JULY 2013 Volume 20 Number 7 msmr MEDICAL SURVEILLANCE MONTHLY REPORT Mentl Helth Issue PAGE 2 Editoril: the mentl helth of our deploying genertion Richrd F. Stoltz, PhD PAGE 4 Summry of mentl disorder hospitliztions, ctive nd reserve components, U.S. Armed Forces, 2000-2012 PAGE 12 Surveillnce Snpshot: nxiety disorders, ctive component, U.S. Armed Forces, 2000-2012 PAGE 13 Mentl disorders nd mentl helth problems mong recruit trinees, U.S. Armed Forces, 2000-2012 Ptrick Monhn, MD, MPH; Zheng Hu, MS; Ptrici Rohrbeck, DrPH, MPH, CPH PAGE 19 Surveillnce Snpshot: mentl disorder hospitliztions mong recruit trinees, U.S. Armed Forces, 2000-2012 PAGE 20 Mlingering nd fctitious disorders nd illnesses, ctive component, U.S. Armed Forces, 1998-2012 PAGE 25 Surveillnce Snpshot: conditions dignosed concurrently with insomni, ctive component, U.S. Armed Forces, 2003-2012 SUMMARY TABLES AND FIGURES PAGE 26 Deployment-relted conditions of specil surveillnce interest A publiction of the Armed Forces Helth Surveillnce Center
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Editoril The Mentl Helth of Our Deploying Genertion Richrd F. Stoltz, PhD (CAPT, USN) there s fmous sying tht the only victor in wr is medicine. History hs provided us with mple lessons lerned from previous wrs, just s militry medicine is benefiting from knowledge gined from the lst 12 yers of persistent wrfre. These lessons hve led to n unprecedented understnding of how best to respond, implement nd deliver mentl helth services on nd off the bttlefield. More thn 2.6 million service members of the ctive component, Ntionl Gurd nd Reserve hve deployed mny repetedly in support of combt opertions in Irq nd Afghnistn over the lst 12 yers. It is well recognized tht exposure to combt cn increse the risk of developing mentl helth conditions. Although the mjority of service members who hve deployed will not develop depression, nxiety, or post-trumtic stress disorder (PTSD), everyone who hs deployed will chnge to some degree nd, once home, will find new norml in firly quick mount of time. For some service members, though, it doesn t work tht wy. Some combt veterns hve witnessed gruesome events. They might hve seen their best efforts fil to prevent their friends from being killed or wounded by improvised explosive device (IED) explosions or other hostile fire. They hve hd to come to terms with the fct tht ny person, including women nd children, could be their enemy. Even more disturbing, they my hve been involved in the ccidentl deths of innocent civilins including children. Sometimes the relity of wht these service members hve experienced is indescribble nd usully unimginble to those who hve not been to wr nd witnessed its horrors. When mny service members return from deployments, they re confused nd ferful nd they experience high levels of depression, nxiety, or symptoms of PTSD they do not fully understnd. Mny troubled service members despertely wnt to sleep better t night but cn t. They long to feel more inner pece nd to not repetedly revisit memories of pst horrific experiences. They yern to be better spouses, better prents, nd better friends, but ren t sure how to mke tht hppen. They my experience n increse in lcohol buse but hve trouble cutting bck. All of this might be excerbted by physicl injuries nd vrious trums from previous deployments. Some service members my try to convince themselves tht their problems re not serious in order to justify their decision to void seeking professionl help. They serch for wys to block n wreness of their inner mlise. This my work temporrily, but ny relief is usully short lived, thwrting their bility to hel. Others my wnt professionl help but fer it will hrm their creers or they will be perceived s wek by those closest to them. Mny who tke the courgeous step to receive tretment re plesed with the results. Whether tht ssistnce involves socil support, eduction, group therpy, mindbody medicine, virtul relity, hypnosis, spiritul counseling, cognitive behviorl therpy, mindfulness, medittion, or other interventions, it is impertive to recognize tht the best tretment for some my not be the best tretment for others nd sometimes it tkes while to figure this out. It s eqully importnt to understnd tht wht service members minds needed to do to increse their chnces of survivl in combt is the opposite of wht their minds will need to do to hel. In the combt setting blocking out inner turmoil nd remining fully lert to one s dngerous environment is criticl. In sfe settings it is importnt to find wys to work through troubling thoughts nd feelings tht wr Pge 2 MSMR Vol. 20 No. 7 July 2013
well result in long-term mentl helth disbilities for thousnds of heroes who hve courgeously ventured into hrm s wy. 1 Though our militry nd civilin helth cre system hs much broder understnding of the common struggles endured fter decde of unconventionl wrfre, the journey is not yet complete. The demnd to continuously improve our knowledge nd methods to effectively prepre, screen, dignose nd tret service members with mentl helth concerns will persist long fter ll of our ntion s heroes hve returned home. Author Affilition: Defense Centers of Excellence for Psychologicl Helth nd Trumtic Brin Injury (DCoE) (Cpt Stoltz). REFERENCES 1. Den ET Jr. Shook over hell: post-trumtic stress, Vietnm, nd the Civil Wr. Cmbridge, MA: Hrvrd University Press; 1997: 35. often genertes. In combintion with therpy it s often helpful for service members to shre their combt experiences with other veterns who ve hd similr experiences. Exercise, good nutrition nd helthy sleep re lso beneficil. There is still much to lern bout how best to help service members who re experiencing highly tretble conditions such s PTSD, depression, nxiety nd substnce buse. Mjor efforts by the militry helth cre system hve incresed tretment resources nd ccess to cre. Inititives undertken to promote help-seeking behvior for mentl helth concerns hve gined significnt trction nd enbled mny to receive help. Our knowledge nd skill in implementing multiple, evidencebsed tretment modlities continue to improve. Ongoing reserch on optimum wys to ssist nd tret service members hs gretly intensified over the lst severl yers nd is lredy showing promising results. This month s edition of the MSMR highlights the strk relity tht wr is hell. Forceful nd intense physicl nd mentl stress is nturl result. If the lessons of the lst wr re lmost lwys ignored in the next wr s historin Eric T. Den, Jr. implies, then the lst 12 yers could very YOU HURT. WE HELP. Psychologicl nd Emotionl Well-Being Your job isn t esy. You re sked to do things most people cn t do, be in situtions most people cn t hndle or mke decisions most people couldn t fthom. These chllenges my plce big toll on you. Yet, to be successful in the Nvy nd Mrine Corps, you hve to be resilient nd psychologiclly strong. Tht s where the Helth Promotion nd Wellness Deprtment of the Nvy nd Mrine Corps Public Helth Center cn help. We hve the resources nd tools to help you nvigte stress nd strengthen your resilience so you cn perform t your best. If you or someone you know is in crisis, plese cll the Militry Crisis Line for confidentil support t 1-800-273-TALK (8255) nd Press 1. To lern how our progrms cn help keep you fit for service nd improve your overll helth, visit us t WWW.MED.NAVY.MIL/SITES/NMCPHC/HEALTH-PROMOTION NAVY AND MARINE CORPS PUBLIC HEALTH CENTER PREVENTION AND PROTECTION START HERE July 2013 Vol. 20 No. 7 MSMR Pge 3
Summry of Mentl Disorder Hospitliztions, Active nd Reserve Components, U.S. Armed Forces, 2000-2012 Mentl disorders re the leding cuse of hospitl bed dys nd the second leding cuse of medicl encounters for ctive component service members in the U.S. militry. Mentl disorder-relted hospitliztions mong militry members hve incresed in both number nd durtion since 2006; mentl disorders re the only illness/injury ctegory for which hospitliztion rtes hve mrkedly incresed during the first 11 yers of the Irq nd Afghnistn wrs. Between 2000 nd 2012, 159,107 ctive component service members experienced 192,317 mentl disorder hospitliztions. There were pproximtely 87 percent more mentl disorder-relted hospitliztions in 2011 (n=21,646) thn in 2000 (n=11,604); in 2012, this number declined slightly (n=21,360). The overll increse since 2006 ws lrgely due to shrp increses in hospitliztions for post-trumtic stress disorder (PTSD), depression, lcohol buse nd dependence, nd djustment disorder (% increses in hospitliztions, 2006-2012: PTSD: 192%; depression: 66%; lcohol buse nd dependence: 110%; djustment disorder: 52%). Similr rtes of increse occurred mong members of the reserve component. The percentge of mentl disorder hospitliztion records with second (concurrent) mentl disorder dignosis incresed during the surveillnce period; more thn hlf of ll service members hospitlized for mentl disorder hd second mentl disorder dignosis documented during the sme hospitliztion. mentl disorders ccount for more hospitliztions of U.S. service members thn ny other mjor dignostic ctegory. 1,2 Mentl disorder-relted hospitliztions mong militry members hve incresed in both number nd durtion since 2006; 3 in ddition, mentl disorders re the only illness/ injury ctegory for which hospitliztion rtes hve incresed during the Irq nd Afghnistn wrs. 4 The public helth impct nd occuptionl burden ssocited with mentl disorder-relted hospitliztions is considerble; for exmple, ttrition rtes for service members within six months of mentl disorder-relted hospitliztion re four times higher thn those for hospitliztion for other injuries or illness 5 nd the risk of dying from suicide is gretly elevted in ctive component service members who hve been hospitlized for mentl disorder..6 This report documents the number nd length of mentl disorder-relted hospitliztions in the ctive nd reserve components of the U.S. Armed Forces during the pst 13 yers. The frequencies of cooccurring mentl disorder dignoses re lso exmined. METHODS The surveillnce period ws 1 Jnury 2000 to 31 December 2012. The surveillnce popultion included ll individuls who served in the ctive nd reserve (Reserve nd Gurd) components of the U.S. Armed Services t ny time during the surveillnce period. Endpoints of nlyses were mentl disorder-relted hospitliztions; for nlysis purposes, these were defined by hospitliztion records with primry (firstlisted) dignoses of mentl disorder or dignosis of suicidl idetion. For summry purposes, mentl disorder-relted hospitliztions were grouped into twelve ctegories: djustment disorders, lcohol buse nd dependence, substnce buse nd dependence, nxiety, post-trumtic stress disorder (PTSD), depression, bipolr disorder, personlity disorders, schizophreni, other psychoses, other mentl helth disorders nd suicidl idetion (Tble 1). Hospitliztions with suicidl idetion s the primry dignosis re summrized only from 2006 forwrd s the dignostic code for suicidl idetion ws not dded to the Interntionl Clssifiction of Diseses (ICD-9-CM) until October 2005. An individul could be counted in more thn one mentl disorder ctegory. All unique hospitliztion records were summrized; n individul could be counted multiple times if tht individul hd multiple mentl disorder-relted hospitliztion records occurring on different dys. Some nlyses were performed only for the subset of the six most frequent mentl disorder hospitliztions (i.e., hospitliztions for djustment disorder, lcohol buse nd dependence, bipolr disorder, depression, PTSD, nd substnce buse nd dependence). For these six ctegories of mentl disorder-relted hospitliztion, the percentges of mentl disorder-relted hospitliztions with nother mentl disorder dignosis in dignostic positions two through eight in the sme hospitliztion record were clculted. RESULTS During the 13-yer surveillnce period, 159,107 ctive component service members experienced totl of 192,317 mentl disorder hospitliztions. Annul numbers of mentl disorder-relted Pge 4 MSMR Vol. 20 No. 7 July 2013
TABLE 1. Mentl disorder ctegories nd dignostic codes (ICD-9-CM) Dignostic ctegory ICD-9 codes ICD-9 mentl disorders Adjustment disorders 309.0x-309.9x (excluding 309.81) Anxiety disorders 300.0x, 300.2x, 300.3 Post-trumtic stress disorder (PTSD) 309.81 Bipolr disorder 296.0x, 296.1x, 296.4x, 296.5x, 296.6x, 296.7, 296.8x Depressive disorders Personlity disorders Schizophreni 296.20-296.35, 296.90, 300.4, 311.xx, 301.6, 301.7, 301.81, 301.82, 301.83, 301.84, 301.89, 301.9 301.0, 301.10, 301.11, 301.12, 301.13, 301.20, 301.21, 301.22, 301.3, 301.4, 301.50, 301.51, 301.59, 301.6, 301.7, 301.81, 301.82, 301.83, 301.84, 301.89, 301.9 295.xx Other psychotic disorders 293.81, 293.82, 297.0x-297.3x, 297.8, 297.9, 298.0. 298.1, 298.2, 298.3, 298.4, 298.8, 298.9 Alcohol buse/dependence disorders 303.xx, 305.0x, 291.81, 291.0 Substnce buse/dependence disorders 304.xx, 305.2x-305.9x (excluding 305.1) Other mentl helth disorder Any other code between 290-319 (excluding 305.1, 299.xx, 315.xx, 317.xx-319.xx) Suicidl idetion V62.84 hospitliztions remined firly stble from 2000 through 2006 nd then monotoniclly incresed through 2011 nd stbilized in 2012 (Figure 1). There were pproximtely 87 percent more mentl disorder-relted hospitliztions in 2011 (n=21,646) thn in 2000 (n=11,604); in 2012, this number declined slightly (n=21,360) (Figure 1). The overll increse since 2006 ws lrgely due to shrp increses in hospitliztions for PTSD, depression, lcohol buse nd dependence, nd djustment disorder (% increses in hospitliztions, 2006-2012: PTSD: 192%; depression: 66%; lcohol buse nd dependence: 110%; djustment disorder: 52%) (Figure 1). During the sme period, 22,456 reserve component service members experienced totl of 26,925 mentl disorder hospitliztions. The number of mentl disorder-relted hospitliztions lmost doubled from 2002 (n=961) to 2003 (n=1,868) nd then remined reltively stble though 2006. As in the ctive component, nnul numbers of mentl disorder-relted hospitliztions fter 2006 incresed ech yer through 2011; between 2006 (n=1,919) nd 2011 (n=3,101), mentl disorder-relted hospitliztions incresed by pproximtely 62 percent (Figure 2). In ctive component service members, during ech yer from 2000 to 2003, there were more hospitliztions for djustment disorders thn ny other ctegory of mentl disorders; however, during ech yer from 2004 to 2012, there were more hospitliztions for depression thn ny other ctegory of mentl disorders (Figure 1). In 2000, FIGURE 1. Number of mentl disorder hospitliztions by ctegory, ctive component, U.S. Armed Forces, 2000-2012 FIGURE 2. Number of mentl disorder hospitliztions by ctegory, reserve component, U.S. Armed Forces, 2000-2012 22,000 Suicidl idetion 3,200 Suicidl idetion 20,000 Other mentl helth 2,800 Other mentl helth 18,000 Other psychoses Other psychoses 16,000 Schizophreni 2,400 Schizophreni No. of hospitliztions 14,000 12,000 10,000 Personlity Bipolr Depression No. of hospitliztions 2,000 1,600 Personlity Bipolr Depression 8,000 6,000 4,000 2,000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 PTSD 1,200 PTSD Anxiety 800 Anxiety Substnce buse/dependence Alcohol buse/dependence 400 Adjustment 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Substnce buse/dependence Alcohol buse/dependence Adjustment July 2013 Vol. 20 No. 7 MSMR Pge 5
FIGURE 3. Incidence rtes of mentl disorder hospitliztions by ctegory, ctive component, U.S. Armed Forces, 2000-2012 Incidence rte per 10,000 person-yers 450.0 400.0 350.0 300.0 250.0 200.0 150.0 100.0 50.0 0.0 2000 2001 2002 2003 2004 2005 The dignostic code for suicidl idetion (V62.84) ws not vilble until October 2005 PTSD=post-trumtic stress disorder 2006 2007 hospitliztion rtes for djustment disorders were higher thn for ny other mentl disorder ctegory (306.8 per 10,000 personyers [p-yrs]); in 2004, hospitliztion rtes for depression (247.8 per 10,000 p-yrs) exceeded those of djustment disorder (224.2 2008 2009 2010 2011 2012 Depression Adjustment Alcohol buse/dependence PTSD Other mentl helth Substnce buse/dependence Bipolr Anxiety Other psychoses Suicidl idetion Schizophreni Personlity per 10,000 p-yrs). Hospitliztion rtes for depression continued to increse through 2012 nd remined higher thn rtes in ny other mentl disorder ctegory (Figure 3). Among reserve component service members, there were more hospitliztions for depression thn for djustment disorders in every yer of the surveillnce period (Figure 2). The men nd medin length of mentl disorder-relted hospitliztions vried substntilly by mentl disorder ctegory (dt not shown). Between 2000 nd 2012, hospitliztions for schizophreni hd the longest medin lengths of ny mentl disorder-relted hospitliztions, lthough the medin length for these hospitliztions declined over the course of the time period (medin length in 2000: 19 dys versus medin length in 2012: 10 dys). In contrst, both men nd medin lengths of hospitliztions for lcohol buse nd dependence nd PTSD incresed between 2009 nd 2012. The nnul men length of hospitliztions where lcohol buse nd dependence ws the primry dignosis incresed from 9 dys in 2009 to 12 dys in 2012; similr increses in medin length were lso observed (2009: 4 dys; 2012: 6 dys). The lrgest increse in length of hospitliztion ws observed for PTSD-relted hospitliztions; the length of PTSD-relted hospitliztions incresed from men of 10 dys nd medin length of 6 dys in 2000 to men length of 17 dys nd medin length of 9 dys in 2012. Men nd medin lengths of hospitliztion for other ctegories of mentl disorder-relted hospitliztions remined reltively stble over the 13-yer period (dt not shown). FIGURE 4. Percentge of mentl disorder hospitliztions for the six most common conditions with nother mentl disorder dignosis nd with n lcohol/substnce buse dignosis, ctive component, U.S. Armed Forces, 2000-2012 Percentge of hospitliztions 85.0 80.0 75.0 70.0 65.0 60.0 55.0 50.0 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Another mentl disorder dignosis Alcohol/substnce buse dignosis 2000 2012 2000 2012 2000 2012 2000 2012 2000 2012 2000 2012 Depression Adjustment Alcohol buse/dependence PTSD Bipolr Substnce buse/dependence Pge 6 MSMR Vol. 20 No. 7 July 2013
TABLE 2. Frequencies of dignoses in other dignostic positions (dx2-dx8) for mentl disorder hospitliztions, ctive component, U.S. Armed Forces, 2000-2012 Frequency of ICD-9-CM codes in the secondry dignostic position (dx2) Adjustment Alcohol buse/dependence Substnce buse/dependence No. Code Description No. Code Description No. Code Description 1 4,980 V6284 Suicidl idetion 1,257 3051 Nondependent tobcco use disorder 403 30401 Opioid type dependence continuous use 2 3,310 3019 Unspecified personlity disorder 1,188 311 Depressive disorder NEC 328 30400 Opioid type dependence unspec use 3 2,523 30500 Nondependent lcohol buse 1,036 V6284 Suicidl idetion 276 311 Depressive disorder NEC 4 1,620 V622 5 1,548 V6110 Other occuptionl circumstnces/ mldjustment Unspec counseling for mritl/prtner problems 921 30981 PTSD 262 2920 Drug withdrwl 777 30391 Other/unspecifi ed lcohol dependence; continuous drinking 256 30500 Nondependent lcohol buse 6 1,469 3051 Nondependent tobcco use disorder 689 29181 Alcohol withdrwl 249 30981 PTSD 7 1,328 V6229 Creer choice problem 641 30390 Other/unspecifi ed lcohol dependence 224 30390 Other/unspecified lcohol dependence 8 1,303 30183 Borderline personlity disorder 549 29620 Mjor depressive ffective disorder; single episode 186 3051 Nondependent tobcco use disorder 9 944 30390 Other/unspecified lcohol dependence 444 30000 Anxiety stte unspecifi ed 165 30000 Anxiety stte unspecified 10 850 30981 PTSD 422 4019 Unspecifi ed essentil hypertension 159 V6284 Suicidl idetion Frequency of ICD-9-CM codes in the 3rd-8th dignostic position (dx3-dx8) Adjustment Alcohol buse/dependence Substnce buse/dependence No. Code Description No. Code Description No. Code Description 1 5,444 V6229 Creer choice problem 3,971 3051 Nondependent tobcco use disorder 1,303 3051 Nondependent tobcco use disorder 2 5,034 3051 Nondependent tobcco use disorder 1,777 4019 Unspecifi ed essentil hypertension 609 30981 PTSD 3 4,913 V622 4 3,525 V6110 Other occuptionl circumstnces/ mldjustment Unspecified counseling for mritl/ prtner problems 1,523 30981 PTSD 462 311 Depressive disorder NEC 1,418 311 Depressive disorder NEC 419 30000 Anxiety stte unspecified 5 2,049 3019 Unspecified personlity disorder 1,383 V6229 Creer choice problem 402 V6229 Creer choice problem 6 1,279 V602 Indequte mteril resources 1,052 V6110 Unspecifi ed counseling for mritl/ prtner problems 7 1,250 V625 Legl circumstnces 986 V622 Other occuptionl circumstnces/ mldjustment 8 1,178 V6289 Other psychologicl/physicl stress 954 30000 Anxiety stte unspecifi ed 279 V622 389 33829 Other chronic pin 290 7242 Lumbgo Other occuptionl circumstnces/ mldjustment 9 1,132 30500 Nondependent lcohol buse 654 53081 Esophgel refl ux 261 3019 Unspecifi ed personlity disorder 10 1,129 30183 Borderline personlity disorder 615 3019 Unspecifi ed personlity disorder 242 4019 Unspecifi ed essentil hypertension NEC=Not elsewhere clssified;ptsd=post-trumtic stress disorder Chrcteristics of the six most frequent mentl disorder relted hospitliztions Between 2000 nd 2012, the six most frequent primry dignoses for mentl disorder-relted hospitliztions mong ctive component militry members were s follows: depression (n=55,586), djustment disorder (n=49,790), lcohol buse nd dependence (n=28,645), PTSD (n=11,033), bipolr disorder (n=9,808), nd substnce buse nd dependence (n=8,059). In generl, greter thn 50 percent of mentl disorder-relted hospitliztions hd co-occurring mentl disorder dignosis in secondry dignostic position in the sme hospitliztion record. Overll, the percentges of co-occurring mentl disorder dignoses incresed between 2000 nd 2012 for every ctegory of mentl disorder-relted hospitliztion (Figure 4). PTSD hospitliztions hd the highest percentge of co-occurring mentl July 2013 Vol. 20 No. 7 MSMR Pge 7
TABLE 2. Continued. Frequencies of dignoses in other dignostic positions (dx2-dx8) for mentl disorder hospitliztions, ctive component, U.S. Armed Forces, 2000-2012 Frequency of ICD-9-CM codes in the secondry dignostic position (dx2) PTSD Depression Bipolr No. Code Description No. Code Description No. Code Description 1 867 311 Depressive disorder NEC 6,370 V6284 Suicidl idetion 644 V6284 Suicidl idetion 2 813 V6284 Suicidl idetion 3,781 30981 PTSD 605 30981 PTSD 3 521 30500 Nondependent lcohol buse 2,472 30500 Nondependent lcohol buse 389 30500 Nondependent lcohol buse 4 519 29620 Mjor depressive ffective disorder; single episode 1,840 30000 Anxiety stte unspecifi ed 320 3051 Nondependent tobcco use disorder 5 513 30390 Other/unspecified lcohol dependence 1,704 3019 Unspecifi ed personlity disorder 311 30390 Other/unspecifi ed lcohol dependence 6 479 V705 Helth exmintion 1,561 30390 Other/unspecifi ed lcohol dependence 244 3019 Unspecifi ed personlity disorder 7 332 29633 Mjor depressive ffective disorder recurrent episode; severe degree 1,192 3051 Nondependent tobcco use disorder 230 V622 Other occuptionl circumstnces/ mldjustment 8 282 29690 Unspecified episodic mood disorder 950 30183 Borderline personlity disorder 206 30183 Borderline personlity disorder 9 206 30000 Anxiety stte unspecified 834 3009 Unspecifi ed nonpsychotic mentl disorder 174 30000 Anxiety stte unspecified 10 203 29630 Mjor depressive ffective disorder recurrent episode; unspecified degree 738 3004 Dysthymic disorder 123 30590 Other mixed/unspecified drug buse Frequency of ICD-9-CM codes in the 3rd-8th dignostic position (dx3-dx8) PTSD Depression Bipolr No. Code Description No. Code Description No. Code Description 1 1,733 3051 Nondependent tobcco use disorder 5,988 3051 Nondependent tobcco use disorder 1,160 3051 Nondependent tobcco use disorder 2 801 V6229 Creer choice problem 3,320 V6229 Creer choice problem 691 V622 3 681 V705 Helth exmintion of defi ned subpopultions 3,218 V622 Other occuptionl circumstnces or mldjustment Other occuptionl circumstnces or mldjustment 616 V6229 Creer choice problem 4 641 4019 Unspecifi ed essentil hypertension 3,026 30981 Posttrumtic stress disorder 499 30981 Posttrumtic stress disorder 5 623 V1552 6 603 V622 7 547 30500 Personl history of trumtic brin injury Other occuptionl circumstnces or mldjustment Nondependent lcohol buse unspecifi ed drinking behvior 2,453 V6110 8 543 33829 Other chronic pin 1,720 30500 Unspecifi ed counseling for mritl nd prtner problems 356 3019 Unspecifi ed personlity disorder 1,999 3019 Unspecifi ed personlity disorder 303 4019 Unspecifi ed essentil hypertension 1,852 V6284 Suicidl idetion 271 30500 Nondependent lcohol buse unspecifi ed drinking behvior 268 V6110 Nondependent lcohol buse unspecifi ed drinking behvior Unspecifi ed counseling for mritl nd prtner problems 9 542 30000 Anxiety stte unspecified 1,581 4019 Unspecifi ed essentil hypertension 267 30183 Borderline personlity disorder 10 538 311 Depressive disorder not elsewhere clssified 1,522 30183 Borderline personlity disorder 257 V1541 Personl history of physicl buse NEC=Not elsewhere clssifi ed;ptsd=post-trumtic stress disorder disorder dignoses (77.3%); this percentge incresed every yer between 2006 nd 2012 (2006: 70.2%; 2012: 82.5%). Overll, PTSD hospitliztions lso hd the highest percentge of co-occurring dignoses relted to lcohol or substnce buse or dependence (2000-2012: 27.8%); this proportion incresed every yer between 2004 (16.3%) nd 2010 (30.1%), nd then slightly declined (2011: 28.5%; 2012: 29.0%) (Figure 4). Among hospitliztions for ech of the six most frequent primry dignoses of mentl disorder, suicidl idetion ws listed s one of the top three most frequent co-occurring dignoses except for hospitliztions for substnce buse nd dependence, for which it ws listed s the tenth most frequent co-occurring dignosis (Tble 2). With the exception of hospitliztions for lcohol buse nd dependence, hospitliztion rtes for ech of the six selected mentl disorders were highest in the Army; Pge 8 MSMR Vol. 20 No. 7 July 2013
TABLE 3. Incident counts nd incidence rtes of mentl disorder hospitliztions, ctive component, U.S. Armed Forces, 2000-2012 Adjustment Alcohol buse/ disorder Substnce buse/ disorder PTSD Depression Bipolr No. Rte RR No. Rte RR No. Rte RR No. Rte RR No. Rte RR No. Rte RR Totl 49,790 268.3 28,645 154.3 8,059 43.4 11,033 59.4 55,586 299.5 9,808 52.8 Service Army 25,147 378.1 1.00 13,468 202.5 1.00 5,507 82.8 1.00 7,592 114.1 1.00 28,427 427.4 1.00 4,875 73.3 1.00 Nvy 9,929 220.0 0.58 4,651 103.0 0.51 740 16.4 0.20 939 20.8 0.18 9,623 213.2 0.50 1,924 42.6 0.58 Air Force 8,474 189.3 0.50 5,934 132.5 0.65 948 21.2 0.26 874 19.5 0.17 11,939 266.7 0.62 1,880 42.0 0.57 Mrine Corps 5,699 236.9 0.63 3,501 145.6 0.72 683 28.4 0.34 1,569 65.2 0.57 4,571 190.0 0.44 940 39.1 0.53 Cost Gurd 541 105.6 0.28 1,091 212.9 1.05 181 35.3 0.43 59 11.5 0.10 1,026 200.2 0.47 189 36.9 0.50 Sex Mle 38,885 245.1 1.00 25,297 159.4 1.00 7,196 45.4 1.00 9,200 58.0 1.00 41,726 263.0 1.00 7,464 47.0 1.00 Femle 10,905 404.7 1.65 3,348 124.3 0.78 863 32.0 0.71 1,833 68.0 1.17 13,860 514.4 1.96 2,344 87.0 1.85 Rce/ethnicity White, non-hispnic 31,732 272.5 1.00 20,444 175.6 1.00 6,472 55.6 1.00 7,469 64.1 1.00 36,815 316.2 1.00 6,838 58.7 1.00 Blck, non-hispnic 8,426 264.4 0.97 3,401 106.7 0.61 593 18.6 0.33 1,319 41.4 0.65 8,227 258.2 0.82 1,427 44.8 0.76 Other 9,632 258.3 0.95 4,800 128.7 0.73 994 26.7 0.48 2,245 60.2 0.94 10,544 282.8 0.89 1,543 41.4 0.70 Mles ge <20 8,963 628.2 1.00 1,270 89.0 1.00 422 29.6 1.00 220 15.4 1.00 4,950 346.9 1.00 822 57.6 1.00 20-24 19,129 364.1 0.58 10,555 200.9 2.26 3,162 60.2 2.03 3,228 61.4 3.98 18,336 349.0 1.01 3,525 67.1 1.16 25-29 6,249 186.6 0.30 5,852 174.7 1.96 2,097 62.6 2.12 2,787 83.2 5.40 8,936 266.8 0.77 1,575 47.0 0.82 30-34 2,480 106.6 0.17 3,005 129.2 1.45 840 36.1 1.22 1,464 62.9 4.08 4,451 191.3 0.55 751 32.3 0.56 35-39 1,309 65.4 0.10 2,479 123.8 1.39 417 20.8 0.70 895 44.7 2.90 2,990 149.3 0.43 451 22.5 0.39 40-49 719 51.5 0.08 1,990 142.6 1.60 241 17.3 0.58 591 42.4 2.75 1,928 138.2 0.40 315 22.6 0.39 50+ 36 32.6 0.05 146 132.4 1.49 17 15.4 0.52 15 13.6 0.88 135 122.4 0.35 25 22.7 0.39 Femles ge <20 3,322 1,155.2 1.00 295 102.6 1.00 76 26.4 1.00 225 78.2 1.00 2,173 755.6 1.00 312 108.5 1.00 20-24 5,178 533.7 0.46 1,604 165.3 1.61 389 40.1 1.52 766 78.9 1.01 6,004 618.8 0.82 1,043 107.5 0.99 25-29 1,410 235.5 0.20 666 111.3 1.08 228 38.1 1.44 369 61.6 0.79 2,769 462.6 0.61 511 85.4 0.79 30-34 563 158.1 0.14 312 87.6 0.85 86 24.1 0.91 193 54.2 0.69 1,351 379.3 0.50 224 62.9 0.58 35-39 287 106.9 0.09 202 75.2 0.73 49 18.3 0.69 162 60.3 0.77 884 329.3 0.44 150 55.9 0.52 40-49 135 69.8 0.06 256 132.3 1.29 30 15.5 0.59 114 58.9 0.75 643 332.4 0.44 99 51.2 0.47 50+ 10 50.7 0.04 13 65.9 0.64 5 25.4 0.96 4 20.3 0.26 36 182.6 0.24 5 25.4 0.23 Ever deployed prior to mentl disorder hospitliztion No 34,477 310.0 1.00 12,865 115.7 1.00 3,370 30.3 1.00 1,660 14.9 1.00 28,375 255.2 1.00 4,777 43.0 1.00 Yes 9,831 132.1 0.43 9,513 127.9 1.11 2,915 39.2 1.29 6,637 89.2 5.98 14,658 197.0 0.77 2,086 28.0 0.65 No. of deployments prior to mentl disorder hospitliztion No. % No. % No. % No. % No. % No. % 0 (never deployed) 35,401 78.3 13,063 57.9 3,433 54.1 1,858 21.9 29,217 66.6 4,997 70.5 1 6,703 14.8 5,868 26.0 2,039 32.1 3,445 40.6 9,254 21.1 1,404 19.8 2 2,189 4.8 2,403 10.6 623 9.8 1,988 23.4 3,590 8.2 468 6.6 3+ 939 2.1 1,242 5.5 253 4.0 1,204 14.2 1,814 4.1 214 3.0 Rte per 10,000 person-yers RR=Rte rtio;ptsd=post-trumtic stress disorder July 2013 Vol. 20 No. 7 MSMR Pge 9
FIGURE 5. Number of bed dys for mentl disorder hospitliztions by selected ctegories, ctive component, U.S. Armed Forces, 2000-2012 No. of bed dys 55,000 50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 Adjustment Alcohol buse/dependence Substnce buse/dependence Post-trumtic stress disorder Depression Bipolr 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 the Cost Gurd s hospitliztion rte for lcohol buse nd dependence ws slightly higher thn the Army s (RR: 1.05) (Tble 3). Femles were more likely to be hospitlized for djustment disorders, PTSD, depression, nd bipolr disorder nd reltively less likely to be hospitlized for lcohol nd substnce buse or dependence thn mles. Both mles nd femles less thn 20 yers of ge hd the highest hospitliztion rtes for djustment disorder. Hospitliztion rtes for lcohol nd substnce buse nd dependence were highest in mles nd femles between the ges of 20 nd 29. Hospitliztion rtes for PTSD peked for mles in the 25-29 ge group; for femles, rtes were highest in those 20-24 yers of ge. For mles, hospitliztion rtes for depression nd bipolr disorder were highest in those 20-24 yers of ge, while these hospitliztion rtes were highest in the youngest femles (Tble 3). Almost 80 percent of service members hospitlized for djustment disorder hd never deployed prior to their hospitliztions; on the other hnd, only 21.9 percent of those hospitlized with PTSD s the primry dignosis hd never deployed. Overll, those who hd deployed t lest once prior to their mentl disorder-relted hospitliztion hd lower hospitliztion rtes for djustment disorder, depression nd bipolr disorder nd higher hospitliztion rtes for lcohol nd substnce buse nd dependence nd PTSD compred to those who hd never deployed (Tble 3). During the 13-yer surveillnce period, ctive component members were hospitlized for totl of 1,262,172 dys (3,458 cumultive person-yers) for tretment of these six mentl disorders. The nnul number of hospitl bed dys for tretment of mentl disorders remined firly stble until 2006; from 2006 through 2012, the nnul bed dys incresed for every disorder except bipolr disorder (Figure 5). The nnul number of hospitl bed dys ssocited with primry dignosis of PTSD, depression nd lcohol buse nd dependence incresed the most drmticlly fter 2006. EDITORIAL COMMENT This report documents continued increses in the numbers of mentl disorder-relted hospitliztions mong U.S. militry members since 2006; the increses overll re lrgely due to shrp rises in hospitliztions in recent yers for PTSD, depression, lcohol buse nd dependence, nd djustment disorders. The increses in mentl disorderrelted hospitliztions documented in this report re cuse for concern for severl resons; mong these is the demonstrted ssocition between psychitric hospitliztion nd risk of suicide. The ssocition between suicidl idetion nd psychitric hospitliztion is well documented. In n nlysis of psychitric hospitliztions in U.S. Nvy enlisted personnel, Booth- Kewley nd Lrson demonstrted strong ssocition between suicidl idetion nd hospitliztion for djustment disorder. 7 Other studies in militry popultions hve demonstrted similr ssocitions between suicide idetion nd other mentl disorders. 8 This report demonstrted tht suicidl idetion is frequent co-occurring dignosis in mny mentl disorder-relted hospitliztions. While the medin durtion of ll cuse hospitliztions hs remined stble since 2003, medin durtions of hospitliztions vry significntly by dignostic ctegory. 2 This report documents continued increses in men nd medin hospitliztion lengths for certin mentl disorders, specificlly, hospitliztions for PTSD nd lcohol buse nd dependence. Mny service members with mentl disorder-relted hospitliztion hd dignosis for nother mentl disorder in the sme record; mong ctive component members, 77 percent of service members hospitlized for PTSD hd nother mentl disorder dignosis in the sme record. Approximtely 28 percent of the PTSD hospitliztions hd dditionl dignoses of lcohol or substnce buse nd dependence. The comorbidity of PTSD nd lcohol misuse hs been incresingly recognized not only in Irq nd Afghnistn veterns but in veterns of other conflicts. 9-11 The incresing durtions of mentl disorder-relted hospitliztions my be due, in prt, to the chllenges of providing cre to service members presenting with multiple nd complex mentl disorder dignoses. The findings of this report reflect incresed hospitliztion rtes of cliniclly significnt mentl disorders, such s PTSD, mong veterns of one or more combt deployments. However, it is lso noteworthy tht significnt proportion of mentl disorder-relted hospitliztions occurred in service members who hd never deployed. For exmple, lmost 8 out of 10 service members hospitlized for djustment disorder hd not deployed prior to their hospitliztion. This finding my be relted to the observtion tht hospitliztion rtes for some mentl disorders Pge 10 MSMR Vol. 20 No. 7 July 2013
re highest in the youngest (nd lest experienced) service members (i.e., <20 yers). The findings of this report should be interpreted in light of severl limittions. This report included hospitliztions in fixed militry tretment fcilities or those hospitliztions pid for by the Militry Helth System (MHS). It did not include hospitliztions tht occurred in the combt theter, bord ships, during field exercises; however, the rte clcultions did include the person-time for the individuls in these loctions. Therefore, hospitliztion rtes for mentl disorders re likely underestimted. Similrly, while this report summrized records of mentl disorder-relted hospitliztions in reserve members, only hospitliztions tht occurred in militry medicl fcility or were pid for by the MHS were cptured. Mny, if not most, reserve members hve lternte mens of receiving medicl cre (i.e., privte medicl insurnce); therefore, this report likely gretly underestimtes the number of mentl disorder-relted hospitliztions in members of the reserve component. 5. Hoge CW, Toboni HE, Messer SC, Bell N, Amoroso P, Ormn DT. The occuptionl burden of mentl disorders in the U.S. militry: psychitric hospitliztions, involuntry seprtions, nd disbility. Am J Psychitry. 2005 Mr; 162(3):585-591. 6. Luxton DD, Trofimovich L, Clrk LL. Suicide risk mong U.S. service members fter psychitric hospitliztion, 2001-2011. Psychtr Serv. 2013; 64(7): 626-629. 7. Booth-Kewley S, Lrson GE. Predictors of psychitric hospitliztion in the Nvy. Mil Med. 2006; 170(1):87-93. 8. Bossrte R, Knox K, Piegri R, Altieri J, Kemp J, Ktz I. Prevlence nd chrcteristics of suicide idetion nd ttempts mong ctive militry nd vetern prticipnts in Ntionl Helth Survey. Am J Public Helth. 2012;102:S38-40. 9. Jcobson IG, Ryn MA, Hooper TI, et l. Alcohol use nd lcohol-relted problems before nd fter militry combt deployment. JAMA. 2008;300(6):663-675. 10. Hoge CW, Cstro CA, Messer SC, McGurk D, Cotting DI, Koffmn RL. Combt duty in Irq nd Afghnistn, mentl helth problems, nd brriers to cre. New Engl J Med. 2004;351(1):13-22. 11. Sel KH, Bertenthl D, Miner CR, Sen S, Mrmr C. Bringing the wr bck home: mentl helth disorders mong 103,788 US veterns returning from Irq nd Afghnistn seen t Deprtment of Veterns Affirs fcilities. Arch Intern Med. 2007;167(5):476-482. REFERENCES 1. Armed Forces Helth Surveillnce Center. Absolute nd reltive morbidity burdens ttributble to vrious illnesses nd injuries, U.S. Armed Forces, 2012. MSMR. 2012 Apr;20(4):5-10. 2. Armed Forces Helth Surveillnce Center. Hospitliztions mong members of the ctive component, U.S. Armed Forces, 2012. MSMR. 2012 Apr;20(4):11-17. 3. Armed Forces Helth Surveillnce Center. Hospitliztions for mentl disorders, ctive components, U.S. Armed Forces, Jnury 2000-December 2009. MSMR. 2010 Nov;17(1):14-16. 4. Armed Forces Helth Surveillnce Center. Signture scrs of the long wr. MSMR. 2013 Apr;20(4):2-4. July 2013 Vol. 20 No. 7 MSMR Pge 11
Surveillnce Snpshot: Anxiety Disorders, Active Component, U.S. Armed Forces, 2000-2012 FIGURE. Incidence rtes of nxiety disorder by subctegories, ctive component, 2000-2012 Incidence rte per 10,000 person-yers 225.0 200.0 175.0 150.0 125.0 100.0 75.0 50.0 25.0 0.0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Anxiety sttes Anxiety disorder (not otherwise specified) Phobic disorders Obsessivecompulsive disorder Anxiety disorder (not otherwise specified) is subctegory of the nxiety sttes ctegory. Anxiety disorders re ctegorized into severl diverse types bsed on their cuse or the focus of the nxiety. The three subctegories tht comprise nxiety disorders s described previously (pge 5) re nxiety sttes, phobic disorders, nd obsessive compulsive disorder. During the surveillnce period (2000-2012), mong ctive component service members the nnul incidence rtes of the nxiety sttes ctegory incresed 425 percent (rte difference [RD]: 172.7), phobic disorders incresed by 32.7 percent (RD: 3.3), nd obsessive compulsive disorders incresed by 9.8 percent (RD: 0.4) (Figure). Anxiety disorder (not otherwise specified [NOS]), subset of the nxiety sttes ctegory, hd the highest overll incidence rte (92.0 per 10,000 p-yrs), nd lrgest percent increse (424.9%) mong ll 5-digit codes tht mke-up the nxiety disorder ctegory. The dignosis of nxiety disorder NOS is used when the ptient s nxiety or phobi do not meet the forml criteri for specific nxiety disorder, but the symptoms re significnt enough to be disruptive or distressing to the individul. 1-2 Furthermore, this dignosis my be used if the symptoms hve not persisted long enough. The dignostic criteri for dignosis of generlized nxiety disorder dignosis specify tht the symptoms must hve lsted for more thn six months). 1 Therefore, it is not surprising tht this dignosis is the incident (first) code recorded for mjority of individuls dignosed with nxiety. Further nlysis to clrify the finl, more specific nxiety disorder dignosis is wrrnted. 1. The Myo Clinic. Anxiety. Found t: http://www.myoclinic.com/helth/nxiety/ds01187/dsection=symptoms. Accessed on: 23 July 2013. 2. Mier W, Buller R, Sonntg A, Heuser I. Subtypes of pnic ttcks nd ICD-9 clssifiction. Eur Arch Psychitr Neurol Sci. 1986;235:361-366. Pge 12 MSMR Vol. 20 No. 7 July 2013
Mentl Disorders nd Mentl Helth Problems Among Recruit Trinees, U.S. Armed Forces, 2000-2012 Ptrick Monhn, MD, MPH (Col, USAF); Zheng Hu, MS; Ptrici Rohrbeck, DrPH, MPH, CPH (Mj, USAF) Annul counts nd rtes of incident dignoses of mentl disorders or mentl helth problems hve incresed in the U.S. militry ctive component since 2000, but less is known bout recruit trinees. From 2000 to 2012, 49,999 ctive component recruit trinees were dignosed with t lest one mentl disorder, nd 7,917 hd multiple mentl disorder dignoses. Annul incidence rtes of t lest one mentl disorder decresed by pproximtely 37.4 percent over the lst 13 yers. Approximtely 80.5 percent of ll incident mentl disorder dignoses were ttributble to djustment disorders, depression, nd other mentl disorders. Rtes of incident mentl disorder dignoses were higher in femles thn mles. Even though the Army hd the highest overll incidence rtes of mentl disorders, the Air Force hd slightly higher rtes for djustment disorder, nd the Nvy hd higher rtes of lcohol buserelted disorders, post-trumtic stress disorder (PTSD), nxiety, other psychoses, nd personlity disorders. These findings document differences in the mentl disorders experienced by recruit trinees compred to members of the ctive component of the U.S. militry overll. Continued focus on detection nd tretment of mentl helth issues during bsic trining is wrrnted. mentl disorders ccount for significnt morbidity, helth cre utiliztion, disbility, nd ttrition from militry service. 1 A recent descriptive epidemiologicl study of mentl disorders nd mentl helth problems in the ctive component between 2000 nd 2011 showed tht, for most ctegories of mentl disorders, rtes of incident dignoses were highest mong the youngest (nd thus most junior) service members. 2 Crude incidence rtes of djustment disorders, post trumtic stress disorder (PTSD), personlity disorders, other mentl disorders, schizophreni, nd other psychoses were higher mong the youngest (less thn 20 yers of ge) group of service members. 2 Also, significnt proportion of mentl helth problems relted to life circumstnces occurred in the first six months of service members militry service. 2 Psychitric disorders re mong the top ten cuses of conditions tht existed before service nd of disbility dischrges ech yer. 3 Existing prior to service (EPS) medicl conditions re defined s those verified to hve existed before the recruit begn militry service nd if the complictions leding to dischrge rose no more thn 180 dys fter the recruit trinee begn duty. 3 Approximtely five percent of ll new ctive duty enlistees (excluding U.S. Air Force recruit trinees) re dischrged within six months of enlistment due to complictions of medicl conditions tht existed prior to service. 4 Mentl disorder resons for EPS dischrge vry by service: psychitric cuses ccounted for the most EPS dischrges in the Army (29.1%) nd the Mrine Corps (43.9%) between 2007 nd 2011, while the percentge in the Air Force for tht period ws 0.4 percent. 5 The most common cuses of hospitliztions within the first yer of service from 2005 to 2010 were neurotic or personlity disorders (16.7%) nd other psychoses (5.9%). 5 Few studies hve evluted militry personnel longitudinlly fter dignosis of mentl disorder. Hoge et l. 6 demonstrted tht, mong militry cohort in the 1990s, 47 percent of those hospitlized for the first time with mentl disorder left militry service within six months; this proportion ws significntly higher thn tht for ny one of 15 other disese ctegories. While five to six percent of Air Force recruit trinees hve historiclly experienced emotionl difficulties tht result in referrl for psychologicl evlution, 7 one study in Air Force recruit trinees found tht only 58 percent of those referred for mentl helth evlution nd returned to duty ultimtely grduted from bsic militry trining; 8 the most common reson for dischrge ws EPS (26%) followed by continued mentl helth problems (21%). Another study in Air Force recruit trinees showed n nnul mentl disorder-relted seprtion rte of 4.2 percent; djustment disorders nd depressive disorders were the most frequent dignoses relted to recommendtion for seprtion. 9 This report summrizes counts, rtes, nd trends of incident mentl disorder-specific dignoses (ICD-9-CM: 290.0-319.0) mong ctive component U.S. recruit trinees over 13-yer surveillnce period. It lso summrizes counts, rtes, nd trends of incident mentl helth problems (documented with mentl helth-relted V-codes) mong ctive component U.S. recruit trinees during the sme time period. METHODS The surveillnce period ws 1 Jnury 2000 to 31 December 2012. The surveillnce popultion included ll individuls who entered bsic trining in the U.S. Armed Forces t the grdes of E1 to E4 t ny time during the surveillnce period. Recruit trinees were followed for their service specific bsic trining periods July 2013 Vol. 20 No. 7 MSMR Pge 13
rnging from 6 to 10 weeks; recruit trinees who hd to repet ll or portion of their bsic trining period were excluded. No surveillnce ws conducted for recruit trinees during ny follow-on trining such s Advnced Individul Trining (AIT) or other jobs requiring technicl trining. Cost Gurd dt prior to 2007 ws incomplete nd thus excluded from the report. All dt used to determine incident mentl disorder-specific dignoses nd mentl helth problems were derived from records routinely mintined in the Defense Medicl Surveillnce System. These records document both mbultory encounters nd hospitliztions of ctive component members of the U.S. Armed Forces in fixed militry nd civilin (if reimbursed through the Militry Helth System) tretment fcilities. For surveillnce purposes, mentl disorders were scertined from records of medicl encounters tht included mentl disorder-specific dignoses (ICD-9-CM 290-319, the entire mentl disorders section of the ICD-9-CM coding guide) in the first or second dignostic position; dignoses of pervsive developmentl disorder (ICD-9-CM: 299.xx), specific delys in development (ICD-9-CM: 315.xx), nd mentl retrdtion (ICD-9-CM: 317.xx- 319.xx) were excluded from the nlysis. Dignoses of mentl helth problems were scertined from records of helth cre encounters tht included V-coded dignoses indictive of psychosocil or behviorl helth issues in the first or second dignostic position. For summry purposes, mentl disorder-specific dignoses indictive of djustment rection, substnce buse, nxiety disorder, PTSD, or depressive disorder were grouped into ctegories defined by Sel et l. 10 nd previously reported in the MSMR 11 with two modifictions s follows: depressive disorder, not elsewhere clssified (ICD- 9-CM: 311) ws included in the depression ctegory insted of the other mentl dignoses ctegory. Also, lcohol buse nd dependence dignoses nd substnce buse nd dependence dignoses were treted s two discrete ctegories. Dignoses indictive of personlity disorder or other psychotic disorders were grouped using the ctegories developed by the Agency for Helthcre Reserch nd Qulity (AHRQ). 12 A cse of schizophreni ws defined s n ctive component service member with t lest one hospitliztion or four outptient encounters tht were documented with schizophreni-specific dignoses (ICD-9-CM: 295). V-coded dignoses indictive of mentl helth problems were grouped into five ctegories using previously published criteri. 13 Ech incident dignosis of mentl disorder (ICD-9-CM: 290-319) or mentl helth problem (selected V-codes) ws defined by hospitliztion with n indictor dignosis in the first or second dignostic position; two outptient visits within 180 dys documented with indictor dignoses (from the sme mentl disorder or mentl helth problem-specific ctegory) in the first or second dignostic positions; or single outptient visit in psychitric or mentl helth cre specilty setting (defined by Medicl Expense nd Performnce Reporting System [MEPRS] code: BF) with n indictor dignosis in the first or second dignostic position. As described previously, the cse definition for schizophreni required four outptient encounters. Service members who were dignosed with more thn one mentl disorder during the surveillnce period were considered incident cses in ech ctegory in which they fulfilled the cse-defining criteri. Service members could be incident cses only once in ech mentl disorder-specific ctegory. Only service members with no incident mentl disorder-specific dignoses (ICD-9-CM: 290-319) during the surveillnce period were eligible for inclusion s cses of incident mentl helth problems (selected V-codes). RESULTS During the 13-yer surveillnce period, 49,999 or 2.4 percent of ll ctive component recruit trinees were dignosed with t lest one mentl disorder; of these individuls, 7,917 (15.8%) were dignosed with mentl disorders in more thn one dignostic ctegory (Tble 1). Overll, there were 59,419 incident dignoses of mentl disorders in ll dignostic ctegories. Among ctive component recruit trinees, nnul rtes of incident dignoses of t lest one mentl disorder decresed by pproximtely 37.0 percent during the period (incident dignoses of t lest one mentl disorder, by yer: 2000: n=4,933, rte=159.8 cses per 1,000 person-yers [p-yrs]; 2012: n=2,695, rte=100.7 per 1,000 p-yrs) (Figure 1). Over the entire period, pproximtely 80.5 percent of ll incident mentl disorder dignoses were ttributble to djustment disorders (n=30,253; 50.9%), depression (n=9,177; 15.4%), nd other mentl disorders (n=8,383; 14.1%); reltively few incident dignoses were ttributble to schizophreni (n=253; 0.4%), substnce buse nd dependence relted disorders TABLE 1. Incident dignoses nd incidence rtes of mentl disorders (ICD-9-CM: 290-319), recruit trinees, U.S. Armed Forces, 2000-2012 Ctegory No. Rte b % of totl popultion Adjustment disorders 30,253 84.5 1.4 Alcohol buse nd dependence 763 2.1 0.0 Anxiety 3,705 10.3 0.2 Depression 9,177 25.6 0.4 Post-trumtic stress disorder (PTSD) 1,181 3.3 0.1 Personlity disorders 3,943 11.0 0.2 Schizophreni 253 0.7 0.0 Substnce buse nd dependence 768 2.1 0.0 Other psychoses 993 2.8 0.1 Other mentl disorders 8,383 23.3 0.4 >1 ctegory of mentl disorder 7,917 22.0 0.4 Any mentl disorder dignosis c 49,999 139.1 2.4 An individul my be cse within ctegory only once per lifetime (censored person-time) b Rte per 1,000 person-yers c At lest one reported mentl disorder dignosis Pge 14 MSMR Vol. 20 No. 7 July 2013
FIGURE 1. Incidence rtes of mentl disorder dignoses by ctegory, recruit trinees, U.S. Armed Forces, 2000-2012 Incidence rte per 1,000 person-yers 110.0 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Adjustment disorders Depression Other mentl disorders Anxiety disorders Personlity disorders Alcohol buse/dependence PTSD Schizophreni Other psychoses Substnce buse/dependence FIGURE 2. Incidence rtes of mentl disorder dignoses by selected ctegories nd ge group, recruit trinees, U.S. Armed Forces, 2000-2012 Incidence rte per 1,000 person-yers 90.0 75.0 60.0 45.0 30.0 15.0 0.0 Adjustment Alcohol buse/dependence 18-20 21-24 25+ PTSD Anxiety Depression Personlity Schizophreni Other psychoses (n=768; 1.3%), nd lcohol buse nd dependence (n=763; 1.3%) (Tble 1). Crude rtes of incident dignoses of ll mentl disorders decresed during the surveillnce period prticulrly fter 2009. Throughout the entire period, crude incidence rtes for djustment disorders were significntly higher compred to ny other mentl disorder ctegory. The crude incidence rtes for djustment disorders fluctuted between 81.8 per 1,000 p-yrs (in 2000) to 107.8 per 1,000 p-yrs (in 2008), but declined stedily fter 2009; nnul rtes were lower ech yer fter 2010 thn in ny of the previous 11 yers (Figure 1). Crude incidence rtes for other mentl disorders incresed shrply from 2005 to 2006, but then declined from 2006 through 2012. The crude incidence rtes for depression grdully incresed from 2003 through 2007, but continuously decresed fter 2007. In contrst, crude incidence rtes of dignoses of personlity disorders declined stedily during the surveillnce period, nd crude incidence rtes for nxiety, schizophreni, other psychoses, PTSD, nd lcohol nd substnce buse-relted disorders were reltively stble or declined during the period (Figure 1). In generl, rtes of incident mentl disorder dignoses remined stedy with incresing ge, except for nxiety disorders, depression, schizophreni, nd other psychoses, which hd higher rtes in individuls ge 25 nd bove compred to younger recruit trinees ( Figures 2). In contrst, crude incidence rtes of personlity disorders were lower in individuls ge 25 nd bove compred to younger trinees. Crude incidence rtes of djustment, nxiety, nd personlity disorders s well s depression were pproximtely twice s high mong femles s mles, nd crude incidence rtes of PTSD were 5.6 times higher mong femles (femles: 11.5 per 1,000 p-yrs; mles: 1.7 per 1,000 p-yrs) (Figure 3). Overll incidence rtes of mentl disorders were higher in the Army (169.2 per 1,000 p-yrs) nd lower in the Mrine Corps (92.6 per 1,000 p-yrs) thn in ny of the other Services. Army incidence rtes incresed from 2002 through 2004, peked in 2004 nd 2008, nd stedily decresed from 2008 through the end of the period. Among the services, overll incidence rtes were the second highest in the Air Force (145.7 per 1,000 p-yrs); nnul rtes in the Air Force shrply decresed from 2006 through 2010 but slightly incresed in 2012 (Figure 4). Among Nvy recruit trinees, there were peks in nnul incidence rtes in 2000 (220.11 per 1,000 p-yrs) nd 2007 (194.3 per 1,000 p-yrs); nnul rtes in the Nvy grdully declined from 2007 through 2011 nd then incresed in 2012. Among Mrine Corps recruit trinees, nnul incidence rtes remined reltively stedy from 2000 through 2009 nd then slowly declined from 2009 through 2012. The 2012 rte mong Mrine Corps trinees (45.8 per 1,000 p-yrs) ws the lowest FIGURE 3. Incidence rtes of mentl disorder dignoses by selected ctegories nd gender, recruit trinees, U.S. Armed Forces, 2000-2012 Incidence rte per 1,000 person-yers 150.0 125.0 100.0 75.0 50.0 25.0 0.0 Adjustment Alcohol buse/dependence Femle Mle PTSD Anxiety Depression Personlity Schizophreni Other psychoses nnul rte mong ny Service during the surveillnce period. Among Cost Gurd recruit trinees, nnul incidence rtes from 2007 through 2011 slowly incresed, then shrply declined in 2012 (59.2 per 1,000 p-yrs) (Figure 4). Even though Army recruit trinees hd the highest overll incidence rtes of mentl disorders, Air Force trinees hd slightly higher rtes of djustment disorders; rtes of djustment disorder dignoses were more thn twice s high in the Army nd the Air Force s in the other services. Rtes of depression dignoses were higher mong recruit trinees of the Army nd Nvy thn July 2013 Vol. 20 No. 7 MSMR Pge 15
FIGURE 4. Incidence rtes of mentl disorder dignoses by service, recruit trinees, U.S. Armed Forces, 2000-2012 Incidence rte per 1,000 person-yers 250.0 200.0 150.0 100.0 50.0 0.0 2000 2001 2002 2003 2004 2005 2006 2007 2008 Dt ws not complete for the Cost Gurd until 2007 2009 2010 2011 Army Nvy Mrine Corps Air Force Cost Gurd 2012 FIGURE 5. Incidence rtes of mentl disorder dignoses by selected ctegories nd service, recruit trinees, U.S. Armed Forces, 2000-2012 Incidence rte per 1,000 person-yers 140.0 120.0 100.0 80.0 60.0 40.0 20.0 0.0 Adjustment Army Nvy Mrine Corps Air Force Cost Gurd Alcohol buse/dependence PTSD Anxiety Depression Personlity Schizophreni Other psychoses the other services; nd compred to their counterprts, Nvy trinees hd the highest rtes of lcohol buse-relted disorders, PTSD, nxiety, personlity disorders, nd other psychoses. The crude incidence rte of personlity disorders in the Nvy ws 5.8 times higher thn the Army nd 2.6 times higher thn the Mrine Corps (Figure 5). During the surveillnce period, there were 11,273 incident reports of mentl helth problems (documented with V-codes) or 0.5 percent mong ll ctive component recruit trinees who were not dignosed with mentl disorder (ICD-9-CM: 290-319). During the period, nerly 98.9 percent of ll incident reports of mentl helth problems were relted to life circumstnces (e.g., filure to djust, mritl problems, finncil difficulties, berevement, cculturtion difficulties) (n=11,145) (Tble 2). Rtes of ny mentl helth problems (s reported with V-codes) were reltively stble during the period with smll pek in 2006, but decresing since 2007 nd then stbilized (Figure 6). Compred to rtes of ny mentl helth problem, ny mentl disorder dignosis rtes were consistently higher (139.1 per 1,000 p-yrs compred to 31.4 per 1,000 p-yrs) ( Tbles 1, 2, Figure 6). Of note, rtes of ny mentl disorder dignoses decresed from 2008 through 2010 nd hve been reltively stble since (Figure 6). Rtes of mentl helth problems relted to life circumstnces declined from 2000 to 2004 (28.6 per 1,000 p-yrs), incresed to shrp pek in 2006 (44.7 per 1,000 p-yrs), nd then declined shrply through 2008 (19.8 per 1,000 p-yrs). This ctegory remined stble since 2008. The crude incidence rte of life circumstnce-relted problems ws more thn 54 percent lower in the lst yer (2012: 19.9 per 1,000 p-yrs) compred to the first yer of the period (2000: 44.1 per 1,000 p-yrs) (dt not shown). Among mentl helth problems, the Cost Gurd hd the highest rte of life circumstnce-relted dignoses, which ws 20.6 times higher thn the Army, 17.0 times higher thn the Mrine Corps, nd 3.7 times higher thn the Air Force (Figure 7). EDITORIAL COMMENT This report provides comprehensive overview of incident dignoses of mentl disorders nd reports of mentl helth problems mong ctive component recruit trinees of the U.S. Armed Forces during the lst 13 yers. The report reitertes nd reemphsizes previously reported findings regrding mentl disorders/problems mong U.S. militry members. This report, however, illumintes differences between mentl disorders/mentl helth problems of recruit trinees compred to those of ctive component service members in generl. There re unique nd inherently stressful physicl nd mentl chllenges ssocited with the introduction of civilins to militry environments nd the commencement of bsic militry (recruit) trining. Even though mjority (over 90%) of recruit trinees go through their trining without mentl disorder incident, some present with mentl helth-relted TABLE 2. Incident dignoses nd rtes of mentl helth problems (V-codes) mong those without mentl disorder dignoses (ICD-9-CM: 290-319), recruit trinees, U.S. Armed Forces, 2000-2012 Ctegory No. Rte b % of totl popultion Prtner reltionship 42 0.1 0.0 Fmily circumstnce 73 0.2 0.0 Mltretment relted 7 0.0 0.0 Life circumstnce problem 11,145 31.1 0.5 Mentl, behviorl, nd substnce buse 30 0.1 0.0 >1 type of V-code 24 0.1 0.0 Any V-code c 11,273 31.4 0.5 An individul my be cse within ctegory only once per lifetime (censored person-time) b Rte per 1,000 person-yers c At lest one reported mentl helth problem (V-coded) Pge 16 MSMR Vol. 20 No. 7 July 2013
FIGURE 6. Incidence rtes of ny mentl disorder dignosis or ny mentl helth problem, recruit trinees, U.S. Armed Forces, 2000-2012 Incidence rte per 1,000 person-yers FIGURE 7. Incidence rtes of mentl helth problems by ctegory nd service, recruit trinees, U.S. Armed Forces, 2000-2012 Incidence rte per 1,000 person-yers 175.0 150.0 125.0 100.0 75.0 50.0 25.0 0.0 Army Nvy Mrine Corps Air Force Cost Gurd 175.0 150.0 125.0 100.0 75.0 50.0 25.0 0.0 Mentl disorder dignosis (ICD-9-CM: 290-319) Mentl helth problem (V-codes) 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Life circumstnces problems tht could result in dischrges from militry service either during bsic trining or during their first duty ssignments. As result, erly psychologicl evlutions nd incresed ccess to mentl helth services during the bsic trining period my help retin otherwise motivted nd qulified service men nd women. The ntures nd mgnitudes of mentl disorders nd relted problems in militry bsic trining should be interpreted with considertion tht the mjority of recruit trinees re 25 yers of ge or younger. In this regrd, the Centers for Disese Control nd Prevention (CDC) reported tht mentl disorders re chronic helth conditions tht my interfere with helthy development nd continue to cuse problems into dulthood. 14 Bsed on the Ntionl Reserch Council nd Institute of Medicine report, n estimted 13 to 20 percent of children in the U.S. experience mentl helth disorder in given yer. 14 This lrge nd growing problem of mentl disorders in the dolescent U.S. popultion will ffect militry service when young nd otherwise helthy dults re recruited nd present for bsic trining; mentl disorder-relted problems my re-surfce during the bsic trining period. In the U.S. dolescent popultion, the most common mentl disorders re ttention deficit hyperctivity disorder (ADHD), disruptive behviorl disorders such s oppositionl defint disorder nd conduct disorder, utism spectrum disorders, mood nd nxiety disorders including depression, substnce use disorders, nd Tourette syndrome. 14 In this study cohort, djustment disorders, depression, other mentl disorders, nxiety, nd personlity disorders were the most common dignoses. These findings suggest tht mentl disorders nd mentl helth problems in ctive component recruit trinees prtilly reflect the ptterns observed in the dolescent U.S. popultion. The findings of this report re consistent with previously identified ge-relted risks in the ctive component U.S. Armed Forces. For most ctegories of mentl disorders nd mentl helth problems, rtes of incident dignoses were highest mong the youngest (nd thus likely most junior) service members. Since recruit trinees re the youngest nd most junior of ll militry members nd new to the militry environment, they my not perceive stigms nd/ or fers of negtive impcts on their militry creers when seeking mentl helth cre. As result, nd in comprison to ctive component (older nd higher rnking) service members, recruit trinees my be more likely to seek mentl helth cre thn those who re older. Other findings of this report re different from previous reports identifying mentl disorder-relted risks in the ctive component U.S. Armed Forces. Of note, rtes of mentl disorders nd mentl helth problems mong recruit trinees hve either declined or remined stble over the pst 13 yers, wheres the mjority of the sme mentl disorder outcomes hve incresed mong ctive component service members. 2 In both popultions, djustment disorders hd the highest incidence rte compred to other mentl disorders, yet when compred to the ctive component popultion, the rte ws twice s high in recruit trinees. The higher rte in trinees my be the result of individuls experiencing stressful, fstpced, nd intense environment such s bsic trining for the first time in their lives. In both popultions, femles experience higher incidence rtes of mentl disorders compred to mles. Although this reltionship pplies to ll mentl disorder ctegories in recruit trinees, ctive component mles hve higher incidence rtes thn femles for lcohol nd substnce buse-relted disorders nd PTSD. 2 Alcohol nd substnce use is prohibited in bsic trining, nd since it is strictly monitored environment, the incidence rtes re mong the lowest compred to other mentl disorders. As result, lcohol nd substnce buse problems re not common in the bsic trining popultion. Similrly, PTSD is often ssocited with deployments nd is therefore more likely to occur mong ctive component service members thn recruit trinees. When compring the impct of service ffilition on mentl disorder incidence, service members in the Army hd consistently higher rtes thn ny of the other Services over the pst 12 yers; ll Services showed incresing trends. 2 Among recruit trinees, service ffilition does not present clerly observble trend, which my be due to the vrition in nd chnges to trining content nd length over the pst 13 yers. Incidence rtes for mentl disorders by Service in recruit trinees hve fluctuted, nd in recent yers Army, Mrine Corps, nd Cost Gurd show decresing trends, while Nvy nd Air Force rtes show incresing trends. There re significnt limittions to this report tht should be considered when interpreting the results. For exmple, incident cses of mentl disorders nd mentl helth problems were scertined from ICD-9-CM coded dignoses tht were reported on stndrdized dministrtive records of outptient clinic visits nd hospitliztions. Such records re not completely relible indictors of the numbers nd types of mentl disorders nd mentl helth problems tht ctully ffect militry members. For exmple, the numbers reported here re underestimtes to the extent tht ffected service members did not seek cre or received cre tht is not routinely documented in records tht were used for this nlysis; tht mentl disorders nd July 2013 Vol. 20 No. 7 MSMR Pge 17
mentl helth problems were not dignosed or reported on stndrdized records of cre; nd/or tht some indictor dignoses were miscoded or incorrectly trnscribed on the centrlly trnsmitted records. On the other hnd, some conditions my hve been erroneously dignosed or miscoded s mentl disorders or mentl helth problems (e.g., screening visits). Additionlly, no prior medicl history ws vilble, so ech initil mentl disorder encounter ws considered n incident dignosis even though some mentl disorder-relted conditions my hve existed prior to service. Finlly, s with most helth surveillnce-relted nlyses mong U.S. militry members, this report relies on dt in the Defense Medicl Surveillnce System (DMSS). The DMSS integrtes records of nerly ll medicl encounters of ctive component members in fixed (i.e., not deployed or t se) militry medicl fcilities. Administrtive medicl record systems, like DMSS, enble comprehensive surveillnce of medicl conditions of interest through identifiction of likely cses; such cses re identified by using surveillnce cse definitions tht re bsed entirely or in prt on indictor ICD-9-CM codes. Other considertions in the construction of surveillnce cse definitions include the clinicl setting in which dignoses of interest re mde (e.g., hospitliztion, relevnt specilty clinic), frequency nd timing of indictor dignoses, nd the priority with which dignoses of interest re reported (e.g., first listed versus others). Author ffilitions: Uniformed Services University of the Helth Sciences (Col Monhn); Armed Forces Helth Surveillnce Center (Mj Rohrbeck, Ms Hu) Militry Medicine: Recruit Medicine. Wshington, DC: Government Printing Office; 2006:59-79. 5. Accession Medicl Stndrds Anlysis & Reserch Activity, Attrition & Morbidity Dt for FY 2011 Accessions, Annul Report 2012:77. 6. Hoge CW, Lesikr SE, Guevr R, et l. Mentl disorders mong U.S. militry personnel in the 1990s: ssocition with high levels of helth cre utiliztion nd erly militry ttrition. Am J Psychitry. 2002;159(9):1576-1583. 7. Cigrng JA, Todd S, Crbone EG, Fiedler E. Mentl helth ttrition from Air Force bsic militry trining. Mil Med. 1998;163:834-838. 8. Crbone EG, Cigrng JA, Todd SL, Fiedler ER. Predicting outcome of militry bsic trining for individuls referred for psychologicl evlution. Journl Pers Assess. 1999;72(2):256-265. 9. Englert DR. Mentl helth evlutions of U.S. Air Force bsic militry trining nd technicl trining students. Mil Med. 2003;168(11):904-910. 10. Sel KH, Bertenthl D, Miner CR, Sen S, Mrmr C. Bringing the wr bck home: mentl Photo by Cpl. Pete Thibodeu Photo by PhotoAlto/Michele Constntini helth disorders mong 103 788 US veterns returning from Irq nd Afghnistn seen t Deprtment of Veterns Affirs fcilities. Arch Intern Med. Mrch 12, 2007;167(5):476-482. 11. Armed Forces Helth Surveillnce Center. Reltionships between the nture nd timing of mentl disorders before nd fter deploying to Irq/Afghnistn, ctive component, U.S. Armed Forces, 2002-2008. MSMR. 2009;16(2):2-6. 12. Agency for Helthcre Reserch nd Qulity. Found t: http://meps.hrq.gov/dt_stts/downlod _dt/pufs/h120/h120_icd9codes.shtml. Accessed on: August 6, 2013. 13. Grvey Wilson A, Messer S, Hoge C. U.S. militry mentl helth cre utiliztion nd ttrition prior to the wrs in Irq nd Afghnistn. Soc Psychitry Psychitr Epidemiol. 2009;44(6):473-481. 14. Center for Disese Control Fetures: Children s Mentl Helth New Report. Found t: http://www.cdc.gov/fetures/ ChildrensMentlHelth/ Published My 17, 2013. Updted My 21, 2013. Accessed July 23, 2013. REAL WARRIORS. REAL BATTLES. REFERENCES 1. Hoge CW, Toboni HE, Messer SC, Bell N, Amoroso P, Ormn DT. The occuptionl burden of mentl disorders in the U.S. militry: psychitric hospitliztions, involuntry seprtions, nd disbility. Am J Psychitry. 2005;162(3):585-591. 2. Armed Forces Helth Surveillnce Center. Mentl disorders nd mentl helth problems, ctive component, U.S. Armed Forces, 2000-2011. MSMR. 2012;19(6):11-17. 3. Accession Medicl Stndrds Anlysis & Reserch Activity, Attrition & Morbidity Dt for FY 2011 Accessions, Annul Report 2012:76. 4. Niebuhr DW, Powers TE, Li Y, Millikn AM. Morbidity nd ttrition relted to medicl conditions in recruits. In: Lenhrt MK, ed. Textbooks of Photo by SrA. Gin Chivenotti REAL STRENGTH. REACHING OUT MAKES A REAL DIFFERENCE. Discover rel stories of courge in the bttle ginst combt stress. Cll Toll Free 866-966-1020 www.relwrriors.net Pge 18 MSMR Vol. 20 No. 7 July 2013
Surveillnce Snpshot: Mentl Disorder Hospitliztions Among Recruit Trinees, U.S. Armed Forces, 2000-2012 FIGURE. Hospitliztions for mentl disorders mong recruit trinees, 2000-2012 800 250.0 No. of hospitliztions 700 600 500 400 300 200 100 200.0 150.0 100.0 50.0 Incidence rte per 10,000 person-yers 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 0.0 Adjustment disorders Alcohol buse nd dependence Anxiety disorders Depressive disorders PTSD Personlity disorders Substnce buse nd dependence Other psychoses Other mentl helth disorder Schizophreni Suicidl idetion (V62.84) Bipolr Disorder Totl rte Recruit trinees re defi ned s ctive component members of the Army, Nvy, Air Force, Mrine Corps, or Cost Gurd with rnk of E1 to E4 who served t one of nine bsic trining loctions during service-specific trining period following first-ever personnel record. b The ICD-9 code for suicidl idetion ws not vilble before 2005 During the 13-yer surveillnce period (2000-2012), there were 6,723 hospitliztions for mentl disorders mong U.S. Armed Forces recruit trinees (Figure). On verge, 517 recruit trinees were hospitlized yerly due to mentl disorder. The highest number nd rte of mentl disorder-relted hospitliztions were in 2000 (n=793; 240.1 per 10,000 personyers [p-yrs]) nd the lowest number nd rte were in 2011 (n=275; 104.0 per 10,000 p-yrs). From 2008 to 2012 there ws 45.5 percent decrese in the rte of mentl disorder-relted hospitliztions. Adjustment disorder ws the most commonly recorded mentl disorder dignosis ssocited with hospitliztion mong recruit trinees (verge: 282 per yer), while depressive disorder ws the second most common dignosis (verge: 79 per yer). July 2013 Vol. 20 No. 7 MSMR Pge 19