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Thursday, March 02, 2006

JAMA's Iraq Combat Mental Health Study: A Review

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
It continues:
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.

Study Authors

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.]

Study Results

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%
The study states, “The 8.5% compares closely with baseline data from another study of soldiers surveyed before they deployed for the first time to Iraq and Afghanistan.”

Soldiers and Marines scoring 2 or more on the 4-item PTSD scale:

  • OIF: 9.8%
  • OEF: 4.7%
  • Other: 2.1%
Soldiers and Marines referred for a mental health problem:

  • OIF: 4.3%
  • OEF: 2.0%
  • Other:0.9%
The 4.3% translates to 42,506 OIF veterans screening positive. Of these, 18.3% (7,797) were referred for a mental health problem.

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%
Of 14,777 veterans who were hospitalized, 35% reported a mental health problem. Other mental health care stats for our OIF veterans:

  • 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
A few cautionary notes borne out by the data that do not bode well for the current mental health assessment process and our ability to diagnose and treat combat-related PTSD:

  • 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

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.

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