Study shows scope of mental health risk
Nearly one-third of troops home from Iraq sought care
By Kelly Kennedy
Times staff writer
A newly released study shows that nearly a third of all soldiers and Marines who served in Iraq sought mental health care within a year of returning home.
The study, reported in the March 1 issue of the Journal of the American Medical Association, also revealed that 19.1 percent of soldiers and Marines returning from Iraq “met the risk criteria for a mental health concern” during mandatory screenings, and 12.1 percent of the returnees were later diagnosed with a mental health disorder.
Charles Hoge, a doctor in the division of psychiatry and neuroscience at the Walter Reed Army Institute of Research, said he wasn’t surprised by the study’s findings, which showed those serving in Iraq were much more likely to report health concerns than those serving in Afghanistan, Bosnia or Kosovo because they’re more likely to have participated in combat operations.
Research showed that 31 percent of all soldiers and Marines returning from Iraq sought help from a mental health clinic within a year of returning home. However, complaints reported during those visits included not only nightmares and other possible symptoms of combat experience, but also concerns about marital problems, worries over other family members and other issues not necessarily related to warfare, said Hoge, who headed up the study.
After decades of watching war vets suffer the long-term effects of post-traumatic stress disorder, including alcoholism, depression, drug abuse or problems with family members, doctors say the results of the study could be valuable in cutting the incidence of PTSD and other mental health conditions.
“Our hope, of course, is that by getting soldiers to seek help early, we’ll prevent some of the long-term consequences that we’ve seen in the past,” Hoge said. “It was most important to find out, ‘Did soldiers use the services within the first two months?’ That’s exactly what we’re encouraging them to do.”
Since the beginning of the war in Iraq, returning military personnel have been required to fill out a mental health survey within a week of their redeployment.
Hoge said it took a little bit of time for everyone to get on track with the mandate, but researchers were able to use the reports from 303,905 soldiers and Marines screened between May 1, 2003, and April 30, 2004.
They used only soldiers and Marines because they were more likely to have faced combat than airmen and sailors.
The combat vets were asked about alcohol and drug use, nightmares, re-experiencing trauma, emotional numbing, avoiding talking about what they saw or did at war and exaggerated emotional response to routine situations — issues pertaining to PTSD — as well as whether they were interested in receiving help or whether they had thought about hurting or killing themselves or others. They were not asked about prior trauma, which is significant because several traumatic events can compound the effects or trigger the onset of PTSD.
They were also asked if they had seen anyone killed or wounded, if they had fired their weapons during direct combat, and if they ever felt they were in great danger of being killed. They found that 19 percent of those in Iraq screened for a potential mental health disorder, while those in Afghanistan screened at 11 percent and those in other areas were at 8.5 percent.
“Nineteen percent is significant,” Hoge said. “But it’s not surprising.”
Researchers then tracked the soldiers and Marines for 12 months to see who sought help through military health services, who was diagnosed with a mental health disorder, who went back more than once, and who sought help immediately as opposed to several months after returning.
Researchers did not track those who went to their chaplains or to employee or family-assistance programs, or those who mentioned problems while seeing a doctor for an issue other than mental health.
They found that almost 17 percent of those soldiers and Marines left the service within a year of their return; that National Guard and reserve soldiers were about 2 percentage points more likely to screen positive; and that of the 21,822 soldiers and Marines who screened positive for PTSD, 80 percent reported seeing someone being killed or killing someone themselves. About 50 percent of 200,798 people who screened negative for PTSD had been in similar situations.
In search of early warnings
Soldiers returning from combat have long reported mental health concerns, but in the 15 years since Desert Storm, attitudes toward the disorders have changed.
“The mental health issues were not studied until years or even decades after wars in the past,” Hoge said. “There’s a lot more awareness in the military, as well as awareness of mental health issues in general. There was certainly more awareness after Desert Storm, but there still was not the level of research.”
“It’s the first time during any war that they’ve had mandatory screening,” he added. “It’s part of a national effort to see how we’re doing.”
By taking care of problems early, the government may save itself money by preventing cases that, in previous wars, popped up 30, 40 or even 50 years after the war ended. The JAMA study also looked at how long it takes people to realize they have a problem.
A recent study cited in the JAMA article showed that service members are more than twice as likely to report mental health concerns three to four months after returning from deployment, compared to when they first arrive home.
“We found in some of our surveys that people don’t report any concerns when they get back, but three to four months later, they do,” Hoge said. “A lot of soldiers are excited to be home and excited to be out of the war zone, so it’s not until they’ve been home for a while that they realize some of the problems are persisting.”
Hoge said mental health professionals learned of the delay from the Vietnam War, but that “the reality is most people develop problems shortly after returning home. They just may not realize it’s a problem that needs help.”
Though Hoge said it’s important to get soldiers into treatment quickly, the report also questions whether the Department of Defense’s health care system is capable of handling so many cases.
Out of every 1,000 soldiers and Marines in the study, about 118 sought mental health care. The study may help the Department of Defense and the Veterans Affairs Department estimate what services will be needed in the future.
The study also showed that while 19 percent of Marines and soldiers screened positive for a mental health issue, only 7.6 percent were referred to a clinic to get help. The others went on their own.
“Presumably, in many instances the symptoms were considered sufficiently mild to be managed conservatively either through routine primary care or through re-evaluation at a later date,” the report states.
The report shows screening might be good in predicting who’s not well, but not in determining who will seek help.
Department of Defense officials have to get a handle on the situation not only to prepare the health care system, but also because mental disorders — both combat- and non-combat-related -— are the leading reason people leave the military, according to a study cited in the JAMA report.
Hoge said soldiers and Marines are not required to be screened a second time within three to six months of their return from combat zones, but some new programs have been put into place to train soldiers to be more aware and look out for other service members.
“We certainly want to get the word out to soldiers and their family members early,” Hoge said. “That’s what’s different in this war from past wars.”