Corporal Havier A. Perez, warehouse clerk, Recruit Clothing, Service Company, marks the size and height of a recruit during receiving at Marine Corps Recruit Depot San Diego, this spring. A new report calls for more intensive screening for schizophrenia before enlisting new servicemembers. (Photo by Lance Cpl. Jose Gonzalez)

SALEM, VA—The most common age for diagnosis of schizophrenia is late teens to early 30s. Research suggests that symptoms tend to show up earlier in men, often in the early 20s but slightly later in women, the late 20s or early 30s.

A new study pointed out, that at least in males, those ages match up with most military recruits. The result, according to the report published online by the journal Neuropsychiatry, is that many new servicemembers “experience their prodromal and early manifestations of schizophrenia prior to enlistment or after joining the United States armed forces. The schizophrenia often goes undetected clinically until during or after basic training.”

What happens next is rarely good for anyone, emphasized the Salem, VA, VAMC-led research. “The diagnosis of schizophrenia spectrum and other psychotic disorders most often ends the soldiers’ military careers prematurely,” study authors wrote. “The result is a substantial financial burden for the United States military and for the individual.”

The answer, according to lead author Mark B. Detweiler, MD, staff psychiatrist at the Salem VAMC and colleagues, should be improved upfront screening for schizophrenia before bringing recruits into the military system.

“Studies suggest that schizophrenia is underdiagnosed prior to enlistment, during active duty, particularly in combat theaters,” the study noted. “A more efficient screening process for schizophrenia would reduce the number of military recruits with nascent schizophrenia reaching active duty where a diagnosis of schizophrenia reduces the ability of United States Armed Forces to meet their mission expectations and goals.”

As for the cost of a more comprehensive screening protocol for schizophrenia, the authors noted that “the potential cost savings of a more comprehensive screening protocol for schizophrenia for the United States armed forces and the United States government may outweigh the cost of losing soldiers from active duty and paying them lifetime service-connected schizophrenia disability payments each month until their death.”

The researchers suggested the issue is personal for them, explaining, “As clinicians who have worked with active duty soldiers, reserve duty soldiers and veterans with the diagnosis of schizophrenia, in this paper we suggest an improved schizophrenia screening protocol to be employed for pre- and post-enlistment, including the identification of schizophrenia among combat troops being evaluated for PTSD in the battle field or after returning to garrison in addition to veterans entering the VA medical system.”

The article described the process by which the rigors of enlistment can actually hasten the appearance of schizophrenic symptoms in those developing the condition. “Military recruits with a genetic predisposition and epigenetic enhancers for schizophrenia such as childhood abuse, neglect and the use of street drugs prior to or during their military service, risk having an earlier schizophrenia onset when coupled with the stress of military training and active duty,” the researchers noted. “Complicating this situation, in order to avoid detection and removal from active duty and probable military discharge, once entered into the military and on active duty, it is uncommon for soldiers to voluntarily admit to symptoms of depression, odd or bizarre thoughts, paranoia or hallucinations until they are relatively incapacitated. Moreover, given the challenge of meeting recruiting and active duty preparedness requirements, the needs of the military mission objectives are sometimes viewed by commanders as superseding the soldiers’ personal needs. It has been reported that United States military troops with significant psychological problems have been sent to Iraq or kept in combat, even though the responsible commanders and medical staff have been aware of signs of mental illness. Such problems complicate the diagnosis of schizophrenia in the military arena.”

Essentially, the study proposes a multistep screening protocol for schizophrenia at the following points:

  • pre-enlistment at Armed Forces Recruiting Stations;
  • during boot camp;
  • prior to MOS training graduation;
  • during active duty when screening for PTSD in combat or post-combat; and
  • at admission to any VAMCs

As a first step, study authors emphasized, “Once a person seeking to enlist in the armed forces presents at a recruiting station, they should be asked to have their primary care physician screen for: drug use (with urine drug screen) within one to two months of presentation; their mental health history; and their family’s mental illness history. Perhaps the most important elements of this history would include a history of schizophrenia, schizoaffective disorder, bipolar disorder, depression, mania or schizophreniform disorder. For the primary care provider, such an evaluation has been made progressively easier due to advanced technology involving electronic medical records which permits rapid review of an individual’s medical history.”

If the past medical record review allows the process to continue, the potential recruit would be administered the Prodromal Questionnaire (PQ-B), a self-report screening measure for psychosis risk syndromes. The researchers explained that the tool can differentiate between patients with the prodromal schizophrenia and the more advanced forms characterized by psychotic features.

If the PQ-B—administered by the military recruiter or at a screening center—the next step would be testing for a biological marker of single nucleotide polymorphism (SNP) in the gene SLC1A1 on chromosome 9p24, encoding the neuronal glutamate transporter EAAC1, the article suggests. A positive test would disqualify the person for military service and would become part of the military electronic records on potential recruits.

Ongoing Screening

In case the mental disorder is not detected, or symptoms appear later, study authors urged “a major effort” to make sure a recruit doesn’t graduate from basic training or military occupational specialty training with underlying schizophrenia. “Therefore, it is proposed that, during basic training and prior to MOS school graduation, all soldiers would receive the Raven Progressive Matrices test 20-minute version as a preliminary rapid screen for schizophrenia. This test is helpful, as some astute individuals who fear that they have a mental illness will probably not understand that this is an indirect screen for schizophrenia and other mental disorders. This would be followed by the PQ-B along with the Brief Cognitive Assessment Tool for Schizophrenia. If positive, the screen for the biological marker of the single nucleotide polymorphism (SNP) in the gene SLC1A1 on chromosome 9p24, encoding the neuronal glutamate transporter EAAC1b would follow.”

Once servicemembers have transferred to their duty stations, further testing for schizophrenia should be triggered only with signs of altered mental status, especially paranoia and delusional disorders, according to the report. “The PQ–B should be used aggressively during active duty at the lowest threshold of schizophrenia symptomatology in garrison. This is most critical when an active duty soldier is being evaluated for PTSD in a combat theater,” study authors explain.

Another schizophrenia screening should occur after military service ends and a veteran is admitted to a VAMC. The article suggested that all veterans should be screened for schizophrenia using the PQ-B by clinical technicians, nurses or social workers.

A positive result would lead to a psychiatric consult where route schizophrenia screening would occur using DSM 5 diagnostic criteria. After other biologic and psychiatric disorders were ruled out, the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) assessment tool could be used to enable the treatment team to better meet the needs of the veteran for intermediate and future care.

Currently, the U.S. Army uses only educational achievement, cognitive testing and a brief psychiatric screening for mental illnesses, according to the authors, who pointed out that “confidential surveys and interviews with 5,428 soldiers at Army bases in the United States revealed that 20 percent of these soldiers had a mental illness (e.g., depression, panic disorder, ADHD, intermittent explosive disorder, substance use disorder) prior to enlisting in the Army.”

“These data support the argument that the proficiency of recent United States military medical services screens of recruits and active duty soldiers for mental illnesses including schizophrenia is less than ideal,” they added, even with other military services using slightly more intensive screening.

Further complicating diagnosis is the large number of troops who have PTSD. “In the most recent combat theaters, the prevalence of PTSD has been relatively similar: 11-20 percent in a given year for Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF); 12 percent in a given year for the Persian Gulf intervention (Desert Storm); and 15 percent in a given year for the Vietnam military action. It is estimated that about 30 percent of Vietnam veterans will have had PTSD in their lifetime. It is now understood that PTSD may mask the early stages of comorbid schizophrenia.”

The researchers discussed how, during the Iraq and Afghanistan conflicts, it was difficult to diagnosis schizophrenia among active duty and reserve duty soldiers in active combat because of overlap with PTSD symptoms. “In part this is due to the fact that the primary objective of the United States armed forces medical services has been to identify PTSD at its earliest stages to reduce morbidity. Therefore, it would be helpful to have a more aggressive and consistent screening protocol for schizophrenia to accompany every PTSD screen in active duty soldiers. If comorbid schizophrenia is missed or the diagnosis delayed, the underlying schizophrenia most often progresses and worsens the prognosis,” they wrote.

“Based on ongoing medical and psychiatric problems in the United States military, new diagnostic protocols for recruits and active unit soldiers would be beneficial for both the military and the individuals involved,” the study team concluded.

1Detwieler MB, Chudhary AS, Murphy PF. Screening for Schizophrenia in Recruits, Active Duty Soldiers and Veterans: Can we do a Better Job? Neuropsychiatry (2017) Volume 7, Issue 5