DTIC ADA611844: Lifetime Prevalence of DSM-IV Mental Disorders Among New Soldiers in the U.S. Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

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DEPRESSIONANDANXIETY00:1–12(2014)
Research Article
LIFETIME PREVALENCE OF DSM-IV MENTAL
DISORDERS AMONG NEW SOLDIERS IN THE U.S. ARMY:
RESULTS FROM THE ARMY STUDY TO ASSESS RISK
AND RESILIENCE IN SERVICEMEMBERS (ARMY STARRS)
AnthonyJ.Rosellini,Ph.D.,1 StevenG.Heeringa,Ph.D.,2 MurrayB.Stein,M.D.,M.P.H.,3,4
RobertJ.Ursano,M.D.,5 WaiTatChiu,A.M.,1 LisaJ.Colpe,Ph.D.,M.P.H.,6 CarolS.Fullerton,Ph.D.,5
StephenE.Gilman,Sc.D.,7 IrvingHwang,M.A.,1 JamesA.Naifeh,Ph.D.,5 MatthewK.Nock,Ph.D.,8
MariaPetukhova,Ph.D.,1 NancyA.Sampson,B.A.,1 MichaelSchoenbaum,Ph.D.,6 AlanM.Zaslavsky,Ph.D.,1
∗
andRonaldC.Kessler,Ph.D.1
Background: The prevalence of 30-day mental disorders with retrospectively
reportedearlyonsetsissignificantlyhigherintheU.S.Armythanamongsocio-
demographicallymatchedcivilians.Thisdifferencecouldreflecthighprevalence
ofpreenlistmentdisordersand/orhighpersistenceofthesedisordersinthecontext
ofthestressesassociatedwithmilitaryservice.Thesealternativescantosomeex-
tentbedistinguishedbyestimatinglifetimedisorderprevalenceamongnewArmy
recruits. Methods:TheNewSoldierStudy(NSS)intheArmyStudytoAssess
Risk and Resilience in Servicemembers (Army STARRS) used fully structured
measurestoestimatelifetimeprevalenceof10DSM-IVdisordersinnewsoldiers
reporting for Basic Combat Training in 2011–2012 (n = 38,507). Prevalence
was compared to estimates from a matched civilian sample. Multivariate re-
gression models examined socio-demographic correlates of disorder prevalence
and persistence among new soldiers. Results: Lifetime prevalence of having at
least one internalizing, externalizing, or either type of disorder did not differ
significantlybetweennewsoldiersandcivilians,althoughthreespecificdisorders
(generalized anxiety, posttraumatic stress, and conduct disorders) and multi-
morbidity were significantly more common among new soldiers than civilians.
Although several socio-demographic characteristics were significantly associated
withdisorderprevalenceandpersistence,theseassociationswereuniformlyweak.
Conclusions:Newsoldiersdiffersomewhat,butnotconsistently,fromcivilians
1Department of Health Care Policy, Harvard Medical School, 8Department of Psychology, Harvard College, Cambridge,
Boston,Massachusetts Massachusetts
2UniversityofMichiganInstituteforSocialResearch,AnnAr-
Contractgrantsponsor:DepartmentoftheArmy,U.S.Department
bor,Michigan
3Departments of Psychiatry and Family and Preventive ofHealthandHumanServices,andNIH/NIMH;contractgrantnum-
ber:U01MH087981.
Medicine, University of California San Diego, La Jolla, Cali-
fornia ∗Correspondenceto:RonaldC.Kessler,DepartmentofHealthCare
4VASanDiegoHealthcareSystem,SanDiego,California
Policy, Harvard Medical School, 180 Longwood Avenue, Boston,
5CenterfortheStudyofTraumaticStress,DepartmentofPsy-
MA02115.E-mail:[email protected]
chiatry,UniformedServicesUniversityoftheHealthSciences,
Receivedforpublication27June2014;Revised15August2014;
Bethesda,Maryland
Accepted24August2014
6NationalInstituteofMentalHealth,Bethesda,Maryland
7Departments of Social and Behavioral Sciences, and Epi- DOI10.1002/da.22316
demiology, Harvard School of Public Health, Boston, Mas- PublishedonlineinWileyOnlineLibrary
sachusetts (wileyonlinelibrary.com).
(cid:3)C 2014WileyPeriodicals,Inc.
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Lifetime Prevalence of DSM-IV Mental Disorders Among New Soldiers in
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the U.S. Army: Results from the Army Study to Assess Risk and
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2 Rosellinietal.
in lifetime preenlistment mental disorders. This suggests that prior findings of
higherprevalenceofcurrentdisorderswithpreenlistmentonsetsamongsoldiers
thanciviliansarelikelydueprimarilytoamorepersistentcourseofearly-onset
disorders in the context of the special stresses experienced by Army personnel.
DepressionandAnxiety00:1–12,2014. (cid:2)C 2014WileyPeriodicals,Inc.
Key words: military personnel; mental disorders; prevalence; epidemiology;
demographics
INTRODUCTION The higher absolute prevalence of 30-day disorders
M withearlyonsetsamongsoldiersthancivilianscouldbe
ental disorders are leading causes of U.S. military
duetoanyofthreeprocesses:(1)recallerrorinretrospec-
morbidity.[1] This high relative burden of mental dis-
tiveAOOreports;(2)early-onsetdisordersand/ortheir
orders could reflect the fact that soldiers are physically
riskfactorsbeingpositivelyassociatedwithArmyenlist-
healthy at the time of enlistment due to serious physi-
ment;and(3)higherchronicityofearly-onsetdisorders
caldisordersbeingexclusionsfrommilitaryservice,but
amongsoldiersthancivilians(possiblyduetothespecial
might also be due partly to a high absolute burden of
stressors associated with Army service). The first pos-
mental disorders in the military compared to civilians.
sibility is implausible because methodological research
The scant data on this issue suggest that military per-
suggeststhatthetendencyinsuchdatingerrorsistore-
sonnelonactivedutyhavehigherratesofsomemental callfirstonsetasmorerecentthanactuallyoccurred,[15]
disorders than civilians.[2] The most rigorous study of
and there is no reason to think that recall error would
thisissuetodatecomesfromaself-reportsurvey,theAll-
be greater among soldiers than civilians. However, the
ArmyStudy(AAS),intheArmy Study to Assess Risk and
remainingpossibilitiesarebothplausible.
Resilience in Servicemembers (Army STARRS).[3,4] The
Adjudication between these two possibilities could
AAS assessed a representative sample of nondeployed
be important in helping to design Army preventive in-
U.S. Army soldiers exclusive of those in Basic Com-
terventions, including early interventions for high-risk
bat Training (BCT) and found that the prevalence of
groupsorearlytreatmentifsoldierswerefoundtohave
havingatleastonecommonpsychiatricdisorderinthe
significantly higher rates of child-adolescent disorders
30daysbeforeinterviewwasconsiderablyhigheramong
than civilians. The data in the AAS did not allow for
these soldiers (25.1%) than a civilian sample calibrated
this analysis, as lifetime prevalence was assessed only
to have similar socio-demographics as soldiers and
amongsoldierswith30-daydisorders.However,useful
not to have exclusions for enlistment (11.6%).[5] Al-
informationonthisissuecouldbeobtainedbycompar-
though this higher prevalence in the Army might be
inglifetimeprevalenceofmentaldisordersamongnew
due to the unique stressors associated with military
Army recruits and civilians. We present the results of
service,[6–9] another possibility is that differential selec-
suchastudyinthecurrentreport,examiningpreenlist-
tionexistsintomilitaryserviceonthebasisofpreenlist-
mentprevalenceandsocio-demographiccorrelatesofa
mentmentaldisordersorriskfactorsforsuchdisorders.
numberofcommonmentaldisorders.
Evaluatingtherelativeimportanceofthesetwopossibil-
itiesisimportantgivenrecentdiscussionsaboutoptimal
recruitment, retention, and health care delivery strate-
MATERIALS AND METHODS
giesforanall-volunteerArmyduringtimesofwar.[10,11]
TheAASprovidedsomelimitedinformationonthis
SAMPLE
issuebyaskingrespondentsretrospectivelytoreportthe
Data come from the Army STARRS New Soldier Study (NSS).
age-of-onset (AOO) of their 30-day mental disorders.
UnliketheAAS,whichdidnotincludesoldiersinBCT,theNSSwas
Three-quarters(76.6%)ofrespondentsreportedonsets
carriedoutexclusivelyamongnewsoldierswhohadalreadybeensuc-
priortoenlistment.Thishighproportionshouldnotbe cessfulinpassingthescreeninghurdlesforArmyenlistment(i.e.,for
surprising, as general population epidemiological stud- histories of criminal behaviors, severe physical disorders-handicaps,
iesfindmostlifetimementaldisordershavechildhood- andseverementalillness)[16]andwereabouttobeginBCTatoneof
adolescenceonsets.[12–14] Butamorestrikingresultwas threeArmyInstallations(FortBenning,GA;FortJackson,SC;and
that a significantly higher proportion of respondents FortLeonardWood,MO)betweenApril2011andNovember2012.
with30-daydisordersintheciviliancomparisonsample Datacollectionoccurredduringthedaysimmediatelypriortostart-
reportedearlyonsets(91.2%vs.76.6%,χ2 =10.7,P= ingBCTwhennewsoldierswereprocessed(e.g.,completingphysical
1 exams;issuanceofuniforms).Samplessizeswereproportionaltothe
.001).However,absoluteprevalenceof30-daydisorders
relativesizeofthecohortsacrossinstallations.Recruitmentbeganby
withpreenlistmentonsetswasnonethelesssignificantly
selectingaweeklysampleof200–300newsoldiersineachinstallation
higheramongsoldiersthancivilians(19.2%vs.10.6%, toattendastudyoverviewandinformedconsentpresentationforthe
χ2 =10.4,P=.001). study.ArmySTARRSstaffworkedcloselywithArmycoordinatorsto
1
DepressionandAnxiety
ResearchArticle:MentalDisordersAmongNewU.S.ArmySoldiers 3
guaranteethatthesesampleswererepresentativeofallnewsoldiersin ages-of-onsetthanothers.[13]Althoughthisisonlyaroughmeasureof
eachweeklycohort.Theoverviewandinformedconsentpresentation persistence,itisnonethelessusefulinprovidingageneralsenseofhow
explainedstudypurposes,confidentiality,emphasizedthatparticipa- oftenpreenlistmentdisordersarepersistentratherthanshortlived.
tionwasvoluntary,andansweredallquestionsbeforeseekingwritten Wedistinguishedbetweeninternalizingandexternalizingdisorders
informed consent to (i) complete a self-administered questionnaire based on empirical evidence for this distinction.[22] Five internaliz-
(SAQ),(ii)linkadministrativerecordstoSAQresponses,and(iii)par- ingdisorderswereassessed:majordepressiveepisode(MDE),bipolar
ticipateinfuturedatacollections.Identifyinginformation(e.g.,name, I-IIorsubthresholdbipolardisorder(BPD),generalizedanxietydis-
SSN)wascollectedfromconsentingrespondentsandkeptinaseparate order(GAD),panicdisorder(PD),andposttraumaticstressdisorder
securefile.Theserecruitment,consent,anddataprotectionprocedures (PTSD),alongwithfiveexternalizingdisorders:intermittentexplosive
wereapprovedbytheHumanSubjectsCommitteesoftheUniformed disorder(IED),conductdisorder(CD),oppositionaldefiantdisorder
ServicesUniversityoftheHealthSciencesfortheHenryM.Jackson (ODD),substanceusedisorder(SUD;alcoholordrugabuseorde-
Foundation(theprimarygrantee),theInstituteforSocialResearchat pendence),andattention-deficit/hyperactivitydisorder(ADHD).The
theUniversityofMichigan(theorganizationcollectingthedata),and SUDassessmentincludednotonlyillicitdrugsbutalsomisusedpre-
allothercollaboratingorganizations. scriptiondrugsbasedonevidencethatprescriptiondrugmisuseiscon-
The38,507NSSrespondentsconsideredhererepresentallcon- siderablymorecommonthanillicitdruguseintheArmy.[23]Diagnoses
senting soldiers who completed the SAQ April 2011–November inbothsurveysweremadewithoutDSM-IVdiagnostichierarchyor
2012. All new soldiers selected to attend the informed consent organicexclusionrules.Asreportedindetailelsewhere,[24] anArmy
session did so, virtually all (99.9%) provided consent, and most STARRSclinicalreappraisalstudyfoundgoodconcordancebetween
(93.7%)completedthefullSAQ(seeAppendixTable5,availableat CIDI-SCandmodifiedPCLdiagnosesandindependentclinicaldi-
www.armystarrs.org/publications).Incompletesurveyswereprimarily agnosesbasedonblindedStructuredClinicalInterviewsforDSM-IV
duetotimeconstraints(e.g.,cohortsarrivinglateorhavingtoleave (SCID).[25] The clinical reappraisal study also found CIDI-SC and
early;certainrespondentsbeingunabletofullycompletethesurveys PCLprevalenceestimateswereunbiasedrelativetoSCIDestimates
duringtheallottedtime).Mostsoldierswhocompletedthesurveyalso (χ2 =0.0–0.6,P=.89–.43).Theearlierreport,[24] whichincluded
1
providedconsentforand weresuccessfullylinkedtotheir adminis- detailedconcordanceresultsforeachofthe10disordersstudiedhere,
trativerecords(77.0%).Allanalysesreportedhereutilizeacombined isavailableelsewhere(www.armystarrs.org/publications).
analysisweightthatbothadjustsfordifferentialadministrativerecord Socio-Demographics. Socio-demographics included respon-
linkageconsentamongsoldierswhocompletedthesurveyandincludes dentage,sex,race-ethnicity,soldiereducation,maritalstatus,religion,
apoststratificationoftheseconsentweightstoknowndemographicand soldierandparentnativity,andparenteducationrelativetorespon-
servicecharacteristicsofthepopulationofnewsoldiersattendingBCT denteducation.SeparatequestionswereaskedaboutHispanicethnic-
duringthestudyperiod.AdetaileddescriptionofNSSclusteringand ity(yes–no)andrace(White,BlackorAfrican-American,AmericanIndian
weightingisavailableelsewhere.[17] orNativeAmerican,Asian[e.g.,Chinese,Filipino,Indian],NativeHawai-
ianorotherPacificIslander,andOther),withresponsescollapsedinto
summary categories of Non-Hispanic Black, Non-Hispanic White,
THECOMPARISONCIVILIANSAMPLE
Hispanic,andOther.
LifetimeprevalenceofDSM-IVdisorderswascomparedtoesti-
matesfromasubsampleoftheNationalComorbiditySurveyRepli-
cation(NCS-R)[18] limitedtorespondentswholackedself-reported
exclusions for Army service (histories of criminal behaviors, se-
ANALYSISMETHODS
verephysicaldisorders-handicaps,andseverementalillness)andwas
weightedtohavethesamemultivariatedistributionastheNSSona Cross-tabulationswereusedtoestimatedisorderprevalence.Com-
rangeofsocio-demographicsseparatelyamongsoldiersintheRegu- parisonofprevalenceestimatesintheNSSandthecomparisoncivilian
larArmyandintheArmyNationalGuardorArmyReserve.Ade- samplewasusedtodetermineifpreenlistmentprevalencewashigher
tailed discussion of the civilian sample and calibration is presented amongnewsoldiersthancivilians.Socio-demographicpredictorsof
elsewhere.[19] disorder onset and persistence were examined to determine if high
preenlistmentdisorderriskwasisolatedinasmallsubsetofnewsol-
diers or widely distributed. Logistic regression was used to predict
MEASURES
lifetimedisordersandnegativebinomialregressiontopredictdisorder
Diagnostic Assessment. NSSrespondentsself-administereda persistencecontrollingforAOOandnumberofyearssinceonset.Co-
computerizedversionoftheCompositeInternationalDiagnosticIn- efficientsandstandarderrorswereexponentiatedinlogisticmodelsto
terviewscreeningscales(CIDI-SC)[20]andascreeningversionofthe createoddsratios(ORs)with95%confidenceintervalsandinnega-
PTSDChecklist(PCL)[21]toassess10lifetimeDSM-IVmentaldisor- tivebinomialmodelstocreateincidentrateratios(IRRs;theexpected
ders.Wefocusedonlifetimeprevalenceratherthan30-dayprevalence differenceinmeannumberofyearsofpersistenceassociatedwitha1
becausewewereinterestedinstudyingdifferencesintheratesofany unitincreaseinthepredictor)with95%confidenceintervals.Strength
preenlistment mental disorders rather than current disorders at the ofassociationswasevaluatedwithCramer’sV(ϕc).
timeofaccession.TheNCS-Rassessedthesamelifetimedisorders Allanalyseswerecarriedoutusingweighteddata.Designeffects
withthefullCIDI,[20]whichmeansthatbetween-surveycomparisons duetoweightingandimplicitstratificationbylocationandcluster-
ofprevalenceareinexact.RespondentsintheNSSbutnotNCS-Rwith ingwerehandledbyusingthedesign-basedTaylorserieslinearization
lifetimedisorderswerealsoaskedhowmanyyearseachdisorderhad method[26]toestimatestandarderrors.Pseudo-strataweredefinedto
beenpresentatleastsomeofthetime.Weexaminedtheseresponses implement this method based on location and bi-weekly time win-
toassesspersistenceofpreenlistmentdisordersbothbystudyingthe dowstreatingeachweeklytime-spaceclusterasaseparatesampling
absolutenumberofyearsinwhicheachdisorderoccurredbeyondthe errorcalculationunit.Significanceofpredictorsetswasevaluatedus-
yearofonsetandalsotheratioofnumberofyearsinwhicheachdis- ingdesign-basedWaldχ2tests.AllanalyseswerecarriedoutwithSAS
orderoccurredbeyondtheyearofonsetdividedbythetotalnumber Version9.3,[27]withprocsurveyfreqtoestimateprevalence,procsurvey-
ofyearssinceonset.Thelatterratioswerecalculatedattheaggregate logistictoestimatelogisticmodels,andprocgenmodtoestimatenegative
levelforeachdisordertoadjustforsomedisordershavingmuchearlier binomialmodels.
DepressionandAnxiety
4 Rosellinietal.
RESULTS substantivelysmall(3.6vs.3.4;χ2=4.9,P=.027).Mean
1
persistenceratioswereintherange33.2–60.7%forthe
SOCIO-DEMOGRAPHICDISTRIBUTIONS
Regular Army and 31.6–62.0% for the Guard/Reserve
Distributions of socio-demographic variables in the and BPD was the only disorder with a persistence
weightedNSSRegularArmyandNationalGuard/Army ratio that significantly differed in the Regular Army
Reserve (Guard/Reserve) were comparable to those in than Guard/Reserve (41.9% vs. 48.3%, χ2 = 4.9, P =
1
thetargetpopulationofallnewsoldiers(Table1). .027). Mean persistence was generally higher for ex-
ternalizing (3.4–4.5) than internalizing (1.4–3.0) dis-
LIFETIMEDISORDERPREVALENCE orders with the exception of SUD. It is notewor-
The estimated lifetime prevalence in the total NSS thy that the two highest persistence ratios were for
sample was 38.7% for any DSM-IV/CIDI-PCL disor- PD (60.7–62.0%) and IED (57.0–58.4%), both of
der, 19.8% for internalizing disorder, and 31.8% for which are characterized by repeated and uncontrol-
any externalizing disorders. PTSD was the most com- lable attacks (of fear in the case of PD and anger in
mon internalizing disorder (12.6%) and IED the most the case of IED) out of proportion to precipitating
commonexternalizingdisorder(14.6%).Thesegeneral events.
patterns were very similar in the Regular Army and
Guard/Reserve, although prevalence was consistently
SOCIO-DEMOGRAPHICPREDICTORSOF
somewhat higher in the latter than former, with the
PREVALENCEANDPERSISTENCE
Guard/Reserve having higher prevalence of any dis-
The vast majority of associations between socio-
order (40.0% vs. 37.6%; χ2 = 14.0, P < .001), any
1 demographics and lifetime disorders were statistically
internalizing disorder (21.0% vs. 18.8%; χ12 = 19.4, significant in multivariate models, including 22 of 24
P < .001), each internalizing disorder other than BPD in pooled models (Table 4) and 51 of 80 in models for
(3.3–13.3% vs. 2.7–12.1%; χ2 = 7.2–19.7, P < .001 to individual disorders. (The tables for individual disor-
1
P=.007),andtwoexternalizingdisorders(IED,ADHD; dersareavailableat(www.armystarrs.org/publications).
7.0–15.1%vs.5.9–14.2%;χ2=4.5–9.3,P=.002–.034; These associations were for the most part in the direc-
1
Table2). tion predicted by previous research: higher rates of in-
Lifetime prevalence differences between all new sol- ternalizing disorders among women and soldiers with
diersandtheciviliansamplewerenotsignificantforthe Non-Western religions; higher rates of externalizing
aggregate variables representing any DSM-IV/CIDI- disordersamongmenandtheunmarried;andinverseas-
PCL disorder (38.7% vs. 36.5%; χ2 = 0.1, P = .76), sociations of age, minority status (Non-Hispanic Black
1
any internalizing disorder (19.8% vs. 20.3%; χ2 = 0.0, andHispanic),soldierandparenteducation,andimmi-
P=.93),oranyexternalizingdisorder(31.8%vs.128.8%; grant status with both internalizing and externalizing
χ2 =0.2,P=.62).However,prevalenceofthreeindi- disorders. However, these statistically significant asso-
1 ciations were all small in substantive terms (ϕ in the
vidual disorders (GAD, PTSD, CD) were significantly c
range.00–.07).
higher among soldiers than civilians. The differences
The significant associations of socio-demographics
in GAD (8.2% vs. 1.2%; χ2 = 245.0, P < .001) and
1 with disorder persistence were less consistent: 16 of 27
PTSD(12.6%vs.2.5%;χ2=44.5,P<.001)weremuch
1 associations in pooled models and 29 of 81 in models
morestrikingthanthedifferenceinCD(5.9%vs.3.3%;
for individual disorders. Persistence was higher among
χ2=3.9,P=.048).Thesedifferencesresultedinasignif- women than men and Non-Hispanic Whites than mi-
1
icantly higher proportion of new soldiers than civilians norities(onlyforexternalizingdisorders),loweramong
having multi-morbidity (3+ lifetime disorders; 11.3% immigrantsthan1standlatergenerationAmericans,and
vs. 6.5%; χ2 = 4.0, P = .046). These soldier-versus- inversely related both to AOO and to time-since-onset
1
civiliandifferenceswerebroadlysimilarwhenexamined (see Table 5). Parent education was related inversely
separatelyintheRegularArmyandGuard/Reserveex- to persistence of internalizing disorders and positively
cludingthattheprevalenceofCDwasnotsignificantly to persistence of externalizing disorders. Religion, sol-
higher among new soldiers in the Guard/Reserve than diereducation,andmaritalstatuswereunrelatedtoper-
civilians(5.5%vs.3.6%;χ2 =1.6,P=.21). sistence. As with prevalence, the statistically significant
1
associations with persistence were small in substantive
PERSISTENCEOFLIFETIMEDSM-IV/CIDI-PCL terms(ϕc intherange.02–.09)otherthanthoseinvolv-
DISORDERS ing age-of-onset and time-since-onset (ϕc in the range
.06–.27).
Mean years of disorder persistence (exclusive of
ADHD, for which persistence was not assessed) across
disorders was comparable among new soldiers in
DISCUSSION
the Regular Army (1.3–4.5) and Guard/Reserve (1.2–
4.4) (Table 3). IED was the only disorder with Theaboveresultsareimportantindemonstratingthat
mean persistence significantly different in the Regular new soldiers in the U.S. Army during 2011–2012, al-
ArmythanGuard/Reserve,althoughthedifferencewas though having higher rates of GAD, PTSD, CD, and
DepressionandAnxiety
ResearchArticle:MentalDisordersAmongNewU.S.ArmySoldiers 5
TABLE1.Distributionsofsocio-demographicandArmycareervariablesinquarter22011throughquarter42012of
theArmySTARRSNewSoldierStudyanalysissampleandthetargetpopulationofallcomparablenewU.S.Army
soldiersa
RegularArmy Guard/Reserve
Unweighted Weighted Population Unweighted Weighted Population
% SE % SE % % SE % SE %
Genderb
Male 86.4 0.4 86.2 0.5 86.3 78.6 0.6 78.2 0.7 78.5
Female 13.6 0.4 13.8 0.5 13.7 21.4 0.6 21.8 0.7 21.5
Race/ethnicityb
Non-HispanicBlack 17.5 0.4 17.7 0.4 20.3 16.4 0.3 16.0 0.4 17.9
Non-HispanicWhite 61.2 0.4 58.0 0.5 61.3 60.4 0.5 61.0 0.6 64.3
Hispanic 14.4 0.3 16.4 0.3 12.9 15.9 0.3 15.0 0.4 11.9
Other 6.9 0.2 7.9 0.2 5.5 7.3 0.2 8.1 0.3 5.8
Soldiereducationb
Lessthanhighschool 4.3 0.1 4.3 0.1 4.4 20.7 0.4 28.8 0.7 29.2
Completedhighschool 87.1 0.4 87.6 0.4 87.6 70.9 0.5 63.5 0.7 63.1
Somecollege/collegegraduate 8.6 0.3 8.1 0.4 8.0 8.3 0.4 7.7 0.4 7.7
Maritalstatusb
Currentlymarried 13.8 0.3 15.3 0.4 15.1 9.7 0.3 8.9 0.4 8.4
Nevermarried 86.2 0.3 84.7 0.4 84.1 90.2 0.3 90.9 0.4 90.4
Previouslymarried 0.0 0.0 0.0 0.0 0.9 0.2 0.0 0.1 0.0 1.2
Religionc
Protestant 55.7 0.4 54.8 0.5 56.5 57.2 0.4 57.1 0.5 50.3
Catholic 16.9 0.3 17.2 0.3 14.9 19.2 0.3 19.2 0.4 11.9
Otherreligion 3.9 0.1 4.3 0.2 1.7 4.2 0.1 4.2 0.2 1.3
Noreligion 23.5 0.3 23.8 0.4 26.8 19.5 0.3 19.5 0.4 36.5
Nativityd
Immigrant 6.7 0.2 7.4 0.3 – 7.2 0.2 6.9 0.2 –
Firstgeneration 12.1 0.2 13.2 0.3 – 12.4 0.3 12.3 0.3 –
Second+generation 81.2 0.4 79.5 0.4 – 80.4 0.4 80.8 0.4 –
ParenteducationrelativetoSoldiereducationd
Parentscollegegraduate 27.0 0.4 26.5 0.4 – 27.8 0.4 28.1 0.4 –
Parentssomecollegecompleted 23.4 0.3 23.6 0.3 – 24.0 0.4 23.9 0.4 –
Allother 49.6 0.4 49.9 0.4 – 48.2 0.5 48.0 0.5 –
Age-at-enlistmentb
17-18 22.6 0.7 24.3 0.8 23.5 28.3 0.6 33.2 0.9 33.5
19 21.1 0.4 21.1 0.4 21.3 20.3 0.4 19.6 0.4 18.8
20 15.1 0.3 14.6 0.3 14.7 13.6 0.3 12.9 0.3 12.9
21 10.2 0.3 10.0 0.3 10.0 8.9 0.2 8.6 0.3 8.3
22-24 18.3 0.4 17.2 0.4 17.2 14.6 0.3 13.0 0.3 13.5
25+ 12.7 0.3 12.9 0.4 13.2 14.3 0.4 12.7 0.5 13.0
ArmySTARRS,ArmyStudytoAssessRiskandResilienceinServicemembers;SE,standarderror.
aThepopulationdatawereobtainedfromtheDefenseManpowerDataCenterMasterPersonnelandContingencyTrackingSystem(CTS)for
allnewsoldiersintheRegularArmy,ArmyNationalGuard,andArmyReserve.ResultsarebasedonmonthlyCTSsnapshotsforthe20-month
periodbetweenApril2011andNovember2012.TheArmySTARRSNewSoldierStudyanalysisincluded38,507participants(RegularArmyn=
21,840;Guard/Reserven=16,667),andthetargetpopulationofcomparablenewU.S.Armysoldiersincluded251,068(RegularArmyn=150,337;
Guard/Reserven=100,731).Theestimateofpopulationsizeisaveragedoverthe20monthstogeneratethepopulationdata.
bGender, race/ethnicity, soldier education, marital status, and age-at-enlistment were used to poststratify the sample to the population. This
allowedthepopulationestimatestobeidenticaltotheweightedestimates,exceptforthesmallnumberofcaseswhereself-reportdatadifferedfrom
administrativedata.
cReligionwasincludedinthepoststratificationfortheRegularArmyandGuardsoldiers,butwasnotincludedinthepoststratificationtothe
populationforReservesoldiersbecauseitwasnotsignificantinthefinalstepwiseregressionmodel.
dNativityandparenteducationwerenotusedforpoststratificationbecausenomeasuresofthesevariableswereavailableinthetotalpopulation.
Immigrant=thesoldierwasnotbornintheUnitedStates;Firstgeneration=thesoldierwasbornintheUnitedStatesbutatleastoneparent
wasnotbornintheUnitedStates;Second+generation=thesoldierandboththesoldier’sparentswerebornintheUnitedStates;Parentscollege
graduate=atleastoneparentcompletedcollegeandthesoldierhadalowerlevelofeducationthancollegegraduation;Parentssomecollege=at
leastoneparentcompletedsomecollegeandthesoldierhadalowerlevelofeducation.
DepressionandAnxiety
6 Rosellinietal.
TABLE2.EstimatedlifetimeprevalenceofDSM-IVinternalizingandexternalizingdisordersinquarter22011
throughquarter42012oftheArmySTARRSNewSoldierStudyandseparatelyinacalibratednationalcivilian
comparisonsample
Totalsample RegularArmy Guard/Reserve
NSS NCS-R NSSa NCS-Rb NSSa NCS-Rb
% SE % SE % SE % SE % SE % SE
I.Internalizingdisorders
MDE 7.8 0.2 11.2 4.0 7.2 0.2 11.8 4.7 8.6 0.4 10.5 3.4
BPD 3.6 0.1 6.5 2.9 3.5 0.2 7.0 3.1 3.6 0.2 5.9 2.8
GAD 8.2* 0.2 1.2 0.4 7.5* 0.2 0.5 0.1 9.1* 0.3 2.0 0.8
PD 2.9 0.1 4.0 2.6 2.7 0.1 4.2 2.9 3.3 0.2 3.7 2.2
PTSD 12.6* 0.2 2.5 1.5 12.1* 0.3 2.3 1.6 13.3* 0.3 2.9 1.5
Anyinternalizingdisorder 19.8 0.3 20.3 5.6 18.8 0.3 21.7 6.2 21.0 0.4 18.7 4.9
II.Externalizingdisorders
IED 14.6 0.2 13.5 3.9 14.2 0.3 14.8 4.5 15.1 0.3 11.8 3.4
CD 5.9* 0.2 3.3 1.3 6.2* 0.2 3.0 1.2 5.5 0.2 3.6 1.5
ODD 10.3 0.2 6.9 3.2 10.3 0.2 7.0 3.4 10.2 0.3 6.8 3.0
SUD 12.6 0.2 13.9 3.6 12.6 0.3 15.0 3.9 12.6 0.3 12.6 3.4
ADHDc 6.4 0.2 5.1 2.8 5.9 0.2 5.1 2.8 7.0 0.3 5.2 2.7
Anyexternalizingdisorder 31.8 0.3 28.8 6.1 31.3 0.4 30.8 6.3 32.4 0.4 26.4 6.1
III.Total
Anyoftheabovedisorders 38.7 0.3 36.5 7.3 37.6 0.4 38.5 7.6 40.0 0.5 34.1 7.2
Exactly1lifetimedisorder 18.9 0.2 17.1 4.5 18.3 0.3 17.7 4.7 19.6 0.4 16.4 4.2
Exactly2lifetimedisorders 8.5 0.2 12.8 4.3 8.3 0.2 13.8 4.6 8.8 0.3 11.6 4.1
3+lifetimedisorders 11.3* 0.2 6.5 2.4 11.1 0.3 6.9 2.7 11.6* 0.3 6.0 2.0
(n) (38,507) (3,514) (21,840) (1,757) (16,667) (1,757)
DSM-IV, diagnostic and statistical manual of mental disorders, fourth edition; Army STARRS, Army Study to Assess Risk and Resilience in
Servicemembers;SE,standarderror;NSS,NewSoldierStudy;NCS-R,NationalComorbiditySurvey-Replication;MDE,majordepressiveepisode;
BPD,bipolarI-IIorsubthresholdbipolardisorder;GAD,generalizedanxietydisorder;PD,panicdisorder;PTSD,posttraumaticstressdisorder;
IED,intermittentexplosivedisorder;CD,conductdisorder;ODD,oppositionaldefiantdisorder;SUD,substanceusedisorder;ADHD,attention-
deficit/hyperactivitydisorder.
∗SignificantdifferencebetweenNSSandNCS-R(withinthetotalsample,RegularArmy,andGuard/Reservesamples)atthe.05level,two-sided
test.
aSixindividualdisordersweresignificantlymoreprevalentintheNSSGuard/ReservethantheNSSRegularArmyatthe.05level,two-sided
test:MDE,GAD,PD,PTSD,IED,ADHD.Ratesofanyinternalizingdisorder,anylifetimedisorder,andexactlyonelifetimedisorderwerealso
significantlymoreprevalentintheNSSGuard/ReservethantheNSSRegularArmy.CDwastheonlydisorderthatwassignificantlymoreprevalent
intheNSSRegularArmythantheNSSGuard/Reserve.
bPrevalenceratesintheNCS-RRegularArmyandNCS-RGuard/Reservedidnotsignificantlydifferfromoneanotheratthe.05level,two-sided
test.
cADHD symptoms were assessed in the NSS only over the past six months, while they were assessed for childhood in the NCS-R and only
respondentswhometcriteriaduringchildhoodwerethenassessedforthepastsixmonths.Thus,imputedADHDwasusedtoestimateratesinthe
NCS-R.
multi-morbidity than civilians, did not differ signifi- selection bias into military service based on such per-
cantly from otherwise comparable civilians in lifetime sonality characteristics as sensation-seeking, impulsiv-
prevalence of having at least one earlier-onset mental ity,andphysicalaggressiveness.[32–35] Thesedifferences
disorder(38.7%ofnewsoldiersvs.36.5%ofrespondents in prevalence of PTSD, GAD, and CD contributed to
inthecalibratedciviliansample).Whilethisrateofdis- a significantly higher proportion of new soldiers than
ordersmightseemhighatasuperficiallevel,itisimpor- civilians having a history of 3+ multi-morbid mental
tanttorecognizethatmanyormostofthesecasescould disorders(11.3%vs.6.5%).Thepreenlistmentdisorders
havebeenrelativelymild.Thefindingofhigherlifetime of new soldiers were also relatively persistent, with re-
PTSD prevalence among new soldiers than civilians is currencesoccurringin32.5–61.3%ofyearssubsequent
consistent with research showing high rates of preen- to onset across disorders. These persistence results are
listment trauma exposure among military trainees,[28] generally consistent with the small amount of previous
while preenlistment PTSD may have also contributed researchthathasbeencarriedoutonbetween-disorder
tohighpreenlistmentGADduetoGADoftendevelop- differencesinpersistence.[36,37]
ingeitherinconjunctionwith(particularlywhenignor- Lifetimeprevalenceandpersistencewerenotstrongly
ing DSM’s hierarchy exclusion, as we did here) or sec- relatedtothesocio-demographiccharacteristicsofnew
ondary to PTSD.[29–31] The higher lifetime prevalence soldiers,althoughthesignsofthesemodestassociations
of CD among new soldiers than civilians could reflect were generally consistent with those found in previous
DepressionandAnxiety
ResearchArticle:MentalDisordersAmongNewU.S.ArmySoldiers 7
TABLE3.NumberofyearsofrecurrenceofDSM-IVinternalizingandexternalizingdisordersinquarter22011
throughquarter42012intheArmySTARRSNewSoldierStudy
Total RegularArmy Guard/Reserve Total
Mean SE Proportiona SE Mean SE Proportiona SE Mean SE Proportiona SE (n)
I.Internalizingdisorders
MDE 2.0 0.1 49.2 1.2 2.1 0.1 48.5 1.5 2.0 0.1 49.9 1.5 (2,544)
BPD 1.8 0.1 44.7 1.4 1.7 0.1 41.9* 2.0 1.9 0.1 48.3 2.1 (1,225)
GAD 2.1 0.1 52.3 1.0 2.2 0.1 51.4 1.4 2.1 0.1 53.3 1.5 (2,524)
PD 3.0 0.1 61.3 1.4 3.0 0.1 60.7 2.1 3.0 0.1 62.0 1.7 (1,016)
PTSD 1.5 0.0 34.6 0.9 1.5 0.0 34.9 1.3 1.4 0.0 34.3 1.1 (4,171)
II.Externalizingdisordersb
IED 3.5 0.0 57.7 0.6 3.6* 0.0 57.0 0.8 3.4 0.1 58.4 0.8 (5,387)
CD 3.6 0.1 43.4 1.1 3.7 0.1 43.7 1.3 3.5 0.1 42.9 1.9 (1,907)
ODD 4.4 0.1 51.8 0.8 4.5 0.1 51.6 1.0 4.4 0.1 52.2 1.2 (3,663)
SUD 1.2 0.0 32.5 0.7 1.3 0.0 33.2 1.0 1.2 0.1 31.6 1.2 (3,796)
DSM-IV, diagnostic and statistical manual of mental disorders, fourth edition; Army STARRS, Army Study to Assess Risk and Resilience in
Servicemembers; SE, standard error; MDE, major depressive episode; BPD, bipolar I-II or subthreshold bipolar disorder; GAD, generalized
anxietydisorder;PD,panicdisorder;PTSD,posttraumaticstressdisorder;IED,intermittentexplosivedisorder;CD,conductdisorder;ODD,
oppositionaldefiantdisorder;SUD,substanceusedisorder;ADHD,attention-deficit/hyperactivitydisorder.
∗Significant difference between the NSS Regular Army and NSS Guard/Reserve at the .05 level, two-sided test. Only one disorder differed
significantlyinmeanpersistence(IED)andanotherinproportionalpersistence(BPD)acrosssamples.
aProportionofyearswithrecurrenceistheratioofnumberofyearsinepisodebeyondtheyearofonsettototalnumberofyearssinceonset.
bPersistenceofattention-deficit/hyperactivitydisorderisnotassessedbytheCIDIscreeningscalesandisthusexcludedfromthistable.
studies.Forinstance,womenhadhigherratesofinter- tourofduty)isonepossibility,butthiswouldseemun-
nalizing disorders than men,[5,38] while Hispanics and likelygivenevidencethatsoldierswhohavebeentreated
Non-HispanicBlackshadlowerratesofmostdisorders formentaldisorderswhileinservicearelesslikelythan
than Non-Hispanic Whites.[39–42] The lower rates of other soldiers to remain in service.[46,47] Recall bias in
preenlistment disorders among immigrants are consis- datingageofdisorderonsetalsoseemsunlikelygiventhe
tentwiththe“healthyimmigrant”effectfoundingeneral tendencyforsuchdatingerrorstowardtelescoping.[15]A
populationstudies.[43–45] moreplausiblepossibility,inourview,isthatearly-onset
We noted in the introduction that an earlier Army mentaldisordersbecamemorechronicinthecontextof
STARRSreportofactivedutysoldiersexcludingthosein thehigherpreenlistmentprevalenceofsomeanxietydis-
BCTfoundthe30-dayprevalenceofhavingatleastone ordersandCDamongsoldiersthanciviliansinconjunc-
common DSM-IV disorder to be considerably higher tion with exposure to the special stresses experienced
among soldiers (25.1%) than a calibrated sample of by Army personnel. This possibility is indirectly con-
civilians (11.6%) and that the absolute prevalence of sistent with evidence that childhood adversities, which
30-day disorders with retrospectively-reported preen- arestronglyrelatedtoearly-onsetmentaldisorders,in-
listment onsets was significantly higher among soldiers teract with later traumatic experiences to increase risk
(19.2%)thancivilians(10.6%).Wealsonotedthatthis and severity of adult mental disorders[48–50] as well as
difference between soldiers and civilians could be due withthefindingintheearlierArmySTARRSreportthat
either to higher prevalence of preenlistment disorders 30-daymentaldisorderswithpreenlistmentonsetswere
orhigherpersistenceofpreenlistmentmentaldisorders moreseverelyimpairingthanthosethatonlystartedaf-
in the years after enlistment among soldiers than civil- terenlistment.[5]
ians.Thepossibilityofhigherpreenlistmentprevalence If preenlistment disorders do, in fact, have higher
is of special importance because it raises the question persistenceamongsoldiersthancivilians,thentargeted
whether early interventions should be carried out with postenlistmentinterventionsmightmakesensewithsol-
newsoldiers. diershavingahistoryofpersistentpreenlistmentmental
How should we make sense of the earlier Army disorders.Althoughthesewouldpresumablybeclinical
STARRS finding that the proportion of soldiers with interventions,theycouldalsohaveasecondarypreven-
30-daydisordersandpreenlistmentfirstonsetsishigher tion focus given that preenlistment disorders are pow-
thaninacalibratedciviliansampleinlightofthefinding erfulriskfactorsforseriousemotionalproblemsduring
reportedherefromtheNSSoflessconsistentdifferences later years of service. Screening to exclude applicants
in lifetime prevalence between new soldiers and civil- from service based on common preenlistment mental
ians?DifferentialselectionoutoftheArmy(i.e.,soldiers disorders,incomparison,wouldseemlessfeasiblegiven
with preenlistment mental disorders being more likely thehighprevalenceandwidesocio-demographicdistri-
than other soldiers to remain in service beyond a first butionofsuchdisorders.
DepressionandAnxiety
8 Rosellinietal.
TABLE4.Socio-demographicpredictorsoflifetimedisordersinquarter22011throughquarter42012oftheArmy
STARRSNewSoldierStudy(n=38,507)a
Anyinternalizing Anyexternalizing Anydisorder
OR (95%CI) OR (95%CI) OR (95%CI)
Sex
Women 1.7* (1.6–1.9) 0.9* (0.9–1.0) 1.2* (1.2–1.3)
Men – – – – – –
χ2 184.1* 5.0* 38.6*
1
ϕc 0.03 0.00 0.01
Race/ethnicity
Non-HispanicBlack 0.6* (0.5–0.6) 0.8* (0.8–0.9) 0.7* (0.7–0.8)
Non-HispanicWhite – – – – – –
Hispanic 0.7* (0.6–0.8) 0.9* (0.8–1.0) 0.8* (0.8–0.9)
Other 0.9 (0.8–1.1) 1.0 (1.0–1.1) 1.0 (0.9–1.1)
χ2 162.8* 46.7* 138.0*
3
ϕc 0.03 0.02 0.02
Soldiereducation
Somecollege/collegegraduate 0.8* (0.7–0.9) 0.8* (0.8–0.9) 0.8* (0.7–0.9)
Completedhighschool – – – – – –
Lessthanhighschool 1.0 (0.9–1.1) 1.0 (1.0–1.1) 1.0 (0.9–1.1)
χ2 10.3* 16.0* 16.4*
2
ϕc 0.01 0.01 0.01
Maritalstatus
Married – – – – – –
Previously/nevermarried 0.9 (0.8–1.1) 1.1* (1.0–1.2) 1.0 (0.9–1.1)
χ2 1.0 5.6* 0.6
1
ϕc 0.00 0.00 0.00
Religion
Protestant – – – – – –
Catholic 0.9 (0.8–1.0) 1.0 (0.9–1.0) 0.9 (0.9–1.0)
Otherreligion 1.3* (1.1–1.4) 1.1 (1.0–1.3) 1.2* (1.1–1.3)
Noreligion 1.0 (0.9–1.1) 1.0 (1.0–1.1) 1.0 (1.0–1.1)
χ2 15.6* 8.3* 15.3*
3
ϕc 0.01 0.01 0.01
Nativity
Immigrant 0.8* (0.7–0.9) 0.8* (0.7–0.9) 0.8* (0.7–0.9)
Firstgeneration 1.0 (0.9–1.1) 1.0 (0.9–1.1) 1.0 (0.9–1.1)
Second+generation – – – – – –
χ2 9.1* 21.2* 20.0*
2
ϕc 0.01 0.01 0.01
ParenteducationrelativetoSoldiereducation
Parentscollegegraduateb 1.0 (0.9–1.0) 1.0 (0.9–1.0) 1.0 (0.9–1.0)
Parentssomecollegecompletedb 0.9* (0.8–0.9) 0.9* (0.8–0.9) 0.9* (0.8–0.9)
Allother – – – – – –
χ2 12.0* 14.3* 18.1*
2
ϕc 0.01 0.01 0.01
Agec
Standardizedage 0.8* (0.8–0.8) 0.9* (0.8–0.9) 0.8* (0.8–0.9)
χ2 73.8* 78.9* 100.2*
1
ϕc 0.02 0.02 0.02
DSM-IV, diagnostic and statistical manual of mental disorders, fourth edition; Army STARRS, Army Study to Assess Risk and Resilience in
Servicemembers;OR,oddsratio;CI,confidenceinterval.
∗Significantlydifferentfromthereferencegroup(indicatedby–)atthe.05level,two-sidedtest.
aBased on a series of multivariate logistic regression equations controlling for version of the New Soldier Study survey, site of BCT, service
component,andallsocio-demographicpredictorslistedhere.
bParentscollegegraduate=atleastoneparentcompletedcollegeandthesoldierhadalowerlevelofeducationthancollegegraduation;Parents
somecollege=atleastoneparentcompletedsomecollegeandthesoldierhadalowerlevelofeducation.
cThemeanageofnewsoldierswas20.8years.
DepressionandAnxiety
ResearchArticle:MentalDisordersAmongNewU.S.ArmySoldiers 9
TABLE5.Socio-demographicpredictorsofpersistenceoflifetimedisordersinquarter22011throughquarter42012
oftheArmySTARRSNewSoldierStudya
Anyinternalizing Anyexternalizing Anydisorder
IRR (95%CI) IRR (95%CI) IRR (95%CI)
Sex
Women 1.2* (1.1–1.3) 1.1* (1.0–1.2) 1.1* (1.1–1.2)
Men – – – – – –
χ2 11.1* 5.3* 17.8*
1
ϕc 0.03 0.02 0.03
Race/ethnicity
Non-HispanicBlack 1.0 (0.9–1.1) 0.9* (0.8–0.9) 0.9* (0.8–1.0)
Non-HispanicWhite – – – – – –
Hispanic 1.0 (0.9–1.1) 0.9* (0.8–1.0) 0.9* (0.8–1.0)
Other 1.0 (0.8–1.1) 0.7* (0.6–0.8) 0.8* (0.8–0.9)
χ2 0.5 45.0* 25.1*
3
ϕc 0.01 0.06 0.03
Soldiereducation
Somecollege/collegegraduate 0.9 (0.7–1.1) 0.9 (0.8–1.1) 0.9 (0.8–1.1)
Completedhighschool – – – – – –
Lessthanhighschool 1.0 (0.9–1.1) 1.0 (0.9–1.1) 1.0 (0.9–1.1)
χ2 1.2 0.9 0.9
2
ϕc 0.01 0.01 0.01
Maritalstatus
Married – – – – – –
Previously/nevermarried 1.0 (0.9–1.2) 1.0 (0.9–1.1) 1.0 (0.9–1.1)
χ2 0.1 0.1 0.2
1
ϕc 0.00 0.00 0.00
Religion
Protestant – – – – – –
Catholic 1.0 (0.9–1.1) 1.0 (0.9–1.1) 1.0 (0.9–1.1)
Otherreligion 1.1 (0.9–1.3) 1.0 (0.9–1.2) 1.1 (1.0–1.2)
Noreligion 1.1 (1.0–1.2) 1.0 (1.0–1.1) 1.0 (1.0–1.1)
χ2 2.6 0.9 4.0
3
ϕc 0.02 0.01 0.01
Nativity
Immigrant 0.7* (0.6–0.8) 0.8* (0.7–1.0) 0.8* (0.7–0.9)
Firstgeneration 0.9 (0.8–1.0) 0.8* (0.7–0.9) 0.8* (0.8–0.9)
Secondgeneration – – – – – –
χ2 16.4* 21.4* 33.4*
2
ϕc 0.04 0.04 0.04
ParenteducationrelativetoSoldiereducation
Parentscollegegraduateb 0.9* (0.8–1.0) 1.1* (1.0–1.2) 1.0 (0.9–1.0)
Parentssomecollegecompletedb 0.9 (0.8–1.0) 1.0 (1.0–1.1) 1.0 (0.9–1.0)
Allother – – – – – –
χ2 10.2* 8.5* 0.2
2
ϕc 0.03 0.02 0.00
Age
AOO 0.9* (0.9–0.9) 0.9* (0.9–0.9) 0.9* (0.9–0.9)
χ2 91.8* 86.7* 154.4*
1
ϕc 0.09 0.08 0.08
Timesinceonset 0.9* (0.9–0.9) 0.8* (0.8–0.9) 0.9* (0.8–0.9)
χ2 184.7* 623.0* 800.9*
1
ϕc 0.13 0.20 0.18
(n) (11,480) (14,753) (26,233)
ArmySTARRS,ArmyStudytoAssessRiskandResilienceinServicemembers;IRR,incidentrateratio;AOO,ageofonset.
∗Significantlydifferentfromthereferencegroup(indicatedby–)atthe.05level,two-sidedtest.
aBasedonaseriesofnegativebinomialequationscontrollingforversionoftheNewSoldierStudysurvey,siteofBCT,servicecomponent,andall
socio-demographicpredictorslistedhere.
bParentscollegegraduate=atleastoneparentcompletedcollegeandthesoldierhadalowerlevelofeducationthancollegegraduation;Parents
somecollege=atleastoneparentcompletedsomecollegeandthesoldierhadalowerlevelofeducation.
DepressionandAnxiety