Anonymous Surveys Can Be Valuable in Military Mental-Health Screening Study Finds

WASHINGTON — Despite intensive efforts by the military to reduce the stigma of seeking help, troops still might be reluctant to report mental-health problems, suggests a new study of U.S. Army soldiers from one infantry brigade combat team.

Troops undergo screening for mental-health issues when they return from deployment from Iraq or Afghanistan as part of routine post-deployment health assessments. The Post-Deployment Health Assessment (PDHA) is given to military personnel immediately at the end of their deployment, followed up 90 to 180-days later by the Post-Deployment Health Reassessment (PDHRA).

Used in conjunction with a brief evaluation from a primary-care provider, these assessments, which are entered into the servicemember’s electronic medical record, are meant to help the provider determine whether there is any need for further physical or mental health evaluation and treatment.

The study authors noted, however, that “some post-deployment assessments have produced lower-than-expected rates of mental-health concerns, and investigators have suggested the possibility that non-anonymous, unitwide assessments linked to healthcare might discourage some soldiers from honestly reporting their war-related mental-health concerns.”

In 2008, the researchers sought to assess how willing a brigade returning from Iraq would be to report mental-health problems, if reporting were done anonymously. In addition to completing the electronic-survey portion of the PDHA, 2,500 soldiers from the returning brigade also were invited to complete an additional voluntary anonymous paper survey. These soldiers were informed that the additional survey was for research purposes only and that the survey would remain completely anonymous.

Anonymous Surveys

With 1,712 of these troops participating, the researchers found that reporting of depression, PTSD, suicidal ideation and interest in receiving care were twofold to fourfold higher on the anonymous survey, compared with the routine PDHA. Overall, 20.3% of soldiers who screened positive for depression or PTSD reported that they were not comfortable reporting their answers honestly on the routine post-deployment screening, according to the study.

“Congressionally mandated post-deployment screening is a hallmark health policy aimed to improve the care of servicemembers returning from Iraq and Afghanistan. In addition, multiple education efforts have been initiated to decrease stigma. However, despite these efforts, stigma seems to remain pervasive in the military,” the study authors wrote.

The study authors told U.S. Medicine that they do not believe the results are any indication the PDHA screening is not a “good process,” rather that additional strategies are needed to reach those uncomfortable seeking help.

“I think it is important to note that the current process of the post-deployment health reassessment is very valuable and works very well for the soldiers who have already made the decision to seek help,” said study author Army Col. George Appenzeller, MD. “I think what this study shows is that, as we continue to move forward, engaging soldiers in seeking healthcare, we need to look at additional strategies, as well. This is absolutely not saying that the PDHA process is not a good process. It is a very good process, but we need to seek additional ways to reach soldiers.”

Study author Lt. Col. Christopher Warner, MD, said one initiative started by the Army to reach troops is to move behavioral health resources into primary care, where troops and their families already receive routine medical help.

“It is creating an additional venue where soldiers can ask for help who may have stigma about going to a behavioral health clinic,” he said.

Still, Warner also acknowledged that stigma is an ongoing issue. “I think stigma will continue to be an issue that we will always be challenged by. What we are going to have to continue to have to find is ways to help individuals feel comfortable overcoming that stigma and ask for help,” he said. “Department of Defense senior leadership has done phenomenal work on encouraging soldiers to seek help and finding ways to help reduce suicide, but we will continue to face challenges that we will have to develop new systems and mechanisms to overcome these stigmas that arise.”

The authors wrote that the study is the “first to provide a direct measure of the level of discomfort with reporting honestly on the routine PDHA and the willingness to receive a mental-health referral, particularly for those who screened positive for a mental-health concern.”

“This study adds to the growing body of literature that questions the effectiveness of self-report surveys. This study does not invalidate the post-deployment screening process but provides caution to policymakers that clinical screening alone cannot be expected to identify most servicemembers in need of treatment. Post-deployment screening provides one of several routes to care. Further research is needed on the range of strategies to enhance clinical engagement,” they wrote.

The study, “Importance of Anonymity to Encourage Honest Reporting in Mental Health Screening After Combat Deployment,” was published in the October 2011 issue of the Archives of General Psychiatry.

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