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Abstract

Since 2001, the US military has increasingly relied on National Guard and reserve component forces to meet operational demands. Differences in preparation and military engagement experiences between active component and reserve component forces have long suggested that the psychiatric consequences of military engagement differ by component. We conducted a systematic review of prevalence and new onset of psychiatric disorders among reserve component forces and a meta-analysis of prevalence estimates comparing reserve component and active component forces, and we documented stage-sequential drivers of psychiatric burden among reserve component forces. We identified 27 reports from 19 unique samples published between 1985 and 2012: 9 studies reporting on the reserve component alone and 10 reporting on both the reserve component and the active component. The pooled prevalence for alcohol use disorders of 14.5% (95% confidence interval: 12.7, 15.2) among the reserve component was higher than that of 11.7% (95% confidence interval: 10.9, 12.6) among the active component, while there were no component differences for depression or post-traumatic stress disorder. We observed substantial heterogeneity in prevalence estimates reported by the reserve component. Published studies suggest that stage-sequential risk factors throughout the deployment cycle predicted alcohol use disorders, post-traumatic stress disorder and, to a lesser degree, depression. Improved and more standardized documentation of the mental health burden, as well as study of explanatory factors within a life-course framework, is necessary to inform mitigating strategies and to reduce psychiatric burden among reserve component forces.

alcoholism, depression, mental health, military medicine, stress disorders, post-traumatic, veterans’ health

INTRODUCTION

The US Armed Forces span 2 executive departments of the federal government (Department of Defense and Department of Homeland Security) and are composed of more than 2.7 million armed services members coordinating to ensure national security. The US military includes 2 components; the full-time, or active, component includes more than 1.4 million soldiers (US Army), sailors (US Navy), marines (US Marine Corp), airmen (US Air Force), and coastguardsmen (US Coast Guard), while the part-time, or reserve, component includes more than 1.2 million Army and Air National Guardsmen and members of the Army, Navy, Marine, Air Force, and Coast Guard Reserve.

During the early to mid-20th century, the active component deployed worldwide at the command of the President or Congress, while the National Guard largely supported individual states, and reserves were a trained operational force in reserve ready to augment the active component when required. Although all reserve component forces receive training and equipment similar to those of their active component counterparts, National Guard and reserve service members are citizen soldiers who generally serve 1 weekend a month and 15 days annually. Further, there are substantive administrative differences between National Guard and reserve forces. For example, although the Army, Navy, Marine, Air Force, and Coast Guard reserves are managed regionally at the federal level similarly to the active component, the Army and Air National Guard perform both federal and state operations. In summary, National Guard forces are managed by their respective state governments but can be called into federal service by the President of the United States as needed during a time of war or crisis. In a time of war (e.g., Korean War, Vietnam War), it was expected that reserve component service members would be called upon to augment active component service members in operational roles, principally in combat support or combat service support. In the aftermath of the Vietnam War, the Total Force Policy was adopted to treat the 2 components as a single operational force. The first significant demonstration of the unified operational force created by the Total Force Policy was during Operation Enduring Freedom (OEF; October 2001–present day) and Operation Iraqi Freedom (OIF; March 2003–December 2011), which exerted substantial demand on the US Armed Forces to train and deploy combat-ready troops to multiple fronts for over 10 years of sustained conflict. As a result of the high operational tempo experienced through OEF/OIF, the military began to place a greater reliance on the reserve component to meet demands. During the height of mobilization in OIF/OEF, reserve component forces constituted approximately 40% of deployed service members in combat operations.

This reliance on the reserve component is not idiosyncratic to OEF/OIF; it is part of the Department of Defense's long-term strategic vision to increase the size, roles, and responsibilities of the reserve component moving forward (1–4). During the 21st century, the reserve component has assumed key support roles during both domestic (e.g., Hurricanes Katrina and Sandy) and international (e.g., OEF/OIF, humanitarian relief following 2010 Haiti earthquake) operations, exposing service members to a range of potentially traumatic events, including witnessing the mass casualties and destructions of national disasters (5, 6), and traumatic combat exposures comparable to active component service members’ experiences when activated for deployment (7). Further, following combat deployment, reserve component service members face particular readjustment challenges that have been documented to increase their psychiatric disorder burden, relative to their active component counterparts (7). Some of the challenges they face include the vulnerability associated with deployment without one's own unit, which is associated with lower unit cohesion and reduced social support (8); unique family life and relationship difficulties (9); uncertain employment status upon return (9); and expectations of a smooth postdeployment readjustment and rapid resumption of predeployment civilian roles (9). Further, the eligibility of reserve component service members to receive active duty health services is conditional upon being called, or ordered, by the federal government to active service for more than 30 days in support of a contingency operation. During this time of activation, as well as 30 days pre- and postactivation, reserve component service members and their families may receive health services through the TRICARE system. Further, reserve component service members who incur, or aggravate, a disease or injury as a result of federally assigned active service duties may be eligible for benefits through the Veterans Administration (10).

Given the US Armed Forces’ growing reliance on the reserve component (1), a better understanding of the mental health of this group is warranted. To the best of our knowledge, there has been no systematic review that has assessed whether there are differences between the reserve component and active component in terms of burden and drivers of psychiatric disorders. Similarly, there has been no review of stage-sequential risk factors for psychiatric disorders in the reserve component.

Informed by these gaps in the literature, this review aimed to do the following: 1) document the prevalence and incidence estimates of the Diagnostic and Statistical Manual of Mental Disorders (DSM) psychiatric disorders in the reserve component among current service members and veterans; 2) compare the prevalence and incidence estimates between the reserve component and the active component where possible; and 3) assess which pre-, peri-, postdeployment factors are consistently associated with psychiatric burden among reserve component service members, guided by a stage-sequential framework of their engagement in military combat operations (Figure 1).

Figure 1.

Schematic of predeployment, perideployment, and postdeployment influences on observed mental health in US National Guard and reserve service members, 1985–2012.

Figure 1.

Schematic of predeployment, perideployment, and postdeployment influences on observed mental health in US National Guard and reserve service members, 1985–2012.

METHODS

Search strategy

In January 2014, we searched MEDLINE and PsycINFO databases with the OVID interface for original empirical research articles estimating the prevalence and incidence of psychiatric disorders in the US National Guard and reserve component. We used Medical Subject Headings (MeSH) terms when possible to expand the breadth of our search. The primary database search was supplemented by a search of MEDLINE through PubMed restricted to the prior 6 months (from June 2013 until January 14, 2014) to capture any articles published ahead of print and not captured in the Ovid system. We searched the identified relevant review article bibliographies for additional citations. Only English language articles were considered.

Our search algorithm was as follows: (“veteran*” OR military personnel (MeSH)) AND [(“psychiatry*” OR psychiatry (MeSH)) OR (“mental health*” OR mental health (MeSH)) OR (“psychology*” or psychology (MeSH)) OR (“behavioral health*” OR behavioral symptoms (MeSH) OR stress disorders (MeSH) OR “risk taking*” OR alcohol-related disorders (MeSH) OR substance-related disorders (MeSH))].

Study selection

Three of the authors (G. H. C., D. S. F., L. S.) 1) reviewed titles identified by the above search, 2) reviewed abstracts retained in the title review, and 3) reviewed full articles identified in the abstract review. Throughout this process, the authors were in close contact to resolve problems and answer questions as they arose; disagreements were resolved by the senior author (S. G.).

Studies meeting these 4 criteria were considered eligible for the systematic review: 1) They were population-based studies, representative of a clearly defined base population; 2) the sample included US National Guard and reserve component service members; 3) studies included prevalence or incidence estimates of psychiatric disorders based on the DSM; and 4) studies included samples from the Vietnam War era or later. We excluded samples from countries other than the United States because of substantial operational differences in the structure and functioning of reserve component forces across countries.

Data extraction and management

Three review authors (G. H. C., D. S. F., L. S.) extracted the following data using a standardized article assessment form developed by the authors: dates of study, study design (e.g., cross-sectional, longitudinal cohort), inclusion and exclusion criteria, response rate, number of participants, participant characteristics (e.g., gender, era of service, percentage of participants deployed), description of outcome, psychiatric diagnosis and assessment tools, effect estimates, and predictors. We tested the assessment form to ensure standardization of data collection among the authors and double checked all extracted results.

Prevalence estimates of psychiatric disorder were considered to be the number of cases divided by the sample size. Although we set out to examine incidence rates, we identified no studies that considered the number of new cases divided by the sample size at risk during a given time period, but only the number of new-onset disorders identified between 2 interview intervals that typically centered around a deployment. Therefore, we presented estimates of new-onset psychiatric disorders in lieu of incidence rates.

Stage-sequential risk factors for psychiatric disorders, identified from studies that met the inclusion criteria, were reported if they fit clearly into the pre-, peri-, and postdeployment stages, as outlined in Figure 1. These factors were identified by searching included studies for associations between stage-sequential risk factors and the outcome(s) of focus. We describe each included risk factor and the psychiatric disorder predicted.

Data analysis

Data were examined in 3 phases. First, we tabulated all extracted data from studies estimating prevalence or new onset of psychiatric disorders in the reserve component, documenting the following: study era; number of National Guard and reserve component service members in the study; specific reserve component (i.e., National Guard, reserve); whether study participants’ survey responses were identified to the military (i.e., military database); length of recall in cross-sectional studies or length of investigation in cohort studies; measures assessing psychiatric disorders; sample characteristics (e.g., postdeployment, nondeployed); and prevalence estimates for alcohol use disorders (alcohol abuse or dependence), depression, and post-traumatic stress disorder (PTSD). If more than one cross-sectional report was available for the same study sample, the most comprehensive report was selected.

To accomplish our second aim, we calculated the standard error and variance for each study reporting prevalence of psychiatric disorders in both the reserve component and active component. Next, we weighted each study by sample size and performed separate analyses for each disorder. Heterogeneity of data was assessed with the Q test and I2 statistic by using Microsoft Excel (11). Because we anticipated heterogeneity of prevalence estimates due to differences in study methodologies and measurement tools, we used random-effects models to calculate pooled prevalence estimates and 95% confidence intervals. Statistical differences in prevalence estimates by component were assessed by comparing 95% confidence intervals. The meta-analysis was performed in Microsoft Excel for Macintosh (12).

Third, using the stage-sequential framework presented in Figure 1, we identified predictors of psychiatric disorders throughout the deployment cycle documented in the published literature.

RESULTS

Search results

Figure 2 shows a flow diagram documenting the total number of reports screened, excluded on the basis of screening criteria, and final number included for this review. We identified 8,457 citations through the Ovid system and 790 potential ahead-of-print or recent-print articles through PubMed with the initial search strategy, including 619 duplicates. Of these citations, 7,283 studies were excluded by reviewing the title and abstract with the aforementioned criteria. After full examination of the remaining 751 articles, 724 were excluded for the reasons shown in Figure 2. Finally, 27 reports met the inclusion criteria and were included in this systematic review.

Figure 2.

Flowchart of literature search for systematic review and meta-analysis of prevalence and incidence estimates of psychiatric disorders in US National Guard and reserve service members, including literature published between 1970 and 2014.

Figure 2.

Flowchart of literature search for systematic review and meta-analysis of prevalence and incidence estimates of psychiatric disorders in US National Guard and reserve service members, including literature published between 1970 and 2014.

Characteristics of the included studies

Among the 27 identified manuscripts, 21 documented prevalence estimates (Table 1), and 6 documented incidence estimates (Table 2). Overall, 19 unique studies produced the 27 manuscripts, with 14 of the 27 total manuscripts developed from 5 studies, including the Ohio Army National Guard Mental Health Initiative, the Readiness and Resilience in National Guard Soldiers Study, the Millennium Cohort Study, the New Jersey National Guard Study, and the Iowa Persian Gulf Study Group. Sample sizes ranged from 124 (13) to 222,183 (14). Overall, the median sample size was 2,616 participants (interquartile range, 537–35,998). The DSM outcomes observed included alcohol abuse and/or dependence; PTSD and anxiety disorders other than PTSD (i.e., generalized anxiety disorder, panic disorder); depression (i.e., major depressive disorder, other depression); and eating disorders (i.e., bulimia, anorexia). However, only alcohol use disorders, depression, and PTSD risk estimates were documented in multiple studies, enabling comparison. Therefore, we concentrated on these 3 psychiatric disorders for the review. Disorders were assessed predominantly by using self-reported scales (n = 16) as compared with clinician diagnosis (n = 2); the Readiness and Resilience in National Guard Soldiers Study used both self-reported scales and clinical interviews.

Table 1.

Source, Era, Sample Size, and Methodological Aspects of the Cross-sectional Prevalence Studies Included in the Review (in Alphabetical Order of First Author by Era), 1985–2012

First Author, Year (Reference No.) Total No. National Guard and Reserves Identified Reporting Method Length of Investigation/Recall Measures Survey Timing Prevalence Estimate, %
AUD Depression PTSD 
Operation Enduring Freedom/Operation Iraqi Freedom
Allison-Aipa, 2010 (37) 51,078 Reserves Yes Self-report Current AUD: TICS; depression: PHQ-2; PTSD: PC-PTSD Postdeployment 14.0 14.0 16.0 
Goldmann, 2012 (38) 2,616 National Guard No Self-report Current PTSD: PCLaPostdeployment 9.6 
Kim, 2010 (15) 1,510 (3 months), 758 (6 months) National Guard and reserves No Self-report Current Depression: PHQ-9; PTSD: PCLbPostdeployment 3.6 (3 months), 5.5 (12 months) 13.0 (3 months), 17.0 (12 months) 
Milliken, 2007 (39) 31,885 National Guard and reserves Yes Self-report Current AUD: TICS; depression: PHQ-2; PTSD: PC-PTSD Postdeployment 15.0 (6 months) 3.8 (3 months), 13.0 (6 months) 12.7 (≥2) and 6.6 (≥3) (3 months); 24.5 (≥2) and 14.3 (≥3) (6 months) 
Martin, 2007 (14) 87,136 National Guard and reserves Yes Self-report Current PTSD: PC-PTSD Postdeployment 11.7 
Kline, 2010 (40) 2,543 National Guard No Self-report Current AUD: NSDUH; depression: PHQ-9; PTSD: PCLdPredeployment 7.2c3.4 6.7 
Kline, 2011 (41) 1,665 National Guard No Self-report Current AUD: NSDUH; depression: PHQ-9; PTSD: PCLdPostdeployment 12.6c5.8 10.8 
Pietrzak, 2009 (42) 394 National Guard No Self-report Current PTSD: PCLdPostdeployment 20.1 
Riddle, 2007 (43) 76,476 National Guard and reserves No Self-report 30-days AUD: PHQ; depression: PHQ-9; PTSD: PCLbGeneral 14.1 2.7 2.2 
Kehle, 2011 (44) 348 National Guard No Interview Current AUD: SCID; depression: SCID; PTSD: CAPS Postdeployment 12.9 14.7 6.6 
Polusny, 2011 (45) 516 National Guard No Self-report Current PTSD: PCLePredeployment 3.7 
Seal, 2007 (46) 49,401 National Guard and reserves No VA diagnosis on file 2001–2005 PTSD: ICD-9 diagnosis Veteran 12.9 
Shea, 2010 (13) 124 National Guard and reserves No Interview Current AUD and depression: SCID; PTSD: CAPS Postdeployment 8.9 12.1 14.5 
Thomas, 2010 (7) 1,585 (3 months), 2,684 (12 months) National Guard No Self-report Current AUD: TICS; Depression: PHQ-9; PTSD: PCLbPostdeployment 14.5 (3 months), 15.0 (12 months) 10.1 (3 months), 13.7 (12 months) 14.7 (3 months), 24.6 (12 months) 
Persian Gulf War
Benotsch, 2000 (47) 348 National Guard and reserves No Self-report Current PTSD: PCLaPostdeployment 10.9 
Holmes, 1998 (48) 296 National Guard No Self-report Current PTSD: Mississippi Scale Postdeployment 6.8 
179 Nondeployed 1.7 
Iowa Persian Gulf War Study Group, 1997 (16) 911 National Guard and reserves No Self-report Current AUD: CAGE; depression: PRIME-MD; PTSD: PCLdPostdeployment 19.4 10.1 2.0 
831 Nondeployed 16.8 5.3 1.1 
Kang, 2003 (49) 7,174 National Guard and reserves No Self-report Current PTSD: PC-PTSD Postdeployment 13.3 
Ross, 1993 (50) 251 National Guard and reserves No Self-report Current PTSD: Mississippi Scale General 5.0 
Sutker, 1993 (51) 275 National Guard and reserves No Self-report Current Depression: BDI; PTSD: PCL and Mississippi Scale Postdeployment 22.0 19.0 (Mississippi Scale), 16.0 (PCL) 
Vietnam War
Stretch, 1985 (52) 925 Reserves No Self-report Current PTSD: VEVAS Deployed veterans 10.9 
Nondeployed veterans 1.5 
First Author, Year (Reference No.) Total No. National Guard and Reserves 
Book Description:

Reappraisal of the pioneering humanist scholar Biondo Flavio. During his lifetime the historian and antiquarian Biondo Flavio (1392– 1463) struggled to obtain recognition as a major contributor to the humanistic movement of the fifteenth century. Throughout the Renaissance, fellow Italian scholars far too often condemned rather than endorsed his scholarly works. His troublesome career and mixed reputation among his peers stand in stark contrast with the highly innovative character of his learning, which proved to be ground-breaking for the further development of various strands of historical and antiquarian research in the Early Modern Age. The authors of this volume aim to contribute to a reappraisal of this pioneering humanist scholar by a fresh assessment of his major writings in the fields of historical linguistics, historiography, Roman topography, and historical geography. Contributors: Angelo Mazzocco (Mount Holyoke College), Marc Laureys (Universität Bonn), Giuseppe Marcellino (Scuola Normale Superiore di Pisa), Fulvio Delle Donne (Università della Basilicata), Fabio Della Schiava (Universität Bonn), Paolo Pontari (Università di Pisa), Catherine Castner (University of South Carolina), Jeffrey White (St. Bonaventure University), Frances Muecke (University of Sydney)

eISBN: 978-94-6166-191-3

Subjects: Language & Literature