Paul Sullivan, executive director of Veterans for Common Sense, a nonprofit advocacy group, said he was discouraged, but not surprised, that so few service members are being seen by mental-health specialists. The need to maintain troop strength, he believes, is one reason. “They’re just not doing it,” he said of military leaders. “They don’t have enough bodies to deploy to the war zone, and there’s not enough clinicians” to do evaluations. “This was not supposed to happen again,” Sullivan added, making reference to legislation passed after the Gulf War that aimed to ensure that troops’ baseline health was recorded before they deployed. “We were not supposed to send unfit soldiers into the war zone.”
Few Medical Exams Are Ordered, Despite Pressure From Congress.
March 9, 2008 – The U.S. military continues to order mental health evaluations for only a tiny fraction of deploying combat troops, despite a congressional order to improve screening and evidence that mental illness is a growing problem in the Armed Forces, newly obtained data show.
Fewer than 1 percent of troops sent to war in 2007 received referrals to a mental health specialist as part of the pre-deployment screening process, according to Pentagon data obtained by The Courant.
Those numbers contrast with several military studies that have found mental-health problems in close to 10 percent of service members awaiting deployment. Most recently, Army researchers reported last month that among troops deployed to Afghanistan in late 2006 and early 2007, 9.6 percent had a diagnosis or a drug prescription indicating a mental health problem in the year before they were sent to war.
Under pressure from Congress, the Pentagon in late 2006 pledged to improve the mental-health screening of troops preparing to go to war. Soon afterward referrals to mental health specialists jumped sharply. But even at the peak, in March 2007, only 2.4 percent of service members were sent to a mental-health professional by screeners. And the spike was short-lived. Two months later, referrals had fallen back below 1 percent, and have stayed there ever since.
Although Congress in 1997 ordered the military to conduct an “assessment of mental health” for all deploying troops, that assessment consists of a single question on a health form, asking troops whether they have sought mental health care in the past year. Even for those who answer “yes” to that question, barely 1 in 10 were referred to a mental health professional last year, and 85 percent were ultimately deemed combat-ready.
Paul Sullivan, executive director of Veterans for Common Sense, a nonprofit advocacy group, said he was discouraged, but not surprised, that so few service members are being seen by mental-health specialists. The need to maintain troop strength, he believes, is one reason.
“They’re just not doing it,” he said of military leaders. “They don’t have enough bodies to deploy to the war zone, and there’s not enough clinicians” to do evaluations.
“This was not supposed to happen again,” Sullivan added, making reference to legislation passed after the Gulf War that aimed to ensure that troops’ baseline health was recorded before they deployed. “We were not supposed to send unfit soldiers into the war zone.”
Military health officials, however, said the low referral rate was not an indication that the screening process was flawed.
“Since this is a relatively recent process, and there is no similar procedure in civilian health care, we do not know what the optimal referral rates should be,” said Col. Elspeth Cameron Ritchie, psychiatry consultant to the Army Surgeon General. “In any case, good clinical judgment is always utilized.”
In defending its screening process, the military noted in a report to Congress last year that among deployed troops who indicated past mental health care or received a mental health referral, only 1 percent were later evacuated for psychiatric reasons. Ritchie said last week that psychiatric evacuations from the war zone have remained steady, and low, throughout the war, ranging from about 20 to 40 a month — even as reported mental health problems among deployed troops have grown.
Todd Bowers, director of government affairs for Iraq and Afghanistan Veterans of America, said evacuations are not a good measure of the quality of pre-deployment screening. “For every one that is evacuated, I guarantee there’s approximately 10 who are dealing with these same type of issues,” said Bowers, who served two tours in Iraq with the Marine Corps. “But because of the stigma … they’re trying to push forward.”
A military report released last week found that repeat deployments are straining soldiers’ mental well-being, with 27.2 percent of noncommissioned officers on third and fourth deployments screening positive for depression, anxiety or acute stress. Bowers said the impact of repeat deployments highlights the need for widespread mental health screening before troops are sent into war.
“I think everyone should sit in front of a mental health professional and be properly screened to make sure they’re all right, to make sure they’re squared away, especially those who have deployed in the past,” he said.
The pre-deployment figures were obtained from a database of questionnaires filled out by the 342,911 troops preparing for deployment in 2007, including troops who were being deployed for the first time and those in the process of being sent back for subsequent tours. The data include the service members’ answers to medical questions and notations on whether they were referred to specialists and whether they were ultimately cleared for deployment. The database was released to The Courant with names and other identifying information redacted.
The data suggest that troops remain reluctant to disclose mental health concerns on the pre-deployment forms, despite efforts by the military to combat the stigma associated with psychiatric care. In 2006, just under 4 percent of troops disclosed that they had sought mental health care in the previous year. That figure rose in 2007 to about 4.7 percent, but is still less than the military’s own estimates of the percentage of troops who have mental health issues.
A recently published Army study, for example, found that about 7 percent of troops deployed to Afghanistan had one or more prescriptions for psychoactive drugs filled in the six months prior to deployment. The drugs included anticonvulsants, antidepressants, sedatives and antipsychotics.
Military officials say that in addition to the questionnaire, they rely on observations from commanders and fellow service members to identify troops who may not be mentally fit for combat. But unless troops disclose past mental health care on the form, professional referrals for further evaluation are extremely rare. In 2007, fewer than one in 400 service members who answered “no” to the mental health question were referred for a professional evaluation.
Though the referral rate remains small, it is an increase over the earliest years of the war, when as few as 0.3 percent of troops were referred for a mental health evaluation. And among troops who disclosed past mental health care, the percent referred to a specialist rose from 6.4 percent during the first three years of the Iraq war, to 9.6 percent over the past six months.
Following a May 2006 Courant series detailing gaps in military mental health care, Congress approved legislation directing the military to establish mental health “minimum standards” for combat deployment. Congress also ordered the military to establish clinical guidelines for determining when service members should be referred for a mental health evaluation before being cleared for deployment.
In response, the Pentagon issued new rules in late 2006 directing that service members with mental health disorders should be sent to war only if they demonstrate a “pattern of stability, without significant symptoms” for at least three months prior to deployment. In addition, troops who are prescribed psychiatric medications less than three months before deploying were not to be deployed to war unless there was evidence the drugs were working and had no significant side effects.
Ritchie last week described the new policy as “much more stringent” than prior rules, though she acknowledged that the number of soldiers excluded from deployment had remained small.
Troops who disclose possible mental health problems on the pre-deployment form are seen by low-level medical providers, who decide if a referral to a mental health professional is warranted. In a report to Congress last year, Dr. S. Ward Casscells, assistant secretary of defense for health affairs, said screeners are well-trained and follow clinical guidelines when making referral decisions. Ritchie said those screeners can generally resolve health-care issues.
The military increased its focus on mental health following a spate of suicides in Iraq in 2003, and praised its suicide-prevention programs when the number of self-inflicted deaths dropped dramatically in 2004. But in 2005, and each year since, the suicide rate has reached the level that alarmed Pentagon officials early in the war. At least 145 service members have killed themselves in the Iraq war.
In response, the military has established programs to improve troop “resiliency” and help service members recognize and address combat stress in their comrades. Military leaders have also attempted to increase the number of behavioral health professionals in the war zone, although the ratio of professionals to troops has dropped steadily as the military struggles to find psychologists and counselors willing to enlist. Last week, top military health officials said they would begin recruiting civilian mental health providers to augment those in uniform.