More Evidence Needed in Military Mental Illness Prevention Programs

An Institute of Medicine (IOM) panel recommends that the Department of Defense use only evidence-based methods to screen for and prevent psychological disorders among military personnel and their families, and follow up by evaluating those programs more effectively to see how well they work.

Preventive approaches used thus far have been limited by “insufficient empirical evidence” for many programs, coupled with a “lack of a systematic process to select validated measures for use in judging the performance of the structure, process, and outcomes of all prevention initiatives for enhancing psychological health,” according to the IOM committee, which was chaired by Kenneth Warner, Ph.D., a professor of public health and of health management and policy at the University of Michigan School of Public Health in Ann Arbor.

The February report dealt only with prevention programs, not those involving treatment. A separate report on treatments for posttraumatic stress disorder in military populations is expected from the IOM later this year.

“We requested the report, and we are grateful for it,” said Navy Capt. Richard Stoltz, director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, speaking on behalf of the Defense Department. “I see it as professionally done and helpful to us, and as we go through it, we will make adjustments.”

The IOM’s message to the Pentagon need not be construed as entirely negative, said a psychiatrist who has served on other IOM panels.

The IOM committee was “saying that this is a situation that could be fixed, and in doing so the Department of Defense would make a big difference and change the public health of service members and their families,” said Bennett Leventhal, M.D., a research scientist at the Nathan S. Kline Institute for Psychiatric Research in Orangeburg, N.Y., and a professor in the Department of Disability and Human Development at the University of Illinois, Chicago.

The report offered four major recommendations: (1) the Defense Department should use only evidence-based resilience, prevention, and reintegration programs and eliminate those that do not meet that criterion; (2) only validated instruments should be employed to screen service members at every stage of their careers, from recruitment through training and deployment, reintegration, and discharge; (3) the department should evaluate its interventions; (4) the department should use only “comprehensive universal, selective, and indicated evidence-based prevention programming” aimed at military families and targeted at “family violence, substance abuse, stress reaction, stigma, and depression;” and (5) it should examine community risks and interventions (such as alcohol availability) to military mental health.

The department has not approached prevention blindly, said Stoltz.

“We pay attention to the literature for the scientific background,” he said in an interview. “But clearly when the longest war in our history broke out, we started with a wide variety of prevention programs rather than waiting for individuals to develop some diagnosis and then treating it.”

There may be another complicating dimension, as well.

“The real issue for the military services is that the existing evidence base is derived from clinical trials in classic out-patient settings, like the Veterans Health Administration,” said Douglas Zatzick, M.D., a professor and associate vice chair for health services research in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine in Seattle. The exigencies of military life, training programs, and deployments roughen the path for some prevention and treatment plans.

“Many people arguing for evidence-based care are efficacy researchers, and they don’t get this,” said Zatzick, who has served on other IOM committees dealing with military mental health. “It’s not that people within the department don’t want to use evidence-based methods, but they have to translate them into very different service-delivery settings.”

Finally, service members are not single entities, added Leventhal.

“They have families and support systems, and if those are not part of the intervention and not part of the evaluation, you will not solve the problem,” he said. “The IOM committee sees the issue of psychological health as a system problem, not as an individual soldier/sailor/Marine/airman problem.” ■

The Institute of Medicine report, “Preventing Psychological Disorders in Service Members and Their Families: An Assessment of Programs,” is posted at http://www.iom.edu/Reports/2014/Preventing-Psychological-Disorders-in-Service-Members-and-Their-Families.aspx