Opiate-related dependence/abuse and PTSD exposure among the active-component U.S. military, 2001 to 2008.

BACKGROUND: Over the past 5 years, diagnoses for opiate abuse or dependency and post-traumatic stress disorder (PTSD) have increased across all U.S. military services. Moreover, in the United States, opiate prescription dependence and abuse has now surpassed all other illicit drugs of abuse with the exception of marijuana. Some research indicates that PTSD is predictive of substance dependence and abuse, while other research suggests that substance dependence and abuse may lead to events that trigger PTSD. This dichotomy has not been extensively explored within a military population. METHODS: Using conditional multiple logistic regression analysis, a matched case-control study with 18,606 active-component U.S. military service members was conducted to examine the relationship between opiate dependence or abuse and PTSD. RESULTS: Among the 18,606 service members included in the analysis, 21% were cases and 79% were controls. Thirteen percent of service members with substance dependence or abuse diagnosis had a prior PTSD diagnosis compared to 1% of controls. After, adjusting for sociodemographic and military characteristics, the odds of having a prior diagnosis of PTSD was 28 (95% CI: 21.24-37.78) times greater for service members with opiate abuse/dependency compared to controls. CONCLUSION: These findings suggest active duty military personnel diagnosed with PTSD should be closely monitored to reduce the likelihood of future morbidity because of opiate dependence or abuse.

An epidemiological assessment of reintegration and behavioral health risk at Joint Base Lewis-McCord, Washington.

Soldiers from a brigade at Joint Base Lewis-McChord, Washington, were alleged to have committed numerous crimes, including murder of civilians, during a recent deployment. This study was done to assist the command with (1) analyzing the climate and challenges facing redeploying Soldiers; (2) assessing behavioral risk at both individual and unit levels through targeted reintegration screening; and (3) recommending mitigating strategies to enhance current reintegration processes and reduce the level of high-risk behavior among Soldiers following deployment. The findings from this public health investigation suggest levels of risk and major areas of concern during the redeployment period varied across battalions within the brigade and that risk stratification postdeployment was not correlated with discernible differences in predeployment indicators. Acts of violence were limited to the deployment and immediate postdeployment periods and were allegedly perpetrated by a very small number of Soldiers.

An examination of successful soldier postdeployment transition from combat to garrison life.

Previous studies have shown that combat exposures and deployment-related stressors have negative implications on soldiers' postdeployment health and well-being. The current study aimed to examine the individual and combined effects of organizational and social support on the success of soldiers' postdeployment reintegration. In this study, 2,922 U.S. soldiers were surveyed from a brigade combat team at 90-120 days postdeployment, measuring soldiers' perceptions of postdeployment transition home, occupational and social support, stigma and barriers associated with accessing behavioral health care, and previous behavioral health care. Logistic regression analysis indicated that soldiers reporting a positive postdeployment transition home (n = 1,776; 61%) was significantly associated with leadership perceptions, adjusted odds ratio (AOR) = 1.19, 95% confidence interval (CI) [1.02, 1.39], unit cohesion, AOR = 1.29, 95% CI [1.09, 1.53], personal support, AOR = 1.37, 95% CI [1.23, 1.52], perceived levels of stigma, AOR = 0.73, 95% CI [0.65, 0.82] barriers to accessing care, AOR = 0.86, 95% CI [0.76, 0.97], and previously accessing behavioral health care, AOR = 0.34, 95% CI [0.28, 0.43]. These findings suggest redeploying soldiers may benefit from programs aimed at improving self-efficacy and coping through fostering occupational and social support, with special concern taken to reduce stigma and barriers to care across the Army.

Assessment of subthreshold and developing behavioral health concerns among U.S. army soldiers.

This study aimed to merge existing methodologies of identifying high-risk soldiers to create a comprehensive testable model to assist leaders in the identification, mitigation, and prevention of negative behavioral health (BH) issues. In 2011, a total of 2,664 active duty U.S. Army soldiers completed a survey of demographic and military characteristics, combat exposures, and BH diagnoses and symptoms. Multivariable linear and logistic regression models were fit to examine the relationship between demographic and military characteristics, subthreshold behavioral and social health issues, and positive screening for BH symptoms. The "recent loss of someone close" and self-reporting a history of BH issues were the strongest and most consistent predictors of subthreshold behavioral and social health issues. This study found that individual and occupational factors were associated with subthreshold behavioral and social health issues, which were in turn, associated with screening positive for BH symptoms. The recent loss of someone close (an indicator of grief and loss) was not the study's primary research question, but warrants further investigation to determine its impact on the mental well-being of soldiers.

The association between combat exposure and negative behavioral and psychiatric conditions.

This study evaluated the association between cumulative combat exposures and negative behavioral and psychiatric conditions. A total of 6128 active-duty soldiers completed a survey approximately 6 months after their unit's most recent combat deployment. The soldiers self-reported combat exposures and behavioral and psychiatric conditions. Multivariable logistic regression was used to assess the association between cumulative combat exposures and behavioral and psychiatric outcomes. In comparison with the referent group of soldiers not previously deployed, the soldiers categorized as having the highest cumulative combat exposures were significantly associated with self-reporting a history of behavioral and psychiatric diagnoses, problematic alcohol misuse, aggression, criminal behavior, and physical altercations with a significant other. The magnitude and the consistency of the association among the soldiers with the highest number of combat exposures suggest that the number of cumulative combat deployment exposures is an important consideration for identifying and treating high-risk soldiers and units returning from combat.

The association between US Army enlistment waivers and subsequent behavioral and social health outcomes and attrition from service.

Soldiers granted enlistment waivers for medical concerns, misconduct, or positive alcohol/drug tests may or may not be associated with an increased likelihood of negative behavioral outcomes. Soldiers in the population examined (n = 8,943) who were granted enlistment waivers from 2003 to 2008 were significantly more likely to subsequently be screened for alcohol/substance abuse, test positive for illicit substances, or receive an Army separation for behavioral misconduct. These associations were highest among Soldiers granted waivers for nonlawful alcohol/drug violations. Soldiers granted waivers for felony offenses and serious nontraffic violations were significantly less likely to separate from the Army compared with Soldiers not granted enlistment waivers.

Prevalence of childhood trauma among U.S. Army soldiers with suicidal behavior.

In 2009, suicide was reported to be the third leading cause of death among U.S. Army personnel. The increase of suicides in the Army indicates the need for additional research to better understand the problem. Research in civilian populations found that experiencing childhood trauma increases the risk for various negative health outcomes, including suicide and suicide attempts, during adulthood. To date, there has been very little focus on pre-existing mental health before joining the service because of a lack of existing data. Participants were active duty Army Soldiers who attempted or completed suicide as identified by the Department of Defense Suicide Event Report. Among Soldiers exhibiting suicidal behavior, analyses were completed to identify significant associations with specific types of childhood trauma experienced before joining the Army. The prevalence of childhood trauma in this population was 43.3% among the suicide cases and 64.7% among the attempt cases. The most common types of childhood trauma among Soldiers were family problems and abuse. The need for further research among military populations is clear given the high prevalence of childhood trauma found among these Soldiers with suicidal behavior and the lack of complete data for this population.

Interaction of combat exposure and unit cohesion in predicting suicide-related ideation among post-deployment soldiers.

Suicide is one of the leading causes of death among U.S. Army soldiers. Suicide-related ideation, which is associated with suicide attempts and suicide, can cause considerable distress. In a sample of 1,663 recently redeployed soldiers, we used factor analysis and structural equation modeling to test the associations between combat exposure, unit cohesion, and their interaction in predicting suicide-related ideation. We found that combat exposure was a significant risk factor for suicide-related ideation, while unit cohesion was a significant protective factor. The significant interaction between the two factors indicated that soldiers who experienced greater combat exposure but also had higher levels of unit cohesion had relatively lower levels of suicide-related ideation. In addition, those who had higher levels of combat exposure and lower unit cohesion were most at risk for suicide-related ideation. Our findings indicate the importance of unit cohesion in protecting soldiers from suicide-related ideation and suggest a higher risk group of soldiers who should be targeted for interventions.

Factors associated with physical aggression among US Army soldiers.

There are a growing number of studies that have approximated levels of aggression and associated outcomes among combat veterans returning from Iraq and Afghanistan using brief screening assessments. However, further research to evaluate the relative role of combat exposures and overt physical behaviors is required to further elucidate potential associations between military service, combat deployment, and overt physical aggression. The purpose of the current study was to assess the prevalence of self-reported physical aggression in a sample of US Army soldiers using an adaptation of the Revised Conflict Tactics Scale (CTS2), and examine factors associated with higher levels of aggression. A population-based cross-sectional study was conducted at a single US Army Installation within a sample of active duty US Army soldiers (n = 6,128) from two large units. Anonymous surveys were collected 6 months following deployment to measure overt aggressive behaviors, posttraumatic stress disorder, anxiety, depression, traumatic brain injury, and misuse of alcohol. There were a relatively higher number of minor and severe physical overt aggressive actions reported among soldiers who previously deployed, notably highest among deployed soldiers reporting the highest levels of combat intensity. Soldiers screening positive for the misuse of alcohol were also significantly more likely to report relatively higher levels of physical aggression. This study quantified overt aggressive behaviors and associated factors, showing increasing combat exposures may result in increased physical aggression. Clinicians treating service members returning from combat may consider assessing relative levels of combat.

An epidemiologic investigation of homicides at Fort Carson, Colorado: summary of findings.

In response to an apparent clustering of homicides at Fort Carson, Colorado, the U.S. Army Public Health Command (formerly the U.S. Army Center for Health Promotion and Preventive Medicine) Behavioral and Social Health Outcomes Program conducted a multidisciplinary epidemiologic consultation to identify factors contributing to violent behavior among soldiers at Fort Carson. This article summarizes the findings of the epidemiologic consultation report as provided to the Secretary of the Army and the Fort Carson Senior Mission Commander and released in its entirety publicly July 2009 and elaborates on the mixed-methods analytic approach used to study a complex behavioral issue at the community level. To aid in answering the key study questions, six study arms were designed and carried out: (1) index case analysis, (2) confinee interviews, (3) analysis of installation-level trends, (4) retrospective cohort analysis, (5) soldier focus groups and interviews, and (6) aggression risk factors survey. Although not conclusive, the findings suggest a combination of individual, unit, and environmental factors converged to increase the risk of violent behaviors, which made clustering of negative outcomes more likely.

Mental health risk factors for suicides in the US Army, 2007--8.

OBJECTIVE: Suicides among active duty US Army personnel have been increasing since 2004, surpassing comparable civilian rates in 2008. This analysis uses US military data to assess suicide rates for the 2-year period 2007--8, and examines relative risks (RR) of suicide associated with mental health disorders. METHODS: Historical trends of US Army suicides were assessed using 1977--2008 data from Army G-1 (Personnel). Suicide rates, RR and the 2000--8 trends of mental health disorders were calculated using data from the Defense Casualty Information Processing System and Defense Medical Surveillance System. RESULTS: A total of 255 soldiers committed suicide in 2007--8 (2008 rate 20.2 per 100 000). Factors associated with higher suicide risk included male gender, lower enlisted rank and mental health disorders treated on an outpatient basis (RR 3.9), as well as a number of mental health disorders (mood disorders, anxiety disorders, post-traumatic stress disorder, personality/psychotic disorders, substance-related disorders and adjustment disorder; RR range 4.7--24.5). Analysis of historical trends suggested that 25--50% of the suicides that occurred in 2008 might have been related to the major commitment of troops to combat beginning in 2003. CONCLUSIONS: The recent increase in suicides parallels an increase in the prevalence of mental disorders across the army. This finding suggests that increasing rates of clinically treated psychopathology are associated with increasing rates of suicides; these rates probably serve as sentinels for suicide risk in this population. Soldiers seeking treatment for mental disorders and substance abuse should be a focus for suicide prevention.

The association between deployment-related posttraumatic growth among U.S. Army soldiers and negative behavioral health conditions.

OBJECTIVES: This study assessed posttraumatic growth (PTG) in a sample of U.S. Army Soldiers using the Post-Traumatic Growth Inventory (PTGI), and the relationship between PTG and negative behavioral health (BH) conditions. DESIGN: A sample of Soldiers with prior combat deployment experience (n = 1,834) completed an anonymous survey including demographics, the PTGI, and negative BH conditions. RESULTS: Among previously deployed Soldiers, those reporting the highest number of combat experiences also reported significantly higher overall PTG. A significant inverse relationship was observed between PTG and recent suicidal ideation, whereby Soldiers reporting recent suicidal ideation reported significantly lower overall PTG. CONCLUSIONS: This study quantified PTG resulting from deployment and demonstrated the degree to which combat experiences might result in PTG.

Psychiatric and general medical conditions comorbid with schizophrenia in the National Hospital Discharge Survey.

OBJECTIVE: Morbidity and mortality from general medical conditions are elevated among patients with schizophrenia compared with the general U.S. population. More than 50% of patients with schizophrenia have one or more comorbid psychiatric or general medical conditions. This study determined types of comorbid disorders and their prevalence among hospitalized patients with and without schizophrenia. METHODS: Data from the National Hospital Discharge Survey, a nationally representative sample, were analyzed for 1979-2003 (N=5,733,781 discharges). For discharges of patients aged 15 to 64 with at least one comorbid condition, the conditions of those with a primary diagnosis of schizophrenia (N=26,279) were compared with those with other primary diagnoses (N=1,936,876). Proportional morbidity ratios (PMRs) were calculated. RESULTS: The proportion of discharges listing schizophrenia, particularly schizoaffective disorder, increased significantly over time among both males and females. The proportion was higher among males, blacks, and discharges in the Northeast. Discharge records with a primary diagnosis of schizophrenia showed higher proportions of all comorbid psychiatric conditions examined and of some general medical conditions, including acquired hypothyroidism (PMR=2.9), contact dermatitis and other eczema (PMR=2.9), obesity (PMR=2.0), epilepsy (PMR=2.0), viral hepatitis (PMR=1.4), diabetes type II (PMR=1.2), essential hypertension (PMR=1.2), and various chronic obstructive pulmonary diseases (PMR range 1.2-1.5). CONCLUSIONS: Knowledge of the risks of comorbid psychiatric and general medical conditions is critical both for clinicians and for patients with schizophrenia. Closer attention to prevention, early diagnosis, and treatment of comorbid conditions may decrease associated morbidity and mortality and improve prognosis among patients with schizophrenia.

Assessment of recruit motivation and strength study: preaccession physical fitness assessment predicts early attrition.

BACKGROUND: The Assessment of Recruit Motivation and Strength (ARMS) study was designed to pilot-test the use of a physical fitness screening tool for Army applicants before basic training. METHODS: The ARMS test consists of two components, namely, a 5-minute step test and push-ups. Attrition among 7,612 recruits who underwent preaccession ARMS testing and began service between May 2004 and December 2005 was studied. RESULTS: ARMS test performance was found to be significantly related to risk of attrition within 180 days; the hazard ratios for failing relative to passing the ARMS test were 2.27 (95% confidence interval, 1.70-3.04) among female subjects and 1.36 (95% confidence interval, 1.13-1.64) among male subjects. The attributable risk of attrition associated with failing the ARMS test was approximately 40% among female subjects and approximately 30% among male subjects. DISCUSSION: The ARMS study is the first prospective study conducted in the U.S. Army to assess physical fitness before accession. Physical fitness and motivation to serve were shown to correlate with attrition during initial entry training.

Retention of mild asthmatics in the navy (REMAIN): a low-risk approach to giving mild asthmatics an opportunity for military service.

OBJECTIVE: Rising U.S. asthma prevalence will be reflected in military applicants. We studied retaining mild asthmatics on active duty. METHODS: A cohort study at Great Lakes Naval Training Center from 2000 to 2002 compared recruits diagnosed during basic training with mild asthma to matched comparison recruits on outpatient visits, hospitalizations, and discharge through August 2003. RESULTS: A total of 136 asthmatic and 404 control subjects were enrolled. Overall attrition was greater among the asthma cohort (p < 0.01), largely during training. Asthmatics used more health care than controls during training (0.1 vs. 0.004 per person-month). No asthma-related hospitalizations or deaths occurred during the study. CONCLUSIONS: Although attrition during recruit training was higher in mild asthmatics, nearly 40% of recruits were retained on active duty without significant risk of hospitalization or excessive outpatient treatment after recruit training. These findings argue for consideration of a trial on active duty for recruits with mild asthma.

Selected infectious agents and risk of schizophrenia among U.S. military personnel.

OBJECTIVE: A number of studies have reported associations between Toxoplasma gondii (T. gondii) infection and the risk of schizophrenia. Most existing studies have used small populations and postdiagnosis specimens. As part of a larger research program, the authors conducted a hypothesis-generating case control study of T. gondii antibodies among individuals discharged from the U.S. military with a diagnosis of schizophrenia and serum specimens available from both before and after diagnosis. METHOD: The patients (N=180) were military members who had been hospitalized and discharged from military service with a diagnosis of schizophrenia. Healthy comparison subjects (3:1 matched on several factors) were members of the military who were not discharged. The U.S. military routinely collects and stores serum specimens of military service members. The authors used microplate-enzyme immunoassay to measure immunoglobulin G (IgG) antibody levels to T. gondii, six herpes viruses, and influenza A and B viruses and immunoglobulin M (IgM) antibody levels to T. gondii in pre- and postdiagnosis serum specimens. RESULTS: A significant positive association between the T. gondii IgG antibody and schizophrenia was found; the overall hazard ratio was 1.24. The association between IgG and schizophrenia varied by the time between the serum specimen collection and onset of illness. CONCLUSION: The authors found significant associations between increased levels of scaled T. gondii IgG antibodies and schizophrenia for antibodies measured both prior to and after diagnosis.

Results from a hypothesis generating case-control study: herpes family viruses and schizophrenia among military personnel.

BACKGROUND: Herpes family viruses can cause central nervous system inflammatory changes that can present with symptoms indistinguishable from schizophrenia and therefore are of interest in schizophrenia research. Most existing studies of herpes viruses have used small populations and postdiagnosis specimens. As part of a larger research program, we conducted a hypothesis-generating case-control study of selected herpes virus antibodies among individuals discharged from the US military with schizophrenia and pre- and postdiagnosis sera. METHODS: Cases (n = 180) were servicemembers hospitalized and discharged from military service with schizophrenia. Controls, 3:1 matched on several factors, were members not discharged. The military routinely collects and stores members' serum specimens. We used microplate enzyme immunoassay to measure immunoglobulin G (IgG) antibody levels to 6 herpes viruses in pre- and postdiagnosis specimens. Conditional logistic regression was used, and the measure of association was the hazard ratio (HR). RESULTS: Overall, we found a significant association between human herpes virus type 6 and schizophrenia, with an HR of 1.17 (95% confidence interval [CI] = 1.04, 1.32). Women and blacks had significant negative associations with herpes simplex virus type 2 and cytomegalovirus; among blacks, there was a significant positive association with herpes simplex virus type 1. Among men, there was a HHV-6 temporal effect with an HR of 1.41 (95% CI = 1.02, 1.96) for sera drawn 6-12 months before diagnosis. DISCUSSION: Findings from previous studies of herpes family viruses and schizophrenia have been inconsistent. Our study is based on a larger population than most previous studies and used serum specimens collected before onset of illness. This study adds to the body of knowledge and provides testable hypotheses for follow-on studies.

Evaluation of data obtained from military disability medical administrative databases for service members with schizophrenia or bipolar disorder.

OBJECTIVE: We are studying associations between selected biomarkers and schizophrenia or bipolar disorder among military personnel. To assess potential diagnostic misclassification and to estimate the date of illness onset, we reviewed medical records for a subset of cases. METHODS: Two psychiatrists independently reviewed 182 service medical records retrieved from the Department of Veterans Affairs. Data were evaluated for diagnostic concordance between database diagnoses and reviewers. Interreviewer variability was measured by using proportion of agreement and the kappa statistic. Data were abstracted to estimate date of onset. RESULTS: High levels of agreement existed between database diagnoses and reviewers (proportion, 94.7%; kappa = 0.88) and between reviewers (proportion, 92.3%; kappa = 0.87). The median time between illness onset and initiation of medical discharge was 1.6 and 1.1 years for schizophrenia and bipolar disorder, respectively. CONCLUSIONS: High levels of agreement between investigators and database diagnoses indicate that diagnostic misclassification is unlikely. Discharge procedure initiation date provides a suitable surrogate for disease onset.