Abstract
Purpose
The purpose of this study was to examine the effect of depression on the association between a history of military service and life satisfaction among a nationally representative sample of US males.
Methods
Data from 57,905 men were obtained from the 2006 Behavioral Risk Factor Surveillance (BRFSS) survey that assessed depression, history of military service, and life satisfaction. Multivariable logistic regression was conducted, controlling for demographics and physical health characteristics.
Results
In non-depressed men, a history of military service was associated with higher odds of life satisfaction, OR (95%CI) = 1.39 (1.07, 1.81). However, the interaction between depression and a history of military service was significant, OR (95%CI) = 0.56 (0.38–0.84), such that a history of military service was associated with equivalent odds of satisfaction in depressed men, OR (95%CI) = 0.78 (0.56–1.09).
Conclusions
Intervention efforts targeting depression in men with a history of military service may have a significant impact on their well being. Future research should replicate these findings, examine potential mechanisms of the effects, and study the utility of life satisfaction measures in this population.
Life satisfaction is an evaluative judgment of one’s subjective well-being [1]. In a prospective data set spanning up to 20 years, lower baseline life satisfaction predicted later work disability [2], all-cause mortality [3], death by unintentional injury [4], and suicide [5]. Because of the association between life satisfaction and poor health-related outcomes, it is important to study its correlates.
Although there is a paucity of research on the relationship between military service and life satisfaction, there is reason to believe that the relationship is neutral or positive. Men with a history of military service report equivalent or better health-related quality of life, a construct similar to life satisfaction, than men without a history of military service [6]. Pre-enlistment screening may prevent individuals who may be at risk for being dissatisfied with life, such as those with psychotic disorders, alcohol or drug dependence, serious legal problems (e.g., more than one felony conviction, felony with three or more non-traffic offenses, felony drug distribution or trafficking, three or more driving while intoxicated convictions), or debilitating medical conditions, from enlisting [7, 8]. The financial compensation and healthcare that is provided during and after military service and the pride many servicemen take in serving their country may also increase their satisfaction with life.
The relationship between a history of military service and life satisfaction, however, may be different for men with psychiatric conditions. Psychiatric morbidity is negatively correlated with life satisfaction [9]. Depression in particular has a robust negative association with life satisfaction [10], and its treatment leads to improved satisfaction with life [11, 12]. In men with a history of military service, psychiatric conditions such as depression may be more deleterious due to co-occurring combat-related injuries and illnesses [13–15], and the reluctance to seek mental health treatment that is often observed in military populations [16, 17]. Indeed, Veterans who receive care from the Veterans Health Administration (VHA) have been shown to report worse health-related quality of life than individuals enrolled in other healthcare systems [18]. Thus, the presence of depression may identify a population of men with a history of military service who are less likely to be satisfied with their lives.
To our knowledge, this is the first study to examine correlates of life satisfaction in a representative sample of men from 36 U.S. states, with a focus on history of military service and depression. Based on previous findings, we hypothesized that a history of military service would increase the odds of life satisfaction in non-depressed men. We also hypothesized that depression would modify the effect of military service on life satisfaction, such that depressed men with a history of military service would be less likely to be satisfied with life than depressed men without a military history.
Methods
The Behavior Risk Factor Surveillance System (BRFSS) survey is coordinated by the Centers for Disease Control and Prevention (CDC) and collects data from a nationally representative sample of non-institutionalized adults from all U.S. states, Washington D.C., Guam, the U.S. Virgin Islands, and Puerto Rico [19]. It is a state-based study that includes a core questionnaire, optional modules, and state added questions. In 2006, 51 of the 53 states, commonwealths, and territories used a disproportionate random sampling design (the U.S. Virgin Islands and Puerto Rico used a random sampling design), with a median response rate of 51.4% (range: 35.1%–66.0%). An optional anxiety and depression module was used by 36 states (names are available on the BRFSS website) and provided the sample for this study [20]. To promote standardization, all states used a computer-assisted telephone interviewing system. All analyses were conducted with information from the de-identified dataset available from the CDC website (www.cdc.gov/BRFSS). Additional information about survey design and administration is available from the data quality summary report [21]. The Institutional Review Board of the Syracuse VA Medical Center approved this study.
Measures
Dependent Variable
Life satisfaction was assessed with a single item that has been validated as a measure of general well-being [22]. The item asked respondents to rate the question “In general, how satisfied are you with your life?” on a four-point scale ranging from 1) Very satisfied, 2) Satisfied, 3) Dissatisfied, to 4) Very Dissatisfied. For clinical interpretation, the answer was dichotomized to satisfied (1 and 2) and dissatisfied (3 and 4), and reverse coded so that life satisfaction was the outcome.
Independent Variables
History of military service was assessed with the question “Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?” Participants who answered “yes” were categorized as having a history of military service. This item identifies individuals in the active military, Reserves, and Guard who are currently stationed or staying in the US, as well as those with a history of previous military service. Previous analyses of 2001 BRFSS data indicate that approximately 91% of male respondents with a history of military service were Veterans and 9% were active duty, Reserves, or National Guard [6].
The PHQ-8 (Patient Health Questionnaire) was used to measure clinically significant depressive symptoms. It is identical to the validated PHQ-9 [23, 24], but does not include the death and suicidal ideation item which was excluded from the 2006 BRFSS questionnaire. To match other BRFSS rating scales, participants were asked the number of days they experienced each symptom in the past two weeks. For these analyses, responses were converted back to the original 4-point PHQ-9 scale, ranging from “1 = not at all” (converted from 0–1 day), “2 = several days” (2–6 days), “3 = more than half the days” (7–11 days), to “4 = nearly every day” (12–14 days). The eight items were summed for a total score. A score of ten, the accepted cutoff for moderate depression for the PHQ-9 [24], was used as the cutoff for a positive screen. The PHQ-8 is validated [25], has been used in BRFSS studies [26], and case identification using the 10-point cutoff is virtually identical to the PHQ-9 (r = .998) [27].
To eliminate potential confounds, a number of covariates was controlled for. Dichotomous covariates included relationship status (married or member of an unmarried couple vs. living alone, divorced, or widowed), education (some college or more vs. less than college), income (> $50,000 vs. < $50,000), physical disability that requires special equipment (yes vs. no), smoker (smoked more > 100 cigarettes and smoke every day or some days vs. not at all and smoked > 100 cigarettes but don’t currently smoke), heavy drinking (>2 drinks per day vs. ≤ 2 drinks per day), told you have diabetes (yes vs. no, no pre-diabetes or borderline diabetes), and ever had a heart attack (yes vs. no). Categorical covariates included age (24–34, 25–44, 45–54, 55–64 vs. ≥65), for which imputed categories were used [21], and race/ethnicity (non-Hispanic black, Hispanic, non-Hispanic other vs. non-Hispanic white,).
Analyses
Descriptive statistics were calculated to compare the full and analytical samples. Multivariable logistic regression was used to estimate the odds of being satisfied with life in regards to depression, history of military service, and the interaction of history of depression and military service, after controlling for demographics, unhealthy behaviors, and existing disability and illnesses. All logistic regressions were calculated using sampling weights to adjust for non-response and survey design (for more information see [28]). Missing data was managed using listwise deletion.
Results
The analytical sample consisted of 57,905 males with complete data. Descriptive statistics indicated that the analytical sample differed from the full sample for the majority of demographic categories (see Table 1).
Table 1.
Comparison of Men with and without a History of Military Service in the Full and Analytic Sample
| Full Sample (N = 134,290)Percentage (95%CI) | Analytic Sample (N = 57,905)Percentage (95%CI) | |||
|---|---|---|---|---|
|
| ||||
| Military Service (N = 46,493) | No Military Service (N = 87,797) | Military Service (N = 19,630) | No Military Service (N = 38,275) | |
| Age | ||||
| 18–34 | 4.47 (4.28, 4.66) | 22.32 (22.05, 22.60) | 5.44 (5.13, 5.76) | 23.18 (22.75, 23.60) |
| 35–44 | 8.17 (7.92, 8.42) | 21.95 (21.67, 22.22) | 9.55 (9.14, 9.96) | 22.93 (22.50, 23.35) |
| 45–54 | 12.50 (12.20, 12.80) | 27.11 (26.82, 27.40) | 13.86 (13.38, 14.34) | 27.18 (26.73, 27.62) |
| 55–64 | 27.91 (27.51, 28.32) | 16.29 (16.05, 16.54) | 29.79 (29.15, 30.42) | 16.08 (15.71, 16.44) |
| 65+ | 46.95 (46.50, 47.40) | 12.33 (12.11, 12.54) | 41.36 (40.67, 42.04) | 10.64 (10.33, 10.95) |
| Race/Ethnicity | ||||
| Non-Hispanic, White | 85.37 (85.05, 85.70) | 77.04 (76.76, 77.32) | 83.21 (82.69, 83.73) | 76.30 (75.87, 76.73) |
| Non-Hispanic, Black | 5.79 (5.58, 6.00) | 7.25 (7.08, 7.42) | 5.98 (5.64, 6.31) | 7.08 (6.82, 7.34) |
| Hispanic | 3.59 (3.42, 3.76) | 9.12 (8.97, 9.36) | 4.49 (4.20, 4.78) | 9.56 (9.26, 9.85) |
| Non-Hispanic, Other | 5.25 (5.04, 5.45) | 6.55 (6.38, 6.71) | 6.32 (5.98, 6.66) | 7.05 (6.80, 7.31) |
| Married or Cohabit | 66.39 (65.96, 66.82) | 63.66 (63.34, 63.98) | 68.69 (68.04, 69.33) | 65.66 (65.18, 66.13) |
| Some College or More | 62.76 (61.32, 62.20) | 59.39 (59.06, 59.71) | 64.42 (63.75, 65.09) | 61.32 (60.83, 61.80) |
| Income of $50,000 or More | 42.28 (41.81, 42.76) | 49.08 (48.73, 49.43) | 44.59 (53.89, 45.28) | 49.46 (48.96, 49.96) |
| Physical Disability | 12.18 (11.88, 12.48) | 6.68 (6.52, 6.85) | 10.95 (10.52, 11.39) | 6.14 (5.90, 6.38) |
| Smoker | 18.32 (17.97, 18.68) | 21.20 (20.93, 21.47) | 18.95 (18.40, 19.50) | 20.73 (20.32, 21.13) |
| Heavy Drinker | 5.14 (4.94, 5.34) | 5.60 (5.44, 5.75) | 5.61 (5.29, 5.94) | 6.12 (5.88, 6.36) |
| Diabetes | 15.54 (15.22, 15.87) | 8.61 (8.43, 8.80) | 14.51 (14.02, 15.01) | 8.41 (8.13, 8.68) |
| History of Heart Attack | 13.19 (12.88, 13.50) | 5.18 (5.04, 5.33) | 12.29 (11.83, 12.75) | 4.84 (4.62, 5.05) |
| Depression | 6.40 (6.06, 6.74) | 6.46 (6.21, 6.71) | ||
In the multivariate analysis, a history of military service was associated with higher odds of life satisfaction in non-depressed men, OR (95%CI) = 1.39 (1.07–1.81) (Table 1). However, the interaction between a history of military service and depression was significant, OR (95%CI) = 0.56 (0.38–0.84), indicating that depression influenced the association between military service and life satisfaction. When adjusted ORs were calculated [29], a history of military service reduced the odds of life satisfaction in depressed men, OR (95%CI) = 0.78 (0.56–1.09), but not to the level of statistical significance. Thus, depression mitigated the positive impact of a history of military service on life satisfaction such that depressed men with a history of military service were just as likely to be satisfied with life, OR = 0.07 (0.05–0.10), as depressed men without a military history, OR = 0.09 (0.07–0.12) (with ORs using non-military non-depressed as a reference group). The interaction remained significant in sensitivity analysis in which the full PHQ-8 score was added to the model to adjust for the severity of depression. Covariates that were associated with lower odds of life satisfaction included ages 35–54, non-black non-Hispanic minority status, smoking, and heavy drinking. Having an income over $50,000 a year and being in a relationship were associated with higher odds of life satisfaction.
Discussion
Non-depressed men with a history of military service were 39% more likely to be satisfied with life than non-depressed men without a history of military service. Rigorous covariate coverage eliminated explanations associated with demographics, smoking and alcohol use, physical disability, and common medical diseases, suggesting that the reason lies elsewhere. Department of Defense (DOD) enlistment standards may exclude populations of men who are presumably less likely to be satisfied with life [7], and benefits from the DOD and VHA may increase life satisfaction. However, it is also possible that this sub-group of men found meaning in their military service and was therefore more likely to be satisfied with their lives.
Depression modified the relationship between a history of military service and life satisfaction such that depressed men with a military history were no more likely to be satisfied with life than depressed men without a history. Characteristics associated with depression, such as the tendency to negatively appraise experiences, may prevent depressed men with a military from benefitting from their service [30, 31]. However, there are also other potential explanations for the effect. Psychiatric disorders other than depression impact life satisfaction [32], and often co-occur with depressive disorders [33]. The presence of depression may identify a sub-population of men that also have military-related disorders that were not accounted for such as post-traumatic stress disorder (PTSD) [13, 14] or traumatic brain injury (TBI) [15], which may mitigate the benefits of military service. The reluctance to seek treatment in men with a history of military service may further increase the deleterious effect of depression in members of this sub-population [16, 17].
These findings suggest that intervention efforts targeting depressed men with a military history may have a significant impact on increasing their sense of well-being. Additional research is needed to identify appropriate interventions as the mechanisms for the association are unknown and may be influenced by a number of factors including depressive symptoms, co-occurring psychiatric disorders, and help seeking behaviors. Given the association of life satisfaction with negative outcomes [2–5], measures of life satisfaction might also provide a helpful tool for identifying men with a history of military service who may be at elevated risk for negative outcomes, as they may not elicit the stigmatization associated with psychiatric symptoms in some military populations [16].
It is important to note the limitations of the study. BRFSS is a telephone survey, and the 2006 median response rate was low at 51.4% [21]. The participation rate, however, was consistent with that of other telephone-based epidemiological studies, and analyses using BRFSS and other surveys suggest that reduced participation is weakly associated with bias [34]. Furthermore, the demographics of men with a history of military service were similar to that of the National Survey of Veterans, available from Department of Veteran Affairs website [35]. BRFSS data is cross-sectional and relies solely on participants self-report, with the associated limitations. In many studies, life satisfaction is assessed with multiple items [1, 5], whereas our measure was a single item. Important service-related variables that may explain the findings were not measured such as Veteran and active duty status, branch of service [16, 17, 36, 37], combat exposure [37], trauma exposure [38], mental health care utilization and early discharge [17], and rank during service. The survey did not assess the presence of psychiatric disorders other than depression that may also explain the findings. Several important subpopulations were also excluded from the sample, including women and men currently serving in combat zones.
These findings identify a potentially important domain of inquiry in men with a history of military service. Military service is associated higher odds of life satisfaction in non-depressed men, but equivalent odds in depressed men. DOD and VHA intervention efforts targeting depressed men may therefore have a significant impact on the well-being of men with a history of military service. Future research should replicate these findings, examine possible mechanisms of the effects, and study the potential utility of life satisfaction measures in men with a history of military service.
Table 2.
Correlates of Life Satisfaction in Males (N = 57,905)
| Variables | Life Satisfaction |
|---|---|
|
| |
| OR adjusted (95%CI) | |
| Age | |
| 18–34 | 1.02 (0.69, 1.49) |
| 35–44 | 0.80 (0.55, 1.17) |
| 45–54 | 0.65 (0.46, 0.91)* |
| 55–64 | 0.69 (0.49, 0.97) |
| ≥ 65 | 1.00 |
| Race/Ethnicity | |
| Black | 0.88 (0.63, 1.23) |
| Hispanic | 1.03 (0.71, 1.50) |
| Other | 0.71 (0.51, 0.98)* |
| White | 1.00 |
| Relationship Status | |
| In a Relationship | 2.15 (1.76, 2.63)*** |
| Not in a Relationship | 1.00 |
| Education | |
| Some College or More | 1.00 (0.82, 1.22) |
| Less than College | 1.00 |
| Income | |
| $50,000 or more | 1.64 (1.25, 2.15)*** |
| Less than $50,000 | 1.00 |
| Physical Disability | |
| Yes | 0.60 (0.47, 0.77)*** |
| No | 1.00 |
| Smoker | |
| Yes | 0.58 (0.47, 0.73)*** |
| No | 1.00 |
| Heavy Drinker | |
| Yes | 0.67 (0.46, 0.98)* |
| No | 1.00 |
| Diabetes | |
| Yes | 0.80 (0.60, 1.08) |
| No | 1.00 |
| Heart Attack | |
| Yes | 1.14 (0.86, 1.52) |
| No | 1.00 |
| Depression | |
| Yes | 0.09 (0.07, 0.12)*** |
| No | 1.00 |
| History of Military Service | |
| Yes | 1.39 (1.07, 1.81)* |
| No | 1.00 |
| History of Military Service X Depression | 0.56 (0.38, 0.84)** |
P < .001
P < .01
P < .05
Acknowledgments
This study was funded by the Department of Veterans Affairs, VISN 2 Center of Excellence for Suicide Prevention.
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