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 focuses on the results of the active component.
This report examines the mental health and emotional health scores. Some results are also compared to the Healthy People 2020 (HP2020) goals for the US Department of Health and Human Services population.
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.
General Mental health status
The HRBS assesses overall mental health status using the Kessler-6 (K6), a commonly used measure of severe non-specific psychological distress. The K6 is designed to distinguish between anxiety that indicates a psychiatric disorder that would be identified and treated by a clinician, 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 people with a score of 13 or more as suffering from severe psychological distress, which is in line with accepted industry practice.
According to the HRBS, 16.4 percent (confidence interval [CI]: 15.5-17.4) of all active duty service members reported experiencing severe psychological distress in the past year and 9.6 percent (CI: 8.7-10.4) in the past 30 days. By comparison, the National Survey on Drug Use and Health (NSDUH) found that 10.8% of US adults aged 18 and older experienced severe psychological distress in the past year.
The NSDUH and similar surveys using K6 found that 2.9-5.2% of US adults experienced severe psychological distress in the past 30 days. In other words, severe psychological distress appears to be more common among military personnel than in the US population in general. In the Army, Navy, and Marines, severe psychological distress is more common than in other services. It is also higher among younger service members than in other services.
Although the majority of people who experience traumatic events do not develop PTSD, those with PTSD suffer significant disability, morbidity, and health risk behaviors compared to the general population. Exposure to traumatic events, particularly combat, is a known risk in military service. PTSD can contribute to soldiers' suspension, absenteeism and abuse.
In the 2018 HRBS, PTSD was measured by a brief screening survey that asked respondents whether 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. It should be noted that this does not mean that a doctor has made or will make a formal diagnosis of PTSD.
The HRBS showed that 10.4% (CI: 9.6-11.1) of operational participants were likely to have PTSD, higher than the estimated rate of likely PTSD in the general population (around 3.5% in the past year), but lower than some estimates of likely PTSD in military personnel (13-18%) after recent combat operations. Probable PTSD was more common in the Army, Navy and Marine Corps than in the Air Force and Coast Guard.
Aggression and Anger
Anger and aggression were common among veterans. Angry or aggressive behavior can lead military personnel to physically harm 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 slapped someone, made a violent threat, or fought or hit someone.
Overall, 49.1 percent (CI 47.9-50.3) of operational staff reported that at least one of these four behaviors had occurred in the past 30 days, and 7.1 percent reported that one or more of these behaviors had occurred at least five times in the past 30 days.
Angry and aggressive behaviors in the past 30 days were more common in the Army, Navy and Marines than in the Air Force and Coast Guard. The frequency of angry and aggressive behavior in the past 30 days was higher in the Navy than in all other services.
Sexual assault can have serious consequences for both the victim and society. Negative consequences for the victim may include direct physical harm from the assault itself, increased risk of sexually transmitted diseases, pregnancy, mental health problems (e.g. PTSD), and chronic physical health problems.
The 2018 HRBS survey found that 9.6 percent (CI: 9.0-10.2) of all active duty service members reported experiencing unwanted sexual contact since joining the military, and 2.5 percent (CI: 2.1-2.9) reported experiencing unwanted sexual contact in the past 12 months. These figures were similar across services.
Women were significantly more likely to report unwanted sexual contact than men. Among women in the active component, 31.6% (CI 29.7-33.4) reported having experienced unwanted sexual contact since joining the military, and 9.1% (CI 7.7-10.5) had experienced it in the past 12 months.
Among men in the active component, 5.2% (CI 4.6-5.7%) reported unwanted sexual contact after joining the military, and 1.2% (CI 0.9-1.5%) had experienced it in the past 12 months. It is important to note that the WGRA (Workplace and Gender Relations in the Active Duty Military) survey and the HRBS survey measure different constructs. The WGRA measures sexual violence.
The HRBS measures unwanted sexual contact, which is a broader construct. The HRBS defines unwanted sexual contact 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. The 2018 HRBS questions are also not comparable to current civilian surveys.
Physical abuse is associated with a number of negative consequences, including PTSD and other psychological problems. The HP2020 target is to reduce the number of physical assaults from 21.3 to 19.2 per 1000 population.
According to the HRBS, 5.3 percent (CI: 4.8-5.8) of military personnel have experienced physical violence since joining the military, and 1.1 percent (CI: 0.8-1.4) reported experiencing physical violence in the past 12 months.
In 2016, 1.7% of those aged 12 and older reported experiencing physical violence in the past year. Active duty Marines were more likely to report experiencing physical violence since joining the military than members of any other service.
Suicide rates have increased in most US states in recent years. In 2017, the suicide death rate was 14.0 suicide deaths per 100,000 population; the HP2020 program aims to reduce this rate to 10.2 per 100,000 population.
Reports of an increase in suicide rates among active duty service members have attracted considerable attention and prompted significant investment in research and prevention. In guiding these efforts, it is important to assess service members' experiences of suicidal thoughts and behaviours.
According to 2018 HRBS data, in the past 12 months, 8.3 percent (CI: 7.5-9.0) of all active-duty service members reported suicidal thoughts, 2.7 percent (CI: 2.3-3.2) reported suicide plans, and 1.2 percent (CI: 0.9-1.6) reported suicide attempts. These figures are higher than in the general population.
The 2018 NSDUH survey found that of all adults aged 18 years and older, 4.3% had suicidal thoughts, 1.3% had suicide plans, and 0.6% reported suicide attempts. On the active side, suicidal thoughts in the past 12 months were more common in the Army, Navy and Marines than in the Air Force and Coast Guard.
Several forms of gambling have become increasingly available and legal in the United States. The increasing availability of gambling has raised concerns about problem gambling, which has harmful consequences for the individual, and gambling disorder, a psychiatric disorder characterized by loss of control over gambling behavior and severe 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 “had to lie to people important to you about how much you gamble” or whether they had “ever felt the need to gamble more and more and more money” in the past 12 months.
Those who answered yes to either of these questions were considered to have a gambling problem. The HBRS study found that 1.6% (CI 1.3-1.9) of the active population had a gambling problem. This is lower than the estimated 2.3% of problem gamblers among US civilians in the early 2000s.
Services for Mental Health
Military personnel and civilians have long been concerned about the underuse of mental health services. Therefore, the HRBS survey asked respondents about their use of mental health services, their need for mental health services, and barriers to accessing mental health services.
Overall, 25.5 percent (CI: 24.4-26.5) of active duty military reported using mental health services in the past 12 months. This 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 having received mental health services.
In active duty units, more military, Marine Corps, and Navy personnel used mental health services in the past 12 months than Air Force or Coast Guard personnel (Figure 4). Those who used mental health services reported an average of 11.9 visits (CI 11.0-12.9), with little variation between services.
Among all respondents, 6.8% (CI 6.2-7.5) reported having an unmet need for mental health care in the past 12 months. Respondents who felt that their needs were not met included both those who received no care and those who received some care but reported needing more or different care 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; 53.7% (CI 50.2-57.3) reported this reason. This result is consistent with studies of the civilian population, which show that lack of 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 manager/unit head 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, 34.2% (CI 33.1-35.4) answered yes.
Summary and Suggestions for Politics
HRBS 2018 shows that symptoms of psychological distress are common among service members. Left untreated, these symptoms can persist and lead to significant functional impairments that affect military well-being and force readiness.
The military already invests significant resources in military mental health monitoring and programs to mitigate the negative impact of mental health problems on soldiers' well-being. The Department of Defense and the Coast Guard must continue their efforts to monitor, understand and support soldiers' mental health.
About half of Active Component members also reported recent angry or aggressive behavior. About a tenth reported unwanted sexual contact since joining the military, and nearly a third of women reported unwanted sexual contact. Around one in 20 active service personnel reported experiencing physical violence during their military service.
Around one in 12 active military personnel reported suicidal thoughts in the past year, almost twice the rate of 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 military should also collect more data on suicide risk indicators to improve prevention efforts.
RAND conducted the 2018 HRBS survey among active duty and reserve military personnel in the US Air Force, Army, Navy, Marine Corps, and Coast Guard from October 2018 to March 2019. The 2018 HRBS survey 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 9.6%, giving a final analytical sample of 17 166 responses. Missing data were handled using imputation, a statistical procedure in which available data are used to estimate missing values.
To represent the active population, RAND researchers weighted responses to account for over-sampling of service members in some sections. Point estimates and 95% CIs are presented in this research report.
RAND researchers tested whether there were differences in each outcome by 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 for all possible pairwise comparisons by factor levels (e.g. men and women).
Readers interested in these differences should refer to the full final report of the active component of HRBS 2018. This summary is one of eight in the active 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 the results and policy implications. A similar series of eight reports discusses the results of the reserve component.
Restrictions and Limitations
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.
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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.