Spinal pain and major depression in a military cohort: bias analysis of dependent misclassification in electronic medical records.

BACKGROUND: Spinal pain and major depression are prevalent conditions in adult populations and are particularly impactful in the military. However, the temporal relationship between these two conditions remains poorly understood. METHODS: Using data extracted from electronic medical records, we assessed the association between incident diagnoses of spinal pain and major depression in a cohort of 48,007 Canadian Armed Forces personnel followed from January 2017 to August 2018. We used multivariate Poisson regression to measure the association between the period prevalence of these two conditions. We used probabilistic bias modelling to correct our estimates for misclassification of spinal pain and major depression. RESULTS: After correcting for misclassification with probabilistic bias modelling, subjects newly diagnosed with spinal pain during the study period were 1.41 times (95% interval 1.25, 1.59) more likely also to be diagnosed with incident major depression, and personnel newly diagnosed with major depression were 1.28 times (95% interval 1.17, 1.39) more likely also to be diagnosed with spinal pain, compared to undiagnosed counterparts of the same age and sex. Without bias corrections, we would have overestimated the magnitude of the association between major depression and spinal pain by a factor of approximately 2.0. CONCLUSION: Our results highlight a moderate and bi-directional association between two of the most prevalent disorders in military populations. Our results also highlight the importance of correcting for misclassification in electronic medical record data research.

Mental Health Service Use in Depressed Military Personnel: A Systematic Review.

INTRODUCTION: Major depression is a leading cause of morbidity in military personnel and an important impediment to operational readiness in military organizations. Although treatment options are available, a large proportion of individuals with depression do not access mental health services. Quantifying and closing this treatment gap is a public health priority. However, the scientific literature on the major depression treatment gap in military organizations has never been systematically reviewed. METHODS: We systematically searched the EMBASE, MEDLINE, and PsychINFO databases for studies measuring recent mental health service use in personnel serving in the armed forces of a Five-Eye country (Australia, Canada, New Zealand, the United Kingdom, or the United States). We excluded studies conducted with retired veterans. Because of the substantial heterogeneity in included studies, we did not pool their results. Instead, we computed median period prevalence of mental health service use. RESULTS: Twenty-eight studies were included in the systematic review; 12 had estimated mental health service use in personnel with depression, and another 16 had estimated mental health service use in personnel with depression or another mental health disorder. The period prevalence of mental health service use in depressed military personnel ranged from 20 to 75% in 12 included studies, with a median of 48%, over 2-12 months. The other 16 studies yielded similar conclusions; they reported period prevalence of mental health service use in personnel with any mental health disorder ranging from 14 to 75%, with a median of 36%, over 1-12 months. The median was higher in studies relying on diagnostic interviews to identify depressed personnel, compared to studies relying on screening tools (60% vs. 44%). CONCLUSIONS: There is a large treatment gap for major depression in particular, and for mental health disorders in general, among military personnel. However, our results highlight the association between the use of measurement tools and treatment gaps: estimated treatment gaps were larger when depressed patients were identified by screening tools instead of diagnostic interviews. Researchers should be wary of overestimating the mental health treatment gap when using screening tools in future studies.

Mental Health Service Utilization in Depressed Canadian Armed Forces Personnel.

BACKGROUND: Major depression is prevalent, impactful, and treatable in military populations, but not all depressed personnel seek professional care in a given year. Care-seeking patterns (including the use of primary vs. specialty care) and factors associated with the likelihood of mental health service utilization in depressed military personnel are poorly understood. METHODS: Our sample included 520 Regular Force respondents to the 2013 Canadian Forces Mental Health Survey. All study participants had past-year major depression. Subjects reported whether they had spoken about their mental health with at least one health professional in the past 12 months. We used multivariate Poisson regression to explore factors associated with past-year mental health service use. RESULTS: Three-quarters of Canadian military personnel with past-year depression had sought mental health care in the previous 12 months. Among care-seeking personnel, 70% had seen a psychologist or psychiatrist, while 5% had exclusively received care from a primary care physician. Belief in the effectiveness of mental health care was the factor most strongly associated with care seeking. Female gender, functional impairments, and psychiatric comorbidities were also associated with care seeking. Surprisingly, stigma perceptions had no independent association with care seeking. CONCLUSIONS: The proportion of depressed Canadian Armed Forces personnel who seek professional care and who access specialty mental health care is higher than in most other populations. However, an important minority of patients are not accessing health services. Efforts to further increase mental health service utilization in the Canadian military should continue to target beliefs about the effectiveness of mental health care.

The 2013 Canadian Forces Mental Health Survey: Background and Methods.

OBJECTIVE: The 2013 Canadian Forces Mental Health Survey (CFMHS) collected detailed information on mental health problems, their impacts, occupational and nonoccupational determinants of mental health, and the use of mental health services from a random sample of 8200 serving personnel. The objective of this article is to provide a firm scientific foundation for understanding and interpreting the CFMHS findings. METHODS: This narrative review first provides a snapshot of the Canadian Armed Forces (CAF), focusing on 2 key determinants of mental health: the deployment of more than 40,000 personnel in support of the mission in Afghanistan and the extensive renewal of the CAF mental health system. The findings of recent population-based CAF mental health research are reviewed, with a focus on findings from the very similar mental health survey done in 2002. Finally, key aspects of the methods of the 2013 CFMHS are presented. RESULTS: The findings of 20 peer-reviewed publications using the 2002 mental health survey data are reviewed, along with those of 25 publications from other major CAF mental health research projects executed over the past decade. CONCLUSIONS: More than a decade of population-based mental health research in the CAF has provided a detailed picture of its mental health and use of mental health services. This knowledge base and the homology of the 2013 survey with the 2002 CAF survey and general population surveys in 2002 and 2012 will provide an unusual opportunity to use the CFMHS to situate mental health in the CAF in a historical and societal perspective.

Prevalence of Past-Year Mental Disorders in the Canadian Armed Forces, 2002-2013.

OBJECTIVE: More than 40,000 Canadian Armed Forces (CAF) personnel have deployed in support of the mission in Afghanistan since 2002. Over the same period, the CAF strengthened its mental health system. This article explores the effect of these events on the prevalence of past-year mental disorders over the period 2002-2013. METHOD: The data sources were 2 highly comparable population-based mental health surveys of CAF Regular Force personnel done in 2002 and 2013 (n = 5155 and 6996, respectively). Data were collected via in-person interviews with Statistics Canada personnel using the World Health Organization's Composite International Diagnostic Interview to assess past-year disorders. RESULTS: In 2013, 16.5% had 1 or more of the 6 past-year disorders assessed in the survey, with the most common conditions being major depressive episode (MDE), posttraumatic stress disorder (PTSD), and generalized anxiety disorder (GAD), which affected 8.0%, 5.3%, and 4.7%, respectively. The prevalence of PTSD, GAD, and panic disorder has increased significantly since 2002 (adjusted odds ratios from logistic regression models = 2.1, 3.0, and 1.9, respectively), while no change was seen for MDE. The comorbidity of mood and anxiety disorders increased significantly over time, being seen in 27.4% and 41.0% of those with mental disorders in 2002 and 2013, respectively. CONCLUSION: There has been an increase in the prevalence of PTSD and other anxiety disorders and of the extent of comorbidity of mood and anxiety disorders in CAF personnel over the period 2002-2013.

Prevalence Comparison of Past-year Mental Disorders and Suicidal Behaviours in the Canadian Armed Forces and the Canadian General Population.

OBJECTIVE: Military personnel in Canada and elsewhere have been found to have higher rates of certain mental disorders relative to their corresponding general populations. However, published Canadian data have only adjusted for age and sex differences between the populations. Additional differences in the sociodemographic composition, labour force characteristics, and childhood trauma exposure in the populations could be driving these prevalence differences. Our objective is to compare the prevalence of past-year mental disorders and suicidal behaviours in the Canadian Armed Forces Regular Force with the rates in a representative, matched sample of Canadians in the general population (CGP). METHODS: Data sources were the 2013 Canadian Forces Mental Health Survey and the 2012 Canadian Community Health Survey-Mental Health. CGP sample was restricted to match the age range, employment status, and history of chronic conditions of Regular Force personnel. An iterative proportional fitting method was used to approximate the marginal distribution of sociodemographic and childhood trauma variables in both samples. RESULTS: Relative to the matched CGP, Regular Force personnel had significantly higher rates of past-year major depressive episode, generalized anxiety disorder, and suicide ideation. However, lower rates of alcohol use disorder were seen in Regular Force personnel relative to the matched CGP sample. CONCLUSIONS: Factors other than differences in sociodemographic composition and history of childhood trauma account for the excess burden of mental disorders and suicidal behaviours in the Canadian Armed Forces. Explanations to explore in future research include occupational trauma, selection effects, and differences in the context of administration of the 2 surveys.

Disability and Mental Disorders in the Canadian Armed Forces.

OBJECTIVES: The initial goal was to validate the use of a self-report measure of disability in the Canadian Armed Forces (CAF). The main goal was to document the extent of disability in personnel with and without mental disorders. METHODS: Data were obtained from the 2013 Canadian Forces Mental Health Survey; the sample included 6700 Regular Forces personnel. Disability was measured with the 12-item version of the World Health Organization Disability Assessment Schedule (WHODAS-2); established cut points were used to demarcate severe, moderate, minimal, and no disability. The following recent (past-year) and remote (lifetime but not past-year) disorders were assessed with diagnostic interviews: posttraumatic stress disorder, major depressive episode, generalized anxiety disorder, panic disorder, and alcohol use disorder. RESULTS: The WHODAS-2 showed good internal consistency (α = 0.89) and a 1-factor structure. Most personnel had no disability (59.2%) or minimal disability (30.8%). However, an important minority had moderate or severe disability (8.4% and 1.6%, respectively). Individuals with recent disorders reported greater disability than those without lifetime disorders, although many had minimal or no disability (41.2% and 24.7%, respectively). Disability increased with the number of recent disorders. Relative to those without lifetime disorders, individuals with remote disorders showed slightly greater disability, but most had no disabilty (57.1%) or minimal disability (35.0%). CONCLUSIONS: The 12-item WHODAS-2 is a valid measure of disability in the CAF. Mental disorders may be important drivers of disability in this population, although limited residual disability is seen in individuals with remote disorders.

Occupational outcomes following mild traumatic brain injury in Canadian military personnel deployed in support of the mission in Afghanistan: a retrospective cohort study.

OBJECTIVE: Deployment-related mild traumatic brain injury (MTBI) occurs in a significant number of military personnel but its long-term impacts are unclear. This study explores the impact of deployment-related MTBI on continued fitness-for-duty, with the ultimate intent of identifying potential targets for intervention to attenuate its effects. PARTICIPANTS: Consisted of 16 193 Canadian Armed Forces (CAF) personnel who deployed in support of the mission in Afghanistan and completed an enhanced postdeployment screening (EPDS) questionnaire over the period January 2009-July 2012. PRIMARY OUTCOME: The primary outcome was development of permanent medical unfitness defined as a 'career-limiting medical condition' (CL-MC). The secondary outcome was the diagnostic categories recorded for each individual at the time a CL-MC was established. DESIGN: This study used a retrospective cohort design. Linked administrative and health data provided the primary outcome and the diagnoses responsible for it. Survival analysis was used to estimate the risk of a CL-MC and Cox regression provided adjusted HRs (aHRs) for the association between a CL-MC and MTBI, accounting for key covariates and confounders. Diagnostic categories associated with CL-MCs were identified. RESULTS: Over a median follow-up period of 3.42 years, 6.57% of the study population developed a CL-MC. MTBI was independently associated with CL-MCs (aHR=1.65, 95% CI 1.35 to 2.03). Mental disorders and musculoskeletal conditions were the primary diagnoses associated with CL-MCs (identified as the primary diagnosis in 55.4% and 25.9%, respectively), and a neurological condition was only documented in 5.8% of those with MTBI who developed a CL-MC CONCLUSIONS: Deployment-related MTBI was associated with adverse occupational outcome but mental disorders and musculoskeletal conditions primarily drove subsequent medical unfitness. These findings support a diagnostic and treatment approach focusing on these comorbidities as the most promising strategy to minimise the burden of disability in MTBI-exposed military personnel.

Deployment-related mild traumatic brain injury, mental health problems, and post-concussive symptoms in Canadian Armed Forces personnel.

BACKGROUND: Up to 20% of US military personnel deployed to Iraq or Afghanistan experience mild traumatic brain injury (mTBI) while deployed; up to one-third will experience persistent post-concussive symptoms (PCS). The objective of this study was to examine the epidemiology of deployment-related mTBI and its relationship to PCS and mental health problems (MHPs) in Canadian Armed Forces (CAF) personnel. METHODS: Participants were 16153 personnel who underwent post-deployment screening (median =136 days after return) following deployment in support of the mission in Afghanistan from 2009 - 2012. The screening questionnaire assessed mTBI and other injuries while deployed, using the Brief Traumatic Brain Injury Screening Tool. Current MHPs and PCS were assessed using items from the Patient Health Questionnaire, the Patient Checklist for PTSD, and the Cognitive Failures Questionnaire. Log-binomial regression explored the association of mTBI, other injuries, and MHPs with PCS, using the presence of 3 or more of 7 PCS as the outcome. Results are expressed as adjusted prevalence ratios (PR). RESULTS: mTBI while deployed was reported in 843 respondents (5.2%). Less severe forms of mTBI (associated only with having been dazed or confused or having "seen stars") predominated. Blast was reported as a mechanism of injury in half of those with mTBI. Multiple PCS were present in 21% of those with less severe forms of mTBI and in 27% of those with more severe forms of mTBI (i.e., mTBI associated with loss of consciousness or post-traumatic amnesia). After adjustment for confounding, mTBI had no statistically significant association with PCS relative to non-TBI injury. In contrast, MHPs had a strong association with reporting 3 or more PCS (adjusted prevalence ratio (PR) =7.77). CONCLUSION: Deployment-related mTBI prevalence was lower than in many US reports; most of those who had had mTBI were free of multiple PCS. PCS was strongly associated with MHPs but not with mTBI. Careful assessment of MHPs is essential in personnel with a history of combat-related mTBI and PCS.

Prevalence and correlates of mental health problems in Canadian Forces personnel who deployed in support of the mission in Afghanistan: findings from postdeployment screenings, 2009-2012.

OBJECTIVE: An important minority of military personnel will experience mental health problems after overseas deployments. Our study sought to describe the prevalence and correlates of postdeployment mental health problems in Canadian Forces personnel. METHOD: Subjects were 16 193 personnel who completed postdeployment screening after return from deployment in support of the mission in Afghanistan. Screening involved a detailed questionnaire and a 40-minute, semi-structured interview with a mental health clinician. Mental health problems were assessed using the Patient Health Questionnaire and the Posttraumatic Stress Disorder Checklist-Civilian Version. Logistic regression was used to explore independent risk factors for 1 or more of 6 postdeployment mental health problems. RESULTS: Symptoms of 1 or more of 6 mental health problems were seen in 10.2% of people screened; the most prevalent symptoms were those of major depressive disorder (3.2%), minor depression (3.3%), and posttraumatic stress disorder (2.8%). The strongest risk factors for postdeployment mental health problems were past mental health care (adjusted odds ratio [AOR] 2.89) and heavy combat exposure (AOR 2.57 for third tertile, compared with first tertile). These risk groups might be targeted in prevention and control efforts. In contrast to findings from elsewhere, Reservist status, deployment duration, and number of previous deployments had no relation with mental health problems. CONCLUSIONS: An important minority of personnel will disclose symptoms of mental health problems during postdeployment screening. Differences in risk factors seen in different nations highlight the need for caution in applying the results of research in one population to another.

Postdeployment military mental health training: cross-national evaluations.

Deployments increase risk for adjustment problems in service members. To mitigate this increased risk, mental health training programs have been developed and implemented in several nations. As part of a coordinated effort, three nations adapted a U.S. mental health training program that had been validated by a series of group randomized trials demonstrating improvement in postdeployment adjustment. Implementation of evidence-based programs in a new context is challenging: How much of the original program needs to remain intact in order to retain its utility? User satisfaction rates can provide essential data to assess how well a program is accepted. This article summarizes service member ratings of postdeployment mental health training and compares ratings from service members across four nations. The participating nations (Canada, New Zealand, United Kingdom, and the United States) administered mental health training to active duty military personnel in their respective nations. Following the training, military personnel completed an evaluation of the training. Overall, across the four nations, more than 70% of military personnel agreed or strongly agreed that they were satisfied with the mental health training. Although some differences in evaluations were observed across nations, components of training that were most important to overall satisfaction with the training were strikingly similar across nations. Fundamentally, it appears feasible that despite cultural and organizational differences, a mental health training program developed in one nation can be successfully adapted for use in other nations.

Mental health of Canadian Forces members while on deployment to Afghanistan.

OBJECTIVE: The deployed environment poses special challenges to the delivery of effective in-theatre mental health care. Our study sought to identify the prevalence and impact of symptoms of mental health problems in Canadian Forces (CF) personnel serving in Task Force Afghanistan; and, to determine the use of, and perceived need for, mental health services in CF personnel while deployed. METHODS: Our study consisted of a cross-sectional survey of all 2779 CF personnel deployed to the province of Kandahar, Afghanistan, from February 15, 2010, to March 15, 2010. RESULTS: An important minority (8.5%) of the 1572 respondents (response rate = 57%) exceeded civilian criteria for symptoms of acute traumatic stress, major depression, or generalized anxiety. Prevalence of these 3 mental health problems increased with higher combat exposure and location in more isolated posts. A much larger fraction (31%) reported suffering a stress, emotional, alcohol, or family problem during the deployment. Only a minority of respondents with a mental health problem (26%) were currently interested in getting help. Almost one-half of respondents with a mental health problem perceived occupational dysfunction as a result, though two-thirds of respondents with occupational dysfunction were in the group without the 3 mental health problems assessed. CONCLUSIONS: The needs base for psychosocial support extends beyond personnel who meet conventional questionnaire criteria for traumatic stress, depression, or generalized anxiety. Future research is needed to understand what precise problems are driving this larger needs base and what precise supports (clinical or nonclinical) would be most appropriate.

Beyond battlemind: evaluation of a new mental health training program for Canadian forces personnel participating in third-location decompression.

INTRODUCTION: Battlemind training, which improves postdeployment well-being, has been part of Canada's postdeployment Third-location Decompression (TLD) program since 2006. In 2010, a new educational program drawing on Battlemind was implemented to make it more consistent with Canada's current mental health training strategy. METHODS: Subjects consisted of 22,113 Canadian personnel returning from Afghanistan via TLD in Cyprus; 3,024 (14%) received the new program. Pre-/post-training attitude and self-efficacy questionnaires assessed the impact of the training. In addition, a quasi-experimental approach used questionnaires administered at the end of TLD to compare the satisfaction, attitudes, and self-efficacy under the old vs. new program. RESULTS: Pre-/post-training questionnaires showed medium to large positive effects of the training on targeted attitudes and self-efficacy (Cohen's d = 0.44-1.02). Participants completing the new program were more satisfied with the educational program (adjusted odds ratio = 3.2), perceived the TLD to be more valuable (odds ratio = 1.7), and had at least certain more favorable post-TLD attitudes and self-efficacy (d ranging from 0.00 to 0.29). CONCLUSION: All of these findings point to the superiority of the new program. However, quasi-experimental approaches are bias-prone, and it is unknown whether these advantages will translate into meaningful improvements in well-being.

Evaluation of a third-location decompression program for Canadian Forces members returning from Afghanistan.

BACKGROUND: Service members returning from combat can experience difficulty adapting to home life. To help ease this transition, the Canadian Forces provides a Third-location Decompression (TLD) program in Cyprus to members returning from deployment to Afghanistan. METHODS: The 5-day program consists of individual free time, structured recreational activities, and educational programming. Its perceived value and impact were measured immediately afterward and 4 to 6 months later. RESULTS: Respondents overwhelmingly supported the TLD concept, with 95% agreeing that "some form of TLD is a good idea." Eighty-one percent of participants found the program valuable, and 83% recommended it for future deployments to Afghanistan. Perceived value persisted 4 to 6 months after return, and 74% felt that it helped to make reintegration easier for them. CONCLUSION: Canadian Forces members saw value in the TLD program, and most members believed that the program had its intended effect of making the reintegration process easier for them.

Pancreatitis associated with simvastatin plus fenofibrate.

OBJECTIVE: To report a case of acute necrotizing pancreatitis associated with simvastatin and fenofibrate use. CASE SUMMARY: A 70-year-old white man presenting with rapid onset of abdominal pain, nausea, and vomiting was diagnosed with acute pancreatitis. On bowel rest, his condition deteriorated secondary to systemic inflammatory response syndrome, and he was transferred to a tertiary hospital's intensive care unit (ICU). He had been taking fenofibrate for 1 year; 6 months prior to this admission, he had been taking simvastatin 3 days of the week and fenofibrate the other 4 days of the week. The pancreatic tissue became necrotic, requiring surgical debridement. After a hospital stay of 121 days, including multiple ICU admissions, the patient died secondary to a bowel perforation. DISCUSSION: Although idiopathic pancreatitis cannot be ruled out in this patient, no causes of pancreatitis were identified other than drug induced. Five cases of acute pancreatitis caused by simvastatin have been reported; no case reports were found for fenofibrate. The onset of pancreatitis relative to the duration of therapy with simvastatin supports this medication as a possible cause of the pancreatitis. CONCLUSIONS: Drug-induced pancreatitis is well established as an adverse effect of some medications, although most are substantiated only with case reports. Given the absence of other apparent causes, simvastatin and fenofibrate should be considered as possible causes of pancreatitis in this patient.