Impact of financial reimbursement on retention rates in military clinical trial research: A natural experiment within a multi-site randomized effectiveness trial with active duty service members.

INTRODUCTION: Achieving adequate retention rates in clinical trials is essential to ensuring meaningful results. Although financial reimbursement is an effective strategy to increase participant retention, current policies restrict the use of federal funds to reimburse U.S. active duty Service members for research participation. It is unknown whether permitting financial reimbursement among this population would improve trial retention rates. A recent randomized effectiveness trial received approval to provide reimbursement to Service member participants several months after recruitment began, creating a natural experiment to study the effects of financial reimbursement on retention. MATERIALS AND METHODS: Active duty Service members recruited from six U.S. military treatment facilities (N = 666) were enrolled in a collaborative care study and completed assessments at baseline, three-, six-, and 12-months. Data on study assessment completion rates at three- and six-months were analyzed using the mixed-effects binary logit model to determine the probabilities of completing assessments based on reimbursement status. RESULTS: Participants who received reimbursement were significantly more likely to complete study assessments at both time-points than participants who did not receive reimbursement (p < 0.01). Survey completion was 5% and 4% greater among participants offered reimbursement at three- and six-month time-points, respectively. CONCLUSION: Results suggest that providing Service members with reimbursement for research participation is associated with modest increases in retention rates in clinical trials. Findings provide useful insight for researchers, funding agencies, and policy-makers in considering retention strategies to maximize the value and impact of military research.

Predictors of Posttraumatic Stress Disorder, Anxiety Disorders, Depressive Disorders, and Any Mental Health Condition Among U.S. Soldiers and Marines, 2001-2011.

Understanding mental health disorder diagnosis and treatment seeking among active-duty military personnel is a topic with both clinical and policy implications. It has been well documented in military populations that individual-level military experience, including deployment history and combat exposure, influences mental health outcomes, but the impact of unit-level factors is less well understood. In the current study, we used administrative longitudinal data to examine a comprehensive set of unit- and individual-level predictors of posttraumatic stress disorder (PTSD), non-PTSD anxiety disorders, depressive disorders, and overall mental health diagnoses among Army and Marines Corps personnel. Using Cox survival models for time-dependent variables, we analyzed time from military accession (between January 1, 2001 and December 31, 2011) until first mental health diagnosis for 773,359 soldiers and 332,093 Marines. Prior diagnosis of a substance abuse disorder during one's military career, hazard ratios (HRs) = 1.68-3.10, and cumulative time spent deployed, HRs = 1.11-2.04, were the most predictive risk factors for all outcomes. Male sex, HRs = 0.35-0.57, and officer rank, HRs = 0.13-0.23, were the most protective factors. Unit-level rate of high deployment stress was a small but significant predictor of all outcomes after controlling for individual-level deployment history and other predictors, HRs = 1.01-1.05. Findings suggest both unit- and individual-level risk and protective factors of mental health diagnoses associated with treatment seeking. Clinical, including mental health assessment and management, and policy implications related to the military environment and the individual as it relates to mental health disorders are discussed.

Socioecological Risk and Protective Factors for Smoking Among Active Duty U.S. Military Personnel.

Introduction: Cigarette smoking can have negative consequences in military populations including injury, reduced physical endurance, higher frequency of sick days, and reduced combat readiness. This study used the socioecological model to understand individual, interpersonal, and organizational influences on cigarette smoking among military members. Materials and Methods: The sample for this secondary analysis was drawn from personnel at 24 large U.S. military installations, six from each service branch. Analyses included 4,728 personnel who were classified as current cigarette smokers. Generalized linear mixed models were used to estimate the associations among risk and protective factors from multiple ecological levels for smoking intensity and nicotine dependence. Results: Smoking to fit in with one's unit, being in the Army, smoking as a reaction to stress, and work-related stressors were all related to increased intensity of smoking and nicotine dependence. More active coping was associated with lower nicotine dependence and reduced smoking intensity. Conclusion: Results based on the socioecological model identify influencing factors and suggest possible interventions for smoking cessation. Reducing tobacco use in the military will require coordinated interventions that address multilevel determinants of use and improve military health. This is important to the strategic alignment of policy and services across the continuum of health care needs.

Resilience as a moderating factor between stress and alcohol-related consequences in the Army National Guard.

Due to the current prolonged conflicts in Iraq and Afghanistan, members of the United States National Guard and Reserve have shifted from a historically support-based role to an integral segment of combat efforts. Clinical and epidemiological research studies conducted on both civilian and military populations have documented high rates of comorbidity of stress disorders and substance use disorders. It is widely understood that excessive alcohol use is an issue among military personnel. The aim of this paper is to describe risk factors for alcohol-related serious consequences in a study of Army National Guard service members, as well as the role of resilience in protecting against these risks. Members of the National Guard (N=320) participated in the survey. We conducted a multiple regression to predict alcohol-related serious consequences and a simple moderation analysis was performed. After controlling for race, education, and deployment history, several variables emerged as significant predictors of alcohol-related consequences. Higher stressors, lower resilience, younger age, being unmarried and not living as married, being male, and identifying as non-Hispanic were associated with higher levels of serious alcohol-related consequences. Results revealed that resilience significantly moderated the relationship between stress and alcohol-related consequences. This study furthers our understanding of the alcohol-stress relationship by contextualizing it in terms of behaviors related to alcohol, as opposed to measuring consumption only. Most importantly, our work extends prior research in its examination of resilience as a moderator of the relationship between stress and serious alcohol-related consequences.

Posttraumatic Stress Disorder in U.S. Military Primary Care: Trajectories and Predictors of One-Year Prognosis.

We examined the longitudinal course of primary care patients in the active duty Army with posttraumatic stress disorder (PTSD) and identified prognostic indicators of PTSD severity. Data were drawn from a 6-site randomized trial of collaborative primary care for PTSD and dpression in the military. Subjects were 474 soldiers with PTSD (scores ≥ 50 on the PTSD Checklist -Civilian Version). Four assessments were completed at U.S. Army installations: baseline, and follow-ups at 3 months (92.8% response rate [RR]), 6 months (90.1% RR), and 12 months (87.1% RR). Combat exposure and 7 validated indicators of baseline clinical status (alcohol misuse, depression, pain, somatic symptoms, low mental health functioning, low physical health functioning, mild traumatic brain injury) were used to predict PTSD symptom severity on the Posttraumatic Diagnostic Scale (Cronbach's α = .87, .92, .95, .95, at assessments 1-4, respectively). Growth mixture modeling identified 2 PTSD symptom trajectories: subjects reporting persistent symptoms (Persisters, 81.9%, n = 388), and subjects reporting improved symptoms (Improvers 18.1%, n = 86). Logistic regression modeling examined baseline predictors of symptom trajectories, adjusting for demographics, installation, and treatment condition. Subjects who reported moderate combat exposure, adjusted odds ratio (OR) = 0.44, 95% CI [0.20, 0.98], or who reported high exposure, OR = 0.39, 95% CI [0.17, 0.87], were less likely to be Improvers. Other baseline clinical problems were not related to symptom trajectories. Findings suggested that most military primary care patients with PTSD experience persistent symptoms, highlighting the importance of improving the effectiveness of their care. Most indicators of clinical status offered little prognostic information beyond the brief assessment of combat exposure.

Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care: A Randomized Clinical Trial.

IMPORTANCE: It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression. OBJECTIVE: To determine effectiveness of a centrally assisted collaborative telecare (CACT) intervention for PTSD and depression in military primary care. DESIGN, SETTING, AND PARTICIPANTS: The STEPS-UP study (Stepped Enhancement of PTSD Services Using Primary Care) is a randomized trial comparing CACT with usual integrated mental health care for PTSD or depression. Patients, mostly men in their 20s, were enrolled from 18 primary care clinics at 6 military installations from February 2012 to August 2013 with 12-month follow-up completed in October 2014. INTERVENTIONS: Randomization was to CACT (n = 332) or usual care (n = 334). The CACT patients received 12 months of stepped psychosocial and pharmacologic treatment with nurse telecare management of caseloads, symptoms, and treatment. MAIN OUTCOMES AND MEASURES: Primary outcomes were severity scores on the PTSD Diagnostic Scale (PDS; scored 0-51) and Symptom Checklist depression items (SCL-20; scored 0-4). Secondary outcomes were somatic symptoms, pain severity, health-related function, and mental health service use. RESULTS: Of 666 patients, 81% were male and the mean (SD) age was 31.1 (7.7) years. The CACT and usual care patients had similar baseline mean (SD) PDS PTSD (29.4 [9.4] vs 28.9 [8.9]) and SCL-20 depression (2.1 [0.6] vs 2.0 [0.7]) scores. Compared with usual care, CACT patients reported significantly greater mean (SE) 12-month decrease in PDS PTSD scores (-6.07 [0.68] vs -3.54 [0.72]) and SCL-20 depression scores -0.56 [0.05] vs -0.31 [0.05]). In the CACT group, significantly more participants had 50% improvement at 12 months compared with usual care for both PTSD (73 [25%] vs 49 [17%]; relative risk, 1.6 [95% CI, 1.1-2.4]) and depression (86 [30%] vs 59 [21%]; relative risk, 1.7 [95% CI, 1.1-2.4]), with a number needed to treat for a 50% improvement of 12.5 (95% CI, 6.9-71.9) and 11.1 (95% CI, 6.2-50.5), respectively. The CACT patients had significant improvements in somatic symptoms (difference between mean 12-month Patient Health Questionnaire 15 changes, -1.37 [95% CI, -2.26 to -0.47]) and mental health-related functioning (difference between mean 12-month Short Form-12 Mental Component Summary changes, 3.17 [95% CI, 0.91 to 5.42]), as well as increases in telephone health contacts and appropriate medication use. CONCLUSIONS AND RELEVANCE: Central assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01492348.

Mental Health Utilization Patterns During a Stepped, Collaborative Care Effectiveness Trial for PTSD and Depression in the Military Health System.

BACKGROUND: Integrated health care models aim to improve access and continuity of mental health services in general medical settings. STEPS-UP is a stepped, centrally assisted collaborative care model designed to improve posttraumatic stress disorder (PTSD) and depression care by providing the appropriate intensity and type of care based on patient characteristics and clinical complexity. STEPS-UP demonstrated improved PTSD and depression outcomes in a large effectiveness trial conducted in the Military Health System. The objective of this study was to examine differences in mental health utilization patterns between patients in the stepped, centrally assisted collaborative care model relative to patients in the collaborative care as usual-treatment arm. METHODS: Patients with probable PTSD and/or depression were recruited at 6 large military treatment facilities, and 666 patients were enrolled and randomized to STEPS-UP or usual collaborative care. Utilization data acquired from Military Health System administrative datasets were analyzed to determine mental health service use and patterns. Clinical complexity and patient characteristics were based on self-report questionnaires collected at baseline. RESULTS: Compared with the treatment as usual arm, STEPS-UP participants received significantly more mental health services and psychiatric medications across primary and specialty care settings during the year of their participation. Patterns of service use indicated that greater clinical complexity was associated with increased service use in the STEPS-UP group, but not in the usual-care group. CONCLUSIONS: Results suggest that stepped, centrally assisted collaborative care models may increase the quantity of mental health services patients receive, while efficiently matching care on the basis of the clinical complexity of patients.

Gender Differences in Posttraumatic Stress Disorder and Help Seeking in the U.S. Army.

BACKGROUND: Inconsistent findings between studies of gender differences in mental health outcomes in military samples have left open questions of differential prevalence in posttraumatic stress disorder (PTSD) among all United States Army soldiers and in differential psychosocial and comorbid risk and protective factor profiles and their association with receipt of treatment. METHODS: This study assesses the prevalence and risk factors of screening positive for PTSD for men and women based on two large, population-based Army samples obtained as part of the 2005 and 2008 U.S. Department of Defense Surveys of Health Related Behaviors among Active Duty Military Personnel. RESULTS: The study showed that overall rates of PTSD, as measured by several cutoffs of the PTSD Checklist, are similar between active duty men and women, with rates increasing in both men and women between the two study time points. Depression and problem alcohol use were strongly associated with a positive PTSD screen in both genders, and combat exposure was significantly associated with a positive PTSD screen in men. Overall, active duty men and women who met criteria for PTSD were equally likely to receive mental health counseling or treatment, though gender differences in treatment receipt varied by age, race, social support (presence of spouse at duty station), history of sexual abuse, illness, depression, alcohol use, and combat exposure. CONCLUSIONS: The study demonstrates that the prevalence of PTSD as well as the overall utilization of mental health services is similar for active duty men compared with women. However, there are significant gender differences in predictors of positive PTSD screens and receipt of PTSD treatment.

Combat-Acquired Traumatic Brain Injury, Posttraumatic Stress Disorder, and Their Relative Associations With Postdeployment Binge Drinking.

OBJECTIVE: To examine whether experiencing a traumatic brain injury (TBI) on a recent combat deployment was associated with postdeployment binge drinking, independent of posttraumatic stress disorder (PTSD). METHODS: Using the 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel, an anonymous survey completed by 28 546 personnel, the study sample included 6824 personnel who had a combat deployment in the past year. Path analysis was used to examine whether PTSD accounted for the total association between TBI and binge drinking. MAIN MEASURES: The dependent variable, binge drinking days, was an ordinal measure capturing the number of times personnel drank 5+ drinks on one occasion (4+ for women) in the past month. Traumatic brain injury level captured the severity of TBI after a combat injury event exposure: TBI-AC (altered consciousness only), TBI-LOC of 20 or less (loss of consciousness up to 20 minutes), and TBI-LOC of more than 20 (loss of consciousness >20 minutes). A PTSD-positive screen relied on the standard diagnostic cutoff of 50+ on the PTSD Checklist-Civilian. RESULTS: The final path model found that while the direct effect of TBI (0.097) on binge drinking was smaller than that of PTSD (0.156), both were significant. Almost 70% of the total effect of TBI on binge drinking was from the direct effect; only 30% represented the indirect effect through PTSD. CONCLUSION: Further research is needed to replicate these findings and to understand the underlying mechanisms that explain the relationship between TBI and increased postdeployment drinking.

Overweight and obesity trends among active duty military personnel: a 13-year perspective.

BACKGROUND: The U.S. population has shown increasing rates of overweight and obesity in recent years, but similar analyses do not exist for U.S. military personnel. It is important to understand these patterns in the military because of their impact on fitness and readiness. PURPOSE: To assess prevalence and trends in overweight/obesity among U.S. service members and to examine the associations of sociodemographic characteristics, exercise, depression, and substance use with these patterns. METHODS: Analyses performed in 2013 used five large population-based health-related behavior surveys conducted from 1995 to 2008. Main outcome measures were overweight and obesity among active duty military personnel based on BMI. RESULTS: Combined overweight and obesity (BMI≥25) increased from 50.6% in 1995 to 60.8% in 2008, primarily driven by the rise in obesity (BMI≥30) from 5.0% to 12.7%. For overweight, military women showed the largest increase. For obesity, all sociodemographic groups showed significant increases, with the largest among warrant officers, senior enlisted personnel, and people aged 36-45 years. Adjusted multinomial logit analyses found that service members aged 26 years and older, men, non-Hispanic blacks and Hispanics, enlisted personnel, married personnel, and heavy drinkers had the highest risk both for overweight and obesity. CONCLUSIONS: Combined overweight and obesity in active duty personnel rose to more than 60% between 1995 and 2008, primarily because of increased obesity. The high prevalence of overweight and obesity needs attention and has implications for Department of Defense efforts to improve the health, fitness, readiness, and quality of life of the Active Forces.

Implementing collaborative primary care for depression and posttraumatic stress disorder: design and sample for a randomized trial in the U.S. military health system.

BACKGROUND: War-related trauma, posttraumatic stress disorder (PTSD), depression and suicide are common in US military members. Often, those affected do not seek treatment due to stigma and barriers to care. When care is sought, it often fails to meet quality standards. A randomized trial is assessing whether collaborative primary care improves quality and outcomes of PTSD and depression care in the US military health system. OBJECTIVE: The aim of this study is to describe the design and sample for a randomized effectiveness trial of collaborative care for PTSD and depression in military members attending primary care. METHODS: The STEPS-UP Trial (STepped Enhancement of PTSD Services Using Primary Care) is a 6 installation (18 clinic) randomized effectiveness trial in the US military health system. Study rationale, design, enrollment and sample characteristics are summarized. FINDINGS: Military members attending primary care with suspected PTSD, depression or both were referred to care management and recruited for the trial (2592), and 1041 gave permission to contact for research participation. Of those, 666 (64%) met eligibility criteria, completed baseline assessments, and were randomized to 12 months of usual collaborative primary care versus STEPS-UP collaborative care. Implementation was locally managed for usual collaborative care and centrally managed for STEPS-UP. Research reassessments occurred at 3-, 6-, and 12-months. Baseline characteristics were similar across the two intervention groups. CONCLUSIONS: STEPS-UP will be the first large scale randomized effectiveness trial completed in the US military health system, assessing how an implementation model affects collaborative care impact on mental health outcomes. It promises lessons for health system change.

Trends in mental health services utilization and stigma in US soldiers from 2002 to 2011.

OBJECTIVES: We characterized trends in mental health services utilization and stigma over the course of the Afghanistan and Iraq wars among active-component US soldiers. METHODS: We evaluated trends in mental health services utilization and stigma using US Army data from the Health-Related Behavior (HRB) surveys from 2002, 2005, and 2008 (n = 12,835) and the Land Combat Study (LCS) surveys administered to soldiers annually from 2003 to 2009 and again in 2011 (n = 22,627). RESULTS: HRB and LCS data suggested increased mental health services utilization and decreased stigma in US soldiers between 2002 and 2011. These trends were evident in soldiers with and without posttraumatic stress disorder (PTSD), major depressive disorder (MDD), or PTSD and MDD. Despite the improving trends, more than half of soldiers with mental health problems did not report seeking care. CONCLUSIONS: Mental health services utilization increased and stigma decreased over the course of the wars in Iraq and Afghanistan. Although promising, these findings indicate that a significant proportion of US soldiers meeting criteria for PTSD or MDD do not utilize mental health services, and stigma remains a pervasive problem requiring further attention.

Trends in binge and heavy drinking, alcohol-related problems, and combat exposure in the U.S. military.

Population-based Department of Defense health behavior surveys were examined for binge and heavy drinking among U.S. active duty personnel. From 1998-2008, personnel showed significant increases in heavy drinking (15% to 20%) and binge drinking (35% to 47%). The rate of alcohol-related serious consequences was 4% for nonbinge drinkers, 9% for binge drinkers, and 19% for heavy drinkers. Personnel with high combat exposure had significantly higher rates of heavy (26.8%) and binge (54.8%) drinking than their counterparts (17% and 45%, respectively). Heavy and binge drinking put service members at high risk for problems that diminish force readiness and psychological fitness.

Chaplaincy and mental health in the department of Veterans affairs and department of defense.

Chaplains play important roles in caring for Veterans and Service members with mental health problems. As part of the Department of Veterans Affairs (VA) and Department of Defense (DoD) Integrated Mental Health Strategy, we used a sequential approach to examining intersections between chaplaincy and mental health by gathering and building upon: 1) input from key subject matter experts; 2) quantitative data from the VA / DoD Chaplain Survey (N = 2,163; response rate of 75% in VA and 60% in DoD); and 3) qualitative data from site visits to 33 VA and DoD facilities. Findings indicate that chaplains are extensively involved in caring for individuals with mental health problems, yet integration between mental health and chaplaincy is frequently limited due to difficulties between the disciplines in establishing familiarity and trust. We present recommendations for improving integration of services, and we suggest key domains for future research.

Military report more complementary and alternative medicine use than civilians.

OBJECTIVES: The study objective was to estimate complementary and alternative medicine (CAM) use among active duty military and compare data with civilian use. DESIGN: A global survey on CAM use in the 12 previous months was conducted. Final participants (16,146) were stratified by gender, service, region, and pay grade. Analysis included prevalence of CAM use, demographic and lifestyle characteristics. RESULTS: Approximately 45% of respondents reported using at least one type of CAM therapy. Most commonly used therapies were as follows: prayer for one's own health (24.4%), massage therapy (14.1%), and relaxation techniques (10.8%). After exclusion of prayer for one's own health, adjusting to the 2000 U.S. census, overall CAM use in the military (44.5%) was higher than that in comparable civilian surveys (36.0% and 38.3%). CONCLUSIONS: Military personnel reported using three CAM stress-reduction therapies at 2.5-7 times the rate of civilians. Among the military, high utilization of CAM practices that reduce stress may serve as markers for practitioners assessing an individual's health and well-being.

Postdeployment alcohol use, aggression, and post-traumatic stress disorder.

Current military personnel are at risk of developing serious mental health problems, including chronic stress disorders and substance use disorders, as a result of military deployment. The most frequently studied effect of combat exposure is post-traumatic stress disorder (PTSD). High-risk behaviors, including alcohol use and aggression, have been associated with PTSD, but the optimal cutoff score on the PTSD Checklist (PCL) for determining the risk for these behaviors has not been clearly delineated. Using postdeployment active duty (AD) and Reserve component military personnel, the relation between various cutoff scores on the PCL and engaging in high-risk behaviors was examined. AD personnel, for every outcome examined, showed significantly greater odds for each problem behavior when PCL scores were 30 or higher compared to those with PCL scores in the 17 to 29 range. A similar pattern was shown for Reserve component personnel with respect to several problem behaviors, although not for alcohol use behaviors. The differences in problem behaviors for these two populations may be an indication that deployment experiences and combat exposure affect them differently and suggest that despite lower critical PCL scores, AD personnel may be at higher risk for developing problems as a function of the deployment cycle.

Influence of spirituality on depression, posttraumatic stress disorder, and suicidality in active duty military personnel.

Understanding the role of spirituality as a potential coping mechanism for military personnel is important given growing concern about the mental health issues of personnel returning from war. This study seeks to determine the extent to which spirituality is associated with selected mental health problems among active duty military personnel and whether it moderates the relationship between combat exposure/deployment and (a) depression, (b) posttraumatic stress disorder (PTSD), and (c) suicidality in active duty military personnel. Data were drawn from the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Over 24,000 randomly selected active duty personnel worldwide completed an anonymous self-report questionnaire. High spirituality had a significant protective effect only for depression symptoms. Medium, as opposed to high or low, levels of spirituality buffered each of the mental health outcomes to some degree. Medium and low spirituality levels predicted depression symptoms but only among those with moderate combat exposure. Medium spirituality levels also predicted PTSD symptoms among those with moderate levels of combat exposure and predicted self-reported suicidal ideation/attempt among those never deployed. These results point to the complex relationship between spirituality and mental health, particularly among military personnel and the need for further research.

Prevalence of perceived stress and mental health indicators among reserve-component and active-duty military personnel.

OBJECTIVES: We examined stress levels and other indicators of mental health in reservists and active-duty military personnel by deployment status. METHODS: We used data from the Department of Defense Health-Related Behaviors surveys, which collect comprehensive, population-based data for reserve and active-duty forces. Data were collected from 18 ,342 reservists and 16, 146 active-duty personnel. RESULTS: Overall, with adjustment for sociodemographic and service differences, reservists reported similar or less work and family stress, depression, and anxiety symptoms than did active-duty personnel. However, reservists who had been deployed reported higher rates of suicidal ideation and attempts than did active-duty personnel who had been deployed and higher rates of post-traumatic stress disorder symptomatology than did any active-duty personnel and reservists who had not been deployed. The highest rates of suicidal ideation and attempts were among reservists who had served in theaters other than Iraq and Afghanistan. CONCLUSIONS: Our results suggest that deployment has a greater impact on reservists than on active-duty members, thus highlighting the urgent need for services addressing reservists' unique postdeployment mental health issues. Also, deployment to any theater, not only Iraq or Afghanistan, represents unique threats to all service members' mental well-being.

Evaluation of two web-based alcohol interventions in the U.S. military.

OBJECTIVE: The U.S. military has traditionally had high rates of alcohol misuse and alcohol-related problems, necessitating effective treatment programs that minimize participant burden. Web-based interventions have shown promise as efficient treatment options for college students and adults but have not been widely evaluated in the military. This study evaluated the efficacy of two web-based alcohol interventions originally created for civilians and then adapted for U.S. military personnel. METHOD: Two web-based alcohol interventions, Alcohol Savvy and Drinker's Check-Up, were adapted for use among military populations. The interventions were evaluated using a convenience sample of 3,070 active-duty military personnel at eight installations. Following a baseline survey, participants were assigned to one of three treatment conditions: (a) Alcohol Savvy, (b) Drinker's Check-Up, or (c) control (no program participation). Follow-up surveys were completed by 1,072 participants 1 month following baseline and by 532 participants 6 months following baseline. RESULTS: At 1-month follow-up, participants who completed the Drinker's Check-Up intervention had significant reductions in multiple measures of alcohol use relative to controls. Positive outcomes were found for average number of drinks consumed per occasion, frequent heavy episodic drinker status, and estimated peak blood alcohol concentration. These reductions in alcohol use at the 1-month follow-up were maintained at the 6-month follow-up. There were no statistically significant changes in alcohol use for participants who completed Alcohol Savvy. CONCLUSIONS: This study expands the literature on the effectiveness of web-based treatment for alcohol misuse. Findings indicate that web-based programs (Drinker's Check-Up in particular) can significantly decrease several indicators of alcohol use in U.S. military personnel.

Overlap in use of different types of tobacco among active duty military personnel.

OBJECTIVE: To describe the prevalence and overlapping combinations in past thirty-day cigarette use, smokeless tobacco use, and cigar use in the active duty U.S. military. METHODS: Data were taken from the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. A total of 28,546 service members participated for a response rate of 70.6%. RESULTS: Analyses showed that 41.2% of active duty service members used one or more forms of tobacco in the past month. Cigarette use only was most prevalent (21.3%); other combinations were much lower ranging from 0.7% to 13.5%. Multinomial regression modeling yielded no consistent patterns in sociodemographic groups with higher risk of using one or more types of tobacco concurrently. Frequency and quantity of cigarette use were related to tobacco use patterns. From 60% to 67% of smokers were daily users of cigarettes only or cigarettes in combination with other tobacco types. The majority of cigarette users (54%-69%) smoked 15 or fewer cigarettes/day regardless of tobacco use patterns, but those who smoked at heaviest levels were most likely to use all 3 tobacco types (19%). CONCLUSIONS: Four of 10 service members place themselves at increased risk of tobacco-related illness and disease by using one or more types of tobacco. Daily cigarette smokers and very heavy smokers are at highest risk of using multiple tobacco types. Further research is needed to better understand the levels of use and the reasons for use of multiple types of tobacco.