Mental Health Standards for Combat Deployment

To the Editor: In the January 2011 issue, Larson and colleagues (1) reported results from a study of the relationship between predeployment and in-theater diagnoses of mental disorders among U.S. military personnel. Their important publication adds significantly to what can unfortunately only be described as a sparse literature related to mental health standards for U.S. combat deployments, despite nearly ten years of conflict.

Notwithstanding the authors' rigorous methodology, their work appears to have assumed a greater degree of compliance than the evidence supports with policies designed to restrict the deployment of individuals with disqualifying mental health conditions. In addition, their conclusions, which advise caution in further tightening deployment standards, contrast with evidence from recent studies that have found that existing practices fail to identify many persons with disqualifying conditions.

As early as 2007 two large retrospective studies found evidence of major shortcomings in the effectiveness of current predeployment mental health screening processes. In one study nearly half of deployed military personnel with documented mental health encounters in the year before deployment had failed to report such care on the standardized predeployment screening form (2). This instrument, still in use today and unmodified since its introduction in 1999, contains only one mental health-related question. The study also found that of 11,179 cohort members who had undergone predeployment mental health screening, only 31 (.2%) received a mental health referral. A related analysis found widespread predeployment misprescribing of mefloquine, an antimalarial agent—a germane finding in that this drug is specifically contraindicated and prohibited by policy for use among persons with mental disorders (3). Nearly one in seven military personnel with documented neuropsychiatric contraindications were nonetheless issued the drug—clear evidence that health care providers were unaware of pertinent details of mental health history at the time of prescribing.

The predeployment screening practices in place when the data used by Larson and colleagues were collected were therefore clearly suboptimal. A recent prospective study found that a proposed enhanced predeployment screening that involved administration of a detailed 15-item questionnaire increased predeployment rates of mental health referral a remarkable 38-fold over the rate in the earlier study (2)—to 7.7% (4). Yet even with these improvements, only 74 of 10,678 cohort members (.6%) were ultimately deemed nondeployable on the basis of mental health conditions. An additional 96 who were found nondeployable on the basis of their disqualifying use of psychoactive medications were subsequently deemed “mission essential” and received waivers to deploy (4). How many fewer would have been deemed nondeployable under current screening practices is not clear.

Mental health standards for deployment that at best disqualify only 1.6% of deploying personnel and that permit more than half of the disqualified individuals to be deployed with what appear to be cursory waivers may hardly be considered overly restrictive. Given the laxity of current practices, Larson and colleagues' concerns that further tightening restrictions on deployment might lead to greater avoidance of care seem premature. On the contrary, enhancing predeployment screening (4), enforcing medical record review (2,3), and improving adherence to current standards by sharply restricting the issuance of waivers (4) may be more appropriate recommendations.