This is the first study to assess the sensitivity and other test characteristics of responses to PreDHA questions for identifying a recent mental health disorder diagnosis among deployed U.S. service members. This study found a prevalence of recent mental health disorder diagnosis of 4.2% among those with one or more PreDHA completed in the 90 days prior to deployment and available for analysis in DMSS. Although this study found that subjects with a recent mental health disorder diagnosis were significantly more likely to answer pertinent questions on the PreDHA in the affirmative, more than half of such subjects provided no indication of their diagnosis on their most recent PreDHA.
This study found that the sensitivity of the question "during the past year, have you sought counseling or care for your mental health?" in identifying a recent mental health disorder diagnosis was only 48.2%. Subjects with a recent mental health disorder diagnosis were over 41 times as likely to answer this question in the affirmative as those without, but this study also found that almost 50 subjects needed to be screened with PreDHA to identify one subject with a recent mental health disorder diagnosis who indicated such a response. Including affirmative responses to additional relevant questions, including those inquiring about current health concerns or problems did not appreciably increase the sensitivity of self-reported data. Furthermore, although subjects with a recent mental health disorder diagnosis were over twice as likely to endorse current medical or dental problems (OR = 2.88), or to have questions or concerns about their health as those without (OR = 2.28), only 23.4% of those with a mental health disorder diagnosis endorsed current medical or dental problems, and only 6.5% endorsed any current questions or concerns about their health.
These findings fit with those of other researchers, who have noted among deploying and redeploying U.S. service members perceptions of significant stigma associated with mental health conditions [9
], and a tendency among U.S. service members towards underreporting as well as a preference towards declining treatment. A major study of U.S. service members preparing for deployment to Iraq found among those who screened positive for major depression, generalized anxiety, or PTSD, 86% acknowledged a problem, but only 40% were interested in receiving help [9
]. Among a larger sample of service members screening positive, a majority indicated perceived barriers to receiving mental health care, including concerns that others in their unit would lose confidence in them, view them as being weak, or blame them for their mental health problems [9
]. The expression of these concerns might be expected to increase in the context of mass-screening programs such as PreDHA which are often conducted at unit-level.
Perhaps not surprisingly, therefore, this study found a very low rate of pertinent health care provider referrals. Less than one-third of 1% of all subjects with an available PreDHA (0.3%) received such a referral. Almost 860 subjects had to be screened with PreDHA to result in a single pertinent referral for a subject with a recent mental health disorder diagnosis. Of subjects receiving such a referral, approximately 6 in 10 (61.2%) had answered in the affirmative to one or more pertinent question on their most recent PreDHA, and those indicating a positive response to such questions were over nine times (OR = 9.34) as likely to be referred as those who did not. According to current guidance [7
], upon completion by the service member, responses to PreDHA are to be immediately reviewed by a "medic, nurse, medical technician or corpsman"
, and any positive responses to (among others) questions 7, 2 and 8 "requires referral to a trained health care provider (physician, physician assistant, nurse practitioner, advanced practice nurse, independent duty corpsman, independent duty medical technician, or Special Forces medical sergeant)"
]. Existing DoD guidance is not clear as to whether this referral requires appropriate additional annotation by the trained health care provider on the PreDHA, or merely requires the PreDHA to be reviewed and certified by such a provider.
Of note in this analysis, subjects who had a recent mental health disorder diagnosis but denied having such a history were not statistically more likely to be identified by the provider as "not deployable"
than those without such a history, which suggests that these subjects might have been able to successfully conceal or minimize a potentially disqualifying condition. Whether the 21 "not deployable"
subjects with a mental health disorder diagnosis were appropriately deployed in accordance with current DoD guidance and regulations is not clear by this study's methodology. Existing DoD instructions [7
] describe only the manner in which PreDHAs are to be completed, but do not provide guidance as to what patterns of subject-provided responses constitutes a disqualification for deployment; nor do they formalize a mechanism for ensuring that service members flagged by the provider as "not deployable"
, in fact, are not deployed. A recent policy memorandum drafted in response to Congressional concerns [26
]"provides guidance on deployment... for military personnel who experience psychiatric disorders"
and states that "diagnosed conditions that are not amenable or anticipated not amenable to treatment and restoration to full functioning within one year of treatment should generally be considered unfitting...."
The memorandum specifically states that "psychotic and bipolar disorders are considered disqualifying for deployment"
. This study found evidence of 5 subjects with diagnoses of psychoses and 14 subjects with diagnoses of bipolar and manic disorder. Whether these subjects were appropriately deployed is also not clear by this study's methodology.
This study has a number of important limitations that require the results to be interpreted in context. Most significantly, this study included only service members who were identified on official rosters as being deployed; not the larger cohort of service members who were administered PreDHA in anticipation of deployment. Limitations in data available within the DMSS precluded accurately identifying this cohort; future studies using alternate methodologies might assess the number of service members who may have been identified as "not deployable" and who did not subsequently deploy.
This study, as with previous research on deployment-related mental health issues [12
], relied upon medical surveillance data in the DMSS to identify the presence of pertinent mental health disorder diagnoses. The strengths and limitations of this data have been previously described [12
], although research has demonstrated good correlation between ICD-9CM coded mental health disorder diagnoses and evidence of psychoactive pharmacotherapy [28
], confirming the utility of surveillance databases in identifying functional psychiatric morbidity.
This study examined only records of ICD-9CM diagnostic codes corresponding to pertinent mental health disorders, and did not assess ICD-9CM "V-coded" visits for counseling not associated with a formal diagnosis [29
], nor visits to social workers, chaplains, and other counselors practicing outside of administrative systems whose data is captured by the DMSS. Including such data as evidence of a recent mental health disorder diagnosis might have improved the validity and test characteristics of the PreDHA. For example, making the assumption that all subjects without evidence of diagnosis who had answered question #7 in the affirmative, in fact, had received some form of counseling or care for a mental health disorder, independent of documented diagnosis, would have increased the sensitivity of the question, as written, to 65.6% and decreased the NNS to 24.5 (data not shown).
This study included ADHD in the definition of a mental health disorder diagnosis. Although a remote history of ADHD may not always be considered problematic, in U.S. military settings a recent active diagnosis of ADHD remains highly relevant. A recent study of health care operations in Iraq [30
] confirms that " [d]eployment of soldiers with chronic mental health disorders such as anxiety, attention deficit disorder, and depression is problematic
..." Furthermore, the previously mentioned policy memorandum [26
] states "[p]sychotropics clinically and operationally problematic during deployments include... stimulants
", which are commonly prescribed to treat ADHD. In the present analysis, of the 615 subjects with a recent mental health disorder diagnosis, 101 subjects (16.4%) were identified with a recent diagnosis of attention-deficit disorders, with or without hyperactivity. Of these, the vast majority (92%) received primary outpatient diagnosis, highly suggestive of active disorder. Furthermore, there is a high prevalence of treated attention-deficit disorder conditions among deployed personnel as suggested by a recent published study [20
], in which 78 of 11,725 deployed subjects (0.67%) had been prescribed a pharmacologic treatment for ADHD prior to deployment; highly comparable to the 101 of 15,195 (0.66%) diagnosed with an attention-deficit spectrum diagnosis in this present analysis.
As this analysis examined electronic medical records only for evidence of a recent diagnosis, remote histories not requiring continued treatment would not necessarily have been identified. Additionally, while ADHD is recognized professionally as a mental health diagnosis, service members who consider their condition as other than a "mental health issue or problem" may have responded in the negative to the question on the PreDHA despite recent diagnosis. Future analyses should be performed to address to what extent perception of this condition, and other conditions, could have influenced the results of this study.
This study examined only PreDHA data successfully integrated and available for analysis in the DMSS. Of the study cohort, a total of 4,016 subjects (26.4%) had no PreDHA available within the 90 days prior to deployment. Of the subjects without an available PreDHA, 150 (3.7%) had a mental health diagnosis. The methodology of this study was unable to determine whether a PreDHA was actually administered to these subjects. Although completion of the PreDHA is mandatory, no formal system exists to validate the correct transmission of PreDHA data from military service-specific sources to AFHSC, nor to provide timely confirmation to the service member, his or her commander, or his or her health care provider of successful integration of the service member's data into the DMSS prior to deployment.
Independent of these limitations, this study demonstrates that the subject-reported data collected during the PreDHA process is of questionable validity. Existing policy [26
] states that "it is the responsibility of the Service member to report past or current physical or mental health conditions or concerns and associated treatments"
. The results of this study provide strong evidence that relying on self-report alone may be insufficient policy for screening for disqualifying or significant mental health conditions. These results support the recent conclusions of the Department of Defense Task Force on Mental Health, a special body established at the direction of Congress to "examine matters relating to mental health and the Armed Forces"
. In the Task Force's final report, it was noted that its members "were told on multiple site visits that the validity of the Pre-Deployment Health Assessment suffers because service members underreport their mental health concerns..."
In the policy memorandum announcing the introduction of the PreDHA in 1998 [3
], it was noted that the objective of the assessments was merely to provide "quick confirmation and documentation of a service member's health readiness for deployment or redeployment and to determine if there is a need for a clinician's evaluation before deployment or redeployment. Future revisions of deployment health assessments shall require pilot testing and question validation before being put into use"
]. Furthermore, this memorandum stated that "deployment-related mental health screening will be addressed in a separate policy memorandum"
. Since this original announcement released over ten years ago, no such policy memorandum has been issued, and no formal validation of the PreDHA has been published or undertaken.