US Military Service Members Research Articles

Mental Health Treatment Rates During Pregnancy and Post Partum in US Military Service Members

Although new parents' mental health is known to decline, less is known about changes in therapy attendance, especially among military service members. To investigate changes in therapy attendance among new parents and by parental leave length. This cohort study of US Army and Navy service members from January 1, 2013, to December 31, 2019, compared parents' monthly therapy attendance with matched nonparents' across childbirth and compared mothers' weekly therapy attendance before vs after returning to work. Eligible monthly sample members included service members with first births from January 1, 2014, to December 31, 2017, and 12 months of data before to 24 months after birth and nonparents with 36 months of data. Eligible weekly sample members included mothers with first births from January 1, 2013, to June 30, 2019, and data from 12 months before to 6 months after birth and nonparents with 18 months of data. Data analysis was performed from July 1, 2023, to January 15, 2024. Those exposed to parenthood had no prior children, acquired a dependent younger than 1 year, and, for mothers, had an inpatient birth. Unexposed matches did not add a dependent younger than 1 year. Monthly counts of mental health therapy sessions and any therapy sessions (weekly). The monthly sample included 15 554 193 person-month observations, representing 321 200 parents and matches, including 10 193 mothers (3.2%; mean [SD] age, 25.0 [4.9] years), 50 865 nonmother matches (15.8%; mean [SD] age, 25.0 [5.0] years), 43 365 fathers (13.5%; mean [SD] age, 26.4 [4.8] years), and 216 777 nonfather matches (67.5%; mean [SD] age, 26.4 [4.8] years). The weekly sample included 17 464 mothers. Mothers went to 0.0712 fewer sessions at 1 month post partum (95% CI, -0.0846 to -0.0579) compared with 10 months before birth. Fathers went to 0.0154 fewer sessions in the month of birth (95% CI, -0.0194 to -0.0114) compared with 10 months before. Parents with preexisting treatment needs had larger decreases in treatment. Weekly therapy attendance increased by 0.555 percentage points (95% CI, 0.257-0.852) when mothers returned to work from 6 weeks of leave and 0.953 percentage points (95% CI, 0.610-1.297) after 12 weeks of leave. In this cohort study of new parents, therapy attendance decreased around childbirth, especially among parents with prior mental health needs and mothers with longer maternity leaves. These findings suggest that more accessible treatment, including home visits or telehealth appointments, is needed.

Increased Risk of Monoclonal Gammopathy of Undetermined Significance in US Military Service Members: A Case-Control Study of 1,068 Service Members Deployed to Either Europe or Iraq, with or without Reported Burn Pit and Toxic Smoke Exposure

Background:Monoclonal Gammopathy of Undetermined Significance (MGUS) is a plasma cell disorder which may lead to and in all cases precedes multiple myeloma (MM). Although, the etiology of MGUS is unknown, multiple studies have shown an association between MGUS and pesticide exposure (Kachuri et al, Int. J. Cancer 2013). Furthermore, soldiers and First Responders may be at higher risk of developing MGUS as evidenced by a 2.4-fold increased risk for MGUS in Vietnam Veterans exposed to Agent Orange (Landgren et al, JAMA Oncol. 2015) and a 1.8-fold higher risk in World Trade Center (9/11 attacks)-exposed fire fighters compared to reference populations (Landgren et al, JAMA Oncol. 2018). US Service Members deployed to the Southwest Asia theater of military operations (e.g., Iraq and Afghanistan) may have been exposed to various airborne hazards including smoke and fumes from open burn pits (chemical, paint, munitions, petroleum, plastic, rubber, medical, human, and food waste), oil well fires, and aircraft fuel/exhaust. Researchers are currently investigating the long-term consequences from these exposures. We were motivated to determine whether US Service Members deployed to Iraq were at increased risk of developing MGUS. Methods: Serum samples and clinical data (N=1,068) were attained from the Armed Forces Health Surveillance Division (AFHSD), the central epidemiologic health registry and biorepository for the US Military after IRB exemptions were granted. A total of 534 US Service Members who deployed to Iraq between January 1, 2005 and June 30, 2007 and reported burn pit exposure, smoke, burning trash, etc. on their post-deployment health assessment form (exposed cases) were matched 1:1 to 534 Members deployed to Germany (matched controls) who were never deployed to Southwest Asia and denied toxic exposure. All cases were deployed ≥ 6 months, were ≥ 35 years old at time of deployment, remained in the military ≥ 10 years and had serum available in the AFHSD repository 10 years after deployment. Matched criteria included deployment year (+/- 10 years), age (+/- 3 years), sex, service branch, military rank, and occupation category. The 10-year post-deployment samples underwent laboratory testing to screen for monoclonal protein by immunofixation (IFE) using pentavalent antisera with positive samples confirmed and typed using IFE gels (Sebia) and for serum free light chains (sFLC; Sebia) performed on the DYNEX Agility platform. IFE-positive samples underwent serum protein electrophoresis (SPEP) quantification by capillary electrophoresis (Sebia). Results:The median age of exposed Service Members was 37 years (range: 35-52) and 37 years (range: 35-55) for controls (Table 1). In both cohorts, the frequency of White (64.8%), Black (18.7%), Hispanic (7.5%), and male (89%) patients were the same as was the distribution of military occupation, rank, and service branch. The median number of days deployed for exposed vs controls was 243 and 852, respectively. There was no statistically significant difference between burn pit exposed and controls in the combined prevalence of MGUS (IFE+ monoclonal protein) and light chain (LC) MGUS (abnormal sFLC ratio), 6.7% (95% Confidence Interval (CI): 4.8-9.2%) vs 5.4% (95% CI: 3.7-7.7%), respectively (p=0.22). Similarly, there was no difference in prevalence when assessing IFE+ or sFLC+ cases separately (Table 2). The prevalence of MGUS or LC-MGUS for all 1,068 Service Members was 6.1% (95% CI: 4.7-7.7%). Conclusion:In our cohort of 534 Service Members deployed to Iraq and exposed to burn pits and other airborne toxic hazards (cases) there was no statistically significant difference in the prevalence of MGUS compared to 534 deployed to Germany (matched controls). Interestingly, the overall prevalence of MGUS/LC-MGUS in this combined deployed population was 6.1%. When taking into account that the median age at deployment was 37 years and samples were attained 10 years later (approximately at an age of 47 years), the observed prevalence is 3-fold higher than that reported in the Icelandic iStopMM study (2% in the 41-50 -year age group). Future studies are needed to further elucidate causes for the increased prevalence of MGUS/LC-MGUS in deployed US Military Service Members. This contents is the sole responsibility of the authors and do not necessarily reflect the views, opinions or policies of the US Government nor endorsement of commercial products mentioned.

National Trends in Cochlear Implantation Across the Department of the Defense: A Case for Inclusion as a General Otolaryngology Core Competency.

With ongoing national expansions in cochlear implantation (CI) candidacy criteria, more patients qualify for CI today than ever before. Among US veterans and military service members, the prevalence of qualifying degrees of hearing loss secondary to occupational noise exposure exceeds the general population. The primary aim of the current work was to evaluate CI trends across the military health system. Database review. Military and civilian practices. Department of Defense (DoD) beneficiaries who underwent CI. CI rates between 2010 and 2019. A total of 3,573 cochlear implant operations were performed among DoD beneficiaries from 2010 to 2019. A majority of patients (55%) were older than 64 years, with the next most commonly implanted age group being 0 to 4 years of age (14%). From 2010 to 2019, annual CI increased at a rate of 7.9% per year for all implantation over the study period ( r = 0.97, p < 0.0001); there was a statistically significant difference of this rate compared with tympanoplasty, which was used as a reference procedure (rate, -1.9%; p = 0.03). This trend was similar for beneficiaries implanted both in military (11.9% per year, r = 0.77, p = 0.009) and civilian facilities (7.7% per year, r = 0.96, p < 0.0001); there was no statistically significant difference between the annual growth rates of these groups ( p = 0.68). Although the number of devices implanted is rapidly increasing among DoD beneficiaries, reported national utilization rates remain low. This disparity likely exists in the general public, considering the aging demographic in the West and continual expansions in US Federal Drug Administration labeling. These data suggest that widespread expansion of the procedure to general otolaryngology practices will be required to meet current and future demands for CI. For this reason, CI should be considered for "key indicator" designation among residency training programs.

The association between kinesiophobia and functional limitations in service members with knee pain

BackgroundKnee diagnoses account for more than 50% of lower extremity musculoskeletal conditions in non-deployed US Service members. However, there is limited information regarding kinesiophobia in Service members with non-operative knee diagnoses. HypothesesThe objectives of this study were to determine the prevalence of high levels of kinesiophobia in US military Service members with knee pain across different knee diagnoses, and to determine the relationships between kinesiophobia and lower extremity function and/or specific functional limitations in Service members with knee pain. It was hypothesized Service members with knee pain would exhibit high levels of kinesiophobia across all knee diagnoses examined, and higher levels of both kinesiophobia and pain would be associated with worse self-reported function in this population. It was also hypothesized higher levels of kinesiophobia would be associated with functional activities with high knee loading. DesignRetrospective cohort study. Level of evidenceIV. MethodsSixty-five US Service members presenting to an outpatient physical therapy clinic were included in this study (20 females; age = 30.8 ± 7.7 years; height = 1.74 ± 0.9 m; mass = 80.7 ± 16.2 kg). Inclusion criterion was the presence of knee pain (duration = 50 ± 59 months); exclusion criterion was knee pain as a sequela of knee surgery. Data regarding demographic, pain chronicity, pain by Numeric Rating Scale (NRS), Tampa Scale of Kinesiophobia (TSK), and Lower Extremity Functional Scale (LEFS) were retrospectively obtained from patients’ medical records. A high level of kinesiophobia was defined as a TSK score of greater than 37 points. Patient diagnoses included: osteoarthritis (n = 16); patellofemoral pain syndrome (n = 23); and other non-operative knee diagnoses (n = 26). Commonality analysis was utilized to determine the effects of age, height, mass, NRS, and TSK on LEFS score. Predictor values were interpreted as <1% = negligible, >1% = small; >9% = moderate, >25% = large. Additionally, exploratory item-specific analyses examined the strength of the relationships between kinesiophobia and LEFS item responses. Binary logistic regression determined if difficulty with an individual LEFS item could be predicted from either NRS or TSK score. Statistical significance was set at P < 0.05. ResultsHigh levels of kinesiophobia were identified in 43 individuals (66%). NRS and TSK explained 19.4% and 8.6% of the unique variance in LEFS, and 38.5% and 20.5% of total variance, respectively. Age, height, and mass explained negligible to small proportions of the unique variance in LEFS. TSK and NRS were independent predictors for 13/20 individual LEFS items, with odds ratios ranging from 1.12 to 3.05 (P < 0.05). ConclusionThe majority of US Service members in this study exhibited high levels of kinesiophobia. Kinesiophobia was significantly related to self-reported functional scores and performance on individual functional tasks in Service members with knee pain. Clinical relevanceTreatment strategies addressing both fear of movement and pain reduction in patients with knee pain may help optimize functional outcomes.

Clusters of conditions among US service members diagnosed with mild TBI from 2017 through 2019.

Many US Military Service Members (SMs) newly diagnosed with mild Traumatic Brain Injury (mTBI) may exhibit a range of symptoms and comorbidities, making for a complex patient profile that challenges clinicians and healthcare administrators. This study used clustering techniques to determine if conditions co-occurred as clusters among those newly injured with mTBI and up to one year post-injury. We measured the co-occurrence of 41 conditions among SMs diagnosed with mTBI within the acute phase, one or three months post-mTBI diagnosis, and chronic phase, one year post-mTBI diagnosis. Conditions were identified from the literature, clinical subject matter experts, and mTBI care guidelines. The presence of conditions were based on medical encounters recorded within the military health care data system. Through a two-step approach, we identified clusters. Principal component analysis (PCA) determined the optimal number of clusters, and hierarchical cluster analyses (HCA) identified the composition of clusters. Further, we explored how the composition of these clusters changed over time. Of the 42,018 SMs with mTBI, 23,478 (55.9%) had at least one condition of interest one-month post-injury, 26,831 (63.9%) three months post-injury, and 29,860 (71.1%) one year post injury. Across these three periods, six clusters were identified. One cluster included vision, cognitive, ear, and sleep disorders that occurred one month, three months, and one year post-injury. Another subgroup included psychological conditions such as anxiety, depression, PTSD, and other emotional symptoms that co-occurred in the acute and chronic phases post-injury. Nausea and vomiting symptoms clustered with cervicogenic symptoms one month post-injury, but later shifted to other clusters. Vestibular disorders clustered with sleep disorders and headache disorders one-month post-injury and included numbness and neuropathic pain one year post-injury. Substance abuse symptoms, alcohol disorders, and suicidal attempt clustered one year post-injury in a fifth cluster. Speech disorders co-occurred with headache disorders one month and one year post-injury to form a sixth cluster. PCA and HCA identified six distinct subgroups among newly diagnosed mTBI patients during the acute and chronic phases post-injury. These subgroups may help clinicians better understand the complex profile of SMs newly diagnosed with mTBI.

Evaluation of Safe Firearm Storage Messaging in a Sample of Firearm-Owning US Military Service Members

Nearly two-thirds of military suicides involve firearms, and safe firearm storage is rare. To examine whether US military service members endorse greater openness to safe firearm storage depending on the content of the visual message they are randomly assigned to view. This comparative effectiveness study used a 3 × 2 × 2 factorial design to randomize US military service members to view 1 of 12 visual messages on safe firearm storage. Willingness to use safe firearm storage practices was assessed immediately before and after exposure to the message. Participants were recruited using the KnowledgePanel Calibration approach. Inclusion criteria included current membership in the US military and current firearm ownership. The KnowledgePanel sample was fielded from December 3 to 27, 2021, with a 76% completion rate and 45 individuals determined to be qualified (28% qualification rate). The opt-in sample was fielded December 7, 2021, through January 4, 2022, with 699 individuals (3%) qualified and 674 included in the final data set. Messages shared the same image and text on safe firearm storage but varied in messenger occupation (eg, primary care physician, security forces, or combat controller), the presence of text validating the perspective of firearm owners, and the presence of text validating the drive for home protection. Outcomes included changes in willingness to use 4 at-home (unloaded, separate from ammunition, in a locked location, and with a locking device) and 3 away-from-home (with family or friend, at a firearm retailer, or at a law enforcement agency) firearm storage practices. All analyses, including sample descriptives, are based on weighted data. Of the 719 individuals in the data set, 367 (median [range] age, 33.64 [18-86] years; 80.4% male; 71.4% White) who endorsed not currently storing firearms using the methods assessed were included in analyses. In a multivariate analysis of variance, a significant interaction was found among time, messenger profession, gun-friendly text, and home protection text across all outcomes (Wilks' λ F = 2.09; P = .01; pη2 = 0.040); however, in a post hoc repeated-measures analysis of variance, the interaction was statistically significant only for storing firearms away from home with a trusted family member or friend (F = 5.42; P = .005; pη2 = 0.030). The profession of the messenger was more consistently associated with shifts in willingness than was the message content, although this varied across storage options. The findings of this comparative effectiveness study suggest that several combinations of messenger and content may be associated with willingness to endorse safe firearm storing practices, with particularly consistent positive findings for messages featuring security forces. The scalability and dosage potential of this intervention may render visual messaging valuable for promoting safe firearm storage at the population level.

Dietary Supplement and Prescription Medication Use Among US Military Service Members With Clinically Diagnosed Medical Conditions: The US Military Dietary Supplement Use Study

BackgroundUse of prescription medications (PMs) with dietary supplements (DSs) can be hazardous because of potential adverse interactions, but patterns of dual use in military service members (SMs) has not been examined. ObjectiveInvestigate dual use of filled PMs (FPMs) and DSs, factors associated with dual use, and dual use among SMs with clinically diagnosed medical conditions (CDMCs). DesignCross-sectional. Data on FPMs and CDMCs were obtained from medical surveillance records. Between December 2018 and August 2019, participants completed a questionnaire on DS use in the previous 6 months. ParticipantsA stratified random sample of 26,880 SMs from all military services. Main outcome measuresPrevalence of dual use of FPMs with DSs within a 6-month period, demographic/lifestyle factors associated with dual use, and prevalence of dual use among SMs with CDMCs. Statistical analysisPrevalences were calculated as percents, χ2 statistics examined differences across various strata of demographic and lifestyle characteristics, and univariable and multivariable logistic regression determined the odds of using FPMs with DSs for various CDMCs. ResultsAbout one-half (49%) of SMs had dual use of FPMs with DSs in the 6-month period. Dual use was higher among women; increased with older age, more formal education, higher body mass index, and more physical activity; was highest among American Indian SMs and lowest among Asian SMs; was higher among former tobacco users; and was highest among Army personnel and lowest among Marine Corps personnel. The overall prevalence of dual use in the 6-month period was higher among those with a CDMC than those without (62% vs 19%), and this relationship was maintained for 20 International Classification of Diseases, Revision 10, code groupings covering virtually all CDMCs. ConclusionThis is the first study to document a high prevalence of dual FPMs and DSs in SMs, especially among those with CDMCs.

The Role of the Inflammatory Response in Mediating Functional Recovery Following Composite Tissue Injuries.

Composite tissue injuries (CTI) are common among US Military Service members during combat operations, and carry a high potential of morbidity. Furthermore, CTI are often complicated due to an altered wound healing response, resulting in part from a dysregulation of the innate and adaptive immune responses. Unlike normal wound healing, in CTI, disruptions occur in innate immune responses, altering neutrophil functions, macrophage activation and polarization, further impacting the functions of T regulatory cells. Additionally, the biological underpinnings of these unfavorable wound healing conditions are multifactorial, including various processes, such as: ischemia, hypoxia, low nutrient levels, and altered cell metabolic pathways, among others, all of which are thought to trigger anergy in immune cells and destabilize adaptive immune responses. As a result, impaired wound healing is common in CTI. Herein, we review the altered innate and adaptive immune cells and their metabolic status and responses following CTI, and discuss the role a multi-pronged immunomodulatory approach may play in facilitating improved outcomes for afflicted patients.

Long-term prescription opioid use among US military service members injured in combat.

During the Global War on Terrorism, many US Military service members sustained injuries with potentially long-lasting functional limitations and chronic pain. We sought to understand the patterns of prescription opioid use among service members injured in combat. We queried the Military Health System Data Repository to identify service members injured in combat between 2007 and 2011. Sociodemographics, injury characteristics, treatment information, and costs of care were abstracted for all eligible patients. We surveyed for prescription opioid utilization subsequent to hospital discharge and through 2018. Negative binomial regression was used to identify factors associated with cumulative prescription opioid use. We identified 3,981 service members with combat-related injuries presenting during the study period. The median age was 24 years (interquartile range [IQR], 22-29 years), 98.5% were male, and the median follow-up was 3.3 years. During the study period, 98% (n = 3,910) of patients were prescribed opioids at least once and were prescribed opioids for a median of 29 days (IQR, 9-85 days) per patient-year of follow-up. While nearly all patients (96%; n = 3,157) discontinued use within 6 months, 91% (n = 2,882) were prescribed opioids again after initially discontinuing opioids. Following regression analysis, patients with preinjury opioid exposure, more severe injuries, blast injuries, and enlisted rank had higher cumulative opioid use. Patients who discontinued opioids within 6 months had an unadjusted median total health care cost of US $97,800 (IQR, US $42,364-237,135) compared with US $230,524 (IQR, US $134,387-370,102) among those who did not discontinue opioids within 6 months (p < 0.001). Nearly all service members injured in combat were prescribed opioids during treatment, and the vast majority experienced multiple episodes of prescription opioid use. Only 4% of the population met the criteria for sustained prescription opioid use at 6 months following discharge. Early discontinuation may not translate to long-term opioid cessation in this population. Epidemiology study, level III.

Comparison of Posttraumatic Stress Disorder Checklist Instruments From Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition vs Fifth Edition in a Large Cohort of US Military Service Members and Veterans

The definition of posttraumatic stress disorder (PTSD) changed markedly between the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and DSM-5, creating challenges for studies and in medical settings spanning this transition. To evaluate the ability to compare and assess PTSD, based on DSM-IV and DSM-5 criteria, using PTSD Checklists (PCLs). This diagnostic study was conducted with survey data collected in October 2019, from the Millennium Cohort Study, a population-based US military cohort study. The population for the present study was restricted to a subset of initial web responders of the 2019 survey cycle, randomly assigned to 1 of 4 survey groups. Each group received the DSM-IV and DSM-5 PCL (PCL-Civilian [PCL-C] version and PCL for DSM-5 [PCL-5]). PCL instruments were counterbalanced to control for order effects. Survey data were used to assess PTSD (using the PCL-C and PCL-5), major depressive disorder (using the Patient Health Questionnaire), generalized anxiety (using the Generalized Anxiety Disorder scale), and problem drinking (using the Patient Health Questionnaire). Demographic and military characteristics included age, sex, race/ethnicity, marital status, education, service branch, pay grade, enrollment panel, and military service status. Among the 1921 participants (mean [SD] age, 50.1 [12.5] years), 1358 (70.7%) were men, 1638 (85.3%) were non-Hispanic White individuals, 1440 (75.0%) were married, and 1190 (61.9%) had at least a bachelor's degree; 295 (15.4%) had probable PTSD according to DSM-IV criteria with PCL-C compared with 286 (14.9%) using DSM-5 criteria with PCL-5 (κ = 0.77). There was substantial agreement between PCLs for probable PTSD based on DSM-IV criteria (295 [15.4%] with PCL-C; 316 [16.4%] with PCL-5; κ = 0.80) and DSM-5 criteria (286 [14.9%] with PCL-5; 258 [13.4%] with PCL-C; κ = 0.77). Estimated PTSD sum scores showed excellent agreement with observed scores. Using an established crosswalk, PCL-5 sum scores estimated with the PCL-C were similar to observed PCL-5 scores. Of the 17 corresponding items between the 2 instruments, 16 had substantial agreement. Appending 2 additional PCL-C items to the PCL-5 did not significantly alter estimates. The PCL-C and PCL-5 had nearly identical associations with comorbid conditions. The findings of this diagnostic study suggest that PTSD can be successfully assessed and compared over time with either PCL instrument in veteran and military populations.

Network Analysis of Research on Mild Traumatic Brain Injury in US Military Service Members and Veterans During the Past Decade (2010-2019).

To evaluate trends in the extant literature on mild traumatic brain injury (mTBI) in military service members and veterans using network analysis based on a comprehensive search of original, peer-reviewed research articles involving human participants published between January 1, 2010, and December 31, 2019. Specifically, we employed network analysis to evaluate associations in the following areas: (1) peer-reviewed journals, (2) authors, (3) organizations/institutions, and (4) relevant key words. Included studies were published in peer-reviewed journals available on Web of Science database, using US military service members or veterans. Bibliometric network analytical review. Outcomes for each analysis included number of articles, citations, total link strength, and clusters. The top publishing journals were (1) Journal of Head Trauma and Rehabilitation, (2) Military Medicine, (3) Brain Injury, (4) Journal of Neurotrauma, and (5) Journal of Rehabilitation Research and Development. The top publishing authors were (1) French, (2) Lange, (3) Cooper, (4) Vanderploeg, and (5) Brickell. The top research institutions were (1) Defense and Veterans Brain Injury Center, (2) Uniformed Services University of the Health Sciences, (3) University of California San Diego, (4) Walter Reed National Military Medical Center, and (5) Boston University. The top co-occurring key words in this analysis were (1) posttraumatic stress disorder (PTSD), (2) persistent postconcussion symptoms (PPCS), (3) blast injury, (4) postconcussion syndrome (PCS), and (5) Alzheimer's disease. The results of this network analysis indicate a clear focus on veteran health, as well as investigations on chronic effects of mTBI. Research in civilian mTBI indicates that delaying treatment for symptoms and impairments related to mTBI may not be the most precise treatment strategy. Increasing the number of early, active, and targeted treatment trials in military personnel could translate to meaningful improvements in clinical practices for managing mTBI in this population.

Skin cancer in the US Military.

There is an increased risk for melanomas and keratinocyte cancers in those who have served on active duty in the US Military. We believe that an increased exposure to UV radiation, minimal sun-protective strategies, and a paucity of education regarding the risks of UV exposure are primarily responsible for the increased prevalence of skin cancer in this population. Although mitigating these risks is important, it cannot come at the expense of combat effectiveness and military mission readiness. This review proposes education of individual military servicemembers regarding skin cancer prevention and identification, increasing the utilization of sun-protective clothing, and promoting the increased use of sunscreen as measures to decrease the overall risk of cutaneous malignancies in US Military servicemembers.

385 External Validation of a Massive Transfusion Protocol App-Based Algorithm in Military Combat Casualties

The most common cause of preventable death in US Military Service members is hemorrhagic shock, which is managed with tourniquets, blood administration, and damage control surgery. Administration of resuscitative blood products has been done by military providers since WWII and has since become common place in civilian hospitals. In the setting of limited resources while deployed, the use of a clinical decisionmaking calculator can help mitigate and expedite the decision of activating the massive transfusion protocol (MTP). The purpose of this research was to externally validate the ability of an app-based MTP algorithm developed by Mena et al. to predict the need for a massive transfusion (MT) in a military combat casualty dataset. Using casualty data from Operation Enduring Freedom (OEF), the Mena et al. MTP algorithm calculated the predicted probability of the need to receive a MT and was evaluated by calculating the area under the receiver operating characteristic curve (AUROC), specificity, and sensitivity. The AUROC for predicting MT was 0.84 (95% CI: 0.80-0.88) with specificity of 0.96 and sensitivity of 0.25 when assuming moderate and high categories (Pr > 0.070) is positive for MT. Using OEF casualty data, the MTP algorithm correctly categorized 96.4% of non-MT casualties ‘‘very low’’ or ‘‘low’’ and 3.0% moderate and 0.7% as high probability of MT. Alternatively,24.5% of MT casualties were categorized as ‘‘high’’ or ‘‘moderate,’’ with 31.6% and 43.9%categorized as “low” or “very low” probability of MT. The algorithm showed moderate ability in predicting the need for MT in combat casualties. With a specificity of 0.96, it is particularly useful in categorizing and ruling out the need for MT. With a sensitivity of 0.25, the algorithm lacks identification of those who will need MT, categorizing 76% in “very low” and “low” probabilities who ultimately required MT. The results suggest that especially with adjustments to mechanism of injury to aid in better prediction of the need for MTP.

Long-Term Prescription Opioid Use among US Military Service Members Injured in Combat

Long-Term Prescription Opioid Use among US Military Service Members Injured in Combat

Association of Suicide Risk With Transition to Civilian Life Among US Military Service Members

Although interest is high in addressing suicide mortality after the transition from military to civilian life, little is known about the risk factors associated with this transition. To support the ongoing suicide surveillance work of the US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention, examining these factors is important for targeting suicide prevention efforts. To examine the prevalence, patterns, and associated characteristics of suicide mortality among US service members after separation from military active status. This retrospective population-based cohort study obtained demographic and military service data from the VA/Department of Defense Identity Repository. Individuals who served on active duty in the US Army, Navy, Air Force, Marine Corps, or Coast Guard after September 11, 2001, and who separated from active status between January 1, 2010, and December 31, 2017, were included in the cohort. Data analyses were conducted from September 9, 2019, to April 1, 2020. Suicide mortality within 6 years after separation from military service. A total of 1 868 970 service members (1 572 523 men [84.1%]; mean [SD] age at separation, 30.9 [9.9] years) separated from the military during the study period. Through the end of the study period (December 31, 2017), 3030 suicides (2860 men and 170 women) were identified as having occurred within 6 years of separation from the military. Statistically significant differences in suicide risk were found by demographic and military service characteristics. Suicide rates after separation were time dependent, generally peaking 6 to 12 months after separation and declining only modestly over the study period. Male service members had a statistically significantly higher hazard of suicide than their female counterparts (hazard ratio [HR], 3.13; 95% CI, 2.68-3.69). Younger individuals (aged 17-19 years; HR, 4.46 [95% CI, 3.71-5.36]) had suicide hazard rates that were approximately 4.5 times higher than those who transitioned at an older age (≥40 years). Service branch remained a risk factor for suicide even 6 years after separation; those who separated from the Marine Corps (HR, 1.55; 95% CI, 1.36-1.78) and the Army (HR, 1.48; 95% CI, 1.31-1.67) had a higher hazard than those who transitioned from the Air Force. The hazard for those who separated from the active component was higher than for those who separated from the reserve component (HR, 1.29; 95% CI, 1.18-1.42). Service members with a shorter length of service had a higher hazard (HR, 1.26; 95% CI, 1.11-1.42) than those with a longer service history. Results of this study show that not all service members who recently transitioned from military life had the same risk of suicide. The data suggest that awareness of military service and demographic characteristics can help identify those most at risk for suicide to target prevention efforts.

Mental Health of Children of Deployed and Nondeployed US Military Service Members: The Millennium Cohort Family Study.

Families experience multiple stressors as a result of military service. The purpose of this study was to investigate the associations among service member deployment experiences, family and military factors, and children's mental health using baseline data from the Millennium Cohort Family Study, a study designed to evaluate the health and mental health effects of military service on families, including children. This study examined administrative data on deployment status (combat, noncombat, and no deployments), as well as service member- and spouse-reported data on deployment experiences and family functioning in relation to the mental health of children in the family who were aged 9 to 17 years. Most children were not reported to have mental health, emotional, or behavioral difficulties regardless of parental deployment status. For an important minority of children, however, parental deployments with combat, compared with those with no deployment, were associated with a parental report of attention-deficit disorder/attention-deficit hyperactivity disorder and depression as diagnosed by a clinical provider, after accounting for demographics, psychosocial context, and military factors. Children's odds of a parental report of depression were significantly higher in both the combat and the noncombat deployment groups than in the no deployment group. These findings extend our understanding of the association between parental deployments and children's mental health, with implications for services and training mental health providers serving military families.

Posttraumatic stress disorder diagnosis is associated with reduced parasympathetic activity during sleep in US veterans and military service members of the Iraq and Afghanistan wars.

To determine whether high-frequency heart rate variability (HF-HRV) during sleep differs between those with and without posttraumatic stress disorder (PTSD) as a function of sleep type (non-rapid eye movement [NREM] vs. rapid eye movement [REM]), and to explore this relationship across successive sleep cycles. Participants with PTSD were hypothesized to have lower HF-HRV across both REM and NREM sleep. Sixty-two post-9/11 military veterans and service members completed self-report measures of sleep quality, insomnia severity, and disruptive nocturnal behaviors. Participants then completed a laboratory-based polysomnographic study night with concurrent HRV assessment. Participants with PTSD (N = 29) had lower HF-HRV in overall NREM sleep relative to those without PTSD (N = 33) (F(1, 54) = 4.24, p = .04). Groups did not differ on overall HF-HRV during REM sleep. HF-HRV increased over the night for the sample as a whole during both NREM and REM sleep. PTSD status did not moderate the association between HF-HRV and sleep cycles. However, the PTSD group had lower HF-HRV in the first t(155) = 2.67, p = .008, and fourth NREM cycles, t(155) = 2.11, p = .036, relative to participants without PTSD. Findings suggest blunted parasympathetic modulation during NREM sleep in a young cohort of military veterans and service-members with PTSD. Findings are concerning considering the increased risk of incident cardiovascular events associated with impaired parasympathetic nervous system function. Reduced parasympathetic modulation may be one mechanism underlying the increased prevalence of cardiovascular disease (CVD) among veterans with PTSD.

Collaborative Care for Depression and Posttraumatic Stress Disorder: Evaluation of Collaborative Care Fidelity on Symptom Trajectories and Outcomes.

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. 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). 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. A total of 666 US Military Service members screening positive for probable PTSD or depression through primary care. 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. 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. 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. Clinicaltrials.gov Identifier NCT01492348.

Symptom Reporting Patterns of US Military Service Members with a History of Concussion According to Duty Status.

To compare symptom reporting patterns of service members with a history of concussion based on work status: full duty, limited duty, or in the Medical Evaluation Board (MEB)/disability process. Retrospective analysis of 181 service members with a history of concussion (MEB n = 56; limited duty n = 62; full duty n = 63). Neurobehavioral Symptom Inventory (NSI) Validity-10 cutoff (>22) and Mild Brain Injury Atypical Symptoms Scale (mBIAS) cutoffs (≥10 and ≥8) were used to evaluate potential over-reporting of symptoms. The MEB group displayed significantly higher NSI scores and significantly higher proportion scored above the mBIAS ≥10 cutoff (MEB = 15%; limited duty = 3%; full duty = 5%). Validity-10 cutoff did not distinguish between groups. MEB but not limited duty status was associated with increased risk of over-reporting symptoms in service members with a history of concussion. Results support the use of screening measures for over-reporting in the MEB/disability samples.

Childhood adverse life events, disordered eating, and body mass index in US Military service members.

US service members appear to be at high-risk for disordered eating. Further, the military is experiencing unprecedented prevalence of overweight and obesity. US service members also report a high prevalence of childhood adverse life event (ALE) exposure. Despite consistent links between early adversity with eating disorders and obesity, there is a dearth of research examining the association between ALE exposure and disordered eating and weight in military personnel. An online survey study was conducted in active duty personnel to examine childhood ALE history using the Life Stressor Checklist - Revised, disordered eating using the Eating Disorder Examination - Questionnaire total score, and self-reported body mass index (BMI, kg/m2 ). Among 179 respondents, multiple indices of childhood ALE were positively associated with disordered eating. Traumatic childhood ALE and subjective impact of childhood ALE were associated with higher BMI and these associations were mediated by disordered eating. Findings support evaluating childhood ALE exposure among service members with disordered eating and weight concerns. Moreover, findings support the need for prospective research to elucidate these relationships.