Soldiers back from Iraq report more mental distress after they've been home
for six months than when they first return, and National Guard and Reserve
soldiers are twice as likely to need mental health care as their regular-Army
peers, according to an Army study.
The study compared health assessments of 88,235 soldiers given just as they
returned from the war zone with their responses to a similar evaluation four
to 10 months later.
"The rates that we previously reported based on surveys taken
immediately on return home from deployment substantially underestimate the
mental health burden," said Col. Charles Milliken, M.C., Jennifer
Auchterlonie, M.S., and Col. Charles Hoge, M.C., in the November 14
Journal of the American Medical Association. Milliken and Hoge are
psychiatrists. Hoge is director of the division of psychiatry and neuroscience
at the Walter Reed Army Institute of Research, and Milliken is a principal
The new study compared results from the Post-Deployment Health Assessment,
or PDHA, which is the screening questionnaire that troops must take as they
return from overseas deployments. The same authors published a report in March
2006 documenting responses on the PDHA of 303,905 Army soldiers and Marines
who had served in Iraq and Afghanistan. Their current study is based on a
second round of screening with the Post-Deployment Health Re-Assessment
(PDHRA), which was completed between June 1, 2005, and December 31, 2006, and
covers only U.S. Army soldiers who served in Iraq (Psychiatric News,
April 7, 2006). Both surveys ask soldiers to answer questions on their health,
followed by a brief interview with a physician, physician assistant, or nurse
practitioner. The survey results become part of the soldiers' military health
record and can be evaluated later, along with all episodes of care.
Higher rates of psychological symptoms reported in the second assessment
might be considered a positive sign that the Army is finding symptoms that
arise later or were concealed in the first survey. Recognizing symptoms early
could allow earlier intervention and a less severe course of any disorder,
said Milliken at the briefing. However, some findings may also reveal
shortcomings in the existing military mental health care system.
Soldiers were considered to be at mental health risk if they screened
positive for some items related to depression, posttraumatic stress disorder,
suicidal ideation, and interpersonal aggression and conflict. Overall, mental
health risk for active component troops was 17 percent as they returned from
Iraq and 27 percent on average of six months later; the risk for National
Guard members and reservists rose from 17.5 percent to 35.5 percent. There
were also significant jumps in posttraumatic stress disorder (PTSD) and
depression symptoms in the six months between the two screenings.
Soldiers with high rates of depression or PTSD symptoms in the first round
often showed symptomatic improvement by the second screening, but there was a
doubling of new cases among those who had had normal scores on the PDHA.
When the results of the two screenings were combined, 20 percent of active
and 40 percent of National Guard or Reserve soldiers required mental health
By comparison, a compulsory screening of 1,442 Canadian land, sea, and air
force members who served in Afghanistan found that four to six months after
their return, 20 percent had symptoms of at least one mood, anxiety, or
alcohol use disorder. Follow-up interviews led to referrals for 23 percent of
the total, mostly for psychosocial issues, according to a study by Mark
Zamorski, M.D., of the Canadian Forces Health Services Group Headquarters.
Only 1.1 percent of the U.S. soldiers received a mental health referral
after taking both the PDHA and PDHRA, implying that new symptoms developed in
the half year after returning from Iraq or reflecting an unwillingness to
admit symptoms immediately upon arrival for fear of delaying home-coming or
harming a career.
The sharpest increases were reported for interpersonal conflicts at home or
work, rising from 3.5 percent to 14 percent among active component troops, and
from 4.2 percent to 21 percent among Guard and Reserve soldiers.
The fourfold increase in the last category "highlights the potential
impact of this war on family relationships," said the authors. It also
highlights the fact that family mental health care is not available on
military posts as is other routine health care. Spouses and children must turn
to the TRICARE contractor insurance network, a system described as"
inadequately resourced, inconvenient, and cumbersome" by a review
panel earlier this year.
"When soldiers come back for the first time, they're just glad to be
home," said Brig. Gen. Stephen Jones, M.C., assistant surgeon general
for force projection, suggesting one explanation for the difference at a news
briefing announcing the results of the survey. "But then they re-enter
family relationships, and stress levels at home go up."
Milliken and colleagues were also critical of the Army's handling of
reported alcohol problems. Although 6,669 of the 56,350 active troops said
they had alcohol problems, only 134 were referred for further services, and
only 29 actually sought help within three months. This finding may reflect
current military policy on alcohol misuse, they said. Mental health standards
attempt to balance confidentiality with an officer's need to know whether a
soldier is fit to serve. However, "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
Active component troops and Guard or Reserve soldiers reported similar
levels of combat exposure when they first returned, so the different rates of
symptoms they reported in the later screening may be due to other
circumstances, primarily lack of access to health care, said Milliken.
"Active soldiers can get care on the base, but more than half of the
Guard or Reserve soldiers had passed the time in which they were eligible for
care through the Department of Defense," he said. Reservists may also
lack the close support from unit members after they come home and face
stresses in a sudden return to civilian jobs.
The researchers also noted an apparent inverse relationship between
treatment and improvement in PTSD symptoms, an anomaly that, said the authors,"
may indicate that treatment for PTSD is not optimal in military health
clinics because soldiers are not receiving a sufficient number of sessions or
the provided treatment is ineffective."
Several encouraging points were identified in the new study, said Milliken
and Jones at the briefing. For example, 61 percent of active soldiers referred
for care received services, and most who sought services on their own did so
within 30 days of screening.
For soldiers with symptoms that earlier were not considered serious enough
to warrant referral, simply filling out the PDHRA may have spurred the
decision to visit a clinician, said the authors.
Army brass and medical officials have also taken steps in the years since
the recent conflicts began to decrease the stigma associated with having or
reporting symptoms of psychological stress. They stepped up programs to
educate troops about mental health issues and the inevitable stresses of
deployment and combat. Soldiers now hear that help seeking is a sign of
strength rather than weakness. Last summer, the service required leaders at
every level to learn and then teach their subordinates about PTSD and
traumatic brain injury. These efforts may have helped soldiers filling out the
PDHRA to acknowledge their mental health needs and ask for help, said
Conducting the screenings and studying their value during wartime was a new
step for the Armed Forces, he said. "The Army's efforts to care for the
mental health of soldiers through early identification, early treatment, and
education during this conflict are unprecedented."
An abstract of "Longitudinal Assessment of Mental Health
Problems Among Active and Reserve Component Soldiers Returning From the Iraq
War" is posted at<http://jama.ama-assn.org/cgi/content/abstract/298/18/2141>.▪