Prevalence of Past-Year Mental Disorders in the Canadian Armed Forces, 2002-2013

Coping style as a risk factor for future alcohol use disorder: A 16-year longitudinal study in a Canadian military sample

BACKGROUND

Coping strategies used in response to stress have the potential to influence the development of mental health disorders, including alcohol use disorders. The current study investigated whether coping strategies placed an individual at greater likelihood for developing a future alcohol use disorder.

METHODS

This study used data from the Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey; a nationally representative 16-year follow-up survey, with initial data collected in the 2002 Canadian Community Health Survey - Canadian Forces Supplement. The total sample from the two datasets included 2941 individuals who were Regular Force members in 2002. Coping styles included problem-focused, avoidant, and self-medication. Adjusted logistic regression analyses examined relationships between coping style (in 2002) and alcohol use disorders (developed between 2002 and 2018).

RESULTS

Self-medication coping in 2002 was associated with any alcohol disorder since last interview (i.e., 2002-2018) (AOR 1.26; 95 % CI, 1.02-1.57) and during the past year (adjusted odds ratios [AOR 1.26; 95 % CI, 1.08-1.47]), as well as past-year binge drinking (AOR 1.19; 95 % CI, 1.09-1.29). Problem-focused coping was protective against past-year alcohol abuse (AOR 0.84; 95 % CI, 0.71-1.00) and any alcohol use disorder (AOR 0.87; 95 % CI 0.76-1.00).

CONCLUSION

Coping styles were strongly associated with future alcohol use disorders. Notably, results show the risk extended over a 16-year period. Findings suggest the use of self-medicating coping strategies places an individual at increased risk of developing alcohol use disorders, while problem-focused coping may decrease future risk of alcohol use disorders.

Problem drinking recognition among UK military personnel: prevalence and associations

PURPOSE

Despite the higher prevalence of problem drinking in the UK military compared to the general population, problem recognition appears to be low, and little is known about which groups are more likely to recognise a problem. This study examined prevalence of problem drinking recognition and its associations.

METHODS

We analysed data from 6400 regular serving and ex-serving personnel, collected in phase 3 (2014-2016) of the King's Centre for Military Health Research cohort study.

MEASUREMENTS

Participants provided sociodemographic, military, health and impairment, life experiences, problem drinking, and problem recognition information. Problem drinking was categorised as scores ≥ 16 in the AUDIT questionnaire. Associations with problem recognition were examined with weighted logistic regressions.

FINDINGS

Among personnel meeting criteria for problem drinking, 49% recognised the problem. Recognition was most strongly associated (ORs ≥ 2.50) with experiencing probable PTSD (AOR = 2.86, 95% CI = 1.64-5.07), social impairment due to physical or mental health problems (AOR = 2.69, 95% CI = 1.51-4.79), adverse life events (AOR = 2.84, 95% CI = 1.70-4.75), ever being arrested (AOR = 2.99, CI = 1.43-6.25) and reporting symptoms of alcohol dependence (AOR = 3.68, 95% CI = 2.33-5.82). To a lesser extent, recognition was also statistically significantly associated with experiencing psychosomatic symptoms, feeling less healthy, probable common mental health disorders, and increased scores on the AUDIT.

CONCLUSION

Half of UK military personnel experiencing problem drinking does not self-report their drinking behaviour as problematic. Greater problem drinking severity, poorer mental or physical health, and negative life experiences facilitate problem recognition.

Trastorno de estrés postraumático y calidad de vida del paciente post COVID-19 en atención primaria

Objetivo

Determinar la asociación entre los síntomas de trastorno por estrés postraumático (TEPT) con la calidad de vida relacionada con la salud (CVRS) del paciente post-COVID-19 en Atención Primaria.

Diseño

Estudio transversal, multicéntrico, con muestreo probabilístico aleatorizado.

Emplazamiento

Centros de Atención Primaria de Ica-Perú.

Participantes

Seiscientos treinta y seis pacientes con diagnóstico previo de COVID-19.

Mediciones principales

La variable síntomas de TEPT, fue medida con el cuestionario COVID-19-PTSD y la CVRS con la escala EuroQol (EQ-5D). Se analizaron factores sociodemográficos y de salud que incluyó el síndrome post-COVID-19. Se realizó un análisis descriptivo y se calcularon razones de prevalencia (RP) crudas y ajustadas, mediante modelos lineales generalizados de la familia Poisson, para buscar asociación entre las variables.

Resultados

De los participantes, el 21,4% presentó síntomas de TEPT; el 33,6%, síntomas de excitación disfórica y ansiosa; el 22,3%, intrusión, evitación y afecto negativo; 22,6%, anhedonia, y el 23,6%, comportamiento exteriorizante. El 50,3% reveló al menos un componente de la CVRS afectada; el 35,5%, problemas vinculados con ansiedad/depresión; el 34,9%, dolor/malestar; el 11%, actividad cotidiana; el 10,7%, movilidad y el 6,6%, cuidado personal. La presencia de síntomas de TEPT mostró asociación con la CVRS afectada (RP = 2,46: IC del 95%: 2,19-2,78). Asimismo, ciertas variables sociodemográficas y de salud se asociaron con los síntomas de TEPT y la CVRS afectada.

Conclusiones

Los síntomas de TEPT incrementan la probabilidad de afectar la CVRS del paciente post-COVID-19. Existen variables sociodemográficas y de salud potencialmente modificables que podrían mermar los síntomas de TEPT y mejorar la CVRS.

A Scoping Review on the Prevalence and Determinants of Post-Traumatic Stress Disorder among Military Personnel and Firefighters: Implications for Public Policy and Practice

INTRODUCTION

Firefighters and military personnel are public safety personnel who protect the safety of individuals and their properties. They are usually exposed to traumatic events leaving them at risk of developing mental health conditions such as post-traumatic stress disorder (PTSD). Increasing concern is being raised regarding the mental health impacts, specifically PTSD, among military personnel and firefighters.

OBJECTIVE

There is an increased exposure of firefighters and military personnel to traumatic events and the attendant risk of developing post-traumatic stress disorder. It is crucial to ascertain the level of PTSD amongst this cohort and determinants to formulate policies and practices that mitigate the risk and protect public safety personnel. This scoping review sought to determine the prevalence of PTSD among this cohort globally and to explore determinants of this mental health condition.

METHODS

A literature search in databases including MEDLINE, CINAHL, PubMed, PsycINFO, and EMBASE was conducted electronically from May 2021 to 31 July 2021. Two reviewers independently assessed full-text articles according to the predefined inclusion criteria and screening process undertaken to identify studies for the review. Articles were screened with a third reviewer, resolving conflicts where necessary and further assessing them for eligibility. During article selection, the PRISMA checklist was adopted, and with the Covidence software, a total of 32 articles were selected for the final examination. For the eligible studies, data extraction was conducted, information was collated and summarized, and the findings were reported. Original qualitative and quantitative data on the prevalence and predictors of PTSD among veterans, military, and firefighters were reported.

RESULTS

The prevalence of PTSD was 57% for firefighters and 37.8% for military personnel. Demographic factors, job factors, social support, injuries, physical and psychological factors, and individual traits were the main predictors of PTSD in this cohort.

CONCLUSION

This information is vital for developing and implementing prevention and intervention strategies for PTSD in military personnel and firefighters. Recognizing and addressing factors that predict PTSD will help to improve mental wellbeing and increase productivity. More peer-reviewed studies are needed on the prevalence of PTSD amongst these cohorts.

Decreased Emotional Dysregulation Following Multi-Modal Motion-Assisted Memory Desensitization and Reconsolidation Therapy (3MDR): Identifying Possible Driving Factors in Remediation of Treatment-Resistant PTSD

Multi-modal motion-assisted memory desensitization and reconsolidation therapy (3MDR), an interactive, virtual reality-assisted, exposure-based intervention for PTSD, has shown promising results for treatment-resistant posttraumatic stress disorder (TR-PTSD) among military members (MMs) and veterans in randomized controlled trials (RCT). Previous research has suggested that emotional regulation (ER) and emotional dysregulation (ED) may be factors which are correlated with symptom severity and maintenance of TR-PTSD. This embedded mixed-methods pilot study (n = 9) sought to explore the impact of 3MDR on ER and ED of MMs and veterans. Difficulties in Emotional Regulation Scale (DERS-18) data were collected at baseline, prior to each session, and at one week, one month, and three months postintervention and analyzed. Qualitative data collected from sessions, debriefs, and follow-up interviews were transcribed and descriptively analyzed. Results demonstrated statistically significant decreases in DERS-18 scores from preintervention to postintervention at each timepoint. Qualitatively, participants perceived improvements in ER within specified DERS-18 domains. We describe how 3MDR's unique and novel approach addresses ED through cognitive-motor stimulation, narration, divergent thinking, reappraisal of aversive stimuli, dual-task processing, and reconsolidation of traumatic memories. More studies are needed to better understand the underlying neurobiological mechanisms by which 3MDR addresses ER and PTSD.

Lifetime Prevalence and Comorbidity of Mental Disorders in the Two-wave 2002-2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS): Prévalence et Comorbidité de Durée de vie Des Troubles Mentaux Dans l'Enquête de Suivi Sur la Santé Mentale Auprès des Membres des Forces Armées Canadiennes et Des ex-Militaires (ESSMFACM) en Deux Cycles de 2002 à 2018

OBJECTIVE

The current study used the Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS) to (1) examine the incidence and prevalence of mental disorders and (2) estimate the comorbidity of mental disorders over the follow-up period.

METHOD

The CAFVMHS (2018) is a longitudinal study with two time points of assessment. The sample is comprised of 2,941 Canadian Forces members and veterans who participated in the 2002 Canadian Community Health Survey: Canadian Forces Supplement. The World Health Organization Composite International Diagnostic Interview (WHO-CIDI) was utilized to diagnose Diagnostic and Statistical Manual-IV post-traumatic stress disorder (PTSD), major depressive episode (MDE), generalized anxiety disorder, social anxiety disorder (SAD), and alcohol abuse and dependence. Self-report health professional diagnoses were assessed for attention deficit hyperactivity disorder (ADHD), mania, obsessive compulsive disorder (OCD), and personality disorder. We established weighted prevalence of mental disorders and examined the association between mental disorders using logistic regression.

RESULTS

In 2018, lifetime prevalence of any WHO-CIDI-based or self-reported mental disorder was 58.1%. Lifetime prevalence of any mood or anxiety disorder or PTSD was 54.0% in 2018. MDE (39.9%), SAD (25.7%), and PTSD (21.4%) were the most common mental disorders. There was a substantial increase in new onset or recurrence/persistence of mental disorders between the two measurement points (16-year assessment gap); 2002-2018 period prevalences were 43.5% for mood and anxiety disorder and 16.8% for alcohol abuse or dependence. The prevalence of self-reported ADHD, OCD, any personality disorder, and mania were 3.3%, 3.0%, 0.8%, and 0.8%, respectively. Comorbidity between mental disorders increased over the follow-up.

CONCLUSIONS

This study demonstrates a high burden of mental disorders among a large Canadian military and veteran cohort. These findings underscore the importance of prevention and intervention strategies to reduce the burden of mental disorders and alcohol use disorders in these populations.

Course and Predictors of Major Depressive Disorder in the Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey: Cours et Prédicteurs du Trouble de Dépression Majeure Dans l'Enquête de Suivi Sur la Santé Mentale Auprès Des Membres des Forces Armées Canadiennes et des ex-Militaires

OBJECTIVES

The present report is the first study of Canadian military personnel to use longitudinal survey data to identify factors that determine major depressive episodes (MDEs) over a period of 16 years.

METHODS

The study used data from the Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS) collected in 2018 (n = 2,941, response rate 68.7%) and linked baseline data from the same participants that were collected in 2002 when they were Canadian Regular Force members. The study used structured interviews to identify 5 common Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition mental disorders and collected demographic data, as well as information about traumatic experiences, childhood adversities, work stress, and potential resilience factors. Respondents were divided into 4 possible MDE courses: No Disorder, Remitting, New Onset, and Persistent/Recurrent. Relative risk ratios (RRRs) from multinomial regression models were used to evaluate determinants of these outcomes.

RESULTS

A history of anxiety disorders and post-traumatic stress disorder (RRRs: 1.50 to 20.55), mental health service utilization (RRRs: 1.70 to 12.34), veteran status (RRRs: 1.64 to 2.15), deployment-associated traumatic events (RRRs: 1.71 to 2.27), sexual traumas (RRRs: 1.91 to 2.93), other traumas (RRRs: 1.67 to 2.64), childhood adversities (RRRs: 1.39 to 1.97), avoidance coping (RRRs 1.09 to 1.49), higher frequency of religious attendance (RRRs: 1.54 to 1.61), and work stress (RRRs: 1.05 to 1.10) were associated with MDE courses in most analyses. Problem-focused coping (RRRs: 0.73 to 0.91) and social support (RRRs: 0.95 to 0.98) were associated with protection against MDEs.

CONCLUSIONS

The time periods following deployment and trauma exposure and during the transition from active duty to veteran status are particularly relevant for vulnerability to depression in military members. Interventions that enhance problem-focused coping and social support may be protective against MDEs in military members.

Rationale and Methodology of the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS): A 16-year Follow-up Survey: Raison D'être Et Méthodologie De L'enquête De Suivi Sur La Santé Mentale Des Membres Des Forces Armées Canadiennes Et Des Anciens Combattants, 2018 (ESSMFACM)

OBJECTIVE

Knowledge is limited regarding the longitudinal course and predictors of mental health problems, suicide, and physical health outcomes among military and veterans. Statistics Canada, in collaboration with researchers at the University of Manitoba and an international team, conducted the Canadian Armed Forces Members and Veterans Mental Health Follow-Up Survey (CAFVMHS). Herein, we describe the rationale and methods of this important survey.

METHOD

The CAFVMHS is a longitudinal survey design with 2 time points (2002 and 2018). Regular Force military personnel who participated in the first Canadian Community Health Survey Cycle 1.2-Mental Health and Well-Being, Canadian Forces Supplement (CCHS-CFS) in 2002 (N = 5,155) were reinterviewed in 2018 (n = 2,941). The World Mental Health Survey-Composite International Diagnostic Interview was used with the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria.

RESULTS

The CAFVMHS includes 2,941 respondents (66% veterans; 34% active duty) and includes data on mental disorder diagnoses, physical health conditions, substance use, medication use, general health, mental health services, perceived need for care, social support, moral injury, deployment experiences, stress, physical activity, military-related sexual assault, childhood experiences, and military and sociodemographic information.

CONCLUSIONS

The CAFVMHS provides a unique opportunity to further understand the health and well-being of military personnel in Canada over time to inform intervention and prevention strategies and improve outcomes. The data are available through the Statistics Canada Research Data Centres across Canada and can be used cross-sectionally or be longitudinally linked to the 2002 CCHS-CFS data.

Course and Predictors of Posttraumatic Stress Disorder in the Canadian Armed Forces: A Nationally Representative, 16-Year Follow-up Study: Cours et prédicteurs du trouble de stress post-traumatique dans les Forces armées canadiennes: une étude de suivi de 16 ans nationalement représentative

OBJECTIVE

This study examined baseline risk and protective predictors and interim correlates of the persistence/recurrence, remission, and onset of posttraumatic stress disorder (PTSD) in a 16-year prospective, nationally representative sample of Canadian Forces members and veterans.

METHODS

The 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey is a prospective study of 2,941 regular force service members and veterans who participated in the 2002 Canadian Community Health Survey on Mental Health and Wellbeing: Canadian Forces Supplement (n = 5,155; ages 15 to 64 years; response rate 68%). PTSD diagnoses in 2002 and 2018 were used to create 4 groups: (1) no lifetime, (2) remitted, (3) new onset, and (4) persistent/recurrent PTSD. Multinomial regressions were conducted to identify predictors of PTSD courses.

RESULTS

Female sex, being a junior noncommissioned member (vs. officer), and land (vs. air) operations in 2002 were associated with all PTSD courses relative to no lifetime PTSD (relative risk ratio [RRR] range: 1.28 to 3.65). After adjusting for sociodemographic variables, baseline predictors of all PTSD courses included lifetime mental disorder, history of mental health care utilization, all trauma type categories (deployment-associated, sexual, "other"), and the number of lifetime traumatic events (RRR range: 1.14 to 8.95). New ("since 2002") traumas, transitioning to veteran status, and alcohol dependence were mostly associated with the new onset and persistent/recurrent PTSD courses (RRR range: 1.79 to 4.31), while mental health care utilization and greater avoidance coping were associated with all PTSD courses (RRR range: 1.10 to 17.87). Protective factors for several PTSD courses at one or both time points included social support, social network size, and problem-focused coping (RRR range: 0.71 to 0.98).

CONCLUSIONS

This is the first population-based survey to examine the longitudinal course of PTSD in Canadian Forces members. Prevention and intervention programs focused on bolstering social support and active coping strategies as possible protective factors/correlates may help mitigate the development and persistence of PTSD.

Patterns of distress associated with exposure to potentially morally injurious events among Canadian Armed Forces service members and Veterans: A multi-method analysis

OBJECTIVE

This study describes patterns of distress associated with exposure to potentially morally injurious experiences (PMIEs) in a Canadian military sample.

METHOD

Thematic analysis was performed on interviews from PMIE-exposed military members and Veterans. Participants also completed structured diagnostic interviews, and measures of trauma exposure and psychopathology. Multiple regression examined associations among these variables. Information on pharmacological treatment and past diagnoses are reported.

RESULTS

Eight qualitative themes were identified: changes in moral attitudes, increased sensitivity and reactivity to moral situations, loss of trust, disruptions in identity, disruptions in spirituality, disruptions in interpersonal relatedness, rumination, and internalizing and externalizing emotions and behaviors. Self-report data revealed that degree of PMIE exposure was meaningfully associated with posttraumatic stress disorder.

CONCLUSION

Qualitative but not quantitative findings supported existing models of moral injury (MI). Additional research is needed to examine the impact of PMIE type on mental health, and to test basic assumptions of MI theory.

The neural, behavioral, and epidemiological underpinnings of comorbid alcohol use disorder and post-traumatic stress disorder

Alcohol use disorder (AUD) and (PTSD) frequently co-occur and individuals suffering from this dual diagnosis often exhibit increased symptom severity and poorer treatment outcomes than those with only one of these diseases. Although there have been significant advances in our understanding of the neurobiological mechanisms underlying each of these disorders, the neural underpinnings of the comorbid condition remain poorly understood. This chapter summarizes recent epidemiological findings on comorbid AUD and PTSD, with a focus on vulnerable populations, the temporal relationship between these disorders, and the clinical consequences associated with the dual diagnosis. We then review animal models of the comorbid condition and emerging human and non-human animal research that is beginning to identify maladaptive neural changes common to both disorders, primarily involving functional changes in brain reward and stress networks. We end by proposing a neural framework, based on the emerging field of affective valence encoding, that may better explain the epidemiological and neural findings on AUD and PTSD.

The influence of depression-PTSD comorbidity on health-related quality of life in treatment-seeking veterans

OBJECTIVE

Posttraumatic stress disorder (PTSD) and depression substantially impair health-related quality of life (HRQOL) for many Canadian Armed Forces (CAF) veterans. Although PTSD and depression are highly comorbid, little is known about whether the disorders may interact in their association with HRQOL. We sought to investigate whether depressive symptoms modify the relation between PTSD and HRQOL in treatment-seeking veterans.

METHOD

We accessed the clinical data of 545 CAF veterans aged 18 to 65 years who were seeking treatment at a specialized clinic in London, Ontario. We used hierarchical linear regression to assess the additive and multiplicative relations between depression and PTSD symptoms on HRQOL, controlling for age and alcohol/substance abuse. Simple slopes were examined to probe significant interactions.

RESULTS

Probable PTSD and major depression were present in 77.4% and 85.3% of the sample, respectively, and 73.0% of the sample presented with probable PTSD-depression comorbidity. Depression symptoms significantly modified the relation between PTSD symptoms and overall mental HRQOL (β = 0.12, p <0.001, ∆R²  = 0.014), and role impairment due to emotional difficulties (β = 0.20, p <0.001, ∆R²  = 0.035). Simple slope analyses revealed the impact of PTSD was greater among those with lower depression symptoms and became weaker with greater depression symptom severity. In adjusted models, only depression was significantly associated with all mental and physical HRQOL domains; PTSD was not associated with physical HRQOL, role emotional impairment, or vitality.

CONCLUSIONS

For those with severe comorbid depression, PTSD symptoms were no longer associated with mental HRQOL, particularly in areas related to emotional functioning. Findings suggest the importance of targeting depression in patients presenting with PTSD-depression comorbidity.

A Cross-Sectional Study of the Relationship between Previous Military Experience and Mental Health Disorders in Currently Serving Public Safety Personnel in Canada

OBJECTIVE

There is an increased incidence of some mental health disorders such as post-traumatic stress disorder (PTSD) in some members of the military and in some public safety personnel (PSP) such as firefighters, police officers, paramedics, and dispatchers. Upon retirement from the armed forces, many individuals go on to second careers as PSP. Individuals with prior military experience may be at even greater risk than nonveterans for developing mental health disorders. The present study was designed to examine the relationship between prior military service and symptoms of mental health disorders in PSP.

METHODS

This is a cross-sectional, observational study. Data for this study were collected from an anonymous, web-based, self-report survey of PSP in Canada. Invitations to participate were sent to PSP via their professional organizations. Indications of mental disorder(s) and symptom severity were assessed using well-validated self-report screening measures.

RESULTS

Of the survey respondents who provided this information, 631 (6.8%) had prior armed forces experience; however, not all responses were complete. Ex-military PSP reported significantly more exposure to traumatic events and were approximately 1.5 times more likely to screen positive for indications of PTSD, mood, anxiety, or acute stress disorders and to have contemplated suicide than those without prior armed forces experience.

CONCLUSIONS

In our study, individuals in PSP with prior service experience in the armed forces were more likely to screen positive for indicators of some mental health disorders. Accordingly, mental health practitioners should inquire about previous service in the armed forces when screening, assessing, and treating PSP.

Incidence of major depression diagnoses in the Canadian Armed Forces: longitudinal analysis of clinical and health administrative data

PURPOSE

Major depression is a leading cause of morbidity in military populations. However, due to a lack of longitudinal data, little is known about the rate at which military personnel experience the onset of new episodes of major depression. We used a new source of clinical and administrative data to estimate the incidence of major depression diagnoses in Canadian Armed Forces (CAF) personnel, and to compare incidence rates between demographic and occupational factors.

METHODS

We extracted all data recorded in the electronic medical records of CAF Regular Force personnel, at every primary care and mental health clinical encounter since 2016. Using a 12-month lookback period, we linked data over time, and identified all patients with incident diagnoses of major depression. We then linked clinical data to CAF administrative records, and estimated incidence rates. We used multivariate Poisson regression to compare adjusted incidence rates between demographic and occupational factors.

RESULTS

From January to December 2017, CAF Regular Force personnel were diagnosed with major depression at a rate of 29.2 new cases per 1000 person-years at risk. Female sex, age 30 years and older, and non-officer ranks were associated with significantly higher incidence rates.

CONCLUSIONS

We completed the largest study to date on diagnoses of major depression in the Canadian military, and have provided the first estimates of incidence rates in CAF personnel. Our results can inform future mental health resource allocation, and ongoing major depression prevention efforts within the Canadian Armed Forces and other military organizations.

New perspectives on the neurobiology of PTSD: High-resolution imaging of neural circuit (dys)function with magnetoencephalography

Introduction: Combat-related posttraumatic stress disorder (PTSD) is increasingly conceptualized in psychiatry as a disorder of dysfunctional neural circuits. Advances in neuroimaging have enabled the study of those networks non-invasively. PTSD is currently assessed using subjective self-reporting to inform crucial decisions, such as fitness to deploy, but objective markers would aid in diagnosis and return-to-deployment decisions. Methods: Magnetoencephalography (MEG) allows investigation of neural circuit function via imaging of brain waves (known as neural oscillations) that index information processing in the brain and would prove a reliable, objective, biomarker. These measures of brain function establish how regions communicate to form brain circuits that support thinking and behaviour. Results: Studies into intrinsic brain function, both during rest and when engaged in a task designed to tap into cognitive dysfunction, have found these neurobiological mechanisms are disrupted in PTSD and are a reliable objective marker of illness. We now know that these alterations in brain function are directly related to core symptoms of PTSD and comorbid cognitive-behavioural challenges. Discussion: Continued characterization of neural function using MEG and related methods will advance understanding of the neurobiology underlying PTSD; allow for the identification of biomarkers that, coupled with machine learning, will aid in diagnoses; provide individualized therapeutic targets for neurostimulation; predict treatment outcomes; and track disorder remission in military personnel and Veterans who are disproportionately affected by this devastating illness.

Cyr K, Sareen J, Elhai JD, Zamorski MA. Comorbidity Patterns of Psychiatric Conditions in Canadian Armed Forces Personnel

OBJECTIVE

Posttraumatic stress disorder (PTSD) is often accompanied by other mental health conditions, including major depressive disorder (MDD), substance misuse disorders, and anxiety disorders. The objective of the current study is to delineate classes of comorbidity and investigate predictors of comorbidity classes amongst a sample of Canadian Armed Forces (CAF) Regular Force personnel.

METHODS

Latent class analyses (LCAs) were applied to cross-sectional data obtained between April and August 2013 from a nationally representative random sample of 6700 CAF Regular Force personnel who deployed to the mission in Afghanistan.

RESULTS

MDD was the most common diagnosis (8.0%), followed by PTSD (5.3%) and generalized anxiety disorder (4.7%). Of those with a mental health condition, LCA revealed 3 classes of comorbidity: a highly comorbid class (8.3%), a depressed-only class (4.6%), and an alcohol use-only class (3.1%). Multinomial logit regression showed that women (adjusted relative risk ratio [ARRR] = 2.77; 95% CI, 2.13 to 3.60; P < 0.01) and personnel reporting higher trauma exposure (ARRR = 4.18; 95% CI, 3.13 to 5.57; P < 0.01) were at increased risk of membership in the comorbid class compared to those without a mental health condition. When compared to those with no mental health condition, experiencing childhood abuse increased the risk of being in any comorbidity class.

CONCLUSIONS

Results provide further evidence to support screening for and treatment of comorbid mental health conditions. The role of sex, childhood abuse, and combat deployment in determining class membership may also prove valuable for clinicians treating military-related mental health conditions.

Suicide in Canadian veterans living in Ontario: a retrospective cohort study linking routinely collected data

OBJECTIVES

To compare the risk of death by suicide in male veterans with age-matched civilians.

DESIGN

Retrospective cohort study linking provincial administrative databases between 1990 and 2013 with follow-up complete until death or December 31, 2015.

SETTING

Population-based study in Ontario, Canada.

PARTICIPANTS

Ex-serving Canadian Armed Forces and Royal Canadian Mounted Police veterans living in Ontario who registered for provincial health insurance were included. A civilian comparator group was matched 4:1 on age and sex.

MAIN OUTCOME

Death by suicide was classified using standard cause of death diagnosis codes from a provincial registry of mandatory data collected from death certificates. Fine and Gray sub-distribution hazards regression compared the risk of death by suicide between veterans and civilians. Analyses were adjusted for age, residential region, income, rurality and major physical comorbidities.

RESULTS

20 397 male veterans released to Ontario between 1990 and 2013 and 81 559 age-sex matched civilians were included. 4.2% of veterans died during the study time frame, compared with 6.5% of the civilian cohort. Death by suicide was rare in both cohorts, accounting for 4.6% and 3.6% of veteran and civilian deaths, respectively. After adjustment for confounders, veterans had an 18% lower risk of dying from causes other than suicide (HR 0.82, 95% CI 0.76 to 0.89) and a similar risk of dying by suicide (HR 1.01, 95% CI 0.71 to 1.43), compared with civilians.

CONCLUSIONS

Deaths by suicide were rare in male veterans residing in Ontario. Our findings demonstrate that veterans had a similar risk of suicide-related mortality as an age-matched civilian population. A better understanding of effective suicide prevention as well as clarifying pathways to seeking and receiving mental health supports and services are important areas for future consideration.

Mental Health Service Utilization in Depressed Canadian Armed Forces Personnel

BACKGROUND

Major depression is prevalent, impactful, and treatable in military populations, but not all depressed personnel seek professional care in a given year. Care-seeking patterns (including the use of primary vs. specialty care) and factors associated with the likelihood of mental health service utilization in depressed military personnel are poorly understood.

METHODS

Our sample included 520 Regular Force respondents to the 2013 Canadian Forces Mental Health Survey. All study participants had past-year major depression. Subjects reported whether they had spoken about their mental health with at least one health professional in the past 12 months. We used multivariate Poisson regression to explore factors associated with past-year mental health service use.

RESULTS

Three-quarters of Canadian military personnel with past-year depression had sought mental health care in the previous 12 months. Among care-seeking personnel, 70% had seen a psychologist or psychiatrist, while 5% had exclusively received care from a primary care physician. Belief in the effectiveness of mental health care was the factor most strongly associated with care seeking. Female gender, functional impairments, and psychiatric comorbidities were also associated with care seeking. Surprisingly, stigma perceptions had no independent association with care seeking.

CONCLUSIONS

The proportion of depressed Canadian Armed Forces personnel who seek professional care and who access specialty mental health care is higher than in most other populations. However, an important minority of patients are not accessing health services. Efforts to further increase mental health service utilization in the Canadian military should continue to target beliefs about the effectiveness of mental health care.

Stigma doesn't discriminate: physical and mental health and stigma in Canadian military personnel and Canadian civilians

Background

Illness-related stigma has been identified as an important public health concern. Past research suggests there is a disproportionate risk of mental-health stigma in the military, but this same finding has not yet been established for physical-health stigma. The current study aimed to assess the independent contribution of mental and physical health on both enacted stigma (discriminatory behaviour) and felt stigma (feelings of embarrassment) and to determine whether these associations were stronger for military personnel than civilians.

Methods

Data were obtained from the 2002 Canadian Community Health Survey - Mental Health and Well-being and its corresponding Canadian Forces Supplement. Logistic regressions were used to examine a potential interaction between population (military [N = 1900] versus civilian [N = 2960]), mental health, and physical health in predicting both enacted and felt stigma, with adjustments made for socio-demographic information, mental health characteristics, and disability.

Results

Mental health did not predict enacted or felt stigma as a main effect nor in an interaction. There was a strong link between physical health and enacted and felt stigma, where worse physical health was associated with an increased likelihood of experiencing both facets of stigma. The link between physical health and enacted stigma was significantly stronger for military personnel than for civilians.

Conclusions

Physical health stigma appears to be present for both civilians and military personnel, but more so for military personnel. Elements of military culture (e.g., the way care is sought, culture of toughness, strict fitness requirements) as well as the physical demands of the job could be potential predictors of group differences.

Do Investments in Mental Health Systems Result in Greater Use of Mental Health Services? National Trends in Mental Health Service Use (MHSU) in the Canadian Military and Comparable Canadian Civilians, 2002-2013

BACKGROUND

Mental disorders constitute a significant public health problem worldwide. Ensuring that those who need mental health services access them in an appropriate and timely manner is thus an important public health priority. We used data from 4 cross-sectional, nationally representative population health surveys that employed nearly identical methods to compare MHSU trends in the Canadian military versus comparable civilians.

METHOD

The surveys were all conducted by Statistics Canada, approximately a decade apart (Military-2002, Military-2013, Civilian-2002, and Civilian-2012). The sample size for the pooled data across the surveys was 35,984. Comparisons across the 4 surveys were adjusted for differences in need in the 2 populations at the 2 time points.

RESULTS

Our findings suggested that first, in the Canadian military, there was a clear and consistent pattern of improvement (i.e., increase) in MHSU over the past decade across a variety of provider types. The magnitudes of the changes were large, representing an absolute increase of 7.15% in those seeking any professional care, corresponding to an 84% relative increase. Second, in comparable Canadian civilians, MHSU remained either unchanged or increased only slightly. Third, the increases in MHSU over time were consistently greater in the military than in the comparable civilian sample.

CONCLUSIONS

Our findings point to advantages with respect to MHSU of the military mental health system over the civilian system in Canada; these advantages have widened substantially over time. These findings speak strongly to the potential impact of analogous changes in other health systems, both military and civilian.

Risk Factors, Clinical Presentations, and Functional Impairments for Generalized Anxiety Disorder in Military Personnel and the General Population in Canada

OBJECTIVE

This study sought to examine differences in sociodemographic risk factors, comorbid mental conditions, clinical presentations, and functional impairments associated with past-year generalized anxiety disorder (GAD) between Canadian Armed Forces (CAF) Regular Force personnel and the Canadian general population (CGP).

METHOD

Data were from 2 nationally representative surveys collected by Statistics Canada: 1) the Canadian Community Health Survey on Mental Health, collected in 2012 ( N = 25,113; response rate = 68.9%); and 2) the Canadian Forces Mental Health Survey, collected in 2013 ( N = 8,161; response rate = 79.8%).

RESULTS

The prevalence of lifetime and past-year GAD was significantly higher in the CAF (12.1% and 4.7%) than in the CGP (9.5% and 3.0%). Comorbid mental disorders were strongly associated with GAD in both populations. Although the content area of worry and the GAD symptoms endorsed were similar, CAF personnel were significantly more likely to endorse specific types of worries (i.e., success at school/work, social life, mental health, being away from home or loved ones, and war or revolution) and specific symptoms of GAD (i.e., restless, keyed up, or on edge and more irritable than usual) than civilians, after adjusting for sociodemographic covariates and comorbid mental disorders. CAF personnel with past-year GAD reported significantly higher functional impairment at home than civilians with past-year GAD.

CONCLUSION

GAD is a substantial public health concern associated with significant impairment and disability in both military and civilian populations. GAD in military and civilian populations shows similarities and differences: Key similarities include its extensive comorbidity and significant functional impairment, whereas key differences include the focus of worries and symptom profile.

"That Guy, Is He Really Sick at All?" An Analysis of How Veterans with PTSD Experience Nature-Based Therapy

Serving in the military leads to mental diseases, such as post-traumatic stress disorder (PTSD), for a percentage of soldiers globally. The number of veterans with PTSD is increasing and, although medication and psychological treatments are offered, treatment results could be improved. Historically, different forms of nature-based therapy have been used for this target group. However, in spite of anecdotally good results, studies measuring the effect of this form of therapy are still lacking. The aim of this study is to explore how veterans with PTSD manage their everyday lives during and after a ten-week nature-based intervention in a therapy garden.

METHODS

Eight veterans participated in qualitative interviews, which were conducted during a one-year period and were analyzed using interpretative phenomenological analysis (IPA).

RESULTS

Five themes emerged from the IPA analysis: Bodily symptoms; relationships; building new identities; the future; and lessons learned. All the participating veterans gained a greater insight into and mastering of their condition, achieved better control of their lives, and developed tools to handle life situations more appropriately and to build a new identity. This improved their ability to participate in social activities and employment.

CONCLUSION

The results should be considered in the future treatment of veterans with PTSD.

Mental Health Services Use Trends in Canadian Veterans: A Population-Based Retrospective Cohort Study in Ontario

OBJECTIVE

A substantial evidence base in the peer-reviewed literature exists investigating mental illness in the military, but relatively less is documented about mental illness in veterans. This study uses provincial, administrative data to study the use of mental health services by Canadian veterans in Ontario.

METHOD

This was a retrospective cohort study of Canadian Armed Forces and Royal Canadian Mounted Police veterans who were released between 1990 and 2013 and resided in Ontario. Mental health-related primary care physician, psychiatrist, emergency department (ED) visits, and psychiatric hospitalisations were counted. Repeated measures were presented in 5-year intervals, stratified by age at release.

RESULTS

The cohort included 23,818 veterans. In the first 5 years following entry into the health care system, 28.9% of veterans had ≥1 mental health-related primary care physician visit, 5.8% visited a psychiatrist at least once, and 2.4% received acute mental health services at an ED. The use of mental health services was consistent over time. Almost 8% of veterans aged 30 to 39 years saw a psychiatrist in the first 5 years after release, compared to 3.5% of veterans aged ≥50 years at release. The youngest veterans at release (<30 years) were the most frequent users of ED services for a mental health-related reason (5.1% had at least 1 ED visit).

CONCLUSION

Understanding how veterans use the health care system for mental health problems is an important step to ensuring needs are met during the transition to civilian life.

Psychiatric comorbidity pattern in treatment-seeking veterans

This study investigated comorbidity patterns in treatment-seeking veterans and currently-serving Canadian Forces members of an outpatient mental health clinic from September 2006-September 2014. Using a retrospective cohort design, latent class analysis was conducted to determine latent classes of comorbidity (including posttraumatic stress disorder [PTSD], major depressive disorder [MDD], generalized anxiety disorder, panic disorder, and alcohol use disorder [AUD]). Multiple logistic regression was used to determine which covariates (age, gender, number of deployments, and service duration) were predictors of latent class membership. Among the 486 participants, 79.2% had more than one probable mental health condition. The most common comorbidity was PTSD and MDD (61.5%), followed by PTSD and GAD (52.3%). Among those with PTSD, almost all (95%) had a subsequent condition, predominantly MDD (82.6% of those with PTSD had MDD). A two-class model was the best fitting model with a high comorbidity and a low comorbidity class. Older age and shorter service duration significantly increased the probability of being in the high comorbidity class when not controlling for member status. Results showed that treatment-seeking veterans and military personnel have high rates of comorbidity, particularly alongside PTSD. Therefore, it is critical for clinicians to be able to assess and treat comorbidity.

Total and cause-specific mortality of Finnish military personnel following service in international peacekeeping operations 1990-2010: a comprehensive register-based cohort study

OBJECTIVES

To estimate total and cause-specific mortality after international peacekeeping deployments among the Finnish military peacekeeping personnel in comparison to the general population of similar age and sex.

DESIGN

A register-based study of a cohort of military peacekeeping personnel in 1990-2010 followed for mortality until the end of 2013. Causes of death were obtained from the national Causes of Death Register. The standardised mortality ratio (SMR) for total and cause-specific mortality was calculated as the ratio of observed and expected number of deaths.

SETTING

Finland (peacekeeping operations in different countries in Africa, Asia and in an area of former Yugoslavia in Europe).

PARTICIPANTS

14 584 men and 418 women who had participated in international military peacekeeping operations ending between 1990 and 2010.

INTERVENTIONS

Participation in military peacekeeping operations.

MAIN OUTCOME

Total and cause-specific mortality.

RESULTS

209 men and 3 women died after their peacekeeping service. The SMR for all-cause mortality was 0.55 (95% CI 0.48 to 0.62). For the male peacekeeping personnel, the SMR for all diseases was 0.44 (95% CI 0.35 to 0.53) and for accidental and violent deaths 0.69 (95% CI 0.57 to 0.82). The SMR for suicides was 0.71 (95% CI 0.53 to 0.92).

CONCLUSIONS

Even though military peacekeeping personnel are working in unique and often stressful conditions, their mortality after their service is lower compared with the general population. Military peacekeeping personnel appear to be a selected population group with low general mortality and no excess risk of any cause of death after peacekeeping service.

Prevalence of Past-Year Mental Disorders in the Canadian Armed Forces, 2002-2013

OBJECTIVE

More than 40,000 Canadian Armed Forces (CAF) personnel have deployed in support of the mission in Afghanistan since 2002. Over the same period, the CAF strengthened its mental health system. This article explores the effect of these events on the prevalence of past-year mental disorders over the period 2002-2013.

METHOD

The data sources were 2 highly comparable population-based mental health surveys of CAF Regular Force personnel done in 2002 and 2013 (n = 5155 and 6996, respectively). Data were collected via in-person interviews with Statistics Canada personnel using the World Health Organization's Composite International Diagnostic Interview to assess past-year disorders.

RESULTS

In 2013, 16.5% had 1 or more of the 6 past-year disorders assessed in the survey, with the most common conditions being major depressive episode (MDE), posttraumatic stress disorder (PTSD), and generalized anxiety disorder (GAD), which affected 8.0%, 5.3%, and 4.7%, respectively. The prevalence of PTSD, GAD, and panic disorder has increased significantly since 2002 (adjusted odds ratios from logistic regression models = 2.1, 3.0, and 1.9, respectively), while no change was seen for MDE. The comorbidity of mood and anxiety disorders increased significantly over time, being seen in 27.4% and 41.0% of those with mental disorders in 2002 and 2013, respectively.

CONCLUSION

There has been an increase in the prevalence of PTSD and other anxiety disorders and of the extent of comorbidity of mood and anxiety disorders in CAF personnel over the period 2002-2013.

Perceived Need for and Perceived Sufficiency of Mental Health Care in the Canadian Armed Forces: Changes in the Past Decade and Comparisons to the General Population

OBJECTIVES

Failure to perceive need for care (PNC) is the leading barrier to accessing mental health care. After accessing care, many individuals perceive that their needs were unmet or only partially met, an additional problem related to perceived sufficiency of care (PSC). The Canadian Armed Forces (CAF) invested heavily in workplace mental health in the past decade to improve PNC/PSC; yet, the impact of these investments remains unknown. To assess the impact of these investments, this study 1) captures changes in PNC/PSC over the past decade in the CAF and 2) compares current PNC/PSC between the CAF and civilians.

METHODS

Data were drawn from the 2013 and 2002 CAF surveys and the 2012 civilian mental health survey (total N = ∼40 000), conducted by Statistics Canada using similar methodology. Exclusions were applied to the civilian sample to make them comparable to the military sample. Prevalence rates for No need, Need met, Need partially met, and Need unmet categories across service types (Information, Medication, Counselling and therapy, Any services) were calculated and compared between 1) the 2 CAF surveys and 2) the 2013 CAF and 2012 civilian surveys after sample matching.

RESULTS

Reports of Any need and Need met were higher in the CAF in 2013 than in 2002 by approximately 6% to 8% and 2% to 8%, respectively, and higher in the CAF than in civilians by 3% to 10% and 2% to 8%, respectively.

CONCLUSIONS

These results suggest that investments in workplace mental health, such as those implemented in the CAF, can lead to improvements in recognizing the need for care (PNC) and subsequently getting those needs met (PSC).

Prevalence Comparison of Past-year Mental Disorders and Suicidal Behaviours in the Canadian Armed Forces and the Canadian General Population

OBJECTIVE

Military personnel in Canada and elsewhere have been found to have higher rates of certain mental disorders relative to their corresponding general populations. However, published Canadian data have only adjusted for age and sex differences between the populations. Additional differences in the sociodemographic composition, labour force characteristics, and childhood trauma exposure in the populations could be driving these prevalence differences. Our objective is to compare the prevalence of past-year mental disorders and suicidal behaviours in the Canadian Armed Forces Regular Force with the rates in a representative, matched sample of Canadians in the general population (CGP).

METHODS

Data sources were the 2013 Canadian Forces Mental Health Survey and the 2012 Canadian Community Health Survey-Mental Health. CGP sample was restricted to match the age range, employment status, and history of chronic conditions of Regular Force personnel. An iterative proportional fitting method was used to approximate the marginal distribution of sociodemographic and childhood trauma variables in both samples.

RESULTS

Relative to the matched CGP, Regular Force personnel had significantly higher rates of past-year major depressive episode, generalized anxiety disorder, and suicide ideation. However, lower rates of alcohol use disorder were seen in Regular Force personnel relative to the matched CGP sample.

CONCLUSIONS

Factors other than differences in sociodemographic composition and history of childhood trauma account for the excess burden of mental disorders and suicidal behaviours in the Canadian Armed Forces. Explanations to explore in future research include occupational trauma, selection effects, and differences in the context of administration of the 2 surveys.