Guiding Army Commanders' Decision-making Process in Managing Their Suicide Prevention Programs.

PURPOSE OF REVIEW: This paper focuses on how mental health professionals working with Army commanders can help them make decisions based on valid population-based metrics. We first summarize the scope of the impact of suicides on the Army. We then describe the process by which decision-making can be optimized. RECENT FINDINGS: The currently available tools in the US Army including BH Pulse, Unit Risk Inventory, The Azimuth Check, and the Army Readiness Assessment Program have a role in assisting mental health professionals. The specific advantages of BH Pulse over the other tools are highlighted. The US Army has been committed to enhancing its suicide prevention program through comprehensive policies, procedures, and provisions of resources. Commanders are expected to interact with the suicide prevention programs in their units and maximize the systems in place to prevent suicides and other negative mental health outcomes. Commanders are expected to receive cues and signals from a variety of data sources to assist their decision-making process. We discuss the specific advantages of BH Pulse and recommend its routine use for primary prevention and utilizing this tool after incidents to make data-driven, justifiable decisions. Finally, recommendations are provided on enhancing a unit's suicide prevention program.

Posttraumatic Stress Disorder Symptom Clusters in Service Members Predict New-Onset Depression Among Military Spouses.

Military operations in Iraq and Afghanistan have brought increased attention to posttraumatic stress disorder (PTSD) among service members and, more recently, its impact on spouses. Existing research has demonstrated that PTSD among service members is associated with depression among military spouses. In the current study, we extended these findings by using data from service member-spouse dyads enrolled in the Millennium Cohort Family Study for which the service member had evidence of PTSD (n = 563). Prospective analyses identified the association between PTSD symptom clusters reported by the service member and new-onset depression among military spouses. Over the 3-year study period, 14.4% of these military spouses met the criteria for new-onset depression. In adjusted models, service member ratings of symptoms in the effortful avoidance cluster, odds ratio (OR) = 1.61, 95% CI [1.03, 2.50], predicted an increased risk of new-onset depression among military spouses, whereas reexperiencing symptoms, adjusted OR = 0.57; 95% CI [0.32, 1.01], were marginally protective. These findings suggest that PTSD symptom clusters in service members differentially predict new-onset depression in military spouses, which has implications for treatment provision.

The Impact of Military and Nonmilitary Experiences on Marriage: Examining the Military Spouse's Perspective.

There has been conflicting research regarding direct association between deployments and marital quality, particularly from the military spouse's perspective. In the current study, we sought to extend past research by examining the direct association between both military and nonmilitary experiences and military spouse marital quality using 2011-2013 baseline data from the Millennium Cohort Family Study, a large sample of military couples representing all U.S. service branches and components. Military experiences were assessed using electronic deployment records to capture the number and length of deployments since 2001, and service members reported combat experience and symptoms indicative of posttraumatic stress disorder (PTSD). Military spouses reported on service members' recent time away from home, nonmilitary family stressors, and marital quality. Results of the logistic regression model adjusted for demographic, relationship, and military covariates indicated that most military experiences did not have a direct statistical association with low marital quality except service member PTSD, odds ratio (OR) = 1.54, 95% CI [1.17, 2.04]. Rather, nonmilitary experiences of the military spouse, including lack of social support, OR = 2.68, 95% CI [2.07, 3.47]; caregiver burden, OR = 1.56, 95% CI [1.22, 1.99]; work-family conflict, OR = 1.42, 95% CI [1.18, 1.69]; and financial strain, OR = 1.27, 95% CI [1.03, 1.55], increased odds of low marital quality. Implications of these findings include providing additional supports to address nonmilitary family stressors that are particularly salient to military spouses with an aim to promote marital quality.

Depression among military spouses: Demographic, military, and service member psychological health risk factors.

BACKGROUND: More than a decade of war has strained service members and their families and the psychological health of military spouses is a concern. This study uses data from the largest study of military families in the United States to examine the demographic, military-specific, and service member mental health correlates of probable diagnosis of major depressive disorder (MDD) among military spouses. METHODS: Data were from service member-spouse dyads from all branches of the U.S. military. Demographic and military-specific factors were assessed using administrative personnel records and survey data. RESULTS: Of the 9,038 spouses, 4.9% had a probable diagnosis of MDD. In unadjusted models, spouses of service members who deployed and experiencecd combat-related events, were enlisted, had a probable posttraumatic stress disorder (PTSD) diagnosis, or screened positive for alcohol misuse were more likely to screen positive for MDD. In adjusted models, only spouses married to enlisted service members or those with PTSD had increased risk for MDD. Other demographic and military-related factors associated with MDD in spouses included less educational attainment, unemployment, having four or more children, and having prior military service (although not currently serving in the military) in the adjusted models. CONCLUSIONS: Findings characterize demographic, military, and service member psychological health factors that are associated with depression among military spouses. These findings imply that deployment alone may not negatively affect military spouses, but rather it may be the mental health impact on the service member, especially PTSD that increases the odds for MDD among military spouses.

Measuring Aggregated and Specific Combat Exposures: Associations Between Combat Exposure Measures and Posttraumatic Stress Disorder, Depression, and Alcohol-Related Problems.

Research has shown combat exposure to be associated with negative mental health outcomes. Different combat exposure measures are not composed of the same combat experiences, and few combat exposure measures have been directly compared to another measure. Furthermore, research about the unique associations between specific combat experiences and mental health is lacking. We investigated associations between new-onset posttraumatic stress disorder (PTSD), new-onset depression, and alcohol-related problems and two commonly used measures of combat among a sample of 20,719 recently deployed U.S. military personnel. A 13-item measure assessed both direct and indirect combat exposures, and a 5-item measure assessed only indirect exposures. Both combat measures were associated with all outcomes in the same direction (e.g., PTSD, odds ratio [OR] = 2.97 vs. 4.01; depression, OR = 2.03 vs. 2.42; alcohol-related problems, OR = 1.41 vs. 1.62, respectively, for the 5- and 13-item measures). The 13-item measure had a stronger association with some outcomes, particularly PTSD. Each specific item had significant bivariate associations with all outcomes, ORs = 1.43-4.92. After adjusting for other combat exposures, items assessing witnessing abuse, feeling in danger, and knowing someone injured or killed remained associated with all outcomes, ORs = 1.18-2.72. After this adjustment, several items had unexpected protective associations with some mental health outcomes. Results indicated these two combat exposure measures were approximately equally effective for determining risk for negative mental health outcomes in a deployed population, despite having different content. Additional research is needed to replicate and understand how specific combat exposures affect health.

A Decade of War: Prospective Trajectories of Posttraumatic Stress Disorder Symptoms Among Deployed US Military Personnel and the Influence of Combat Exposure.

Posttraumatic stress disorder (PTSD) is a common psychiatric disorder among service members and veterans. The clinical course of PTSD varies between individuals, and patterns of symptom development have yet to be clearly delineated. Previous studies have been limited by convenience sampling, short follow-up periods, and the inability to account for combat-related trauma. To determine the trajectories of PTSD symptoms among deployed military personnel with and without combat exposure, we used data from a population-based representative sample of 8,178 US service members who participated in the Millennium Cohort Study from 2001 to 2011. Using latent growth mixture modeling, trajectories of PTSD symptoms were determined in the total sample, as well as in individuals with and without combat exposure, respectively. Overall, 4 trajectories of PTSD were characterized: resilient, pre-existing, new-onset, and moderate stable. Across all trajectories, combat-deployed service members diverged from non-combat-deployed service members, even after a single deployment. The former also generally had higher PTSD symptoms. Based on the models, nearly 90% of those without combat exposure remained resilient over the 10-year period, compared with 80% of those with combat exposure. Findings demonstrate that although the clinical course of PTSD symptoms shows heterogeneous patterns of development, combat exposure is uniformly associated with poor mental health.

Sleep and Health Resilience Metrics in a Large Military Cohort.

STUDY OBJECTIVES: Examine the relationship between self-reported sleep parameters and indicators of resilience in a US military population (n = 55,021). METHODS: Longitudinal analyses (2001-2008) were conducted using subjective data collected from Millennium Cohort Study questionnaires and objective data from military records that included demographics, military health, and deployment information. Subjective sleep duration and insomnia symptoms were collected on the study questionnaire. Resilience metrics included lost work days, self-rated health, deployment, frequency and duration of health care utilization, and early discharge from the military. Generalized estimating equations and survival analyses were adjusted for demographic, military, behavioral, and health covariates in all models. RESULTS: The presence of insomnia symptoms was significantly associated with lower self-rated health, more lost work days, lower odds of deployment, higher odds of early discharge from military service early, and more health care utilization. Those self-reporting < 6 h (short sleepers) or > 8 h (long sleepers) of sleep per night had similar findings, except for the deployment outcome in which those with the shortest sleep were more likely to deploy. CONCLUSIONS: Poor sleep is a detriment to service members' health and readiness. Leadership should redouble efforts to emphasize the importance of healthy sleep among military service members, and future research should focus on the efficacy of interventions to promote healthy sleep and resilience in this population. COMMENTARY: A commentary on this article appears in this issue on page 963.

Longitudinal assessment of gender differences in the development of PTSD among US military personnel deployed in support of the operations in Iraq and Afghanistan.

Divergent findings from previous research examining gender differences in the development of posttraumatic stress disorder (PTSD) among US military members deployed to the operations in Iraq or Afghanistan (recent operations) prompted this study utilizing a matching approach to examine whether risk for new-onset PTSD and PTSD severity scores differed by gender. US military members from the Millennium Cohort Study deployed in support of the recent operations were followed for approximately 7 years from baseline through 2 follow-up periods between 2001 and 2008. Propensity score matching was used to match 1 male to each female using demographic, military, and behavioral factors including baseline sexual assault. Analyses were stratified by combat experience defined as reporting at least one of five exposures during follow-up. Outcome measures included a positive screen for PTSD and severity scores measured by the PTSD Patient Checklist-Civilian Version. Discrete-time survival analysis quantified the association between gender and incident PTSD. Among 4684 matched subjects (2342 women and men), 6.7% of women and 6.1% of men developed PTSD during follow-up. Results showed no significant gender differences for the likelihood of developing PTSD or for PTSD severity scores among women and men who reported combat experience and among those who did not. This study is the first of its kind to match a large population of male and female service members on important baseline characteristics including sexual assault. Findings suggest that while combat deployed personnel develop PTSD, women do not have a significantly different risk for developing PTSD than men after experiencing combat.

Marital status, marital quality, and heart rate variability in the MIDUS cohort.

Previous research has shown marital status and marital quality are consistent predictors of health outcomes, including cardiovascular disease and mortality. To better understand the relationship among marital status, marital quality, and cardiovascular health, we examined how marital status and marital quality were associated with an early indicator of deteriorating cardiovascular health, high-frequency heart rate variability (HF-HRV). This study uses data from the National Survey of Midlife in the United States (MIDUS) Biomarker Substudy (N = 907) to examine differences in HF-HRV by traditional marital status categories (married, divorced, widowed, and never married) as well as further differentiating between the continuously married and remarried. In addition, links were also examined between HF-HRV and changes in marital quality (marital satisfaction, support, strain) among individuals in long-term marriages. No significant differences in HF-HRV were observed between married persons and those widowed, divorced, and never married. However, continuously married individuals had higher HF-HRV than remarried adults. Increases in marital satisfaction and support over 10 years were associated with higher HF-HRV, whereas increased marital strain over 10 years was associated with lower HF-HRV. Higher HF-HRV among the continuously married compared with the remarried suggests that previous marital disruptions may have lasting effects on cardiovascular health or that there may be other differences between the remarried versus those who remain married to the same person. Associations between marital quality and HF-HRV suggest that variations in the quality of one's marriage may affect cardiovascular health.

Marital Quality, Gender, and Markers of Inflammation in the MIDUS Cohort.

Marital quality is an important factor for understanding the relationship between marriage and health. Low-quality relationships may not have the same health benefits as high-quality relationships. To understand the association between marital quality and health, we examined associations between two indicators of marital quality (marital support and marital strain) and two biomarkers of inflammation (interleukin-6 and C-reactive protein) among men and women in long-term marriages using data from the Survey of Midlife in the United States (N = 542). Lower levels of spousal support were associated with higher levels of inflammation among women but not men. Higher levels of spousal strain were weakly and inconsistently associated with higher levels of inflammation among women and men; the effects were diminished with the addition of psychosocial and behavioral covariates. These findings suggest marital quality is an important predictor of inflammation, especially among women.

Stress and abdominal fat: preliminary evidence of moderation by the cortisol awakening response in Hispanic peripubertal girls.

Stress and the cortisol awakening response (CAR) have been independently linked to increases in abdominal fat depots. This cross-sectional study examined the CAR as a moderator of the association between stress, visceral adipose tissue (VAT), and subcutaneous abdominal adipose tissue (SAT) in a sample (N = 23) of female peripubertal Hispanic girls aged from 8 to 11. The study included: (i) monitored salivary cortisol collection, (ii) VAT and SAT obtained by multislice magnetic resonance imaging, and (iii) a stressful life events checklist with four domain-specific subscales: peer, family, personal, and school. Regression analysis indicated an interaction of school-related life events and CAR on VAT and SAT, with greater numbers of school-related events being related to greater VAT and SAT for girls with high CAR, but no association with VAT or SAT for girls with low CAR. Similar to job stress in adults, school-related stress in children may contribute to central adiposity, especially for girls with high CAR.

The relative contributions of race/ethnicity, socioeconomic status, health, and social relationships to life satisfaction in the United States.

PURPOSE: To evaluate racial/ethnic disparities in life satisfaction and the relative contributions of socioeconomic status (SES; education, income, employment status, wealth), health, and social relationships (social ties, emotional support) to well-being within and across racial/ethnic groups. METHODS: In two cross-sectional, representative samples of U.S. adults (the 2001 National Health Interview Survey and the 2007 Behavioral Risk Factor Surveillance System; combined n > 350,000), we compared life satisfaction across Whites, Hispanics, and Blacks. We also evaluated the extent to which SES, health, and social relationships 'explained' racial/ethnic group differences and compared the magnitude of variation explained by life satisfaction determinants across and within these groups. RESULTS: Relative to Whites, both Blacks and Hispanics were less likely to be very satisfied. Blacks were somewhat more likely to report being dissatisfied. These differences were reduced or eliminated with adjustment for SES, health, and social relationships. Together, SES and health explained 12-15% of the variation in life satisfaction, whereas social relationships explained an additional 10-12% of the variance. CONCLUSIONS: Racial/ethnic life satisfaction disparities exist for Blacks and Hispanics, and these differences are largest when comparing those reporting being 'satisfied' to 'very satisfied' versus 'dissatisfied' to 'satisfied.' SES, health, and social relationships were consistently associated with life satisfaction, with emotional support having the strongest association with life satisfaction.