The Health Behavior and Behavior Survey (HRBS) is the US Department of Defense's (DoD) primary survey of the health, health behaviors and well-being of military personnel. The HRBS, which has been conducted regularly for more than 30 years, covers areas that may affect military readiness or the ability to meet the demands of military life.
The Department of Defense commissioned the RAND Corporation to review and implement the 2018 HRBS for active and reserve military personnel. This report examines the results for the Reserve.
This summary examines the results for mental health and mental health. Some results are also compared to the Healthy People 2020 (HP2020) goals for the US population set by the US Department of Health and Human Services.
Because military personnel are significantly different from the general population (for example, members of the armed forces are more likely to be young and male than the general population), these comparisons are presented for comparative purposes only.
Status of Mental Health
The HRBS assessed overall mental health status using the Kessler Mental Health Scale 6 (K6), a commonly used measure of non-specific severe psychological distress. The K6 is designed to distinguish between anxiety that indicates a psychiatric disorder that would be identified and treated by a physician, and anxiety that is commonly experienced but does not indicate illness.
Respondents were asked about their level of stress in the past 30 days and the worst month in the past year they had experienced. The researchers calculated a K6 score and classified respondents with a score of 13 or more as suffering from severe psychological distress, in line with accepted industry practice.
According to the HRBS, 10.7 percent (confidence interval [CI]: 9.9-11.5) of all reservists reported experiencing severe psychological distress in the past year and 6.5 percent (CI: 5.8-7.1) in the past 30 days.
In comparison, the National Survey on Drug Use and Health (NSDUH) found that 10.8% of US adults aged 18 years or older had experienced severe psychological distress in the past year; the NSDUH and similar surveys using K6 found that 2.9-5.2% of US adults had experienced severe psychological distress in the past 30 days.
Although most people who have experienced a traumatic event do not develop post-traumatic stress disorder (PTSD), people with PTSD suffer from significant impairment, higher morbidity and higher risk behaviours than the general population.
Exposure to traumatic events, particularly combat, is a known risk in military service. PTSD can contribute to military personnel's suspension, absenteeism and misconduct. In the 2018 HRBS, PTSD was measured by a brief screening survey that asked if they had experienced a traumatic life event and, if so, whether they had experienced symptoms typical of PTSD in the past 30 days.
Responses to the screening measure were used to identify respondents who were likely to have PTSD, meaning that they had a high likelihood of developing PTSD based on the confirmation of typical symptoms. This does not mean that a doctor has made or will make a formal diagnosis of PTSD.
The HRBS survey showed that 9.3 percent (CI: 8.6-9.9) of reservists reported symptoms consistent with probable PTSD in the past 30 days. This was higher than the estimate for probable PTSD in the past year in the general population (3.5% ).
Aggresion and Anger
Anger and aggression are common among veterans. Angry or aggressive behavior can lead to military personnel physically harming themselves or others, can lead to domestic violence and other illegal acts, and can impair military readiness.
The 2018 HRBS survey asked respondents how often in the past 30 days they had been angry at someone and yelled or screamed at them, been angry at someone and punched, hit or stomped on someone, made violent threats, or fought or hit someone.
Overall, 46.9 percent (CI 45.7-48.1) of reservists reported using at least one of these four behaviors in the past 30 days, and 6.2 percent (CI 5.6-6.8) reported using one or more of these behaviors at least five times in the past 30 days.
Sexual Violence and Abuse
Sexual violence can have serious consequences for both the victim and society. Negative consequences for the victim can include direct physical harm from the assault itself, increased risk of sexually transmitted infections, pregnancy and mental health problems such as stress disorder and chronic physical health problems.
The 2018 HRBS survey found that 7.8 percent (CI: 7.3-8.3) of all reservists reported experiencing unwanted sexual intercourse since joining the military and 1.6 percent (CI: 1.2-1.9) reported experiencing unwanted sexual intercourse in the past 12 months. Women reported experiencing unwanted sexual contact significantly more often than men.
Among reservists, 24.0% (CI 22.5-25.6) reported unwanted sexual contact since joining the military and 4.6% (CI 3.5-5.6) reported unwanted sexual contact in the past 12 months. Among male reservists, 3.6% (CI 3.1-4.2) reported unwanted sexual contact since joining the army and 0.8% (CI 0.5-1.1) reported it in the last 12 months. It is important to note that the Work and Gender Responsiveness Survey (WGRR) and HRBS for reservists measure different concepts.
The WGRR measures sexual offences. HRBS measures unwanted sexual contact, which is a broader concept. In the HRBS, unwanted sexual contact is defined as “the number of times someone has touched you sexually, had sex with you, or tried to have sex with you when you did not or could not give consent.” By sexual touching we mean any sexual touching, oral, anal or vaginal intercourse. Therefore, the results of the two studies are not comparable.
Physical aggression is associated with a number of negative consequences, including PTSD and other psychological problems. One of the HP2020 targets is to reduce physical aggression from 21.3 to 19.2 per 1000 population.
According to the HRBS, 3.8% (CI: 3.4-4.2) of reservists reported experiencing physical violence since joining the military, and 0.7% (CI: 0.5-0.9) reported experiencing physical violence in the past 12 months, while 1.7% of those aged 12 and older reported experiencing physical violence in the past year in 2016.
Suicide rates have increased in most US states in recent years. In 2017, the suicide death rate was 14.0 deaths per 100,000 population; the HP2020 program aims to reduce the rate to 10.2 deaths per 100,000 population.
Reports of an increase in suicides among military personnel have attracted considerable attention and led to significant investment in research and prevention. In guiding these efforts, it is important to assess service members' experiences of suicidal thoughts and behaviours.
The 2018 HRBS survey found that in the past 12 months, 6.0 percent (CI: 5.4-6.6) of all reservists confirmed suicidal ideation, 2.0 percent (CI: 1.6-2.4) reported suicide plans, and 0.9 percent (CI: 0.6-1.3) reported suicide attempts.
These figures are higher than in the general population. The 2018 NSDUH survey found that among all adults aged 18 years and older, 4.3% confirmed suicidal ideation, 1.3% confirmed suicide plans, and 0.6% reported suicide attempts.
Many forms of gambling are increasingly available and legal in the US. The increasing availability of gambling raises concerns about problem gambling, which has harmful consequences for the individual, and gambling disorder, a psychiatric disorder characterised by loss of control over gambling behaviour and severe functional impairment.
Both problem gambling and gambling disorder are associated with other problem behaviours and adverse life events. Concerns about problem gambling and gambling disorders among the military have increased due to evidence that military personnel are at high risk.
In the 2018 HRBS, pathological gambling was assessed using the Lie-Bet questionnaire. This questionnaire asked respondents whether they had been forced to “lie to people important to them about their gambling” or whether they had “ever felt the need to gamble more and more money” in the past 12 months.
People who answer yes to either of these questions are considered to have a gambling problem. According to the HBRS survey, 1.7% (CI: 1.4-2.1) of reservists had a gambling problem. This is lower than the estimated 2.3% problem gamblers among US civilians in the early 2000s.
Mental health Offers
Military personnel and civilians have long been concerned about the low use of mental health services among those who need them. In response, the HRBS survey asked respondents about their use of mental health services, unmet needs for mental health services and barriers to accessing mental health services.
Overall, 21.0% (CI: 20.1-21.9%) of reservists reported having used mental health services in the past 12 months. This proportion was higher than comparable figures for the general population; in the 2018 NSDUH survey, 15.2% of 18-25 year olds and 16.1% of 26-49 year olds reported receiving mental health services. Those who had used mental health services reported an average of 9.7 visits (CI 9.0-10.5) in the past year.
Among all respondents, 4.6% (CI 4.1-5.0) reported an unmet need for mental health care in the past 12 months. Respondents with an unmet need included both those who received no treatment and those who received some treatment but reported needing more or different treatment than they received.
HRBS asked two groups of respondents why they did not seek mental health treatment. The first group included those who reported that they felt they needed treatment that they did not receive. The second group included those who scored 8 or higher on the K6 scale, indicating at least moderate anxiety, but who also did not receive mental health treatment.
The most common reason for not seeking mental health help for these two groups of respondents was that they did not feel they needed it; 55.8% (CI 51.6-60.0) reported this reason. This result is consistent with studies of the civilian population, which show that lack of perceived need is the most common reason why people with mental health problems do not seek treatment.
Other frequently cited reasons for not seeking mental health treatment – “It would have harmed my career”, “Members of my unit may trust me less”, “My supervisor/unit manager may think badly of me or treat me differently” – are related to the potential negative career-related consequences of seeking treatment.
In the HRBS survey, participants were asked whether they thought that seeking mental health counselling or treatment through the military would be detrimental to their military career. Overall, 29.9% (CI 28.8-30.9) answered in the affirmative.
Comparisons with Active Members
RAND researchers developed regression models to compare HRBS results for active and reserve military personnel, taking into account respondents' demographic characteristics. Significant differences between reservists and active duty service members included the following:
- Lower likelihood of having serious psychological problems and PTSD.
- Lower likelihood of recent anger or aggressive behavior, unwanted sexual contact, and physical aggression.
- Lower likelihood of suicidal thoughts, plans and attempts.
- Are less likely to use mental health services or feel that their need for mental health services is unmet.
Conclusions and policy implications
The 2018 HRBS shows that symptoms of mental distress were prevalent among service members. Left untreated, these symptoms can persist and lead to significant functional impairments that impact military well-being and force readiness.
The military is already investing significant resources in military mental health monitoring and programs to mitigate the negative impact of mental health on soldiers' well-being. The Department of Defense, the services, and the Coast Guard must continue their efforts to monitor, understand, and support military mental health. Suicidal ideation is more common among reservists than the general population.
The military has made significant investments in efforts to understand and prevent suicide in the military. Future work should examine whether different prevention strategies (e.g. according to risk level) are needed for different service groups. The Ministry of Defence, the services and the Coast Guard should also collect more information on suicide warning signs in order to improve prevention efforts.
RAND conducted the 2018 HRBS survey among active duty and reserve military personnel in the U.S. from October 2018 to March 2019. Five reserve components – Air Force, Army, Navy, Marine Corps, and Coast Guard – and two National Guard components – Air National Guard and Army National Guard – participated in the Reserve Component Survey.
The 2018 HRBS was a confidential online survey that allowed researchers to target reminders to non-respondents and reduce survey burden by linking responses to administrative data. The sample was selected using a random sampling method stratified by grade level, grade and gender.
The overall weighted response rate to the survey was 9.4%, resulting in a final analytical sample of 16,475 responses for the reserve. To address missing data, RAND researchers used imputation, a statistical procedure that uses available data to estimate missing values. To represent the reserve population, responses were weighted to avoid underrepresenting service members in certain strata. Point estimates and 95% CIs are presented in this survey report.
RAND researchers tested whether there were differences in each outcome at key factor levels or subgroups – service area, salary level, gender, race/ethnicity, and age group – using a two-step procedure based on the Rao-Scott chi-square test for overall differences in factor levels, and if the overall test was statistically significant, a two-sample t-test examining all possible pairwise comparisons between factor levels (e.g. men and women).
Readers interested in these differences should consult the full final report of the HRBS 2018 Reserve Component. This summary is one of eight in the Reserve Component; this summary and six of the other seven summaries correspond to different chapters in the full report, with the eighth summary providing an overview of all findings and policy implications. A similar series of eight reports analyses the results of the active component.
The response rate to the survey is considered low. While low response rates do not automatically mean that the survey data are biased, they do increase the possibility of bias. As with any self-report survey, social desirability bias is possible, especially for sensitive questions and topics. For some groups, representing a small percentage of the total military population, survey estimates may be inaccurate and should be interpreted with caution.
David W. Newton is a board certified pharmacist and also has been a board member for boards of examiners for the National Association of Boards of Pharmacy since 1983. His areas of expertise are primarily pharmaceuticals as well as cannabinoids. You can read an article about his expertise in CBD on the National Library of Medicine.