Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War

Charles Milliken, Jennifer Auchterlonie, and Charles Hoge, Journal of the American Medical Association

This is the first study, to our knowledge, to look at mental health concerns longitudinally among soldiers returning from Iraq using the DoD’s screening programs. The study shows that the rates that we previously reported based on surveys taken immediately on return from deployment substantially underestimate the mental health burden. In contrast to the rates of mental health concerns recorded immediately on return, soldiers reported increased mental health concerns and were referred at much higher rates several months later at the time of the PDHRA. Reporting mental health concerns was also associated with attrition from military service.

A recent congressionally mandated task force found the existing DoD mental health system to be overburdened, understaffed, and underresourced. This study suggests that the mental health problems identified by Veterans Affairs clinicians in more than a quarter of recent combat veterans may have already been present within months of returning from war. The combined DoD screening identified 20.3% to 42.4% of soldiers as requiring mental health treatment, consistent with rates reported among recent veterans seeking care at Veterans Affairs facilities. This emphasizes the enormous opportunity for a better-resourced DoD mental health system to intervene early before soldiers leave active duty. The literature on comorbidity and treatment of early PTSD symptoms argues for the desirability of intervening before work or relationships are compromised, before symptoms become chronically entrenched, or before comorbid conditions develop.

The same task force also found that DoD is failing to provide adequate mental health care to military family members. Although soldiers’ rates of PTSD and depression increased substantially between the 2 assessments, the 4-fold increase in concerns about interpersonal conflict highlights the potential impact of this war on family relationships and mirrors findings from prior wars. Furthermore, although stigma deters many soldiers from accessing mental health care, spouses are often more willing to seek care for themselves or their soldier-partner, making them important in a comprehensive early intervention strategy. At present, however, spouse-initiated treatment is hindered by lack of parity of access. 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.

Although National Guard and Army Reserve soldiers had similar results as active soldiers at redeployment from Iraq, by the time of the PDHRA, they reported higher rates of problems and were referred at substantially higher rates than active component soldiers. These higher rates applied to both mental health and general health problems. One reason may be that reservists have concerns with securing ongoing health care for deployment-related problems. Although active component soldiers have ready access to health care, for reservists, standard DoD health insurance benefits (TRICARE) expire 6 months and standard VA benefits expire 24 months after return to civilian status. More thanhalf of the guard and reserve soldiers in this sample were beyond the standard DoD benefit window by the time they took their PDHRA. Although stigma concerns may suppress reporting on the PDHRA among active soldiers, for guard and reserve soldiers, securing ongoing health care may be a more prevailing concern. Other potential factors unique to reservists may be the lack of day-to-day support from war comrades and the added stress of transitioning back to civilian employment.

Another important finding is that soldiers frequently reported alcohol problems yet were very rarely referred for alcohol treatment and infrequently followed-up if referred. One likely reason is that using these treatment services, even when a soldier self-refers, is not confidential. Under present military policies, accessing alcohol treatment triggers automatic involvement of a soldier’s commander and can have negative career ramifications if the soldier fails to comply with the treatment program. This is in contrast to a variety of protections surrounding mental health care that balance the need of the commander to know when a soldier is mentally unfit for duty with the soldier’s medical confidentiality. Given the high rate of alcohol misuse following combat and its comorbidity with PTSD and relationship problems, it is important that military policies be conducive to encouraging self-referral, referral from medical professionals, and confidential treatment before alcohol-related behaviors necessitate formal involvement of the soldier’s commander.

This study is unique in endeavoring to evaluate the effectiveness of a mass population mental health screening program. The findingsindicate that the postdeployment assessments do not seem to be redundant; they identify and refer 2 largely distinct cohorts. The program documents a substantial increase in mental health needs several months after return from deployment. Among active soldiers referred for mental health care on the PDHRA, 61.0% were documented to receive services, which compares favorably with civilian follow-up rates. Although the majority of soldiers who used mental health services had not been referred, most who sought care did so within 30 days of screening, and this was associated with having reported mental health concerns on the questionnaire. These data suggest that the screening process may have encouraged self-referral among soldiers with symptoms that were initially not considered serious enough to warrant clinician referral. This is important because perceptions of stigma are greater among soldiers with mental health symptoms than soldiers without symptoms. Factors that may have promoted help seeking include recognition of symptoms, communication with a clinician, and unit-focused mental health education that accompanies the screenings.

Several factors make it difficult to conclude that the PDHA portion of the screening program is effective. Most soldiers with significant PTSD symptoms on the initial PDHA screen had improvement of symptoms without treatment, and there was no relationship of referral to symptom improvement. One possible explanation is the inherent psychometric properties of the screening tools. Even the best mental health clinical measures will have poor predictive value when applied on a population level (particularly positive predictive value, which will not likely exceed 50%). Another consideration is that PTSD symptoms may be more transient immediately on return from deployment than at the later time of the PDHRA. It is possible that elements of the screening process, such as normalization of symptoms during unit education or by the clinician, may have facilitated resolution of theseearly symptoms.

The inverse relationship between mental health treatment and improvement in PTSD symptoms and the 37% improvement rate among soldiers who received 3 or more sessions is counterintuitive. Even among soldiers with PTSD symptoms who were referred from the PDHA, recovery was highest among those who did not follow-up with an appointment. This apparent ineffectiveness of treatment should be interpreted with caution. The 37% response is not inconsistent with the response rate in some PTSD treatment studies, and soldiers may not have had sufficient time to respond to treatment (median follow-up 4 months). In addition, those who use mental health services are more likely to have severe or comorbid conditions than those who do not utilize services, and this relationship was indeed observed among soldiers with PTSD symptoms who were not referred from the PDHA screening. However, among soldiers with PTSD symptoms who were referred, there was no significant difference in the rate of measurable comorbid mental health concerns on the PDHA between those who used services and those who did not. In the context of the recent DoD task force findings, these results may indicate that treatment for PTSD is not optimal in military health clinics because soldiers are either not receiving a sufficient number of sessions or the provided treatment is ineffective. An important requirement for implementing any population mental health screening program is that adequate resources are available to cope with the workload generated by the screening process.

In terms of treatment efficacy, some studies suggest that combat-related PTSD may be more refractory than PTSD from other traumas, which may be due in part to the emergence of other comorbid problems after return home. Manualized psychotherapy modalities have been largely based on single-event traumas in noncombat settings, and there is a lack of clinical efficacy studies conducted during the early postcombat period. Thus, in addition to documenting the large need for care among soldiers several months after return from combat, this study highlights the need for randomized clinical trials during the early postdeployment period; evaluation of existing clinical practice guidelines; and further scientific appraisal of the risks, benefits, and resources needed for population mental health screening.

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