Christopher H. Warner

Psychological Effects of Deployments on Military Families

FULL DISCLOSURE POLICY In accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support, all CME providers are required to disclose to the activity audience the relevant financial relationships of the planners, teachers, and authors involved in the development of CME content. An individual has a relevant financial relationship if he or she has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the CME activity content over which the individual has control. Relationship information appears at the beginning of each CME-accredited article in this issue.

Effectiveness of Mental Health Screening and Coordination of In-Theater Care Prior to Deployment to Iraq: A Cohort Study

OBJECTIVE The authors assessed the effectiveness of a systematic method of predeployment mental health screening to determine whether screening decreased negative outcomes during deployment in Iraqs combat setting. METHOD Primary care providers performed directed mental health screenings during standard predeployment medical screening. If indicated, on-site mental health providers assessed occupational functioning with unit leaders and coordinated in-theater care for those cleared for deployment. Mental health-related clinical encounters and evacuations during the first 6 months of deployment in 2007 were compared for 10,678 soldiers from three screened combat brigades and 10,353 soldiers from three comparable unscreened combat brigades. RESULTS Of 10,678 soldiers screened, 819 (7.7%, 95% confidence interval [CI]=7.2-8.2) received further mental health evaluation; of these, 74 (9.0%, 95% CI=7.1-11.0) were not cleared to deploy and 96 (11.7%, 95% CI=9.5-13.9) were deployed with additional requirements. After 6 months, soldiers in screened brigades had significantly lower rates of clinical contacts than did those in unscreened brigades for suicidal ideation (0.4%, 95% CI=0.3-0.5, compared with 0.9%, 95% CI=0.7-1.1), for combat stress (15.7%, 95% CI=15.0-16.4, compared with 22.0%, 95% CI=21.2-22.8), and for psychiatric disorders (2.9%, 95% CI=2.6-3.2, compared with 13.2%, 95% CI=12.5-13.8), as well as lower rates of occupational impairment (0.6%, 95% CI=0.4-0.7, compared with 1.8%, 95% CI=1.5-2.1) and air evacuation for behavioral health reasons (0.1%, 95% CI=0.1-0.2, compared with 0.3%, 95% CI=0.2-0.4). CONCLUSIONS Predeployment mental health screening was associated with significant reductions in occupationally impairing mental health problems, medical evacuations from Iraq for mental health reasons, and suicidal ideation. This predeployment screening process provides a feasible system for screening soldiers and coordinating mental health support during deployment.

Soldier Attitudes toward Mental Health Screening and Seeking Care upon Return from Combat

OBJECTIVE This study examined soldier attitudes about postdeployment mental health screening, treatment, barriers to care, strategies for overcoming barriers, and settings, personnel and timing for conducting postdeployment mental health screening. METHODS Deploying soldiers participated in a voluntary anonymous survey. RESULTS Of 3,294 soldiers, 2,678 (81.3%) responded to the survey. When the three most endorsed perceived barriers to mental health care (negative perception by unit members, negative perception by leaders, and being viewed as weak) were examined, approximately 15% fewer soldiers endorsed the perceptions, compared with a previous study conducted at the beginning of the war. Receipt of training focused on managing psychological problems associated with increased agreement to seek treatment. Participants endorsed surveys, interviews, and unit providers as preferred instruments and providers for postdeployment screening. Soldiers endorsed encouragement from family members and friends as the preferred approach to reducing barriers to mental health care. CONCLUSION Extensive educational programs seemed to have reduced the stigma related to receiving mental health care. Programs that focus on friend and family member encouragement of soldiers to seek mental health assistance should continue. Postdeployment screening should be conducted under conditions in which soldiers are most likely to report problems honestly.

Division Mental Health in the New Brigade Combat Team Structure: Part II. Redeployment and Postdeployment

OBJECTIVE Recent Army transformation has led to significant changes in roles and demands for division mental health staff members. This article focuses on redeployment and postdeployment. METHODS The postdeployment health assessment behavioral health screening and referral process and redeployment plan are reviewed, and data on postdeployment rates of negative events are reported. RESULTS All soldiers and many of their families participated in an aggressive education program. Of the 19,500 soldiers screened, 2,170 (11.1%) were referred for behavioral health consultation; of those referred, 219 (10.1%) were found to be at moderate or high risk for mental health issues (1.1% of total screened). Of the moderate/highrisk soldiers, 146 (71.9%) accepted follow-up mental health treatment upon return to home station. Fewer cases of driving under the influence, positive drug screens, suicidal gestures/ attempts, crimes, and acts of domestic violence were seen, in comparison with rates seen after an earlier deployment of this unit to Iraq. CONCLUSIONS A formalized approach with command support and coordination can have a positive impact on successful referral and treatment and reduce negative postdeployment events.

Disordered Eating in Entry-Level Military Personnel

OBJECTIVE The goal was to determine the prevalence of and risk factors for disordered eating in an entry-level U.S. Army population. METHODS A cross-sectional survey of advanced individual training U.S. Army soldiers at Aberdeen Proving Ground, Maryland, was performed with an anonymous self-report survey containing demographic factors, history (including abuse and psychiatric treatment), and Eating Attitudes Test-26. RESULTS Of 1,184 advanced individual training soldiers approached, 1090 participated. The response rate was 91.2% (955 men and 135 women). Forty percent were overweight (body mass index of > or =25), 11% reported a psychiatric history, 26% reported a history of abuse, and 9.8% endorsed disordered eating (male, 7.0%; female, 29.6%), as defined by Eating Attitudes Test-26. Factors that placed soldiers at higher risk for disordered eating were female gender (odds ratio, 5.63; 95% confidence interval, 3.32-9.57; p < 0.00005), overweight (odds ratio, 3.06; 95% confidence interval, 1.92-4.89; p < 0.00005), previous psychiatric treatment (odds ratio, 1.87; 95% confidence interval, 1.04-3.36; p = 0.035), and history of verbal abuse (odds ratio, 2.02; 95% confidence interval, 1.16-3.51; p = 0.014). CONCLUSIONS Our study shows a higher than expected rate of disordered eating in advanced individual training soldiers with identifiable risk factors. This indicates an important need for further study, effective screening, preventive counseling, and early intervention for treatment.

Outbreak of SandFly Fever in Central Iraq, September 2007

An outbreak of nonspecific febrile illnesses occurred among U.S. Army troops in September 2007 at a remote, newly established, rural-situated patrol base, south of Baghdad, Iraq. Soldiers displayed an acute flu-like syndrome with symptoms of fever, headache, malaise, and myalgia. A total of 14 cases was identified and treated presumptively as query fever. Subsequent convalescent serum specimens confirmed 13 (92.9%) positive for sandfly Sicilian virus and 3 (21.4%) positive for Coxiella burnetii, with two positive for both. One sandfly Sicilian virus case tested positive for Brucella spp. This outbreak emphasizes the potential for multiple simultaneous disease exposures to endemic diseases in nonindigenous military personnel at remote military locations in Iraq. Recommendations include increased theater disease surveillance, medical training, and vector control.

Suicide Prevention in a Deployed Military Unit

Objective: Military suicide and parasuicidal behaviors have been increasing over the last several years, with rates highest in the deployed environment. This article presents a deployment cycle-specific suicide prevention plan utilized during one U.S. Army division’s 15-month deployment to Iraq. Methods: Education, identification, and intervention programs were implemented at each phase of the deployment cycle based on the specific unit activities and predicted stressors. Results: During the deployment, there was an annual suicide rate of 16/100,000 within the trial cohort, compared to a theater rate of 24/100,000. Peaks in suicidal ideation and behaviors occurred during months two, six, and twelve of deployment. Conclusions: A deployment cycle prevention program may decrease rates of suicide in the combat environment. This program may serve as a model for other suicide prevention programs.

Managing Aviator Fatigue in a Deployed Environment: The Relationship Between Fatigue and Neurocognitive Functioning

The current military battlefield requires aviators to make split-second decisions that often have life-and-death consequences, making identifying predictors of diminished cognitive performance a vital aeromedical and safety concern. The current study explored the relationship between aviator effectiveness, as determined by sleep-wake patterns, and neurocognitive functioning in a brigade-size rotary wing aviation element deployed in Iraq. Actigraphy and the Fatigue Avoidance Scheduling Tool (FAST) were used to assess the ratio of sleep-wake patterns over a 24-hour time period, and a computerized multitasking measure, which mimics the task demands of flying, was utilized to evaluate neurocognitive functioning during preflight operations. Results showed a significant positive association between level of effectiveness and neurocognitive functioning before flight operations. The reported sleep habits and trends in types of sleep difficulties are noted. The results speak to the potential efficacy of using actigraphy and software to evaluate a pilots effectiveness before flight operations, and suggest that flight surgeons and psychologists may be able to play a vital role in improving overall sleep patterns and enhancing the warfighting efforts of aviators in combat. They also suggest that mandated crew rest and evaluation of total reported sleep time may not be sufficient to ensure optimum performance levels.

The management of post traumatic stress disorder (PTSD) in the primary care setting

Recent geopolitical events, including the terrorist attacks on the United States on September 11, 2001, and ongoing military operations in Iraq, have raised awareness of the often severe psychological after-effects of these and other types of traumatic events. Post traumatic stress disorder (PTSD) represents the most severe of these sequelae. PTSD is an under-recognized and under-treated chronic anxiety disorder associated with significant psychosocial morbidity, substance abuse, and a number of other negative health outcomes. Fortunately, the biologic underpinnings of this complex disorder and new advances in treatment are being realized. Early detection by primary care providers and rapid initiation of treatment are the keys to successful management of the disorder.

Postdeployment health reassessment : A sustainable method for brigade combat teams

OBJECTIVE The Postdeployment Health Reassessment (PDHRA) was mandated in 2006 and the 3rd Infantry Division was the first unit to perform a large-scale implementation. This article outlines a reproducible model for conducting PDHRA using only existing resources. METHODS The PDHRA (DD 2900) screening and referral processes are reviewed and data on positive screens are reported. RESULTS Of the 12,817 soldiers who participated in the mass screening, 1,460 (11.4%) were referred for behavioral health, 815 (6.4%) for primary care, 71 (0.01%) for specialty services, and 9 (0.001%) for emergency services. Consult requests were higher in maneuver brigades than in support units (12.1% versus 8.6% for behavioral health and 6.9% versus 4.4% for primary care referrals). All (1,460, 100%) of the behavioral health consults were completed on-site and the unit incurred no additional financial cost in conducting this process. CONCLUSIONS This method for performing a large-scale implementation of the PDHRA provides a flexible, efficient, and cost-effective process that could be implemented at the brigade combat team level without difficulty and in most locations without significant impact on other medical demands.