Abstract
Objectives. We examined stress levels and other indicators of mental health in reservists and active-duty military personnel by deployment status.
Methods. We used data from the Department of Defense Health-Related Behaviors surveys, which collect comprehensive, population-based data for reserve and active-duty forces. Data were collected from 18 342 reservists and 16 146 active-duty personnel.
Results. Overall, with adjustment for sociodemographic and service differences, reservists reported similar or less work and family stress, depression, and anxiety symptoms than did active-duty personnel. However, reservists who had been deployed reported higher rates of suicidal ideation and attempts than did active-duty personnel who had been deployed and higher rates of post-traumatic stress disorder symptomatology than did any active-duty personnel and reservists who had not been deployed. The highest rates of suicidal ideation and attempts were among reservists who had served in theaters other than Iraq and Afghanistan.
Conclusions. Our results suggest that deployment has a greater impact on reservists than on active-duty members, thus highlighting the urgent need for services addressing reservists’ unique postdeployment mental health issues. Also, deployment to any theater, not only Iraq or Afghanistan, represents unique threats to all service members’ mental well-being.
The US military reserve component, which includes both Reserve and National Guard personnel, provides trained units and qualified persons for active-duty service in time of war or national emergency. Reserve-component personnel may be called to active-duty status to supplement the active-duty component during such times. National Guard units also provide personnel in response to state emergencies. As of July 2008, the total strength of the US military reserve component was 1.1 million, with approximately 10% serving with the active-duty component.1 Once activated, reserve-component service members proceed through the same deployment stages and processes as do active-duty forces. However, they face additional challenges associated with being “citizen Soldiers,” such as arranging extended leaves of absence with civilian employers, planning for reintegration upon their return, and making arrangements for their families. Furthermore, the uncertainty that often accompanies activation and deactivation and the organizational constraints, such as lack of equipment and training readiness, have been associated with their psychological well-being.2
Milliken et al.3 found, on the basis of Post-Deployment Health Assessment and Post-Deployment Health Re-Assessment interviews, that more than twice as many reserve-component as active-duty service members returning from Operation Iraqi Freedom (OIF) reported symptoms sufficient to require mental health treatment (42.4% vs 20.3%, respectively). Although important, their study was limited to a sample of recently returning service members who may not be representative of the broader active-duty and reserve-component populations and thus may not provide an accurate picture of the relative mental health needs between and within components of the total force. Therefore, a need exists for population-based data comparing the mental health needs of active-duty and reserve-component personnel.
Drawing on 2 comprehensive surveys, we helped to fill this data gap by providing the first population-based assessment and comparison of reserve-component and active-duty mental health on the basis of selected indicators during the OIF and Operation Enduring Freedom (OEF) conflicts. This work augments existing research2 by examining specific mental health issues encountered by reservists, as suggested by Milliken et al.,3 rather than a global but somewhat vague construct of psychological well-being.
METHODS
All data were drawn from 2 US Department of Defense Surveys of Health-Related Behaviors (HRB): the 2006 reserve-component4 and the 2005 active-duty5 surveys. Although a series of active-duty surveys have been conducted over the years, the 2006 reserve-component survey is the first survey conducted for the reserve component. As the only large-scale, representative, population-based surveys of the total force (excluding the Coast Guard), the HRB Surveys generate the most comprehensive data on both the reserve-component and active-duty forces. Although the Post-Deployment Health Assessment and Post-Deployment Health Re-Assessment include brief screenings for physical and mental health concerns, such as alcohol use and post-traumatic stress disorder (PTSD), the HRB Surveys cover a much broader array of topics with greater depth. Institutional review board approval was granted through both RTI International and Department of Defense review boards, and the surveys were deemed to be of minimal risk.
The sample sizes for the 2006 reserve-component and the 2005 active-duty surveys were 18 342 (55.3% response rate) and 16 146 (51.8% response rate), respectively. Both surveys were self-administered via anonymous, paper questionnaires. Participants were selected to represent men and women in all pay grades of the active-duty and reserve-component forces worldwide who were not absent without leave, incarcerated, recruits, or undergoing a permanent change of station. Data were collected primarily from participants in group sessions at military installations (90%) and were obtained by mail for those not attending group sessions (10%).
We compared estimates of mental health indicators for active-duty personnel with estimates for 2 reserve-component groups: (1) Active Guard/Reserve Program participants or full-time National Guard reservists, hereafter referred to as “full-time reservists,” and (2) all others, hereafter referred to as “traditional reservists.” Full-time reservists differ from traditional reservists in that they serve full time, have many of the same privileges (including medical benefits) as active-duty personnel, and serve primarily as direct support to traditional reservists.6 Traditional reservists, by contrast, typically participate in one weekend per month of training and attend a 2-week training session once yearly, except during activation or deployment cycles.
Measures
Questionnaires for the active-duty and reserve-component surveys used the same or similar items for all constructs. In addition to demographic items, surveys included questions assessing stress, mental health, and deployment-related issues.
Stress.
Respondents were asked to indicate the level of stress they attributed to their military work, to intimate and family relationships, and, for women, to being a woman in the military, and to provide information on the perceived impact of stress on their military performance. Respondents who reported experiencing “a lot” (work and family) or “a great deal/a fairly large amount” (being a woman in the military) of stress were categorized as having high stress related to these factors, respectively.
Anxiety.
To screen for generalized anxiety disorder (GAD) symptoms, the surveys used a set of items adapted from the Patient Health Questionnaire.7 If respondents reported feeling nervous, anxious, or “on edge” or that they had been worrying about different issues (the first questions in the set) for several days, other symptoms were examined. Respondents who also reported experiencing 3 or more symptoms on more than half of the past 30 days were considered to have met the screening criteria for GAD.
Depression.
Need for further depression evaluation was assessed by using the 3-item Version A Burnam depression screen.8 Personnel were defined as needing further evaluation or assessment if they (1) felt sad, blue, or depressed for 2 weeks or more in the past 12 months or (2) reported 2 or more years in their lifetime of feeling depressed and felt depressed “much of the time” in the past 12 months and (3) felt depressed on 1 or more days in the past week. This scale has shown high sensitivity and good positive predictive value for detecting depressive disorder.9
Post-traumatic stress disorder.
The PTSD Checklist-Civilian Version (PCL-C)10 was used to screen for PTSD and included 17 questions asking about the symptoms of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).11 The civilian rather than the military version (PCL-M) was used to capture PTSD symptoms that may be the result of nonmilitary experiences (e.g., traumatic exposures occurring before being in the National Guard/Reserve).12 Items include characteristics such as loss of interest in activities the respondent used to enjoy and having physical reactions when reminded of a stressful experience. Respondents indicated how much they have been bothered by each of the 17 symptoms with items scored from 0 (“not at all”) to 4 (“extremely”). Items were summed to obtain a total score, with scores greater than or equal to 50 indicating a positive screen for PTSD.13
Suicidal ideation and suicide attempts.
Suicidal ideation and suicide attempts were assessed by asking respondents about the occurrence of suicidal thoughts and suicide attempts within the past year and relative to joining the military.
Operational theater and frequency of deployment.
Items regarding theater and frequency of deployment (during the 36 months preceding survey administration) were included to assess the impact of deployment on mental health outcomes. Three groups were defined for operational theater: (1) those who had served in either Iraq or Afghanistan (OIF or OEF); (2) those who had served in other operational theaters besides OIF or OEF such as the Gulf War, Somalia, and the like; and (3) those who had not been deployed to an operational theater. Deployment frequency contrasted those who had never been deployed with those who had been deployed 1 or more times in the past 3 years.
Statistical Analyses
We conducted our analyses with SAS version 9.1 (SAS Institute Inc, Cary, NC) and SUDAAN version 9.0 (Research Triangle Institute, Research Triangle Park, NC). Initial sample weights were constructed by using probability of selection at each stage of the study design. Variables used in the sampling included service or reserve component, location (within the continental United States or outside the continental United States), gender, and pay grade. These weights were adjusted for survey eligibility and nonresponse after data collection was completed. The weights were also poststratified and included age, race, and ethnicity. Data were standardized to service or reserve component, gender, age, pay grade (enlisted or officer), marital status, education, and race/ethnicity distributions for the total reserve and active-duty components, respectively, by using the predicted marginals approach.14 Significance testing between groups was conducted by using the t test. Analyses were conducted by deployment status and theater by using standardized data to control for demographic differences between those who had been deployed and those who had not and between those who served in different operational theaters.
RESULTS
The sociodemographic characteristics of the reservists and active-duty personnel are presented in Table 1. Overall, the groups were similar with regard to gender and race/ethnicity; all groups were mainly male and non-Hispanic white. Reservists were more likely to have higher levels of education than did active-duty personnel and were older on average than were active-duty personnel. Significantly more full-time reservists and active-duty personnel than traditional reservists were married. Across all 3 groups, most personnel were in lower pay grades, that is, E1 to E6. Full-time reservists had the largest percentages of E7-E9 enlisted and senior officers. Full-time reservists were likely to have been deployed at rates similar to active-duty personnel, and both were significantly more likely to have been deployed in the past year than were traditional reservists.
TABLE 1—
Sociodemographic Characteristics of the Eligible Participant Population: US Department of Defense Surveys of Health-Related Behaviors, 2006 Reserve Component and 2005 Active Duty Component
| Sociodemographic Characteristics | Traditional Reserve Component,a % (SE) | Full-Time Reserve Component,b % (SE) | Active-Duty Component,c % (SE) |
| Service branch | |||
| Army | 42.2 (5.1) | 40.8 (8.0) | 31.8 (5.0) |
| Army National Guard | 23.2 (4.5) | 22.0 (7.1) | |
| Navy | 9.8 (2.2) | 1.9 (0.5) | 26.8 (3.5) |
| Marine Corps | 5.3 (0.7) | 1.6 (0.7) | 12.7 (2.2) |
| Air Force | 10.4 (4.3) | 25.1 (8.5) | 28.7 (3.0) |
| Air National Guard | 9.1 (2.9) | 8.7 (2.4) | |
| Gender | |||
| Male | 82.5 (1.6) | 82.5 (2.2) | 85.2 (0.7) |
| Female | 17.5 (1.6) | 17.5 (2.2) | 14.8 (0.7) |
| Race/Ethnicity | |||
| White, non-Hispanic | 69.0 (3.5) | 69.1 (4.9) | 64.4 (1.2) |
| African American, non-Hispanic | 14.4 (1.8) | 14.3 (2.8) | 17.6 (1.0) |
| Hispanic | 11.0 (1.9) | 10.5 (2.0) | 8.8 (0.5) |
| Other | 5.6 (1.8) | 6.1 (2.5) | 9.2 (0.6) |
| Education | |||
| ≤ high school | 25.8 (2.0)e,f | 16.0 (2.1)d,f | 33.9 (1.5)d,e |
| Some college | 47.9 (0.9)d | 47.5 (2.6) | 44.1 (1.3)d |
| College graduate or higher | 26.2 (1.8)e | 36.5 (3.4)d,f | 22.0 (1.7)e |
| Age, y | |||
| ≤ 24 | 32.0 (2.1)e,f | 9.2 (1.2)d,f | 40.9 (1.9)d,e |
| 25–34 | 28.3 (1.0)d | 27.5 (3.1)d | 36.0 (1.0)d,e |
| 35–44 | 25.5 (1.1)e,f | 39.8 (2.1)d,f | 19.7 (1.1)d,e |
| ≥ 45 | 14.2 (0.9)e,f | 23.5 (2.3)d,f | 3.4 (0.4)d,e |
| Marital status | |||
| Not married, unknown | 52.0 (1.9)e,f | 33.8 (3.5)d,f | 45.5 (1.4)d,e |
| Married | 48.0 (1.9)e,f | 66.2 (3.5)d,f | 54.5 (1.4)d,e |
| Pay grade | |||
| E1-E3 | 19.6 (2.0)e | 5.0 (1.2)d,f | 24.0 (1.7)e |
| E4-E6 | 56.9 (1.9)e,f | 46.0 (3.9)d | 49.6 (1.8)d |
| E7-E9 | 9.9 (0.9)e | 27.8 (1.8)d,f | 9.7 (0.8)e |
| W1-W5 | 1.0 (0.6) | 1.7 (1.1) | 1.0 (0.1) |
| O1-O3 | 5.6 (0.6)d | 5.7 (1.2)d | 9.4 (1.0)d,e |
| O4-O10 | 7.0 (0.9)e | 13.8 (2.9)d,f | 6.3 (0.8)e |
| Any deployment in past y | 18.8 (1.9)e,f | 24.9 (2.2)d | 29.9 (2.5)d |
Note. Table displays the weighted percentage of reservists and active-duty personnel by sociodemographic characteristic. Initial sample weights were derived by using probability of selection at each stage of the study design. Variables used in the sampling included service component, service location (within the continental United States or outside the continental United States), gender, and pay grade. These weights were adjusted for survey eligibility and nonresponse after data collection was completed. The weights were also poststratified and included age, race, and ethnicity. Percentages may not sum to 100 because of rounding.
Unweighted n = 15 212.
Unweighted n = 3130. Full-time reserve component refers to the Active Guard or Reserve Program and full-time National Guard or reservist.
Unweighted n = 16 146.
Estimate is significantly different from the traditional reserve component at the 95% confidence level.
Estimate is significantly different from the full-time reserve component at the 95% confidence level.
Estimate is significantly different from active-duty personnel at the 95% confidence level.
Stress and Mental Health
Because of the demographic differences between reserve-component and active-duty personnel, we adjusted the analyses comparing the groups for gender, race/ethnicity, education, age, marital status, pay grade, and service or reserve component. The adjusted estimates in Table 2 showed that active-duty personnel were significantly more likely to report high stress associated with carrying out military duties than were traditional reservists or full-time reservists; however, high family stress did not differ significantly between traditional reservists, full-time reservists, and active-duty personnel. Women on active duty were significantly more likely than were traditional and full-time reservists to report that they experienced a “great deal” or a “fairly large amount” of stress associated with being a woman in the military.
TABLE 2—
Results of Comparative Analyses of Stress and Mental Health: US Department of Defense Surveys of Health-Related Behaviors, 2006 Reserve Component and 2005 Active Duty Component
| Stress or Mental Health Variable | Traditional Reserve Component, % (SE) | Full-Time Reserve Component,a % (SE) | Active-Duty Component, % (SE) |
| Stress while carrying out military duties, past 12 mo | |||
| Unadjusted | 12.9 (1.3)b | 18.4 (1.7)c | 32.5 (0.9)d |
| Adjusted | 12.3 (1.1)b | 19.0 (1.8)c | 33.2 (0.9)d |
| High stress in family, past 12 mo | |||
| Unadjusted | 19.2 (0.7)b | 16.9 (1.6)b | 18.9 (0.5)b |
| Adjusted | 18.9 (0.6)b | 18.6 (1.7)b | 18.9 (0.5)b |
| Need for further depression evaluation | |||
| Unadjusted | 18.8 (0.6)b | 17.7 (1.9)b | 22.3 (0.8)c |
| Adjusted | 17.5 (0.5)b | 19.0 (1.8)b | 23.2 (0.8)c |
| Met screening criteria for GAD symptoms, past 30 d | |||
| Unadjusted | 10.7 (0.7)b | 8.0 (0.9)c | 12.7 (0.5)d |
| Adjusted | 10.1 (0.6)b | 8.5 (1.0)b | 13.1 (0.5)c |
| Need for further PTSD evaluation, past 30 d | |||
| Unadjusted | 7.7 (0.8)b | 5.4 (0.7)c | 6.7 (0.5)b,c |
| Adjusted | 6.9 (0.6)b | 6.1 (0.8)b | 7.1 (0.6)b |
| Stress as a womane, past 12 mo | |||
| Unadjusted | 22.2 (1.0)b | 27.2 (3.9)b | 35.5 (1.2)c |
| Adjusted | 21.0 (1.0)b | 27.9 (3.7)b | 36.7 (1.2)c |
| Limited usual activities for ≥ 11 d in past mo because of poor mental health | |||
| Unadjusted | 1.9 (0.3)b | 3.0 (0.6)b,c | 2.9 (0.2)c |
| Adjusted | 1.7 (0.3)b | 3.8 (0.8)c | 3.0 (0.3)c |
| Suicidal ideation, past y | |||
| Unadjusted | 5.5 (0.4)b | 4.2 (0.5)c | 4.9 (0.3)b,c |
| Adjusted | 5.0 (0.4)b | 5.5 (0.6)b | 5.1 (0.3)b |
| Suicide attempt, past y | |||
| Unadjusted | 1.8 (0.3)b | 0.6 (0.2)c | 0.8 (0.1)c |
| Adjusted | 1.5 (0.2)b | 0.8 (0.3)b,c | 0.9 (0.1)c |
Note. GAD = generalized anxiety disorder; PTSD = post-traumatic stress disorder. Table displays the percentage of reservists and active-duty personnel who reported stress and mental health problems. Adjusted estimates were standardized to gender, race/ethnicity, education, age, marital status, pay grade, and service or reserve component.
Full-time reserve component refers to the Active Guard or Reserve Program and full-time National Guard or reservist.
Estimates within rows not sharing a common superscript letter differ significantly, P < .05.
Estimate is among women only. Refers to those who indicated a “great deal” or a “fairly large amount” of stress with being a woman in the military.
Active-duty personnel were significantly more likely to need further evaluation for depression than were either of the reserve-component groups and were more likely to have met the screening criteria for GAD symptoms than were the reserve-component groups. Of interest, we found no significant difference between reservists and active-duty personnel in the likelihood of meeting the screening criteria for PTSD when we adjusted for sociodemographic differences.
Stress, Mental Health, and Deployment
Traditional reservists and active-duty personnel are contrasted in Table 3 regarding stress and mental health indicators by deployment status during the past 36 months. Full-time reservists were not included because of their different military roles and functions. Our focus was on the adjusted estimates.
TABLE 3—
Results of Comparative Analyses of Stress and Mental Health by Deployment Status: US Department of Defense Surveys of Health-Related Behaviors, 2006 Reserve Component and 2005 Active Duty Component
| Traditional Reserve Component |
Active-Duty Component |
|||
| Stress or Mental Health Variable | Deployed ≥ 1 Time, % (SE) | Not Deployed, % (SE) | Deployed ≥ 1 Time, % (SE) | Not Deployed, % (SE) |
| Stress while carrying out military duties, past 12 mo | ||||
| Unadjusted | 14.4 (0.9)a | 11.2 (2.3)a | 34.2 (1.0)b | 29.9 (1.4)c |
| Adjusted | 13.8 (0.9)a | 10.5 (2.0)a | 35.4 (1.0)b | 30.3 (1.3)c |
| High stress in family, past 12 mo | ||||
| Unadjusted | 19.9 (0.6)a | 18.7 (1.2)a,b | 19.9 (0.7)a | 17.7 (0.8)b |
| Adjusted | 20.3 (0.7)a | 18.1 (1.0)a,b | 20.3 (0.7)a | 17.6 (0.8)b |
| Need for further depression evaluation | ||||
| Unadjusted | 19.9 (0.9)a,b | 17.8 (0.9)b | 22.6 (0.8)c | 21.2 (1.2)a,c |
| Adjusted | 19.1 (1.0)a | 16.2 (0.7)b | 24.0 (0.8)c | 21.6 (1.0)a |
| Met screening criteria for GAD symptoms, past 30 d | ||||
| Unadjusted | 10.9 (0.7)a | 10.3 (1.3)a,b | 13.0 (0.6)b | 12.0 (0.9)a,b |
| Adjusted | 10.4 (0.7)a,b | 9.5 (1.0)b | 13.7 (0.6)c | 12.2 (0.8)a,c |
| Limited usual activities for ≥ 11 d in past mo because of poor mental healthe | ||||
| Unadjusted | 2.4 (0.4)a | 1.2 (0.3)b | 3.1 (0.3)a | 2.5 (0.4)a |
| Adjusted | 2.5 (0.4)a | 1.2 (0.2)b | 3.2 (0.3)a | 2.5 (0.4)a |
| Need for further PTSD evaluation, past 30 d | ||||
| Unadjusted | 9.0 (0.7)a | 6.6 (1.2)a,b | 7.2 (0.6)b | 5.8 (0.7)b |
| Adjusted | 8.4 (0.7)a | 5.9 (0.8)b,d | 7.6 (0.6)a,b | 6.1 (0.8)d |
| Suicidal ideation, past y | ||||
| Unadjusted | 6.9 (0.4)a | 4.1 (0.5)b | 5.1 (0.4)b | 4.6 (0.4)b |
| Adjusted | 7.1 (0.5)a | 3.8 (0.4)b | 5.4 (0.4)b | 4.5 (0.4)b |
| Suicide attempt, past y | ||||
| Unadjusted | 2.3 (0.4)a | 1.1 (0.2)b | 0.9 (0.1)b | 0.6 (0.2)b |
| Adjusted | 2.3 (0.5)a | 0.9 (0.2)b | 1.0 (0.1)b | 0.6 (0.2)b |
Note. GAD = generalized anxiety disorder; PTSD = post-traumatic stress disorder. Table displays the percentage of reservists and active-duty personnel by deployment status in the past 36 months who reported the stress and mental health issues indicated. Adjusted estimates were standardized to gender, race/ethnicity, education, age, marital status, pay grade, and service or reserve component.
Estimates within rows not sharing a common superscript letter differ significantly, P < .05.
Based on respondents’ perception of number of days when mental health limited usual activities.
As shown, active-duty personnel reported significantly higher levels of stress while carrying out military duties than did reservists. Active-duty personnel who had been previously deployed were significantly more likely to report high stress while carrying out military duties than were those who had not been deployed, whereas previously deployed reservists reported stress levels similar to those of their nondeployed counterparts. Stress in the family showed a similar pattern to stress at work; however, we found no significant difference in the level of family stress between reservists who had been deployed and active-duty personnel who had been deployed. Reservists showed the same general directional pattern as did active-duty personnel on both stress indicators with regards to deployment, but the differences were smaller and nonsignificant between reservist groups.
Reservists and active-duty personnel showed similar patterns of needing further depression evaluation and meeting the screening criteria for anxiety symptoms by deployment status category. Previously deployed personnel were significantly more likely to need further depression evaluation than were nondeployed personnel, but showed no differences in anxiety symptoms associated with deployment. Of interest, few reservists or active-duty personnel felt that poor mental health limited their activities in the past month.
The association between deployment status and meeting the screening criteria for PTSD symptoms was similar for reservists and active-duty personnel. Those who had been deployed showed significantly higher proportions of meeting the criteria than did those who were not deployed.
We found notable differences by deployment status between reservists and active-duty personnel in reports of suicidal ideation and suicide attempts. Reservists who had been previously deployed were significantly more likely to report these behaviors than were those who had not been deployed, whereas active-duty personnel showed no significant differences as the result of deployment. Previously deployed reservists also showed higher rates of both suicidal ideation and attempts than did their active-duty counterparts.
Traditional reservists and active-duty personnel are contrasted in Table 4 regarding stress and mental health indicators by operational theater where they served: those who served in OIF or OEF; those who served in other operational theaters, but not OIF or OEF; and those who had not served in an operational theater (i.e., those who had not been deployed to an operational theater). Operational theaters have diverse environmental and mission-related factors associated with them and may therefore differentially affect stress and mental health issues. As shown, higher prevalences of stress and stress-related problems were associated with military operational theaters. Although reservists overall showed lower work stress than did active-duty personnel, those who had served in OIF or OEF in the past 36 months reported significantly higher stress while carrying out military duties than did those in other theaters and those who had not served in a theater. By contrast, active-duty personnel who served in OIF or OEF reported a significantly higher prevalence of stress while carrying out military duties than that reported by those who had not served in a theater. For family stress, reservists who served in OIF or OEF reported significantly higher family stress than did those who did not serve in a theater, whereas active-duty personnel showed no significant differences in family stress related to theater.
TABLE 4—
Results of Comparative Analyses of Stress and Mental Health by Theater of Operation: US Department of Defense Surveys of Health-Related Behaviors, 2006 Reserve Component and 2005 Active Duty Component
| Traditional Reserve Component |
Active-Duty Component |
|||||
| Stress or Mental Health Variable | Served in OIF or OEF, % (SE) | Served in Other Theater,a % (SE) | Did Not Serve in Theater, % (SE) | Served in OIF or OEF, % (SE) | Served in Other Theater,a % (SE) | Did Not Serve in Theater, % (SE) |
| Stress while carrying out military duties, past 12 mo | ||||||
| Unadjusted | 16.4 (1.9)b | 9.3 (1.2)c | 10.5 (1.6)c | 33.7 (1.1)d | 29.6 (1.6)e | 32.4 (1.7)d,e |
| Adjusted | 15.9 (1.6)b | 10.0 (1.1)c | 9.4 (1.4)c | 34.9 (1.1)d | 33.2 (1.7)d,e | 31.2 (1.5)e |
| High stress in family, past 12 mo | ||||||
| Unadjusted | 20.9 (1.6)b | 17.7 (1.4)b,c | 18.5 (1.3)b,c | 19.4 (0.8)b | 16.6 (1.0)c | 19.8 (1.0)b |
| Adjusted | 21.5 (1.2)b | 19.2 (1.4)b,c | 17.0 (1.1)c | 19.8 (0.8)b | 18.6 (1.2)b,c | 18.5 (1.0)b,c |
| Need for further depression evaluation | ||||||
| Unadjusted | 21.2 (1.6)b,d | 16.2 (1.1)c | 17.5 (1.1)b,c | 21.6 (0.9)d | 18.0 (1.2)b,c | 25.1 (1.6)d |
| Adjusted | 20.7 (1.3)b,d | 17.2 (1.3)b,c | 15.0 (1.0)c | 23.1 (0.8)d | 21.8 (1.2)d | 23.7 (1.5)d |
| Met screening criteria for GAD symptoms, past 30 d | ||||||
| Unadjusted | 12.7 (1.8)b,c,d | 9.4 (1.0)b | 9.3 (0.6)b | 12.6 (0.7)c,d | 10.6 (0.9)b,c | 13.7 (0.8)d |
| Adjusted | 12.5 (1.4)b,d | 10.1 (1.1)b,c | 8.1 (0.5)c | 13.3 (0.7)d | 12.7 (1.0)b,d | 12.9 (0.8)d |
| Limited usual activities for ≥ 11 d in past mo because of poor mental healthf | ||||||
| Unadjusted | 1.8 (0.3)b,c | 2.8 (0.8)c,d,e | 1.4 (0.4)b | 3.2 (0.3)e | 2.0 (0.3)b,c,d | 3.0 (0.5)d,e |
| Adjusted | 1.9 (0.3)b | 3.7 (0.9)b,d | 1.1 (0.3)c | 3.4 (0.4)d | 2.9 (0.5)b,d | 2.5 (0.5)b,d |
| Need for further PTSD evaluation, past 30 d | ||||||
| Unadjusted | 10.7 (1.8)b | 7.0 (1.0)c | 5.0 (0.8)c,d | 7.0 (0.7)b,c | 4.4 (0.6)d | 7.3 (0.9)b,c |
| Adjusted | 10.1 (1.2)b | 8.2 (1.1)b,c | 4.2 (0.6)d | 7.5 (0.7)c | 6.1 (0.7)c,d | 6.7 (0.9)c |
| Suicidal ideation, past y | ||||||
| Unadjusted | 5.9 (0.5)b | 7.7 (1.4)b | 3.9 (0.6)c,d | 4.9 (0.5)b,c,d | 3.7 (0.6)d | 5.4 (0.5)b,c |
| Adjusted | 6.4 (0.6)b,d | 9.8 (1.7)d | 3.1 (0.5)e | 5.3 (0.5)b,c | 5.2 (0.8)b,c | 4.5 (0.5)c |
| Suicide attempt, past y | ||||||
| Unadjusted | 1.4 (0.2)b,c | 3.9 (1.3)b | 1.0 (0.3)c,d | 0.8 (0.1)d | 0.6 (0.2)d | 0.8 (0.2)d |
| Adjusted | 1.6 (0.3)b | 5.3 (1.8)c | 0.7 (0.2)d | 0.9 (0.1)b,d | 1.1 (0.3)b,d | 0.7 (0.2)d |
Note. GAD = generalized anxiety disorder; OEF = Operation Enduring Freedom; OIF = Operation Iraqi Freedom. PTSD = post-traumatic stress disorder. Table displays the percentage of reservists and active-duty personnel by location of deployment who reported the stress and mental health issues indicated. Adjusted estimates were standardized to gender, race/ethnicity, education, age, marital status, pay grade, and service or reserve component.
Other theater included Operations Desert Shield/Desert Storm (e.g., the Persian Gulf), Operation Just Cause (e.g., Panama), Operation Restore Hope (e.g., Somalia), Operation Uphold Democracy (e.g., Haiti), Operations Joint Endeavor or Joint Guard (e.g., Bosnia), Operation Safe Haven (e.g., Cuba), Tsunami Relief (e.g., South Asia), other combat peace-keeping missions, and other remote assignments (this excludes hurricane relief and Homeland Security and airport security or security for active-duty installations). Respondents serving in OIF or OEF, as well as another theater, appear only in the OIF or OEF column.
Estimates within rows not sharing a common superscript letter differ significantly, P < .05.
Based on respondents’ perception of number of days when mental health limited usual activities.
Operational theater was not associated with rates of depression, anxiety symptoms, or mental health limiting normal activities for active-duty personnel but it was associated for reservists. Reservists who served in OIF or OEF were significantly more likely to report symptoms related to mental health than were those who did not serve in a theater. Meeting the screening criteria for symptoms of PTSD differed strikingly between reservists and active-duty personnel by theater. Reservists who served in OIF or OEF showed significantly higher proportions of PTSD symptoms than did active-duty personnel regardless of theater and higher proportions than did reservists who did not serve in a theater but not significantly higher than reservists who served in other theaters.
Suicidal ideation and suicide attempts also showed striking differences between reservists and active-duty personnel by theater. Suicidal ideation or thoughts were more likely to be reported by reservists who served in OIF or OEF or in other theaters than by those who did not serve in a theater. Suicide attempts were significantly higher among reservists who served in OIF or OEF and in theaters other than OIF or OEF than among those who did not serve in a theater. Notably, the proportion for those serving in other theaters was the highest of any reserve-component or active-duty personnel category. Active-duty personnel showed no statistically significant differences by theater.
DISCUSSION
Reservists reported significant mental health issues, particularly as related to deployment. Although high stress and other mental health issues were slightly less common among reservists than among active-duty personnel overall, the higher rates of high stress and other mental health issues among reservists associated with deployment are noteworthy, particularly in the absence of systems designed to deal with these issues specifically in this population. Especially concerning are the higher PTSD symptomatology and significantly greater suicidal ideation and suicide attempts among deployed compared with nondeployed reservists relative to deployed compared with nondeployed active-duty personnel. Our findings suggest a differential impact of deployment on reservists and the need to address the unique requirements of returning reservists as they navigate the reintegration process.
Deployed personnel showed significantly higher rates of meeting the screening criteria for PTSD than did nondeployed personnel. Deployment was also related to perceived work and family stress among active-duty personnel. High family stress was comparable between both groups across deployment categories. Additionally, a greater percentage of both active-duty personnel and reservists who had been deployed reported depression symptoms compared with those who had not been deployed. Reservists who were deployed were significantly more likely to report suicidal ideation and suicide attempts than were their nondeployed counterparts. These findings illustrate the stress that deployment (including the possibility of upcoming deployment) can place on the families of all service members and support growing concerns that deployments are taking a significant toll on the mental health of both active and reserve personnel.3
Among reservists, OIF or OEF service was associated with higher levels of family stress and symptoms of depression, anxiety, PTSD, and poor mental health limiting normal activities. Significantly more reservists who served in OIF or OEF showed PTSD symptoms compared with any active-duty personnel and reservists not serving in a theater. Likewise, suicide attempts were significantly higher in all theaters than among those who did not serve in a theater. These findings suggest that deployment to any theater, not only to OIF or OEF, may represent unique threats to the mental well-being of service members. Of particular note was that the highest rate of suicidal behavior was among those reservists who had served in theaters other than OIE or OEF. We are currently examining this unexpected finding with additional analyses; this is an area requiring further research. Consideration of programs and services to address these threats should include a wide range of situational and environmental factors associated with the realities of deployment in general, in addition to those factors associated with specific theaters such as OIF or OEF.
Our findings are consistent with previous data indicating that reservists report similar and in some cases higher rates of mental health issues than do their active-duty counterparts3 and expand existing research through examination of a broader spectrum of factors related to these issues. The additional stressors that reservists face, including uncertainty associated with workload, environments, and timelines,2 exacerbate mental well-being issues. For example, although active-duty personnel showed higher rates of depression and anxiety symptoms than did reservists, unlike their active-duty counterparts, reservists do not typically live in a day-to-day culture in which the anxieties associated with deployment are a way of life. Rather, their typical culture involves balancing the competing demands of a military career with that of a civilian career. When deployments do occur, the associated anxieties are not familiar. Reservists also face uncertainty about whether the civilian jobs they left will be available when they return from deployment.
Our findings represent issues that are becoming increasingly salient to policymakers at all levels. Recently proposed legislation underscores the need for the evaluation and implementation of mental health services for reserve-component personnel. In April 2008, the National Guard and Reserve Mental Health Access Act of 2008 was introduced to the US Senate with a focus “to expand and improve mental health care and reintegration programs for members of the National Guard and Reserve.”15 Such legislation will be increasingly important as more service members cycle through the deployment process and return home to their civilian lives.
Limitations
The present study had several limitations that should be considered when interpreting our study findings. The active-duty and reserve-component data were collected 1 year apart (active duty in 2005, reserve component in 2006), and comparisons between the groups may contain bias to the extent that events in the year between the surveys may have influenced the reported behaviors. Specifically, varying events during the periods in the OIF and OEF theaters may have influenced the experiences, and ultimately responses, of both groups. Express examination of the effects of deployment theater on mental health outcomes accounted for some events and their influences, and continuing research should consider these potentially differential effects as related to emergent deployment theaters.
Another limitation was the response rates of the surveys. Although the 52% to 55% response rates were low for civilian surveys, the onsite administration of the health-related behaviors surveys is unique among military surveys and achieved the highest response rate of any population-based military survey. Most personnel unavailable to participate in the survey were deployed, although large numbers of recently deployed personnel participating in the survey provided confidence in the generalizability of the findings. To mitigate potential biasing effects of differential nonresponse, we weighted and adjusted the data to represent the population of eligible active-duty personnel.16
Finally, the data were based on self-report and may have been subject to recall errors and ambiguities caused by questions with various interpretations and to potential bias resulting from the sensitive nature of some questions surrounding mental health issues. Some concern exists that personnel might not reveal information about issues that they believe could jeopardize their military careers. However, because the surveys were pretested and because of the large numbers of respondents, the use of sampling weights, and strong research design and rigorous procedures to encourage honest reporting (including anonymity of survey responses), we believe the extent of potential bias to be small.16
Conclusions
The present study provided the first population-based assessment and comparison of mental health issues among active-duty and reserve-component service members. Furthermore, our study extended previous work by incorporating personnel from all service branches rather than focusing on select branches3,17 or unit types2 and by examining a broader range of issues in greater depth. Although both active and reserve personnel were impacted by deployment, our findings suggest a differential impact of deployment on reservists and highlight the urgent need for mental health services for this population. Deployed reservists reported greater PTSD symptomatology and suicidal ideation and attempts than did nondeployed reservists, which suggests areas for intervention in this distinct population of service members. Our findings also suggest that deployment to any theater, not only to OIF or OEF, may represent unique threats to the mental well-being of all service members. Continued research efforts aimed at providing services and interventions tailored to reservists will better facilitate the successful return and reintegration of service members experiencing postdeployment mental health issues.
Acknowledgments
The 2005 active-duty and 2006 reserve-component Health-Related Behaviors surveys were conducted by RTI International under the sponsorship of the Office of the Assistant Secretary of Defense (Health Affairs) and the TRICARE Management Activity (Health Program Analysis and Evaluation Directorate) under cooperative agreement number DAMD17-00-2-0057 and contract number W81XWH-05-F-0917, respectively. This study was supported by the US Department of the Army (grant W81XWH-08-1-0170).
We thank the following individuals for outstanding reviews of the article: Alyssa Mansfield, PhD, Janice Brown, PhD, Laura Strange, PhD, Carolyn Reyes, MPH, and Michael Witt, MA, of RTI International. We extend special thanks to Michael Witt for providing his statistical expertise.
The views, opinions, and findings contained herein are those of the authors and should not be construed as an official Department of Defense position, policy, or decision unless so designated by other official documentation. The funding organization had no role in the design and conduct of the study; the collection, management, analysis, or interpretation of the data; or the preparation of this article.
Human Participant Protection
This study was approved by two independent institutional review boards and was deemed to be of minimal risk.
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