Mental Problems in Returning Vets: Delayed Testing Shows Higher Rates

Many veterans face mental illnesses on return from duty, but for how long and to what extent? Psychiatrist Charles S. Milliken and colleagues are on a mission to measure the mental health needs of returning soldiers from Iraq, including soldier assessment and use of mental health care, using 2 surveys--the Post-Deployment Health Assessment (PDHA) and the Post-Deployment Health Reassessment (PDHRA). The results of their analyses were reported in the November 2007 issue of JAMA.

To identify mental health concerns among soldiers, the Department of Defense administers the PDHA almost immediately on return from deployment. However, this raises concerns that certain mental health issues (such as posttraumatic stress disorder [PTSD], depression, and alcohol abuse disorder) may be overlooked because of the screening's timing. Therefore, the Department of Defense introduced a second assessment, the PDHRA, to be administered 3 to 6 months after soldiers' return.

The PDHRA is administered using a self-report questionnaire followed by a brief interview with a primary care physician, physician assistant, or nurse practitioner. Upon completion, the clinician reviews the answers and is directed to use his or her judgment in determining who needs a referral for further evaluation. The results of both the PDHA and PDHRA become part of a soldier's permanent medical record and part of the Defense Medical Surveillance System.

A total of 88,235 soldiers were accounted for in this analysis; 90.8% were men, 58.2% were married, and the mean age was 30.4 years. Active (n = 56,350) and National Guard and Reserve (n = 31,885) soldiers' results were separated.

As expected, soldiers indicated more mental health distress on the PDHRA than on the PDHA and were referred at higher rates following administration of the PDHRA. Of the symptoms, concerns about interpersonal conflict increased the most (3.5% to 14% active; 4.2% to 21.1% reserve). In addition, PTSD, depression, and overall mental health risk also increased in both groups; 6669 Active soldiers (11.8%) endorsed alcohol misuse. Of the total, 3925 (4.4%) were referred for mental health care on the basis of the PDHA, and 10,288 (11.7%) were referred on the basis of the PDHRA--a sharp increase.

Among National Guard and Army Reserve soldiers, referrals for mental health concerns were substantially higher on the PDHRA than they were for active soldiers (36.2% vs 14.7%). They also reported more health concerns and were referred at higher rates for any health concern (20.8% vs 16.5%).

The authors concluded that the rates determined on the basis of the PDHA "substantially underestimate the mental health burden." They note that the combined PDHA and PDHRA screening identified 20.3% to 42.4% of soldiers requiring mental health treatment, which is similar to the reported rates at Veterans Affairs facilities.***

--Cortney Mears