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Effectiveness of Mental Health Screening and Coordination of In-Theater Care Prior to Deployment to Iraq: a Cohort Study

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Effectiveness of Mental Health Screening and Coordination of In-Theater Care Prior to Deployment to Iraq: a Cohort Study Article Effectiveness of Mental Health Screening and Coordination of In-Theater Care Prior to Deployment to Iraq: A Cohort Study Christopher H. Warner, M.D. Objective: The authors assessed the ef- with additional requirements. After 6 fectiveness of a systematic method of pre- months, soldiers in screened brigades George N. Appenzeller, M.D. deployment mental health screening to had signifi cantly lower rates of clinical determine whether screening decreased contacts than did those in unscreened negative outcomes during deployment in brigades for suicidal ideation (0.4%, 95% Jessica R. Parker, Psy.D. Iraq’s combat setting. CI=0.3–0.5, compared with 0.9%, 95% CI=0.7–1.1), for combat stress (15.7%, 95% Carolynn M. Warner, M.D. Method: Primary care providers per- CI=15.0–16.4, compared with 22.0%, 95% formed directed mental health screenings CI=21.2–22.8), and for psychiatric disor- Charles W. Hoge, M.D. during standard predeployment medical ders (2.9%, 95% CI=2.6–3.2, compared screening. If indicated, on-site mental with 13.2%, 95% CI=12.5–13.8), as well as health providers assessed occupational lower rates of occupational impairment functioning with unit leaders and coordi- (0.6%, 95% CI=0.4–0.7, compared with nated in-theater care for those cleared for 1.8%, 95% CI=1.5–2.1) and air evacuation deployment. Mental health-related clini- for behavioral health reasons (0.1%, 95% cal encounters and evacuations during CI=0.1–0.2, compared with 0.3%, 95% the fi rst 6 months of deployment in 2007 CI=0.2–0.4). were compared for 10,678 soldiers from three screened combat brigades and Conclusions: Predeployment mental 10,353 soldiers from three comparable health screening was associated with sig- unscreened combat brigades. nifi cant reductions in occupationally im- pairing mental health problems, medical Results: Of 10,678 soldiers screened, 819 evacuations from Iraq for mental health (7.7%, 95% confi dence interval [CI]=7.2– reasons, and suicidal ideation. This pre- 8.2) received further mental health evalu- deployment screening process provides a ation; of these, 74 (9.0%, 95% CI=7.1– feasible system for screening soldiers and 11.0) were not cleared to deploy and 96 coordinating mental health support dur- (11.7%, 95% CI=9.5–13.9) were deployed ing deployment. (Am J Psychiatry Warner et al.; AiA:1–8) The U.S. military began psychological screening in the of World War II, these screens came to be viewed as exces- early 20th century. During World War I, the Army Alpha sive and ineffective in accurately predicting resilience to and Beta tests and psychiatric interviews were used to the stresses of war, and it was thought that they resulted screen the massive infl ux of military recruits needed to in a substantial and excessive loss of potential recruits fi ght the war (1). At that time, the personality and esti- (4–7). After World War II, psychiatric screening methods mated intellectual functioning of each potential recruit were modifi ed to focus on identifying and disqualifying were assessed, and recommendations were made regard- only those with gross psychiatric disorders. This process ing suitability for military service and service specialties. has remained in place since then, with minor modifi ca- The decisions that were made largely refl ected the belief tions over time. that psychiatric symptoms and illnesses indicated a “weak Although screening continues, there is debate over the personality”; individuals with psychoneurotic illness were role that preexisting medical and psychiatric conditions not normal and thus were not capable of marshaling the have in making individuals more vulnerable to negative defenses needed to serve during war (1). Historians gen- outcomes in times of stress. There are confl icting data as erally view this method of screening potential recruits for to whether preexisting psychological conditions are a con- military service as a failure (2). tributing factor to psychiatric attrition in a combat zone In 1941, Harry Stack Sullivan was appointed as a psy- and whether an effective screening mechanism exists chiatric consultant to the Selective Service System and (8–16). Common themes of previous studies of the sub- helped develop a more comprehensive screening system ject include fl awed methodology and outcomes based on using screening interviews (3). However, over the course the inconsistent screening application, use of personality AJP in Advance ajp.psychiatryonline.org 1 PREDEPLOYMENT MENTAL HEALTH SCREENING AND COORDINATION OF IN-THEATER CARE or intelligence scales to identify vulnerability or predict working in areas with high-intensity combat engagement, future behavior, low thresholds for severity scales, and which have been reported to have higher rates of PTSD high false positive rates. and other mental health problems compared with U.K. Since 1997, U.S. military units have conducted routine forces (23, 24). medical evaluations prior to deployment to ensure that In this article, we present data from a 2007 program soldiers do not have acute or chronic medical conditions evaluation of the effectiveness of a systematic method of that might impede performance during deployment. predeployment mental health screening using the new Those who are found to have a serious medical condition DOD criteria to determine whether screening decreased or who would be unable to receive the necessary level of negative outcomes for soldiers deployed in combat set- medical care in theater are not cleared to deploy. tings in Iraq. Although observational in nature, this study In 2006, media reports asserted that military psychia- presents the only systematic assessment of predeploy- trists and other medical providers were sending mentally ment screening of U.S. forces in Iraq and hence is of unfi t service members into combat zones (17, 18). Later vital importance in understanding the potential impact that year, the U.S. Department of Defense (DOD) devel- of current predeployment screening policies in enhanc- oped a minimum mental health standard for deployment. ing safety and ensuring continuity of care for deploying This policy provided guidelines for what conditions are soldiers. This study and its methods depart from previ- acceptable for military medical providers to manage in ous U.S. and U.K. studies, which focused on using men- theater and what level of treatment can be provided during tal health and personality scales to predict vulnerability a deployment (19). Individuals being treated for psychotic and exclude individuals from deployment. Rather, we or bipolar disorders are barred from deployment, and the focus on predeployment psychiatric diagnoses, treatment deployability of those with other psychiatric and behav- needs, illness severity, and illness-related risks in order to ioral conditions are assessed using an algorithm based improve mental health care for soldiers by linking them to on symptom severity, duration of treatment, stability of ongoing treatment during deployment. the condition, and level of care required. Table 1 summa- rizes the key details of the policy and includes additional Method guidance from the Central Command responsible for the Iraq and Afghanistan combat theaters (19, 20). Congress In this study, which was approved by the Eisenhower recently expanded the requirement for predeployment Army Medical Center institutional review board, we com- mental health screening to include “PTSD [posttraumatic pared three infantry brigades from the Third Infantry stress disorder], suicidal tendencies, and other behavioral Division deploying from Fort Stewart, Ga., to Iraq in early issues” in order to determine which service members 2007 with three infantry brigades that were attached to need additional care or treatment (21). However, there are the division from other posts. The mental health screen- virtually no scientifi c studies to help guide the military in ing process was implemented in the three brigades from how to do this most effectively. Fort Stewart according to the procedures outlined in Fig- While the DOD policy and new Congressional require- ure 1. The process was not implemented in the three other ments mandate predeployment mental health screening brigades because of the complexity of merging the divi- on all deploying U.S. military personnel, these policies sion together, the staggered deployment of brigades into have not been based on evidence supporting the effective- Iraq over a period of 7 months, and the lack of suffi cient ness of screening, and very little research has been con- time available between policy release and deployment for ducted in this area. all brigades. Because the six brigades did not deploy at the We are aware of only one study (22) that systematically same time but rather over a 7-month period, comparable assessed the effectiveness of predeployment screening outcomes could be tracked systematically only for the fi rst in relation to recent operations in Iraq and Afghanistan. 6 months of deployment for all six brigades, after which In this U.K. study, psychological symptom scales with the Division Headquarters, including the clinical investi- thresholds designed to indicate distress were used to gators, redeployed. detect common mental disorders. The aim was to predict All six brigades were deployed to the same region of cen- subsequent disorders 2 to 3 years after deployment. Like tral Iraq from 2007 to 2008 as part of that period’s surge previous studies, it focused on trying to predict the devel- of forces. All were comparably sized active-duty brigade opment of mental disorders rather than seeking to identify combat teams with more than one prior deployment to or effectively manage the disorders during a deployment. Iraq (although nearly half of the soldiers had no prior The authors concluded that screening for mental disor- deployments), and all were assigned to the same division ders before deployment to Iraq would not have reduced (Multi-National Division–Center) for operational control.
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