To the Editor: Hoge et al. (July 1 issue)1 assessed mental healthproblems in members of the U.S. Army and Marine Corps who wereinvolved in combat operations in Iraq and Afghanistan. Additionalanalyses might further elucidate their interesting findings.
First, a large proportion of the participants were positivefor more than one disorder on screening. It is important tolearn about the frequency of multiple disorders2 and whetherdeployment and combat experiences were independently associatedwith depression and anxiety.3 Also, roughly one quarter of thedeployed personnel reported alcohol misuse, which has been shownto be associated with combat-related post-traumatic stress disorderin previous research.4 Untreated affected combatants might usealcohol as self-medication for psychological symptoms.5 It wouldbe instructive to know whether such a relationship between lackof treatment and alcohol abuse exists in the present study.
Second, the authors compared perceived barriers to mental healthcare between respondents who met screening criteria for a mentaldisorder and those who did not. A more informative approach,in terms of public health implications, might be to compareperceived barriers to care between service members with mentalhealth 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{at}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. [Free Full Text]
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. [CrossRef][Medline]
Neria Y, Bromet EJ. Comorbidity of PTSD and depression: linked or separate incidence. Biol Psychiatry 2000;48:878-880. [Medline]
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. [Free Full Text]
To the Editor: Hoge et al. identified substantial barriers totreatment of psychological distress in combat personnel returningfrom Iraq and Afghanistan. The authors recommended providingmental health services within the primary care setting to overcomethe 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 asmany patients as did a similar primary care clinic followingthe usual referral procedures. In our current study, we areexamining the two-year outcome of treating psychological symptomswith this model in a sample of 48 referred patients (unpublisheddata). Of these, 40 (83 percent) have indicated that the availabilityof a mental health professional in primary care is helpful;15 patients (31 percent) have specifically cited the lack ofstigma or the easier access as benefits. Among the participantswho were interviewed, there were 19 (40 percent) who refusedtreatment or dropped out.
Veterans are more likely to use mental health services in primarycare settings. Such programs for returning combat veterans havethe 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{at}med.va.gov
The authors reply: Drs. Gross and Neria point out areas forfurther analysis as we continue to evaluate the mental healthimpact of current combat operations, including risk factors,multiple psychiatric disorders, and barriers to care. We aregrateful to Drs. Engel and Aquilino for providing data thatsupport an important strategy to reduce barriers to care. Mentalhealth services are typically delivered in hospital- or office-basedspecialty clinics. On the basis of our experience with membersof the Army and Marine Corps, we believe that the delivery ofmental health services in primary care clinics would establishthese services as routine, facilitate screening for mental healthproblems, and improve awareness and treatment of these problemsby primary care professionals.
Primary care has been referred to as the de facto mental healthservice system.1 In the military, mental disorders are the sixthleading illness category (as defined by the International Classificationof Diseases, Ninth Revision) for ambulatory treatment, are nearlyas common as respiratory conditions, and frequently occur alongwith other medical conditions.2,3 However, specialty treatmentfor mental health problems is associated with unique barriersto care, particularly stigma. It is plausible that mental healthspecialty clinics contribute to stigmatization through separateclinics, entrances, and medical records, particularly in a militaryenvironment where soldiers often live and work together andmay not have privacy when they use a clinic on post.
The military offers unique opportunities to study new modelsof service delivery. These include having one location to goto for "sick call" (the term that soldiers use for an urgentor walk-in primary care visit) that offers care for both medicaland mental health problems; providing mental health serviceson a walk-in basis (no appointment necessary); establishingprocedures to document care for mental health problems in theregular medical record; and ensuring confidentiality, startingwith not having to state the reason for a primary care visituntil the patient is face to face with the health professional.We hope that our study will energize further research and testingof 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{at}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. [Abstract]
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. [Free Full Text]
Previous
