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The Dilemma of Wartime Public Mental Health

Although my interests at the time had been squarely in the area of infectious diseases, in the months prior to my deployment, through my work I had become increasingly aware of the growing toll of mental illnesses on our forces. In a 2006 report, our analysts had identified a notable increase in the rate of clinical encounters for mental health disorders—up 12 % since the start of the wars—higher than in any other category of disease [8]. My analysts had also reported noting a high prevalence of psychotropic drug use in the sample pharmacy datasets they had begun examining. Yet when I recommended that our center devote more attention to the study of mental health problems, such as had previously been done [9], my proposal was initially met with disinterest. Much of the public health community appeared to feel that work of this nature was not the proper domain of epidemiologists and Preventive Medicine physicians, but rather of psychiatrists, a small group of whom were already involved in research in these areas [10].

It was around this time that I received my temporary reassignment orders. Increasingly intrigued by the idea of mental disorders as a potential military public health problem, it was with this perspective that I returned to Ft. Bragg to join the 82nd Airborne Division for deployment. Within days of my arrival, I would quickly realize how relevant this perspective would be to my deployment, and how my public health colleagues’ perceptions of the problem posed by mental disorders lagged the realities I observed within front-line combat units.

This first became clear as we assembled at the airfield, preparing to board our flights for deployment. There, we were told by medics of the 82nd Airborne Division—much to my surprise—to reach into a large garbage bag and grab a box of medicine that had been collected in bulk from the local military pharmacy. The box contained mefloquine, which we were to begin taking to prevent malaria while overseas.

From my training in travel medicine, I was very aware that mefloquine could not be safely prescribed to those with certain pre-existing mental health problems [11]. How did whoever had prescribed the drug know that everyone deploying with me was free of contraindicating mental health conditions? The prior AMSA analysis had suggested that across the Army as a whole, these contraindicating mental health problems were relatively common. I convinced myself that the 82nd Airborne Division was an elite unit, with rigid eligibility criteria, and presumably the soldiers deploying with me had been carefully screened prior to deployment.

However, once in Afghanistan, over the long hours that would follow, I would gradually learn through personal discussions with a number of my fellow unit members that many were in fact taking psychotropic drugs that had been prescribed by military healthcare providers in the days prior to their deployment. As the weeks progressed, these colleagues—many still improperly taking mefloquine [12] — would confess their continued struggles with various psychiatric symptoms, some of which had been diagnosed, but some of which were being empirically treated with these drugs without documented indication.

Intrigued by what I now perceived as a potentially very serious public health problem, I undertook a formal analysis under the authority of the 82nd Airborne Division Surgeon. Reaching back to my AMSA colleagues outside of Washington, DC, I requested data on prescription drug utilization as well as the medical and psychiatric histories of our force. Working on a ruggedized laptop AMSA had provided me for my deployment, I spent my evenings in the relative comfort of our dusty Soviet-era office, combing through the data.

The results of my analysis were surprising: Of the force that had deployed to Afghanistan under our command, a significant number—slightly fewer than 5 % — had received a formal mental health diagnosis in the year prior. More surprisingly, as my anecdotal experience had suggested, approximately 7 % had received a psychotropic drug in the 6 months prior to deployment [13].

In one of our infantry battalions, on the front lines of a particularly grueling fight, these figures were even higher: 15 % had received a mental health diagnosis, and 7.7 % had received a psychotropic drug, within the year prior [14]. Among our female service members, these rates were even higher—approximately double that of the deployed force as a whole [13]. Examining specific diagnoses, my data indicated we had even deployed personnel with recently diagnosed psychotic and bipolar disorders [15].

The obvious question these data raised to me was, how had this occurred? In the weeks prior to deployment, the soldiers of our task force had been “screened” for eligibility, including through the administration of a health survey then known as a “Pre-Deployment Health Assessment” (PHA) that included the question “During the past year, have you sought counseling or care for your mental health?” Requesting the electronic responses from these forms from my AMSA colleagues, I then examined how those soldiers who had known medical encounters for mental health problems had responded.

On my completing this analysis, the answer to my question was immediately obvious: of those with documented mental health diagnoses, only 48 %—less than half—had admitted to their seeking such care on the health survey [16]. Rushed for time, often having to see hundreds of soldiers in a day, the healthcare providers conducting the pre-deployment checks as these surveys were completed were likely not reviewing, or did not have, the medical records that would have revealed this underreporting.

Unlike the scar or the crutch that betrays an earlier physical injury, these mental health conditions exhibited no outward sign, and went mostly unnoticed by the examining healthcare provider unless the soldier specifically admitted to them. And, as my discussions with many confirmed, our soldiers of the 82nd Airborne Division were motivated, willing, and able to remain silent about their conditions, in many cases so as to not risk being found ineligible for deployment.

Indeed, soon after I completed my analysis, a Department of Defense report was published that noted that members of its mental health study team “were told on multiple site visits that the validity of the Pre-Deployment Health Assessment suffers because service members underreport their mental health concerns if they are eager to deploy” [17].

In the months prior to our deployment, in response to Congressional direction, formal policy guidance had been published by the Department of Defense that had clearly stated that “[a]ny condition or treatment for that condition that negatively impacts on the mental status of behavioral capability of an individual must be evaluated [emphasis added] to determine the potential impact both to the individual Service member and to the mission” [18]. Interestingly, this same document noted that “[i]t is the responsibility of the Service member [emphasis added] to report past or current... mental health conditions... and associated treatments, including prescribed medications.”

With my public health investigation substantiating published observations from site visits of the low validity of existing screenings, and with my analysis demonstrating that over half of those with mental health conditions were failing to meet their responsibility to self-report—it was clear that the evaluation mandated by this Department of Defense policy was often simply not being performed.

Although this large-scale circumvention of a Congressionally directed policy mandate may have seemed wholly unacceptable to a military culture obsessed with compliance with regulations, what I quickly came to realize, working within the headquarters of a deployed unit, was that the practice of relying on known inaccurate self-reported data—whether tacitly condoned or not—unmistakably benefited our military leadership, which was struggling after a half-decade of war with how to manage critical shortages in the number of deployable soldiers amidst the effects of recruiting shortages and the “surge” [19].

Such shortages would have been greatly exacerbated by the loss of even a few percent of a unit’s strength, such as would have occurred if otherwise seemingly healthy personnel were to be found ineligible through a rigid application of published deployment mental health standards [20]. For example, in certain units in our task force, which deployed with little more than minimum staffing levels, disqualification of even a fraction of those with prior mental health histories or psychotropic drug use would have threatened the unit’s ability to successfully “make mission” and deploy with adequate strength.

As I explored these issues more in private discussions with mostly junior 82nd Airborne Division officers, it became clear that such a critical failure would not have been considered acceptable among our senior commanders. There was consequently an implicit understanding that these mental health policies were not to take precedence over more practical military considerations.

I would learn through these revealing conversations that the practice of “turning a blind eye” to potentially disqualifying mental health conditions had become so widespread in certain units as to be almost an open secret. What had not been clear at the time among those officers involved in the practice was its relevance in predicting subsequent patterns of disease within the force. Later research would confirm that besides increasing the already difficult burden of providing effective treatment for prevalent mental disorders while deployed, exposing those with pre-existing clinical or even subclinical mental health disorders to the seemingly endless stresses of war would risk exacerbating the disorder, and could significantly increase the risk of new, more serious illness, including posttraumatic stress disorder [21, 22].

With full consideration of these risks, the faithful practice of preventive psychiatry would have required military psychiatrists to more frequently advocate for the early return home, and even the early separation from the military, of those seen for significant mental health problems on deployment. However, such a practice would clearly have been contrary to decades of organizational doctrine, which has long stressed the principles of expectancy and early return to duty, in consonance with the Army Medical Department’s motto, “To Conserve Fighting Strength” [23].

Thus also, the faithful practice of public health would have required myself and other Preventive Medicine physicians to vigorously advocate for more effective predeployment screening, less flexible interpretation of published deployment standards, and the issuance of far fewer waivers than would become standard in future years even as screenings gradually improved [20].

For a junior medical officer, adopting either practice could have been perceived as at odds with the immediate needs of the military mission, and could have risked being seen by one’s colleagues as “squandering the fighting strength.” I learned this on my deployment as I increasingly stressed my belief in the significance of my findings and of the need for preventive action, first to the 82nd Airborne Surgeon, and then to the broader military Preventive Medicine community, only to be faced with significant organizational inertia and opposition. Unlike my earlier proposal to improve recruit immunization, my proposals to improve the study of mental disorders at AMSA, and then to improve deployment screening and mental health prevention efforts more broadly while deployed, were soundly rejected by medical leadership.

Although some of my efforts would soon inform a formal policy change first within the Army [24] and then across the wider force [25] to significantly decrease the use of mefloquine, my larger goals of emphasizing mental health as a significant public health problem throughout the military—perhaps quite understandably in retrospect—failed to meet with the success I had enjoyed earlier in my career.

With little focus on primary and secondary prevention [26], in the years that followed, the military, and particularly the Army, faced what can only be described as an unchecked epidemic of mental illness, psychotropic drug use [27], and suicide [28]. While I was deployed, AMSA updated its annual summary of clinical encounters to note that over the 2 years through 2006, the rate of visits for mental disorders had increased nearly 20 % in the prior 2 years to become the fourth most common category of disease [8].

Subsequent annual tabulations confirmed a steady increase in the number of ambulatory encounters for mental health disorders over successive prior 5 year periods: 27 % in 2007, 55 % in 2008, 68 % in 2009, and—remarkably—120 % by 2010—doubling since the year it had first attracted my concern [29]. Where once relatively uncommon, mental disorders became the second leading cause of clinical encounters in the military, behind only musculoskeletal disorders, injuries, and poisonings [30], and accounting, on average, for 150 clinic visits per 100 service members per year [31].

Where once used only rarely [27], antidepressants became the third most common class of drug prescribed within the military, behind only opioids and nonsteroidal anti-inflammatory agents (e.g., Motrin), and prescribed within the Army at a rate of 50 prescriptions per 100 soldiers per year [32]. Mental health disorders also became the leading cause of hospitalization in the military [30], resulting in over 15 hospitalizations per 1000 service members per year, each on average nearly a week long [33]. In the Army, these rates were over double that of the other military services, resulting in the hospitalization of 28 per 1000 soldiers per year [33]—or nearly 3 %. Perhaps not surprisingly, excluding those due to war, suicides became the leading cause of death [34].

My deployment to Afghanistan in 2007—at the inflection point of this epidemic—made me realize how unprepared the field of military Preventive Medicine was for the professional challenges posed by this new epidemic. The profession’s traditional practices—which emphasized the prevention of diseases where prevention doctrine almost perfectly aligned with the goals of military leadership—was challenged by the novel need to prevent mental disorders. For these, the only effective interventions, such as limiting the recruiting, deployment, or retention of particularly vulnerable individuals, would sharply diverge with the priorities of military leaders operating within the limitations of a shrinking all-volunteer force.

Owing to the negative attention my work attracted, my deployment also unexpectedly altered the trajectory of my career. Although I would continue my advocacy upon my return from deployment, the constraints of military service would frequently limit my ability to publish my findings and opinions without concerns of retaliation [35]. Early press reports of my work [15, 36] would also soon make me the subject of significant unwelcome scrutiny.

When my uncomfortable period of obligated service ended some years later, I reluctantly resigned my commission and returned to civilian life, where I elected to pursue additional graduate study at Johns Hopkins to further explore my developing interest in public mental health and the prevention of mental disorders among military personnel.

Now back in Baltimore as a civilian, I am now able to publish broadly and advocate for the prevention of mental disorders within the military, across such fields as traumatic brain injury [37, 38], the surveillance of mental health disorders [29], and, particularly, the mental health effects of antimalarial drugs [39]. Ironically, I now find myself a more effective advocate for the public health of those in uniform, than I was when this was notionally my duty.

The early satisfaction I felt speaking with young soldiers of the 82nd Airborne Division, who I was pleased to learn on my deployment to Afghanistan had been spared unnecessary immunizations thanks to my vaccine program, I now feel from those who tell me how they were spared from the risks of mefloquine as a result of its near-elimination from military use [40], or who were awarded fair disability compensation for its ill-effects [41]. Thanks in part to my work, these are now increasingly and more widely recognized. I could have never imagined, as I reached into the garbage bag to grab my box of this medication as I boarded the plane to Afghanistan, that this simple action would take my career in this direction, and lead me to the area of specialization and expertise I enjoy today.

 
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