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	Most Vets at Risk for Post-Traumatic Stress Aren't Screened
	By Neil Osterweil, MedPage Today Staff Writer Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine. May 12, 2006
	MedPage Today Action Points Explain to interested patients that combat veterans may be suffering from post-traumatic stress disorder (PTSD), substance abuse, major depression, and difficulties functioning. Note that this study suggests that only one in five veterans deemed at risk for PTSD by Pentagon criteria may get further evaluation by military doctors and need community mental health services.
	Review WASHINGTON, May 12 — Only one in five veterans returning from combat duty in Iraq or Afghanistan with signs of post-traumatic stress disorder (PTSD) is actually screened for it, the Government Accountability Office reported. Using data provided by the Department of Defense, GAO investigators found in review that 9,145 (5%) of the 178,664 service men and women deployed in Afghanistan or Iraq may be at risk for developing PTSD, but only 2,029 (22%) of the at-risk group were referred for further mental health evaluations. In March, researchers from the Walter Reed Army Institute of Research reported in the Journal of the American Medical Association that 35% of Iraq war veterans sought mental health services for any reason in the year after returning home. Of them, 12% per year received a diagnosis of a mental health problem, the investigators found, and an additional 23% per year were seen in mental health clinics but did not receive a diagnosis. More than half of those who were referred for a mental health problem received follow-up care, but less than 10% of all returning vets who were treated for mental health problems were referred through the military's screening program, those investigators found. The Pentagon requires all service personnel returning from combat areas to complete a four-item questionnaire to identify soldiers who may be at risk for developing PTSD, and health providers interview service personnel after they complete it. Those returning from combat areas are asked: "Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you... have had any nightmares about it or thought about it when you did not want to? tried hard not to think about it or went out of your way to avoid situations that remind you of it? were constantly on guard, watchful, or easily startled? felt numb or detached from others, activities, or your surroundings?" Guidelines issued jointly by the Veterans Administration and the Department of Defense state that three out of four positive responses on the questionnaires indicate a potential for PTSD. Yet of the 9,145 service men and women who were at risk, only 22% were actually referred for further evaluation, the GAO researchers found. "According to Department of Defense officials, not all of the service members with three or four positive responses to the PTSD screening questions will need referrals for further mental health evaluations," the GAO investigators wrote. "The Department of Defense relies on providers' clinical judgment to decide who needs a referral." In its review, the agency found that the frequency of referrals for PTSD evaluations varied with the branch of the service, with the Army and Air Force providers each referring about 23% with three out of four positive answers on the screening questionnaire, compared with 18% for Navy providers, and 15% for the Marines. "However, Department of Defense did not identify the factors its providers used in determining which Operation Enduring Freedom/Operation Iraqi Freedom service members needed referrals," GAO investigators noted. "Knowing the factors upon which Department of Defense health care providers based their clinical judgments in issuing referrals could help explain variation in the referral rates and allow Department of Defense to provide reasonable assurance that such judgments are being exercised appropriately," they added. In a letter to the Surgeon General of the U.S. Army, Lieutenant General Kevin Kiley, Senator Barbara Boxer, (D-Calif.), said that the findings represent a health care emergency, and demanded "immediate steps to rectify this deplorable lack of care for our men and women in uniform." Previous studies have shown that after other wars and military engagements, returning soldiers are at a significantly increased risk for PTSD, substance abuse, major depression, and difficulties functioning in the day-to-day work and home environments. IN their JAMA study, the Walter Reed researchers found that among service personnel returning from Iraq, 9.8% had scores of two or more on the four-item posttraumatic stress disorder scale, compared with 4.7% of those who had been in Afghanistan, and 2.1% for those coming back from deployment elsewhere. The adjusted odds ratio for a high posttraumatic stress disorder score among Iraq veterans compared with Afghanistan veterans was 2.52, 95% CI, 2.30-2.76; P <0.001, and compared with veterans deployed to other places, the adjusted OR was 5.51, 95% CI, 5.20- 5.83; P<0.001. The authors found that "the prevalence rates of mental health problems and combat experiences were consistently higher" following deployment to Iraq than to Afghanistan or other locations. In a separate study published earlier this month, Harvard Medical School investigators who studied Vietnam War combat veterans and their non-combatant identical twins found that those soldiers with subtle deficits in certain neurologic soft signs were significantly more likely to suffer from PTSD, and that they shared these features with their twin brothers. The findings suggest that some people are predisposed to be susceptible to post-traumatic stress disorder, the researchers concluded. Related articles: · Post-Traumatic Stress in Vietnam GIs Seen as Pre-Existing · Iraq Vets Bringing Home Mental Health Needs at High Rate Disclaimer The information presented in this activity is that of the authors and does not necessarily represent the views of the University of Pennsylvania School of Medicine, MedPage Today, and the commercial supporter. Specific medicines discussed in this activity may not yet be approved by the FDA for the use as indicated by the writer or reviewer. Before prescribing any medication, we advise you to review the complete prescribing information, including indications, contraindications, warnings, precautions, and adverse effects. Specific patient care decisions are the responsibility of the healthcare professional caring for the patient. Please review our Terms of Use.
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