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Introduction Prior studies have identified associations between specific health conditions and occupational impairments in the U.S. military, but little is known about the relative magnitude of impairments associated with different mental and physical health conditions among military service members. The goal of this study is to comparatively assess occupational impairment associated with mental and physical conditions among active duty military service members. Materials and Methods Data on 11,055 U.S. active duty service members were from the Department of Defense 2015 Health Related Behaviors Survey, an anonymous online health survey. Items assessed common mental and physical health conditions. Absenteeism was assessed as number of lost work days and presenteeism was assessed as number of work days with impaired functioning in the past 30 days. This research was approved by the RAND Human Subjects Protections Committee. Results Back pain (23%) and anxiety (14%) were the most prevalent conditions in the sample. Mental health conditions (anxiety, depression, and PTSD) were associated with more absentee and presentee days than physical conditions. Adjusting for physical health conditions, anxiety, depression, and PTSD showed robust associations with both absenteeism and presenteeism. Conclusions Common mental health conditions such as anxiety, depression, and PTSD showed robust associations with absenteeism and presenteeism among active duty U.S. military service members. Efforts to rigorously evaluate and improve existing military screening programs and reduce barriers to accessing and engaging in mental healthcare may help to reduce work absenteeism and presenteeism among active duty service members.

Behavioral health integration is uncommon among U.S. physician practices despite recent policy changes that may encourage its adoption.To describe factors influencing physician practices' implementation of behavioral health integration.Semistructured interviews with leaders and clinicians from physician practices that adopted behavioral health integration, supplemented by contextual interviews with experts and vendors in behavioral health integration.30 physician practices, sampled for diversity on specialty, size, affiliation with parent organizations, geographic location, and behavioral health integration model (collaborative or co-located).47 physician practice leaders and clinicians, 20 experts, and 5 vendors.Qualitative analysis (cyclical coding) of interview transcripts.Four overarching factors affecting physician practices' implementation of behavioral health integration were identified. First, practices' motivations for integrating behavioral health care included expanding access to behavioral health services, improving other clinicians' abilities to respond to patients' behavioral health needs, and enhancing practice reputation. Second, practices tailored their implementation of behavioral health integration to local resources, financial incentives, and patient populations. Third, barriers to behavioral health integration included cultural differences and incomplete information flow between behavioral and nonbehavioral health clinicians and billing difficulties. Fourth, practices described the advantages and disadvantages of both fee-for-service and alternative payment models, and few reported positive financial returns.The practice sample was not nationally representative and excluded practices that did not implement or sustain behavioral health integration, potentially limiting generalizability.Practices currently using behavioral health integration face cultural, informational, and financial barriers to implementing and sustaining behavioral health integration. Tailored, context-specific technical support to guide practices' implementation and payment models that improve the business case for practices may enhance the dissemination and long-term sustainability of behavioral health integration.American Medical Association and The Commonwealth Fund.

ObjectivesTo evaluate feasibility and acceptability of a group-based nature recreation intervention (nature hiking) and control condition (urban hiking) for military Veterans with post-traumatic stress disorder (PTSD).Design and settingA pilot randomised controlled trial conducted in the US Pacific Northwest.ParticipantsVeterans with PTSD due to any cause.InterventionsTwenty-six participants were randomised to a 12-week intervention involving either six nature hikes (n=13) or six urban hikes (n=13).Primary and secondary outcome measuresFeasibility was assessed based on recruitment, retention and attendance. Questionnaires and postintervention qualitative interviews were conducted to explore intervention acceptability. Questionnaires assessing acceptability and outcomes planned for the future trial (eg, PTSD symptoms) were collected at baseline, 6 weeks, 12 weeks (immediately after the final hike) and 24 weeks follow-up.ResultsOf 415 people assessed for eligibility/interest, 97 were interested and passed preliminary eligibility screening, and 26 were randomised. Mean completion of all questionnaires was 91% among those in the nature hiking group and 68% in those in the urban hiking group. Over the course of the intervention, participants in the nature and urban groups attended an average of 56% and 58%, respectively, of scheduled hikes. Acceptability of both urban and nature hikes was high; over 70% reported a positive rating (ie, good/excellent) for the study communication, as well as hike locations, distance and pace. Median PTSD symptom scores (PTSD Checklist-5) improved more at 12 weeks and 24 weeks among those in the nature versus urban hiking group.ConclusionsThis pilot study largely confirmed the feasibility and acceptability of nature hiking as a potential treatment for Veterans with PTSD. Adaptations will be needed to improve recruitment and increase hike attendance for a future randomised controlled trial to effectively test and isolate the ways in which nature contact, physical activity and social support conferred by the group impact outcomes.Trial registration numberNCT03997344.

Battlefield medical advances, improvements in protective equipment, and progress in surgical reconstruction and rehabilitation have led to questions about when to emphasize limb salvage over other treatment options — such as amputation — for individuals with severe blast-related limb injuries. These conference proceedings summarize findings, conclusions, and recommendations of an expert-led meeting held in March 2019 that addressed such questions.

There is increasing concern over the common, repetitive forms of blast—often unrelated to combat—to which military members are exposed during service, and how those exposures could affect the central nervous system, potentially resulting in neurological and emotional consequences. The authors of this report review the relevant literature and identify research and policy gaps related to military occupational blast exposure.

Burns are one of the most difficult types of injury for which to care, and about 5–20 percent of combat-related casualties during Operation Iraqi Freedom and Operation Enduring Freedom included severe burns. Blast-related burn injuries are associated with infection, disability, and mortality. To identify areas that are understudied, RAND researchers conducted a literature review and synthesis of the evidence surrounding blast-related burn injury.

Women military veterans are at increased risk of suicide compared to non-veterans, but little is known about the mental health service preferences and needs of women veterans in crisis. This study used qualitative, secondary source key informant interviews to ascertain the experiences of women veterans in crisis from 54 responders working at the Veterans Crisis Line. Responders indicated that women veterans reported different experiences with Veterans Administration (VA) and non-VA care, though drivers of satisfaction or dissatisfaction were similar. Availability of specialty care, sensitivity to veterans' issues or Military Sexual Trauma, strong provider relationships, and continuity of care contributed to satisfaction; lengthy appointment wait times, limited service options, and insensitivity to veterans' issues contributed to dissatisfaction. Responders suggested that barriers limiting VA access for women veterans are perceived as similar to non-VA care. Findings suggest that caller experiences with providers drive satisfaction with VA and non-VA mental health services.

Using data collected from a 2012 - 2016 randomized trial, the effectiveness of enhanced collaborative care for PTSD and depression was evaluated using probable diagnostic status as the primary outcome. Exclusion criteria were then applied to a 2011 disease registry to examine the representativeness of the trial sample and estimate the potential reach of the intervention. Population impact was derived from the estimated effectiveness and reach of the intervention.Enhanced collaborative care was associated with a significantly greater probability of PTSD/depression remission by the end of the trial (conditional effect = -0.066, chisq = 51.1, p0.001). Based on the effectiveness and reach of the enhanced intervention, an estimated 250 (out of the 3,436) more Army soldiers with PTSD and/or depression would experience diagnostic remission during the preceding year if the enhanced model was available.The population framework permits the estimated differential impact of two collaborative care models to inform implementation considerations. These results highlight the value of applying public health models to identify front line treatments.

ObjectiveThe purpose of this study was to examine the associations between oil spill exposure, trauma history, and behavioral health 6 years after the Deepwater Horizon oil spill (DHOS). We hypothesized that prior trauma would exacerbate the relationship between oil spill exposure and behavioral health problems.MethodsThe sample included 2,520 randomly selected adults in coastal areas along the Gulf of Mexico. Participants reported their level of oil spill exposure, trauma history, depression, anxiety/worry, illness anxiety, and alcohol use.ResultsIndividuals with more traumatic experiences had a significantly higher risk for all measured behavioral health problems after controlling for demographic factors and DHOS exposure. Those with higher levels of DHOS exposure were not at greater risk for behavioral health problems after controlling for prior trauma, with the exception of illness anxiety. There was no evidence that trauma history moderated the association between DHOS exposure and behavioral health.ConclusionsFindings suggest that trauma exposure may be a better indicator of long-term behavioral health risk than DHOS exposure among disaster-prone Gulf Coast residents. DHOS exposure may be a risk factor for illness anxiety but not more general behavioral health concerns. Trauma history did not appear to exacerbate risk for behavioral health problems among Gulf residents exposed to the DHOS. (Disaster Med Public Health Preparedness. 2019;13:497-503)

Abstract. Background: Crisis support services have historically been offered by phone-based suicide prevention hotlines, but are increasingly becoming available through alternative modalities, including Internet chat and text messaging. Aims: To better understand differences in the use of phone and chat/text services. Method: We conducted semistructured interviews with call responders at the Veterans Crisis Line who utilize multimodal methods to respond to veterans in crisis. Results: Responders indicated that veterans may access the chat/text service primarily for reasons that included a desire for anonymity and possible inability to use the phone. Responders were divided on whether callers and chatters presented with different issues or risk of suicide; however, they suggested that veterans frequently use chat/text to make their first contact with mental health services. Limitations: We spoke with call responders, not the veterans themselves. Additionally, as this is qualitative research, applicability to other settings may be limited. Conclusion: While new platforms offer promise, participants also indicated that chat services can supplement phone lines, but not replace them.

Introduction: Achieving adequate retention rates in clinical trials is essential to ensuring meaningful results. Although financial reimbursement is an effective strategy to increase participant retention, current policies restrict the use of federal funds to reimburse U.S. active duty Service members for research participation. It is unknown whether permitting financial reimbursement among this population would improve trial retention rates. A recent randomized effectiveness trial received approval to provide reimbursement to Service member participants several months after recruitment began, creating a natural experiment to study the effects of financial reimbursement on retention. Materials and methods: Active duty Service members recruited from six U.S. military treatment facilities (N = 666) were enrolled in a collaborative care study and completed assessments at baseline, three-, six-, and 12-months. Data on study assessment completion rates at three- and six-months were analyzed using the mixed-effects binary logit model to determine the probabilities of completing assessments based on reimbursement status. Results: Participants who received reimbursement were significantly more likely to complete study assessments at both time-points than participants who did not receive reimbursement (p

RAND Corporation researchers developed a framework for assessing the maturity of knowledge products — outputs from health science research. An assessment results in assignment to a knowledge readiness level: scientific foundation, applied knowledge, or application to specific, real-world contexts. Those assignments can help the U.S. Army make better research portfolio decisions.

The Posttraumatic Stress Disorder (PTSD) Checklist (PCL) is a 17-item self-report measure of PTSD symptom severity that has demonstrated excellent psychometric properties across a variety of settings, purposes, and populations. The PCL is widely used in busy Department of Defense primary care settings as part of routine PTSD screening, requiring that it is easy for patients to complete and providers to score. The clinical utility of the PCL may be improved through use of a zero-anchored Likert-type response scale by providing intuitive anchors for respondents and fewer calculations for clinic staff; however, changes to the response scale may invalidate the known psychometric properties of the measure. The purpose of this study is to evaluate the equivalence of a zero-anchored PCL to the traditional one-anchored PCL. Differences in total scores were examined using inferential confidence intervals. Substantial overlap of the inferential confidence intervals and small Rg (maximum probable difference) value of 0.68 indicated that the zero-anchored PCL is equivalent to the one-anchored PCL on the basis of our specified delta (amount of difference considered inconsequential). These findings support the use of a zero-anchored PCL in clinical practice, and more broadly, the use of zero-anchored measures in the larger field of psychological assessment.

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 (Cronbach's 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.

Background: Integrated health care models aim to improve access and continuity of mental health services in general medical settings. STEPS-UP is a stepped, centrally assisted collaborative care model designed to improve posttraumatic stress disorder (PTSD) and depression care by providing the appropriate intensity and type of care based on patient characteristics and clinical complexity. STEPS-UP demonstrated improved PTSD and depression outcomes in a large effectiveness trial conducted in the Military Health System. The objective of this study was to examine differences in mental health utilization patterns between patients in the stepped, centrally assisted collaborative care model relative to patients in the collaborative care as usual-treatment arm. Methods: Patients with probable PTSD and/or depression were recruited at 6 large military treatment facilities, and 666 patients were enrolled and randomized to STEPS-UP or usual collaborative care. Utilization data acquired from Military Health System administrative datasets were analyzed to determine mental health service use and patterns. Clinical complexity and patient characteristics were based on self-report questionnaires collected at baseline. Results: Compared with the treatment as usual arm, STEPS-UP participants received significantly more mental health services and psychiatric medications across primary and specialty care settings during the year of their participation. Patterns of service use indicated that greater clinical complexity was associated with increased service use in the STEPS-UP group, but not in the usual-care group. Conclusions: Results suggest that stepped, centrally assisted collaborative care models may increase the quantity of mental health services patients receive, while efficiently matching care on the basis of the clinical complexity of patients.

Over the past decade, there has been growing recognition of the mental health consequences associated with deployment and service by military service personnel. This study examined potential barriers to mental health care faced by members of the military in accessing needed services.This qualitative study of stakeholders was conducted across six large military installations, encompassing 18 Army primary care clinics, within the context of a large randomized controlled trial. Stakeholders included patients recruited for the study (N=38), health care providers working within site clinics (N=31), and the care managers employed to implement the intervention protocol (N=7).Issues raised across stakeholder groups fell into two main categories: structural factors associated with the Army medical system and institutional attitudes and cultural issues across the U.S. military. Structural issues included concerns about the existing capacity of the system, for example, the number of providers available to address the population's needs and the constraints on clinic hours and scheduling practices. The institutional attitude and cultural issues fell into two main areas: attitudes and perceptions by the leadership and the concern that those attitudes could have negative career repercussions for those who access care.Although there have been significant efforts to improve access to mental health care, stakeholders within the military health system still perceive significant barriers to care. Efforts to ensure adequate and timely access to high-quality mental health care for service members will need to appropriately respond to capacity constraints and organizational and institutional culture.

Purpose Multiple physical symptoms (MPS) have historically been observed after deployment to a combat zone and are often disabling in nature. This study examined longitudinal trends in MPS status and its relationship to deployment in U.S. military service members. Methods Using longitudinal data from panel 1 participants in the Millennium Cohort Study (n = 76,924), MPS status was assessed at three time points (2001–2008) using the 15-item Patient Health Questionnaire. Probability of reporting MPS was analyzed using mixed-effects multinomial logit regression, with time and deployment experience as main explanatory variables. Results After adjustment for demographic, military, and health characteristics, service members who deployed with combat were significantly more likely to report MPS at each time point compared with those not deployed (odds ratio [OR] and 95% confidence interval [CI] for wave 1 = 1.49 [1.47–1.52], wave 2 = 1.73 [1.69–1.78], wave 3 = 2.08 [2.03–2.12]), and those who deployed without combat (OR and CI for wave 1 = 2.66 [2.59–2.74], wave 2 = 1.81 [1.75–1.87]; wave 3 = 1.68 [1.63–1.74]). Conclusions Longitudinal trends indicate that the probability of reporting MPS has increased consistently over time only for those deployed, regardless of combat experience.

The 2015 Health Related Behaviors Survey sought information on the health, health-related behaviors, and well-being of active-duty service members. This brief reviews results for mental and emotional health.

The 2015 Health Related Behaviors Survey sought information on the health, health-related behaviors, and well-being of active-duty service members. This infographic reports key findings across the Air Force.

The 2015 Health Related Behaviors Survey sought information on the health, health-related behaviors, and well-being of active-duty service members. This brief reviews results for substance use, particularly use of alcohol, tobacco, and medication.

The 2015 Health Related Behaviors Survey sought information on the health, health-related behaviors, and well-being of active-duty service members. This brief summarizes results for broad topics of the survey, such as substance use and mental health.

The 2015 Health Related Behaviors Survey sought information on the health, health-related behaviors, and well-being of active-duty service members. This brief reviews results for sexual behavior and health.

The 2015 Health Related Behaviors Survey sought information on the health, health-related behaviors, and well-being of active-duty service members. This brief reviews results for health promotion and disease prevention.

As former U.S. Army Surgeon General Horoho points out, a large fraction of what determines the health and readiness of our military families does not occur during appointments with professionals, but rather within the "Lifespace-where health really happens...." Indeed, when children of military families experience psychosocial difficulties, such stress impacts the service members' personal well-being and ability to focus at work, impairing their capacity to attend to the mission. As such, the Department of Defense (DoD) has instituted a family readiness system to bolster resiliency within military families, including children, e.g., by linking families with support networks. Bolstering military family resiliency, including the prevention of and effective intervention for child psychosocial problems, is an important issue at all levels of the DoD. Service members, leaders, and policy makers have a vested interest in promoting mission readiness and a healthy force. Research can play an important role in shaping decision-making by consolidating what is currently known and not known about a particular expertise area. To date, there has been no consolidation of research regarding outcomes associated with military community support and the programs that currently exist to bolster child and family resiliency. Given the importance of military families to mission readiness, a review of the relevant research is warranted.This commentary article reviews the literature on community support for military children, provides an overview of currently available resources, discusses concerns with the current provision of support services to military families, and offers recommendations for future research, policy, and implementation of military community support programs.Although there is a dearth of research on available support programs, there appears to be no lack of services available to military families. However, several steps could be taken to make these resources into a more supportive system. Family members must be able to identify what support services exist, distinguish which service is most suitable for their needs, and be able to readily access these services in a resource-conserving manner. Considerable overlap in support services seems to suggest limited coordination between organizations and service providers, particularly in regard to the government/civilian interface, which inherently lies outside of DoD control. This overlap suggests a redundancy, which may not be efficient economically or in regard to accessing support. There also may be some confusion over which support service is most suitable for the consumer's need. Although some overlap is useful, such as the provision of different services to different populations (e.g., having separate programs for the Army, Navy, Air Force, and Marine subcultures), limited organization and parsimonious provision of services makes it particularly difficult for spouses and family members to navigate resources. Initial attempts are being made to organize and consolidate resources in both the government and civilian sectors. However, it is clear that these initiatives have not completely solved problems related to resource access, redundancy, and lack of research-supported efficacy.

BACKGROUND: Despite the growing consensus that collaborative care is effective, limited research has focused on the importance of collaborative care fidelity as it relates to mental health clinical outcomes. OBJECTIVE: To assess the relationship of collaborative care fidelity on symptom trajectories and clinical outcomes among military service members enrolled in a multi-site randomized controlled trial for the treatment of depression and posttraumatic stress disorder (PTSD). DESIGN: Study data for our analyses came from a two-parallel arm randomized trial that evaluated the effectiveness of a centralized collaborative care model compared to the existing collaborative care model for the treatment of PTSD and depression. All patients were included in the analyses to evaluate how longitudinal trajectories of PTSD and depression scores differed across various collaborative care fidelity groupings. PARTICIPANTS: A total of 666 US Military Service members screening positive for probable PTSD or depression through primary care. MAIN MEASURES: Disease registry data from a web-based clinical management support tool was used to measure collaborative care fidelity for patients enrolled in the trial. Participant depression and PTSD symptoms were collected independently from research survey assessments at four time points across the 1-year trial period. Treatment utilization records were acquired from the Military Health System administrative records to determine mental health service use. KEY RESULTS: Consistent and late fidelity to the collaborative care model predicted an improving symptom trajectory over the course of treatment. This effect was more pronounced for patients with depression than for patients with PTSD. CONCLUSIONS: Long-term fidelity to key collaborative care elements throughout care episodes may improve depression outcomes, particularly for patients with elevated symptoms. More controlled research is needed to further understand the influence of collaborative care fidelity on clinical outcomes. TRIAL REGISTRATION: Clinicaltrials.gov Identifier NCT01492348

Collaborative care models hold promise as a means to improve the Military Health System (MHS) to better meet the mental health needs of U.S. military personnel. This article describes an Army-wide collaborative care initiative, RESPECT-Mil (“Re-engineering Systems of Primary Care Treatment for Depression and PTSD in the Military”), aimed at improving care for soldiers with depression and post traumatic stress disorder. Essential to the implementation of RESPECT-Mil has been the use of a centralized coordinating team to facilitate collaborative care practice and policy activities across the multiple levels of the MHS. The article explores the relevance of collaborative care frameworks to the social work profession and concludes with a discussion of future directions for the social work field to promote greater involvement in the integrated care movement.

Objective Patients with medically unexplained syndromes (MUS) often do not receive appropriate healthcare. A critical time for effective healthcare is the inception of MUS. The current study examined data from a prospective longitudinal study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) soldiers to understand the relationship of increasing physical symptom burden to healthcare utilization. Methods Data was examined from a prospective study of OEF/OIF soldiers assessed before and one year after deployment (n = 336). Physical symptom burden was measured with the Patient Health Questionnaire (PHQ-15). Analyses were conducted with polynomial regression and response surface analysis (RSA). Results Increases in physical symptom burden predicted greater healthcare utilization one year after deployment: primary care practitioner (slope = − 0.26, F = 4.07, p = 0.04), specialist (slope = − 0.43, F = 8.67, p = 0.003), allied health therapy (e.g., physical therapy) (slope = − 0.41, F = 5.71, p = 0.02) and mental health (slope = − 0.32, F = 4.04, p = 0.05). There were no significant difference in utilization between those with consistently high levels and those with increases in physical symptom burden. Conclusion This is the first prospective study to examine, and show, a relationship between onset of clinically significant physical symptoms and greater healthcare utilization. Our data suggest that patients with increasing physical symptom burden have the same level of healthcare as patients with chronic physical symptom burden. Needed next steps are to better understand the quality of care at inception and determine how to intervene so that recommended approaches to care are provided from the onset.

BACKGROUND With their rapidly expanding roles in the military, women service members experience significant stressors throughout their deployment experience. However, there are few studies that examine changes in women Veterans’ stressors before and after deployment. OBJECTIVE This study examines the types of stressors women Veterans report before deployment, immediately after deployment, 3 months after deployment, and 1 year post-deployment. DESIGN Descriptive data on reported stressors was collected at four time points of a longitudinal study (HEROES Project). Open-ended responses from the Coping Response Inventory (CRI) were coded into six possible major stressor categories for analysis. PARTICIPANTS Seventy-nine Army National Guard and Reserve female personnel deploying to Operation Enduring Freedom (OFF)/Operation Iraqi Freedom (OIF) were surveyed prior to deployment. Of these participants, 35 women completed Phase 2, 41 completed Phase 3, and 48 completed Phase 4 of the study. KEY RESULTS We identified six major stressor categories: (1) interpersonal (i.e., issues with family and/or friends), (2) deployment-related and military-related, (3) health concerns, (4) death of a loved one, (5) daily needs (i.e., financial/housing/transportation concerns), and (6) employment or school-related concerns. At all time points, interpersonal issues were one of the most common type of stressor for this sample. Daily needs concerns increased from 3 months post-deployment to 1 year post-deployment. CONCLUSIONS Interpersonal concerns are commonly reported by women Veterans both before and after their combat experience, suggesting that this is a time during which interpersonal support is especially critical. We discuss implications, which include the need for a more coordinated approach to women Veterans’ health care (e.g., greater community-based outreach), and the need for more and more accessible Veterans Affairs (VA) services to address the needs of female Veterans.

The Department of Defense (DoD) is implementing universal behavioral health screening for all DoD health-care beneficiaries presenting to military primary care clinics. The PTSD Checklist-Civilian Version (PCL-C; Weathers, Litz, Herman, Huska, & Keane, 1993) is used for the identification of posttraumatic stress disorder (PTSD); however, the operating characteristics of the PCL-C remain unstudied in this population. This study examined the operating characteristics of the PCL-C in a sample of 213 patients from 3 Washington, D.C., area military primary care clinics. Blinded raters independently assessed PTSD using the PTSD Symptom Scale Interview (Foa, Riggs, Dancu, & Rothbaum, 1993) as the diagnostic criterion standard. The receiver operating characteristic curve revealed that PCL-C scores accounted for 92% of the area under the curve. A PCL-C score of 31 optimized sensitivity (0.93) and specificity (0.90), and the multilevel likelihood ratio was 5.50 (95% confidence interval [2.26, 13.37]). Internal consistency (0.97) and test-retest reliability (0.87 after a median 13 days) were strong. Results suggest that a PCL-C score of 31 is the optimal cutoff score for use in a military primary care setting serving active duty service members, dependents, and retirees. These findings offer military primary care providers preliminary data to interpret PCL-C scores and to inform treatment decisions as part of routine clinical practice.

A meta-analysis of 25 epidemiological studies estimated the prevalence of recent Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) major depression (MD) among U.S. military personnel. Best estimates of recent prevalence (standard error) were 12.0% (1.2) among currently deployed, 13.1% (1.8) among previously deployed, and 5.7% (1.2) among never deployed. Consistent correlates of prevalence were being female, enlisted, young (ages 17-25), unmarried, and having less than a college education. Simulation of data from a national general population survey was used to estimate expected lifetime prevalence of MD among respondents with the sociodemographic profile and none of the enlistment exclusions of Army personnel. In this Simulated sample, 16.2% (3.1) of respondents had lifetime MD and 69.7% (8.5) of first onsets occurred before expected age of enlistment. Numerous methodological problems limit the results of the meta-analysis and simulation. The article closes with a discussion of recommendations for correcting these problems in future surveillance and operational stress studies.

Background Women veterans are at increasingly high risk of suicide, but little is known about the concerns and needs of this population. This is, in part, owing to the low base rate of suicide and the inability to conduct retrospective interviews with individuals who died. In this study, we used a qualitative approach to gain insight about the concerns and nature of comments regarding suicidal ideation and intent among women veterans calling the Veterans Crisis Line (VCL). Methods Fifty-four VCL call responders were interviewed in the spring of 2015. They were asked about the concerns and level of suicide risk of women veteran callers with whom they have spoken and about the ways in which women callers are similar to or different from men callers. Interviews were transcribed and thematic analyses were conducted to examine patterns or themes emerging from the data. Findings Military sexual trauma and non-suicidal self-harm were two commonly reported concerns of women veteran callers according to responders. VCL responders also noted differences between men and women veteran callers, including differences in clinical presentation, suicidal means, and protective factors. Conclusions Our findings shed light on potential avenues to prevent suicide among women veterans, although we spoke to VCL responders about their impressions, rather than to women veterans themselves. Efforts to 1) prevent and treat the consequences of military sexual trauma, 2) recognize, prevent, and treat non-suicidal self-harm, and 3) restrict access to lethal means most commonly reported among women veteran callers may be helpful to mitigate suicide risk in this vulnerable group of veterans.

Mental health problems in service members often go untreated. This study focused on factors related to interest in receiving help in a survey sample of 577 combat veterans who were screened positive for posttraumatic stress disorder, depression, or generalized anxiety disorder 3 months after returning from Iraq. Over three quarters of respondents recognized that they had a current problem, but only 40% were interested in receiving help. Interest in receiving help was associated with recognizing a problem and receiving mental health services in the past year. More negative attitudes toward mental health care were associated with lower interest in receiving help; paradoxically, more negative perceptions of unit stigma were associated with increased interest in receiving help. Further studies are needed to better define the relationship between stigma perceptions, interest in receiving care, and actual care utilization and to determine whether attitudes toward mental health care can be modified through changes in how care is delivered. Attitudes toward mental health care should be considered in treatment interventions.

Although documentation that war infl icts psychological casualties dates back to the American Civil War and earlier, most research began after the Vietnam confl ict, when studies focused on post-traumatic stress disorder (PTSD). With ongoing confl icts in Iraq and Afghanistan, there has been signifi cant research to illuminate the epidemiology of war-related psychological casualties. Signifi cant fi ndings include an appreciation for the role combat plays in the development of mental disorders, including PTSD and traumatic brain injury (TBI). Recent research has endeavoured to understand and improve psychological resilience to temper potentially adverse mental health effects of military service in the theatre of combat operations. Over 2 million US service members have now deployed and returned over 3 million times to the Iraq and Afghanistan confl icts. Mental health providers in the Departments of Defense and Veterans Affairs healthcare systems have consequently observed steep increases in mental health service use among these personnel. The Departments have responded aggressively to bolster staffi ng levels, increase capacity, improve available services, and anticipate future needs. Scientists and clinicians continue efforts to understand the determinants, prevention, recognition, and treatment of combat-related mental disorders.

Suicide is a leading cause of death among men and women in the United States Military. Using a retrospective chart review design, the current study investigated gender differences on documented traumas for people admitted to a military inpatient psychiatric unit for suicide-related thoughts or behaviors (N = 656). Men more often had no documented lifetime traumas and women more often had 2 or more trauma types. Women had significantly more documented incidences of childhood sexual abuse, adulthood sexual assault, adulthood physical assault, and pregnancy loss. The gender gap in documented trauma types for childhood and adulthood traumas persisted even after adjusting for demographic variables, psychiatric diagnoses, and comorbid trauma types (i.e., trauma types other than the one being used as the dependent variable). Given the observed gender differences in documented traumas, professionals working with military women admitted for suicide-related thoughts or behaviors need to consider trauma in the context of treatment.

Background Posttraumatic stress disorder (PTSD) is prevalent in primary care, frequently goes undetected and can be highly debilitating when untreated. Objective We assessed the operating characteristics of a single-item PTSD screener (SIPS) for primary care and compared it to a commonly used four-item primary care PTSD screener (PC-PTSD). The SIPS asks: “Were you recently bothered by a past experience that caused you to believe you would be injured or killed … not bothered, bothered a little, or bothered a lot?” Methods A total of 3234 patients from three Washington, DC, area military primary care clinics completed the SIPS. Independent, blinded assessments using a structured diagnostic PTSD interview were completed in 213 of these patients. Results The SIPS yielded a reasonable range of likelihood ratios, suggesting capacity to discriminate between low- and high-probability PTSD patients. However, the SIPS sensitivity was only 76% for those reporting “bothered a little” and the four-item PC-PTSD yielded significantly better test characteristics on Receiver–Operator Curve analysis. Conclusion A single, user-friendly primary care PTSD screening question with three response options, while sensible and worth further investigation, failed to offer sound test characteristics for PTSD screening. Ways of improving SIPS performance are discussed.

The PTSD Checklist (PCL) is among the most widely used self-report instruments for assessing PTSD. To determine PCL's performance on a population level, the authors combined data from published studies that compared the PCL with structured diagnostic interviews. Weighted average sensitivities and specificities were calculated for cutoff categories most often reported in the literature. Weighted average sensitivity decreased from .85 to .39 and specificity increased from .73 to .97 for cutoffs ranging from 30 to 60. The PCL's ability to accurately estimate PTSD prevalence varied as a function of cutoff and true PTSD prevalence. In populations with a true PTSD prevalence of 15% or less, cutoff values below 44 will substantially overestimate PTSD prevalence. Uncalibrated use of the PCL for prevalence estimation may lead to large errors.

The authors report an 8-week randomized, controlled proof-of-concept trial of a new therapist-assisted, Internet-based, self-management cognitive behavior therapy versus Internet-based supportive counseling for posttraumatic stress disorder (PTSD).Service members with PTSD from the attack on the Pentagon on September 11th or the Iraq War were randomly assigned to self-management cognitive behavior therapy (N=24) or supportive counseling (N=21).The dropout rate was similar to regular cognitive behavior therapy (30%) and unrelated to treatment arm. In the intent-to-treat group, self-management cognitive behavior therapy led to sharper declines in daily log-on ratings of PTSD symptoms and global depression. In the completer group, self-management cognitive behavior therapy led to greater reductions in PTSD, depression, and anxiety scores at 6 months. One-third of those who completed self-management cognitive behavior therapy achieved high-end state functioning at 6 months.Self-management cognitive behavior therapy may be a way of delivering effective treatment to large numbers with unmet needs and barriers to care.

Objective To gain insight about Department of Defense providers’ and health care beneficiaries’ opinions regarding provider–patient communication of health care for post-deployment health concerns. Methods Thirty-five Department of Defense primary care providers and 14 military beneficiaries participated in focus groups at five military medical treatment facilities. We audiotaped, transcribed, and qualitatively analyzed semi-structured focus group interviews to determine attitudes and beliefs about war-related health concerns, symptoms, and health care quality. Results Focus groups revealed important insights about provider and patient perspectives of communication and care in four general areas: physician–patient trust, validity of symptoms and concerns, exchange of health information, and barriers to care. Conclusion Provider–patient communication contributes to patient satisfaction with medical care; poor communication may contribute to decreased patient satisfaction and provider effectiveness. The military health care system poses several challenges to provider–patient communication: the dual nature of the provider's role, the occupational relationship between illness and health care, pre- and post-deployment issues, and continuity of care impact patient and provider perspectives. The prevalence of various beneficiary and provider concerns regarding health care communication requires further study, particularly for the severely wounded. Practice implications The quality of information exchanged and of the interpersonal relationship impact medical decision making, particularly in occupational health settings such as the military. Attention to these issues may improve patient outcomes including satisfaction, adherence, trust, health status, and quality of life.

The global war on terrorism has led to increased concern about the ability of the U.S. healthcare system to respond to casualties from a chemical, biological, or radiological agent attack. Relatively little attention, however, has focused on the potential, in the immediate aftermath of such an attack, for large numbers of casualties presenting to triage points with acute health anxiety and idiopathic physical symptoms. This sort of "mass idiopathic illness" is not a certain outcome of chemical, biological, or radiological attack. However, in the event that this phenomenon occurs, it could result in surges in demand for medical evaluations that may disrupt triage systems and endanger lives. Conversely, if continuous primary care is not available for such patients after initial triage, many may suffer with unrecognized physical and emotional injuries and illness. This report is the result of an expert planning initiative seeking to facilitate triage protocols that will address the possibility of mass idiopathic illness and bolster healthcare system surge capacity. The report reviews key triage assumptions and gaps in knowledge and offers a four-stage triage model for further discussion and research. Optimal triage approaches offer flexibility and should be based on empirical studies, critical incident modeling, lessons from simulation exercises, and case studies. In addition to staging, the proposed triage and longitudinal care model relies on early recognition of symptoms, development of a registry, and use of non-physician care management to facilitate later longitudinal followup and collaboration between primary care and psychiatry for the significant minority of patients who develop persistent idiopathic symptoms associated with reduced functional status.

Studies of soldiers from prior wars conducted many years after combat have shown associations between combat-related posttraumatic stress disorder (PTSD) and physical health problems. The current Iraq war has posed a considerable PTSD risk, but the association with physical health has not been well studied.The authors studied 2,863 soldiers using standardized self-administered screening instruments 1 year after their return from combat duty in Iraq.Among all participants, 16.6% met screening criteria for PTSD. PTSD was significantly associated with lower ratings of general health, more sick call visits, more missed workdays, more physical symptoms, and high somatic symptom severity. These results remained significant after control for being wounded or injured.The high prevalence of PTSD and its strong association with physical health problems among Iraq war veterans have important implications for delivery of medical services. The medical burden of PTSD includes physical health problems; combat veterans with serious somatic concerns should be evaluated for PTSD.

In recent years, research-methods literature mainly addressing controlled clinical trials has arisen regarding explanatory and pragmatic treatment trials. Explanatory trials tend to examine causal mechanisms and questions of efficacy and value internal validity (creating optimal study conditions) over generalizability (using study results to understand treatment effects in real-life patient populations). In contrast, pragmatictrials value “external relevance” (generalizability) of study results over “internal elegance” so that clinicians and health policymakers can better understand how treatments might impact their patients and policies.This review draws inspiration from these contrasting explanatory and pragmatic perspectives and develops them for clinical and research pertaining to idiopathic physical symptoms and related syndromes (eg, somatization disorder, chronic fatigue syndrome, multiple chemical sensitivities, irritable bowel syndrome). Explanatory and pragmatic perspectives are used to examine these idiopathies with regard to causation, case definition, labels, and treatment. It is concluded that idiopathic symptom syndromes are fundamentally pragmatic clinical and research challenges. For epidemiologic and methodologic reasons, the complex explanations for these syndromes remain largely elusive. Even so, scientific and clinical pragmatism offers the opportunity to reduce disagreement between competing medical disciplines and between clinicians and affected patients with regard to irreconcilable etiologic questions and to remain evidence-based in the care of patients.

Background: Initial posttraumatic stress disorder (PTSD) care is often delayed and many with PTSD go untreated. Acupuncture appears to be a safe, potentially nonstigmatizing treatment that reduces symptoms of anxiety, depression, and chronic pain, but little is known about its effect on PTSD. Methods: Fifty-five service members meeting research diagnostic criteria for PTSD were randomized to usual PTSD care (UPC) plus eight 60-minute sessions of acupuncture conducted twice weekly or to UPC alone. Outcomes were assessed at baseline and 4, 8, and 12 weeks postrandomization. The primary study outcomes were difference in PTSD symptom improvement on the PTSD Checklist (PCL) and the Clinician-administered PTSD Scale (CAPS) from baseline to 12-week follow-up between the 2 treatment groups. Secondary outcomes were depression, pain severity, and mental and physical health functioning. Mixed model regression and t test analyses were applied to the data. Results: Mean improvement in PTSD severity was significantly greater among those receiving acupuncture than in those receiving UPC (PCLD=19.8±13.3 vs. 9.7±12.9, P

This research examines excess mortality among American veterans age 70 years or older during a two-to-three year interval from 1993/94 to the end of 1995. Using a structural hazard rate model, we analyzed data on a sample of respondents age 70 or over from the Survey of Asset and Health Dynamics among the Oldest Old (AHEAD). We found that at age 70, older veterans have a slightly higher death rate than their nonveteran counterparts, implying a mortality crossover right before this age. Such excess mortality among veterans increases considerably with age, when other factors are held equal. The direct and indirect effects of veteran status on mortality by means of physical and mental health mostly perform in opposite directions, and such effects vary greatly in magnitude and direction as a function of age. The intervening effects of physical and mental health status decrease substantially with increasing age. Many of the mechanisms inherent in the excess mortality among older veterans are not captured by variations in their health status, especially among the oldest-old. A more extensive study on this topic is urgently needed.

This article describes issues in the design of an ongoing multisite randomized clinical trial of psychotherapy for treating posttraumatic stress disorder (PTSD) in female veterans and active duty personnel. Research aimed at testing treatments for PTSD in women who have served in the military is especially important due to the high prevalence of PTSD in this population. VA Cooperative Study 494 was designed to enroll 384 participants across 12 sites. Participants are randomly assigned to receive 10 weekly sessions of individual psychotherapy: Prolonged Exposure, a specific cognitive-behavioral therapy protocol for PTSD, or present-centered therapy, a comparison treatment that addresses current interpersonal problems but avoids a trauma focus. PTSD is the primary outcome. Additional outcomes are comorbid problems such as depression and anxiety; psychosocial function and quality of life; physical health status; satisfaction with treatment; and service utilization. Follow-up assessments are conducted at the end of treatment and then 3 and 6 months after treatment. Both treatments are delivered according to a manual. Videotapes of therapy sessions are viewed by experts who provide feedback to therapists throughout the trial to ensure adherence to the treatment manual. Discussion includes issues encountered in multisite psychotherapy trials along with the rationale for our decisions about how we addressed these issues in CSP #494.

The 20th century offered many examples of post-war syndromes such as Da Costa's syndrome, irritable heart, shell shock, effort syndrome, medical evacuation syndrome, post-traumatic stress disorder, and Gulf War syndrome. These post-war syndromes occur under conditions of substantial medical and scientific uncertainty, conditions that potentially magnify the impact of social context on clinical care for these syndromes. This article reviews the social circumstances surrounding four post-war syndromes. The case is made that social context has significantly impacted professional and lay perceptions of causal mediators, relevant risk factors, defining symptoms, and appropriate therapies for these syndromes. Furthermore, it is argued that social context influences what parties are held responsible for post-war syndromes, and what clinical disciplines are ultimately deemed appropriate to provide legitimate post-war illness care.

Among the 1.4 million active duty U.S. military service members, 6% receive outpatient treatment for a mental disorder each year. Over 25% of these service members leave military service within 6 months, a rate that is more than two times higher than the rate following treatment for any other illness category. There is clearly a need to define psychiatric research priorities and an unprecedented opportunity to enhance the field of psychiatric research in general using the well-characterized military population. The first priority is to better define the burden of mental disorders in terms of incidence, prevalence, severity, risk factors, and health care use. The impact of mental disorders on occupational functioning, particularly among new recruits, needs to be better characterized. Suicide research should include efforts to validate mortality data, define the normal level of rate variability, and establish surveillance for clusters. The highly structured occupational environment of the military lends itself to studies of preventive interventions designed to reduce disability or occupational attrition resulting from mental/behavioral problems.

In the aftermath of the terrorist action at the Pentagon there was a critical operational need to understand and document the extent of injuries, illnesses, and exposures sustained by Service members and civilian employees at the Pentagon. It was decided to develop and administer a brief questionnaire to the Pentagon employees that would contain questions about exposures, new or worsening injuries or illnesses, mental health, and factors suggested by the literature to increase risk or be protective for these outcomes. This report describes the development the mental health portion of this questionnaire. Most mental health instruments are very lengthy, limiting their usefulness as rapid public health assessment tools. This brief instrument was designed to cover four main symptom domains, as well as key risk/protective factors, thought to be most important following the terrorist attack. The symptom domains were: acute and post-traumatic stress symptoms, depression, anxiety/panic attacks, and alcohol abuse. Further analyses will assess the usefulness of this questionnaire as a public health tool for rapid assessment of mental health symptoms following the attack. Language: en