Comparison of Select Health Outcomes by Deployment Health Assessment Completion

MILITARY MEDICINE, 181, 2:123, 2016 Comparison of Select Health Outcomes by Deployment Health Assessment Completion Tina M. Luse, MPH; Jean Slosek, MPH; Christopher Rennix, ScD, MS, CIH Abstract The Department of Defense (DoD) requires service members to complete regular health assessments for identification of deployment-related physical/behavioral issues and environmental/occupational exposures. Compliance among active duty Department of the Navy personnel varies; however, and the impact of incomplete assessments on generalizability of results is unclear. This study examines the differences between Navy and Marine Corps service members who completed both the Post-Deployment Health Assessment and Post-Deployment Health Reassessment (n = 9,452) as compared to service members who never attempted either form (n = 5,603) in fiscal year 2010. Deployment rosters, assessments, and clinical data were analyzed to determine certified assessment completion rates and incidence of certain health conditions in these populations. Only 38.9% of applicable personnel met the completion and certification criteria for the required assessments. Service members who did not complete the forms were distinctly different demographically and at increased risk for psychotropic drug use, post-traumatic stress disorder diagnosis, and traumatic brain injury diagnosis following deployment. The prevailing assumption that the risk of adverse health effects on operational forces can be estimated using the population that completed the required assessments is incorrect, and the true operational impact and medical burden of these conditions may be underestimated. BACKGROUND DoD mandates the administration of health assessments to service members of the U.S. Armed Forces deployed to locations outside of the continental United States with nonfixed U.S. medical treatment facilities for greater than 30 days. Completion of health assessments is required within specific timeframes before and after deployment. Assessments following deployment identify physical and behavioral health issues and the extent of high-risk environmental and occupational exposures that occurred during deployment. The Post- Deployment Health Assessment (PDHA) is required to be completed during in-theater medical out-processing or within 30 days after returning from deployment. The Post-Deployment Health Reassessment (PDHRA) continues to identify health concerns that may have emerged after deployment, regardless of the outcomes of previous assessment forms, within 90 to 180 days after returning from deployment. 1 Studies and reports have relied on the post deployment assessments including the PDHA and PDHRA as tools for measuring the prevalence of self-reported behavioral health conditions, such as depression and post-traumatic stress disorder (PTSD), as well as deployment-related injuries including traumatic brain injuries (TBI) among service members returning from deployment. A 2004 study of U.S. combat infantry units who completed an anonymous survey indicated that 29.2% of Marines met broad screening criteria for depression, anxiety, or PTSD after returning from Iraq or EpiData Center Department, Navy and Marine Corps Public Health Center, 620 John Paul Jones Circle, Suite 100, Portsmouth, VA 23708-2103. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. doi: 10.7205/MILMED-D-15-00019 Afghanistan. Of those with a positive screen, nearly 45% indicated interest in receiving professional help. 2 Another 2006 population-based study found that 19.1% of Army and Marine service members who returned from Iraq and 11.3% of service members who returned from Afghanistan reported some behavioral health concern on the PDHA. 3 The Deployment Health Assessment (DHA) process provides valuable opportunities for healthcare intervention and data collection, but despite the DoD mandate, rates of assessment completion fall short within the Department of Navy (DON). Based on reports completed by the Navy and Marine Corps Public Health Center, in the first two quarters of 2010, PDHRA compliance among Active Duty (AD) Marines averaged at 53% and was even lower for Sailors (internal document). Reasons service members do not complete DHAs include differences in implementation among units, lack of motivation to complete surveys, denial of any health problem, fear of losing leave time, apprehension of stigma associated with seeking behavioral health care, and concerns for future deployment based on medical care. 4,5 Results compiled from analyses of the DHAs are used to inform leadership and policy makers across the DON; however, little is known about the health outcomes of DON service members who do not complete the requirement. The impact of incomplete assessments on generalizability of results to the health of the total force is unclear. Service members who do not complete both the PDHA and PDHRA may differ demographically and have different post-deployment health outcomes from those with completed assessments. Service members not captured in the DHA process may experience greater or different behavioral health or medical risks, and their needs may therefore be unknown and unmet by their chain of command and healthcare providers. Even though DHAs are required during periods surrounding a deployment, MILITARY MEDICINE, Vol. 181, February 2016 123

service members may be redeployed even if previous assessments were not completed. The degree to which underlying medical conditions may be exacerbated during a new deployment is unknown. The purpose of this study was to determine the potential differences between AD DON personnel who completed both the PDHA and PDHRA as compared to AD DON personnel who never attempted either form. Differences between these populations demographics, deployment histories, and markers of behavioral and physical health characteristics were described. METHODS To investigate the possible differences between the DHA compliant and DHA noncompliant populations, a retrospective cohort study of AD DON deployed service members with certified health assessments and AD DON deployed service members who never completed the health assessments was conducted. The Defense Manpower Data Center (DMDC) Contingency Tracking System (CTS) database contains deployment related pay records for DON personnel deployed to areas in support of U.S. Central Command (CENTCOM). DMDC CTS was used to identify Navy and Marine Corps personnel who deployed to Iraq or Afghanistan for at least 30 days, and who returned from deployment in fiscal year 2010 (October 1, 2009 September 30, 2010). If multiple deployments meeting these study criteria were identified, then the first deployment for each individual within the timeframe was selected for analysis. The relevant deployments were then matched to electronic Deployment Health Assessment records, maintained at the EpiData Center, Navy and Marine Corps Public Health Center, to determine PDHA and PDHRA completion status. An individual was considered to have completed the post deployment health assessment cycle and was classified as Certified if both the PDHA and PDHRA were certified by a health care provider within the DON required timeframe (±60 days or 90 210 days after return from deployment, respectively). An individual was classified as Never Attempted if there was no record of ever completing the PDHA and PDHRA within the compliance timeframe. All records from individuals who completed one survey, but not both, were excluded. To determine demographic characteristics and active duty status following deployment, service members in the Certified andneverattemptedpopulationswerematchedtodmdc personnel records, which contain monthly rosters of all service members. Service members whose status was reserve, retired, or withdrew from military service within 210 days of returning from deployment (the total time allowed from end of deployment to completion of the PDHRA) were excluded from the final study population. These individuals were no longer eligible for care within the Military Health System and would be lost to follow-up. The Standard Inpatient Data Record and the Standard Ambulatory Data Record were then used to identify medical encounters for selected behavioral and physical health conditions from the beginning of the related deployment through the 210 day compliance period. A case of PTSD, depressive disorder, or other behavioral health disorder required one condition specific International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis code (Table I) from any diagnostic field in the inpatient setting or two diagnostic codes (on the same or different days) in the outpatient setting. Suicide attempt or ideation was considered a case if a service member had one condition specific diagnosis code in the inpatient or outpatient setting. The Standard Inpatient Data Record and Standard Ambulatory Data Record databases were also reviewed for the ICD-9-CM codes recognized by the Armed Forces Health Surveillance Center to identify TBI cases. 6 Service members required one ICD-9-CM diagnosis code of TBI (in any diagnosis field) in the inpatient or outpatient setting to be considered a case. A TBI case was classified as mild TBI (mtbi) if the initial TBI encounter record had a mtbi ICD-9-CM code in any of the diagnosis fields without any indication of a more severe TBI diagnosis in the same record. The mtbi case definition was created from the Armed Forces Health Surveillance Center TBI case definition and in consultation with subject matter experts (unpublished). In addition to inpatient and outpatient medical encounter records, pharmacy records were reviewed to capture further evidence of behavioral health conditions. Composite Health Care System outpatient pharmacy data were used to identify psychotropic prescriptions dispensed from the beginning of deployment through the 210 day compliance period. Only completed transactions were considered. Records were classified into three categories of treatment: narcotics, selective serotonin reuptake inhibitors (SSRIs), and others psychotropic drugs. Table II provides a list of all drugs used to categorize the study population. Each individual was assessed to determine if he or she received prescriptions from one or more drug categories. Demographics, deployment characteristics, and risk factors between the Certified and Never Attempted groups were compared. All relative risks (RRs) were calculated with a TABLE I. ICD-9 Code Categories Category ICD-9-CM Codes Depressive Disorder 296, 300.4, 311 PTSD 309.81 Suicide Ideation 958.9; E950 E959; V62.84 and Attempts TBI 312.2, 800, 801, 803, 804, 850, 850.11 850.12, 805.2 805.5, 805.5, 851 854, 950.1 950.3, 959.01; V15.5 0 V15.5 9, V15.5 A V15.5 F, V15.52 0 V15.52 9, V15.52 A V15.52 F, V15.59 0 V15.5 99, V15.59 A V15.59 F Other Behavioral 290 308.8, 309.82 317, 958.9; V628.4 Health Diagnoses 124 MILITARY MEDICINE, Vol. 181, February 2016

TABLE II. Psychotropic Drugs of Interest Category Sub-Category Drug Names Narcotics Acetaminophen w/ Codeine Hydrocodone Oxycodone SSRIs Citalopram Dapoxetine Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline Other Antidepressants Amitriptyline Bupropion Mirtazapine Nortriptyline Anxiolytics Alprazolam Clonazepam Diazepam Lorazepam Sleep aids Eszopiclone Zolpidem Stimulants Amphetamine Dextroamphetamine 95% confidence interval (CI). SAS version 9.2 (SAS Institute, Cary, North Carolina) was used in this analysis. RESULTS There were 41,868 deployed Navy and Marine Corps service members who returned from a 30 days or greater deployment to Afghanistan or Iraq between October 1, 2009 and September 30, 2010; 17,599 (42.2%) were excluded (9,505 reserve status and 8,094 retired or left service). Of the remaining 24,269 deployers, 9,452 (38.9%) personnel met the completion and certification criteria for the PDHA and PDHRA (Certified group), 5,603 (23.1%) personnel did not complete either assessment (Never Attempted group), and 9,214 (38.0%) service members had varying degrees of partial survey completion and were excluded. Demographic and deployment rates for the Certified and Never Attempted groups are described in Table III; the RR calculations describe the likelihood of completing a certified assessment, and therefore being in the certified population, when compared to the reference group. RRs less than 1 identify a decreased likelihood of being in the Certified group. When compared to Sailors, Marines were somewhat more likely to be in the Certified group with a CI slightly above one. The age of the total study population ranged from 18 to 65 years with a median age of 26 and 28 years in the Certified and Never Attempted groups, respectively. Service members in each consecutively older age category were less likely, when compared to the youngest age category, to be in the Certified group. Service members in age groups above 36 years were at least 20% less likely to be in the Certified group compared to the 17 to 20 age group. The study population consisted predominately of enlisted personnel (85.1%) at the junior (n = 5,656) and mid-grade enlisted (n = 6,085) ranges. Commissioned/warrant officers were less likely to have completed the DHAs when compared to enlisted personnel (RR: 0.87, 95% CI: 0.84, 0.90). Overall, 68.7% of the deployments in this study were to Afghanistan. Members who returned from Afghanistan were less likely to be in the Certified group than those who returned from Iraq. For 41.5% of the study population, the deployment in this study was the first time they deployed to Operation Iraqi Freedom/Operation Enduring Freedom for 30 days or more. The average length of this deployment was 193 days (6.5 months). When compared to service members deployed for less than 100 days, individuals deployed for more than 100 days but less than 400 days were 45 to 75% more likely to have completed the assessment process. For those service members deployed for more than 400 days, individuals were less likely to be in the Certified group. There were 247 service members admitted to the hospital during or within 30 days after deployment, 215 of which (87.0%) were in the group that did not complete assessments. Service members who were hospitalized following deployment may not have the opportunity to complete the assessments on time and therefore, were less likely to be in the Certified group (RR: 0.09, 95% CI: 0.06, 0.12). In the Certified group, 1,902 (20.1%) service members were prescribed at least one of the psychotropic drugs of interest; 1,394 (24.9%) were in the Never Attempted group (Table IV). Approximately 17% (n = 321) of those in the Certified group were prescribed a drug from two or more drug classes compared to 25% (n = 342) in the Never Attempted group. Individuals prescribed drugs from any of the three psychotropic drug classes were less likely to be in the Certified group. Among the drug sub-classes, service members prescribed narcotics or other behavioral health drug use were significantly less likely to be in the group that completed the assessments (RR: 0.89, 95% CI: 0.85, 0.92 and RR: 0.80, 95% CI: 0.76, 0.84, respectively), whereas SSRI use was not. Of the total study population, 300 cases of PTSD and 247 cases of depressive disorder were identified. Among the group that did not complete the assessments, there were 141 cases of PTSD (47.0% of PTSD cases) and 103 cases of depressive disorder (41.7% of depressive disorder cases). Individuals who had PTSD were less likely to complete the assessment process as those without a diagnosis of PTSD (RR: 0.84, 95% CI: 0.76, 0.94). For major depressive disorder and other behavioral health diagnoses, the difference between the Certified group and the Never Attempted group was not statistically significant. There were 445 TBI cases of which 351 (78.9%) were classified as mtbi. Individuals in the Never Attempted group had almost a 30% (RR: 0.71, 95% CI: 0.64, 0.79) MILITARY MEDICINE, Vol. 181, February 2016 125

TABLE III. Characteristics of Population Certified (C) Never Attempted (NA) RR (C/NA) Demographic n % of total n % of total Measure c 95% CI Total 9,452 100 5,603 100 Service Navy 3,421 36.2 2,167 38.7 Marine Corps 6,031 63.8 3,436 61.3 1.04 1.01 1.07 Age 17 20 796 8.4 318 5.7 21 25 3,430 36.3 1,753 31.3 0.93 0.89 0.97 26 30 2,231 23.6 1,318 23.5 0.88 0.84 0.92 31 35 1,391 14.7 961 17.2 0.83 0.79 0.87 36 40 1,057 11.2 785 14.0 0.80 0.76 0.85 41 45 401 4.2 320 5.7 0.78 0.72 0.84 46+ 146 1.5 148 2.6 0.69 0.62 0.78 Rank Enlisted 8,200 86.8 4,608 82.2 Officer/Warrant 1,252 13.2 995 17.8 0.87 0.84 0.90 Country of Deployment a Afghanistan 6,265 66.3 4,081 72.8 Iraq 3,187 33.7 1,522 27.2 1.12 1.09 1.15 Number of Deployments b 1 4,268 45.2 1,975 35.2 2 2,926 31.0 1,782 31.8 0.91 0.88 0.93 3 1,669 17.7 1,176 21.0 0.86 0.83 0.89 4 487 5.2 443 7.9 0.77 0.72 0.82 5+ 102 1.1 227 4.1 0.45 0.39 0.53 Number of Days Deployed 30 99 1,069 11.3 1,489 26.6 100 199 3,040 32.2 1,979 35.3 1.45 1.38 1.53 200 299 4,420 46.8 1,628 29.1 1.75 1.67 1.84 300 399 834 8.8 311 5.6 1.74 1.65 1.85 400+ 89 0.9 196 3.5 0.75 0.63 0.89 a If member was deployed to both Afghanistan and Iraq (n = 474), then the country deployed to longest was reported. b CTS data only include CENTCOM related deployment; shipboard or deployments in other Combatant Commands (COCOMs) were not included. c Reference group indicated by. higher risk of being diagnosed with TBI than those in the Certified group. DISCUSSION The prevailing assumption that the risk of adverse health effects on operational forces can be estimated using the population that completed the required health assessments is incorrect. AD DON service members who do not complete both the PDHA and PDHRA following a deployment are distinctively different from those who do complete the forms both demographically and with some significant behavioral health outcomes. First time deployers, who are mostly in the younger age groups, are more likely to complete the DHA forms than those who have deployed several times and are in the older age categories. Younger service members are possibly more encouraged from leadership or are tracked more closely to complete the DHA forms in comparison to their older colleagues. In addition, older members may feel as though completing the forms over multiple deployments is cumbersome, repetitive, and has little impact on their overall health. Regarding health outcomes, compared to those who did complete the forms, AD DON service members who did not fill out the DHA forms were more likely to have a psychotropic drug prescription, PTSD diagnosis, or TBI diagnosis following deployment. The number of members with an outcome of suicide ideation/attempt was low. Study members with suicide ideation were less likely to complete the assessment process, though the precision of the estimate is questionable because of the wide CI. Similar to previous analyses, this study found that 61.1% of service members who remained active duty during the 210 follow-up timeframe had partial completion or did not complete both the PDHA and the PDHRA. It is unclear if individuals not completing the forms are inherently different or if medical counseling during the PDHA and PDHRA provider review accomplishes the intended goal of the health assessment process to provide an opportunity for a member to discuss health concerns in a structured manner. Regardless of the cause, medical leadership at both the unit and command levels should put more emphasis on ensuring all service members, and in particular those in older age categories, 126 MILITARY MEDICINE, Vol. 181, February 2016

TABLE IV. Psychotropic Drug Use, Injury, and Behavioral Health by Deployment Health Assessment Status Certified (C) Never Attempted (NA) RR (C/NA) Physical/Behavioral Characteristic n % n % Measure a 95% CI Psychotropic Drug Use SSRIs Use Yes 290 58.7 204 41.3 0.93 0.87 1.01 No 9,162 62.9 5,399 37.1 Narcotics Use Yes 1,213 56.7 926 43.3 0.89 0.85 0.92 No 8,239 63.8 4,677 36.2 Other Drugs Use Yes 784 51.4 740 48.6 0.80 0.76 0.84 No 8,668 64.1 4,863 35.9 Any Drug Use* Yes 1,902 57.7 1,394 42.3 0.90 0.87 0.93 No 7,550 64.2 4,209 35.8 Injury mtbi Yes 161 45.9 190 54.1 0.73 0.65 0.81 No 9,291 63.2 5,413 36.8 TBI Yes 201 45.2 244 54.8 0.71 0.64 0.79 No 9,251 63.3 5,359 36.7 Behavioral Health Major Depression Yes 144 58.3 103 41.7 0.93 0.83 1.03 No 9,308 62.9 5,500 37.1 PTSD Yes 159 53.0 141 47.0 0.84 0.76 0.94 No 9,293 63.0 5,462 37.0 Suicide (Ideation/Attempt) Yes 14 40.0 21 60.0 0.64 0.42 0.96 No 9,438 62.8 5,582 37.2 Other Behavioral Health Yes 679 59.2 467 40.8 0.94 0.89 0.99 No 8,773 63.1 5,136 36.9 a Reference group indicated by. *Any drug use includes SSRIs, narcotics, or other drugs. complete the DHA forms, thus increasing the likelihood that members receive the post deployment healthcare needed. Results from DHAs, including self-screened questionnaires for behavioral health conditions, are used to inform medical leadership and policymakers. Yet with less than half of returning deployers completing the full assessment process, this analysis showed that the true operational impact and medical burden of these conditions may be underestimated, and the policies drawn from these analyses alone may not reflect all healthcare needs. Enforcement and oversight of the current policy directing commands to complete DHAs after deployment is not adequate, as large numbers of service members do not complete the assessment process. Based on the findings in this analysis, the policy should be updated with more rigorous guidelines, thus ensuring that all service members complete the process, and have the opportunity to get the medical attention they may need. Limitations There were several limitations in this analysis. Behavioral health diagnoses and psychotropic drug use before deployment were not identified. Although service members with severe behavioral health concerns should be restricted from deployment, conditions such as mild TBI and controlled or minor behavioral health conditions would not necessarily limit a member s eligibility to deploy. Members who are aware that they have been diagnosed with these conditions before deployment may be less likely to complete assessments postdeployment. In addition, the behavioral health conditions and prescription drugs monitored in this analysis were limited to those that are of particular interest to Navy and Marine Corps leadership. Investigation of other health conditions, including anxiety, alcohol abuse, substance abuse, and sleep disorders, could potentially strengthen the results here and should be analyzed. Our study was further limited by the inability to include and follow service members who left active duty after deployment. Service members who were identified as reservists, or as leaving the service within 210 days of returning from deployment, were excluded. This constituted approximately 42% of the population returning from deployment. These service members most likely would not receive medical treatment from the Military Health System, and therefore, could not be followed for this specific analysis. It is likely that reservists and veterans would have different outcomes than the service members who remained on active duty status as the active duty service members must maintain a high standard of fitness to remain in service. In addition, any data available on these populations would not be comparable as veterans and reservists have less access to healthcare and mental health specialization on returning to civilian life than their active duty counterparts. Along with the exclusion of reservists and separated service members, the population of this analysis also excluded service members in all DoD branches except the Navy and MILITARY MEDICINE, Vol. 181, February 2016 127

Marine Corps, and results are therefore not representative of the entire DoD. A similar analysis using Army or Air Force data may identify different results. The strength of this analysis also depends upon the quality and inclusiveness of the source data. DMDC provides monthly snapshots of each active duty, reserve, and deployed Navy and Marine Corps service member s personnel record. Data are provided to DMDC by the services and analyses are dependent on the quality and completeness of these data. Deployment start and end dates were derived from the Defense Finance and Accounting Service as well as the Navy Individual Personnel TEMPO Program and may not reflect the true dates of deployment. Service members who were deployed for greater than 400 days may have been permanently stationed in CENTCOM and not deployed. These individuals were erroneously entered into the DMDC CTS deployment rosters. Data from permanently stationed personnel could not be distinguished from members who were deployed. Lastly, this analysis is limited by the availability of certain medical encounter and prescription information. For both medical encounters and prescriptions, no in-theater or shipboard data were available. In addition, any outpatient services provided outside of the military health network were not available for analysis. This limitation should apply equally to both those in the Certified and Never Attempted groups but may decrease the overall number of psychotropic drugs dispensed and behavioral health concerns reported here. REFERENCES 1. Department of Defense Instruction 6490.03. Deployment Health, August 11, 2006. Available at http://www.dtic.mil/whs/directives/corres/pdf/ 649003p.pdf; accessed December 16, 2014. 2. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL: Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351(1): 13 22. 3. Hoge CW, Milliken CS: Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006; 295(9): 1023 32. 4. Warner CH, Appenzeller GN, Grieger T, et al: Importance of anonymity to encourage honest reporting in mental health screening after combat deployment. Arch Gen Psychiatry 2011; 68(10): 1065 71. 5. Kim PY, Thomas JL, Wilk JE, Castro CA, Hoge CW: Stigma, barriers to care and use of mental health services among active duty and National Guard soldiers after combat. Psychiatr Serv 2010; 61(6): 582 88. 6. Armed Forces Health Surveillance Center (AFHSC). Section 13 Neurology, traumatic brain injury (TBI), DoD standard surveillance case definition for TBI adapted for AFHSC use, AFHSC surveillance case definitions, FINAL October 2011. Available at http://afhsc.army.mil/ documents/pubs/documents/casedefs/web_13_neurology_apr12.pdf; accessed December 16, 2014. 128 MILITARY MEDICINE, Vol. 181, February 2016