Child Abuse Experiences and Perceived Need for Care and Mental Health Service Use among Members of the Canadian Armed Forces

Roles of Psychological Distress and Social Support in the Relationship Between Childhood Maltreatment and Perceived Needs for Mental Health Care

Childhood maltreatment is a major public health issue worldwide. It increases a range of health-risk behaviors, psychological and physical problems, which are associated with an increased need for mental health services in adulthood. Identification of mediating factors in the relationship between maltreatment and seeking mental health care may help attenuate the negative consequences of childhood maltreatment and promote more appropriate treatment. This study aims to examine whether the relationship between childhood maltreatment and perceived need for mental health care is mediated by psychological distress and/or moderated by social support. Data from the Canadian Community Health Survey-Mental Health 2012 are analyzed. A total of 8,993 participants, who had complete information on childhood maltreatment and diagnoses of mental disorders or psychological distress, are included in this study. Structural equation modeling and the PROCESS macro were used to identify relationships among childhood maltreatment, perceived needs for mental health care, and psychological distress. Hierarchical linear regression was then used to verify the moderated mediation model. We found that psychological distress partially mediated the effect of childhood maltreatment on perceived needs for mental health care in adulthood. Social support played an important role in terms of moderating the relationship between maltreatment and perceived needs for care. For those with a history of childhood maltreatment, those who perceived a low level of social support were more likely to have higher levels of psychological distress and perceived need for mental health care. This is the first study to identify the separate and combined roles of psychological distress and social support in the relationship between childhood maltreatment and perceived need for mental health care. Selective prevention strategies should focus on social support to improve mental health services among people with a history of childhood maltreatment.

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.

Exposures to Potentially Psychologically Traumatic Events Among Nurses in Canada

BACKGROUND

Nurses are regularly exposed to diverse potentially psychologically traumatic events (PPTEs) as a function of their work. Cumulative exposure to PPTEs can lead to clinically significant symptoms of mental disorders.

PURPOSE

We designed the current study to investigate the prevalence of different PPTEs among Canadian nurses and estimate the associations between diverse exposures and several mental disorders.

METHODS

Canadian nurses (i.e., registered nurses, registered psychiatric nurses, licensed practical nurses, nurse practitioners) completed an online, self-reported survey. In total, 4067 participants (94.8% women) completed all relevant survey measures.

RESULTS

Nurses reported exposures to several PPTE categories including severe human suffering, life threatening illness or injury, and physical assault, often 11 or more times. There were significant (p<.05) associations between diverse traumatic events and all mental disorders (i.e., Posttraumatic Stress Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, Panic Disorder) except Alcohol Use Disorder.

CONCLUSIONS

The current findings suggest that Canadian nurses are substantially exposed to traumatic events, which vary by several sociodemographic categories. PPTE exposures were significantly associated with mental disorders; that is, if PPTEs were eliminated among Canadian nurses in the sample, symptoms would be reduced between 42.0% and 58.0%.

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.

Comparison of past-year mental health services use in Canadian Army, Navy, and Air Force personnel

Introduction: What causes the excess burden of mental disorders and related outcomes in the Army remains unclear. Deployment-related trauma has been one intuitive explanation. However, there may be other factors at play – for example, lower mental health services use (MHSU) in Army personnel. This study compares MHSU across the Canadian Army, Navy, and Air Force. Methods: Data were drawn from the 2013 Canadian Forces Mental Health Survey. The sample consisted of Regular Force members ( N = 6,696). The primary outcomes for past-year MHSU were: (1) any past-year MHSU; (2) intensity of care (total clinical contact hours), and (3) perceived helpfulness of care (PHC). ­Modified Poisson regression and analysis of covariance (ANCOVA) were used to assess the relationship between the elements (Army, Navy, Air Force) and each outcome, adjusting for sociodemographic and military characteristics, as well as clinical variables such as the presence of five past-year mental disorders. Results: In unadjusted analyses, Army personnel had significantly greater past-year MHSU and intensity of care relative to Air Force personnel. No significant relationship was found between the element and any of the MHSU parameters after adjustment. Discussion: Differences in past-year MHSU are an unlikely contributing factor to the higher risk of mental disorders and related outcomes among Army personnel; the true explanation must lie elsewhere. Findings argue for a system-wide, and not element-specific, approach to improving Canadian Armed Forces (CAF) programs and services.

Contribution of traumatic deployment experiences to the burden of mental health problems in Canadian Armed Forces personnel: exploration of population attributable fractions

PURPOSE

Mental health problems are prevalent after combat; they are also common in its absence. Estimates of deployment-attributability vary. This paper quantifies the contribution of different subtypes of occupational trauma to post-deployment mental health problems.

METHODS

Participants were a cohort of 16,193 Canadian personnel undergoing post-deployment mental health screening after return from the mission in Afghanistan. The screening questionnaire assessed post-traumatic stress disorder, depression, panic disorder, generalized anxiety disorder, and exposure to 30 potentially traumatic deployment experiences. Logistic regression estimated adjusted population attributable fractions (PAFs) for deployment-related trauma, which was treated as count variables divided into several subtypes of experiences based on earlier factor analytic work.

RESULTS

The overall PAF for overall deployment-related trauma exposure was 57.5% (95% confidence interval 44.1, 67.7) for the aggregate outcome of any of the four assessed problems. Substantial PAFs were seen even at lower levels of exposure. Among subtypes of trauma, exposure to a dangerous environment (e.g., receiving small arms fire) and to the dead and injured (e.g., handling or uncovering human remains) had the largest PAFs. Active combat (e.g., calling in fire on the enemy) did not have a significant PAF.

CONCLUSIONS

Military deployments involving exposure to a dangerous environment or to the dead or injured will have substantial impacts on mental health in military personnel and others exposed to similar occupational trauma. Potential explanations for divergent findings in the literature on the extent to which deployment-related trauma contributes to the burden of mental disorders are discussed.

The relation between adverse childhood experiences and moral injury in the Canadian Armed Forces

Background: There is increasing evidence that moral injuries (MIs) may affect the mental health of Canadian Armed Forces (CAF) members and veterans. Despite knowledge suggesting that MIs are related to multiple negative mental health outcomes, including the onset of post-traumatic stress disorder (PTSD), it is unknown whether pre-traumatic variables, including the presence of childhood abuse, are related to MIs. Objective: This study seeks to investigate the potential relationship between adverse childhood experiences and later onset MI in military members. Methods: Thirty-three patients newly admitted to an inpatient unit for treatment of trauma-related disorders received a standardized self-assessment package, including the PTSD Checklist for DSM-5 (PCL-5), the Moral Injury Events Scale (MIES; adapted for the Canadian context), and the Adverse Childhood Experiences Questionnaire (ACE-Q), which is a retrospective measure of childhood abuse. Results: Analyses revealed a significant relation between childhood emotional abuse and the presence of MI in adulthood. Specifically, emotional abuse during childhood was correlated with total score on the MIES (p = 0.006) and with its two subscales, perceived betrayals (p = 0.022) and perceived transgressions (p = 0.016). These correlations remained significant when controlling for age and gender. Conclusions: Among CAF members and veterans, childhood events are related to the presence of MI during adulthood. These preliminary data are provocative in suggesting that emotional abuse during childhood may increase the likelihood of endorsing MI during adult military service. Further work is needed to identify pre-traumatic variables that may serve to increase risk or enhance resilience to the development of MI in military members.

Dissociative symptoms mediate the relation between PTSD symptoms and functional impairment in a sample of military members, veterans, and first responders with PTSD

Background: Posttraumatic Stress Disorder (PTSD) is associated with significant functional impairment in important areas, including interpersonal relationships and occupational or educational roles. Preliminary evidence suggests that the dissociative subtype of PTSD (PTSD+DS), characterized by marked symptoms of depersonalization and derealization, is associated with increased functional impairment and disease severity, including among military members and veterans diagnosed with PTSD. Similarly, first responders (e.g. police, fire, paramedics) have also been found to experience dissociative symptoms. Despite these findings, little work has investigated whether dissociative symptoms are related to heightened functional impairment among these populations. Objective: We examined the relation between functional impairment and symptom level variables, including dissociative symptoms of depersonalization and derealization among military members, veterans, and first responders with probable PTSD. We further investigated the hypothesis that dissociative symptoms mediate the relation between PTSD symptomatology and functional impairment. Method: Eighty-one medical charts of inpatients at a residential PTSD treatment programme were accessed via retrospective review. Sixty-two were included in the present analyses. Comparison of means on symptom measures between first responders and military members/veterans were conducted, followed by correlational and mediation analyses. Results: Compared with first responders, military members and veterans showed higher levels of derealization, functional impairment, alexithymia, anxiety, and depression. Within the total sample, dissociative symptoms emerged as the strongest correlate of functional impairment and, among the dissociative symptom clusters, derealization symptoms demonstrated the strongest relation with impairment. Mediation analyses revealed that total dissociative symptoms and derealization symptoms significantly mediated the relation between PTSD symptoms and functional impairment. Conclusions: These findings highlight the importance of assessing and treating dissociative symptoms, consistent with the dissociative subtype of PTSD, among military members, veterans, and first responders with PTSD. Successful recovery on a functional and symptomatic level may necessitate treatment of dissociative symptoms, particularly derealization.