Gender differences in substance use treatment utilization in the year prior to deployment in Army service members

Post-Deployment Screening In The Military Health System: An Opportunity To Intervene For Possible Alcohol Use Disorder

Unhealthy alcohol use in the military remains a serious threat to health and military readiness and raises the question of how to improve detection that facilitates diagnosis and treatment. Army active duty soldiers are routinely screened for possible alcohol use disorder in pre- and post-deployment health surveillance surveys. We examined the likelihood of having a follow-up behavioral health visit or receiving an alcohol use disorder diagnosis among soldiers returning from deployments associated with the Afghanistan or Iraq operations in fiscal years 2008-13, based on their post-deployment screening results. After we controlled for demographic and military treatment facility characteristics, military history, and comorbidities, we found that people who screened positive for possible alcohol use disorder were significantly more likely to have such a visit and receive such a diagnosis. Routine post-deployment alcohol screening represents an opportunity for timely intervention by the Military Health System for military members whose results indicate elevated risk for alcohol use disorder.

Army Warrior Care Project (AWCP): Rationale and methods for a longitudinal study of behavioral health care in Army Warrior Transition Units using Military Health System data, FY2008-2015

OBJECTIVES

Warrior Transition Units (WTUs) are specialized military units co-located with major military treatment facilities providing a Triad of Care involving primary care physicians, case managers, and military leadership to soldiers needing comprehensive medical care. We describe the rationale and methods for studying behavioral health care in WTUs and characterize soldiers assigned to WTUs.

METHODS

The Army Warrior Care Project (AWCP) analyzes U.S. Department of Defense Military Health System data to examine behavioral health problems and service utilization among Army soldiers who were assigned to WTUs after returning from Afghanistan and Iraq deployments, FY2008-2015.

RESULTS

WTU members (N = 31,094) comprised 3.5% of the AWCP cohort (N = 883,091). Almost all (96.5%) had one WTU assignment for a median of 327 days; 77.3% were assigned before deployment ended, ≤30 or >365 days post-deployment; 59.4% had deployment-related behavioral health diagnoses.

CONCLUSIONS

An overwhelming majority of soldiers had one WTU assignment for almost a year. A substantial proportion of WTU soldiers had psychological impairment, which limited performance of their military duties. The AWCP is the first longitudinal study of redeployed soldiers assigned to WTUs and provides a unique opportunity to advance our understanding of behavioral health among soldiers needing comprehensive medical care after combat deployments.

Characteristics of U.S. Army Reserve and National Guard couples who use family readiness programs

Use of family readiness programs (FRPs) by military families is not well understood. This work uses the Gelberg-Andersen Behavioral Model to identify characteristics of Reserve and National Guard (R/NG) couples who access FRPs. Data are from Operation: SAFETY, a study of R/NG soldiers and partners. Logistic regression models examined odds of accessing FRPs based on predisposing, enabling, and need factors. Greater length of military service, greater presence of non-military social ties, and civilian partner reports of adequate support during deployment were associated with higher likelihood of accessing FRPs. Results provide information on FRP utilization and may help inform outreach efforts.

Purchased Behavioral Health Care Received by Military Health System Beneficiaries in Civilian Medical Facilities, 2000-2014

Introduction

Behavioral health conditions are a significant concern for the U.S. military and the Military Health System (MHS) because of decreased military readiness and increased health care utilization. Although MHS beneficiaries receive direct care in military treatment facilities, a disproportionate majority of behavioral health treatment is purchased care received in civilian facilities. Yet, limited evidence exists about purchased behavioral health care received by MHS beneficiaries. This longitudinal study (1) estimated the prevalence of purchased behavioral health care and (2) identified patient and visit characteristics predicting receipt of purchased behavioral health care in acute care facilities from 2000 to 2014.

Materials and Methods

Medical claims with Major Diagnostic Code 19 (mental disorders/diseases) or 20 (alcohol/drug disorders) as primary diagnoses and TRICARE as the primary/secondary payer were analyzed for MHS beneficiaries (n = 17,943) receiving behavioral health care in civilian acute care facilities from January 1, 2000, to December 31, 2014. The primary dependent variable, receipt of purchased behavioral health care, was modeled for select mental health and substance use disorders from 2000 to 2014 using generalized estimating equations. Patient characteristics included time, age, sex, and race/ethnicity. Visit types included inpatient hospitalization and emergency department (ED). Time was measured in days and visits were assumed to be correlated over time. Behavioral health care was described by both frequency of patients and visit type. The University of South Carolina Institutional Review Board approved this study.

Results

From 2000 to 2014, purchased care visits increased significantly for post-traumatic stress disorder, adjustment, anxiety, mood, bipolar, tobacco use, opioid/combination opioid dependence, nondependent cocaine abuse, psychosocial problems, and suicidal ideation among MHS beneficiaries. The majority of care was received for mental health disorders (78.8%) and care was most often received in EDs (56%). Most commonly treated diagnoses included mood, tobacco use, and alcohol use disorders. ED visits were associated with being treated for anxiety (excluding post-traumatic stress disorder; Adjusted odds ratio [AOR]: 9.14 [95% confidence interval (CI): 8.26, 10.12]), alcohol use disorders (AOR = 1.67 [95% CI: 1.53, 1.83]), tobacco use (AOR = 1.16 [95% CI: 1.06, 1.26]), nondependent cocaine abuse (AOR = 5.47 [95% CI: 3.28, 9.12]), nondependent mixed/unspecified drug abuse (AOR = 7.30 [95% CI: 5.11, 10.44]), and psychosis (AOR = 1.38 [95% CI: 1.20, 1.58]). Compared with adults age 60 yr and older, adolescents (ages 12-17 yr), and adults under age 60 yr were more likely to be treated for suicidal ideation, adjustment, mood, bipolar, post-traumatic stress disorder, nondependent cocaine, and mixed/unspecified drug abuse. Adults under age 60 yr also had increased odds of being treated for tobacco use disorders, alcohol use disorders, and opioid/combination opioid dependence compared with adults age 60 yr and older.

Conclusions

Over the past 15 yr, purchased behavioral health care received by MHS beneficiaries in acute care facilities increased significantly. MHS beneficiaries received the majority of purchased behavioral health care for mental health disorders and were treated most often in the ED. Receiving behavioral health care in civilian EDs raises questions about access to outpatient behavioral health care and patient-centered care coordination between civilian and military facilities. Given the influx of new Veterans Health Administration users from the MHS, findings have implications for military, veteran, and civilian facilities providing behavioral health care to military and veteran populations.

Medical-encounter mental health diagnoses, non-fatal injury and polypharmacy indicators of risk for accident death in the US Army enlisted soldiers, 2004-2009

Accidents are a leading cause of deaths in U.S. active duty personnel. Understanding accident deaths during wartime could facilitate future operational planning and inform risk prevention efforts. This study expands prior research, identifying health risk factors associated with U.S. Army accident deaths during the Afghanistan and Iraq war. Military records for 2004-2009 enlisted, active duty, Regular Army soldiers were analyzed using logistic regression modeling to identify mental health, injury, and polypharmacy (multiple narcotic and/or psychotropic medications) predictors of accident deaths for current, previously, and never deployed groups. Deployed soldiers with anxiety diagnoses showed higher risk for accident deaths. Over half had anxiety diagnoses prior to being deployed, suggesting anticipatory anxiety or symptom recurrence may contribute to high risk. For previously deployed soldiers, traumatic brain injury (TBI) indicated higher risk. Two-thirds of these soldiers had first TBI medical-encounter while non-deployed, but mild, combat-related TBIs may have been undetected during deployments. Post-Traumatic Stress Disorder (PTSD) predicted higher risk for never deployed soldiers, as did polypharmacy which may relate to reasons for deployment ineligibility. Health risk predictors for Army accident deaths are identified and potential practice and policy implications discussed. Further research could test for replicability and expand models to include unobserved factors or modifiable mechanisms related to high risk. PTSD predicted high risk among those never deployed, suggesting importance of identification, treatment, and prevention of non-combat traumatic events. Finally, risk predictors overlapped with those identified for suicides, suggesting effective intervention might reduce both types of deaths.

A Maisonneuve Fracture in an Active Duty Sailor: A Case Report

Maisonneuve fractures are relatively well known in the sports medicine, and orthopedic communities, however, can be commonly missed among primary care providers. The following case outlines an active duty 35-yr-old female patient who presented with acute pain on the left ankle and lower leg after she misjudged a step. The injury is a combination of high fibular and medial malleolar fractures with a disruption of the tibiofibular syndesmosis ligaments. This is a result of extreme external rotation and pronation of a fixed foot. The proper diagnosis is reliant on ankle and tibiofibular films, to include orthogonal views. This case serves as a reminder to always examine joints above and below the injury site, obtain orthogonal views of a fracture, as well as the unstable nature of syndesmosis injuries. This fracture is commonly a sports-related injury; thus, it is particularly important for military providers to be aware of Maisonneuve fractures and the common pitfalls in diagnosis and treatment.

Postdeployment Behavioral Health Screens and Linkage to the Veterans Health Administration for Army Reserve Component Members

OBJECTIVE

Approximately three to six months after returning from deployment, military service members complete the Post-Deployment Health Reassessment (PDHRA), which includes screens for alcohol misuse, depression, and posttraumatic stress disorder (PTSD). To determine whether Army Reserve Component (RC) members (Army National Guard and Army Reserve) with positive screening scores on the PDHRA receive needed care, the investigators examined the association between positive scores and enrollment and utilization of care ("linkage") in the Veterans Health Administration (VHA), as well as rescreening scores, diagnosis, and behavioral treatment in VHA.

METHODS

Mixed-effects regression models were used to predict linkage to VHA within six months after RC members (N=73,164) completed the PDHRA, with alcohol misuse, depression, and PTSD screen scores as key independent variables. Regression models were stratified by gender and National Guard versus Reserve status. Among those who linked to VHA (N=25,168), screening scores and subsequent diagnosis and treatment in VHA were also examined.

RESULTS

Army RC members with positive PTSD and depression screening scores were more likely than those with negative screens to link to VHA, and most (54%-84%) received VHA treatment once diagnosed. Positive screens for alcohol misuse were associated with linkage to VHA for men but not for women, and treatment rates for alcohol use disorders were relatively low (0%-25%) for both men and women diagnosed as having an alcohol use disorder.

CONCLUSIONS

The finding that Army RC members with greater indications of behavioral health problems linked to VHA is encouraging. However, more outreach and treatment engagement strategies could be directed to those with alcohol use disorder, particularly women.

Pre-deployment Year Mental Health Diagnoses and Treatment in Deployed Army Women

We estimated the prevalence of select mental health diagnoses (MHDX) and mental health treatment (MHT), and identified characteristics associated with MHT during the pre-deployment year (365 days before deployment) in active duty Army women (N = 14,633) who returned from Iraq or Afghanistan deployments in FY2010. Pre-deployment year prevalence estimates were: 26.2 % for any select MHDX and 18.1 % for any MHT. Army women who had physical injuries since FY2002 or any behavioral health treatment between FY2002 and the pre-deployment year had increased odds of pre-deployment year MHT. During the pre-deployment year, a substantial percentage of Army women had MHDX and at least one MHT encounter or stay. Future research should determine if pre-deployment MHDX among Army women reflect vulnerability to future MHDX, or if pre-deployment MHT results in protection from chronic symptoms.

The Association of Combat Exposure With Postdeployment Behavioral Health Problems Among U.S. Army Enlisted Women Returning From Afghanistan or Iraq

An association between combat exposure and postdeployment behavioral health problems has been demonstrated among U.S. military service members returning from Afghanistan or Iraq in predominantly male samples, yet few studies have focused on the experiences of women. Using data from the longitudinal, observational Substance Use and Psychological Injury Combat (SUPIC) Study, we explored the self-report of 4 combat exposure items and postdeployment behavioral health screening results for 42,397 Army enlisted women who had returned from Afghanistan or Iraq from fiscal years 2008 through 2011. We ran multivariate logistic regression models to examine how a constructed composite combat exposure score (0, 1, 2, 3+) was associated with screening positive postdeployment for posttraumatic stress disorder (PTSD), depression, and at-risk drinking among active duty (AD) and National Guard/Reserve (NG/R) women. AD and NG/R women commonly reported being wounded, injured, assaulted, or hurt (17.3% and 29.0%, respectively). In all 6 multivariate models, Army women with any report of combat exposure had increased odds of the behavioral health problem (i.e., PTSD, depression, or at-risk drinking). The magnitude of the association between combat exposure and PTSD was most striking, indicating increased odds of PTSD as combat exposure score increased. AD and NG/R women with a combat exposure score of 3+ had increased odds of PTSD, 20.7, 95% confidence interval (CI) [17.0, 25.1] and 27.8, 95% CI [21.0, 36.9], respectively. Women who report combat exposure may benefit from early prevention and confidential intervention to promote postdeployment health and reduce long-term behavioral health problems.

Alcohol Screening and Intervention Among United States Adults who Attend Ambulatory Healthcare

BACKGROUND

There is limited data on the extent to which indicated alcohol interventions are delivered in U.S. ambulatory care settings.

OBJECTIVE

To assess the receipt of alcohol-related services, including assessment of use, advice to reduce drinking, and information about alcohol treatment, during ambulatory care visits.

DESIGN

Secondary data analysis of the 2013 National Survey on Drug Use and Health, a cross-sectional, nationally representative survey of civilians in the non-institutionalized U.S. general population (response rate 71.7 %).

PARTICIPANTS

Adult ambulatory care users in the public use data file who did not obtain emergency or inpatient services (n = 17,266).

MAIN MEASURES

Measurements included respondents' alcohol consumption, heavy episodic drinking, alcohol use disorder, healthcare use, and receipt of alcohol-related interventions.

KEY RESULTS

Approximately 71.1 % of ambulatory care users received an alcohol assessment. Among past-month heavy episodic drinkers without an alcohol use disorder who reported receiving an alcohol assessment, 4.4 % were advised to cut back. Among individuals with alcohol abuse and alcohol dependence who reported receiving an alcohol assessment, 2.9 % and 7.0 %, respectively, were offered information about treatment.

CONCLUSIONS

Rates of alcohol screening and assessment were relatively high among adults who attended healthcare visits, but rates of intervention were low, even when individuals were assessed for use. Efforts are needed to expand delivery of interventions when patients are identified as positive for risky drinking, hazardous alcohol use, and alcohol use disorders during ambulatory care visits.

Military Social Work: Opportunities and Challenges for Social Work Education

Military social work is a specialized field of practice spanning the micro-macro continuum and requiring advanced social work knowledge and skills. The complex behavioral health problems and service needs of Iraq and Afghanistan veterans highlight the need for highly trained social work professionals who can provide militarily-relevant and culturally-responsive evidence-informed services. Responding to the military behavioral health workforce and service needs of recently returned veterans presents both opportunities and challenges for military social work education. This article discusses the rationale for a military social work specialization, the need for military social work education, and opportunities and challenges for social work education. An integrated model of intellectual capital is proposed to guide strategic planning for future military social work education.