Lifetime Traumatic Brain Injury and Risk of Post-Concussive Symptoms in the Millennium Cohort Study

Traumatic brain injury (TBI) is prevalent among active duty military service members, with studies reporting up to 23% experiencing at least one TBI, with 10-60% of service members reporting at least one subsequent repeat TBI. A TBI has been associated with an increased risk of cumulative effects and long-term neurobehavioral symptoms, impacting operational readiness in the short-term and overall health in the long term. The association between multiple TBI and post-concussive symptoms (PCS), however, defined as symptoms that follow a concussion or TBI, in the military has not been adequately examined. Previous studies in military populations are limited by methodological issues including small sample sizes, the use of non-probability sampling, or failure to include the total number of TBI. To overcome these limitations, we examined the association between the total lifetime number of TBI and total number of PCS among U.S. active duty military service members who participated in the Millennium Cohort Study. A secondary data analysis was conducted using the Millennium Cohort Study's 2014 survey (n = 28,263) responses on self-reported TBI and PCS (e.g., fatigue, restlessness, sleep disturbances, poor concentration, or memory loss). Zero-inflated negative binomial models calculated prevalence ratios (PRs) and 95% confidence intervals (CIs) for the unadjusted and adjusted associations between lifetime TBIs and PCS. A third of military participants reported experiencing one or more TBIs during their lifetime with 72% reporting at least one PCS. As the mean number of PCS increased, mean lifetime TBIs increased. The mean number of PCS by those with four or more TBI (4.63) was more than twice that of those with no lifetime TBI (2.28). One, two, three, and four or more TBI had 1.10 (95% CI: 1.06-1.15), 1.19 (95% CI: 1.14-1.25), 1.23 (95% CI: 1.17-1.30), and 1.30 times (95% CI: 1.24-1.37) higher prevalence of PCS, respectively. The prevalence of PCS was 2.4 (95% CI: 2.32-2.48) times higher in those with post-traumatic stress disorder than their counterparts. Active duty military service members with a history of TBI are more likely to have PCS than those with no history of TBI. These results suggest an elevated prevalence of PCS as the number of TBI increased. This highlights the need for robust, longitudinal studies that can establish a temporal relationship between repetitive TBI and incidence of PCS. These findings have practical relevance for designing both workplace safety prevention measures and treatment options regarding the effect on and from TBI among military personnel.

Alcohol motivations associated with frequency of alcohol use, binge drinking, and alcohol problems among active duty junior enlisted soldiers and non-commissioned officers

Problematic alcohol use is a serious threat to the behavioral health of active-duty Service Members (ADSM), resulting in numerous calls from governmental agencies to better understand mechanistic factors contributing to alcohol misuse within the military. Alcohol use motives are reliable predictors of alcohol-related behaviors and are considered malleable targets for prevention and intervention efforts. However, empirical research indicates that drinking motives vary across contextually distinct populations. Although some research has been conducted among veteran and reservist populations, limited work has been specifically focused on ADSM and no research has evaluated motives and alcohol metrics among ADSM based on military rank. Participants for the current study included 682 ADSM recruited from a large military installation in the U.S. Structural equation modeling evaluated associations between four drinking motives (i.e., enhancement, social, conformity, coping) and three alcohol misuse metrics (i.e., alcohol frequency, binge frequency, alcohol problems). Three models were evaluated: one full (combined) model and two separate models based on military rank - junior enlisted (i.e., E1-E4) and non-commissioned officers (NCOs) (i.e., E5-E9). Results for junior enlisted ADSM indicated that coping and enhancement motives were most strongly associated with all alcohol misuse metrics. However, among NCOs, results indicated that alcohol problems were only associated with coping motives. Notably, results also indicated that alcohol use motives accounted for substantively more variance across all alcohol-related metrics among NCOs. Findings generally support extant military-related literature indicating use of alcohol for coping (e.g., with anxiety) as the motivation most consistently associated with increased alcohol misuse. However, novel findings highlight enhancement motives - using alcohol to attain some positive internal reward - as another, often stronger, motivation impacting alcohol use outcomes. Further, findings highlight notable distinctions between alcohol use motives (i.e., coping vs. enhancement) and the impact of alcohol use motives (i.e., effect size) on alcohol metrics between junior enlisted and NCOs.

Cumulative Blast Exposure During a Military Career Negatively Impacts Recovery from Traumatic Brain Injury

Sub-concussive injuries have emerged as an important factor in the long-term brain health of athletes and military personnel. The objective of this study was to explore the relationship between service member and veterans (SMVs) lifetime blast exposure and recovery from a traumatic brain injury (TBI). A total of 558 SMVs with a history of TBI were examined. Lifetime blast exposure (LBE) was based on self-report (M = 79.4, standard deviation = 392.6; range = 0-7500) categorized into three groups: Blast Naive (n = 121), Low LBE (n = 223; LBE range 1-9), and High LBE (n = 214; LBE >10). Dependent variables were the Neurobehavioral Symptom Inventory (NSI) and Post-traumatic Stress Disorder Checklist-Civilian (PCL-C) and the Traumatic Brain Injury Quality of Life (TBI-QOL). Analyses controlled for demographic factors (age, gender, and race) as well as TBI factors (months since index TBI, index TBI severity, and total number lifetime TBIs). The Blast Naive group had significantly lower NSI and PCL-C scores compared with the Low LBE group and High LBE group, with small to medium effect sizes. On the TBI-QOL, the Blast Naïve group had better quality life on 10 of the 14 scales examined. The Low LBE did not differ from the High LBE group on the PCL-C, NSI, or TBI-QOL. Blast exposure over an SMV's career was associated with increased neurobehavioral and post-traumatic stress symptoms following a TBI. The influence of psychological trauma associated with blasts may be an important factor influencing symptoms as well as the accuracy of self-reported estimates of LBE.

Qualitative Analysis of Bystander Intervention Among Young Adult Male Soldiers Who Engage in At-Risk Drinking

Bystander intervention-when someone intervenes to help in situations that pose a risk for harm-is a promising strategy for sexual violence prevention. In the current study, a sample of U.S. Army male soldiers (N = 10; ages 18-24) who engaged in at-risk drinking completed a 90-min individual semi-structured interview to understand the ways in which soldiers intervene to address risk for sexual violence. Two independent raters coded soldier responses using thematic analysis and identified eight main themes: (a) recognizing risk for sexual violence; (b) labeling situations as problematic and taking responsibility; (c) facilitators of intervention; (d) barriers to intervention; (e) intervention strategies; (f) reactions and consequences to intervention; (g) alcohol's influence on intervention; and (h) using bystander intervention to shift cultural norms. As soldiers reported noticing more extreme risks for violence, prevention interventions may help service members identify situations earlier in the continuum of harm. Soldiers anticipated intervening in a way that was physical and aggressive, which could facilitate physical altercation and result in collateral misconduct. Results from the present study reveal ways that bystander intervention programs for civilians can be tailored to address the unique individual, situational, and contextual factors relevant to the military. These findings also highlight the importance of teaching soldiers indirect and nonaggressive strategies for intervention.

Cross validation of the Personality Assessment Inventory (PAI) Cognitive Bias Scale of Scales (CB-SOS) over-reporting indicators in a military sample

Following the development of the Cognitive Bias Scale (CBS), three other cognitive over-reporting indicators were created. This study cross-validates these new Cognitive Bias Scale of Scales (CB-SOS) measurements in a military sample and contrasts their performance to the CBS. We analyzed data from 288 active-duty soldiers who underwent neuropsychological evaluation. Groups were established based on performance validity testing (PVT) failure. Medium effects (d = .71 to .74) were observed between those passing and failing PVTs. The CB-SOS scales have high specificity (≥.90) but low sensitivity across the suggested cut scores. While all CB-SOS were able to achieve .90, lower scores were typically needed. CBS demonstrated incremental validity beyond CB-SOS-1 and CB-SOS-3; only CB-SOS-2 was incremental beyond CBS. In a military sample, the CB-SOS scales have more limited sensitivity than in its original validation, indicating an area of limited utility despite easier calculation. The CBS performs comparably, if not better, than CB-SOS scales. CB-SOS-2's differences in performance in this study and its initial validation suggest that its psychometric properties may be sample dependent. Given their ease of calculation and relatively high specificity, our study supports the interpretation of elevated CB-SOS scores indicating those who are likely to fail concurrent PVTs.

Developing a mental toughness program for basic military training

To build a warfighter from the ground up, training should include not only the core competencies required for job performance in the Fleet but also the mental toughness expected to handle the stress, fatigue, and call for sudden action required of all sailors on duty, regardless of occupation. Recruit Training Command (RTC) has embarked on a program to provide explicit training to recruits on the development of toughness in boot camp. This program is multifaceted, including three pilot programs (two all-male pilots, one integrated/mixed gender pilot) for mental skill training. Recruit divisions were assigned to either mental toughness (MT) condition or active control (AC). The MT group received daily, 10-min guided mindfulness exercises, three "just-in-time" trainings in sports psychology skills, and an on-command focusing exercise. Results varied across the three pilots with the exception of on-time graduation rates, which favored the MT condition in every pilot. Taken together, the three MT pilot studies show possible benefits for performance during boot camp with MT practice, and predictable advantages for graduation rates.

Prospective association of attachment style with suicide attempts among US Army soldiers

BACKGROUND

Insecure attachment styles are associated with retrospectively reported suicide attempts (SAs). It is not known if attachment styles are prospectively associated with medically documented SAs.

METHODS

A representative sample of US Army soldiers entering service (n = 21 772) was surveyed and followed via administrative records for their first 48 months of service. Attachment style (secure, preoccupied, fearful, dismissing) was assessed at baseline. Administrative medical records identified SAs. Discrete-time survival analysis examined associations of attachment style with future SA during service, adjusting for time in service, socio-demographics, service-related variables, and mental health diagnosis (MH-Dx). We examined whether associations of attachment style with SA differed based on sex and MH-Dx.

RESULTS

In total, 253 respondents attempted suicide. Endorsed attachment styles included secure (46.8%), preoccupied (9.1%), fearful (15.7%), and dismissing (19.2%). Examined separately, insecure attachment styles were associated with increased odds of SA: preoccupied [OR 2.5 (95% CI 1.7-3.4)], fearful [OR 1.6 (95% CI 1.1-2.3)], dismissing [OR 1.8 (95% CI 1.3-2.6)]. Examining attachment styles simultaneously along with other covariates, preoccupied [OR 1.9 (95% CI 1.4-2.7)] and dismissing [OR 1.7 (95% CI 1.2-2.4)] remained significant. The dismissing attachment and MH-Dx interaction was significant. In stratified analyses, dismissing attachment was associated with SA only among soldiers without MH-Dx. Other interactions were non-significant. Soldiers endorsing any insecure attachment style had elevated SA risk across the first 48 months in service, particularly during the first 12 months.

CONCLUSIONS

Insecure attachment styles, particularly preoccupied and dismissing, are associated with increased future SA risk among soldiers. Elevated risk is most substantial during first year of service but persists through the first 48 months. Dismissing attachment may indicate risk specifically among soldiers not identified by the mental healthcare system.

Maximal Aerobic Capacity as a Predictor of Performance on ACFT Total Score of ROTC Cadets

The Army Combat Fitness Test (ACFT) is a newly developed test that assesses the combat readiness of U.S. Army soldiers. The purpose of this cross-sectional study is to determine if VO2max can predict performance outcomes of the ACFT in ROTC cadets. This understanding can provide a better understanding of the aerobic demands of the ACFT. Cadets (50 males, 14 females; aged 21.43 ± 4.10 years) completed the 6-event ACFT (maximum trap-bar deadlift [MDL], standing power throw [SPT], hand-release pushups [HRPU], sprint-drag-carry shuttle run [SDC], plank [PLK], and 2-mile run [2MR]). The cadets conducted a maximal treadmill running test following the Bruce protocol. The ability of VO2max (mL·kg-1·min-1) to predict ACFT performance was determined with a linear regression model. Significance was set at p < 0.05. VO2max was significantly and positively correlated to MDL (r = .253, p = .044), HRPU (r = .486, p < .001), SDC (r = .495, p < .001), PLK (r = .628, p < .001) 2MR (r = .612, p < .001) and overall ACFT score (r = .619, p < .001) but not SPT (r = .203, p = .108). VO2max significantly explained 38% (p < .001) of the variance on the total ACFT scores with a beta coefficient of 4.338. There is a gap in understanding how VO2max impacts performance in the newly implemented ACFT. For every 1 mL·kg-1·min-1 increase in VO2max, ACFT total scores increased by 4 points. These findings support the need for further research due to the trends of U.S. Army personnel failing the 2MR, which can be associated with an insufficient aerobic capacity.

From trenches to technology: a narrative review of sleep medicine in the military

Diagnoses of military-relevant sleep disorders have increased substantially since the terrorist attacks of 9-11. The cause of this increase appears to be complicated and multifactorial, with military and civilian populations clearly differing with respect to both the nature and distribution of sleep disorders diagnoses. In part, these differences may be attributable to the fact that a majority of service members (SMs) are chronically sleep restricted - an unavoidable consequence of continuous and sustained military operations that 'set the stage' for development of specific sleep disorders. The purpose of this narrative review is to describe the military relevance of several common sleep disorders, assess the extent to which these disorders currently constitute a burden on the military healthcare system, and suggest strategies to alleviate that burden. The military healthcare system does not have enough sleep providers to address the immediate and long-term consequences of sleep disorders in military personnel. Digital technologies and education packages can be leveraged to improve access to care.

The Tägerwilen II report: Recommendations from the NATO Prehospital Care Improvement Initiative Task Force

BACKGROUND

The Committee of the Chiefs of Military Medical Services (COMEDS) initiated the Prehospital Care Improvement Initiative Task Force (PHCII TF) to advise on how to improve prehospital care within NATO nations. The Task Force consisted of the NATO Military Health Care Working Group and its subordinated expert panels, including the Blood Panel, the Emergency Medicine Panel and the Special Operations Forces Medicine Panel.

METHOD

The PHCII TF identified four key prehospital care themes for exploration: 1) Tactical Casualty Care, 2) Blood Far Forward), 3) Forward Surgical Capabilities), and 4) Prolonged Casualty Care. A consensus experimentation workshop explored the four themes, utilizing a modified Delphi technique and Utstein rotations during syndicate work, resulting in 83 consensus statements. The consensus statements were further evaluated on six criteria: actionable, measurable, urgent, interoperability, low risk/threat and impact.

RESULTS

The 83 consensus statements, when weighted against the six criteria, resulted in 15 recommendations, focusing on standardization of training, ensuring provision of evidence-based practices and removing legislative barriers to improve prehospital care.

CONCLUSION

The recommendations on these four themes reflect the most significant priorities in improving prehospital care, and must be incorporated in the on-going revision of NATO doctrine.

Racial and ethnic differences in the association between mild traumatic brain injury and work duty limitations in the US military

OBJECTIVE

This study examined racial and ethnic differences in the association between mild traumatic brain injury (mTBI) and work duty limitations in active-duty service members (ADSMs).

METHODS

This study used retrospective and cross-sectional data from the 2019-2021 Military Health System Data Repository on 910,700 ADSMs who were 18-64 years old and were grouped into racial and ethnic categories of White, non-Hispanic; Black, non-Hispanic; Hispanic/Latino; and Asian or Pacific Islander, non-Hispanic.

RESULTS

Descriptive statistics showed that Black, Hispanic/Latino, and Asian or Pacific Islander patients had a lower proportion of having a diagnosis of mTBI compared to White patients (ps < 0.001). Further, the proportion of history of deployment varied by racial and ethnic group and deployment location. Multivariate logistic regression results showed odds of 1.52 (p < 0.001) for White patients with mTBI, odds of 1.61 (p < 0.001) for Black patients with mTBI, odds of 1.57 (p < 0.001) for Hispanic/Latino patients with mTBI, and odds of 1.99 (p < 0.001) for Asian or Pacific Islander patients with mTBI for being placed on work duty limitations.

DISCUSSION

These results advance our understanding of the work duty limitations for racial/ethnic minority patients with mTBI in the Military Health System.

Transformational leadership, well-being, morale, and readiness: The mediating role of empowerment

Transformational leadership is embedded in the value system of the Canadian military ethos. Research suggests that transformational leadership can be viewed as a form of empowering leadership facilitating empowered psychological states among their followers, which in turn, enhances their performance, wellbeing, and engagement. The current study examined the associations between transformational leadership and Canadian Armed Forces members' psychological distress, morale, and pre-deployment readiness and the mediating role of psychological empowerment in these relationships. A path analysis model of the data collected through a pre-deployment survey completed by Canadian Armed Force (CAF) members (N = 2,391) revealed that transformational leadership was associated with lower psychological distress and greater morale and these relationships were partly explained by increased feelings of empowerment, namely higher levels of autonomy, competence, and meaning. Furthermore, transformational leadership was also associated with higher perceptions of pre-deployment readiness, and this was partly explained by increased feelings of meaning and competence. The results of this research suggest that transformational leadership is an effective strategy to bolster psychological resources and readiness in the CAF.

Project Safe Guard: Challenges and opportunities of a universal rollout of peer-delivered lethal means safety counseling at a US military installation

INTRODUCTION

The US Department of Defense recommends lethal means safety counseling (LMSC) to promote firearm injury prevention via secure storage of personal firearms. We describe the rollout of a universal, peer-delivered adaptation of Project Safe Guard (PSG)-a brief, single-session LMSC discussion-at a US Space Force installation.

METHOD

Program evaluation data were collected via anonymous, voluntary, and online surveys. Of approximately 862 eligible active-duty service members and embedded civilians, 324 completed the preprogram survey and 68 and 37 completed the 1- and 2-month follow-ups, respectively.

RESULTS

At preprogram, 69.1% agreed that peer-delivered LMSC is appropriate. After rollout, 100% of the 222 firearm locking devices available to service members were requested from the on-base Violence Prevention Integrator. The effectiveness of PSG was indeterminable due to the low survey response rates.

CONCLUSIONS

Despite strong preprogram support for peer-delivered LMSC and behavioral indicators of secure firearm storage (e.g., firearm locking device requests), several challenges limited the uptake and evaluability of the PSG program in this naturalistic environment, including military survey fatigue and competing mission priorities. Additional work is needed to determine the effectiveness of peer-delivered LMSC in a military context. Sustained base support and military-civilian collaborations will be critical.

The MedXFit-study - CrossFit as a workplace health intervention: a one-year, prospective, controlled, longitudinal, intervention study

Introduction

Workplace health interventions aim to motivate employees toward healthy behaviors to improve fitness and health in the long-term. We investigated whether CrossFit® is an effective training concept to achieve these goals in inactive employees with sedentary occupations.

Methods

The study followed a prospective, controlled intervention design. Employees were invited to participate in intervention group (IG) or control group (CG) on their own preferences. Inclusion criteria were a predominantly sedentary occupation and execution of less than two muscle and/or mobility enhancing training sessions per week at the time of enrolling. The IG did at least two times a week a CrossFit training of 1 h. Mobility, strength, well-being, and back-issues were measured at the beginning, after 6, and 12 months. Participants in the CG were free to choose any other activities offered at the same time (e.g., circuit training, meditation, full body stability training). Adherence, respectively, behavioral change and maintenance qualities were evaluated based on the COM-B system and presence of behavior maintenance motives.

Results

89 employees were enrolled into the trial, from where 21 dropped out due to external factors (24%). From the remaining participants, 10 out of 39 (26%) in the IG and 1 out of 29 (4%) in the CG stopped for intrinsic reasons, leading to a non-adherence to the intervention of 22 percentage points. Motivation for behavioral change and maintenance in the IG was primarily driven by enhanced physical and psychological capability. Development of physical capability was evident by significant improvements (p < 0.001) in the IG compared to the CG for mobility (d = 3.3), maximal isometric strength (min. d = 1.7, max. d = 2.5), as well as reduction in pain intensity (p = 0.003, r = 0.4) and frequency (p = 0.009, r = 0.35) after 12 months. Significant improvements between the 6-month and the 12-month measurement in mobility and 6 out of 8 strength measures within the IG indicated the effectiveness of CrossFit beyond the beginner phase.

Conclusion

CrossFit is a motivating training concept that led to long-term health and fitness improvements in inactive employees doing sedentary work and should be given greater consideration in workplace health promotion.

Incidence and health care burden of uterine fibroids among female service members in the active component of the U.S. Armed Forces, 2011-2022

Uterine fibroids are the most common benign tumors of the uterus among women of reproductive age, disproportionally affecting non-Hispanic Black women compared to other races and ethnicities. This report is an update of a 2011 MSMR report that examined uterine fibroids among female active component service members in the U.S. Armed Forces from 2001 to 2010. Incident uterine fibroids were identified for this report from inpatient and outpatient medical encounter data from 2011 to 2022. Health care burden was estimated utilizing uterine fibroid-related inpatient and outpatient diagnostic and procedure codes. Crude incidence rates and incidence rate ratios were calculated to compare rate differences between subpopulations. A total of 16,046 new uterine fibroid cases were identified, with an incidence rate of 63.5 cases per 10,000 person-years (95% confidence interval: 62.5-64.5). The highest incidence rates were observed among service women 40 years and older, non-Hispanic Black women, and those who served in the Army. Health care burden analysis showed that, even with increases in medical encounters and individuals affected, the numbers of hospital bed days declined over time. The decline in uterine fibroid-related hospital bed days could be attributed to early diagnoses and minimally-invasive treatments. Continued promotion of uterine fibroid awareness can potentially help further reduce uterine fibroid-related impacts on military readiness.

A summary of the U.S. Marine Recruit Assessment Program (RAP) procedures and survey from 2003 to 2021

The Recruit Assessment Program (RAP) is a cross-sectional, baseline survey of U.S. Marine recruits administered at Marine Corps Recruit Depot, San Diego. This report presents RAP study procedures and survey content that was administered to 229,015 participants between 2003 and 2021. Self-reported data were collected on recruit demographics, physical and mental health, adverse life experiences, lifestyle and risky behaviors, and substance use. In 2013, the survey was updated to remove questions with other linkable and reliable sources and those with low completion rates and low relevance to Marine health research; the removal of these items allowed for the addition of instrument measures for major depression, post-traumatic stress disorder, anger, and resilience with no significant change to overall survey length. Average completion rates are approximately 95%. Multiple studies have shown the utility of RAP data collected thus far as a robust data repository of pre-service health and behavioral measures.

Gender Differences in Psychological Outcomes Following Surf versus Hike Therapy among U.S. Service Members

BACKGROUND

Surf and hike therapies have demonstrated effectiveness as adjunct interventions for service members with major depressive disorder (MDD). This study explores gender differences in intervention outcomes following a pragmatic, randomized controlled trial of Surf and Hike Therapy for service members with MDD (N = 96; men, n = 46; women, n = 50).

METHODS

Clinician-administered and self-report measures (depression, anxiety, positive affect, negative affect, resilience, and pain) were completed at preprogram, postprogram, and 3-month follow-up; brief measures (depression/anxiety and positive affect) were completed before and after each session.

RESULTS

Multilevel modeling results showed that anxiety decreased from pre- to postprogram and significantly differed by gender (B = -2.26, p = 0.029), with women reporting greater reductions. The remaining outcomes from pre- to postprogram demonstrated significant improvements that did not differ by gender (ps = 0.218-0.733). There were no gender differences through follow-up (ps = 0.119-0.780). However, within sessions, women reported greater improvements in depression/anxiety (B = -0.93, p = 0.005) and positive affect (B = 3.73, p = 0.001). The change in positive affect scores within sessions was greater for women in Hike Therapy compared to men (p = 0.016).

CONCLUSIONS

Overall, results demonstrate that both genders benefit from adjunctive Surf and Hike Therapies, but women exhibit a better response in terms of longer-term anxiety and immediate psychological outcomes.

Blood consumption in the Role 2 setting: A Department of Defense Trauma Registry analysis

BACKGROUND

The Role 2 setting represents the most far-forward military treatment facility with limited surgical and holding capabilities. There are limited data to guide recommendations on blood product utilization at the Role 2. We describe the consumption of blood products in this setting.

STUDY DESIGN AND METHODS

We analyzed data from 2007 to 2023 from the Department of Defense Trauma Registry (DODTR) that received care at a Role 2. We used descriptive and inferential statistics to characterize the volumes of blood products consumed in this setting. We also performed a secondary analysis of US military, Coalition, and US contractor personnel.

RESULTS

Within our initial cohort analysis of 15,581 encounters, 17% (2636) received at least one unit of PRBCs or whole blood, of which 11% received a submassive transfusion, 4% received a massive transfusion, and 1% received a supermassive transfusion. There were 6402 encounters that met inclusion for our secondary analysis. With this group, 5% received a submassive transfusion, 2% received a massive transfusion, and 1% received a supermassive transfusion.

CONCLUSIONS

We described volumes of blood products consumed at the Role 2 during recent conflicts. The maximum number of units consumed among survivors exceeds currently recommended available blood supply. Our findings suggest that rapid resupply and cold-stored chain demands may be higher than anticipated in future conflicts.

Military affected by the first wave of COVID-19 in Senegal: stress and resilience factors during care

COVID-19 had a psychological impact on the population, particularly those affected. Our objective was to investigate stress and resilience factors in the Senegalese soldiers affected during the first wave of COVID-19. Our retrospective and qualitative study included military personnel listed as contacts, suspects, or positive cases and supported by the Armed Forces Psychological Support Program during the period of isolation. The stress factors were health-related, sociological, and occupational. The conditions and the experience of isolation, stigmatization, and suspension of their professional projects were concerns for the soldiers. They had relied on personal, familial, and professional resources to cultivate resilience during the quarantine. Isolation during the pandemic showed psychological consequences, the foundations of which have been found in our study.

Longitudinal effects of military separation and mental health symptomatology on substance use among a cohort of reservists

OBJECTIVE

The relationship between mental health and substance use among military populations is well-established, and evidence suggests these risks may be greater for those who have left the military. However, it is less clear what independent effects leaving the military may have on substance use behaviors. This study examined the longitudinal relationship between leaving the military and substance use outcomes (hazardous drinking, frequent heavy drinking, non-medical use of prescription drugs, illicit drug use) in a cohort of Reserve and National Guard (R/NG) soldiers. Further, we examined whether mental health symptoms moderate the relationship between leaving the military and substance use.

METHOD

Analyses used data (N=485 soldiers) from the first four annual waves of Operation: SAFETY, an ongoing prospective cohort study of US Army R/NG soldiers and their spouses. We used generalized estimating equations (GEE) to examine the relationships between military status (former vs. current soldier) and substance use outcomes over four years. Lastly, we examined interactions between military status and mental health indicators (anxiety, anger, depression, and PTSD) on substance use over time.

RESULTS

After controlling for sex, age, race, years of military service, sleep problems, bodily pain, and substance use norms, being a former soldier, compared to a current soldier, was associated with greater odds of current illicit drug use (AOR: 2.86; 95% CI: 1.47, 5.57; p<.01). Mental health symptomatology did not moderate the relationship between leaving the military and current drug use.

CONCLUSIONS

Leaving the military in and of itself may result in increased drug use for some individuals, regardless of mental health symptomatology.

Clinical Gaps-in-Noise Measures in Blast-Exposed Veterans: Associations with Electrophysiological and Behavioral Responses

It has been established that blast exposure and brain injury can result in self-reported and measured auditory processing deficits in individuals with normal or near-normal hearing sensitivity. However, the impaired sensory and/or cognitive mechanisms underlying these auditory difficulties are largely unknown. This work used a combination of behavioral and electrophysiological measures to explore how neural stimulus discrimination and processing speed contribute to impaired temporal processing in blast-exposed Veterans measured using the behavioral Gaps-in-Noise (GIN) Test. Results confirm previous findings that blast exposure can impact performance on the GIN and effect neural auditory discrimination, as measured using the P3 auditory event-related potential. Furthermore, analyses revealed correlations between GIN thresholds, P3 responses, and a measure of behavioral reaction time. Overall, this work illustrates that behavioral responses to the GIN are dependent on both auditory-specific bottom-up processing beginning with the neural activation of the cochlea and auditory brainstem as well as contributions from complex neural networks involved in processing speed and task-dependent target detection.

Brief video training for suicide prevention in veterans: A randomized controlled trial of VA S.A.V.E

INTRODUCTION

VA S.A.V.E. (Signs; Ask; Validate; Encourage/Expedite) is a gatekeeper training developed by the Department of Veterans Affairs (VA) that teaches individuals to identify and assist veterans at risk for suicide. Although VA S.A.V.E. has been widely disseminated, rigorous evaluation is lacking.

METHODS

In a pilot randomized controlled trial of a brief, video-based version of VA S.A.V.E., individuals were recruited through Facebook, randomized to VA S.A.V.E. versus an attention control condition, and completed 6-month follow-up. A subgroup (n = 15) completed interviews. We used a mixed methods framework to integrate quantitative and qualitative findings.

RESULTS

Among 214 participants, 61% were spouses/partners of veterans and 77% had prior suicide exposure. Sixty-seven percent (n = 68) of VA S.A.V.E. participants watched the entire video, and satisfaction and usability were highly rated. At 6-month follow-up, compared to the control group, the VA S.A.V.E. group had a higher proportion of participants use each gatekeeper behavior (66.7%-84.9% vs. 44.4%-77.1%), and used significantly more total gatekeeper behaviors (2.3 ± 0.9 vs. 1.8 ± 1.0; p = 0.01). Interviews supported positive reactions, learning, and behavior change from VA S.A.V.E.

CONCLUSION

VA S.A.V.E. merits further investigation into its effectiveness as a brief, scalable gatekeeper training for suicide prevention in veterans.

Longitudinal associations between insomnia, cannabis use and stress among US veterans

Insomnia is highly prevalent among military veterans, with rates nearly double that of civilian populations. Insomnia typically co-occurs with other psychological problems, including substance use (e.g. cannabis) and perceived stress. Much of the research focused on insomnia, stress and cannabis use explores cannabis as a sleep aid and a mechanism for stress relief. However, recent theoretical and empirical evidence suggests a dynamic interplay between insomnia, cannabis use and perceived stress, yet few longitudinal studies exist. Using a sample of 1105 post-9/11 veterans assessed over four time points across 12 months, we used latent difference score modelling to examine proportional change between insomnia, perceived stress and cannabis use. Results revealed a complex interplay between all three constructs. In particular, we show that higher prior levels of insomnia are associated with greater increases in perceived stress, and greater prior levels of stress are associated with greater increases in cannabis use. Perhaps more importantly, our results also point to cannabis use as a catalyst for greater increases in both stress and insomnia severity. Our results suggest there may be both benefits and costs of cannabis use among veterans. Specifically, for veterans who experience chronic sleep problems, perceived stress may become overwhelming, and the benefit of stress reduction from increased cannabis use may come at the cost of increasing insomnia symptomology.

Prevalence of Sexual Violence and Intimate Partner Violence Among US Military Veterans: Findings from Surveys with Two National Samples

BACKGROUND

Sexual violence (SV) and intimate partner violence (IPV) experiences are major social determinants of adverse health. There is limited prevalence data on these experiences for veterans, particularly across sociodemographic groups.

OBJECTIVE

To estimate the prevalence of SV before, during, and after military service and lifetime and past-year IPV for women and men, and explore differences across sociodemographic groups.

DESIGN

Data are from two national cross-sectional surveys conducted in 2020. Weighted prevalence estimates of SV and IPV experiences were computed, and weighted logistic regression models were used for comparisons across gender, race, ethnicity, sexual orientation, and age.

PARTICIPANTS

Study 1 included veterans of all service eras (N = 1187; 50.0% women; 29% response rate). Study 2 included recently separated post-9/11 veterans (N = 1494; 55.2% women; 19.4% response rate).

MAIN MEASURES

SV was assessed with the Deployment Risk and Resilience Inventory-2 (DRRI-2). IPV was assessed with the extended Hurt-Insult-Threaten-Scream Tool.

KEY RESULTS

Women were more likely than men to experience pre-military SV (study 1: 39.9% vs. 8.7%, OR = 6.96, CIs: 4.71-10.28; study 2: 36.2% vs. 8.6%, OR = 6.04, CIs: 4.18-8.71), sexual harassment and/or assault during military service (study 1: 55.0% vs. 16.8%, OR = 6.30, CIs: 4.57-8.58; study 2: 52.9% vs. 26.9%, OR = 3.08, CIs: 2.38-3.98), and post-military SV (study 1: 12.4% vs. 0.9%, OR = 15.49, CIs: 6.42-36.97; study 2: 7.5% vs. 1.5%, OR = 5.20, CIs: 2.26-11.99). Women were more likely than men to experience lifetime IPV (study 1: 45.7% vs. 37.1%, OR = 1.38, CIs: 1.04-1.82; study 2: 45.4% and 34.8%, OR = 1.60, CIs: 1.25-2.04) but not past-year IPV (study 1: 27.9% vs. 28.3%, OR = 0.95, CIs: 0.70-1.28; study 2: 33.1% vs. 28.5%, OR = 1.24, CIs: 0.95-1.61). When controlling for gender, there were few differences across other sociodemographic groups, with the exception of sexual orientation.

CONCLUSIONS

Understanding veterans' experiences of SV and IPV can inform identification and intervention efforts, especially for women and sexual minorities.

Healthcare utilization and readiness outcomes among soldiers with post-deployment at-risk drinking, by multimorbidity class

Although alcohol use disorder (AUD) regularly co-occurs with other conditions, there has not been investigation of specific multimorbidity classes among military members with at-risk alcohol use. We used latent class analysis (LCA) to cluster 138,929 soldiers with post-deployment at-risk drinking based on their co-occurring psychological and physical health conditions and indicators of alcohol severity. We examined the association of these multimorbidity classes with healthcare utilization and military readiness outcomes. Latent class analysis was conducted on 31 dichotomous indicators capturing alcohol use severity, mental health screens, psychological and physical health diagnoses, and tobacco use. Longitudinal survival analysis was used to examine the relative hazards of class membership regarding healthcare utilization (e.g., emergency department visit, inpatient stay) and readiness outcomes (e.g., early separation for misconduct). Latent class analysis identified five classes: Class 1 -Relatively Healthy (51.6 %); Class 2 - Pain/Tobacco (17.3 %); Class 3 - Heavy Drinking/Pain/Tobacco (13.1 %); Class 4 - Mental Health/Pain/Tobacco (12.7 %); and Class 5 - Heavy Drinking/Mental Health/Pain/Tobacco (5.4 %). Musculoskeletal pain and tobacco use were prevalent in all classes, though highest in Classes 2, 4, and 5. Classes 4 and 5 had the highest hazards of all outcomes. Class 5 generally exhibited slightly higher hazards of all outcomes than Class 4, demonstrating the exacerbation of risk among those with heavy drinking/AUD in combination with mental health conditions and other multimorbidity. This study provides new information about the most common multimorbidity presentations of at-risk drinkers in the military so that targeted, individualized care may be employed. Future research is needed to determine whether tailored prevention and treatment approaches for soldiers in different multimorbidity classes is associated with improved outcomes.

Toward personalized care for insomnia in the US Army: a machine learning model to predict response to cognitive behavioral therapy for insomnia

STUDY OBJECTIVES

The standard of care for military personnel with insomnia is cognitive behavioral therapy for insomnia (CBT-I). However, only a minority seeking insomnia treatment receive CBT-I, and little reliable guidance exists to identify those most likely to respond. As a step toward personalized care, we present results of a machine learning (ML) model to predict CBT-I response.

METHODS

Administrative data were examined for n=1,449 nondeployed US Army soldiers treated for insomnia with CBT-I who had moderate-severe baseline Insomnia Severity Index (ISI) scores and completed one or more follow-up ISIs 6-12 weeks after baseline. An ensemble ML model was developed in a 70% training sample to predict clinically significant ISI improvement (reduction of at least two standard deviations on the baseline ISI distribution). Predictors included a wide range of military administrative and baseline clinical variables. Model accuracy was evaluated in the remaining 30% test sample.

RESULTS

19.8% of patients had clinically significant ISI improvement. Model AU-ROC (SE) was 0.60 (0.03). The 20% of test sample patients with highest probabilities of improvement were twice as likely to have clinically significant improvement as the remaining 80% (36.5% versus 15.7%; χ21=9.2, p=.002). Nearly 85% of prediction accuracy was due to ten variables, the most important of which were baseline insomnia severity and baseline suicidal ideation.

CONCLUSIONS

Pending replication, the model could be used as part of a patient-centered decision-making process for insomnia treatment. Parallel models will be needed for alternative treatments before such a system is of optimal value.

Being a parent of a soldier is a challenging experience - stress, anxiety, and depression among parents of Israeli soldiers

At any given moment, a notable proportion of parents worldwide have at least one child serving in the military. The aim of this study is to assess the prevalence of depression, anxiety, and stress in the sample of parents of Israeli soldiers and to assess the difference in this prevalence by type of service (combat vs. non-combat) and other demographic characteristics of parents and soldiers. A cross-sectional study of a convenience sample of 202 Israeli parents who were interviewed during January-September 2023. Depression Anxiety Stress Scale (DASS-21) was used to measure the emotional states of depression, anxiety, and stress (with cut-off points of ≥5, ≥4, and ≥8, respectively). Having depression, anxiety, or stress was defined as psychological distress. Parents' demographics and child's service characteristics were included in the multivariable logistic regression model, with psychological distress as a dependent variable. Almost a quarter (22.8%) of parents experienced distress, defined as having high depression, anxiety, or stress score. In a multivariable model, combat service (vs. non-combat) was significantly associated with distress: parents of combat soldiers were four times more likely to report distress than parents of non-combat soldiers (OR = 3.9; 95% CI: 1.3-11.8). Highly classified service preventing the child from sharing information with the parents was significantly associated with distress (OR = 2.6; 95% CI: 1.2-5.3). Most distressed parents (78.3%) did not seek professional help, with the vast majority of those seeking assistance were female. Given the substantial proportion of parents suffering from mental distress found in this study, especially parents of combat soldiers and those serving in highly classified positions, healthcare professionals should be aware of parents' difficulties, be proactive in gathering information about their mental well-being, and be prepared to provide professional help.

Differentiating social environments of high-risk professionals and specialised nurses: a qualitative empirical study on social embeddedness

Objective: High-risk professionals and specialised nurses in hospitals are frequently exposed to potentially traumatic events. Psychotrauma researchers have extensively studied personal risk factors of traumatisation among high-risk professionals, but it is hard to understand psychological functioning when professionals are decontextualised from their social environment. Generally, it has been well documented that to reduce the risk of posttraumatic stress disorder (PTSD) or other mental health problems related to traumatisation, it is essential to be embedded in a supportive social environment. However, study results among and within these occupational groups show great variety and even inconsistencies as to what is a supportive social environment.Method: This ethnographical research, including participant observation, in-depth interviews, and document analysis, explored the social environment of firefighters, police officers, ambulance paramedics, specialised nurses, and military personnel and aims to explore their social connections and embeddedness. We performed a thematic content analysis of data to identify themes related to social or emotional support, social relationships, and stress or traumatisation.Results: An analysis of the observational field notes, which covered 332 h of participant observation and 71 evenly distributed formal in-depth interviews, identified four themes related to social connections and embeddedness: Family, Hierarchical relations versus autonomy, Group versus individual, and Conditional family 'love'. Results revealed that the military, police, and professional firefighters have family-like hierarchical connections and highly value group unity. Paramedics and most specialised nurses, however, tend to value individuality and autonomy in their work relationships.Conclusion: This research shows noticeable differences in the social environments and social connections of these professionals, which implicates that prevention and mental health treatment might also have to be differentiated among occupational groups.

Exercise self-efficacy remains unaltered during military service

Background

Exercise self-efficacy is a crucial aspect of adopting and maintaining a physically active lifestyle. Regular physical activity may enhance exercise self-efficacy. This study aimed to investigate the baseline associations of physical fitness, physical activity, and body composition with exercise self-efficacy and the effects of military service on exercise self-efficacy. Methods: The sample consisted of healthy young Finnish conscripts (n = 243) undergoing military service. The participants were divided into two groups: an intervention group undergoing a high-intensity functional training program (n = 113) and a control group undergoing traditional physical training within their military service (n = 130). Exercise self-efficacy (adoption and barrier) and aerobic and muscular fitness were measured thrice (baseline, month 3, and month 5). Self-reported leisure-time physical activity and measured fat percentage were collected at baseline.

Results

Adoption and barrier exercise self-efficacy correlated positively with aerobic and muscular fitness and leisure time physical activity (r = 0.33-0.59, p < 0.001), and barrier self-efficacy negatively with fat percentage (r = -0.15, p < 0.05) at baseline. No changes in adoption (time p = 0.912) and barrier self-efficacy (time p = 0.441) occurred during the military service. There were no differences between groups in these changes (group × time interaction p = 0.643 for adoption self-efficacy and p = 0.872 for barrier self-efficacy). Change in muscular fitness correlated positively with change in barrier self-efficacy in the high-intensity functional training group (r = 0.35, p < 0.05). Conclusions: Exercise self-efficacy is positively associated with physical fitness and physical activity among young males. However, military service, whether it involves high-intensity functional physical training or more diverse traditional physical training, does not improve exercise self-efficacy.

Fetters and the Design of Bondage Objects in Britain During the 1970s and 1980s

This article examines the development of male bondage in Britain during the 1970s and 1980s through an examination of products designed by Jim Stewart, who founded the company Fetters in 1976. Through research using primary written sources, interviews with early customers, users and business partners, and the objects themselves, this paper situates Fetters designs within the broader infrastructures that were essential for the development of the material culture of male BDSM. The research finds that the primary contacts and inspiration came from outside of the emergent gay leather scene, in particular the cult of Houdini and publications that facilitated collecting of esoteric objects. Furthermore, military culture is shown to have influenced the design and mediation of bondage objects in a way that was fundamental to their design and functioning. This analysis therefore highlights some tensions surrounding cultural aspects of sexual identity that were negotiated through the design and development of objects produced at Fetters.

Weight loss medication prescription prevalence in the active component, 2018-2023

The U.S. military has witnessed rising obesity among active component service members. The Department of Defense authorized coverage of weight loss medications in 2018, but no study has evaluated prescription prevalence within the active component. This descriptive retrospective cohort study analyzed data from active component U.S. military service members from January 2018 through June 2023. The study used data from the Defense Medical Surveillance System to determine prescription period prevalence of weight loss medication. Data on demographics, body mass index, and history of diabetes were considered. The study revealed a 100-fold increase in the prescription period prevalence of weight loss agents in the active component from their initial authorization date. Demographics associated with higher prescription period prevalence were non-Hispanic Black race and ethnicity, female sex, and older age. Service members in the health care occupations and the Navy had higher prevalence compared to other service branches and occupations. The findings indicate a significant rise in the period prevalence of weight loss prescriptions over time. Further research is recommended to assess the effectiveness, safety, and use in austere military environments.

Military members during the coronavirus disease 2019 (COVID-19) pandemic

This report describes ivermectin prescription fill rates among U.S. active component service members (ACSM) over time during the early phases of the COVID-19 pandemic. Information about the unsubstantiated benefits of ivermectin for coronavirus 2019 (COVID-19) prevention and treatment was widely available online early in the COVID-19 pandemic. Ivermectin prescription fill rates increased among ACSM during periods of Alpha and Delta coronavirus variant predominance, but not during the predominance of the Omicron variant. At the peak of the fill rate curve, in August 2021, rates were higher among men compared to women, older compared to younger age groups, senior officers compared to junior officers, senior enlisted compared to junior enlisted service members, and those with a bachelor's or advanced degree compared to those without a bachelor's degree. Ivermectin prescriptions were more likely to have been filled at a retail pharmacy than at a military hospital or clinic. During the COVID-19 pandemic fill rates for ivermectin prescriptions among ACSM increased, including those without a qualifying diagnosis. Rates peaked in August 2021 but subsequently declined. The decrease in ivermectin fill rates was coincident with vigorous efforts to correct previous misinformation and implement pre-authorization requirements for prescriptions. Research on the impact of unproven online claims about clinical and public health interventions has potential to curtail future unnecessary and potentially harmful treatments.

Serum GFAP, NfL, and tau concentrations are associated with worse neurobehavioral functioning following mild, moderate, and severe TBI: a cross-sectional multiple-cohort study

Introduction

The purpose of this study was to examine whether blood-based biomarkers associate with neurobehavioral functioning at three time points following traumatic brain injury (TBI).

Materials and methods

Participants were 328 United States service members and veterans (SMVs) prospectively enrolled in the Defense and Veterans Brain Injury Center-Traumatic Brain Injury Center of Excellence (DVBIC-TBICoE) 15-Year Longitudinal TBI Study, recruited into three groups: uncomplicated mild TBI (MTBI, n = 155); complicated mild, moderate, severe TBI combined (STBI, n = 97); non-injured controls (NIC, n = 76). Participants were further divided into three cohorts based on time since injury (≤12 months, 3-5 years, and 8-10 years). Participants completed the Minnesota Multiphasic Personality Inventory-2-Restructured Format (MMPI-2-RF) and underwent blood draw to measure serum concentrations of glial fibrillary acidic protein (GFAP), neurofilament light (NfL), and tau. A total of 11 MMPI-2-RF scales were examined (e.g., depression, anxiety, anger, somatic, cognitive symptoms). Stepwise hierarchical regression models were conducted within each group.

Results

Significant associations were found between biomarkers and MMPI-2-RF scales (all p < 0.05; R2Δ > 0.10). GFAP was inversely related to (a) neurological complaints in the MTBI group at ≤12 months, (b) demoralization, anger proneness in the STBI group at ≤12 months, and (c) head pain complaints in the STBI group at 8-10 years. NfL was (a) related to low positive emotions in the NIC group; and inversely related to (b) demoralization, somatic complaints, neurological complaints, cognitive complaints in the MTBI group at ≤12 months, (c) demoralization in the STBI group at ≤12 months, and (d) demoralization, head pain complaints, stress/worry in the STBI group at 3-5 years. In the STBI group, there were meaningful findings (R2Δ > 0.10) for tau, NFL, and GFAP that did not reach statistical significance.

Discussion

Results indicate worse scores on some MMPI-2-RF scales (e.g., depression, stress/worry, neurological and head pain complaints) were associated with lower concentrations of serum GFAP, NfL, and tau in the sub-acute and chronic phase of the recovery trajectory up to 5 years post-injury, with a reverse trend observed at 8-10 years. Longitudinal studies are needed to help elucidate any patterns of association between blood-based biomarkers and neurobehavioral outcome over the recovery trajectory following TBI.

Patient-centeredness and psychometric properties of the Defense and Veterans Pain Rating Scale 2.0 (DVPRS)

OBJECTIVE

This study aims to assess the patient-centeredness and psychometric properties of the Defense and Veterans Pain Rating Scale 2.0 (DVPRS) as a patient-reported outcome measure (PROM) for pain assessment in a military population.

DESIGN

A critical evaluation of the DVPRS was conducted, considering its fit-for-purpose as a PROM and its patient-centeredness using the National Health Council's Rubric to Capture the Patient Voice.

SETTING

The study focused on the use of the DVPRS within the Department of Defense (DoD) and Veterans Health Administration (VA) healthcare settings.

SUBJECTS

The DVPRS was evaluated based on published studies and information provided by measure developers. The assessment included content validity, reliability, construct validity, and ability to detect change. Patient-centeredness and patient engagement were assessed across multiple domains.

METHODS

Two independent reviewers assessed the DVPRS using a tool/checklist/questionnaire, and any rating discrepancies were resolved through consensus. The assessment included an evaluation of psychometric properties and patient-centeredness based on established criteria.

RESULTS

The DVPRS lacked sufficient evidence of content validity, with no patient involvement in its development. Construct validity was not assessed adequately, and confirmatory factor analysis was not performed. Patient-centeredness and patient engagement were also limited, with only a few domains showing meaningful evidence of patient partnership.

CONCLUSIONS

The DVPRS as a PROM for pain assessment in the military population falls short in terms of content validity, construct validity, and patient-centeredness. It requires further development and validation, including meaningful patient engagement, to meet current standards and best practices for PROMs.

Organizational citizenship behavior in the military context: Are we missing the mark?

Organizational citizenship behavior (OCB), discretionary behavior that promotes organizational effectiveness, is a well-developed construct with great importance to the military. Despite its significance, few studies have examined OCB within the armed services. Those that have tended to use existing OCB scales without additional validation and only minimal adaptation to the military context. This is problematic because of the distinctive features of the American armed services, such as the substantial power leaders possess to compel behavior and the uniqueness of behaviors that create military value. The purpose of this study is to develop and validate five OCBs and a second-order OCB factor that are fully discretionary and produce unique and substantial value for the military. These military OCBs include sacrificing, providing positive word-of-mouth endorsement of the military, voluntary retention in the organization, voluntary participation in activities, and use of services that improve welfare and readiness. Some of these behaviors are so vital that the military could not achieve its mission without them. This study also seeks to understand and assess antecedents of military OCB. Using survey data from several Army populations and a series of validation analyses, the results reveal five military OCB factors, a second-order OCB construct, and four new military OCB antecedents. Opportunities and implications for the use of military OCBs are developed and the limitations of the study are examined.

Assessing the dimensionality and construct validity of the military stigma scale across current service members

US service members are at elevated risk for distress and suicidal behavior, compared to the general US population. However, despite the availability of evidence-based treatments, only 40% of Service members in need of mental health care seek help. One potential reason for the lower use of services is that service members experience stigma or concerns that the act of seeking mental health care from a mental health provider carries a mark of disgrace. The Military Stigma Scale (MSS) was designed to assess two theoretical dimensions of help-seeking stigma (public and self), specifically among service members. The goal of the current study was to further examine the validity of the MSS among 347 active duty service members. Examination of unidimensional, two-factor, and bifactor models revealed that a bifactor model, with a general (overall stigma), two specific factors (public and self-stigma), and one method factor (accounting for negatively worded items) provided the best fit to the data. Ancillary reliability analyses also supported the MSS measuring a broad stigma factor associated with seeking mental health care in the military. Subsequent model analyses showed that the MSS was associated with other stigma-related constructs. Overall, findings suggest that the MSS is a reliable and validated scale that can be used to assess military help-seeking stigma and to evaluate results of programs designed to reduce stigma.

Predicting ranger attrition

Elite military programs such as the 75th Ranger Regiment's Ranger Assessment and Selection Program (RASP) see rates of attrition often in excess of 50%, and amplify the need to identify and screen candidates based on their probability of successful matriculation. Models were developed (and cross-validated) to predict attrition from RASP using the physical abilities, cognitive abilities, and personality scores collected during candidate admissions screening. We report both regression weights and standardized odds ratios for optimum models of candidate success over three program timeframes to enable an understanding of the relative importance of each predictor. In spite of physical abilities scores being used to select RASP candidates, they were the strongest predictors of RASP attrition. Personality scores accounted for more variance in predicting candidate success than cognitive ability scores. Personality predictors, especially dimensions related to Openness, were better at predicting week one attrition than attrition in later weeks. The use of a single, aggregated candidate probability score for making admissions decisions is discussed, along with additional practical and scientific implications.

Bidirectional Associations Between Pain and Perceived Stress Among Veterans: Depressive Disorder as a Predisposing Factor

OBJECTIVE

Military veterans who were injured in combat very often report pain along with co-occurring perceived stress and preexisting depressive disorder. The systems model of pain is a theoretical model suggesting that pain and perceived stress are bidirectionally associated at the within-person level, and associations are heightened among those with depressive disorder. However, the systems model of pain has not been adequately tested. Testing the systems model of pain could illuminate salient treatment targets for combat-injured veterans with pain and co-occurring psychological problems.

METHODS

The present study empirically tests the systems model of pain among a sample of combat-injured veterans ( N = 902) surveyed five times during an 18-month period. We used a multigroup, autoregressive latent trajectory with structured residual statistical model to test the within-person associations between pain and perceived stress and determine whether associations differ between veterans with and without a positive screen for depressive disorder.

RESULTS

In line with the systems model of pain, pain and perceived stress were bidirectionally associated only among combat-injured veterans with depressive disorder. Among such veterans, perceived stress was positively associated with subsequent pain ( b = 0.12; 95% confidence interval = 0.06-0.17), and pain was positively associated with subsequent perceived stress ( b = 0.44; 95% CI = 0.11-0.77).

CONCLUSIONS

Our work highlights the interplay between pain and its psychological correlates among a particularly at-risk population. Clinicians addressing pain and perceived stress among combat-injured veterans should be prepared to identify and address depressive disorder.

Evaluation of the Effectiveness of ROTC Army Cadet Exercise Training for the Army Combat Fitness Test

The Army Combat Fitness Test (ACFT) is used to evaluate the fitness level of potential Cadets for military readiness. The purpose of this study was to evaluate the effectiveness of the exercise training program implemented by an Army Reserve Officers' Training Corps (ROTC) program to gauge the performance metrics of the ACFT.

METHODS

Twenty-six student Cadets of the ROTC at the University of Alabama at Birmingham (UAB) program participated in the study. Over an 8-month period, the ROTC Cadets trained on campus three days per week. Training was performed in a circuit training format and each participant cycled through each of the four training stations (Strength, Conditioning, Core, and Endurance) for 15 minutes each session (for a total training time of 60 minutes). Each Cadet had body mass and body composition assessed as well as each component of the ACFT [maximum dead lift (MDL), standing power throw (SPT), hand release push-up (HRP), sprint-drag-carry (SDC), leg tuck/plank (LTK/PLK), and 2-mile run (2MR)]. Each variable was evaluated at three time points (pre-, mid-, and post-training program).

RESULTS

There was a significant difference in the 2MR score between time points [F(2,50) = 4.530, p = .016, η2 = 0.153] with a significant difference between time point at pre- and post-training (p = .02). No other variables displayed a significant change: body mass (p = .741), body fat percentage (p = .238), MDL (p = .061), SPT (p = .308), HRP (p = .126), SDC (p = 0.132), LTK/PLK (p = 0.583).

CONCLUSION

The results of this study suggest that the short-term training program used improves 2MR, but not other components of the ACFT over the course of an academic year.

Lower-body muscular power predicts performance on urban combat simulation

BACKGROUND

Military operations in urban environments requires faster movements and therefore may place greater demands on soldier strength and anaerobic ability.

OBJECTIVE

The aim was to study how physical fitness and body composition are associated with occupational test for urban combat soldiers before and after a 5-day military field exercise (MFE).

METHODS

Twenty-six conscripts (age = 20±1 yrs.) volunteered, of which thirteen completed the study. Occupational performance was determined by using the newly developed Urban Combat Simulation test (UCS); which included 50-m sprinting, moving a truck tire (56 kg) 2 meters with a sledgehammer, a 12-m kettlebell carry (2×20 kg) up the stairs with a 3-m ascent, 4-time sandbag lifts (20 kg) with obstacle crossing, and a 20-m mannequin (85 kg) drag. Aerobic and muscle fitness, as well as anaerobic capacity were measured, and, body composition was assessed with multifrequency bioimpedance analysis.

RESULTS

The UCS performance correlated significantly with standing long jump performance, as well as lower and upper body maximal strength before (r = -0.56 to -0.66) and after (r = -0.59 to -0.68) MFE, and, with body mass and FFM before (r = -0.81 to -0.83) and after (r = -0.86 to -0.91) MFE. In the regression analyses, fat free mass (R2 = 0.50, p = 0.01) and counter movement jump in combat load (R2 = 0.46, p = 0.009) most strongly explained the UCS performance.

CONCLUSION

This study demonstrated that muscle mass and lower body explosive force production together with maximal strength are key fitness components related to typical urban combat soldiers' military tasks. Physical training developing these components are recommended.

Cancer incidence in the US military: An updated analysis

BACKGROUND

Military and general populations differ in factors related to cancer occurrence and diagnosis. This study compared incidence of colorectal, lung, prostate, testicular, breast, and cervical cancers between the US military and general US populations.

METHODS

Data from the US Department of Defense's Automated Central Tumor Registry (ACTUR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program were analyzed. Persons in ACTUR were active-duty members 20-59 years old during 1990-013. The same criteria applied to persons in SEER. Age-adjusted incidence rates, incidence rate ratios, and 95% confidence intervals were calculated by sex, race, age, and cancer stage. Temporal trends were analyzed.

RESULTS

ACTUR had higher rates of prostate and breast cancers, particularly in 40- to 59-year-olds. Further analyses by tumor stage showed this was primarily confined to localized stage. Incidence rates of colorectal, lung, testicular, and cervical cancers were significantly lower in ACTUR than in SEER, primarily for regional and distant tumors in men. Temporal incidence trends were generally similar overall and by stage between the populations, although distant colorectal cancer incidence tended to decrease starting in 2006 in ACTUR whereas it increased during the same period in SEER.

CONCLUSION

Higher rates of breast and prostate cancers in servicemembers 40-59 years of age than in the general population may result from greater cancer screening utilization or cumulative military exposures. Lower incidence of other cancers in servicemembers may be associated with better health status.

Quantification of daily workload, energy expenditure, and sleep of US Marine recruits throughout a 10-week boot camp

BACKGROUND

During periods of high-volume vigorous exercise, United States Marine Corps recruits often experience musculoskeletal injuries. While the program of instruction (POI) for basic training is a defined training volume, the total workload of boot camp, including movements around the base, is unknown.

OBJECTIVE

The present study aimed to quantify the daily total workload, energy expenditure, and sleep during basic recruit training at Marine Corps Recruit Depot (MCRD) San Diego.

METHODS

Eighty-four male recruits from MCRD San Diego wore wrist wearable physiological monitors to capture their complete workload (mileage from steps), energy expenditure, and sleep throughout the 10-week boot camp.

RESULTS

Marine recruits traveled an average of 11.5±3.4 miles per day (M±SD), expended 4105±823 kcal per day, and slept an average of 5 : 48±1 : 06 hours and minutes per night. While the POI designates a total of 46.3 miles of running and hiking, the actual daily average miles yielded approximately 657.6±107.2 miles over the 10-week boot camp.

CONCLUSION

Recruit training requires high physical demand and time under tension due to the cumulative volume of movements around base in addition to the POI planned physical training.

Characterising the physical demands of critical tasks across the Royal Australian Air Force

BACKGROUND

Militaries have historically utilised generic physical fitness tests to assess physical readiness, but there has been a recent shift to develop physical employment standards (PES) based on actual job demands.

OBJECTIVE

The purpose of this investigation was to characterise the physical demands of critical tasks performed by Royal Australian Air Force (RAAF) personnel to inform PES development.

METHODS

Job task analysis were performed for 27 RAAF trades. Criterion tasks were identified through a systematic approach involving workshops and field-observations. The identified tasks were assessed for dominant physical capacity and grouped into movement-based clusters. Psychophysiological measures were collected from personnel performing the tasks.

RESULTS

Of 87 criterion tasks, 92% were characterised as manual handling dominant. Across these 87 tasks the principal physical capacities were: muscular strength (59%), muscular endurance (52%) and cardiorespiratory endurance (39%). The most common movement clusters were Lift to Platform (44%) and Lift and Carry (38%). Lift to Platform tasks required lifting to a median height of 1.32 m (1.20 -1.65 m) and a median mass of 25.0 kg (21.0 -28.9 kg) per person. Median carry mass was 25.0 kg (22.4 -36.1 kg) per person and distance was 26.0 m (17.5 -50.0 m). Median task mean 'Vdot;O2, HR and RPE were 1.8 L.min- 1 (1.5-2.2 L.min- 1), 137 b.min- 1 (120-144) and 13 (12-14).

CONCLUSIONS

The high proportion of manual handling criterion tasks emphasises the importance of these activities and the underlying physical capacities for RAAF personnel. Current fitness assessments are unlikely to predict job task performance.

Suicide risk profiles among service members and veterans exposed to suicide

OBJECTIVES

Rates of suicide exposure are high among service members and Veterans and are especially concerning given the link between suicide exposure and subsequent suicide risk. However, to date, it is unclear which individuals who are exposed to suicide are subsequently at high risk for suicide. Latent profile analysis (LPA) can provide information on unique risk profiles and subgroups of service members and Veterans who have higher suicide risk after suicide exposure, which has not yet been empirically studied. The purpose of this study was to utilize LPA to identify subgroups of service members and Veterans who are at the highest risk for suicidal thoughts and behaviors following suicide exposure.

METHODS

We analyzed data using LPA from 2570 service members and Veterans (82.1% male, 69.5% White, and 12.1% Latino/a/x) who completed the Military Suicide Research Consortium's Common Data Elements, a battery of self-report suicide-related measures. Psychopathology, substance use, mental health service utilization, interpersonal theory of suicide, and suicide exposure variables were used to validate classes.

RESULTS

Three latent classes emerged from analyses, one low-risk class and two-high risk classes with differing profile compositions (one primarily differentiated by anxiety symptoms and one differentiated by substance use).

CONCLUSION

Class-specific recommendations for suicide prevention efforts will be discussed.

Doxycycline Prophylaxis for Skin and Soft Tissue Infections in Naval Special Warfare Trainees, United States1

In 2015, several severe cases of skin and soft tissue infection (SSTI) among US Naval Special Warfare trainees prompted the introduction of doxycycline prophylaxis during the highest-risk portion of training, Hell Week. We performed a retrospective analysis of the effect of this intervention on SSTI incidence and resulting hospital admissions during 2013-2020. In total, 3,371 trainees underwent Hell Week training during the study period; 284 SSTIs were diagnosed overall, 29 of which led to hospitalization. After doxycycline prophylaxis was introduced, admission rates for SSTI decreased from 1.37 to 0.64 admissions/100 trainees (p = 0.036). Overall SSTI rates remained stable at 7.42 to 8.86 SSTIs/100 trainees (p = 0.185). Hospitalization rates per diagnosed SSTI decreased from 18.4% to 7.2% (p = 0.009). Average length of hospitalization decreased from 9.01 days to 4.33 days (p = 0.034). Doxycycline prophylaxis was associated with decreased frequency and severity of hospitalization for SSTIs among this population.

Sex differences in US military personnel with insomnia, obstructive sleep apnea, or comorbid insomnia and obstructive sleep apnea

STUDY OBJECTIVES

The aim of this study was to evaluate sex-related differences in symptoms of sleep disorders, sleep-related impairment, psychiatric symptoms, traumatic brain injury, and polysomnographic variables in treatment-seeking military personnel diagnosed with insomnia, obstructive sleep apnea (OSA), or comorbid insomnia and OSA (COMISA).

METHODS

Participants were 372 military personnel (46.2% women, 53.8% men) with an average age of 37.7 (standard deviation = 7.46) years and median body mass index of 28.4 (5.50) kg/m2. Based on clinical evaluation and video-polysomnography, participants were diagnosed with insomnia (n = 118), OSA (n = 118), or COMISA (n = 136). Insomnia severity, excessive daytime sleepiness, sleep quality, nightmare disorder, sleep impairment, fatigue, posttraumatic stress disorder, anxiety, depression symptoms, and traumatic brain injury were evaluated with validated self-report questionnaires. Descriptive statistics, parametric and nonparametric t-tests, and effect sizes were used to assess sex differences between men and women.

RESULTS

There were no significant differences between women and men with insomnia or OSA in sleep-related symptoms, impairment, or polysomnography-based apnea-hypopnea index. Military men with COMISA had a significantly greater apnea-hypopnea index as compared to military women with COMISA, but women had greater symptoms of nightmare disorder, posttraumatic stress disorder, and anxiety.

CONCLUSIONS

In contrast to civilian studies, minimal differences were observed in self-reported sleep symptoms, impairment, and polysomnography metrics between men and women diagnosed with the most frequent sleep disorders in military personnel (ie, insomnia, OSA, or COMISA) except in those with COMISA. Military service may result in distinct sleep disorder phenotypes that differ negligibly by sex.

CITATION

Mysliwiec V, Pruiksma KE, Matsangas P, et al. Sex differences in US military personnel with insomnia, obstructive sleep apnea, or comorbid insomnia and obstructive sleep apnea. J Clin Sleep Med. 2024;20(1):17-30.

Food desert residence has limited impact on veteran fecal microbiome composition: a U.S. Veteran Microbiome Project study

IMPORTANCE

Social and economic inequities can have a profound impact on human health. The inequities could result in alterations to the gut microbiome, an important factor that may have profound abilities to alter health outcomes. Moreover, the strong correlations between social and economic inequities have been long understood. However, to date, limited research regarding the microbiome and mental health within the context of socioeconomic inequities exists. One particular inequity that may influence both mental health and the gut microbiome is living in a food desert. Persons living in food deserts may lack access to sufficient and/or nutritious food and often experience other inequities, such as increased exposure to air pollution and poor access to healthcare. Together, these factors may confer a unique risk for microbial perturbation. Indeed, external factors beyond a food desert might compound over time to have a lasting effect on an individual's gut microbiome. Therefore, adoption of a life-course approach is expected to increase the ecological validity of research related to social inequities, the gut microbiome, and physical and mental health.