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Deployments Take MH Toll on Soldiers and Providers

Longer deployments and not enough time between them are fraying the nerves of U.S. Army soldiers, but the good news is that more soldiers are willing to seek mental health care.

Multiple deployments, extended tours of duty in Iraq, and less time at home between them have kept the rate of mental health problems among U.S. soldiers close to that of previous years, despite a decline in overall combat exposure, according to the latest annual report from Army researchers.

About 18 percent of U.S. Army soldiers serving in Iraq screened positive for mental health problems, according to data collected in October and November 2007. That figure rose to 27 percent for those on their third tour. At the same time, troops also said they had greater difficulty getting mental health services, while the personnel assigned to help them complained of shortages in their ranks and more burnout.

Among the good news in the report was that soldiers in Iraq said they felt less stigma about seeking mental health care, continuing a steady downward trend. Unit cohesion and special training designed to improve adjustment to battlefield stress apparently have lessened mental health problems too. The percentage of soldiers reporting high unit morale rose from 2006 to 2007, although the Army did not provide exact figures.

The U.S. Army's Fifth Mental Health Advisory Team (MHAT-V) surveyed 2,295 soldiers in Iraq and 699 in Afghanistan, augmented with interviews, and also questioned mental health care, primary care, and unit chaplain teams. The MHAT investigators announced the findings on March 7 at the Pentagon. MHAT surveys have been conducted since 2003.

The MHAT surveys are intended to result in improved mental health services to soldiers, said Maj. General Gale Pollock, deputy surgeon general for force management, at a news briefing.

"Our goal is to get every soldier the health care he or she needs," said Pollock. "These advisory teams help us learn how and where we can better meet those needs."

MHAT-V also made public for the first time survey data from soldiers fighting in Afghanistan. They now screen positive for symptoms at rates similar to those of troops in Iraq, a change from previous studies showing fewer psychological effects of service in that country. Combat exposure there is now at least as high as that seen in Iraq. Also, troops say they have difficulty getting mental health care, and providers say they have difficulty reaching soldiers in the field, said the report.

Tours of duty now last 15 months, rather than 12, and mental health screening results showed increasing problems toward the middle of soldiers' deployment, but improvement toward the end as soldiers looked forward to going home—"redeployment optimism," according to Army psychologist Lt. Col. Paul Bliese, who led the study team. ("Redeployment" is the military term for "coming home.")

The stress of multiple deployments also appears to be taking its toll. Soldiers on their second, third, or fourth deployment were at increased risk for low morale, mental health problems, and degraded performance due to stress or emotional problems, said the report. Sergeants and other noncommissioned officers—the backbone of any army—make up a larger proportion of those who have returned to Iraq more than once. They screen positive for mental health problems at rates of 11 percent during a first tour, but at 27 percent during a third or fourth.

Longer time between deployments would help soldiers "reset" emotionally, said Bliese at the briefing. Soldiers get 12 months back at their home bases after the standard 15-month deployment, but a year is not enough to let them recover from the mental health problems related to being in war, he said.

"We need to look at ways to slow down the deployment, but there are no quick fixes," added Pollock.

Homefront Troubles Exact Severe Toll

About 15 percent to 20 percent of married service members said they were considering divorce or separation. Homefront stress is the most common reason soldiers seek care in the war zones. Family stressors in particular concern health officials, especially given their ties to suicide. Both MHAT-V and last year's Army suicide report said that "failed relationships with spouses or intimate partners" is the highest risk factor for suicide.

Suicide rates in 2007 among soldiers in both Iraq and Afghanistan remained higher than historic Army rates. Eighty-nine suicide deaths among active-duty troops have been confirmed for 2007, while 32 cases are still being investigated as possible suicide deaths. There were 102 confirmed suicides in 2006. Suicidal ideation peaks around mid-deployment and continues to rise beyond the six-month point.

Unethical Behavior Tied to MH Problems

The survey also found that unethical behavior toward noncombatants had not increased overall from 2006. However, said the report, "Soldiers who screened positive for mental health problems of depression, anxiety, or acute stress were significantly more likely to report engaging in unethical behaviors," such as insulting or hitting civilians or damaging private property unnecessarily while on patrol.

The Army team also surveyed 131 mental health professionals—psychiatrists, psychologists, social workers, nurses, and Army mental health specialists. They were short on equipment and personnel, they said. Their own mental well-being was poor, and their ability to do their jobs was also compromised by long deployments.

The Army is trying to hire an additional 275 psychiatrists, psychologists, social workers, and other professionals to work in the United States and in Europe, said Elspeth Cameron Ritchie, M.D., psychiatry consultant to the Army surgeon general, at the news briefing. "We have found 148, an improvement, but not where we want to be."

Thus far, civilian employees or contractors working to fill the Pentagon's needs for health care have worked in the United States or at bases in Germany or Korea to free up uniformed providers for the war zones. MHAT-V recommended that the Army augment military mental health specialists with civilians who would volunteer to serve "downrange," in Iraq. A shortened military obligation might lure others to join the service in uniform, but that option is still in an early stage, said Pollock.

The team also suggested that TRICARE, the contracted health care plan for service members and their families, expand benefits to include marital and family counseling services.

"Every year we've found problems, make recommendations, and try to improve," said Ritchie, who has served on all the MHAT teams. "But many psychiatric disorders, like PTSD, may manifest later, so as a nation we must look to take care of our troops for the long term to prevent the problems that happened with veterans after the Vietnam War."

A redacted version of the "Mental Health Advisory Team V" report is posted at <www.armymedicine.army.mil/news/mhat/mhat_v/MHAT_V_OIFandOEF-Redacted.pdf>.

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