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1.  The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
Psychiatry  2014;77(2):107-119.
Although the suicide rate in the U.S. Army has traditionally been below age-gender matched civilian rates, it has climbed steadily since the beginning of the Iraq and Afghanistan conflicts and since 2008 has exceeded the demographically matched civilian rate. The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent epidemiological and neurobiological study designed to generate actionable evidence-based recommendations to reduce Army suicides and increase knowledge about risk and resilience factors for suicidality and its psychopathological correlates. This paper presents an overview of the Army STARRS component study designs and of recent findings.
Army STARRS includes six main component studies: (1) the Historical Administrative Data Study (HADS) of Army and Department of Defense (DoD) administrative data systems (including records of suicidal behaviors) for all soldiers on active duty 2004–2009 aimed at finding administrative record predictors of suicides; (2) retrospective case-control studies of fatal and nonfatal suicidal behaviors (each planned to have n = 150 cases and n = 300 controls); (3) a study of new soldiers (n = 50,765 completed surveys) assessed just before beginning basic combat training (BCT) with self-administered questionnaires (SAQ), neurocognitive tests, and blood samples; (4) a cross-sectional study of approximately 35,000 (completed SAQs) soldiers representative of all other (i.e., exclusive of BCT) active duty soldiers; (5) a pre-post deployment study (with blood samples) of soldiers in brigade combat teams about to deploy to Afghanistan (n = 9,421 completed baseline surveys), with sub-samples assessed again one, three, and nine months after returning from deployment; and (6) a pilot study to follow-up SAQ respondents transitioning to civilian life. Army/DoD administrative data are being linked prospectively to the large-scale survey samples to examine predictors of subsequent suicidality and related mental health outcomes.
Main outcome measures
Measures (self-report and administratively recorded) of suicidal behaviors and their psychopathological correlates.
Component study cooperation rates are comparatively high. Sample biases are relatively small. Inefficiencies introduced into parameter estimates by using nonresponse adjustment weights and time-space clustering are small. Initial findings show that the suicide death rate, which rose over 2004–2009, increased for those deployed, those never deployed, and those previously deployed. Analyses of administrative records show that those deployed or previously deployed were at greater suicide risk. Receiving a waiver to enter the Army was not associated with increased risk. However, being demoted in the past two years was associated with increased risk. Time in current deployment, length of time since return from most recent deployment, total number of deployments, and time interval between most recent deployments (known as dwell time) were not associated with suicide risk. Initial analyses of survey data show that 13.9% of currently active non-deployed regular Army soldiers considered suicide at some point in their lifetime, while 5.3% had made a suicide plan, and 2.4% had attempted suicide. Importantly, 47–60% of these outcomes first occurred prior to enlistment. Prior mental disorders, in particular major depression and intermittent explosive disorder, were the strongest predictors of these self-reported suicidal behaviors. Most onsets of plans-attempts among ideators (58.3–63.3%) occurred within the year of onset of ideation. About 25.1% of non-deployed U.S. Army personnel met 30-day criteria for a DSM-IV anxiety, mood, disruptive behavior, or substance disorder (15.0% an internalizing disorder; 18.4% an externalizing disorder) and 11.1% for multiple disorders. Importantly, three-fourths of these disorders had pre-enlistment onsets.
Integration across component studies creates strengths going well beyond those in conventional applications of the same individual study designs. These design features create a strong methodological foundation from which Army STARRS can pursue its substantive research goals. The early findings reported here illustrate the importance of the study and its approach as a model of studying rare events particularly of national security concern. Continuing analyses of the data will inform suicide prevention for the U.S. Army.
PMCID: PMC4075436  PMID: 24865195
2.  The Reliability and Validity of the Self-Reported Drinking Measures in the Army’s Health Risk Appraisal Survey 
The reliability and validity of self-reported drinking behaviors from the Army Health Risk Appraisal (HRA) survey are unknown.
We compared demographics and health experiences of those who completed the HRA with those who did not (1991–1998). We also evaluated the reliability and validity of eight HRA alcohol-related items, including the CAGE, weekly drinking quantity, and drinking and driving measures. We used Cohen’s κ and Pearson’s r to assess reliability and convergent validity. To assess criterion (predictive) validity, we used proportional hazards and logistical regression models predicting alcohol-related hospitalizations and alcohol-related separations from the Army, respectively.
A total of 404,966 soldiers completed an HRA. No particular demographic group seems to be over- or underrepresented. Although few respondents skipped alcohol items, those who did tended to be older and of minority race. The alcohol items demonstrate a reasonable degree of reliability, with Cronbach’s α = 0.69 and test-retest reliability associations in the 0.75–0.80 range for most items over 2- to 30-day interims between surveys. The alcohol measures showed good criterion-related validity: those consuming more than 21 drinks per week were at 6 times the risk for subsequent alcohol-related hospitalization versus those who abstained from drinking (hazard ratio, 6.36; 95% confidence interval=5.79, 6.99). Those who said their friends worried about their drinking were almost 5 times more likely to be discharged due to alcoholism (risk ratio, 4.9; 95% confidence interval=4.00, 6.04) and 6 times more likely to experience an alcohol-related hospitalization (hazard ratio, 6.24; 95% confidence interval=5.74, 6.77).
The Army’s HRA alcohol items seem to elicit reliable and valid responses. Because HRAs contain identifiers, alcohol use can be linked with subsequent health and occupational outcomes, making the HRA a useful epidemiological research tool. Associations between perceived peer opinions of drinking and subsequent problems deserve further exploration.
PMCID: PMC2141695  PMID: 12766628
Alcohol; Military; Reliability; Validity; Survey
3.  Predictors of Suicide and Accident Death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
JAMA psychiatry  2014;71(5):493-503.
The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent study designed to generate actionable recommendations to reduce Army suicides and increase knowledge of risk and resilience factors for suicidality.
To present data on prevalence, trends, and basic sociodemographic and Army experience correlates of suicides and accident deaths among active duty Regular Army soldiers between January 1, 2004, and December 31, 2009, and thereby establish a foundation for future Army STARRS investigations.
Analysis of trends and predictors of suicide and accident deaths using Army and Department of Defense administrative data systems. Participants were all members of the US Regular Army serving at any time between 2004 and 2009.
Death by suicide or accident during active Army service.
The suicide rate rose between 2004 and 2009 among never deployed and currently and previously deployed Regular Army soldiers. The accident death rate fell sharply among currently deployed soldiers, remained constant among the previously deployed, and trended upward among the never deployed. Increased suicide risk was associated with being a man (or a woman during deployment), white race/ethnicity, junior enlisted rank, recent demotion, and current or previous deployment. Sociodemographic and Army experience predictors were generally similar for suicides and accident deaths. Time trends in these predictors and in the Army’s increased use of accession waivers (which relaxed some qualifications for new soldiers) do not explain the rise in Army suicides.
Predictors of Army suicides were largely similar to those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. The existence of a time trend in suicide risk among never-deployed soldiers argues indirectly against the view that exposure to combat-related trauma is the exclusive cause of the increase in Army suicides.
PMCID: PMC4124912  PMID: 24590048
4.  Design of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi-component epidemiological and neurobiological study designed to generate actionable evidence-based recommendations to reduce U.S. Army suicides and increase basic knowledge about the determinants of suicidality. This report presents an overview of the designs of the six component Army STARRS studies. These include: an integrated study of historical administrative data systems (HADS) designed to provide data on significant administrative predictors of suicides among the more than 1.6 million soldiers on active duty in 2004–2009; retrospective case-control studies of suicide attempts and fatalities; separate large-scale cross-sectional studies of new soldiers (i.e., those just beginning Basic Combat Training [BCT], who completed self-administered questionnaires [SAQ] and neurocognitive tests and provided blood samples) and soldiers exclusive of those in BCT (who completed SAQs); a pre-post deployment study of soldiers in three Brigade Combat Teams about to deploy to Afghanistan (who completed SAQs and provided blood samples) followed multiple times after returning from deployment; and a platform for following up Army STARRS participants who have returned to civilian life. DoD/Army administrative data records are linked with SAQ data to examine prospective associations between self-reports and subsequent suicidality. The presentation closes with a discussion of the methodological advantages of cross-component coordination.
PMCID: PMC3992857  PMID: 24318217
Suicide; mental disorders; U.S. Army; epidemiologic research design; design effects; sample bias; sample weights; survey design efficiency; survey sampling
5.  Field procedures in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi-component epidemiological and neurobiological study of unprecedented size and complexity designed to generate actionable evidence-based recommendations to reduce U.S. Army suicides and increase basic knowledge about determinants of suicidality by carrying out coordinated component studies. A number of major logistical challenges were faced in implementing these studies. The current report presents an overview of the approaches taken to meet these challenges, with a special focus on the field procedures used to implement the component studies. As detailed in the paper, these challenges were addressed at the onset of the initiative by establishing an Executive Committee, a Data Coordination Center (the Survey Research Center [SRC] at the University of Michigan), and study-specific design and analysis teams that worked with staff on instrumentation and field procedures. SRC staff, in turn, worked with the Office of the Deputy Under Secretary of the Army (ODUSA) and local Army Points of Contact (POCs) to address logistical issues and facilitate data collection. These structures, coupled with careful fieldworker training, supervision, and piloting contributed to the major Army STARRS data collection efforts having higher response rates than previous large-scale studies of comparable military samples.
PMCID: PMC3992884  PMID: 24038395
Suicide; mental disorders; U.S. Army; epidemiologic research design; design effects; sample bias; sample weights; survey design efficiency; survey sampling
6.  Returning home: forced conscription, reintegration, and mental health status of former abductees of the Lord's Resistance Army in northern Uganda 
BMC Psychiatry  2009;9:23.
Since the late 1980s, the Lord's Resistance Army (LRA), a spiritualist rebel group in northern Uganda, has killed and mutilated thousands of civilians and abducted an estimated 52,000 to 75,000 people to serve as soldiers, porters, and sex slaves for its commanders. This study examines the types of violence to which former abductees have been exposed and the extent to which these acts have affected their psychological well-being.
This is a cross-sectional study of 2,875 individuals selected through a multi-stage stratified cluster sampling design conducted in 8 districts of northern Uganda. Multivariate logistic regressions were performed with symptoms for Post-traumatic Stress Disorder (PTSD) and depression as the main outcome measures.
One-third of the respondents (33%) self-reported having experienced abduction (49% among the Acholi, the largest tribal group in northern Uganda). Over half (56%) of all the respondents and over two-thirds of those who experienced abduction met the criteria for symptoms of post-traumatic stress disorder (PTSD). Multivariate analysis shows that several factors increased the risk of former LRA abductees developing symptoms of PTSD. These factors included gender (females were more susceptible than males), being a member of the Acholi ethnic group, participating in or witnessing a cumulative number of traumatic events, and encountering difficulties re-integrating into communities after abduction. Factors associated with increased risk of meeting criteria for symptoms of depression included older age of males at the time of abduction, lower score on social relationship scale, high incidence of general traumatic event exposure, high incidence of forced acts of violence, and problems reintegrating into communities after abduction.
Abduction and forced conscription of civilians has affected the psychological well-being of a significant number of northern Ugandans. The sources of psychological trauma are multiple, ranging from witnessing to being forced to commit violent acts, and compounded by prolonged exposure to violence, often for months or years. Community-based mental health care services and reintegration programs are needed to facilitate the reintegration of former abductees back into their communities.
PMCID: PMC2693494  PMID: 19445689
7.  Quality of Life and Affective Well-Being in Middle-Aged and Older People with Chronic Medical Illnesses: A Cross-Sectional Population Based Study 
PLoS ONE  2011;6(4):e18952.
There has been considerable research into the impact of chronic illness on health-related quality of life. However, few studies have assessed the impact of different chronic conditions on general quality of life (QOL). The objective of this paper was to compare general (rather than health-related) QOL and affective well-being in middle aged and older people across eight chronic illnesses.
Methods and Findings
This population-based, cross-sectional study involved 11,523 individuals aged 50 years and older, taking part in wave 1 of the English Longitudinal Study of Ageing. General QOL was assessed using the CASP-19, happiness was evaluated using two items drawn from the GHQ-12, and depression was measured with the CES-D. Analysis of covariance and logistic regression, adjusting for age, gender and wealth, were performed. General QOL was most impaired in people with stroke (mean 37.56, CI 36.73–38.39), and least in those reporting cancer (mean 41.78, CI 41.12–42.44, respectively), compared with no illness (mean 44.15, CI 43.92–44.39). Stroke (mean 3.65, CI 3.58–3.73) was also associated with the greatest reduction in positive well-being whereas diabetes (mean 3.81, CI 3.76–3.86) and cancer were least affected (3.85, CI 3.79–3.91), compared with no illness (mean 3.97, CI 3.95–4.00). Depression was significantly elevated in all conditions, but was most common in chronic lung disease (OR 3.04, CI 2.56–3.61), with more modest elevations in those with osteoarthritis (OR 2.08, CI 1.84–2.34) or cancer (OR 2.07, CI 1.69–2.54). Multiple co-morbidities were associated with greater decrements in QOL and affective well-being.
The presence of chronic illness is associated with impairments in broader aspects of QOL and affective well-being, but different conditions vary in their impact. Further longitudinal work is needed to establish the temporal links between chronic illness and impairments in QOL and affective well-being.
PMCID: PMC3084723  PMID: 21559485
8.  Prolonged sedentary time and physical activity in workplace and non-work contexts: a cross-sectional study of office, customer service and call centre employees 
To examine sedentary time, prolonged sedentary bouts and physical activity in Australian employees from different workplace settings, within work and non-work contexts.
A convenience sample of 193 employees working in offices (131), call centres (36) and customer service (26) was recruited. Actigraph GT1M accelerometers were used to derive percentages of time spent sedentary (<100 counts per minute; cpm), in prolonged sedentary bouts (≥20 minutes or ≥30 minutes), light-intensity activity (100–1951 cpm) and moderate-to-vigorous physical activity (MVPA; ≥1952 cpm). Using mixed models adjusted for confounders, these were compared for: work days versus non-work days; work hours versus non-work hours (work days only); and, across workplace settings.
Working hours were mostly spent sedentary (77.0%, 95%CI: 76.3, 77.6), with approximately half of this time accumulated in prolonged bouts of 20 minutes or more. There were significant (p<0.05) differences in all outcomes between workdays and non-work days, and, on workdays, between work- versus non-work hours. Results consistently showed “work” was more sedentary and had less light-intensity activity, than “non-work”. The period immediately after work appeared important for MVPA. There were significant (p<0.05) differences in all sedentary and activity outcomes occurring during work hours across the workplace settings. Call-centre workers were generally the most sedentary and least physically active at work; customer service workers were typically the least sedentary and the most active at work.
The workplace is a key setting for prolonged sedentary time, especially for some occupational groups, and the potential health risk burden attached requires investigation. Future workplace regulations and health promotion initiatives for sedentary occupations to reduce prolonged sitting time should be considered.
PMCID: PMC3546308  PMID: 23101767
Occupational sitting; Active time; Workers; Leisure-time
9.  Recurrent Dislocation of the Shoulder Joint 
Dr. Anthony F. DePalma is shown. Photograph provided with kind permission of the Art Committee of Thomas Jefferson University, Philadelphia, PA.
Dr. DePalma was the first editor of Clinical Orthopaedics and Related Research, established by the recently formed Association of Bone and Joint Surgeons. The idea of forming the Association of Bone and Joint surgeons had been conceived by Dr. Earl McBride of Oklahoma City in 1947, and organized by a group of twelve individuals (Drs. Earl McBride, Garrett Pipkin, Duncan McKeever, Judson Wilson, Fritz Teal, Louis Breck, Henry Louis Green, Howard Shorbe, Theodore Vinke, Paul Williams, Eugene Secord, and Frank Hand) [9]. The first organizational meeting was held in conjunction with the 1949 Annual Meeting of the AAOS [9] and the first annual meeting held April 1–2, 1949 in Oklahoma City. Drs. McBride and McKeever invited Dr. DePalma to attend that meeting and join the society. According to DePalma, “Even at this small gathering, there were whisperings of the need of another journal to provide an outlet for the many worthy papers written on clinical and basic science subjects” [7]. The decision to form a new journal was finalized in 1951, and Drs. DePalma and McBride signed a contract with J.B. Lippincott Company. Dr. DePalma was designated Editor-in-Chief, and the journal became a reality in 1953 with the publication of the first volume. From the outset he established the “symposium” as a unique feature, in which part of the articles were devoted to a particular topic. Dr. DePalma served as Editor for 13 years until 1966, when he resigned the position and recommended the appointment of Dr. Marshall R. Urist. At his retirement, Clinical Orthopaedics and Related Research was well established as a major journal.
Dr. Anthony F. DePalma was born in Philadelphia in 1904, the son of immigrants from Alberona in central Foggia, Italy [1]. He attended the University of Maryland for his premedical education, then Jefferson Medical College, from which he graduated in 1929. He then served a two-year internship (common at the time) at Philadelphia General Hospital. Jobs were scarce owing to the Depression, and he felt fortunate to obtain in 1931 a position as assistant surgeon at the Coaldale State Hospital, in Coaldale, Pennsylvania, a mining town. However, he became attracted to orthopaedics and looked for a preceptorship (postgraduate training in specialties was not well developed at this time before the establishments of Boards). In the fall of 1932, he was appointed as a preceptor at the New Jersey Orthopaedic Hospital, an extension of the New York Orthopaedic Hospital. In 1939 he acquired Board certification (the first board examination was offered in 1935 for a fee of $25.00 [2]) and was appointed to the NJOH staff [1].
Dr. DePalma volunteered for military service in 1942, and served first at the Parris Island Naval Hospital in South Carolina, then on the Rixey, a hospital ship. In addition to serving to evacuate casualties to New Zealand, his ship was involved in several of the Pacific island assaults (Guam, Leyte, Okinawa). In 1945, he was assigned to the Naval Hospital in Philadelphia [1].
On his return to Philadelphia, he contacted staff members at Jefferson Medical College, including the Chair, Dr. James Martin, and became good friends with Dr. Bruce Gill (a professor of Orthopaedics at the University of Pennsylvania, and one of the earliest Presidents of the AAOS). After he was discharged from the service, he joined the staff of the Department of Orthopaedic Surgery at Jefferson, where he remained the rest of his career. He succeeded Dr. Martin as Chair in 1950, a position he held until 1970 when he reached the mandatory retirement age of 65. He closed his practice and moved briefly to Pompano Beach, Florida, but the lure of academia proved too powerful, and in January, 1971, he accepted the offer to develop a Division of Orthopaedics at the New Jersey College of Medicine and became their Chair. He committed to a five-year period, and then again moved to Pompano Beach, only to take the Florida State Boards and open a private practice in 1977. His practice grew, and he continued that practice until 1983 at the age of nearly 79. Even then he continued to travel and lecture [1].
We reproduce here four of his many contributions on the shoulder. The first comes from his classic monograph, “Surgery of the Shoulder,” published by J. B. Lippincott in 1950 [2]. In this article he describes the evolutionary development of the shoulder, focusing on the distinction between various primates, and relates the anatomic changes to upright posture and prehensile requirements. The remaining three are journal articles related to frozen shoulder [1], recurrent dislocation [3], and surgical anatomy of the rotator cuff [6], three of the most common shoulder problems then and now. He documented the histologic inflammation and degeneration in various tissues including the coracohumeral ligaments, supraspinatus tendon, bursal wall, subscapularis musculotendinous junction, and biceps tendon. Thus, the problem was rather more global than localized. He emphasized, “Manipulation of frozen shoulders is a dangerous and futile procedure.” For recurrent dislocation he advocated the Magnuson procedure (transfer of the subscapularis tendon to the greater tuberosity) to create a musculotendinous sling. All but two of 23 patients he treated with this approach were satisfied with this relatively simple procedure. (Readers will note the absence of contemporary approaches to ascertain outcomes and satisfaction. The earliest outcome musculoskeletal measures were introduced in the 60s by Larson [11] and then by Harris [10], but these instruments were physician-generated and do not reflect the rather more rigorously validated patient-generated outcome measures we use today. Nonetheless, the approach used by Dr. DePalma reflected the best existing standards of reporting results.) Dr. DePalma’s classic article, “Surgical Anatomy of the Rotator Cuff and the Natural History of Degenerative Periarthritis,” [6] reflected his literature review and dissections of 96 shoulders from 50 individuals “unaware of any (shoulder) disability” and mostly over the age of 40. By the fifth decade, most specimens began to show signs of rotator cuff tearing and he found complete tears in nine specimens from “the late decades.” He concluded,
“Based on the…observations, one can reasonably construct the natural history of periarthritis of the shoulder. It is apparent that aging is an important etiological factor, and with aging certain changes take place in the connective tissue elements of the musculotendinous cuff…it is also apparent that in slowly developing lesions of this nature compensating adjustments in the mechanics of the joint take place so that severe alterations in the mechanics of the joint do not appear. However, one must admit that such a joint is very vulnerable and, if subjected to minor trauma, the existing degenerative lesion would be extended and aggravated.”
Thus, he clearly defined the benign effects of rotator cuff tear in many aging individuals, but also the potential to create substantial pain and disability.
Dr. DePalma was a prolific researcher and writer. In addition to his “Surgery of the Shoulder,” he wrote three other books, “Diseases of the Knee: Management in Medicine and Surgery” (published by J.B. Lippincott in 1954) [4], “The Management of Fractures and Dislocations” (a large and comprehensive two volume work published by W.B. Saunders in 1959, and going through 5 reprintings) [5], and “The Intervertebral Disc” (published by W.B. Saunders in 1970, and written with his colleague, Dr. Richard Rothman) [8]. PubMed lists 62 articles he published from 1948 until 1992.
We wish to pay tribute to Dr. DePalma for his vision in establishing Clinical Orthopaedics and Related Research as a unique journal and for his many contributions to orthopaedic surgery.
DePalma A. Loss of scapulohumeral motion (frozen shoulder). Ann Surg. 1952;135:193–204.DePalma AF. Origin and comparative anatomy of the pectoral limb. In: DePalma AF, ed. Surgery of the Shoulder. Philadelphia: JB Lippincott; 1950:1–14.DePalma AF. Recurrent dislocation of the shoulder joint. Ann Surg. 1950;132:1052–1065.DePalma AF. Diseases of the Knee: Management in Medicine and Surgery. Philadelphia, PA: JB Lippincott Company; 1954.DePalma AF. The Management of Fractures and Dislocations—An Atlas. Philadelphia: WB Saunders Company; 1959.DePalma AF. Surgical anatomy of the rotator cuff and the natural history of degenerative periarthritis. Surg Clin North Am. 1963;43:1507–1520.DePalma AF. A lifetime of devotion to the Janus of orthopedics. Bridging the gap between the clinic and laboratory. Clin Orthop Relat Res. 1991;265:146–169.DePalma AF, Rothman RH. The Intervertebral Disc. Philadelphia: WB Saunders Company; 1970.Derkash RS. History of the Association of Bone and Joint Surgeons. Clin Orthop Relat Res. 1997;337:306–309.Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737–755.Larson CB. Rating scale for hip disabilities. Clin Orthop Relat Res. 1963;31:85–93.
PMCID: PMC2505210  PMID: 18264840
10.  The Health of the American Slave Examined by Means of Union Army Medical Statistics 
The health status of the American slave in the 19th century remains unclear despite extensive historical research. Better knowledge of slave health would provide a clearer picture of the life of the slave, a better understanding of the 19th-century medicine, and possibly even clues to the health problems of modern blacks. This article hopes to contribute to the literature by examining another source of data. Slaves entering the Union Army joined an organization with standardized medical care that generated extensive statistical information. Review of these statistics answers questions about the health of young male blacks at the time American slavery ended.
PMCID: PMC2561819  PMID: 3881595
11.  Demographic, Physical, and Mental Health Factors Associated with Deployment of U.S. Army Soldiers to the Persian Gulf 
Military medicine  2000;165(10):762-772.
A total of 675,626 active duty Army soldiers who were known to be at risk for deployment to the Persian Gulf were followed from 1980 through the Persian Gulf War. Hospitalization histories for the entire cohort and Health Risk Appraisal surveys for a subset of 374 soldiers were used to evaluate prewar distress, health, and behaviors. Deployers were less likely to have had any prewar hospitalizations or hospitalization for a condition commonly reported among Gulf War veterans or to report experiences of depression/suicidal ideation. Deployers reported greater satisfaction with life and relationships but displayed greater tendencies toward risk-taking, such as drunk driving, speeding, and failure to wear safety belts. Deployed veterans were more likely to receive hazardous duty pay and to be hospitalized for an injury than nondeployed Gulf War-era veterans. If distress is a predictor of postwar morbidity, it is likely attributable to experiences occurring during or after the war and not related to prewar exposures or health status. Postwar excess injury risk may be explained in part by a propensity for greater risk-taking, which was evident before and persisted throughout the war.
PMCID: PMC2141685  PMID: 11050874
12.  Rationale and Methods of the Substance Use and Psychological Injury Combat Study (SUPIC): A Longitudinal Study of Army Service Members Returning from Deployment in FY2008–2011 
Substance use & misuse  2013;48(10):863-879.
SUPIC will examine whether early detection and intervention for post-deployment problems among Army Active Duty and National Guard/Reservists returning from Iraq or Afghanistan are associated with improved long-term substance use and psychological outcomes. This paper describes the rationale and significance of SUPIC, and presents demographic and deployment characteristics of the study sample (N=643,205), and self-reported alcohol use and health problems from the subsample with matched post-deployment health assessments (N=487,600). This longitudinal study aims to provide new insight into the long-term post-deployment outcomes of Army members by combining service member data from the Military Health System and Veterans Health Administration.
PMCID: PMC3793632  PMID: 23869459
Military Health System; deployment; observational study design; outcomes; urinanalysis; active duty; National Guard/Reservists; veterans; alcohol use disorder; posttraumatic stress disorder; depression
13.  Serosurvey and Observational Study of US Army Veterinary Corps Officers for Q Fever Antibodies from 1989 to 2008 
Zoonoses and Public Health  2013;61(4):271-282.
Since World War II, the military has experienced outbreaks of Q fever among deploying units including recent case reports of Q fever in US military personnel returning from serving in the Middle East during Operation Iraqi Freedom and Operation Enduring Freedom. Occupational exposure and prevalence of Q fever among US Army Veterinary Corps officers have not been examined. A retrospective serosurvey and observational study of 500 military veterinarians were conducted using archived serum specimens from military veterinarians who entered and served between 1989 and 2008 and were tested for exposure to Coxiella burnetii. Corresponding longitudinal health-related, demographic, medical and deployment data were examined. A total of 69 (13.8%) individuals at military entry and 85 (17%) had late career positive titres. A total of 18 (3.6%) individuals showed seroconversion. Women were more likely to be seropositive after military service [prevalence ratio (PR) 1.96; 95% confidence interval (CI) 1.15–3.35] and were also more likely to seroconvert (incidence rate ratio 3.55; 95% CI 1.19–12.7). Women who deployed to Operation Iraqi Freedom were more likely to be seropositive (PR 3.17; 95% CI 1.03–9.71). Veterinarians with field service and pathology specialties had the highest incidence rates (7.0/1000 PY; 95% CI 4–12 and 3–19, respectively). This is the first report documenting US military veterinarians' exposure to C. burnetii. Military veterinarians are at risk prior to service, with moderate number of new cases developing during service and most maintaining titres for long periods of time. Women consistently demonstrated higher seroprevalence and incidence levels. As increasing numbers of women enter the veterinary profession and subsequently the US Army, this may warrant close monitoring. This study likely underestimates exposure and risk and does not address chronic health effects, which may be valuable to explore in future health studies.
PMCID: PMC4171783  PMID: 23859558
Q fever; Coxiella burnetii; military; veterinarian; zoonoses; serosurvey
14.  Behavioral Health Competence: An Exploration of Army Reserve Occupational Therapists 
The behavioral health competence of Army Reserve Occupational Therapists (OT) was examined by electronic survey to determine current levels of competence and highlight pre-deployment training needs. Results indicated that while Army Reserve OTs report high levels of behavioral health competence, many questions regarding diagnosis, assessment, evaluation, treatment planning, intervention, and progress arose throughout deployment. OT’s often relied on skills from Level II fieldwork education and entry-level didactic education for competency. Perceived competencies may be compromised by curriculum changes in entry-level education, available fieldwork settings, and a lack of adequate training currently available prior to deployment.
PMCID: PMC4215552  PMID: 25368437
Army Reserve; behavioral health care; mental health; competence; fieldwork
15.  Cross-sectional assessment of prevalence and correlates of blood-borne and sexually-transmitted infections among Afghan National Army recruits 
BMC Infectious Diseases  2012;12:196.
Few data are available in Afghanistan to shape national military force health practices, particularly with regard to sexually-transmitted infections (STIs). We measured prevalence and correlates of HIV, syphilis, herpes simplex 2 virus (HSV-2), and hepatitis C virus (HCV) among Afghan National Army (ANA) recruits.
A cross-sectional sample of male ANA recruits aged 18–35 years were randomly selected at the Kabul Military Training Center between February 2010 and January 2011. Participants completed an interviewer-administered questionnaire and serum-based rapid testing for syphilis and hepatitis C virus antibody on-site; HIV and HSV-2 screening, and confirmatory testing were performed off-site. Prevalence of each infection was calculated and logistic regression analysis performed to identify correlates.
Of 5313 recruits approached, 4750 consented to participation. Participants had a mean age of 21.8 years (SD±3.8), 65.5% had lived outside Afghanistan, and 44.3% had no formal education. Few reported prior marijuana (16.3%), alcohol (5.3%), or opiate (3.4%) use. Of sexually active recruits (58.7%, N = 2786), 21.3% reported paying women for sex and 21.3% reported sex with males. Prevalence of HIV (0.063%, 95% CI: 0.013- 0.19), syphilis (0.65%, 95% CI: 0.44 – 0.93), and HCV (0.82%, 95% CI: 0.58 – 1.12) were quite low. Prevalence of HSV-2 was 3.03% (95% CI: 2.56 - 3.57), which was independently associated with age (Adjusted Odds Ratio (AOR) = 1.04, 95% CI: 1.00 - 1.09) and having a television (socioeconomic marker) (AOR = 1.46, 95% CI: 1.03 – 2.05).
Though prevalence of HIV, HCV, syphilis, and HSV-2 was low, sexual risk behaviors and intoxicant use were present among a substantial minority, indicating need for prevention programming. Formative work is needed to determine a culturally appropriate approach for prevention programming to reduce STI risk among Afghan National Army troops.
PMCID: PMC3482585  PMID: 22909128
Afghanistan; Military populations; HIV; Sexual risk behavior; Drug use
16.  Drinking and Spouse Abuse Among U.S. Army Soldiers 
This study examines the relationship between typical weekly drinking and perpetration of spouse abuse as well as the relationship between the perpetrator’s typical weekly drinking and alcohol use during the abuse event among U.S. Army male soldiers.
Cases include all active duty, male, enlisted Army spouse abusers identified in the Army’s Central Registry who had also completed an Army Health Risk Appraisal Survey (HRA) between 1991 and 1998 (N = 9534). Cases were matched on sex, rank, and marital status with 21,786 control subjects who had also completed an HRA.
In multivariate logistic regression models, heavy drinkers (22 or more drinks per week) were 66% more likely to be spouse abusers than were abstainers (odds ratio 1.66; 95% confidence interval 1.40–1.96). In addition, self-reported moderate and heavy drinkers were three times as likely and light drinkers (1–7 drinks per week) were twice as likely as nondrinkers to be drinking during the time of the abuse event.
Self-reported heavy drinking is an independent risk factor for perpetration of spouse abuse among male, enlisted Army soldiers. Even 5 years or more after ascertainment of typical drinking habits, there is a significant association between self-reported heavy drinking and alcohol involvement at the time of the spouse abuse event. Personnel who work with perpetrators and victims of spouse abuse should be trained carefully to query about current and typical drinking patterns.
PMCID: PMC1351131  PMID: 15608606
Spouse Abuse; Violence; Alcohol; Injury; Military
17.  Reassessment of the lethal London fog of 1952: novel indicators of acute and chronic consequences of acute exposure to air pollution. 
Environmental Health Perspectives  2001;109(Suppl 3):389-394.
This article develops and assesses novel indicators of respiratory and other morbidity and mortality following London's lethal smog in the winter of 1952. Public health insurance claims, hospital admission rates for cardiac and respiratory disease, pneumonia cases, mortality records, influenza reports, temperature, and air pollutant concentrations are analyzed for December-February 1952-1953 and compared with those for the previous year or years. Mortality rates for the smog episode from December 1952 to February 1953 were 50-300% higher than the previous year. Claims that the smog only elevated health risks during and immediately following the peak fog 5-9 December 1952 and that an influenza epidemic accounted fully for persisting mortality increases in the first 2 months of 1953 are rejected. We estimate about 12,000 excess deaths occurred from December 1952 through February 1953 because of acute and persisting effects of the 1952 London smog. Pollution levels during the London smog were 5-19 times above current regulatory standards and guidelines and approximate current levels in some rapidly developing regions. Ambient pollution in many regions poses serious risks to public health.
PMCID: PMC1240556  PMID: 11427388
18.  Confidence in the efficacy and safety of dietary supplements among United States active duty army personnel 
United States Army Soldiers regularly use dietary supplements (DS) to promote general health, enhance muscle strength, and increase energy, but limited scientific evidence supports the use of many DS for these benefits. This study investigated factors associated with Soldiers’ confidence in the efficacy and safety of DS, and assessed Soldiers’ knowledge of federal DS regulatory requirements.
Between 2006 and 2007, 990 Soldiers were surveyed at 11 Army bases world-wide to assess their confidence in the effectiveness and safety of DS, knowledge of federal DS regulations, demographic characteristics, lifestyle-behaviors and DS use.
A majority of Soldiers were at least somewhat confident that DS work as advertised (67%) and thought they are safe to consume (71%). Confidence in both attributes was higher among regular DS users than non-users. Among users, confidence in both attributes was positively associated with rank, self-rated diet quality and fitness level, education, and having never experienced an apparent DS-related adverse event. Fewer than half of Soldiers knew the government does not require manufacturers to demonstrate efficacy, and almost a third incorrectly believed there are effective pre-market federal safety requirements for DS.
Despite limited scientific evidence supporting the purported benefits and safety of many popular DS, most Soldiers were confident that DS are effective and safe. The positive associations between confidence and DS use should be considered when developing DS-related interventions or policies. Additionally, education to clarify Soldiers’ misperceptions about federal DS safety and efficacy regulations is warranted.
PMCID: PMC3598849  PMID: 23051046
Consumer beliefs; Military; Government regulation; Dietary supplement health and education act (DSHEA)
19.  Out of hours attendance in an army practice. 
There is some evidence that rates of out of hours calls in army general practices are higher than the average for the NHS. In an attempt to reduce out of hours demand a programme of preventive and educational initiatives for patients was introduced at an army practice in Hohne, West Germany early in 1985. This included regular child development clinics, well woman clinics, a practice booklet and leaflets about the management of simple illnesses, a library of books and videos for patients and health education videos in the waiting room. The project was complemented by an audit of doctors' prescribing habits followed by drawing up agreed protocols for the treatment of common disorders such as sore throat. Annual attendance rates per registered patient were recorded for 1984-86 to compare use of out of hours services by patients before and after the introduction of the project. Out of hours attendance rates fell by 35% (from 0.17 per annum to 0.11 per annum) overall and by 61% in young children. The total annual attendance rate dropped by 14% (from 5.13 to 4.43) during the same period, but fell by only 1% over the same period at a similar practice in Osnabruck. The decrease was particularly marked for out of hours attendances which the doctor classified as lower urgency: attendances classed as very low urgency decreased by 78% between 1984 and 1986 but those classed as medium urgency decreased by only 2%.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC1371659  PMID: 1878273
20.  On the Home Front: Stress for Recently Deployed Army Couples 
Family process  2011;50(2):235-247.
Military couples who have experienced deployment and reintegration in current U.S. military operations frequently experience stress regarding the dangers and effects of such experiences. The current study evaluated a sample of 300 couples with an active duty Army husband and civilian spouse who experienced a deployment within the year prior to the survey (conducted in 2007). Wives generally reported greater levels of emotional stress compared to husbands. Overall, higher levels of stress were found for couples who reported lower income and greater economic strain, perceive the need for more support and are unsure about how to get support, have more marital conflict, and are generally less satisfied with the Army and the current mission. Husband combat exposure was also associated with more stress for husbands and wives. Additionally, for wives, stress was related to greater child behavior problems and a sense of less Army concern for families. The results suggest areas of intervention with military couples to help them cope with the challenges of military life and deployment.
PMCID: PMC4209478  PMID: 21564063
21.  Mosquito Species Composition and Plasmodium vivax infection Rates for Korean Army Bases near the Demilitarized Zone in the Republic of Korea, 2011 
Vivax malaria is a significant military and civilian health threat in northern Republic of Korea (ROK). Mosquito collections were performed at two ROK army installations, Paju near the demilitarized zone (DMZ) using black light traps in 2011. The DMZ, a 4 km wide border, is the northernmost point of the ROK and separates the ROK from the Democratic People's Republic of Korea (DPRK). Anopheles spp. were identified by polymerase chain reaction and screened for Plasmodium vivax sporozoites. Of 4,354 female Anopheles mosquitoes identified, Anopheles kleini (61.8%) was the most frequently collected, followed by Anopheles pullus (16.0%), Anopheles belenrae (9.0%), Anopheles sinensis (7.4%), Anopheles sineroides (4.2%), and Anopheles lesteri (1.6%). Anopheles kleini, An. pullus, and An. sineroides showed the highest population densities in June, whereas population densities were highest for An. belenrae, An. lesteri, and An. sinensis in August. The maximum likelihood estimation (estimated number of positive mosquitoes/1,000) for P. vivax was highest for An. lesteri (28.9), followed by An. sineroides (23.3), An. belenrae (15.8), An. sinensis (9.6), An. pullus (5.8) and An. kleini (4.2). The seasonal maximum likelihood estimation (MLE) values were variable among Anopheles species. Anopheles belenrae, An. Pullus, and An. sineroides showed the highest seasonal MLE's in July, whereas An. lesteri and An. sinensis exhibited the highest seasonal MLEs in September and An. kleini during August. This is the first report implicating An. sineroides as a vector of P. vivax in the ROK, and extends our knowledge of the distribution and potential role in malaria transmission.
PMCID: PMC3541740  PMID: 23243112
22.  Precipitating Circumstances of Suicide among Active Duty U.S. Army Personnel Versus U.S. Civilians, 2005–2010 
To help understand suicide among soldiers, we compared suicide events between active duty U.S. Army versus civilian decedents to identify differences and inform military prevention efforts. We linked 141 Army suicide records from 2005 to 2010 to National Violent Death Reporting System (NVDRS) data. We described the decedents’ military background and compared their precipitators of death captured in NVDRS to those of demographically matched civilian suicide decedents. Both groups commonly had mental health and intimate partner precipitating circumstances, but soldier decedents less commonly disclosed suicide intent.
PMCID: PMC4384804  PMID: 25093259
23.  Spouse Abuse and Alcohol Problems Among White, African American, and Hispanic U.S. Army Soldiers 
Prior studies suggest racial/ethnic differences in the associations between alcohol misuse and spouse abuse. Some studies indicate that drinking patterns are a stronger predictor of spouse abuse for African Americans but not whites or Hispanics, while others report that drinking patterns are a stronger predictor for whites than African Americans or Hispanics. This study extends prior work by exploring associations between heavy drinking, alcohol-related problems, and risk for spouse abuse within racial/ethnic groups as well as variations associated with whether the perpetrator is drinking during the spouse abuse incident.
Cases (N = 7,996) were all active-duty male, enlisted Army spouse abusers identified in the Army’s Central Registry (ACR) who had also completed an Army Health Risk Appraisal (HRA) Survey between 1991 and 1998. Controls (N = 17,821) were matched on gender, rank, and marital and HRA status.
We found 3 different patterns of association between alcohol use and domestic violence depending upon both the race/ethnicity of the perpetrator and whether or not alcohol was involved in the spouse abuse event. First, after adjusting for demographic and psychosocial factors, weekly heavy drinking (>14 drinks per week) and alcohol-related problems (yes to 2 or more of 6 alcohol-related problem questions, including the CAGE) were significant predictors of domestic violence among whites and Hispanics only. Also for the white soldiers, the presence of family problems mediated the effect of alcohol-related problems on spouse abuse. Second, alcohol-related problems predicted drinking during a spouse abuse incident for all 3 race groups, but this relation was moderated by typical alcohol consumption patterns in Hispanics and whites only. Finally, alcohol-related problems predicted drinking during a spouse abuse incident, but this was a complex association moderated by different psychosocial or behavioral variables within each race/ethnic group.
These findings suggest important cultural/social influences that interact with drinking patterns.
PMCID: PMC2141684  PMID: 17010139
Alcohol; Violence; Intimate Partner Violence; Ethnicity; Race; Army
24.  Thirty-Day Prevalence of DSM-IV Mental Disorders Among Nondeployed Soldiers in the US Army 
JAMA psychiatry  2014;71(5):504-513.
Although high rates of current mental disorder are known to exist in the US Army, little is known about the proportions of these disorders that had onsets prior to enlistment.
To estimate the proportions of 30-day DSM-IV mental disorders among nondeployed US Army personnel with first onsets prior to enlistment and the extent which role impairments associated with 30-day disorders differ depending on whether the disorders had pre-vs post-enlistment onsets.
A representative sample of 5428 soldiers participating in the Army Study to Assess Risk and Resilience in Servicemembers completed self-administered questionnaires and consented to linkage of questionnaire responses with administrative records.
Thirty-day DSM-IV internalizing (major depressive, bipolar, generalized anxiety, panic, and posttraumatic stress) and externalizing (attention-deficit/ hyperactivity, intermittent explosive, alcohol/drug) disorders were assessed with validated self-report scales. Age at onset was assessed retrospectively. Role impairment was assessed with a modified Sheehan Disability Scale.
A total of 25.1% of respondents met criteria for any 30-day disorder (15.0% internalizing; 18.4% externalizing) and 11.1% for multiple disorders. A total of 76.6% of cases reported pre-enlistment age at onset of at least one 30-day disorder (49.6% internalizing; 81.7% externalizing). Also, 12.8% of respondents reported severe role impairment. Controlling for sociodemographic and Army career correlates, which were broadly consistent with other studies, 30-day disorders with pre-enlistment (χ82=131.8, P < .001) and post-enlistment (χ72=123.8, P < .001) ages at onset both significantly predicted severe role impairment, although pre-enlistment disorders were more consistent powerful predictors (7 of 8 disorders significant; odds ratios, 1.6–11.4) than post-enlistment disorders (5 of 7 disorders significant; odds ratios, 1.5–7.7). Population-attributable risk proportions of severe role impairment were 21.7% for pre-enlistment disorders, 24.3% for post-enlistment disorders, and 43.4% for all disorders.
Interventions to limit accession or increase resilience of new soldiers with pre-enlistment mental disorders might reduce prevalence and impairments of mental disorders in the US Army.
PMCID: PMC4057988  PMID: 24590120
25.  Parallel Psychometric and Cognitive Modeling Analyses of the Penn Face Memory Test in the Army Study to Assess Risk and Resilience in Service Members 
The psychometric properties of the Penn Face Memory Test (PFMT; Gur et al., 1997) were investigated in a large sample (4,236 participants) of U.S. Army Soldiers undergoing computerized neurocognitive testing. Data were drawn from the initial phase of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), a large-scale study directed towards identifying risk and resilience factors for suicidal behavior and other stress-related disorders in Army Soldiers. In this paper we report parallel psychometric and cognitive modeling analyses of the PFMT to determine whether ability estimates derived from the measure are precise and valid indicators of memory in the Army STARRS sample.
Single-sample cross-validation methodology combined with exploratory factor and multidimensional item response theory techniques were used to explore the latent structure of the PFMT. To help resolve rotational indeterminacy of the exploratory solution, latent constructs were aligned with parameter estimates derived from an unequal-variance signal detection model.
Analyses suggest that the PFMT measures two distinct latent constructs, one associated with memory strength and one associated with response bias, and that test scores are generally precise indicators of ability for the majority of Army STARRS participants.
These findings support the use of the PFMT as a measure of major constructs related to recognition memory and have implications for further cognitive-psychometric model development.
PMCID: PMC3600160  PMID: 23383967
cognitive-psychometric modeling; item response theory; Penn Face Memory Test; Army STARRS

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