Combat Duty in Iraq Linked With High Use of Mental Health Services

About one-third of U.S. military personnel from the war in Iraq access mental health services after their return home, according to a study in the March 1 issue of JAMA.

The U.S. military has conducted population-level screening for mental health problems among all service members returning from deployment to Afghanistan, Iraq, and other locations. To date, no systematic analysis of this program has been conducted, and studies have not assessed the impact of these deployments on mental health care utilization after deployment, according to background information in the article. Such information is an important part of measuring the mental health burden of the current war and assuring that there are adequate resources to meet the mental health care needs of veterans returning from Iraq and Afghanistan.

Previous research conducted after other military conflicts has shown that deployment and exposure to combat result in increased risk of posttraumatic stress disorder (PTSD), major depression, substance abuse, functional impairment in social and employment settings, and the increased use of health care services.

Charles W. Hoge, M.D., of Walter Reed Army Institute of Research, Silver Spring, Md., and colleagues conducted a study to determine the relationship between deployment to Iraq and Afghanistan and mental health care use during the first year after return home. The researchers analyzed the results of the Post-Deployment Health Assessment completed by Army soldiers and Marines between May 1, 2003, and April 30, 2004, on return from deployment to Afghanistan (n=16,318), Iraq (n=222,620), and other locations (n=64,967). Health care utilization and occupational outcomes were measured for 1 year after deployment or until leaving the service if this occurred sooner. The assessment screened for such conditions as posttraumatic stress disorder, major depression, and other mental health problems.

The prevalence rates of mental health problems and combat experiences were consistently higher following deployment to Iraq than Afghanistan or other locations. Overall, 19.1 percent of soldiers and Marines who returned from Iraq met the risk criteria for a mental health concern, compared with 11.3 percent for Afghanistan and 8.5 percent for other locations.

Exposure to a combat situation was correlated with screening positive for PTSD among Iraq veterans. Of 21,822 service members who screened positive for PTSD after returning from Iraq, 79.6 percent reported witnessing persons being wounded or killed or engaging in direct combat during which they discharged their weapon compared with 47.8 percent of 200,798 who screened negative for PTSD.

Iraq veterans used inpatient and outpatient mental health services at higher rates after deployment than Afghanistan veterans and service members who deployed to other locations. Among 222,620 Iraq veterans, 31 percent were documented to have had at least 1 outpatient mental health care visit within the first year postdeployment. The annualized rate of utilization of mental health services among Iraq veterans was 35 percent. This included 12 percent per year who accessed services for a mental health problem. More than 50 percent of those referred for a mental health reason were documented to receive follow-up care although less than 10 percent of all service members who received mental health treatment were referred through the screening program.

“... this study provides new data showing the strong relationship between combat duty and a variety of mental health outcomes and most importantly high mental health care utilization in the first year after deployment. The 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. Additional research is needed beyond a year after deployment to determine the long-term burden that this war will have on the mental health care system,” the authors write.
(JAMA. 2006;295:1023-1032. )

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