Influence of military component and deployment-related experiences on mental disorders among Canadian military personnel who deployed to Afghanistan: a cross-sectional survey

Risk and protective factors for self-harm and suicide behaviours among serving and ex-serving personnel of the UK Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force: A systematic review

BACKGROUND

Self-harm and suicide behaviours are a major public health concern. Several factors are associated with these behaviours among military communities. Identifying these factors may have important implications for policy and clinical services. The aim of this review was to identify the risk and protective factors associated with self-harm and suicide behaviours among serving and ex-serving personnel of the United Kingdom Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force.

METHODS

A systematic search of seven online databases (PubMed, Web of Science, Embase, Global Health, PsycINFO, PTSDpubs and CINAHL) was conducted alongside cross-referencing, in October 2022. Following an a priori PROSPERO approved protocol (CRD42022348867), papers were independently screened and assessed for quality. Data were synthesised using a narrative approach.

RESULTS

Overall, 28 papers were included: 13 from Canada, 10 from the United Kingdom, five from Australia and none from New Zealand. Identified risk factors included being single/ex-relationship, early service leavers, shorter length of service (but not necessarily early service leavers), junior ranks, exposure to deployment-related traumatic events, physical and mental health diagnoses, and experience of childhood adversity. Protective factors included being married/in a relationship, higher educational attainment, employment, senior ranks, and higher levels of perceived social support.

CONCLUSION

Adequate care and support are a necessity for the military community. Prevention and intervention strategies for self-harm and suicide behaviours may be introduced early and may promote social networks as a key source of support. This review found a paucity of peer-reviewed research within some populations. More peer-reviewed research is needed, particularly among these populations where current work is limited, and regarding modifiable risk and protective factors.

Service and demographic factors, health, trauma exposure, and participation are associated with adjustment for former Australian Defense Force members

Approximately 50% of transitioning service members report difficulty adjusting to civilian life. However, there is limited research exploring factors that influence adjustment for former Australian Defence Force (ADF) members. The aim of this study was to investigate the influence of demographic and service-related characteristics, trauma exposure, health, and participation in meaningful occupations on adjustment for former ADF members. One hundred and ninety-eight former ADF members completed a voluntary, online survey containing validated self-report measures for adjustment, health, and exposure to combat and military sexual trauma. Participation in meaningful occupations was assessed using open-ended questions and a rating scale for frequency of participation. A more difficult adjustment was reported by participants who had completed operational service, reported exposure to combat and/or military sexual trauma, had poor physical health and were discharged for medical reasons. Other characteristics associated with a difficult adjustment included emotional distress, involuntary discharge, age category 30-49 years, final rank of Senior Noncommissioned Officer/Warrant Officer or below, and discharge 6-8 years previously. Employment, voluntary work and care, and social and community interaction were associated with an easier adjustment. Screening tools that consider health, age, deployment type, final rank, type of discharge and exposure to combat or military sexual trauma may be helpful to identify and refer high risk individuals to employment, rehabilitation or transition support programs.

Recommendations for follow-up care during post-deployment screening of Canadian Armed Forces personnel: how well does self-reported mental health predict referral decisions?

OBJECTIVE

Canadian Armed Forces (CAF) post-deployment screening aims to facilitate early care for members with mental health issues. The process consists of a questionnaire to screen for mental health problems, followed by an interview with a healthcare provider during which recommendations for follow-up care are provided if needed. In this study, we examined the association of self-reported mental health from the screening questionnaire with recommendation for follow-up care during the interview.

DESIGN

Using screening data collected from CAF members who deployed from 2009 to 2012 (n=14 957), logistic regression analysis was conducted to examine the association of self-reported mental health from the screening questionnaire with clinicians' recommendation for follow-up care.

RESULTS

In total, 19.7% of screened individuals were recommended for follow-up care. In the adjusted logistic regression model, some demographic characteristics, as well current and prior mental healthcare and self-reported mental health problems, had a substantial association with recommendation for follow-up. Compared with each mental health problem's lowest severity category, recommendation for follow-up care was higher by approximately 12%-17% for those with mild to severe depression, 7% for those with panic disorder, 8%-10% for those with mild to severe anxiety, 8% for those experiencing high levels of stressors, 4%-10% for those at risk of alcohol use disorder and 7%-12% for those at risk of post-traumatic stress disorder.

CONCLUSIONS

Although the presence of mental health problems was significantly associated with receiving a follow-up recommendation, the relationships between self-reported mental health and subsequent recommendations for care were not as high as expected. Although this may partly reflect time delays between the questionnaire and interview, further research is needed on the extent to which other factors contributed to referral decisions.

Does recommended mental health follow-up care occur after postdeployment screening in the Canadian Armed Forces? A retrospective cohort study

OBJECTIVE

To determine Canadian service members' level of adherence to a recommendation for mental health services follow-up that was assigned by clinicians during postdeployment screening.

DESIGN

Retrospective cohort study.

SETTING

Canadian military population.

PARTICIPANTS

The cohort consisted of personnel (n=28 460) with a deployment within the 2009-2014 time frame. A stratified random sample (n=3004) was selected for medical chart review. However, we restricted our analysis to individuals whose completed screening resulted in a recommendation for mental health services follow-up (sample n=316 (weighted n=2034) or 11.2% of screenings.

INTERVENTIONS

Postdeployment health screening.

PRIMARY OUTCOME MEASURE

The outcome was adherence to a screening-indicated mental health services follow-up recommendation, assessed within 90 days, a preferred delay, and within 365 days, a delay considered partially associated with the screening recommendation.

RESULTS

Adherence within 90 days of screening was 71.1% (95% CI 59.7% to 82.5%) for individuals with 'major' mental health concerns, 36.1% (95% CI 23.9% to 48.4%) for those with 'minor' mental health concerns, and 46.8% (95% CI 18.6% to 75.0%), for those with psychosocial mental health concerns; the respective 365-day adherence fractions were 85.3% (95% CI 76.1% to 94.5%), 55.7% (95% CI 42.0% to 69.4%) and 48.6% (95% CI 20.4% to 76.9%). Logistic regression indicated that a 90-day adherence among those with a 'major' mental health concern was higher among those screening after 2012 (adjusted OR (AOR) 5.45 (95% CI 1.08 to 27.45)) and lower, with marginal significance, among those with deployment durations greater than 180 days (AOR 0.35 (95% CI 0.11 to 1.06)).

CONCLUSIONS

On an individual level, screening has the potential to identify when a care need is present and a follow-up assessment can be recommended; however, we found that adherence to this recommendation is not absolute, suggesting that administrative checks and possibly, process refinements would be beneficial to ensure that care-seeking barriers are minimised.

Prevalence and predictors of anxiety disorder courses in the Canadian Armed Forces

Few studies have examined the longitudinal courses of anxiety disorders in military members. This study examined the prevalence and predictors of courses of any anxiety disorder in members and veterans of the Canadian Armed Forces, including no lifetime, remitted, new onset, and persistent/recurrent anxiety disorder. The 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey is a 16-year follow-up of n = 2941 participants from the Canadian Community Health Survey: Canadian Forces Supplement in 2002. Diagnoses of any DSM-IV anxiety disorder (i.e., generalized anxiety, social anxiety, and/or panic disorder) in 2002 and 2018 were used to create four anxiety course groups. A large proportion of the sample (36.3 %; new onset = 24.6 %, remitting = 6.9 %, and persistent/recurrent = 4.8 %) met criteria for an anxiety disorder during one or both time points. Factors at baseline and/or between 2002 and 2018, including income, education, military rank, comorbidity of PTSD or depression, deployment history, and traumatic events, were positively associated with most anxiety courses relative to no anxiety in analyses. Targeted interventions are needed to help mitigate anxiety disorders among this population. Social support and active coping were protective factors for most anxiety courses and may need to be incorporated into targeted interventions.

Pathways to mental health care in active military populations across the Five-Eyes nations: An integrated perspective

Military service is associated with increased risk of mental health problems. Previous reviews have pointed to under-utilization of mental health services in military populations. Building on the most recent systematic review, our narrative, critical review takes a complementary approach and considers research across the Five-Eyes nations from the past six years to update and broaden the discussion on pathways to mental healthcare in military populations. We find that at a broad population level, there is improvement in several indicators of mental health care access, with greater gains in initial engagement, time to first treatment contact, and subjective satisfaction with care, and smaller gains in objective indicators of adequacy of care. Among individual-level barriers to care-seeking, there is progress in improving recognition of need for care and reducing stigma concerns. Among organizational-level barriers, there are advances in availability of services and cultural acceptance of care-seeking. Other barriers, such as concerns around confidentiality, career impact, and deployability persist, however, and may account for some remaining unmet need. To address these barriers, new initiatives that are more evidence-based, theoretically-driven, and culturally-sensitive, are therefore needed, and must be rigorously evaluated to ensure they bring about additional improvements in pathways to care.

Association of Child Maltreatment and Deployment-related Traumatic Experiences with Mental Disorders in Active Duty Service Members and Veterans of the Canadian Armed Forces: Association de la Maltraitance des Enfants et des Expériences Traumatisantes Liées au Déploiement Avec les Troubles Mentaux Chez les Membres du Service Actif et Les Anciens Combattants des Forces Armées Canadiennes

OBJECTIVE

Mental health among military personnel is an important public health priority. It is known that military personnel experience a high prevalence of child maltreatment and deployment-related traumatic events (DRTEs) and both are related to mental health outcomes. However, few, if any, studies have examined the cumulative and interactive effects of child maltreatment and DRTEs on mental health disorders in a sample of active duty service members and military veterans.

METHODS

Data were from the Canadian Armed Forces (CAF) Members and Veterans Mental Health Follow-up Survey collected in 2018 (N = 2,941, response rate = 68.7%), a 16-year follow-up survey of CAF Regular Force members interviewed in 2002. Five types of child maltreatment and 10 types of DTREs were assessed for impact on mental health. Mental disorders included past 12-month generalized anxiety disorder (GAD), panic disorder, social phobia, and major depressive episode (MDE). Past 12-month symptoms of posttraumatic stress disorder (PTSD) were also examined.

RESULTS

The prevalence of any exposure to child maltreatment and DRTEs was 62.5% and 68.6%, respectively. All types of child maltreatment were associated with increased odds of past 12-month PTSD symptoms and mental disorders with the exception of physical abuse and GAD as well as childhood exposure to intimate partner violence and panic disorder. Cumulative effects of having experienced both child maltreatment and DRTEs increased the odds of past 12-month PTSD symptoms, GAD, social phobia, and MDE. No interaction effects were significant.

CONCLUSIONS

The prevalence of a child maltreatment history is high among active Canadian military and veterans. As well, child maltreatment may increase the likelihood of mental disorders across the life span. This may be especially true for individuals who also experience DRTEs. Understanding these relationships may provide insight into developing effective interventions for military personnel and veteran mental health outcomes.

Does screening shorten delays to care for post-deployment mental disorders in military personnel? A longitudinal retrospective cohort study

OBJECTIVE

To determine whether post-deployment screening is associated with a shorter delay to diagnosis and care among individuals identified with a deployment-related mental disorder.

DESIGN

Retrospective cohort study.

SETTING

Canadian military population.

PARTICIPANTS

The cohort consisted of personnel (n=28 460) with a deployment within the 2009 to 2014 time frame. A stratified random sample (n=3004) was selected for medical chart review. We restricted our analysis to individuals who had an opportunity to undergo screening and were subsequently diagnosed with a mental disorder that a clinician indicated was deployment-related (n=1157).

INTERVENTIONS

Post-deployment health screening.

MAIN OUTCOME MEASURE

The outcome was delay to diagnosis and care, the latency from individuals' deployment return to their mental disorder diagnosis date. Cox proportional hazards regression assessed screening's influence on this outcome.

RESULTS

74.4% of the study population had screened. Overall, the median delay to care was 766 days, 578 days among screeners and 928 days among non-screeners-a 350-day difference. Cox regression indicated that screeners had a significantly shorter delay to care (adjusted HR (aHR), 1.43 (95% CI, 1.11 to 1.86)). Screening findings had a substantial influence on delay to care. Identification of a mental health concern, whether a 'major' concern (aHR, 3.36 (95% CI, 2.38 to 4.73)) or a 'minor' concern (aHR, 1.46 (95% CI, 1.08 to 1.99)), and a recommendation for mental health services follow-up (aHR, 2.35 (95% CI, 1.73 to 3.21)) were strongly associated with shorter delays to care relative to non-screeners.

CONCLUSIONS

Reduced delays to care are anticipated to lead to beneficial outcomes for both the individual and military organisation. We found that screening was associated with a shortened delay to care for mental disorders that were deployment-related. Future work will further explore this screening's components and optimisation strategies.

Differences between the Canadian military's Regular and Reserve Forces in perceived need for care, mental health services use and perceived sufficiency of care: a cross-sectional survey

OBJECTIVE

The primary objective was to explore differences in perceived need for care (PNC), mental health services use (MHSU) and perceived sufficiency of care (PSC) between Canadian Armed Forces Regular Force (RegF) and Reserve Force (ResF) personnel with an objective need for mental health services.

DESIGN

Data came from the 2013 Canadian Armed Forces Mental Health Survey, a cross-sectional survey of serving personnel (n=72 629). Analyses were among those with an Afghanistan deployment and an identified mental disorder (population n=6160; sampled n=868). Logistic regression compared PNC, MHSU and PSC between RegF and ResF. Covariate-adjusted marginal prevalence difference estimates were computed.

PRIMARY OUTCOME MEASURE

The primary outcomes were PNC, MHSU and PSC. Each had three service categories, including an aggregate 'any' of the three: (1) information about problems, treatments or services; (2) medication and (3) counselling.

RESULTS

ResF had an 10.5% (95% CI -16.7% to -4.4%) lower perceived need for medication services but PNC differences were not significant for other service categories. MHSU tended to be lower for ResF; 9.1% (95%CI -15.5% to -2.6%) lower for medication, 5.4% (95% CI -11.5% to 0.7%) lower, with marginal significance, for counselling and 11.3% (95% CI -17.3% to -5.2%) lower for the 'any' service category. Additionally, ResF tended to have a lower fully met need for care; 13.4% (95% CI -22.1% to -4.6%) lower for information, 15.3% (95% CI -22.9% to -7.6%) lower for counselling and 14.6% (95% CI -22.4% to -6.8%) lower for the 'any' service category.

CONCLUSIONS

Our findings suggest MHSU and PSC differences between Canadian RegF and ResF personnel that are not fully accounted for by PNC differences. Deficits in ResF members' perceptions of the sufficiency of information services and counselling services suggest perceived, or experienced, barriers to care beyond any PNC barriers. Additional research assessing barriers to mental healthcare is warranted.

Retrospective cohort study of compliance with post-deployment screening in the Canadian Armed Forces

OBJECTIVE

Canadian Armed Forces (CAF) personnel who return from certain international deployments are required to complete post-deployment screening (PDS) 90 to 180 days post-deployment; the primary goal of PDS is early detection of mental health problems that aims for reduced delays to care provision. We investigated service members' compliance with the PDS completion requirement and the factors associated with this compliance; a secondary objective was to investigate completion timing.

DESIGN

The study used a retrospective cohort of CAF personnel (n=28 460) who had deployments over 01 January 2009 to 31 December 2014; inferences were based on a probabilistic sample (n=3004).

PRIMARY OUTCOME

The primary outcome was PDS completion. We assessed the timing of PDS completion, comparing non-compliant (early, late or no completion) with compliant completions (90 to 180 days post-deployment) among deployments that required screening. Kaplan-Meier plots summarised time-to-completion and logistic regression assessed the covariate associations with compliant completion. Covariate-adjusted marginal compliance prevalence differences (MPD) were computed.

RESULTS

67.3% (95% CI65.0 to 69.6) of deployments that required PDS had one completed; 43.3% (95%CI 40.6 to 46.0) were completed within the compliant period. Compliant completion was higher with lower ranks (MPD=10.6%, relative to officers), combat arms occupations (MPD=8.4%), Afghanistan deployments (MPD=19.2%), longer deployments (MPD=10.1%) and among those without a past mental health problem (MPD=9.7%).

CONCLUSIONS

Our findings suggest that some selective processes may be occurring where those perceived to be at higher risk for post-deployment mental health problems are more compliant with PDS completion. However, PDS completion and compliant completion were lower than expected and this suggests a need to reinforce instruction on the guidelines and objectives of PDS among service members in the CAF.