Pre-Deployment Stress, Mental Health, and Help-Seeking Behaviors Among Marines

Abstract

The Marine Corps Operational Stress Control and Readiness (OSCAR) program is designed to provide mental health support to marines by embedding mental health personnel within Marine Corps units and increasing the capability of officers and senior noncommissioned officers to improve the early recognition and intervention of marines exhibiting signs of stress. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury have asked RAND to evaluate the OSCAR program. As part of this evaluation, RAND conducted a large survey of marines who were preparing for a deployment to Iraq or Afghanistan in 2010 or 2011. This article describes the methods and findings from this survey. The results are among the first to shed light on the pre-deployment mental health status of marines, as well as the social resources they draw on when coping with stress and their attitudes about seeking help for stress-related problems. The 2,620 marines in the survey sample had high rates of positive screens for current major depressive disorder (12.5 percent) and high-risk drinking (25.7 percent) and reported having experienced more potentially traumatic events over their lifetime than adult males in the general population. Marines in the sample also reported relying on peers for support with stress and perceiving moderate levels of support from the Marine Corps for addressing stress problems.

Background

U.S. military forces have been engaged in extended conflicts in Iraq and Afghanistan since 2001. During that time, service members have faced extended deployments and exposure to combat or other stressful situations. While most military personnel cope well with these stressors, many experience difficulties handling stress at some point, and some experience mental health problems as a consequence. The prevalence of posttraumatic stress disorder (PTSD) among returning U.S. service members is estimated at 5–20 percent, with variations in this estimate due to differences in how the population is defined and which measures are used (Ramchand et al., 2011). The literature suggests that certain populations of service members may be at higher risk for deployment-related mental health problems, including those with greater combat exposure (Seal et al., 2009; Hoge, Auchterlonie, and Milliken, 2006). Numerous programs have been developed to assist service members with deployment-related stress and mental health problems; a recent RAND report estimated that the U.S. Department of Defense (DoD) alone funds over 200 such programs.

One such program, the Marine Corps Operational Stress Control and Readiness (OSCAR) program, is intended to provide mental health support to marines by (1) embedding mental health personnel within Marine Corps units and (2) increasing the capability of officers and senior NCOs to improve the early recognition and intervention of marines exhibiting signs of stress. To this end, select officers and senior NCOs at the battalion and company levels attend a one-day training course that delivers instruction on OSCAR principles, as well as the recognition, intervention, and referral of marines with potential stress injuries. Our research team is evaluating the impact of the OSCAR program. This article presents the results of the first phase of our evaluation study.

Purpose of This Study

This study presents findings from a pre-deployment survey of 2,620 marines scheduled for deployment to Afghanistan or Iraq. We developed the survey primarily as a means of gathering baseline information to support our evaluation of the OSCAR program. However, it also provides unique information about marines' mental health prior to deployment, as well as their attitudes toward stress and seeking help for mental health issues. Though a great deal of research has examined mental health and stress-related concerns among military service members following deployment, this report contributes to the nascent literature on the mental health status of service members prior to deployment. This report also contributes to an understanding of the magnitude of mental health problems and associated vulnerabilities that are present prior to service members' first deployment, as roughly half of the marines in this study had never deployed as of the time of the survey.

Specifically, the pre-deployment survey asked questions about four main topics:

• mental health burden (i.e., mental health status and high-risk drinking behavior)

• prior exposure to traumatic events

• resources for coping with stress

• attitudes toward coping with stress and seeking help.

Methods

The survey was administered as part of a study designed to determine whether marines in battalions that received OSCAR training fared better in terms of stress and mental health–related outcomes from pre- to post-deployment relative to marines in battalions that did not receive OSCAR training. The study was quasi-experimental, in that the two survey groups were not created by random assignment but by comparing two naturally occurring groups that were similar at baseline. The study included a survey both before and after deployment; this report describes the findings from the pre-deployment survey.

The pre-deployment survey was conducted in person with marines from seven battalions (three service support battalions and four infantry battalions) preparing for a combat deployment to Afghanistan. The survey was fielded in group settings to 2,975 marines on base between March 2010 and December 2011. A total of 2,620 marines completed the survey, representing a cooperation rate of 88.1 percent.

The survey included questions about sociodemographic and service history characteristics, any lifetime history of traumatic events, current stress, mental health status, high-risk drinking, the use of social resources to cope with stress and potential mental health problems, and attitudes toward stress response and recovery. When available, well-validated measures of these constructs were used. When well-validated measures did not exist, we borrowed relevant questions from other surveys or created original questions to assess the construct.

Since our survey sample was not a random sample, the survey data were weighted to match the sociodemographic and service history characteristics of the larger population of marines who deployed to Iraq or Afghanistan in 2010 or 2011. This study design affords stronger inferences regarding the mental health status and high-risk drinking behavior within this population in advance of deployment.

Key Findings

Mental Health Burden

The 2,620 marines in the survey sample had high rates of positive screens for current major depressive disorder (MDD) (12.5%) and high-risk drinking (25.7%). Rates of these problems were three to four times higher among enlisted marines than officers based on the officers surveyed. Rates of high-risk drinking were particularly high among junior enlisted marines (rank E1–E3), with roughly a third (33.1%) reporting high-risk alcohol use. Rates of these problems did not vary significantly by type of battalion or deployment history.

To place these findings in context, we compared them to estimates of the prevalence of these problems from nationally representative datasets, which found that the rate of current depression among adult males in the U.S. general population was 6.4 percent. Data from a nationally representative survey, the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), indicate that, adjusting for the age distribution of our sample of marines, 16.1 percent of adult males in the U.S. population engage in high-risk drinking behavior, as measured by the cutoff applied in our study. Of particular interest, even those marines in our sample who had never deployed had higher rates of positive screens for current major depressive disorder (12.4%; 95% confidence interval [CI] [10.4%, 14.4%]) and high-risk drinking behavior (25.2%; 95% CI [21.8%, 28.7%]) relative to adult males in the U.S. general population.

Previous Exposure to Traumatic Events

The survey asked marines about exposure to potentially traumatic events during their lifetime. On average, marines in the sample reported that they had experienced 3.9 (95% CI [3.6, 4.1]) types of potentially traumatic events over their lifetime (out of a possible 17 types of events). The types of events most frequently reported were motor vehicle accidents (66.4%); the sudden, unexpected death of a loved one (45.4%); and physical assault (38.0%). Just over one-quarter (28.2%) of marines reported having experienced a natural disaster, 4.7 percent of marines reported having experienced a sexual assault, and 19.2 percent of marines reported having experienced combat.

The total number of potentially traumatic events experienced varied significantly by rank, battalion type, and deployment history. A significantly higher number of events was reported by marines of rank E4–E9 (mean [M] = 4.30, 95% CI [3.82, 4.77]) relative to marines of rank E1–E3 (M = 3.55, 95% CI [3.36, 3.74]) and officers (M = 2.89, 95% CI [2.28, 3.49]); by marines in infantry battalions (M = 4.18, 95% CI [3.89, 4.48]) relative to marines in service support battalions (M = 3.55, 95% CI [3.35, 3.75]); and by marines who had previously deployed to Iraq or Afghanistan (M = 5.21, 95% CI [4.31, 6.11]) relative to marines who had not previously deployed (M = 3.39, 95% CI [3.24, 3.54]).

To put these findings in context, we compared them to findings from the National Comorbidity Survey (NCS), a nationally representative survey in which respondents were asked to indicate which of several types of potentially traumatic events they had directly experienced during their lifetime (Kessler et al., 1995). In comparison to adult males in the general population, a higher proportion of marines in our study reported having experienced different types of potentially traumatic events. This finding might be expected given that roughly half of the marines in our study had previously deployed to Iraq or Afghanistan and would likely have had exposure to several types of potentially traumatic events during their deployment. However, even among the subset of marines in our study who had never deployed, the rates of having experienced potentially traumatic events were higher than those of adult males in the U.S. general population: Only (11.1%) of the NCS general male population (compared with 37.4 percent of the sample of marines who had never deployed) had directly experienced a physical assault; 18.9 percent of the general male population had experienced a natural disaster (compared with 26.8 percent of marines who had never deployed); and 0.7 percent of the general male population had experienced a sexual assault (compared with 5.0 percent of marines who had never deployed).

The Use of Resources for Coping with Stress

The survey also asked respondents about what kinds of social or other resources they turn to for help in coping with stress. Marines were asked whether they had ever talked with, or recommended that a buddy talk with, a number of types of individuals that could be used as resources for dealing with stress.

Most marines reported having used (79.3%) or recommended (88.7%) one or more of the following resources for dealing with stress: a buddy, leader, chaplain, corpsman, or unit medical officer. The most common type of resource cited by respondents when dealing with their own stress was a buddy (71.9%). Similarly, the majority of marines reported recommending a buddy as a resource to others in need of help with stress (84.0%). After buddies, leaders were the next most popular resource for helping oneself (49.7%) and for recommending to a buddy (67.7%).

We found significant differences between marines who had previously deployed to Iraq or Afghanistan at least once and marines who had never deployed in the types of resources recommended to a buddy for help with stress. Marines who had previously deployed were significantly more likely than those who had never deployed to report having recommended any type of resource for help (ever-deployed: 91.0%; never-deployed: 88.0%), as well as every specific type of resource aside from a buddy: leaders (ever-deployed: 71.9%; never-deployed: 66.4%), corpsmen (ever-deployed: 44.5%; never-deployed: 34.6%), chaplains (ever-deployed: 70.9%; never-deployed: 57.1%), and unit medical officers (ever-deployed: 35.9%; never-deployed: 25.8%). In notable contrast, there were no differences between those who had previously deployed and those who had never deployed in the use of resources for help with one's own stress.

Attitudes Toward Coping with Stress and Perceived Levels of Support

Marines were asked about their attitudes toward stress-related issues, as well as their perceptions of available support. Our research team created original items to measure respondents' attitudes about several issues related to stress and how to cope with it. These included: their self-perceived readiness; the ability to handle their own stress and help a peer handle his or her stress; the perceived efficacy of their peers and leaders in resolving their own stress problems and helping the respondent to resolve his or her stress problems; the extent to which they believe the responsibility to handle stress problems is shared by all marines; and the perceived stigmatization of or support for seeking help for stress problems at the level of the respondent's peers, leaders, unit, and the Marine Corps overall.

Overall, marines reported positive attitudes toward their own and others' abilities to cope with stress. On a five-point scale, with “1” representing the least positive attitude, “3” being neutral, and “5” representing the most positive attitude, respondents registered a mean score of 4.01 (95% CI [3.97, 4.05]).

We found significant differences in attitudes toward stress response and recovery by rank. Junior enlisted marines (E1–E3) reported the least positive attitudes toward stress response and recovery (M = 3.92, 95% CI [3.86, 3.97]) compared to E4–E9 marines (M = 4.06, 95% CI [4.00, 4.13]) and officers (M = 4.12, 95% CI [4.02, 4.22]).

We also found a significant differences by deployment history. Marines who had never deployed endorsed significantly less-positive attitudes toward stress response and recovery (M = 3.98, 95% CI [3.94, 4.03]) compared to marines who had deployed once or more (M = 4.10, 95% CI [4.04, 4.16]). There were no differences by battalion type.

Respondents also reported on a five-point scale that they perceived moderate levels of support for help-seeking (M = 3.12, 95% CI [3.06, 3.18]). We did not find significant differences in the perceived support for help-seeking by rank, battalion type, or deployment history.

Conclusions and Recommendations

Pre-Deployment Mental Health Burden

The results suggest that, even prior to deployment, marines face a substantial mental health burden. They are also more likely than their counterparts in the general population to have been exposed to traumatic events. Potential mental health problems may be even greater among junior enlisted marines. Therefore, marines would benefit from a greater emphasis on pre-deployment screening and assessment to facilitate problem resolution prior to deployment.

Recommendation 1: Consider implementing programs to identify and address mental health and alcohol use problems prior to deployment.

Recommendation 2: Investigate the relationship between the pre-deployment mental health burden, experiences while in theater, and the likelihood of developing longer-term mental health problems.

Recommendation 3: Target prevention and treatment efforts toward junior enlisted marines.

Recommendation 4: Consider additional training in combat and operational stress for junior enlisted marines.

Attitudes Toward Coping with Stress and Seeking Help and the Use of Help-Seeking Resources

The marines in our sample generally expressed positive attitudes toward stress response and recovery, and they perceived moderate levels of support for seeking help related to mental health problems. However, some stigma around mental health problems was apparent.

Recommendation 5: Provide training in stress recognition and response to all marines.

Recommendation 6: Continue to make multiple resources for help available to accommodate varied preferences.

Concluding Observation

Even prior to a deployment, marines face a mental health burden higher than that of the general U.S. population and also report higher levels of exposure to trauma. These results suggest that pre-deployment mental health deserves greater attention, from both DoD program planners and researchers seeking to understand service members' mental health and well-being across the deployment cycle.