Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War
Charles S. Milliken, MD; Jennifer L. Auchterlonie, MS; Charles W. Hoge, MD
JAMA. 2007;298(18):2141-2148.
ABSTRACT
Context To promote early identification of mental health problems among combat veterans, the Department of Defense initiated population-wide screening at 2 time points, immediately on return from deployment and 3 to 6 months later. A previous article focusing only on the initial screening is likely to have underestimated the mental health burden.
Objective To measure the mental health needs among soldiers returning from Iraq and the association of screening with mental health care utilization.
Design, Setting, and Participants Population-based, longitudinal descriptive study of the initial large cohort of 88 235 US soldiers returning from Iraq who completed both a Post-Deployment Health Assessment (PDHA) and a Post-Deployment Health Re-Assessment (PDHRA) with a median of 6 months between the 2 assessments.
Main Outcome Measures Screening positive for posttraumatic stress disorder (PTSD), major depression, alcohol misuse, or other mental health problems; referral and use of mental health services.
Results Soldiers reported more mental health concerns and were referred at significantly higher rates from the PDHRA than from the PDHA. Based on the combined screening, clinicians identified 20.3% of active and 42.4% of reserve component soldiers as requiring mental health treatment. Concerns about interpersonal conflict increased 4-fold. Soldiers frequently reported alcohol concerns, yet very few were referred to alcohol treatment. Most soldiers who used mental health services had not been referred, even though the majority accessed care within 30 days following the screening. Although soldiers were much more likely to report PTSD symptoms on the PDHRA than on the PDHA, 49% to 59% of those who had PTSD symptoms identified on the PDHA improved by the time they took the PDHRA. There was no direct relationship of referral or treatment with symptom improvement.
Conclusions Rescreening soldiers several months after their return from Iraq identified a large cohort missed on initial screening. The large clinical burden recently reported among veterans presenting to Veterans Affairs facilities seems to exist within months of returning home, highlighting the need to enhance military mental health care during this period. Increased relationship problems underscore shortcomings in services for family members. Reserve component soldiers who had returned to civilian status were referred at higher rates on the PDHRA, which could reflect their concerns about their ongoing health coverage. Lack of confidentiality may deter soldiers with alcohol problems from accessing treatment. In the context of an overburdened system of care, the effectiveness of population mental health screening was difficult to ascertain.
There is a lot to digest here. The bottom line is that, taken together, the two screenings indicate a rate of mental health problems of about 20% for active-duty soldiers, and a staggering 42% for reserve soldiers. Actually, bother numbers are staggering, but the 42% number is astonishingly staggering.
Second, the one good finding, is that a lot of people who had PTSD symptoms at the time of the first screening seemed improved by the time of the second screening, six months later.
I have some concerns about the way the screening was conducted:
Soldiers complete a self-report questionnaire and then undergo a brief interview with a primary care physician, physician assistant, or nurse practitioner...Both assessments include a 2-item depression instrument from the Patient Health Questionnaire (PHQ) and the Primary Care 4-item posttraumatic stress disorder screen (PC-PTSD). A question on suicidal ideation from the PHQ and a question on interpersonal aggressive ideation were included on the self-administered section of the PDHA and on the clinician section of the PDHRA.
In other words, the screening was hardly comprehensive. Unfortunately, it would be exceedingly difficult to do a comprehensive assessment of 88,235 people. I would have more faith in this if they had a mental health professional conduct about two hours of screening for the first assessment, and one for the second. It is doubtful that they have the personnel that would be needed for that. I think for epidemiological purposes, it is a pretty good study. The problem, from a clinical standpoint, is that it would be difficult to use a screening like that to make treatment decisions for any individual veteran.
It is important to look at al clinical categories, not just the PTSD. While the PTSD is what is generating the headlines ( 1 2 3 4 ), the screening detected many other problems, too. Not all of these problems are diagnosable mental illness, but a problem does not have to fit into a recognized clinical category in order to be important. In particular, the study noted a high (and increasing) rate of interpersonal problems:
Concerns about interpersonal conflict increased the most (active, 3.5% to 14.0%; reserve, 4.2% to 21.1%)
This means that the distress is affecting not only the vets, but those close to them as well.
Perhaps the greatest concern mentioned in the study is this:
A recent congressionally mandated task force found the existing DoD mental health system to be overburdened, understaffed, and underresourced...Unlike other routine health care that is readily available to active soldiers and their families on-post, family–member mental health care is generally only available through the civilian TRICARE insurance network, a system that has been documented to be inadequately resourced, inconvenient, and cumbersome.
Earlier, I commented that I doubted that they have the capacity to do comprehensive assessments on all those returning soldiers. If that is true, imagine how difficult it would be to provide treatment to all those who need it. Then extend that to the family members, and you get an idea of how massive this problem is.
