The Department of Defense appears to be making a real effort
to
determine the scope of the problem. They now have published
the results of a second screening of 88,235 returning soldiers.
In their most recent study, they acknowledge that the prior
study missed a lot. Moreover, they now worry that even the
second study is missing some. In a nice gesture, the
style="font-style: italic;">Journal of the American Medical
Association has made the results openly accessible. (The
results of the first study also are openly accessible,
href="http://jama.ama-assn.org/cgi/content/full/295/9/1023">here.)
href="http://jama.ama-assn.org/cgi/content/full/298/18/2141"> style="font-weight: bold;">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
style="font-style: italic;">epidemiological
purposes, it is a pretty good study. The problem, from a
style="font-style: italic;">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 (
href="http://www.newscientist.com/article/dn12917-mental-effects-of-war-delayed-for-months.html">1
href="http://www.abcnews.go.com/Health/Depression/story?id=3860975&page=1">2
href="http://www.army.mil/-news/2007/11/14/6090-army-study-finds-delayed-combat-stress-reporting/">3
href="http://www.washingtonpost.com/wp-dyn/content/article/2007/11/13/AR2007111301459.html">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.
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