Diagnostic and functional outcomes of adjustment disorder in U.S. active duty service members.

BACKGROUND: Adjustment disorder (AD) is a commonly diagnosed psychiatric disorder. However, little is known about its course, predictors of its diagnostic outcomes, or its association with functional impairment. Our primary aim was to examine diagnostic transitions of service members with an incident AD diagnosis (IADx) to one of three states: 1) another psychiatric diagnosis, 2) chronic AD, or 3) no psychiatric diagnosis. Secondary outcomes included predictors of diagnostic course and functional outcomes associated with follow-up diagnoses. METHODS: Health records of a random sample of 10,720 service members with an IADx were analyzed using multinomial logit regression and hazard rate model with competing risks. RESULTS: IADx transitions were 24.3 % to another psychiatric diagnosis, 8.9 % with chronic AD, and 43.7 % without a diagnosis. Nearly a quarter (23.1 %) separated from service. Deployment was the strongest predictor of transitioning to another diagnosis. Those who transitioned to another diagnosis separated at an increased rate and with more adverse outcomes. LIMITATIONS: Diagnostic findings are based on data in the electronic health record, and we could not specifically identify the stressor that precipitated an AD diagnosis. These findings describe the course of AD in military personnel and may not generalize to civilians. CONCLUSIONS: AD, as initially diagnosed, represents a heterogeneous disorder with an enduring impact across the military career for a considerable proportion of service members. As an early indicator of more severe psychiatric outcomes, an IADx may signal an opportunity for early intervention and screening, particularly in service members with a history of deployment.

Outcomes and prognosis of adjustment disorder in adults: A systematic review.

Adjustment disorder (AD) is one of the most commonly diagnosed mental health disorders and is generally conceptualized to be mild and short-lived. Despite the frequent use of AD in clinical settings, little is known about the prognosis of this condition. Our goal was to systematically review research on a range of AD outcomes in order to provide a broad characterization of AD prognosis. We conducted searches in MEDLINE, EMBASE, and PsycINFO. We included 31 cohort or randomized controlled trials with a total of 1,385,358 participants. Many patients maintained an AD diagnosis or were diagnosed with another mental health disorder months to years after initial diagnosis. Patients with AD tended to show symptom improvement at higher rates and to utilize less treatment than did patients with other disorders. AD-diagnosed groups experienced subsequent development of numerous physical conditions, such as infection, cancers, Parkinson's disease, and cardiovascular events, at higher rates than did control groups. Results were mixed regarding suicidality and occupational impairment. We rated most studies as having a moderate risk of bias. Based on limited findings, AD appears to progress as a milder disorder than do other disorders, but it not uncommonly transitions to more severe mental health states and may predict the development of future health issues, both mental and physical. Future prospective research that conforms to prognosis study guidelines is needed to better understand the course of this common disorder.

Adjustment disorders: A research gaps analysis.

Adjustment disorders are among the most commonly diagnosed mental health disorders in both civilian and military clinical settings. Despite their high prevalence, adjustment disorders have received little research attention. The many gaps in our understanding of this group of disorders hinder the development of adequate, evidence-based treatment protocols. This study utilizes a systematic methodology to identify and prioritize research gaps in adjustment disorders. We used authoritative source reports to identify gaps in research domains from foundational science to services research. Subject-matter experts conducted literature searches to substantiate and refine research gaps, and stakeholders assessed the importance and impact of this work for researchers and policy-makers. We identified 254 possible research-needs statements, which were ultimately reduced to 11 final, prioritized research gaps. Two gaps addressed prevention and screening and three addressed treatment and services research. Six gaps addressed foundational science, epidemiology, and etiology research domains, highlighting the need for basic research. Until some of the basic science questions are resolved (e.g., diagnostic clarity, valid screening, and assessment measures) about adjustment disorders, we may not be able to develop adequate evidence-based interventions for the disorders, and it will be difficult to understand the trajectory of these disorders throughout treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A systematic analysis and prioritization of suicide prevention research gaps.

OBJECTIVE: This study identified and prioritized research gaps for suicide prevention in the Department of Defense to inform future research investments. METHODS: The 2019 VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide was the primary source document for research gaps, supplemented by an updated literature search. Institutional stakeholders rated the identified research gaps and ranked the gap categories. We used Q factor analysis to derive a list of the prioritized research gaps and category rankings. RESULTS: Thirty-five research gaps were identified and prioritized. The highest rated research gap topic was lethal means safety interventions and their effectiveness in increasing safety behaviors and/or reducing suicide-related outcomes. Research on the effectiveness of crisis response planning and several other non-pharmacological interventions (e.g., implementation of cognitive-behavioral therapy, technology-based behavioral interventions, and applications of dialectical behavior therapy to non-Borderline patients) were also rated highly by stakeholders. CONCLUSIONS: This work generated a list of priorities for future suicide research as evaluated by Departments of Defense and Veterans Affairs stakeholders. Our findings can help guide the efforts of suicide researchers and inform decisions about future research funding for suicide prevention.

Demographic, Behavioral, and Proximal Risk Factors for Gambling Disorder in the US Military.

BACKGROUND AND OBJECTIVES: To estimate the diagnostic prevalence and incidence of gambling disorder among United States service members and to identify associated risk factors, including demographics, history of mental illness or substance misuse, and proximity to legalized gambling vicinities. METHODS: Gambling disorder cases comprised active component Service members who received a pathological or problem gambling diagnosis between October 1, 2005 and September 30, 2015. There were 901 cases (392 incidents) during the study period. Controls were matched on the case military entrance date (N = 43,564). Geospatial distance between gambling venue and military treatment facilities were calculated, then multivariable logistic regression and survival analyses were conducted. RESULTS: The 10-year prevalence of gambling disorder was 6.6 per 100,000. Men were 3.5 times more likely than women to receive a gambling disorder diagnosis. Other risk factors included age over 24, Asian or Black race, formerly married, and enlisted rank. The odds of gambling disorder increased with duration and proximity to gambling venues, ranging from 2.0 to 3.9. Service members with prior substance misuse or mental health conditions were 3.9 times and 6.3 times more likely to receive a disordered gambling diagnosis than those without substance misuse or mental illness history, respectively. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: The results of this study reveal that proximity to gambling venues and slot machines on bases, as well as a history of substance misuse or mental disorders, are important risk factors for gambling disorder in the US military. Department of Defense screening policies that focus on high-risk populations are appropriate. (Am J Addict 2021;00:00-00).

A systematic review evaluating screening instruments for gambling disorder finds lack of adequate evidence.

OBJECTIVES: To date, no research has systematically evaluated screening instruments for gambling disorder to assess their accuracy and the quality of the research. This systematic review evaluated screening instruments for gambling disorder to inform decision makers about choices for population-level screening. STUDY DESIGN AND SETTING: On May 22, 2017 and January 4, 2019, we searched PubMed, PsycInfo, EMBASE, and Cochrane for studies that evaluated screening instruments for gambling disorder. Studies were included if (1) the screening instrument was in English, (2) the screening instrument was compared to a reference standard semistructured interview based on Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases diagnoses of gambling disorder, and (3) data were reported on psychometric properties of the instrument. RESULTS: We identified 31 different screening instruments from 60 studies. Only three instruments from three separate studies were eligible for inclusion in the systematic review. CONCLUSION: Few screening instruments for gambling disorder have been validated with sufficient methodological quality to be recommended for use across a large health system.

Typologies of Combat Exposure and Their Effects on Posttraumatic Stress Disorder and Depression Symptoms.

The present study identified distinct classes of U.S. military service members based on their combat experiences and examined mental health outcomes and longitudinal growth curves of posttraumatic stress disorder (PTSD) and depression symptoms associated with each class. Participants were 551 active duty service members who screened positive for PTSD and/or depression based on DSM-IV-TR criteria. All participants completed the Combat Experiences Scale at baseline as well as PTSD and depression measures at baseline and at 3-, 6-, and 12-month follow-ups. A latent class analysis identified four classes of service members based on their combat experiences: limited exposure, medical exposure, unit exposure, and personal exposure. Service members in the personal exposure class were characterized by a distinct mental health profile: They reported a higher level of PTSD symptoms at baseline and a higher prevalence of traumatic brain injury and PTSD diagnoses during the course of the study. The limited exposure class was more likely to receive diagnoses of depression and adjustment disorders. All classes except the medical exposure class demonstrated a slight decrease in PTSD and depression symptoms over time. However, participants in the limited exposure class had a larger decrease in PTSD and depression symptoms earlier in care but did not demonstrate superior long-term symptom improvements at 12 months compared to the other groups. These results inform PTSD development models and have implications for the screening and clinical management of combat-exposed service members.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Tipologías de Exposición a Combate y sus Efectos en el Trastorno de Estrés Postraumático y Síntomas Depresivos. EXPERIENCIAS TRAUMÁTICAS DE COMBATE, TEPT Y DEPRESIÓN El presente estudio identificó clases distintivas de miembros del servicio militar de los EEUU basados en sus experiencias de combate y examinó los resultados en salud mental y las curvas de crecimiento longitudinal del Trastorno de Estrés Postraumático (TEPT) y síntomas depresivos asociados con cada clase. Los participantes fueron 551 miembros en servicio activo que resultaron positivo para TEPT y/o depresión basado en los criterios DSM-IV-R. Todos los participantes completaron la Escala de Experiencias de Combate así como también medidas de TEPT y Depresión, al inicio y a los 3, 6 y 12 meses de seguimiento. Un análisis de grupos latente identificó cuatro clases de miembros del servicio basados en sus experiencias de combate: exposición limitada, exposición médica, exposición de la unidad, y exposición personal. Los miembros del servicio en el grupo de exposición personal se caracterizaron por un perfil distintivo de salud mental: Ellos reportaron, al inicio, niveles más altos de síntomas de TEPT y prevalencias más altas de diagnósticos de lesión traumática cerebral y TEPT durante el curso del estudio. El grupo de exposición limitada tuvo mayor probabilidad de recibir los diagnósticos de depresión y trastorno de adaptación. Todos los grupos, excepto el grupo de exposición médica, demostraron una leve disminución en los síntomas de TEPT y depresión con el tiempo. Sin embargo, los participantes en el grupo de exposición limitada tuvieron una disminución mayor en síntomas de TEPT y depresión al inicio de la atención, pero no demostraron una mejoría mayor de los síntomas a largo plazo a los 12 meses en comparación con los otros grupos. Estos resultados sirven de base para los modelos de desarrollo de TEPT y tienen implicaciones para la detección y manejo clínico de los miembros en servicio expuestos a combate.

Identifying research gaps in substance use disorder: A systematic methodology and prioritized list.

Background: This paper presents a new methodology for identifying and prioritizing research gaps, contributing to the nascent literature on systematic ways to identify research gaps. Objectives: The goal of this paper is to report on a gaps analysis of substance use disorder (SUD) research. Based on input from Military Health System stakeholders, we selected the following subtopics as priorities: alcohol use disorder (AUD) and comorbid conditions, prescription opioids, and novel synthetic drugs (NSDs), including synthetic cannabinoids, synthetic cathinones, novel synthetic opioids, and e-cigarette use. Methods: Statements of research needs were extracted from authoritative source reports. A work group of 13 subject matter experts then supplemented, consolidated, and refined the statements. Support for each statement was rated based on predetermined metrics to produce a list of high-priority potential research gaps. Work group members searched both published and ongoing research literature to determine whether these potential gaps were sufficiently addressed in the literature. Finally, to prioritize the gaps, work group members rated them on a set of metrics. Results: The work group reduced 175 statements of research needs to a list of 18 final prioritized gaps: nine for AUD, four for prescription opioids, and five for NSDs. For each topic, we present a prioritized list of gaps. Conclusions: This paper describes a method to identify and prioritize research gaps relevant to military and civilian research and presents the prioritized SUD gaps. Our methodology and findings can inform policy makers, researchers, and funding agencies as they consider investments in future research.

Application of a new method for linking anonymous survey data in a population of soldiers returning from Iraq.

PURPOSE: This study provides a unique application of a procedure to link anonymous survey records as a means to assess mental health problems among soldiers after return from deployment to Iraq. The research purpose is to validate the use of a linkage method on anonymous survey data for longitudinal analysis. METHODS: This research analyzes surveys completed by soldiers at three (N = 4,903), six (N = 3,110), and 12 (N = 2,544) months post-Operation Iraqi Freedom (OIF) deployment. To protect anonymity while also allowing for longitudinal analysis, the survey includes four self-generated codes for matching the surveys from individual soldiers. The surveys were linked using Link Plus (Centers for Disease Control and Prevention, Atlanta, GA). Three matched groups (3-6 months, 6-12 months, and 3-12 months) were created, matching on the anonymous codes and demographic variables. An internal validation of the linkage results was performed and selection bias was assessed. RESULTS: The matched records showed very high agreement in variables not included in the matching procedure and were similar to the unmatched records with regard to demographics and post-traumatic stress disorder (PTSD) prevalence. CONCLUSIONS: The use of self-generated codes protects anonymity while the method utilized and validated in this paper allows for longitudinal data analysis. The results support an absence of any notable selection bias.

Stability of combat exposure recall in Operation Iraqi Freedom veterans.

PURPOSE: This study evaluates changes in recall of combat exposures over the first year after return from deployment. The research purpose is to assess whether recall of combat exposures is consistent at different time points; if not, what demographic and/or PTSD symptom risk factors exist for any directional instability. METHODS: Surveys completed by soldiers at 3, 6, and 12 months post-Operation Iraqi Freedom (OIF) deployment were linked for longitudinal analysis in a previous study in which three matched datasets were created: 3-6 months (N = 768), 6-12 months (N = 341), and 3-12 months (N = 445). Post-traumatic stress disorder (PTSD) was assessed by using the National Center for PTSD Checklist. The reliability of recall for 36 combat exposures was quantified. The effects of demographics and change in PTSD score on combat exposure recall were assessed. RESULTS: The results showed an average of 80% to 90% agreement in combat exposure reporting between the time points. Every one-unit change in PTSD score was associated with a 0.1- to 0.5-unit change in recall of combat exposures over time. CONCLUSIONS: This study demonstrates that over the first year after return from deployment to Iraq, recall of combat experiences remained stable, and PTSD was slightly associated with increased reporting of combat exposures over time.

U.S. military mental health care utilization and attrition prior to the wars in Iraq and Afghanistan.

OBJECTIVE: Health care utilization studies of mental disorders focus largely on the ICD-9 category 290-319, and do not generally include analysis of visits for mental health problems identified under V-code categories. Although active duty service members represent a large young adult employed population who use mental health services at similar rates as age-matched civilian populations, V-codes are used in a larger proportion of mental health visits in military mental health care settings than in civilian settings. However, the utilization of these diagnoses has not been systematically studied. The purpose of this study is to characterize outpatient behavioral health visits in military health care facilities prior to Operation Iraqi Freedom, including the use of diagnoses outside of the ICD-9 290-319 range, in order to evaluate the overall burden of mental health care. This study establishes baseline rates of mental health care utilization in military mental health clinics in 2000 and serves as a comparison for future studies of the mental health care burden of the current war. METHODS: All active duty service members who received care in military outpatient clinics in 2000 (n = 1.35 million) were included. Primary diagnoses were grouped according to mental health relevance in the following categories: mental disorders (ICD-9 290-319), mental health V-code diagnoses (used primarily by behavioral health providers that were indicative of a potential mental health problem), and all other diagnoses. Rates of service utilization within behavioral health clinics were compared with rates in other outpatient clinics for each of the diagnostic groups, reported as individuals or visits per 1,000 person-years. Cox proportional hazard regression was used to produce hazard ratios as measures of association between each of the diagnostic groups and attrition from military service. Time to attrition in months was the difference between the date of military separation and the date of first clinic visit in 2000. Data were obtained from the Defense Medical Surveillance System. RESULTS: The total number of individuals who utilized behavioral health services in 2000 was just over 115 per 1,000 person-years, almost 12% of the military population. Out of every 1,000 person-years, 57.5 individuals received care from behavioral health providers involving an ICD-9 290-319 mental disorder diagnosis, and an additional 26.7 per 1,000 person-years received care in behavioral health clinics only for V-code diagnoses. Attrition from service was correlated with both categories of mental health-related diagnoses. After 1 year, approximately 38% of individuals who received a mental disorder diagnosis left the military, compared with 23% of those who received mental health V-code diagnoses and 14% of those who received health care for any other reason (which included well visits for routine physicals). CONCLUSIONS: This study establishes baseline rates of pre-war behavioral healthcare utilization among military service members, and the relationship of mental health care use and attrition from service. The research indicates that in the military population the burden of mental illness in outpatient clinics is significantly greater when V-code diagnoses are included along with conventional mental disorder diagnostic codes.

Strengthening the validity of population-based suicide rate comparisons: an illustration using U.S. military and civilian data.

The objectives of this study were to generate precise estimates of suicide rates in the military while controlling for factors contributing to rate variability such as demographic differences and classification bias, and to develop a simple methodology for the determination of statistically derived thresholds for detecting significant rate changes. Suicide rate estimates were calculated for the military population and each service branch over 11 years, directly standardized to the 2000 U.S. population. Military rates were highly comparable across branches and were approximately 20% lower than the civilian rate. Direct adjustment essentially controlled for the demographic confounds in this sample. Applying the Poisson-based method, we demonstrate that suicide rate fluctuations as large as 20-40% in any year may be attributed to random error.

Behavioral, demographic, and prior morbidity risk factors for accidental death among men: a case-control study of soldiers.

BACKGROUND: In the United States, the leading cause of death for young men is unintentional injury. The experience of the U.S. Army, because it comprises mostly young men, provides insights into factors associated with risk of accidental death. Between 1990 and 1998, accidents accounted for more than half of all deaths of men on active duty in the U.S. Army. METHODS: All men on active duty in the U.S. Army who died in an accident between 1990 and 1998 were included in the study. For each accidental death case, four randomly selected controls were also included, matched on gender and contemporaneous military service. RESULTS: In multivariate analyses, accidental death victims were more likely to be unmarried, limited to a high school education, in combat-specific occupations, veterans of a recent deployment, and previously hospitalized for an "injury/poisoning," "mental disorder," or "sign/symptom/ill-defined condition." Of behaviors reported on routine health risk assessments, the strongest predictor of a subsequent fatal accident was motorcycle use while the most excess deaths were attributable to consuming more than five alcoholic drinks per week. CONCLUSIONS: There are characteristics, experiences, and behaviors that predict accidental death risk. The findings may inform safety and health promotion programs aimed at young adults.