6
Mental Health

A high level of contextual performance is expected in the military (Fiedler, Oltmanss, and Turkheimer, 2004). This contextual performance is related to building and maintaining the military’s social and organizational structure (Hogan and Rybicki, 1998). The prototype military personnel is expected to get the job done, volunteer for tasks, get along well with others, obey orders, rules, and procedures, and support the military’s objectives (Fiedler, Oltmanss, and Turkheimer, 2004). Emotional stability and conscientiousness are important factors for successful military job performance (Salgado, 1998).

A major component of the success of a mission is the ability of a soldier to adapt to mission stressors (Shigemura and Nomura, 2002). This includes missions for both wartime and peacetime. Psychological adaptation is therefore a critical mental health component for military personnel. Stressors associated with transition from civilian to military life include changes in living arrangements, geographic locations, peer relationships, support systems, schedules, priorities, and control over one’s life (McCraw and Bearden, 1990). Separation from family and friends, difficulties in communication with home, and loss of privacy are other common stressors (Orsillo et al., 1998).

Soldiers in wartime missions must deal effectively with the stress and anxiety associated with potential loss of their lives and their fellow soldiers. Peacekeeping missions also have a number of stressors that require psychological adaptation. Stressors associated with peacekeeping missions include isolation, a sense of powerlessness, boredom, coping with the mission’s unpredictability, dealing with shifting rules of engagement,



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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards 6 Mental Health A high level of contextual performance is expected in the military (Fiedler, Oltmanss, and Turkheimer, 2004). This contextual performance is related to building and maintaining the military’s social and organizational structure (Hogan and Rybicki, 1998). The prototype military personnel is expected to get the job done, volunteer for tasks, get along well with others, obey orders, rules, and procedures, and support the military’s objectives (Fiedler, Oltmanss, and Turkheimer, 2004). Emotional stability and conscientiousness are important factors for successful military job performance (Salgado, 1998). A major component of the success of a mission is the ability of a soldier to adapt to mission stressors (Shigemura and Nomura, 2002). This includes missions for both wartime and peacetime. Psychological adaptation is therefore a critical mental health component for military personnel. Stressors associated with transition from civilian to military life include changes in living arrangements, geographic locations, peer relationships, support systems, schedules, priorities, and control over one’s life (McCraw and Bearden, 1990). Separation from family and friends, difficulties in communication with home, and loss of privacy are other common stressors (Orsillo et al., 1998). Soldiers in wartime missions must deal effectively with the stress and anxiety associated with potential loss of their lives and their fellow soldiers. Peacekeeping missions also have a number of stressors that require psychological adaptation. Stressors associated with peacekeeping missions include isolation, a sense of powerlessness, boredom, coping with the mission’s unpredictability, dealing with shifting rules of engagement,

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards struggling with conflicting personal views, being unable to identify a clear enemy, and questionable lasting impact of the mission (Bartone, Adler, and Vaitkus, 1998; Lundin and Otto, 1996; Henshaw, 1993; Maguen et al., 2004). This chapter examines the mental health standards currently in place, to characterize the youth population in terms of these standards, and to assess the current system for tracking the progress of enlistees with preexisting mental health conditions during their first term of enlistment. The focus is on such mental conditions as depression and anxiety disorders and their effects on the individual’s ability to function in a military context. (An examination of normal personality measures related to job performance is outside the scope of the committee’s charge.) MENTAL HEALTH OF THE YOUTH POPULATION According to Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services, 1999), almost 21 percent of children ages 9 to 17 in the United States have a diagnosable mental or addictive disorder associated with at least minimum impairment. The prevalence rate is 11 percent when significant functional impairment is required as part of the diagnostic criteria. This means that a total of 4 million children have a major mental illness resulting in significant impairment at school, at home, and with peers. In 1991-1992 the National Institute of Mental Health conducted the Methods for the Epidemiology for Child and Adolescent Mental Disorders Survey with a sample of 1,285 youth ages 9 to 17. It found that 11.5 percent met criteria for a psychiatric disorder with moderate impairment: anxiety disorders (7.2 percent), depression (4.2 percent), disruptive behavior disorders (6 percent), and substance use disorder (2 percent) (Shaffer et al., 1996). As is evident from the sum of the individual rates of prevalence, there is substantial psychiatric comorbidity in this population, in particular between anxiety disorders and depression and substance abuse and depression. Demographic features were as follows: female (44.6 percent) and male (55.4 percent), Caucasian or other (64 percent), black (20 percent), and Hispanic (15.7 percent) (Narrow et al., 1998). Estimates of the prevalence rate of attention deficit hyperactivity disorder (ADHD) among youth range from 7 to 16 percent (Faraone et al., 2003). Prevalence rates in boys have been found to be two to three times higher than for girls (Ford, Goodman, and Meltzer, 2003; Dulcan et al., 1997). Recent evidence demonstrates that childhood ADHD is a predictor for adolescent substance use (Molina and Pelham, 2003). Stimulant therapy for childhood ADHD has been shown to reduce the risk of subsequent adolescent drug and alcohol use disorders (Wilens et al., 2003).

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards The Youth Risk Behavior Surveillance System (YRBSS), conducted in 2003, was a national school-based survey of 15,214 students in grades 9 to 12. Students were asked about depressive symptoms and suicide during the 12 months preceding the survey. Over a quarter (28.6 percent) of students nationwide reported that they felt so sad or hopeless almost every day for more than two weeks that they stopped doing some usual activities. The prevalence rate was higher among girls (35.5 percent) than boys (22 percent). The prevalence rate was higher among Hispanic (35 percent) than white (26 percent) and black (26.3 percent) students. Combining gender and ethnicity, the prevalence rates were as follows: Hispanic girls (45 percent), white girls (33 percent), black girls (31 percent), Hispanic boys (26 percent), black boys (22 percent), and white boys (19.6 percent). During the 12 months preceding this survey, 17 percent of students reported that they had seriously considered suicide, 8.5 percent of students attempted suicide one or more times, and 3 percent of students made a suicide attempt that resulted in an injury, poisoning, or overdose that required treatment. Anxiety disorders have a high prevalence rate in youth. The rate of childhood anxiety disorders in a primary care setting has been reported to be 35 percent (Chavira el al., 2004). In a sample of incoming college freshman, 11.8 percent of the students reported experiencing a panic attack during the past year (Valentiner, Mounts, and Deacon, 2004). Differences in assignment of diagnoses have been found to be based on the ethnicity of the youth. For example, one study reported that blacks were more likely to be assigned a diagnostic code related to abuse or neglect of a child and were less likely to be diagnosed with a mood disorder when compared with non-Hispanic whites. Hispanics were more likely than non-Hispanic whites to be diagnosed with adjustment disorders, anxiety disorders, and psychotic disorders and were less likely to be diagnosed with attention deficit hyperactivity disorder (Yeh et al., 2002). In summary, a synthesis of these varying prevalence rates suggests that, in the youth population from which the military draws its enlistees, roughly 10 to 15 percent of older adolescents will have at least one criterion-based psychiatric diagnosis that causes a high level of functional impairment (other than attention deficit hyperactivity disorder), with a significant proportion of those suffering from two or more psychiatric disorders. Psychotropic Medication Use There has been a substantial increase in the use of psychotropic medications, particularly antidepressants and stimulants, for children and adolescents with psychiatric disorders.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards Patterns in the use of psychotropic medication for treatment of 900,000 youths ages 2 to 19 were assessed from the time period 1987-1996 using patient prescription data from Medicaid services and a health maintenance organization (Zito et al., 2003). The total psychotropic medication prevalence for youth increased by 200 to 300 percent during that period of time and included most classes of medication. There was a 4- to 10-fold increase for antidepressants and a 3- to 7-fold increase for stimulants. The 1996 prevalence rate for psychotropic medication in youth ranged from 5.9 to 6.3 percent, with stimulants and antidepressants ranked first and second. The authors concluded that the utilization of psychotropic medication by youth during the 1990s nearly reached adult utilization rates. The prevalence of the use of psychotropic medications among youths in 1999-2000 ranged from 3.5 to 4.5 percent in the age group 0 to 17. This information was obtained from youth enrolled in a children’s insurance program in the mid-Atlantic states (Safer, Zito, and Gardner, 2004). An estimate of the use of psychotropic medication by 559,769 youth with psychiatric diagnoses in the U.S. Mental Health Service System was conducted in 1997 (Warner, Pottick, and Muckherjee, 2004). Estimates of medication use among youth ages 6 to 12 and ages 13 to 17 were similar (33 and 34 percent, respectively). Boys had significantly higher rates of medication use than girls (35 compared with 28 percent). The diagnoses and percentage treated with medication were as follows: psychotic disorders (66 percent), attention deficit hyperactivity disorder (52 percent), mood disorder (45 percent), anxiety disorder (32 percent), conduct disorder (28 percent), personality disorders (23 percent), developmental and pervasive disorders (20 percent), and adjustment disorder (15.5 percent). Overall, 32.5 percent of youth in the mental health service system were treated with a psychotropic medication. A retrospective study to assess antidepressant utilization was conducted using outpatient prescription and clinical service records of youths ages 2 to 19 and enrolled in Medicaid and health maintenance organizations during 1988-1999 (Zito et al., 2002). It was found that there was a 3-to 5-fold increase in the prevalence of antidepressant treatment of youth who were younger than 20 years old. The prevalence rate for antidepressant use in youth was 0.6 percent in 1988 and 1.9 percent in 1994. Attention deficit hyperactivity disorder, followed by depression, was the most common diagnosis associated with antidepressant use. The prevalence rate of the use of antidepressants for youths younger than age 18 was assessed using nationwide data of ambulatory prescription claims for the years 1998-2002 (Delate et al., 2004). The overall prevalence of antidepressant use among children increased from 1.6 percent in 1998 to 2.4 percent in 2002, for an annual adjusted increase of 9.2 percent.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards The growth in the overall prevalence of antidepressant use was greater among girls (68 percent) than boys (34 percent). In summary, among youth populations with a diagnosis of depression, anxiety, or other psychiatric disorder other than attention deficit hyperactivity disorder, roughly one-third to one-half receive psychotropic medication, for an overall rate of 4 to 6 percent of psychotropic drug use among adolescents of an age from which military enlistees are drawn. Of those adolescents with attention deficit hyperactivity disorder, roughly half will be using stimulant medication. Treatment Services In the Methods for the Epidemiology for Child and Adolescent Mental Disorders Survey, for youth with a psychiatric disorder, ambulatory services were used by 24 to 45 percent and school-based services were used by 27 to 64 percent. Those who used inpatient services ranged from 2 to 15 percent (Narrow et al., 1998). Psychiatric hospitalization among youth ages 5 to 18 from 1990-1999 was assessed in a retrospective cross-sectional time trend study using the Washington State Comprehensive Hospital Abstract Reporting System dataset (Garrison et al., 2004). The rate of hospitalization for school-age children (ages 5 to 14) increased by 22 percent during the 1990s (from 8 percent in 1990 to 13 percent in 1999). Among adolescents ages 15 to 19, there was no significant change in the rate of psychiatric hospitalization, but the proportion of hospitalizations due to psychiatric conditions increased from 14.5 percent in 1990 to 21.5 percent in 1999. Mental illness accounted for one-third of all hospital days for youth in 1999 and surpassed injury as the leading cause of hospitalization for youth in Washington State. Of 3,803 youth ages 2 to 14 in the child welfare system, 48 percent had clinically significant emotional or behavioral problems. However, only one-fourth (11.7 percent) received any specialty mental health care during the 12 months prior to the survey. Outpatient services were used most commonly (15 percent), whereas psychiatric hospitalization was the least commonly used service (3 percent) (Burns et al., 2004). Ethnicity has been related to receipt of mental health treatment services. Compared with whites, black and Asian teenagers with depression were found to be less likely to seek mental health treatment, especially in the case of males (Sen, 2004). Socioeconomic factors have been associated with mental health service utilization in youths. Elevated service use for boys compared to girls and for single-parent compared to two-partner households as well as

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards underuse by blacks and Hispanic groups have been reported (Zahner and Daskalakis, 1997). In summary, of those adolescents with a psychiatric disorder, roughly 5 to 10 percent will have received inpatient treatment services. When the above studies of prevalence, psychotropic medication use, and hospitalization are synthesized, the following picture emerges. Of a population of 10,000 older adolescents from which the military draws its enlistees, roughly 2,500 will experience symptoms of a psychiatric disorder other than attention deficit hyperactivity disorder, of whom roughly 1,000 to 1,200 will suffer severe functional impairment from their psychiatric disorder. Of these, roughly 400 to 600 will be prescribed psychotropic medication, and 20 to 60 will be hospitalized as part of their treatment program. Of the same 10,000 adolescents, roughly 800 will have attempted suicide and 300 will have made a serious suicide attempt. Also, of the same 10,000 adolescents, roughly 750 to 1,500 will be diagnosed with attention deficit hyperactivity disorder, and, of those, about 250 to 500 will be receiving treatment with stimulant or antidepressant medication. MENTAL HEALTH OF THE MILITARY POPULATION Lifetime prevalence rates of mental disorders were determined for the total active-duty U.S. Army population from 2000 using a logistic regression projection (Messer et al., 2004). This method was used because no observations were available and sociodemographic differences were prominent. The predicted prevalence rates for the Army population were as follows: any mental disorder (37.5 percent), depressive disorders (6 percent), anxiety disorders (16.6 percent), antisocial personality disorder (8.3 percent), and schizophrenia (1 percent). Mental disorders among U.S. military personnel were investigated using an analysis of hospitalizations among all active-duty military personnel from 1990 to 1999 and ambulatory visits from 1996 to 1999 (Hoge et al., 2002). The category of mental disorders was the leading discharge diagnosis among men and second leading diagnosis among women. Mental disorders accounted for 13 percent of all hospitalizations and 23 percent of all inpatient bed days. A total of 47 percent of individuals hospitalized for the first time for a mental disorder left military service within six months. The rate of attrition was significantly higher than the 12 percent rate of attrition after hospitalization for other disease categories. In 1998 and 1999, 6 percent of the military population received ambulatory mental health services. The researchers concluded that mental disorders are the most important source of medical and occupational morbidity among active-duty U.S. military personnel.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards A cohort of U.S. Army soldiers first psychiatrically hospitalized in 1998 was followed up for two years (Hoge et al., 2005). The attrition rate within six months following a hospitalization for mental disorder was 45 percent compared with 11 percent for other medical illnesses. A secondary mental health diagnosis also increased the risk of attrition to 27 percent at six months. Mental health–related separations for Air Force basic military trainees were assessed for the year 2001:4.2 percent of separations were attributable to mental health disorders, with adjustment disorders and depressive disorders being the top diagnostic categories (Englert, Hunter, and Sweeney, 2003). In the 2000 annual report, AMSARA described a five-year, retrospective cohort study of the relationship between waivers for mental health and attrition during the first two years of service. This study compared 502 first-time enlistees across the Services who were granted waivers for depression with a matched group of 1,501 recruits who were qualified on all physical, medical, and mental criteria. The overall results show that recruits with mental health waivers are significantly less likely to remain in military service than those in the comparison group; the probability of retention was .62 versus .72 at the two-year mark. Specific analyses by Service and gender were also performed. For men in the Marine Corps, the retention rate for those with waivers was significant lower; for men in the Navy, it was marginally lower; and for men in the Army, there were no significant differences between the two groups. For woman in the Army, the retention rate was significantly lower for those with waivers, whereas for women in the Navy, no significant differences were found. The mental health effects of exposure to combat duty in Iraq or Afghanistan for U.S. combat infantry units (three Army units and one Marine Corps unit) were investigated by Hoge et al. (2004). In these groups, exposure to combat was significantly greater among those deployed to Iraq than those deployed to Afghanistan. After duty in Iraq, 15.6 to 17 percent of the military personnel met screening criteria for major depression, generalized anxiety, or posttraumatic stress disorder compared with 9.3 percent before deployment to Iraq. After duty in Afghanistan, 11.2 percent met criteria for these disorders. Posttraumatic stress disorder accounted for the largest difference in the pre- and postdeployment rates. Importantly, only 23 to 40 percent of these military personnel sought mental health care. Concern about stigmatization as well as other barriers (e.g., difficulty scheduling an appointment, difficulty getting time off from work, transportation problems) were cited by military personal as reasons for not seeking mental health care. These data are less complete than those for the general adolescent population described above, so there is considerably greater difficulty in

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards building a complete picture of prevalence, treatment, and consequences of mental illness in military populations. In general, of 10,000 active-duty military personnel, perhaps 3,000 to 3,500 will experience some form of mental illness or psychiatric symptoms during their military career, with roughly similar short-term risk in the period following deployment to combat duty, such as in Iraq or Afghanistan. Of these, perhaps only 750 to 1,400 will seek care for their mental illness, which is similar to the roughly 600 such personnel who seek mental illness care in general in any single year. Mental disorders are the leading cause of medical and occupational morbidity, hospitalization, and separation for a medical reason, but population-based risk and prevalence data for such outcomes are not available. MILITARY STANDARDS In 2005 the Department of Defense (DoD) revised the list of mental health disorders that are causes for rejection for appointment, enlistment, or induction into military service. The disorders included are categorized as learning, psychiatric, and behavioral (E1.25): For learning disorders and attention deficit hyperactivity disorder, the criteria have been changed to allow eligibility for individuals who can demonstrate passing academic performance without the use of academic or work accommodations or medications in the previous 12 months. Any individual with current or a history of psychotic disorders, such as schizophrenia, paranoid disorder, or other unspecified psychosis, is disqualified. Current mood disorders, such as major depression, bipolar disorder, or depressive disorder not otherwise specified, are disqualifying. In addition, a history of mood disorders requiring outpatient care for longer than six months by a physician or other mental health professional, or inpatient treatment in a hospital or residential facility, is disqualifying. A history of symptoms consistent with a mood disorder of repeated nature that impairs school, social, or work efficiency is also disqualifying. Current or a history of anxiety disorders, including panic disorder, agoraphobia, social phobia, simple phobias, obsessive-compulsive disorder, acute reactions to stress, and posttraumatic disorder are disqualifying conditions. Any individual with current or a history of adjustment disorder within the previous three months is disqualified. A history of suicidal behavior, including gesture or attempts or a history of self-mutilation, is disqualifying. Current or a history of conduct or behavioral disorders is disqualifying due to concerns about the ability to adapt to military service.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards Current or a history of personality disorders is disqualifying because of concern that immaturity, instability, personality inadequacy, impulsiveness, or dependency will interfere with adjustment to military service. Current or a history of dissociative disorders, including hysteria and depersonalization, as well as current or a history of a somatoform disorder, such as hypochondriasis or chronic pain disorder, are disqualifying conditions. Individuals with current receptive or expressive language disorder that interferes with the production of speech or ability to repeat commands are disqualified. Any individual with current or a history of psychosexual conditions, such as transsexualism, exhibitionism, transvestism, voyeurism or other paraphilias, are disqualified. Age cutoffs are used for some standards. After the 13th birthday, if an individual has enuresis, encopresis, or sleepwalking, then he or she is disqualified. Similarly, eating disorders, including anorexia nervosa and bulimia, occurring after the 13th birthday and lasting longer than three months are disqualifying conditions. A single item on the medical prescreen form, which is completed at the recruiting station, is related to psychiatric disorders (Item 16). The item is worded “seen a psychiatrist, psychologist, counselor or other professional for any reason (inpatient or outpatient) including counseling or treatment for school, adjustment, family, marriage or any other problem to include depression, or treatment for alcohol, drug or substance abuse.” If an applicant responds “yes” to Item 16, he or she is requested to explain the affirmative response. All documentation relating to an affirmative response is sent directly from the treating clinician or hospital to the military entrance processing station (MEPS) chief medical officer. If an applicant has been diagnosed or treated since age 12 for attention deficit disorder or attention deficit hyperactivity disorder, academic skills or perceptual deficit, or has an individual education plan, the recruiter is instructed to contact the MEPS for additional instruction. At the military entrance processing station, recruits complete a medical history questionnaire. A history of treatment for a mental condition depends solely on self-report. Although recruits undergo a medical evaluation, there is no formal psychiatric assessment. DATA AVAILABILITY As noted in Chapter 3 there is a paucity of available data on health and medical conditions in military databases. In some cases data are not

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards entered into the system; in other cases, data accessibility is limited due to privacy concern; and in still other cases, relevant data on conditions and outcomes are not linked. As for all other categories of health and medical conditions, data on the number and percentage of applicants who are screened out at the recruiting stations for mental health reasons are not collected. Data on the number and percentage of medical prescreens identified with mental health issues (positive response to Item 16 on the medical prescreen form) that are forwarded to the MEPS are also not collected. The committee obtained data from the MEPCOM Integrated Resource System (MIRS) for medical failures and waivers from May 1, 2003, to April 30, 2005, in all active forces. Of 429,116 total applicants, 4,303 failed for psychiatric reasons (Code 40), or 6.1 percent of all failures. Of the 4,303 failures, 1,468 were granted a waiver (34 percent). Using standardized medical billing and diagnostic codes (International Classification of Diseases [ICD]), the 4,303 psychiatric failures are divided among roughly 50 diagnoses, of which roughly 25 percent are attention deficit and hyperactivity disorder and related problems, 15 percent are drug and alcohol abuse and related disorders, and the remainder are categorized among a wide range of mood and anxiety disorders (see tables in Appendix B). The number and percentage of recruits per year who leave the military during basic or advanced training due to all psychiatric conditions are available, but not for specific diagnoses or mental illness conditions. The number and percentage of recruits with mental health waivers who leave during basic or advanced training are believed to be available by linking existing databases, but this information is not generally sought nor used by the military, not routinely monitored for patterns or trends, and not routinely available. The number and percentage of applicants with mental health waivers who receive mental health care in basic or advanced training could possibly be determined through detailed review of individual medical charts and personnel databases, but for obvious reasons this approach has some significant cost implications, as well as raising the issue of privacy concerns. Similarly, no data are available about the attrition of recruits who have received outpatient mental health care, but these data could also be developed with appropriate direction and financial support. The 2003 Annual Report of the Accessions Medical Standards Analysis and Research Activity makes limited data available about mental health disqualifications, waivers, hospitalization, and “existing prior to service” discharges: Mental health disqualifications: In 2002, the mental health conditions for which medical disqualifications occurred at the MEPS were

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards coded: neurotic disorders (1.4 percent, N = 918 people) and depressive disorders (0.4 percent, N = 271 people). Waivers at MEPS: Data are available for the top 10 DoD diagnoses of waivers considered and granted for active-duty enlisted applicants in 1997-2001 and 2002 for the Army, Navy, Marines, and Air Force. Diagnoses of physiological malfunction arising from mental factors; neurotic, mood, somatoform, dissociative or factious disorders; attention deficit hyperactivity disorder; and major depression accounted for the mental health disorders that resulted in granting of a waiver (see Table 6-1). Hospitalization: Hospitalization data are available for Army active enlistees for the period 1997-2002. The category of neurotic and personality disorders and the category of other psychoses accounted for all mental health hospitalizations (see Table 6-2). Existing prior to service discharges: Existing prior to service (EPTS) discharges of enlistees occur < 180 or fewer days after beginning military service. Data on EPTS discharges for active-duty enlistees are available for the period 1997-2002. Psychiatric conditions were the most common cause of EPTS discharges reported for the Navy and the Marines (47 and 36 percent, respectively) and the second leading cause of discharge in the Army (15 percent) (see Table 6-3). In 2001, according to data from the Army, the Marines, and the Navy, there were 207 EPTS discharges for depression. No Air Force records were reviewed because of a policy of administratively discharging recruits with mental illness. The percentage of EPTS discharge/accessions were as follows: Marines 0.22; Army 0.16; Navy 0.08; total 0.15. A study conducted at Fort Leonard Wood, Missouri, from September 2002 to March 2003 found that reliance on EPTS coding alone underestimated the number of mental health conditions that contributed to discharge. Psychiatric conditions were also coded under non-EPTS codes (i.e., other mental and physical conditions and entry-level separation). CURRENT SCREENING PROCESS Psychiatric Exclusion Criteria There is increased recognition of depression in children and a concomitant increase in the use of mental health treatment for this disorder in youth. The typical duration of treatment is approximately one year for a single episode of depression. The current DoD fitness standards exclude any individual who has a history of a mood disorder for which outpatient treatment has been rendered for longer than six months by a physician or mental health professional. In effect, that criterion eliminates any appli-

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards TABLE 6-1 Waivers Granted for Active-Duty Applicants for the Four Services       1997-2001 2002       Applied Granted Applied Granted Service Codea Definition Count % Count % Count % Count % Rank Army 306 Physiological malfunction arising from mental factors 845 2.2 844 2.9 352 2.4 350 4.0 7   314 Attention deficit hyperactivity disorder 510 1.3 402 1.4 325 2.3 279 3.2 9 Navy 733 Physiological malfunction arising from mental factors 969 3.8 696 4.9 314 6.3 210 9.2 8   300 Neurotic, mood, somatoform, dissociative or factitious disorders 723 2.8 361 2.6 104 2.1 17 0.8 9 Marines 733 Physiological malfunction arising from mental factors 607 4.0 455 5.2 153 5.0 114 8.9 8   300 Neurotic, mood, somatoform, dissociative or factitious disorders 424 2.8 235 2.7 126 4.2 52 4.1 9   314 Attention deficit hyperactivity disorder 373 2.5 263 3.0 158 5.2 100 7.8 10 Air Force 314 Attention deficit hyperactivity disorder 402 4.1 304 7.3 127 4.6 91 6.1 5   296 Major depressive disorder 288 2.9 117 2.8 47 1.7 29 2.0 8 aICD-9 code for Army applicants; DoD code for all others.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards TABLE 6-2 Hospitalization Rate for Active-Duty Personnel (Army) Category 1997-2001 2002 Rank Neurotic and personality disorders 8.53 8.51 3 Other psychoses 3.21 3.60 6 TABLE 6-3 Existing Prior to Service Discharges of Enlistees, 1997-2002   Army Navy Marines Air Force Category Count % Count % Count % Count % Psychiatric-other 2,986 14.8 7,629 46.6 2,649 36.2 92 2.2 Schizophrenia 37 0.2 43 0.3 11 0.2 1 0.0   SOURCE: Accession Medical Standards Analyses and Research Activity (2003). cant who has ever received treatment for a mood disorder in the past. For example, if a nine-year-old received treatment for depression during fourth grade and had no further episodes of depression, he or she would be disqualified from military service. Consideration should be given to altering this disqualifying criterion because (1) there will be increasing numbers of applicants who have received treatment for depressive disorders and (2) there is no evidence base to support exclusion of individuals who have received outpatient care for longer than 6 months. A more reasonable approach would be to use an age cutoff, similar to that used for eating disorders, such as disqualification if a mood disorder occurs after the 13th birthday. As is the case for depression, there is increased recognition of the early age of onset of anxiety disorders. The DoD fitness standards exclude any individual who has a history of anxiety disorders. For example, an individual with separation anxiety disorder at age six who refused to go to school because he wanted to stay home with his mother would therefore be disqualified from serving in the military. Given the high prevalence of anxiety disorders in youth and the lack of scientific rationale for the exclusion of an individual with a history of anxiety disorders, consideration should be given to altering this disqualifying criterion. An age cutoff for occurrence or treatment of these disorders may be appropriate, such as disqualification if the disorder occurs after the 13th birthday.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards Medical Prescreen of Medical History Report Unlike most other items on the medical prescreen, which lists specific disorders, the one item that is related to mental health is a treatment item. The item is very broad and includes any psychiatric disorder or mental health concern and any treatment. Because this item is so broad and sweeping, disorders that would be of more concern regarding enlistment in the military service have equal weight with minor mental health issues. The medical prescreen should include mental health items of clinical importance, which can be explained more fully as noted in the instructions in Item 2B if the applicant responds affirmatively. Potential prescreen items include a history of suicide attempts, depression, bipolar disorder (manic depressive illness), anxiety disorder, attention deficit hyperactivity disorder requiring medication treatment within the past year, schizophrenia and psychotic conditions, and psychiatric hospitalization. DoD has issued a small business innovative research request for proposals to develop a screening test for detection of major psychiatric disorders in young adults. The aim is to develop a reliable screening instrument to identify individuals at risk of having a mental health problem prior to entering the military. However, there is significant controversy about the utility and value of mass screening for mental health conditions in the military. Rona and colleagues (Rona, Hyams, and Wessely, 2005) emphasize the need for caution, citing the lack of acceptability of screening instruments, obstacles to confidentiality, questionable validity of available instruments, potential to cause more harm than benefit, and diversion of resources from more effective mental health care programs. On the basis of a literature review relating to World Wars I and II, Jones, Hyams, and Wessely (2003) concluded that screening programs did not succeed in reducing the incidence of mental health problems. Medical Evaluation In addition to a medical history form, it would be reasonable to have recruits complete a brief questionnaire regarding current symptoms of mental disorders, which could subsequently be reviewed by the medical officer at the MEPS. The Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ) is a self-administered instrument that has high sensitivity (75 percent) and specificity (90 percent) (Spitzer et al., 1999). The questionnaire includes items related to depression, anxiety, and somatic symptoms and alcohol abuse. It takes approximately three minutes for a physician to review it. This screening questionnaire or others selected should be studied specifically in military populations with regard to performance characteristics.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards The current medical evaluation does not include a formal psychiatric assessment. The medical evaluation provides an opportunity to identify in person individuals who have psychiatric disorders that may adversely affect their performance in the military or lead to attrition or discharge. A brief standardized mental status examination that would address mood, anxiety, psychotic symptoms, and suicide would be important to include as a routine component of the medical evaluation. The addition of this examination has the potential to identify individuals who did not reveal a preexisting condition on the screening forms either through conscious omission or lack of awareness. CONCLUSIONS AND RECOMMENDATIONS Disqualifying Criterion The current DoD fitness standards exclude any individual who has a history of a mood disorder for which outpatient treatment has been rendered for longer than six months by a physician or mental health professional. Consideration should be given to altering the disqualifying criterion for depression because (1) there will be increasing numbers of applicants who have received treatment for depressive disorders and (2) there is no evidence base to support exclusion of individuals who have received outpatient care for longer than six months. As is the case for depression, there is increased recognition of the early age of onset of anxiety disorders. The DoD fitness standards exclude any individuals who have a history of anxiety disorders. Given the high prevalence of anxiety disorders in youth and the lack of scientific rationale for the exclusion of an individual with a history of anxiety disorders, consideration should be given to altering this disqualifying criterion. The committee’s determination of a reasonable cutoff was based on clinical evidence from the civilian youth population. For an adolescent, it takes one to two years to recover from an episode of major depression (Emslie, Mayes, and Ruberu, 2005). Following discontinuation of medication, the period of relapse is greatest during the first year of medication withdrawal. Because relapse rates are high in adolescents, a medication-free period of two years (e.g., ages 16-17) would allow time to assess the clinical response. A cutoff for disqualification of the 13th birthday is a conservative stance designed to decrease the likelihood of a recurrent episode of depression during combat duty. A similar clinical logic applies to anxiety disorders. Recommendation 6-1: We recommend that disqualification for mood and anxiety disorders should occur only if disorders occur after the

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards applicant’s 13th birthday. We recognize that the imprecision with which age cutoffs can accurately predict the likelihood of performance problems due to mental illness suggests that waivers may be commonly requested, and frequently granted, for illness occurring after age 13. However, using the 13th birthday as a cutoff allows sufficient time for clinical follow-up of a diagnosed mood or anxiety disorder to identify potential recruits with a risk of recurrence Mental Health Screening There is a single item on the self-report medical prescreen form completed at the recruiting station that is related to psychiatric disorders. Applicants are asked whether they have “seen a psychiatrist, psychologist, counselor or other professional for any reason (inpatient or outpatient) including counseling or treatment for school, adjustment, family, marriage or any other problem to include depression, or treatment for alcohol, drug or substance abuse.” Applicants responding “yes” are requested to explain the affirmative response, and all documentation relating to an affirmative response is to be sent directly from the treating clinician or hospital to the MEPS chief medical officer. The committee concludes that the single item (2.a.(16), DD Form 2807-2) addressing psychiatric disorders on the medical prescreen form does not contain sufficient specificity for research and evaluation purposes. Recommendation 6-2: Specific mental health disorders should be included on the medical prescreen report form. Recommended items include depression after the age of 13, bipolar disorder (manic depressive illness) after the age of 13, anxiety disorders after the age of 13, exposure to trauma, attention deficit hyperactivity disorder with medication treatment in the past year, schizophrenia and psychotic disorders, and hospitalization for mental illness care. A positive response to this screening question would require open-ended amplification regarding the specific diagnosis. At the MEPS, the available information about the history of treatment for a mental condition depends solely on self-report. The committee concludes that the history questionnaire can usefully be augmented with a short set of questions regarding current symptoms and that a brief standardized mental status examination that addresses mood, anxiety, psychotic symptoms, and suicide would be important to include as a routine component of the medical evaluation.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards Recommendation 6-3: A brief self-report questionnaire regarding current symptoms of mental health conditions should be administrated at the MEPS. Recommendation 6-4: A brief mental status examination should be conducted by the medical officer at the MEPS. There is minimal systematic data collected by the Services regarding individuals with mental health conditions. The prevalence and impact of specific mental health conditions on military performance or attrition rates require further careful study. Mental illness is often coded in vague terms (e.g., adjustment disorder) or is handled administratively without attaching a diagnostic category. Some elements of a complete database describing the impact of mental illness on military personnel exist, and the committee has reason to think that other data elements could be developed through appropriate linkage of existing databases. Recommendation 6-5: Data about mental health disorders from recruitment through active duty should be collected and maintained so that informed decisions can be made regarding recruitment and retention of applicants with mental illness. These data should be obtained for all the Services and should create an accurate picture of the impact of mental illness on military personnel from recruitment through separation, with a particular focus on the outcome of recruits who request and receive mental illness waivers for specific diagnoses, as well as the rates and diagnoses leading to attrition during training and active duty. Further studies using complete data sets should be designed to determine whether there are any differences in retention and performance between recruits with and without a history of psychiatric disorders, such as depression and anxiety disorders.