COUNTERING MILITARY RECRUITMENT
Articles: Military Service: Casualties
Adequacy of Mental Health Screening and Care in the Military Is
Questioned
Richard A. Sherer, Psychiatric Times, Vol. XXIII, No. 8
July 2006
US military officials are attempting to rebut charges of lax mentalhealth 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.
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