Col Robert R. Ireland, USAF MC (Ret.); Amii M. Kress, MPH; Lucinda Z. Frost, PsyD

Transcription

1 MILITARY MEDICINE, 177, 10:1149, 2012 Association Between Mental Health Conditions Diagnosed During Initial Eligibility for Military Health Care Benefits and Subsequent Deployment, Attrition, and Death by Suicide Among Active Duty Service Members Col Robert R. Ireland, USAF MC (Ret.); Amii M. Kress, MPH; Lucinda Z. Frost, PsyD ABSTRACT Objective: To examine incidence of mental health diagnoses during initial service of U.S. active duty military members and identify associations with deployment, attrition, and suicide. Methods: A retrospective cohort of 576,502 service members (SMs) newly enlisted between 2003 and 2006 was identified. Data included medical encounter, deployment and attrition, and suicide. Multivariable logistic regression models examine the association between mental health diagnoses coded within the SMs first 6 months of eligibility for health care benefits and deployment. Multivariable Cox proportional hazards models quantify the association between mental health diagnoses and attrition and suicide. Results: The cumulative incidence of mental health diagnoses was approximately 9% at 6 months of service. Adjustment, depressive, and anxiety disorders were most common. Those with any mental health diagnosis during initial eligibility had increased risk of early attrition and were 77% less likely to deploy. Early mental health diagnoses were not statistically significantly associated with death by suicide. Conclusion: Mental health diagnoses during initial eligibility are common and associated with reduced odds of deployment and increased risk of early attrition. Policies designed to either retain or discharge SMs with a mental health diagnosis identified during initial training merit close examination in light of these findings. INTRODUCTION The U.S. military imposes medical accession standards to ensure those newly recruited are fit and able to meet the needs of the military. 1 Accession standards are intended to filter applicants with specific chronic conditions, including mental disorders and those unable to pass physical fitness tests or who are outside of weight standards. Accession medical standards are generally more restrictive than the standards applied after successful completion of basic and initial specialty training. New recruits are required to be healthy and able to perform their job at the time of induction to help mitigate the risks of premature attrition, untoward health care burden, and loss of duty time to illness and sick leave. Once the accession requirements have been met and the new recruit is inducted, medical standards for retention may become less stringent than those required for accession. For example, those identified with an episode of a nonsevere mental disorder during their first months of service may be retained if stable with treatment, whereas were the same disorder present at the time of application for service, the accession standards would not have been met. Increased retention became more evident in 2006 owing to a decline in those enlisting in the military concomitant with the increased need for military personnel associated with the conflicts in Iraq and Afghanistan. Also at play was consideration of recoupment of the investment in the inductees Office of the Assistant Secretary of Defense (Health Affairs)/Clinical and Program Policy, 5111 Leesburg Pike, Skyline 5, Suite 601, Falls Church, VA recruitment and initial training. In Fiscal Year 1993, the estimated costs of recruiting, screening and training an individual through basic training were approximately $28, In 2005, the $28,800 estimate was adjusted to 2004 dollars which converted to $33,372 average cost per enlistee. 3 A subsequent analysis conducted by a University of California Blue Ribbon Commission in 2006 accounting for overhead and technical training estimated that actual costs were 91% more, over a decade, than those costs obtained by using the Government Accountability Office (GAO) methods. The incidence of mental health disorders during initial eligibility has not previously been studied systematically. There are data on medical separations based on GAO and Service-specific studies. In the late 1990s, 30 to 35% of service members (SMs) separated before completion of the first term of service of approximately 4 years. About 10 to 15% of these individuals were discharged in the first 6 months of duty. 3 The most common reasons for medical discharge were asthma, back pain/orthopedic problems, and psychiatric conditions. Previous data on medical discharges indicate that the rate of medical discharge for psychiatric conditions in 1995 was 65/100, The Air Force has been the leader in the Service-specific research. Among Air Force basic trainees, the mental health-related separation rate for calendar year 2001 was approximately 4.2%. 5 Adjustment disorders and depressive disorders were the most common diagnostic categories related to recommendations for early discharge. 5 Air Force trainees recommended for discharge often had a history of depression, expressed a lack of motivation to continue in the military, reported suicidal MILITARY MEDICINE, Vol. 177, October

2 ideation, and typically had withheld information on their mental health history during Military Entrance Processing Station assessment. 6 The burden of mental health disorders during initial eligibility is not well documented. There are several studies quantifying the prevalence of mental health disorders among retained SMs. Before the current conflicts, Operations Enduring Freedom and Iraqi Freedom, mental disorders were the leading hospitalization discharge diagnosis among men and the second leading diagnosis category among women. 7 Approximately 6% of active duty personnel received ambulatory care for mental disorders annually, and 13% of active duty hospitalizations were attributed to mental disorders. 7 There is a much richer body of mental health research focusing on SMs returning from deployment. Unfortunately, these studies are not applicable to this study because the entire cohort is new to the military. This study was designed to examine and quantify outcomes associated with the retention of those SMs identified as having a mental health disorder diagnosed during their first 6 months health care eligibility. The intent was to examine the findings of associations between those diagnosed with a mental disorder during this time period with deployment, attrition, and death by suicide for implications that may inform policy, especially policy related to retention standards. This study was determined to be exempt from an Institutional Review Board review as determined by the Department of Defense (DoD) Health Affairs TRICARE Management Activity Exemption Determination Official, September METHODS Study Cohort The study population was selected from a census of SMs, aged 17 to 34, who were new accession active duty and activated National Guard or Reserve between October 1, 2003 and December 31, 2006 (N = 900,410). Newly Eligible for TRICARE, the Health Maintenance Organization-like health care benefit option in the Military Health System (MHS) is an administrative designation that new recruits are given upon completion of their initial paperwork, usually within the first 48 hours of their arrival at basic training. The first date of TRICARE eligibility was used as a proxy for time of entry into the Service, expediting identification of SMs newly accessed over a period of time and setting initial time boundaries from which to mark any emerging mental health data. Analyses were restricted to newly eligible active duty personnel (N = 576,502) because the health care utilization data are considered more robust for those on active status as their on-going care is directly administered through the Military Treatment Facility-delivered benefit program. All demographic data were based on data collected at the date of entry into the cohort. This information included age, gender, marital status, Service, and rank. Measures Mental Health Diagnoses For purposes of these analyses, the SMs first 6 months benefit coverage under the military health care system was coined the period of initial eligibility. The first 2 to 3 months include boot camp or basic training and subsequently there may be a continuation of basic training or technical or specialty training, depending on the requirements of the career field. SMs were categorized as having a mental health diagnosis during initial eligibility if they had a coded mental health diagnosis event recorded in the MHS clinical administrative database or in the network administrative claims database (care received external to the MHS). The International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) mental disorders diagnostic codes were used as this is the diagnostic classification system for health care encounters. Individuals whose only coded mental disorder diagnosis was related to nicotine use (ICD9 code: 305.1) or mental retardation (ICD9 codes: ) were excluded and added to the comparison group for all analyses. There were 172 individuals with a coded diagnosis of mental retardation and 165 (95.9%) of these individuals had another coded mental health diagnosis and were therefore included in the mental health diagnosis group. There were 17,537 individuals with a nicotine use diagnosis. 22% (n = 3897) of these were included in the mental health diagnosis group because of a co-occurring mental health diagnosis. The Behavioral Health Coding Handbook (BHCH), a mental health diagnosis coding taxonomy inclusive of all ICD-9-CM mental diagnoses, was used to sort the individual ICD-9-CM mental disorder diagnoses into broader categories of types of disorders for study analysis and reporting purposes. 8 BHCH groupings correspond, in general, to the diagnostic chapters in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revised (DSM-IV- TR). 8 The diagnostic codes listed in the DSM-IV-TR are considered to be legal and valid ICD-9-CM codes and either one of these coding systems DSM-IV-R or ICD-9- CM and their subsequent revisions may be cross-walked with each other and retain internal consistency. 9 The health care claims data were merged with personnel, discharge, deployment, and suicide data. Outcomes Deployment data was based on the DoD Contingency Tracking System deployment file, which is used identifying the location of deployed SMs. Early attrition was defined as a tour of duty less than 4 years, the standard length of time for an active duty tour. Time in service was based on cumulative months of health care eligibility. SMs with less than 48 months of eligibility, a proxy for a 4-year tour, were defined as early attrition. Data for the aforementioned outcomes were available through December 31, Death by suicide was identified using data from the Office of the 1150 MILITARY MEDICINE, Vol. 177, October 2012

3 Armed Forces Medical Examiner. This data was available through December 31, Analyses Descriptive analyses were used to describe the demographic characteristics of the study cohort. Bivariable analyses were used to examine the prevalence of mental health diagnoses at several times (4-weeks, 8-weeks, and 6-months) during initial eligibility. After reviewing the data in conjunction with the a priori research question focusing on the initial eligibility in its entirety, all subsequent analyses were based on mental health diagnoses through the first 6 months of eligibility. Bivariable analyses, c 2 tests for categorical variables, and t-tests for continuous variables were used to compare the mental health diagnoses by demographic characteristics. Multivariable logistic regression was used to identify demographic characteristics associated with having a mental health diagnosis during initial eligibility. Deployment Multivariable logistic regression was also used to quantify the association between a mental health diagnosis during initial eligibility and subsequent deployment. This model controlled for demographic covariates including gender, rank, Department, age, and marital status at baseline. Attrition The attrition analysis was restricted to a subcohort of active duty SMs newly eligible between October 31, 2003 and December 31, 2003 in order to have at least 48 months of follow-up. To address the null hypothesis related to early attrition, the cohort of SMs who died by suicide (N = 13) or were discharged for personality disorder (N = 551) were not included in the early attrition group but contributed person time until their date of death by suicide or discharge date when they were administratively censored (time no longer counted to increase accuracy of the person-year denominator in the study group). All other participants were administratively censored on December 31, The resulting cohort consisted of 39,596 active duty SMs. In order to assess the relationship between mental health diagnosis during initial eligibility and early attrition, a multivariable Cox proportional hazard model was developed. The model controlled for gender, Department, age, and deployment. Death by Suicide A Cox proportional hazards model was used to assess the relationship between mental health diagnosis during initial eligibility and death by suicide. Cohort members who were not identified as a death by suicide case were administratively censored on their last date of eligibility or December 31, SAS version and STATA Version 10 were used for analyses. 10,11 RESULTS Incidence of Mental Health Diagnoses The study cohort consisted of 576,502 active duty SMs, aged 17 to 34, with an initial eligibility start date between October 1, 2003 and December 31, The demographic characteristics of the cohort are presented in Table I. The majority were male (84%), between 17 and 24 years of age (88%), single (88%), and enlisted (94%). Approximately 42% were in the Army, 18% in the Air Force, 18% the Marine Corps, and 22% in the Navy. There were notable demographic differences in cumulative mental health diagnoses at 6 months of service statistically significant at p < using c 2 tests for categorical variables and t-tests for continuous variables (age). Diagnoses were more common among women (16%) compared to men (7%), and SMs aged 17 to 24 had a greater incidence compared to those aged 25 to 34, 8.8% and 8.3%, respectively (Table I). Enlisted had a greater incidence of mental health diagnoses, 9%, compared to officers, 2%. There were also Department differences in mental health diagnoses. The Army incidence was 11%, Navy 8%, and Air Force and Marine Corps 6%. By year cumulative incidence of mental health diagnoses by Department may reflect a change in application of Army retention standards at the end of 2005, resulting in a 14% rate of mental diagnoses during the first 6 months of service in 2006 (Table II). Prevalence of mental health diagnoses was also calculated at the first 4 and 8 weeks of service by year and Department (Table III). In the TABLE I. Demographics of Active Duty SMs, Aged 17 to 34, Newly Eligible Between October 1, 2003 and December 31, 2006 by Mental Health Diagnosis During First 6 Months of Eligibility Mental Health Diagnosis Study Cohort During First 6 Months N % N % p-value Total Gender Female Male < Age Category < Mean ± SD ± ± 3.25 Service Army Air Force Marines Navy < Rank Cadet Enlisted Officer Other < Marital Status Married Single < MILITARY MEDICINE, Vol. 177, October

4 TABLE II. By Year Incidence of Mental Health Diagnoses During Initial Eligibility (1st 6 Months Service) Among Active Duty SMs, Aged 17 to 34, Newly Eligible Between October 1, 2003 and December 31, N n % N n % N n % N n % p-value Total 39,596 2, ,811 15, ,587 14, ,508 17, < Army 15,034 1, ,309 7, ,081 7, ,635 10, < Air Force 9, ,784 2, ,919 1, ,139 2, < Marines 7, ,234 1, ,785 2, ,943 2, < Navy 8, ,484 3, ,802 3, ,791 3, TABLE III. Cumulative Incidence of Mental Health Diagnoses during Initial Eligibility among SMs, Ages 17 to 34, Newly Eligible between October 1, 2003 and December 31, 2006 First 4 Weeks First 8 Weeks First 6 Months Total N N % N % N % Total Army Air Force Marines Navy p-value < for c 2 tests for difference in incident MH DX by Service at all time intervals. total population, the cumulative incidence of mental health diagnoses increased from 2.6% at 4 weeks to 4.0% at 8 weeks and 7.7% at 6 months. The most notable increase occurred in the Army with incidence of a coded mental diagnosis by 6 months rising from 8.7% in 2003 to 13.8% in Although year of initial eligibility was statistically significantly associated with mental health diagnoses in the other Services, there was not a notably increasing trend. Table IV presents the incidence of mental health diagnoses using CBHIG Diagnostic Groups to identify what types of diagnoses were most common. The overall incidence of any mental health diagnosis during the first 6 months was 876 per 10,000. The most common diagnoses groups were Adjustment Disorder, 445/10,000; Depression, 363/10,000; and Anxiety, 205/10,000. SMs frequently had more than one diagnosis. The mean number of unique diagnoses was 1.93 (SD 1.17) with a range from 1 to 11. Deployment Approximately 41% of the study cohort was identified as having a deployment: more commonly men, 43%, than women, 26%; and slightly greater among ages 25 to 34, 45%, compared to those aged 17 to 24, 40%. Deployment was more prevalent in the Army, 50%, and Marine Corps, 46%, compared to the Navy, 31%, and Air Force, 26%. Sixteen percent of individuals with a mental health diagnosis during initial eligibility deployed compared to 43% of those without a mental health diagnosis who deployed. The association between a mental health diagnosis during initial eligibility and odds of deployment was examined, controlling for sociodemographics with TABLE IV. Incidence of Mental Health Diagnoses by CBHIG Diagnostic Groups During Initial Eligibility Among Active Duty SMs, Aged 17 to 34, Newly Eligible Between October 1, 2003 and December N Incidence/10,000 Total Mental Health Diagnosis Events a Identified During Initial Eligibility by ICD-9-CM Diagnostic Groupings Adjustment Disorder Depression Anxiety Personality Disorder Psychophysiological Motor Disorder Alcohol Substance Child-Adolescent Non-Alcohol Substance Manic-Bipolar Suicidal Ideation Sleep Disorder Suicide and Self-Inflicted Injury Psychoses Organic Enuresis/Encopresis Eating Disorder Schizophrenia Impulse Control Disorder Sex Disorder Med Factors Affecting Psych Condition Dementia a Categories are not mutually exclusive; the same individual may be included in more than 1 category. a multivariable logistic regression model. Those with a mental health diagnosis were 77% less likely to deploy compared to those without a mental health diagnosis, controlling for the covariates listed gender, age, rank, Service, and marital status (Table V). These data support the phenomena of the Healthy Warrior Effect, a result of restrictions on deploying members with unstable mental disorders. 12 Males, individuals aged 25 to 34, those in the Army, Marine Corps, and Navy compared to the Air Force, and enlisted all had increased odds of deployment. Attrition The cohort consisted of 39,032 AD SMs, of whom 5,088 (13%) did not complete 48 months of Service. Approximately 1152 MILITARY MEDICINE, Vol. 177, October 2012

5 TABLE V. Multivariable Models of the Relationship Between Early Career Mental Health Diagnoses and Subsequent Deployment and Early Attrition Among Active Duty SMs, Aged 17 to 34, Newly Eligible Between October 1, 2003 and December 31, 2006 Deploy Early Attrition Death by Suicide N (%) (40.57) 5115 (12.92) 266 (0.046) Odds Ratio 95% CI Hazard Ratio 95% CI Hazard Ratio 95% CI Univariable Mental Health Diagnosis During Initial Eligibility Yes 0.24 (0.238, 0.250) 1.72 (1.57, 1.87) 0.87 (0.54, 1.39) No Multivariable a Mental Health Diagnosis During Initial Eligibility Yes 0.23 (0.22, 0.24) 1.19 (1.09, 1.31) 0.95 (0.59, 1.52) No Gender Female Male 1.9 (1.87, 1.94) 1.47 (1.35, 1.59) 4.62 (2.45, 8.72) Age Category (0.92, 0.95) 1.06 (0.98, 1.15) 1.09 (0.75, 1.58) Service Army 2.96 (2.91, 3.01) 4.03 (3.71, 4.38) 2.28 (1.50, 3.46) Air Force Marines 2.24 (2.20, 2.29) 0.3 (0.25, 0.35) 2.2 (1.40, 3.46) Navy 1.26 (1.24, 1.29) 0.68 (0.60, 0.76) 0.89 (0.53, 1.49) Rank Enlisted 1.1 (1.08, 1.12) 3.27 (2.41, 4.44) NA Officer 1 1 Marital Status Married 1 1 NA Single 0.86 (0.83, 0.89) 1.07 (0.98, 1.16) Deployed Yes 0.46 (0.44, 0.49) 0.96 (0.75, 1.23) No NA 1 a Multivariable logistic regression was used to model odds of deployment because actual date of deployment was not available; Cox proportional hazard model was used to model hazard of early attrition in a sub-cohort of with adequate follow-up time. 84% were male, 87% were aged 17 to 24, 97% enlisted, and 87% single. Approximately 38% were Army, 23% Air Force, 18% Marines, and 21% Navy. The cohort s overall incidence rate of early attrition was 328/10,000 person-years of follow-up. (Person-years is time at risk in years that all persons contributed to the study.) The hazard of attrition appeared to peak around 3 years of eligibility (Fig. 1). The incidence rate was 529/10,000 personyears of follow-up among those with a mental health diagnosis (see Table VI for break-out by diagnosis category) during initial eligibility and 313/10,000 person-years of follow-up among those without a mental health diagnosis. The incidence rate ratio was 1.69 indicating 69% increased rate of early attrition among those with a mental health diagnosis during initial eligibility compared to those without a mental health diagnosis during initial eligibility, p < In both univariable and multivariable models, the hazard ratio for the association between mental health diagnosis during initial eligibility and eligibility of less than 48 months was statistically significant, p < Univariable regression indicates that a mental health diagnosis during initial eligibility is associated with close to a 72% increased risk of early attrition (<48 months of eligibility). After controlling for demographic and Service characteristics, mental health diagnosis during initial eligibility is associated with a 19% increased risk of early attrition (<48 months of eligibility) (Table V). Certain demographic characteristics were also significantly associated with completion of less than 48 months of service. Males are statistically more likely than females, and enlisted SMs are more likely than officers, to serve less than 48 months. Individuals in the Army are four times more likely than the Air Force to have less than 48 months of eligibility. Individuals in the Marine Corp and Navy are statistically significantly less likely than the Air Force to have less than 48 months of eligibility. Death by Suicide There were 266 individuals, or 13/100,000 person-years of follow-up among those with initial eligibility between October 1, 2003 and December 31, 2006 who subsequently died by suicide during the study follow-up through December 31, The incidence rate of suicide was smaller among individuals with a mental health diagnosis (11.6/100,000 person-years) MILITARY MEDICINE, Vol. 177, October

6 FIGURE 1. Attrition time to event (unadjusted). compared to individuals without a mental health diagnosis (13.6/100,000 person-years); this difference is not statistically significant. In multivariable analyses, there was not an association between mental health diagnoses during initial eligibility and subsequent death by suicide. DISCUSSION This study was based upon identifying active duty SMs with mental diagnoses during initial eligibility with the focus on potential issues related to early application of less stringent retention standards before completion of initial military training. Before this study, early career mental health diagnoses were not systematically studied. The proportion of active duty SMs who receive a mental health diagnosis during initial eligibility (8.75%) is concerning and warrants further evaluation to include validation of the diagnoses with medical records. Although early career mental diagnoses were not associated with an increased risk of death by suicide, they were associated with other outcomes of potential significance for policy: a 69% increased rate of attrition and 77% reduced odds of deploying. The impact of findings such as these on manning for combat end strength may merit future cost benefit analyses to quantify opportunity costs of retaining members with early mental diagnoses, as SM authorizations are fixed by Congress. Specifically, future studies should clarify the overall effects of personnel policies that lower accession or retention standards, or apply retention standards to personnel with less than 6 months of military service. TABLE VI. Service of Less Than 48 Months by Mental Health Diagnoses During Initial Eligibility Among Active Duty SMs, Aged 17 to 34, Newly Eligible Between October 1, 2003 and December 31, 2006 Less than 48 Months of Eligibility N n Incidence/10,000 p-value Total Mental Health Diagnosis No Mental Health Diagnosis <0.0001l Mental Health Diagnosis Events a Identified During Initial Eligibility by ICD-9-CM Diagnostic Groupings Med Fact Affecting Psych Condition * 0 0 NA Adjustment Disorder < Enuresis/Encoporesis 27 * * NA Eating Disorder 22 * * NA Sleep Disorder 57 * * NA Sex Disorder NA Personality Disorder Psychophysiological Anxiety < Child-Adolescent Psychoses < Depression < Manic-Bipolar Non-Alcohol Substance < Alcohol Substance Organic 27 * * NA Dementia NA Schizophrenia 19 * * NA Impulse Control Disorder * * * NA Motor Disorder * * * NA Suicidal Ideation NA Suicide and Self-Inflicted Injury 33 * * NA NA, 25% of the cells have expected counts less than 5 therefore results from c 2 analyses may not be valid. a Diagnoses categories are NOT mutually exclusive; individuals may have more than 1 unique mental health diagnosis MILITARY MEDICINE, Vol. 177, October 2012

7 Mental disorders are a known risk factor for suicide. However, increases in SMs retained with early career mental health diagnoses did not account for increases in military suicides over the same time period. Such might be explained by cohort members being formally diagnosed and their conditions treated, as opposed to those with potentially undiagnosed, untreated disorders, or by the cohort s 77% decreased rate of deployment, a risk factor for suicide. 13,14 The majority of those diagnosed with most mental diagnoses did complete 48 months of service. Though completion rate was lower than for those not so diagnosed, an argument can be made for the efficacy care in terms of assisting most members with mental diagnoses to complete their tours of duty. Several limitations should be considered when interpreting the results. First, the study relied on a proxy measure for entry into the military, the start date for TRICARE eligibility. Although this is not an ideal measure, any measurement error associated with this proxy is likely to be both nondifferential and independent (not associated with the exposure, mental health diagnosis, or outcomes) and will therefore not induce a significant bias. Second, the study has all of the limitations of a retrospective cohort study including the use of coded diagnoses from medical claims. These diagnoses were not confirmed with medical record review. Third, the estimates presented are likely an underestimate of the true burden of mental health disorders. This study is based on SMs who sought medical care and were diagnosed with a mental health condition. There are likely many more SMs who do not seek care for such conditions as a result of perceived stigma. Last, the results are not readily generalized to the U.S. population. Although the U.S. military is not representative of the general population, it represents an important segment of the adult working population. 7 Despite these limitations, this study has numerous strengths and important policy implications. The study was population-based, consisting of a census of active duty SMs who were new to the military between 2003 and This cohort is diverse with respect to ethnicity, gender, age, and education. The MHS clinical administrative data include all medical claims data (inpatient, outpatient, military, and civilian providers) for these SMs. All SMs also have equal access to comprehensive medical care. The quantification of the study outcome, mental health diagnoses, is considered to be extremely inclusive. This is the first study to be able to provide a population-based estimate of the burden of mental health disorders among new SMs. This study demonstrated that clinical administrative data can be used to address policy questions in a timely fashion. Hypothesis development began in April 2008, data utilization agreements were completed in August 2008, and IRB protocol was approved as exempt and data extracted in September Analyses were completed in January Results were presented to the DoD Accession Standards Working Group in June 2009 and to Pentagon Personnel leadership in September 2009, The results of this study indicate mental health disorders are common in initial eligibility. In the general population, mental disorders are associated with morbidity, disability, reduced quality of life, occupational morbidity (absenteeism, unemployment), and high health care utilization Previous research in military cohorts has shown that mental health conditions are a significant predictor of disability, medical discharge, early attrition, and increased health care utilization. 7,15 Among SMs hospitalized with a mental disorder, almost half left military service within 6 months. 7 These findings provide information that contributes to understanding the potential outcomes of policy that regulates the recruitment and retention of SMs. The results indicate that the long-term implications of implementing less stringent retention standards during initial training warrants careful monitoring by the Military Departments and the DoD. It will be important to evaluate these findings in entirety with findings from follow-on analyses whenever retention polices are changed. The end goal of the information garnered from such a series of analyses is to assist decision-makers in appraising and reconciling current policy, as needed, to enable sustainment of the operational end strength required for military force readiness. ACKNOWLEDGMENTS The authors would like to acknowledge Ms. Linda Cottrell, Contractor, former Health Care Data Analyst, Kennell and Associates, Inc., Falls Church, VA, for her exceptional guidance in establishing the study cohort and extracting relevant data. This study was funded by the Office of the Assistant Secretary of Defense (Health Affairs). REFERENCES 1. Clark KL, Mahmoud RA, Krauss MR, et al: Reducing medical attrition: the role of the accession medical standards analysis and research activity. Mil Med 1999; 164(7): Government Accountability Office: Military Attrition: Better Data, Coupled with Policy Changes, Could Help the Services Reduce Early Separations. GAO, Available at ns98213.pdf; accessed January 22, Government Accountability Office: Financial Costs and Loss of Critical Skills Due to DOD s Homosexual Conduct Policy Cannot Be Completely Estimated. GAO, Available at accessed January 22, Government Printing Office: Military Attrition: DOD Could Save Millions by Better Screening Enlisted Personnel. GAO, Available at accessed January 22, Englert DR, Hunter CL, Sweeney BJ: Mental health evaluations of U.S. Air Force basic military training and technical training students. Mil Med 2003; 168(11): Cigrang JA, Carbone EG, Todd S, Fiedler E: Mental health attrition from Air Force basic military training. Mil Med 1998; 163(12): Hoge CW, Lesikar SE, Guevara R, et al: Mental disorders among U.S. military personnel in the 1990s: association with high levels of health care utilization and early military attrition. Am J Psychiatry 2002; 159(9): USAF Medical Support Agency, Population Health Support Division: Behavioral Health Coding Handbook, Intellectual property of the Department of Defense used with permissions. Available at MILITARY MEDICINE, Vol. 177, October

8 .pdhealth.mil/guidelines/downloads/afbehavioralhealthcodinghandbook05.pdf; accessed January 22, American Psychiatric Association Website: DSM-ICD Coding Crosswalk. Available at DSMIVTR/DSMICDCodingCrosswalk.aspx; accessed January 22, Statistical Analysis Software: SAS Version Cary, NC, SAS Institute Inc., Available at accessed January 22, Data Analysis and Statistical Software: Statistical Software: Release College Station, TX, Stata Corporation, Available at accessed January 22, Wilson J, Jones M, Fear NT, et al: Is previous psychological health associated with the likelihood of Iraq War deployment? An investigation of the healthy warrior effect. Am J Epidemiol 2009; 169(11): Black SA, Gallaway MS, Bell MR, Ritchie EC: Prevalence and risk factors associated with suicides of Army Soldiers Mil Psychol 2011; 23: Hoge CW, Toboni HE, Messer SC, Bell N, Amoroso P, Orman DT: The occupational burden of mental disorders in the U.S. military: psychiatric hospitalizations, involuntary separations, and disability. Am J Psychiatry 2005; 162: Broadhead WE, Blazer DG, George LK, Tse CK: Depression, disability days and days lost from work in a prospective epidemiologic survey. JAMA 1990; 264: Hays RD, Wells KB, Sherbourne CD, et al: Functioning and well-being outcomes of patients with depression compared with chronic general medical illness. Arch Gen Psychiatry 1995; 52: Kessler RC, Frank RG: The impact of psychiatric disorders on work loss days. Psychol Med 1997; 27: Klerman GL, Weissman MM, Ouellette R, et al: Panic attacks in the community: social morbidity and health care utilization. JAMA 1991; 265: Klerman GL, Weissman MM: The course, morbidity, and costs of depression. Arch Gen Psychiatry 1992; 49: Murray CJL, Lopez AD (editors): Global Burden of Disease and Injury Series: The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability From Diseases, Injuries, and Risk Factors in 1990 and Projected to Cambridge, Harvard University Press on behalf of World Health Organization and World Bank, Simon G, Ormel J, VonKorff M, Barlow W: Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry 1995; 152: Wells KB, Sherbourne CD: Functioning and utility for current health of patients with depression or chronic medical conditions in managed, primary care practices. Arch Gen Psychiatry 1999; 56: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health: Mental Health: A Report of the Surgeon General. Rockville, MD, Available at accessed January 28, Wells KB, Stewart A, Hays RD, et al: The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1989; 262: MILITARY MEDICINE, Vol. 177, October 2012