Caffeine and energy drink use by combat arms soldiers in Afghanistan as a countermeasure for sleep loss and high operational demands.

OBJECTIVES: Combat deployments are characterized by high operational demands with limited opportunities for sleep leading to fatigue and degraded cognitive and operational performance. Caffeine in moderate doses is recognized as an effective intervention for physical and cognitive decrements associated with sleep loss. METHODS: This report is based on data collected by two separate, independently conducted surveys administered in Afghanistan in 2011-2012. It assessed caffeine use and sleep disruption among U.S. Army combat soldiers (J-MHAT 8; n = 518) and among deployed soldiers with different military assignments (USARIEM Deployment Survey; n = 260). RESULTS: Daily caffeine intake assessed in the J-MHAT 8 survey averaged 404 ± 18 mg. In the USARIEM Deployment Survey, intake was 303 ± 29 mg and was significantly higher among combat arms soldiers (483 ± 100 mg) compared to combat service support personnel (235 ± 23 mg). In both surveys, over 55% of total caffeine intake was from energy drinks. Additional sources of caffeine included coffee, tea, sodas, gum, candy, and over-the-counter medications. Higher caffeine intake was not associated with ability to fall asleep at night or wake-up in the morning (J-MHAT 8 survey). Higher caffeine consumption was associated with disrupted sleep from high operational tempo and nighttime duties of combat operations. DISCUSSION: Overall caffeine consumption and energy drink use in Afghanistan was greater than among non-deployed soldiers and civilians. Caffeine was frequently used as a countermeasure during night operations to offset adverse effects of sleep loss on physical and cognitive function, consistent with current Department of the Army recommendations.

Unethical battlefield conduct reported by soldiers serving in the Iraq war.

Research involving military service members has shown a strong relationship between combat experiences and increased risk for posttraumatic stress disorder (PTSD) and other mental health problems. Comparatively little research has examined the relationship between combat experiences, PTSD, aggression, and unethical conduct on the battlefield, although news stories sometimes suggest links between unethical conduct and disorders such as PTSD. This study systematically examined whether unethical conduct is a proxy for aggression and whether specific combat experiences and PTSD are independently associated with unethical behavior. The results of this study indicate that aggression (ß = 0.30) and specific combat experiences (particularly, witnessing war atrocities [ß = 0.14] and fighting [ß = 0.13]) are much more strongly associated with unethical conduct than is PTSD (ß = 0.04).

Mental health training with soldiers four months after returning from Iraq: randomization by platoon.

Military personnel report significant and increasing mental health problems in the months following return from combat. Nevertheless, studies have not assessed the impact of mental health training with this at-risk population. The present study evaluated the efficacy of a prototype mental health training module designed for U.S. soldiers 3-6 months after returning from combat; the module was a component of the Battlemind Training system. Soldiers (N = 1,645) were randomly assigned by platoon to 1 hour of training or a survey-only control group. Baseline surveys were conducted immediately before training; a training satisfaction survey was administered immediately after training, and a follow-up survey was administered 6 months later. Immediate postsession surveys were conducted with 681 subjects, and follow-up surveys were conducted with 542 soldiers. The Battlemind Training module received positive ratings from participants, and those who received it reported significantly better adjustment in terms of posttraumatic stress disorder symptoms, depression, and life satisfaction at follow-up compared to those in the survey-only control group. Changes in attitudes about the stigma of seeking mental health care were found immediately posttraining, but not at follow-up. The findings demonstrate that brief mental health training can be effective in reducing mental health systems with at-risk occupational groups.

Alcohol problems, aggression, and other externalizing behaviors after return from deployment: understanding the role of combat exposure, internalizing symptoms, and social environment.

OBJECTIVES: The study examined whether elevated rates of externalizing behaviors following deployment could be explained by internalizing symptoms (depression, anxiety, and PTSD symptoms), and health of the social environment (unit leadership, organizational support, and stigma/barriers to care). DESIGN: A model of combat exposure, social environment, internalizing symptoms, and externalizing behaviors was tested in a military unit following a fifteen-month deployment to Iraq. The sample included 1,397 soldiers assessed four month post-deployment; 589 of these soldiers were assessed again nine months post-deployment. RESULTS: Externalizing behaviors were highly stable over the five-month post-deployment period. Both social environment and internalizing symptoms were significantly associated with level of externalizing behaviors at four months and nine months post-deployment, but combat exposure alone significantly predicted change in externalizing behaviors over the follow-up period. CONCLUSIONS: Results suggest the need to broaden the scope of interventions targeted to combat veterans and have implications for care providers and military leaders.

Mild traumatic brain injury in U.S. Soldiers returning from Iraq.

BACKGROUND: An important medical concern of the Iraq war is the potential long-term effect of mild traumatic brain injury, or concussion, particularly from blast explosions. However, the epidemiology of combat-related mild traumatic brain injury is poorly understood. METHODS: We surveyed 2525 U.S. Army infantry soldiers 3 to 4 months after their return from a year-long deployment to Iraq. Validated clinical instruments were used to compare soldiers reporting mild traumatic brain injury, defined as an injury with loss of consciousness or altered mental status (e.g., dazed or confused), with soldiers who reported other injuries. RESULTS: Of 2525 soldiers, 124 (4.9%) reported injuries with loss of consciousness, 260 (10.3%) reported injuries with altered mental status, and 435 (17.2%) reported other injuries during deployment. Of those reporting loss of consciousness, 43.9% met criteria for post-traumatic stress disorder (PTSD), as compared with 27.3% of those reporting altered mental status, 16.2% with other injuries, and 9.1% with no injury. Soldiers with mild traumatic brain injury, primarily those who had loss of consciousness, were significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somatic and postconcussive symptoms than were soldiers with other injuries. However, after adjustment for PTSD and depression, mild traumatic brain injury was no longer significantly associated with these physical health outcomes or symptoms, except for headache. CONCLUSIONS: Mild traumatic brain injury (i.e., concussion) occurring among soldiers deployed in Iraq is strongly associated with PTSD and physical health problems 3 to 4 months after the soldiers return home. PTSD and depression are important mediators of the relationship between mild traumatic brain injury and physical health problems.

Coming home may hurt: risk factors for mental ill health in US reservists after deployment in Iraq.

BACKGROUND: Little research has been conducted on the factors that may explain the higher rates of mental health problems in United States National Guard soldiers who have deployed to the Iraq War. AIMS: To examine whether financial hardship, job loss, employer support and the effect of deployment absence on co-workers were associated with depression and post-traumatic stress disorder (PTSD). METHOD: Cross-sectional data were obtained from 4034 National Guard soldiers at two time points. All measures were assessed by self-report. RESULTS: The four factors were associated with depression and PTSD, with variability based on outcome and time point. For example, job loss increased the odds of meeting criteria for depression at 3 and 12 months and for PTSD at 12 months; the negative effect of deployment absence on co-workers increased the likelihood of meeting criteria for PTSD, but not depression, at both time points. CONCLUSIONS: The findings demonstrate that National Guard soldiers have unique post-deployment social and material concerns that impair their mental health.

Mental health advisory teams: a proactive examination of mental health during combat deployments.

Mental health advisory teams (MHATs) conduct comprehensive mental health surveillance of US service members in combat environments. Since 2003, six teams have deployed to Iraq and four have deployed to Afghanistan, and results have played a key role influencing behavioural health policy. The repeated deployments of the teams have provided opportunities for processes to be refined, and this refinement has led to a scientifically rigorous and replicable approach. In this article we focus on two themes. The first theme is how changes in sampling have influenced the nature of the inferences drawn from the survey-based surveillance data. The second theme is how the ability to utilize different forms of data has served to strengthen the programme. Focusing on these two themes provides a way to discuss key findings, recommendations and limitations while also interspersing practical observations intended to help inform the design of broad-scale, in-theatre mental health surveillance efforts. We believe that future surveillance efforts should build on the lessons of the MHATs and attempt to replicate the more rigorous sampling methods; nonetheless, we also strive to convey that large surveillance efforts are valuable even if they cannot be executed with random sampling.

Effect of transition home from combat on risk-taking and health-related behaviors.

Transition home following a combat deployment involves a period of adjustment. Exploratory and confirmatory factor analyses of a new 16-item transition scale were conducted with 2 samples and resulted in 4 factors (Benefit, Appreciation, Anger/Alienation, and Guilt/Remorse). In Study 1 (N = 1,651), the number of combat events was positively related to Anger/Alienation 4 months later even after controlling for posttraumatic stress disorder (PTSD) symptoms, partial r = .18, p < .001. In Study 2 (N = 647), after controlling for PTSD symptoms, Anger/Alienation assessed at 4 months postdeployment predicted more risk-taking behaviors 4 months later, partial r = .10, p = .01. Appreciation predicted fewer unhealthy habits, partial r = -.13, p = .001, whereas Anger/Alienation predicted more unhealthy habits, partial r = .09, p = .024. Results demonstrate the importance of broadening the conceptualization of adjustment in combat veterans.

Mild traumatic brain injury (concussion) during combat: lack of association of blast mechanism with persistent postconcussive symptoms.

OBJECTIVE: To determine whether screening for a blast mechanism of concussion identifies individuals at higher risk of persistent postconcussive symptoms (PCS). SETTING: United States Army post. PARTICIPANTS: 3952 US Army infantry soldiers were administered anonymous surveys 3 to 6 months after returning from a yearlong deployment to Iraq. MAIN OUTCOME MEASURES: Self-reported concussion (defined as an injury that resulted in being "dazed, confused, or 'seeing stars'"; "not remembering the injury"; or "losing consciousness [knocked out]): Patient Health Questionnaire 15-item scale for physical symptoms and PCS; Posttraumatic Stress Disorder Checklist; and Patient Health Questionnaire depression module. RESULTS: Of the 587 soldiers (14.9% of the total sample) who met criteria for concussion, 201 (34.2%) reported loss of consciousness, and 373 (63.5%) reported only an alteration of consciousness without loss of consciousness; 424 (72.2%) reported a blast mechanism, and 150 (25.6%) reported a nonblast mechanism. Among soldiers who lost consciousness, blast mechanism was significantly associated with headaches and tinnitus 3 to 6 months postdeployment compared with a nonblast mechanism. However, among the larger group of soldiers reporting concussions without loss of consciousness, blast was not associated with adverse health outcomes. CONCLUSIONS: Blast mechanism of concussion was inconsistently associated with PCS, depending on the definition of concussion utilized. A self-reported history of blast mechanism was not associated with persistent PCS for the majority of US soldiers with concussions.

Time-driven battlemind psychological debriefing: a group-level early intervention in combat.

Military personnel who experience combat-related events are more likely to report mental health problems yet few early interventions have been designed to do more than assess those with problems or treat those with diagnoses. Psychological debriefing is one early intervention technique that has been used with military populations to reduce symptoms across entire groups. Although there are several different kinds of debriefings, this article describes time-driven Battlemind Psychological Debriefing procedures for use during a combat deployment. The five phases include: Introduction, Event, Reactions, Self and Buddy Aid, and Battlemind Focus. The paper reviews implementation guidelines, scientific support for Battlemind Psychological Debriefing, and feedback from military behavioral health providers in Iraq. Comparisons with other military debriefing models identify unique features and how Battlemind Psychological Debriefing is integrated into the larger Battlemind Training system.

Testing the effects of using a behavioral health provider to deliver a routine post-deployment assessment for soldiers returning from combat.

Studies indicate that changes in postdeployment behavioral health care delivery are necessary to improve symptom-reporting and treatment-seeking. The present study compared two behavioral health strategies implemented during the Post-Deployment Health Assessment (PDHA) with soldiers within the first months of returning from a combat deployment. A quasi-experimental, longitudinal study compared soldiers (N = 1,612) interviewed by a behavioral health (BH) provider and soldiers (N = 1,326) interviewed by a primary care provider using the standard PDHA procedure. Surveys pre- and post-PDHA and four months later assessed treatment-seeking attitudes; PDHA data and BH clinic use were compiled and compared by each interview strategy. Soldiers interviewed by a BH provider rated interview usefulness, quality, and comfort reporting BH concerns more positively than soldiers interviewed by a primary care provider using the standard procedure. However, there were no differences in treatment-seeking attitudes, provider referral rates, or use of BH services in the 4 months after the PDHA. Although there were initial positive reports of the interview with the BH Provider, there was no evidence BH provider interviews resulted in any lasting improvements in treatment-seeking or long-term treatment attitudes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Post-combat invincibility: violent combat experiences are associated with increased risk-taking propensity following deployment.

Combat exposure is associated with increased rates of mental health problems such as post-traumatic stress disorder, depression, and anxiety when Soldiers return home. Another important health consequence of combat exposure involves the potential for increased risk-taking propensity and unsafe behavior among returning service members. Survey responses regarding 37 different combat experiences were collected from 1252 US Army Soldiers immediately upon return home from combat deployment during Operation Iraqi Freedom. A second survey that included the Evaluation of Risks Scale (EVAR) and questions about recent risky behavior was administered to these same Soldiers 3 months after the initial post-deployment survey. Combat experiences were reduced to seven factors using principal components analysis and used to predict post-deployment risk-propensity scores. Although effect sizes were small, specific combat experiences, including greater exposure to violent combat, killing another person, and contact with high levels of human trauma, were predictive of greater risk-taking propensity after homecoming. Greater exposure to these combat experiences was also predictive of actual risk-related behaviors in the preceding month, including more frequent and greater quantities of alcohol use and increased verbal and physical aggression toward others. Exposure to violent combat, human trauma, and having direct responsibility for taking the life of another person may alter an individual's perceived threshold of invincibility and slightly increase the propensity to engage in risky behavior upon returning home after wartime deployment. Findings highlight the importance of education and counseling for returning service members to mitigate the public health consequences of elevated risk-propensity associated with combat exposure.

Prevalence of mental health problems, treatment need, and barriers to care among primary care-seeking spouses of military service members involved in Iraq and Afghanistan deployments.

Military spouses must contend with unique issues such as a mobile lifestyle, rules and regulations of military life, and frequent family separations including peacekeeping and combat deployments. These issues may have an adverse effect on the health of military spouses. This study examined the mental health status, rates of care utilization, source of care, as well as barriers and stigma of mental health care utilization among military spouses who were seeking care in military primary care clinics. The data show spouses have similar rates of mental health problems compared to soldiers. Spouses were more likely to seek care for their mental health problems and were less concerned with the stigma of mental health care than were soldiers. Services were most often received from primary care physicians, rather than specialty mental health professionals, which may relate to the lack of availability of mental health services for spouses on military installations.

Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.

BACKGROUND: The current combat operations in Iraq and Afghanistan have involved U.S. military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans. METHODS: We studied members of four U.S. combat infantry units (three Army units and one Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or three to four months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and post-traumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments. RESULTS: Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care. CONCLUSIONS: This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care.

Discontinuous growth modeling of adaptation to sleep setting changes: individual differences and age.

INTRODUCTION: Biomedical devices allow investigators to collect long-term repeated measures data to study adaptation. We examined 26 d of actigraph sleep data and tested for individual differences in sleep patterns prior to, during, and after a transition of sleeping in garrison to sleeping in a field exercise setting. In addition, we examined whether the individual difference variable of participant age (a continuous variable ranging from 19-29 yr) was related to sleep patterns. METHODS: Actigraph data was obtained from 77 cadets participating in a month-long military training program. At day 17, participants transitioned from sleeping in garrison to sleeping in a field exercise setting. A discontinuous growth model tested for individual differences in 1) overall sleep time, 2) garrison sleep slope, 3) the transition, and 4) the sleep slope during the field exercise setting. RESULTS: Individuals varied significantly in their overall sleep time, pattern of sleep in garrison, and the degree to which sleep decreased at the transition. The decline in sleep at the transition was related to participant age such that increases in age were associated with larger declines in sleep minutes. DISCUSSION: Individuals display significant variability in sleep patterns that can be detected using discontinuous growth models. The individual difference variable of participant age explains some of this variability. Much of the variability, however, remains unexplained. Future work will benefit from using discontinuous growth models to identify and model individual difference variables such as age when examining response patterns and transitions in data collected in applied field settings.

The Impact of Unit Membership on Smoking Among Soldiers.

Cultural, organizational, and dyadic influences have been found to be associated with smoking in the military while group-level influences have been identified in the general population. However, there are few studies examining group-level influences in the military and none using group-level analyses. Such studies are essential for understanding how to optimally forestall or cease smoking. This study, using mixed effects modelling, examined whether unit membership influenced smoking behavior in soldiers from brigade combat teams. Unit membership was assessed in 2008 to 2009 at the company level (n = 2204) and in 2012 at the platoon level (n = 452). Smoking was assessed by the number of daily cigarettes smoked (range: 0-99) with smoking status (nonsmoker vs. smoker) and smoking level (none, smoker, and heavy [20 + cigarettes/day]) as the outcomes. For both samples, unit membership was not significantly associated with a soldier's propensity to smoke when comparing either all smokers to nonsmokers or heavy smokers to smokers. These results suggest typical military unit-level training programs are unlikely to be the most effective mode of intervention for smoking prevention or cessation. Smoking rates in the military may be influenced instead by small group or individual relationships or by overall military culture.

Resilience training with soldiers during basic combat training: randomisation by platoon.

BACKGROUND: Resilience Training has the potential to mitigate mental health symptoms when provided during initial military training. METHODS: The present study examined the impact of Resilience Training on US soldier well-being and attitudes during Basic Combat Training. Platoons were randomly assigned to Resilience Training or Military History provided during the first few days of Basic Combat Training. Surveys were conducted at baseline, post-intervention, and 3, 6, and 9 weeks. RESULTS: The sample resulted in a total of 1,939 soldiers who completed at least the baseline and one follow-up survey. There were no significant differences between conditions in terms of depression symptoms, anxiety symptoms, or sleep problems. However, while anxiety decreased in both conditions, the rate of decrease was faster in the Resilience Training condition. In contrast, Resilience Training had a slower rate of increase in group cohesion over time than the Military History condition. In addition, Resilience Training was associated with greater confidence in helping others and received more positive ratings than Military History. CONCLUSIONS: Findings demonstrate that the brief Resilience Training studied here may have some utility in supporting mental health and peer support but may not benefit unit climate.

Building social resilience in soldiers: A double dissociative randomized controlled study.

Can social resilience be trained? We report results of a double-dissociative randomized controlled study in which 48 Army platoons were randomly assigned to social resilience training (intervention condition) or cultural awareness training (active control group). The same surveys were administered to all platoons at baseline and after the completion of training to determine the short-term training effects, generalization effects beyond training, and possible adverse effects. Multilevel modeling analyses indicated that social resilience, compared with cultural awareness, training produced small but significant improvements in social cognition (e.g., increased empathy, perspective taking, & military hardiness) and decreased loneliness, but no evidence was found for social resilience training to generalize beyond these training foci nor to have adverse effects. Moreover, as predicted, cultural awareness, compared with social resilience, training produced increases in knowledge about and decreases in prejudice toward Afghans. Additional research is warranted to determine the long-term durability, safety, and generalizability of social resilience training.

Family-supportive work environments and psychological strain: a longitudinal test of two theories.

Based on the Job Demands-Resources (JDR) model (E. Demerouti, A. B. Bakker, F. Nachreiner, & W. B. Schaufeli, 2001, The job demands-resources model of burnout. Journal of Applied Psychology, 86, 499-512) and Conservation of Resources (COR) theory (S. E. Hobfoll, 2002, Social and psychological resources and adaptation. Review of General Psychology, 6, 307-324), we tested three competing models that predict different directions of causation for relationships over time between family-supportive work environments (FSWE) and psychological strain, with two waves of data from a military sample. Results revealed support for both the JDR and COR theories, first in the static model where FSWE at Time 1 predicted psychological strain at Time 2 and when testing the opposite direction, where psychological strain at Time 1 predicted FSWE at Time 2. For change models, FSWE predicted changes in psychological strain across time, although the reverse causation model was not supported (psychological strain at Time 1 did not predict changes in FSWE). Also, changes in FSWE across time predicted psychological strain at Time 2, whereas changes in psychological strain did not predict FSWE at Time 2. Theoretically, these results are important for the work-family interface in that they demonstrate the application of a systems approach to studying work and family interactions, as support was obtained for both the JDR model with perceptions of FSWE predicting psychological strain (in both the static and change models), and for COR theory where psychological strain predicts FSWE across time.

NATO survey of mental health training in army recruits.

To-date, there has been no international review of mental health resilience training during Basic Training nor an assessment of what service members perceive as useful from their perspective. In response to this knowledge gap, the North Atlantic Treaty Organization (NATO) Human Factors & Medicine Research & Technology Task Group "Mental Health Training" initiated a survey and interview with seven to twenty recruits from nine nations to inform the development of such training (N = 121). All nations provided data from soldiers joining the military as volunteers, whereas two nations also provided data from conscripts. Results from the volunteer data showed relatively consistent ranking in terms of perceived demands, coping strategies, and preferences for resilience skill training across the nations. Analysis of data from conscripts identified a select number of differences compared to volunteers. Subjects also provided examples of coping with stress during Basic Training that can be used in future training; themes are presented here. Results are designed to show the kinds of demands facing new recruits and coping methods used to overcome these demands to develop relevant resilience training for NATO nations.