Post-Deployment Screening in the Military Health System: An Opportunity to Intervene for Possible Alcohol Use Disorder

Abstract

Unhealthy alcohol use in the military remains a serious threat to health and military readiness, and begs the question how detection that facilitates diagnosis and treatment might be improved. Army active duty Soldiers are routinely screened for possible alcohol use disorder in pre- and post-deployment health surveillance surveys. We examined the likelihood of a follow-up behavioral health visit or alcohol use disorder diagnosis among Soldiers returning from deployments associated with the Afghanistan or Iraq operations, fiscal years 2008 through 2013, based on their post-deployment screening results. Those who screened positive for possible alcohol use disorder were significantly more likely to receive such a visit, and to receive an alcohol use disorder diagnosis, after controlling for demographics, military history, comorbidities, and military treatment facility characteristics. Routine post-deployment alcohol screening represents an opportunity for timely intervention by the Military Health System, among military members whose results indicate elevated risk for alcohol use disorder.

Introduction

Unhealthy alcohol use increases risk for and impedes recovery from numerous conditions common to military members including depression, posttraumatic stress disorder (PTSD), and suicidality.(1–3) It is associated with a myriad of health and occupational consequences including cancer, cardiovascular events, injuries, and violence.(4) Military members, who are predominantly male and age thirty or younger, drink greater quantities of alcohol than their same-age civilian peers, and high rates of binge drinking and unhealthy alcohol use impede military readiness.(5–7) Deployments specifically to the Afghanistan and Iraq operations may further contribute to increased vulnerability to alcohol problems during the post-deployment months.(8, 9)

The 2013 Institute of Medicine (IOM) committee on Substance Use Disorders in the U.S. Armed Forces deemed unhealthy alcohol use a significant public health crisis.(10) The IOM found that while the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders provided excellent guidance for screening, brief intervention and referral to treatment (SBIRT) for alcohol problems, the Department of Defense (DoD) was not systematically implementing these practices within the Military Health System (MHS).(11) The IOM found that the DoD policy requiring mandatory disclosure of alcohol use problems to a military member’s Commander discourages screening for alcohol use problems within the MHS, increases stigma, and inhibits early access to treatment. Among numerous recommendations, the IOM called for: increased routine screening for unhealthy alcohol use in primary care, use of technology for screening, conducting brief interventions for those at risk for alcohol use disorder (AUD), implementing evidence-based treatments, integrating alcohol care within behavioral health and other medical care, and offering confidential/voluntary treatment options to decrease stigma.(10)

Since the IOM report was released, the Army has primarily met the mandate for alcohol screening via the Periodic Health Assessment; an annual readiness tool that also reviews questions of medical fitness, deployability, and retention. Army Behavioral Health clinics use automated technology for screening, but most Primary Care clinics do not.(12) The Army has integrated substance use care within behavioral health and placed a Behavioral Health Provider within Primary Care clinics. In March of 2019, the Secretary of the Army directed implementation of a voluntary/confidential alcohol treatment option consistent with the IOM recommendation.(13)

Since 2008, the DoD has included standardized alcohol consumption screening items for military members returning from Afghanistan or Iraq within the DoD’s post-deployment health surveillance program. Information from this surveillance program has provided prevalence estimates of post-deployment at-risk drinking.(14, 15) Yet, a study by Larson et al. revealed that a significant proportion of Soldiers with scores indicative of possible AUD were not referred for a primary care or behavioral health visit by the provider assessing the screening results, identifying a missed opportunity for early intervention.(15) Alcohol screening data captured systematically on the post-deployment surveillance program represents an opportunity for the DoD to intervene early for potential alcohol problems, yet previous studies have not examined if military members identified with positive alcohol screens received future behavioral health care or an AUD diagnosis within the MHS.

This study was designed to address these knowledge gaps among a population-based cohort of Army active duty Soldiers returning from a deployment associated with the Afghanistan or Iraq conflicts, FY 2008 through 2013. First, we provide the first population estimates of the proportion of Soldiers with a positive alcohol screen on the Post-Deployment Health Re-Assessment (PDHRA), typically administered 3–9 months post-deployment, who received a follow-up behavioral health visit within the MHS. While we do not know if alcohol use was assessed during these visits, the behavioral health visit reflects an opportunity to provide assessment, brief intervention, or to begin treatment for alcohol use if warranted. Second, we reveal what proportion of Soldiers with a positive alcohol screen received an AUD diagnosis within 150 days of completing the PDHRA. When examining factors associated with receiving a behavioral health visit or an AUD diagnosis, we included demographics, military characteristics, comorbidities, and military treatment facility (MTF) characteristics. Following the IOM’s recommendation of adopting a public health model of prevention for substance use problems, this study provides new information about how the DoD’s post-deployment surveillance screening data may be used as an opportunity to intervene early for alcohol problems.

Study Data and Methods

Sources of Data.

Data were drawn from the Substance Use and Psychological Injury Combat (SUPIC) study, a longitudinal, observational study of post-deployment health among active duty and reserve Soldiers returning from a deployment associated with the Afghanistan or Iraq conflicts.(16) SUPIC data were drawn from the: Contingency Tracking system (i.e., deployment history), Defense Enrollment Eligibility Reporting System (i.e., demographics), Post-deployment Health Re-Assessment (Form DD 2900), Military Data Repository (i.e., diagnoses, encounters/claims, procedures), Defense Medical Information System ID (i.e., MTF characteristics), and the Defense Medical Human Resource System (i.e., provider capacity).

Sample.

The sample was drawn from the SUPIC active duty cohort returning from an index deployment in fiscal years 2008–2013 (n=544,244), and restricted to Soldiers who completed the PDHRA within 30–300 days post-deployment (n=407,199). Soldiers were excluded if they did not complete the PDHRA alcohol screening items (n=19,157), or if we could not assign them to a MTF (n=8,804), bringing the analytic sample to 379,238 Soldiers.

Measures.

Positive screens for at-risk and severe alcohol use were assessed with the Alcohol Use Disorders Identification Test-consumption items (AUDIT-C), a screen for at-risk drinking and possible AUD that has been validated with Veterans with military service since September 11, 2001.(17) We created a 3-level, gender-specific, ordinal measure to capture no/low-risk, at-risk, and severe alcohol use for detecting AUD. For males, the groups were no/low-risk (0–3), at-risk (4–6), and severe alcohol use (7–12); for females the groups were no/low-risk (0–2), at-risk (3–4), and severe alcohol use (5–12). The at-risk cut-points were based on traditional scores used in the field,(11, 15) and severe cut-points were based on a study with Veterans where there was specificity of .90 or above in predicting DSM-IV alcohol abuse or dependence.(17)

Study outcomes were 1) receiving a behavioral health visit (i.e., mental health or substance use), and 2) receiving an AUD diagnosis, both measured by scan of all MHS inpatient and outpatient medical records, during the 150 days following the PDHRA. This included care provided in either the direct care system at MTFs or by civilian providers and paid for by the military (i.e., purchased care).

Soldier demographic characteristics included gender, race/ethnicity, age group, and marital status. Military characteristics included pay-grade, number of previous deployments, and fiscal year return from index deployment. Comorbidities included positive screens on the PDHRA for PTSD,(18) and depression,(19) receiving a traumatic brain injury (TBI) diagnosis 90 days prior to the PDHRA, and receiving an AUD diagnosis in the MHS prior to the index deployment. Additional dichotomous PDHRA covariates which could influence interaction with the health care system included: being wounded, injured, assaulted or hurt on the index deployment; being hospitalized since the index deployment; and three measures of help-seeking. The help-seeking measures indicate interest in scheduling an appointment with a healthcare provider to discuss health concerns; receiving information or assistance for a stress, emotional, or alcohol concern; and receiving information or assistance for a family or relationship concern.

Military Treatment Facility characteristics included: MTF facility type reflective of size (i.e., small [clinic-only], medium [hospital and clinic], or large [medical center of hospital and clinics]); and mental health provider capacity, defined as the full-time equivalent of mental health providers at a MTF during the month of the PDHRA, per 100,000 persons served during the year.

We included a policy change measure to reflect changes to the MHS’s Army Substance Abuse Program (ASAP) during our study window. The DoD moved all ASAP resources including manpower and equipment from Medical Command to Installation Command in October, 2010. ASAP asserted that this may have negatively impacted scheduling, tracking, and documentation of treatment.(10) The Army reversed this decision in 2016, after our study window. We included the policy change measure to examine if this ASAP administration change influenced study outcomes.

Analyses.

Soldiers were assigned to a MTF based on their location during the month of the PDHRA per the MHS enrollment file (see Appendix).(20) Because estimated effects of variables varied significantly by facility type, the MTFs were stratified for analyses into small, medium, and large facilities, as described above. Factor analysis was used to identify sets of correlated comorbidities, which generated two scales: a behavioral health comorbidity scale (PTSD, depression, help seeking measures); and an injury scale (wounded/injured/assaulted/hurt, hospitalized, TBI diagnosis). We examined each outcome using hierarchical linear models that nested Soldiers within MTFs. Models were restricted to Soldiers who screened positive for at-risk or severe alcohol use (n=153,650), and included a measure of MTF mental health provider capacity at the time of the Soldier’s PDHRA and the ASAP policy change variable. Other measures included demographics, military characteristics, pre-deployment AUD diagnosis, and the two comorbidity scales described above. Analyses were conducted in SAS version 9.4.

Limitations.

Our sample included Army active duty Soldiers returning from deployments associated with the Afghanistan and Iraq conflicts in Fiscal Years 2008 to 2013 in the existing SUPIC database and may not be generalizable to other Services, reserve component members, other time periods, or deployments to other locations. It is possible that while the ASAP program was moved to Installation Command in 2010 that alcohol treatment was not documented consistently in the electronic medical records. We do not observe other behavioral health treatment, such as Military OneSource or self-help groups, or Commander-based education/prevention programs. There is potential for under-reporting of alcohol use on the PDHRA since it is not anonymous; nevertheless reported consumption rates were high.(21) We do not know if Soldiers excluded from the sample because of missing alcohol data (4.7%) were more likely to report higher consumption than other Soldiers.

Results

Sample Characteristics.

The analysis sample was predominantly male (89.7%), White/non-Hispanic (57.1%), age 21–29 (59.8%), and junior enlisted (51.5%). Almost 69% were returning from their first deployment, 2.6% had an AUD diagnosis prior to the index deployment, 4.5% had a TBI diagnosis in the 90 days preceding the PDHRA, and 4.6% were hospitalized since returning from the index deployment. Over 17% reported being wounded, injured, assaulted, or hurt on the index deployment, 8.3% screened positive for depression, and 7.0% screened positive for PTSD (see Appendix).(20) Information about characteristics of the full SUPIC Army active duty cohort has been published elsewhere.(22)

Post-deployment Alcohol Screening Results.

Post-deployment alcohol screening on the PDHRA indicated that 29.9% of the sample was at-risk and 10.7% screened positive for severe alcohol use indicative of possible AUD (see Exhibit 1). A higher proportion of males than females were in the at-risk group (30.6% vs. 23.6%), yet similar proportions of males and females were in the severe alcohol use group.

Exhibit 1:

Post-deployment alcohol screening results, by gender and overall

	Female		Male		Total
	(n = 39107)		(n = 340131)		(n = 379238)
Post-deployment alcohol screening result	n	Percent of Females	n	Percent of Males	n	Percent of Total
No/low risk	25890	66.2%	199698	58.7%	225588	59.5%
At-risk	9221	23.6%	104056	30.6%	113277	29.9%
Severe alcohol use	3996	10.2%	36377	10.7%	40373	10.7%

SOURCE Authors’ analysis of data from the Substance Use and Psychological Injury Combat study of Soldiers who completed the Post-deployment Health Re-Assessment after return from a deployment associated with the Afghanistan or Iraq conflicts in fiscal years 2008–2013.

NOTES Alcohol screening results were derived from the Alcohol Use Disorders Identification Test-consumption items.

Study Outcomes.

Overall, 35.3% of the sample received a behavioral health visit within 150 days of the PDHRA (Exhibit 2). Soldiers who screened positive for severe alcohol use (48.5%), and Soldiers who received an AUD diagnosis prior to the index deployment (52.3%), were significantly more likely to receive a behavioral health visit. Overall, 3.5% of the sample was diagnosed with an AUD within 150 days of the PDHRA. Soldiers who screened positive for severe alcohol use were significantly more likely than those who screened no/low risk to receive an AUD diagnosis in the outcome window (10.5% versus 2.3%, respectively, p <.001). Similarly, Soldiers with a previous AUD diagnosis before the index deployment were significantly more likely than those without a previous AUD diagnosis to receive an AUD diagnosis in the outcome window (18.3% versus 3.1%, p <.001).

Exhibit 2:

Likelihood of a post-deployment follow-up behavioral health visit or alcohol use disorder diagnosis, by post-deployment alcohol screening results and pre-deployment alcohol use disorder diagnosis status (n = 379,238)

	Had a follow-up behavioral health visit			Received an alcohol use disorder diagnosis
	n = 133995 (35.3%)		n = 13224 (3.5%)
	n	Percent	n		Percent
Post-deployment alcohol screening result
No/low risk	73848	32.7%	5126		2.3%
At-risk	40580	35.8%	3858		3.4%
Severe alcohol use	19567	48.5%	4240		10.5%
Alcohol use disorder diagnosis pre-deployment
Yes	5241	52.3%	1830		18.3%
No	128754	34.9%	11394		3.1%

SOURCE Authors’ analysis of data from the Substance Use and Psychological Injury Combat study of Soldiers who completed the Post-deployment Health Re-Assessment after return from a deployment associated with the Afghanistan or Iraq conflicts in fiscal years 2008–2013.

NOTES Alcohol screening results were derived from the Alcohol Use Disorders Identification Test-consumption items. Receipt of a follow-up behavioral health visit and alcohol use disorder diagnosis were assessed within 150 days following completion of the Post-deployment Health Re-Assessment.

Study findings were similar in direction and magnitude across the stratified models by the three MTF facility types. Thus, associations of study outcomes are displayed in Exhibit 3 from Soldiers assigned to medium-sized facilities only (55.4% of Soldiers, n = 210,124). Results for small and large facilities can be found in the Appendix.(20)

Exhibit 3:

Associations of Soldier and Treatment characteristics with receiving a post-deployment behavioral health visit or an alcohol use disorder diagnosis among Soldiers with a positive post-deployment alcohol screen, within medium-sized facilities (n = 81,611)

	Had a follow-up behavioral health visit	Received an alcohol use disorder diagnosis
	n = 28,233	n = 4,738
	Adjusted odds ratio	Adjusted odds ratio
Soldier Characteristics
Female	1.18***	0.54***
Race/Ethnicity (ref = Caucasian)
American Indian/Alaska Native	1.02	1.75*
Asian/Pacific Islander	1.02	1.03
Black/African American	0.99	1.25***
Hispanic	0.98	1.05
Other	1.00	1.08
Rank (ref = junior enlisted)
Senior enlisted	0.87***	0.56***
Junior officer	0.54***	0.18***
Senior officer	0.60***	0.29***
Warrant officer	0.54***	0.35***
Age group (ref = 18–20)
21–29	0.90***	0.72***
30–39	0.81***	0.59***
40+	0.76***	0.51***
Married (ref = Married)
Separated	0.99	1.13*
Never Married	0.88***	1.23***
Post-deployment alcohol screening result (ref = At-risk)
Severe alcohol use	1.29***	2.44***
Prior deployments (ref = 0)
1	0.98	0.77***
2+	0.97	0.77**
Alcohol use disorder diagnosis pre-deployment	1.55***	3.70***
Behavioral health comorbidity scale	2.05***	1.42***
Injury scale	1.24***	1.20***
Treatment Characteristics
Full-time equivalent of mental health providers at treatment facility	1.00	1.00

SOURCE Authors’ analysis of data from the Substance Use and Psychological Injury Combat study of Soldiers who completed the Post-deployment Health Re-Assessment (PDHRA) after return from a deployment associated with the Afghanistan or Iraq conflicts in fiscal years 2008–2013.

NOTES Receipt of a follow-up behavioral health visit and alcohol use disorder diagnosis were assessed within 150 days following completion of the PDHRA. Models also control for fiscal year of return from index deployment and the Army Substance Abuse Program policy change variable, which captured the shift of the Army Substance Abuse Program from Medical Command to Installation Command in October, 2010. Military treatment facilities were categorized based on size: small [clinic-only], medium [hospital and clinic], and large [medical center of hospital and clinics]). This exhibit presents results from medium-sized facilities. Results for small and large facilities can be found in the Appendix. Positive post-deployment alcohol use screens were defined as scoring in the at-risk range (4–6 for males and 3–4 for females) or severe alcohol use range (7+ for males and 5+ for females) on the Alcohol Use Disorders Identification Test-consumption items. The behavioral health comorbidity scale is a sum score (0–5) of positive screens on the PDHRA related to behavioral health (post-traumatic stress disorder; depression; three measures of help-seeking) and the injury scale is a sum score (0–3) of self-report on the PDHRA of being wounded, injured, assaulted, or hurt during the index deployment; being hospitalized since the index deployment; and receipt of a traumatic brain injury diagnosis 90 days prior to the PDHRA. ref = reference group.

^*p < .05,

^**p < .01,

^***p < .001.

As displayed in Exhibit 3, the characteristics significantly associated with the greatest odds of receiving a behavioral health visit within 150 days after the PDHRA were the behavioral health comorbidity scale inclusive of positive screens for PTSD, depression, and the three help-seeking measures (adjusted odds ratio [AOR] 2.05, confidence interval [CI] 1.79–2.35), having received an AUD diagnosis prior to the index deployment (AOR 1.55, CI 1.36–1.77), and having received a positive screen for severe alcohol use (AOR 1.29, CI 1.17–1.42). Soldiers with an AUD diagnosis before the index deployment had the greatest odds of receiving an AUD diagnosis within the first 150 days following the PDHRA (AOR 3.70, CI 3.03–4.51), followed by Soldiers who screened positive for severe alcohol use (AOR 2.44, CI 2.30–2.59). The behavioral health comorbidity scale inclusive of positive screens for PTSD, depression, and the three help-seeking measures was significantly associated with increased odds of receiving an AUD diagnosis (AOR 1.42, CI 1.39–1.45). Of note, the measure of MTF mental health provider capacity and the ASAP policy change variable were not significantly associated with study outcomes, other than a slight increase in mental health providers at large facilities increasing the odds of a receiving a behavioral health visit (AOR 1.02, CI 1.00–1.04 – see Appendix).(20)

Discussion

This is the first study to reveal the proportion of a cohort of Army Soldiers returning from a deployment associated with the Afghanistan or Iraq conflicts with positive post-deployment alcohol screens on the DoD’s PDHRA who received a follow-up behavioral health visit or AUD diagnosis within the MHS. We found that 40.5% of Soldiers returning from deployment in fiscal years 2008–2013, had a positive alcohol screen, including 10.7% with severe alcohol use scores indicative of possible AUD. In the 150 days following a positive alcohol screen, over half of Soldiers screening positive for severe alcohol use did not receive a behavioral health visit. Only 10.5% of Soldiers with a severe alcohol use screen were diagnosed with an AUD.

This low follow-up rate parallels earlier findings by Brandeis team members which found that approximately two-thirds of Soldiers who screened positive for severe alcohol use in the first two months post-deployment were not referred for a follow-up visit by the clinician reviewing the screening scores with the Soldier.(15) Towards the end of our study window (i.e., at the end of 2013), the DoD updated its post-deployment health surveillance program to include additional requirements that may allow for better identification of unhealthy alcohol use at the time of the screening.(23) Yet, it is unknown if these changes have led to improvement in outcomes for those identified with post-deployment alcohol problems. To further increase the likelihood of early intervention for alcohol problems, military members with severe alcohol use screens on the PDHRA could be provided with an automatic referral to see a behavioral health specialist to provide additional alcohol screening and assessment.

Having an AUD diagnosis prior to the index deployment was associated with the greatest odds of receiving an AUD diagnosis following the PDHRA, suggesting that a portion of Soldiers continue in their military service, and are deployed, with AUD. Our study did not evaluate what AUD treatment, if any, was utilized by this group during their military service. Soldiers with a positive severe alcohol use screen were significantly more likely to receive an AUD diagnosis, suggesting that routine alcohol screening data captured on the PDHRA is a useful tool for the MHS to identify post-deployment military members at increased risk for AUD. It is probable that AUD within the study population is higher than 3.5%; likely due to Soldiers under-reporting alcohol use on the PDHRA, minimizing their answers during the review of responses with the provider to avoid a referral, or not following up with the referral and thus never being assessed.(10) Warner et al (21) found rates of behavioral health item endorsement on anonymous surveys two-to-four times higher than identical items on the DoD’s non-anonymous post-deployment health assessment.

While a larger proportion of male than female Soldiers screened positive for at-risk alcohol use, there was not a large gender-based difference in the proportions screening positive for severe alcohol use. Prior literature has found almost double the rates of risky drinking among male Veterans compared to females.(17, 24) Female Soldiers were more likely to receive a behavioral health visit than males, yet were less likely to receive an AUD diagnosis. Prior research is inconsistent, with some studies indicating female Soldiers are more likely than males to utilize mental health treatment, and other research indicating the opposite.(25, 26)

The measure we used to assess possible influence of the DoD’s mid-study policy change for ownership of its Army Substance Abuse Program was not significantly associated with study findings.

Military Treatment Facility Characteristics

We expected to observe variation among MTFs in study outcomes that was related to capacity to identify and treat behavioral health problems. Our models did indicate significant variation in the outcomes by size of facility that required stratified analyses; this suggests the inherent size of a MTF influences its capacity for behavioral health services and eventual diagnosis of AUD. We did not, however, find significant results due to variation in the number of FTE mental health providers at MTFs other than a small, significant increase in odds of receipt of a behavioral health visit at large facilities.

During the study window, there was a concerted effort by the Services to increase mental health capacity due to increased demand, and overall mental health manpower grew 15% from 2009–2015.(27) The Services also bolstered access through structural changes by including mental health providers in medical homes, via telehealth, and within the Army by creating Embedded Behavioral Health Clinics within units.(27, 28) These simultaneous initiatives may have led to better access across facilities and reduced variation by MTF. However, our results indicate that increasing mental health provider capacity within MTFs alone may not be sufficient to improve access to behavioral health services or identification of AUD.

Policy Implications and Recommendations

The Army implemented a pilot program, the Confidential Alcohol Treatment and Education Program, which had positive results in encouraging voluntary treatment seeking, including proactively mitigating negative career implications.(29) Until this barrier is eliminated, despite its strong civilian evidence basis, SBIRT’s effectiveness will be limited for military members, especially career military members, who along with their spouses, have understandable career and economic concerns. This not only impacts military readiness, but since early intervention for alcohol problems has the potential to save lives, it also influences morbidity and mortality.(10) If alcohol problems are not addressed early in the MHS, this burden grows, complicates treatment of PTSD, depression and other co-occurring disorders, and will eventually be transferred to the Veterans Health Administration and civilian providers. Thus, we contend that unhealthy alcohol use may be a “canary in the coal mine,” and failure to heed its warning signals decreases the success of critical public health initiatives underway within the DoD and Veterans Health Administration (e.g., suicide prevention, sexual assault prevention). Our study found utility in the DoD’s post-deployment surveillance program to capture indicators of unhealthy alcohol use, and highlighted a need for the DoD to improve its responsiveness to these warning signals. Other policy and cultural changes are also needed to improve early identification of, and treatment for alcohol problems. This includes reducing the stigma of seeking help for alcohol use problems and eliminating actual or perceived negative career ramifications associated with diagnosis of AUD in the military when no indiscipline has occurred.

In March of 2019, the Secretary of the Army released a new Army Directive to implement a voluntary program for alcohol use treatment, including confidential care not requiring Commander notification unless indiscipline, safety, mission, or security are involved.(13) This policy is intended to encourage routine early identification, to include alcohol screening in primary care, and to enhance the opportunity for early referral for treatment earlier in the course of illness. This Army Directive represents a monumental change for treating alcohol use within the military and is directly in line with the IOM recommendations.(10) With the implementation of this Directive, the pieces are now nearly in place for the Army to implement SBIRT as envisioned by the IOM within Army Primary Care clinics. Automated Behavioral Health Data Platform screening for AUDs has been implemented Army-wide in Behavioral Health clinics, which can be expanded into Primary Care clinics. The new voluntary/confidential treatment is intended to allow Soldiers to frankly answer screening questions and act on referrals to care without career concerns. Additionally, a Primary Care integrated Behavioral Health provider is in place to assist when screening concerns require a more sustained intervention, and outpatient alcohol specialty care now exists within Behavioral Health clinics embedded within units.(12) The use of this evidence-based approach for prevention and treatment of alcohol problems will allow for early identification of problems among a predominantly younger, heavy drinking cohort of Soldiers.

Policies should be updated to allow similar care DoD-wide: to expand automated Behavioral Health Data Platform alcohol screening in Primary Care clinics, to create a voluntary/confidential care option for alcohol to decrease stigma/career concerns, and to promote integration of all alcohol care and documentation into the medical system in Behavioral Health and Primary Care clinics.(12, 30)

Future Research

A future paper by the study team will investigate whether improved engagement in alcohol use treatment for Soldiers with a positive screen for possible AUD could reduce military attrition. Future study is needed to evaluate the implementation of the new Army Directive for voluntary/confidential alcohol treatment to determine if stigma is indeed reduced, if evidence-based treatments are being offered in line with IOM recommendations, and if screening effectiveness, access and outcomes are improved. In 2017, Congress mandated the most significant restructuring of the MHS in decades, shifting the administration of MTFs from the individual Services to the Defense Health Agency, in part to free up the Services to focus more on readiness.(31) This reorganization may present new opportunities for the DoD to enhance the surveillance and subsequent treatment of unhealthy alcohol use, including the opportunity for other Services to adopt the Army’s new Directive for voluntary/confidential alcohol treatment.

Conclusions

Unhealthy alcohol use remains a public health crisis in the military. Military members returning from deployments are systematically screened for possible AUD as part of the DoD’s post-deployment health assessment program. Our findings suggest that timely identification of alcohol-related problems, as well as access to voluntary, confidential, and evidence-based treatment, could be facilitated if military members with positive post-deployment alcohol screens were further assessed within the Military Health System.