|
 |
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
© 2008 American Public Health Association
DOI: 10.2105/AJPH.2008.141291
LETTER |
The author is with King’s College London, Institute of Psychiatry, King’s Centre for Military Health Research, London, England.
Correspondence: Requests for reprints should be sent to Roberto J. Rona, PhD, FFPH, Professor of Public Health, King’s College London, Institute of Psychiatry, Department of Psychological Medicine, Weston Education Centre, Cutcombe Road, London SE5 9RJ, United Kingdom (e-mail: roberto.rona{at}iop.kcl.ac.uk).
The audit evaluation by Seal et al. of the Veterans Administration Postdeployment Mental Health Screening1 demonstrated that half of eligible veterans were not screened (52%) while attending a primary care setting; of those who were screened, the majority were identified as possible cases of posttraumatic stress disorder (69%), but many were not interested in pursuing matters further by attending a mental health facility. Readers are entitled to wonder if the reality was that clinicians, veterans, and administrators were not keen on the screening program itself, because the sampling frame was made up of only those attending primary care facilities, and not all veterans entitled to screening. One might also wonder why the authors only contemplated ways of increasing participation rate in the screening program without reflecting more on the relative lack of enthusiasm in the program. The researchers showed little interest in discussing further the value of a screening program based on fair or only satisfactory sensitivities and specificities, and with low certainty of an accurate diagnosis. It is a pity that the authors did not use the opportunity to raise questions about a costly (in terms of time and resources) screening program that identifies too many veterans with a possible posttraumatic stress disorder but has yet to be assessed for its effectiveness or efficacy. A randomized controlled trial is the only way to assess if a screening program does more good than harm and represents value for money.2,3
Overall, I believe that the laudable desire to improve the care of veterans with mental health problems—an objective to which I am just as committed as the authors—should not detract from the need to take a clear, evidence-based approach to achieving this goal. At present, I am not convinced that large-scale mental health screening remains the best or most cost-effective way of achieving this end. Other options include making services more attractive, taking into account the culture of the military and veteran communities when providing such services, avoiding labeling or stigmatization, and ensuring that interventions target the small minority of those really in need and not the larger numbers of those with transient reactions to the realities of deployment.
If we do not take a reflective view of this type of screening, then future commentators looking back on our efforts may pen papers with titles such as "Didn’t Ask—Never Found Out."
Accepted for publication April 10, 2008.
References
1. Seal KH, Bertenthal D, Maguen S, Gima K, Chu A, Marmar CR. 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. Am J Public Health.2008;98: 714–720.
2. Hakama M. Screening. Chapter 6. In: Holland WW, Detels R, Knox G, eds. Applications in Public Health. 2nd ed. Oxford Textbook of Public Health. Vol 3. Oxford, England: Oxford Medical Publications; 1991:91–106.
3. Raffle AE, Muir Gray JA. Screening: Evidence and Practice. Oxford, England: Oxford University Press; 2007.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |