Screening soldiers twice instead of just once in the months after they return from war zones may help clinicians catch more war-related mental health problems.
So says new research that suggests that repeat mental health screenings for soldiers can significantly improve both their mental health and their access to proper care.
In a study published in the Journal of the American Medical Association, researchers found that screening soldiers twice helps identify more who need further treatment.
Also, since the second screening identified problems such as post-traumatic stress disorder (PTSD) in soldiers who had not been so diagnosed during the initial screening, the results suggest that these conditions may manifest themselves several months after a tour of duty.
"We set up two screening programs: one when they initially return from Iraq and another three to six months later," says study author Dr. Charles Milliken. "By doing the second screen, we found a whole other group that was missing, and it's actually a larger group. More soldiers are reporting problems during the second screening."
Milliken and colleagues at the Walter Reed Army Institute of Research looked at more than 88,000 soldiers and found that conflicts in interpersonal relationships increased fourfold in between the first and second screenings. Additionally, the proportion suffering from PTSD increased from 12 to 17 percent for active soldiers and from 13 to 24.5 percent for reserve soldiers. Cases of depression and overall mental health risk also increased from the first to second screenings.
In total, researchers found that 20 percent of active and 42 percent of reserve soldiers required mental health treatment -- a number some may find very high.
"The most important thing about this study has to be the continuing and increasing cost of the war in Iraq," says Simon Wessely, a psychiatrist at the King's Center for Military Health Research in London. "The figure that 40 percent of reservists are identified as requiring more formal mental health evaluation makes you pause and reflect."
Despite the increases in mental health problems six months after soldiers return from war, the study does not mean that soldiers aren't receiving good health care the first time around. In fact, researchers found that more than half of the soldiers who were experiencing problems in the first screening were doing better by the second one.
Instead, the second screening identifies soldiers who were missed by the first one or who developed symptoms after a few months of being at home.
There are several reasons why veterans develop mental health problems several months after returning from war, says Dr. Israel Liberzon, professor of psychiatry and director of the Trauma, Stress, and Anxiety Research Center at the University of Michigan.
"One possibility is that people get more support in the beginning from family members and friends," he says. "A second possibility is that soldiers tend to under report problems in the beginning because they feel like some of the symptoms are relatively manageable and that they can take care of themselves.
"Only when they persist do people realize that they need to be addressed."
Milliken says time is also a factor.
"Some of the people that we miss in the first screening have earlier versions of the problems," he says.
"Depression takes time for the situation to unfold. If someone lost a buddy over there, there might not have been a lot of time or space to dwell on it. Only later the sadness sets in."
In addition, others stressors can pile up in the months after returning from war that eventually force soldiers to get care. And as the illness persists, people become more aware of how it disrupts their ability to function.
"The key is to appreciate that mental health outcomes from serious and repeated combat trauma is not an 'outcome' but an unfolding process over time," says Brett Litz, associate director of the behavioral sciences division of the National Center for PTSD. "The key is to provide the expectation to apparently well service members that they still are at risk."
What surprised the researchers most, however, was not that so many soldiers develop mental health problems months later but rather that the screening process itself encourages soldiers to seek care.
"There is something about the screen that makes it more OK to recognize problems and to go get help," says Milliken. "There is a stigma about mental health; it's not something that soldiers are inclined to recognize and go get treatment for. The screening changes those attitudes."
Indeed, stigma is a major barrier that soldiers face when seeking mental health care. In an article published in the most recent edition of Journal of Military Psychology, Litz writes that although 80 percent of Iraq and Afghanistan service members with a mental health disorder acknowledged they had a problem, only 40 percent were interested in receiving help.
"Modern career service members are very concerned about stigma and may be ashamed of opening themselves up the mental health professionals," Litz states. "They are also concerned about appearing weak or sick and expect that it will negatively impact their careers."
Experts agree that screening is important to identify soldiers who are affected by stigma associated with treatment, but how much screening and when to do it are still up for debate.
"The real question is, 'What is the most appropriate time to screen given limited resources?'" Liberzon says. "The people who are screening aren't providing care, so the more you screen, the more you decrease resources towards treatment."
While that question has yet to be answered, Wessely notes the study is a step in the right direction to improving veterans' mental health.
"What this paper shows is the challenge that remains to make sure that those who do require mental health care are identified without fear of stigma, are treated with evidence-based interventions, and are not overlooked," he says.