Active Duty US Army Personnel Research Articles

Association Between Responsibility for the Death of Others and Postdeployment Mental Health and Functioning in US Soldiers

Rates of suicidal thoughts and behaviors (STBs) in US soldiers have increased sharply since the terrorist attacks on September 11, 2001, and postdeployment posttraumatic stress disorder (PTSD) remains a concern. Studies show that soldiers with greater combat exposure are at an increased risk for adverse mental health outcomes, but little research has been conducted on the specific exposure of responsibility for the death of others. To examine the association between responsibility for the death of others in combat and mental health outcomes among active-duty US Army personnel at 2 to 3 months and 8 to 9 months postdeployment. This cohort study obtained data from a prospective 4-wave survey study of 3 US Army brigade combat teams that deployed to Afghanistan in 2012. The sample was restricted to soldiers with data at all 4 waves (1-2 months predeployment, and 2-3 weeks, 2-3 months, and 8-9 months postdeployment). Data analysis was performed from December 12, 2020, to April 23, 2021. Primary outcomes were past-30-day PTSD, major depressive episode, STBs, and functional impairment at 2 to 3 vs 8 to 9 months postdeployment. Combat exposures were assessed using a combat stress scale. The association of responsibility for the death of others during combat was tested using separate multivariable logistic regression models per outcome adjusted for age, sex, race and ethnicity, marital status, brigade combat team, predeployment lifetime internalizing and externalizing disorders, and combat stress severity. A total of 4645 US soldiers (mean [SD] age, 26.27 [6.07] years; 4358 men [94.0%]) were included in this study. After returning from Afghanistan, 22.8% of soldiers (n = 1057) reported responsibility for the death of others in combat. This responsibility was not associated with any outcome at 2 to 3 months postdeployment (PTSD odds ratio [OR]: 1.23 [95% CI, 0.93-1.63]; P = .14; STB OR: 1.19 [95% CI, 0.84-1.68]; P = .33; major depressive episode OR: 1.03 [95% CI, 0.73-1.45]; P = .87; and functional impairment OR: 1.12 [95% CI, 0.94-1.34]; P = .19). However, responsibility was associated with increased risk for PTSD (OR, 1.42; 95% CI, 1.09-1.86; P = .01) and STBs (OR, 1.55; 95% CI, 1.03-2.33; P = .04) at 8 to 9 months postdeployment. Responsibility was not associated with major depressive episode (OR, 1.30; 95% CI, 0.93-1.81; P = .13) or functional impairment (OR, 1.13; 95% CI, 0.94-1.36; P = .19). When examining enemy combatant death only, the pattern of results was unchanged for PTSD (OR, 1.44; 95 CI%, 1.10-1.90; P = .009) and attenuated for STBs (OR, 1.46; 95 CI%, 0.97- 2.20; P = .07). This cohort study found an association between being responsible for the death of others in combat and PTSD and STB at 8 to 9 months, but not 2 to 3 months, postdeployment in active-duty soldiers. The results suggest that delivering early intervention to those who report such responsibility may mitigate the subsequent occurrence of PTSD and STBs.

Gender differences in limited duty time for lower limb injury.

Among active-duty military personnel, lower limb musculoskeletal injuries and related conditions (injuries) frequently arise as unintended consequences of physical training. These injuries are particularly common among women. The practical impact of such injuries on temporary military occupational disability has not been estimated with precision on a large scale. To determine the proportion of service time compromised by limited duty days attributable to lower limb injuries, characterize the time affected by these limitations in terms of specific lower limb region and compare the limited duty time between male and female soldiers. Administrative data and individual limited duty assignments (profiles) were obtained for active-duty US Army personnel who served in 2014. Lower limb injury-related profiles were used to calculate the percent of person-time requiring duty limitations by gender and body region. The study group was 568 753 soldiers of whom 14% were women. Nearly 13% of service days for active-duty US Army soldiers required limited duty for lower limb injuries during 2014. Knee injuries were responsible for 45% of those days. Within integrated military occupations, female soldiers experienced 27-57% more time on limited duty for lower limb injuries compared with men. The substantial amount of limited duty for lower limb musculoskeletal injuries among soldiers highlights the need for improvement in training-related injury screening, prevention and timely treatment with particular attention to knee injuries. The excessive impact of lower limb injuries on female soldiers' occupational functions should be a surveillance priority in the current environment of expanding gender-integrated training.

Internet and In-Person Cognitive Behavioral Therapy for Insomnia in Military Personnel: A Randomized Clinical Trial.

Compare in-person and unguided Internet-delivered cognitive behavioral therapy for insomnia (CBTi) with a minimal contact control condition in military personnel. A three-arm parallel randomized clinical trial of 100 active duty US Army personnel at Fort Hood, Texas. Internet and in-person CBTi were comparable, except for the delivery format. The control condition consisted of phone call assessments. Internet and in-person CBTi performed significantly better than the control condition on diary-assessed sleep efficiency (d = 0.89 and 0.53, respectively), sleep onset latency (d = -0.68 and -0.53), number of awakenings (d = -0.42 and -0.54), wake time after sleep onset (d = -0.88 and -0.50), the Insomnia Severity Index (d = -0.98 and -0.51), and the Dysfunctional Beliefs and Attitudes About Sleep Scale (d = -1.12 and -0.54). In-person treatment was better than Internet treatment on self-reported sleep quality (d = 0.80) and dysfunctional beliefs and attitudes about sleep (d = -0.58). There were no differences on self-reported daytime sleepiness or actigraphy-assessed sleep parameters (except total sleep time; d = -0.55 to -0.60). There were technical difficulties with the Internet treatment which prevented tailored sleep restriction upward titration for some participants. Despite the unique, sleep-disrupting occupational demands of military personnel, in-person and Internet CBTi are efficacious treatments for this population. The effect sizes for in-person were consistently better than Internet and both were similar to those found in civilians. Dissemination of CBTi should be considered for maximum individual and population benefits, possibly in a stepped-care model.

Risk Factors for Mild Traumatic Brain Injury among US Army Soldiers

The Defense and Veterans Brain Injury Center (2015 DVBIC) reported more than 120,000 mild traumatic brain injury (mTBI) cases since the year 2000 among active duty US Army personnel. Increasing evidence suggests mTBI as a risk factor for development of mental health disorders (MHD) and post-traumatic stress disorder (PTSD). PURPOSE: To determine risk factors for mTBI, PTSD, and MHD and the association of mTBI and non-head injuries with subsequent PTSD and MHD among US Army active duty Soldiers. METHODS: This prospective cohort study utilized the Total Army Injury and Health Outcomes Database (TAIHOD) to analyze soldiers’ (N=1,261,297) medical encounter data between 2002 and 2011. International Classification of Diseases, Ninth Revision [ICD-9] codes were used to identify outcomes of interest: mTBI (CDC surveillance definition for mTBI), PTSD (ICD-9-CM 309.81), and MHD (ICD-9-CM codes to identify depression and anxiety, while excluding the diagnostic code of PTSD [ICD-9-CM 309.81]). Non-head (torso, spine, extremity) injuries were identified by ICD-9-CM codes using the Barell Injury Diagnosis Matrix. RESULTS: From 2002 to 2011 incident mTBI, PTSD, and MHD were found in: 79,505, 71,454, and 285,731 soldiers, respectively. The average injury rate per 1000 soldier years for mTBI, PTSD, and MHD were 17.23, 15.37, and 67.99, respectively. Sustaining a prior (>12 mos.) non-head injury was a significant risk factor for subsequent mTBI (OR 9.82, 95% CI 9.62-10.02). MTBI was associated with increased risk for both subsequent (>12 mos.) PTSD (OR 5.67, 95% CI 5.37-5.98) and MHD (OR 2.99, 95% CI 2.89-3.10). Non-head injury was associated with an increased risk for PTSD (OR 2.15, 95% CI 2.10-2.19) and MHD (OR 2.17, 95% CI 2.15-2.20) to a lesser degree than mTBI. CONCLUSION: Soldiers are at greater risk for developing PTSD and other MHDs for more than a year after an mTBI exposure versus non-head injuries. Identifying populations at risk for mTBI, and those with a previous mTBI exposure, are important consideration for mental health surveillance and intervention programs for both military and civilians. The views, opinions and/or findings contained herein are those of the authors and should not be construed as an official Department of the Army position, or policy.

EVALUATING POTENTIAL IATROGENIC SUICIDE RISK IN TRAUMA-FOCUSED GROUP COGNITIVE BEHAVIORAL THERAPY FOR THE TREATMENT OF PTSD IN ACTIVE DUTY MILITARY PERSONNEL.

To determine whether group cognitive processing therapy-cognitive only version (CPT-C) is associated with iatrogenic suicide risk in a sample of active duty US Army personnel diagnosed with posttraumatic stress disorder (PTSD). Possible iatrogenic effects considered include the incidence and severity of suicide ideation, worsening of preexisting suicide ideation, incidence of new-onset suicide ideation, and incidence of suicide attempts among soldiers receiving group CPT-C. Comparison with group present-centered therapy (PCT) was made to contextualize findings. One hundredeight soldiers (100 men, eight women) diagnosed with PTSD were randomized to receive either group CPT-C or group PCT. PTSD diagnosis was confirmed via structured clinician interview. Suicide ideation, depression severity, and PTSD severity were assessed at pretreatment, weekly during treatment, and 2 weeks, 6 months, and 12 months posttreatment. Rates of suicide ideation significantly decreased across both treatments. Among soldiers with pretreatment suicide ideation, severity of suicide ideation significantly decreased across both treatments and was maintained for up to 12 months posttreatment. Exacerbation of preexisting suicide ideation was uncommon in both treatments. New-onset suicide ideation was rare and similar across both treatments (<16%). There were no suicide attempts during treatment or follow-up in either group. Change in depression symptoms predicted change in suicide risk. Suicide-related outcomes were similar across both treatments and primarily associated with comorbid depression. Suicide-related outcomes in group CPT-C were rare and comparable to patterns observed in an active, nontrauma-focused therapy, even among soldiers who entered treatment with suicide ideation. NCT01286415, https://clinicaltrials.gov/ct2/show/NCT01286415.

Blended courage: Moral and psychological courage elements in mental health treatment seeking by active duty military personnel

We propose that seeking mental health care in an environment with heightened stigma may combine elements of both psychological and moral courage. Interviews of 32 active duty US Army personnel about their process of seeking current mental health care were analyzed for themes of voluntary action, personal risk, and noble or worthwhile goals (benefits). Risks and benefits were divided into internal risks and benefits, characteristic of psychological courage; and external risks and benefits, characteristic of moral courage. Concerns about external risks were themes in all narratives, while concerns about internal risks were themes in only about half of narratives. Both internal and external benefits of treatment were themes in approximately three-quarters of the narratives, whereas doubts about internal (but not external) benefits were also expressed at a similar rate. Thus, participants described an act of blended courage, with social risks of moral courage taken for wellness goals of psychological courage.

Mental health risk factors for suicides in the US Army, 2007–8

ObjectiveSuicides among active duty US Army personnel have been increasing since 2004, surpassing comparable civilian rates in 2008. This analysis uses US military data to assess suicide rates for the...

Caffeine consumption in active duty US Army personnel

Caffeine consumption in active duty US Army personnel

HIV incidence trends among white and african-american active duty United States Army personnel (1986-2003).

To analyze HIV incidence rate (IR) trends among white and African-American active duty US Army personnel between 1986 and 2003. Joinpoint regression was applied to identify time periods when significant changes in HIV IRs occurred, along with the corresponding annual percentage changes (APCs). African-Americans had a higher IR than white personnel (0.34/1,000 vs. 0.07/1,000; P < 0.001). Among white personnel, 2 significant time periods of changing HIV IRs were found: between 1986 and 1989 (APC = -31.1; P = 0.006) and between 1989 and 2003 (APC = -5.7; P = 0.003). Among African-Americans, a significant decline in HIV IRs was observed only between 1986 and 1991 (APC = -19.4; P < 0.001). This study revealed that the HIV IRs seem to have increased in 2 African-American groups: unmarried personnel and health care professionals. This cohort study (1,280 incident HIV infections among 1.5 million persons with 8.4 million person-years of follow-up) provides invaluable information on HIV trends in the United States Army. Despite an overall decline in HIV IRs, certain subpopulation among African-American personnel were observed to have increasing HIV IRs. Future research is needed to identify the current behavioral risk factors associated with HIV infection among US Army personnel.

Hospital Admissions Associated with Traumatic Brain Injury in the US Army during Peacetime: 1990s Trends

Introduction: This paper examines 10-year trends in traumatic brain injury (TBI)-related hospitalization rates for active duty US Army personnel in the 1990s. It does this within the context of various factors, including enhanced injury prevention policies and changed hospital admission practices, that may have affected TBI hospitalization rates. It also compares TBI hospitalization rates in the Army to those from an age-comparable segment of the US civilian population over this time period. Methods: Crude (unadjusted) incidence rates for all active duty US Army personnel hospitalized with a TBI diagnosis from fiscal years (FY) 1990 to 1999 were calculated. Once the trends were identified, the percentage change in the overall rate, as well as the rates for different TBI severity levels, and in-hospital deaths from FY1990 and FY1999 were analyzed. Changes in age- and gender-specific rates as well as crude rates for cases with and without other injuries and cases treated in military and civilian hospitals were also analyzed. Rate ratios were used to compare aggregated 5-year TBI hospitalization rates in the Army to rates for civilians 17–49 years of age during the following time periods: 1990–1994 and 1995–1999. The rates used in the comparison were adjusted to control for differences in age and gender. Results: The overall incidence of TBI-related hospitalization in the Army decreased 75% from FY1990 to FY1999. The rates for all TBI severity levels decreased, but the rate for mild TBI decreased more than the rates for moderate and severe TBI. The rate of in-hospital deaths from TBI also decreased. Rates decreased similarly for males and females, across all age groups, as well as for cases with and without other injuries. TBI rates decreased for Army personnel treated in military hospitals but changed minimally for Army personnel treated in civilian hospitals. The Army’s TBI hospitalization rates were generally higher than civilian rates in the early 1990s but by the late 1990s, most of the Army’s rates were lower than or equal to the civilian rates. Conclusions: The incidence of TBI-related hospitalization in the active duty US Army decreased markedly (75%) during the 1990s. As a result, most of the Army’s TBI hospitalization rates were lower than civilian rates by the late 1990s. Effective injury prevention and changes in the Army population were two of the factors that likely contributed to the decrease in rates for all TBI severity levels, while changes in hospital admission practices likely contributed to the disproportionate decrease in the Army’s rates for mild TBI.

Does Occupation Explain Gender and Other Differences in Work-Related Eye Injury Hospitalization Rates?

We sought to determine whether demographic differences in eye injury rates persist after adjusting for occupational exposure. On-duty eye injury hospitalizations were linked to occupation among active-duty US Army personnel. Eye injury rates were higher for white soldiers, men, and for younger soldiers, even after adjusting for occupational group and specific job titles using multivariate models. This finding contrasts with studies of other injuries, suggesting that occupation does not fully account for variations in eye injury risk. Because protective eye-wear can prevent most serious eye injuries, we hypothesize that differences in protective eye-wear use between men and women may contribute to differences in eye injury rates, although follow-up studies are needed to confirm this. Prevention efforts should consider targeting high-risk demographic groups in addition to high-risk occupations.

Vitamin K1 intake and coronary calcification

The activity of matrix Gla-protein (MGP), a potent inhibitor of vascular calcification, is dependent on carboxylation using vitamin K as a co-factor. In animals, low intake of total vitamin K has been shown to accelerate vascular calcification via the MGP mechanism. This has led to the hypothesis that low levels of dietary vitamin K intake may be a risk factor for accelerated vascular calcification in humans due to decreased MGP activity. Additionally, some authors have suggested that current recommended daily intake values for vitamin K might be insufficient to fully inhibit vascular calcification via the MGP mechanism. The aim of this study was to examine the relationship between dietary vitamin K1 (the most prevalent dietary form of vitamin K) intake and premature coronary artery calcification (CAC) in an asymptomatic screening population. We conducted a prospective study of 807 consecutive active-duty US Army personnel, 39-45 years of age, without known coronary heart disease. Vitamin K1 intake was measured with the Block Dietary Questionnaire and CAC was identified using electron-beam computed tomography (EBCT). We found no significant correlation between CAC score and vitamin K1 intake (r = 0.132, P = 0.106). Multivariate analysis with adjustment for cardiac risk factors showed no association between dietary vitamin K1 intake and CAC. Dietary vitamin K1 (phylloquinone) intake appears to be unrelated to premature coronary calcification in a screening population. Further investigation into the relationship of vascular calcification and other forms of vitamin K1 (menaquinones) is indicated.

Alcohol intake is not associated with subclinical coronary atherosclerosis

Background The inverse relation between alcohol intake and clinical coronary artery disease (CAD) is well established, although the mechanisms remain speculative. We studied the relation between alcohol intake and subclinical CAD to assess the possible role of alcohol in atherogenesis. Methods We conducted a prospective study of 731 consecutive, consenting, active-duty US Army personnel (39 to 45 years of age) without known CAD who were undergoing a routine physical examination. Each participant was surveyed with the validated Block dietary questionnaire, which included detailed information on alcohol intake as wine, beer, or liquor. Subclinical CAD was determined by means of electron beam computed tomography to quantify coronary artery calcification (CAC). Results The mean age was 42 (±2); 83% were male, 71% were white, and 82% were college graduates. The prevalence of CAC was 18.6% (mean CAC score = 12 ± 69). Twenty-two percent drank alcohol daily, with an average of 2.4 drinks per day. Systolic blood pressure was correlated with number of drinks per day ( r = 0.10, P = .025). Among drinkers, HDL was weakly correlated with daily alcohol consumption ( r = 0.10, P = .025). There was no relation between the CAC score and the alcohol intake as measured by drinks per day (OR, 1.02; 95% CI, 0.64 to 1.63; 1.13, 0.59 to 2.15; 1.26, 0.69 to 2.59, for less than 1, 1 to 2, and more than 2 drinks per day, respectively). Stratified analyses based on type of alcohol and multivariate analyses indicated no independent relation between any type or quantity of alcohol intake and the presence or extent of coronary calcification. Conclusions Alcohol intake does not appear to be inversely related to subclinical CAC, implying that previous observations of a protective effect of alcohol on clinical CAD may involve factors related to plaque stability rather than atherogenesis.

Validation of the MEDFICTS dietary questionnaire: a clinical tool to assess adherence to American Heart Association dietary fat intake guidelines.

BackgroundDietary assessment tools are often too long, difficult to quantify, expensive to process, and largely used for research purposes. A rapid and accurate assessment of dietary fat intake is critically important in clinical decision-making regarding dietary advice for coronary risk reduction. We assessed the validity of the MEDFICTS (MF) questionnaire, a brief instrument developed to assess fat intake according to the American Heart Association (AHA) dietary "steps".MethodsWe surveyed 164 active-duty US Army personnel without known coronary artery disease at their intake interview for a primary prevention cardiac intervention trial using the Block food frequency (FFQ) and MF questionnaires. Both surveys were completed on the same intake visit and independently scored. Correlations between each tools' assessment of fat intake, the agreement in AHA step categorization of dietary quality with each tool, and the test characteristics of the MF using the FFQ as the gold standard were assessed.ResultsSubjects consumed a mean of 36.0 ± 13.0% of their total calories as fat, which included saturated fat consumption of 13.0 ± 0.4%. The majority of subjects (125/164; 76.2%) had a high fat (worse than AHA Step 1) diet. There were significant correlations between the MF and the FFQ for the intake of total fat (r = 0.52, P < 0.0001) and saturated fat (r = 0.52, P < 0.0001). Despite these modest correlations, the currently recommended MF cutpoints correctly identified only 29 of 125 (23.3%) high fat (worse than AHA Step 1) diets. Overall agreement for the AHA diet step between the FFQ and MF (using the previously proposed MF score cutoffs of 0–39 [AHA Step 2], 40–70 [Step 1], and >70 [high fat diet]) was negligible (kappa statistic = 0.036). The MF was accurate at the extremes of fat intake, but could not reliably identify the 3 AHA dietary classifications. Alternative MF cutpoints of <30 (Step 2), 30–50 (Step 1), and >50 (high fat diet) were highly sensitive (96%), but had low specificity (46%) for a high fat diet. ROC curve analysis identified that a MF score cutoff of 38 provided optimal sensitivity 75% and specificity 72%, and had modest agreement (kappa = 0.39, P < 0.001) with the FFQ for the identification of subjects with a high fat diet.ConclusionsThe MEDFICTS questionnaire is most suitable as a tool to identify high fat diets, rather than discriminate AHA Step 1 and Step 2 diets. Currently recommended MEDFICTS cutpoints are too high, leading to overestimation of dietary quality. A cutpoint of 38 appears to be providing optimal identification of patients who do not meet AHA dietary guidelines for fat intake.

Cardiovascular News

Cardiovascular News

Do conventional risk factors predict subclinical coronary artery disease? Results from the Prospective Army Coronary Calcium Project

Background Recent guidelines recommend against the routine use of coronary artery calcification (CAC) detection because the additive value over clinical prediction tools is uncertain. We compared CAC, with use of electron-beam computed tomography (EBCT), with clinical and serologic coronary risk factors for the identification of patients with increased coronary heart disease risk. Methods and Results We studied 630 active-duty US Army personnel (39-45 years old) without known coronary artery disease (CAD) who were undergoing a routine physical examination as required by regulations. Each participant underwent clinical and serologic risk factor screening and EBCT. The cohort (mean age 42 ± 2 years, 82% male) had a low predicted risk of coronary events (mean 5-year Framingham risk index [FRI] 1.6% ± 1.2%). The prevalence of coronary calcification was 17.6% (male 20.6%, female 4.3%). Significant univariate correlates of CAC were total and low-density lipoprotein [LDL] cholesterol, triglycerides, systolic blood pressure, and body mass index. However, only LDL cholesterol was independently associated with CAC. There was a significant but weak relationship between CAC and the Framingham risk index (FRI) (receiver-operator characteristic [ROC] curve area 0.62 ± 0.03, P <.001), which was not different from the relationship between CAC and LDL cholesterol alone (ROC curve area 0.61 ± 0.03, P <.001). The prevalence of any CAC in men increased slightly across increasing quartiles of FRI: 17.0%, 20.8%, 33.0%, and 29.2% (P =.033). Other risk factors (family history, homocysteine, insulin, lipoprotein[a], and fibrinogen) were not related to CAC. Conclusions In this age-homogeneous, low-risk screening cohort, conventional coronary risk factors significantly underestimated the presence of premature, subclinical calcified coronary atherosclerosis. These data support the potential of CAC detection as an anatomic, plaque-burden diagnostic test to identify patients who may require more intensive risk-reduction therapies, independent of predicted clinical risk. (Am Heart J 2001;141:463-8.)

Correlates of human immunodeficiency virus infection risk behavior in male attendees of a clinic for sexually transmitted disease.

Human immunodeficiency virus (HIV) infection risk behavior was evaluated in a cross-sectional survey of 400 male active-duty US Army personnel who presented at a sexually transmitted disease (STD) clinic with symptoms of acute urethritis. High-risk partners were common, and nearly one-quarter of the sample had previously had STDs. Logistic regression models examined correlates of HIV exposure risk, of inconsistent condom use, and of having partners with increased risk of HIV infection. Frequent partner turnover, sex "binging," negative attitudes toward condom use, and engaging in sex during military leaves were important correlates of risk. Individuals with HIV infection risk behavior generally were cognizant of their risk for HIV infection. Implications for intervention are discussed.

Quarterly Report to the Domestic Policy Council on the Prevalence and Rate of Spread of HIV and AIDS in the United States

This report includes trends in reported cases of AIDS; trends in prevalence and incidence of Human Immunodeficiency Virus Type 1 (HIV-1) infection; status of HIV-1 antibody surveys; data on HIV-2; and a comparison of AIDS mortality and years of potential life lost (YPLL) with other major diseases. By March 14, 1988, a total of 56,212 cases of AIDS had been reported in the US; nearly 10,000 of these cases have been reported since the last report, on November 30, 1987. More than 31,400 cases have resulted in death. The 416 cases of AIDS reported during the past 12 months among children under 13 years of age represent an 85% increase over the total for the previous year; 75% of these children acquired their infection perinatally, probably before birth, from their infected mothers. Accurate estimates of the prevalence and rate of spread of HIV-1 infection in the entire US population are not possible at this time. More precise estimates are available only for certain subgroups of the general population such as blood donors and applicants for military service. Among active-duty US Army personnel who have been tested more than once, 7.7/10,000/year have become infected since their 1st test. The 1st reported case of AIDS caused by HIV-2 in the US was diagnosed in December 1987. The patient was a recent visitor from West Africa, where HIV-2 was originally described, and denied sexual intercourse, use of nonsterile needles, or donation of blood while in the US.