DEPARTMENT OF THE ARMY

HEADQUARTERS, UNITED STATES ARMY MEDICAL COMMAND

2050 WORTH ROAD
FORT SAM HOUSTON, TX 78234-6000

REPLYTO
ATTENTION OF

OTSG/MEDCOM Policy Memo 08-018

MCCG 1 9 MAY 2008
Expires 19 MAY 2010

MEMORANDUM FOR Commanders, MEDCOM Regional Medical Commands

SUBJECT: Screening for Post-Traumatic Stress Disorder (PTSD) and mild Traumatic Brain
Injury (mTBI) Prior to Administrative Separations

1. References.

a. Army Regulation (AR) 635-200, Active Duty Enlisted Administrative Separations,

6 June 2005.

b. Army Medical Action Plan, Phase III task, "Consider mTBI and PTSD Separations",
July 2007.

c. Sigford, B., M.D., Veterans Affairs, National Director, Physical Medicine and
Rehabilitation, December 2007. Screening and Evaluation of Possible TBI in OEF/OIF
Veterans, Brief.

d. Post Traumatic Stress Disorder Checklist (PCl) for DSM-IV, 1 November 1994.
Weathers, Litz, Huska, & Keane, National Center for PTSD - Behavioral Science Division.

2. Purpose. To outline procedures for PTSD and mTBI screening of Soldiers considered
for administrative separations, including but not limited to Chapter 9, Alcohol or other Drug
Abuse Rehabilitation Failure; Chapter 13, Unsatisfactory Performance; Chapter 5·13,
Personality Disorder; Chapter 5-17, Other Mental Health Condition; and Chapter 14-12,
Patterns of Misconduct, reference 1.a.

3. Proponent. The proponent for this policy is HQ, MEDCOM, Office of the Assistant
Chief of Staff for Health Policy and Services, AnN: MCHO-Cl-H.

4. Responsibilities.

a. The Surgeon General has overall responsibility for policy guidance in defining
and implementing the Army Medical Department's behavioral healthcare screening
requirements.

b. The Directorate of Health Policy and Services, through the Proponency Chiefs of the
Offices for Behavioral Health and Rehabilitation and Integration are responsible for the
distribution of behavioral health evaluation and mTBI requirements and reviewing, revlsinq,
updating, and deleting existing policies conflicting with these requirements.
MCCG
SUBJECT: Screening for Post-Traumatic Stress Disorder (PTSD) and mild Traumatic Brain
Injury (mTSI) Prior to Administrative Separations

c. Medical Treatment Facility (MTF) Commanders will ensure that all So ldiers are
screened for PTSD and mTSI during rout ine mental health evaluations for administrative
separations related to the Chapters identified in paragraph 2., above.

5. Discussion.

a. There has been concern that Soldiers with undiagnosed or untreated PTSD or mTSI
are being adm inistratively discharged from the Army. Therefore. it is paramount that the
Army adequately assesses every one of these Soldiers for PTSD or mTBI.

b. This guidance refers to Soldiers who receive mental health evaluations from behavioral
health dinician s for administrative separations.

6. Policy.

a. Behavioral Health Departments within each MTF will ensure that Soldiers receiving
mental health evaluations related to the Chapters identified in paragraph 2., above are
conducted by a behavioral health clinician lAW AR 635-200. Evidence of documentation of a
screen for both PTSD and mTBI must be part of DA Form 3822-R , Report of Mental Stalus
Evaluation and documented in the progress note located in the Soldiers' Armed Forces
Health longitudinal Technology Application (AHlTA) record .

b. There are screening tools (enclosures 1 and 2) for both PTSD and mTSI that can
assist the clinician during the assessment. These tools are also located at
httos:J/wINw.us.army.m il/suite/pageI222. The consensus of the subject matter experts is
that the VA screening questions and the pel found at the website above are the best tools
for screening in this population . It should be noted that the mTBI screening tools are not
diagnostic. Any positive mTBI screen will require a further evaluation to establish the
correct diagnosis with referral and other testing if necessary. Other a ssessment tools may
be added at the discretion of the clinician.

7. Point of contact is~ (b)(6)

f i6)- - - - "'-'''"--- - - - - - - - - - - - - - - - - - - - - ---,

2 Ends ERIC B. SCHOOMAKER

1. PCl lieutenant General
2. VHA TBI Clinical Reminder Commanding
and Screening Tool

2
NSN7~'78

HEALTH RECORD
I CHRONOLOGICAL RECORD OF MEDICAL CARE
SYMPTOMS DIAGNOSIS TREATMENT, TREATING ORGANIZA-nON (Sian seen entry)

Dale: PTSD CheckJist - Military Version (PCL-M)

Instructions: Belowis a list of problems and complaints that veterans sometimes havein response
to stressful military experiences. Pleaseread each onecarefully, put an "X" in the box to indicate
how milchyou have been bothered by that problem in the last month.

:-.Jo. Response: Not at A llttle Moderately Quite a Extremelv

all(\) bit (2) (3) bit (4) (S) •
I. Repeated, disturbing memories. thoughts;Dr images
of a stressful rnilitarvcxoerience? \
2. Repeated, disturbing dreams of a stressful military :
experience? ,
3. Suddenly acting or feeling as if a stressfulmilitary
,
I experiencewere happening again(as if you were
reliving it)? I
4. Feeling very upset when something remindedyou of
a stressful military experience?
5. HaviElgphysical reactions (e.g.•heart pounding,
trouble breathing, or sweating) when sometlling
remilldedyou ofa stressful militarY exoerience? I
6. Avoid thmking about or talking about a stressful
military experience or avoid IJavingfeelmgs related
to it?
I I
7. Avoid aaivitles or situatiolU because they remind I

you of a stressful militarY exDcricnce?

8. Trouble remembering important parts of a stressful
militarYexperlence?
9. Loss of interest in /hinD /Iwz you uscd to cnlov?
10. Feeling distant or cut oJffrom other oeoDlc?
11. Feeling emotionally numb or being unable to have I
Iovinz (celinas for those close to you? 1
12. Feelinlt as ifyourfulIIre will somehow be ClIt short? ! --!
13. Trouble laflin/! or stay/nl!as/up? I
14. i Feeling lrrltabl« <iT havina anR7'V au/bursts? I
15. Hav!1I1t difficultyconcentraJinll? ,
16. Bema "$JI1)er alert' or watchfulon guard?
17. Feelina jumpy or easily startled?

Iwcathcn. r.w..Huska, J.A.. Keane, T.M. PCL-M/tJ' fJSM-1Y. B05lDn: l':alional Centerfor i'TSD·· llebavi0T31 Scittlee Dr.';sicn, 1991.
This is I (lOVrnlmcnl «locum""t in thepublicdom';:l

I Score: I
PATIENTS IDENTiFICII,TION (Use t,~:s SQace fDrMechsnicar RECORDS ~I
Imprint) MAINTAINED AT:
PATIENTS NAI'!E /I.,st. First. Mit1dtelnillaf) SEX

RELATIO~SHI" TO SPONSOR ISTATUS RA'IK.:GRAOE

Date Arrived AOR:
SPONSeR'S NAME \CRGA,..IZATION
Date DepartingAOR:
DEPARTJSE1l.V,CE ISSNIlOENTlFlCATlDN NO, C"iE OF B:Rr~
AFSC:
STANDARDFORII600 (QEV 5·~1
C~RONOLOGICAL RECORD OFMEDICAL CARE PnIse~tlId ~y
GSI- &c.d leMR
No. of Previous Deployments to AOR: _ FIRMR 141 CFR1.Ol045.:C5
 VHA TBI Clinical Reminder and Screening Tool

Section 1: During any of your OIF/OEF deployment(s) did you experience any of the
following events?
(Check all that apply)

D Blast or Explosion
D Vehicular accident/crash (any vehicle, including aircraft)
D Fragment wound or bullet wound above the shoulders
o Fall

Section 2: Did you have any of these IMMEDIATELY afterwards?

(Check all that apply)

o Losing consciousness/"knocked out"

o Being dazed, confused or "seeing stars"
D Not remembering the event
o Concussion
D Head injury

Section 3: Did any of tile following problems begin or get worse afterwards?
(Check all that apply)

D Memory problems or lapses

D Balance problems or Dizziness
o Sensitivity to bright light
D Irritability
D Headache
D Sleep problems

Section 4: In the past week, have you had any of the symptoms [rom Section 3?
(Check all that apply)

D Memory problems or lapses

o Balance problems or dizziness
o Sensitivity to bright light
D Irritability
D Headaches
o Sleep problems
 1

The Association Between Number of Deployments to Iraq and Mental Health

Screening Outcomes in U.S. Army Soldiers

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Funding Source: This study was unfunded

*Corresoondence: _
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 2

1 Abstract

2 Context: High rates of mental health concerns have been documented in Army Soldiers

3 deployed in support of Operation Iraqi Freedom (Olf'). To our knowledge, there are no peer-

4 reviewed studies that have examined the impact of multiple Olf deployments on mental health

5 functioning.

6 Objective: To compare the post-deployment mental health screening results of Soldiers with one

7 or two deployments to Iraq.

8 Design & Setting: Cross sectional study of routine mental health screening data collected in the

9 Soldier Wellness Assessment Program at Fort Lewis, Washington.

10 Participants: A total of 3548 Regular U.S. Army Soldiers (2,877 returning from their first

11 deployment to Iraq, and 671 Soldiers evaluated after their second deployment to Iraq).

12 Main Outcome Measure(s): Standardized measures screened for Major Depression, Other

13 Depression, Post-traumatic stress disorder (PTSD), Panic, Other Anxiety, and hazardous alcohol

14 consumption 90 to 180 days after returning from Iraq.

15 Results: There was a significant association between number of deployments and mental health

16 screening results such that Soldiers with two deployments showed greater odds of screening

17 positive for Other Depressive Syndrome [Odds Ratio (OR)=1.46, p=.045] and Other Anxiety

18 Syndrome (OR=1.32, p=.047). After adjusting for demographic factors and combat exposure on

19 most recent deployment, Soldiers with two Iraq deployments showed significantly greater odds

20 of screening positive for Major Depression (OR= 1.70, p=.02), Other Depressive Syndrome

21 (OR=1.73, p=.007), PTSD (OR=1.90, p<.OOl), Panic (OR=1.85, p=.04), and Other Anxiety

22 Syndrome (OR=1.71, p<.OOl). There was no significant difference in odds of screening positive

23 for hazardous alcohol consumption.

 3

1 Conclusions: These results provide preliminary evidence that multiple deployments to Iraq may

2 be a risk factor for mental health concerns.

3
 4

1 INTRODUCTION

2 High rates of mental health concerns have been documented in Army Soldiers deployed

3 in support of Operation Iraqi Freedom (OIF). In an early study by Hoge and colleagues, 1

4 Soldiers assessed three to four months after a deployment to Iraq screened positive for post-

S traumatic stress disorder (PTSD) in 13% of cases; depression and generalized anxiety were each

6 observed in about 8% of cases, and alcohol misuse was observed in over 20% of cases. With the

7 exception of generalized anxiety, these rates were significantly higher than pre-deployment

8 screening rates observed in a comparable U.S. Army unit. In a separate study, routine post-

9 deployment screening data collected within two weeks ofretuming from Iraq revealed that

10 Soldiers and Marines screened positive for a mental health problem in 19% of cases, compared

11 to 8.5% returning from non-OIF/Operation Enduring Freedom (OEF) operational locations.'

12 Similar results have been reported in veteran populations. Examining over 103,000

13 OIF/OEF veterans, Seal and colleagues' reported that 25% ofa clinical Veteran Affairs (VA)

14 sample had been diagnosed with a mental health disorder, including 13% with PTSD. The rate

15 ofPTSD diagnoses in a similar VA sample was reportedly 3.7 times higher among Soldiers or

16 Marines who served in ground units in Iraq or Afghanistan compared to Navy or Air Force

17 veterans of OIF/OEF. 4

18 The importance of these results is underscored by the association between anxiety or

19 mood disorders, and functional impairments. The National Survey ofthe Vietnam Generation

20 revealed that veterans with lifetime diagnoses ofPTSD and major depression showed

21 significantly lower employment rates and hourly wages compared to veterans without these

22 disorders.' PTSD has been associated with increased marital distress and parental adjustment

23 problems.v" In addition, OIF/OEF veterans with PTSD or hazardous alcohol consumption

 5

1 reported a lower quality of life," Furthermore, Soldiers studied one year after deployment to OlP

2 showed strong associations between PTSD and physical health problems." These impairments in

3 job performance, intimate and family relationships, quality oflife, and physical health suggests

4 that OlP veterans with mental disorders may face significant functional challenges.

5 There is currently speculation as to whether multiple deployments to Iraq may exacerbate

6 the frequency and severity of mental health problems described above. Multiple deployments

7 may increase the cumulative stress an individual experiences, and it increases the probability that

8 Soldiers will be exposed to combat. Deployment stressors can include a sense of isolation,

9 relationship stress, homefront problems, challenges associated with adjusting to a new

10 environment, a threatened sense of safety, traumatic stress, long work hours, and stressors

11 associated with a variety of other operational demands. Concomitant reductions in usual coping

12 resources may also impact mental health functioning. In contrast, potential protective factors

13 such as unit cohesion, effective leadership, mentoring, training, and access to other resources in

14 theater may mediate the impact of deployment stress.

15 To our knowledge, there are no peer-reviewed studies that have examined the impact of

16 multiple OlP deployments on mental health functioning. Army reports from the Office ofthe

17 Surgeon Multinational Force-Iraq and the Office ofthe Surgeon General, U.S. Army Medical

18 Command have reported mixed results. 10, II There is evidence that exposure to multiple traumas

19 may increase the risk for mental health problems. For example, a Swedish study of 1824

20 randomly selected individuals from the general population revealed that trauma frequency was

21 significantly associated with an increased risk ofPTSD. 12 Similar results have been noted in

22 patients hospitalized at trauma centers. 13 In addition, among Service Members who worked in a
 6

1 mortuary during the Persian Gulf War, greater changes in PTSD symptoms were observed in

2 groups with the greatest exposure to human remains."

3 The purpose ofthis study was to determine ifthere is a relationship between multiple

4 deployments and mental health problems as identified by mental health screening outcomes for

5 Soldiers with one or two deployments to Iraq.

6 METHODS

7 Study Population

8 Data were retrospectively analyzed from the Soldier Wellness Assessment Pilot Program

9 (SWAPP) database at Fort Lewis. The SWAPP is an extension ofthe standard Post-Deployment

10 Health Reasssessment (PDHRA) program mandated by the Assistant Secretary of Defense for

11 Health Affairs since 2005. The PDHRA provides a global health assessment, including mental

12 health screening, for all Service Members 90 to 180 days after returning from an operational

13 deployment. In the standard Army process, Soldiers complete the three page PDHRA form

14 electronically, and a qualified healthcare professional (nurse practitioner, physician assistant, or

15 physician) reviews the information, conducts a brief interview, and recommends further

16 evaluation or referrals as indicated.P

17 During the SWAPP process, Soldiers first complete on a computer an expanded set of

18 screening measures that includes the standard PDHRA and additional items for demographics

19 and military information, psychosocial history, mental health screening (see Measures section

20 below), deployment exposures and stressors, and resiliency factors. Soldiers are seen by medical

21 personnel for injury prevention, smoking cessation, or other reported physical concerns as

22 needed, and a credentialed behavioral health provider meets individually with each Soldier. A
 7

1 nurse practitioner reviews all aspects of the Soldier's SWAPP encounters, and administrative

2 support staffmeet with each Soldier to schedule follow-up appointments.

3 The SWAPP's post-deployment screening data from September 7, 2005 to April 27,2007

4 were analyzed. All Service Members in the database were Regular, active duty Soldiers. Cases

5 were included in the analysis when they met two criteria: (1) Iraq was reported as the

6 deployment's operational location; (2) the total historical number of deployments reported in

7 support of Operation Iraqi Freedom was one or two. There were not enough Soldiers with three

8 deployments in the database to expand the analysis to include this group. Cases were included

9 when they were screened within at least 60-days of the target PDHRA timeframe. Soldiers with

10 reported histories of deployment in support of Operation Enduring Freedom were excluded from

11 the analysis. The final sample included 2,877 Soldiers returning from their first deployment to

12 Iraq, and 671 Soldiers evaluated after their second deployment to Iraq. Two subjects were

13 observed in both groups. The study was approved by the Department of Clinical Investigations

14 at Madigan Army Medical Center.

15 Measures

16 SWAPP mental health screening measures included the depression and anxiety modules

17 from the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PHQ)16-18,

18 the Primary Care Posttraumatic Stress Disorder Screen (PC-PTSD)19, and the Alcohol Use

19 Disorder Detection Test (AUDIT).2o In addition, 4 combat exposure items were adapted from

20 the Deployment Risk and Resilience Inventory."

21 PHQ. The PHQ is a self-report measure that can be entirely self-administered by

22 patients.l" Standardized algorithms'" 22, 23 screen patients for threshold disorders that correspond

23 to specific DSM-IV criteria, and subthreshold disorders that require fewer symptoms than a
 8

1 DSM-IV diagnosis. The Depression and Anxiety modules administered in the SWAPP provide

2 screening results for threshold disorders, including Major Depression, Panic Disorder, and Other

3 Anxiety Disorder; the subthreshold disorder of Other Depressive Disorder is also screened. The

4 PHQ is widely used and has established reliability and validity. 16, 17,24,25

5 PC-PTSD. The PC-PTSD is a brief, four-item (Yes-No) self-report screening instrument

6 for PTSD that is a standard part ofthe PDHRA. The PC-PTSD demonstrated sound

7 psychometric properties for cutoff scores of2 (sensitivity = .91, specificity = .72) and 3

8 (sensitivity = .78, specificity = .87) compared to diagnoses based on the Clinician Administered

9 Scale for PTSD (CAPS). 19 Since cutoff scores of either 2 or 3 may be appropriate, depending on

10 the clinical setting, 19 we analyzed results for both cut-points (PTSD-2, PTSD-3).

11 AUDIT. The AUDIT is a 10-item self-report measure that screens for hazardous or

12 harmful alcohol consumption.j" Item responses range from 0 (Never) to 4 (Daily or Almost

13 Daily) with total scores ranging from 0 to 40. The standard cutoff score of 8 for hazardous or

14 harmful consumption has consistently demonstrated favorable sensitivity and specificity in

15 numerous studies. 26-29 The AUDIT is internally consistent." and has shown good test-retest

16 reliability."

17 Combat exposure. The SWAPP screening included four Yes-No questions about combat

18 experienced during the most recent deployment, adapted from the DRRI. 2 1 Items asked the

19 following: During combat operations did you (1) become wounded or injured; (2) personally

20 witness a unit member, ally, enemy, or civilian being killed; (3) see the bodies of dead soldiers or

21 civilians; (4) kill others in combat (or have reason to believe others were killed as result of your

22 actions).

23
 9

1 Statistical Analyses

2 Chi-square tests of association and t-tests were used to compare demographic and combat

3 exposure variables between groups with one or two Iraq deployments. Logistic regression was

4 used to examine associations between the number of Iraq deployments and mental health

5 screening outcomes (positive, negative). Multivariate logistic regression models were used to

6 examine the associations irrespective of age, sex, race/ethnic background, rank, education,

7 marital status, and combat exposure.

8 RESULTS

9 Subject Characteristics

10 Subject demographics are presented in Table 1. Soldiers with two Iraq deployments

11 differed from those with one deployment in terms of age, rank, education, and marital status.

12 There was no difference between the groups in racial/ethnic background or sex.

13 There was no difference between Soldiers with one or two deployments in terms ofthe

14 number of days between departure from theater and screening date (Mean ± SD = 105.51 ±
15 37.62; 108.14 ± 35.94, respectively). Soldiers were deployed for an average of 11.33 months

16 (SD = 2.19) in the group with one deployment and 11.03 months (SD = 2.41) in the group with

17 two deployments. For Soldiers with two deployments, the median arrival date in theater (Oct.

18 31, 2005) was about a year later than the median arrival date for Soldiers with one deployment to

19 Iraq (October 13, 2004). Subjects reported significantly lower frequencies of combat exposure

20 during their second deployment compared to Soldiers who recently returned from their first Iraq

21 deployment (Table 2).

22

23
 10

1 Mental Health Screening Results

2 There was a significant association between number of deployments and mental health

3 screening results in the univariate analyses for Other Depressive Syndrome (OR = 1.46, P =

4 .045) and Other Anxiety Syndrome (OR = 1.32, P = .047; Table 3). After adjusting for

5 demographic factors and combat exposure, Soldiers with two Iraq deployments showed

6 significantly increased odds of screening positive for Major Depression (OR = 1.70, P = .02),

7 Other Depressive Syndrome (OR = 1.73, P = .007), PTSD-2 (OR = 1.64, P <.001), PTSD-3 (OR

8 = 1.90, P < .001), Panic (OR = 1.85, P = .04), and Other Anxiety Syndrome (OR = 1.71, P <

9 .001). There was no difference between the groups in the odds of screening positive for

10 hazardous alcohol use.

11 These analyses were repeated after adding the number of days between screening and

12 departure from theater to the model. The results were unchanged with the exception of Panic

13 which no longer showed a significant association with number of Iraq deployments (OR = 1.78,

14 P = .055).

15 DISCUSSION

16 The results of this study provide preliminary evidence that multiple deployments to Iraq

17 may be a risk factor for some mental health concerns. The odds of screening positive for Other

18 Depression and Other Anxiety Syndrome was higher for Soldiers on their second deployment to

19 Iraq compared to those screened after a first deployment to Iraq.

20 These findings differ from results of the Mental Health Advisory Team (MHAT)-III

21 Report" which found that Soldiers with multiple deployments to Iraq showed higher rates of

22 acute stress, but not depression or anxiety, compared to Soldiers on their first deployment to Iraq.

23 Our results are more consistent with the recent MHAT-IV Report!' which found that Soldiers
 11

1 deployed to Iraq more than once were more likely to screen positive for depression, anxiety, or

2 acute stress. However, different recruitment procedures, participant characteristics, and outcome

3 measures limit comparability. In addition, it is important to note that the MHAT Reports are

4 based on data collected from Soldiers during deployment, while our results were collected from

5 Soldiers about 3 to 6 months after returning from deployment. Some research suggests that

6 results obtained immediately following a deployment may differ substantially from assessments

7 conducted several months later.32

8 After adjusting for demographic factors and combat exposure on the most recent

9 deployment, the odds of screening positive for Major Depression, Other Depressive Syndrome,

10 PTSD, Panic, and Other Anxiety Syndrome was 64 to 90% higher for Soldiers with two

11 deployments. These findings suggest that the odds of developing a mental health problem are

12 higher for Soldiers after a second deployment, irrespective ofthe combat they are exposed to

13 during their second tour. The factors contributing to these findings are unknown. Information

14 about combat exposure during first deployments (among Soldiers with two deployments) was not

15 available. Thus, the impact of additive combat exposures across multiple deployments remains

16 unknown. In addition, the impact of cumulative deployment stress, such as homefront stressors

17 and difficulties associated with working in an operational theater may contribute to these

18 findings. Additional research is needed to determine how the etiology of mental health disorders

19 following a second deployment may differ from Soldiers deployed to Iraq only once.

20 Interpretation of our findings would benefit from more information on how Soldiers with

21 one or two deployments may differ. While we were able to examine basic demographic features

22 and recent combat exposure, we do not know how the group with two deployments adjusted after

23 their first deployment compared to their entire cohort. Soldiers identified with a post-
 12

1 deployment mental health condition that renders them unfit for duty are not deployed again until

2 treatment proves successful. In addition, Service Members who screen positive for mental health

3 concerns are more likely to leave military service in the year following a deployment?

4 Therefore, it is possible that the group with two deployments represented a healthier, more

5 resilient group. However, it is also possible that a number of Soldiers were successfully treated

6 for mental health concerns before deploying a second time. The impact of prior treatment

7 history on mental health functioning after a second deployment is unknown. A longitudinal

8 study of the effects of multiple deployments on mental health would be helpful to clarify these

9 Issues.

10 Analyses of demographic features revealed group differences on a number of variables.

11 These group effects were expected, as Soldiers with two deployments likely had longer military

12 careers. Therefore, differences in age, rank, education, and marital status are intuitive. The

13 difference between groups on combat exposure is less intuitive. Soldiers reported significantly

14 lower levels of combat exposure during their second deployment compared to the group with

15 only one deployment. This finding may be due, in part, to the fact that Soldiers' second

16 deployment occurred, on average, about a year later in the history of the conflict when combat

17 operations may have differed. It is also possible that Soldiers deployed to Iraq for a second time

18 may differ from Soldiers on a first deployment in some way that makes them less likely to see

19 combat. Possibilities include rank, Army selection criteria for a second deployment, duty

20 assignments for Soldiers with prior theater experience, or differences in attrition from the Army

21 by occupational duty.

22 Rates ofpositive screens for mental health disorders were generally lower than those

23 reported by Hoge and colleagues.' For example, while Hoge et al. reported that 15% of their
 13

1 Army sample screened positive for major depression on the PHQ after deployment to Iraq, we

2 observed a rate of 4% for our total sample using the same measure. However, significant

3 differences between study methods may account for these differences. Hoge et al.'s study

4 utilized an anonymous survey with a specific infantry division, three to four months after an 8-

5 month deployment to Iraq in December 2003. Our results were obtained from non-anonymous,

6 standard post-deployment screening efforts at Fort Lewis for Soldiers from a variety of units,

7 three to six months after deployments (of varying lengths) to Iraq, from September 2005 to April

8 2007. Many ofthese factors likely contributed to the differences in the results. For example,

9 since our sample included non-combat units, combat exposure may have been reduced in our

10 sample compared to Hoge et al.'s study. In support of this hypothesis, 62% ofHoge et al.'s

11 sample endorsed responsibility for the death of others (combatants and noncombatants)

12 compared to 33% of our total sample.

13 In contrast, the rates we observed were higher than those reported in a recent study that

14 examined population-based results of Army Soldiers and Marines screened within two weeks of

15 returning from a deployment to Iraq.' Utilizing the 2-point cutoff score for the PC-PTSD, the

16 investigators reported a PTSD-positive screen rate of9.8% in their Iraq sample; this compares to

17 a rate of about 21% in our total sample using the same measure. Both studies included similar

18 questions about whether the Service Members saw dead bodies; the rate in our sample was

19 higher with 67% positive, compared to 49.5% in the Hoge et al. 2 study. Thus, some of the

20 differences between the two studies could be due to higher levels of combat exposure in our local

21 sample. Unfortunately, other combat exposure items were not appropriate for comparison.

22 However, another important difference between the studies was the timing ofthe screening. The

23 Hoge et a1. 2 study was conducted within two weeks of returning from deployment, while our data
 14

1 was gathered about three to six months after deployment. As noted above, some data suggests

2 that Service Members are much more likely to report mental health problems three to four

3 months after deployment compared to shortly after returning.32

4 The results of the current research should be confirmed in future studies, as the cross-

5 sectional design limits conclusions. In addition, all study subjects were drawn from one Army

6 installation in Tacoma, WA with a large active duty population, including several Stryker

7 brigades. These Soldiers may differ from the broader Army in a number of ways, and the results

8 may not generalize to the rest of the Army. Generalizability is further reduced by the fact that

9 the current study included only Regular active duty Soldiers. Furthermore, it is important to

10 emphasize that these results were obtained with self-administered screening instruments; these

11 results do not reflect diagnostic rates. In addition, the time-frame of the study period may prove

12 important for studying mental health outcomes of multiple deployments. As the theater matures

13 and the mission requirements of Operation Iraqi Freedom evolve, the nature of the stressors that

14 Soldiers experience may change. Therefore, rates examined during one time frame of the

15 Conflict may not generalize to other periods.

16 The importance of understanding the mental health effects of multiple deployments is

17 likely to grow as the number of Service Members with two or more deployments increases. The

18 results of this study provide preliminary evidence that the risk of mental health problems may

19 increase following a second deployment to Iraq. As the number of Service Members deployed

20 for second tours increases, these findings may have significant implications for the demand on

21 mental health treatment resources.

22

23
 15

I Disclosures & Acknowledgements: All authors report no competing interests. This was an

2 unfunded study. The opinions or assertions contained herein are the private views of the authors

3 and arenot to be construed as official or reflecting the views of the Department of the Anny or

4 the Department of Defense. The authors thankj1b)(6) IPhD, ABPP,E 6_) ---.J

5 PhD,E 6) E 6) IMD, E 6) !MD, MPH, FACPM for their

6 contributions.
 16

References

1. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting Dr, Koffman RL. Combat duty in

Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. Jul 1

2004;351(1): 13-22.

2. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health

services, and attrition from military service after returning from deployment to Iraq or

Afghanistan. Jama. Mar 1 2006;295(9): 1023-1032.

3. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing the war back home:

mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan

seen at Department of Veterans Affairs facilities. Arch Intern Med. Mar 12

2007; 167(5):476-482.

4. Kang HK, Hyams KC. Mental health care needs among recent war veterans. N Engl J

Med. Mar 31 2005;352(13):1289.

5. Savoca E, Rosenbeck R. The civilian labor market experiences of Vietnam-era veterans:

the influence of psychiatric disorders. J Ment Health Policy Econ. Dec 1 2000;3(4):199-

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 17

8. Erbes C, Westermeyer J, Engdahl B, Johnsen E. Post-traumatic stress disorder and

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9. Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC. Association of

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10. Office of the Surgeon Multinational Force-Iraq and Office ofthe Surgeon General United

States Army Medical Command: Mental Health Advisory Team (MHAT-III) Report.

May 29,2006.

11. Office of the Surgeon Multinational Force-Iraq and Office ofthe Surgeon General United

States Army Medical Command: Mental Health Advisory Team (MHAT-IV) Report.

November 17, 2006.

12. Frans 0, Rimmo PA, Aberg L, Fredrikson M. Trauma exposure and post-traumatic stress

disorder in the general population. Acta Psychiatr Scand. Apr 2005;111(4):291-299.

13. Zatzick D, Jurkovich G, Russo J, et al. Posttraumatic distress, alcohol disorders, and

recurrent trauma across level 1 trauma centers. J Trauma. Aug 2004;57(2):360-366.

14. McCarroll JE, Ursano RJ, Fullerton CS, Liu X, Lundy A. Effects of exposure to death in

a war mortuary on posttraumatic stress disorder symptoms of intrusion and avoidance. J

Nerv Ment Dis. Jan 2001;189(1):44-48.

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Post-Deployment Health Reassessment Program (PDHRA). OTSGIMEDCOM Policy

Memo 06-005. March 7,2006.

 18

16. Spitzer RL, Kroenke K, Williams lB. Validation and utility of a self-report version of

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23. Spitzer RL, Williams lB, Kroenke K, Hornyak R, McMurray J. Validity and utility ofthe

PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic

 19

patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. Am

J Obstet Gynecol. Sep 2000;183(3):759-769.

24. Fann JR, Bombardier CH, Dikmen S, et al. Validity of the Patient Health Questionnaire-9

in assessing depression following traumatic brain injury. J Head Trauma Rehabil. Nov-

Dec 2005;20(6):501-511.

25. Means-Christensen AJ, Arnau RC, Tonidandel AM, Bramson R, Meagher MW. An

efficient method of identifying major depression and panic disorder in primary care. J

Behav Med. Dec 2005;28(6):565-572.

26. Maisto SA, Carey MP, Carey KB, Gordon CM, Gleason JR. Use of the AUDIT and the

DAST-10 to identify alcohol and drug use disorders among adults with a severe and

persistent mental illness. Psychol Assess. Jun 2000;12(2):186-192.

27. Bradley KA, Bush KR, McDonell MB, Malone T, Fihn SD. Screening for problem

drinking: comparison of CAGE and AUDIT. Ambulatory Care Quality Improvement

Project (ACQUIP). Alcohol Use Disorders Identification Test. J Gen Intern Med. Jun

1998;13(6):379-388.

28. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol

consumption questions (AUDIT-C): an effective brief screening test for problem

drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use

Disorders Identification Test. Arch Intern Med. Sep 141998;158(16):1789-1795.

29. CherpiteI CJ. Comparison of screening instruments for alcohol problems between black

and white emergency room patients from two regions ofthe country. Alcohol Clin Exp

Res. Nov 1997;21(8):1391-1397.

 20

30. Reinert DF, Allen JP. The Alcohol Use Disorders Identification Test (AUDIT): a review

of recent research. Alcohol Clin Exp Res. Feb 2002;26(2):272-279.

31. Daeppen JB, Yersin B, Landry U, Pecoud A, Decrey H. Reliability and validity of the

Alcohol Use Disorders Identification Test (AUDIT) imbedded within a general health

risk screening questionnaire: results of a survey in 332 primary care patients. Alcohol

Clin Exp Res. May 2000;24(5):659-665.

32. Bliese P, Wright K, Adler A, Thomas J. Validation ofthe 90 to 120 day short form

psychological screen (Research Report 2004-002). Heidelberg, Germany: US Army

Medical Research Unit Europe; 2004.

 21

Table 1. Demographics Characteristics by Number of Deployments

Number of Deployments
1 2
n % n %
(Mean) (SD) (Mean) (SD) P
Age a (27.42) (5.84) (29.08) (5.91) <.001
Sex Male 2627 92.7 600 90.8 .09
Female 207 7.3 61 9.2
RacelEthnicity American Indian
or Alaskan 73 2.6 22 3.3 .28
Native
Asian 122 4.3 28 4.2 .94
Pacific Islander 92 3.2 28 4.2 .21
Black 324 11.4 85 12.9 .30
Hispanic 337 11.9 66 10.0 .17
White 1925 67.9 434 65.7 .26
Other 86 3.0 25 3.8 .32
Rank E1-E4 1243 43.9 164 24.8 <.001
E5-E9 1228 43.3 424 64.1
Officer 329 11.6 57 8.6
Warrant Officer 34 1.2 16 2.4
Education Some High
100 3.5 18 2.7 .041
School
High School
982 34.7 218 33.0
Graduate
Some College
1141 40.3 305 46.1
but No Degree
Associates
162 5.7 41 6.2
Degree
College Graduate
(Bachelor's 360 12.7 64 9.7
Degree)
Postgraduate or
Professional 89 3.1 15 2.3
Degree
Marital Status Never married 979 34.5 155 23.4 <.001
Married 1594 56.2 403 61.0
Separated 125 4.4 35 5.3
Divorced 135 4.8 68 10.3
Widowed 1 <1 0 0
Note: For Race/Ethnic Status, Soldiers were asked to select all that applied
a Means and SDs are presented
 22

Table 2. Combat Exposure During First and Second OIP Deployments

Number of Deployments
1 2
n % n % p
Wounded 416 14.7 69 lOA .005
or Injured

Witnessed 1441 50.8 183 27.7 <.001

Killing

Saw Dead 2028 71.6 338 51.1 <.001

Bodies

Killed 1064 37.5 101 15.3 <.001

Others
 23

Table 3. Mental Health Screening Results by Number of Iraq Deployments

Number of Deployments
1 2
No. Pos'!n % No. Pos'!n % Crude OR (95% CI) Adjusted ORa (95% CI)
Major 114/2772 4.1 30/651 4.6 1.13 (.75, 1.70) 1.70* (1.09,2.65)
Depression

Other 119/2772 4.3 40/651 6.1 1.46* (1.01, 2.11) 1.73* (1.17,2.57)
Depression

PTSD-2 580/2803 20.7 137/653 21.0 1.02 (.83, 1.26) 1.64** (1.30,2.08)

PTSD-3 322/2803 11.5 85/653 13.0 1.15 (.89, 1.49) 1.90** (1.43, 2.52)

Panic 56/2817 2.0 17/660 2.6 1.30 (.75, 2.26) 1.85* (1.03, 3.33)

Other 250/2823 8.9 75/660 11.4 1.32* (1.004, 1.73) 1.71** (1.27,2.30)
Anxiety

ETOH 408/2808 14.5 85/657 12.9 .87 (.68, 1.12) 1.27 (.97, 1.68)

* p<.05, **p<.OOI
Note: OR = Odds Ratio; No. Pos. = Number that Screened Positive; PTSD-2 = Results from the
PC-PTSD using a cutoff score of 2; PTSD- 3 = Results from the PC-PTSD using a cutoff score of
3. Denominators differ because subjects did not answer every question. Subjects with missing
data did not differ from the rest ofthe sample in terms of Age, Sex, RacelEthnicity, Rank,
Education, Marital Status, percent who had Combat Injuries, percent who Saw Dead Bodies, or
percent who reported Killing Others. A higher proportion of subjects with missing data reported
Seeing Dead Bodies.
a Adjusted for Age, Sex, Education, RaciallEthnic Background, Rank, Marital Status, Combat
Exposure
 DEPARTMEi\T OF THE AR~IY
IIL\OQt:,\RTERS.I·~IT[DSTATES ..\ R\I\' \IEDICAL CO\II\'It\ND
2050 WORTII ROM}
FORT SA\I 1I00'STO~.TX 78234-6000

REPLYlt>
.~ TIl::-iTIO:-i Of

OTSG/MEDCOM Policy Memo 09-012

MCHO-CL 113 MAR 2009

Expires 13 March 2011

MEMORANDUM FOR Commanders, MEDCOM Regional Medical Commands

SUBJECT: MEDCOM Procedures for Chapter 5, paragraph 5-13 and 5-17 Personality
Disorder (PD) Separations

1. References.

a, Department of Defense Instruction (0001) 1332,14, "Enlisted Administrative

Separations". Aug 08.

b. Anny Regulation (AR) 635-200, Active Duty Enlisted Administrative Separations,

6 Jun 05.

c. OTSG/MEDCOM Policy 08-018, Screening for Post-Traumatic Stress Disorder

(PTSD) and mild Traumatic Brain Injury (mTBI) Prior to Administrative Separations, 19 May
08.

d. MEDCOM memorandum MCCG, Review of Personality Disorder (Chapter 5,

paragraph 5-13) Administrative Separations, 6 Aug 07.

2. Purpose. To outline new PD procedures under reference 1b., Chapter 5, paragraph 5-

13 and 5-17.

3. Proponent. The proponent for this policy is the Director, Behavioral Health Proponency.
Office of The Surgeon General (OTSG), AnN: DASG-HSZ.

4. Responsibilities.

a. The Surgeon General has overall responsibility for policy guidance in defining
and implementing the Army Medical Department's behavioral healthcare screening
requirements.

b. The Directorate of Health Policy and Services, Proponency Office for Behavioral
Health. is responsible for the distribution of behavioral health policies and reviewing,
revising, updating, and deleting existing policies conflicting with these requirements.
MCHO-CL
SUBJECT: MEDCOM Procedures for Chapter 5, paragraph 5-13 and 5-17 Personality
Disorder (PO) Separations

c. Medical treatment facility (MTF) Commanders will ensure that all Soldiers who are
referred for PD separations follow the procedures outlined below.

5. Discussion.

a. There has been concern that Soldiers with undiagnosed or untreated PTSD or mTBI
are administratively discharged from the Army. MEDCOM has previously issued two
policies addressing PO and screening for PTSD and mTBI (references 1c. and 1d.).

b. Reference 1a. outlines updated requirements. These requirements are similar but not
identical to the policy changes that the Army issued. This policy memorandum consolidates
the different requirements.

c. This guidance refers to Soldiers who receive mental health evaluations from behavioral
health clinicians for Chapter 5, paragraph 5-13 and 5-17 PD administrative separations.

6. Policy.

a. 00011332.14, enclosure 3. paragraph 3a(8), Enlisted Administrative Separations.

prescribes the following requirements for separations on the basis of enlisted Soldiers who
have served or are currently serving in imminent danger pay areas:

(1) A Psychiatrist or PhD-level Psychologist must diagnose the PD.

(2) A peer or higher-level mental health professional must corroborate the diagnosis.

(3) The Army Surgeon General must endorse the diagnosis.

(4) The diagnosis must address PTSD or other co-morbid mental illness, if present.

b. For Chapter 5. paragraph 5-13, PD evaluations:

(1) In the case of Soldiers who have served or are currently serving in an imminent
danger pay area and are within the first 24 months of active duty service, the MTF Chief of
Behavioral Health (or an equivalent official) must first corroborate the diagnosis of PO for
separation under AR 635-200, Chapter 5, paragraph 5-13.

(2) The corroborated diagnosis will be forwarded for final review and confirmation by
the Director, Proponency of Behavioral Health. OTSG (DASG-HSZ).

(3) Medical review of the PD diagnosis will consider whether PTSD and/or mTBI
may be significant contributing factors to the diagnosis.

2
MCHO-CL
SUBJECT: MEDCOM Procedures for Chapter 5, paragraph 5-13 and 5-17 Persona lity
Disorder (PO) Separations

(4) A Soldier will not be processed for administrative separation under

AR 635-200, Chapter 5. paragraph 5-13 . jf PTSD, mTBI , or other co-morbid mental illness
are significant contributing factors to a diagnosis of PD. but will be evaluated under the
physical disability system in accordance with AR 635-40.

c. For Chapter 5. paragraph 5-17 PO evaluations:

(1) In the case of Soldiers who have served or are currently serving in an imminent
danger pay area and have 24 months or more of active duty service , the MTF Chief of
Behavioral Health (or an equivalent official) must corroborate the diagnosis of PO for
separation under AR 635-200. Chapter 5. paragraph 5-17 .

(2) The corroborated diagnosis will be forwarded for final review and confirmation by
the Director. Proponency of Behavioral Health.

(3) Medical review of the PO diagnosis will consider whether PTSD and/or mTS!. or
other co-morbid menial illness diagnosis may be significant contributing factors to the
diagnosis.

(4) A Soldier will nol be processed for administrative separation under AR 635-200.
Chapter 5, paragraph 5-17 , if PTSD or mTSI are significant contributing factors to a
diagnosis of PO, but will be evaluated under the physical disability system in accordance with
AR 635-40.

7. Our point of contact iS I(b)(6 ) 'Director. Proponency of Behavioral Health.

OTSG, The corroborated diagnosis. with all supporting medical documentation, will be
forwarded for final review and endorsement to the OTSG (DASG-HSZ). 5109 leesburg Pike .
Suite 693 . Falls Church . Virginia 22041-3258.

FOR THE COMMANDER:

~fo~E~
Chief of Staff