Screening for Postpartum Depression in Military Women with the Postpartum Depression Screening Scale

Each year, approximately 16,000 women on active duty in the U.S. military experience the birth of a child. A descriptive, longitudinal, prospective design was used to gather data with the Postpartum Depression Screening Scale. Depression was measured after delivery but before hospital discharge (time 1), 2 weeks after delivery (time 2), and 6 to 8 weeks after delivery (time 3). Mothers were found to be experiencing the greatest severity of symptoms in the category of sleeping and eating disturbances. Almost one-half of the mothers in this study scored either significant postpartum depressive symptoms or positive screening for postpartum depression after delivery. This number remained virtually unchanged at time 2. By time 3, 40% of women still reported depressive symptoms. At 2 weeks and 6 weeks after delivery, 13% and 11% of mothers, respectively, had positive screening for postpartum depression, consistent with the national average of 10 to 15%. Future research is needed to examine issues surrounding postpartum depression of military women.

Suicide and the air force mental health provider: frequency and impact

Although suicide is relatively common among mental health patients, few studies have been published detailing the effects of a patient's suicide on his or her mental health provider. We reviewed data from 97 active duty, Air Force, mental health providers who responded to an anonymous survey. Forty-eight percent of the providers had experienced a patient's suicide. One-third of them reported a sense of responsibility for that patient's death. More than 20% reported significant emotional or behavioral changes following the death. Many providers experienced alterations in their self-esteem and their use of peer consultation following the suicide. Speaking to clergy members, friends, and other providers was generally beneficial following the suicide of a patient. Recommendations are given to minimize the impact of this tragedy on providers.

Millennium Cohort: the 2001-2003 baseline prevalence of mental disorders in the U.S. military

OBJECTIVES

The 12-month prevalence of common mental illnesses in the United States is estimated to be 26%, accounting for an increasing fraction of all disability in the general population. The U.S. military is a unique group involved in response and defense during times of conflicts and disasters. The mental health of service members affects organizational productivity and effectiveness and is of great importance to the health of U.S. military members and public health in general.

STUDY DESIGN AND SETTING

In the present report, the authors describe the baseline prevalence of mental disorders in a large U.S. military cohort, the Millennium Cohort, established for a 22-year longitudinal study of the health effects of military service. Using crude and weighted prevalence and multivariable logistic regression, the mental health morbidity of the Millennium Cohort is reported for various demographics.

RESULTS

These analyses suggest that although the cohort compares favorably to other populations, there are military subpopulations, including women, younger, less educated, single, white, short-term service, enlisted, and Army members, who are at greater odds for some mental disorders.

CONCLUSION

With ongoing U.S. involvement in combat operations around the world, these baseline data are essential to assessing long-term mental health morbidity in U.S. military service members.

Psychiatry and the military: an update

The United States has historically been concerned about the successful adjustment of its military members returning from war. These concerns are based on the recognition that war-zone exposures may have considerable negative emotional or behavior consequences. As the global war on terror continues, the United States military medical system will be required to address issues at the interface of psychiatry and the law. Despite clinical advances within the theater of war and at tertiary facilities in the United States, some military members will develop chronic and disabling mental illness as a result of traumatic exposure and exacerbated by the demands of the austere and dangerous operational environment. The extent to which violent and aggressive behavior in the aftermath of deployment can be attributed to combat experience remains an area of debate and ongoing investigation. However, experience suggests that a very small subgroup of the hundreds of thousands of war veterans deployed in conjunction with the current conflict in Iraq has already been involved in violent crimes. For this group, military forensic psychiatrists will be called on to make determinations of competency and criminal responsibility and to inform the courts about the potential contributions of war-related distress or disorder to criminal behavior. Though the overwhelming majority of war veterans will not be involved in criminal proceedings, a minority will develop career-ending (and in rare instances, life-ending) disabilities as a result of mental illness. For those who are no longer fit for duty, the military Physical Disability Evaluation System must make determinations of the extent to which future military performance and future civilian social and occupational function have been compromised. For a small yet highly visible minority of returning veterans, questions about the cause, precipitants, and manner of death will necessitate psychological autopsies. This article highlighted recent updates in military forensic psychiatry and the mechanisms through which answers to questions of disability and criminal culpability, and motivation underpinning self-injurious behavior, are determined within the United States military. As the global war on terror progresses, further experience and study of our country's judicial processes, disability system, and the policies and procedures governing psychological autopsies must evolve to meet these increasing demands.

Health care utilization by United Nations peacekeeping veterans with co-occurring, self-reported, post-traumatic stress disorder and depression symptoms versus those without

It remains to be determined whether patients with comorbid post-traumatic stress disorder (PTSD) and depression use more health care resources than do those without. United Nations peacekeeping veterans from Canada were divided into four groups, i.e., PTSD alone (n = 23), depression alone (n = 167), comorbid PTSD and depression (n = 119), and neither (n = 164), and compared with respect to total number of visits to any health care professional in the past year. Analysis of variance revealed that the groups significantly differed in total visits. Post hoc analyses indicated that veterans with co-occurring PTSD and depression symptoms had more visits than did those in the other groups and that veterans with PTSD symptoms alone and depression symptoms alone had more visits than did those with neither PTSD nor depression. Additional analyses revealed that veterans with co-occurring PTSD and depression symptoms made more visits to general practitioners, specialists, pharmacists, and mental health professionals than did the others. Future research directions and implications for treatment planning are discussed.

Child Sexual Abuse and Adulthood Sexual Assault among Military Veteran and Civilian Women

The purpose of this study was to investigate childhood sexual abuse (CSA), adulthood sexual victimization (ASV), and adulthood sexual assault experiences in a comparison sample of female military veterans (n = 142) and civilian community members (n = 81). Women veterans were significantly more likely than civilian women to report adult sexual assault. Although comparable rates of CSA and ASV were found across groups, veterans more frequently reported having been sexually abused by a parental figure, reported longer durations of CSA, and significantly greater severity of ASV than civilians. Implications for mental health professionals providing sexual trauma services to female military personnel and veterans are discussed.

The mental health of U.S. military women in combat support occupations

BACKGROUND

The proportion of women in the U.S. military is increasing, and they are being selected into jobs that are more combat related. However, the mental health effects of working in combat support occupations among military women have not been previously evaluated.

METHODS

Active-duty enlisted Navy and Marine Corps women in combat support (n = 10,299) and noncombat support (n = 63,478) occupations were followed for 2 years between January 1, 1994, and August 31, 2001. Hospitalization diagnoses were examined and organized into eight categories of mental disorders; Cox proportional hazards modeling was used to describe these outcomes.

RESULTS

Women in combat support occupations were found to be significantly less likely to be hospitalized for a mental disorder than women in all other military occupations.

CONCLUSIONS

These results are reassuring but may be confounded by a healthy worker selection effect. Further studies are needed to assess how service in combat support occupations affects the long-term health of U.S. military women.

Psychological Morbidity During The 2002 Deployment To Afghanistan

Questionnaires were completed by military personnel on arrival (n=1,696) in Kabul, Afghanistan and then again on departure (n=1,134). Analysis of the 113 personnel who completed both the arrivals and departures questionnaire revealed a lower alcohol use score after deployment (AUDIT mean difference (post-deployment - pre-deployment) = -0.39, 95% confidence interval (CI) = - 1.25 - +0.47) and no significant change to mental health (GHQ mean difference = 0.55, 95% CI = -0.07 - +1.17). An increase in psychosomatic symptoms (GHQ A mean difference = 0.22, 95% CI = -0.03 - +0.47) is considered to result from the adverse conditions, but it is not supported by other mental ill health markers. In conclusion, there appeared to be no negative effect on mental health from deployment to Afghanistan.

Treatment of psychiatric disorders onboard an aircraft carrier assisted with psychotropic medication: a retrospective review describing one aspect of Navy Force health protection

Navy clinical psychologists, assigned to aircraft carriers, are playing an increasing role in not only implementing Navy force health protection, but also in further specializing the delivery of mental health evaluation, treatment, and disposition services at the "tip of the spear." An aircraft carrier's medical department, augmented with a clinical psychologist, is now better able to coordinate diagnostic, psychotropic, and psychotherapeutic treatments for both shipboard and air wing personnel. This retrospective review reports the outcomes of a 6-month treatment program for personnel, assigned to the USS Constellation (CV-64), who were prescribed a psychotropic medication while receiving psychotherapy. We concluded that psychotropic medications can be safely and effectively used onboard an aircraft carrier. Furthermore, personnel prescribed psychotropic medication successfully completed their assigned duties and obtained recommendations for advancement and retention. Lastly, our medical department proactively fulfilled the Navy force health protection tenet of preserving a healthy and fit force.

A randomized trial of short-term acute residential treatment for veterans

OBJECTIVE

A variety of alternatives to acute psychiatric hospital care have been developed over the past several decades. including San Diego's short-term acute residential treatment (START) program, now comprising a certified and accredited network of six facilities with a total of 75 beds. This study compared outcomes, patient satisfaction, and episode costs for a sample of 99 veterans who received acute care either at an inpatient unit at a Department of Veterans Affairs (VA) hospital or at a START facility.

METHODS

Consenting participants were randomly assigned to one of the two treatment settings. Follow-up was conducted at two months. During the follow-up period, participants received treatment as usual. Multiple standardized measures were used to maximize validity in assessing symptoms, functioning, and quality of life.

RESULTS

Participants who were treated in either a hospital or the START program showed significant improvement between admission, discharge, and two-month follow-up, with few statistically significant differences between the groups in symptoms and functioning. There was some evidence that START participants had greater satisfaction with services. Mean costs for the index episode were significantly lower for START participants (65 percent lower) than for those who were treated in the hospital.

CONCLUSIONS

The results of this study suggest that the START model provides effective voluntary acute psychiatric care in a non-hospital-based setting at considerably lower cost. Efforts to replicate and evaluate the model at additional locations merit attention.

Follow-up of Pentagon employees two years after the terrorist attack of September 11, 2001

OBJECTIVE

This study examined probable posttraumatic stress disorder (PTSD) and probable depression, degree of psychological distress, and rates of mental health treatment in a sample of Pentagon staff two years after the terrorist attack of September 11, 2001.

METHODS

Anonymous surveys were administered to staff at one Pentagon work center. Respondents were asked about exposure to the attack; injuries; exposure to dead bodies or families of the deceased; psychological distress; and use of mental health services. Probable PTSD and depression were assessed with the PCL-17 and the PHQ-9.

RESULTS

A total of 267 responses were received. Fourteen percent of the sample had probable PTSD, and 7 percent had probable depression. Staff who were at the Pentagon on the day of the attack were more likely to have probable PTSD and probable depression. Exposure through watching television was not associated with a higher frequency of probable PTSD, probable depression, or distress. Injury during the attack was associated with a higher frequency of probable PTSD, probable depression, and distress. Respondents who were exposed to dead bodies or who acted as lay counselors to families of the deceased were more likely to have probable PTSD and depression and to report chronic distress. Of those with probable PTSD, 70 percent made at least one mental health visit during the next two years. Of those with probable depression, 74 percent reported at least one mental health visit.

CONCLUSIONS

Direct exposure to the September 11 terrorist attack on the Pentagon, injury during the attack, and exposure to dead bodies or acting as a lay counselor to families of persons who were killed during the attack were all associated with higher frequencies of probable psychiatric illness and higher levels of psychological distress two years after the attack. Among survivors who had probable psychiatric illness, more than two-thirds received mental health treatment after the attack.

Suicide in the Army: A Review of Current Information

This article summarizes findings on demographic factors, distal risk factors, and proximal risk factors for suicide and reports recent data on suicide by Army personnel. In addition, the article offers recommendations to reduce the risk of suicide and suicide attempt in the Armed Services and suggests possible directions for future research on suicide in the military.

Geographic Relocation Frequency, Resilience, and Military Adolescent Behavior

Frequent relocations have historically been viewed negatively and are perceived to lead to aberrant behavior. Military adolescents are a highly mobile population with a highly variable number of relocations. This study assessed parental perceptions of military adolescents' conduct and behavior in the context of relocation experience. Parents of military adolescents were surveyed for their children's history of conduct and behavior, with 179 completed surveys being returned from geographically separate sites. The average number of relocations experienced by the adolescents was 4.89. Parental perceptions of relocations improved with the number of relocations experienced (p < 0.05). As more relocations were experienced, children's behavior improved (p < 0.05), when controlling for age. The data suggested that relocation frequency was a more predictive measure of improved parental perceptions and decreased aberrant behavior. Data from this study suggest that relocation frequency may be a more critical factor in resilience development than the actual number of relocations experienced.

Psychiatric Referrals during Peace and Wartimes: A Nigerian Experience

Using a questionnaire administered by us, we sought to investigate the differences between patients referred to the psychiatric department of a Nigerian military general hospital during peacetime and those referred during the civil war in Liberia in which Nigerian soldiers were involved as peacekeepers. Referrals to psychiatry in peacetime were quite few but increased considerably during the period of combat in direct relation to the increase in the number of surgical wounded in action cases. Organic mental disorders and anxiety disorders were more frequently referred in peacetime than in war, whereas substance abuse disorders were more frequent during the combat period. Non-psychotic psychiatric conditions were less referred in the wartime group, partly because of nonrecognition at the mission areas and also because of recovery in front-line areas or consideration of their evacuation as a nonpriority. Mental health workers engaged at the mission areas require more training in the identification of such cases.

Dissemination and evaluation of marriage education in the Army

The effectiveness of marriage education was evaluated in two separate samples of primarily married couples in which at least one member of the couple was on active duty in the U.S. Army. The intervention was delivered by Army chaplains. Effects replicated well in the two samples, and demonstrated that marriage education was well received by this population and resulted in improvements in relationship functioning. Changes in relationship quality were examined separately for males and females, and also for couples in which both members of the couple were Caucasian as compared with all other couples. There were no significant differences in changes over time (i.e., from pre- to postmarriage education) among males and females or among couples with different ethnic makeup. These results have important implications for the generalizability of marriage education to diverse samples in nontraditional contexts.

Risk, psychiatry and the military

The relationship between combat and psychiatric breakdown has been well recognised for decades. The change to smaller, professional armed forces has reduced the risk of large-scale acute psychiatric casualties, and should have led to a corresponding decrease in long-term ill health, but this expected reduction seems not to have happened. Likewise, attempts at preventing psychiatric injury, by screening before deployment or debriefing after, have been disappointing. Three reasons for this are proposed: a rethinking of the relationship between trauma and long-term outcome, catalysed by the attempts of US society to come to terms with the Vietnam conflict; a broadening of the scope of psychiatric injury as it moved to the civilian sector; and the increased prominence of unexplained syndromes and contested diagnoses such as Gulf War syndrome. Traditional psychiatric injury is predictable, proportionate and can, in theory, be managed. These newer forms of injury are in contrast unanticipated, paradoxical, ill understood and hard to manage. Traditional approaches to risk management by reducing exposure have not been successful, and may increase risk aversion and reduce resilience. However, the experiences of civilians in wartime or the military show that people are not intrinsically risk-averse, provided they can see purpose in accepting risk.

Screening for physical and psychological illness in the British Armed Forces: II: Barriers to screening--learning from the opinions of Service personnel

OBJECTIVE

To identify any potential barriers to the effectiveness of a military health screening programme based on the beliefs of British Service personnel.

METHODS

As part of a pilot evaluation of the suitability of a new health screening questionnaire for the British Armed Forces, 73 men and women from the three Services, of various ranks and age, underwent a semi-structured interview after completing a screening questionnaire. Participants were asked about the veracity of their answers and their views regarding a screening questionnaire. Afterwards questionnaires were sent to 4496 randomly selected personnel from the three Services, which validated the main emerging themes. A constant comparative method of analysis was used to identify and categorise all ideas presented.

RESULTS

The main barriers to health screening were lack of trust, perceived low quality of healthcare, and perceived lack of concern within the institution about work environments and home life. The central issue was 'confidence' in military health care provision. Screening was considered worthwhile, but many confided that they would not honestly answer some items in the questionnaire. Lack of trust in medical confidentiality, stigmatisation and fears that the process would jeopardise career prospects were stressed. Many Service personnel admitted to seeking medical help outside the Armed Forces.

CONCLUSIONS

Concerns raised by Service personnel may endanger the value of a screening programme and the provision of health services. Greater emphasis needs to be placed upon gaining the confidence of those targeted for health screening.

Post-traumatic stress disorder symptoms among military health professionals in Turkey

This descriptive study investigated traumatic experiences and post-traumatic stress disorder symptoms among military professionals in Turkey. The sample included 225 military health professionals who were in charge in districts in which traumatic events occurred frequently in the past decade. The Impact of Event Scale, Beck Anxiety Inventory, and Symptom Checklist were used to obtain data in the study. More than one-half of the health professionals had experienced at least one traumatic event. Those who had a history of traumatic experience and loss of relatives or friends reported more symptoms than did those who had not experienced traumatic events. As expected, health professionals who had traumatic experiences were more likely to have higher Impact of Event Scale scores than were those who had not experienced physical or psychological trauma. The findings indicate that health professionals are as affected by traumatic events as are those in other settings or occupations. Future research should focus on the long-term effects of post-traumatic stress among health professionals.

Psychiatric Symptoms and Cognitive Appraisal following the Near Sinking of a Research Submarine

OBJECTIVE

This study assessed the stress reactions of a submarine crew forced to abandon their vessel in high seas after flooding and fire damaged their ship.

METHODS

The remaining crew members (n = 22) were surveyed 7 months after the incident regarding exposures, initial emotional responses, peritraumatic dissociation, subsequent life events, current safety appraisal, and current symptoms of posttraumatic stress disorder (PTSD) and depression.

RESULTS

At 7 months, 9.1% met criteria for PTSD and none met criteria for depression. Higher levels of depressive symptoms were associated with previous traumatic exposures, subsequent life events, and higher levels of PTSD symptoms; higher levels of PTSD symptoms were associated with greater peritraumatic dissociation and initial emotional response.

CONCLUSION

Acute exposures of highly trained professionals to potentially fatal events may not result in high levels of posttraumatic symptoms. Previous and subsequent life events may play a more significant role in the level of postdisaster symptoms.

Sense of coherence among Finnish young men--a cross-sectional study at military call-up

The aim of this study was to study associations between sense of coherence (based on Antonovsky's theory), and mental health problems, the use of mental health services, substance use, predisposition to suicide and possible psychiatric diagnosis among Finnish young men. The study included 2314 18-year-old young men who attended military call-up in autumn 1999 and completed the 13-item Orientation to Life Questionnaire (SOC-13) questionnaire (89.1% of the study sample attending military call-up). Furthermore, all young men had a medical examination at military call-up, including evaluation of possible psychiatric disorder. Suicidality, perceived mental health problems, psychiatric diagnosis at military call-up medical examination, use of mental health services, excessive alcohol consumption and use of illicit drugs were identified as independent factors associated with sense of coherence. Sense of coherence is a valuable construction in psychiatric evaluation of adolescents. SOC-13 can be used both in clinical practice and in epidemiological research to evaluate the adolescent's health resources. Future research on its applications in clinical practice is warranted.

Psychosocial effects of the BOOT STRAP intervention in Navy recruits

The purpose of this prospective study was to investigate the effects of the Boot Camp Survival Training for Navy Re cruits--A Prescription (BOOT STRAP) intervention on stress depression, situational events, interpersonal factors, and recruit training performance. Divisions of Navy recruits were randomly selected and 801 recruits participated for the 9 weeks of their training. Recruits "at risk" for depression were randomly assigned to the intervention or nonintervention groups, and the remaining recruits served as the comparison group. The at-risk recruits who received the BOOT STRAP intervention significantly increased their sense of belonging, experienced less loneliness, used more problem-solving coping skills, and decreased insecure attachment by the end of recruit training. Percentages of recruits in the study success fully completing basic training were 84% of the comparison group, 86% of the intervention group, and only 74% of the nonintervention group. Results suggest that the BOOT STRAP intervention improves recruit functioning, strengthens train ing performance, helps reduce attrition, and may have impor tant implications for stress and depression interventions.