Kristine Rae Olmsted

Alcohol use and negative consequences among active duty military personnel.

AIMS An examination of alcohol use patterns in the active duty military to determine the relations of drinking levels and self-reported negative outcomes. DESIGN A population-based cross-sectional study design using two-stage complex sampling methodology. SETTING Paper and pencil surveys were administered anonymously in groups at 64 U.S. military installations worldwide. PARTICIPANTS Randomly selected active duty members (28,546) at major military installations representing the total active force, with the exception of recruits, cadets, and incarcerated personnel. MEASURES Personnel were classified into five drinking levels ranging from abstainer to heavy drinker based on quantity and frequency of alcohol intake. Negative outcomes were measured as self-reported serious consequences of alcohol use and alcohol-related productivity loss. Risk for other alcohol related problems was assessed by the Alcohol Use Disorders Identification Test (AUDIT). FINDINGS Alcohol negative outcomes showed a curvilinear dose-response relationship with drinking levels. Higher levels of drinking were associated with higher rates of alcohol problems, but problem rates were notably higher for heavy drinkers. Heavy alcohol users showed nearly three times the rate of self-reported serious consequences and over twice the rate of self-reported productivity loss than moderate/heavy drinkers. Heavy drinkers also had the highest risk for alcohol problems on the AUDIT. One fifth of military personnel were heavy drinkers and were most likely aged 18 to 35. CONCLUSIONS Prevention and clinical interventions should include a major focus on heavy drinkers. Commanders and peers should be trained in recognizing signs of heavy alcohol use and in approaching heavy alcohol users in a way that will foster positive attitudes as opposed to defensiveness and stigma.

Dynamics of Stigma for Alcohol and Mental Health Treatment Among Army Soldiers

Stigma associated with substance abuse is less understood than stigma of mental health. Moreover, neither issue has been studied in depth within the military. We conducted focus groups with soldiers at six installations to explore how perceptions regarding substance abuse and mental health issues influenced attitudes toward treatment of these issues. Analyses indicate that negative attitudes toward treatment for alcohol abuse are based on their association with infractions that precipitate treatment and acceptance for soldiers with deployment-related mental health issues. However, the military context appears to moderate the influence of perceived responsibility and danger on stigmatization. Our data suggest several strategies that may useful in reducing stigma associated with alcohol abuse treatment in the military.

Stigma as a Barrier to Substance Abuse and Mental Health Treatment

This article provides an overview of stigma associated with mental health and substance abuse treatment in military settings and discusses articles included in this issue. These articles examine the predictors of and barriers to treatment entry; assess the influence of military culture and unit influences on attitudes toward treatment; examine unique challenges associated with reserve personnel; and address policy changes to improve access to care. We review challenges associated with reducing stigma and the importance of policy, culture, education, and leadership to effect the desired changes.

Mental Health and Substance Abuse Treatment Stigma Among Soldiers

Few studies have compared persons in treatment to those not in treatment with regard to perceived stigma. We surveyed soldiers to examine differences in stigma perceptions among those in treatment for substance abuse and/or mental health problems (n = 470) and those not in treatment (n = 966). Analyses revealed that soldiers in treatment perceived greater stigma regarding mental health treatment compared with soldiers not in treatment. These findings support the notion that personnel most in need of treatment perceive greater stigma associated with these services and as a result may be less likely to pursue them. We discuss the implications of our findings for theory, research, and practice.

Trends in Mental Health Services Utilization and Stigma in US Soldiers From 2002 to 2011

OBJECTIVES We characterized trends in mental health services utilization and stigma over the course of the Afghanistan and Iraq wars among active-component US soldiers. METHODS We evaluated trends in mental health services utilization and stigma using US Army data from the Health-Related Behavior (HRB) surveys from 2002, 2005, and 2008 (n = 12,835) and the Land Combat Study (LCS) surveys administered to soldiers annually from 2003 to 2009 and again in 2011 (n = 22,627). RESULTS HRB and LCS data suggested increased mental health services utilization and decreased stigma in US soldiers between 2002 and 2011. These trends were evident in soldiers with and without posttraumatic stress disorder (PTSD), major depressive disorder (MDD), or PTSD and MDD. Despite the improving trends, more than half of soldiers with mental health problems did not report seeking care. CONCLUSIONS Mental health services utilization increased and stigma decreased over the course of the wars in Iraq and Afghanistan. Although promising, these findings indicate that a significant proportion of US soldiers meeting criteria for PTSD or MDD do not utilize mental health services, and stigma remains a pervasive problem requiring further attention.

Implementing collaborative primary care for depression and posttraumatic stress disorder: Design and sample for a randomized trial in the U.S. military health system☆

BACKGROUND War-related trauma, posttraumatic stress disorder (PTSD), depression and suicide are common in US military members. Often, those affected do not seek treatment due to stigma and barriers to care. When care is sought, it often fails to meet quality standards. A randomized trial is assessing whether collaborative primary care improves quality and outcomes of PTSD and depression care in the US military health system. OBJECTIVE The aim of this study is to describe the design and sample for a randomized effectiveness trial of collaborative care for PTSD and depression in military members attending primary care. METHODS The STEPS-UP Trial (STepped Enhancement of PTSD Services Using Primary Care) is a 6 installation (18 clinic) randomized effectiveness trial in the US military health system. Study rationale, design, enrollment and sample characteristics are summarized. FINDINGS Military members attending primary care with suspected PTSD, depression or both were referred to care management and recruited for the trial (2592), and 1041 gave permission to contact for research participation. Of those, 666 (64%) met eligibility criteria, completed baseline assessments, and were randomized to 12 months of usual collaborative primary care versus STEPS-UP collaborative care. Implementation was locally managed for usual collaborative care and centrally managed for STEPS-UP. Research reassessments occurred at 3-, 6-, and 12-months. Baseline characteristics were similar across the two intervention groups. CONCLUSIONS STEPS-UP will be the first large scale randomized effectiveness trial completed in the US military health system, assessing how an implementation model affects collaborative care impact on mental health outcomes. It promises lessons for health system change.

Overlap in Use of Different Types of Tobacco Among Active Duty Military Personnel

OBJECTIVE To describe the prevalence and overlapping combinations in past thirty-day cigarette use, smokeless tobacco use, and cigar use in the active duty U.S. military. METHODS Data were taken from the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. A total of 28,546 service members participated for a response rate of 70.6%. RESULTS Analyses showed that 41.2% of active duty service members used one or more forms of tobacco in the past month. Cigarette use only was most prevalent (21.3%); other combinations were much lower ranging from 0.7% to 13.5%. Multinomial regression modeling yielded no consistent patterns in sociodemographic groups with higher risk of using one or more types of tobacco concurrently. Frequency and quantity of cigarette use were related to tobacco use patterns. From 60% to 67% of smokers were daily users of cigarettes only or cigarettes in combination with other tobacco types. The majority of cigarette users (54%-69%) smoked 15 or fewer cigarettes/day regardless of tobacco use patterns, but those who smoked at heaviest levels were most likely to use all 3 tobacco types (19%). CONCLUSIONS Four of 10 service members place themselves at increased risk of tobacco-related illness and disease by using one or more types of tobacco. Daily cigarette smokers and very heavy smokers are at highest risk of using multiple tobacco types. Further research is needed to better understand the levels of use and the reasons for use of multiple types of tobacco.

Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care: A Randomized Clinical Trial

IMPORTANCE It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression. OBJECTIVE To determine effectiveness of a centrally assisted collaborative telecare (CACT) intervention for PTSD and depression in military primary care. DESIGN, SETTING, AND PARTICIPANTS The STEPS-UP study (Stepped Enhancement of PTSD Services Using Primary Care) is a randomized trial comparing CACT with usual integrated mental health care for PTSD or depression. Patients, mostly men in their 20s, were enrolled from 18 primary care clinics at 6 military installations from February 2012 to August 2013 with 12-month follow-up completed in October 2014. INTERVENTIONS Randomization was to CACT (n = 332) or usual care (n = 334). The CACT patients received 12 months of stepped psychosocial and pharmacologic treatment with nurse telecare management of caseloads, symptoms, and treatment. MAIN OUTCOMES AND MEASURES Primary outcomes were severity scores on the PTSD Diagnostic Scale (PDS; scored 0-51) and Symptom Checklist depression items (SCL-20; scored 0-4). Secondary outcomes were somatic symptoms, pain severity, health-related function, and mental health service use. RESULTS Of 666 patients, 81% were male and the mean (SD) age was 31.1 (7.7) years. The CACT and usual care patients had similar baseline mean (SD) PDS PTSD (29.4 [9.4] vs 28.9 [8.9]) and SCL-20 depression (2.1 [0.6] vs 2.0 [0.7]) scores. Compared with usual care, CACT patients reported significantly greater mean (SE) 12-month decrease in PDS PTSD scores (-6.07 [0.68] vs -3.54 [0.72]) and SCL-20 depression scores -0.56 [0.05] vs -0.31 [0.05]). In the CACT group, significantly more participants had 50% improvement at 12 months compared with usual care for both PTSD (73 [25%] vs 49 [17%]; relative risk, 1.6 [95% CI, 1.1-2.4]) and depression (86 [30%] vs 59 [21%]; relative risk, 1.7 [95% CI, 1.1-2.4]), with a number needed to treat for a 50% improvement of 12.5 (95% CI, 6.9-71.9) and 11.1 (95% CI, 6.2-50.5), respectively. The CACT patients had significant improvements in somatic symptoms (difference between mean 12-month Patient Health Questionnaire 15 changes, -1.37 [95% CI, -2.26 to -0.47]) and mental health-related functioning (difference between mean 12-month Short Form-12 Mental Component Summary changes, 3.17 [95% CI, 0.91 to 5.42]), as well as increases in telephone health contacts and appropriate medication use. CONCLUSIONS AND RELEVANCE Central assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01492348.

Unit cohesion, resilience, and mental health of soldiers in basic combat training

Military unit cohesion has been shown to correlate with physical and psychological outcomes. However, little is known about the development of cohesion in the early days of military service during Basic Combat Training (BCT) and how it relates to positive support and the negative stressors of training. The current study assessed the development of unit cohesion across the 10-week BCT period (N = 1,939), and the relation of cohesion to stress, resilience, mental health measures, and BCT outcomes (graduation, passing the Army Physical Fitness Test, and final Basic Rifle Marksmanship scores). The sample was primarily male (62%), under age 25 (88%), and unmarried (88%). All putative mediators showed significant change over time. Unit cohesion increased over time (slope 0.22; p < .001), and these increases were associated with decreases in psychological distress (p < .001), sleep problems (p < .001), and tolerance of BCT stressors (p < .001), as well as increases in resilience (p < .001), confidence managing stress reactions (p < .001), and positive states of mind (p < .001). Unit cohesion was indirectly associated with successful graduation and passing the Army Physical Fitness Test through cohesion-related improvement in psychological distress, resilience, and confidence managing reactions to stress. Sleep problems also mediated BCT graduation. Cohesion effects on the Basic Rifle Marksmanship scores were mediated by psychological distress and tolerance of BCT stressors only. These results suggest that unit cohesion may play a key role in the development of psychological health among new soldiers.