Screening for Psychological Illness in Military Personnel

Abstract

ONGOING EVENTS IN IRAQ AND AFGHANISTAN HAVE led to renewed calls to implement widespread screening of members of armed forces to identify those at risk of future psychiatric injury before deployment and to identify those with psychological problems on their return home. If the military could predict who will develop psychological illness due to combat stress, military personnel and commanders would benefit during conflict, and veterans would have fewer mental health problems following a war. The current calls for widespread screening are not new. Psychological screening based on psychiatric interview was put into practice on a massive scale by the United States during World War II, but was a major failure. By the time General George C. Marshall stopped the program in 1944, 2 million men had been rejected as psychologically vulnerable, and thus unable to serve their country. Many of these individuals were later reenlisted, and the majority were satisfactory soldiers. Somewhat mindful of the historical experience, the military’s current emphasis has been less in predicting vulnerability before exposure to stressful environment and more on detecting and managing psychological illness just before and after deployment. This new outlook was stimulated first by reports of psychological illness in the military, beginning in the aftermath of the Vietnam War, and subsequently by the health problems reported after the 1991 Gulf War, as well as media attention, disability costs, and greater responsiveness to these issues by governments and military officials. The United States and Australia have taken steps toward implementing deployment-related screening. In 1998, the US Department of Defense introduced short predeployment and postdeployment questionnaires, which included limited screening for physical and psychological illnesses. In 2003, the Australian Defence Force introduced more elaborate screening, comprising several psychological tests, including screening for posttraumatic stress disorder (PTSD), followed by a short interview, but it has not been formally implemented. A similar approach has been supported but not implemented by the US forces in Europe. Although psychological screening efforts have been supported both within the military and by some mental health professionals, sound evidence that the programs are effective and that the benefits of screening outweigh the psychological and financial costs have been lacking. In this article, we review current evidence to determine what prerequisites are necessary to provide a firm basis for implementing a military psychological screening program. Screening is defined herein as the examination of a generally healthy population to classify individuals as likely or unlikely to have the condition that is the object of screening. Screening for psychological illness is based on symptom reporting. Because of the costs and potential adverse effects of screening, there are generally agreed upon criteria that need to be satisfied before implementing a screening program. We propose 6 criteria for implementing a screening program to detect psychological morbidity in the military.