A systematic analysis and prioritization of suicide prevention research gaps

OBJECTIVE

This study identified and prioritized research gaps for suicide prevention in the Department of Defense to inform future research investments.

METHODS

The 2019 VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide was the primary source document for research gaps, supplemented by an updated literature search. Institutional stakeholders rated the identified research gaps and ranked the gap categories. We used Q factor analysis to derive a list of the prioritized research gaps and category rankings.

RESULTS

Thirty-five research gaps were identified and prioritized. The highest rated research gap topic was lethal means safety interventions and their effectiveness in increasing safety behaviors and/or reducing suicide-related outcomes. Research on the effectiveness of crisis response planning and several other non-pharmacological interventions (e.g., implementation of cognitive-behavioral therapy, technology-based behavioral interventions, and applications of dialectical behavior therapy to non-Borderline patients) were also rated highly by stakeholders.

CONCLUSIONS

This work generated a list of priorities for future suicide research as evaluated by Departments of Defense and Veterans Affairs stakeholders. Our findings can help guide the efforts of suicide researchers and inform decisions about future research funding for suicide prevention.

Demographic, Behavioral, and Proximal Risk Factors for Gambling Disorder in the US Military

BACKGROUND AND OBJECTIVES

To estimate the diagnostic prevalence and incidence of gambling disorder among United States service members and to identify associated risk factors, including demographics, history of mental illness or substance misuse, and proximity to legalized gambling vicinities.

METHODS

Gambling disorder cases comprised active component Service members who received a pathological or problem gambling diagnosis between October 1, 2005 and September 30, 2015. There were 901 cases (392 incidents) during the study period. Controls were matched on the case military entrance date (N = 43,564). Geospatial distance between gambling venue and military treatment facilities were calculated, then multivariable logistic regression and survival analyses were conducted.

RESULTS

The 10-year prevalence of gambling disorder was 6.6 per 100,000. Men were 3.5 times more likely than women to receive a gambling disorder diagnosis. Other risk factors included age over 24, Asian or Black race, formerly married, and enlisted rank. The odds of gambling disorder increased with duration and proximity to gambling venues, ranging from 2.0 to 3.9. Service members with prior substance misuse or mental health conditions were 3.9 times and 6.3 times more likely to receive a disordered gambling diagnosis than those without substance misuse or mental illness history, respectively.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

The results of this study reveal that proximity to gambling venues and slot machines on bases, as well as a history of substance misuse or mental disorders, are important risk factors for gambling disorder in the US military. Department of Defense screening policies that focus on high-risk populations are appropriate. (Am J Addict 2021;00:00-00).

Establishing an Evidence Synthesis Capability For Psychological Health Topics in the Military Health System

BACKGROUND

To promote evidence-based health care, clinical providers and decision makers rely on scientific evidence to inform best practices. Evidence synthesis (ES) is a key component of this process that serves to inform health care decisions by integrating and contextualizing research findings across studies.

OBJECTIVE

This paper describes the process of establishing an ES capability in the Military Health System dedicated to psychological health topics.

RESEARCH DESIGNS

The goal of establishing the current ES capability was to facilitate evidence-based decision-making among clinicians, clinic managers, research funders, and policymakers, through the production and dissemination of trustworthy ES reports. We describe how we developed this capability, provide an overview of the types of evidence syntheses products we use to respond to different stakeholders, and detail the procedures established for selecting and prioritizing synthesis topics.

RESULTS

We report on the productivity, acceptability, and impact of our efforts. Our reports were used by a variety of stakeholders and working groups, briefed to major committees, included in official reports and policies, and cited in clinical practice guidelines and the peer-reviewed literature.

CONCLUSIONS

Our experiences thus far suggest that the current ES capability offers a needed service within our health system. Our framework may help inform other agencies interested in developing or sponsoring a similar capability.

Lower obesity rate during residence at high altitude among a military population with frequent migration: a quasi experimental model for investigating spatial causation

We sought to evaluate whether residence at high altitude is associated with the development of obesity among those at increased risk of becoming obese. Obesity, a leading global health priority, is often refractory to care. A potentially novel intervention is hypoxia, which has demonstrated positive long-term metabolic effects in rats. Whether or not high altitude residence confers benefit in humans, however, remains unknown. Using a quasi-experimental, retrospective study design, we observed all outpatient medical encounters for overweight active component enlisted service members in the U.S. Army or Air Force from January 2006 to December 2012 who were stationed in the United States. We compared high altitude (>1.96 kilometers above sea level) duty assignment with low altitude (<0.98 kilometers). The outcome of interest was obesity related ICD-9 codes (278.00-01, V85.3x-V85.54) by Cox regression. We found service members had a lower hazard ratio (HR) of incident obesity diagnosis if stationed at high altitude as compared to low altitude (HR 0.59, 95% confidence interval [CI] 0.54–0.65; p<0.001). Using geographic distribution of obesity prevalence among civilians throughout the U.S. as a covariate (as measured by the Centers for Disease Control and Prevention and the REGARDS study) also predicted obesity onset among service members. In conclusion, high altitude residence predicts lower rates of new obesity diagnoses among overweight service members in the U.S. Army and Air Force. Future studies should assign exposure using randomization, clarify the mechanism(s) of this relationship, and assess the net balance of harms and benefits of high altitude on obesity prevention.

Mental health diagnoses and counseling among pilots of remotely piloted aircraft in the United States Air Force

Remotely piloted aircraft (RPA), also known as drones, have been used extensively in the recent conflicts in Iraq and Afghanistan. Although RPA pilots in the U.S. Air Force (USAF) have reported high levels of stress and fatigue, rates of mental health (MH) diagnoses and counseling in this population are unknown. We calculated incidence rates of 12 specific MH outcomes among all active component USAF RPA pilots between 1 October 2003 and 31 December 2011, and by various demographic and military variables. We compared these rates to those among all active component USAF manned aircraft (MA) pilots deployed to Iraq/Afghanistan during the same period. The unadjusted incidence rates of all MH outcomes among RPA pilots (n=709) and MA pilots (n=5,256) were 25.0 per 1,000 person-years and 15.9 per 1,000 person-years, respectively (adjusted incidence rate ratio=1.1, 95% confidence interval=0.9-1.5; adjusted for age, number of deployments, time in service, and history of any MH outcome). Th ere was no significant difference in the rates of MH diagnoses, including post-traumatic stress disorder, depressive disorders, and anxiety disorders between RPA and MA pilots. Military policymakers and clinicians should recognize that RPA and MA pilots have similar MH risk profiles.

Prevalence of and risk factors for autopsy-determined atherosclerosis among US service members, 2001-2011

CONTEXT

Autopsies of US service members killed in the Korean and Vietnam wars demonstrated that atherosclerotic changes in the coronary arteries can appear early in the second and third decades of life, long before ischemic heart disease becomes clinically apparent.

OBJECTIVE

To estimate the current prevalence of coronary and aortic atherosclerosis in the US armed forces.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of all US service members who died of combat or unintentional injuries in support of Operations Enduring Freedom and Iraqi Freedom/New Dawn between October 2001 and August 2011 and whose cardiovascular autopsy reports were available at the time of data collection in January 2012. Prevalence of atherosclerosis was analyzed by various demographic characteristics and medical history. Classifications of coronary atherosclerosis severity were determined prior to data analysis and designed to provide consistency with previous military studies: minimal (fatty streaking only), moderate (10%-49% luminal narrowing of ≥1 vessel), and severe (≥50% narrowing of ≥1 vessel).

MAIN OUTCOME MEASURES

Prevalence of coronary and aortic atherosclerosis in the US armed forces and by age, sex, self-reported race/ethnicity, education, occupation, service branch and component, military rank, body mass index at military entrance, and International Classification of Diseases, Ninth Revision, Clinical Modification, diagnoses of cardiovascular risk factors.

RESULTS

Of the 3832 service members included in the analysis, the mean age was 25.9 years (range, 18-59 years) and 98.3% were male. The prevalence of any coronary atherosclerosis was 8.5% (95% CI, 7.6%-9.4%); severe coronary atherosclerosis was present in 2.3% (95% CI, 1.8%-2.7%), moderate in 4.7% (95% CI, 4.0%-5.3%), and minimal in 1.5% (95% CI, 1.1%-1.9%). Service members with atherosclerosis were significantly older (mean [SD] age, 30.5 [8.1] years) than those without (mean [SD] age, 25.3 [5.6] years; P < .001). Comparing atherosclerosis prevalence among with those with no cardiovascular risk factor diagnoses (11.1% [95% CI, 10.1%-12.1%]), there was a greater prevalence among those with a diagnosis of dyslipidemia (50.0% [95% CI, 30.3%-69.7%]; age-adjusted prevalence ratio [PR], 2.09 [95% CI, 1.43-3.06]), hypertension (43.6% [95% CI, 27.3%-59.9%]; age-adjusted PR, 1.88 [95% CI, 1.34-2.65]), or obesity (22.3% [95% CI, 15.9%-28.7%]; age-adjusted PR, 1.47 [95% CI, 1.10-1.96]), but smoking (14.1% [95% CI, 8.0%-20.2%]) was not significantly associated with a higher prevalence of atherosclerosis (age-adjusted PR, 1.12 [95% CI, 0.73-1.74]).

CONCLUSION

Among deployed US service members who died of combat or unintentional injuries and received autopsies, the prevalence of atherosclerosis varied by age and cardiovascular risk factors.

Training initiatives within the AFHSC-Global Emerging Infections Surveillance and Response System: support for IHR (2005)

Training is a key component of building capacity for public health surveillance and response, but has often been difficult to quantify. During fiscal 2009, the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) supported 18 partner organizations in conducting 123 training initiatives in 40 countries for 3,130 U.S. military, civilian and host-country personnel. The training assisted with supporting compliance with International Health Regulations, IHR (2005). Training activities in pandemic preparedness, outbreak investigation and response, emerging infectious disease (EID) surveillance and pathogen diagnostic techniques were expanded significantly. By engaging local health and other government officials and civilian institutions, the U.S. military’s role as a key stakeholder in global public health has been strengthened and has contributed to EID-related surveillance, research and capacity-building initiatives specified elsewhere in this issue. Public health and emerging infections surveillance training accomplished by AFHSC-GEIS and its Department of Defense (DoD) partners during fiscal 2009 will be tabulated and described.

Seasonal and environmental determinants of leptospirosis and scrub typhus in small mammals captured at a U.S. military training site (Dagmar North), Republic of Korea, 2001-2004

OBJECTIVE

This study sought to identify seasonal and environmental determinants of scrub typhus, murine typhus, and leptospirosis in small mammals trapped at Dagmar North training area, Gyeonggi Province, South Korea.

METHODS

Small mammals received titer assays to the aforementioned diseases. Logistic regression analyses were conducted to determine whether associations existed between risk of small-mammal infection and independent variables such as season of capture, habitat, small-mammal species, and sex.

RESULTS

Murine typhus was not detected among the animals assayed. Risk of scrub typhus infection was associated with season, habitat, and small-mammal species. Risk of leptospirosis infection was associated with season and habitat.

CONCLUSIONS

These findings indicate determinants of infection exist for scrub typhus and leptospirosis at this training site. This information can be used for developing appropriate preventive medicine plans and coordinating troop activity during periods of reduced exposure decreasing the likelihood of disease transmission to humans.

Chromatography of xanthines on ion-exchange resins

Short columns of a 4% crosslinked cation-exchange resin gave good chromatography of xanthines, including caffeine, theophylline and hypoxanthine, and related polar aromatic compounds. Elution volumes and sequences can be modified by changing pH, solvent composition and resin counter-ion. A macroporous cation-exchange resin showed exaggerated counter-ion effects. A method is described for determining caffeine and theophylline in blood serum, using the 4% crosslinked resin with aqueous sodium phosphate eluent of pH 7.5; the temperature was 65 degrees. Detection limits are 10 ng and less.