Soc Psychiatry Psychiatr Epidemiol DOI 10.1007/s00127-014-0981-2
ORIGINAL PAPER
Mental health among a nationally representative sample of United States Military Reserve Component Personnel Dale W. Russell • Gregory H. Cohen Robert Gifford • Carol S. Fullerton • Robert J. Ursano • Sandro Galea
•
Received: 16 June 2014 / Accepted: 10 November 2014 Ó Springer-Verlag (outside the USA) 2014
Abstract Purpose Estimate prevalence of lifetime, current year, and current month depression and post-traumatic stress disorder (PTSD) among US military reservists. Methods Structured interviews were performed with a nationally representative military reserve sample (n = 2,003). Sociodemographic characteristics, military experiences, lifetime stressors, and psychiatric conditions were assessed. Depression was measured with the PHQ-9, and PTSD (deployment and non-deployment related) was assessed with the PCL-C. Results Depression (21.63 % lifetime, 14.31 % current year, and 5.99 % current month) was more common than either deployment-related PTSD (5.49 % lifetime, 4.98 % current year, and 3.62 % current month) or non-deployment-related PTSD (5.40 % lifetime, 3.91 % current year, and 2.32 % current month), and branch-related differences were found. Non-deployment-related trauma was associated with non-deployment-related PTSD and depression in a dose–response fashion; deployment-related trauma was associated with deployment-related PTSD and depression in a dose–response fashion. Conclusions The study reveals notable differences in PTSD and depression prevalence by service branch that D. W. Russell (&) R. Gifford C. S. Fullerton R. J. Ursano Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University, F. Edward Hebert School of Medicine, 4301 Jones Bridge Road, Bethesda, MD 20814, USA e-mail: [email protected] G. H. Cohen S. Galea Department of Epidemiology, Columbia University, Mailman School of Public Health, 722 W 168th Street, Room 1508, New York, NY 10032-3727, USA e-mail: [email protected]
may be attributable to a combination of factors including greater lifetime trauma exposures and differing operational military experiences. Our findings suggest that service branch and organizational differences are related to key protective and/or risk factors, which may prove useful in guiding prevention and treatment efforts among reservists. Keywords Posttraumatic stress disorder Depression Military Reserves National Guard
Introduction Operations in Iraq and Afghanistan have exposed military personnel from many countries to the traumas associated with war. In the United States (US), the wars have generated over two million military combat veterans [1], over one million of whom have been diagnosed with one or more psychological disorders [2]. A significant proportion of these service members are Reserve Component (RC; part-time employees) personnel who were called upon to support the Active Component (AC; full-time employees) in an unprecedented manner during these wars [2]; _ENREF_4 for example, RC soldiers accounted for nearly half of the Army’s ground forces at the height of combat operations [1]. Both the Reserves and National Guard comprise the RC; however, the federal government controls the Reserves whereas control of the National Guard resides with each state or territory until called upon by the President of the United States. Given the large representation of RC personnel among combat veterans, research is needed to understand the impact of military service in this population. While there is ample empirical evidence that numerous psychopathologies (e.g., post-traumatic stress disorder, depression, and substance use disorders) are associated with military operations
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among AC personnel following an operational deployment [3–8], there is a relative dearth of comparable research assessing the health consequences among RC personnel post-deployment. As both post-deployment general and behavioral healthcare support for RC personnel differ by service branch, it is also critically important to investigate mental health outcomes across service branches and deployment experiences [6–9]. Given the paucity of empirical research assessing the psychological consequences of continued military operations on the RC, this research aims to address this shortcoming using unique data from a nationally representative survey of RC personnel.
Methods Source population The study population was drawn in 2009 from a stratified simple random sample of 10,000 Reservists and 10,000 National Guard service members. This sample was provided by the Defense Manpower Data Center, the US military’s human resource information source for *42 million current and former service members. From the 20,000 RC service members, a stratified random sample of 10,260 was invited to participate in the study using pre-stamped opt-out letters. After 3 weeks, 509 (5 %) of those contacted elected to opt out. Attempts were made to contact the 9,751 RC personnel who did not return the opt-out card by telephone until the enrollment goal of approximately 2,000 was achieved. Of the 9,751 attempted contacts, 29 % (2,866) had non-working or incorrect numbers listed, and 35 % (3,386) could not be reached. Of those remaining, 3,499 were successfully contacted (36 % of the invited sample), 324 (9 %) were ineligible as they were no longer in the military, 61 (1 %) were disqualified because they could not speak English well enough, had health or hearing problems, were deceased, or had a pay grade of O-7 or above (i.e., held the rank of general officer); 14 (0.4 %) only partially completed the survey, and 1,097 (31 %) did not wish to participate. In total, 2,003 consented and completed the survey. Based on the American Association for Public Opinion Research (AAPOR) definitions [10], the overall cooperation rate was 68.24 %, and the overall response rate was 34.1 %. Respondents were provided $25 in compensation for their time and effort. The study protocol was approved by the US Army Medical Command’s Congressionally Directed Medical Research Program the US Army Medical Research & Materiel Command’s Human Research Protection Office, and the Institutional Review Boards at both the Uniformed Services University and Columbia University. Complex survey weights were constructed in SUDAAN version 11 [11], using the Wtadjst procedure, to account for
123
sampling design, sociodemographic characteristics related to survey non-response, and sociodemographic representativeness of the sampling universe—the entire national RC population at time of sampling in 2009. To examine sociodemographic representativeness of our weighted study estimates, we compared them with the sampling universe distributions of key demographic characteristics—gender, race, age, and rank. As presented in ‘‘Appendix’’, universe population proportions for each distribution of demographic characteristics were examined to see whether they lay within the 95 % confidence intervals (CIs) of our study proportion estimates. Overall, study sample distributions are broadly comparable by component and branch to the sampling universe, with some minor differences that we note below. We purposefully oversampled women in the Marine Corps Reserves study sample, which had a slightly higher proportion of women than the sampling universe. Relative to the sampling universe, the Navy Reserves study sample had a higher proportion of individuals 45 and older, while the Air National Guard study sample had a lower proportion of those 45 and older, and a higher proportion of those 18–24. In relation to the sampling universe, the Reserves Total study sample had a slightly lower proportion of individuals of other race, while the study samples of the Navy Reserves and Army National Guard had slightly higher proportions of individuals of other race; the study sample Marine Corps had a slightly higher proportion of black individuals; and the study sample Navy Reserves had a higher proportion of white individuals. Relative to the sampling universe estimates, study sample Reserves Total and Army Reserves had slightly lower proportions of junior enlisted service members; study sample Reserves Total, National Guard Total, Army Reserves, and Army National Guard had higher proportions of NCOs; the Navy Reserves study sample has a higher proportion of Senior NCOs; and the study sample Reserves Total, National Guard Total, and Army National Guard all had lower proportions of Officers. Measures Respondents completed a 40-min computer-assisted telephone survey. The survey collected information on demographics, military history, deployment experiences, lifetime stressors, and mental health status. Non-deployment traumatic experiences were identified using a list of 25 traumatic events [12]; if a respondent endorsed any event(s), they were then asked to indicate if the event(s) happened in relation to their most recent deployment. Additionally, deployment-related traumatic experiences were identified with a list of three traumatic events specific to military service in relation to one’s most recent deployment [13]. Therefore, 28 potential deploymentrelated traumatic experiences were presented. Finally,
Soc Psychiatry Psychiatr Epidemiol
respondents were asked to briefly describe any other extraordinarily stressful situation(s) or event(s) not captured by the 25 non-deployment-related events and the 28 deployment-related experiences presented. The mental health outcomes of interest included deployment-related post-traumatic stress disorder (PTSD), non-deployment-related PTSD, and depression. Deployment-related PTSD entails symptomology resulting from the ‘‘worst’’ traumatic event that occurred during a respondent’s most recent military deployment, while nondeployment-related PTSD refers to ‘‘worst’’ event outside of the most recent deployment. The PTSD Checklist Civilian version (PCL-C) was used to assess PTSD symptoms [14, 15]. Additional questions were posed to assess the duration of symptoms and functional impairment in order to fulfill the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR edition) criterion for a PTSD diagnosis [16]. To be classified as having a PTSD symptom, respondents had to report that the symptom occurred at least ‘‘some of the time’’ (i.e., 3 on a 1–5 scale). As per the DSM-IV-TR, respondents were classified as having PTSD if they had experienced fear, helplessness, or horror as a result of a traumatic event (criterion A1 and A2); at least one symptom of re-experiencing the traumatic event (criterion B); at least three symptoms of avoidance or numbing (criterion C); at least two symptoms of hypervigilance (criterion D); at least a 1 month duration of these symptoms (criterion E); and significant social or functional impairment as a result of these symptoms (criterion F) [16]. This screening algorithm maximized sensitivity and specificity for non-deployment-related (0.47, 0.94) and deployment-related PTSD (0.50, 0.93), in a contemporaneous sample of Ohio Army National Guard soldiers [17]. Depression was assessed using the Primary Care Evaluation of Mental Health Disorders Patient Health Questionnaire-9 (PHQ-9) [18]. Respondents were classified with depression if they endorsed at least two symptoms from the PHQ-9, one of which had to be anhedonia or depressed mood, and had the symptoms concurrently for at least a month. This screening approach maximizes sensitivity (0.51) and specificity (0.83) for Major Depressive Disorder as assessed by the Structured Clinical Interview (SCID) [19] per the DSM-IV-TR Axis I Disorders [16]. Onset timing and symptom duration were also measured. Statistical analysis Distributions of demographics and military characteristics of the sample were stratified by each RC service branch: US Army Reserves (USAR), Army National Guard (ARNG), US Air Force Reserves (USAFR), Air National Guard (ANG), US Navy Reserve (USNR), and US Marine Corps Reserve (USMCR) and compared using Chi-square tests (see
Appendix 1a for Universal Ns). Second, the prevalence of deployment-related PTSD, non-deployment-related PTSD, and depression were examined and compared by service branch with Chi-square tests. Third, logistic regression models were constructed to examine the relationships between deployment and non-deployment traumas and odds of deployment-related PTSD, non-deployment-related PTSD, and depression. All weighted statistical analyses were conducted using SAS-callable SUDAAN, version 11. Data were prepared for analysis with SAS 9.2 [20].
Results Table 1 lists the number and distribution of selected characteristics in the total sample, by service component and branch. Most respondents were male (82.22 %), white (79.63 %), between 18 and 35-years old (61.07 %), married (48.85 %), made less than $60,000 per year (58.79 %), had attended some college (51.35 %), had been exposed to 1 or more lifetime non-deployment-related traumatic events (89.9 %), and 1 or more deployment-related traumatic events (68.87 %). The majority of respondents were junior enlisted (pay levels E1–E4; 39.76 %) or basic-level noncommissioned officers (pay levels E5-E6; 36.08 %) and had previously deployed (72.35 %), with 42.3 % having deployed more than once. Among those with deployment experiences, the majority (58.39 %) had deployed to a conflict zone, although most (65.79 %) reported not having participated in active combat operations. There were a number of statistically significant differences between the Reserves and the National Guard. Relative to the National Guard, the Reserves had a higher proportion of women (21.2 vs. 14.45 %), those making [$60,000 (46.87 vs. 35.67 %), personnel with a college or graduate degree (32.05 vs. 23.16 %), and officers (16.16 vs. 9.19 %). Relative to the Reserves, the National Guard had a higher proportion of personnel aged 18–34 (64.47 vs. 57.58 %), white respondents (83.48 vs. 75.69 %), personnel with 1 or more deployments (74.27 vs. 70.38 %), personnel deployed to conflict zones (64.72 vs. 51.52 %), and personnel who participated in active combat operations during their most recent deployment (40.37 vs. 27.5 %). All but one comparison of the selected characteristic distributions by service branch were statistically significant. The Army National Guard was the largest branch in the sample (41.55 %) and the Marine Corps Reserve the smallest (5.87 %). Females were least likely to serve in the Marine Corps Reserve (6.91 %) and most likely to serve in the Air Force Reserve (25.64 %). The Air Force Reserve had the highest proportion of personnel aged C35 (58.54 %), and the Marine Corps Reserve had the highest distribution of personnel \35 (89.12 %). While all of the branches were
123
123
1,618
Male
658
538
351
25–34
35–44
45?
236
930
College/graduate degree
693
Never married
191
911
785
105
0
1–4
5–11
12?
Number of lifetime nondeployment-related traumatic events
250
Formerly married
Married
1,058
903
769
Some college
Marital status
327
High school diploma or less
Education
1,015
B$60,000
[$60,000
Income
5.27
38.76
45.95
10.01
38.98
12.17
48.85
27.56
51.35
21.09
41.21
58.79
4.72
244
Other
15.65
1,520
Black
79.63
14.83
24.1
31.79
29.28
82.22
17.78
100
White
Race
456
18–24
Age
385
2,003
49.4
(%) 970
N 50.6
(%)
National Guard
78.8
21.2 825
147 85.55
14.45
18.06
24.36
31.47
26.11
134
257
337
244
11.67
23.86
32.1
32.37
75.69 5.43
18.88
777 100
94
83.48 4.02
12.5
53.13 46.87
550 392
64.33 35.67
32.05
50.13
17.82
323
461
185
37.73
11.99
50.27 344
127
500
51
432
453
88
4.71
41.01
44.73
9.55
54
353
458
103
v2 ðdf ¼ 3Þ ¼ 1:34; p = 0.26
349
123
558
v2 ðdf ¼ 2Þ ¼ 0:69; p = 0.50
446
442
142
5.82
36.57
47.14
10.47
40.2
12.34
47.47
23.16
52.54
24.3
v2 ðdf ¼ 2Þ ¼ 12:31; p \ 0.0001
538
465
v2 ðdf ¼ 1Þ ¼ 22:63; p \ 0.0001
136
150
743
v2 ðdf ¼ 2Þ ¼ 8:6; p \ 0.0001
217
281
321
212
v2 ðdf ¼ 3Þ ¼ 6:32; p \ 0.0001
793
238
v ðdf ¼ 1Þ ¼ 13:71; p \ 0.0001
2
1,033
N
N
(%)
Reserves
Total
Female
Gender
Total
Sociodemographic and military characteristics
8.44
(%) 509
N 26.32
(%)
Army Reserve
74.36
140 369
22.97 77.03
29.89
28.65
26.97
14.5
96
145
173
95
14.97
24.38
34.71
25.95
79.27 6.71
14.02
342 70
97
71 5.52
23.47
38.43 61.57
249 246
57.94 42.06
42.75
46.27
10.98
216
216
77
29.81
49.51
20.69
27.26
12.58
60.15
169
76
264
37.95
14.17
47.88
6
75
78
13
3.79
38.58
50.55
7.09
30
212
216
50
5.24
42.24
41.37
11.14
v2 ðdf ¼ 15Þ ¼ 2:05; p = 0.01
42
23
110
v2 ðdf ¼ 10Þ ¼ 6:85; p \ 0.0001
94
66
16
v2 ðdf ¼ 10Þ ¼ 12:66; p \ 0.0001
113
58
v2 ðdf ¼ 5Þ ¼ 12:99; p \ 0.0001
26
18
132
v2 ðdf ¼ 10Þ ¼ 3:63; p \ 0.0001
57
55
45
19
v2 ðdf ¼ 15Þ ¼ 12:93; p \ 0.0001
127
25.64
v ðdf ¼ 5Þ ¼ 9:42; p \ 0.0001 49
2
176
N
Air Force Reserve
Table 1 Distribution of selected characteristics for the total sample and by service component and branch
15
53
115
29
62
29
124
107
90
17
110
100
22
14
179
37
65
72
41
170
45
215
N
7.16
24.26
55.15
13.43
34.03
12.07
53.9
44.25
46.81
8.95
48.46
51.54
4.46
7.76
87.78
14.89
29.25
30.65
25.21
80.17
19.83
8.99
(%)
Air National Guard
39
300
343
74
282
98
376
216
371
168
282
450
78
80
598
97
192
265
203
655
102
757
N
5.54
39.21
45.42
9.83
41.53
12.39
46.07
18.61
53.78
27.62
32.87
67.13
3.93
13.53
82.55
10.97
22.69
32.42
33.92
86.71
13.29
41.55
(%)
Army National Guard
9
68
77
13
90
5
73
45
91
31
67
98
21
20
126
9
18
61
80
155
13
168
N
4.89
39.12
47.67
8.33
59.18
2.8
38.02
18.26
60.54
21.2
34.6
65.4
4.73
14.88
80.39
2.74
8.14
31.3
57.82
93.09
6.91
5.87
(%)
Marine Corps Reserve
6
77
82
12
48
19
111
91
69
18
112
60
19
15
143
55
63
42
18
142
36
178
N
3.85
40.86
47.39
7.9
32.74
11.04
56.22
37.66
48.81
13.53
55.66
44.34
4.36
12.42
83.22
26.22
31.01
26.22
16.56
78.82
21.18
8.77
(%)
Navy Reserve
Soc Psychiatry Psychiatr Epidemiol
421
351
227
4–5
6?
12.63
451
Senior NCO (E7–E9)
514
No
577
599
302
1
2–3
4?
629
Non-conflict zone
983
No
65.79
34.21
41.61
58.39
13.6
29.03
29.72
27.65
27.65
72.35
N
15.2
23.34
29.19
32.26
120
184
204
230
17.22
25
27.72
30.07
16.16
13.19
35.98
34.68
169
100
336
352
29.62
70.38 230
738
12.85
25.96
31.57
29.62
155
317
266
230
14.33
32.02
27.92
25.73
25.73
74.27
9.19
9.9
36.18
44.73
48.48
51.52 267
461 35.28
64.72
535
194 72.5
27.5 448
276 59.63
40.37
v2 ðdf ¼ 1Þ ¼ 23:59; p \ 0.0001
362
370
v ðdf ¼ 1Þ ¼ 24:28; p \ 0.0001
2
147
282
311
284
v2 ðdf ¼ 3Þ ¼ 3:45; p = 0.02
284
740
v2 ðdf ¼ 1Þ ¼ 3:03; p = 0.08
282
124
320
294
v2 ðdf ¼ 3Þ ¼ 14:85; p \ 0.0001
107
167
217
249
(%)
(%)
N
(%)
Army Reserve
5.43
18.12
34.42
42.03
67
80
97
114
21.02
24.9
26.25
27.84
22.92
22.07
36.82
18.19
140
60
155
148
15.39
11.96
34.86
37.78
26.92
73.08 150
358 32.56
67.44
24.03
25.26
23.79
26.92
51
152
155
150
8.21
27.58
31.65
32.56
69.87
30.13
161
194
40.85
59.15
109
13
88.21
11.79
254
98
69.34
30.66
v2 ðdf ¼ 5Þ ¼ 29:25; p \ 0.0001
85
35
v ðdf ¼ 5Þ ¼ 41:0; p \ 0.0001
2
44
42
37
49
v2 ðdf ¼ 15Þ ¼ 5:93; p \ 0.0001
49
123
v2 ðdf ¼ 5Þ ¼ 2:13; p = 0.06
64
33
52
25
v2 ðdf ¼ 15Þ ¼ 12:54; p \ 0.0001
8
22
41
52
v2 ðdf ¼ 15Þ ¼ 10:19; p \ 0.0001
N
Air Force Reserve
142
16
115
44
71
53
40
48
48
164
35
34
93
50
6
18
41
99
N
89.08
10.92
73.7
26.3
32.94
24.62
18.93
23.51
23.51
76.49
10.06
15.79
44.04
30.1
3.51
11.18
25.29
60.02
(%)
Air National Guard
306
260
152
417
84
264
226
182
182
574
134
66
243
302
114
166
163
131
N
Chi square test p value indicates whether the null hypothesis that there are no significant differences across branches can be rejected
53.13
46.87
26.95
73.05
10.35
33.61
29.84
26.2
26.2
73.8
9
8.63
34.48
47.9
20.26
28.07
28.25
23.42
(%)
Army National Guard
Percentages may not add up to 100 % due to missing values. All proportions and statistics are weighted to account for survey sampling design
470
Yes
Active combat participation on most recent deployment
831
Conflict zone
Most recent deployment location
514
0
Number of deployments
1,478
Yes
Deployment experience
Officer
656
224
NCO (E5–E6)
36.08 11.53
646
39.76
16.25
24.2
28.42
31.12
Junior enlisted (E1–E4)
Rank
479
1–3
(%)
National Guard
v2 ðdf ¼ 3Þ ¼ 0:64; p = 0.59
N
N
(%)
Reserves
Total
0
Number of lifetime deployment-related traumatic events
Sociodemographic and military characteristics
Table 1 continued
61
59
25
93
21
39
60
47
47
120
22
8
42
96
25
33
38
24
N
51.65
48.35
20.2
79.8
10.36
21.04
36.75
31.85
31.85
68.15
6.89
4.21
22.17
66.73
20.63
27.43
33.58
18.36
(%)
Marine Corps Reserve
111
24
91
48
31
49
59
38
38
139
56
23
71
25
7
32
41
59
N
79.35
20.65
66.14
33.86
17.96
25.03
35.18
21.84
21.84
78.16
18.23
14.35
47.85
19.57
5.57
21.5
29.67
43.25
(%)
Navy Reserve
Soc Psychiatry Psychiatr Epidemiol
123
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majority white, the Army Reserve had the highest distribution of non-whites (black 23.47 % and other 5.52 %). The Air Force Reserve and Navy Reserve had the highest percentages of personnel with a college degree (42.75 and 37.66 %) and making more than $60,000 per year (61.57 and 55.66 %). The Marine Corps Reserve had the highest proportions of those never married (59.18 %) compared to the other service branches. The Marine Corps Reserve and the Army National Guard had the greatest proportions of personnel with C4 deployment-related traumatic events (48.06 and 48.33 %). The Army Reserve had the highest proportion of personnel with C5 non-deployment-related traumatic events (47.48 %). The Marine Reserves had the highest proportion (66.73 %) of Junior Enlisted service members, while the lowest proportions were found among the Air Force Reserves (18.19 %) and the Navy Reserves (19.57 %). In contrast, the Air Force Reserves (22.92 %) and the Navy Reserves (18.23 %) had the highest proportions of Officers, while the Marine Corps Reserve (6.89 %) had the lowest. Among all of the respondents, 72.35 % had deployment experiences, with the Navy Reserve reporting the highest proportion (78.16 %). Among those with a deployment experience, the Marine Corps Reserve had the highest proportion of personnel most recently deployed to an area of conflict (79.8 %) and who participated in active combat (48.35 %). In comparison, among those who had been deployed, the Air National Guard had the smallest proportion of those most recently deployed to an area of conflict (26.3 %) with only 10.92 % participating in active combat operations. Table 2 lists the frequency and prevalence of each disorder (i.e., deployment-related PTSD, non-deploymentrelated PTSD, and depression) for the total sample by service branch. In the total sample, 5.49 % report lifetime deployment-related PTSD, 5.4 % report lifetime nondeployment-related PTSD, and 21.63 % report lifetime depression. There were no significant differences in the distribution of depression or PTSD between the Reserves and National Guard. There were, however, statistically significant differences in the distributions of disorder by branch. Army National Guard respondents had the highest proportions of lifetime and past month deployment-related PTSD (6.17 %, 4.82 %) and the highest proportions of lifetime, past year, and past month non-deployment-related PTSD (6.43, 4.97, 3.07 %). The Navy Reserves had levels of lifetime (6.37 %) and current year (4.59 %) nondeployment-related PTSD comparable to the Army National Guard. The Army Reserve had the highest proportion of current year deployment-related PTSD (5.91 %), and had lifetime and past month deployment-related PTSD proportions (6.15, 4.06 %) comparable to those of the Army National Guard. In contrast, Air National Guard respondents were least likely to report deployment-related PTSD (1.24, 1.24, and 0.55 %) and non-deployment-
123
related PTSD (1.24, 0.67, and 0.67 %). Examining the distribution of depression across the service branches, the Marine Corps Reserve had the highest proportions of lifetime, past year, and past month depression (30.76, 19.67, and 8.75 %), while the Air National Guard had the lowest proportions (15.04, 6.65, 1.02 %). Table 3 reports the odds ratios for both non-deployment and deployment-related PTSD and depression outcomes (lifetime, current year, and current month) in relation to nondeployment and deployment-related traumatic experiences. The number of non-deployment-related traumatic events was positively associated, in a dose–response fashion relationship, with non-deployment-related PTSD and depression but not with deployment-related PTSD. Conversely, the number of deployment-related traumatic events had a positive, dose– response relationship with deployment-related PTSD and depression, but not with non-deployment-related PTSD.
Discussion Among this nationally representative RC sample, nondeployment-related trauma had a dose–response relationship with both non-deployment-related PTSD and depression, while deployment-related trauma had a dose– response relationship with deployment-related PTSD and depression. Army National Guard respondents reported the highest levels of lifetime (6.17 %), and current month (4.82 %) deployment-related PTSD, while those in the Army Reserves reported a slightly higher level of current year deployment-related PTSD (5.91 %) and had comparable levels of lifetime (6.15 %) and current month (4.06 %) deployment-related PTSD. In contrast, the Air National Guard reported the lowest levels of deploymentrelated PTSD (lifetime—1.24 %, current year—1.24 %, and current month—0.55 %). The Army National Guard also had the highest levels of non-deployment-related PTSD (lifetime—6.43 %, current year—4.97 %, current month—3.07 %), with the Navy Reserve having comparable levels of lifetime (6.37 %) and current year nondeployment-related PTSD, while the Air National Guard had the lowest levels (lifetime—1.24 %, current year— 0.67 %, current month—0.67 %). In regards to depression, the Marine Corps Reserve reported the highest levels of lifetime (30.76 %), current year (19.67 %), and current month (8.75 %) depression, while those in the Air National Guard reported the lowest levels (15.04, 6.65, and 1.02 %). The relative elevations in deployment-related PTSD prevalence among the Army Reserves, and Army National Guard, non-deployment-related PTSD prevalence among the Army Reserves and Navy Reserves, and depression prevalence among Army National Guard and Marine Corps Reserve respondents may be attributable to a number of
2,003
1,478
Total ever deployed
72.35
100
5.99
14.31
21.63
2.32
3.91
5.4
3.62
4.98
5.49
100
49.4
970
50.6
(%)
5.76
37
5.24
5
34
4.95
3.17
26
4.02
5.25
48
5.54
3.57
36
4.23
1.96
23
2.66
21.23
209
22.02
13.63
134
14.97
741
1,033
56 70.36
49.46
5.86 737
970
57 74.3
50.54
6.13
v ðdf ¼ 1Þ ¼ 0:05; p = 0.82
2
132
v2 ðdf ¼ 1Þ ¼ 0:6; p = 0.44
221
v ðdf ¼ 1Þ ¼ 0:16; p = 0.69
2
16
v2 ðdf ¼ 1Þ ¼ 0:84; p = 0.36
30
v2 ðdf ¼ 1Þ ¼ 0:46; p = 0.5
45
v ðdf ¼ 1Þ ¼ 0:06; p = 0.8
2
21
v2 ðdf ¼ 1Þ ¼ 0:61; p = 0.44
32
v ðdf ¼ 1Þ ¼ 0; p = 0.97
2
38
v2 ðdf ¼ 1Þ ¼ 0:15; p = 0.7
1,033
N
National Guard
8.44
(%) 509
N 26.32
(%)
Army Reserve
2
5.44
19
6.15
3.9
18
5.91
2
0
12
4.06
5.3
22
4.86
3.82
14
3.28
2
0
11
2.69
16.36
115
21.87
10.39
66
13.98
123
176
8
73.08
8.44
4.58
359
510
30
67.48
26.35
6.58
v ðdf ¼ 5Þ ¼ 7:03; p \ 0.0001
2
17
v2 ðdf ¼ 5Þ ¼ 4:83; p \ 0.0001
29
v ðdf ¼ 5Þ ¼ 3:51; p \ 0.0001
0
v2 ðdf ¼ 5Þ ¼ 6:95; p \ 0.0001
5
v2 ðdf ¼ 5Þ ¼ 4:59; p \ 0.0001
7
v ðdf ¼ 5Þ ¼ 4:26; p \ 0.0001
0
v2 ðdf ¼ 5Þ ¼ 7:41; p \ 0.0001
4
v ðdf ¼ 5Þ ¼ 2:79; p = 0.02
5
v2 ðdf ¼ 5Þ ¼ 3:28; p = 0.01
176
N
Air Force Reserve
164
215
2
13
33
2
2
3
1
2
2
215
N
76.49
8.99
1.02
6.65
15.04
0.67
0.67
1.24
0.55
1.24
1.24
8.99
(%)
Air National Guard
573
755
55
121
176
21
34
45
25
32
35
757
N
73.83
41.55
7.23
16.77
23.53
3.07
4.97
6.43
4.82
5.81
6.17
41.55
(%)
Army National Guard
a
Frequency is among those who have deployment experience
Chi square test p value indicates whether the null hypothesis that there are no significant differences across branches can be rejected
Percentages may not add up to 100 % due to missing values. All proportions and statistics are weighted to account for survey sampling design
2,003
113
Current month
Total
266
Current year
39
Current month Depression
430
66
Current year
Lifetime
93
Lifetime
47
66
Current year
Current month Non-deployment-related PTSD
75
a
(%)
N
N
(%)
Reserves
Total
Lifetime
Deployment-related PTSD
Total
Psychopathology
Table 2 Psychopathology prevalence by service component and branch
120
168
13
30
48
3
4
7
4
4
5
168
N
68.15
5.87
8.75
19.67
30.76
2.34
2.95
5.18
3.26
3.26
4.31
5.87
(%)
Marine Corps Reserve
139
179
5
19
29
2
7
9
5
6
9
178
N
77.9
8.80
2.98
11.67
17.61
1.34
4.59
6.37
3.63
4.68
5.91
8.77
(%)
Navy Reserve
Soc Psychiatry Psychiatr Epidemiol
123
123
AOR (95 %CI)
AOR (95 %CI)
0.91 (0.35–2.37)
1.21 (0.47–3.15)
0.73 (0.18–2.93)
1–4
5–11
12?
0.88 (0.21–3.74)
1.30 (0.46–3.62)
0.95 (0.34–2.66)
1
1
2.08 (1.08–4.00)
5.32 (2.81–10.08)
1-3
4–5
6?
5.12 (2.62–10.03)
1.61 (0.79–3.25)
1
–
1
6.87 (3.07–15.36)
1.64 (0.69–3.94)
1
–
0.33 (0.05–1.99)
0.76 (0.24–2.39)
0.79 (0.26–2.42)
b
a
1.54 (0.70–3.41)
2.77 (1.41–5.46)
1.93 (0.97–3.84)
1
3.67 (1.34–10.06)
3.22 (1.88–5.54)
1
–
AOR (95 %CI)
2.07 (0.83–5.16)
3.18 (1.41–7.18)
2.43 (1.07–5.49)
1
3.06 (0.98–9.54)
2.82 (1.54–5.16)
1
–
AOR (95 %CI)
Non-deployment-related PTSD was assessed only among those with C1 non-deployment-related traumatic event
Deployment-related PTSD was assessed only among those with C1 deployment-related traumatic event
All models adjusted for gender, income, education, marital status, and paygrade
–
0
Number of deployment-related traumatic events
1
0
AOR (95 %CI)
Current year (N = 1,292)
Lifetime (N = 1,292)
Current month (N = 915)
Lifetime (N = 915)
Current year (N = 915)
Non-deployment-related PTSDb
Deployment-related PTSDa
Number of non-deployment-related traumatic events
Total
Sociodemographic and military characteristics
Table 3 Relationships between trauma exposure and PTSD and depression
1.97 (0.70–5.53)
2.14 (0.85–5.42)
1.97 (0.76–5.05)
1
4.11 (1.13–14.98)
2.91 (1.35–6.26)
1
–
AOR (95 %CI)
Current month (N = 1,292)
2.86 (1.85–4.41)
1.88 (1.27–2.78)
1.27 (0.86–1.88)
1
7.07 (3.35–14.91)
2.72 (1.49–4.97)
1.42 (0.78–2.58)
1
AOR (95 %CI)
Lifetime (N = 1,414)
Depression
3.44 (2.06–5.73)
2.07 (1.29–3.32)
1.29 (0.79–2.09)
1
7.81 (3.19–19.13)
2.75 (1.28–5.91)
1.65 (0.77–3.54)
1
AOR (95 %CI)
Current year (N = 1,414)
12.88 (4.78–34.66)
5.09 (1.86–13.97)
3.46 (1.24–9.68)
1
3.72 (0.91–15.23)
1.78 (0.54–5.83)
1.44 (0.44–4.77)
1
AOR (95 %CI)
Current month (N = 1,414)
Soc Psychiatry Psychiatr Epidemiol
Soc Psychiatry Psychiatr Epidemiol
factors that distinguish these groups’ sociocultural backgrounds and experiences (e.g., post-deployment social support, higher lifetime traumatic exposure, and varying intensity of military experiences). For example, personnel in the Army National Reserves (73.05 %), the Marine Corps Reserves (79.80 %), and the Army Reserves (59.15 %) were more likely to experience conflict zone deployments than members of other branches. Additionally, the greatest exposure to 1 or more deployment-related traumas was reported among the Marine Reserves (81.64 %), Army Reserves (72.17 %), and Army National Guard (76.58 %). Finally, individuals in the Marine Corps Reserves (57.82 %), Army National Guard (33.92 %), and Army Reserves (25.95 %) had the highest proportions of individuals under 25. These findings are indeed consistent with prior work demonstrating that combat deployment and exposure to combat-deployment-related trauma are both associated with depression [21] and PTSD [22], as is younger age [23]. This study of the prevalence of mental health disorders among the RC component service members can also be viewed in comparison with prevalence estimates from studies of service members from the active duty component. A current prevalence meta-analysis [24] found no differences in prevalence estimates of depression or PTSD, in comparisons of RC vs. active duty personnel. This suggests that while there are differences by branch within the RC, there are likely no differences between the RC and active duty components in aggregate measures of depression and PTSD prevalence. As expected, the number of deployment-related traumatic events was positively associated with deploymentrelated PTSD. Importantly, however, a similar relationship was found for depression for both deployment-related as well as non-deployment-related traumatic events. Although the relationship between depression and trauma exposure has previously been reported in military [2] and civilian populations [25, 26], it has not often been examined in detail. Better understanding depression outcomes in relation to traumatic events is important in further clarifying this association and identifying possible depression subtypes. The findings from this study should be interpreted with some caveats in mind. First, the assessments are based on self-reports and therefore subject to respondent recall bias, social desirability affects, and potential biases associated with the sensitive-nature of the questions; however, this limitation is offset as appraisals were made using the validated PCL-C and the PHQ-9 screening tools, which exhibit excellent specificity and moderate sensitivity [14, 17, 18]. In particular, respondents who did not screen positive for either probable PTSD or depression were unlikely to be misdiagnosed using this approach [17]. Although random sampling and post-stratification weighting were used to ensure that the sample was representative of the RC population, it is possible that unmeasured selection bias still
influenced the findings. Lastly, the findings are limited in that they represent cross-sectional data.
Conclusion Reserve Component service members face unique challenges in the process of preparing for, undertaking, and returning from a military combat deployment, including the need to quickly reintegrate into civilian life [6, 27–31]. This study highlights distinct differences between each of the US military’s RC service branches (i.e., Army, Air Force, Marine Corps, and Navy) and service components (Federal Reserves and state/territorial National Guard) with regard to the rates of PTSD, depression, and exposure to both deployment and non-deployment-related traumatic events. The differences in mental health outcomes between these groups suggest as one possibility, differences in the sociocultural fabric of these subcultures within the overarching military culture. Another possibility is that there are differences in specific types of trauma exposures that are tied to service branch. Finally, it is possible that individuals with characteristics that lend vulnerability or immunity to PTSD and depression differentially select into their service branch. The findings suggest that service branches within the RC have varying mental health needs, and military leaders should consider implementing targeted behavioral health screenings and tailored treatment interventions to account for each service branch’s specific operational deployment needs. To guide these interventions, future research should also seek to understand the organizational differences— cultural, traumatic exposure related, and selection related, between the RC service branches that drive the differing rates of PTSD and depression. The findings also carry implications for other nations’ militaries, many of which maintain organizational structures and subcomponents similar to the US military (i.e., AC and RC; separate land, sea, and air forces) and whose members are experiencing similar issues [4, 32–36]. To further identify cultural, social, and organizational differences between militaries, branches, and subcomponents, future research should give focus to comparing mental health outcomes across militaries internationally. Such comparative efforts could provide novel insights into protective and/or risk factors by which to guide the development of prevention and treatment efforts. Conflict of interest
None.
Appendix See Tables 4, 5, 6.
123
123 701,353
271,918 206,907 125,667
25–34
35–44
45?
40,170
Other
270,693 101,755 125,322
NCO (E5–E6)
Senior NCO (E7–E9)
Officer
355,748
127,463
Black
Rank Junior enlisted (E1–E4)
648,651
White
Race
249,074
18–24
Age
152,220
Male
853,581
14.68
11.92
31.71
41.68
4.92
15.62
79.46
14.70
24.20
31.90
29.20
82.20
17.80
100
451
224
656
646
236
244
1,520
351
538
658
456
1,618
385
2,003
12.63 (11.48–13.88)
11.53 (10.12–13.1)
36.08 (33.8–38.42)
39.76 (37.43–42.14)
4.72 (4.11–5.41)
15.65 (13.89–17.60)
79.63 (77.65–81.48)
14.83 (13.33–16.46)
24.1 (22.20–26.11)
31.79 (29.64–34.02)
29.28 (27.05–31.61)
82.22 (80.36–83.93)
17.78 (16.07–19.64)
100
(% (95 %CI))
N
N
(%)
Study total
Sampling Universe total
Female
Gender
Total
Sociodemographic and military characteristics
70,330
45,819
119,449
150,355
23,711
70,335
265,034
61,010
95,712
118,337
103,231
297,701
80,596
385,953
N
18.22
11.87
30.95
38.96
6.60
19.59
73.81
16.13
25.30
31.28
27.29
78.70
21.30
45.22
(%)
Universe Reserves total
282
124
320
294
136
150
743
217
281
321
212
793
238
1,031
N
16.16 (14.31–18.21)
13.19 (11.07–15.63)
35.98 (32.76–39.32)
34.68 (31.52–37.97)
5.43 (4.52–6.5)
18.88 (16.23–21.85)
75.69 (72.69–78.46)
18.06 (15.79–20.58)
24.36 (21.69–27.23)
31.47 (28.45–34.67)
26.11 (23.13–29.32)
78.8 (75.98–81.37)
21.2 (18.63–24.02)
49.4 (48.49–50.31)
(% (95 %CI))
Study Reserves total
Table 4 Comparison of selected characteristics of reserve population (2008) and study sample: component totals
54,992
55,936
151,244
205,393
15,994
56,785
377,800
63,243
108,987
150,765
144,588
397,158
70,425
467,565
N
11.76
11.96
32.35
43.93
3.55
12.60
83.85
13.53
23.31
32.24
30.92
84.94
15.06
54.78
(%)
Universe National Guard total
169
100
336
352
100
94
777
134
257
337
244
825
147
972
N
9.19 (7.85–10.73)
9.9 (8.14–12)
36.18 (33–39.49)
44.73 (41.35–48.16)
4.02 (3.25–4.96)
12.5 (10.28–15.13)
83.48 (80.81–85.84)
11.67 (9.78–13.87)
23.86 (21.12–26.73)
32.1 (29.1–35.26)
32.37 (29.12–35.8)
85.55 (83.03–87.75)
14.45 (12.25–16.97)
50.6 (49.69–51.51)
(% (95 %CI))
Study National Guard total
Soc Psychiatry Psychiatr Epidemiol
20,996
16,772
25–34
35–44
45?
3,550
Black
Other
14,473
25,216
13,544
14,753
Junior enlisted (E1–E4)
NCO (E5–E6)
Senior NCO (E7–E9)
Officer
Rank
49,825
10,849
White
Race
8,391
21,827
18–24
Age
17,002
50,984
Male
67,986
21.70
19.92
37.09
21.29
5.53
16.89
77.58
24.70
30.90
32.10
12.30
75.00
25.00
7.96
64
33
52
25
26
18
132
57
55
45
19
127
49
176
22.92 (17.74–29.08)
22.07 (15.94–29.73)
36.82 (29.15–45.22)
18.19 (12.29–26.08)
6.71 (4.43–10.05)
14.02 (8.93–21.34)
79.27 (72.04–85.02)
29.89 (23.20–37.56)
28.65 (22.05–36.30)
26.97 (20.33–34.83)
14.5 (9.15–22.20)
74.36 (66.69–80.78)
25.64 (19.22–33.31)
8.44 (7.92–9.0)
(% (95 %CI))
N
N
(%)
Study Air Force Reserve
Universe Air Force Reserve
Female
Gender
Total
Sociodemographic and military characteristics
35,980
24,079
55,877
89,361
10,469
45,957
140,313
32,238
45,890
65,055
62,108
156,739
48,557
205,297
N
Universe Army Reserve
17.53
11.73
27.22
43.53
5.32
23.36
71.32
15.70
22.40
31.70
30.30
76.30
23.70
24.05
(%)
140
60
155
148
70
97
342
96
145
173
95
369
140
509
N
15.39 (12.89–18.27)
11.96(9.25-15.34)
34.86(30.39-39.62)
37.78(33.08-42.72)
5.52 (4.29–7.09)
23.47 (19.49–27.99)
71 (66.48–75.14)
14.97 (12.11–18.35)
24.38 (20.69–28.48)
34.71 (30.33–39.37)
25.95 (21.64–30.77)
77.03 (72.96–80.65)
22.97 (19.35–27.04)
26.32 (25.46–27.20)
(% (95 %CI))
Study Army Reserve
3,696
1,898
6,554
26,362
2,170
2,986
30,119
1,213
4,037
11,326
21,934
36,619
1,891
38,510
N
9.60
4.93
17.02
68.45
6.15
8.46
85.38
3.10
10.50
29.40
57.00
95.10
4.90
4.51
(%)
Universe Marine Corps Reserve
Table 5 Comparison of selected characteristics of reserve population (2008) and study sample: reserves by branch
22
8
42
96
21
20
126
9
18
61
80
155
13
168
N
6.89 (4.41–10.62)
4.21 (2.03–8.53)
22.17 (16.37–29.31)
66.73 (59.11–73.56)
4.73 (3.01–7.35)
14.88 (9.72–22.12)
80.39 (73.26–85.98)
2.74 (1.40–5.32)
8.14 (4.94–13.13)
31.3 (24.57–38.92)
57.82 (49.88–65.37)
93.09 (87.78–96.20)
6.91 (3.80–12.22)
5.87 (5.54–6.21)
(% (95 %CI))
Study Marine Corps Reserve
14,509
5,330
29,159
17,469
7,522
10,543
44,777
10,787
24,789
20,129
10,798
53,359
13,146
66,508
N
21.83
8.02
43.87
26.28
11.97
16.78
71.25
16.20
37.30
30.30
16.20
80.20
19.80
7.79
(%)
Universe Navy Reserve
56
23
71
25
19
15
143
55
63
42
18
142
36
178
N
18.23 (13.85–23.62)
14.35 (9.56–20.97)
47.85 (39.85–55.97)
19.57 (13.47–27.54)
4.36 (2.71–6.95)
12.42 (7.62–19.6)
83.22 (76.21–88.47)
26.22 (20.1–33.42)
31.01 (24.29–38.65)
26.22 (19.7–33.97)
16.56 (10.75–24.64)
78.82 (71.44–84.7)
21.18 (15.3–28.56)
8.77 (8.25–9.33)
(% (95 %CI))
Study Navy Reserve
Soc Psychiatry Psychiatr Epidemiol
123
Soc Psychiatry Psychiatr Epidemiol Table 6 Comparison of selected characteristics of reserve population (2008) and study sample: National Guard by branch Sociodemographic and military characteristics
Universe Air National Guard
Study Air National Guard
Universe Army National Guard
Study Army National Guard
N
(%)
N
N
(%)
N
(% (95 %CI))
109,196
12.79
215
8.99 (8.59–8.41)
358,391
41.99
757
41.61 (40.73–42.5)
20,168 89,028
18.50 81.50
45 170
19.83 (14.81–26.03) 80.17 (73.97–85.19)
50,257 308,130
14.00 86.00
102 655
13.29 (10.9–16.1) 86.71 (83.9–89.1)
18–24
19,032
17.40
41
25.21 (19.15–32.42)
125,556
35.00
203
33.92 (30.23–37.81)
25–34
36,208
33.20
72
30.65 (24.66–37.38)
114,557
32.00
265
32.42 (29.03–35.99)
35–44
31,712
29.00
65
29.25 (23.33–35.97)
77,275
21.60
192
22.69(19.77-25.9)
45?
22,244
20.40
37
14.89 (10.79–20.21)
40,999
11.40
97
10.97 (8.91–13.45)
White
90,087
85.60
179
87.78 (82.64–91.55)
287,713
83.31
598
82.55 (79.46–85.26)
Black
9,341
8.88
14
7.76 (4.57–12.87)
47,444
13.74
80
13.53 (10.96–16.58)
Other
5,808
5.52
22
4.46 (2.83–6.96)
10,186
2.95
78
3.93 (3.09–4.98)
Total
(% (95 %CI))
Gender Female Male Age
Race
Rank Junior enlisted (E1–E4)
26,326
24.11
50
30.1 (23.64–37.47)
179,067
49.96
302
47.9 (44.06–51.76)
NCO (E5–E6)
45,025
41.24
93
44.04 (37.16–51.15)
106,219
29.64
243
34.48 (30.92–38.21)
Senior NCO (E7–E9)
23,497
21.52
34
15.79 (11.34–21.56)
32,439
9.05
66
8.63 (6.78–10.93)
Officer
14,326
13.12
35
10.06 (7.17–13.96)
40,666
11.35
134
9 (7.53–10.72)
References 1. Institute of Medicine (2010) Returning home from Iraq and Afghanistan—Assessment of readjustment needs of veterans, service members, and their families. National Academies Press, Washington 2. Tanielian TL, Jaycox L (eds) (2008) Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery (Vol. 720). RAND Corporation, California 3. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL (2004) Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 351(1):13–22 4. Hotopf M, Hull L, Fear NT, Browne T, Horn O, Iversen A, Wessely S (2006) The health of UK military personnel who deployed to the 2003 Iraq war: a cohort study. Lancet 367(9524):1731–1741 5. Kulka RA (1988) Contractual report of findings from the National Vietnam veterans readjustment study. Research Triangle Institute 6. Milliken CS, Auchterlonie JL, Hoge CW (2007) Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA 298(18): 2141–2148 7. Thomas JL, Wilk JE, Riviere LA, McGurk D, Castro CA, Hoge CW (2010) Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Arch Gen Psychiatry 67(6):614–623 8. Vogt D, Smith B, Elwy R, Martin J, Schultz M, Drainoni ML, Eisen S (2011) Predeployment, deployment, and postdeployment risk factors for posttraumatic stress symptomatology in female and male OEF/OIF veterans. J Abnorm Psychol 120(4):819 9. La Bash HA, Vogt DS, King LA, King DW (2009) Deployment Stressors of the Iraq War Insights From the Mainstream Media. J Interpers Violence 24(2):231–258
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10. American Association for Public Opinion Research (2011) Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys, 7th edn. AAPOR, New york 11. Research Triangle Institute (2012) SUDAAN [computer program]. Research Triangle Institute, Research Triangle Park 12. Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P (1998) Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry 55(7):626–632 13. Vogt DS, Proctor SP, King DW, King LA, Vasterling JJ (2008) Validation of scales from the Deployment Risk and Resilience Inventory in a sample of Operation Iraqi Freedom veterans. Assessment 15(4):391–403 14. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA (1996) Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther 34(8):669–673 15. Ruggiero KJ, Del Ben K, Scotti JR, Rabalais AE (2003) Psychometric properties of the PTSD Checklist-Civilian version. J Trauma Stress 16(5):495–502 16. Association American Psychiatric (ed) (2000) Diagnostic and statistical manual of mental disorders: DSM-IV-TR. American Psychiatric Pub, Washington 17. Prescott MR, Tamburrino M, Calabrese JR, Liberzon I, Slembarski R, Shirley E, Galea S (2014) Validation of lay-administered mental health assessments in a large Army National Guard cohort. Int J Method Psych 23(1):109–119 18. Kroenke K, Spitzer RL, Williams JB (2001) The PHQ-9. J Gen Intern Med 16(9):606–613 19. First MB (2007) Structured Clinical Interview for DSM-IV-TR Axis I Disorders: SCID-I. Biometrics Research Department, New York State Psychiatric Institutute 20. Institute SAS (2008) SAS [computer program]. SAS Institute, Cary
Soc Psychiatry Psychiatr Epidemiol 21. Wells TS, LeardMann CA, Fortuna SO et al (2010) A prospective study of depression following combat deployment in support of the wars in Iraq and Afghanistan. Am J Public Health 100(1): 90–99 22. Smith TC, Ryan MA, Wingard DL et al (2008) New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study. BMJ 336(7640):366–371 23. Riddle JR, Smith TC, Smith B et al (2007) Millennium Cohort: the 2001-2003 baseline prevalence of mental disorders in the U.S. military. J Clin Epidemiol 60(2):192–201 24. Cohen G, Fink D, Sampson L and Galea S (2014) Mental Health Among Reserve Component Military Service Members And Veterans. Epidemiologic Reviews 25. Kendler KS, Karkowski LM, Prescott CA (1999) Causal relationship between stressful life events and the onset of major depression. Am J Psychiatry 156(6):837–841 26. Nandi A, Tracy M, Beard JR, Vlahov D, Galea S (2009) Patterns and predictors of trajectories of depression after an urban disaster. Ann Epidemiol 19(11):761–770 27. Gorman LA, Blow AJ, Ames BD, Reed PL (2011) National Guard families after combat: mental health, use of mental health services, and perceived treatment barriers. Psychiatr Serv 62:28–34 28. Lane ME, Hourani LL, Bray RM, Williams J (2012) Prevalence of perceived stress and mental health indicators among reserve component and active-duty military personnel. Am J of Public Health 102:1213–1220
29. Riviere LA, Kendall-Robbins A, McGurk D, Castro CA, Hoge CW (2011) Coming home may hurt: risk factors for mental ill health in US reservists after deployment in Iraq. Br J Psychiatry 198:136–142 30. O’Brien CP, Oster M, Morden E (2012) Substance use disorders in the U.S. Armed Forces. National Academies Press, Washington 31. Russell DW, Whalen R, Riviere L, Clark-Walper K, Bliese PD, Thomas JL (2014) Embedded behavioral health providers: an assessment with the Army National Guard. Psychol Serv 11(3):265–272 32. Iversen AC, Greenberg N (2009) Mental health of regular and reserve military veterans. Adv Psychiatr Treat 15:100–106 33. Browne T, Hull L, Horn O, Jones M, Murphy D, Fear NT et al (2007) Explanations for the increase in mental health problems in UK reserve forces who have served in Iraq. Br J Psychiatry 190:484–489 34. Engelhard IM, Van den Hout MA, Weerts J, Arntz A, Hox JJCM, McNally RJ (2007) Deployment-related stress and trauma in Dutch soldiers returning from Iraq. Br J Psychiatry 191:140–145 35. Zamorski MA, Rusu C, Garber BG (2014) Prevalence and correlates of mental health problems in Canadian Forces personnel who deployed in support of the mission in Afghanistan: findings from postdeployment screenings, 2009–2012. Can J Psychiatry 59(6):319–326 36. Bleier J, McFarlane A, McGuire A, Treloar S, Waller M, Dobson A (2011) Risk of adverse health outcomes associated with frequency and duration of deployment with the Australian Defence Force. Mil Med 176(2):139–146
123
ORIGINAL PAPER
Mental health among a nationally representative sample of United States Military Reserve Component Personnel Dale W. Russell • Gregory H. Cohen Robert Gifford • Carol S. Fullerton • Robert J. Ursano • Sandro Galea
•
Received: 16 June 2014 / Accepted: 10 November 2014 Ó Springer-Verlag (outside the USA) 2014
Abstract Purpose Estimate prevalence of lifetime, current year, and current month depression and post-traumatic stress disorder (PTSD) among US military reservists. Methods Structured interviews were performed with a nationally representative military reserve sample (n = 2,003). Sociodemographic characteristics, military experiences, lifetime stressors, and psychiatric conditions were assessed. Depression was measured with the PHQ-9, and PTSD (deployment and non-deployment related) was assessed with the PCL-C. Results Depression (21.63 % lifetime, 14.31 % current year, and 5.99 % current month) was more common than either deployment-related PTSD (5.49 % lifetime, 4.98 % current year, and 3.62 % current month) or non-deployment-related PTSD (5.40 % lifetime, 3.91 % current year, and 2.32 % current month), and branch-related differences were found. Non-deployment-related trauma was associated with non-deployment-related PTSD and depression in a dose–response fashion; deployment-related trauma was associated with deployment-related PTSD and depression in a dose–response fashion. Conclusions The study reveals notable differences in PTSD and depression prevalence by service branch that D. W. Russell (&) R. Gifford C. S. Fullerton R. J. Ursano Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University, F. Edward Hebert School of Medicine, 4301 Jones Bridge Road, Bethesda, MD 20814, USA e-mail: [email protected] G. H. Cohen S. Galea Department of Epidemiology, Columbia University, Mailman School of Public Health, 722 W 168th Street, Room 1508, New York, NY 10032-3727, USA e-mail: [email protected]
may be attributable to a combination of factors including greater lifetime trauma exposures and differing operational military experiences. Our findings suggest that service branch and organizational differences are related to key protective and/or risk factors, which may prove useful in guiding prevention and treatment efforts among reservists. Keywords Posttraumatic stress disorder Depression Military Reserves National Guard
Introduction Operations in Iraq and Afghanistan have exposed military personnel from many countries to the traumas associated with war. In the United States (US), the wars have generated over two million military combat veterans [1], over one million of whom have been diagnosed with one or more psychological disorders [2]. A significant proportion of these service members are Reserve Component (RC; part-time employees) personnel who were called upon to support the Active Component (AC; full-time employees) in an unprecedented manner during these wars [2]; _ENREF_4 for example, RC soldiers accounted for nearly half of the Army’s ground forces at the height of combat operations [1]. Both the Reserves and National Guard comprise the RC; however, the federal government controls the Reserves whereas control of the National Guard resides with each state or territory until called upon by the President of the United States. Given the large representation of RC personnel among combat veterans, research is needed to understand the impact of military service in this population. While there is ample empirical evidence that numerous psychopathologies (e.g., post-traumatic stress disorder, depression, and substance use disorders) are associated with military operations
123
Soc Psychiatry Psychiatr Epidemiol
among AC personnel following an operational deployment [3–8], there is a relative dearth of comparable research assessing the health consequences among RC personnel post-deployment. As both post-deployment general and behavioral healthcare support for RC personnel differ by service branch, it is also critically important to investigate mental health outcomes across service branches and deployment experiences [6–9]. Given the paucity of empirical research assessing the psychological consequences of continued military operations on the RC, this research aims to address this shortcoming using unique data from a nationally representative survey of RC personnel.
Methods Source population The study population was drawn in 2009 from a stratified simple random sample of 10,000 Reservists and 10,000 National Guard service members. This sample was provided by the Defense Manpower Data Center, the US military’s human resource information source for *42 million current and former service members. From the 20,000 RC service members, a stratified random sample of 10,260 was invited to participate in the study using pre-stamped opt-out letters. After 3 weeks, 509 (5 %) of those contacted elected to opt out. Attempts were made to contact the 9,751 RC personnel who did not return the opt-out card by telephone until the enrollment goal of approximately 2,000 was achieved. Of the 9,751 attempted contacts, 29 % (2,866) had non-working or incorrect numbers listed, and 35 % (3,386) could not be reached. Of those remaining, 3,499 were successfully contacted (36 % of the invited sample), 324 (9 %) were ineligible as they were no longer in the military, 61 (1 %) were disqualified because they could not speak English well enough, had health or hearing problems, were deceased, or had a pay grade of O-7 or above (i.e., held the rank of general officer); 14 (0.4 %) only partially completed the survey, and 1,097 (31 %) did not wish to participate. In total, 2,003 consented and completed the survey. Based on the American Association for Public Opinion Research (AAPOR) definitions [10], the overall cooperation rate was 68.24 %, and the overall response rate was 34.1 %. Respondents were provided $25 in compensation for their time and effort. The study protocol was approved by the US Army Medical Command’s Congressionally Directed Medical Research Program the US Army Medical Research & Materiel Command’s Human Research Protection Office, and the Institutional Review Boards at both the Uniformed Services University and Columbia University. Complex survey weights were constructed in SUDAAN version 11 [11], using the Wtadjst procedure, to account for
123
sampling design, sociodemographic characteristics related to survey non-response, and sociodemographic representativeness of the sampling universe—the entire national RC population at time of sampling in 2009. To examine sociodemographic representativeness of our weighted study estimates, we compared them with the sampling universe distributions of key demographic characteristics—gender, race, age, and rank. As presented in ‘‘Appendix’’, universe population proportions for each distribution of demographic characteristics were examined to see whether they lay within the 95 % confidence intervals (CIs) of our study proportion estimates. Overall, study sample distributions are broadly comparable by component and branch to the sampling universe, with some minor differences that we note below. We purposefully oversampled women in the Marine Corps Reserves study sample, which had a slightly higher proportion of women than the sampling universe. Relative to the sampling universe, the Navy Reserves study sample had a higher proportion of individuals 45 and older, while the Air National Guard study sample had a lower proportion of those 45 and older, and a higher proportion of those 18–24. In relation to the sampling universe, the Reserves Total study sample had a slightly lower proportion of individuals of other race, while the study samples of the Navy Reserves and Army National Guard had slightly higher proportions of individuals of other race; the study sample Marine Corps had a slightly higher proportion of black individuals; and the study sample Navy Reserves had a higher proportion of white individuals. Relative to the sampling universe estimates, study sample Reserves Total and Army Reserves had slightly lower proportions of junior enlisted service members; study sample Reserves Total, National Guard Total, Army Reserves, and Army National Guard had higher proportions of NCOs; the Navy Reserves study sample has a higher proportion of Senior NCOs; and the study sample Reserves Total, National Guard Total, and Army National Guard all had lower proportions of Officers. Measures Respondents completed a 40-min computer-assisted telephone survey. The survey collected information on demographics, military history, deployment experiences, lifetime stressors, and mental health status. Non-deployment traumatic experiences were identified using a list of 25 traumatic events [12]; if a respondent endorsed any event(s), they were then asked to indicate if the event(s) happened in relation to their most recent deployment. Additionally, deployment-related traumatic experiences were identified with a list of three traumatic events specific to military service in relation to one’s most recent deployment [13]. Therefore, 28 potential deploymentrelated traumatic experiences were presented. Finally,
Soc Psychiatry Psychiatr Epidemiol
respondents were asked to briefly describe any other extraordinarily stressful situation(s) or event(s) not captured by the 25 non-deployment-related events and the 28 deployment-related experiences presented. The mental health outcomes of interest included deployment-related post-traumatic stress disorder (PTSD), non-deployment-related PTSD, and depression. Deployment-related PTSD entails symptomology resulting from the ‘‘worst’’ traumatic event that occurred during a respondent’s most recent military deployment, while nondeployment-related PTSD refers to ‘‘worst’’ event outside of the most recent deployment. The PTSD Checklist Civilian version (PCL-C) was used to assess PTSD symptoms [14, 15]. Additional questions were posed to assess the duration of symptoms and functional impairment in order to fulfill the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR edition) criterion for a PTSD diagnosis [16]. To be classified as having a PTSD symptom, respondents had to report that the symptom occurred at least ‘‘some of the time’’ (i.e., 3 on a 1–5 scale). As per the DSM-IV-TR, respondents were classified as having PTSD if they had experienced fear, helplessness, or horror as a result of a traumatic event (criterion A1 and A2); at least one symptom of re-experiencing the traumatic event (criterion B); at least three symptoms of avoidance or numbing (criterion C); at least two symptoms of hypervigilance (criterion D); at least a 1 month duration of these symptoms (criterion E); and significant social or functional impairment as a result of these symptoms (criterion F) [16]. This screening algorithm maximized sensitivity and specificity for non-deployment-related (0.47, 0.94) and deployment-related PTSD (0.50, 0.93), in a contemporaneous sample of Ohio Army National Guard soldiers [17]. Depression was assessed using the Primary Care Evaluation of Mental Health Disorders Patient Health Questionnaire-9 (PHQ-9) [18]. Respondents were classified with depression if they endorsed at least two symptoms from the PHQ-9, one of which had to be anhedonia or depressed mood, and had the symptoms concurrently for at least a month. This screening approach maximizes sensitivity (0.51) and specificity (0.83) for Major Depressive Disorder as assessed by the Structured Clinical Interview (SCID) [19] per the DSM-IV-TR Axis I Disorders [16]. Onset timing and symptom duration were also measured. Statistical analysis Distributions of demographics and military characteristics of the sample were stratified by each RC service branch: US Army Reserves (USAR), Army National Guard (ARNG), US Air Force Reserves (USAFR), Air National Guard (ANG), US Navy Reserve (USNR), and US Marine Corps Reserve (USMCR) and compared using Chi-square tests (see
Appendix 1a for Universal Ns). Second, the prevalence of deployment-related PTSD, non-deployment-related PTSD, and depression were examined and compared by service branch with Chi-square tests. Third, logistic regression models were constructed to examine the relationships between deployment and non-deployment traumas and odds of deployment-related PTSD, non-deployment-related PTSD, and depression. All weighted statistical analyses were conducted using SAS-callable SUDAAN, version 11. Data were prepared for analysis with SAS 9.2 [20].
Results Table 1 lists the number and distribution of selected characteristics in the total sample, by service component and branch. Most respondents were male (82.22 %), white (79.63 %), between 18 and 35-years old (61.07 %), married (48.85 %), made less than $60,000 per year (58.79 %), had attended some college (51.35 %), had been exposed to 1 or more lifetime non-deployment-related traumatic events (89.9 %), and 1 or more deployment-related traumatic events (68.87 %). The majority of respondents were junior enlisted (pay levels E1–E4; 39.76 %) or basic-level noncommissioned officers (pay levels E5-E6; 36.08 %) and had previously deployed (72.35 %), with 42.3 % having deployed more than once. Among those with deployment experiences, the majority (58.39 %) had deployed to a conflict zone, although most (65.79 %) reported not having participated in active combat operations. There were a number of statistically significant differences between the Reserves and the National Guard. Relative to the National Guard, the Reserves had a higher proportion of women (21.2 vs. 14.45 %), those making [$60,000 (46.87 vs. 35.67 %), personnel with a college or graduate degree (32.05 vs. 23.16 %), and officers (16.16 vs. 9.19 %). Relative to the Reserves, the National Guard had a higher proportion of personnel aged 18–34 (64.47 vs. 57.58 %), white respondents (83.48 vs. 75.69 %), personnel with 1 or more deployments (74.27 vs. 70.38 %), personnel deployed to conflict zones (64.72 vs. 51.52 %), and personnel who participated in active combat operations during their most recent deployment (40.37 vs. 27.5 %). All but one comparison of the selected characteristic distributions by service branch were statistically significant. The Army National Guard was the largest branch in the sample (41.55 %) and the Marine Corps Reserve the smallest (5.87 %). Females were least likely to serve in the Marine Corps Reserve (6.91 %) and most likely to serve in the Air Force Reserve (25.64 %). The Air Force Reserve had the highest proportion of personnel aged C35 (58.54 %), and the Marine Corps Reserve had the highest distribution of personnel \35 (89.12 %). While all of the branches were
123
123
1,618
Male
658
538
351
25–34
35–44
45?
236
930
College/graduate degree
693
Never married
191
911
785
105
0
1–4
5–11
12?
Number of lifetime nondeployment-related traumatic events
250
Formerly married
Married
1,058
903
769
Some college
Marital status
327
High school diploma or less
Education
1,015
B$60,000
[$60,000
Income
5.27
38.76
45.95
10.01
38.98
12.17
48.85
27.56
51.35
21.09
41.21
58.79
4.72
244
Other
15.65
1,520
Black
79.63
14.83
24.1
31.79
29.28
82.22
17.78
100
White
Race
456
18–24
Age
385
2,003
49.4
(%) 970
N 50.6
(%)
National Guard
78.8
21.2 825
147 85.55
14.45
18.06
24.36
31.47
26.11
134
257
337
244
11.67
23.86
32.1
32.37
75.69 5.43
18.88
777 100
94
83.48 4.02
12.5
53.13 46.87
550 392
64.33 35.67
32.05
50.13
17.82
323
461
185
37.73
11.99
50.27 344
127
500
51
432
453
88
4.71
41.01
44.73
9.55
54
353
458
103
v2 ðdf ¼ 3Þ ¼ 1:34; p = 0.26
349
123
558
v2 ðdf ¼ 2Þ ¼ 0:69; p = 0.50
446
442
142
5.82
36.57
47.14
10.47
40.2
12.34
47.47
23.16
52.54
24.3
v2 ðdf ¼ 2Þ ¼ 12:31; p \ 0.0001
538
465
v2 ðdf ¼ 1Þ ¼ 22:63; p \ 0.0001
136
150
743
v2 ðdf ¼ 2Þ ¼ 8:6; p \ 0.0001
217
281
321
212
v2 ðdf ¼ 3Þ ¼ 6:32; p \ 0.0001
793
238
v ðdf ¼ 1Þ ¼ 13:71; p \ 0.0001
2
1,033
N
N
(%)
Reserves
Total
Female
Gender
Total
Sociodemographic and military characteristics
8.44
(%) 509
N 26.32
(%)
Army Reserve
74.36
140 369
22.97 77.03
29.89
28.65
26.97
14.5
96
145
173
95
14.97
24.38
34.71
25.95
79.27 6.71
14.02
342 70
97
71 5.52
23.47
38.43 61.57
249 246
57.94 42.06
42.75
46.27
10.98
216
216
77
29.81
49.51
20.69
27.26
12.58
60.15
169
76
264
37.95
14.17
47.88
6
75
78
13
3.79
38.58
50.55
7.09
30
212
216
50
5.24
42.24
41.37
11.14
v2 ðdf ¼ 15Þ ¼ 2:05; p = 0.01
42
23
110
v2 ðdf ¼ 10Þ ¼ 6:85; p \ 0.0001
94
66
16
v2 ðdf ¼ 10Þ ¼ 12:66; p \ 0.0001
113
58
v2 ðdf ¼ 5Þ ¼ 12:99; p \ 0.0001
26
18
132
v2 ðdf ¼ 10Þ ¼ 3:63; p \ 0.0001
57
55
45
19
v2 ðdf ¼ 15Þ ¼ 12:93; p \ 0.0001
127
25.64
v ðdf ¼ 5Þ ¼ 9:42; p \ 0.0001 49
2
176
N
Air Force Reserve
Table 1 Distribution of selected characteristics for the total sample and by service component and branch
15
53
115
29
62
29
124
107
90
17
110
100
22
14
179
37
65
72
41
170
45
215
N
7.16
24.26
55.15
13.43
34.03
12.07
53.9
44.25
46.81
8.95
48.46
51.54
4.46
7.76
87.78
14.89
29.25
30.65
25.21
80.17
19.83
8.99
(%)
Air National Guard
39
300
343
74
282
98
376
216
371
168
282
450
78
80
598
97
192
265
203
655
102
757
N
5.54
39.21
45.42
9.83
41.53
12.39
46.07
18.61
53.78
27.62
32.87
67.13
3.93
13.53
82.55
10.97
22.69
32.42
33.92
86.71
13.29
41.55
(%)
Army National Guard
9
68
77
13
90
5
73
45
91
31
67
98
21
20
126
9
18
61
80
155
13
168
N
4.89
39.12
47.67
8.33
59.18
2.8
38.02
18.26
60.54
21.2
34.6
65.4
4.73
14.88
80.39
2.74
8.14
31.3
57.82
93.09
6.91
5.87
(%)
Marine Corps Reserve
6
77
82
12
48
19
111
91
69
18
112
60
19
15
143
55
63
42
18
142
36
178
N
3.85
40.86
47.39
7.9
32.74
11.04
56.22
37.66
48.81
13.53
55.66
44.34
4.36
12.42
83.22
26.22
31.01
26.22
16.56
78.82
21.18
8.77
(%)
Navy Reserve
Soc Psychiatry Psychiatr Epidemiol
421
351
227
4–5
6?
12.63
451
Senior NCO (E7–E9)
514
No
577
599
302
1
2–3
4?
629
Non-conflict zone
983
No
65.79
34.21
41.61
58.39
13.6
29.03
29.72
27.65
27.65
72.35
N
15.2
23.34
29.19
32.26
120
184
204
230
17.22
25
27.72
30.07
16.16
13.19
35.98
34.68
169
100
336
352
29.62
70.38 230
738
12.85
25.96
31.57
29.62
155
317
266
230
14.33
32.02
27.92
25.73
25.73
74.27
9.19
9.9
36.18
44.73
48.48
51.52 267
461 35.28
64.72
535
194 72.5
27.5 448
276 59.63
40.37
v2 ðdf ¼ 1Þ ¼ 23:59; p \ 0.0001
362
370
v ðdf ¼ 1Þ ¼ 24:28; p \ 0.0001
2
147
282
311
284
v2 ðdf ¼ 3Þ ¼ 3:45; p = 0.02
284
740
v2 ðdf ¼ 1Þ ¼ 3:03; p = 0.08
282
124
320
294
v2 ðdf ¼ 3Þ ¼ 14:85; p \ 0.0001
107
167
217
249
(%)
(%)
N
(%)
Army Reserve
5.43
18.12
34.42
42.03
67
80
97
114
21.02
24.9
26.25
27.84
22.92
22.07
36.82
18.19
140
60
155
148
15.39
11.96
34.86
37.78
26.92
73.08 150
358 32.56
67.44
24.03
25.26
23.79
26.92
51
152
155
150
8.21
27.58
31.65
32.56
69.87
30.13
161
194
40.85
59.15
109
13
88.21
11.79
254
98
69.34
30.66
v2 ðdf ¼ 5Þ ¼ 29:25; p \ 0.0001
85
35
v ðdf ¼ 5Þ ¼ 41:0; p \ 0.0001
2
44
42
37
49
v2 ðdf ¼ 15Þ ¼ 5:93; p \ 0.0001
49
123
v2 ðdf ¼ 5Þ ¼ 2:13; p = 0.06
64
33
52
25
v2 ðdf ¼ 15Þ ¼ 12:54; p \ 0.0001
8
22
41
52
v2 ðdf ¼ 15Þ ¼ 10:19; p \ 0.0001
N
Air Force Reserve
142
16
115
44
71
53
40
48
48
164
35
34
93
50
6
18
41
99
N
89.08
10.92
73.7
26.3
32.94
24.62
18.93
23.51
23.51
76.49
10.06
15.79
44.04
30.1
3.51
11.18
25.29
60.02
(%)
Air National Guard
306
260
152
417
84
264
226
182
182
574
134
66
243
302
114
166
163
131
N
Chi square test p value indicates whether the null hypothesis that there are no significant differences across branches can be rejected
53.13
46.87
26.95
73.05
10.35
33.61
29.84
26.2
26.2
73.8
9
8.63
34.48
47.9
20.26
28.07
28.25
23.42
(%)
Army National Guard
Percentages may not add up to 100 % due to missing values. All proportions and statistics are weighted to account for survey sampling design
470
Yes
Active combat participation on most recent deployment
831
Conflict zone
Most recent deployment location
514
0
Number of deployments
1,478
Yes
Deployment experience
Officer
656
224
NCO (E5–E6)
36.08 11.53
646
39.76
16.25
24.2
28.42
31.12
Junior enlisted (E1–E4)
Rank
479
1–3
(%)
National Guard
v2 ðdf ¼ 3Þ ¼ 0:64; p = 0.59
N
N
(%)
Reserves
Total
0
Number of lifetime deployment-related traumatic events
Sociodemographic and military characteristics
Table 1 continued
61
59
25
93
21
39
60
47
47
120
22
8
42
96
25
33
38
24
N
51.65
48.35
20.2
79.8
10.36
21.04
36.75
31.85
31.85
68.15
6.89
4.21
22.17
66.73
20.63
27.43
33.58
18.36
(%)
Marine Corps Reserve
111
24
91
48
31
49
59
38
38
139
56
23
71
25
7
32
41
59
N
79.35
20.65
66.14
33.86
17.96
25.03
35.18
21.84
21.84
78.16
18.23
14.35
47.85
19.57
5.57
21.5
29.67
43.25
(%)
Navy Reserve
Soc Psychiatry Psychiatr Epidemiol
123
Soc Psychiatry Psychiatr Epidemiol
majority white, the Army Reserve had the highest distribution of non-whites (black 23.47 % and other 5.52 %). The Air Force Reserve and Navy Reserve had the highest percentages of personnel with a college degree (42.75 and 37.66 %) and making more than $60,000 per year (61.57 and 55.66 %). The Marine Corps Reserve had the highest proportions of those never married (59.18 %) compared to the other service branches. The Marine Corps Reserve and the Army National Guard had the greatest proportions of personnel with C4 deployment-related traumatic events (48.06 and 48.33 %). The Army Reserve had the highest proportion of personnel with C5 non-deployment-related traumatic events (47.48 %). The Marine Reserves had the highest proportion (66.73 %) of Junior Enlisted service members, while the lowest proportions were found among the Air Force Reserves (18.19 %) and the Navy Reserves (19.57 %). In contrast, the Air Force Reserves (22.92 %) and the Navy Reserves (18.23 %) had the highest proportions of Officers, while the Marine Corps Reserve (6.89 %) had the lowest. Among all of the respondents, 72.35 % had deployment experiences, with the Navy Reserve reporting the highest proportion (78.16 %). Among those with a deployment experience, the Marine Corps Reserve had the highest proportion of personnel most recently deployed to an area of conflict (79.8 %) and who participated in active combat (48.35 %). In comparison, among those who had been deployed, the Air National Guard had the smallest proportion of those most recently deployed to an area of conflict (26.3 %) with only 10.92 % participating in active combat operations. Table 2 lists the frequency and prevalence of each disorder (i.e., deployment-related PTSD, non-deploymentrelated PTSD, and depression) for the total sample by service branch. In the total sample, 5.49 % report lifetime deployment-related PTSD, 5.4 % report lifetime nondeployment-related PTSD, and 21.63 % report lifetime depression. There were no significant differences in the distribution of depression or PTSD between the Reserves and National Guard. There were, however, statistically significant differences in the distributions of disorder by branch. Army National Guard respondents had the highest proportions of lifetime and past month deployment-related PTSD (6.17 %, 4.82 %) and the highest proportions of lifetime, past year, and past month non-deployment-related PTSD (6.43, 4.97, 3.07 %). The Navy Reserves had levels of lifetime (6.37 %) and current year (4.59 %) nondeployment-related PTSD comparable to the Army National Guard. The Army Reserve had the highest proportion of current year deployment-related PTSD (5.91 %), and had lifetime and past month deployment-related PTSD proportions (6.15, 4.06 %) comparable to those of the Army National Guard. In contrast, Air National Guard respondents were least likely to report deployment-related PTSD (1.24, 1.24, and 0.55 %) and non-deployment-
123
related PTSD (1.24, 0.67, and 0.67 %). Examining the distribution of depression across the service branches, the Marine Corps Reserve had the highest proportions of lifetime, past year, and past month depression (30.76, 19.67, and 8.75 %), while the Air National Guard had the lowest proportions (15.04, 6.65, 1.02 %). Table 3 reports the odds ratios for both non-deployment and deployment-related PTSD and depression outcomes (lifetime, current year, and current month) in relation to nondeployment and deployment-related traumatic experiences. The number of non-deployment-related traumatic events was positively associated, in a dose–response fashion relationship, with non-deployment-related PTSD and depression but not with deployment-related PTSD. Conversely, the number of deployment-related traumatic events had a positive, dose– response relationship with deployment-related PTSD and depression, but not with non-deployment-related PTSD.
Discussion Among this nationally representative RC sample, nondeployment-related trauma had a dose–response relationship with both non-deployment-related PTSD and depression, while deployment-related trauma had a dose– response relationship with deployment-related PTSD and depression. Army National Guard respondents reported the highest levels of lifetime (6.17 %), and current month (4.82 %) deployment-related PTSD, while those in the Army Reserves reported a slightly higher level of current year deployment-related PTSD (5.91 %) and had comparable levels of lifetime (6.15 %) and current month (4.06 %) deployment-related PTSD. In contrast, the Air National Guard reported the lowest levels of deploymentrelated PTSD (lifetime—1.24 %, current year—1.24 %, and current month—0.55 %). The Army National Guard also had the highest levels of non-deployment-related PTSD (lifetime—6.43 %, current year—4.97 %, current month—3.07 %), with the Navy Reserve having comparable levels of lifetime (6.37 %) and current year nondeployment-related PTSD, while the Air National Guard had the lowest levels (lifetime—1.24 %, current year— 0.67 %, current month—0.67 %). In regards to depression, the Marine Corps Reserve reported the highest levels of lifetime (30.76 %), current year (19.67 %), and current month (8.75 %) depression, while those in the Air National Guard reported the lowest levels (15.04, 6.65, and 1.02 %). The relative elevations in deployment-related PTSD prevalence among the Army Reserves, and Army National Guard, non-deployment-related PTSD prevalence among the Army Reserves and Navy Reserves, and depression prevalence among Army National Guard and Marine Corps Reserve respondents may be attributable to a number of
2,003
1,478
Total ever deployed
72.35
100
5.99
14.31
21.63
2.32
3.91
5.4
3.62
4.98
5.49
100
49.4
970
50.6
(%)
5.76
37
5.24
5
34
4.95
3.17
26
4.02
5.25
48
5.54
3.57
36
4.23
1.96
23
2.66
21.23
209
22.02
13.63
134
14.97
741
1,033
56 70.36
49.46
5.86 737
970
57 74.3
50.54
6.13
v ðdf ¼ 1Þ ¼ 0:05; p = 0.82
2
132
v2 ðdf ¼ 1Þ ¼ 0:6; p = 0.44
221
v ðdf ¼ 1Þ ¼ 0:16; p = 0.69
2
16
v2 ðdf ¼ 1Þ ¼ 0:84; p = 0.36
30
v2 ðdf ¼ 1Þ ¼ 0:46; p = 0.5
45
v ðdf ¼ 1Þ ¼ 0:06; p = 0.8
2
21
v2 ðdf ¼ 1Þ ¼ 0:61; p = 0.44
32
v ðdf ¼ 1Þ ¼ 0; p = 0.97
2
38
v2 ðdf ¼ 1Þ ¼ 0:15; p = 0.7
1,033
N
National Guard
8.44
(%) 509
N 26.32
(%)
Army Reserve
2
5.44
19
6.15
3.9
18
5.91
2
0
12
4.06
5.3
22
4.86
3.82
14
3.28
2
0
11
2.69
16.36
115
21.87
10.39
66
13.98
123
176
8
73.08
8.44
4.58
359
510
30
67.48
26.35
6.58
v ðdf ¼ 5Þ ¼ 7:03; p \ 0.0001
2
17
v2 ðdf ¼ 5Þ ¼ 4:83; p \ 0.0001
29
v ðdf ¼ 5Þ ¼ 3:51; p \ 0.0001
0
v2 ðdf ¼ 5Þ ¼ 6:95; p \ 0.0001
5
v2 ðdf ¼ 5Þ ¼ 4:59; p \ 0.0001
7
v ðdf ¼ 5Þ ¼ 4:26; p \ 0.0001
0
v2 ðdf ¼ 5Þ ¼ 7:41; p \ 0.0001
4
v ðdf ¼ 5Þ ¼ 2:79; p = 0.02
5
v2 ðdf ¼ 5Þ ¼ 3:28; p = 0.01
176
N
Air Force Reserve
164
215
2
13
33
2
2
3
1
2
2
215
N
76.49
8.99
1.02
6.65
15.04
0.67
0.67
1.24
0.55
1.24
1.24
8.99
(%)
Air National Guard
573
755
55
121
176
21
34
45
25
32
35
757
N
73.83
41.55
7.23
16.77
23.53
3.07
4.97
6.43
4.82
5.81
6.17
41.55
(%)
Army National Guard
a
Frequency is among those who have deployment experience
Chi square test p value indicates whether the null hypothesis that there are no significant differences across branches can be rejected
Percentages may not add up to 100 % due to missing values. All proportions and statistics are weighted to account for survey sampling design
2,003
113
Current month
Total
266
Current year
39
Current month Depression
430
66
Current year
Lifetime
93
Lifetime
47
66
Current year
Current month Non-deployment-related PTSD
75
a
(%)
N
N
(%)
Reserves
Total
Lifetime
Deployment-related PTSD
Total
Psychopathology
Table 2 Psychopathology prevalence by service component and branch
120
168
13
30
48
3
4
7
4
4
5
168
N
68.15
5.87
8.75
19.67
30.76
2.34
2.95
5.18
3.26
3.26
4.31
5.87
(%)
Marine Corps Reserve
139
179
5
19
29
2
7
9
5
6
9
178
N
77.9
8.80
2.98
11.67
17.61
1.34
4.59
6.37
3.63
4.68
5.91
8.77
(%)
Navy Reserve
Soc Psychiatry Psychiatr Epidemiol
123
123
AOR (95 %CI)
AOR (95 %CI)
0.91 (0.35–2.37)
1.21 (0.47–3.15)
0.73 (0.18–2.93)
1–4
5–11
12?
0.88 (0.21–3.74)
1.30 (0.46–3.62)
0.95 (0.34–2.66)
1
1
2.08 (1.08–4.00)
5.32 (2.81–10.08)
1-3
4–5
6?
5.12 (2.62–10.03)
1.61 (0.79–3.25)
1
–
1
6.87 (3.07–15.36)
1.64 (0.69–3.94)
1
–
0.33 (0.05–1.99)
0.76 (0.24–2.39)
0.79 (0.26–2.42)
b
a
1.54 (0.70–3.41)
2.77 (1.41–5.46)
1.93 (0.97–3.84)
1
3.67 (1.34–10.06)
3.22 (1.88–5.54)
1
–
AOR (95 %CI)
2.07 (0.83–5.16)
3.18 (1.41–7.18)
2.43 (1.07–5.49)
1
3.06 (0.98–9.54)
2.82 (1.54–5.16)
1
–
AOR (95 %CI)
Non-deployment-related PTSD was assessed only among those with C1 non-deployment-related traumatic event
Deployment-related PTSD was assessed only among those with C1 deployment-related traumatic event
All models adjusted for gender, income, education, marital status, and paygrade
–
0
Number of deployment-related traumatic events
1
0
AOR (95 %CI)
Current year (N = 1,292)
Lifetime (N = 1,292)
Current month (N = 915)
Lifetime (N = 915)
Current year (N = 915)
Non-deployment-related PTSDb
Deployment-related PTSDa
Number of non-deployment-related traumatic events
Total
Sociodemographic and military characteristics
Table 3 Relationships between trauma exposure and PTSD and depression
1.97 (0.70–5.53)
2.14 (0.85–5.42)
1.97 (0.76–5.05)
1
4.11 (1.13–14.98)
2.91 (1.35–6.26)
1
–
AOR (95 %CI)
Current month (N = 1,292)
2.86 (1.85–4.41)
1.88 (1.27–2.78)
1.27 (0.86–1.88)
1
7.07 (3.35–14.91)
2.72 (1.49–4.97)
1.42 (0.78–2.58)
1
AOR (95 %CI)
Lifetime (N = 1,414)
Depression
3.44 (2.06–5.73)
2.07 (1.29–3.32)
1.29 (0.79–2.09)
1
7.81 (3.19–19.13)
2.75 (1.28–5.91)
1.65 (0.77–3.54)
1
AOR (95 %CI)
Current year (N = 1,414)
12.88 (4.78–34.66)
5.09 (1.86–13.97)
3.46 (1.24–9.68)
1
3.72 (0.91–15.23)
1.78 (0.54–5.83)
1.44 (0.44–4.77)
1
AOR (95 %CI)
Current month (N = 1,414)
Soc Psychiatry Psychiatr Epidemiol
Soc Psychiatry Psychiatr Epidemiol
factors that distinguish these groups’ sociocultural backgrounds and experiences (e.g., post-deployment social support, higher lifetime traumatic exposure, and varying intensity of military experiences). For example, personnel in the Army National Reserves (73.05 %), the Marine Corps Reserves (79.80 %), and the Army Reserves (59.15 %) were more likely to experience conflict zone deployments than members of other branches. Additionally, the greatest exposure to 1 or more deployment-related traumas was reported among the Marine Reserves (81.64 %), Army Reserves (72.17 %), and Army National Guard (76.58 %). Finally, individuals in the Marine Corps Reserves (57.82 %), Army National Guard (33.92 %), and Army Reserves (25.95 %) had the highest proportions of individuals under 25. These findings are indeed consistent with prior work demonstrating that combat deployment and exposure to combat-deployment-related trauma are both associated with depression [21] and PTSD [22], as is younger age [23]. This study of the prevalence of mental health disorders among the RC component service members can also be viewed in comparison with prevalence estimates from studies of service members from the active duty component. A current prevalence meta-analysis [24] found no differences in prevalence estimates of depression or PTSD, in comparisons of RC vs. active duty personnel. This suggests that while there are differences by branch within the RC, there are likely no differences between the RC and active duty components in aggregate measures of depression and PTSD prevalence. As expected, the number of deployment-related traumatic events was positively associated with deploymentrelated PTSD. Importantly, however, a similar relationship was found for depression for both deployment-related as well as non-deployment-related traumatic events. Although the relationship between depression and trauma exposure has previously been reported in military [2] and civilian populations [25, 26], it has not often been examined in detail. Better understanding depression outcomes in relation to traumatic events is important in further clarifying this association and identifying possible depression subtypes. The findings from this study should be interpreted with some caveats in mind. First, the assessments are based on self-reports and therefore subject to respondent recall bias, social desirability affects, and potential biases associated with the sensitive-nature of the questions; however, this limitation is offset as appraisals were made using the validated PCL-C and the PHQ-9 screening tools, which exhibit excellent specificity and moderate sensitivity [14, 17, 18]. In particular, respondents who did not screen positive for either probable PTSD or depression were unlikely to be misdiagnosed using this approach [17]. Although random sampling and post-stratification weighting were used to ensure that the sample was representative of the RC population, it is possible that unmeasured selection bias still
influenced the findings. Lastly, the findings are limited in that they represent cross-sectional data.
Conclusion Reserve Component service members face unique challenges in the process of preparing for, undertaking, and returning from a military combat deployment, including the need to quickly reintegrate into civilian life [6, 27–31]. This study highlights distinct differences between each of the US military’s RC service branches (i.e., Army, Air Force, Marine Corps, and Navy) and service components (Federal Reserves and state/territorial National Guard) with regard to the rates of PTSD, depression, and exposure to both deployment and non-deployment-related traumatic events. The differences in mental health outcomes between these groups suggest as one possibility, differences in the sociocultural fabric of these subcultures within the overarching military culture. Another possibility is that there are differences in specific types of trauma exposures that are tied to service branch. Finally, it is possible that individuals with characteristics that lend vulnerability or immunity to PTSD and depression differentially select into their service branch. The findings suggest that service branches within the RC have varying mental health needs, and military leaders should consider implementing targeted behavioral health screenings and tailored treatment interventions to account for each service branch’s specific operational deployment needs. To guide these interventions, future research should also seek to understand the organizational differences— cultural, traumatic exposure related, and selection related, between the RC service branches that drive the differing rates of PTSD and depression. The findings also carry implications for other nations’ militaries, many of which maintain organizational structures and subcomponents similar to the US military (i.e., AC and RC; separate land, sea, and air forces) and whose members are experiencing similar issues [4, 32–36]. To further identify cultural, social, and organizational differences between militaries, branches, and subcomponents, future research should give focus to comparing mental health outcomes across militaries internationally. Such comparative efforts could provide novel insights into protective and/or risk factors by which to guide the development of prevention and treatment efforts. Conflict of interest
None.
Appendix See Tables 4, 5, 6.
123
123 701,353
271,918 206,907 125,667
25–34
35–44
45?
40,170
Other
270,693 101,755 125,322
NCO (E5–E6)
Senior NCO (E7–E9)
Officer
355,748
127,463
Black
Rank Junior enlisted (E1–E4)
648,651
White
Race
249,074
18–24
Age
152,220
Male
853,581
14.68
11.92
31.71
41.68
4.92
15.62
79.46
14.70
24.20
31.90
29.20
82.20
17.80
100
451
224
656
646
236
244
1,520
351
538
658
456
1,618
385
2,003
12.63 (11.48–13.88)
11.53 (10.12–13.1)
36.08 (33.8–38.42)
39.76 (37.43–42.14)
4.72 (4.11–5.41)
15.65 (13.89–17.60)
79.63 (77.65–81.48)
14.83 (13.33–16.46)
24.1 (22.20–26.11)
31.79 (29.64–34.02)
29.28 (27.05–31.61)
82.22 (80.36–83.93)
17.78 (16.07–19.64)
100
(% (95 %CI))
N
N
(%)
Study total
Sampling Universe total
Female
Gender
Total
Sociodemographic and military characteristics
70,330
45,819
119,449
150,355
23,711
70,335
265,034
61,010
95,712
118,337
103,231
297,701
80,596
385,953
N
18.22
11.87
30.95
38.96
6.60
19.59
73.81
16.13
25.30
31.28
27.29
78.70
21.30
45.22
(%)
Universe Reserves total
282
124
320
294
136
150
743
217
281
321
212
793
238
1,031
N
16.16 (14.31–18.21)
13.19 (11.07–15.63)
35.98 (32.76–39.32)
34.68 (31.52–37.97)
5.43 (4.52–6.5)
18.88 (16.23–21.85)
75.69 (72.69–78.46)
18.06 (15.79–20.58)
24.36 (21.69–27.23)
31.47 (28.45–34.67)
26.11 (23.13–29.32)
78.8 (75.98–81.37)
21.2 (18.63–24.02)
49.4 (48.49–50.31)
(% (95 %CI))
Study Reserves total
Table 4 Comparison of selected characteristics of reserve population (2008) and study sample: component totals
54,992
55,936
151,244
205,393
15,994
56,785
377,800
63,243
108,987
150,765
144,588
397,158
70,425
467,565
N
11.76
11.96
32.35
43.93
3.55
12.60
83.85
13.53
23.31
32.24
30.92
84.94
15.06
54.78
(%)
Universe National Guard total
169
100
336
352
100
94
777
134
257
337
244
825
147
972
N
9.19 (7.85–10.73)
9.9 (8.14–12)
36.18 (33–39.49)
44.73 (41.35–48.16)
4.02 (3.25–4.96)
12.5 (10.28–15.13)
83.48 (80.81–85.84)
11.67 (9.78–13.87)
23.86 (21.12–26.73)
32.1 (29.1–35.26)
32.37 (29.12–35.8)
85.55 (83.03–87.75)
14.45 (12.25–16.97)
50.6 (49.69–51.51)
(% (95 %CI))
Study National Guard total
Soc Psychiatry Psychiatr Epidemiol
20,996
16,772
25–34
35–44
45?
3,550
Black
Other
14,473
25,216
13,544
14,753
Junior enlisted (E1–E4)
NCO (E5–E6)
Senior NCO (E7–E9)
Officer
Rank
49,825
10,849
White
Race
8,391
21,827
18–24
Age
17,002
50,984
Male
67,986
21.70
19.92
37.09
21.29
5.53
16.89
77.58
24.70
30.90
32.10
12.30
75.00
25.00
7.96
64
33
52
25
26
18
132
57
55
45
19
127
49
176
22.92 (17.74–29.08)
22.07 (15.94–29.73)
36.82 (29.15–45.22)
18.19 (12.29–26.08)
6.71 (4.43–10.05)
14.02 (8.93–21.34)
79.27 (72.04–85.02)
29.89 (23.20–37.56)
28.65 (22.05–36.30)
26.97 (20.33–34.83)
14.5 (9.15–22.20)
74.36 (66.69–80.78)
25.64 (19.22–33.31)
8.44 (7.92–9.0)
(% (95 %CI))
N
N
(%)
Study Air Force Reserve
Universe Air Force Reserve
Female
Gender
Total
Sociodemographic and military characteristics
35,980
24,079
55,877
89,361
10,469
45,957
140,313
32,238
45,890
65,055
62,108
156,739
48,557
205,297
N
Universe Army Reserve
17.53
11.73
27.22
43.53
5.32
23.36
71.32
15.70
22.40
31.70
30.30
76.30
23.70
24.05
(%)
140
60
155
148
70
97
342
96
145
173
95
369
140
509
N
15.39 (12.89–18.27)
11.96(9.25-15.34)
34.86(30.39-39.62)
37.78(33.08-42.72)
5.52 (4.29–7.09)
23.47 (19.49–27.99)
71 (66.48–75.14)
14.97 (12.11–18.35)
24.38 (20.69–28.48)
34.71 (30.33–39.37)
25.95 (21.64–30.77)
77.03 (72.96–80.65)
22.97 (19.35–27.04)
26.32 (25.46–27.20)
(% (95 %CI))
Study Army Reserve
3,696
1,898
6,554
26,362
2,170
2,986
30,119
1,213
4,037
11,326
21,934
36,619
1,891
38,510
N
9.60
4.93
17.02
68.45
6.15
8.46
85.38
3.10
10.50
29.40
57.00
95.10
4.90
4.51
(%)
Universe Marine Corps Reserve
Table 5 Comparison of selected characteristics of reserve population (2008) and study sample: reserves by branch
22
8
42
96
21
20
126
9
18
61
80
155
13
168
N
6.89 (4.41–10.62)
4.21 (2.03–8.53)
22.17 (16.37–29.31)
66.73 (59.11–73.56)
4.73 (3.01–7.35)
14.88 (9.72–22.12)
80.39 (73.26–85.98)
2.74 (1.40–5.32)
8.14 (4.94–13.13)
31.3 (24.57–38.92)
57.82 (49.88–65.37)
93.09 (87.78–96.20)
6.91 (3.80–12.22)
5.87 (5.54–6.21)
(% (95 %CI))
Study Marine Corps Reserve
14,509
5,330
29,159
17,469
7,522
10,543
44,777
10,787
24,789
20,129
10,798
53,359
13,146
66,508
N
21.83
8.02
43.87
26.28
11.97
16.78
71.25
16.20
37.30
30.30
16.20
80.20
19.80
7.79
(%)
Universe Navy Reserve
56
23
71
25
19
15
143
55
63
42
18
142
36
178
N
18.23 (13.85–23.62)
14.35 (9.56–20.97)
47.85 (39.85–55.97)
19.57 (13.47–27.54)
4.36 (2.71–6.95)
12.42 (7.62–19.6)
83.22 (76.21–88.47)
26.22 (20.1–33.42)
31.01 (24.29–38.65)
26.22 (19.7–33.97)
16.56 (10.75–24.64)
78.82 (71.44–84.7)
21.18 (15.3–28.56)
8.77 (8.25–9.33)
(% (95 %CI))
Study Navy Reserve
Soc Psychiatry Psychiatr Epidemiol
123
Soc Psychiatry Psychiatr Epidemiol Table 6 Comparison of selected characteristics of reserve population (2008) and study sample: National Guard by branch Sociodemographic and military characteristics
Universe Air National Guard
Study Air National Guard
Universe Army National Guard
Study Army National Guard
N
(%)
N
N
(%)
N
(% (95 %CI))
109,196
12.79
215
8.99 (8.59–8.41)
358,391
41.99
757
41.61 (40.73–42.5)
20,168 89,028
18.50 81.50
45 170
19.83 (14.81–26.03) 80.17 (73.97–85.19)
50,257 308,130
14.00 86.00
102 655
13.29 (10.9–16.1) 86.71 (83.9–89.1)
18–24
19,032
17.40
41
25.21 (19.15–32.42)
125,556
35.00
203
33.92 (30.23–37.81)
25–34
36,208
33.20
72
30.65 (24.66–37.38)
114,557
32.00
265
32.42 (29.03–35.99)
35–44
31,712
29.00
65
29.25 (23.33–35.97)
77,275
21.60
192
22.69(19.77-25.9)
45?
22,244
20.40
37
14.89 (10.79–20.21)
40,999
11.40
97
10.97 (8.91–13.45)
White
90,087
85.60
179
87.78 (82.64–91.55)
287,713
83.31
598
82.55 (79.46–85.26)
Black
9,341
8.88
14
7.76 (4.57–12.87)
47,444
13.74
80
13.53 (10.96–16.58)
Other
5,808
5.52
22
4.46 (2.83–6.96)
10,186
2.95
78
3.93 (3.09–4.98)
Total
(% (95 %CI))
Gender Female Male Age
Race
Rank Junior enlisted (E1–E4)
26,326
24.11
50
30.1 (23.64–37.47)
179,067
49.96
302
47.9 (44.06–51.76)
NCO (E5–E6)
45,025
41.24
93
44.04 (37.16–51.15)
106,219
29.64
243
34.48 (30.92–38.21)
Senior NCO (E7–E9)
23,497
21.52
34
15.79 (11.34–21.56)
32,439
9.05
66
8.63 (6.78–10.93)
Officer
14,326
13.12
35
10.06 (7.17–13.96)
40,666
11.35
134
9 (7.53–10.72)
References 1. Institute of Medicine (2010) Returning home from Iraq and Afghanistan—Assessment of readjustment needs of veterans, service members, and their families. National Academies Press, Washington 2. Tanielian TL, Jaycox L (eds) (2008) Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery (Vol. 720). RAND Corporation, California 3. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL (2004) Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 351(1):13–22 4. Hotopf M, Hull L, Fear NT, Browne T, Horn O, Iversen A, Wessely S (2006) The health of UK military personnel who deployed to the 2003 Iraq war: a cohort study. Lancet 367(9524):1731–1741 5. Kulka RA (1988) Contractual report of findings from the National Vietnam veterans readjustment study. Research Triangle Institute 6. Milliken CS, Auchterlonie JL, Hoge CW (2007) Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA 298(18): 2141–2148 7. Thomas JL, Wilk JE, Riviere LA, McGurk D, Castro CA, Hoge CW (2010) Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Arch Gen Psychiatry 67(6):614–623 8. Vogt D, Smith B, Elwy R, Martin J, Schultz M, Drainoni ML, Eisen S (2011) Predeployment, deployment, and postdeployment risk factors for posttraumatic stress symptomatology in female and male OEF/OIF veterans. J Abnorm Psychol 120(4):819 9. La Bash HA, Vogt DS, King LA, King DW (2009) Deployment Stressors of the Iraq War Insights From the Mainstream Media. J Interpers Violence 24(2):231–258
123
10. American Association for Public Opinion Research (2011) Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys, 7th edn. AAPOR, New york 11. Research Triangle Institute (2012) SUDAAN [computer program]. Research Triangle Institute, Research Triangle Park 12. Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P (1998) Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry 55(7):626–632 13. Vogt DS, Proctor SP, King DW, King LA, Vasterling JJ (2008) Validation of scales from the Deployment Risk and Resilience Inventory in a sample of Operation Iraqi Freedom veterans. Assessment 15(4):391–403 14. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA (1996) Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther 34(8):669–673 15. Ruggiero KJ, Del Ben K, Scotti JR, Rabalais AE (2003) Psychometric properties of the PTSD Checklist-Civilian version. J Trauma Stress 16(5):495–502 16. Association American Psychiatric (ed) (2000) Diagnostic and statistical manual of mental disorders: DSM-IV-TR. American Psychiatric Pub, Washington 17. Prescott MR, Tamburrino M, Calabrese JR, Liberzon I, Slembarski R, Shirley E, Galea S (2014) Validation of lay-administered mental health assessments in a large Army National Guard cohort. Int J Method Psych 23(1):109–119 18. Kroenke K, Spitzer RL, Williams JB (2001) The PHQ-9. J Gen Intern Med 16(9):606–613 19. First MB (2007) Structured Clinical Interview for DSM-IV-TR Axis I Disorders: SCID-I. Biometrics Research Department, New York State Psychiatric Institutute 20. Institute SAS (2008) SAS [computer program]. SAS Institute, Cary
Soc Psychiatry Psychiatr Epidemiol 21. Wells TS, LeardMann CA, Fortuna SO et al (2010) A prospective study of depression following combat deployment in support of the wars in Iraq and Afghanistan. Am J Public Health 100(1): 90–99 22. Smith TC, Ryan MA, Wingard DL et al (2008) New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study. BMJ 336(7640):366–371 23. Riddle JR, Smith TC, Smith B et al (2007) Millennium Cohort: the 2001-2003 baseline prevalence of mental disorders in the U.S. military. J Clin Epidemiol 60(2):192–201 24. Cohen G, Fink D, Sampson L and Galea S (2014) Mental Health Among Reserve Component Military Service Members And Veterans. Epidemiologic Reviews 25. Kendler KS, Karkowski LM, Prescott CA (1999) Causal relationship between stressful life events and the onset of major depression. Am J Psychiatry 156(6):837–841 26. Nandi A, Tracy M, Beard JR, Vlahov D, Galea S (2009) Patterns and predictors of trajectories of depression after an urban disaster. Ann Epidemiol 19(11):761–770 27. Gorman LA, Blow AJ, Ames BD, Reed PL (2011) National Guard families after combat: mental health, use of mental health services, and perceived treatment barriers. Psychiatr Serv 62:28–34 28. Lane ME, Hourani LL, Bray RM, Williams J (2012) Prevalence of perceived stress and mental health indicators among reserve component and active-duty military personnel. Am J of Public Health 102:1213–1220
29. Riviere LA, Kendall-Robbins A, McGurk D, Castro CA, Hoge CW (2011) Coming home may hurt: risk factors for mental ill health in US reservists after deployment in Iraq. Br J Psychiatry 198:136–142 30. O’Brien CP, Oster M, Morden E (2012) Substance use disorders in the U.S. Armed Forces. National Academies Press, Washington 31. Russell DW, Whalen R, Riviere L, Clark-Walper K, Bliese PD, Thomas JL (2014) Embedded behavioral health providers: an assessment with the Army National Guard. Psychol Serv 11(3):265–272 32. Iversen AC, Greenberg N (2009) Mental health of regular and reserve military veterans. Adv Psychiatr Treat 15:100–106 33. Browne T, Hull L, Horn O, Jones M, Murphy D, Fear NT et al (2007) Explanations for the increase in mental health problems in UK reserve forces who have served in Iraq. Br J Psychiatry 190:484–489 34. Engelhard IM, Van den Hout MA, Weerts J, Arntz A, Hox JJCM, McNally RJ (2007) Deployment-related stress and trauma in Dutch soldiers returning from Iraq. Br J Psychiatry 191:140–145 35. Zamorski MA, Rusu C, Garber BG (2014) Prevalence and correlates of mental health problems in Canadian Forces personnel who deployed in support of the mission in Afghanistan: findings from postdeployment screenings, 2009–2012. Can J Psychiatry 59(6):319–326 36. Bleier J, McFarlane A, McGuire A, Treloar S, Waller M, Dobson A (2011) Risk of adverse health outcomes associated with frequency and duration of deployment with the Australian Defence Force. Mil Med 176(2):139–146
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