Amy M. Millikan

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.

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.

Combat Exposure, Unit Cohesion, and Demographic Characteristics of Soldiers Reporting Posttraumatic Growth

Posttraumatic growth (PTG) refers to the positive cognitive, spiritual, emotional, and social changes that can occur after a traumatic experience. The current study uses data from 1,663 soldiers who participated in a voluntary survey 6 months after redeployment. The purpose of this study was to predict posttraumatic growth from combat exposure, unit cohesion, and demographic characteristics. We found that greater combat exposure and stronger unit cohesion were associated with more PTG. Being married, a minority, and a junior enlisted soldier were also predictive of greater PTG. Our study defines a group of soldiers with low PTG who are at risk for adverse psychosocial problems. Our results suggest that unit cohesion could be targeted and strengthened to improve PTG.

The association between combat exposure and negative behavioral and psychiatric conditions

Abstract 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.

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.

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.

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.

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.

The Association Between U.S. 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.