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Carreno-Davidson JT, Faller TN, Richardson MD, Roy TC. Behavioral Health-related Reasons for Permanent Duty Limitation Profiles in the U.S. Army: Population-Based Data from 2017 to 2019. Mil Med 2023; 188:444-449. [PMID: 37948224 DOI: 10.1093/milmed/usad183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/20/2023] [Accepted: 05/10/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION When warfighters are unable to fight, they are formally removed from battle through temporary or permanent duty limitation profiles. This study uses a population-based data repository to characterize permanent behavioral health (BH)-related profiles across the army for an identified 2-year period. The absolute risk of a permanent duty limitation for specific BH categories was also examined. MATERIALS AND METHODS This study utilized a retrospective population-based design to identify all new BH diagnoses across the U.S. Army. Service members identified as having a new BH diagnosis were tracked for 12 months following the diagnosis to determine the recommendation of a permanent duty limitation profile. RESULTS From 2017 to 2018, 16% (n = 102,440) of service members received a "new" BH diagnosis. Less than 10% (9.5%; n = 9,752) of soldiers diagnosed with a BH disorder were issued a permanent BH-related duty profile within 12 months of the initial diagnosis. The absolute risk of a permanent profile was highest for soldiers diagnosed with a psychotic or delusional disorder (42%; n = 324) followed by dissociative or somatoform disorders (26%; n = 178) and eating disorders (23%; n = 108). CONCLUSIONS Military regulations dictating medical readiness and retention standards reflect both the standards required for mission readiness and a layer of medical protection for the service member. This study provides important information on the relationship between a new BH diagnosis and the likelihood that a service member will be referred for a retirement evaluation.
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Affiliation(s)
- Jamie T Carreno-Davidson
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Theresa N Faller
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
- Department of Mental Health, John Hopkins University, Baltimore, MD 21205, USA
| | - Melissa D Richardson
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Tanja C Roy
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
- Operational Health Services, Army Public Health Center, Aberdeen Proving Ground, MD 21010, USA
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Ripperger MA, Kolli J, Wilimitis D, Robinson K, Reale C, Novak LL, Cunningham CA, Kasuske LM, Grover SG, Ribeiro JD, Walsh CG. External Validation and Updating of a Statistical Civilian-Based Suicide Risk Model in US Naval Primary Care. JAMA Netw Open 2023; 6:e2342750. [PMID: 37938841 PMCID: PMC10632956 DOI: 10.1001/jamanetworkopen.2023.42750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/29/2023] [Indexed: 11/10/2023] Open
Abstract
Importance Suicide remains an ongoing concern in the US military. Statistical models have not been broadly disseminated for US Navy service members. Objective To externally validate and update a statistical suicide risk model initially developed in a civilian setting with an emphasis on primary care. Design, Setting, and Participants This retrospective cohort study used data collected from 2007 through 2017 among active-duty US Navy service members. The external civilian model was applied to every visit at Naval Medical Center Portsmouth (NMCP), its NMCP Naval Branch Health Clinics (NBHCs), and TRICARE Prime Clinics (TPCs) that fall within the NMCP area. The model was retrained and recalibrated using visits to NBHCs and TPCs and updated using Department of Defense (DoD)-specific billing codes and demographic characteristics, including expanded race and ethnicity categories. Domain and temporal analyses were performed with bootstrap validation. Data analysis was performed from September 2020 to December 2022. Exposure Visit to US NMCP. Main Outcomes and Measures Recorded suicidal behavior on the day of or within 30 days of a visit. Performance was assessed using area under the receiver operating curve (AUROC), area under the precision recall curve (AUPRC), Brier score, and Spiegelhalter z-test statistic. Results Of the 260 583 service members, 6529 (2.5%) had a recorded suicidal behavior, 206 412 (79.2%) were male; 104 835 (40.2%) were aged 20 to 24 years; and 9458 (3.6%) were Asian, 56 715 (21.8%) were Black or African American, and 158 277 (60.7%) were White. Applying the civilian-trained model resulted in an AUROC of 0.77 (95% CI, 0.74-0.79) and an AUPRC of 0.004 (95% CI, 0.003-0.005) at NBHCs with poor calibration (Spiegelhalter P < .001). Retraining the algorithm improved AUROC to 0.92 (95% CI, 0.91-0.93) and AUPRC to 0.66 (95% CI, 0.63-0.68). Number needed to screen in the top risk tiers was 366 for the external model and 200 for the retrained model; the lower number indicates better performance. Domain validation showed AUROC of 0.90 (95% CI, 0.90-0.91) and AUPRC of 0.01 (95% CI, 0.01-0.01), and temporal validation showed AUROC of 0.75 (95% CI, 0.72-0.78) and AUPRC of 0.003 (95% CI, 0.003-0.005). Conclusions and Relevance In this cohort study of active-duty Navy service members, a civilian suicide attempt risk model was externally validated. Retraining and updating with DoD-specific variables improved performance. Domain and temporal validation results were similar to external validation, suggesting that implementing an external model in US Navy primary care clinics may bypass the need for costly internal development and expedite the automation of suicide prevention in these clinics.
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Affiliation(s)
- Michael A. Ripperger
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jhansi Kolli
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Drew Wilimitis
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katelyn Robinson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carrie Reale
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Laurie L. Novak
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Lalon M. Kasuske
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | | | - Colin G. Walsh
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee
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Curley JM, Clarke-Walper KM, Nugent KL, Wilk JE. Behavioral Health Provider Attitudes Toward Behavioral Health Profiles in the U.S. Army. Mil Med 2021; 187:34-39. [PMID: 34244786 DOI: 10.1093/milmed/usab254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/14/2021] [Accepted: 06/15/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION U.S. Army healthcare providers' use of profiles to document and communicate behavioral health (BH) condition limitations to commanders is vital to understanding both the individual soldier's BH readiness for missions and, as an aggregate, the unit's overall BH readiness status. Quantitative work exploring the link between soldier attitudes toward BH profiles and treatment utilization found that profiles may actually promote increases in treatment-seeking behavior in those receiving conventional BH services. BH provider attitudes on the subject, however, have not been quantitatively explored. Using data from the recently described Behavioral Health Readiness and Decision-Making Instrument (B-REDI) study, the current inquiry addresses this by examining BH providers' pre-/post-B-REDI attitudes toward BH profiles, including therapeutic alliance, to better understand how BH profiles may impact BH treatment. METHODS This study was approved by the WRAIR Institutional Review Board and is part of the larger B-REDI study. BH providers (n = 307) across five installations supporting active duty U.S. Army Divisions completed surveys longitudinally across three time points from September 2018 to March 2019. The survey specific to this study included five items, developed by WRAIR, assessing BH provider attitudes toward BH profiles. Of the providers who completed the survey, 250 (81%) consented to participate in the study and 149 (60%) completed the 3-month follow-up survey. RESULTS Over 80% of BH providers expressed agreement with each of three items assessing rationale for issuing BH profiles in both the pre- and post B-REDI period. Specifically, most providers agreed that profiles facilitate commander support to the soldier, afford soldiers resources for recovery, and give commanders increased understanding of soldier health for mission planning. Twenty-six percent of BH providers agreed, 46% were neutral, and 28% disagreed on whether profile impact on the soldier was positive or not in the pre-B-REDI period, but there was a significant positive trend relative to baseline in the post B-REDI period. The vast majority of providers (≥94%) did not endorse agreement that BH profiles negatively impact therapeutic alliance in either the pre- or post-B-REDI period. CONCLUSIONS Assuming that therapeutic alliance and perceptions of BH profile impact on soldiers are useful proxy measures of how treatment utilization may be affected by profiling, this inquiry fails to establish any meaningful negative association between them. This may provide some additional reassurance to BH providers and policymakers that efforts to improve readiness decision-making, such as B-REDI, and increased profiling in conventional military BH settings may not negatively impact treatment utilization rates.
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Affiliation(s)
- Justin M Curley
- Headquarters, Department of the Army, Office of the Deputy Under Secretary of the Army, Arlington, VA 22202, USA
| | - Kristina M Clarke-Walper
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Katie L Nugent
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Joshua E Wilk
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
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Aranda M, Poloni D, Coffin E, Hendren B. Profiles After Acute Traumatic Injury: The Non-battle Injury Impact on Readiness at a Single Military Treatment Facility. Mil Med 2021; 186:565-570. [PMID: 33372671 DOI: 10.1093/milmed/usaa566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/02/2020] [Accepted: 12/17/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Physical profiling is critical to the individual medical readiness of all military service members. This classification system provides detailed information about an individual's functional abilities. Profile information is used in determining whether a service member is medically deployable or non-deployable. Limited research has been conducted on the impact of acute traumatic injuries on duty status and profiles in the non-deployed setting. The purpose of this study was to characterize injured service members presenting to a CONUS MTF emergency department whose acute traumatic injury resulted in a profile. MATERIALS AND METHODS A retrospective review of patients who presented to the Dwight D. Eisenhower Army Medical Center emergency department with traumatic injuries from January 1, 2019, to December 31, 2019, was performed. Patients were identified by searching electronic encounter records for trauma-specific ICD-10 codes. Returned patient records were then reviewed for active duty status, branch, age, gender, rank, mechanism, protective equipment, substance use, procedures, and disposition. Profiles of soldiers were reviewed for indication and duration. Patients with profiles were compared to those without profiles. Correlation with age was determined by t-test, correlation with profile length was determined by ANOVA, and correlation with the remaining categorical variables was determined with chi-squared analysis. RESULTS Eight hundred and thirty-two service members were reviewed. One hundred and eight (13%) soldiers had a profile. Patients were 23.2% female with no difference between the two groups. Patients were an average of 28.7 years old. The most common mechanisms were physical training (PT) (33.1%) and falls (12.9%). Physical training and motor vehicle collisions were more common in the profile group. Combatives and crush injuries of the hand were less common in the profile group. Major procedures were more common in the profile group, and minor procedures were less common. Admissions, quarters, immediate referrals, and release without limitations were more common in the profile group. The mean duration of profiles was 48.9 days, and 7.4% were permanent. CONCLUSIONS Non-battle injuries in the garrison setting are a significant threat to readiness. This analysis of acute traumatic injuries suggests that mechanism of injury was similar to previous reports with PT and falls being most common. Interventions should be targeted at PT and motor vehicle collisions as these were more common in the profile group. This series is also similar to previous reports that extremity injuries are the most common cause of profiles. However, TBIs were more common in our analysis. Further research that encompasses all garrison MTF acute traumatic injuries is needed to define the true impact on readiness and guide development of injury prevention strategies.
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Affiliation(s)
- Marcos Aranda
- Department of General Surgery, Dwight D. Eisenhower Army Medical Center, Ft. Gordon, GA 30905, USA
| | - Dana Poloni
- Department of General Surgery, Dwight D. Eisenhower Army Medical Center, Ft. Gordon, GA 30905, USA
| | - Elisabeth Coffin
- Department of General Surgery, Dwight D. Eisenhower Army Medical Center, Ft. Gordon, GA 30905, USA
| | - Bryan Hendren
- Department of General Surgery, Dwight D. Eisenhower Army Medical Center, Ft. Gordon, GA 30905, USA
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Curley JM, McDonald JL, Nugent KL, Clarke-Walper KM, Penix EA, Riviere LA, Kim PY, Wilk JE. Soldier Attitudes Toward Behavioral Health Profiles in the US Army. Mil Med 2021; 185:84-91. [PMID: 31247103 DOI: 10.1093/milmed/usz133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/02/2019] [Accepted: 05/21/2019] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Behavioral health (BH) readiness is a critical component of U.S. Army personnel readiness. Medical providers issue BH profiles in order to communicate BH-related duty limitations to the commander and reflect BH force readiness on both micro/macro-levels. A recent report indicates BH profile underutilization may be significantly elevating U.S. Army safety and mission-failure risks, and a study of BH provider decision-making suggests some providers may be hesitant to use profiles due to concerns that soldiers' attitudes toward BH profiles may negatively impact treatment utilization. This potential link, however, has not been empirically examined. This study addresses this gap by assessing soldiers' attitudes towards BH profiles to better understand how BH profiles may impact treatment utilization and explore for any BH profile-related stigma effect. METHODS Approved by the Walter Reed Army Institute of Research (WRAIR) Institutional Review Board as part of the Land Combat Study II, the survey specific to this study included eight WRAIR-developed items assessing soldier attitudes toward BH profiles. Soldiers (N = 1,043) from two active duty U.S. Army brigades completed cross-sectional, anonymous surveys in 2017-2018. Soldier self-reported BH care utilization was assessed and used to create sub-groups for analysis. RESULTS A majority of soldiers indicated that being placed on a BH profile would make them as or more likely to seek (71%) and no more or less likely to drop out (84%) of BH care. Among soldiers who had received BH care, BH profiles were associated with more favorable treatment seeking attitudes among those inclined to access conventional BH services and less favorable treatment seeking and maintenance attitudes among those inclined to access BH services from sources incapable of issuing profiles. Negative attitudes towards BH profiles were significantly more prevalent when compared to physical injury profiles, except in the group who had received BH care from a source incapable of issuing a profile. No significant proportional differences were observed among soldiers toward the rationale for BH profiles. Almost all soldiers (95% or greater) preferred their BH condition not come to the commander's attention during pre-deployment screening (SRP), choosing either BH profile or crisis options instead. CONCLUSIONS Results suggest soldiers who would be less likely to seek or more likely to drop out of BH care due to a BH profile may be those that are less likely to access conventional BH services in the first place. This may provide some preliminary reassurance to conventional providers that increased BH profiling practices may not be inversely proportional to the amount of BH care delivered and may encourage treatment-seeking behaviors among the population they serve. Soldiers seeking BH care from sources incapable of issuing a profile may be sensitive to a potential BH profile-related stigma effect (possibly more global profile-related effect in this group), which should be factored into policy outreach efforts. A BH profile represents a more palatable BH duty limitation disclosure option for many soldiers, and supports the merits of a disclosure process that is earlier than SRP for promoting risk mitigation and more honest appraisals of BH mission-readiness levels.
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Affiliation(s)
- Justin M Curley
- Department of Military Psychiatry, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | - Jennifer L McDonald
- U.S. Army Medical Research Directorate- West, Joint Base Lewis-McChord, 9933 W. Johnson, Tacoma, WA 98433
| | - Katie L Nugent
- Department of Military Psychiatry, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | - Kristina M Clarke-Walper
- Department of Military Psychiatry, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | - Elizabeth A Penix
- Department of Military Psychiatry, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | - Lyndon A Riviere
- Department of Military Psychiatry, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | - Paul Y Kim
- Department of Military Psychiatry, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | - Joshua E Wilk
- Department of Military Psychiatry, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
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Curley JM, Nugent KL, Clarke-Walper KM, Penix EA, Macdonald JB, McDonald JL, Wilk JE. Results of the Behavioral Health Readiness Evaluation and Decision-Making Instrument Study. Mil Med 2021; 186:142-152. [PMID: 33499474 DOI: 10.1093/milmed/usaa401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/05/2020] [Accepted: 10/01/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Recent reports have demonstrated behavioral health (BH) system and individual provider challenges to BH readiness success. These pose a risk to winning on the battlefield and present a significant safety issue for the Army. One of the most promising areas for achieving better BH readiness results lies in improving readiness decision-making support for BH providers. The Walter Reed Army Institute of Research (WRAIR) has taken the lead in addressing this challenge by developing and empirically testing such tools. The results of the Behavioral Health Readiness Evaluation and Decision-Making Instrument (B-REDI) field study are herein described. METHODS The B-REDI study received WRAIR Institutional Review Board approval, and BH providers across five U.S. Army Forces Command installations completed surveys from September 2018 to March 2019. The B-REDI tools/training were disseminated to 307 providers through random clinic assignments. Of these, 250 (81%) providers consented to participate and 149 (60%) completed both initial and 3-month follow-up surveys. Survey items included a wide range of satisfaction, utilization, and proficiency-level outcome measures. Analyses included examinations of descriptive statistics, McNemar's tests pre-/post-B-REDI exposure, Z-tests with subgroup populations, and chi-square tests with demographic comparisons. RESULTS The B-REDI resulted in broad, statistically significant improvements across the measured range of provider proficiency-level outcomes. Net gains in each domain ranged from 16.5% to 22.9% for knowledge/awareness (P = .000), from 11.1% to 15.8% for personal confidence (P = .001-.000), and from 6.2% to 15.1% for decision-making/documentation (P = .035-.002) 3 months following B-REDI initiation, and only one (knowledge) failed to maintain a statistically significant improvement in all of its subcategories. The B-REDI also received high favorability ratings (79%-97% positive) across a wide array of end-user satisfaction measures. CONCLUSIONS The B-REDI directly addresses several critical Army BH readiness challenges by providing tangible decision-making support solutions for BH providers. Providers reported high degrees of end-user B-REDI satisfaction and significant improvements in all measured provider proficiency-level domains. By effectively addressing the readiness decision-making challenges Army BH providers encounter, B-REDI provides the Army BH health care system with a successful blueprint to set the conditions necessary for providers to make more accurate and timely readiness determinations. This may ultimately reduce safety and mission failure risks enterprise-wide, and policymakers should consider formalizing and integrating the B-REDI model into current Army BH practice.
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Affiliation(s)
- Justin M Curley
- Headquarters, Department of the Army, Office of the Deputy Under Secretary of the Army, Arlington, VA, 22202, USA
| | - Katie L Nugent
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD, 20910, USA
| | - Kristina M Clarke-Walper
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD, 20910, USA
| | - Elizabeth A Penix
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD, 20910, USA
| | - James B Macdonald
- Department of Behavioral Health, Madigan Army Medical Center, Tacoma, WA, 98431, USA
| | - Jennifer L McDonald
- U.S. Army Medical Research Directorate- West, Walter Reed Army Institute of Research, Tacoma, WA, 98433, USA
| | - Joshua E Wilk
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, MD, 20910, USA
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