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Study: Months after tour, mental issues show

A new Army study finds that soldiers returning from the Iraq war are more likely to report mental health problems several months later rather than immediately following their return — and reserve component troops are twice as likely to report such problems with the passage of time.

On average, one in five active-duty soldiers and more than two in five reservists who served in Iraq, and were included in the study, required referral for mental health treatment, researchers said.

The study, the combined result of initial and follow-on post-deployment screenings of 88,235 active and reserve soldiers who filled out questionnaires between June 2005 and December 2006, validates a decision made two years ago to institute a follow-on mental health screening three to six months after returning home from the war, Army researchers said. It was the first-ever study of troops who had completed both screenings.

Marine Corps records were excluded, because while Marines also filled out the surveys, the follow-on questionnaire had not been widely distributed to Marine Corps units during the study period, so the results “may not be representative,” researchers said.

The Army team’s findings are being published Wednesday in the Journal of the American Medical Association. Col. (Dr.) Charles Milliken, an Army psychiatrist and principal investigator for the Walter Reed Army Institute of Research Division of Psychiatry and Neuroscience, called the effort “part of the Army’s continuing efforts to better understand the human dimension of war, the physical and the psychological impact of combat on our soldiers.”

The Army is doing the assessments, a combination of answers to survey questions and follow-ups by clinicians, in order to “reach out” to soldiers stressed by their deployments “and get them the care that they need,” Milliken said.

“This is all about reducing stigma, and breaking down the barriers to getting care,” he said.

The work was submitted to JAMA, Milliken said, “not only to be transparent, but to involve the entire medical community in our efforts.”

The previous study, published in JAMA in March 2006, reported preliminary findings that troops were more likely to report mental health problems months after returning from Afghanistan and Iraq rather than immediately after getting home, making it likely that some problems were being missed. As a result of those findings, the Defense Department instituted the follow-on screening, which this time included only Iraq war veterans.

In the new initial screenings, the numbers for active and reserve troops “look almost identical” and came in with an average of 4 percent needing referrals for treatment, Milliken said. Several months later, researchers found the need for referrals for both physical and mental problems rose significantly.

From the first to the follow-on screening, the most significant increase in problems reported by returning troops was in interpersonal conflict (active-duty troops, to 14 percent from 4 percent; reserves, to 21.1 percent from 4.2 percent).

Other problem areas also showed increases: post-traumatic stress disorder (active troops, to 16.7 percent from 11.8 percent; reserves, to 24.5 percent from 12.7 percent); depression (active troops, to 10.3 percent from 4.7 percent; reserves, to 13 percent from 3.8 percent); and overall mental health risk (active troops, to 27.1 percent from 17 percent; reserves, to 35.5 percent from 17.5 percent).

“When you come back ... you’re feeling great,” said Brig. Gen. Stephen Jones, the U.S. Army Medical Command’s assistant surgeon general. “You’re almost euphoric. And you don’t have any problems in the world. You’re just glad to be home. And then over the next three to four weeks, you get home, you re-establish the relationships with your family, and the normal stress that everybody feels when they return home starts to surface.”

Jones called it a “normal, adaptive response we see with everybody. And so we would expect to see the stress levels at home go up. It’s one reason that we sought to have the second survey, so we could identify those folks and provide them with treatment.”

The Army doctors said they couldn’t state conclusively why reservists report a higher rate of problems; Milliken noted the similar and relatively low rates of problems reported by both components on the initial post-deployment assessment, and said in-theater Mental Health Advisory Team studies produce similar results.

“We don’t think it’s about the war exposures, or a basic resiliency difference,” Milliken said. “It may be a difference in just the health coverage situation they’ve got.”

When they return three to six months later for the follow-on screening, many reserve troops have uncertainty about whether they qualify for government health care due to war-related problems. Milliken said that at the time of the second screening, half of them are already beyond the period in which they qualify for transitional health care under Tricare, “so the whole issue of medical coverage is already on their mind.”

That benefit, the Transitional Assistance Management Program, provides Tricare coverage for 180 days after separation from active duty for Guard and reserve members who are called up in support of a contingency operation for more than 30 days. Their family members also qualify for the transitional coverage.

At the same time, Milliken said, a Department of Veterans Affairs representative at the armory is explaining that Afghanistan and Iraq war veterans can get up to two years of VA treatment without having to prove a service-connected disability, and that if they develop a problem beyond that window, it is valuable to have it documented.

In contrast, active troops who have returned “know they can walk into sick call any time and get care,” Jones said.

Of the 88,235 soldiers who had completed both forms from the same deployment, 56,350 were active-duty troops. All told, 90.8 percent were men; 58.2 percent were married; and the mean age was 30.4 years.