Prevalence of psychiatric morbidity in United States military spouses: The Millennium Cohort Family Study

Piloting the home ship: Understanding the deployment experience of Canadian Special Operations Forces Command spouses

Special Operations Forces (SOF) members are frequently deployed to hostile environments for prolonged periods of time, and their families are exposed to unique difficulties and stressors. The purpose of this study was to describe the lived experience of Canadian Special Operations Forces Command (CANSOFCOM) spouses as it relates to the intensity of the SOF deployment process. As part of a larger study, semi-structured interviews were conducted with 29 spouses of CANSOFCOM members. The interviews were coded and analyzed using thematic analysis to identify the central dimensions of spouses' experience with deployment. Participants reflected on their experiences, from pre-deployment to post-deployment, and as they transitioned between deployments, across social/relational, practical/instrumental, and psychological/emotional dimensions. The findings raised important concerns regarding perpetual transitions for the family unit and exhaustion among spouses faced with a deployment loop that never closes. Although results echoed previous studies, in terms of the strain of solo-parenting and coping with children's emotional needs, communication and maintaining connections, these aspects were uniquely affected by repeated deployments, prolonged time away, operations security, and high organizational demands. Although many spouses acquired the strength and skills to cope with the lifestyle, the findings suggest several opportunities to tailor resources and support services to their dynamic needs.

The role of problem solving appraisal and support in the relationship between stress exposure and posttraumatic stress symptoms of military spouses and service member partners

Using a stress process lens, this paper considers the interrelationship between individual and family-level stress exposures and military spouse resources, including problem-solving appraisals and problem-solving support (PSS), and their associations with posttraumatic stress symptoms (PTSS) among both partners in military marital dyads. The study employs data from the Millennium Cohort Family Study, a longitudinal survey of married military dyads, with an initial panel of 9,872 spouses enroled from 2011 to 2013. A structural equation model explored the associations between service member and spouse childhood maltreatment exposure, nonmilitary and military stressors, as well as interactions with spouse resources on self-reported PTSS among both service member (SM) and spouse (SP). Among our findings, spouse childhood maltreatment muted later self-reported problem-solving appraisal and support. Spouse resources, in turn, had both protective (problem-solving appraisal) and promotive (problem-solving support) effects on PTSS for both service members and spouses. These findings emphasise the central role of spouses in military families, as more psychological resources among spouses appeared to buffer against the deleterious effects of stress exposure on both their own and their partners mental health.

Early and recent military and nonmilitary stressors associated with posttraumatic stress symptoms among military service members and their spouses

Disparities in posttraumatic stress symptoms (PTSS) have been observed among military service members (SMs) and spouses (SPs) compared to their civilian peers, but exposure to military stressors does not adequately explain observed differences. Using a stress process framework, this study considered the associations between early and recent military and nonmilitary stressors and PTSS among SMs and SPs. We analyzed data from 3,314 SM-SP dyads in the Millennium Cohort and Millennium Cohort Family Studies. Accounting for covariates, multiple linear regression and dominance analyses were employed to consider the effects of SM and SP childhood maltreatment, recent nonmilitary stressors (e.g., financial difficulties), and recent military stressors (e.g., deployment) on their own and their partner's self-reported PTSS. For both SMs and SPs, childhood maltreatment was the strongest predictor of their own PTSS, followed by nonmilitary stressors. Couple crossover dynamics were evident as SP maltreatment and nonmilitary stressors significantly predicted SM PTSS, and SM maltreatment predicted SP PTSS. Maltreatment also multiplied the effects of SM, product term B = 0.92, p = .031, and SP, product term B = 0.75, p = .004, nonmilitary stressors. The findings emphasize the essential role of exposure to early adversity in understanding PTSS among SMs and SPs, as childhood maltreatment strongly predicted PTSS and exacerbated the effects of other stressors on PTSS. Providers should assess for early adversity among both SMs and SPs and consider the provision of services at the couple level given the potential for the transmission of stress within couples.

Association between Preoperative Psychiatric Morbidities and Mortality after Oncologic Surgery: A Nationwide Cohort Study from 2002 to 2019 in South Korea

We aimed to examine whether preoperative psychiatric morbidities affect 30-day postoperative mortality. Using a nationwide registration database in South Korea, the study included all patients who underwent curative cancer surgery from 1 January 2002 to 31 December 2019. Patients underwent surgery for breast, laryngeal, lung, thyroid, gastric, colorectal, esophageal, liver, pancreatic, kidney, bladder, testicular, prostate, vulvar, uterine, or brain cancer. Depression, anxiety disorder, substance abuse, and post-traumatic stress disorder were considered preoperative psychiatric morbidities. Among the 944,794 patients in the final analysis, 5490 (0.6%) died within 30 days of the surgery, and 24,370 (2.6%) had preoperative psychiatric morbidities. Multivariable logistic regression analysis showed that preoperative psychiatric morbidities were associated with a higher (adjusted odds ratio [aOR]: 1.23; 95% confidence interval [CI]: 1.09, 1.39; p = 0.001) 30-day mortality rate than the rate noted for patients without preoperative psychiatric morbidities. This association was significant in the breast (aOR: 3.31, 95% CI: 1.36, 8.07; p = 0.009), lung (aOR: 1.54, 95% CI: 1.19, 2.01; p = 0.001), and kidney (aOR: 1.87, 95% CI: 1.06, 3.31; p = 0.03) cancer groups in the subgroup analyses. In South Korea, preoperative psychiatric morbidities are considered to be associated with increased 30-day postoperative mortality.

Comparing the effect of emotional freedom technique on sleep quality and happiness of women undergoing breast cancer surgery in military and nonmilitary families: A quasi-experimental multicenter study

PURPOSE

The aim of this study was to compare the effect of emotional freedom technique (EFT) on sleep quality and happiness of women who underwent breast cancer surgery and lived in military and nonmilitary families.

DESIGN AND METHODS

The patients were randomly divided into four groups of military intervention (n = 34), nonmilitary intervention (n = 33), military control (n = 31), and nonmilitary control (n = 35). Data were collected using demographic information form, Pittsburgh Sleep Quality Index, and Oxford Happiness Questionnaire.

FINDINGS

The mean scores of sleep quality and happiness in military and nonmilitary intervention groups improved significantly immediately and 1 month after the intervention compared to control groups (p < 0.001). However, there was no statistically significant difference between the military and nonmilitary intervention groups regarding the mean scores of sleep quality and happiness before, immediately, and 1 month after the intervention (p > 0.05).

PRACTICE IMPLICATIONS

Given the efficacy of EFT in improving sleep quality and happiness, it is recommended that this technique be taught to nurses to implement in the entire process of providing nursing care to cancer patients.

The mental health and wellbeing of spouses, partners and children of emergency responders: A systematic review

Emergency responders (ERs), often termed First Responders, such as police, fire and paramedic roles are exposed to occupational stressors including high workload, and exposure to trauma from critical incidents, both of which can affect their mental health and wellbeing. Little is known about the impact of the ER occupation on the mental health and wellbeing of their families. The aim of the current study was to investigate what mental health and wellbeing outcomes and experiences have been researched internationally in ER families, and to examine the prevalence and associated risk and protective factors of these outcomes. We conducted a systematic review in accordance with an a priori PROSPERO approved protocol (PROSPERO 2019 CRD42019134974). Forty-three studies were identified for inclusion. The majority of studies used a quantitative, cross-sectional design and were conducted in the United States; just over half assessed police/law enforcement families. Themes of topics investigated included: 1) Spousal/partner mental health and wellbeing; 2) Couple relationships; 3) Child mental health and wellbeing; 4) Family support and coping strategies; and 5) Positive outcomes. The review identified limited evidence regarding the prevalence of mental health and wellbeing outcomes. Family experiences and risk factors described were ER work-stress spillover negatively impacting spousal/partner wellbeing, couple relationships, and domestic violence. Traumatic exposure risk factors included concerns family had for the safety of their ER partner, the negative impact of an ER partners’ mental health problem on the couples’ communication and on family mental health outcomes. Protective factors included social support; however, a lack of organisational support for families was reported in some studies. Study limitations and future research needs are discussed. Progressing this area of research is important to improve knowledge of baseline needs of ER families to be able to target interventions, improve public health, and support ER’s operational effectiveness.

Posttraumatic Stress Disorder in a Cohort of Pregnant Active Duty U.S. Military Servicewomen

The present study aimed to describe the demographic and occupational characteristics, comorbidities, and psychotropic medication receipt associated with posttraumatic stress disorder (PTSD) diagnosis during pregnancy among a sample of active duty U.S. military servicewomen. Data from the U.S. Department of Defense Birth and Infant Health Research program were used to identify pregnancies in active duty servicewomen from 2007 through 2014. Demographic and occupational data were linked with electronic medical and pharmacy records to capture mental health diagnoses and medication receipt dates. Cases of PTSD were identified by the presence of ICD-9-CM Diagnostic Code 309.81 on maternal records from 1 year before the date of the last menstrual period through the end of pregnancy. Of 134,244 identified pregnancies among active duty servicewomen, 2,240 (1.7%) met the case criteria for PTSD. Women with a PTSD diagnosis compared to those without a PTSD diagnosis were more likely to be White non-Hispanic (51.3% vs. 47.4%), unmarried (33.3% vs. 28.2%), in the Army (49.6% vs. 35.8%) or Marine Corps (10.9% vs. 8.0%), in a service and supply occupation (18.2% vs. 13.6%), and to have a junior enlisted rank (56.3% vs. 50.1%) and have been previously deployed (51.2% vs. 39.6%), RRs = 1.15-1.75. Among PTSD cases, the most common mental health comorbidities were depressive disorder (60.9%), adjustment disorder (43.4%), and anxiety disorder (39.3%). During pregnancy, 44.2% of PTSD cases and 7.2% of noncases received psychotropic medications. Demographic and occupational characteristics, comorbidities, and psychotropic medication use differed substantially among PTSD cases and noncases in this large records-based study.

High-risk and Long-term Opioid Prescribing to Military Spouses in the Millennium Cohort Family Study

INTRODUCTION

The use and misuse of opioids by active service members has been examined in several studies, but little is known about their spouses' opioid use. This study estimates the number of military spouses who received high-risk or long-term opioid prescriptions between 2010 and 2014, and addresses how the Military Health System can help prevent risky prescribing in order to improve military force readiness.

MATERIALS AND METHODS

This study used data from the Millennium Cohort Family Study, a nationwide survey of 9,872 spouses of service members with 2 to 5 years of military service, augmented with information from the military's Pharmacy Data Transaction Service about prescriptions for controlled drugs dispensed to these service members' spouses. Our objectives were to estimate the prevalence of opioid prescribing indicative of long-term use (≥60 day supply or at least one extended-release opioid prescription in any 3-month period) and, separately, high-risk use (daily dosage of ≥90 morphine mg equivalent or total dosage of ≥8,190 morphine mg equivalent, or prescriptions from more than three pharmacies, or concurrent prescriptions). For each of these dependent variables, we conducted bivariate analyses and multiple logistic regression models using information about spouses' physical health, sociodemographic characteristics, substance use behaviors, perceived social support, and stresses associated with military stress, among others. Informed consent, including consent to link survey responses to medical and personnel records, was obtained from all participants. The Naval Health Research Center's Institutional Review Board and the Office of Management and Budget approved the study.

RESULTS

Spouses were predominantly female (86%), had not served in the military themselves (79%), and were spouses of enlisted (91%) active duty (86%) service members. Almost half (47.6%) of spouses obtained at least one opioid prescription during the 2-year observation window, and 8.5% had received opioid prescriptions that posed risk to their health. About 7% met the criteria for receipt of high-risk opioid prescriptions, 3% obtained opioids from three or more pharmacies during a 3-month period, and 4% of spouses who received any opioids received both long-term and high-risk prescriptions. Adverse childhood experiences, physical pain, and lack of social support were associated with increased odds of obtaining high-risk opioid prescriptions.

CONCLUSIONS

Approximately 48% of military spouses had used Military Health System insurance to fill at least one opioid prescription during the 2-year observation period. The Department of Defense has taken measures to minimize high-risk opioid prescribing, including passing prescribing guidelines in 2017, establishing the controlled drug management analysis reporting tool, establishing a pain management education and training program, and more. These efforts should continue to expand as reducing the numbers of service members and spouses at risk for adverse events may be effective in reducing opioid misuse and improve the overall health and safety of military spouses and thus, the readiness of the U.S. Armed Forces.

Critical analysis of the Armed Forces Covenant Fund Trust Aged Veterans Fund

BACKGROUND

Relatively little research is available regarding the specific needs of older military veterans and the services introduced to support them. In 2016, the Armed Forces Covenant Fund Trust launched the Aged Veterans Fund (AVF), to understand the impact that military service may have on ageing, and to support initiatives targeting their health and well-being. This fund was financed for 5 years and included 19 UK portfolio projects.

METHOD

The paper presents a retrospective evaluation on the processes and impact of the AVF, with the intent of informing policy, educational services, service providers and stakeholders of the lessons learnt. The inclusion criteria was veterans and their families aged 65 years of age or over. In 2019, data were drawn from documentary evidence related to the programmes. Qualitative analysis were performed on 78 eligible sources and 10 themes were identified.

RESULTS

Programmes were rolled out via collaborative partnerships referrals, focusing on person-centred or skill-exchange approaches. Challenges were encountered, such as capacity and timelines issues. A limited amount of associated cost-savings was observed, even if examples of sustainability and high satisfaction were reported. Evidence was found of programmes boosting health and well-being outcomes, in raising awareness, and in positively impacting on clinical practice, such as re-admission rates.

CONCLUSION

The AVF programmes were successful in their intent to provide support to older veterans and their families. The findings provide indicators of the next steps required for the support of ageing veterans. Further investigation of the cost-effectiveness of age-friendly veterans' services is needed.

Evaluating serious stress in military veterans, their carers and families: a protocol

In 2018, the Armed Forces Covenant Fund Trust (ACFT) allocated approximately £4M to seven UK projects to address serious stress in military veterans, their carers and families. These programmes commenced between May and October 2019 and will conclude in August 2021.

This paper outlines the protocol for the evaluation of the Tackling Serious Stress programme and the novel support provided to grant holders. Entry into the programmes was through multiple routes, including self-referrals with an anticipated sample of approximately 2000 participants. A common outcomes framework was designed to measure outcomes. Grant holders accepted ownership for data collection and quality and were supported through accompanying guidance material.

Veterans were often reluctant to seek support, and the anonymous and confidential nature of the evaluation plus the study team’s military background helped address this. Participants’ voices were a key part in developing the protocol, leading to results to inform policy and highlight success, efficiency and cost effectiveness, and providing markers for future development.

The study provided a reservoir of information. Interim reports indicated compliance with performance indicators and provided timely evidence. Shared learning provided grant holders with an indication of what was helping the beneficiaries and what needed to be improved. The combination of all data sets provided the ACFT with a resource to demonstrate success and insight into projects where improvement was required, and indicators of how to redress these problems. The study protocol provided a platform for building lasting partnerships.

Posttraumatic Stress Disorder Symptom Clusters in Service Members Predict New-Onset Depression Among Military Spouses

Military operations in Iraq and Afghanistan have brought increased attention to posttraumatic stress disorder (PTSD) among service members and, more recently, its impact on spouses. Existing research has demonstrated that PTSD among service members is associated with depression among military spouses. In the current study, we extended these findings by using data from service member-spouse dyads enrolled in the Millennium Cohort Family Study for which the service member had evidence of PTSD (n = 563). Prospective analyses identified the association between PTSD symptom clusters reported by the service member and new-onset depression among military spouses. Over the 3-year study period, 14.4% of these military spouses met the criteria for new-onset depression. In adjusted models, service member ratings of symptoms in the effortful avoidance cluster, odds ratio (OR) = 1.61, 95% CI [1.03, 2.50], predicted an increased risk of new-onset depression among military spouses, whereas reexperiencing symptoms, adjusted OR = 0.57; 95% CI [0.32, 1.01], were marginally protective. These findings suggest that PTSD symptom clusters in service members differentially predict new-onset depression in military spouses, which has implications for treatment provision.

Alcohol misuse and separation from military service: A dyadic perspective

OBJECTIVE

Alcohol misuse is a prevalent problem among military service members and their spouses. Service member alcohol misuse may contribute to poor job performance, legal infractions, and failure to meet physical standards. Spousal alcohol misuse may indicate problems with military life. However, limited information is available about how alcohol misuse in military families affects occupational outcomes, specifically military attrition.

METHOD

The current study examined 7,965 opposite sex married couples from the Millennium Cohort Family Study with one military and one civilian/veteran partner. Both partners reported on three measures of alcohol misuse (binge drinking, alcohol problems, and heavy weekly drinking). The associations between each partner's measures of alcohol misuse and subsequent military separation were evaluated using logistic regression. Sex, concordance of alcohol misuse, mental health, and service branch were explored as moderators.

RESULTS

In fully adjusted models, service member alcohol problems were directly related to military separation. Additionally, service member heavy weekly drinking was strongly associated with military separation among female service members but not male service members. Service member and spouse binge drinking interacted such that when only one partner reported binge drinking military separation was less likely, but both partners' binge drinking conveyed a marginally increased risk of military separation.

CONCLUSIONS

Prevalence of alcohol misuse was high among military families. Service member alcohol misuse was more strongly related to military separation than spouse alcohol misuse. Additionally, heavy weekly drinking among female service members may be an indicator of a significant issue that merits interventions aimed at retaining these service members.

Associations of warzone veteran mental health with partner mental health and family functioning: Family Foundations Study

INTRODUCTION

Warzone participation is associated with increased risk of stress-related psychopathology, including posttraumatic stress disorder (PTSD) and depression. Prior research suggests that the mental health of spouses of warzone veterans (WZVs) is linked to that of their partners. Additionally, PTSD among WZVs has been associated with marital dysfunction. Less is known about the effects of depression among WZVs on partner mental health and family relationships. We sought in this study to examine associations between WZV PTSD and depression and partner mental health and relationship outcomes.

METHODS

Using a nationally dispersed sample of Iraq and Afghanistan veterans and their married and unmarried intimate partners, 245 dyads completed structured psychiatric interviews and psychometric surveys assessing family functioning and relationship aggression.

RESULTS

Adjusted regression analyses indicated that depression among WZVs was associated with partner depression and anxiety disorders. WZV PTSD and depression were also associated with partner-reported relationship dysfunction, dissatisfaction, and communication issues, and higher rates of intimate partner aggression victimization and perpetration.

CONCLUSIONS

Mental health consequences of war extend beyond WZVs to the mental health of their intimate partners and their relationships with intimate partners.

Association of military life experiences and health indicators among military spouses

Background

The health and well-being of military spouses directly contribute to a robust military force by enabling the spouse to better support the active duty member’s career. In order to understand the overall health and well-being of military spouses, we assessed health indicators among military spouses using the Healthy People 2020 framework and examined associations of these health indicators with military experiences and psychosocial factors.

Methods

Using data from the Millennium Cohort Family Study, a U.S. Department of Defense-sponsored survey of 9872 spouses of service members with 2–5 years of military service, we examined attainment of Healthy People 2020 goals for spouses and service members, including healthy weight, exercise, sleep, and alcohol and tobacco use. Multivariable logistic regression models assessed associations of spouse health indicators with stressful military life experiences and social support, adjusting for demographics and military descriptors. The spousal survey was administered nationwide in 2011.

Results

The majority of military spouses met each health goal assessed. However, less than half met the healthy weight and the strength training goals. Reporting greater perceived family support from the military was associated with better behavioral health outcomes, while having no one to turn to for support was associated with poorer outcomes. Using the Healthy People 2020 objectives as a framework for identifying key health behaviors and benchmarks, this study identified factors, including military-specific experiences, that may contribute to physical health behaviors and outcomes among military spouses. With respect to demographic characteristics, the findings are consistent with other literature that women are more likely to refrain from risky substance use and that greater education is associated with better overall health outcomes.

Conclusions

Findings suggest that enhanced social and military support and tailored programming for military spouses may improve health outcomes and contribute to the well-being of military couples. Such programming could also bolster force readiness and retention.

Mental health in spouses of U.S. Gulf War veterans

Veterans' spouses are at risk for mental distress and substance use. We examined long term psychological functioning in spouses from a national cohort of 1991 Gulf War era veterans. From clinical interviews, spouses of deployed veterans (n = 488) did not have a greater prevalence of post-war mental disorders compared to spouses of non-deployed veterans (n = 536); however, in couples that were living together since the war, there was an increased risk of anxiety disorders or any one disorder. On questionnaires, the impact varied but was most consistently observed in more severe depression and greater functional impairment in spouses of deployed compared to non-deployed veterans. If a veteran developed post-war anxious/depressive disorders or any one mental disorder, the matched spouse was more likely to develop post-war anxious/depressive disorders or any one mental disorder, respectively. Veteran combat exposure did not similarly increase the risk of spouse post-war mental disorders. Greater spouse self-reported symptomatology was observed in spouses of veterans with anxious/depressive disorders even when controlling for deployment. In summary, the war conferred greater risk for spouse mental disorders and distress for spouses of veterans with mental health disorders, with some increased risk for spouses of deployed veterans, especially in couples together since the war.

Design and methods for the Ranger Resilience and Improved Performance on Phospholipid bound Omega-3's (RRIPP-3 study)

Intake of nutrients fundamental for optimal neuronal function is of increasing interest. The potential importance of omega-3 highly unsaturated fatty acids (HUFAs) for optimizing emotional states, cognitive function, and mental health has been demonstrated in observational studies and randomized controlled trials. Omega-3 (HUFAs), specifically EPA (eicosapentaenoic acid) and docosahexaenoic acid (DHA), are concentrated in neural tissues and are essential for neural function, normative neurodevelopment, neurotransmitter, and neural immune functions. Omega-3 HUFAs must be obtained from the diet, predominantly from marine sources such as fish and other seafood. HUFAs also can be found in a variety of dietary supplements (omega-3 fatty acid esters, fish oil and krill oil). As dietary supplements, omega-3 HUFAs (fatty acid esters, fish and krill oils) differ substantially in their physicochemical properties and nutrient content. Here we present the design and methods for the Ranger Resilience and Improved Performance on Phospholipid bound Omega-3's (RRIPP-3) study. RRIPP-3 was a double blind, randomized, controlled trial among individuals in the United States (US) Army Infantry Basic Officer Leaders Course (IBOLC) and following US Ranger School training (RC) at Fort Benning, GA of omega-3 HUFA on krill oil versus placebo supplementation. The RRIPP-3 study sought to determine if krill oil supplementation with omega-3 HUFAs supports aspects of cognitive functioning critical to battlefield success when measured immediately after an intense combat simulation. Sub-analyses addressed basic improvements in IBOLC performance. We also describe additional outcome measures critical for interpretation of the study results, such as diet and other dietary supplement use.