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LAY SUMMARYIt is important that individuals who need mental health services receive adequate care. Mental health service use (MHSU) intensity is one measure of care adequacy. This study compares changes in the past decade in mental health service use intensity in Canadian military members and civilians. Mental health service intensity increased in both military and comparable civilians over the past decade. These findings show improvements in adequacy of care and are consistent with other studies reporting improvements in other aspects of mental health service use. However, there is a need to look at other indicators of care adequacy, such as the type of care received, in future studies.

Introduction: What causes the excess burden of mental disorders and related outcomes in the Army remains unclear. Deployment-related trauma has been one intuitive explanation. However, there may be other factors at play – for example, lower mental health services use (MHSU) in Army personnel. This study compares MHSU across the Canadian Army, Navy, and Air Force. Methods: Data were drawn from the 2013 Canadian Forces Mental Health Survey. The sample consisted of Regular Force members ( N = 6,696). The primary outcomes for past-year MHSU were: (1) any past-year MHSU; (2) intensity of care (total clinical contact hours), and (3) perceived helpfulness of care (PHC). ­Modified Poisson regression and analysis of covariance (ANCOVA) were used to assess the relationship between the elements (Army, Navy, Air Force) and each outcome, adjusting for sociodemographic and military characteristics, as well as clinical variables such as the presence of five past-year mental disorders. Results: In unadjusted analyses, Army personnel had significantly greater past-year MHSU and intensity of care relative to Air Force personnel. No significant relationship was found between the element and any of the MHSU parameters after adjustment. Discussion: Differences in past-year MHSU are an unlikely contributing factor to the higher risk of mental disorders and related outcomes among Army personnel; the true explanation must lie elsewhere. Findings argue for a system-wide, and not element-specific, approach to improving Canadian Armed Forces (CAF) programs and services.

Introduction: Military clinicians often need to assess fitness for duty after a mental disorder diagnosis. The ability to respond to the psychological demands of deployment is a primary consideration. This analysis explores whether personnel with past mental health problems are more vulnerable to the effects of combat. Methods: Data came from 16,944 Canadian Armed Forces personnel undergoing post-deployment screening in 2009–2012 after deployment in support of the mission in Afghanistan. Those who had previous deployments ( n = 9,852) and those who were currently in mental health care ( n = 588) were excluded, leaving 6,504 in the analysis sample. The primary outcomes were the presence of one or more of six common mental health problems assessed by the screening questionnaire and the SF-36 Health Survey Mental Component Summary (MCS), a dimensional measure of general mental health. Logistic and linear regression were used to assess the interaction between past mental health care (a proxy for past mental health) and a 30-item combat exposure scale. Results: Past mental health care and combat were strongly and independently associated with both primary outcomes, but no statistically significant interaction was seen for either. Discussion: The effects of past mental health and combat on post-deployment mental health are simply additive. Those with past mental health problems are not, on average, more vulnerable to the effects of combat. The variability in outcome at the individual level and the treatability of common mental disorders argue for an individualized approach to fitness-for-duty decisions.

Abstract Background Intimate partner violence (IPV) is prevalent and is associated with a broad range of adverse consequences. In military organizations, IPV may have special implications, such as the potential of service-related mental disorders to trigger IPV. However, the Canadian Armed Forces (CAF) have limited data to guide their prevention and control efforts. Methods Self-reported IPV perpetration, victimization, and their correlates were assessed on a cross-sectional survey of a stratified random sample of currently-serving Canadian Regular Forces personnel (N = 2157). The four primary outcomes were perpetration or victimization of any physical and/or sexual or emotional and/or financial IPV over the lifespan of the current relationship. Results Among the 81% of the population in a current relationship, perpetration of any physical and/or sexual IPV was reported in 9%; victimization was reported in 15%. Any emotional and/or financial abuse was reported by 19% (perpetration) and 22% (victimization). Less physically injurious forms of abuse predominated. Logistic regression modelling showed that relationship dissatisfaction was independently associated with all four outcomes (OR range = 2.3 to 3.7). Probable depression was associated with all outcomes except physical and/or sexual IPV victimization (OR range = 2.5 – 2.7). PTSD symptoms were only associated with physical and/or sexual IPV perpetration (OR = 3.2, CI = 1.4 to 7.9). High-risk drinking was associated with emotional and/or financial abuse. Risk of IPV was lowest in those who had recent deployment experience; remote deployment experience (vs. never having deployed) was an independent risk factor for all IPV outcomes (OR range = 2.0 – 3.4). Conclusions IPV affects an important minority of military families; less severe cases predominate. Mental disorders, high-risk drinking, relationship dissatisfaction, and remote deployment were independently associated with abuse outcomes. The primary limitations of this analysis are its use of self-report data from military personnel (not their intimate partners) and the cross-sectional nature of the survey. Prevention efforts in the CAF need to target the full spectrum of IPV. Mental disorders, high-risk drinking, and relationship dissatisfaction are potential targets for risk reduction. Additional research is needed to understand the association of remote deployment with IPV.

Introduction: The Canadian Armed Forces (CAF) have made access to mental health care a priority. Access to care is typically conceptualized as in-person interactions with health care providers; however, it can also include virtual health care services. Virtual health care is health services delivered through an Internet platform. Internet-based interventions are promising for increasing mental health care access among CAF personnel; however, increased reliance on Internet technology for service provision may create disparate access. Accordingly, a recent nationally representative sample of CAF Regular Forces personnel was examined with the following aims: (1) provide estimates of different types of Internet use for mental health-related problems and contrast such estimates with usage rates for other forms of professional and paraprofessional care; (2) examine the relationship between Internet use for mental health-related problems, professional mental health service use, and perceived need for care; and (3) identify individual predictors of Internet use for mental health-related problems. Methods: Prevalence estimates were computed for all variables of interest and multivariate logistic regression analyses served to identify predictors of Internet use. Results: The results indicate that the Internet is more readily accessed for mental health care than other forms of paraprofessional services but remains less commonly accessed than in-person mental health care providers. Results also indicate that the Internet is primarily used to obtain information about symptoms or where to get help. Discussion: Findings suggest few individual barriers exist for accessing the Internet and Internet-based technologies may be a viable alternative for increasing access to mental health resources among CAF personnel and their families.

OBJECTIVE: We examined the overlap between mood and anxiety disorders and psychological distress and their associations with functional status in Canadian Armed Forces (CAF) personnel. METHOD: Data on Regular Forces personnel (N = 6700) were derived from the 2013 Canadian Forces Mental Health Survey, a nationally representative survey of the CAF personnel. Current psychological distress was assessed using the Kessler K10 scale. Past-month mood and anxiety disorders were assessed using the World Health Organization World Mental Health Composite Diagnostic Interview. RESULTS: The prevalence of psychological distress was the same as that of any past-month mood or anxiety disorder (7.1% for each). A total of 3.8% had both distress and past-month mood or anxiety disorder, 3.3% had past-month disorder without psychological distress, while another 3.3% had psychological distress in the absence of a past-month mood or anxiety disorder. After adjusting for age, sex, marital, education, income, language, element, rank, and alcohol use disorder, individuals with both psychological distress and past-month mood and anxiety disorders exhibited the highest levels of disability, days out of role, and work absenteeism relative to those with neither mental disorders nor psychological distress. Relative to individuals with both disorder and distress, those who endured distress in the absence of mental disorder exhibited lower, but meaningful, levels of disability compared with those with neither disorder nor distress. CONCLUSIONS: Disability is most severe among CAF personnel with both distress and past-month mood and anxiety disorders. Nevertheless, distress in the absence of disorder is prevalent and is associated with meaningful levels of disability.

Abstract Background Up to 20% of US military personnel deployed to Iraq or Afghanistan experience mild traumatic brain injury (mTBI) while deployed; up to one-third will experience persistent post-concussive symptoms (PCS). The objective of this study was to examine the epidemiology of deployment-related mTBI and its relationship to PCS and mental health problems (MHPs) in Canadian Armed Forces (CAF) personnel. Methods Participants were 16153 personnel who underwent post-deployment screening (median =136 days after return) following deployment in support of the mission in Afghanistan from 2009 – 2012. The screening questionnaire assessed mTBI and other injuries while deployed, using the Brief Traumatic Brain Injury Screening Tool. Current MHPs and PCS were assessed using items from the Patient Health Questionnaire, the Patient Checklist for PTSD, and the Cognitive Failures Questionnaire. Log-binomial regression explored the association of mTBI, other injuries, and MHPs with PCS, using the presence of 3 or more of 7 PCS as the outcome. Results are expressed as adjusted prevalence ratios (PR). Results mTBI while deployed was reported in 843 respondents (5.2%). Less severe forms of mTBI (associated only with having been dazed or confused or having "seen stars") predominated. Blast was reported as a mechanism of injury in half of those with mTBI. Multiple PCS were present in 21% of those with less severe forms of mTBI and in 27% of those with more severe forms of mTBI (i.e., mTBI associated with loss of consciousness or post-traumatic amnesia). After adjustment for confounding, mTBI had no statistically significant association with PCS relative to non-TBI injury. In contrast, MHPs had a strong association with reporting 3 or more PCS (adjusted prevalence ratio (PR) =7.77). Conclusion Deployment-related mTBI prevalence was lower than in many US reports; most of those who had had mTBI were free of multiple PCS. PCS was strongly associated with MHPs but not with mTBI. Careful assessment of MHPs is essential in personnel with a history of combat-related mTBI and PCS.

Introduction: The Canadian Armed Forces (CAF) mental health training and education (MHTE) program seeks primarily to enhance well-being and performance through enhancement of resilience and mental health literacy. Wider dissemination of its MHTE program is a strategic priority for the CAF, but the extent of MHTE exposure and risk factors for low exposure are unknown. The objectives of this paper are (1) to describe the extent of exposure to MHTE, and (2) to explore factors associated with less exposure. Methods: The 2013 CAF Mental Health Survey ( n = 8,165) assessed exposure to MHTE in six specific training contexts. Modified Poisson regression and ordered logistic regression explored risk factors for lack of any MHTE exposure and for fewer total training hours, respectively. Results: 69.7% of respondents had exposure to MHTE over the previous 5 years. The median number of training hours in those with at least some exposure was 11 (inter-quartile range 5 to 24). Similar risk factors were identified for no MHTE exposure and for fewer MHTE hours, though the models had relatively poor predictive value. Discussion: While most CAF personnel have had at least some exposure to MHTE, the extent of exposure varies substantially, and a significant fraction have had no exposure at all. While targeting groups with low exposure identified in this analysis makes sense, the substantial variability of exposure within those groups demonstrates the need for administrative data on training exposure at the individual level on an ongoing basis.

BACKGROUND: Mental disorders constitute a significant public health problem worldwide. Ensuring that those who need mental health services access them in an appropriate and timely manner is thus an important public health priority. We used data from 4 cross-sectional, nationally representative population health surveys that employed nearly identical methods to compare MHSU trends in the Canadian military versus comparable civilians. METHOD: The surveys were all conducted by Statistics Canada, approximately a decade apart (Military-2002, Military-2013, Civilian-2002, and Civilian-2012). The sample size for the pooled data across the surveys was 35,984. Comparisons across the 4 surveys were adjusted for differences in need in the 2 populations at the 2 time points. RESULTS: Our findings suggested that first, in the Canadian military, there was a clear and consistent pattern of improvement (i.e., increase) in MHSU over the past decade across a variety of provider types. The magnitudes of the changes were large, representing an absolute increase of 7.15% in those seeking any professional care, corresponding to an 84% relative increase. Second, in comparable Canadian civilians, MHSU remained either unchanged or increased only slightly. Third, the increases in MHSU over time were consistently greater in the military than in the comparable civilian sample. CONCLUSIONS: Our findings point to advantages with respect to MHSU of the military mental health system over the civilian system in Canada; these advantages have widened substantially over time. These findings speak strongly to the potential impact of analogous changes in other health systems, both military and civilian.

Introduction: The characteristics of one's social environment, including one's family or household composition, are recognized determinants of health and well-being. At the same time, a great deal of research has demonstrated the positive effect of social support on mental health in military populations. Methods: The aim of the current study was to provide a description of the various family/household characteristics of a sample of 6,696 CAF Regular Force members, including their marital status, living arrangement, and number of dependants, as well as the relationships of these characteristics with positive mental health (PMH). In addition, this study explored the role of social support as a possible mediating mechanism in these relationships. Results: Without accounting for levels of social support, it was found that service members who were married or in a common-law relationship demonstrated higher PMH, while those who were separated or divorced demonstrated lower PMH compared to their single counterparts. PMH also differed by living arrangement, with higher levels reported by service members living with others. Further analysis revealed that greater PMH reported by service members who were married or in a common-law relationship or who live with others could be attributed to their higher levels of social support. Discussion: Taken together, results emphasize the importance of social support as one of the mechanisms involved in the relationship between PMH and family/household composition. Given the limited research available on the combined effect of a variety of family/household factors, results of this work fill an important gap in the literature on the understanding of more complex relationships among these factors.

BACKGROUND: Major depression is prevalent, impactful, and treatable in military populations, but not all depressed personnel seek professional care in a given year. Care-seeking patterns (including the use of primary vs. specialty care) and factors associated with the likelihood of mental health service utilization in depressed military personnel are poorly understood. METHODS: Our sample included 520 Regular Force respondents to the 2013 Canadian Forces Mental Health Survey. All study participants had past-year major depression. Subjects reported whether they had spoken about their mental health with at least one health professional in the past 12 months. We used multivariate Poisson regression to explore factors associated with past-year mental health service use. RESULTS: Three-quarters of Canadian military personnel with past-year depression had sought mental health care in the previous 12 months. Among care-seeking personnel, 70% had seen a psychologist or psychiatrist, while 5% had exclusively received care from a primary care physician. Belief in the effectiveness of mental health care was the factor most strongly associated with care seeking. Female gender, functional impairments, and psychiatric comorbidities were also associated with care seeking. Surprisingly, stigma perceptions had no independent association with care seeking. CONCLUSIONS: The proportion of depressed Canadian Armed Forces personnel who seek professional care and who access specialty mental health care is higher than in most other populations. However, an important minority of patients are not accessing health services. Efforts to further increase mental health service utilization in the Canadian military should continue to target beliefs about the effectiveness of mental health care.

OBJECTIVE: This study sought to examine differences in sociodemographic risk factors, comorbid mental conditions, clinical presentations, and functional impairments associated with past-year generalized anxiety disorder (GAD) between Canadian Armed Forces (CAF) Regular Force personnel and the Canadian general population (CGP). METHOD: Data were from 2 nationally representative surveys collected by Statistics Canada: 1) the Canadian Community Health Survey on Mental Health, collected in 2012 (N = 25,113; response rate = 68.9%); and 2) the Canadian Forces Mental Health Survey, collected in 2013 (N = 8,161; response rate = 79.8%). RESULTS: The prevalence of lifetime and past-year GAD was significantly higher in the CAF (12.1% and 4.7%) than in the CGP (9.5% and 3.0%). Comorbid mental disorders were strongly associated with GAD in both populations. Although the content area of worry and the GAD symptoms endorsed were similar, CAF personnel were significantly more likely to endorse specific types of worries (i.e., success at school/work, social life, mental health, being away from home or loved ones, and war or revolution) and specific symptoms of GAD (i.e., restless, keyed up, or on edge and more irritable than usual) than civilians, after adjusting for sociodemographic covariates and comorbid mental disorders. CAF personnel with past-year GAD reported significantly higher functional impairment at home than civilians with past-year GAD. CONCLUSION: GAD is a substantial public health concern associated with significant impairment and disability in both military and civilian populations. GAD in military and civilian populations shows similarities and differences: Key similarities include its extensive comorbidity and significant functional impairment, whereas key differences include the focus of worries and symptom profile.