Combat and operational stress programs and interventions: A scoping review using a tiered prevention framework.

Beginning in 1999, Department of Defense policy directed the military services to develop Combat and Operational Stress Control (COSC) programs to address prevention, early identification, and management of the negative effects of combat and operational stress. The aim of this study is to provide a narrative review of COSC programs and organize them into a prevention framework to clarify gaps and future directions. A systematic search was conducted to identify studies between 2001 and 2020 in peer-reviewed articles or government-sponsored reports describing an evaluation of COSC programs. The target population of these programs was US service members who had participated in an intervention designed to address combat or operational stress in a deployed, operational, or field setting. These programs then were rated for level of evidence and categorized using a tiered prevention model. This search identified 36 published evaluations of 19 COSC programs and interventions from. Most programs were described as effective in addressing target outcomes, with behavioral health outcomes reported for 13 of the 19 identified programs; the remaining six focused on knowledge base and behavior changes. Delivery of these prevention programs also ranged from peer-based implementation to formal treatment, including programs at all prevention levels. COSC interventions show promise for helping service members manage stress, with more than half of the programs showing evidence from studies using randomized designs. Future iterations of COSC program evaluations should explore the development of a joint curriculum using existing content in a tiered prevention framework.

Outcome metrics utilized in evaluations of programs and interventions for combat and operational stress: A review of psychometric properties.

The Department of Defense has mandated combat and operational stress control (COSC) efforts for the Services since 1999. Although several COSC-related programs have been implemented, few have undergone evaluation, and no standardized metrics have been established to assess their effectiveness and utility. The purpose of this review was to characterize the content and psychometrics of measures that have been utilized as outcome metrics in evaluations of COSC-related programs and interventions. Systematic literature searches were conducted for publications that: a) evaluated at least one measure from U.S. service members who participated in a program or intervention to prevent or reduce the adverse effects of combat and operational stress; and b) reported U.S. data on the internal consistency, test-retest reliability, convergent validity, and sensitivity/specificity of the identified measures. This process identified 15 measures for which psychometric properties were reviewed for acceptability based on recommended criteria. Identified measures varied from well-validated measures to newer instruments for which more data is needed on one or more of the target psychometric properties. Aside from internal consistency, psychometric data from U.S. military samples were sparse. Results further suggested that some measures might have reduced sensitivity in service members under certain conditions, such as large-scale screening. Additional studies are needed to validate COSC-relevant measures in service members. Future evaluations of programs and interventions for combat and operational stress should select measures that will increase the consistency of the literature, allow comparisons across studies, and ensure alignment with the objectives of identified programs.

Military chaplains and mental health clinicians: Overlapping roles and collaborative opportunities.

Military chaplains and mental health clinicians have unique professional roles and functions within the Department of Defense. However, they also have intersecting roles in delivering care to service members with mental health issues. Although diagnosis and treatment of clinical disorders is the primary focus of mental health clinicians, military chaplains are often the first contact made by service members seeking help for mental health concerns, due in part to issues of greater accessibility, ensured confidentiality, and less stigma. There is growing recognition of the importance of spirituality in the well-being and readiness of service members, as many mental health issues have a spiritual dimension. As a result, chaplains and mental health clinicians often address many of the same issues, albeit with different approaches. This review examines overlap in the work of chaplains and mental health clinicians and contrasts their complementary treatment approaches. These overlapping issues and complementary approaches highlight the potential for greater collaboration between these two professional groups, which could be beneficial for the care of service members. (PsycInfo Database Record (c) 2023 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).

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.

More than expected? Assessing departures from additivity in health care utilization after mild traumatic brain injury in military personnel with pre-existing mental health conditions.

OBJECTIVE: Prior research indicates that there is an additive association between traumatic brain injury and mental health diagnoses on health-care utilization. This assumed additivity has not been formally assessed. The objective of this study was to estimate additive and multiplicative interactions associated with mild traumatic brain injury (mTBI) and pre-existing health conditions. METHOD: Active-duty military patient records over a nine-year period were sampled within four exposure groups (N = 4500 per group) defined jointly by incident mTBI and pre-existing mental health diagnoses. Outpatient and inpatient health encounters were compared between the four exposure groups using generalized linear models for count and proportion outcomes. Additive interactions were estimated using the interaction contrast ratio. Multiplicative interactions were estimated as a product term in the generalized linear models. RESULTS: The joint association of mTBI and pre-existing mental health diagnoses with health-care utilization, overall, was less than multiplicative and greater than additive. Patients with both exposures experienced more health-care utilization than expected under the assumed additivity (independence) of the two exposures. PTSD and anxiety diagnoses were the MH diagnoses associated with the largest interaction contrast values specific to total outpatient encounters. CONCLUSIONS: Studies of the interaction of two diagnoses on subsequent health-care utilization should examine both additive and multiplicative interactions. The greater-than-additive findings in this study indicate that there may be synergy, for at least some patients, between mTBI injury and mental health that complicates the treatment course.

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.

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.