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Charles W. Hoge, MD; Jennifer L. Auchterlonie, MS; Charles S. Milliken, MD

JAMA. 2006;295:1023-1032.

Context  The US military has conducted population-level screening for mental health problems among all service members returning from deployment to Afghanistan, Iraq, and other locations. To date, no systematic analysis of this program has been conducted, and studies have not assessed the impact of these deployments on mental health care utilization after deployment.

Objectives  To determine the relationship between combat deployment and mental health care use during the first year after return and to assess the lessons learned from the postdeployment mental health screening effort, particularly the correlation between the screening results, actual use of mental health services, and attrition from military service.

Design, Setting, and Participants  Population-based descriptive study of all Army soldiers and Marines who completed the routine postdeployment health assessment between May 1, 2003, and April 30, 2004, on return from deployment to Operation Enduring Freedom in Afghanistan (n = 16 318), Operation Iraqi Freedom (n = 222 620), and other locations (n = 64 967). Health care utilization and occupational outcomes were measured for 1 year after deployment or until leaving the service if this occurred sooner.

Main Outcome Measures  Screening positive for posttraumatic stress disorder, major depression, or other mental health problems; referral for a mental health reason; use of mental health care services after returning from deployment; and attrition from military service.

Results  The prevalence of reporting a mental health problem was 19.1% among service members returning from Iraq compared with 11.3% after returning from Afghanistan and 8.5% after returning from other locations (P<.001). Mental health problems reported on the postdeployment assessment were significantly associated with combat experiences, mental health care referral and utilization, and attrition from military service. Thirty-five percent of Iraq war veterans accessed mental health services in the year after returning home; 12% per year were diagnosed with a mental health problem. More than 50% of those referred for a mental health reason were documented to receive follow-up care although less than 10% of all service members who received mental health treatment were referred through the screening program.

Conclusions  Combat duty in Iraq was associated with high utilization of mental health services and attrition from military service after deployment. The deployment mental health screening program provided another indicator of the mental health impact of deployment on a population level but had limited utility in predicting the level of mental health services that were needed after deployment. The high rate of using mental health services among Operation Iraqi Freedom veterans after deployment highlights challenges in ensuring that there are adequate resources to meet the mental health needs of returning veterans.

Author Affiliations: Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research (Drs Hoge and Milliken) and Army Medical Surveillance Activity, US Army Center for Health Promotion and Preventive Medicine (Ms Auchterlonie), Washington, DC.

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