From Baghdad To America (16 page)

Against the backdrop of the Global War on Terror, the psychological health needs of America's military service members, their families, and their survivors pose a daunting and growing challenge to the Department of Defense. Although it is acknowledged that the work of the Task Force is necessarily incomplete and that the recommendations presented herein provide only the groundwork for a comprehensive strategic plan to support the psychological health of service members and their families, the immediacy of these needs imparts a sense of urgency to this report. As such, the Task Force urges the Department of Defense to adopt a similar sense of urgency in rapidly developing and implementing a plan of action.

easily-accessible continuum of treatment for psychological health of service members and their families in both the Active and Reserve Components.

The Task Force's findings related to each of the four goals related to the vision discussed above are summarized briefly below:

1. Building a culture of support for psychological health
   
   • Stigma in the military remains pervasive and often prevents service members from seeking needed care.
     
   • Mental health professionals are not sufficiently accessible to service members.
     
   • Leaders, family members, and medical personnel are insufficiently trained in matters relating to psychological health.
     
   • Some Department of Defense policies, including those related to command notification or selfdisclosure of psychological health issues, are overly conservative.
     
   • Existing processes for psychological assessment are insufficient to overcome the stigma inherent in seeking mental health services.
     
2. Ensuring a full continuum of excellent care for service members and their families
   
   • Significant gaps in the continuum of care for psychological health remain, specifically related to which services are offered, where services are offered, and who receives services.
     
   • Continuity of care is often disrupted during transitions among providers.
     
   • There are not sufficient mechanisms in place to assure the use of evidence-based treatments or the monitoring of treatment effectiveness
     
   • Family members have difficulty obtaining adequate mental health treatment.
     
3. Providing sufficient resources and allocating them according to requirements
   
   • The military system does not have enough fiscal or personnel resources to adequately support the psychological health of service members and their families in peace and during conflict.
     
   • Military treatment facilities lack the resources to provide a full continuum of psychological health care services for active duty service members and their families.
     
   • The number of active duty mental health professionals is insufficient and likely to decrease without substantial intervention.
     
   • The TRICARE network benefit for psychological health is hindered by fragmented rules and policies, inadequate oversight, and insufficient reimbursement.
     
4. Empowering leadership
   
   • Provision of a continuum of support for psychological health for military members and their families depends on the cooperation of many organizations with different authority structures and funding streams.
     
   • The Task Force found insufficient collaboration among organizations at the installation, Service and Department of Defense levels to provide and coordinate care for the psychological health of service members and their families.
     

BACKGROUND

The current combat operations in Iraq and Afghanistan have involved U.S. military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans.

METHODS

We studied members of four U.S. combat infantry units (three Army units and one Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or three to four months after their return from combat duty in Iraq or Afghanistan (n = 3671). The outcomes included major depression, generalized anxiety, and post-traumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments.

RESULTS

Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care.

CONCLUSIONS

This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care.

Reprinted from
THE NEW ENGLAND JOURNAL OF MEDICINE
(ISSN 0028-4793) Vol. 351:13-22 (July 1, 2004).

Copyright © 2004 Massachusetts Medical Society. All rights reserved.

Printed in the U.S.A. Fax: (781) 893-8103
www.nejm.org

T
HE RECENT MILITARY OPERATIONS IN Iraq and Afghanistan, which have involved the first sustained ground combat undertaken by the United States since the war in Vietnam, raise important questions about the effect of the experience on the mental health of members of the military services who have been deployed there. Research conducted after other military conflicts has shown that deployment stressors and exposure to combat result in considerable risks of mental health problems, including post-traumatic stress disorder (PTSD), major depression, substance abuse, impairment in social functioning and in the ability to work, and the increased use of health care services.
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One study that was conducted just before the military operations in Iraq and Afghanistan began found that at least 6 percent of all U.S. military service members on active duty receive treatment for a mental disorder each year.
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Given the ongoing military operations in Iraq and Afghanistan, mental disorders are likely to remain an important health care concern among those serving there.

Many gaps exist in the understanding of the full psychosocial effect of combat. The all-volunteer force deployed to Iraq and Afghanistan and the type of warfare conducted in these regions are very different from those involved in past wars, differences that highlight the need for studies of members of the armed services who are involved in the current operations. Most studies that have examined the effects of combat on mental health were conducted among veterans years after their military service had ended.
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A problem in the methods of such studies is the long recall period after exposure to combat.
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Very few studies have examined a broad range of mental health outcomes near to the time of subjects' deployment.

Little of the existing research is useful in guiding policy with regard to how best to promote access to and the delivery of mental health care to members of the armed services. Although screening for mental health problems is now routine both before and after deployment
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and is encouraged in primary care settings,
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we are not aware of any studies that have assessed the use of mental health care, the perceived need for such care, and the perceived barriers to treatment among members of the military services before or after combat deployment.

We studied the prevalence of mental health problems among members of the U.S. armed services who were recruited from comparable combat units before or after their deployment to Iraq or Afghanistan. We identified the proportion of service members with mental health concerns who were not receiving care and the barriers they perceived to accessing and receiving such care.