The relative impact of injury and deployment on mental and physical quality of life among military service members

Claire Kolaja; Sheila F. Castañeda; Susan I. Woodruff; Rudolph P. Rull; Richard F. Armenta; for the Millennium Cohort Study Team

doi:10.1371/journal.pone.0274973

Peer Review History

Original SubmissionMarch 23, 2022
14 Jun 2022 Decision Letter - Gabriel G. De La Torre, Editor PONE-D-22-08419The Relative Impact of Injury and Deployment on Mental and Physical Quality of Life among Military Service MembersPLOS ONE Dear Dr. Kolaja, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jul 29 2022 11:59PM If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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I review it myself in order to determine whether it (a) is appropriate for this journal (sometimes the topic or focus is more appropriate for another journal; (b), is consistent with current publishing preferences and priorities, or (c) is unlikely to reach the standards usually required for publication. Based on reviewers reports I recommend major revision. I hope that reviewers comments may help you improve the document before resubmitting revision. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: No Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The introduction requires a better explanation of why this study is necessary. I understand that with such a large sample and a 4-year follow-up this study is quite interesting and relevant. However, the discourse is not well constructed and I did not find it easy to read (I am not a native speaker). The first thing I need to understand is why this study is necessary, what gaps or gaps does it fill that other previous studies have not done, what factors have influenced the quality of life of the participants according to previous studies, have received any kind of treatment in both physical and mental health, which ones? It is also not clear to me what the research problem is. I think that with the potential data and the number of participants the work has to give much more play and statistical analysis based on its longitudinally. It requires figures such as the participant selection procedure and follow-up graphs. There are many errors when quoting, in the text I have indicated that they should be corrected. For example, instead of "...rapid effective medical care.(1)" it should read "rapid effective medical care (1)." Thus throughout the document. What were your hypotheses by the way? The material and methods section should be divided into sections: participants and selection procedure, instruments clearly explained, and data analysis to be performed,... If you don't explain the instruments well, how can the rest of us interpret the results obtained? The discussion is not based on the results of the data correctly because they have not done a longitudinal statistical analysis properly. It is worthwhile for the impact of the work, the number of participants and the collective that they are that this work is polished and better written and presented. Reviewer #2: This manuscript explores the possible impacts of injury and deployment on the mental and physical quality of life of military service members. The topic, as such, is of great interest to physicians, psychologists, neuroscientists, and other readers, not to mention the military itself. The goal of the study is to understand the relative contribution of deployment and injury status (both battle and non-battle) on the long-term physical and mental Quality of Life of service members. However, this objective strikes me as not clear or concise, i.e., too broad. Establish a quantifiable objective. What are you trying to find out with this study in more operational terms. In terms of method. Introduce the participants. Show the profile of the participants. Since data on covariates (i.e., age, marital status, education, education, component, service branch, pay grade, 156 number of deployments, health behaviors, mental health, and life stressors) were assessed at the 157 baseline survey. Sex, age at baseline, race and ethnicity (i.e., non-Hispanic White, non-Hispanic 158 Black, and other), present the sample with these data. How old are they? What gender? Why were PTSD Symptoms described according to the criteria defined in DSM-IV, if DSM V already exists? Recently, the DSM-5 (American Psychiatric Association, APA, 2013) separated the diagnostic classes for depressive and anxiety disorders. It would be interesting to see if there is an underlying anxiety disorder, independent of PTSD. What is the future work? By changing these recommendations I consider that the manuscript is ready for publication. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Jose M Mestre, Department of Psychology, Universidad de Cadiz, Spain Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: PONE-D-22-08419.pdf https://doi.org/10.1371/journal.pone.0274973.r001
Revision 1
5 Aug 2022 Author Response Response to Reviewer Comments PONE-D-22-08419 We appreciate the Reviewers’ thoughtful and positive comments and suggestions. Our responses to Reviewers’ comments and a detailed description of manuscript changes are outlined below in bolded text following the Reviewers’ comments. Our edits to the manuscript are identifiable with highlighted changes as instructed. Reviewer #1: The introduction requires a better explanation of why this study is necessary. I understand that with such a large sample and a 4-year follow-up this study is quite interesting and relevant. However, the discourse is not well constructed and I did not find it easy to read (I am not a native speaker). The first thing I need to understand is why this study is necessary, what gaps or gaps does it fill that other previous studies have not done, what factors have influenced the quality of life of the participants according to previous studies, have received any kind of treatment in both physical and mental health, which ones? It is also not clear to me what the research problem is. RESPONSE: Thank you for pointing out the introduction could be strengthened. To address this, we have modified the introduction for ease of understanding. Specifically, the first paragraph now introduces the prevalence of injured U.S. service members from recent military conflicts; the second paragraph introduces quality of life and the reason to examine it as an outcome; and the third paragraph lays out the previous research on risk factors associated with quality of life, including military specific risk factors. Finally, the end of the introduction now explicitly states the rational for this study. In the introduction we have highlighted that much of the previous literature has focus on certain type of injuries (such as amputation or concussion) in relation to specific diagnosable outcomes (such as PTSD), lacked a control groups (i.e., those not deployed and those deployed who were not injured), were cross-sectional, or were not able compare battle with non-battled injuries even though non-battle injuries account for a third of causalities. Data from the Millennium Cohort Study was able to address these limitations in a representative, longitudinal cohort where enrollment was not based on injury and was able to examine the combined effect of deployment and injury type on QOL, which has been increasingly recognized as an integral component of healthcare. I think that with the potential data and the number of participants the work has to give much more play and statistical analysis based on its longitudinally. RESPONSE: We appreciate the reviewer’s concern about the statistical methods used for this project. From the comments we are unsure what statistical analyses are being requested but in reviewing the literature we found that two time point analysis, as we applied, is recommended for longitudinal studies to measure changes in score (Garcia, 2017). This statistical method has advantages as it is simple to apply and understand. As the Millennium Cohort Study is an ongoing longitudinal study the analyses conducted for this project relied on survey data available from 2001 to 2016. In addition, this analytic technique has been used for several Millennium Cohort Study projects previously (Adler et al., 2020; Cooper et al, 2020; Jacobson et al., 2021). References: Adler, Amy B., et al. "Magnitude of problematic anger and its predictors in the Millennium Cohort." BMC Public Health 20.1 (2020): 1-11. Cooper, Adam D., et al. "Mental health, physical health, and health-related behaviors of US Army Special Forces." Plos one 15.6 (2020): e0233560. Garcia, Tanya P., and Karen Marder. "Statistical approaches to longitudinal data analysis in neurodegenerative diseases: Huntington’s disease as a model." Current neurology and neuroscience reports 17.2 (2017): 1-9. Jacobson, Isabel G., et al. "Combat Experience, New-Onset Mental Health Conditions, and Posttraumatic Growth in US Service Members." Psychiatry 84.3 (2021): 276-290. It requires figures such as the participant selection procedure and follow-up graphs. RESPONSE: Thank you for the suggestion; we have added a new Figure 1 which is a time line and Figure 2 which is a flowchart showing how we arrived at the eligible sample. There are many errors when quoting, in the text I have indicated that they should be corrected. For example, instead of "...rapid effective medical care.(1)" it should read "rapid effective medical care (1)." Thus throughout the document. RESPONSE: Thank you for pointing we were not following the correct formatting guidelines; we have corrected the citations throughout the paper. What were your hypotheses by the way? RESPONSE: We appreciate this suggestion and have added our hypothesis, “1. injured service members will report poorer QOL than non-injured participants and 2. battle-injured service members will report the overall lowest QOL.”, at the end of the introduction. The material and methods section should be divided into sections: participants and selection procedure, instruments clearly explained, and data analysis to be performed,... RESPONSE: To better navigate the Methods Section we have added sub-headers (i.e., “Participants”, “Selection procedure”, and “Measures”) as suggest (see page 5 of the manuscript). If you don't explain the instruments well, how can the rest of us interpret the results obtained? RESPONSE: Thank you for this suggestion, we have provided additional language and references to the methods section to clarifying the instruments used and how they were scored. The discussion is not based on the results of the data correctly because they have not done a longitudinal statistical analysis properly. RESPONSE: As mentioned above, we have applied a recommended and widely used statistical method that has been applied to previous Millennium Cohort Study projects. In this study, participants were measured at two time points, with an average of 4.3 years between the surveys and all risk factors were assessed at baseline (e.g., before the outcomes of interest) so that temporal associations could be examined. The discussion section is first divided into paragraphs by the primary predictor, deployment and injury status, then touches on the effect of baseline QOL (see paragraph 5 in the discussion), limitations and strengths of this project, and conclusions. We have edited the discussion throughout to clarifying when we are discussing our findings. It is worthwhile for the impact of the work, the number of participants and the collective that they are that this work is polished and better written and presented. RESPONSE: We appreciate the reviewer’s feedback and suggestions on how to improve the manuscript. The paper has been edited throughout to clarify the rationale for the project and the statistical analyses used. Figure 1 below shows that two Millennium Cohort Study surveys (black points) were used for all eligible participants with an average of 4.3 years between completed surveys. The injured participants completed a Millennium Cohort Study survey before and after the injury, while the rest of the participants were categorized based on deployment date information from administrative data observed between Time 1 and Time 2. We have included a timeline as Figure 1 and a flowchart as Figure 2 to the paper. Reviewer #2: This manuscript explores the possible impacts of injury and deployment on the mental and physical quality of life of military service members. The topic, as such, is of great interest to physicians, psychologists, neuroscientists, and other readers, not to mention the military itself. The goal of the study is to understand the relative contribution of deployment and injury status (both battle and non-battle) on the long-term physical and mental Quality of Life of service members. However, this objective strikes me as not clear or concise, i.e., too broad. Establish a quantifiable objective. What are you trying to find out with this study in more operational terms. RESPONSE: Thank you for this suggestion, we have modified the introduction to clarify the aims and added hypotheses at the end of the introduction so that readers understand the rational for this project. In terms of method. Introduce the participants. Show the profile of the participants. Since data on covariates (i.e., age, marital status, education, education, component, service branch, pay grade, 156 number of deployments, health behaviors, mental health, and life stressors) were assessed at the 157 baseline survey. Sex, age at baseline, race and ethnicity (i.e., non-Hispanic White, non-Hispanic 158 Black, and other), present the sample with these data. How old are they? What gender? RESPONSE: We appreciate your suggestions and have add information about the sociodemographic characteristics of the Millennium Cohort Study to the methods section. Why were PTSD Symptoms described according to the criteria defined in DSM-IV, if DSM V already exists? RESPONSE: The Millennium Cohort Study began surveying participants in 2001 before the Diagnostic and Statistical Manual of Mental Disorders updated the case definition for PTSD in 2013. Therefore, this study measured PTSD based on DSM-IV criteria as it was the PTSD measure that was assessed on the surveys between 2001 and 2016. We have added a limitation that the DSM-IV criteria was used for these analyses. The Millennium Cohort Study survey has switched to the PCL-5 in 2019, which corresponds to the DSM-V criteria, so that future studies can utilize that updated version. Additionally, analyses from the 2019 survey cycle found that there is substantial overlap between the two measures (LeardMann et al., 2021). Reference: LeardMann, Cynthia A., et al. "Comparison of posttraumatic stress disorder checklist instruments from diagnostic and statistical manual of mental disorders, vs fifth edition in a large cohort of US military service members and veterans." JAMA network open 4.4 (2021): e218072-e218072. Recently, the DSM-5 (American Psychiatric Association, APA, 2013) separated the diagnostic classes for depressive and anxiety disorders. It would be interesting to see if there is an underlying anxiety disorder, independent of PTSD. RESPONSE: We appreciate the suggestion to investigate other mental health condition as predictors of QOL. Because of the low prevalence for panic and anxiety, as measured by the Patient Health Questionnaire (approximately 2% and 3%, respectively) and small cell sizes (i.e., less than 10) we were prohibit in using these mental health screeners in these analyses but agree future studies should examine the influence of anxiety symptoms. What is the future work? RESPONSE: We plan on extending our research on the long-term impact of injury and types of injury (e.g., musculoskeletal injuries, traumatic brain injury) to examine other health and economic outcomes among veterans and service members. By changing these recommendations, I consider that the manuscript is ready for publication. RESPONSE: Thank you for taking the time to review this publication. Attachments Attachment Submitted filename: Response to Reviewers 28JUL22.docx https://doi.org/10.1371/journal.pone.0274973.r002
8 Sep 2022 Decision Letter - Darrell Eugene Singer, Editor The Relative Impact of Injury and Deployment on Mental and Physical Quality of Life among Military Service Members PONE-D-22-08419R1 Dear Dr. Kolaja, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: They have addressed most of my main concerns. They conducted a large sample and their conclusions were supported by the new amendments. Their article of how prevention and rehabilitation interventions should focus on improving physical health among injured service members to avoid long-term adverse effects might be cited for similar studies with this kind of military samples.. Reviewer #2: Thanks to the authors for taking into consideration the recommendations made by the reviewers. I value positively the inclusion of the two hypotheses to the work. I would recommend, however, that the hypotheses be quantifiable. What is a "poorer QOL" in operational terms? A hypothesis should be measurable and replicable in future work. This way of describing it can lead to ambiguous interpretation of it. On the other hand, I appreciate the clarification regarding the participants, but this should be more detailed. So that it helps the reader to have a clear mental scheme of what this sample consists of. There is a lack of data. I think it would help to describe it in more depth (percentage of each sex, percentages of each race and ethnicity, age ranges, etc). Despite these weaknesses, to be taken into account in future work, I consider the manuscript ready for publication. Translated with www.DeepL.com/Translator (free version) ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: They have addressed most of my main concerns. They conducted a large sample and their conclusions were supported by the new amendments. Their article of how prevention and rehabilitation interventions should focus on improving physical health among injured service members to avoid long-term adverse effects might be cited for similar studies with this kind of military samples.. Reviewer #2: No ******** https://doi.org/10.1371/journal.pone.0274973.r003
Formally Accepted
21 Sep 2022 Acceptance Letter - Darrell Eugene Singer, Editor PONE-D-22-08419R1 The Relative Impact of Injury and Deployment on Mental and Physical Quality of Life among Military Service Members Dear Dr. Kolaja: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Darrell Eugene Singer Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0274973.r004

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