The U.S. Department of Defense (DoD) officials in charge of mental health services for service personnel and their families testified before Congress in July 2005 about efforts to identify and treat service members experiencing mental health problems. Every year, service personnel are screened for mental health problems during a preventive health assessment. Prior to deployment, they receive another screening. Those with unremitting mental health disorders are not deployed, William Winkenwerder Jr., M.D., M.B.A., assistant secretary of defense for health affairs, told the House Subcommittee on Military Personnel. Those for whom a mental health condition has resolved are permitted to stay on maintenance medication during deployment.
Deployed military units embed mental health teams, unique to each service, to support the needs of each service. Military members and their families may also use Military OneSource--a confidential, around-the-clock information, education, referral and counseling service.
In an interview with Psychiatric Times, Michael Kilpatrick, M.D., deputy director of the DoD's Deployment Health Support, explained that just as service members are leaving the Iraq or Afghanistan theaters, or within a few days of their returning home, they are asked to complete a four-page, post-deployment health assessment "that asks them about a full spectrum of medical symptomatology, both physical and mental health, as well as environmental concerns they may have." That assessment includes a face-to-face discussion with a medical provider in the military (e.g., physician, nurse practitioner or physician assistant) and documentation of the individual's responses to the health assessment questions.
"The health care provider who goes over the assessment with the individual does not make a diagnosis but refers the individual to clinical areas for further evaluation and workup to determine if, in fact, there is a diagnosis because of the symptoms or concerns," Kilpatrick continued. For example symptoms such as anxiety, sleep problems and anger management issues may be indicative of possible PTSD. In testimony before the House Veterans Affairs Committee in July 2005, Kilpatrick noted, "Of the 138,000 troops who returned in 2004 and received a post-deployment health assessment, 16% have been referred to mental health providers for further evaluation."
Individuals with mental health referrals have options. "They can go to the base support area that may have counselors and chaplains to deal with it. They can also go to our primary care facilities, and many of those facilities are enhanced with behavioral health specialists, such as psychologists and psychiatrists, working with a primary care physician," Kilpatrick said. Additionally, they could go to a mental health clinic, where they would see a psychologist or psychiatrist.
In testimony before the House Subcommittee on Military Personnel in October 2005, Winkenwerder recognized that "no one who goes to war remains unchanged." In response, he announced that DoD is instituting a short interview questionnaire (Post-Deployment Health Reassessment [PDHRA]) to be filled out by all service members, including those serving in the Reserves or National Guard, three to six months after they return home. The assessment is designed to identify health concerns and conditions that may have emerged following the service member's most recent deployment and to determine the types of information and assistance the individual would like to have. A credentialed health care provider (e.g., physician, physician assistant) reviews the assessment with the service member, discusses health concerns and makes referrals when needed. Active duty members can be referred to their primary care provider or mental health community support. Members of the Reserves or National Guard and separated veterans are referred to TRICARE, the DoD's worldwide health care program, or the VA.
The PDHRA is scheduled to be used broadly by January, according to Kilpatrick. It was initiated because the Army looked at the mental health stressors troops were experiencing while deployed and after they got home, and its research data indicated that "at the three- to six-month period people were subscribing to more symptomatology than they had either at the time they just came home or while they were in the theater."
To create the PDHRA, medical providers from DoD and VA with expertise in developing assessments used questions from standardized, validated survey instruments, Kilpatrick told PT. The PDHRA includes screens for anxiety, PTSD symptoms, interpersonal conflict, alcohol(Drug information on alcohol) abuse and depression. Implementation of the program also has involved leadership and clinician education and training as well as outreach and education for service members.
The PDHRA is undergoing pilot-testing for active duty personnel at three locations, for the National Guard in Arkansas and for the Army Reserve with the 88th Regional Readiness Command with units in six states. In the preliminary trials at active duty sites, researchers found that the percentage of returning troops referred for follow-up medical or mental health treatment was between 30% and 35%, and "it is a 50/50 split between mental/behavioral health and the physical health problems," according to Kilpatrick.
The goal of both the post-deployment assessment and reassessment is to get service members early access to health care, Kilpatrick said, thereby eliminating the risk, for example, of PTSD symptoms developing into chronic PTSD. If care is needed, military and VA providers use jointly developed clinical practice guidelines for acute stress, PTSD, depression, substance use disorders and other health concerns.Importance of Early Intervention
Studies of Vietnam War veterans underscore the importance of early treatment of PTSD symptoms to prevent emergence of other psychiatric and medical disorders. One recent study concluded that Vietnam War veterans with PTSD may be at increased risk of death (Boscarino, 2005).
The national study examined the causes of death among 15,288 male U.S. Army veterans 16 years after they had completed a telephone health survey, which included questions related to PTSD symptoms and substance abuse, and 30 years after their military service. The study confirmed that PTSD was associated with an adjusted all-cause mortality for both Vietnam War era and theater veterans. For PTSD-positive theater vets, the postwar mortality for all-cause, cardiovascular, cancer and external causes (e.g., deaths from suicides, homicides, accidents) was about twice as high as that of Vietnam War veterans without PTSD.
The study was not a sample of patients who show up at VA hospitals, "it was a random sample of all U.S. Army veterans, some of whom got PTSD from Vietnam and some of whom got PTSD from life, and they die after a significant period of time," the study's author, Joseph Boscarino, Ph.D., told PT. The study results point to the importance of prevention and treatment, Boscarino noted.
"If we can prevent or reduce the anxiety levels, we can prevent the long-term psychological sequelae … and we can also reduce [physical] disease outcomes," he said. "We know there are effective treatments for PTSD, the combination therapies are effective and the drug therapies are effective. Cognitive-behavioral therapy appears to be one of the most cost-effective methods, in my opinion, but there are other methods out there that have been effective."
Boscarino acknowledged that various institutions might be concerned about the cost, compensation and disability issues connected with PTSD's link to medical conditions. "I got a call from a military person who said this kind of study is going to affect the nation's defense budget. I responded that it might be the case, but we have an obligation to the men and women in the Armed Forces. We can prevent [PTSD] from happening and if we do so, we will have lower costs, better quality of life and more productivity."
Boscarino also believes that because of efforts by the DoD and VA, outcomes among troops experiencing PTSD who are returning from Iraq and Afghanistan may be much better than those for Vietnam War veterans. "When I was doing my postdoctoral fellowship at the West Haven [Connecticut] VA Hospital in the late 1970s, they were diagnosing many of the combat veterans as being alcoholic and psychotic. They probably were, but it likely had a lot to do with their undiagnosed PTSD," he said, explaining that the PTSD diagnosis was first included in the DSM-IIIin 1980. The VA, he said, now has the tools to screen, diagnose, refer and treat PTSD that it did not have 30 and 40 years ago.