Burden of Insomnia Disorder Among US Active-Duty Military Personnel.

Health and Utilization Burden of OSA Among US Active-Duty Military Personnel.

Introduction Insomnia disorder is common among U.S. military personnel and negatively impacts health and military readiness. Among civilians, insomnia is associated with substantial economic burden; yet, little is known about the burden of insomnia within the US Military Health System (MHS). The MHS is a large, integrated healthcare delivery system with worldwide operations and thus ideal for health services research. This study aimed to determine the association between insomnia disorder and healthcare resource utilization (HCRU) in the MHS. Methods Our data source was the Military Data Repository (MDR) between years 2016-2021. This large data repository includes encounter, procedure, medication, and durable medical equipment information for active-duty military personnel, military dependents, National Guard, and Reserves. Demographic and military information was obtained from the MDR. Inclusion criteria were age < 65 years, active-duty military personnel, 12 months of continuous enrollment before and after first insomnia diagnosis (i.e., the index date), and no evidence of insomnia during the 12 months prior to first diagnosis. Insomnia and comorbid medical and psychiatric conditions were defined based on International Classification of Disease-10th Edition codes. Beneficiaries with insomnia were matched 1:1 with non-insomnia controls on >20 demographic, military, and medical and psychiatric comorbidity variables. Mixed effects models were used to compare non-insomnia related HCRU between groups across multiple points of service: outpatient, inpatient, and emergency department (ED). Results We identified 40,978 MHS beneficiaries with insomnia and 40,978 matched non-insomnia controls. Most (35.9%) beneficiaries with insomnia were between ages 25-34 years, and 20.7% were women. 4.2% of beneficiaries with insomnia had one comorbid medical or psychiatric condition, and 1% had >2 comorbid conditions. Relative to matched non-insomnia controls, beneficiaries with insomnia demonstrated greater 12-month HCRU at every point of service (all p values< 0.001). The incident rate ratio for non-insomnia inpatient visits was RR (95% CI) = 1.96 (1.85,2.08); for non-insomnia outpatient visits was 2.24 (2.23,2.24); and for non-insomnia related ED visits was 1.60 (1.57,1.63). Conclusion Insomnia is associated with substantially increased healthcare resource utilization in the US military health system. Future research should seek to advance personalized medicine approaches to improve outcomes of evidence-based insomnia care. Support (if any) U.S. Department of Defense HT94022210006.

Acute respiratory distress syndrome (ARDS) is associated with significant mortality and long-term morbidity, often preventing survivors from returning to work. This poses particular challenges in the military, where maintaining combat-ready forces depends on the health and readiness of service members. This study investigates ARDS in active duty U.S. military personnel to estimate its broader impact on the military. A retrospective cohort study was conducted with Institutional Review Board (IRB) approval, utilizing the U.S. Military Data Repository, which contains health data from all active duty service members. Acute respiratory distress syndrome was identified using Current Procedural Terminology (CPT) codes and confirmed with chart review. Data were collected on demographics, clinical course, underlying ARDS etiology, survival, and military separation. Statistical analyses included univariate comparisons to identify demographic and clinical factors associated with mortality. The overall incidence of ARDS in active duty personnel was 1.01 per 100,000 person-years, with a 2-fold increase in the post-COVID period (1.55 per 100,000 person-years) compared to the pre-COVID period (0.76 per 100,000 person-years). The most common cause of ARDS was infection (53%), followed by trauma (16%). The mean age of affected servicemembers was 32 years, with a mortality rate of 20%. Among those who survived, 43% failed to return to active duty and were medically separated; 70% of these separations were directly attributable to ARDS or related complications, while 30% were because of other etiologies. Acute respiratory distress syndrome poses significant risks to active duty military personnel, with notable short-term mortality and long-term morbidity, including high rates of medical separation and failure to return to duty. These complications could impact the military overall by decreasing the workforce, impairing military readiness, and introducing financial burdens. Further studies are needed to fully assess functional limitations following ARDS and to optimize management strategies that enhance recovery outcomes for military service members affected by the condition.

Complementary and Alternative Medicine (CAM) covers a heterogeneous spectrum of ancient to new-age approaches that purport to prevent or treat disease. By definition, CAM practices are not part of conventional western-style medicine because there is a perception of insufficient proof that they are safe and effective or because they are not taught in conventional medical and nursing schools. Complementary interventions are typically used together with conventional western-style treatments, whereas alternative interventions are used instead of conventional approaches. When combined with conventional practices they are often labeled Integrative Medicine (IM). Many people in the United States (US) use CAM and IM modalities and its use is increasing. In 1990, a national survey estimated that 33.8% of US adults used CAM modalities in the previous year, which increased to 42.1% in 1997 and 62% in the 2002 National Health Interview Survey (NHIS). These surveys included spiritual healing and “folk” medicine (remedies common, ethnically derived remedies used at home), in the CAM modality definition. Recently published results of the 2007 NHIS used a different CAM modality taxonomy and excluded these practices. When prayer specifically for health reasons was excluded, the 2002 and 2007 NHIS found 36% and 38.3%, respectively, of US adults reported using some form of CAM modality in the last 12 months. These national surveys only include civilian, noninstitutionalized individuals; they do not include our 1.8 million active duty military personnel and families. In the last 10 years, there has been an increase in interest and use of CAM modalities and IM in the military. This important segment of the US population receives health care from both military and civilian practitioners; and is subject to similar health risks as civilians plus additional physical, emotional, and cognitive stress of deployment with associated family separations for both the active duty member and families, and the consequences of combat. It would not be unexpected for military personnel to seek to improve their health through complementary practitioners, potentially at a greater extent due to health and performance expectations, and for the same reasons reported by civilians. This interest in CAM has been accelerated by the surge of chronic pain, chronic stress, and chronic symptoms associated with trauma and injuries from over a decade of wars in Iraq and Afghanistan. However, until recently there were little data to determine which CAM modalities are being used, how often, by whom, and for what purposes. Recently, these informational gaps are being filled in and the current picture is summarized below.

Over 2,100 active duty service members (ADSM) have experienced traumatic limb loss since 2001. Combat-injured ADSMs have over 3 times the odds of developing a behavioral health condition as compared to those with noncombat injuries. Additionally, severity of injury has been associated with increased risk of post-traumatic stress disorder and depression, which increase the risk of suicidal behavior. Despite previous research, studies have not investigated incident behavioral health diagnoses in the 12 months following amputation and the highest-risk subpopulations. A retrospective cohort study using existing electronic health record data identified ADSMs experiencing major limb loss between 2001 and 2017. Incident behavioral health conditions diagnosed in the 12 months following limb loss were identified. Disorders typically diagnosed in childhood were excluded. Wilcoxon rank-sum tests and chi-squared tests calculated differences between those with and without a diagnosis in the 12 months post-amputation. Logistic regression models calculated odds ratios and 95% CIs measuring the association between significant demographic and amputation characteristics and between post-amputation incident behavior health diagnosis and incident traumatic brain injury (TBI) and incident behavioral health diagnosis for each diagnostic category. Approximately 56% of ADSMs were diagnosed with an incident behavioral health condition in the 12 months following major limb loss. Those diagnosed with a condition were likely to be younger, enlisted ADSMs, and sustaining a combat-related lower extremity amputation. The most common diagnosis was adjustment disorder (31%). Over 41% were also diagnosed with a TBI. Unadjusted odds of a behavioral health condition were 3.3 (95% CI: 2.8-4.0) times higher among those also diagnosed with a TBI. In this study, more than half of ADSMs experiencing major limb loss developed incident behavioral health conditions within the first 12 months. This study highlights the need for awareness of the potentially increased risk of these diagnoses in the acute period following amputation.

BackgroundThis paper describes and discusses the transition of and modifications to a weight management randomized controlled trial among active-duty military personnel from an in-person to a virtual format as a result of the COVID-19 pandemic. The original pragmatic cohort-randomized controlled trial was designed to compare the effectiveness of an 8-week group weight management program, ShipShape, to a version of ShipShape enhanced with acceptance and commitment therapy.ObjectiveThe objective of our study was to assess potential differences between in-person and virtual participation in participants’ demographics, motivation, confidence, credibility, expectations, and satisfaction with the interventions; we also examined the pragmatics of the technology and participants’ experiences in virtual-format intervention groups.MethodsA total of 178 active-duty personnel who had failed or were at risk of failing their physical fitness assessment or were overweight or obese were enrolled in the study. In-person (n=149) and virtual (n=29) participants reported demographics, motivation, confidence, credibility, expectations, and satisfaction. Interventionists recorded attendance and participation in the group sessions. Independent-sample 2-tailed t tests and chi-square tests were used to compare the characteristics of the in-person and virtual participants. Pragmatics of the technology and participants’ experiences in the virtual format were assessed through surveys and open-ended questions.ResultsParticipants were 29.7 (SD 6.9) years old on average, 61.8% (110/178) female, and 59.6% (106/178) White and had an average BMI of 33.1 (SD 3.9) kg/m2. Participants were highly motivated to participate and confident in their ability to complete a weight management program. A total of 82.6% (147/178) of all participants attended 5 of the 8 sessions, and participation was rated as “excellent” by interventionists in both formats. The interventions were found to be credible and to have adequate expectations for effectiveness and high satisfaction in both formats. There were no differences between in-person and virtual participants in any of these metrics, other than interventionist-rated participation, for which virtual participants had significantly higher ratings (P<.001). Technical satisfaction with the virtual sessions was rated as “good” to “very good,” and participants were satisfied with the content of the virtual sessions. A word cloud of responses identified “mindfulness,” “helpful,” “different,” “food,” “binder,” and “class” as concepts the virtual participants found most useful about the program.ConclusionsModifications made in response to the COVID-19 pandemic were successful, given the recruitment of active-duty personnel with similar demographic characteristics, attendance levels, and indicators of credibility, expectancy, and satisfaction in the virtual format and the in-person format. This successful transition provides support for the use of virtual or digital weight management interventions to increase accessibility and reach among highly mobile active-duty personnel.Trial RegistrationClinicalTrials.gov NCT03029507; https://clinicaltrials.gov/ct2/show/NCT03029507

Purpose: This study examined the utilization of gender-affirming health care by active-duty service members during the initial 5½ years that transgender and gender-diverse (TGD) individuals were authorized to serve in the U.S. military. The aim of this study was to inform policy discussions regarding inclusion of TGD individuals in the military. Methods: We conducted a retrospective cohort study using administrative health care data from the Military Data Repository (MDR). We assessed the association of demographic factors with the utilization of gender-affirming medical and surgical care. We calculated the incidence rate of initial TGD-related encounters and new prescriptions for gender-affirming hormones among Defense Department Service members between July 2016 and December 2021. Results: We identified 2481 service members with an initial health care encounter with an associated TGD-related diagnosis. More than half (53%) of these service members started gender-affirming hormones, and 14% underwent gender-affirming surgery. Mastectomies and hysterectomies accounted for more than 70% of surgeries. Service members made 3.22 initial encounters with a TGD-related diagnosis per 10,000 service members per year, with an overrepresentation of service members who were designated female in the MDR (8.62), junior enlisted (4.98), and young (4.64). Individuals designated female in the MDR comprised 17% of all service members but accounted for 46% of initial encounters, 51% of new prescriptions, and 73% of surgeries. Conclusion: The study revealed a higher-than-expected number of service members seeking gender-affirming care, particularly among service members designated female in the MDR. Military Health System clinicians provided most of this care, which may mitigate the cost of delivering this essential medical care.

Posttraumatic stress disorder (PTSD) affects approximately 8% of the general population. The prevalence of PTSD is twice as high in active duty service members and military veterans. Few studies have investigated the incidence rates of PTSD in active duty military personnel. The present study evaluated the incidence of PTSD diagnoses and the differences between demographic factors for service members between 2001 and 2017. Data on 182,400 active duty service members between 2001 and 2017 were drawn from the Defense Medical Epidemiological Database and examined by sex, age, service branch, military pay grade, marital status, and race. From 2001 to 2017, the incidence rates of PTSD in the active force (per 1,000 service members) steadily climbed, with a low of 1.24 in 2002 to a high of 12.94 in 2016. Service members most often diagnosed with PTSD were in the U.S. Army, with the enlisted pay grades of E-5-E-9, White, married, male, and between 20 and 24 years old. Statistically significant differences, ps < .001, were found between observed and expected counts across all examined demographic variables. The present study is the first to our knowledge to provide a comprehensive examination of PTSD incidence rates in an active duty military population.

Insomnia is a prevalent condition that can significantly impair cognitive function, emotional regulation, and overall health, particularly affecting military personnel. The COVID-19 pandemic introduced additional stressors that may have exacerbated sleep disturbances among active duty service members (ADSMs). This study aims to analyze trends in insomnia diagnoses and sleep medication prescriptions among U.S. ADSMs during the COVID-19 peri-pandemic period, assessing the potential impact of the pandemic on sleep health. A repeated cross-sectional analysis was conducted using the Military Health System's outpatient and pharmacy records from January 2018 to February 2022. Incident insomnia diagnoses and days supplied for both Food and Drug Administration-approved and off-label medications for insomnia were evaluated with change-point analyses and Poisson regression. The cross-sectional study included 1,858,060 individuals, with 174,542 identified cases of incident insomnia and 2,031,910 individuals for the analysis of medications. Initial findings indicated a decrease in incident insomnia diagnoses during early pandemic periods, likely because of limited health care access. Incident insomnia diagnosis rates gradually returned to near baseline levels as access improved. Food and Drug Administration-approved medication days-supplied decreased significantly, while off-label medication use increased, potentially addressing both insomnia and comorbid conditions. Demographic analysis revealed varying rates by sex, race, age, rank, and geographic location. There were complex changes to rates of incident insomnia and its management among ADSMs during the COVID-19 pandemic period. Although healthcare access disruptions may have initially reduced encounters with incident insomnia diagnoses, ongoing needs for sleep disorder management persist. Changes in medication prescribing practices may highlight a shift towards addressing broader health concerns. Demographic variations in insomnia prevalence underscore the need for tailored interventions. Further research is needed to explore long-term impacts and develop effective interventions.

IntroductionIvacaftor was first approved in 2012 for the treatment of a select population of individuals with cystic fibrosis (CF), a rare, life-shortening genetic disease. Reductions in healthcare resource utilization (HCRU) associated with ivacaftor have been observed during limited follow-up and for selected outcomes in real-world studies. This study aimed to further describe the long-term impact of ivacaftor treatment on multiple measures of HCRU among people with CF (pwCF).MethodsThis retrospective study used US commercial and Medicaid claims data from 2011–2018. We included pwCF ≥ 6 years of age with ≥ 1 claim for ivacaftor and 12 months of continuous health plan enrollment before ivacaftor initiation (“pre-ivacaftor” period) who also had 36 months of continuous enrollment and persistent ivacaftor use (i.e., no gap ≥ 90 days between refills) following initiation (“post-ivacaftor” period). We compared comorbidities occurring pre-ivacaftor versus the last 12 months post-ivacaftor. HCRU outcomes included medication use, inpatient admissions, and outpatient office visits. We compared medication use pre-ivacaftor versus the last 12 months post-ivacaftor and inpatient admissions and outpatient office visits pre-ivacaftor versus the post-ivacaftor period annualized across 36 months.ResultsSeventy-nine pwCF met all criteria, including persistent ivacaftor use during the post-ivacaftor period. Ivacaftor treatment was associated with a significant reduction in pneumonia prevalence (10.1% vs. 26.6%; p < 0.001) and significantly fewer mean [SD] antibiotics claims (8.0 [7.3] vs. 12.3 [11.1]; p < 0.001) in the last 12 months post-ivacaftor versus pre-ivacaftor. In comparing the 36-month post-ivacaftor period to the pre-ivacaftor period, we also observed fewer mean [SD] annual inpatient admissions (0.2 [0.4] vs. 0.4 [0.7]), CF-related inpatient admissions (0.1 [0.2] vs. 0.2 [0.5]), and outpatient office visits (8.8 [4.9] vs. 9.9 [5.4]) (all, p < 0.05).ConclusionLong-term ivacaftor treatment reduced HCRU, consistent with trends observed in prior real-world studies. Our results support the sustained, long-term value of ivacaftor treatment in reducing CF burden.

Meta-analytic findings and clinical practice guidance recommend pharmacological (e.g., pregabalin, duloxetine, and milnacipran) and non-pharmacological (e.g., exercise and sleep hygiene) interventions to reduce symptoms and improve quality of life in people living with fibromyalgia. However, some of these therapies may lack robust evidence as to their efficacy, have side effects that may outweigh benefits, or carry risks. Although the annual prevalence of fibromyalgia in active duty service members was estimated to be 0.015% in 2018, the likelihood of receiving a fibromyalgia diagnosis was 9 times greater in patients assigned female than male and twice as common in non-Hispanic Black than White service members. Therefore, the primary goal of this retrospective study is to examine co-occurring conditions and pain-management care receipt in the 3 months before and 3 months after fibromyalgia diagnosis in active duty service members from 2015 to 2022. Medical record information from active duty service members who received a fibromyalgia diagnosis between 2015 and 2022 in the U.S. Military Health System was included in the analyses. Bivariate analyses evaluated inequities in co-occurring diagnoses (abdominal and pelvic pain, insomnia, psychiatric conditions, and migraines), health care (acupuncture and dry needling, biofeedback and other muscle relaxation, chiropractic and osteopathic treatments, exercise classes and activities, massage therapy, behavioral health care, other physical interventions, physical therapy, self-care management, and transcutaneous electrical nerve stimulation), and prescription receipt (anxiolytics, gabapentinoids, muscle relaxants, non-opioid pain medication, opioids, selective serotonin and norepinephrine inhibitors, and tramadol) across race and ethnicity and assigned sex. Pairwise comparisons were made using a false discovery rate adjusted P value. Overall, 13,663 service members received a fibromyalgia diagnosis during the study period. Approximately 52% received a follow-up visit within 3 months of index diagnosis. Most service members received a co-occurring psychiatric diagnosis (35%), followed by insomnia (24%), migraines (20%), and abdominal and pelvic pain diagnoses (19%) fibromyalgia diagnosis. At least half received exercise classes and activities (52%), behavioral health care (52%), or physical therapy (50%). Less commonly received therapies included other physical interventions (41%), chiropractic/osteopathic care (40%), massage therapy (40%), transcutaneous electrical nerve stimulation (33%), self-care education (29%), biofeedback and other muscle relaxation therapies (22%), and acupuncture or dry needling (14%). The most common prescriptions received were non-opioid pain medications (72%), followed by muscle relaxers (44%), opioids (32%), anxiolytics (31%), gabapentinoids (26%), serotonin-norepinephrine reuptake inhibitor (21%), selective serotonin reuptake inhibitors (20%), and tramadol (15%). There were many inequities identified across outcomes. Overall, service members diagnosed with fibromyalgia received variable guideline-congruent health care within the 3 months before and after fibromyalgia diagnosis. Almost 1 in 3 service members received an opioid prescription, which has been explicitly recommended against use in guidelines. Pairwise comparisons indicated unwarranted variation across assigned sex and race and ethnicity in both co-occurring health conditions and care receipt. Underlying reasons for health and health care inequities can be multisourced and modifiable. It is unclear whether the U.S. Military Health System has consolidated patient resources to support patients living with fibromyalgia and if so, the extent to which such resources are accessible and known to patients and their clinicians.

This study identifies predictors of prescription drug misuse among U.S. active duty service members (ADSM). The 2008 Department of Defense Survey of Health-Related Behaviors (HRB) Among Active Duty Military Personnel indicated that ADSM misuse pain relievers, tranquilizers, sedatives, and stimulants at levels ranging from 2% to 17%. Secondary, multivariate analyses of HRB survey data examined predictors of self-reported prescription drug misuse for 4 distinct drug categories. Receipt of a pain reliever prescription in the past month, year, or previous year were strong predictors (adjusted odds ratio above 2.0) of misuse for all drug categories; receipt of a prescription for anxiety or depression medication in the past year was the strongest predictor of sedative misuse (adjusted odds ratio = 4.46, 95% confidence intervals 3.18-6.24). Absence of a drug testing program was significantly related to the likelihood of drug misuse for all drug categories. ADSM with a history of treatment for pain and mood disorders, and who self-report headaches, sleep disorders, and fatigue are at higher risk for misusing prescription drugs, perhaps in an effort to self-manage symptoms. The results should be interpreted as a starting place for future exploration, not as the sole basis for policy or program development.

Introduction Non-Department of Defense (DoD)-curated health surveillance data on military personnel is limited and that which is generated by sources other than the DoD is rarely analyzed for the purposes of disseminating intelligence about health trends in this population. The purpose of this study was to determine spatiotemporal variations in the prevalence of certain conditions (i.e., hearing loss, vision impairment, and executive dysfunction) among active duty and National Guard/Reserve (NGR) military personnel. Materials and Methods We obtained person-level data from the 2015–2019 United States Census Bureau’s American Community Survey on active duty military personnel (N = 44,503) and NGRs (N = 146,488). We estimated survey-weighted logistic regression models to determine spatiotemporal differences in hearing loss, vision impairment, and executive dysfunction. Results Results showed that when aggregated across time and stratified by military service status, hearing loss was most prevalent (1.71%, 95% CI = 1.55, 1.89), followed by executive dysfunction (1.48%, 95% CI = 1.34, 1.64) and vision impairment (0.65%, 95% CI = 0.55, 0.77), among active duty service members. Among the NGR sample, hearing loss was most prevalent (9.99%, 95% CI = 9.80, 10.18), followed by executive dysfunction (5.35%, 95% CI = 5.20, 5.50) and vision impairment (3.43%, 95% CI = 3.31, 3.55). Overall, disability rates were higher among individuals in the NGR than among those on active duty. Results showed that risk for the aforementioned disabilities varied between 2015 and 2019 and was dependent on the rural location of the respondent’s residence. Specifically, limiting condition prevalence increased from 2015 to 2019 for all types—except for hearing loss among NGRs—among active duty members and NGRs living in rural areas. Conclusions Proper surveillance, education, treatment/rehabilitation, and prevention are essential components of mitigating these impairments to help assure the health, wellness, and combat readiness of our military personnel. Recommendations for future military health surveillance activities and health care services are provided.

PTSD, depression, and treatment outcomes: A latent profile analysis among active duty personnel in a residential PTSD program

A series of recent pharmacological discoveries have produced remarkable advances in psychotherapeutic medications. With the advent of newer antidepressants, there is a high degree of efficacy and a low risk profile. Potential benefits of these medications far outweigh the possible side effects, especially in contrast to older drugs. Navy Medicine now has the ability to treat active duty personnel during a deployment with safe antidepressant medications. The attitudes toward the use of selective serotonin reuptake inhibitors (SSRIs) on active duty service members has been surveyed. Profiles of prescribing patterns and attitudes toward the use of these medications and safety within the context of the operational environment were also surveyed. Group comparisons across various medical specialties and command organizations were made. The survey results suggest a very favorable attitude toward prescribing SSRIs in the active duty population.