Janet's Conner

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Tuesday, May 16, 2006

IRAQ: MENTALLY UNFIT, FORCED TO FIGHT---PART IV........................................


The mandate that troops receive a pre-deployment mental health evaluation grew out of the first Gulf War, when returning service members reported mysterious illnesses that military officers insisted were unrelated to combat. In response, Congress in 1997 ordered the Defense Department to obtain a clear picure of the baseline health of all troops deploying to war zones, including an "assessment of mental-health."

To many members of Congress, that meant a face-to-face encounter with a mental health expert, in part to ensure that troops would be adequately screened for mental illness and would not pose a risk to themselves or others.

Instead, the military's assessment consists of the single yes-or-no answer on a form filled out by deploying service members. "During the past year, have you sought counseling or care for your mental health?"

Defense officials rely on the slef-reported question, even as they acknowledge that the armed forces are beset by a strong aversion to discussing mental health issues. In 2003 and again in 2004, military researchers surveyed soldiers who showed signs of mental illness. Both years, more than half the soldiers said they would be seen as weak and that they would be treated differently if their commanders knew they were having mental health troubles.

"There's still that stigma attached in saying that you've needed to go get help," said retired Navy Cmdr. John S. Class, a deputy director at the Military Officers Association of America.

And that stigma helps explain why only 3% of troops were willing to acknowledge having sought mental health care.

"There's a fair amount of deception," said David Rudd, former chief of psychology service for the Darnall Community Hospital at Fort Hood in Texas. "People simply don't report mental halth problems if they're trying to get into the service.

Rudd said service members would have a harder time deceiving a clinician in a face-to-face interview, and he said a single question is not an adequate mental health screening method.

Col. Elspeth Ritchie, the psychiatric consultant to the Army surgeon general, readily acknowledged that the questionnaire developed by the military to comply with the 1997 law is "not very effective" in identifying troubled soldiers. She said the military relies on fellow soldiers and commanders to pick out colleagues who are mentally unfit.

"The most important things pre-deployment are for people to train and be prepared for combat together," she said. "This is a small medical piece of that...A pen-and-paper screen is seldom going to pick up something that isn't already apparent."

She said the screening was useful for "picking up those who are on medications, to make sure they have the medications that they need" while in Iraq.

Even as Ritchie downplayed the usefulness of pre-deployment screening, she also acknowledged it was an important tool in identifying combat-related mental problems affecting the growing numbers of troops serving second and third tours.

"The pre-deployment screen is going to be useful, because that's going to be a checklist, in that if someone has been on medication or sought counseling, then hey, let's look at this guy or girl a little more carefully to make sure they're going to be OK over there," she said.

Told of The Courant's findings that very few deploying troops receive a mental health evaluation, Ritchie said the questionnaire in not intended to be a barrier to deployment.

"We don't want to deter those who sought counseling from going over," she said.

Some suspect the military intentionally does a poor job screening, in order to deploy as many soldiers as possible.

"It's still a numbers game," said Gerry Mosley, a retired Army Reserve first sergeant with the 296 Transportation Company who said medical screeners showed little interest in soldiers' health when his unit deployed. "I don't think they really want to know what your mental condition is."

Mosley, who called pre-deployment screening "grossly inadequate," said service members with serious mental illnesses are put at great risk when they are sent to war.

"One of two things is going to happen," he said. "They're either going to get worse in-country, or they're going to get a hell of a lot worse when they come home."

But the Courant found that even among the small fraction of service members that indicate a mental health issue, only a handful receive a full "assessment of mental health" from the military.

Answering yes to the mental health question typically triggers an interview with a medical provider---but it isn't with a mental health specialist.

Instead, troops are often questioned by a physician's assistant or medical technicians, who more than 93% of the time, conclude on their own that the service members are mentally fit for deployment to a war zone, The Courant's review found.

Last week, the government Accountability Office reported that among soldiers who screened positive for possible PTSD on a post-deployment questionnaire, only 22% were referred for a mental health evaluation. That figure---which caused outrage among some in Congress---is still more than three times as high as the percentage of soldiers referred to a mental health professional after self-reporting on the pre-deployment form.

Overall, From March 2003 to October 2005, the military processed 935,797 troops facing deployment. Of those, 2,538 were referred for a mental health evaluation---less than 0.3%. That amounts to an average of 18 referrals per week worldwide.

Some troops have gone through the initial screening interview recounted being questioned briefly by a low-level medical provider.

"They didn't go into any depth. It was a few-minutes. 'Why'd you check this? How's it going?' type of thing," said Paul Scaglione, an Army mechanic from Michigan who answered "yes" on the questionnaire before his second deployment to Iraq in November 2004, because he had been treated for depression during his first deployment.

"They don't go like, 'Here's what you should do if you're having problems over there' or 'Are you feeling depressed now?' or anything," said Scaglione, 23. "I don't know if I'd really call it screening.'"

Army sergeant Thomas J. Sweet, 23, of Bismark, N.D., also answered "yes", to the mental health question, based on past diagnoses of attention-deficit disorder and generalized anxiety. But a physician's assistant ruled that Sweet was mentally fit for combat and that there was no need for a referral to a licensed mental health professional.

"How many hours of training does a mental health physician get, unless they're pursuing a specialty in psychiarty?" Sweet's mother, Elizabeth, asks. "Now how many hours in mental health training---in assessment---does a physician's assistant get? I think it's pretty negligible."

A month later, Sweet was sent to Iraq. And 2-1/2 months after that, following a confrontation with a superior, Sweet was found sprawled in a stairway, having shot himself in the head, an Army investigation concluded. It was Thanksgiving Day 2003.

"You have a form," Elizabeth Sweet says. "He honestly checked 'yes' and nothing happened."


Year's before a physician's assistant declared Thomas Sweet mentally fit for war, experts hired by the military had warned that pre-deployment mental health screening was adequate. And 6 months before Sweet deployed, Defense Department officials were summoned to Capitol Hill, where skeptical members of Congress berated them over flaws in the pre-deployment process.

But despite the tough talk, nothing changed.

At a March 2003 hearing of the Subcommittee on National Security, Emerging Threats and International Relations, members of Congress, including the subcommittee chairman, U.S. Rep. Christopher Says, R-14th District, challenged the military's top health official on his interpretation of the law requiring a mental health assessment.

"Let me just tell you, from my standpoint, you're not meeting the letter of the law clearly, and I don't even think you're meeting the spirit of the law," Shays told William Winkenwerder Jr., assistant secretary of defense for health affairs. "So, I'd like to know where it says that the examination should be a self- assessment. Where in the law do you read self-assesment?"

Shays also said he had trouble seeing the diagnostic value of a question that simply asked depolying troops if they have sought mental health counseling. "If you said yes, maybe it's a good thing and maybe more of us should be doing it," Shays said. "And if you say no, maybe you should have. And so, I don't really know what it tells you.

"I don't know whether no or yes is the right answer."

Winkenwerder insisted that not only was the self-reported questionnaire acceptable, but it was actually superior to a hands-on examination, which he described as being "of very little value."

Even after a spike in suicides in 2003, military health leaders defended pre-deployment screening, saying a variety of personal issues---not pre-existing mental illness or the impact of combat---led soldiers in Iraq to kill themselves.

Col. Bruce Crow, an Army suicide prevention expert, told the military-run Armed Forces Press Service in 2004 that none of the soldiers who killed themselves in the war had a history of mental health treatment, and none exhibited warning signs.

Bailey and Sweet, who had pre-existing disorders, were among those soldiers.

A month after the March 2003 congressional hearing, the military issued a revised health assessment questionnaire for soldiers---but only for those returning from war. The new form still relied on self-reporting, but added questions designed to evaluate the soldiers' mental state, not simply whether they had or had not sought counseling.

But the military never changed the pre-deployment form or screening process. And Congress lost the momentum for change.

Class of the Military Officers Association of America, beleives that the Defense Department should at least expand the pre-deployment form, to include better diagnostic questions.

"If you changed the post-deployment questionnaire, then why didn't you make the same changes to the pre-deployment?" Class asked. "It would seem to me as if that would not be a hard thing to do."

Critics, including the GAO, say the military has been reluctant to offer clear and consistent quidelines on what medical and mental conditions ought to disqualify service members from being sent into battle.

Last year, for the first time, the Army identified broad medical conditions that could be incompatible with deployment to a war zone, including psychiatric conditions that might interfere with duty.

That still leaves broad discretion to commanders, and the GAO recommended more specific quidelines "so that in future deployments [the Defense Department] would not experience situations such as those that occured with members being deployed into Iraq who clearly had pre-existing conditions that should have prevented their deployment."

The Defense Department rejected the recommendation.

Some family members of soldiers with psychiatric problems say that regardless of military rules on deployment, their efforts to convince officials that a loved one should not be deployed have been ignored.

Dee Bartlett of San Marcos, Texas, who served seven years in the Army herself, said she had tried to warn her husband's commander that he was mentally unstable and should not be sent to Iraq in early 2003. Her husband, Chris, an 18-year veteran who was assigned to special forces, had been treated for a back injury and depresion and was taking painkillers and Xanax, she said.

"I sat down with his commanding officer about two weeks before they deployed and told him how bad Chris was, that he was just going up and down and using his pain meds to try to sleep," Dee Bartlett said. "I said, 'My concern is he's going to get himself killed or one of you guys killed.'"

Chris, 40, fell apart within weeks of arriving in Iraq and was evacuated to Germany, then back to the U.S. for psychiatric treatment, Dee said. She said he had been in and out of psychiatric hospitals ever since and has tried to kill himself three times. They are now divorced.


Even within the military, some health professionals have been perplexed by the deployment decisions made by medical screeners. At a hospital in Heidelberg, Germany, Army Col. Holly Doyne began receiving e-mails soon after the war began from the staff of a field hospital in Kuwait, complaining about newly arrived troops who were not fit for duty. Among them: a woman on lithium and Zyprexa who had been released just three weeks earlier from a psychiatric hospital.

Before long, Doyne also encountered troops who were evacuated to her medical center, and who never should have been sent to the Middle East in the first place. Doyne and a medical provider in Kuwait drafted and distributed a pointed e-mail, saying medical screeners were not doing their jobs, and too many unfit soldiers were being sent to war.

Doyne thought her criticism has chastened the screeners, but in 2004, a fresh round of soldiers rotated into the war zone---with some of the same problems she had seen earlier in the war.

Doyne, who returned to Germany after a tour in Kuwait, said she is not currently involved in evaluating troops and could not comment on whether mental health screening had improved.

But deployment statistics from the Defense Department indicate growing pressure to send troops into combat, and suggest that screeners are now more likely to deploy troops with possible mental health probelms than they were at the start of the war.

In 2003 and 2004, for example, fewer than 40% of service members who were given a mental health referral were ultimately deployed. In 2005, deployments jumped to 50%.

Among troops who reported receiving mental health care, 84% were ultimately deployed in 2003 and 2004. Last year, the number climbed to 88%.

With no change in the pre-deployment form and no apparent improvement in screening, Elizabeth Sweet fears that soldiers with mental health issues are bing put in the same danger that led to her son, Thomas' death.

"If you aren't using the form any better than you did when you deployed my son, what makes anyone think they're doing it any better now?" she says. "And it's a piece of paper. It was useless."

Source: The Hartford Courant
Story By: Matthew Kauffman and Lisa Chedekel
May 15. s006


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