Marian E. Lane

Substance Use and Mental Health Trends Among U.S. Military Active Duty Personnel: Key Findings From the 2008 DoD Health Behavior Survey

OBJECTIVE Examine substance use and mental health issues among U.S. military personnel. METHODS Data were from the 2008 (and before) population-based Department of Defense Health Related Behavior Surveys. The sample size for the 2008 survey was 28,546 (70.6% response rate). RESULTS Analyses examined substance use, stress, depression, post-traumatic stress disorder (PTSD), suicidal ideation and attempts, deployment, and job satisfaction. Trends show reductions in tobacco use and illicit drug use, but increases in prescription drug misuse, heavy alcohol use, stress, PTSD, and suicidal attempts. Deployment exacerbated some of these behavior changes. Despite the demanding lifestyle, job satisfaction was high. CONCLUSIONS The military has shown progress in decreasing cigarette smoking and illicit drug use. Additional emphasis should be placed on understanding increases in prescription drug misuse, heavy alcohol use, PTSD, and suicide attempts, and on planning additional effective interventions and prevention programs. Challenges remain in understanding and addressing military mental health needs.

Chaplaincy and Mental Health in the Department of Veterans Affairs and Department of Defense

Chaplains play important roles in caring for Veterans and Service members with mental health problems. As part of the Department of Veterans Affairs (VA) and Department of Defense (DoD) Integrated Mental Health Strategy, we used a sequential approach to examining intersections between chaplaincy and mental health by gathering and building upon: 1) input from key subject matter experts; 2) quantitative data from the VA / DoD Chaplain Survey (N = 2,163; response rate of 75% in VA and 60% in DoD); and 3) qualitative data from site visits to 33 VA and DoD facilities. Findings indicate that chaplains are extensively involved in caring for individuals with mental health problems, yet integration between mental health and chaplaincy is frequently limited due to difficulties between the disciplines in establishing familiarity and trust. We present recommendations for improving integration of services, and we suggest key domains for future research.

Influence of Spirituality on Depression, Posttraumatic Stress Disorder, and Suicidality in Active Duty Military Personnel

Understanding the role of spirituality as a potential coping mechanism for military personnel is important given growing concern about the mental health issues of personnel returning from war. This study seeks to determine the extent to which spirituality is associated with selected mental health problems among active duty military personnel and whether it moderates the relationship between combat exposure/deployment and (a) depression, (b) posttraumatic stress disorder (PTSD), and (c) suicidality in active duty military personnel. Data were drawn from the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Over 24,000 randomly selected active duty personnel worldwide completed an anonymous self-report questionnaire. High spirituality had a significant protective effect only for depression symptoms. Medium, as opposed to high or low, levels of spirituality buffered each of the mental health outcomes to some degree. Medium and low spirituality levels predicted depression symptoms but only among those with moderate combat exposure. Medium spirituality levels also predicted PTSD symptoms among those with moderate levels of combat exposure and predicted self-reported suicidal ideation/attempt among those never deployed. These results point to the complex relationship between spirituality and mental health, particularly among military personnel and the need for further research.

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.

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.

Help-seeking behaviors among active-duty military personnel: utilization of chaplains and other mental health service providers

Military chaplains not only conduct religious services, but also provide counseling and spiritual support to military service members, operating as liaisons between soldiers and mental health professionals. In this study, active-duty soldiers (N = 889) reported help-seeking behaviors and mental health. Using logistic regressions, we describe the issues for which soldiers reported seeking help, then outline the characteristics of those who are most likely to seek help from a chaplain. Of the soldiers who sought help from a chaplain within the previous year, 29.9% reported high levels of combat exposure, 50.8% screened positive for depression, 39.1% had probable PTSD, and 26.6% screened positive for generalized anxiety disorder. The participant’s unit firing on the enemy, personally firing on the enemy, and seeing dead bodies or human remains predicted seeing a chaplain. Future research should examine ways to engage soldiers who have had more combat experiences with the chaplain community to address spiritual issues.

The Single Service Member: Substance Use, Stress, and Mental Health Issues

This chapter examines health behaviors of single service members in relation to married service members residing with their spouses and married service members who have deployed without their spouses. Findings drawn from the 2005 Department of Defense (DoD) Survey of Health Related Behaviors Among Active Duty Military Personnel (HRB Survey) show that single service members are at highest risk for substance use and mental health issues. In addition, married service members stationed in locations where they are not able to be accompanied by their spouses (e.g., deployments to combat locations, unaccompanied tours) begin to behave like single service members with regards to higher levels of alcohol, drug, and tobacco use and show similar mental health issues including rates of depression, posttraumatic stress, and suicidal behaviors. Policy implications for addressing these issues are also discussed.

Posttraumatic Stress Disorder in U.S. Military Primary Care: Trajectories and Predictors of One‐Year Prognosis

We examined the longitudinal course of primary care patients in the active duty Army with posttraumatic stress disorder (PTSD) and identified prognostic indicators of PTSD severity. Data were drawn from a 6-site randomized trial of collaborative primary care for PTSD and dpression in the military. Subjects were 474 soldiers with PTSD (scores ≥ 50 on the PTSD Checklist -Civilian Version). Four assessments were completed at U.S. Army installations: baseline, and follow-ups at 3 months (92.8% response rate [RR]), 6 months (90.1% RR), and 12 months (87.1% RR). Combat exposure and 7 validated indicators of baseline clinical status (alcohol misuse, depression, pain, somatic symptoms, low mental health functioning, low physical health functioning, mild traumatic brain injury) were used to predict PTSD symptom severity on the Posttraumatic Diagnostic Scale (Cronbachs α = .87, .92, .95, .95, at assessments 1-4, respectively). Growth mixture modeling identified 2 PTSD symptom trajectories: subjects reporting persistent symptoms (Persisters, 81.9%, n = 388), and subjects reporting improved symptoms (Improvers 18.1%, n = 86). Logistic regression modeling examined baseline predictors of symptom trajectories, adjusting for demographics, installation, and treatment condition. Subjects who reported moderate combat exposure, adjusted odds ratio (OR) = 0.44, 95% CI [0.20, 0.98], or who reported high exposure, OR = 0.39, 95% CI [0.17, 0.87], were less likely to be Improvers. Other baseline clinical problems were not related to symptom trajectories. Findings suggested that most military primary care patients with PTSD experience persistent symptoms, highlighting the importance of improving the effectiveness of their care. Most indicators of clinical status offered little prognostic information beyond the brief assessment of combat exposure.

Effects of sleep issues on suicidal ideation in a military sample: The mediating role of mental health

ABSTRACT The goal of this study was to examine the relationship between sleep issues, mental health (perceived stress, posttraumatic stress disorder [PTSD] symptoms, and depressive symptoms), and suicidal ideation (SI) in a sample of military service members (N = 891) using mediation analyses. Sleep issues were related to SI, stress, PTSD, and depressive symptoms. PTSD, perceived stress, and depressive symptoms mediated the relationship between sleep issues and SI; after accounting for mental health symptoms, sleep no longer had a direct effect on SI. The findings suggest that sleep issues may operate as a risk factor for mental health issues and SI.

Posttraumatic Stress Disorder in U.S. Military Primary Care: Trajectories and Predictors of One-Year Prognosis: PTSD Trajectories and Prognosis Predictors

We examined the longitudinal course of primary care patients in the active duty Army with posttraumatic stress disorder (PTSD) and identified prognostic indicators of PTSD severity. Data were drawn from a 6-site randomized trial of collaborative primary care for PTSD and dpression in the military. Subjects were 474 soldiers with PTSD (scores ≥ 50 on the PTSD Checklist -Civilian Version). Four assessments were completed at U.S. Army installations: baseline, and follow-ups at 3 months (92.8% response rate [RR]), 6 months (90.1% RR), and 12 months (87.1% RR). Combat exposure and 7 validated indicators of baseline clinical status (alcohol misuse, depression, pain, somatic symptoms, low mental health functioning, low physical health functioning, mild traumatic brain injury) were used to predict PTSD symptom severity on the Posttraumatic Diagnostic Scale (Cronbachs α = .87, .92, .95, .95, at assessments 1-4, respectively). Growth mixture modeling identified 2 PTSD symptom trajectories: subjects reporting persistent symptoms (Persisters, 81.9%, n = 388), and subjects reporting improved symptoms (Improvers 18.1%, n = 86). Logistic regression modeling examined baseline predictors of symptom trajectories, adjusting for demographics, installation, and treatment condition. Subjects who reported moderate combat exposure, adjusted odds ratio (OR) = 0.44, 95% CI [0.20, 0.98], or who reported high exposure, OR = 0.39, 95% CI [0.17, 0.87], were less likely to be Improvers. Other baseline clinical problems were not related to symptom trajectories. Findings suggested that most military primary care patients with PTSD experience persistent symptoms, highlighting the importance of improving the effectiveness of their care. Most indicators of clinical status offered little prognostic information beyond the brief assessment of combat exposure.