CREW v. U.S. Department of the Army: Regarding PTSD Diagnoses: 5/24/2011 - Release Part 1

8/6/2019 CREW v. U.S. Department of the Army: Regarding PTSD Diagnoses: 5/24/2011 - Release Part 1

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MCCG

REPLYTOATTENTION OF

DEPARTMENT OFTHEARMYHEADQUARTERS, UNITED STATES ARMY MEDICAL COMMAND2050 WORTH ROAD

FORT SAM HOUSTON, TX 78234-6000

OTSG/MEDCOM Policy Memo 08-0181 9 MAY 2008Expires 19 MAY 2010

MEMORANDUM FOR Commanders, MEDCOM Regional Medical CommandsSUBJECT: Screening fo r Post-Traumatic Stress Disorder (PTSD) and mild Traumatic BrainInjury (mTBI) Prior to Administrative Separations

1. References.a. Army Regulation (AR) 635-200, Active Duty Enlisted Administrative Separations,6 June 2005.b. Army Medical Action Plan, Phase III task, "Consider mTBI and PTSD Separations",

July 2007.c. Sigford, B., M.D., Veterans Affairs, National Director, Physical Medicine andRehabil itation, December 2007. Screening and Evaluation of Possible TBI in OEF/OIFVeterans, Brief.d. Post Traumatic Stress Disorder Checklist (PCl) for DSM-IV, 1 November 1994.Weathers, Litz, Huska, & Keane, National Center for PTSD - Behavioral Science Division.

2. Purpose. To outline procedures for PTSD and mTBI screening of Soldiers consideredfor administrative separations, including but not l imited to Chapter 9, Alcohol or other DrugAbuse Rehabilitation Failure; Chapter 13, Unsatisfactory Performance; Chapter 513,Personality Disorder; Chapter 5-17, Other Mental Health Condition; and Chapter 14-12,Patterns of Misconduct, reference 1.a.3. Proponent. The proponent for this policy is HQ, MEDCOM, Off ice of the AssistantChief of Staff for Health Policy and Services, AnN: MCHO-Cl-H.4. Responsibilities.

a. The Surgeon General has overall responsibil ity for policy guidance in definingand implementing the Army Medical Department's behavioral healthcare screeningrequirements.b. The Directorate of Health Policy and Services, through the Proponency Chiefs of theOffices for Behavioral Health and Rehabilitation and Integration are responsible for thedistribution of behavioral health evaluation and mTBI requirements and reviewing, revlsinq,updating, and deleting existing policies conflicting with these requirements.


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MCCGSUBJECT: Screening fo r Post-Traumatic Stress Disorder (PTSD) and mild Traumatic BrainInjury (mTSI) Prior to Adm inistrative Separations

c. Medical Treatment Facil ity (MTF) Commanders will ensure that all So ldiers arescreened for PTSD and mTSI during rout ine mental health evaluations for administrativeseparations related to the Chapters identified in paragraph 2., above.5. Discussion.

a. There has been concern that Soldiers with undiagnosed or untreated PTSD or mTSIare being administratively discharged from the Army. Therefore. it is paramount that theArmy adequately assesses every one of these Soldiers for PTSD or mTBI.

b. This guidance refers to Soldiers who receive mental health evaluations from behavioralhealth dinicians for administrative separations.6. Policy.

a. Behavioral Health Departments within each MTF will ensure that Soldiers receivingmental health evaluations related to the Chapters identified in paragraph 2., above areconducted by a behavioral health clinician lAW AR 635-200. Evidence of documentation of ascreen for both PTSD and mTBI must be part of DA Form 3822-R, Report of Mental StalusEvaluation and documented in the progress note located in the Soldiers' Armed ForcesHealth longitudinal Technology Application (AHlTA) record .

b. There are screening tools (enclosures 1 and 2) for both PTSD and mTSI that canassist the clinician during the assessment. These tools are also located athttos:J/wINw.us.army.mil/suite/pageI222. The consensus of the subject matter experts isthat the VA screening questions and the pe l found at the website above are the best toolsfor screening in this population . It should be noted that the mTBI screening tools are notdiagnostic. Any positive mTBI screen will require a further evaluation to establish thecorrect diagnosis with referral and other testing if necessary. Other assessment tools maybe added at the discret ion of the clinician.7. Poin t of contact i ) f i6) - - - "'- '''"--- - - - - - - - - - - - - - - - - - - - - --- ,

2 Ends1. PCl2. VHA TBI Clinical Reminderand Screening Tool

ERIC B. SCHOOMAKERlieutenant GeneralCommanding

2


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N S N 7 ~ ' 7 8HEALTHRECORD I CHRONOLOGICAL RECORD OF MEDICAL CARESYMPTOMS DIAGNOSIS TREATMENT, TREATING ORGANIZA-nON (Sian seen entry)

Dale: PTSD CheckJist - Military Version (PCL-M)Instructions: Belowis a list ofproblems andcomplaints thatveterans sometimeshavein responseto stressful military experiences. Pleaseread eachonecarefully, put an "X" in the box to indicatehowmilchyouhavebeenbothered by thatproblem in the last month.:-.Jo. Response: Not at A llttle Moderately Quitea Extremelvall(\) bit (2 ) (3) bit (4) (S ) I. Repeated, disturbingmemories. thoughts;Dr images \f a stressfulrnilitarvcxoerience?2. Repeated, disturbingdreams of a stressfulmilitary :experience? ,3. Suddenly actingorfeelingas if a stressfulmilitary ,Iexperiencewere happening again(as if youwere Ieliving it)?4. Feeling veryupsetwhensomething remindedyou ofa stressfulmilitaryexperience?5. HaviElgphysical reactions (e.g.heart pounding,trouble breathing,or sweating)whensometlling Iemilldedyou of a stressfulmilitarY exoerience?6. Avoid thmkingaboutor talking abouta stressful I Iilitary experienceor avoid IJavingfeelmgs relatedto it?7. Avoid aaivitles or situatiolU because they remind Iyou of a stressfulmilitarY exDcricnce?8. Trouble remembering important partsofa stressfulmilitarYexperlence?9. Loss of interestin /hinD /Iwz you uscdtocnlov?10. Feeling distantor cut oJffromotheroeoDlc?11. Feeling emotionally numbor beingunableto have 1 IIovinz (celinas forthosecloseto you?12. Feelinlt as ifyourfulIIrewill somehowbeClIt short? ! --!13. Trouble laflin/!or stay/nl!as/up? I14. i Feeling lrrltabl


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VHA TBI Clinical Reminder and Screening ToolSection 1: During any of your OIF/OEF deployment(s) did you experience any of thefollowing events?(Check all that apply)

D Blast or ExplosionD Vehicular accident/crash (any vehicle, including aircraft)D Fragment wound or bullet wound above the shoulderso FallSection 2: Did you have any of these IMMEDIATELY afterwards?(Check all that apply)o Losing consciousness/"knocked out"o Being dazed, confused or "seeing stars"D Not remembering the evento ConcussionD Head injurySection 3: Did any of tile following problems begin or get worse afterwards?(Check all that apply)D Memory problems or lapsesD Balance problems or Dizzinesso Sensitivity to bright lightD IrritabilityD HeadacheD Sleep problemsSection 4: In the past week, have you had any of the symptoms [rom Section 3?(Check all that apply)

D Memory problems or lapseso Balance problems or dizzinesso Sensitivity to bright lightD IrritabilityD Headacheso Sleep problems


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The Association Between Numberof Deployments to Iraq and Mental HealthScreening Outcomes in U.S. Army Soldiers

IIb161

Ib)(61

Funding Source : This study was unfunded

*Corresoondence: _COLllbl161C h i e e a r t m f - Ib)(6) -- --

1


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1 Abstract2 Context: High rates ofmental health concerns have been documented in Army Soldiers3 deployed in support ofOperation Iraqi Freedom (Olf'). To our knowledge, there are no peer-4 reviewed studies that have examined the impact ofmultiple Olf deployments on mental health5 functioning.6 Objective: To compare the post-deployment mental health screening results of Soldiers with one7 or two deployments to Iraq.8 Design & Setting: Cross sectional study of routine mental health screening data collected in the9 Soldier Wellness Assessment Program at Fort Lewis, Washington.10 Participants: A total of 3548 Regular U.S. Army Soldiers (2,877 returning from their first11 deployment to Iraq, and 671 Soldiers evaluated after their second deployment to Iraq).12 Main OutcomeMeasure(s): Standardizedmeasures screened for Major Depression, Other13 Depression, Post-traumatic stress disorder (PTSD), Panic, Other Anxiety, and hazardous alcohol14 consumption 90 to 180 days after returning from Iraq.15 Results: There was a significant association between number of deployments and mental health16 screening results such that Soldiers with two deployments showed greater odds of screening17 positive for Other Depressive Syndrome [Odds Ratio (OR)=1.46, p=.045] and Other Anxiety18 Syndrome (OR=1.32, p=.047). After adjusting for demographic factors and combat exposure on19 most recent deployment, Soldiers with two Iraq deployments showed significantly greater odds20 of screening positive for Major Depression (OR=1.70, p=.02), Other Depressive Syndrome21 (OR=1.73, p=.007), PTSD (OR=1.90, p


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31 Conclusions: These results provide preliminary evidence that multiple deployments to Iraq may2 be a risk factor for mental health concerns.3


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1 INTRODUCTION2 High rates ofmental health concerns have been documented in Army Soldiers deployed3 in support ofOperation Iraqi Freedom (OIF). In an early study by Hoge and colleagues,14 Soldiers assessed three to four months after a deployment to Iraq screened positive for post-S traumatic stress disorder (PTSD) in 13% of cases; depression and generalized anxiety were each6 observed in about 8% of cases, and alcohol misuse was observed in over 20% of cases. With the7 exception of generalized anxiety, these rates were significantly higher than pre-deployment8 screening rates observed in a comparable U.S. Army unit. In a separate study, routine post-9 deployment screening data collected within two weeks ofretuming from Iraq revealed that10 Soldiers and Marines screened positive for a mental health problem in 19% of cases, compared11 to 8.5% returning from non-OIF/Operation Enduring Freedom (OEF) operational locations.'12 Similar results have been reported in veteran populations. Examining over 103,00013 OIF/OEF veterans, Seal and colleagues' reported that 25% ofa clinical Veteran Affairs (VA)14 sample had been diagnosed with a mental health disorder, including 13% with PTSD. The rate15 ofPTSD diagnoses in a similar VA sample was reportedly 3.7 times higher among Soldiers or16 Marines who served in ground units in Iraq or Afghanistan compared to Navy or Air Force17 veterans ofOIF/OEF.418 The importance of these results is underscored by the association between anxiety or19 mood disorders, and functional impairments. The National Survey ofthe Vietnam Generation20 revealed that veterans with lifet ime diagnoses ofPTSD and major depression showed21 significantly lower employment rates and hourly wages compared to veterans without these22 disorders.' PTSD has been associated with increasedmarital distress and parental adjustment23 problems.v" In addition, OIF/OEF veterans with PTSD or hazardous alcohol consumption


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51 reported a lower quality of life," Furthermore, Soldiers studied one year after deployment to OlP2 showed strong associations between PTSD and physical health problems." These impairments in3 job performance, intimate and family relationships, quality oflife, and physical health suggests4 that OlP veterans with mental disorders may face significant functional challenges.5 There is currently speculation as to whether multiple deployments to Iraq may exacerbate6 the frequency and severity ofmental health problems described above. Multiple deployments7 may increase the cumulative stress an individual experiences, and it increases the probability that8 Soldiers will be exposed to combat. Deployment stressors can include a sense of isolation,9 relationship stress, homefront problems, challenges associated with adjusting to a new

10 environment, a threatened sense of safety, traumatic stress, long work hours, and stressors11 associated with a variety ofother operational demands. Concomitant reductions in usual coping12 resources may also impact mental health functioning. In contrast, potential protective factors13 such as unit cohesion, effective leadership, mentoring, training, and access to other resources in14 theater maymediate the impact of deployment stress.15 To our knowledge, there are no peer-reviewed studies that have examined the impact of16 multiple OlP deployments on mental health functioning. Army reports from the Office ofthe17 SurgeonMultinational Force-Iraq and the Office ofthe Surgeon General, U.S. Army Medical18 Command have reported mixed results. 10, II There is evidence that exposure to multiple traumas19 may increase the risk for mental health problems. For example, a Swedish study of 182420 randomly selected individuals from the general population revealed that trauma frequency was21 significantly associated with an increased risk ofPTSD.12 Similar results have been noted in22 patients hospitalized at trauma centers. 13 In addition, among Service Members who worked in a


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1 mortuary during the Persian GulfWar, greater changes in PTSD symptoms were observed in2 groups with the greatest exposure to human remains."3 The purpose ofthis study was to determine ifthere is a relationship between multiple4 deployments and mental health problems as identified bymental health screening outcomes for5 Soldiers with one or two deployments to Iraq.6 METHODS7 Study Population8 Data were retrospectively analyzed from the Soldier Wellness Assessment Pilot Program9 (SWAPP) database at Fort Lewis. The SWAPP is an extension ofthe standard Post-Deployment

10 Health Reasssessment (PDHRA) program mandated by the Assistant Secretary of Defense for11 Health Affairs since 2005. The PDHRA provides a global health assessment, including mental12 health screening, for all Service Members 90 to 180 days after returning from an operational13 deployment. In the standard Army process, Soldiers complete the three page PDHRA form14 electronically, and a qualified healthcare professional (nurse practitioner, physician assistant, or15 physician) reviews the information, conducts a briefinterview, and recommends further16 evaluation or referrals as indicated.P17 During the SWAPP process, Soldiers first complete on a computer an expanded set of18 screeningmeasures that includes the standard PDHRA and additional items for demographics19 and military information, psychosocial history, mental health screening (see Measures section20 below), deployment exposures and stressors, and resiliency factors. Soldiers are seen by medical21 personnel for injury prevention, smoking cessation, or other reported physical concerns as22 needed, and a credentialed behavioral health provider meets individuallywith each Soldier. A


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1 nurse practitioner reviews all aspects of the Soldier's SWAPP encounters, and administrative2 support staffmeet with each Soldier to schedule follow-up appointments.3 The SWAPP's post-deployment screening data from September 7, 2005 to April 27,20074 were analyzed. All Service Members in the database were Regular, active duty Soldiers. Cases5 were included in the analysis when they met two criteria: (1) Iraqwas reported as the6 deployment's operational location; (2) the total historical number ofdeployments reported in7 support ofOperation Iraqi Freedom was one or two. Therewere not enough Soldiers with three8 deployments in the database to expand the analysis to include this group. Cases were included

9 when they were screened within at least 60-days of the target PDHRA timeframe. Soldierswith10 reported histories of deployment in support ofOperation Enduring Freedom were excluded from11 the analysis. The final sample included 2,877 Soldiers returning from their first deployment to12 Iraq, and 671 Soldiers evaluated after their second deployment to Iraq. Two subjects were13 observed in both groups. The study was approved by the Department ofClinical Investigations14 at Madigan Army Medical Center.15 Measures16 SWAPP mental health screening measures included the depression and anxiety modules17 from the Primary Care Evaluation ofMental Disorders Patient Health Questionnaire (PHQ)16-18,18 the Primary Care Posttraumatic StressDisorder Screen (PC-PTSD)19, and theAlcohol Use19 Disorder Detection Test (AUDIT).2o In addition, 4 combat exposure items were adapted from20 the Deployment Risk andResilience Inventory."21 PHQ. The PHQ is a self-report measure that can be entirely self-administered by22 patients.l" Standardized algorithms'" 22, 23 screen patients for threshold disorders that correspond23 to specificDSM-IV criteria, and subthreshold disorders that require fewer symptoms than a


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1 DSM-IV diagnosis. The Depression and Anxiety modules administered in the SWAPP provide2 screening results for threshold disorders, including Major Depression, Panic Disorder, and Other3 Anxiety Disorder; the subthreshold disorder ofOther Depressive Disorder is also screened. The4 PHQ is widely used and has established reliability and validity. 16, 17,24,255 PC-PTSD. The PC-PTSD is a brief, four-item (Yes-No) self-report screening instrument6 for PTSD that is a standard part ofthe PDHRA. The PC-PTSD demonstrated sound7 psychometric properties for cutoffscores of2 (sensitivity= .91, specificity= .72) and 38 (sensitivity = .78, specificity = .87) compared to diagnoses based on the ClinicianAdministered

9 Scale for PTSD (CAPS). 19 Since cutoff scores of either 2 or 3 may be appropriate, depending on10 the clinical setting, 19we analyzed results for both cut-points (PTSD-2, PTSD-3).11 AUDIT. The AUDIT is a 10-item self-report measure that screens for hazardous or12 harmful alcohol consumption.j" Item responses range from 0 (Never) to 4 (Daily or Almost13 Daily) with total scores ranging from 0 to 40. The standard cutoffscore of 8 for hazardous or14 harmful consumption has consistently demonstrated favorable sensitivity and specificity in15 numerous studies.26-29 The AUDIT is internally consistent." and has shown good test-retest16 reliability."17 Combat exposure. The SWAPP screening included four Yes-No questions about combat18 experienced during the most recent deployment, adapted from the DRRI. 21 Items asked the19 following: During combat operations did you (1) becomewounded or injured; (2) personally20 witness a unit member, ally, enemy, or civilian being killed; (3) see the bodies ofdead soldiers or21 civilians; (4) kill others in combat (or have reason to believe others were killed as result of your22 actions).23


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1 Statistical Analyses2 Chi-square tests of association and t-tests were used to compare demographic and combat3 exposure variables between groups with one or two Iraq deployments. Logistic regression was4 used to examine associations between the number of Iraq deployments and mental health5 screening outcomes (positive, negative). Multivariate logistic regression models were used to6 examine the associations irrespective of age, sex, race/ethnic background, rank, education,7 marital status, and combat exposure.8 RESULTS9 Subject Characteristics

10 Subject demographics are presented in Table 1. Soldiers with two Iraq deployments11 differed from those with one deployment in terms of age, rank, education, and marital status.12 There was no difference between the groups in racial/ethnic background or sex.13 There was no difference between Soldiers with one or two deployments in terms ofthe14 number of days between departure from theater and screening date (Mean SD = 105.51 15 37.62; 108.14 35.94, respectively). Soldiers were deployed for an average of 11.33 months16 (SD = 2.19) in the group with one deployment and 11.03 months (SD = 2.41) in the group with17 two deployments. For Soldiers with two deployments, the median arrival date in theater (Oct.18 31, 2005) was about a year later than the median arrival date for Soldiers with one deployment to19 Iraq (October 13, 2004). Subjects reported significantly lower frequencies of combat exposure20 during their second deployment compared to Soldiers who recently returned from their first Iraq21 deployment (Table 2).2223


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101 Mental Health Screening Results2 There was a significant associationbetween number ofdeployments andmental health3 screening results in the univariate analyses for OtherDepressive Syndrome (OR = 1.46,P =4 .045) and Other Anxiety Syndrome (OR = 1.32,P = .047; Table 3). After adjusting for5 demographic factors and combat exposure, Soldierswith two Iraq deployments showed6 significantly increased odds of screeningpositive forMajor Depression (OR= 1.70,P = .02),7 Other Depressive Syndrome (OR = 1.73,P = .007),PTSD-2 (OR= 1.64, P


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1 deployed to Iraq more than once were more likely to screen positive for depression, anxiety, or2 acute stress. However, different recruitment procedures, participant characteristics, and outcome3 measures limit comparability. In addition, it is important to note that the MHATReports are4 based on data collected from Soldiers during deployment,while our results were collected from5 Soldiers about 3 to 6 months after returning fromdeployment. Some research suggests that6 results obtained immediately following a deploymentmay differ substantially from assessments7 conducted several months later.328 After adjusting for demographic factors and combat exposure on the most recent

9 deployment, the odds of screening positive forMajor Depression, Other Depressive Syndrome,10 PTSD, Panic, and Other Anxiety Syndromewas 64 to 90% higher for Soldiers with two11 deployments. These findings suggest that the odds ofdeveloping a mental health problem are12 higher for Soldiers after a second deployment, irrespective ofthe combat they are exposed to13 during their second tour. The factors contributingto these findings are unknown. Information14 about combat exposure during first deployments (amongSoldierswith two deployments)was not15 available. Thus, the impact of additive combat exposuresacrossmultiple deployments remains16 unknown. In addition, the impact ofcumulative deployment stress, such as homefront stressors17 and difficulties associated with working in an operational theater may contribute to these18 findings. Additional research is needed to determine how the etiology ofmental health disorders19 following a second deployment may differ fromSoldiers deployed to Iraq only once.20 Interpretation ofour findingswould benefit frommore information on how Soldierswith21 one or two deploymentsmay differ. While wewere able to examine basic demographic features22 and recent combat exposure, we do not knowhow the group with two deployments adjusted after23 their first deployment compared to their entire cohort. Soldiers identified with a post-


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121 deployment mental health condition that renders them unfit for duty are not deployed again until2 treatment proves successful. In addition, ServiceMembers who screen positive for mental health3 concerns are more likely to leave military service in the year following a deployment?4 Therefore, it is possible that the group with two deployments represented a healthier, more5 resilient group. However, it is also possible that a number of Soldiers were successfully treated6 for mental health concerns before deploying a second time. The impact of prior treatment7 history on mental health functioning after a second deployment is unknown. A longitudinal8 study of the effects ofmultiple deployments on mental health would be helpful to clarify these9 Issues.10 Analyses of demographic features revealed group differences on a number ofvariables.11 These group effects were expected, as Soldiers with two deployments likely had longermilitary12 careers. Therefore, differences in age, rank, education, and marital status are intuitive. The13 difference between groups on combat exposure is less intuitive. Soldiers reported significantly14 lower levels of combat exposure during their second deployment compared to the group with15 only one deployment. This finding may be due, in part, to the fact that Soldiers' second16 deployment occurred, on average, about a year later in the history of the conflict when combat17 operations may have differed. It is also possible that Soldiers deployed to Iraq for a second time18 may differ from Soldiers on a first deployment in some way that makes them less likely to see19 combat. Possibilities include rank, Army selection criteria for a second deployment, duty20 assignments for Soldiers with prior theater experience, or differences in attrition from theArmy21 by occupational duty.22 Rates ofpositive screens for mental health disorders were generally lower than those23 reported by Hoge and colleagues.' For example, while Hoge et al. reported that 15% of their


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1 Army sample screened positive for major depression on the PHQ after deployment to Iraq, we2 observed a rate of 4% for our total sample using the same measure. However, significant3 differences between study methods may account for these differences. Hoge et al.'s study4 utilized an anonymous survey with a specific infantry division, three to four months after an 8-5 month deployment to Iraq in December 2003. Our results were obtained from non-anonymous,6 standard post-deployment screening efforts at Fort Lewis for Soldiers from a variety ofunits,7 three to six months after deployments (o fvarying lengths) to Iraq, from September 2005 to April8 2007. Many ofthese factors likely contributed to the differences in the results. For example,

9 since our sample included non-combat units, combat exposure may have been reduced in our10 sample compared to Hoge et al.'s study. In support of this hypothesis, 62% ofHoge et al.'s11 sample endorsed responsibili ty for the death ofothers (combatants and noncombatants)12 compared to 33% ofour total sample.13 In contrast, the rates we observed were higher than those reported in a recent study that14 examined population-based results ofArmy Soldiers and Marines screened within two weeks of15 returning from a deployment to Iraq.' Utilizing the 2-point cutoff score for the PC-PTSD, the16 investigators reported a PTSD-positive screen rate of9.8% in their Iraq sample; this compares to17 a rate of about 21% in our total sample using the same measure. Both studies included similar18 questions about whether the Service Members saw dead bodies; the rate in our samplewas19 higher with 67% positive, compared to 49.5% in the Hoge et al.2 study. Thus, some of the20 differences between the two studies could be due to higher levels of combat exposure in our local21 sample. Unfortunately, other combat exposure items were not appropriate for comparison.22 However, another important difference between the studies was the timing ofthe screening. The23 Hoge et a1.2 study was conducted within two weeks of returning from deployment, while our data


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141 was gathered about three to six months after deployment. As noted above, some data suggests2 that Service Members are much more likely to report mental health problems three to four3 months after deployment compared to shortly after returning.324 The results of the current research should be confirmed in future studies, as the cross-5 sectional design limits conclusions. In addition, all study subjects were drawn from one Army6 installation in Tacoma, WAwith a large active duty population, including several Stryker7 brigades. These Soldiers may differ from the broader Army in a number ofways, and the results8 may not generalize to the rest of the Army. Generalizability is further reduced by the fact that9 the current study included only Regular active duty Soldiers. Furthermore, it is important to10 emphasize that these results were obtainedwith self-administered screening instruments; these11 results do not reflect diagnostic rates. In addition, the time-frame of the study period may prove12 important for studying mental health outcomes ofmultiple deployments. As the theater matures13 and the mission requirements ofOperation Iraqi Freedom evolve, the nature of the stressors that14 Soldiers experience may change. Therefore, rates examined during one time frame of the15 Conflict may not generalize to other periods.16 The importance of understanding the mental health effects ofmultiple deployments is17 likely to grow as the number ofService Members with two or more deployments increases. The18 results of this study provide preliminary evidence that the risk ofmental health problems may19 increase following a second deployment to Iraq. As the number of Service Members deployed20 for second tours increases, these findingsmay have significant implications for the demand on21 mental health treatment resources.2223


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I Disclosures & Acknowledgements: All authors reportno competing interests. This was an2 unfunded study. The opinions or assertions contained herein are the private views of the authors3 and arenot tobe construed as official orreflecting theviews of the Department of the Ann y or4 the DepartmentofDefense. The authors thankj1b)(6) IPhD, ABPP,E 6) ---.J5 PhD,E 6) E 6) IMD,E 6) !MD, MPH, FACPM for their6 contributions.


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2. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use ofmental healthservices, and attrition from military service after returning from deployment to Iraq orAfghanistan. Jama. Mar 1 2006;295(9): 1023-1032.

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23. Spitzer RL, Williams lB , Kroenke K, Hornyak R, McMurray J. Validity and utility ofthePRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic


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patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. AmJ Obstet Gynecol. Sep 2000;183(3):759-769.

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26. Maisto SA, Carey MP, Carey KB, Gordon CM, Gleason JR. Use of the AUDIT and theDAST-10 to identify alcohol and drug use disorders among adults with a severe andpersistent mental illness. Psychol Assess. Jun 2000;12(2):186-192.

27. Bradley KA, Bush KR, McDonell MB, Malone T, Fihn SD. Screening for problemdrinking: comparison ofCAGE and AUDIT. Ambulatory Care Quality ImprovementProject (ACQUIP). Alcohol Use Disorders Identification Test. J Gen Intern Med. Jun1998;13(6):379-388.

28. Bush K, Kivlahan DR, McDonell MB, Fihn SD, BradleyKA. The AUDIT alcoholconsumption questions (AUDIT-C): an effective brief screening test for problemdrinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol UseDisorders Identification Test. Arch Intern Med. Sep 141998;158(16):1789-1795.

29. CherpiteI CJ. Comparison of screening instruments for alcohol problems between blackand white emergency room patients from two regions ofthe country. Alcohol Clin ExpRes. Nov 1997;21(8):1391-1397.


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30. Reinert DF, Allen JP. The Alcohol Use Disorders Identification Test (AUDIT): a reviewof recent research. Alcohol Clin Exp Res. Feb 2002;26(2):272-279.

31. Daeppen JB, Yersin B, Landry U, Pecoud A, Decrey H. Reliability and validity of theAlcohol Use Disorders Identification Test (AUDIT) imbedded within a general healthrisk screening questionnaire: results of a survey in 332 primary care patients. AlcoholClin Exp Res. May 2000;24(5):659-665.

32. Bliese P, Wright K, Adler A, Thomas J. Validation of the 90 to 120 day shortformpsychological screen (Research Report 2004-002). Heidelberg, Germany: US Army

Medical Research Unit Europe; 2004.


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Table 1. Demographics Characteristics by Number ofDeployments

Number of Deployments1 2n % n %(Mean) (SD) (Mean) (SD) P

Agea (27.42) (5.84) (29.08) (5.91)


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Table 2. Combat Exposure During First and Second OIPDeploymentsNumber ofDeployments1 2

n % n % pWounded 416 14.7 69 lOA .005or InjuredWitnessed 1441 50.8 183 27.7


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Table 3. Mental Health Screening Results by Number of Iraq Deployments

Number ofDeployments1 2

No. Pos'!n % No. Pos'!n % Crude OR (95% CI) AdjustedORa (95% CI)Major 114/2772 4.1 30/651 4.6 1.13 (.75, 1.70) 1.70* (1.09,2.65)DepressionOther 119/2772 4.3 40/651 6.1 1.46* (1.01, 2.11) 1.73* (1.17,2.57)DepressionPTSD-2 580/2803 20.7 137/653 21.0 1.02 (.83, 1.26) 1.64** (1.30,2.08)PTSD-3 322/2803 11.5 85/653 13.0 1.15 (.89, 1.49) 1.90** (1.43, 2.52)Panic 56/2817 2.0 17/660 2.6 1.30 (.75, 2.26) 1.85* (1.03, 3.33)Other 250/2823 8.9 75/660 11.4 1.32* (1.004, 1.73) 1.71** (1.27,2.30)AnxietyETOH 408/2808 14.5 85/657 12.9 .87 (.68, 1.12) 1.27 (.97, 1.68)* p


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MCHO-CL

DEPARTMEi\T OF THE A R ~ I YI I L \ O Q t : , \ R T E R S . I ~ I T [ D STATES ..R\I\' \IEDICAL CO\II\'It\ND2050 WORTII ROM}FORT SA\I 1 I 0 0 ' S T O ~ . TX 78234-6000

REPLYlt>. TIl::-iTIO:-i Of

OTSG/MEDCOM Policy Memo 09-012113 MAR 2009

Expires 13 March 2011MEMORANDUM FOR Commanders, MEDCOM Regional Medical CommandsSUBJECT: MEDCOM Procedures for Chapter 5, paragraph 5-13 and 5-17 PersonalityDisorder (PD) Separations

1. References.a, Department of Defense Instruction (0001) 1332,14, "Enlisted AdministrativeSeparations". Aug 08.b. Anny Regulation (AR) 635-200, Active Duty Enlisted Administrative Separations,6 Jun 05.c. OTSG/MEDCOM Policy 08-018, Screening for Post-Traumatic Stress Disorder(PTSD) and mild Traumatic Brain Injury (mTBI) Prior to Administrative Separations, 19 May08.d. MEDCOM memorandum MCCG, Review of Personality Disorder (Chapter 5,paragraph 5-13) Administrative Separations, 6 Aug 07.

2. Purpose. To outline new PD procedures under reference 1b., Chapter 5, paragraph 513 and 5-17.3. Proponent. The proponent for this policy is the Director, Behavioral Health Proponency.Office of The Surgeon General (OTSG), AnN: DASG-HSZ.4. Responsibilities.a. The Surgeon General has overall responsibility for policy guidance in defining

and implementing the Army Medical Department's behavioral healthcare screeningrequirements.b. The Directorate of Health Policy and Services, Proponency Office for BehavioralHealth. is responsible for the distribution of behavioral health policies and reviewing,revising, updating, and deleting existing policies conflicting with these requirements.


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MCHO-CLSUBJECT: MEDCOM Procedures for Chapter 5, paragraph 5-13 and 5-17 PersonalityDisorder (PO) Separations

c. Medical treatment facility (MTF) Commanders will ensure that all Soldiers who arereferred for PD separations follow the procedures outlined below.5. Discussion.

a. There has been concern that Soldiers with undiagnosed or untreated PTSD or mTBIare administratively discharged from the Army. MEDCOM has previously issued twopolicies addressing PO and screening for PTSD and mTBI (references 1c. and 1d.).b. Reference 1a. outlines updated requirements. These requirements are similar but notidentical to the policy changes that the Army issued. This policy memorandum consolidates

the different requirements.c. This guidance refers to Soldiers who receive mental health evaluations from behavioralhealth clinicians for Chapter 5, paragraph 5-13 and 5-17 PD administrative separations.

6. Policy.a. 00011332.14, enclosure 3. paragraph 3a(8), Enlisted Administrative Separations.prescribes the following requirements for separations on the basis of enlisted Soldiers whohave served or are currently serving in imminent danger pay areas:

(1) A Psychiatrist or PhD-level Psychologist must diagnose the PD.(2) A peer or higher-level mental health professional must corroborate the diagnosis.(3) The Army Surgeon General must endorse the diagnosis.(4) The diagnosis must address PTSD or other co-morbid mental illness, if present.

b. For Chapter 5. paragraph 5-13, PD evaluations:(1) In the case of Soldiers who have served or are currently serving in an imminentdanger pay area and are within the first 24 months of active duty service, the MTF Chief ofBehavioral Health (or an equivalent official) must first corroborate the diagnosis of POfor

separation under AR 635-200, Chapter 5, paragraph 5-13.(2) The corroborated diagnosis will be forwarded for final review and confirmation bythe Director, Proponency of Behavioral Health. OTSG (DASG-HSZ).(3) Medical review of the PD diagnosis will consider whether PTSD and/or mTBImay be significant contributing factors to the diagnosis.

2


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MCHO-CLSUBJECT: MEDCOM Procedures for Chapter 5, paragraph 5-13 and 5-17 Persona lityDisorder (PO) Separations

(4) A Soldier will not be processed fo r administrative separation underAR 635-200, Chapter 5. paragraph 5-13. jf PTSD, mTBI , or other co-morbid mental i llnessare significant contributing factors to a diagnosis of PD. but will be evaluated under thephysical disability system in accordance with AR 635-40.c. For Chapter 5. paragraph 5-17 PO evaluations:

(1) In the case of Soldiers who have served or are currently serving in an imminentdanger pay area and have 24 months or more of active duty service , the MTF Chief ofBehavioral Health (or an equivalent official) must corroborate the diagnosis of PO forseparation under AR 635-200. Chapter 5. paragraph 5-17 .

(2) The corroborated diagnosis will be forwarded for final review and confirmation bythe Director. Proponency of Behavioral Health.

(3) Medical review of the PO diagnosis will consider whether PTSD and/or mTS!. orother co-morbid menial illness diagnosismay be significant contributing factors to thediagnosis.

(4) A Soldier will no l be processed for administrative separation underAR 635-200.Chapter 5, paragraph 5-17 , if PTSD or mTSI are significant contributing factors to adiagnosis of PO, but will be evaluated under the physical disabil ity system in accordance withAR 635-40.7. Our point of contact iS I(b)(6) 'Director. Proponency of Behavioral Health.OTSG , The corroborated diagnosis. with all supporting medical documentation, will beforwarded for final review and endorsement to the OTSG (DASG-HSZ). 5109 leesburg Pike .Suite 693 . Falls Church. Virginia 22041-3258.FOR THE COMMANDER:

~ f o ~ E ~Chief of Staff

Documents

CREW v. U.S. Department of the Army: Regarding PTSD Diagnoses: 5/24/2011 - Release Part 1