National Guard Members Research Articles

Oscillating US Department of Defense policies and medical record documentation of gender dysphoria in service members: an observational time-series analysis

BackgroundUnited States military policies regarding service by transgender service members have shifted several times within the past decade. The relationships between policy changes and electronic health record documentation of gender dysphoria, a current and historic policy requisite for gender affirming care receipt, in active duty service members remain unknown.MethodsBayesian estimator of abrupt change, seasonality, and trend models identified changepoints in the proportion of service members who had new and then historical medical record documentation consistent with gender dysphoria from January 2015 to August 2022. Changepoints were evaluated as they related to salient military policy-related events.ResultsApproximately 3,853 active duty and activated National Guard or Reserve service members received a documented diagnosis corresponding to gender dysphoria from January 2015 to August 2022. Four significant changepoints were identified across both time series. Salient historical events that occurred during the changepoint periods were identified for contextualization.ConclusionsClinical documentation of gender dysphoria oscillated with changes to policies and public statements by government leaders, which may in turn, impact military recruitment and retention. This study highlights the need for equitable policies that optimize the strength of a diverse military force. Equity-oriented monitoring is needed to continually examine the impact of military service policies on readiness and retention to support actionable, data-driven improvements to policies and their implementation.

The Link between Deployment-Related Injuries and Suicidal Thinking in the Army National Guard: Examining the Role of Perceived Burdensomeness and Hopelessness

Objective In 2020, Army National Guard members demonstrated greater risk of suicide than their military and civilian counterparts. Though literature on deployment-related experiences and suicidal ideation (SI) is mixed, investigations of specific deployment-related experiences (e.g., injuries) may further elucidate the relationship between deployment and suicide risk. Deployment-related injuries, including pain severity and functional impairment, have been linked to increased risk of SI, and correlates like perceived burdensomeness (PB) and hopelessness. The current study sought to examine the cross-sectional relationship between deployment-related injuries, including pain severity and functional impairment, and severity of SI through PB and hopelessness. Method Immediately post-deployment, Army National Guard members (N = 2,261) completed validated self-report measures on past-week SI, PB, hopelessness, and single items regarding injury sustained during deployment and associated functional impairment and pain severity. Results Indirect effect analyses revealed that experience of deployment-related injury was related to SI through PB and hopelessness (R2 = .1993), functional impairment was related to SI through PB, and pain severity was related to SI through PB. Contrary to hypotheses, hopelessness was not associated with SI when PB was simultaneously considered. Conclusions Army National Guard members who develop a sense of PB related to their injury and functional impairment of that injury may be at increased risk for suicidal ideation. Military suicide-prevention efforts may be potentiated through targeting distorted cognitions such as PB and hopelessness, especially in service members who have been injured.

Understanding a Time of High Risk for Suicide: Adversities Associated with Separation from Military Service among National Guard and Reserve Service Members

Objective The purpose was to examine five types of adversity and their associations with separating from military service among a nationally representative sample of U.S. National Guard and Reserve (NGR) service members. Methods Multivariate logistic regression analyses were conducted to examine the association between separating from the service and adversities, and demographic differences in adversities experienced among those who had separated from the service and those who stayed in the service. Results Those who left the military were more likely to report financial (OR = 1.65, 95% CI = 1.01–2.70) and healthcare access problems (OR = 2.21, 95% CI = 1.10–4.46). Among those who left the military, female service members were more likely to experience interpersonal adversity (OR = 4.28, 95% CI = 1.15–15.87), and Army and Marine service members were more likely to experience job-employment adversity (OR = 4.92, 95% CI = 1.50–16.12) and financial adversity (OR = 6.46, 95% CI = 1.22–34.33). Conclusion Separating service members experience financial adversity and challenges with healthcare access. Interpersonal difficulties are particularly experienced by female service members, and job/employment difficulties experienced by Army and Marine veterans. Continued efforts are needed to facilitate service delivery for NGR separating service members who need them.

Stressful life events and incident depression among U.S. military personnel.

Although stressful life events (i.e., stressors) and depression are often assumed to be linked, the relation between stressors and incident depression is rarely studied, particularly in the military. The National Guard is a part-time subset of the U.S. military for whom civilian life stressors may be particularly salient, due to the soldiers' dual roles and frequent transitions between military and civilian life. We used a dynamic cohort study of National Guard members from 2010 to 2016 to investigate the relationship between recent stressful experiences (e.g., divorce) and incident depression, with an exploratory analysis of effect modification by income. Respondents endorsing at least one of nine past-year stressful events (a time-varying exposure, lagged by 1year) had almost twice the adjusted rate of incident depression compared to those with no stressful events (HR = 1.8; 95% CI 1.4, 2.4). This association may be modified by income: among individuals making under $80,000 per year, those with past-year stressors had twice the rate of depression compared to those with no stressors, but among those making over $80,000, past-year stressors were associated with only 1.2 times the rate of depression. Stressful life events outside of deployment are important determinants of incident depression among National Guard servicemembers, but the effect of these events may be buffered by higher income.

Moral injury and suicidal ideation among female national guard members: Indirect effects of perceived burdensomeness and thwarted belongingness.

Moral injury and suicidal ideation among female national guard members: Indirect effects of perceived burdensomeness and thwarted belongingness.

Support for Policy Changes for Therapy Related to Homefront Missions.

As a result of recent policy change, National Guard and active-duty Reserve service members now have parity with combat veterans to obtain therapy for symptoms arising as a result of their activation for service on homefront missions. Because the authority to treat soldiers serving on homefront missions is new, this article offers suggestions for service delivery to best meet the needs of this population. Now that National Guard and Reserve component soldiers who have responded to national and local emergencies are eligible for therapy, we need to be prepared to provide these services. In addition to addressing systemic staffing concerns, therapists need to be aware of the unique challenges faced by those who have served on homefront missions.

Predictors of Booster Engagement Following a Web-Based Brief Intervention for Alcohol Misuse Among National Guard Members: Secondary Analysis of a Randomized Controlled Trial.

BackgroundAlcohol misuse is a major health concern among military members. Reserve component members face unique barriers as they live off base with limited access to behavioral health services. Web and app-based brief interventions are a promising means to improve access to treatment for those who misuse alcohol, with the use of booster sessions to enhance effectiveness, solidify gains, and reinforce changes. However, little is known about who will engage in booster sessions.ObjectiveThis study aims to evaluate booster engagement across booster delivery modalities (Web and Peer) and identify participant-specific factors associated with booster session engagement.MethodsFollowing a brief web-based alcohol misuse intervention in National Guard members (N=739), we examined engagement in a series of three booster sessions. Using unadjusted and adjusted models, demographic and clinical characteristics that may serve as predictors of booster session engagement were examined across the 2 arms of the trial with different types of booster sessions: peer-delivered (N=245) and web-delivered (N=246).ResultsBooster session completion was greater for Peer than Web Booster sessions, with 142 (58%) service members in the Peer Booster arm completing all three boosters compared with only 108 (44%) of participants in the Web Booster arm (χ23=10.3; P=.006). In a model in which the 2 groups were combined, socioeconomic factors predicted booster engagement. In separate models, the demographic and clinical predictors of booster engagement varied between the 2 delivery modalities.ConclusionsThe use of peer-delivered boosters, especially among subsets of reserve members at risk of lack of engagement, may foster greater uptake and improve treatment outcomes.Trial RegistrationClinicalTrials.gov NCT02181283; https://clinicaltrials.gov/ct2/show/NCT02181283

Cohort profile: the Ohio Army National Guard Mental Health Initiative (OHARNG-MHI).

Rates of mental disorders in the United States military have increased in recent years. National Guard members may be particularly at risk for mental disorders, given their dual role as citizen-soldiers and their increased involvement in combat deployments during recent conflicts. The Ohio Army National Guard Mental Health Initiative (OHARNG-MHI) was launched to assess the prevalence, incidence, and potential causes and consequences of mental disorders in this unique population. OHARNG-MHI is a decade-long dynamic cohort study that followed over 3,000 National Guard members yearly through structured telephone interviews. Findings thus far have applied a pre-, peri-, post-deployment framework, identifying factors throughout the life course associated with mental disorders, including childhood events and more recent events, both during and outside of deployment. An estimated 61% of participants had at least one mental disorder in their lifetime, the majority of which initiated prior to military service. Psychiatric comorbidity was common, as were alcohol use and stressful events. Latent class growth analyses revealed four distinct trajectory paths of both posttraumatic stress and depression symptoms across four years. Only 37% of soldiers with probable past-year mental disorders accessed mental health services in the subsequent year, with substance use disorders least likely to be treated. Strengths of this study include a large number of follow-up interviews, detailed data on both military and non-military experiences, and a clinical assessment subsample that assessed the validity of the telephone screening instruments. Findings, methods, and procedures of the study are discussed, and collaborations are welcome.

Inhibitory Control Moderates the Intervention Effects of a Preventive Parenting Program on Posttraumatic Stress Disorder Symptoms Among Male Service Members.

Military servicemembers face substantial challenges due to war-related trauma exposure, including posttraumatic stress disorder (PTSD). Individuals with deficits in inhibitory control (IC) may have an increased risk of developing PTSD due to a reduced ability to regulate their cognitive responses to and disengage from trauma-related stimuli. After Deployment, Adaptive Parenting Tools (ADAPT) is a mindfulness-infused parenting program for military families that has also been found to have crossover effects on parental mental health. The present study examined whether fathers' IC at baseline affected their response to this emotional skills-focused intervention and further influenced their PTSD symptoms 1 year later. The sample included 282 male National Guard and Reserve (NG/R) service members who had recently been deployed to Iraq or Afghanistan. Fathers were randomly assigned to either the ADAPT program or a control condition, with IC measured at baseline and PTSD symptoms measured at baseline and 1-year follow-up. Intent-to-treat analyses revealed no significant main effect of the intervention on fathers' PTSD symptoms. However, fathers' IC moderated intervention effects on PTSD symptoms, f2 = 0.03. The intervention had more beneficial effects on reducing fathers' PTSD symptoms for participants with low IC at baseline. These findings are consistent with compensatory effects in the risk moderation hypothesis, which suggests that prevention or intervention programs are more effective for high-risk subgroups.

Operational Stress Control during a Pandemic: An Army National Guard Perspective on Lessons Learned during the Response to COVID-19

U.S. Army combat operational stress control doctrine and techniques are effective resources for military leaders preparing for prolonged operations in hostile environments. This doctrine provides an understanding of common sources of stress, stress reactions, and effective leader actions to help mitigate the effects. However, it may be less relevant to Army National Guard members activated to support their states during domestic emergencies. This article reviews the observations of one Behavioral Health Officer activated during the novel coronavirus 19 (COVID-19) pandemic and describes the operational stress experienced by Army National Guard members. Adaptive and maladaptive stress reactions to the stress of the COVID-19 operations are reviewed. The author calls for new or revised combat operational stress doctrine that is relevant to part time, citizen-soldiers activated for domestic emergencies. Aggregating Army National Guard lessons learned in the context of COVID-19 may also help support soldiers in the case that unfortunate future waves of the virus occur and to prepare for future pandemics.

A Machine Learning Approach to Predicting New-onset Depression in a Military Population.

Objective:Depression is one of the most common mental disorders in the United States in both civilian and military populations, but few prospective studies assess a wide range of predictors across multiple domains for new-onset (incident) depression in adulthood. Supervised machine learning methods can identify predictors of incident depression out of many different candidate variables, without some of the assumptions and constraints that underlie traditional regression analyses. The objectives of this study were to identify predictors of incident depression across 5 years of follow-up using machine learning, and to assess prediction accuracy of the algorithms.Methods:Data were from a cohort of Army National Guard members free of history of depression at baseline (n = 1951 men and 298 women), interviewed once per year for probable depression. Classification trees and random forests were constructed and cross-validated, using 84 candidate predictors from the baseline interviews.Results:Stressors and traumas such as emotional mistreatment and adverse childhood experiences, demographics such as being a parent or student, and military characteristics including paygrade and deployment location were predictive of probable depression. Cross-validated random forest algorithms were moderately accurate (68% for women and 73% for men).Conclusions:Events and characteristics throughout the life course, both in and outside of deployment, predict incident depression in adulthood among military personnel. Although replication studies are needed, these results may help inform potential intervention targets to reduce depression incidence among military personnel. Future research should further refine and explore interactions between identified variables.

Unmet Health Care Needs Among Children with Special Health Care Needs Enrolled in Tricare

TRICARE provides health care benefits to nearly two million children of active duty, retired, National Guard, and reserve service members. Child health advocates and congressional reports have raised questions regarding the adequacy access to care for children with military health benefits, particularly children with special health care needs (CSHCN). The objective of this study was to compare the health care experiences of CSHCN in TRICARE with those of CSHCN with other sources of health insurance.A cross‐sectional analysis comparing unmet health care needs among CSHCN with TRICARE versus CSHCN with other sources of health insurance using nationally representative data from three years of the National Survey of Children’s Health (NSCH), 2016‐2018. The NSCH includes a broad range of questions related to child health and health care to provide national level estimates, and the data allow for comparisons between insurance coverage groups and TRICARE. The survey data contain responses from over 100,000 parents or primary caregivers (parents) of children, representative of over 73 million children annually. This includes 804 children who were representative of approximately 367,000 CSHCN covered by TRICARE annually.Children with special health care needs.Overall, 21 percent (95% CI 19‐24 percent) of parents of children covered by TRICARE reported their child had a special health care need, compared to 16 percent of children with commercial insurance (95% CI 15‐16 percent) and 24 percent of children with public insurance (95% CI 23‐25 percent). Eight percent of parents of CSHCN covered by TRICARE (95% CI 4‐16 percent) reported any unmet health care needs in the prior 12 months, compared to 4 percent of CSHCN with private insurance (95% CI 4‐5 percent) and 9 percent of CSHCN with public insurance (95% CI 8‐11 percent). Among specific needs, 3 percent or fewer CSHCN covered by TRICARE had unmet needs for medical, dental, vision, hearing, or mental health care. Similarly, 5 percent or fewer reported difficulty or delays in getting services because of eligibility for coverage of the service, availability in the area, difficulty in getting an appointment, or cost.About 11 percent of parents of CSHCN covered by TRICARE reported usually or always being frustrated in getting needed services for their child during the prior 12 months, compared to 4 percent of those with private insurance and 9 percent of those with public insurance. About 12 percent of parents of CSHCN covered by TRICARE reported problems with paying for their child’s health care needs in the prior 12 months, compared to 23 percent of those with private insurance and 8 percent of those with public insurance.TRICARE is largely meeting the needs of the CSHCN for whom it provides benefits, but there are opportunities for improvement. CSHCN in TRICARE face higher rates of unmet needs than privately insured children, and their parents face higher levels of frustration in getting needed services.TRICARE should continue to work with families of CSHCN to identify specific unmet needs and sources of frustration with getting needed services.

The Effect of Body Composition and Energy Expenditure on Permethrin Biomarker Concentrations Among US Army National Guard Members.

To examine relationships between percent body fat (%BF) and total energy expenditure (TEE) on permethrin exposure among Army National Guard (ARNG) Soldiers wearing permethrin-treated uniforms. ARNG members (n = 47) participated in a 9-day study. Repeated body composition (height, weight, %BF) measurements and daily urine samples, analyzed for permethrin and N,N-diethyl-meta-toluamide (DEET) metabolites, were collected. TEE was determined via doubly labeled water protocol. Linear mixed and regression models were used for analyses. Neither %BF nor TEE were significantly associated with permethrin or DEET biomarkers. However, a significant interaction effect (F = 10.76; P = 0.0027) between laundering history and %BF was observed; 10% higher %BF was significantly associated with 25% higher permethrin biomarker concentrations among those wearing uniforms washed less than or equal to 25 (compared with more than 25) times. Uniform laundering history significantly affects the association between %BF and permethrin-treated uniform exposure.

Prevalence and Severity of Alcohol and Cannabis Use Across the Urban-Rural Continuum in the Michigan National Guard.

The National Guard provides critical support both domestically and abroad with soldiers dispersed throughout America and spanning the urban-rural continuum. To determine if location-specific interventions may be needed, we compared the prevalence and severity of cannabis and alcohol use among National Guard members across localities. Michigan National Guard members were enrolled (N=2,746) during drill weekends as part of a larger randomized behavioral trial. Cannabis (ASSIST; prevalence=5%) and alcohol use (AUDIT; prevalence=82%) were compared using hurdle regression models across locality status after adjusting for covariates. Prevalence of cannabis and alcohol use was predicted by locality (adjusted odds ratio [AOR]=0.913, 95% CI: 0.838-0.986, P=.029; AOR=0.963, 95% CI: 0.929-0.998, P=.038, respectively), with more use in urban localities. Neither severity of cannabis nor alcohol use was predicted by locality status. Prevalence of cannabis and alcohol use in the National Guard is differentially elevated across localities with higher prevalence in more central, densely populated areas. Findings may inform future work considering accessibility and utilization of prevention and treatment services for Guard members across the urban-rural continuum.

TRICARE For Children: Between Medicaid And Marketplace Plans For Comprehensiveness And Cost Sharing.

TRICARE provides health care benefits to nearly two million children of active duty, retired, National Guard, and reserve service members. Child health advocates and congressional reports have raised questions regarding the adequacy of these benefits, compared with other sources of children's health insurance. To help address these questions, we compared TRICARE benefits with benefits from Medicaid and Marketplace plans because they represent alternative sources of coverage for many of the families enrolled in TRICARE. Overall, we found that TRICARE benefits fell in the middle-between Medicaid plans' more comprehensive benefits with no cost sharing and Marketplace plans' more restrictive benefits with higher cost sharing.

Knowledge of suicide history, current depressive symptoms, and future suicide risk within couples

Research on suicide prevention and intervention has overwhelmingly focused on the suicidal individual. However, suicidal individuals exist within interpersonal relationships. This study tests 1) how accurately members of romantic couples know each other's depression symptoms, suicide histories, and risk for future suicidal thoughts and behaviors and 2) whether couple-specific factors moderate those associations. Participants were 43 mixed-sex couples (N = 86 individuals) recruited for a larger study of National Guard or Reserves members and their partners. Participants reported on their own depression symptoms, suicide history and expectation of future suicide risk, as well as their perceptions of their partners' depression symptoms, suicide history and future suicide risk. Effects were tested for moderation by communication style and relationship satisfaction. Results suggest that many individuals knew about their partners' depression symptoms and past suicidal ideation (77%). In contrast, fewer were aware of their partners' future suicide ideation risk (44%) and the minority knew about past suicidal behavior (23%) or risk for future suicide attempt (14%). Associations were not moderated by positive or negative communication styles or relationship satisfaction. Taken together, these results suggest that while romantic partners share some parts of their suicide histories with each other, some aspects are kept private. Notably, regardless of communication style or relationship quality, results were consistent, suggesting that even couples in strong relationships may not be aware of each other's suicide history and risk. Implications for the development of couples-based suicide prevention interventions are discussed.

Prevalence and covariates of problematic gambling among a US military cohort

The availability of and participation in gambling has increased substantially the past several decades, however studies of military members' gambling behaviors are limited. The present study aimed to investigate potential problematic gambling and its association with demographics and behavioral characteristics in a US military cohort. We analyzed cohort data from a telephone survey during 2015–2016 of 1553 Ohio Army National Guard members. We assessed potential problematic gambling by using the 3-item National Opinion Research Center Diagnostic Screen—Loss of Control, Lying, and Preoccupation Screen (NODS-CLiP). Potential correlates examined were demographics, depression, suicidal ideation, smoking status, alcohol use, legal and financial problems, perceived general health status, pain, and impulsivity. Results indicated past-year frequent gambling (at least once per week) and lifetime potential problematic gambling was reported by 13% and 8% of respondents, respectively. Problematic gambling and past-year gambling behaviors were associated in a dose-response relationship from 18% among soldiers gambling once per week to 44% among those gambling 4 or more times per week. Correlates of screening positive for potential problematic gambling included the following: being male, currently unmarried, having left the Guard or retired, minor depression, alcohol dependence, legal problems, and increased pain. Given the higher prevalence of frequent gambling in this military cohort (8%), nearly twice the US prevalence (5%), and the association with negative psychological and behavioral outcomes, routine screening of gambling frequency and problem gambling may be needed to ensure military and veteran populations live the healthiest lives possible.

The Relationship Between Parent–Soldier Communication and Postdeployment Soldier Mental Health

National Guard members experience significant challenges surrounding deployment and reintegration. The supportive role of the relationship with a parent through the deployment cycle merits exploration. This longitudinal study of National Guard soldiers examined the relationship between soldier communication with one or more of their parents predeployment and mental health outcomes at reintegration and one year postdeployment. A stronger predeployment parent–soldier relationship is associated with good mental health outcomes at reintegration, and one year later. Additionally, communicating more frequently with a parent predeployment is indirectly associated with improved mental health outcomes, as long as the parent–soldier relationship is positive.

Civilian Social Support and Posttraumatic Stress Disorder Symptoms among National Guard Members

Increasing evidence suggests that posttraumatic stress disorder (PTSD) symptoms are highly prevalent and pervasive among National Guard members who served in recent wars. Previous meta-analyses report a lack of social support as one of the strongest risk factors for the development of PTSD symptoms. Social support among military members is typically categorized into two types: assistance and support which is received from military leaders and fellow members of one’s unit and civilian social support which is obtained from civilian family and friends. Prior research has demonstrated that unit support is associated with less severe PTSD symptoms. In addition to unit support, the influence of civilian social support was also considered a potent buffer for PTSD symptoms. Civilian social support is important to National Guard members because their experiences integrate military and civilian life more than active duty soldiers. Unlike intensive studies in active duty military personnel, fewer studies have examined the role of social support in National Guard members, and civilian social support is rarely investigated in these limited studies. This review article examines the role of civilian social support in National Guard members as a potential protective factor against the development of PTSD symptoms.

Subthreshold PTSD and PTSD in a prospective-longitudinal cohort of military personnel: Potential targets for preventive interventions.

Prevention of PTSD requires identification of subpopulations contributing most to the population burden of PTSD. This study examines the relative contribution of subthreshold PTSD and probable PTSD on future PTSD in a representative military cohort. We analyze data on 3,457 U.S. National Guard members from the state of Ohio, assessed by telephone annually from 2008 to 2014. At each wave, participants were classified into one of three groups based on the PTSD Checklist: probable PTSD (DSM-IV-TR criteria), subthreshold PTSD (Criterion A1, at least one symptom in each cluster, symptom lasting longer than 30 days, and functional impairment), and no PTSD. We calculated the exposure rate, risk ratio (RR), and population attributable fraction (PAF) to determine the burden of future probable PTSD attributable to subthreshold PTSD compared to probable PTSD. The annualized prevalence of subthreshold PTSD and probable PTSD was respectively 11.9 and 5.0%. The RR for probable PTSD was twice as great among respondents with probable PTSD the prior interview than that of those with subthreshold PTSD (7.0 vs. 3.4); however, the PAF was considerably greater in participants with subthreshold PTSD the prior interview (PAF=35%; 95% confidence interval (CI)=26.0-42.9%) than in those with probable PTSD (PAF=28.0%; 95% CI=21.8-33.8%). Results were robust to changes in subthreshold PTSD definition. Subthreshold PTSD accounted for a substantial proportion of this population's future PTSD burden. Population-based preventive interventions, compared to an approach focused exclusively on cases of diagnosable PTSD, is likely to affect the greatest reduction in this population's future PTSD burden.