Mental healthcare utilisation among Danish formerly deployed military personnel and their civilian counterparts: a cohort study.

Background: Prior studies comparing the mental healthcare utilisation (MHU) of Danish formerly deployed military personnel (FDP) with the general population have not included data on psychotherapy through the Defence or talking therapy with the general practitioner. This study included these and several other data sources in a comprehensive comparison of MHU between Danish FDP and civilians.Methods: First-time deployed military personnel (N = 10,971) who had returned from a mission to Kosovo, Afghanistan, Iraq or Lebanon between January 2005 and July 2017 were included. A sex and birth-year-matched civilian reference group was randomly drawn from the entire Danish non-deployed population (N = 253,714). Furthermore, a sub-cohort, including male FDP and civilians deemed eligible for military service, was defined. These cohorts were followed up in military medical records and registers covering the primary and secondary civilian health sectors from 2005 to 2018, and the rates of MHU were compared.Results: Approximately half of the initial help-seeking for FDP took place through the Defence (49.4%), and the remainder through the civilian healthcare system. When help-seeking through the Defence was not included, MHU was significantly lower among FDP in the main cohort during the first two years (IRR = 0.84, 95% CI: [0.77, 0.92]) compared to civilians. When help-seeking through the Defence was included, MHU was significantly higher among FDP compared to civilians both in the first two years of follow-up (IRR = 2.01, 95% CI: [1.89, 2.13]) and thereafter (IRR = 1.18, 95% CI: [1.13, 1.23]). In the sub-cohort, these differences were even more pronounced both in the first two years of follow-up and thereafter.Conclusions: MHU was higher among Danish FDP compared to civilians only when data from the Defence was included. The inclusion of data on both civilian and military healthcare services is necessary to evaluate the full impact of deployment on MHU among Danish FDP.

This study compared mental healthcare utilisation among Danish deployed military personnel and civilians.Most personnel sought help first through the Defence.When all data sources were included, mental healthcare utilisation was significantly higher among military personnel.

Pooled analysis of all-cause and cause-specific mortality among Nordic military veterans following international deployment.

OBJECTIVES: To investigate all-cause and cause-specific mortality risks, including deaths from external, cardiovascular and cancer causes, among deployed Nordic military veterans in comparison to the general population in each country. DESIGN: Pooled analysis. SETTING: Denmark, Norway, Finland and Sweden. PARTICIPANTS: Military veterans deployed between 1990 and 2010 were followed via nationwide registers and compared with age-sex-calendar-year-specific rates in the general population using pooled standardised mortality ratios (SMRs). MAIN OUTCOMES: All-cause and cause-specific mortality retrieved from each country's Causes of Death Register, including deaths from external, cardiovascular and cancer causes. RESULTS: Among 83 584 veterans 1152 deaths occurred of which 343 were from external causes (including 203 suicides and 129 traffic/transport accidents), 134 from cardiovascular causes and 297 from neoplasms. Veterans had a lower risk of death from any cause (pooled SMR 0.58, 95% CI 0.52 to 0.64), external causes (0.71, 95% CI 0.64 to 0.79), suicide (0.77, 95% CI 0.67 to 0.89), cardiovascular causes (0.54, 95% CI 0.46 to 0.64) and neoplasms (0.78, 95% CI 0.70 to 0.88). There was no difference regarding traffic/transport accidents for the whole period (1.10, 95% CI 0.92 to 1.31) but the pooled point estimate was elevated, though not statistically significant, during the first 5 years (1.17, 95% CI 0.89 to 1.53) but not thereafter (1.01, 95% CI 0.77 to 1.34). For all other causes of death, except suicide, statistically significantly lower risk among veterans was observed both during the first 5 years and thereafter. For suicide, no difference was observed beyond 5 years. Judged from the country-specific SMR estimates, there was a high degree of consistency although statistically significant heterogeneity was found for all-cause mortality. CONCLUSIONS: Nordic military veterans had lower overall and cause-specific mortality than the general population for most outcomes, as expected given the predeployment selection process. Though uncommon, fatal traffic/transport accidents were an exception with no difference between deployed military veterans and the general population.

Deployment experiences and mental health problems as predictors of post-deployment unemployment length: a prospective, register-based study among Danish soldiers.

OBJECTIVES: To test responses of formerly deployed soldiers (FDS) to a questionnaire on deployment experiences in combination with screening levels of post-traumatic stress disorder (PTSD) and depression approximately 6 months after homecoming as predictors of the subsequent probability of gaining employment when unemployed within 5 years post-deployment. DESIGN, SETTING AND PARTICIPANTS: Danish FDS responders (n=3935) and non-responders (n=3046) to a 6-month post-deployment screening questionnaire after returning from a first-ever deployment to Kosovo, Iraq or Afghanistan (2002 to 2012) were included in the study and followed in public registers from 6 months to 5 years post-deployment. PRIMARY AND SECONDARY OUTCOME MEASURES: We tested Cox regression models including deployment experiences (1a), screening levels of PTSD and depressive symptoms (1b), and their combination (2) for FDS responders. For all FDS, a secondary model included a measure on whether they responded to the questionnaire (3). RESULTS: Neither the deployment experiences (1a) of exposure to danger and combat (HR=1.00, 95% CI=0.97 to 1.03) and witnessing consequences of war (HR=1.01, 95% CI=0.96 to 1.06), or the screening levels (1b) of PTSD (HR=1.06, 95% CI=0.84 to 1.33) and depressive symptoms (HR=0.82, 95% CI=0.64 to 1.06) were significant predictors of transitioning from unemployment to employment. Similar results were found for the combined model (2). A tendency among non-respondents (3) to have a lower probability of transitioning from unemployment to employment was found (HR=0.90, 95% CI=0.81 to 1.00). CONCLUSION: Deployment experiences, PTSD and depressive symptoms, as measured at 6-month screening questionnaire, did not predict differences in the probability of gaining employment when unemployed within 5 years post-deployment. However, the findings suggest that those with the least probability of transitioning from unemployment to employment can be found among the non-responders to the post-deployment screening questionnaire.

Low-level cognitive ability in young adulthood and other risk factors of depression in an observational cohort study among deployed Danish soldiers.

PURPOSE: Evidence exists of an association between pre-morbid lower cognitive ability and higher risk of hospitalization for depressive disorder in civilian cohorts. The purpose of this study was to examine the relationship of cognitive ability at conscription with post-deployment depression and the influence of (1) baseline factors: age, gender, and pre-deployment educational level, (2) deployment-related factors: e.g., war-zone stress and social support, and (3) co-morbid PTSD. METHODS: An observational cohort study linking conscription board registry data with post-deployment self-report data. The study population consisted of Danish Army military personnel deployed to different war zones from 1997 to 2015. The association between cognitive ability at conscription and post-deployment depression was analyzed using repeated-measure logistic regression models. RESULTS: Study population totaled 9716 with a total of 13,371 deployments. Low-level cognitive ability at conscription was found to be weakly associated with post-deployment probable depression after adjustment for more important risk factors like gender, education, and deployment-related factors [odds ratio (OR) 0.93, 95% confidence interval (CI) 0.88-0.99]. The co-occurrence rate with PTSD was nearly 60%. When adding co-morbid PTSD as an independent variable, the association between cognitive ability and probable depression became insignificant, OR 0.95, CI 0.89-1.02. CONCLUSIONS: Low cognitive ability at conscription is a risk factor for depression among returning military personnel, but unimportant compared to gender, education, and deployment-related factors. Part of this effect may be related to co-morbid PTSD. Use of cognitive ability score as an isolated selection tool cannot be recommended because of low predictive performance.

Increased Postdeployment Use of Medication for Common Mental Disorders in Danish Gulf War Veterans.

BACKGROUND: Gulf War veterans (GWVs) have an elevated risk of reporting symptoms of mental disorders as compared with nondeployed military controls. A difficulty in the Gulf War health research is that most health outcomes are self-reported; therefore, it is highly relevant to study objective outcomes in this line of research. The Danish National Prescription Registry provides an opportunity to use the prescription of drugs as an objective evaluation of the impact of mental health disorders at the individual level. In this study, we investigated the prescription of drugs and postdeployment hospitalizations for mental disorders among GWVs compared with a control population of nonveterans (NVs). METHODS: A prospective registry study including a cohort of 721 GWVs and a control cohort of 3,629 NVs. Main outcome measures were incidence of (1) use of antidepressants, (2) use of anxiolytic/hypnotic medication, and (3) number of postdeployment psychiatric contacts. The association between outcomes and GWVs status was studied by using time-to-event analysis. The index date was the return date from the last deployment to the Gulf. The follow-up period was the time from index date until December 31, 2014. FINDINGS: GWVs had an elevated average risk over time for use of both types of medication compared with NV. For use of antidepressants the average hazard rate (HR) was 2.56, with 95% confidence interval (CI) = 2.04-3.21 (p < 0.0001); for use of anxiolytic/hypnotic medication the corresponding results were HR = 1.78, CI = 1.37-2.31 (p < 0.0001). The interaction with time was statistically significant with HR increasing with time for both outcomes. Incident use of antidepressants in GWVs after 10 years was two times higher than among NV, after 20 years it was nearly four times higher than among NV. Incident use of anxiolytic/hypnotic medication was one and a half that of NV after 10 years, but nearly three times that of NV after 20 years. There was no difference in rate of postdeployment psychiatric contacts. DISCUSSION/IMPACT/RECOMMENDATIONS: The findings of increased use of antidepressants and anxiolytic or hypnotic medicine among GWVs compared with NVs were rather surprising since we recently, by using the same study population, found that deployment to the Persian Gulf was not associated with increased sickness absence or reduced labor market attachment. However, our results indicate that the mental health of the Danish GWVs is worse than in NV, and that this unfavorable difference increased with time. A possible explanation is that veterans have a high motivation for being in work, and that the deployment-related mental problems they may have acquired do not impair their ability to work, when treated properly. Furthermore, registry-based research in GWVs could include other outcomes, e.g., the use of pain medication, and other military comparison groups, e.g., veterans deployed to other areas than the Persian Gulf in addition to NV. The method of surveillance of military personnel with register data pertinent to health and monitoring outcomes compared with suitable control populations is highly recommended as a tool in the prevention of deployment-related health problems.

Association between the intake of α-linolenic acid and the risk of CHD.

The intake of the mainly plant-derived n-3 PUFA α-linolenic acid (ALA) has been reported to be associated with a lower risk of CHD. However, the results have been inconsistent. Therefore, the objective of the present study was to examine the association between the intake of ALA and the risk of CHD. Potential effect modification by the intake of long-chain n-3 PUFA (n-3 LCPUFA) was also investigated. Data from eight American and European prospective cohort studies including 148 675 women and 80 368 men were used. The outcome measure was incident CHD (CHD event and death). During 4-10 years of follow-up, 4493 CHD events and 1751 CHD deaths occurred. Among men, an inverse association (not significant) between the intake of ALA and the risk of CHD events and deaths was observed. For each additional gram of ALA consumed, a 15 % lower risk of CHD events (hazard ratios (HR) 0·85, 95 % CI 0·72, 1·01) and a 23 % lower risk of CHD deaths (HR 0·77, 95 % CI 0·58, 1·01) were observed. No consistent association was observed among women. No effect modification by the intake of n-3 LCPUFA was observed.

Dietary α-linolenic acid, linoleic acid, and n-3 long-chain PUFA and risk of ischemic heart disease.

BACKGROUND: n-3 (omega-3) PUFA has been proposed as having health-promoting effects, primarily in relation to ischemic heart disease (IHD). Whether these benefits can be achieved by both α-linolenic acid (ALA, 18:3n-3) and n-3 long-chain PUFA (LC-PUFA) is debatable. OBJECTIVE: The objective was to examine the association between ALA intake and risk of IHD in healthy subjects and to see if this was modified by intake of n-3 LC-PUFA or linoleic acid (LA, 18:2 n-6). DESIGN: This was a prospective cohort study of 3277 healthy Danish women and men free of known IHD. RESULTS: Four hundred seventy-one cases of IHD were observed during a median follow-up period of 23.3 y. Higher intake of ALA was not significantly associated with decreased risk of IHD among women or men. Although the HR of IHD was stepwise decreased with increasing ALA intake in men [0.84 (95% CI: 0.62, 1.14) in the medium compared with the lowest tertile (reference) and 0.83 (95% CI: 0.56, 1.24) in the highest compared with the lowest tertile], this change was far from significant (P-trend: 0.39). No evidence of effect modification by n-3 LC-PUFA or LA was observed. High n-3 LC-PUFA intake, in comparison with low intake, was inversely associated with risk of IHD; this trend was significant in women (P = 0.04; HR: 0.62; 95% CI: 0.40, 0.97) but not in men (P = 0.15; HR: 0.74; 95% CI: 0.51, 1.06). No associations were observed between intake of LA and risk of IHD. CONCLUSION: This study suggests that there is no association between ALA intake and risk of IHD, but a high intake of n-3 LC-PUFA had a significant cardioprotective effect in women.