Mental Health Treatment Among Soldiers With Current Mental Disorders in the Army Study to Assess Risk and Resilience in Service Members (Army STARRS)

Modification of Commonly Used Outcome Tools to Quantify the Patient Pain Distress Index Following Acute and Chronic Orthopedic Trauma

INTRODUCTION

Patient-reported outcome measures (PROMs) are an important component of evaluating patient health and are increasingly utilized in orthopedics. However, their use remains inconsistent among orthopedic subspecialties, with only 21% of orthopedic trauma surgeons reporting regular use of PROMs in their practice. While tools for quantifying patient distress in response to pain have been developed, they are often difficult to apply due to extensive questioning and the need for prospective implementation. The purpose of this study was to propose a novel retrospective technique to measure the Pain Distress Index (PDI) using two common PROMs: the visual analog scale (VAS) and the short musculoskeletal functional assessment (SMFA).

METHODS

A total of 797 patients who underwent operative repair of a tibial plateau fracture or revision of long bone nonunion were included. To quantify PDI, a linear trend line was calculated from a scatter plot of SMFA Bothersome Index (BI) vs. VAS pain scores at three months postoperatively. Reported SMFA BI was compared to predicted SMFA BI, and patients were stratified into three cohorts: "limited," "adequate," and "excellent" PDI.

RESULTS

In both cohorts, SMFA Function Index scores at 6 and 12 months postoperatively differed significantly among the limited, adequate, and excellent PDI levels (p < 0.0005, p < 0.0005). Worse PDI (indicating greater distress from pain) was associated with poorer SMFA Function Index scores.

CONCLUSIONS

The combination of SMFA BI and VAS scores may serve as a useful tool to quantify PDI without requiring an additional questionnaire. "Limited" PDI was associated with poorer functional outcomes at 6 and 12 months postoperatively. This method may help predict which patients are at risk for worse functional outcomes and could serve as a retrospective proxy for resilience in future research.

Detecting suicide risk among U.S. servicemembers and veterans: a deep learning approach using social media data

BACKGROUND

Military Servicemembers and Veterans are at elevated risk for suicide, but rarely self-identify to their leaders or clinicians regarding their experience of suicidal thoughts. We developed an algorithm to identify posts containing suicide-related content on a military-specific social media platform.

METHODS

Publicly-shared social media posts (n = 8449) from a military-specific social media platform were reviewed and labeled by our team for the presence/absence of suicidal thoughts and behaviors and used to train several machine learning models to identify such posts.

RESULTS

The best performing model was a deep learning (RoBERTa) model that incorporated post text and metadata and detected the presence of suicidal posts with relatively high sensitivity (0.85), specificity (0.96), precision (0.64), F1 score (0.73), and an area under the precision-recall curve of 0.84. Compared to non-suicidal posts, suicidal posts were more likely to contain explicit mentions of suicide, descriptions of risk factors (e.g. depression, PTSD) and help-seeking, and first-person singular pronouns.

CONCLUSIONS

Our results demonstrate the feasibility and potential promise of using social media posts to identify at-risk Servicemembers and Veterans. Future work will use this approach to deliver targeted interventions to social media users at risk for suicide.

Resilience Improves Patient-Reported Outcomes After Orthopaedic Trauma

OBJECTIVES

To analyze the relationship between patient resilience and patient-reported outcomes after orthopaedic trauma.

METHODS

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Single Level 1 Trauma Center.

PATIENT SELECTION CRITERIA

Patients were selected based on completion of the Patient-Reported Outcomes Measurement Information System (PROMIS) and Brief Resilience Scale (BRS) surveys 6 months after undergoing operative fracture fixation following orthopaedic trauma. Patients were excluded if they did not complete all PROMIS and BRS surveys.

OUTCOME MEASURES AND COMPARISONS

Resilience, measured by the BRS, was analyzed for its effect on patient-reported outcomes, measured by PROMIS Global Physical Health, Physical Function, Pain Interference, Global Mental Health, Depression, and Anxiety. Variables collected were demographics (age, gender, race, body mass index), injury severity score, and postoperative complications (nonunion, infection). All variables were analyzed with univariate for effect on all PROMIS scores. Variables with significance were included in multivariate analysis. Patients were then separated into high resilience (BRS >4.3) and low resilience (BRS <3.0) groups for additional analysis.

RESULTS

A total of 99 patients were included in the analysis. Most patients were male (53%) with an average age of 47 years. Postoperative BRS scores significantly correlated with PROMIS Global Physical Health, Pain Interference, Physical Function, Global Mental Health, Depression, and Anxiety ( P ≤ 0.001 for all scores) at 6 months after injury on both univariate and multivariate analyses. The high resilience group had significantly higher PROMIS Global Physical Health, Physical Function, and Global Mental Health scores and significantly lower PROMIS Pain Interference, Depression, and Anxiety scores ( P ≤ 0.001 for all scores).

CONCLUSIONS

Resilience in orthopaedic trauma has a positive association with patient outcomes at 6 months postoperatively. Patients with higher resilience report higher scores in all PROMIS categories regardless of injury severity. Future studies directed at increasing resilience may improve outcomes in patients who experience orthopaedic trauma.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Racial and Ethnic Differences Among Active-Duty Service Members in Use of Mental Health Care and Perceived Mental Health Stigma: Results From the 2018 Health Related Behaviors Survey

INTRODUCTION

The prevalence of mental health disorders is rising among US service members; however, research is limited on their use of mental health care. The objective of our study was to determine whether racial and ethnic disparities exist in the use of mental health care and perceived mental health stigma among active-duty service members.

METHODS

We obtained data from a sample of 17,166 active-duty service members who participated in the 2018 Department of Defense Health Related Behavior Survey (HRBS). Racial and ethnic groups included Black, Hispanic, White, and other. Yes-no questions about use of mental health care and perceived mental health stigma were our outcome variables. We used multiple logistic regression to assess racial and ethnic differences in mental health care use and perceived mental health stigma by service members. Significance was set at P <.05.

RESULTS

In 2018, approximately 25.5% of service members self-reported using mental health services, and 34.2% self-reported perceived mental health stigma. Hispanic service members (AOR = 0.78) and service members in the "other" racial and ethnic group (AOR = 0.81) were less likely than their White counterparts to have used mental health care. Black (AOR = 0.68) and Hispanic (AOR = 0.86) service members were less likely than their White counterparts to self-report perceived mental health stigma.

CONCLUSION

The 2018 HRBS showed racial and ethnic differences in mental health care use and perceived stigma among US active-duty service members. Perceived stigma was a barrier to use of mental health care among service members with a mental health condition. Culture-sensitive programs customized for different racial and ethnic groups are needed to promote mental health care and reduce perceptions of stigma associated with its use.

Resilience correlates with patient reported outcomes after reverse total shoulder arthroplasty

BACKGROUND

Personal and social factors may account for much of the variation in patient reported outcome scores, yet little evidence exists on how psychological properties affect patient outcomes following reverse total shoulder arthroplasty (rTSA). The objective of this study is to determine if resilience, characterised by the ability to return to a healthy level of function after experiencing stress, correlates with patient reported outcome scores after rTSA.

HYPOTHESIS

Resilience score will correlate positively with patient reported outcomes after rTSA.

METHODS

Seventy-three patients were identified that had undergone primary rTSA with minimum 2-year follow-up (4.7±1.8). These patients completed a phone survey that included the Brief Resilience Scale (BRS), a measure of general resilience in all aspects of life, along with American Shoulder and Elbow Surgeon (ASES), Penn, and Single Assessment Numerical Evaluation (SANE) scores. Mean outcome scores were calculated to identify any correlation between resilience and clinical outcomes.

RESULTS

The mean BRS score was 23.8±4.8 (range 12.0-30.0), with 41 patients classified as normal resilience (NR), 17 patients as low resilience (LR), and 15 as high resilience (HR). Postoperative BRS scores correlated with ASES (r=0.31, p=0.008), Penn (r=0.25, p=0.03), and SANE score (r=0.32, p=0.007). The mean ASES score was 14.0 points lower in the LR group (77.0 points), compared to the HR group (91.0 points; p=0.04). Similarly, the LR group had a mean SANE score that was 18.6 points lower than the HR group (73.4 and 91.9 points, respectively; p=0.021).

DISCUSSION

The observation that greater general life resilience correlates with lower pain intensity, lesser magnitude of limitations, and perception of greater normality of the shoulder after reverse total shoulder arthroplasty emphasises the importance of addressing personal and social health opportunities along with the physical in musculoskeletal care. Resilience may be a useful predictor of outcomes following rTSA.

LEVEL OF EVIDENCE

III.

Resilience as a Predictor of Patient Satisfaction With Nonopioid Pain Management and Patient-Reported Outcome Measures After Knee Arthroscopy

PURPOSE

The purpose of this study was to evaluate the Brief Resilience Score (BRS) as a predictor for patient satisfaction with nonopioid pain management and patient-reported outcome measures (PROMs) after arthroscopic partial meniscectomy or chondroplasty.

METHODS

One hundred seventy-five patients undergoing arthroscopic partial meniscectomy and/or chondroplasty were recruited from a single clinic and were preoperatively stratified into low-to-normal resilience or high resilience groups as measured by the BRS. Satisfaction with nonopioid pain control was assessed at a 2-week follow-up visit using the Hospital Consumer Assessment of Healthcare Provider and Systems questionnaire, and various PROMs were measured at 3 and 6 months postoperatively. Statistical analysis was performed to assess for differences in satisfaction with pain control or PROMs between resilience groups.

RESULTS

Analysis revealed no statistically significant differences between the low-to-normal resilience group and the high resilience group with regard to satisfaction with nonopioid pain control or PROMs assessed at 3- or 6-month follow-ups. Outcome measures [visual analog scale pain, Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain, KOOS Activities of Daily Living, KOOS Quality of Life, Single Assessment Numerical Evaluation (SANE) Knee, and Veterans Rand 12-Item Health Survey Physical and Mental Component Scores] all followed expected trajectories after surgery, without a statistically significant difference between resilience groups.

CONCLUSION

This study provides evidence that preoperative resilience score, as measured by the BRS, does not correlate with postoperative patient-reported functional outcome or satisfaction with a nonopioid pain regimen after knee arthroscopy.

LEVEL OF EVIDENCE

II.

LINKS Training and Unit Support for Mental Health: a Group-randomized Effectiveness Trial

The LINKS curriculum, adapted from Britt et al. (2018a), was designed to improve unit climate, knowledge, and attitudes about mental health treatment seeking in military personnel. The present study extends this research by examining implementation options, comparing the effectiveness of LINKS to an active control condition with training delivered by non-experts and comparing modules that varied in training length. Eight Army platoons were randomly assigned to one of four conditions: (1) 1-h Active Control, (2) 2-h Active Control, (3) 1-h LINKS, or (4) 2-h LINKS. Two platoons were assigned to each condition. Surveys were administered at pre-training (T1), post-training (T2), and 3 months later (T3). Eighty-four participants completed all study phases. Regardless of training content, participants receiving the 2-h modules reported greater training acceptability than those receiving the 1-h modules. At T3, participants in the LINKS conditions reported more mental health knowledge than participants in the Active Control conditions. Sustained effects were also observed on a number of treatment barriers and facilitators, with the LINKS conditions generally leading to better outcomes. At T3, 2-h LINKS condition participants reported receiving more mental health treatment relative to the other conditions. Findings suggest that LINKS can be effectively delivered by non-expert trainers, is a viable intervention for targeting mental health treatment-seeking, and is optimally packaged in a 2-h module. The training might benefit from additional leadership training efforts.

The Resilient Athlete: Lessons Learned in the Military

Resilience, the capacity to recover from a setback or adversity, is a concept that has received considerable recent attention. An individual's resilience predicts their life trajectory following stressful events and this has increasingly been shown in a wide variety of applications. Our understanding of the degree to which we can modify our resilience, and the optimal means to do so, remains in its infancy. The US military has embraced extensive efforts to quantify and build resilience in service members in an effort to preserve the fighting force. We specifically look at the understanding of resilience as it relates to the athletes in terms of competition and return from injury. This article explores the concept of resilience, the efforts to build resilience, lessons learned from the military and applications of the resilience concept to surgical and trauma patients.

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Objectives:

Research suggests a high prevalence of problematic alcohol use among military personnel relative to civilians. Our primary objectives were to compare the prevalence, correlates, help-seeking behaviors, perceived need for care, and barriers to care for alcohol use disorders (AUDs) in the Canadian Armed Forces (CAF) and the Canadian general population (CGP).

Methods:

Data were from 2 nationally representative surveys collected by Statistics Canada: (1) the Canadian Community Health Survey on Mental Health collected in 2012 (N = 25,113; response rate = 68.9%) and (2) the Canadian Forces Mental Health Survey collected in 2013 (N = 8,161; response rate = 79.8%). Descriptive statistics and logistic regression were used to examine differences in outcomes of interest associated with AUDs in the CAF and CGP.

Results:

The prevalence of lifetime AUDs was significantly higher in the CAF (32.0%) than the CGP (20.3%; adjusted odds ratio [AOR] = 1.14, 95% confidence interval [CI, 1.02 to 1.27]) after adjustment for sociodemographic covariates. In contrast, the past-year prevalence of AUDs was significantly lower among CAF personnel (4.5%) than civilians (3.8%; AOR = 0.78, 95% CI [0.61 to 0.99]) after adjustment for sociodemographic covariates. Child abuse history and comorbid mental disorders were strongly associated with past-year AUDs in both populations. CAF personnel compared to the CGP were more likely to perceive a need for care (AOR = 4.15, 95% CI [2.56 to 6.72]) and engage in help-seeking behaviors (significant AORs ranged from 1.85 to 5.54). CAF personnel and civilians with past-year AUDs reported different barriers to care.

Conclusions:

Findings argue for the value of different approaches to address unmet need for AUD care in the CAF and CGP.

Factors Associated With Suicide Ideation in US Army Soldiers During Deployment in Afghanistan

IMPORTANCE

Understanding suicide ideation (SI) during combat deployment can inform prevention and treatment during and after deployment.

OBJECTIVE

To examine associations of sociodemographic characteristics, lifetime and past-year stressors, and mental disorders with 30-day SI among a representative sample of US Army soldiers deployed in Afghanistan.

DESIGN, SETTING, AND PARTICIPANTS

In this survey study, soldiers deployed to Afghanistan completed self-administered questionnaires in July 2012. The sample was weighted to represent all 87 032 soldiers serving in Afghanistan. Prevalence of lifetime, past-year, and 30-day SI and mental disorders was determined. Logistic regression analyses examined risk factors associated with SI. Data analyses for this study were conducted between August 2018 and August 2019.

MAIN OUTCOMES AND MEASURES

Suicide ideation, lifetime and 12-month stressors, and mental disorders were assessed with questionnaires. Administrative records identified sociodemographic characteristics and suicide attempts.

RESULTS

A total of 3957 soldiers (3473 [weighted 87.5%] male; 2135 [weighted 52.6%] aged ≤29 years) completed self-administered questionnaires during their deployment in Afghanistan. Lifetime, past-year, and 30-day SI prevalence estimates were 11.7%, 3.0%, and 1.9%, respectively. Among soldiers with SI, 44.2% had major depressive disorder (MDD) and 19.3% had posttraumatic stress disorder in the past 30-day period. A series of analyses of the 23 grouped variables potentially associated with SI resulted in a final model of sex; race/ethnicity; lifetime noncombat trauma; past 12-month relationship problems, legal problems, and death or illness of a friend or family member; and MDD. In this final multivariable model, white race/ethnicity (odds ratio [OR], 3.1 [95% CI, 1.8-5.1]), lifetime noncombat trauma (OR, 2.1 [95% CI, 1.1-4.0]), and MDD (past 30 days: OR, 31.8 [95% CI, 15.0-67.7]; before past 30 days: OR, 4.9 [95% CI, 2.5-9.6]) were associated with SI. Among the 85 soldiers with past 30-day SI, from survey administration through 12 months after returning from deployment, 6% (5 participants) had a documented suicide attempt vs 0.14% (6 participants) of the 3872 soldiers without SI.

CONCLUSIONS AND RELEVANCE

This study suggests that major depressive disorder and noncombat trauma are important factors in identifying SI risk during combat deployment.

Suicide Typologies in the United States Air Force: A Hierarchical Cluster Analysis

OBJECTIVE

This study describes characteristics of United States Air Force (USAF) suicide decedents and determines subgroups.

METHOD

Retrospective review of demographic, psychiatric, event-related, and psychosocial variables for USAF suicide decedents in the Suicide Event Surveillance System database was conducted between February 1999 and July 2009 (N = 376). Hierarchical cluster analysis was used to determine initial clusters and cluster centroids.

RESULTS

Analyses identified three clusters. Cluster 1 (n = 149) individuals were mostly single or divorced, E-1-E-6 rank, living alone, and less likely to have psychiatric disorder diagnoses or engage with most helping resources. Cluster 2 (n = 126) decedents were mostly married, living with a partner, higher ranking, and least likely to communicate suicide intent. Cluster 3 (n = 101) individuals were mostly E-4-E-6 rank, with the highest rates of most psychiatric diagnoses, previous suicide-related events, engagement with multiple helping resources, communication of intent, and psychosocial precipitants. Clusters differed significantly in marital status, rank, psychiatric diagnoses, precipitants, service utilization, previous suicide-related events, risk factors, communication of intent, location and method of death, and residential status.

CONCLUSIONS

This study identifies empirically based suicide typologies within a military decedent sample. While further research and replications of findings are needed, these typologies have clinical and policy implications for military suicide prevention.

Obsessive-Compulsive Symptom Dimensions and Insomnia: Associations Among a Treatment-Seeking Veteran Sample

Sleep disturbances are a prevalent and pernicious correlate of most emotional disorders. A growing body of literature has recently found evidence for an association between sleep disturbances and obsessive-compulsive disorder (OCD). Though informative, this link has yet to be explored in a veteran population. Further, the degree to which this relationship is accounted for by relevant third variables is limited. The current study investigated the relationship between self-reported insomnia and OCD symptoms after controlling for probable depression and posttraumatic stress disorder (PTSD) using an unselected sample of veterans (N = 57). Most of the sample reported clinically significant OCD (61%) and insomnia symptoms (58%). Results revealed associations between insomnia and OCD unacceptable thoughts/neutralizing compulsions, but not contamination obsessions/washing compulsions, responsibility for harm obsessions/checking compulsions, or symmetry obsessions/ordering compulsions. Findings highlight the need for more research on OCD and sleep problems and clinical work focused on sleep for patients reporting increased OCD symptoms, particularly veterans.

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): progress toward understanding suicide among soldiers

Responding to an unprecedented increase in the suicide rate among soldiers, in 2008 the US Army and US National Institute of Mental Health funded the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), a multicomponent epidemiological and neurobiological study of risk and resilience factors for suicidal thoughts and behaviors, and their psychopathological correlates among Army personnel. Using a combination of administrative records, representative surveys, computerized neurocognitive tests, and blood samples, Army STARRS and its longitudinal follow-up study (STARRS-LS) are designed to identify potentially actionable findings to inform the Army's suicide prevention efforts. The current report presents a broad overview of Army STARRS and its findings to date on suicide deaths, attempts, and ideation, as well as other important outcomes that may increase suicide risk (e.g., mental disorders, sexual assault victimization). The findings highlight the complexity of environmental and genetic risk and protective factors in different settings and contexts, and the importance of life and career history in understanding suicidal thoughts and behaviors.

Predeployment predictors of psychiatric disorder-symptoms and interpersonal violence during combat deployment

BACKGROUND

Preventing suicides, mental disorders, and noncombat-related interpersonal violence during deployment are priorities of the US Army. We used predeployment survey and administrative data to develop actuarial models to identify soldiers at high risk of these outcomes during combat deployment.

METHODS

The models were developed in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Pre-Post Deployment Study, a panel study of soldiers deployed to Afghanistan in 2012-2013. Soldiers completed self-administered questionnaires before deployment and one (T1), three (T2), and nine months (T3) after deployment, and consented to administrative data linkage. Seven during-deployment outcomes were operationalized using the postdeployment surveys. Two overlapping samples were used because some outcomes were assessed at T1 (n = 7,048) and others at T2-T3 (n = 7,081). Ensemble machine learning was used to develop a model for each outcome from 273 predeployment predictors, which were compared to simple logistic regression models.

RESULTS

The relative improvement in area under the receiver operating characteristic curve (AUC) obtained by machine learning compared to the logistic models ranged from 1.11 (major depression) to 1.83 (suicidality).The best-performing machine learning models were for major depression (AUC = 0.88), suicidality (0.86), and generalized anxiety disorder (0.85). Roughly 40% of these outcomes occurred among the 5% of soldiers with highest predicted risk.

CONCLUSIONS

Actuarial models could be used to identify high risk soldiers either for exclusion from deployment or preventive interventions. However, the ultimate value of this approach depends on the associated costs, competing risks (e.g. stigma), and the effectiveness to-be-determined interventions.

The influence of deployment stress and life stress on Post-Traumatic Stress Disorder (PTSD) diagnosis among military personnel

There is increasing recognition that traumatic stress encountered throughout life, including those prior to military service, can put individuals at increased risk for developing Posttraumatic Stress Disorder (PTSD). The purpose of this study was to examine the association of both traumatic stress encountered during deployment, and traumatic stress over one's lifetime on probable PTSD diagnosis. Probable PTSD diagnosis was compared between military personnel deployed in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF; N = 21,499) and those who have recently enlisted (N = 55,814), using data obtained from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Probable PTSD diagnosis was assessed using the PTSD Checklist. The effect of exposure to multiple types (i.e. diversity) of traumatic stress and the total quantity (i.e. cumulative) of traumatic stress on probable PTSD diagnosis was also compared. Military personnel who had been deployed experienced higher rates of PTSD symptoms than new soldiers. Diversity of lifetime traumatic stress predicted probable PTSD diagnosis in both groups, whereas cumulative lifetime traumatic stress only predicted probable PTSD for those who had been deployed. For deployed soldiers, having been exposed to various types of traumatic stress during deployment predicted probable PTSD diagnosis, but cumulative deployment-related traumatic stress did not. Similarly, the total quantity of traumatic stress (i.e. cumulative lifetime traumatic stress) did not predict probable PTSD diagnosis among new soldiers. Together, traumatic stress over one's lifetime is a predictor of probable PTSD for veterans, as much as traumatic stress encountered during war. Clinicians treating military personnel with PTSD should be aware of the impact of traumatic stress beyond what occurs during war.

Nonfatal Suicidal Behaviors in the Administrative Records of Activated U.S. Army National Guard and Army Reserve Soldiers, 2004-2009

OBJECTIVE

The U.S. Army suicide rate increased sharply during the wars in Iraq and Afghanistan. There is limited information about medically documented, nonfatal suicidal behaviors among soldiers in the Army's Reserve Component (RC), which is composed of the Army National Guard and Army Reserve. Here we examine trends and sociodemographic correlates of suicide attempts, suspicious injuries, and suicide ideation among activated RC soldiers.

METHODS

Data come from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Historical Administrative Data Study (HADS), which integrates administrative records for all soldiers on active duty for the years 2004 through 2009 (n = 1.66 million).

RESULTS

We identified 2,937 unique RC soldiers on active duty with a nonfatal suicidal event documented at some point during the HADS study period. There were increases in the annual incidence rates of suicide attempts (71 to 204/100,000 person-years) and suicide ideation (326 to 425/100,000 person-years). Incidence rates for suspicious injuries also generally increased but were more variable. Using hierarchical classification rules, we identified the first instance of each soldier's most severe behavior (suicide attempt versus suspicious injury versus suicide ideation). For each of those suicide- or injury-related outcomes, we found increased risk among those who were female, younger, non-Hispanic White, less educated, never married, and lower-ranking enlisted. These sociodemographic associations significantly differed across outcomes, although the patterns were similar.

CONCLUSION

Results provide a broad overview of nonfatal suicidal trends in the RC during the period 2004 through 2009. They also demonstrate that integration of multiple administrative data systems enriches analysis of the predictors of such events.

Barriers to Initiating and Continuing Mental Health Treatment Among Soldiers in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

U.S. Army soldiers with mental disorders report a variety of barriers to initiating and continuing treatment. Improved understanding of these barriers can help direct mental health services to soldiers in need. A representative sample of 5,428 nondeployed Regular Army soldiers participating in the Army Study to Assess Risk and Resilience in Servicemembers completed a self-administered questionnaire and consented to linking self-administered questionnaire data with administrative records. We examined reported treatment barriers (perceived need, structural reasons, attitudinal reasons) among respondents with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, mental disorders who either did not seek treatment in the past year (n = 744) or discontinued treatment (n = 145). About 82.4% of soldiers who did not initiate treatment and 69.5% of those who discontinued treatment endorsed at least two barriers; 69.8% of never-treated soldiers reported no perceived need. Attitudinal reasons were cited more frequently than structural reasons among never-treated soldiers with perceived need (80.7% vs. 62.7%) and those who discontinued treatment (71.0% vs. 37.8%). Multivariate associations with sociodemographic, Army career, and mental health predictors varied across barrier categories. These findings suggest most soldiers with mental disorders do not believe they need treatment and those who do typically face multiple attitudinal and, to a lesser extent, structural barriers.

Medically Documented Suicide Ideation Among U.S. Army Soldiers

We used administrative data to examine predictors of medically documented suicide ideation (SI) among Regular Army soldiers from 2006 through 2009 (N = 10,466 ideators, 124,959 control person-months). Enlisted ideators (97.8% of all cases) were more likely than controls to be female, younger, older when entering service, less educated, never or previously deployed, and have a recent mental health diagnosis. Officer ideators were more likely than controls to be female, younger, younger when entering service, never married, and have a recent mental health diagnosis. Risk among enlisted soldiers peaked in the second month of service and declined steadily, whereas risk among officers remained relatively stable over time. Risk of SI is highest among enlisted soldiers early in Army service, females, and those with a recent mental health diagnosis.

Resilience correlates with outcomes after total shoulder arthroplasty

BACKGROUND

Resilience, characterized by an ability to bounce back or recover from stress, is increasingly recognized as a psychometric property affecting many outcomes' domains including quality of life, suicide risk in active-duty military personnel, and recovery in cancer patients. This study examines the correlation between resilience, as measured by the Brief Resilience Scale (BRS), and traditional outcome scores including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Penn scores in patients undergoing total shoulder arthroplasty (TSA).

METHODS

Seventy patients undergoing primary anatomic TSA were followed up for a minimum of 2 years (mean, 30 ± 3 months). Patients were stratified into groups a priori, based on deviation from the mean of the BRS score, into low-resilience (LR), normal-resilience (NR), and high-resilience (HR) patients, and outcome scores were calculated for each group.

RESULTS

Postoperative BRS scores significantly correlated with ASES, Penn, and SANE scores (r = 0.41-0.44, P < .004 for all scores). When we evaluated patients based on resilience group, the LR group had a Penn score that was 34 points lower than that in the HR group. Likewise, the LR group had a SANE score that averaged 40 points lower than that in the HR group (SANE score of 53 points in LR group and 92 points in HR group, P = .05). When we evaluated ASES subscores, it appeared that the pain subscale was responsible for most of the difference between the LR and HR groups (29 points and 48 points [out of 50 points], respectively; P = .03).

CONCLUSIONS

Resilience is a major predictor of postoperative outcomes after TSA. Patients who are classified as having LR have outcome scores that are 30 to 40 points lower on traditional outcome scales than patients with HR.

The US framework for understanding, preventing, and caring for the mental health needs of service members who served in combat in Afghanistan and Iraq: a brief review of the issues and the research

This paper reviews the psychological health research conducted in the United States in support of combat veterans from Iraq and Afghanistan, using the Military Psychological Health Research Continuum, which includes foundational science, epidemiology, etiology, prevention and screening, treatment, follow-up care, and services research. The review is limited to those studies involving combat veterans and military families. This review discusses perplexing issues regarding the impact of combat on the mental health of service members such as risk and resilience factors of mental health, biomarkers of posttraumatic stress syndrome (PTSD), mental health training, psychological screening, psychological debriefing, third location decompression, combat and suicide, the usefulness of psychotherapy and drug therapy for treating PTSD, role of advanced technology, telemedicine and virtual reality, methods to reduce stigma and barriers to care, and best approaches to the dissemination of evidence-based interventions. The mental health research of special populations such as women, National Guardsmen and reservists, and military families is also presented. The review concludes by identifying future areas of research.