Veterans who have seen combat in Iraq use mental health services at a high rate in their first year after returning home, compared with veterans returning from other deployments, reported Dr. Charles W. Hoge of the Walter Reed Army Institute of Research, Silver Spring, Md., and his associates.
About one-third of combat veterans returning from Iraq accessed mental health services during their first year back, most of them within 2 months of returning home. “[These] findings have important implications for estimating the level of mental health services that may be needed in military, Veterans Affairs, and civilian practice settings that care for returning veterans,” Dr. Hoge and his associates noted.
They added that their findings provide “further evidence that the war is burdening the health care system at large” (JAMA 2006;295:1023–32).
Dr. Hoge and his associates conducted what they described as the first analysis of data collected in a mass screening for mental health and other health problems among veterans returning from ground combat operations in Afghanistan and Iraq.
In April 2003, the U.S. Department of Defense mandated that all service members complete a three-page questionnaire upon completion of their deployment. The questionnaire addresses the conditions under which they served and their general health, physical symptoms, mental health concerns, and concerns about exposure to hazardous materials.
Much of the questionnaire is devoted to symptoms of posttraumatic stress disorder, depression, aggression, and suicidal ideation. Veterans are also interviewed by a physician, nurse-practitioner, or physician assistant to determine whether referral for further evaluation and treatment is needed.
The researchers analyzed data from these questionnaires from 303,905 Army soldiers and Marines who returned between May 2003 and April 2004 from deployments in Iraq and nearby areas (73%), Afghanistan (5%), and other locations such as Bosnia and Kosovo (21%). (Percentages do not add to 100 because of rounding.)
Veterans who served in Iraq used inpatient and outpatient mental health services at a higher rate (35% per year) than did veterans deployed to other locations.
The prevalences of mental health problems were consistently higher after service in Iraq than in any other location. “Overall, 19.1% of soldiers and Marines who returned from [Iraq] met the risk criteria for a mental health concern, compared with 11.3% for [Afghanistan] and 8.5% for other locations,” the investigators said.
The prevalence of PTSD in particular was 9.8% in combat veterans who served in Iraq, compared with 4.7% for those who served in Afghanistan and 2.1% for other locations. Of the nearly 22,000 veterans returning from Iraq who screened positive for PTSD, about 80% reported that they had witnessed people being wounded or killed or had discharged their own weapons in direct combat, compared with only 48% of those who screened negative for PTSD.
The investigators did point out that their study probably underestimated the use of mental health services by military personnel. For one thing, mental health problems treated in primary care settings might not be coded under the primarydiagnosis. Also, some service members might receive care from civilians without ties to the military health care system.
Despite those limitations, the study findings “emphasize the fact that the need for mental health services is likely to vary as a function of combat exposure,” the researchers said.
Veterans who screened positive for any mental health concern were significantly more likely to leave the service within 1 year than were those who screened negative for mental health concerns. This confirms that mental health problems associated with combat also have later occupational effects, they said.