Depression in Entry-Level Military Personnel

Transcription

1 VOLUME 172 AUGUST 2007 NUMBER 8 ORIGINAL ARTICLES Authors alone are responsible for opinions expressed in the contribution and for its clearance through their federal health agency, if required. MILITARY MEDICINE, 172, 8:795, 2007 Depression in Entry-Level Military Personnel Guarantor: MAJ Christopher H. Warner, MC USA Contributors: MAJ Carolynn M. Warner, MC USA*; MAJ Christopher H. Warner, MC USA ; CPT Jill Breitbach, MSC USA ; Maj James Rachal, USAF MC ; MAJ Theresa Matuszak, MC USA ; CAPT Thomas A. Grieger, MC USN Objective: The goal was to determine the prevalence of, and risk factors for, depression in an entry-level U.S. Army population. Method: A cross-sectional survey of U.S. Army soldiers in advanced individual training was performed by using an anonymous self-report survey including demographic data, history (including abuse and psychiatric treatment), and the Patient Health Questionnaire-9. Results: Soldiers in advanced individual training (n 1,184) were approached, and 1,090 (91.2%; 955 male soldiers and 135 female soldiers) voluntarily chose to participate. Eleven percent reported a psychiatric history, 26% reported a history of abuse, and 15.9% endorsed moderate or more severe current depressive symptoms (male, 15.0%; female, 22.2%). A history of psychiatric treatment (odds ratio, 2.08; 95% confidence interval, ; p 0.009) and a history of verbal abuse (odds ratio, 4.11; 95% confidence interval, ; p 0.000) placed soldiers at higher risk for depression. Conclusions: Our study shows a higher than expected rate of depression in entry-level training soldiers and identifies some risk factors for depression. This indicates an important need for further study, effective screening, preventive counseling, and early intervention. *Department of Family Practice, Winn Army Community Hospital, Fort Stewart, GA Third Infantry Division, Fort Stewart, GA st Special Warfare Center and School (Airborne), Fort Bragg, NC Department of Psychiatry, Ehrling Berquist Clinic, Offutt Air Force Base, NE Department of Psychiatry, General Leonard Wood Army Community Hospital, Fort Leonardwood, MO Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD Presented at the 2005 American Psychiatry Association Annual Meeting, May 21 26, 2005, Atlanta, GA. The stated views are those of the authors and do not represent the views or the policy of the Department of Defense. This manuscript was received for review in October The revised manuscript was accepted for publication in March Introduction his study examines general demographic characteristics, T history of preservice sexual, verbal, and physical abuse, previous mental health treatment, and their association with depression in an entry-level, enlisted military population. Depression is a common mood disorder that impairs both social and occupational functioning. The lifetime prevalence rates of depression are 7 to 12% for men and 20 to 25% for women. 1 Despite the increasing public awareness about mental disorders like depression, many individuals with depression are not identified and do not receive treatment. Primary care clinics are the frontlines for early identification and treatment of behavioral health problems. Each year, one in five primary care patients suffers from a mental illness, whereas 50% receive treatment. 2 4 Depression and anxiety disorders are the most common problems, presenting in 25% of all primary care patients. 5 Specifically, mental health disorders represent 9% of all ambulatory care visits to military primary care clinics and are the fifth leading diagnosis in all ambulatory care visits. 6 Accordingly, in 1999, the U.S. Surgeon General called for mental health care to be recognized as a necessary component of good health and well-being. 7 In response, both the World Health Organization and the U.S. Preventive Services Task Force recommended primary care screening of all patients for depression, 8 and many military primary care clinics are now using mental health screening questionnaires to capture symptoms of depression. The military environment presents unique stressors, including potential injury or death, witnessing the loss of human life, prolonged geographic separation from families, living in close quarters with other soldiers, and being unable to communicate with loved ones. A study of soldiers returning from combat in Iraq and Afghanistan showed that 11.4% of the active duty soldiers and Marines were depressed before deployment and that number rose to 15% after deployment. 9 The study also 795

2 796 Depression in Entry-Level Military Personnel showed that individuals who screened positive for mental health disorders were unlikely to directly seek mental health care. 9 Although that study analyzed the impact of deployment on soldiers, few studies have looked at depression in soldiers as they enter the military. Additionally, studies show that military members are twice as likely to feel stigmatized when seeking mental health care, compared with those seeking medical care, 9 which suggests that primary care providers are critical components in ensuring that individuals with mental illness are identified and offered treatment. Most entry-level, active duty, military personnel are in the primary age range placing them at risk for the onset of depression. Detection, monitoring, and treatment of mental health conditions during entry-level training are extremely important, given the increased demands placed on these individuals. If undetected and untreated, mental health conditions can lead to attrition during entry-level training, which can be extremely costly to the government. A Department of Defense report showed that the U.S. government lost 390 million dollars in fiscal year 1996 because of attrition. 10 In a recent study of the psychological well-being of entry-level soldiers in Army basic training, it was noted that the majority of the soldiers scored within the average range on a mental health screen for a primary care setting. 11 That study did not assess psychiatric history or predisposing factors. In a study of Navy recruits, sailors with a family history of mental illness, a family history of alcohol abuse, or a history of psychiatric problems were more likely to develop depression. 12 Similar risk factors for entry-level Army personnel may also predispose soldiers to developing depression. Multiple methods for improving resilience of soldiers and improving adaptation in stressful environments have been reported. Currently, the Army is implementing training programs targeting soldiers returning from deployment. 13 Initial reports on the effectiveness of this training were presented at the 2006 U.S. Army Force Health Protection Conference and suggested that the training is effective in improving adaptation and may be a viable option for utilization at the entry level. This type of training helps soldiers recognize signs and symptoms of stress and depression in themselves and others and decreases the stigma of seeking assistance. Methods After approval by the institutional review board and the local training command, questionnaires were distributed to personnel undergoing advanced individual training (AIT). The training units were approached in formation; all supervisors and training staff members were excused to limit any impression of coercion. The groups were informed of the nature of the study and offered the opportunity to participate. They were informed that they were not required to participate and that there were no negative consequences of not participating. They were provided educational handouts on depression and advised of available mental health resources should they experience distress as a consequence of participating. Individuals who chose not to participate turned in a blank survey, which prevented them from being identified as nonparticipants. Upon completion, the surveys were dropped into a box and sealed until data entry. Consent forms were separate from the completed surveys to ensure anonymity. The survey consisted of basic demographic information (age, gender, ethnicity, highest level of education, height, weight, history of verbal, physical, and sexual abuse, and history of previous mental health treatment) and the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 is a 9-item, self-administered version of the depression module of the Primary Care Evaluation of Mental Disorders. This test assesses the nine diagnostic criteria for depression, on a scale of 0 ( not at all ) to 3 ( nearly every day ). 14 When the test is used as a screening instrument, the individual responses are summed (scale range, 0 34). In validation studies, a score of 10 on the PHQ-9 had a sensitivity of 88% and a specificity of 88% for major depressive disorder, and scores of 5, 10, 15, and 20 were indicative of mild, moderate, moderately severe, and severe depression, respectively. 14 Internal reliability of the PHQ-9 is excellent, with a reliability correlation of 0.89 for primary care patients and 0.86 for obstetrics/gynecology patients. 14 The questionnaire asked participants whether they had ever received mental health treatment before entering the military and whether the treatment was received 1 year before enlistment. Participants were asked to check a box if they had experienced verbal, physical, and/or sexual abuse. No further definitions of the specific nature of the abuse were provided. Statistical analysis was performed by using SPSS version 11 (SPSS, Chicago, Illinois). For analysis, age was converted to a categorical variable ( 20 years versus 20 years). Race was examined in three ways, that is, Caucasian versus all others, African American versus all others, and Hispanic versus all others. Education level was examined as high school equivalent or less versus some college or college degree. Analyses of risk factors for PHQ-9 scores of 10 were assessed by using logistic regression analysis. Age, gender, race, education, previous sexual abuse, previous verbal abuse, previous physical abuse, and previous mental health treatment were first examined individually, using single-variable logistic regression. To control for the effect of each variable against the others, all variables were then examined together in multivariate logistic regression analyses. Odds ratios, 95% confidence intervals, and p values are reported. Results Of the 1,184 service members approached, 91.2% (n 1090) voluntarily chose to participate. The mean age of the participants was 20.9 years (SD, 3.53 years), with a range of 17 to 37 years. The population was predominantly male (87.6%) and Caucasian (64.2%) and had a high school equivalent or lower education (69.8%). Full demographic data are outlined in Table I. A summary of the survey results is outlined in Table II. Nearly 16% of all respondents cited levels of depressive symptoms consistent with major depressive disorder. Figure 1 outlines a distribution of the severity of depression. More than one-third of all respondents cited at least some level of depressive symptoms. Figure 2 shows the distribution of depressive severity according to gender. More than one-fourth of the participants cited a history of verbal abuse, and nearly one of every 20

3 Depression in Entry-Level Military Personnel 797 TABLE I DEMOGRAPHIC DATA Total Male Female No. of study (87.6%) 135 (12.4%) participants Age, mean SD (years) Race (%) Hispanic American Indian/Alaskan Asian Hawaiian/Pacific Islander African American Caucasian Education level (%) Grade school GED High school Some college College degree GED, general equivalency diploma. TABLE II SUMMARY OF SURVEY RESULTS Total Male Female Psychiatric history (%) History of verbal abuse (%) History of physical abuse (%) History of sexual abuse (%) PHQ-9 score, mean SD Moderate depression (PHQ-9 score of 10) (%) Fig. 1. Depression in active duty soldiers in AIT. participants noted a history of sexual abuse. Figure 3 shows the distribution of abuse history according to gender. Single-variable analysis showed an increased risk of moderate or more severe depression in soldiers with a history of previous psychiatric treatment and a history of verbal or physical abuse. There were no associations between moderate or more severe depression and gender, education level, race, or a history of sexual abuse. When all variables were analyzed together, to control for the effect of each against the others, only a history of psychiatric treatment and a history of verbal Fig. 2. Depression in active duty soldiers in AIT according to gender. Fig. 3. History of reported abuse according to gender. abuse remained significant for increased risk of moderate depression (Table III). Discussion Rates of depression were higher than expected when compared with the normal population, with more than one-third of all respondents citing at least some level of depressive symptoms. More than 15% of male subjects and 22% of female subjects endorsed items on the PHQ-9 that suggest moderate/ severe depression (scores of 10). These rates suggest that depression in entry-level male respondents may be higher than the lifetime prevalence rate found in the general population (7 12%) and the rate of depression in female soldiers is similar to the lifetime prevalence rate in the general population (20 25%). Although lifetime rates of depression are higher for women in the general population, there were no significant relationships found in this study sample when gender, race, and educational history were examined as risk factors for depression. Verbal abuse was the most frequently endorsed category of abuse (46.7% of female subjects and 22.4% of male subjects). One-third (33.3%) of female subjects and 12.6% of male subjects reported a history of physical abuse. Nearly one-fourth (24.4%) of the female soldiers and 3.2% of the male soldiers reported a history of sexual abuse. These findings are consistent with previous sexual abuse studies in the general population, which reported prevalence rates ranging from 10 to 34% for female subjects and up to 5% for male subjects, 15 17

4 798 Depression in Entry-Level Military Personnel TABLE III ASSOCIATIONS BETWEEN PROBABLE DEPRESSION AND DEMOGRAPHIC AND HISTORICAL VARIABLES EXAMINED INDIVIDUALLY Odds Ratio 95% Confidence Interval Single-variable analysis Female gender Caucasian race African American race Hispanic race Higher education Multivariate demographic analysis Female gender Caucasian race African American race Hispanic race Higher education Single-variable analysis Psychiatric history a History of verbal abuse a History of physical abuse a History of sexual abuse Multivariate analysis with demographic data Female gender Caucasian race African American race Hispanic race Higher education Psychiatric history a History of verbal abuse a History of physical abuse History of sexual abuse a Significant relationship. but are somewhat lower than previously reported rates of 35% for sexual abuse and 57% for physical abuse in female Navy recruits. 18 When examined individually, histories of verbal and physical abuse increased the risk for depression. When analyzed with multiple variables, however, only verbal abuse was associated with increased risk. This might be a consequence of soldiers perception of treatment they receive during AIT. Physical and sexual abuse would not generally be common in the controlled environment of AIT. Redirection or correction comments by instructors or others in a position of authority could be perceived as a recurrence of the verbal abuse experienced before entry into military service. One in 10 respondents reported previous mental health treatment, similar to the rates of previous psychiatric treatment found in Navy recruits (12%). 18 Rates of treatment were higher for female subjects (20%), compared with male subjects (9.5%), consistent with reported rates of abuse. As might be expected, psychiatric history was significant as a risk factor for the development of depression. The stress of military training may expose vulnerabilities and weaken adaptive defensive strategies in individuals who previously were not experiencing active symptoms of depression. Military trainees with elevated rates of depression can develop p adaptive strategies and experience symptom reduction through the course of basic training. 11 However, the current study demonstrates even higher rates of possible depression than seen in other training settings. This suggests that AIT may represent a key soldier developmental milestone. With this in mind, specific training and early identification of individuals with predisposing factors might improve adjustment, decrease depression, reduce attrition, and increase combat readiness. Gathering data on history of abuse and previous mental health treatment may be a useful adjunct for depression screening in primary care settings. Because many soldiers may elect to omit information that could potentially bar them from entering the military, it may be best to perform screening during basic training or AIT. In view of the stigma associated with formal mental health encounters, primary care providers may have the best opportunity to perform screening and to provide appropriate treatment or referral. This study is limited in that it is a cross-sectional, self-report survey of a convenience sample. In an environment of high stress, endorsement of depressive symptoms at high levels may represent difficulty adjusting to the situation, rather than major depression. Although the survey was anonymous, some individuals might have been concerned about potential identification and might have reported lower rates of symptoms. The questions used to determine previous mental health treatment and verbal, physical, and sexual abuse have not been validated against clinical interviews, and their psychometric properties are not known. The age of occurrence, nature, and duration of reported abuse were not assessed. This was not a diagnostic survey but, rather, a measure of the possible prevalence of depression in entry-level Army personnel. Determining clear rates of depression would have required formal diagnostic interviews and would have sacrificed anonymity. Finally, the study was conducted among entry-level military personnel, and the findings cannot be applied to the general population. Conclusions This is a large-scale assessment of depression symptoms using a well-validated screening instrument and directed solely at entry-level enlisted personnel. The findings demonstrate that high levels of depressive symptoms are common in this population, and they suggest that a history of verbal abuse and previous psychiatric treatment are predictive of increased risk for depression in this population. Previous research demonstrated higher-than-expected levels of psychiatric illness, such as depression, in military personnel, particularly those returning from deployment 9 and in basic training. 11 This study poses some interesting questions regarding rates of psychiatric illness in the entry-level military population. Given that a psychiatric history is known to place individuals at increased risk for developing subsequent psychiatric problems, this study clearly indicates that military personnel with a history of previous mental health treatment may be at greater risk for depression. Given the known stress of deployment, 9 consistent, effective, and efficient assessment and treatment of the mental health of soldiers is imperative. Educational and outreach programs, coupled with primary care screening, may be of benefit in pursuing these objectives. Early detection of depression, using simple validated measures such as the

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