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Wednesday, November 21, 2007

JAMA: Mental Health Longitudinal Assessment of Returning Iraq War Veterans Study

Last year, a March 2006 Journal of the American Medical Association article outlined the results of a study conducted for the Department of Defense by a team of Walter Reed Army Medical Center researchers. Last week, details of a follow-up study conducted by the same WRAMC team arrived once more in JAMA, shedding light on the health of our returning troops in the months following their combat deployments.

A full review of the study in extended.

Details from PBS News Hour, November 14, 2007:


A month following the start of combat operations in Iraq, the Department of Defense 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 are to 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 was the source of data for the initial Hoge study.

In February 2006, a month prior to the initial study's release, the DoD announced the coming implementation of an additional mental health screening program using the Post-Deployment Health Reassessment (PDHRA) form. Service members would now be required to participate in an additional health screening, which would take place three-to six months after arriving home. The results of this second screening are the focus of this follow-up study.

Study Authors

The November 14, 2007 Journal of the American Medical Association (JAMA) article (Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War) was written by Charles S. Milliken, 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 W. Hoge, 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 follow-up study stating, “The [initial] article also raised concerns that mental health problems might be missed because of the early timing of this screening. It cited preliminary data showing that soldiers were more likely to indicate mental health distress several months after return than upon their immediate return.” In addition to measuring the mental health state of returning troops, the study aimed to discern the "association of screening with mental health care utilization."

Study Participants and Window

Dr. Milliken and his colleagues used the data available from the records of 88,235 U.S. soldiers -- both in the active military component and the National Guard/Reserve -- who'd served in Iraq and had completed both a PDHA and PDHRA upon their return. The Marine population was excluded from this study because the branch had not yet fully implemented use of the second screening during the study period, which was between June 1, 2005 and December 31, 2006. Six months was the median between the two assessments.

Study Questions and Analysis

Researchers looked at the following issues concerning the PDHA/PDHRA self-screening programs:

  1. What percentage of Iraq War veterans had significant mental health problems, and show higher rates at second screening vs. first?
  2. Are there differences in mental health rates between veterans still on active duty and reserve component veterans who've since returned to civilian life?
  3. Are soldiers agreeing to and receiving referrals for alcohol problems?
  4. How many who've received a mental health problem referral get care?
  5. What is the rate of improvement in mental health from first screening to 3-to-6 month follow-up, and is improvement due to referral and care received as a result of such referral?
In both screening forms [which have been updated in September 2007; this study used the original version of the forms], two questions are 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 are 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 are proffered exploring suicide, interpersonal relationships, and interest in receiving care. The PDHRA adds a 2-item alcohol screen and categories for military substance abuse and employee assistance program referrals.

[See the PDHA and PDHRA forms for more detail.]

Study Results

More mental health concerns and significantly higher rates of referrals were reported on second screening via the PDHRA vs. initial screening via the PDHA. Even with the increased PDHRA screening program, most soldiers seeking mental health care help had gone in themselves 30 days after screening vs. being officially referred by the military for such treatment. Not surprisingly, the study found "no direct relationship of referral or treatment with symptom improvement."

On the upside, 49 to 59 percent of those who screened positive for PTSD symptoms on the first screening had improved by second screening. On the downside, a 4-fold increase in interpersonal conflict concerns was cited. In addition, alcohol treatment referrals were low compared to reported alcohol concerns.

Study population:

  • 90.8% men
  • 58.2% married
  • Mean age: 30.4 years
  • 56,350 active component
  • 31,885 National Guard/Reserve
Soldiers requiring mental health treatment based on screenings:

  • Active component: 20.3%
  • Reserve component: 42.4%
Returning troops expressing interpersonal conflict concerns:

  • Active, PDHA: 3.5%
  • Active, PDHRA: 14.0%
  • Reserve, PDHA: 4.2%
  • Reserve, PDHRA: 21.1%
Returning troops citing PTSD-related concerns:

  • Active, PDHA: 11.8%
  • Active, PDHRA: 16.7%
  • Reserve, PDHA: 12.7%
  • Reserve, PDHRA: 24.5%
Returning troops having overall mental health concerns:

  • Active, PDHA: 17.0%
  • Active, PDHRA: 27.1%
  • Reserve, PDHA: 17.5%
  • Reserve, PDHRA: 35.5%
From the study's comment section:

This study suggests that the mental health problems identified by Veterans Affairs clinicians in more than a quarter of recent combat veterans may have already been present within months of returning from war. The combined DoD screening identified 20.3% to 42.4% of soldiers as requiring mental health treatment, consistent with rates reported among recent veterans seeking care at Veterans Affairs facilities. This emphasizes the enormous opportunity for a better resourced DoD mental health system to intervene early before soldiers leave active duty. ...

Although soldiers’ rates of PTSD and depression increased substantially between the 2 assessments, the 4-fold increase in concerns about interpersonal conflict highlights the potential impact of this war on family relationships and mirrors findings from prior wars.

Furthermore, although stigma deters many soldiers from accessing mental health care, spouses are often more willing to seek care for themselves or their soldier-partner, making them important in a comprehensive early intervention strategy. At present, however, spouse-initiated treatment is hindered by lack of parity of access. Unlike other routine health care that is readily available to active soldiers and their families on-post, family–member mental health care is generally only available through the civilian TRICARE insurance network, a system that has been documented to be inadequately resourced, inconvenient, and cumbersome.

In addition, researchers noted the unique difficulties of transitioning National Guard and Reserve forces whose rates of PTSD increased dramatically on second screening:

Although active component soldiers have ready access to health care, for reservists, standard DoD health insurance benefits (TRICARE) expire 6 months and standard VA benefits expire 24 months after return to civilian status. More than half of the guard and reserve soldiers in this sample were beyond the standard DoD benefit window by the time they took their PDHRA. Although stigma concerns may suppress reporting on the PDHRA among active soldiers, for guard and reserve soldiers, securing ongoing health care may be a more prevailing concern. Other potential factors unique to reservists may be the lack of day-to-day support from war comrades and the added stress of transitioning back to civilian employment.

Full report available at JAMA.

Selection of Press Coverage Given Study

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