标题：Getting Beyond “Don’t Ask; Don’t Tell”: an Evaluation of US Veterans Administration Postdeployment Mental Health Screening of Veterans Returning From Iraq and Afghanistan
摘要：Objectives. We sought to evaluate outcomes of the Veterans Administration (VA) Afghan and Iraq Post-Deployment Screen for mental health symptoms. Methods. Veterans Administration clinicians were encouraged to refer Iraq or Afghanistan veterans who screened positive for posttraumatic stress disorder, depression, or high-risk alcohol use to a VA mental health clinic. Multivariate methods were used to determine predictors of screening, the proportions who screened positive for particular mental health problems, and predictors of VA mental health clinic attendance. Results. Among 750 Iraq and Afghanistan veterans who were referred to a VA medical center and 5 associated community clinics, 338 underwent postdeployment screening; 233 (69%) screened positive for mental health problems. Having been seen in primary care (adjusted odd ratio [AOR]=13.3; 95% confidence interval [CI]=8.31, 21.3) and at a VA community clinic (AOR=3.28; 95% CI=2.03, 5.28) predicted screening. African American veterans were less likely to have been screened than were White veterans (AOR=0.45; 95% CI=0.22, 0.91). Of 233 veterans who screened positive, 170 (73%) completed a mental health follow-up visit. Conclusions. A substantial proportion of veterans met screening criteria for co-occurring mental health problems, suggesting that the VA screens may help overcome a “don’t ask, don’t tell” climate that surrounds stigmatized mental illness. Based on data from 1 VA facility, VA postdeployment screening increases mental health clinic attendance among Iraq and Afghanistan veterans. High levels of exposure to combat have characterized the conflicts principally in Iraq and Afghanistan—Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Improvised explosive devices and frequent, unexpected mortar attacks have brought the “front line” to most OIF and OEF military service personnel. 1 In the Vietnam and Persian Gulf wars, level of combat exposure was strongly associated with posttraumatic stress disorder (PTSD), depression, and substance use disorders. 2 , 3 Similarly, an epidemic of mental health disorders is emerging among veterans of OIF and OEF. 4 , 5 Early intervention with evidence-based mental health treatment has been shown to prevent chronic mental illness and associated disability. 6 Mental health screening of combat veterans has the potential to increase early detection of symptoms and early intervention. Since World War I, the US military has conducted mass mental health screening primarily to exclude psychologically vulnerable recruits from service, yet these programs have failed to reduce the incidence of psychological casualties. 7 This experience, coupled with high rates of psychiatric disorders in the aftermath of the Vietnam and Persian Gulf wars, shifted the focus of screening to the detection of mental health symptoms during and after deployment. 8 Recent reports have indicated that service members are more likely to report mental health problems 3 to 4 months after returning from deployment, and delayed presentations of mental health disorders have been documented years after military service. 9 , 10 Accordingly, in June 2004, the Veterans Administration (VA) issued a national directive to initiate the Afghan and Iraq Post-Deployment Screen. 11 The screen consists of brief, previously validated instruments to detect symptoms of PTSD, depression, and high-risk alcohol use among veterans of OIF and OEF who seek VA healthcare. Veterans Administration clinicians are expected to complete the screen and to assess whether veterans who meet screening criteria for depression and high-risk alcohol use require a mental health referral. Veterans Administration clinicians are encouraged to refer patients who meet screening criteria for PTSD for further mental health assessment and treatment. Clinicians at 1 VA medical center and its affiliated community-based clinics were encouraged to refer Iraq and Afghanistan veterans who met screening criteria for PTSD, depression, or high-risk drinking for follow-up mental health assessment. Based on data from this facility, we sought to determine (1) the frequency and predictors of implementation of the VA postdeployment screen; (2) the proportion of veterans with positive screens for PTSD, depression, or high-risk alcohol use; and (3) the proportion of veterans who were seen in a VA mental health clinic within 90 days of screening and beyond.
