Incidence and Risk for Mood and Anxiety Disorders in a Representative Sample of Ohio Army National Guard Members,

Transcription

1 Spotlight on Veterns Helth: After the Wr Incidence nd Risk for Mood nd Anxiety Disorders in Representtive Smple of Ohio Army Ntionl Gurd Members, Dvid S. Fink, MPH Qixun Chen, PhD b Yuto Liu, BS b Mrijo B. Tmburrino, MD c Isrel Liberzon, MD d Edwin Shirley, PhD e Thoms Fine, MA c Gregory H. Cohen, MSW Sndro Gle, MD, DrPH f Joseph R. Clbrese, MD e ABSTRACT Objective. We investigted the incidence of first-onset psychitric disorders mong Ohio Army Ntionl Gurd members nd the sociodemogrphic nd militry fctors ssocited with these incident disorders. We imed to identify potentil risk fctors nd mitigting fctors for rnge of psychitric disorders in representtive militry smple. Methods. We nlyzed dt on representtive smple of 528 Ohio Army Ntionl Gurd members who were ssessed in person nnully for first-onset psychitric disorders from 2008 through 2012 using structured clinicl interviews. We used multivrible discrete-time Cox proportionl hzrd model to determine risk fctors of first-onset nxiety or mood disorders. Results. The nnulized incidence rte of ny first-onset psychitric disorder ws 9.8 per 100 person-yers t risk. Alcohol use disorder nd mjor depressive disorder hd the highest incidence rtes mong the unique disorders under study (5.0 nd 4.2 per 100 person-yers t risk, respectively). We found n ssocition between respondents endorsing pst-yer deployment nd 29% increse in the risk of incident nxiety or mood disorder, wheres the pst-yer experience of ny non-deployment trumtic event ws ssocited with 32% increse in risk of incident nxiety or mood disorder. Conclusion. Soldiers experience substntil burden of first-onset lcohol use disorder nd mjor depressive disorder nnully; the experience of non-deployment relted trumtic events contributes substntilly to incresing risk, suggesting tht ny effort imed t mitigting mood nd nxiety disorders in this popultion must consider the soldier s life experience nd militry experience. Columbi University, Milmn School of Public Helth, Deprtment of Epidemiology, New York, NY b Columbi University, Milmn School of Public Helth, Deprtment of Biosttistics, New York, NY c University of Toledo, Deprtment of Psychitry, Toledo, OH d University of Michign, Deprtment of Psychitry, Ann Arbor, MI e Cse Western Reserve University, Deprtment of Psychitry, Clevelnd, OH f Boston University, School of Public Helth, Boston, MA Address correspondence to: Dvid S. Fink, MPH, Columbi University, Milmn School of Public Helth, Deprtment of Epidemiology, 722 W. 168th St., Rm. 1513, New York, NY ; tel ; fx ; e-mil <dsf2130@columbi.edu> Assocition of Schools nd Progrms of Public Helth 614

2 Mood nd Anxiety Incidence in Ntionl Gurd 615 Since 2001, the U.S. militry hs deployed more thn 2.6 million service members to support the longest sustined ground combt opertion in the ntion s history. These opertions require lengthy, often repetitive, nd demnding deployments by both ctive-duty nd Ntionl Gurd nd Reserve (reserve component) forces. 1 As the militry incresed occuptionl nd personl demnds on soldiers, the percentge of service members dignosed with psychitric disorders incresed by 65% between 2001 nd 2011 (2001: 5,387.1 cses per 100,000 person-yers; 2011: 8,900.5 cses per 100,000 person-yers), 2 the hospitl rte nd number of mbultory visits cused by mentl disorders doubled between 2006 nd 2010, 3 nd the civilin-djusted suicide incidence rte ws surpssed for the first time in 2008 (ctive-duty Army personnel rte in 2008: 20.2 suicides per 100,000 popultion; civilin-djusted rte in 2005: 19.5 suicides per 100,000 popultion). 4 The simultneous increse in militry demnds nd psychitric burden led to scientific nd public discourse on spects of militry service (e.g., deployment) nd helth policy chnges (e.g., incresed wreness of psychitric disorder) tht cused the increse in psychopthology mong service members. 5,6 However, much of the reserch tht supports this ssocition between spects of militry service nd psychitric disorders is bsed on prevlence studies; these studies ssess disese burden but not disese risk. 7 9 Historiclly, the burden of mentl illness hs been lower for militry nd vetern popultions thn for civilins; however, recent evidence suggests this difference hs reversed. 4 In 2014, Kessler nd collegues 10 showed tht the prevlence of 30-dy psychitric disorders is higher mong U.S. service members thn mong sociodemogrphiclly mtched civilins. This finding fits with the contemporry understnding tht militry experiences my led to n incresed psychitric burden. However, this sme report indicted tht most service members with disorders reported tht their symptoms begn before enlistment. 10 Furthermore, popultion-bsed study published in 2014 documented tht service members re more likely thn non-militry civilins to report dverse childhood experiences. 11 These two studies suggest n lterntive mechnism for the militry s psychitric burden tht is driven by chronic, cyclicl, or re-ggrvted pre-militry psychitric symptomology. Although prior reserch provides insight into the burden of mentl illness in the militry, t lest three gps in the literture limit our knowledge bout its risk. First, lthough one in three service members hs never been deployed, 12 most studies restrict nlysis to deploying popultions, limiting inferences bout the risk ssocited with the more generl militry experience. 13 Second, previous militry studies hve reported either the cross-sectionl prevlence or proportion of new-onset psychitric disorder cses. New-onset cses re qulified only by the bsence of disorder t the bseline interview nd disorder dignosis t lter interview, rther thn the bsence of lifetime history of disorder t bseline. Becuse substntil proportion of psychitric disorders begin before militry service, 10 nlyses of first-onset disorders is likely to overestimte the incidence rte of first-onset psychitric disorders during service. Third, previous studies hve focused on only three disorders (lcohol use disorder [AUD], mjor depressive disorder [MDD], nd posttrumtic stress disorder [PTSD]), leding to deficiency of dt on the risk nd burden of severl less prevlent psychitric disorders (e.g., phobis, dysthymi). To ddress these limittions, we investigted sociodemogrphic nd militry predictors of first incidence of psychitric disorders in representtive smple of militry personnel followed during four nnul study wves. We describe the first incidence estimtes of the rtes of psychitric disorders in reservist popultion nd investigte sociodemogrphic nd militry fctors tht my increse the risk of nxiety or mood disorders. METHODS Prticipnts The Ohio Army Ntionl Gurd (OHARNG) Mentl Helth Inititive is n ongoing, popultion-bsed, open, prospective study tht hs enrolled OHARNG service members nnully since We chose the OHARNG for this study becuse of its similrities in severl key demogrphic nd socil fctors to U.S. popultions (e.g., proportion of high school grdutes, per-cpit income) nd Ntionl Gurd popultions (e.g., ge, sex, rnk). 14,15 We conducted this nlysis mong respondents completing the in-person interview component of the lrger prospective telephone survey 16 tht ssessed resilience nd risk fctors for psychitric disorders. The vlidity of the dt collected by telephone ws ssessed by compring them with dt collected through clinicl psychitric interviews, which re considered the gold stndrd for psychitric ssessment. 17 We used dt collected from 2008 through Februry Smple selection occurred in three phses. First, s described elsewhere, 16 the telephone survey rndomly selected currently serving OHARNG members ged $17 yers (n52,616). Using Americn Assocition for Public Opinion Reserch definitions, 18 the overll

3 616 Spotlight on Veterns Helth: After the Wr coopertion rte (defined s number of OHARNG members who consented [n52,834] divided by number of successfully contcted people with working telephone numbers [n54,198]) ws 67.5%, nd the response rte (defined s OHARNG members who completed the survey [n52,616] plus those who consented but were ineligible [n5187] divided by the number of working telephone numbers [n56,154] minus those disqulified [n531]) ws 43.2%; both rtes were similr to other popultion-bsed militry cohort studies, such s Army Study to Assess Risk nd Resilience in Servicemembers (65.1% coopertion rte nd 49.8% response rte). Second, we rndomly invited 1,046 (40%) individuls completing the telephone survey to receive more informtion by postl mil nd prticipte in the clinicl interview; 952 (91%) greed to the clinicl interview. Of these 952 service members, 452 (47.5%) were not contcted before the trgeted number of OHARNG service members (n5500) provided written informed consent nd were enrolled in the study. Third, in 2010, 105 new service members were dded to the smple using the sme protocols used for the bseline smple (n5605). We excluded 77 respondents who were ssessed only t bseline, leving finl nlyticl smple of 528 respondents. Mesures Dignostic ssessment. Trined doctorl- or msters-level clinicins dministered the Structured Clinicl Interview for DSM-IV (SCID) 19 nd Clinicin-Administered PTSD Scle (CAPS) 20 nnully from June 2008 through Februry 2012 in neutrl, privte loction (e.g., privte librry room, prticipnt s home) to ssess first incidence of Dignostic nd Sttisticl Mnul of Mentl Disorders, 4th Edition (DSM-IV) psychitric disorders. 21 The bseline interview ssessed respondents militry, mentl helth, nd tretment history, nd socil nd economic circumstnces, while nnul follow-up ssessments focused on interim mentl helth risk fctors nd dignostic symptomology. The SCID ssesses Axis I disorders, 19 which we ctegorized into three clsses: nxiety disorder (pnic disorder, gorphobi without pnic disorder, specific phobi, socil phobi, nd PTSD), mood disorders (MDD, dysthymi, nd bipolr disorder I/II), nd substnce use disorders (lcohol nd/or drug buse nd/or dependence). All dignoses were bsed on DSM-IV criteri, nd decision tree pproch ws used to record the presence or bsence of ech disorder for current nd lifetime occurrences. We did not include sub-threshold disorders. The CAPS ws dministered twice during ech ssessment to ssess PTSD symptoms: once to ssess symptoms cused by n event described by the prticipnt s the worst event (hereinfter referred to s potentilly trumtic event ) to occur during his or her most recent deployment nd second time to ssess symptoms cused by n event described by the prticipnt s the worst event to occur outside his or her most recent deployment. 22 We defined cse of PTSD by using the frequency $1 nd intensity $2 method, which is the most sensitive nd the originl scoring rule. 20,23 Frequency rtings of symptoms re mde on five-point scle, from 0 (never or none of the time) to 5 (dily or lmost every dy), nd intensity symptoms re lso mde on five-point scle, from 0 (none or no problem with symptom) to 5 (extreme, incpcitting). Thus, symptoms with frequency $1 nd intensity $2 suggest tht the person is experiencing the symptom with t lest mild intensity some of the time. Prticipnts meeting dignostic criteri for PTSD on either CAPS were clssified s hving PTSD. We found monthly interrter relibility for the SCID nd CAPS showed good concordnce between interviewers nd dignostic ssessment methods for our study (free-mrginl multirter κ.0.85). 24 Potentilly trumtic events. We ssessed potentilly trumtic events using the 16-item Life Events Checklist. The Life Events Checklist nd CAPS were developed concurrently with the intent tht the Life Events Checklist would screen for potentilly trumtic events for the CAPS. We selected the originl 16 Life Events Checklist items becuse of their ssocition with PTSD symptomology. 25 In our study, prticipnts were sked bout lifetime potentilly trumtic events t the bseline interview nd pst-yer potentilly trumtic events during follow-up interviews. Sociodemogrphic nd militry chrcteristics. Bseline sociodemogrphic risk fctors included cohort (bseline, dynmic cohort [i.e., the 105 people who were dded fter the bseline cohort, during wve 3]), ge t enrollment, rce (non-hispnic white, non-hispnic blck, other), nd sex. Additionl bseline militry risk fctors included ge t joining the militry nd lifetime deployment (yes/no). Potentil time-vrying risk fctors included mritl sttus (single/never mrried, mrried, previously mrried [seprted, divorced, widowed]), eduction (#high school, some college, $college degree), py grde (enlisted [E1 E9], officer [wrrnt officer 1 5, officer 1 10]), nd deployment (yes/no) since the respondent s lst interview. We lso djusted the model of mood nd nxiety disorder for AUD (never, ever but not lst yer, lst yer) nd drug use disorder (never/ever).

4 Mood nd Anxiety Incidence in Ntionl Gurd 617 Sttisticl nlyses We used sequentil regression multiple imputtion to impute the intervl censoring of disorder symptoms nd missing covrites. 26 We generted five imputtions. Intervl censoring occurred fter bseline when respondent reported the onset of disorder symptoms t follow-up interview but did not prticipte in one or more intermedite interviews. With intervl censoring, it is uncler if the respondent developed the disorder t the time of interview or t n erlier time point. The timing of disorder onset mttered when we clculted the person-yers t risk to estimte incident rtes nd the time to event in survivl dt nlysis. We clculted the number of service members t risk, new cses, nd person-yers t risk of developing ech psychitric disorder. We clculted number of service members t risk s the number of respondents who were disorder-free during their lifetime t bseline (i.e., who did not ever hve dignosis of disorder). New cses were respondents who did not hve dignosis of disorder t bseline nd who received dignosis of the disorder during follow-up. We clculted person-yers t risk of developing ech psychitric disorder from the bseline survey dte to either the dte of disorder onset, loss to follow-up, or end of the study period. We estimted the incidence rte of ech disorder by using intercept-only Poisson regression, in which the number of new cses ws the outcome nd the person-yers t risk ws the offset. We clculted the incidence rte for n ggregte ctegory s the first onset of ny unique disorder mong formerly disorder-free respondents for ll unique disorders in the ctegory t bseline. We clculted incidence rtes for ech unique disorder irrespective of the other disorders in the ctegory. We estimted the odds rtios of risk fctors ssocited with the prevlence of mood or nxiety disorder t bseline using logistic regression. We conducted bivrite nd multivrible logistic regression estimtes with 95% confidence intervls (CIs) of the prevlence of mood or nxiety disorder t bseline. Among the respondents who were disorder-free t bseline nd hd t lest one follow-up interview, we estimted hzrd rtios of incidence using undjusted nd djusted discrete-time Cox proportionl hzrd models. We obtined estimtes nd stndrd errors by fitting the models seprtely in ech of the imputed dtsets first nd then combining the results cross the five imputed dtsets using Rubin s rule. 27,28 We conducted ll sttisticl nlyses using R. 29 RESULTS Of the 528 study prticipnts, most were ged yers (70.9%), mle (87.7%), non-hispnic white (88.4%), enlisted personnel (88.6%), nd previously deployed (57.5%). The demogrphic nd militry chrcteristics of study prticipnts nd the OHARNG popultion were similr, except for mritl sttus: 44.8% of study prticipnts were single nd 44.6% were mrried, wheres 55.4% of the OHARNG popultion were single nd 38.5% were mrried (Tble 1). At bseline, 336 respondents met dignostic criteri for one or more psychitric disorders. The undjusted nd djusted models for bseline disorders were similr for most chrcteristics, with the exception of eduction nd mritl sttus, where the bivrite ssocition ws significnt nd the multivrible ssocition ws Tble 1. Chrcteristics of Ohio Army Ntionl Gurd (OHARNG) members nd smple of the OHARNG popultion, United Sttes, 2008 through 2012 Chrcteristic Study prticipnts (smple) (n5528) N (percent) OHARNG 2008 profile (n510,778) N (percent) Totl 528 (100.0) 10,778 (100.0) Age, in yers (36.6) 6,430 (39.1) (34.3) 5,477 (33.3) (18.8) 3,361 (20.5) $45 55 (10.4) 1,166 (7.1) Sex Mle 462 (87.7) 14,239 (86.6) Femle 65 (12.3) 2,195 (13.4) Rce/ethnicity Non-Hispnic white 466 (88.4) 9,512 (88.3) Non-Hispnic blck 36 (6.8) 1,083 (10.0) Other b 25 (4.7) 183 (1.7) Mritl sttus Single, never mrried 236 (44.8) 5,967 (55.4) Mrried 235 (44.6) 4,154 (38.5) Divorced/seprted/widowed 56 (10.6) 657 (6.1) Rnk Enlisted (E1 E9) 467 (88.6) 9,750 (90.5) Officer (W1 5/O1 10) 60 (11.4) 1,028 (9.5) Ever deployed Yes 303 (57.5) 5,863 (54.4) No 224 (42.5) 4,915 (45.6) Not ll percentges totl to 100 becuse of rounding. b Includes Americn Indin/Alsk Ntive, Asin Americn/Pcific Islnder, or Hispnic E 5 enlisted W 5 wrrnt officer O 5 officer

5 618 Spotlight on Veterns Helth: After the Wr not. Respondents with n nxiety or mood disorder t bseline were more likely to be femle thn mle (djusted odds rtio [AOR] , 95% CI 1.12, 3.25), to hve more potentilly trumtic events (AOR51.56, 95% CI 1.12, 2.16), nd to meet dignostic criteri for lifetime AUD (AOR51.71, 95% CI 1.18, 2.49) or drug use disorder (AOR51.65, 95% CI 1.00, 2.73). We found no ssocition between lifetime deployment nd bseline disorder (Tble 2). Among the 192 respondents who were disorder-free t bseline, 41 respondents were dignosed with firstonset psychitric disorder during the 417 person-yers of follow-up, for n incidence rte of 9.8 individuls per 100 person-yers, or 9.8% per yer (Figure). Although verge incidence rtes cross the ggregte ctegories (i.e., nxiety disorders, mood disorders, substnce use disorders) differed by,1 percentge point (rnge: 3.8% 4.6%), the incidence rtes cross component ctegories of mood disorders nd substnce use disorders were heterogeneous. The two highest incident rtes for ny ctegory were for AUD (5.0%, 95% CI 3.5, 7.0) nd MDD (4.2%, 95% CI 3.0, 5.7) nd the two lowest rtes were for drug use disorder (0.6%, 95% CI 0.3, 1.3) nd bipolr II (0.5%, 95% CI 0.2, 1.1). In contrst, the incidence rtes for nxiety disorders were homogenous, rnging from 0.7% (obsessive-compulsive disorder) to 1.8% (specific phobi). Incident nxiety or mood disorder ws modestly ssocited with pst-yer deployment (djusted hzrd rtio [AHR] , 95% CI 1.00, 1.66), non- deployment relted trumtic event in pst yer (AHR51.32, 95% CI 1.10, 1.59), nd lifetime potentilly trumtic events (AHR52.25, 95% CI 1.11, 4.55). Although lifetime AUD ws not ssocited with incident risk of nxiety or mood disorder, pst-yer AUD ws ssocited with moderte increse in risk (AHR51.68, 95% CI 1.35, 2.08). Finlly, previously mrried respondents were 3.73 (95% CI 1.47, 9.48) times more likely thn those who were single or never mrried to be dignosed with n incident nxiety or mood disorder during follow-up (Tble 3). DISCUSSION In representtive smple of OHARNG members, we documented 9.8 new cses of ny first incidence of DSM-IV disorder per 100 person-yers t risk. Our nlyses produced four mjor findings. First, we found tht the incidence rtes for disorders in this study were considerbly higher thn the U.S. civilin rtes for AUD (5.0% vs. 1.7%) 30 nd MDD (4.2% vs. 1.5%). 30,31 The higher rtes reported for these two disorders could be ttributed to sociodemogrphic differences between Tble 2. Bivrible nd multivrible logistic regression models for lifetime prevlence of nxiety or mood disorders t bseline in smple of Ohio Army Ntionl Gurd members (n=528), United Sttes, 2008 through 2012 Chrcteristic Anxiety or mood disorder Bivrible nlysis OR (95% CI) Multivrible nlysis AOR (95% CI) Age t bseline 1.01 (0.99, 1.03) 1.00 (0.97, 1.03) Age joining militry 1.04 (1.00, 1.08) 1.03 (0.98, 1.08) Cohort b 2008 smple (bseline) Ref. Ref smple 0.98 (0.63, 1.52) 1.46 (0.85, 2.50) Sex Mle Ref. Ref. Femle 1.63 (1.00, 2.64) 1.91 (1.12, 3.25) Rce/ethnicity Non-Hispnic white Ref. Ref. Non-Hispnic blck 0.96 (0.50, 1.85) 1.01 (0.50, 2.05) Other c 0.94 (0.42, 2.08) 0.88 (0.38, 2.04) Eduction #High school Ref. Ref. Some college 0.78 (0.51, 1.20) 0.72 (0.54, 1.13) $College degree 0.56 (0.33, 0.95) 0.68 (0.37, 1.25) Mritl sttus Single/never mrried Ref. Ref. Mrried 1.22 (0.86, 1.74) 1.44 (0.89, 2.34) Divorced/seprted/ 2.12 (1.21, 3.72) 1.91 (0.97, 3.78) widowed Rnk Enlisted (E1 E9) Ref. Ref. Officer (W1 5/O1 10) 0.51 (0.22, 0.77) 0.41 (0.20, 0.87) Ever deployed No Ref. Ref. Yes 0.97 (0.69, 1.35) 0.79 (0.51, 1.24) Potentilly trumtic 1.51 (1.15, 1.98) 1.56 (1.12, 2.16) events Alcohol use disorder Never Ref. Ref. Ever 1.90 (1.36, 2.66) 1.71 (1.18, 2.49) Drug use disorder Never Ref. Ref. Ever 2.20 (1.39, 3.48) 1.65 (1.00, 2.73) Adjusted for ll other vribles in the tble b The study smple comprised 500 people who were recruited in 2008 nd 105 people who were recruited in c Includes Americn Indin/Alsk Ntive, Asin Americn/Pcific Islnder, or Hispnic OR 5 odds rtio CI 5 confidence intervl AOR 5 djusted odds rtio Ref. 5 reference group E 5 enlisted W 5 wrrnt officer O 5 officer

6 Mood nd Anxiety Incidence in Ntionl Gurd 619 Figure. Incidence rtes nd 95% confidence intervls of nxiety, mood, nd substnce use disorders per 100 person-yers t risk, Ohio Army Ntionl Gurd (n=528), 2008 through 2012 Error brs indicte 95% confidence intervls. GAD 5 generlized nxiety disorder PTSD 5 posttrumtic stress disorder OCD 5 obsessive-compulsive disorder MDD 5 mjor depressive disorder the militry nd civilin smples; militry popultions re predominntly younger (75% re #35 yers of ge) nd mle (.80%) compred with the U.S. popultion, which is on verge 35 yers of ge nd 51% femle. Both disorders re commonly ssocited with younger ge, nd mle sex is commonly ssocited with AUD. 32,33 Discrepncies in incidence rtes mong studies my lso reflect differentil exposure to predictors of mentl illness. Militry personnel re twice s likely s civilins to hve dverse childhood experiences, including household substnce buse, physicl buse, nd sexul buse, 11 which hve been documented to increse the risk of AUD nd MDD Second, the incidence rtes for AUD, MDD, nd PTSD in our study were consistent with previously published militry rtes. Two previous studies, the Millennium Cohort Study nd the Rediness nd Resilience in Ntionl Gurd Soldiers study, documented first-onset psychitric disorders in the reserve component nd provide useful comprison. Consistent with previous studies, 58% of our smple hd ever deployed. 12 Insofr s deployment is risk fctor for psychitric disorders, the incidence of AUD (5.0%) nd MDD (4.2%) in our study ws similr to the incidence in non-deployed subsmple of the Millennium Cohort Study but lower thn the incidence in deployed subsmple reporting combt exposure in the Millennium Cohort Study 37,38 nd Rediness nd Resilience in Ntionl Gurd Soldiers study. 39 Tht our incidence estimtes were between those of deployed personnel with combt exposure (6.0% for AUD nd 8.2% for MDD) nd without combt exposure (2.8% for AUD nd 2.8% for MDD) 37,38 could be ttributed, in prt, to the helthy wrrior effect, which proposes

7 620 Spotlight on Veterns Helth: After the Wr Tble 3. Bivrible nd multivrible Cox proportionl hzrd models for incident nxiety or mood disorders in smple of Ohio Army Ntionl Gurd members (n=528), United Sttes, 2008 through 2012 Chrcteristic Anxiety or mood disorder Bivrible nlysis HR (95% CI) Multivrible nlysis AHR b (95% CI) Age t bseline 0.98 (0.96, 1.01) 0.98 (0.93, 1.02) Age joining militry 1.00 (0.93, 1.06) 1.01 (0.93, 1.09) Cohort c 2008 smple (bseline) Ref. Ref smple 1.53 (0.69, 3.40) 1.84 (0.72, 4.74) Sex Mle Ref. Ref. Femle 0.90 (0.32, 2.49) 0.99 (0.33, 2.99) Rce/ethnicity Non-Hispnic white Ref. Ref. Non-Hispnic blck 0.84 (0.26, 2.71) 0.90 (0.26, 3.17) Other d 0.61 (0.09, 4.33) 0.41 (0.06, 3.10) Eduction #High school Ref. Ref. Some college 0.86 (0.42, 1.76) 0.83 (0.40, 1.76) $College degree 0.58 (0.24, 1.40) 0.86 (0.30, 2.48) Mritl sttus Single/never mrried Ref. Ref. Mrried 0.89 (0.49, 1.64) 1.28 (0.59, 2.78) Divorced/seprted/ 2.45 (1.07, 5.59) 3.73 (1.47, 9.48) widowed Rnk Enlisted (E1 E9) Ref. Ref. Officer (W1 5/O1 10) 0.48 (0.17, 1.32) 0.61 (0.17, 2.11) Ever deployed No Ref. Ref. Yes 0.77 (0.44, 1.35) 0.65 (0.32, 1.32) Potentilly trumtic events 1.70 (1.02, 2.86) 2.25 (1.11, 4.55) Time-dependent covrites Deployed, pst yer 2.14 (1.07, 4.29) 1.29 (1.00, 1.66) Trumtic event, pst 1.46 (1.01, 2.11) 1.32 (1.10, 1.59) yer Alcohol use disorder Never Ref. Ref. Ever, but not pst yer 1.17 (0.58, 2.36) 1.09 (0.86, 1.38) Pst yer 1.91 (1.00, 3.66) 1.68 (1.35, 2.08) Drug use disorder Never Ref. Ref. Ever, but not pst yer 1.12 (0.47, 2.63) 0.91 (0.65, 1.29) A totl of 89 episodes; 889 person-yers t risk b Adjusted for ll other vribles in the tble c The study smple comprised 500 people who were recruited in 2008 nd 105 people who were recruited in d Includes Americn Indin/Alsk Ntive, Asin Americn/Pcific Islnder, or Hispnic HR 5 hzrd rtio CI 5 confidence intervl AHR 5 djusted hzrd rtio Ref. 5 reference group E 5 enlisted W 5 wrrnt officer tht the militry is more likely to deploy helthier personnel. 40,41 Furthermore, differences my lso be ssocited with the incresed risk of mentl illness fter stressful combt experiences. 42,43 Third, our observtion tht the incidence rte of first-onset PTSD ws 1.2% per yer ws substntilly lower thn previously documented rtes of first-onset PTSD mong soldiers (2.9% 11.3%) The lower rtes reported for PTSD could be ttributed to the different cse definitions used by studies. Among the reserve component, ll previous prospective studies ssessed first-onset disorder, which is mesure combining dt on disorders tht were not present t bseline but were re-ggrvted during follow-up intervl with dt on first-incidence disorders. Becuse bout one in three PTSD cses begin before militry service, 10 nd becuse PTSD hs been documented to be cyclicl in more thn 25% of cses, 47,48 the higher rtes documented in previous studies could be due to re-ggrvted disorders. Fourth, our finding tht previously mrried respondents nd respondents reporting exposure to trumtic lifetime event or pst-yer event hd the highest incidence of nxiety or mood disorder is consistent with existing literture Reltionship issues re common mong militry personnel. 53,54 Although literture exmining the ssocition mong militry stressors, mentl helth, nd reltionship issues 55 exists, the ssocition between these stressors nd the rising rtes of divorce in militry mrriges is uncler. 56,57 Recent studies proposed medition model whereby the ssocition between combt deployment nd reltionship/mritl stisfction is medited by screening positive for PTSD. 39,58 Other studies provided evidence on the interctive effect of PTSD, lcohol misuse, intimte prtner violence, nd reltionship issues mong civilins nd combt veterns. 59,60 Future nlyses re needed to investigte these two hypotheses explining the interreltionships mong trum, mritl disruption, nd mentl illness in militry personnel. Limittions This study hd severl limittions. First, the dt were susceptible to informtion bis. Although bis ginst reporting embrrssing behviors 61 nd the perception of psychitric illness stigm re prevlent in the militry, 62 we compensted for this concern by ssuring prticipnts confidentility, both verblly nd in writing, before volunteering for this study nd by conducting ll ssessments in neutrl loctions using civilin clinicins nd no militry personnel. Second, these findings my not be generlizble to other reservists (e.g., Nvy Reserve) from other sttes or ctive-duty

8 Mood nd Anxiety Incidence in Ntionl Gurd 621 militry personnel. Although the OHARNG popultion is similr in severl key demogrphic nd socil fctors to the U.S. popultion (e.g., proportion of high school grdutes, per-cpit income) 14 nd Ntionl Gurd popultion (e.g., ge, sex, rnk), 15 our study smple hd higher proportion of respondents who were divorced, seprted, or widowed, group shown to be t incresed risk for mood or nxiety disorder. The higher number of divorced, seprted, nd widowed respondents my hve resulted in incresed incidence rtes. Future repliction of findings in other sttes nd components would improve confidence in our findings. CONCLUSION This study is the first to prospectively estimte first incidence of severl psychitric disorders using goldstndrd clinicl interviews in representtive smple of U.S. rmed services members, OHARNG members. Our study dvnces the literture on militry psychitric epidemiology by overcoming limittions of previous studies tht exmined disorder prevlence or first-onset disorders or restricted nlyses to deployed service members. The greter incidence of nxiety nd mood disorders mong previously mrried respondents nd people experiencing lifetime nd pst-yer potentilly trumtic events underscores the need for heightened vigilnce in identifying nd monitoring service members who re experiencing mritl disruptions, prticulrly in reltion to other potentilly trumtic experiences. The mrginl ssocition between pstyer deployment nd first incidence of nxiety or mood disorder suggests tht studies selecting respondents on deployment sttus limit knowledge bout the cusl mechnisms tht contribute to mentl illness burden in the militry. Therefore, future studies should consider deployment experiences s prt of broder set of lifecourse risk fctors tht cn ffect the psychopthology of mentl illness mong service members. This rticle ws supported by Ntionl Institute on Drug Abuse grnt #T32DA [DSF]. This work ws supported by the Office of the Assistnt Secretry of Defense for Helth Affirs through the Joint Wrfighter Medicl Reserch Progrm under Awrd No. W81XWH , W81XWH , nd W81XWH [DSF, MTB, IL, PC, GHC, LS, ES, TG, ND, TF, PLR, JRC, SG]. The U.S. Army Medicl Reserch Acquisition Activity, 820 Chndler Street, Fort Detrick MD , is the wrding nd dministering cquisition office. Opinions, interprettions, conclusions, nd recommendtions re those of the uthors nd re not necessrily endorsed by the Deprtment of Defense. The funding orgniztion reviewed nd pproved the study but hd no role in the design nd conduct of the study; collection, mngement, nlysis, or interprettion of the dt; or preprtion of the rticle. The informtics support for this reserch ws provided by the Michign Stte University Clinicl nd Trnsltion Sciences Institute, through its Biomedicl Reserch Informtics Core. 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