Adequacy of Mental Health Screening and Care in the Military Is Questioned

July 2006, Vol. XXIII, No. 8

US military officials are attempting to rebut charges of lax mental health screening and treatment procedures for soldiers deployed to Iraq and Afghanistan.

Criticisms of the psychiatric care and facilities available for soldiers in combat zones have appeared in a variety of publications and Web sites. A JAMA study found that 35% of Iraq war veterans accessed mental health care in the year after returning, but that few of those were referred through the military's screening program. And a series of articles that appeared in the Hartford Courant newspaper over a 4-day period in May raised disturbing accusations.

"The U.S. military is sending troops with serious psychological problems into Iraq and is keeping soldiers in combat even after superiors have been alerted to suicide warnings and other signs of mental illness," the Courant reported.

Col Robert Ireland, MD, USAF, told Psychiatric Times, "That's not our policy. If that's the case, I'd like to know about it." Ireland is the program director for mental health policy in the Department of Defense (DOD) Health Affairs Organization. "Our role is to apply standards and make sure people abide by them because we want people who are competent to do what we ask of them," he said.

Critics claim that the military's predeployment mental health assessment of troops scheduled to go to Iraq is inadequate. "[T]he assessment being used is a single mental health question on a pre-deployment form filled out by service members," according to the Courant series.

Ireland countered that pre-deployment screening involves what he called a comprehensive process. "I think some people look at 'comprehensive process' as meaning something that takes place a few days before you leave for [the] theater [of battle]. We're dealing with tens of thousands of people, and it would be impossible to do a full-blown mental health evaluation; and it would be illegal without behavioral evidence that they're a danger to themselves or others or could compromise the mission. Those are the only circumstances for a full-blown mental health evaluation on an involuntary basis. When you do an involuntary evaluation, the quality of the assessment is not as good as one where the patient is seeking your help. You're going to get a lot of 'I really don't want to be here.'

"There seems to be a group of folks who are not familiar with mental health professionals," he added. "They think you just come in the door, and we somehow read your minds and see whether or not psychological testing is indicated.

"The pre-deployment process is not the time to be doing a full-blown evaluation. A 'comprehensive process' refers to ongoing screening and monitoring in the military. When they come in, they're asked if they have a mental health history. While they're in basic, if it seems that they've lied about it, we ask them again. In the military, there is an entire process of evaluation, not just at start of service, but annually, part of their preventive health assessments—someone has been doing it all along."

Beginning in August, all branches of the service will intensify their use of psychological screening questions, he said. "They're not designed for population-based screens, but we are using them anyway. There are always questions about substance abuse, family relationships, and personal conflicts associated with what used to be called the annual physical examination. Now we'll be looking more at things that are indicated based on the person's age, medical history, and so on."

Charges that the military was sending mentally ill troops to combat areas first surfaced in 2004, when United Press International obtained a copy of an October 2003 assessment by the Army that reportedly said, "Variability in pre-deployment screening guidelines for mental health issues may have resulted in some soldiers with mental health diagnoses being inappropriately deployed."

"Perhaps stricter pre-deployment screening is required to keep at-risk soldiers from deploying," the report said. That would help in "identifying soldiers that may become nonfunctional in theater due to mental health problems."

Critics of the military screening programs have focused attention on the number of suicides among active-duty personnel in the war zones of Iraq and Afghanistan. Through April 2006, the DOD listed 12 suicides in Afghanistan and 70 confirmed self-inflicted deaths in Iraq. In addition, 3 deaths in Iraq were classified as undetermined, and 25 deaths resulting from non-hostile causes were under investigation.

In response, the DOD posted an article on its Web site comparing suicides among military personnel with those in the general population aged 20 to 44. According to the article, the suicide rate for all military personnel was 11 per 100,000, compared with a rate of 19.5 per 100,000 20- to 44-year-olds in the general population, based on data extracted from Centers for Disease Control and Prevention (CDC) statistics.

In response to a question, Ireland conceded that the rate for military personnel in combat zones was slightly higher than the number reported for all service personnel. "Broken down by theater, it's still about 12.1 per 100,000 for the Army, including reservists and Army National Guard troops."

Nationally, the CDC reports an ageadjusted rate of 10.83 per 100,000 population in 2003—fractionally less than the rate claimed for all military personnel in the article on the DOD Web site.

But military.com, a Web site devoted to coverage of service-related matters, posted an April 22, 2006, Associated Press (AP) story that reported that suicides are increasing among military personnel. "In 2005, a total of 83 soldiers committed suicide, compared with 67 in 2004, and 60 in 2003-the year US-led forces invaded Iraq. Four other deaths in 2005 are being investigated as possible suicides but have not yet been confirmed," according to the AP story.

"Of the confirmed suicides last year, 25 were soldiers deployed to the Iraq and Afghanistan wars-which amounts to 40% of the 64 suicides by Army soldiers in Iraq since the conflict began in March 2003."

In addition, the AP story reported that civilian suicides in the 18 to 34 age range totaled 12.19 per 100,000 in 2003.

Army suicides in 2005 were the highest since 1993, when 90 service members took their own lives, the site reported.

Earlier this year, an article in JAMA by Charles W. Hoge, MD, of the Walter Reed Army Institute of Research, and his associates¹ reported on a followup study of military personnel who completed post-deployment health assessments between May 1, 2003, and April 30, 2004. It found that "the prevalence of reporting a mental health problem was 19.1% among service members returning from Iraq compared with 11.3% after returning from Afghanistan and 8.5% after returning from other locations."

The study was designed to evaluate the effectiveness of the military's postdeployment screening program, which it found wanting. "Thirty-five percent of Iraq war veterans accessed mental health services in the year after returning home; 12% per year were diagnosed with a mental health problem. More than 50% of those referred for a mental health reason were documented to receive follow-up care although less than 10% of all service members who received mental health treatment were referred through the screening program," the authors said.

Reference
1. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006; 295:1023-1032.