment groups suggest the reductions in caffeine consumption were attributable to the manualized treatment rather than spontaneous with the passage of time. CONCLUSIONS: The present study provides evidence that a gradual caffeine reduction and cessation program may be successfully implemented using a manual-only approach. This time- and cost-effective intervention may be easily adopted by practitioners with limited time or experience with behavioral interventions who want to encourage their patients to reduce caffeine consumption.

Population Impact of PTSD and Depression Care for Military Service Members: Reach and Effectiveness of an Enhanced Collaborative Care Intervention.

Objective: Epidemiologic studies suggest high rates of posttraumatic stress disorder (PTSD) and depression among military members and veterans. To meet the needs of this population, evidence-based treatments are recommended as first-line interventions, based on their clinical efficacy and not the proportion of the target population that the intervention reaches. We apply a public health framework to examine the population impact of an enhanced collaborative care model on a targeted population that takes into account effectiveness and reach. METHODS: Using data collected from a 2012 - 2016 randomized trial, the effectiveness of enhanced collaborative care for PTSD and depression was evaluated using probable diagnostic status as the primary outcome. Exclusion criteria were then applied to a 2011 disease registry to examine the representativeness of the trial sample and estimate the potential reach of the intervention. Population impact was derived from the estimated effectiveness and reach of the intervention. RESULTS: Enhanced collaborative care was associated with a significantly greater probability of PTSD/depression remission by the end of the trial (conditional effect = -0.066, chisq = 51.1, p < 0.001). Based on the effectiveness and reach of the enhanced intervention, an estimated 250 (out of the 3,436) more Army soldiers with PTSD and/or depression would experience diagnostic remission during the preceding year if the enhanced model was available. CONCLUSION: The population framework permits the estimated differential impact of two collaborative care models to inform implementation considerations. These results highlight the value of applying public health models to identify front line treatments.