SEAL ET AL. RESPOND

Abstract

We appreciate Rona’s concerns about population-based mental health screening of Iraq and Afghanistan veterans presenting to Department of Veterans Affairs (VA) medical facilities. The study population included veterans presenting to all outpatient clinics at 1 VA facility, not just primary care. Mental health screening may not have been a clinical priority during medical subspecialty visits, which may partially explain lower screening rates. Recently, in response to changes in national VA policy, postdeployment mental health screening rates in primary care have increased to more than 90%. Further, screening instruments used by the VA, specifically the primary care posttraumatic stress disorder (PTSD) screen, have demonstrated validity,1 and brief screens for PTSD symptoms have been used successfully to detect cases of PTSD in primary care.2 When population-based postdeployment mental health screens were first introduced in VA facilities in 2004, the extent of mental problems stemming from the conflicts in Iraq and Afghanistan were just surfacing. Hoge et al. described stigma surrounding mental illness as a barrier to treatment for soldiers, highlighting that soldiers in greater distress were less likely to seek help.3 Combat veterans might be more willing to disclose and accept treatment for mental health problems from the VA rather than the military. In addition, veterans may report mental health concerns months after returning home when at the VA, rather than immediately on their return when first screened by the military. We concur that universal screening should not be conducted if there is inadequate follow-through of positive screens. In our study, 73% of combat veterans with positive screens attended mental health appointments, as opposed to 18% of veterans not screened. Unfortunately, the majority of mental health visits occurred more than 90 days after the positive screens. Since this study was conducted, however, the VA has greatly augmented its mental health capacity, hiring nearly 100 new psychologists.4 Further, the VA has implemented a national model of integrated, collocated care in which mental health providers embedded in primary care conduct immediate assessment and triage of veterans who screen positive for mental health symptoms.4 Preliminary data from one integrated clinic for Iraq and Afghanistan veterans demonstrated high use of mental health services within primary care. We cannot wait for a randomized controlled trial, as Rona suggests, to decide whether we should continue to screen veterans for combat-related mental disorders. If we don’t ask, they may not tell, and we cannot afford the potential consequences of undetected mental illness in combat veterans.