Critique of a Research Study

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MILITARY MEDICINE, 180, 10:1041, 2015

Mental Health Treatment Among Soldiers With Current Mental Disorders in the Army Study to Assess Risk and Resilience

in Service Members (Army STARRS)

CAPT Lisa J. Colpe, USPHS*; James A. Naifeh, PhD†; Pablo A. Aliaga, MPH†; Nancy A. Sampson, BA‡; Steven G. Heeringa, PhD§; Murray B. Stein, MD, MPH∥¶;

Robert J. Ursano, MD†; Carol S. Fullerton, PhD†; Matthew K. Nock, PhD**; Michael L. Schoenbaum, PhD*; Alan M. Zaslavsky, PhD‡; Ronald C. Kessler, PhD‡;

On behalf of the Army STARRS Collaborators

ABSTRACT A representative sample of 5,428 nondeployed Regular Army soldiers completed a self-administered questionnaire (SAQ) and consented to linking SAQ data with administrative records as part of the Army Study to Assess Risk and Resilience in Service members. The SAQ included information about prevalence and treatment of mental disorders among respondents with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edi- tion (DSM-IV) internalizing (anxiety, mood) and externalizing (disruptive behavior, substance) disorders. 21.3% of soldiers with any current disorder reported current treatment. Seven significant predictors of being in treatment were identified. Four of these 7 were indicators of psychopathology (bipolar disorder, panic disorder, post-traumatic stress disorder, 8+ months duration of disorder). Two were sociodemographics (history of marriage, not being non- Hispanic Black). The final predictor was history of deployment. Treatment rates varied between 4.7 and 71.5% depend- ing on how many positive predictors the soldier had. The vast majority of soldiers had a low number of these predictors. These results document that most nondeployed soldiers with mental disorders are not in treatment and that untreated sol- diers are not concentrated in a particular segment of the population that might be targeted for special outreach efforts. Analysis of modifiable barriers to treatment is needed to help strengthen outreach efforts.

BACKGROUND The U.S. Army suicide rate doubled between 2004–2005 and 2008–2009 and reached an all-time high of 27.9/100,000 person-years in 2012.1 In response, the Army implemented numerous programs, including mandatory suicide prevention training,2 psychological resilience training,3 collaborative

care to help primary care providers recognize and treat com- mon mental disorders,4 telehealth technologies,5 and embed- ding behavioral health providers in brigade combat teams to increase direct treatment access.6 Many of these responses were made in recognition that mental disorders are fundamen- tal causes of suicide,7 that the prolonged military operations

*Office of Clinical and Population Epidemiology Research, Division of Services and Intervention Research, National Institute of Mental Health, Room 7148, Mailstop 9635, 6001 Executive Boulevard, Bethesda, MD 20892.

†Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.

‡Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115.

§Institute for Social Research, University of Michigan, P.O. Box 1248, 426 Thompson Street Ann Arbor, MI 48106-1248.

∥Departments of Psychiatry and Family and Preventive Medicine, Uni-

∥Departments of Psychiatry and Family and Preventive Medicine, University versity of California San Diego, 8939 Villa La Jolla Drive, Suite 200, La Jolla, CA 92037.

¶VA San Diego Healthcare System, 8810 Rio San Diego Drive, San Diego, CA 92108.

**Department of Psychology, Harvard University, William James Hall 1220, 33 Kirkland Street, Cambridge, MA 02138.

The contents are solely the responsibility of the authors and do not necessarily represent the views of the Department of Health and Human Services, National Institute of Mental Health, the Department of the Army, or the Department of Defense.

doi: 10.7205/MILMED-D-14-00686

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in Iraq and Afghanistan have led to high rates of mental dis- orders among soldiers,8 and evidence that many soldiers are reluctant to seek treatment for fear of stigmatization.9–11

Beginning in 2006, the Department of Defense (DoD) man- dated enhanced postdeployment screening to identify soldiers returning from deployment who had behavioral health prob- lems.12–14 However, validation studies find substantial under- reporting in postdeployment screening,13,15 although the narrow focus of these surveys makes it impossible to estimate the extent or correlates of untreated mental disorders.

The current report presents new data on the extent of untreated mental disorders among soldiers based on the Army Study to Assess Risk and Resilience in Service members (Army STARRS; www.armystarrs.org), a large, multicom- ponent epidemiological–neurobiological study of risk and resil- ience factors for suicide among U.S. Army soldiers.16 One component of Army STARRS is a deidentified survey carried out in a representative sample of nondeployed Regular Army soldiers exclusive of those in Basic Combat Training to assess prevalence and correlates of common mental disor- ders. A previous report based on this All Army Study (AAS) documented that soldiers have a substantially higher rate of current mental disorders than sociodemographically matched civilians.17 However, no treatment information was presented in that report. The current report presents such data. We focus on patterns and basic sociodemographic and Army career predictors of current treatment among AAS respon- dents with current mental disorders.

METHODS

Sample Data come from the Q2–4 2011 AAS. Each of these three quarterly AAS replicates consisted surveys carried out in a stratified (by Army Command location) probability sample of units selected without replacement with probabilities pro- portional to authorized unit strength, excluding units of fewer than 30 soldiers (less than 2% of Army personnel) and those deployed to a combat theater. All targeted unit per- sonnel were given a duty assignment to attend an informed consent presentation on study purposes, confidentiality, and the voluntary nature of participation before requesting written informed consent for a group self-administered questionnaire (SAQ). SAQ respondents were additionally asked to consent to link Army/DoD administrative records to their SAQs. Iden- tifying information was collected from consenting respondents and kept in a separate secure file. These recruitment, consent, and data protection procedures were approved by the Human Subjects Committees of the Uniformed Services University of the Health Sciences for the Henry M. Jackson Foundation (the primary grantee) and the Institute for Social Research at the University of Michigan (the organization implementing Army STARRS surveys).

The 5,428 respondents considered here are the Regular Army Q2–4 2011 AAS respondents who completed the

SAQ and provided consent for administrative data linkage. Activated Army Reserve and National Guard respondents were excluded because of small numbers. Although, as noted above, all unit members were given a duty assignment to attend the informed consent session, 23.5% were absent because of conflicting assignments (e.g., shift work assign- ments of military medical or police staff, previously sched- uled training assignments). However, 96.0% of attendees consented to the survey, 98.0% of consenters completed the survey, and 69.2% of completers consented to administrative record linkage. Most incomplete surveys were due to logisti- cal complications (e.g., units either arriving late to survey ses- sions or having to leave early), although some respondents needed more than the allotted 90 minutes to complete the sur- vey. The survey completion–successful–linkage “cooperation” rate was 65.1% (0.96 × 0.98 × 0.692) and the “response” rate was 49.8% ([1–0.235] × 0.651) based on the American Asso- ciation of Public Opinion Research (2015) COOP1 and RR1 calculation methods. Two weights were used to adjust data for discrepancies between sample and population.18 Weight 1 (W1) adjusted for discrepancies in survey responses between the survey completers with and without record linkage. Weight 2 (W2) adjusted for discrepancies between multivari- ate administrative record profiles of weighted (W1) survey completers with record linkage and the target population. Doubly weighted (W1 × W2) data were used in analyses. A more detailed description of AAS weighting is presented elsewhere.19

Measures

Diagnostic Assessment

Respondents completed the Composite International Diag- nostic Interview screening scales (CIDI-SC)20,21 and a modi- fied version of the post-traumatic stress disorder (PTSD) Checklist22 to assess selected 30-day DSM-IV mental disor- ders. Internalizing disorders included major depressive disor- der (MDD), bipolar I–II or subthreshold bipolar disorder (BPD), generalized anxiety disorder (GAD), panic disorder (PD), and PTSD. Externalizing disorders included attention- deficit/hyperactivity disorder (ADHD), intermittent explosive disorder (IED), and substance use disorder (SUD; alcohol or drug abuse or dependence). The SUD assessment included both illicit drugs and misused prescription drugs (the latter defined as use “either without a doctor’s prescription, more than prescribed, or to get high, buzzed, or numbed out”) based on evidence that prescription drug misuse is consider- ably more common than illicit drug use in today’s Army.23

All disorders other than MDD were assessed without DSM- IV diagnostic hierarchy or organic exclusion rules. The CIDI- SC and PTSD Checklist both have good concordance with independent clinical diagnoses in the AAS.21 Duration of cur- rent disorder episodes was determined by asking respondents how many months in the past year they had problems with each current disorder.

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Severity

Severity of health-related role impairment in the 30 days before interview was assessed with a revised Sheehan Dis- ability Scale24 that asked respondents how much problems with their physical health, mental health, or alcohol–drug use interfered with their functioning in each of four role domains on a 0 to 10 Visual Analog Scale labeled no inter- ference (0), mild (1–3), moderate (4–6), severe (7–9), and very severe interference (10). The four role domains were “home management; quality of work on duty; social life”; and “close personal relationships.” Severe role impairment was defined as a 7 to 10 rating in one or more domains.

Treatment

A11 AAS respondents who met criteria for any of the above disorders were asked whether at any time in the past 12 months they received “medication, psychological counseling, or spiri- tual counseling” for “problems with stress, emotions, behav- ior, family problems, or problems with alcohol or drugs”

from each of 11 different kinds of treatment providers. A follow-up question asked “Are you still in treatment or have you stopped treatment?” The analyses reported here focused on respondents in “current” treatment vs. all others (i.e., combining those previously in treatment earlier in the year with those who had no past-year treatment).

Consistent with civilian studies,25–27 reported treatment was grouped into four sectors. “Mental health specialty” treatment was defined as treatment by a mental health pro- fessional in any of three settings: a military facility or a civil- ian facility where the soldier was referred by the military health system; a Veterans Administration facility; or a civilian facility outside any care received from the military health sys- tem. A “mental health professional” was defined as “a psychi- atrist, psychologist, drug or alcohol counselor, mental health counselor, social worker, or marriage and family counselor” seen either in one-on-one sessions, group sessions, or tele- phone sessions.” Treatment in the “general medical sector” was defined as treatment either by a military medic or a gen- eral medical doctor, nurse, or physician’s assistant in any of

TABLE I. Prevalence of Current Mental Health Treatment by Sector Among Soldiers With a 30-Day DSM-IV Mental Disorder in the Army STARRS Q2–4 2011 AAS (n = 1,521)

Mental Disorders na

Type of Current Mental Health Treatment

Population Prevalence

Any Current Treatment

Mental Health Specialtyb

General Medicalc

Human Servicesd Self-helpe

% f (SE) %g (SE) %g (SE) %g (SE) %g (SE) %g (SE)

I. Internalizing Disorders MDD 295 4.8 (0.4) 26.6 (2.0) 19.4 (1.6) 17.1 (2.0) 3.4 (1.2) 3.0 (1.0) BPD 213 3.3 (0.4) 41.3 (3.9) 37.4 (3.7) 25.0 (2.9) 6.7 (1.6) 11.4 (1.9) GAD 351 5.7 (0.4) 38.8 (2.8) 31.2 (2.7) 22.9 (3.7) 5.8 (1.5) 5.3 (1.2) PD 219 3.8 (0.3) 46.9 (5.1) 37.7 (5.8) 34.5 (5.2) 5.4 (1.7) 6.9 (2.1) PTSD 498 8.6 (0.7) 39.1 (1.7) 30.7 (1.9) 22.7 (2.4) 5.5 (1.5) 5.9 (0.9) Any Internalizing Disorder 901 15.0 (0.7) 30.1 (2.0) 23.9 (1.7) 18.0 (1.7) 4.2 (0.9) 4.0 (0.5)

II. Externalizing Disorders ADHD 381 7.0 (0.6) 29.8 (2.5) 24.8 (2.2) 17.0 (2.1) 2.6 (0.9) 3.6 (1.4) IED 753 11.2 (0.7) 20.4 (2.9) 15.6 (2.3) 11.5 (2.2) 3.7 (1.2) 3.3 (1.1) SUD 284 0.5 (0.4) 15.4 (1.8) 9.7 (2.1) 8.3 (1.3) 1.7 (1.0) 3.1 (1.2) Any Externalizing Disorder 1,128 18.4 (0.8) 20.6 (2.2) 15.5 (1.8) 11.5 (1.4) 3.1 (0.8) 2.8 (0.7)

III. Total (Internalizing and Externalizing) Any of the Above Disorders 1,521 25.1 (0.8) 21.3 (1.8) 16.2 (1.4) 12.0 (1.1) 3.1 (0.6) 3.0 (0.5) Number of Disorders 1 838 14.0 (0.8) 12.6 (2.8) 8.5 (2.2) 6.4 (1.4) 2.0 (0.6) 1.1 (0.5) 2 292 4.4 (0.4) 17.4 (3.0) 14.5 (2.6) 11.9 (2.5) 1.6 (0.4) 4.0 (1.5) 3+ 391 6.7 (0.7) 42.0 (2.0) 33.7 (1.9) 23.5 (2.8) 6.2 (1.6) 6.3 (1.1)

χ22 45.8* 40.3* 32.9* 9.8* 16.5*

*Significant association between number of disorders and probability of treatment based on a 0.05-level 2-sided test. aUnweighted number of AAS respon- dents within each row. bMental health specialty defined as treatment by a psychiatrist, psychologist, drug or alcohol counselor, mental health counselor or social worker, or marriage and family counselor. cGeneral medical defined as treatment either by a military medic or by a general medical doctor, nurse, or physician’s assistant. dHuman services defined as counseling by a military chaplain or by a civilian minister, priest, rabbi, or other spiritual advisor. eSelf- help defined as participating in a self-help or support group (without a mental health professional running the group) either at a military facility or associated with the military, or in a civilian self-help or support group. fPopulation prevalence percentages are doubly weighted (Weight 1 × Weight 2) to adjust for discrepancies between the sample and the target Army population. Weight 1 adjusts for discrepancies in survey responses among survey completers with and without administrative record linkage. Weight 2 adjusts for discrepancies between multivariate administrative record profiles of weighted survey com- pleters with record linkage (Weight 1) and the target population. gWeighted “row” percentages denoting the proportion of AAS respondents within each row who are currently receiving each type of mental health treatment.

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three settings: a military facility or civilian facility where the soldier was referred by the military health system; a Veterans Administration facility; or a civilian facility outside any care received from the military health system. Treatment in the “human services sector” was defined as counseling by a mili- tary chaplain or civilian spiritual advisor. Treatment in the “self-help sector,” was classified as participating in a self-help or support group either at a military facility or associated with the military or in civilian setting. A “self-help or support group” was defined as “a group for people with emotional, family, or substance problems run by the people themselves without a mental health professional running the group (emphasis in original).”

Sociodemographic and Army Career Variables

The sociodemographic variables considered here include respondent sex, race/ethnicity (non-Hispanic Black, non- Hispanic White, Hispanic, other), and marital status (currently, previously, and never married). The Army career variables include rank (distinguishing lower-ranking [E1–E4] and higher- ranking [E5–E9] enlisted soldiers from officers [W1–W5/ O1–O9]), number of deployments to a combat theater (0, 1, 2, 3+), and Army Command assignment.

Analysis Procedures AAS data were weighted to adjust for differences in proba- bilities of selection, differential nonresponse, and residual differences between sample and population on population characteristics obtained from Army and DoD administrative data sources. Treatment patterns were examined by comput- ing proportions of soldiers with individual disorders in cur- rent treatment. Logistic regression28 analysis was used to study sociodemographic and Army career correlates of treatment among respondents with one or more current disorders. SEs were estimated using the Taylor series method implemented in SUDAAN Version 8.0.129 to adjust for weighting and clustering. Multivariate significance tests were made with Wald χ2 tests based on the Taylor series method. Statistical significance was evaluated using two-sided design-based tests and the 0.05 level of significance.

RESULTS

Treatment Rates Among Soldiers With Mental Disorders Thirty percent (30.1%) of soldiers with an internalizing dis- order, 20.6% with an externalizing disorder, and 21.3% with any disorder reported current treatment (Table I). The

TABLE II. Proportions of Cases Treated in Each Treatment Sector Among Soldiers With a 30-Day DSM-IV Mental Disorder Who Are Currently in Treatment in the Army STARRS Q2–4 2011 AAS (n = 324)

Mental Disorders na

Type of Current Mental Health Treatment

Specialtyb General Medicalc Human Servicesd Self-helpe

% f (SE) % f (SE) % f (SE) % f (SE)

I. Internalizing Disorders MDD 88 73.0 (4.7) 64.2 (5.7) 12.8 (3.8) 11.4 (3.4) BPD 82 90.6 (2.4) 60.5 (3.5) 16.2 (3.5) 27.6 (3.6) GAD 138 80.5 (3.6) 59.1 (6.2) 15.0 (3.5) 13.6 (2.8) PD 91 80.5 (4.5) 73.5 (5.2) 11.6 (3.0) 14.8 (3.8) PTSD 183 78.5 (3.0) 58.1 (5.0) 14.0 (3.1) 15.0 (1.8) Any Internalizing Disorder 261 79.6 (2.6) 59.7 (3.6) 13.8 (2.5) 13.2 (1.6)

II. Externalizing Disorders ADHD 119 83.2 (2.8) 57.0 (5.3) 8.7 (2.7) 12.1 (3.9) IED 150 76.6 (3.6) 56.2 (6.2) 18.2 (3.9) 16.2 (3.7) SUD 55 62.7 (6.8) 54.1 (5.6) 11.1 (5.7) 20.0 (7.2) Any Externalizing Disorder 236 75.1 (2.7) 55.8 (4.3) 15.0 (3.0) 13.6 (2.6)

III. Total (Internalizing and Externalizing) Any of the Above Disorders 324 76.4 (2.1) 56.2 (3.5) 14.4 (2.2) 13.9 (1.7) Number of Disorders 1 105 67.2 (3.1) 51.2 (5.4) 15.8 (4.0) 8.4 (2.0) 2 60 83.3 (3.3) 68.6 (7.9) 9.5 (2.1) 22.8 (4.2) 3+ 159 80.3 (3.2) 56.0 (4.5) 14.9 (4.0) 14.9 (2.6)

χ22 9.4* 2.7 1.0 4.8

*Significant association between number of disorders and proportional treatment in the sector based on a 0.05-level 2-sided test. aUnweighted number of AAS respondents within each row who are currently receiving any mental health treatment. bMental health specialty defined as treatment by a psychiatrist, psychologist, drug or alcohol counselor, mental health counselor or social worker, or marriage and family counselor. cGeneral medical defined as treatment either by a military medic or by a general medical doctor, nurse, or physician’s assistant. dHuman services defined as counseling by a military chaplain or by a civilian minister, priest, rabbi, or other spiritual advisor. eSelf-help defined as participating in a self-help or support group (without a mental health pro- fessional running the group) either at a military facility or associated with the military, or in a civilian self-help or support group. fWeighted “row” percent- ages denoting the proportion of AAS respondents within each row who are currently receiving each type of mental health treatment.

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treatment rate among soldiers with internalizing disorders was lowest among those with MDD (26.6%) and in the range 38.8 to 41.3% among those with other internalizing disorders. The treatment rate among soldiers with externalizing disorders was lowest among those with SUD (15.4%), higher for IED (20.4%), and highest for ADHD (29.8%). A significant dose– response relationship was found between number of disorders and treatment, with 12.6% of soldiers having 1 disorder, 17.4% of those having 2 disorders, and 42.0% of those hav- ing 3+ disorders in treatment (χ22 = 45.8, p < 0.001). Broadly similar between-disorder differences in treatment patterns were found in each treatment sector.

Proportional Treatment Across Service Sectors Three-fourths (76.4%) of soldiers in current treatment were treated in the mental health specialty sector, 56.2% in the general medical sector, 14.4% in the human services sector, and 13.9% in the self-help sector (Table II). The sum of these four proportions is 160%, which means that a sizable proportion of soldiers received treatment in multiple sectors. The mental health specialty sector was the dominant sector

for each disorder. Proportional treatment in the specialty sec- tor did not vary markedly for internalizing vs. externalizing disorders (79.6% vs. 75.1%), but varied across individual disorders from a high of 90.6% for BPD to a low of 62.7% for SUD. As with the mental health specialty sector, propor- tional treatment in the general medical sector was similar among soldiers with internalizing (59.7%) and externalizing (55.8%) disorders but varied across individual disorders from a high of 73.5% for PD to a low of 54.1% for SUD. The same general pattern held in the human services and self-help sectors, with comparable proportions of treatment of internal- izing and externalizing disorders (13.8% vs. 15.0% in the human services sector; 13.2% vs. 13.6% in the self-help sec- tor) but more substantial variation at the disorder level (from a high of 18.2% for IED to a low of 8.7% for ADHD in the human services sector; from a high of 27.6% for BPD to a low of 12.1% for ADHD in the self-help sector).

Effects of Disorder Duration Two-thirds (64.7%) of soldiers with current disorders reported that at least one of their disorders had a duration of at least

TABLE III. Prevalence of Current Mental Health Treatment by Duration of Disorder Among Soldiers With a 30-Day DSM-IV Mental Disorder in the Army STARRS Q2–4 2011 AAS (n = 1,503)

Mental Disorders

Duration of Mental Disorder

χ22

8–12 Months 5–7 Months 1–4 Months

na %b (SE)

Any Current Treatment

na %b (SE)

Any Current Treatment

na %b (SE)

Any Current Treatment

%c (SE) %c (SE) %c (SE)

I. Internalizing Disorders MDD 143 50.5 (5.2) 37.1 (3.1) 75 26.4 (2.9) 23.2 (7.5) 60 23.2 (4.0) 10.3 (1.4) 7.7* BPD 33 21.0 (2.1) 49.2 (2.6) 45 17.4 (1.7) 29.8 (3.8) 120 61.6 (2.8) 41.5 (4.7) 3.1 GAD 215 67.5 (4.0) 41.8 (2.7) 69 15.0 (3.0) 29.7 (4.1) 62 17.5 (2.7) 38.1 (9.7) 1.9 PD 91 43.3 (4.8) 61.9 (4.6) 57 26.5 (3.2) 47.9 (2.0) 67 30.2 (5.1) 22.5 (5.4) 21.2* PTSD 143 40.5 (1.2) 47.7 (4.5) 81 17.4 (1.3) 39.4 (5.7) 170 42.1 (2.0) 21.1 (4.1) 15.6* Any Internalizing Disorder 512 59.3 (2.2) 38.8 (2.8) 188 19.9 (1.8) 21.0 (3.6) 182 20.8 (1.8) 15.5 (2.9) 30.8*

II. Externalizing Disorders ADHD 381 100.0 — 29.8 (2.5) — — — — — — — — — — — IED 261 38.6 (2.0) 23.7 (5.1) 155 19.6 (1.8) 19.6 (3.1) 316 41.8 (2.5) 18.1 (4.3) 1.1 SUD 55 16.8 (1.8) 30.4 (5.3) 46 20.2 (3.2) 12.7 (1.0) 165 63.0 (4.0) 13.7 (2.1) 3.4 Any Externalizing Disorder 612 60.1 (2.4) 26.6 (2.7) 143 10.3 (1.1) 11.7 (1.7) 347 29.5 (1.8) 13.1 (2.6) 24.7*

III. Total (Internalizing and Externalizing) Any of the above disorders 921 64.7 (2.3) 26.4 (2.3) 238 12.5 (1.3) 16.4 (1.9) 344 22.8 (1.5) 10.7 (2.8) 24.8* Number of disorders 1 354 47.2 (2.5) 15.3 (4.2) 168 17.3 (1.5) 14.8 (1.9) 298 35.5 (2.6) 9.0 (3.0) 4.0* 2 205 72.6 (1.7) 16.6 (2.6) 48 10.5 (1.8) 22.7 (4.9) 39 16.9 (1.7) 17.6 (8.2) 0.6 3+ 362 95.0 (1.5) 42.8 (1.9) 22 4.1 (1.4) 19.3 (1.9) 7 1.0 (0.5) 61.1 — 6.1*

*Significant association between duration of disorder and probability of treatment based on a 0.05-level 2-sided test. aUnweighted number of AAS respon- dents within each cell corresponding to the row heading and specified duration of disorder. 18 respondents did not report duration of disorder and are omitted from the analysis. Consequently, the sums of the 3 n’s in each row do not match all n’s reported in Table I under I. Internalizing disorders: MDD (n = 278 of 295), BPD (198 of 213), GAD (346 of 351), PD (215 of 219), PTSD (394 of 498), any internalizing disorder (882 of 901); II. Externalizing disorders: ADHD (381 of 381), IED (732 of 753), SUD (266 of 284), any externalizing disorder (1,102 of 1,128); and III. Total (internalizing and exter- nalizing): any disorder (1,503 of 1,521), 1 disorder (820 of 838), 2 disorders (292 of 292), 3+ disorders (391 of 391). bWeighted “row” percentages denoting the proportion of AAS respondents within each row reporting a disorder of the specified duration. cWeighted “row” percentages denoting the proportion of AAS respondents within each row and specified duration of disorder who are currently receiving any type of mental health treatment.

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8 months (Table III). This proportion increased with number of disorders (from 47.2% for soldiers with 1 disorder to 95.0% for soldiers with 3+ disorders). Consistently signifi- cant monotonic associations were found between probability of treatment and disorder duration, from a high treatment rate of 26.4% among soldiers with a disorder of long dura- tion (8+ months) to a low of 10.7% among soldiers with a disorder of short duration of 1 to 4 months (χ22 = 24.8, p < 0.001) (Table III). Similar patterns were found separately for internalizing and externalizing disorders, with treatment rates by duration in the range 15.5 to 38.8% (χ22 = 30.8, p < 0.001) for internalizing and 13.1 to 26.6% (χ22 = 24.7, p < 0.001) for externalizing. A dose–response relationship between treatment and number of disorders continued to exist after adjusting for duration, leading to treatment rates ranging from a high of 42.8% among soldiers with 3+ disorders and long duration to a low of 9.0% among soldiers with 1 disorder and short duration.

Effects of Severity of Role Impairment Consistently positive associations were found across disor- ders between current severe role impairment and current treatment. Among all soldiers with current disorders, 32.0% of those with severe role impairment were in treatment compared to 16.4% of those without severe role impair- ment (χ21 = 28.1, p < 0.001) (Table IV). Comparable pat-

terns were found among soldiers with internalizing (37.0% vs. 25.2% in treatment; χ21 = 7.7, p = 0.005) and externaliz- ing (33.0% vs. 15.0% in treatment; χ21 = 26.3, p < 0.001) disorders. The dose–response relationship between number of disorders and treatment persisted both in the presence and absence of severe role impairment, although the relationship was weaker among soldiers with severe role impairment. Among soldiers with exactly 1 disorder, 21.3% of those who reported severe role impairment were in treatment compared to 11.0% of those without severe role impairment (χ21 = 6.7, p = 0.001). As the number of disorders increased, the rates of treatment among those with vs. without severe role impair- ment converged (21.0% vs. 15.6% among soldiers with 2 dis- orders, χ21 = 0.7, p = 0.40; 43.5% vs. 40.1% among soldiers with 3+ disorders, χ21 = 0.7, p = 0.42).

Sociodemographic and Army Career Predictors of Treatment After controlling type, duration, and severity of disorders, treatment was significantly more likely among currently or previously married than never married soldiers and among those with a history of 1 to 2 deployments than the never deployed (Table V). Odds ratios (ORs) were 2.0 to 2.4 in the total sample and similar in separate subsamples of sol- diers with internalizing (OR = 2.3–3.1) and externalizing (OR = 2.1–2.2) disorders. Non-Hispanic Blacks were

TABLE IV. Current Mental Health Treatment by Severity of Role Impairment Among Soldiers With a 30-Day DSM-IV Mental Disor- der in the Army STARRS Q2–4 2011 AAS (n = 1,521)

Mental Disorders

Severity of Mental Disorder

χ21

Severe Role Impairment Not Severe

na %b (SE)

Any Current Treatment

na %b (SE)

Any Current Treatment

%c (SE) %c (SE)

I. Internalizing Disorders MDD 180 61.0 (4.4) 29.2 (3.3) 115 39.0 (4.4) 22.6 (3.4) 1.1 BPD 123 54.6 (3.9) 46.9 (5.1) 90 54.4 (3.9) 34.6 (3.1) 5.6* GAD 218 58.4 (3.5) 43.8 (4.7) 133 41.6 (3.5) 31.8 (5.0) 2.2 PD 107 48.7 (5.1) 59.4 (7.1) 112 51.3 (5.1) 35.1 (2.6) 5.7* PTSD 213 39.3 (2.7) 52.0 (3.3) 285 60.7 (2.7) 30.7 (3.3) 12.4* Any Internalizing Disorder 394 41.5 (2.9) 37.0 (2.9) 507 58.5 (2.9) 25.2 (2.6) 7.7*

II. Externalizing Disorders ADHD 196 46.3 (3.3) 38.8 (4.1) 185 53.7 (3.3) 22.1 (3.6) 7.5* IED 232 27.0 (3.2) 33.7 (4.9) 521 73.0 (3.2) 15.5 (2.8) 19.6* SUD 117 35.4 (2.6) 18.1 (2.6) 167 64.6 (2.6) 14.0 (2.6) 0.9 Any Externalizing Disorder 384 31.2 (2.1) 33.0 (3.0) 744 68.7 (2.1) 15.0 (2.4) 26.3*

III. Total (Internalizing and Externalizing) Any of the Above Disorders 517 31.4 (2.2) 32.0 (2.6) 1,004 68.6 (2.2) 16.4 (2.0) 28.1* Number of Disorders 1 180 18.6 (1.8) 21.3 (6.4) 658 81.4 (1.8) 11.0 (2.1) 6.7* 2 102 33.4 (4.0) 21.0 (3.6) 190 66.6 (4.0) 15.6 (3.4) 0.7 3+ 235 57.0 (3.5) 43.5 (3.1) 156 43.0 (3.5) 40.1 (2.3) 0.7

*Significant association between severity of role impairment and probability of treatment based on a 0.05-level 2-sided test. aUnweighted number of AAS respondents within each cell corresponding to the row heading and specified severity of disorder. bWeighted “row” percentages denoting the proportion of AAS respondents within each row reporting the specified severity of disorder. cWeighted “row” percentages denoting the proportion of AAS respondents within each row and specified severity of disorder who are currently receiving any type of mental health treatment.

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TABLE V. Associations of Sociodemographic, Army Career, and Mental Disorder Characteristics With Current Treatment Among Soldiers With a 30-Day DSM-IV Disorder in the Army STARRS Q2–4 2011 AAS (n = 1,503)

Any Disorder (n = 1,503)

Internalizing (n = 882)

Externalizing (n = 1,102)

Any Disorder Controlling for Positive Predictors (n = 1,503)

OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

I. Sociodemographic Characteristics Gender Male 0.6 (0.3–1.4) 0.7 (0.3–1.8) 0.5 (0.2–1.0) 0.6 (0.3–1.2) Female 1.0 — 1.0 — 1.0 — 1.0 —

χ 21 1.2 0.5 3.5 1.8 Race/Ethnicity Non-Hispanic White 1.0 — 1.0 — 1.0 — 1.0 — Non-Hispanic Black 0.5* (0.3–1.0) 0.4* (0.2–0.8) 0.4* (0.2–0.9) 0.7 (0.4–1.3) Hispanic 1.2 (0.7–1.9) 1.0 (0.6–1.8) 1.3 (0.7–2.4) 1.1 (0.7–1.8) Other 0.8 (0.4–1.7) 0.8 (0.4–1.9) 0.7 (0.3–1.8) 0.8 (0.4–1.6)

χ 23 6.1 7.8* 7.7 3.1 Marital Status Currently Married 2.0* (1.4–2.8) 2.3* (1.7–3.0) 2.2* (1.2–4.0) 1.3 (0.9–1.9) Previously Married 2.4* (1.3–4.5) 3.1* (1.6–5.7) 2.2 (0.8–5.7) 1.5 (0.7–3.4) Never Married 1.0 — 1.0 — 1.0 — 1.0 —

χ 22 19.0* 39.7* 6.8* 2.0 II. Army Career Characteristics

Rank Lower-Ranking Enlisted (E1–E4) 1.1 (0.4–3.2) 1.3 (0.3–6.2) 1.0 (0.4–2.0) 1.1 (0.4–3.1) Higher-Ranking Enlisted (E5–E9) 0.9 (0.3–2.5) 0.8 (0.2–3.4) 1.2 (0.6–2.6) 0.9 (0.3–2.5) Officer (W1–5/O1–9) 1.0 — 1.0 — 1.0 — 1.0 —

χ 22 1.2 4.7 0.9 1.0 Number of Deployments 0 1.0 — 1.0 — 1.0 — 1.0 — 1 2.1* (1.4–3.1) 2.3* (1.4–3.5) 2.1* (1.1–4.1) 1.4 (0.9–2.2) 2 2.0* (1.1–3.7) 2.4* (1.2–4.9) 1.8 (0.8–4.1) 1.4 (0.8–2.4) 3+ 1.5 (0.8–3.0) 1.9 (0.8–4.8) 1.2 (0.5–2.6) 1.1 (0.6–2.0)

χ 23 14.3* 13.2* 7.9* 2.7 Command Forces Command (FORSCOM) 2.0 (1.0–4.2) 1.6 (0.8–3.0) 1.5 (0.6–4.2) 1.8 (0.7–5.1)

Area Commandsa 1.0 — 1.0 — 1.0 — 1.0 — Special Operations Command (USASOC) 3.3 (0.6–17.8) 4.1 (0.8–20.8) 1.6 (0.3–10.5) 2.6 (0.4–16.5) Medical Command (MEDCOM) 2.4 (0.8–6.8) 2.1 (0.7–5.7) 1.6 (0.5–4.9) 2.3 (0.7–7.7) Training and Doctrine Command (TRADOC) 1.2 (0.6–2.2) 0.9 (0.5–1.9) 0.7 (0.2–2.3) 1.0 (0.4–2.5) All Other Commandsb 1.4 (0.4–4.5) 1.6 (0.5–5.5) 0.6 (0.1–2.5) 1.4 (0.3–5.6)

χ 25 9.6 7.1 6.7 8.4 III. Mental Disorder Characteristics

Internalizing Disorders MDD 1.2 (0.8–1.8) 1.1 (0.7–1.9) 1.5 (0.9–2.5) 1.2 (0.8–1.8) BPD 1.8* (1.1–2.8) 1.7* (1.0–2.7) 1.9* (1.0–3.3) 1.1 (0.6–1.9) GAD 1.1 (0.7–1.8) 1.0 (0.6–1.8) 1.6 (0.8–3.1) 1.2 (0.7–2.2) PD 2.4* (1.3–4.4) 2.2* (1.2–4.0) 2.6* (1.5–4.5) 1.4 (0.7–2.8) PTSD 3.6* (2.4–5.5) 3.3* (1.9–5.7) 5.5* (3.0–9.9) 1.6 (0.6–3.8)

χ 25 51.0* 22.4* 55.9* 7.5 Externalizing Disorders ADHD 1.1 (0.7–1.7) 1.4 (0.9–2.1) 0.7 (0.4–1.5) 0.9 (0.6–1.4) IED 1.1 (0.7–1.6) 1.1 (0.7–1.6) 0.6 (0.3–1.3) 1.1 (0.7–1.5) SUD 0.8 (0.5–1.2) 0.6 (0.3–1.2) 0.6 (0.4–1.0) 0.8 (0.5–1.2)

χ 23 1.5 4.2 5.7 1.7 Duration of Disorder 8–12 Months 2.3* (1.4–3.9) 2.4* (1.4–4.2) 1.1 (0.6–2.1) 1.6 (0.9–2.8) 5–7 Months 1.2 (0.7–2.0) 1.4 (0.8–2.4) 0.8 (0.3–1.9) 1.3 (0.7–2.4) 1–4 Months 1.0 — 1.0 — 1.0 — 1.0 —

χ 22 16.2* 9.7* 1.2 4.0 Severity of Disorder Severe Role Impairment 1.4 (1.0–2.1) 1.4 (0.9–2.2) 1.3 (0.8–1.9) 1.4 (1.0–2.1) Not Severe 1.0 — 1.0 — 1.0 — 1.0 —

χ21 3.2 2.2 1.1 3.7

(continued)

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significantly less likely to be in treatment than non-Hispanic Whites, although not among soldiers with externalizing disor- ders. Treatment was unrelated to soldier gender, rank, and command. Three internalizing disorders—PTSD, PD, and BPD—were associated with elevated odds of treatment (OR = 1.7–5.5) in the model that included sociodemographic and Army career predictors. Interestingly, these same three internalizing disorders were significant predictors of treatment among soldiers with externalizing disorders. Severity of role impairment was not a significant predictor of treatment when controlling for sociodemographics and type-duration of disorders.

A Composite Score to Predict Probability of Treatment We attempted to determine whether the predictors considered here can be used to define a relatively small segment of sol- diers who account for a high proportion of untreated cases by creating a summary variable with a range between 0 and 7 that assigned one point to each of the significant predictors noted above (i.e., currently or previously married, history of deployment, diagnoses of BPD and PD one point each, hav- ing any disorder with long duration, and giving two points

for PTSD because of its higher OR than any of the other pre- dictors). Not surprisingly, a strong dose–response relation- ship was found between scores on this variable and current treatment (Table VI). The less obvious finding, though, is that the range of treatment rates was striking: from a high of 71.5% among soldiers with scores of 6 to 7 to a low of 4.7% among soldiers scores of 0 to 1. Only 7.7% of soldiers with current disorders had scores of 6 to 7 and the majority (63.1%) had scores of 0 to 3. One fourth (25.7%) of soldiers in treatment came from those with scores of 6 to 7, whereas only 29.9% of soldiers in treatment came from those with scores of 0 to 3.

CONCLUSIONS Four limitations are noteworthy. First, external validity of results was reduced by the exclusion of soldiers in Basic Combat Training and deployed and by the 65.1% coop- eration rate. The weighting used to correct for incomplete cooperation19 does not guarantee absence of sample bias. Second, smaller Commands, while represented, had small sample sizes, resulting in low power to detect treatment dif- ferences. Third, respondents might have underreported men- tal disorders, although methodological studies show this bias to be reduced by using the confidential self-administration

TABLE V. Continued

Any Disorder (n = 1,503)

Internalizing (n = 882)

Externalizing (n = 1,102)

Any Disorder Controlling for Positive Predictors (n = 1,503)

OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

IV. Count of Positive Predictors 6–7 13.7 (1.1–170.3) 4–5 3.9 (0.7–18.7) 2–3 1.8 (0.6–4.8) 0–1 1.0 —

χ24 5.6

*Significant at the 0.05 level, 2-sided test. CI = confidence interval. aArea Commands include Africa (USARAF), Central (USARCENT), North (USARNORTH), South (USARSO), Europe (USAREUR), and Pacific (USARPAC). bOther Commands include Materials Command (AMC), all other Ser- vice Component Commands (ASCC), and all other Direct Reporting Units (DRU).

TABLE VI. Distribution of Positive Predictors of Treatment by Severity of Role Impairment Among Soldiers With a 30-Day DSM-IV Mental Disorder in the Army STARRS Q2–4 2011 AAS (n = 1,521)

Count of Positive

Predictorsa

Severe Role Impairment (n = 517) Not Severe Role Impairment (n = 1,004) Total (n = 1,521)

% of Sample

Prevalence of Treatment in Subsample

Proportion of all Treatment in Subsample

% of Sample

Prevalence of Treatment in Subsample

Proportion of All Treatment in Subsample

% of Sample

Prevalence of Treatment in Subsample

Proportion of All Treatment in Subsample

% (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE)

6–7 15.3 (2.1) 73.6 (7.8) 35.1 (7.0) 4.2 (1.2) 68.0 (3.4) 17.3 (4.5) 7.7 (1.1) 71.5 (5.3) 25.7 (5.6) 4–5 32.1 (3.6) 37.7 (4.1) 37.8 (6.4) 28.0 (2.0) 29.3 (4.0) 50.2 (3.2) 29.3 (2.1) 32.2 (3.5) 44.3 (4.2) 2–3 42.3 (2.5) 19.6 (3.2) 25.9 (4.0) 55.0 (1.7) 8.5 (1.8) 28.5 (3.3) 51.0 (1.4) 11.4 (2.1) 27.2 (2.9) 0–1 10.4 (1.7) 3.6 (1.6) 1.2 (0.5) 12.8 (1.5) 5.1 (2.3) 4.0 (1.7) 12.1 (1.4) 4.7 (1.9) 2.7 (0.9) Total 100.0 — 32.0 (2.6) 100.0 — 100.0 — 16.4 (2.0) 100.0 — 100.0 — 21.3 (1.8) 100.0 —

aThe count includes predictors found to be significant in the multivariate logistic regression reported in Table IV: currently or previously married (1 point); not non-Hispanic Black (1 point); history of deployment (1 point); diagnoses of BPD (1 point), PD (1 point), and PTSD (2 points, because of its higher OR than any other predictor); and having a disorder with long duration (1 point).

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procedures used in the AAS30 and no evidence of under- reporting was found in blinded clinical reappraisal inter- views.21 Fourth, independent corroborating evidence about treatment is not yet available, although such evidence will become available once AAS data are linked to administra- tive data. Methodological studies in civilian samples based on such comparisons suggest that self-reported treatment somewhat overestimate actual treatment.31,32

Within the context of these limitations, the finding of a 21.3% current treatment rate suggests that the vast majority of soldiers with current mental disorders are not currently in treatment. We did not examine how many of those currently not in treatment were in previous treatment but dropped out, but this will be the focus of a subsequent AAS analysis. It is impossible to compare our estimates of treatment rates with previous Army studies, as no previous studies assessed the same range of disorders as the AAS. Previous studies have been inconsistent in their conclusions about whether treat- ment patterns are high or low among soldiers compared to civilian rates. At one extreme, the DoD “Health Related Behaviors Among Active Duty Military Personnel” survey found that 21% of all the soldiers surveyed (not 21% of the soldiers with current mental disorders, but of “all” soldiers) reported receiving some type of treatment for mental health problems in the 12 months before the survey.33 A similar conclusion was reached in a recent study of mental disorder treatment in the Canadian military.34 Other research, though, suggests that the current treatment rate is quite low in the U.S. Army. For example, a recent follow-up study of soldiers who screened positive for mental health problems after returning from combat deployment found that only 13% received any treatment for these problems in the subsequent year.35

None of these studies, though, assessed “continuity” of treatment. We know from civilian studies that many people drop out of treatment of mental disorders36 and that only a small proportion of patients receive adequate treatment because of this high dropout rate.37 Our results are more akin to those civilian findings in that our focus on current treatment underrepresents soldiers who made only a small number of treatment visits in the past year and then dropped out. As noted above, future analyses of these data will com- pare predictors of dropping out of treatment to predictors of never being in treatment.

Our finding that a higher proportion of soldiers with cur- rent internalizing (30.1%) are currently in treatment than those with externalizing (20.6%) disorders is consistent with civilian data.38 This is most plausibly interpreted as a result of exter- nalizing disorders being associated with lower perceived need for treatment than internalizing disorders.39,40 The compara- tively high treatment rates associated with PD, BPD, PTSD, and GAD among the internalizing disorders might reflect higher levels of psychological distress associated with those disorders than the other internalizing disorders we considered. It is also possible that the symptoms of these disorders are more accepted by soldiers than those of other disorders as

understandable consequences of military life and legitimate reasons for seeking treatment.41 Our findings that persistence and severity are related to treatment are also consistent with civilian studies.37

Our findings that gender, rank, and Army Command are unrelated to current treatment when controlling for the other variables in the model are striking given that previous studies of treatment in military populations have found consistently that women and lower-ranking personnel have elevated treat- ment rates.33,34 It is noteworthy, though, that those studies used a past-year treatment time reference, did not assess the full range of disorders assessed in the AAS, and in most cases did not adjust for differences in disorder prevalence in examining gross associations of these predictors. At the same time, we found that race–ethnicity (only for soldiers with internalizing disorders), marital status, and deployment his- tory are all significant predictors of current treatment even when controlling type of mental disorder. Although other studies have not found a significant relationship between race/ethnicity and treatment, marital status has been shown to be a significant predictors of treatment in many previous studies,33,34 perhaps reflecting the importance of spouses in facilitating professional help-seeking.

We also found that soldiers with mental disorders who deployed once or twice were significantly more likely to be in current treatment than those that never deployed. This association held up even when controlling for type, duration, and severity of disorders, indicating that the effect of deployment history is not because of greater need for treat- ment. The effect of “number” of deployments has not been highlighted in previous studies, although one previous study found a positive association between number of combat exposures and perceived need for treatment.42 Soldiers with multiple deployments presumably were exposed to more deployment-related stressors and, in recent cohorts, more postdeployment health screenings than those with only one deployment. In addition, the Army has worked hard to legit- imize the notion that mental health check-ups after deploy- ment are normative, possibly reducing the sense of stigma associated with treatment among the previously deployed.

Analysis of our summary 0 to 7 count measure docu- mented a wide range of variation in treatment rates based on multivariate predictor profiles. Only 3.6% of the severely impaired soldiers with scores of 0 to 1 were in current treat- ment compared to 73.6% of those with scores of 6 to 7. Importantly, the distribution of the count variable was skewed toward the low end of the range (63.1% of soldiers had scores of 0–1). This means that we cannot use the pre- dictors considered here to define a relatively small segment of soldiers who represent the vast majority of untreated cases. It is conceivable that future research with more exten- sive predictors will achieve this goal, in which case special targeted outreach efforts could be focused on that small seg- ment of the population. Indeed, investigation of this possibil- ity will be a major aim of AAS analyses once the full

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sample is available. In the interim, the most promising line of investigation to address the problem of untreated mental disorders is likely to be to focus on modifiable barriers to initiating treatment and, separately, on barriers to staying in treatment (i.e., not dropping out of treatment) in epidemio- logical studies8 as well as in qualitative studies of pathways to care,43 possibly with a focus on the joint effects of multi- ple barriers and variation in distributions of barriers across important segments of the population.

ACKNOWLEDGMENTS Author Contributions: RCK and NAS had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Conception and design: RJU and RCK; Acquisition of data: LJC; SGH, RCK, and NAS; Analysis and interpretation of data: All authors; Drafting of the manuscript: LJC, RCK; Critical revision of the manuscript for important intellectual content: All authors; Statistical analy- sis: PA, NAS, and AMZ; Obtaining funding: SGH, RCK, and RJU; Admin- istrative, technical, or material support: All authors.

Supervision: All authors. Additional Contributions: The Army STARRS Team consists of

Co-Principal Investigators: RJU (Uniformed Services University of the Health Sciences) and MBS (University of California San Diego and VA San Diego Healthcare System).

Site Principal Investigators: SGH (University of Michigan) and RCK (Harvard Medical School). National Institute of Mental Health (NIMH) col- laborating scientists: LJC and MLS. Army liaisons/consultants: COL Steven Cersovsky, MD, MPH (USAPHC) and Kenneth Cox, MD, MPH (USAPHC). Other team members: PAA (Uniformed Services University of the Health Sciences); COL David M. Benedek, MD (Uniformed Services University of the Health Sciences); K. Nikki Benevides, MA (Uniformed Services University of the Health Sciences); Paul D. Bliese, PhD (University of South Carolina); Susan Borja, PhD (NIMH); Evelyn J. Bromet, PhD (Stony Brook University School of Medicine); Gregory G. Brown, PhD (University of California San Diego); Christina Buckley, BA (Uniformed Services University of the Health Sciences); Laura Campbell-Sills, PhD (University of California San Diego); Catherine L. Dempsey, PhD, MPH (Uniformed Services University of the Health Sciences); Carol S. Fullerton, PhD (Uniformed Services University of the Health Sciences); Nancy Gebler, MA (University of Michigan); Robert K. Gifford, PhD (Uniformed Services University of the Health Sciences); Stephen E. Gilman, ScD (Harvard School of Public Health); Marjan G. Holloway, PhD (Uniformed Services University of the Health Sciences); Paul E. Hurwitz, MPH (Uniformed Ser- vices University of the Health Sciences); Sonia Jain, PhD (University of California San Diego); Tzu-Cheg Kao, PhD (Uniformed Services University of the Health Sciences); Karestan C. Koenen, PhD (Columbia University); Lisa Lewandowski-Romps, PhD (University of Michigan); Holly Herberman Mash, PhD (Uniformed Services University of the Health Sciences); James E. McCarroll, PhD, MPH (Uniformed Services University of the Health Sci- ences); James A. Naifeh, PhD (Uniformed Services University of the Health Sciences); Tsz Hin Hinz Ng, MPH (Uniformed Services University of the Health Sciences); Matthew K. Nock, PhD (Harvard University); Rema Raman, PhD (University of California San Diego); Holly J. Ramsawh, PhD (Uniformed Services University of the Health Sciences); Anthony Joseph Rosellini, PhD (Harvard Medical School); Nancy A. Sampson, BA (Harvard Medical School); LCDR Patcho Santiago, MD, MPH (Uniformed Services University of the Health Sciences); Michaelle Scanlon, MBA (NIMH); Jordan W. Smoller, MD, ScD (Harvard Medical School); Amy Street, PhD (Boston University School of Medicine); Michael L. Thomas, PhD (Univer- sity of California San Diego); Patti L. Vegella, MS, MA (Uniformed Ser- vices University of the Health Sciences); Leming Wang, MS (Uniformed Services University of the Health Sciences); Christina L. Wassel, PhD (Uni- versity of Pittsburgh); Simon Wessely, FMedSci (King’s College London);

Hongyan Wu, MPH (Uniformed Services University of the Health Sci- ences); LTC Gary H. Wynn, MD (Uniformed Services University of the Health Sciences); Alan M. Zaslavsky, PhD (Harvard Medical School); and Bailey G. Zhang, MS (Uniformed Services University of the Health Sci- ences). No one mentioned in the acknowledgement section received any compensation other than salary support for their contribution.

Army STARRS was sponsored by the Department of the Army and funded under cooperative agreement number U01MH087981 with the U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health.

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Mental Health Treatment Among Soldiers With Current Mental Disorders in the Army

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