Combat Duty in Iraq and Afghanistan and Mental Health Problems
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Hoge et al. (July 1 issue)1 assessed mental health problems in members of the U.S. Army and Marine Corps who were involved in combat operations in Iraq and Afghanistan. Additional analyses might further elucidate their interesting findings.
First, a large proportion of the participants were positive for more than one disorder on screening. It is important to learn about the frequency of multiple disorders2 and whether deployment and combat experiences were independently associated with depression and anxiety.3 Also, roughly one quarter of the deployed personnel reported alcohol misuse, which has been shown to be associated with combat-related post-traumatic stress disorder in previous research.4 Untreated affected combatants might use alcohol as self-medication for psychological symptoms.5 It would be instructive to know whether such a relationship between lack of treatment and alcohol abuse exists in the present study.
Second, the authors compared perceived barriers to mental health care between respondents who met screening criteria for a mental disorder and those who did not. A more informative approach, in terms of public health implications, might be to compare perceived barriers to care between service members with mental health problems who received care and those who did not.
Raz Gross, M.D., M.P.H.
Yuval Neria, Ph.D.
Columbia University
New York, NY 10032
rg547@columbia.edu
References
Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.
Forbes D, Creamer M, Hawthorne G, Allen N, McHugh T. Comorbidity as a predictor of symptom change after treatment in combat-related posttraumatic stress disorder. J Nerv Ment Dis 2003;191:93-99.
Neria Y, Bromet EJ. Comorbidity of PTSD and depression: linked or separate incidence. Biol Psychiatry 2000;48:878-880.
Neria Y, Koenen KC. Do combat stress reaction and posttraumatic stress disorder relate to physical health and adverse health practices? An 18-year follow-up of Israeli war veterans. Anxiety Stress Coping 2003;16:227-39.
Bremner JD, Southwick SM, Darnell A, Charney DS. Chronic PTSD in Vietnam combat veterans: course of illness and substance abuse. Am J Psychiatry 1996;153:369-375.
To the Editor: Hoge et al. identified substantial barriers to treatment of psychological distress in combat personnel returning from Iraq and Afghanistan. The authors recommended providing mental health services within the primary care setting to overcome the perceived barriers of mistrust, poor access, and stigma. In 1996, to encourage use of such services by our veterans, mental health providers were situated in one primary care clinic. By doing so, mental health providers assessed four times as many patients as did a similar primary care clinic following the usual referral procedures. In our current study, we are examining the two-year outcome of treating psychological symptoms with this model in a sample of 48 referred patients (unpublished data). Of these, 40 (83 percent) have indicated that the availability of a mental health professional in primary care is helpful; 15 patients (31 percent) have specifically cited the lack of stigma or the easier access as benefits. Among the participants who were interviewed, there were 19 (40 percent) who refused treatment or dropped out.
Veterans are more likely to use mental health services in primary care settings. Such programs for returning combat veterans have the potential to meet an important need.
Anna G. Engel, M.D.
Cheryl A. Aquilino, Ph.D.
Stratton Veterans Affairs Medical Center
Albany, NY 12208
anna.engel@med.va.gov
The authors reply: Drs. Gross and Neria point out areas for further analysis as we continue to evaluate the mental health impact of current combat operations, including risk factors, multiple psychiatric disorders, and barriers to care. We are grateful to Drs. Engel and Aquilino for providing data that support an important strategy to reduce barriers to care. Mental health services are typically delivered in hospital- or office-based specialty clinics. On the basis of our experience with members of the Army and Marine Corps, we believe that the delivery of mental health services in primary care clinics would establish these services as routine, facilitate screening for mental health problems, and improve awareness and treatment of these problems by primary care professionals.
Primary care has been referred to as the de facto mental health service system.1 In the military, mental disorders are the sixth leading illness category (as defined by the International Classification of Diseases, Ninth Revision) for ambulatory treatment, are nearly as common as respiratory conditions, and frequently occur along with other medical conditions.2,3 However, specialty treatment for mental health problems is associated with unique barriers to care, particularly stigma. It is plausible that mental health specialty clinics contribute to stigmatization through separate clinics, entrances, and medical records, particularly in a military environment where soldiers often live and work together and may not have privacy when they use a clinic on post.
The military offers unique opportunities to study new models of service delivery. These include having one location to go to for "sick call" (the term that soldiers use for an urgent or walk-in primary care visit) that offers care for both medical and mental health problems; providing mental health services on a walk-in basis (no appointment necessary); establishing procedures to document care for mental health problems in the regular medical record; and ensuring confidentiality, starting with not having to state the reason for a primary care visit until the patient is face to face with the health professional. We hope that our study will energize further research and testing of new models for mental health services.
Charles W. Hoge, M.D.
Stephen C. Messer, Ph.D.
Carl A. Castro, Ph.D.
Walter Reed Army Institute of Research
Silver Spring, MD 20410
charles.hoge@na.amedd.army.mil
References
Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto U.S. mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry 1993;50:85-94.
Army Medical Surveillance Activity, Department of Defense. Ambulatory visits among active component members, U.S. Army Forces, 2003. Med Surveill Monthly Rep 2004;10:9-14. (Also available at http://amsa.army.mil.)
Hoge CW, Lesikar SE, Guevara R, et al. Mental disorders among U.S. military personnel in the 1990s: association with high levels of health care utilization and early military attrition. Am J Psychiatry 2002;159:1576-1583.
First, a large proportion of the participants were positive for more than one disorder on screening. It is important to learn about the frequency of multiple disorders2 and whether deployment and combat experiences were independently associated with depression and anxiety.3 Also, roughly one quarter of the deployed personnel reported alcohol misuse, which has been shown to be associated with combat-related post-traumatic stress disorder in previous research.4 Untreated affected combatants might use alcohol as self-medication for psychological symptoms.5 It would be instructive to know whether such a relationship between lack of treatment and alcohol abuse exists in the present study.
Second, the authors compared perceived barriers to mental health care between respondents who met screening criteria for a mental disorder and those who did not. A more informative approach, in terms of public health implications, might be to compare perceived barriers to care between service members with mental health problems who received care and those who did not.
Raz Gross, M.D., M.P.H.
Yuval Neria, Ph.D.
Columbia University
New York, NY 10032
rg547@columbia.edu
References
Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.
Forbes D, Creamer M, Hawthorne G, Allen N, McHugh T. Comorbidity as a predictor of symptom change after treatment in combat-related posttraumatic stress disorder. J Nerv Ment Dis 2003;191:93-99.
Neria Y, Bromet EJ. Comorbidity of PTSD and depression: linked or separate incidence. Biol Psychiatry 2000;48:878-880.
Neria Y, Koenen KC. Do combat stress reaction and posttraumatic stress disorder relate to physical health and adverse health practices? An 18-year follow-up of Israeli war veterans. Anxiety Stress Coping 2003;16:227-39.
Bremner JD, Southwick SM, Darnell A, Charney DS. Chronic PTSD in Vietnam combat veterans: course of illness and substance abuse. Am J Psychiatry 1996;153:369-375.
To the Editor: Hoge et al. identified substantial barriers to treatment of psychological distress in combat personnel returning from Iraq and Afghanistan. The authors recommended providing mental health services within the primary care setting to overcome the perceived barriers of mistrust, poor access, and stigma. In 1996, to encourage use of such services by our veterans, mental health providers were situated in one primary care clinic. By doing so, mental health providers assessed four times as many patients as did a similar primary care clinic following the usual referral procedures. In our current study, we are examining the two-year outcome of treating psychological symptoms with this model in a sample of 48 referred patients (unpublished data). Of these, 40 (83 percent) have indicated that the availability of a mental health professional in primary care is helpful; 15 patients (31 percent) have specifically cited the lack of stigma or the easier access as benefits. Among the participants who were interviewed, there were 19 (40 percent) who refused treatment or dropped out.
Veterans are more likely to use mental health services in primary care settings. Such programs for returning combat veterans have the potential to meet an important need.
Anna G. Engel, M.D.
Cheryl A. Aquilino, Ph.D.
Stratton Veterans Affairs Medical Center
Albany, NY 12208
anna.engel@med.va.gov
The authors reply: Drs. Gross and Neria point out areas for further analysis as we continue to evaluate the mental health impact of current combat operations, including risk factors, multiple psychiatric disorders, and barriers to care. We are grateful to Drs. Engel and Aquilino for providing data that support an important strategy to reduce barriers to care. Mental health services are typically delivered in hospital- or office-based specialty clinics. On the basis of our experience with members of the Army and Marine Corps, we believe that the delivery of mental health services in primary care clinics would establish these services as routine, facilitate screening for mental health problems, and improve awareness and treatment of these problems by primary care professionals.
Primary care has been referred to as the de facto mental health service system.1 In the military, mental disorders are the sixth leading illness category (as defined by the International Classification of Diseases, Ninth Revision) for ambulatory treatment, are nearly as common as respiratory conditions, and frequently occur along with other medical conditions.2,3 However, specialty treatment for mental health problems is associated with unique barriers to care, particularly stigma. It is plausible that mental health specialty clinics contribute to stigmatization through separate clinics, entrances, and medical records, particularly in a military environment where soldiers often live and work together and may not have privacy when they use a clinic on post.
The military offers unique opportunities to study new models of service delivery. These include having one location to go to for "sick call" (the term that soldiers use for an urgent or walk-in primary care visit) that offers care for both medical and mental health problems; providing mental health services on a walk-in basis (no appointment necessary); establishing procedures to document care for mental health problems in the regular medical record; and ensuring confidentiality, starting with not having to state the reason for a primary care visit until the patient is face to face with the health professional. We hope that our study will energize further research and testing of new models for mental health services.
Charles W. Hoge, M.D.
Stephen C. Messer, Ph.D.
Carl A. Castro, Ph.D.
Walter Reed Army Institute of Research
Silver Spring, MD 20410
charles.hoge@na.amedd.army.mil
References
Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto U.S. mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry 1993;50:85-94.
Army Medical Surveillance Activity, Department of Defense. Ambulatory visits among active component members, U.S. Army Forces, 2003. Med Surveill Monthly Rep 2004;10:9-14. (Also available at http://amsa.army.mil.)
Hoge CW, Lesikar SE, Guevara R, et al. Mental disorders among U.S. military personnel in the 1990s: association with high levels of health care utilization and early military attrition. Am J Psychiatry 2002;159:1576-1583.