Note: Details on JAMA's Nov 2007 follow-up study here.
A 'perfect storm' of events (Zogby International's poll of Iraq combat troops and a study of today's current military population appearing in the Journal of the American Medical Association) has come together to bring combat-related PTSD into the forefront this week. Both of these barometers of troop health and opinion are ground-breaking. I've already touched upon the Zogby data; here I'll take a look at what the JAMA study reveals.
Click on 'Article Link' below tags for more...
A month following the start of combat operations in Iraq, the Department of Defense (DOD) implemented a post-deployment survey program of its combat veterans. Each service member was (and is still) required to complete the Post-Deployment Health Assessment (PDHA) form. At the same time, troops would also receive a face-to-face assessment by a physician, physician assistant, nurse practitioner, or independent duty corpsman/medical technician.
From the Deployment Health Clinical Center website, the purpose of the screening is to:
- review each combat veteran’s current health
- study the mental health or psychosocial issues commonly associated with deployments
- track special medications taken during the deployment
- make note of possible deployment-related occupational/environmental exposures
- discuss deployment-related health concerns
Positive responses require use of supplemental assessment tools and/or referrals for medical consultation. The provider will document concerns and referral needs and discuss resources available to help resolve any post-deployment issues. The original completed DD Form 2796 will be maintained in the individual's permanent medical record. A copy (paper or electronic) will be sent to the Army Medical Surveillance Activity (AMSA).
The data collected by AMSA is then integrated into the Defense Medical Surveillance System (DMSS) database – and that database is the source of data for the Hoge study.
The March 1, 2006 Journal of the American Medical Association (JAMA) article outlining the results (Mental Health Problems, Use of Mental Health Services, and Attrition From Military Service After Returning From Deployment to Iraq of Afghanistan) was written by the much respected Charles W. Hoge, MD (Division of Psychiatry & Neuroscience, Walter Reed Army Institute of Medical Research); Jennifer L. Auchterlonie, MS (US Army Center for Health Promotion and Preventative Medicine); and Charles S. Milliken, MD (Division of Psychiatry & Neuroscience, Walter Reed Army Institute of Medical Research).
Value and Goal of Study
The authors explain the reason and value for the unprecedented study (never before has population-based study been possible so immediately or fully after or even during combat ops – today's computer databases now make this possible) stating, “Such studies are an important part of measuring the mental health burden of the current war and ensuring that there are adequate resources to meet the mental health care needs of veterans returning from Iraq and Afghanistan.”
Study Participants and Window
Dr. Hoge and his colleagues used the data available from the records of 303,905 Army soldiers and Marines who’d completed a PDHA between May 1, 2003, and April 30, 2004 and had served in either Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), or other locations such as Bosnia or Kosovo. Of this population of service members, 50,611 have been detached from the military.
Study Questions and Analysis
Two questions were used to determine risk factors for depression: one examining depressed mood (“felt down, depressed, or hopeless”), the other anhedonia (“little interest or pleasure in doing things”).
Four questions were included to screen for PTSD of the key domains of PTSD (re-experiencing trauma; numbing; avoidance; and hyperarousal); an affirmative response to 2 out of the 4 questions was taken to mean the troop was considered to be at risk for PTSD. Additionally, four more questions were proffered exploring suicide, interpersonal relationships, and interest in receiving care. [See the PDHA form for more detail.]
Not surprisingly, rates of mental health problems are higher for those deployed to OIF vs. those deployed to OEF or other locations. [One note: All statistics below are for combat soldiers and Marines. The authors explain, “Although Air Force and Navy personnel also serve in the combat environment, the majority of ground combat units are Army and Marine.”]
Soldiers and Marines meeting the risk criteria for mental health concern:
- OIF: 19.1%
- OEF: 11.3%>
- Other: 8.5%
Soldiers and Marines scoring 2 or more on the 4-item PTSD scale:
- OIF: 9.8%
- OEF: 4.7%
- Other: 2.1%
- OIF: 4.3%
- OEF: 2.0%
Cross-component prevalence of mental health problems (screening positive for 1 of the mental health concerns) in OIF troops:
- Active: 18.4%
- National Guard: 21.0%
- Reserve: 20.8%
- Documented to have at least 1 outpatient mental health care visit within one year post-deployment: 31%
- Annualized rate of utilization of mental health services: 35% of persons per year
- Episodes of care per person per year: 3.4 visits
- Among OIF veterans who’d listed mental health concerns on their PDHA form, only 20% were referred for such care.
- Of those who accessed mental health care within a year after deployment, only 7.6% (5,216) has a referral for such on their PDHA form.
- 60% who screened positive for PTSD, generalized anxiety, or depression did not seek treatment.
- Rates of mental health care use has been increasing with each year since 2000, “providing further evidence that the war is burdening the health care system at large.”
Selection of Press Coverage Given Study
- Iraq Vets Bringing Home Mental Health Needs at High Rate
- Study Details Mental Health of War Veterans
- Veterans Report Mental Distress
- 35% of Iraq vets sought therapy after war's 1st year
- Iraq Veterans Using Clinics to Assist Mental Health
Additional Screening Program Implemented by DOD
As already reported at PTSD Combat last month, an additional mental health screening program for our returning troops is being rolled out by the DOD: the Post-Deployment Health Reassessment (PDHRA form). Service members will participate in the health screening three-to six months after arriving home.
- JAMA: Mental Health Longitudinal Assessment of Returning Iraq War Veterans Study
- Study: Drug May Ease Combat PTSD Nightmare Incidence
- Study: War Effects Mental Health of One-Third of Military-Separated OEF/OIF Veterans
- Study: 'Prolonged Exposure' Therapy Superior Treatment for Female PTSD
- Psychiatric News: Iraq and Afghanistan Combat Experiences Compared
- Combat Stress: A Look Back at the New England Medical Journal Study
- A Sample of the Latest PTSD Study Results
- Neuroscience Study: Prefrontal Cortex Hyperactivity in Brain Associated with Learned Fear, PTSD
- Study: Common PTSD Med Guanfacine As Effective As Placebo
- Study: Vets' View on Combat Injury Effects PTSD
- Study: Higher Memory, Attention Lapses for OIF Vets
- Psychological Bulletin from APA: Females Have Higher Rates of PTSD