Publication year
2004
Citation Title
Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.
Journal Name
The New England Journal of Medicine
Journal Volume
351
Issue Number
1
Page Numbers
13-22
DOI
10.1056/NEJMoa040603
Summary
U.S. combat infantry units who deployed to OIF/OEF (3 Army, 1 Marine Corps) completed an anonymous survey to assess the mental health of Service members and to determine use and barriers to accessing mental health services. Service members who deployed to Iraq had higher rates of major depression, generalized anxiety, and posttraumatic stress disorder (PTSD) than those who deployed to Afghanistan. Service members who deployed to Iraq reported high levels of combat experiences (e.g., being shot at or attacked, seeing dead bodies).
Key Findings
The percentage of Service members who met screening criteria for major depression, generalized anxiety or PTSD was significantly higher after duty in Iraq (16-17%) than after duty in Afghanistan (11%). The largest difference between the groups was in the rate of PTSD.
Service members deployed to Iraq reported a very high level of combat experiences, with 94% reporting being shot at, 91% being attacked or ambushed, 93% seeing dead bodies, and 53% handling or uncovering human remains; Soldiers in Afghanistan reported lower, but still substantial rates of such experiences.
After deployment, rates of major depression, PTSD, and alcohol misuse were significantly higher compared to before deployment (e.g., 9% for a broad definition of PTSD before deployment, 15% after).
There was a direct relationship between PTSD prevalence and the number of firefights for both Iraq and Afghanistan deployments (the greater the number of firefights the Service members were exposed to, the higher rates of PTSD).
Implications for Program Leaders
Provide education for families and Service members about the signs and symptoms of mental health problems
Enhance education to decrease stigma surrounding seeking mental health services via providing information on websites and other public areas that emphasize the potential usefulness of treatment and the courage it takes to ask for help
Provide resources and appropriate referrals available for families that may benefit from mental health services
Implications for Policy Makers
Encourage programs that monitor Service members exposed to high levels of combat and assess these personnel more frequently for mental health concerns
Encourage the development and continuation of programs that can promote resilience in Service members, their partners, and children
Recommend integrating mental health education into existing service delivery systems for military families
Methods
Three U.S. Army infantry units completed baseline surveys in January 2003 (one week before a year-long deployment to OIF)
Two Army infantry brigades (one after a six month OEF deployment and the other after an eight month OIF deployment) and two Marine battalions (after a six month OIF deployment) were surveyed three to four months after their return from deployment.
Participants completed measures of PTSD, depression, generalized anxiety, current distress, and use of professional mental health services. Demographic information was also gathered.
Participants
Data were contributed by 2,530 Soldiers pre-deployment to Iraq, 2,856 Soldiers post-deployment, and 815 Marines contributed data post-deployment.
Before deployment Army characteristics (N = 2,530) were as follows: 66% were ages 18-24, 99% were male, 70% were White, 78% had a high school education or less, 63% were E1-E4, and 50% were single.
After Afghanistan deployment Army characteristics (N = 1,962) were as follows: 63% were ages 18-24, 99% were male, 69% were White, 78% had a high school education or less, 63% were E1-E4, and 52% were single.
After Iraq deployment Army characteristics (N = 894) were as follows: 59% were ages 18-24, 98% were male, 60% were White, 82% had a high school education or less, 69% were E1-E4, and 46% were single.
Limitations
This cross-sectional design does not allow implications of causality to be drawn.
Different participants took part in pre- and post-deployment measures; therefore, equivalence of the groups cannot be assumed.
There is a potential selection bias, as some Soldiers and Marines did not participate because they were working elsewhere.
Avenues for Future Research
Utilize a longitudinal design that uses the same participants during both pre- and post-deployment
Explore effective mental health care stigma reduction in military settings to help increase mental health service utilization by those most in need
Gather data from Service members' families to better understand their healthcare utilization
Focus
Multiple Branches
Target Population
Population Focus
Military Component
Abstract
BACKGROUND: The current combat operations in Iraq and Afghanistan have involved U.S. military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans. METHODS: We studied members of four U.S. combat infantry units (three Army units and one Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or three to four months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and post-traumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments. RESULTS: Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care. CONCLUSIONS: This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care.
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