U.S. troops returning from Iraq are more likely to report mental health
problems than those coming back from Afghanistan. In addition, 35 percent of
troops who served in Iraq used mental health services in their first year
home, although only one-third of them had received a mental health diagnosis,
according to a new study by researchers from Walter Reed Army Institute of
Mental health problems were closely tied to posting location and combat
exposure, said the authors. "These findings highlight the challenges in
assuring that staffing levels of mental health services are sufficient to meet
the needs of returning veterans," said Charles W. Hoge, M.D., and
colleagues in the March 1 Journal of the American Medical
U.S. Marine Staff Sgt. Jesus Arriaga of El Paso, Texas, is photographed
upon returning to the Third Battalion, Fourth Marines field base from patrol
in Fallujah, Iraq. Arriaga, 31, was among the first to respond to the suicide
bombing that killed three female Marines on June 23, 2005, and said the horror
of what he saw haunts him.
Photo by Chris Hondros/Getty Images
Information for the study was drawn from the three-page Post-Deployment
Health Assessment (PDHA) given to all service members upon their return from
any deployment. The researchers followed 303,905 Army soldiers and Marines for
up to one year or until they left the service. That figure represents 82
percent of all returning troops. Active-duty Marines were slightly
overrepresented among the 18 percent without a PDHA. The PDHA includes
questions about depression, posttraumatic stress disorder, suicidal ideation,
interpersonal relationships, and interest in receiving care. Troops are also
interviewed immediately after filling out the PDHA by a physician, nurse, or
physician assistant who decides whether they should be referred for further
evaluation or treatment.
Service in Iraq was more hazardous to soldiers' mental health than serving
in Afghanistan or elsewhere, wrote the researchers.
"Overall, 19.1 percent of soldiers and Marines who returned from
[Iraq] met the risk criteria for a mental health concern, compared with 11.3
percent for [Afghanistan] and 8.5 percent for other locations," they
said. The latter rate is close to baseline levels from soldiers surveyed
before initial service in Iraq and Afghanistan.
Soldiers and Marines returning from Iraq were twice as likely to screen
positive for PTSD as those who had served in Afghanistan (9.8 percent versus
4.7 percent) and were twice as likely to be referred for mental health care
(4.3 percent versus 2.0 percent). There were only minor differences in mental
health issues when comparing active service troops with National Guard or
Reserve members, or women with men. Overall, 28.4 percent of Iraq vets and
16.0 percent of Afghanistan vets were referred for any medical follow-up.
Veterans of Iraq were hospitalized more often during deployment (6.6 percent)
than Afghanistan vets (3.6 percent), which may serve as a marker for
The need for mental health services is a function of combat experience, and
ground service in Iraq entailed a greater exposure to combat, according to the
PDHA data. Compared with troops in Afghanistan, troops in Iraq more frequently
saw comrades killed or wounded and were three times more likely to fire their
weapons. Half the soldiers and Marines in Iraq had felt in great danger of
being killed, twice the rate of those who served in Afghanistan.
Both the nature of the war and deployment practices may account for
differences in mental health outcomes in the two theaters. There are no safe
zones in Iraq, Col. Elspeth Cameron Ritchie, M.C., psychiatry consultant to
the U.S. Army surgeon general, told Psychiatric News. "Danger
can come from any direction, and it's hard to tell friend from foe."
The multiple, year-long deployments to the war zone are tough on troops and
their families. In World War II, soldiers, sailors, and Marines knew they were
in for the duration of the war, and troops served only for one year in
Vietnam. But those serving today in Iraq or Afghanistan may be there for a
year, return, adjust to life back in the States, and then have to ship out
again when their units are called up again. They must face the threat of
roadside bombs and stresses on family life at the same time.
That pressure was reflected in the use of mental health services. About 35
percent of Iraq vets used mental health services in the year after they
returned from overseas. The comparable rate for all active Army and Marine
officers and enlistees has steadily risen in recent years, from 14.5 percent
in 2000 to 22.2 percent in 2004.
All wars take a psychological toll on soldiers, and the higher percentage
of service members being treated reflects the exigencies of the present war
and is a sign that barriers to evaluation and care have been reduced, said
That over one-third of these troops are using mental health services
shortly after returning home is "exactly what we want service members to
do and leaders to encourage," said Hoge in a statement.
Of that 35 percent, 12 percent were diagnosed with an ICD-9 mental
disorder, but the other 23 percent received no psychiatric diagnosis.
"It is not clear why there was such high use of mental health
services without a mental health diagnosis," wrote Hoge and colleagues,
but they suggested that less specific codes were used to lessen the stigma of
a mental health diagnosis. Ritchie said that the system is catching"
troubling" symptoms before they rise to the level of
Immediate screening may mask problems that crop up only later. Military
health personnel will now screen returned troops again at 90 and 180 days
after their return, since they are twice as likely to report mental health
concerns then than in the glow of homecoming.
Some veterans' groups have noted delays in getting help, but both Army and
VA sources said they are committed to monitoring and caring for service
members with mental health problems.
The Department of Defense also offers a program called Military OneSource
to troops and their families. It does not offer treatment but does provide
free, confidential counseling and referral, if needed. Military chaplains also
have a program to help families of troops assigned to the war zones.
Because so many Reserve and National Guard units have been sent to the war
zones, civilian mental health professionals may likely see many veterans in
their practices, said Ritchie.
The present study may underestimate the total utilization of service for
mental health problems, concluded Hoge and his team, but its outcomes may help
inform planning for mental health services for returning veterans, whether in
military, VA, or civilian settings.
"Mental Health Problems, Use of Mental Health Services, and
Attrition From Military Service After Returning From Deployment to Iraq or
Afghanistan" is posted at<http://jama.ama-assn.org/cgi/content/full/295/9/1023>.
The Post-Deployment Health Assessment form and additional information about
the process are posted at<www.pdhealth.mil/dcs/dd_form_2796.asp>.▪