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Associations of military divorce with mental, behavioral, and physical health outcomes

  • Lawrence Wang1Email author,
  • Amber Seelig1,
  • Shelley MacDermid Wadsworth2,
  • Hope McMaster1,
  • John E. Alcaraz3 and
  • Nancy F. Crum-Cianflone1
BMC Psychiatry201515:128

https://doi.org/10.1186/s12888-015-0517-7

Received: 6 October 2014

Accepted: 2 June 2015

Published: 19 June 2015

Abstract

Background

Divorce has been linked with poor physical and mental health outcomes among civilians. Given the unique stressors experienced by U.S. service members, including lengthy and/or multiple deployments, this study aimed to examine the associations of recent divorce on health and military outcomes among a cohort of U.S. service members.

Methods

Millennium Cohort participants from the first enrollment panel, married at baseline (2001–2003), and married or divorced at follow-up (2004–2006), (N = 29,314). Those divorced were compared to those who remained married for mental, behavioral, physical health, and military outcomes using logistic regression models.

Results

Compared to those who remained married, recently divorced participants were significantly more likely to screen positive for new-onset posttraumatic stress disorder, depression, smoking initiation, binge drinking, alcohol-related problems, and experience moderate weight gain. However, they were also more likely be in the highest 15th percentile of physical functioning, and be able to deploy within the subsequent 3-year period after divorce.

Conclusions

Recent divorce among military members was associated with adverse mental health outcomes and risky behaviors, but was also associated with higher odds of subsequent deployment. Attention should be given to those recently divorced regarding mental health and substance abuse treatment and prevention strategies.

Background

The associations between divorce and mental and physical health disorders have been investigated in civilian populations [19], demonstrating that divorce is related to lower health-related quality of life [2], and greater disability and mortality [3, 4]. Recent research has shown that divorce is a risk factor for depression, posttraumatic stress disorder (PTSD), and elevated resting blood pressure, and is associated with other disorders such as seasonal affective disorder, social phobias, and bipolar disorder [57, 9]. Conversely, divorce has been linked to increased physical fitness in men [8]. Together, these findings present a clear picture of the physical and mental detriments associated with divorce among a civilian population.

Since the initiation of military operations in Iraq and Afghanistan after September 11th, the increased pace of military deployments has been shown to provide a protective effect against divorce [10] while at the same time, increasing the stress of military life and impacting the quality of marital relationships [1113]. These differing results indicate that the relationship between deployment to Iraq and Afghanistan and divorce is not clear and additional studies are warranted [10, 14, 15]. Recent studies have demonstrated that infidelity and consideration of separation/divorce among military couples have increased during the recent conflicts [14, 15]. Further, service members returning from the war with PTSD or serious injuries, including traumatic brain injury, can strain the marital bond [12]. Overall, these data suggest the importance of exploring the potential effects of divorce on health and military outcomes among service members during an era of persistent conflicts, because these outcomes not only affect quality of life, but also military force readiness [16]. The purpose of this investigation was to utilize a large, representative military cohort, using a prospective design to study the extent to which participants experiencing a recent divorce reported subsequent poor health and military outcomes compared to those who remained married during the same time frame. We hypothesized that, among military, recent divorce is associated with worsened mental and behavioral health, improved physical capability and would have a negative association with deployment and military separation.

Methods

Population and data sources

The Millennium Cohort Study was designed to prospectively assess the short- and long-term health outcomes of service members, and was initiated in 2001 prior to September 11th. Individuals invited to participate in the Millennium Cohort Study were randomly selected from US military rosters with oversampling of selected sub-groups including women, Reserve and National Guard, and those who previously deployed (i.e., 1991 Gulf War or Bosnia, Kosovo, or Southwest Asia between 1998 and 2000) [17, 18]. Participants include active duty, Reserve, and National Guard personnel from all five service branches who voluntarily agreed to complete follow-up surveys approximately every 3 years. The first panel of participants were enrolled during 2001–2003 (n = 77,047), of whom 55,021 (71 %) completed a follow-up survey during 2004–2006. Additional details on Millennium Cohort Study methodology and response rates are described elsewhere [16, 17, 19, 20].

The current study evaluated participants in the first panel who were married at baseline and who were either married or divorced at the time of the follow-up survey (n = 34,500). Since military records were used to confirm marital status, participants who separated from military service before completing both surveys were excluded (n = 3419). In addition, participants missing demographic covariates (sex, birth year, education, race/ethnicity, n = 26), missing military covariates (combat deployment, prior deployment, service component, service branch, pay grade, military occupation n = 707), and with incomplete baseline physical, mental, or behavioral data (history of potential alcohol dependence, smoking status, body mass index, mental and physical functioning, n = 1034) were excluded. This study was approved by the San Diego State University and Naval Health Research Center Institutional Review Boards and written informed consent was obtained from all study participants.

Demographic and military data were obtained from electronic military personnel files, provided monthly by the Defense Manpower Data Center (DMDC). These files provided data on marital status, sex, birth date, race/ethnicity, education, service branch, service component, military pay grade, military occupation, dates of deployment, and date of military separation. Self-reported data collected on the Millennium Cohort Study questionnaires was used to assess all other variables in the analyses, including combat experiences.

Outcome measures

Specific mental, physical, behavioral, and functional health outcomes were selected based on previous findings regarding their impact on force health and readiness [26, 21]. New-onset outcomes of interest were assessed only among those with no symptoms at baseline. Mental health outcomes included new-onset PTSD, new-onset depression, and anxiety/panic. The PTSD Checklist-Civilian Version (PCL-C), a 17-item symptom screening tool, was used to identify participants who screened positive for PTSD [2225]. The PCL-C was scored using the specific criteria, where those who scored 50 or more on the PCL screened positive for PTSD symptoms. Participants screening positive for new-onset depression and anxiety/panic were identified using the PRIME-MD Patient Health Questionnaire (PHQ) [2629]. The PHQ is a standardized tool to screen for mental health disorders based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition.

Physical health outcomes included new-onset hypertension, new-onset diabetes, and weight change. Participants with diabetes and hypertension were identified using self-reported data on the Millennium Cohort questionnaire, where participants indicated a diagnosis from a health care professional. Weight change, determined using self-reported weight at baseline and follow-up, was calculated as the percent change from baseline to follow-up, and was categorized into five levels: extreme gain (>10 %), moderate gain (between 3 and 10 %), stable weight (within 3 % of baseline weight), moderate loss (between 3 and 10 %), and extreme loss (>10 %) [30].

Behavioral outcomes included new-onset alcohol-related problems, new-onset binge drinking, smoking initiation, and smoking recidivism. Alcohol-related problems were identified using the PHQ as making poor decisions regarding alcohol, such as driving under the influence or being hung over at work [2729]. Binge drinking was defined as self-report of drinking five or more drinks on one occasion for men, and four or more drinks on one occasion for women [31]. Smoking initiation was defined as reporting current smoking at follow-up was assessed among baseline nonsmokers, and smoking recidivism, defined as report of current smoking at follow-up was assessed among baseline former smokers.

Functional health outcomes, assessed using the Mental Component Summary (MCS) score and Physical Component Summary (PCS) score, were included to portray a general assessment of mental and physical health status at follow-up. The MCS and PCS were calculated using the Medical Outcomes Study Short Form 36-item Survey for Veterans (SF-36 V), a measure designed to evaluate physical and mental functioning [32, 33]. Both MCS and PCS scores were categorized as one) lowest 15th percentile, two) middle 70th percentile, and three) highest 15th percentile, where a higher score represents better functioning. The resulting groups correspond approximately to participants scoring more than one standard deviation below, within one standard deviation of, and more than one standard deviation above the mean.

Military-specific outcomes from the DMDC included deployment and separation from the military. Deployment (yes/no) was assessed during the 3-year period between the baseline and first follow-up survey in the Stayed Married group, and during the 3–year period following divorce for the Recently Divorced group. While the timing is different for each groups, the length of follow-up during which they had the opportunity to have the outcome (deployment) is the same. This method was chosen to ensure that the outcome occurred following the exposure, and that the time from exposure to outcome was the same. Separation from the military was assessed during the 3 years after the follow-up survey was completed for both groups, since all participants in these analyses remained in the military through their follow-up survey.

Additional variables

Baseline characteristics were included in the analyses to adjust for factors as suggested by previous studies [19, 29, 3449]. Variables included sex, birth year, education, race/ethnicity, military pay grade, service component, service branch, and military occupation. These variables were determined using DMDC records and were backfilled with self-reported data to reduce missing values. Baseline functional health was evaluated with the MCS and PCS using the categorization as described above. A prior history of potential alcohol dependence was assessed at baseline using the CAGE questionnaire (Cutting down, Annoyance by criticism, Guilty feeling, and Eye-opener); those that were categorized as having a history of potential alcohol dependence positively endorsed at least one of the CAGE questions [50, 51]. Baseline smoking status was determined using self-report, where current smokers were defined as those who indicated smoking at least 100 cigarettes in their lifetime and had either not tried to quit or had been unsuccessful at quitting. Baseline body mass index (BMI) was categorized as underweight (<18.5 kg/m2), normal range (18.5–24.9), overweight (25–29.9), or obese (≥30.0) [37].

Combat experience was defined as having personally witnessed at least one of the following events: death due to war, disaster or tragic event; physical abuse; dead or decomposing bodies; maimed soldiers or civilians; or prisoners of war or refugees. Combat was assessed at follow-up among deployers and was reported as having occurred during the same 3-year period as a deployment. Participants were categorized at baseline as deployed with combat experiences, deployed without combat experiences, and non-deployed. An additional deployment variable was included, describing deployment prior to 2001 and was assessed using military personnel records.

Statistical analyses

Chi-square tests of association and unadjusted logistic regression models were used to compare characteristics between divorced and married service members. In multivariable analyses, separate logistic regression models were utilized to compare the odds of each outcome in relation to marital status while adjusting for relevant covariates. Polychotomous logistic regression was used to assess the tiered outcomes including weight change, MCS, and PCS. Multicollinearity was evaluated among all independent variables using a variance inflation factor of four. Final models were determined using a change in estimate approach, where variables were retained if significant (p < 0.05) or confounders (defined as a 10 % change in adjusted odds ratio). Sex and combat deployment were a priori maintained in the adjusted models. Based on this, the final models included sex, birth year, education, race/ethnicity, baseline smoking status, history of potential alcohol dependence, body mass index, baseline MCS and PCS, combat deployment, pay grade, service component, service branch, and occupation. Subanalyses were performed among service members divorced during follow-up, in which those who were divorced for > 2 years at their follow-up survey (reference group) were compared to those divorced for < 1 year, and those divorced for 1–2 years. Data management and statistical analyses were performed using SAS, version 9.3, statistical software (SAS Institute, Inc., Cary, North Carolina).

Results

During the study period, 1545 (5.3 %) service members became divorced and 27,769 remained married. Service members who divorced were proportionally more likely at baseline to be female, younger, less educated, enlisted, active duty, under- or normal weight, and have lower mental and higher physical functioning compared to those who remained married (Table 1). All characteristics were significantly associated with the exposure at p < 0.05, except for service branch (p = 0.74).
Table 1

Baseline demographic, military, and behavioral characteristics by marital statusa

 

Recently divorced

Stayed married

Total

 

n =1545

n = 27,769

n =29,314

Baseline characteristicsb

n

(%)

n

(%)

n

(%)

Sex

  

 Male

959

62.07

22800

82.11

23759

81.05

 Female

586

37.93

4969

17.89

5555

18.95

Age

 

 Born before 1960

236

15.28

7581

27.30

7817

26.67

 1960-1969

668

43.24

13195

47.52

13863

47.29

 1970-1979

599

38.77

6767

24.37

7366

25.13

 1980 and after

42

2.72

226

0.81

268

0.91

Education

 

 Some college or less

1212

78.45

18289

65.86

19501

66.52

 Bachelor’s degree or higher

333

21.55

9480

34.14

9813

33.48

Race/Ethnicity

 

 White, non-Hispanic

1098

71.07

20171

72.64

21269

72.56

 Black, non-Hispanic

214

13.85

2853

10.27

3067

10.46

 Other

233

15.08

4745

17.09

4978

16.98

Combat deployment

 

 Not deployed

1030

66.67

19076

68.70

20106

68.59

 Deployed, without combat

279

18.06

4345

15.65

4624

15.77

 Deployed, with combat

236

15.28

4348

15.66

4584

15.64

Prior deployment

 

 Yes

445

28.80

9053

32.60

9498

32.40

 No

1100

71.20

18716

67.40

19816

67.60

Military pay grade

 

 Enlisted

1263

81.75

18807

67.73

20070

68.47

 Officer

282

18.25

8962

32.27

9244

31.53

Service component

 

 Active duty

873

56.50

14951

53.84

15824

53.98

 Reserve/National Guard

672

43.50

12818

46.16

13490

46.02

Service branch

 

 Army

721

46.67

12940

46.60

13661

46.60

 Navy/Coast Guard

228

14.76

4373

15.75

4601

15.70

 Air Force

538

34.82

9432

33.97

9970

34.01

 Marines

58

3.75

1024

3.69

1082

3.69

Military occupation

 

 Combat specialist

273

17.67

6402

23.05

6675

22.77

 Health care

165

10.68

2997

10.79

3162

10.79

 Other

1107

71.65

18370

66.15

19477

66.44

History of potential alcohol dependencec

 

 Yes

296

19.16

4617

16.63

4913

16.76

 No

1249

80.84

23152

83.37

24401

83.24

Smoking status

 

 Current smoker

317

20.52

3958

14.25

4275

14.58

 Other

1228

79.48

23811

85.75

25039

85.42

Body mass indexd

 

 Underweight and normal weight

701

45.37

8670

31.22

9371

31.97

 Overweight

717

46.41

15975

57.53

16692

56.94

 Obese

127

8.22

3124

11.25

3251

11.09

Mental component summary scoree

 

 Lowest 15th percentile

296

19.16

2568

9.25

2864

9.77

 Middle 70th percentile

1043

67.51

19553

70.41

20596

70.26

 Highest 15th percentile

206

13.33

5648

20.34

5854

19.97

Physical component summary scoree

 

 Lowest 15th percentile

188

12.17

3604

12.98

3792

12.94

 Middle 70th percentile

1065

68.93

20675

74.45

21740

74.16

 Highest 15th percentile

292

18.90

3490

12.57

3782

12.90

a Participants in this study completed a baseline survey in 2001–2003 and completed a follow-up survey in 2004–2006. Marital status assessed from baseline to first follow-up, where those who were “recently divorced” were married at their baseline survey and got divorced before their follow-up survey, those who “stayed married” were married throughout the study period

b All characteristics were significantly associated with exposure at p < 0.05, except for service branch (p = 0.74)

c Potential alcohol dependence is defined as at least 1 positive response to the CAGE questionnaire (Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers)

d Body mass index is defined using Center for Disease Control and Prevention standards of Underweight (Less than 18.5 kg/m2), Normal range (18.5-24.99), Overweight (25–29.9), and Obese (≥30.0)

e Mental component summary score and physical component summary score are obtained from the Short Form-36 Question Health Survey for Veterans (SF-36 V)

Table 2 displays the prevalence of each outcome by marital status. New-onset PTSD, depression, and anxiety were more prevalent among those recently divorced with 4.8 %, 3.0 %, and 3.0 % developing each of these conditions, respectively, between baseline and follow-up. Smoking initiation and recidivism, alcohol-related problems, and binge drinking were also more prevalent in divorced service members compared to those who remained married. Regarding physical health, weight gain was more prevalent in the divorced group, and married individuals were more likely to have a stable weight. Divorced service members were also more likely to be in the lowest 15th percentile for mental functioning, and be in the highest 15th percentile for physical functioning. Finally, divorced service members were proportionately more likely to deploy within 3 years following divorce, but had similar percentages of military separation. All outcomes were significantly associated with exposure at p < 0.05, except for new-onset diabetes (p = 0.08) and military separation (p = 0.33).
Table 2

Prevalence of health and military outcomes by marital statusa

 

Recently divorced

Stayed married

Total

 

N = 1545

N = 27,769

N = 29,314

Outcomeb

n

(%)

n

(%)

n

(%)

Mental health

      

 New-onset posttraumatic stress disorderb

74

4.79

597

2.15

671

2.29

 New-onset depressionc

47

3.04

431

1.55

478

1.63

 Anxiety/Panicc

47

3.04

476

1.72

523

1.78

Behavioral

      

 Smoking initiation

15

0.97

125

0.45

140

0.48

 Smoking recidivism

53

3.43

685

2.47

738

2.52

 New-onset alcohol-related problemsc

62

4.01

727

2.62

789

2.69

 New-onset binge drinkingd

183

11.84

2846

10.25

3029

10.33

Physical health

      

 New-onset hypertension

84

5.44

1646

5.93

1730

5.90

 New-onset diabetes

8

0.52

205

0.74

213

0.73

 Weight changee

      

Extreme weight loss

46

2.98

572

2.06

618

2.11

 Moderate weight loss

169

10.94

3013

10.85

3182

10.85

 Stable weight

572

37.02

12490

44.98

13062

44.56

 Moderate weight gain

522

33.79

7949

28.63

8471

28.90

 Extreme weight gain

120

7.77

1634

5.88

1754

5.98

Functional health

      

 Mental component summary scoref

      

  Lowest 15th percentile

242

15.66

2761

9.94

3003

10.24

  Middle 70th percentile

1061

68.67

19563

70.45

20624

70.36

  Highest 15th percentile

221

14.30

4999

18.00

5220

17.81

 Physical component summary scoref

      

  Lowest 15th percentile

211

13.66

3633

13.08

3884

13.11

  Middle 70th percentile

1031

66.73

19928

71.76

20959

71.50

  Highest 15th percentile

282

18.25

3762

13.55

4044

13.80

Military related outcomes

      

 Deploymentg

541

38.26

8693

31.30

9234

31.64

 Military separationh

205

13.27

3929

14.15

4134

14.10

a Marital status assessed from baseline to first follow-up, where those who were “recently divorced” were married at their baseline survey and got divorced before their follow-up survey, those who “stayed married” were married throughout the study period. The reference category is “stayed married”

b All outcomes were significantly associated with exposure at p < 0.05, except for new-onset diabetes (p = 0.08) and military separation (p = 0.33)

c Posttraumatic stress disorder is defined using the PTSD checklist-civilian version, specific criteria with a cutoff of 50

d Assessed using the Patient Health Questionnaire

e Binge drinking is defined as reporting 5 or more drinks per occasion for men or 4 or more drinks per occasion for women on at least 1 day during the past year

f Extreme weight loss (≥10 % loss), moderate weight loss (between 3 % and 10 % loss), stable weight (within ± 3 %), moderate weight gain (between 3 % and 10 % gain), and extreme weight gain (≥10 % gain)

g Mental component summary score and physical component summary score are obtained from the short form 36 question health survey for veterans (SF-36 V)

h Deployment was assessed from baseline until the follow-up for those in the “stayed married” and in the 3 years following divorce for the “recently divorced” group

i Separation was assessed after the date of the completion of the follow-up survey

In the multivariable models (Table 3), recently divorced service members were more likely to screen positive for new-onset PTSD [Adjusted Odds Ratio (AOR) 1.77; 95 % Confidence Interval (CI): 1.36, 2.30] and new-onset depression (AOR: 1.40; 95 % CI: 1.02, 1.94) than those individuals who stayed married. Models focusing on behavioral health outcomes showed that those who were recently divorced were more likely to initiate smoking (AOR: 2.04; 95 % CI: 1.18, 3.54), develop alcohol-related problems (AOR: 1.52; 95 % CI: 1.15, 2.00), and initiate binge drinking (AOR: 1.51; 95 % CI: 1.26, 1.81) than those who remained married. Regarding physical health outcomes, those who were recently divorced were more likely to experience moderate (between 3 % and 10 %) weight gain (AOR: 1.15; 95 % CI: 1.02, 1.31) than those who remained married. Finally, service members who were recently divorced were more likely to be in the highest 15th percentile of physical health functioning based on the PCS score (AOR: 1.26; 95 % CI: 1.10, 1.46). After adjusting for other covariates in the reduced model, analyses examining deployment and military separation showed that those divorced were more likely to deploy (AOR:1.47; 95 % CI: 1.31, 1.66) than those people who stayed married. Experiencing a recent divorce was not found to be significantly associated with separation from the military.
Table 3

Adjusteda odds of health and military outcomes comparing recently divorced military personnel with those who stayed marriedb

 

Divorced vs. married

Outcomec

AOR

(95 % CI)

Mental health

  

 New-onset posttraumatic stress disorderd

1.77k

(1.36, 2.30)

 New-onset depressione

1.40k

(1.02, 1.94)

 Anxiety/panice

1.24

(0.90, 1.71)

Behavioral

  

 Smoking initiation

2.04k

(1.18, 3.54)

 Smoking recidivism

1.25

(0.93, 1.68)

 New-onset alcohol-related problemse

1.52k

(1.15, 2.00)

 New-onset binge drinkingf

1.51k

(1.26, 1.81)

Physical health

  

 New-onset hypertension

1.13

(0.89, 1.42)

 New-onset diabetes

0.82

(0.40, 1.69)

Weight changeg

  

 Extreme weight loss

1.31

(0.94, 1.80)

 Moderate weight loss

1.08

(0.90, 1.29)

 Stable weight

1.00

-

 Moderate weight gain

1.15k

(1.02, 1.31)

 Extreme weight gain

0.90

(0.73, 1.12)

Functional health

  

 Mental component summary scoreh

  

  Lowest 1 th percentile

1.09

(0.93, 1.28)

  Middle 70th percentile

1.00

-

  Highest 15th percentile

1.02

(0.87, 1.19)

 Physical component summary scoreh

  

  Lowest 15th percentile

1.01

(0.86, 1.20)

  Middle 70th percentile

1.00

-

  Highest 15th percentile

1.26k

(1.10, 1.46)

  Military related outcomes

  

 Deploymenti

1.47k

(1.31, 1.66)

 Military separationj

0.95

(0.80, 1.11)

a Full models were adjusted for all variables: sex, birth year, education, race/ethnicity, baseline smoking status, history of potential alcohol dependence, body mass index, baseline MCS and PCS, combat deployment, pay grade, service component, service branch, and occupation. Reduction of models utilized backwards stepwise regression

b Marital status assessed from baseline to first follow-up, where those who were “recently divorced” were married at their baseline survey and got divorced before their follow-up survey, those who “stayed married” were married throughout the study period. The reference category is “stayed married”

c In outcomes without a reference indication, the reference category is “No”

d Posttraumatic stress disorder is defined using the PTSD checklist-civilian version, specific criteria with a cutoff of 50. e Assessed using the Patient Health Questionnaire

f Binge drinking is defined as reporting 5 or more drinks per occasion for men or 4 or more drinks per occasion for women on at least 1 day during the past year

g Extreme weight loss (≥10 % loss), moderate weight loss (between 3 % and 10 % loss), stable weight (within ± 3 %), moderate weight gain (between 3 % and 10 % gain), and extreme weight gain (≥10 % gain)

h Mental component summary score and physical component summary score are obtained from the Short Form-36 Question Health Survey for Veterans (SF-36 V)

i Deployment was assessed from baseline until the follow-up for those in the “stayed married” and assessed until 3 years after divorce event for the “recently divorced” population

j Separation was assessed after the date of the completion of the follow-up survey

k Adjusted Odds Ratio was found to be statistically significant

Among divorced service members, we examined the association of the timing between the divorce and the assessment of health and military outcomes. We compared those who completed their survey within 1 year after their divorce date with those who had between 2 and 3 years between their divorce and completion of survey. The latter served as the reference group. In the adjusted model, those who completed the survey within a year of their divorce date were significantly more likely to screen positive for new-onset PTSD (AOR: 3.27; 95 % CI: 1.56, 6.86), have alcohol-related problems (AOR: 2.24; 95 % CI: 1.11, 4.53), and binge drinking (AOR: 1.90; 95 % CI: 1.18, 3.06) compared to those who completed the survey between 2 and 3 years after the divorce date (Table 4). They were also less likely to report extreme weight gain (AOR: 0.41; 95 % CI: 0.23, 0.71). We also compared those who had completed their survey between 1 and 2 years after their divorce. The reference group, those with between 2 and 3 years between their divorce and completion of survey, remained the same. In the adjusted model, those who had between 1 and 2 years since divorce were less likely to report binge drinking (AOR: 0.53; 95 % CI: 0.31, 0.90) compared to those who completed the survey between 2 and 3 years after their divorce.
Table 4

Adjusteda odds of health and military outcomes by timing of divorceb

 

<1 year since divorce

1-2 years since divorce

Outcomec

AOR

(95 % CI)

AOR

(95 % CI)

Mental health

    

 New-onset posttraumatic stress disorderd

3.27j

(1.56, 6.86)

1.79

(0.82, 3.92)

 New-onset depressione

1.16

(0.53, 2.53)

1.19

(0.54, 2.60)

Behavioral

    

 Smoking initiation

0.83

(0.25, 2.78)

0.53

(0.14, 2.04)

 New-onset alcohol-related problemse

2.24j

(1.11, 4.53)

1.07

(0.50, 2.29)

 New-onset binge drinkingf

1.90j

(1.18, 3.06)

0.53j

(0.31, 0.90)

Physical health

    

 Weight changeg

    

  Extreme weight loss

1.82

(0.80, 4.14)

0.93

(0.37, 2.31)

  Moderate weight loss

1.54

(0.97, 2.43)

0.93

(0.57, 1.51)

  Stable weight

1.00

-

1.00

-

  Moderate weight gain

0.85

(0.62, 1.16)

0.93

(0.69, 1.27)

  Extreme weight gain

0.41j

(0.23, 0.71)

0.87

(0.54, 1.41)

Functional health

    

 Physical component summary scoreh

    

  Lowest 15th percentile

0.86

(0.57, 1.29)

0.90

(0.60, 1.34)

  Middle 70th percentile

1.00

-

1.00

-

  Highest 15th percentile

1.32

(0.92, 1.88)

0.96

(0.67, 1.38)

Military related outcomes

    

 Deploymenti

1.17

(0.87, 1.56)

1.05

(0.79, 1.40)

a Full models were adjusted for all variables: sex, birth year, education, race/ethnicity, baseline smoking status, history of potential alcohol dependence, body mass index, baseline MCS and PCS, combat deployment, pay grade, service component, service branch, occupation

b Marital status assessed from baseline to first follow-up, where those who were “recently divorced” were married at their baseline survey and got divorced before their follow-up survey. The reference category is > 2 years since divorce

c In outcomes without a reference indication, the reference category is “No”

d Posttraumatic stress disorder is defined using the PTSD checklist-civilian version, specific criteria with a cutoff of 50

e Assessed using the Patient Health Questionnaire

f Binge drinking is defined as reporting five or more drinks per occasion for men or four or more drinks per occasion for women on at least 1 day during the past year

g Extreme weight loss (≥10 % loss), moderate weight loss (between 3 % and 10 % loss), stable weight (within ± 3 %), moderate weight gain (between 3 % and 10 % gain), and extreme weight gain (≥10 % gain)

h Physical component summary score are obtained from the Short Form-36 Question Health Survey for Veterans (SF-36 V)

i Deployment was assessed from baseline until the follow-up for those in the “stayed married” and assessed until 3 years after divorce event for the “recently divorced” population

j Adjusted Odds Ratio was found to be statistically significant

Discussion

This prospective study evaluated the associations of divorce on a comprehensive set of mental, behavioral, physical, and functional health outcomes in a large military cohort during the Iraq and Afghanistan wars. Data on the impact of divorce in a military setting are especially important given the increasing rates of marital distress associated with the recent conflicts [10, 12, 14]. After controlling for baseline sociodemographics and health status, this study showed significant associations between divorce and new-onset PTSD, depression, smoking initiation and recidivism, alcohol-related problems, binge drinking, and moderate weight gain. Study results suggest that special attention should be given to recently divorced individuals regarding mental health and risky health-related behaviors treatment and prevention strategies.

Studies of the consequences of divorce in the general population have revealed a variety of consequences for both adults and children. Although health implications for adults are in part due to selection effects, the bulk of the evidence attributes negative outcomes to the effects of divorce rather than selection [52]. Divorce can result in both acute and chronic stress for adult partners, with significant emotional upheaval that can include conflict, resentment, anger, and sadness [52]. In the military, divorce may mean loss of access to on-base housing or other changes in living arrangements, loss of medical benefits, and reduced family income as well as loss of spousal support and assistance. Although both short- and long-term consequences can occur, declines in well-being are temporary for most individuals [53].

This study found significant associations between divorce and the development of new-onset PTSD. Previous research regarding the relationship of divorce and PTSD has found bidirectional relationships. PTSD has been linked to elevated levels of hostile behavior, decreased capacity for intimacy, marital distress, and domestic violence [54, 55], all which may increase the likelihood of divorce. In a study examining male Vietnam veterans, those with PTSD had more problems in their relationships, more difficulties with intimacy, and had taken more steps toward separation and divorce than veterans not screening positive for PTSD [56]. Life events such as divorce may also generate symptoms of post-traumatic stress similar to other types of trauma such as accidents or abuse [57]. Our study results showed a relationship between divorce and screening positive for PTSD within a 3-year period when compared to those who remained married. This suggests that the mental health effects of divorce occur over a relatively short time period, information that may be helpful for providers caring for recently divorced individuals.

Similarly, our study found a significant association between divorce and depression, which is consistent with results from previous research, including a civilian study that found an association as early as 4-years [58], though our results show a shorter time frame of ≤3 years. Of note, the association between divorce and depression was present when comparing recently divorced service members to those who remained married, but depression was similar among recent divorcees and those who were single. Understanding the temporal proximity of the association between a recent divorce and mental health issues may help enable faster detection and management of these conditions.

Alcohol-related problems are detrimental to overall occupational performance especially during military operations. The present study showed a statistically significant association between divorce and alcohol-related problems and binge drinking. Previous studies have shown that drinking problems increase the risk of divorce [9, 59]. Our results, after controlling for sociodemographic factors and potential alcohol dependence at baseline, support an association between divorce and alcohol use. A longer follow-up period with evaluation of the temporal sequence could further elucidate the link between divorce and alcohol misuse. Our results also indicated that recent divorcees were significantly more likely to initiate smoking. These data support the hypothesis that marital support may be advantageous in reducing risky health-related behaviors [60].

The results of our study indicated a relationship between a recent divorce and improved physical function, and counterintuitively, also moderate weight gain. Given that there was no association with more extreme weight changes, and previous observational research has reported that divorce is associated with increased physical fitness in men [8], we hypothesize that divorce may be linked to increased motivation for physical fitness or the use of exercise to mitigate stress, and that the moderate gain is due to an increase in muscle mass. It is also possible that the moderate weight gain and improved physical fitness is due to the combination of an increase in exercise and alcohol consumption. The exact etiology is impossible to determine using this data, but our incongruent results suggest additional study is needed.

We investigated the hypothesis that a recent divorce may have a negative link with subsequent deployments. However, we found that those who were recently divorced were more likely to deploy within a 3-year period than those who remained married, suggesting that divorce did not adversely impact deployment eligibility. Recently divorced service members may be more likely to volunteer to deploy as a means to escape emotional hardship, although this study did not collect data on reasons for deployment. The study did not find an association between divorce and separation from the military, suggesting that marital status change may not directly affect the military careers of service members in the short term, but further studies are needed.

The time dependent analysis showed that service members who were recently divorced (<1 year) were more likely to report new-onset PTSD, alcohol-related problems, and binge drinking, compared to those who were divorced for >2 years. These findings suggest that mental and behavioral health outcomes are more likely to be reported within a shorter time frame, which is consistent with a previous study that found that length of time from marital separation was the most powerful factor in emotional resolution [61]. Nonetheless, even short-term health and behavioral conditions demonstrated in this study may interfere with both relationships and work performance, and may influence future behaviors. It is also possible that the symptoms detected by screening instruments in this study were a result of traumatic experiences and processes of grief associated with divorce, but do not represent chronic mental or behavioral health conditions.

Our study has notable limitations. Study outcomes were self-reported and were not validated by medical record review; however, the use of validated surveys to detect mental and behavioral health conditions in a military sample has several advantages because these conditions are often underdiagnosed due to stigma [62]. Although previous studies on the Millennium Cohort found it to be representative, responders were proportionally more likely to be women, educated, and white non-Hispanic [16, 63]. Because our follow-up period was 3 years and certain outcomes may develop later, we may have had inadequate time to detect these outcomes. Conversely, the effects of outcomes may not be long-lasting and may have been underestimated. Analyses were only able to assess temporal proximity as opposed to temporal sequence, and thus we were unable to establish causality. PTSD in particular is a complex affliction that is underreported and may also take variable lengths of time to develop, which may cloud possible associations with divorce. Additionally, the number of legally married study participants is also likely to be conservative in relation to real population of military couples, which includes common law and same-sex marriages. Finally, we did not have data on length of marriage or presence of children, which have been shown to affect the marital relationship [64]. A measure of marital satisfaction at baseline would also have been useful to further elucidate the relationship between divorce and health outcomes.

There are also significant strengths. Few data exist regarding the effects of divorce on physical and mental health outcomes directly related to military readiness and capability. The Millennium Cohort Study represents all branches of the US military and unlike many previous studies, our prospective study was able to assess new-onset outcomes. The large sample allowed adequate power for adjustment of many covariates, resulting in more robust comparisons and the ability to detect small differences within subgroups of the study population.

Conclusion

Recent divorce was associated with screening positive for new-onset PTSD, depression, moderate weight gain, tobacco and alcohol use. Despite these findings, recent divorcees were more likely to be physically active and deploy compared to those who remained married. These data suggest that recently divorced service members should be screened for mental health and behavioral risk factors to improve their overall health and readiness. Given the negative health repercussions of divorce, future studies should identify factors associated with divorce in the military setting to reduce the development of these outcomes.

This work represents report 13–40, supported by the Department of Defense, under Work Unit No. 60002. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of the Army, Department of the Air Force, Department of Defense, Department of Veterans Affairs, or the US Government. Approved for public release; distribution is unlimited. This research was conducted in compliance with all applicable federal regulations governing the protection of human subjects (Protocol NHRC.2000.0007).

Declarations

Acknowledgements

In addition to the authors, the Millennium Cohort Study Team includes CPT Carrie Donoho, Melissa Frasco, Andrea Ippolito, Isabel Jacobson, Lauren Kipp, Cynthia LeardMann, Gordon Lynch, Sheila Medina-Torne, Christopher Phillips, Kari Sausedo, Emma Schaller, Beverly Sheppard, Donald Slymen, Katherine Snell, Steven Speigle, Daniel Trone, Jennifer Walstrom, John Wesner, Martin White, and James Whitmer, from the Deployment Health Research Department, Naval Health Research Center, San Diego, CA.

We appreciate the support from the Management Information Division, US Defense Manpower Data Center (Seaside, CA, USA); Military Operational Medicine Research Program and US Army Medical Research and Materiel Command (Fort Detrick, MD, USA). In addition, we thank Michelle LeWark from the Naval Health Research Center (San Diego, CA, USA).

Authors’ Affiliations

(1)
Deployment Health Research Department, Naval Health Research Center
(2)
Purdue University
(3)
San Diego State University

References

  1. Hewitt B, Turrell G, Giskes K. Marital loss, mental health and the role of perceived social support: findings from six waves of an Australian population based panel study. J Epidemiol Community Health. 2012;66(4):308–14.PubMedView ArticleGoogle Scholar
  2. Rhoades GK, Kamp Dush CM, Atkins DC, Stanley SM, Markman HJ. Breaking up is hard to do: the impact of unmarried relationship dissolution on mental health and life satisfaction. J Fam Psychol. 2011;25(3):366–74.PubMedPubMed CentralView ArticleGoogle Scholar
  3. Choi H, Marks NF. Socioeconomic status, marital status continuity and change, marital conflict, and mortality. J Aging Health. 2011;23(4):714–42.PubMedPubMed CentralView ArticleGoogle Scholar
  4. Va P, Yang WS, Nechuta S, Chow WH, Cai H, Yang G, et al. Marital status and mortality among middle Age and elderly Men and women in urban shanghai. PLoS One. 2011;6(11), e26600.PubMedPubMed CentralView ArticleGoogle Scholar
  5. Sbarra DA, Law RW, Lee LA, Mason AE. Marital dissolution and blood pressure reactivity: evidence for the specificity of emotional intrusion-hyperarousal and task-rated emotional difficulty. Psychosom Med. 2009;71(5):532–40.PubMedPubMed CentralView ArticleGoogle Scholar
  6. Kolves K, Ide N, De Leo D. Marital breakdown, shame, and suicidality in men: a direct link? Suicide Life Threat Behav. 2011;41(2):149–59.PubMedView ArticleGoogle Scholar
  7. Gibb SJ, Fergusson DM, Horwood LJ. Relationship separation and mental health problems: findings from a 30-year longitudinal study. Aust N Z J Psychiatry. 2011;45(2):163–9.PubMedView ArticleGoogle Scholar
  8. Ortega FB, Brown WJ, Lee DC, Baruth M, Sui X, Blair SN. In fitness and health? A prospective study of changes in marital status and fitness in men and women. Am J Epidemiol. 2011;173(3):337–44.PubMedView ArticleGoogle Scholar
  9. Breslau J, Miller E, Jin R, Sampson NA, Alonso J, Andrade LH, et al. A multinational study of mental disorders, marriage, and divorce. Acta Psychiatr Scand. 2011;124(6):474–86.PubMedPubMed CentralView ArticleGoogle Scholar
  10. Karney BR, Crown JS. Does Deployment Keep Military Marriages Together or Break Them Apart? Evidence from Afghanistan and Iraq. In: Wadsworth SM, Riggs D, Editors. Risk and Resilience in US Military Families. Springer New York; 2011. p. 23–45.Google Scholar
  11. Gulf War and Health:Volume 7: Long-Term Consequences of Traumatic Brain Injury. Washington DC: The National Academies Press; 2008.Google Scholar
  12. Chapin M. Family resilience and the fortunes of war. Soc Work Health Care. 2011;50(7):527–42.PubMedView ArticleGoogle Scholar
  13. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington DC: The National Academies Press; 2013.Google Scholar
  14. Riviere LA, Merrill JC, Thomas JL, Wilk JE, Bliese PD. 2003–2009 marital functioning trends among U.S. enlisted soldiers following combat deployments. Mil Med. 2012;177(10):1169–77.PubMedView ArticleGoogle Scholar
  15. Harvey SB, Hatch SL, Jones M, Hull L, Jones N, Greenberg N, et al. The long-term consequences of military deployment: a 5-year cohort study of United kingdom reservists deployed to Iraq in 2003. Am J Epidemiol. 2012;176(12):1177–84.PubMedView ArticleGoogle Scholar
  16. Smith TC, Zamorski M, Smith B, Riddle JR, Leardmann CA, Wells TS, et al. The physical and mental health of a large military cohort: baseline functional health status of the Millennium Cohort. BMC Public Health. 2007;7, E340.View ArticleGoogle Scholar
  17. Gray GC, Chesbrough KB, Ryan MA, Amoroso P, Boyko EJ, Gackstetter GD, et al. The Millennium Cohort Study: a 21-year prospective cohort study of 140,000 military personnel. Mil Med. 2002;167(6):483–8.PubMedGoogle Scholar
  18. Ryan MA, Smith TC, Smith B, Amoroso P, Boyko EJ, Gray GC, et al. Millennium Cohort: enrollment begins a 21-year contribution to understanding the impact of military service. J Clin Epidemiol. 2007;60(2):181–91.PubMedView ArticleGoogle Scholar
  19. Jacobson IG, Ryan MA, Hooper TI, Smith TC, Amoroso PJ, Boyko EJ, et al. Alcohol use and alcohol-related problems before and after military combat deployment. JAMA. 2008;300(6):663–75.PubMedPubMed CentralView ArticleGoogle Scholar
  20. Smith TC. Linking exposures and health outcomes to a large population-based longitudinal study: the Millennium Cohort Study. Mil Med. 2011;176(7 Suppl):56–63.PubMedView ArticleGoogle Scholar
  21. Goetzel RZ, Hawkins K, Ozminkowski RJ, Wang S. The health and productivity cost burden of the “top 10” physical and mental health conditions affecting six large U.S. employers in 1999. J Occup Environ Med. 2003;45(1):5–14.PubMedView ArticleGoogle Scholar
  22. Weathers FW, Litz BT, HD S. The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. In: 9th Annual Meeting of the International Society for Traumatic Stress Studies: 1993; San Antonio, Texas. 1993.Google Scholar
  23. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther. 1996;34(8):669–73.PubMedView ArticleGoogle Scholar
  24. Brewin CR. Systematic review of screening instruments for adults at risk of PTSD. J Trauma Stress. 2005;18(1):53–62.PubMedView ArticleGoogle Scholar
  25. Wright KM, Huffman AH, Adler AB, Castro CA. Psychological screening program overview. Mil Med. 2002;167(10):853–61.PubMedGoogle Scholar
  26. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13.PubMedPubMed CentralView ArticleGoogle Scholar
  27. Spitzer RL, Williams JB, Kroenke K, Linzer M, de Gruy 3rd FV, Hahn SR, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA. 1994;272(22):1749–56.PubMedView ArticleGoogle Scholar
  28. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282(18):1737–44.PubMedView ArticleGoogle Scholar
  29. Spitzer RL, Williams JB, Kroenke K, Hornyak R, McMurray J. Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. Am J Obstet Gynecol. 2000;183(3):759–69.PubMedView ArticleGoogle Scholar
  30. Jacobson IG, Smith TC, Smith B, Keel PK, Amoroso PJ, Wells TS, et al. Disordered eating and weight changes after deployment: longitudinal assessment of a large US military cohort. Am J Epidemiol. 2009;169(4):415–27.PubMedView ArticleGoogle Scholar
  31. Naimi TS, Brewer RD, Mokdad A, Denny C, Serdula MK, Marks JS. Binge drinking among US adults. JAMA. 2003;289(1):70–5.PubMedView ArticleGoogle Scholar
  32. Stewart AL, Hays RD, Ware Jr JE. The MOS short-form general health survey. Reliability and validity in a patient population. Med Care. 1988;26(7):724–35.PubMedView ArticleGoogle Scholar
  33. Ware Jr JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473–83.PubMedView ArticleGoogle Scholar
  34. Saarni SI, Viertio S, Perala J, Koskinen S, Lonnqvist J, Suvisaari J. Quality of life of people with schizophrenia, bipolar disorder and other psychotic disorders. Br J Psychiatry. 2010;197(5):386–94.PubMedView ArticleGoogle Scholar
  35. Wells TS, LeardMann CA, Fortuna SO, Smith B, Smith TC, Ryan MA, et al. A prospective study of depression following combat deployment in support of the wars in Iraq and Afghanistan. Am J Public Health. 2010;100(1):90–9.PubMedPubMed CentralView ArticleGoogle Scholar
  36. Forman-Hoffman VL, Peloso PM, Black DW, Woolson RF, Letuchy EM, Doebbeling BN. Chronic widespread pain in veterans of the first Gulf War: impact of deployment status and associated health effects. J Pain. 2007;8(12):954–61.PubMedView ArticleGoogle Scholar
  37. Kline A, Falca-Dodson M, Sussner B, Ciccone DS, Chandler H, Callahan L, et al. Effects of repeated deployment to Iraq and Afghanistan on the health of New Jersey Army National Guard troops: implications for military readiness. Am J Public Health. 2010;100(2):276–83.PubMedPubMed CentralView ArticleGoogle Scholar
  38. Lorenz FO, Wickrama KA, Conger RD, Elder Jr GH. The short-term and decade-long effects of divorce on women’s midlife health. J Health Soc Behav. 2006;47(2):111–25.PubMedView ArticleGoogle Scholar
  39. Sundin J, Jones N, Greenberg N, Rona RJ, Hotopf M, Wessely S, et al. Mental health among commando, airborne and other UK infantry personnel. Occup Med (Lond). 2010;60(7):552–9.View ArticleGoogle Scholar
  40. Davalos ME, French MT. This recession is wearing me out! Health-related quality of life and economic downturns. J Ment Health Policy Econ. 2011;14(2):61–72.PubMedGoogle Scholar
  41. Ross CE, Wu CL. Education, age, and the cumulative advantage in health. J Health Soc Behav. 1996;37(1):104–20.PubMedView ArticleGoogle Scholar
  42. Williams DR, Yan Y, Jackson JS, Anderson NB. Racial differences in physical and mental health: socio-economic status. Stress and discrimination. J Health Psychol. 1997;2(3):335–51.PubMedView ArticleGoogle Scholar
  43. Vogt DS, Samper RE, King DW, King LA, Martin JA. Deployment stressors and posttraumatic stress symptomatology: comparing active duty and National Guard/Reserve personnel from Gulf War I. J Trauma Stress. 2008;21(1):66–74.PubMedView ArticleGoogle Scholar
  44. Singh JA, Nelson DB, Fink HA, Nichol KL. Health-related quality of life predicts future health care utilization and mortality in veterans with self-reported physician-diagnosed arthritis: the veterans arthritis quality of life study. Semin Arthritis Rheum. 2005;34(5):755–65.PubMedView ArticleGoogle Scholar
  45. Singh JA, Borowsky SJ, Nugent S, Murdoch M, Zhao Y, Nelson DB, et al. Health-related quality of life, functional impairment, and healthcare utilization by veterans: veterans’ quality of life study. J Am Geriatr Soc. 2005;53(1):108–13.PubMedView ArticleGoogle Scholar
  46. Butterfield MI, Forneris CA, Feldman ME, Beckham JC. Hostility and functional health status in women veterans with and without posttraumatic stress disorder: a preliminary study. J Trauma Stress. 2000;13(4):735–41.PubMedView ArticleGoogle Scholar
  47. Davila EP, Zhao W, Byrne M, Hooper MW, Messiah A, Caban-Martinez A, et al. Health-related quality of life and nicotine dependence, Florida 2007. Am J Health Behav. 2011;35(3):280–9.PubMedView ArticleGoogle Scholar
  48. Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry. 2005;62(10):1097–106.PubMedView ArticleGoogle Scholar
  49. Kelly SJ, Daniel M, Dal Grande E, Taylor A. Mental ill-health across the continuum of body mass index. BMC Public Health. 2011;11:765.PubMedPubMed CentralView ArticleGoogle Scholar
  50. Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984;252(14):1905–7.PubMedView ArticleGoogle Scholar
  51. Dhalla S, Kopec JA. The CAGE questionnaire for alcohol misuse: a review of reliability and validity studies. Clin Invest Med. 2007;30(1):33–41.PubMedGoogle Scholar
  52. Amato PR. Research on divorce: continuing trends and New developments. J Marriage Fam. 2010;72(3):650–66.View ArticleGoogle Scholar
  53. Hetherington EM. Intimate pathways: changing patterns in close personal relationships across time. Fam Relat. 2003;52(4):318–31.View ArticleGoogle Scholar
  54. Karney BR, Crown JS. Families Under Stress: An Assessment of Data, Theory, and Research on Marriage and Divorce in the Military. Santa Monica: RAND Corporation; 2007.Google Scholar
  55. Lambert JE, Engh R, Hasbun A, Holzer J. Impact of posttraumatic stress disorder on the relationship quality and psychological distress of intimate partners: a meta-analytic review. J Fam Psychol. 2012;26(5):729–37.PubMedView ArticleGoogle Scholar
  56. Riggs DS, Byrne CA, Weathers FW, Litz BT. The quality of the intimate relationships of male Vietnam veterans: problems associated with posttraumatic stress disorder. J Trauma Stress. 1998;11(1):87–101.PubMedView ArticleGoogle Scholar
  57. Mol SS, Arntz A, Metsemakers JF, Dinant GJ, Vilters-van Montfort PA, Knottnerus JA. Symptoms of post-traumatic stress disorder after non-traumatic events: evidence from an open population study. Br J Psychiatry. 2005;186:494–9.PubMedView ArticleGoogle Scholar
  58. Menaghan EG, Lieberman MA. Changes in depression following divorce: a panel study. J Marriage Fam. 1986;48(2):319–28.View ArticleGoogle Scholar
  59. Magura M, Shapiro E. Alcohol consumption and divorce: Which causes which? J Divorce. 1988;12(1):127–36.View ArticleGoogle Scholar
  60. Lee MR, Chassin L, Mackinnon D. The effect of marriage on young adult heavy drinking and its mediators: results from two methods of adjusting for selection into marriage. Psychol Addict Behav. 2010;24(4):712–8.PubMedPubMed CentralView ArticleGoogle Scholar
  61. Gray C, Koopman E, Hunt J. The emotional phases of marital separation: an empirical investigation. Am J Orthopsychiatry. 1991;61(1):138–43.PubMedView ArticleGoogle Scholar
  62. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295(9):1023–32.PubMedView ArticleGoogle Scholar
  63. Smith TC, Smith B, Jacobson IG, Corbeil TE, Ryan MA. Reliability of standard health assessment instruments in a large, population-based cohort study. Ann Epidemiol. 2007;17(7):525–32.PubMedView ArticleGoogle Scholar
  64. Grill E, Weitkunat R, Crispin A. Separation from children as a specific risk factor to fathers’ health and lifestyles. Soz Praventivmed. 2001;46(4):272–8.PubMedView ArticleGoogle Scholar

Copyright

© Wang et al. 2015

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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