Besa Smith

Risk factors associated with suicide in current and former US military personnel.

IMPORTANCE Beginning in 2005, the incidence of suicide deaths in the US military began to sharply increase. Unique stressors, such as combat deployments, have been assumed to underlie the increasing incidence. Previous military suicide studies, however, have relied on case series and cross-sectional investigations and have not linked data during service with postservice periods. OBJECTIVE To prospectively identify and quantify risk factors associated with suicide in current and former US military personnel including demographic, military, mental health, behavioral, and deployment characteristics. DESIGN, SETTING, AND PARTICIPANTS Prospective longitudinal study with accrual and assessment of participants in 2001, 2004, and 2007. Questionnaire data were linked with the National Death Index and the Department of Defense Medical Mortality Registry through December 31, 2008. Participants were current and former US military personnel from all service branches, including active and Reserve/National Guard, who were included in the Millennium Cohort Study (N = 151,560). MAIN OUTCOMES AND MEASURES Death by suicide captured by the National Death Index and the Department of Defense Medical Mortality Registry. RESULTS Through the end of 2008, findings were 83 suicides in 707,493 person-years of follow-up (11.73/100,000 person-years [95% CI, 9.21-14.26]). In Cox models adjusted for age and sex, factors significantly associated with increased risk of suicide included male sex, depression, manic-depressive disorder, heavy or binge drinking, and alcohol-related problems. None of the deployment-related factors (combat experience, cumulative days deployed, or number of deployments) were associated with increased suicide risk in any of the models. In multivariable Cox models, individuals with increased risk for suicide were men (hazard ratio [HR], 2.14; 95% CI, 1.17-3.92; P = .01; attributable risk [AR], 3.5 cases/10,000 persons), and those with depression (HR, 1.96; 95% CI, 1.05-3.64; P = .03; AR, 6.9/10,000 persons), manic-depressive disorder (HR, 4.35; 95% CI, 1.56-12.09; P = .005; AR, 35.6/10,000 persons), or alcohol-related problems (HR, 2.56; 95% CI, 1.56-4.18; P <.001; AR, 7.7/10,000 persons). A nested, matched case-control analysis using 20:1 control participants per case confirmed these findings. CONCLUSIONS AND RELEVANCE In this sample of current and former military personnel observed July 1, 2001-December 31, 2008, suicide risk was independently associated with male sex and mental disorders but not with military-specific variables. These findings may inform approaches to mitigating suicide risk in this population.

A Prospective Study of Depression Following Combat Deployment in Support of the Wars in Iraq and Afghanistan

OBJECTIVE We investigated relations between deployment and new-onset depression among US service members recently deployed to the wars in Iraq and Afghanistan. METHODS We included 40 219 Millennium Cohort Study participants who completed baseline and follow-up questionnaires and met inclusion criteria. Participants were identified with depression if they met the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire criteria for depression at follow-up, but not at baseline. RESULTS Deployed men and women with combat exposures had the highest onset of depression, followed by those not deployed and those deployed without combat exposures. Combat-deployed men and women were at increased risk for new-onset depression compared with nondeployed men and women (men: adjusted odds ratio [AOR]=1.32; 95% confidence interval [CI]=1.13, 1.54; women: AOR=2.13; 95% CI=1.70, 2.65). Conversely, deployment without combat exposures led to decreased risk for new-onset depression compared with those who did not deploy (men: AOR=0.66; 95% CI=0.53, 0.83; women: AOR=0.65; 95% CI=0.47, 0.89). CONCLUSIONS Deployment with combat exposures is a risk factor for new-onset depression among US service members. Post-deployment screening may be beneficial for US service members exposed to combat.

Risk Factors for Community-Associated Methicillin-Resistant Staphylococcus aureus Infections in an Outbreak of Disease among Military Trainees in San Diego, California, in 2002

ABSTRACT An outbreak of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infections was observed in a population of U.S. military trainees in the summer of 2002. A questionnaire was developed and administered to 206 trainees, 22 of whom had MRSA infections. Factors associated with infection were described by multivariable logistic regression modeling and included having a roommate in training with a prior skin infection (odds ratio [OR] = 3.44) or having a family member or friend who worked in a health care setting (OR = 2.79). Previous antibiotic use, hospitalization, or health problems were not associated with MRSA infection. This outbreak of MRSA skin infections in an otherwise-healthy, well-defined, military population provided an opportunity to describe risk factors for CA-MRSA which may help focus prevention efforts in this and other communities.

Cigarette Smoking and Military Deployment : A Prospective Evaluation

BACKGROUND The stress of military deployment may compound occupational stress experienced in the military and manifest in maladaptive coping behaviors such as cigarette smoking. The current study describes new smoking among never-smokers, smoking recidivism among past smokers, and change in daily smoking among smokers in relation to military deployment. METHODS The Millennium Cohort is a 21-year longitudinal study. The current analysis utilized participants (N=48,304) who submitted baseline data (July 2001-June 2003) before the current conflicts in Iraq and Afghanistan and follow-up data (June 2004-January 2006) on health measures. New smoking was identified among baseline never-smokers, smoking recidivism among baseline past smokers, and increased or decreased daily smoking among baseline smokers. Analyses were conducted March 2007-April 2007. RESULTS Among never-smokers, smoking initiation was identified in 1.3% of nondeployers and 2.3% of deployers. Among past smokers, smoking resumption occurred in 28.7% of nondeployers and 39.4% of those who deployed. Smoking increased 44% among nondeployers and 57% among deployers. Those who deployed and reported combat exposures were at 1.6 times greater odds of initiating smoking among baseline never-smokers (95% CI=1.2, 2.3) and at 1.3 times greater odds of resuming smoking among baseline past smokers when compared to those who did not report combat exposures. Other deployment factors independently associated with postdeployment smoking recidivism included deploying for >9 months and deploying multiple times. Among those who smoked at baseline, deployment was not associated with changes in daily amount smoked. CONCLUSIONS Military deployment is associated with smoking initiation and, more strongly, with smoking recidivism, particularly among those with prolonged deployments, multiple deployments, or combat exposures. Prevention programs should focus on the prevention of smoking relapse during or after deployment.

Large Epidemic of Respiratory Illness Due to Adenovirus Types 7 and 3 in Healthy Young Adults

After 25 years of successful control through immunization, respiratory infections due to adenoviruses have reemerged to threaten the health of young adults in the military. Shortly after the loss of adenovirus vaccine supplies, a large outbreak of respiratory illness was observed at the United States Navys sole basic training center. Laboratory testing confirmed 541 cases of adenovirus infection, including 378 cases due to serotype 7 and 132 cases due to serotype 3. This outbreak was remarkable because of its unique serotype distribution and the large amount of data available to describe demographic factors associated with infection. This was the largest outbreak of respiratory illness due to adenovirus types 7 and 3 documented in recent history, and it portends even greater challenges for young adults in the military in the postvaccine era.

Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: prospective US military cohort study

Objective To determine if baseline functional health status, as measured by SF-36 (veterans), predicts new onset symptoms or diagnosis of post-traumatic stress disorder among deployed US military personnel with combat exposure. Design Prospective cohort analysis. Setting Millennium Cohort. Participants Combat deployed members who completed baseline (2001-3) and follow-up (2004-6) questionnaires. Self reported and electronic data used to examine the relation between functional health and post-traumatic stress disorder. Main outcome measures New onset post-traumatic stress disorder as measured by either meeting the DSM-IV criteria with the 17 item post-traumatic stress disorder checklist-civilian version or self report of a physician diagnosis at follow-up with the absence of both at baseline. Results Of the 5410 eligible participants, 395 (7.3%) had new onset symptoms or diagnosis of post-traumatic stress disorder at the time of follow-up. Individuals whose baseline mental or physical component summary scores were below the 15th centile had two to three times the risk of symptoms or a diagnosis of post-traumatic stress disorder by follow-up compared with those in the 15th to 85th centile. Of those with new onset symptoms or diagnosis of post-traumatic stress disorder, over half (58%) of cases occurred among participants with scores below the 15th centile at baseline. Conclusions Low mental or physical health status before combat exposure significantly increases the risk of symptoms or diagnosis of post-traumatic stress disorder after deployment. More vulnerable members of a population could be identified and benefit from interventions targeted to prevent new onset post-traumatic stress disorder.

Newly Reported Respiratory Symptoms and Conditions Among Military Personnel Deployed to Iraq and Afghanistan: A Prospective Population-based Study

Concerns about respiratory conditions have surfaced among persons deployed to Iraq and Afghanistan. Data on 46,077 Millennium Cohort Study participants who completed baseline (July 2001-June 2003) and follow-up (June 2004-February 2006) questionnaires were used to investigate 1) respiratory symptoms (persistent or recurring cough or shortness of breath), 2) chronic bronchitis or emphysema, and 3) asthma. Deployers had a higher rate of newly reported respiratory symptoms than nondeployers (14% vs. 10%), while similar rates of chronic bronchitis or emphysema (1% vs. 1%) and asthma (1% vs. 1%) were observed. Deployment was associated with respiratory symptoms in both Army (adjusted odds ratio = 1.73, 95% confidence interval: 1.57, 1.91) and Marine Corps (adjusted odds ratio = 1.49, 95% confidence interval: 1.06, 2.08) personnel, independently of smoking status. Deployment length was linearly associated with increased symptom reporting in Army personnel (P < 0.0001). Among deployers, elevated odds of symptoms were associated with land-based deployment as compared with sea-based deployment. Although respiratory symptoms were associated with deployment, inconsistency in risk with cumulative exposure time suggests that specific exposures rather than deployment in general are determinants of postdeployment respiratory illness. Significant associations seen with land-based deployment also imply that exposures related to ground combat may be important.

The physical and mental health of a large military cohort: baseline functional health status of the Millennium Cohort

Background:The US military is currently involved in large, lengthy, and complex combat operations around the world. Effective military operations require optimal health of deployed service members, and both mental and physical health can be affected by military operations.Methods:Baseline data were collected from 77,047 US service members during 2001–2003 as part of a large, longitudinal, population-based military health study (the Millennium Cohort Study). The authors calculated unadjusted, adjusted, and weighted means for the Medical Outcomes Study Short Form 36-item Survey for Veterans physical (PCS) and mental component summary (MCS) scores over a variety of demographic and military characteristics at baseline.Results:The unadjusted mean PCS and MCS scores for this study were 53.4 (95% confidence interval: 53.3–53.4) and 52.8 (95% confidence interval: 52.7–52.9). Average PCS and MCS scores were slightly more favorable in this military sample compared to those of the US general population of the same age and sex. Factors independently associated with more favorable health status included male gender, being married, higher educational attainment, higher military rank, and Air Force service. Combat specialists had similar health status compared to other military occupations. Having been deployed to Southwest Asia, Bosnia, or Kosovo between 1998 and 2000 was not associated with diminished health status.Conclusion:The baseline health status of this large population-based military cohort is better than that of the US general population of the same age and sex distribution over the same time period, especially in older age groups. Deployment experiences during the period of 1998–2001 were not associated with decreased health status. These data will serve as a useful reference for other military health studies and for future longitudinal analyses.

Risk of Diabetes in U.S. Military Service Members in Relation to Combat Deployment and Mental Health

OBJECTIVE Few prospective data exist on the risk of diabetes in individuals serving in the U.S. military. The objectives of this study were to determine whether military deployment, combat exposures, and mental health conditions were related to the risk of newly reported diabetes over 3 years. RESEARCH DESIGN AND METHODS Data were from Millennium Cohort Study participants who completed baseline (July 2001–June 2003) and follow-up (June 2004–February 2006) questionnaires (follow-up response rate = 71.4%). After exclusion criteria were applied, adjusted analyses included 44,754 participants (median age 36 years, range 18–68 years). Survey instruments collected demographics, height, weight, lifestyle, military service, clinician-diagnosed diabetes, and other physical and mental health conditions. Deployment was defined by U.S. Department of Defense databases, and combat exposure was assessed by self-report at follow-up. Odds of newly reported diabetes were estimated using logistic regression analysis. RESULTS Occurrence of diabetes during follow-up was 3 per 1,000 person-years. Individuals reporting diabetes at follow-up were significantly older, had greater baseline BMI, and were less likely to be Caucasian. After adjustment for age, sex, BMI, education, race/ethnicity, military service characteristics, and mental health conditions, only baseline posttraumatic stress disorder (PTSD) was significantly associated with risk of diabetes (odds ratio 2.07 [95% CI 1.31–3.29]). Deployments since September 2001 were not significantly related to higher diabetes risk, with or without combat exposure. CONCLUSIONS In this military cohort, PTSD symptoms at baseline but not other mental health symptoms or military deployment experience were significantly associated with future risk of self-reported diabetes.

The occupational role of women in military service: Validation of occupation and prevalence of exposures in the Millennium Cohort Study

Abstract To better understand the US militarys global peacekeeping and combat operations, which may expose a growing population of American servicewomen to challenging occupations and environments. Concordance between self-reported and electronic occupation codes for female participants in the Millennium Cohort was measured using kappa statistics. Multivariable logistic regression modeling was used to assess the odds of five self-reported potentially toxic environmental exposures or disturbing experiences among different occupational categories, while adjusting for demographic and military characteristics, including deployment. Self-reported occupations were moderately to highly reliable when compared with electronic occupation data. Active-duty and Reserve/Guard females differentially reported witnessing death or trauma and exposure to chemical or biological warfare, depleted uranium, or pesticides. Findings suggest that self-reported occupation can be used with a high degree of confidence. Occupational groups with higher odds of reporting military exposures of concern will be followed longitudinally through 2022 and prospectively compared using baseline and follow-up evaluations.