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© 2008 American Public Health Association
DOI: 10.2105/AJPH.2008.141333
LETTER |
Karen H. Seal, Shira Maguen, Daniel Bertenthal, Kristian Gima, and Charles R. Marmar are with the San Francisco VA Medical Center, San Francisco, CA. Karen H. Seal, Shira Maguen, and Charles R. Marmar are also with the University of California, San Francisco.
Correspondence: Requests for reprints should be sent to Karen H. Seal, MD, MPH, San Francisco VA Medical Center, 1450 Clement St, Box 111A-1, San Francisco, CA 94121 (e-mail: karen.seal{at}va.gov).
We appreciate Rona’s concerns about population-based mental health screening of Iraq and Afghanistan veterans presenting to Department of Veterans Affairs (VA) medical facilities. The study population included veterans presenting to all outpatient clinics at 1 VA facility, not just primary care. Mental health screening may not have been a clinical priority during medical subspecialty visits, which may partially explain lower screening rates. Recently, in response to changes in national VA policy, postdeployment mental health screening rates in primary care have increased to more than 90%. Further, screening instruments used by the VA, specifically the primary care posttraumatic stress disorder (PTSD) screen, have demonstrated validity,1 and brief screens for PTSD symptoms have been used successfully to detect cases of PTSD in primary care.2
When population-based postdeployment mental health screens were first introduced in VA facilities in 2004, the extent of mental problems stemming from the conflicts in Iraq and Afghanistan were just surfacing. Hoge et al. described stigma surrounding mental illness as a barrier to treatment for soldiers, highlighting that soldiers in greater distress were less likely to seek help.3 Combat veterans might be more willing to disclose and accept treatment for mental health problems from the VA rather than the military. In addition, veterans may report mental health concerns months after returning home when at the VA, rather than immediately on their return when first screened by the military.
We concur that universal screening should not be conducted if there is inadequate follow-through of positive screens. In our study, 73% of combat veterans with positive screens attended mental health appointments, as opposed to 18% of veterans not screened. Unfortunately, the majority of mental health visits occurred more than 90 days after the positive screens. Since this study was conducted, however, the VA has greatly augmented its mental health capacity, hiring nearly 100 new psychologists.4 Further, the VA has implemented a national model of integrated, collocated care in which mental health providers embedded in primary care conduct immediate assessment and triage of veterans who screen positive for mental health symptoms.4 Preliminary data from one integrated clinic for Iraq and Afghanistan veterans demonstrated high use of mental health services within primary care. We cannot wait for a randomized controlled trial, as Rona suggests, to decide whether we should continue to screen veterans for combat-related mental disorders. If we don’t ask, they may not tell, and we cannot afford the potential consequences of undetected mental illness in combat veterans.
Accepted for publication May 1, 2008.
References
1. Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatry.2004;9: 9–14.[CrossRef]
2. Kimerling R, Ouimette P, Prins A, et al. Brief report: utility of a short screening scale for DSM-IV PTSD in primary care. J Gen Intern Med. 2005.
3. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med.2004;351:13–22.
4. Zeiss AM, Karlin BE. Integration of mental health and primary care services in the Department of Veterans Affairs Health Care System. J Clin Psychol Med Settings.2008;15:73–78.[CrossRef][Web of Science]
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