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The Army is asking soldiers who go to the doctor for ailments such as back pain or colds to answer questions about depression and post-traumatic stress disorder in a bid to identify those who may need help.
About 63,000 soldiers out of 2 million screened during routine doctor appointments since 2007 have tested positive for previously unrecognized and untreated mental health problems, according to Col. Charles Engel, a Walter Reed National Military Medical Center doctor.
“The patients may be there for anything from a broken arm to an upper respiratory problem,” Engel told experts gathered at a recent meeting of the American Psychiatric Association. “Very seldom do people go to their primary care doctor just for stress or depression problems.”
Studies show that the average person with PTSD waits 12 years before being treated. As recently as 2004, only about a quarter of soldiers who were suffering from PTSD were getting specialized care, he said.
“We have a lot of people out there getting no care,” he said.
The program was started in 2007 by the Army Surgeon General, initially at 40 targeted primary care clinics. It now is offered at 88 out of 96 such clinics worldwide and the rest are to join the program this month, Engel said. Each month 100,000 soldiers are screened, he said.
Soldiers who go to the clinics for other health issues are asked to fill out a form with questions designed to identify people suffering from depression or PTSD, he said.
“Guys see these questions over and over again and, eventually, they decide to talk to somebody,” Engel said. “In most of these cases, the patients wouldn’t have said anything in a normal clinic encounter.”
In addition to the screening, the Army is providing mental health training for medical personnel and follow-up treatment for soldiers who test positive for depression and PTSD, Engel said.
Once patients are identified, and if they agree that their issues need to be addressed, doctors work with them to develop a treatment plan. Patients who don’t want to go to a mental health professional can be assigned a nurse trained to follow up with them and help manage their treatment, he said.
The nurses schedule appointments and track symptoms so that the most acute cases receive immediate attention. Patients’ care is reviewed after two months and their treatment is adjusted if there is no significant improvement, Engel said.
“The more times we follow up, the better we get,” he said. “By four to five follow-ups with the nurse, there is a clinically significant effect in their symptom severity.”
The program is seeing positive results, regardless of the type of treatment that patients opt for, which can range from medication to organized talk therapy to simple phone conversations with their nurse, he said.
“In the five years that we have been doing this, there have been only two suicides of patients who followed the program, and they were people who were not in follow-up at the time,” he said.
Fort Bliss, home to the 1st Armored Division, which has seen extensive service in Iraq and Afghanistan in recent years, has screened thousands of soldiers at its two clinics since 2008, according to Dr. Melissa Molina, a family practitioner at the Texas base.
“They are screened when they go for primary care visits for things like shoulder or neck pain,” she said. “We take away the stigma of soldiers having to go and see a psychologist or a behavioral health person.”
The first few times a soldier fills out the mental health questionnaire, they might not indicate that they have any problems, Molina said.
“They might lie. But if they are getting this paper all the time when they are coming to their doctor, they might eventually say: ‘I have issues,’ ” she said.
In one memorable case, Molina treated a lieutenant colonel for high blood pressure for a year before he opened up about mental health issues.
“He’d fill out that paper and it would always be negative, but one day my nurse came and told me he had answered positive to every question,” she said. “I talked to him and he said he had finally decided to admit that he was depressed.”
The officer, who had seen soldiers lose limbs in roadside bombings in Iraq, said he hid his problems because he was worried people would think he was crazy, Molina said.
“He went inside of himself,” she said. “Outwardly, he was this quiet, strong man, but inside, he was boiling over.”
Six weeks on antidepressants and regular calls to the nurse made a big difference, Molina said.
“He came to see me and he was a totally different person,” she said. “He said: ‘I feel good again. I’ve been playing ball with my kid. My family is so much happier because I feel better and don’t just want to go to bed when I get home. I’m not angry and yelling at them.’ ”
At Fort Bliss, nurses call their mental health patients every week or two, Molina said.
“It’s not as formal as having a relationship with a doctor,” she said. “This is a female nurse who will almost act like their mother, and a lot of times they need that.”
In one instance, a soldier called his nurse and told her he was walking down train tracks and thinking about suicide. The nurse called the Military Police, who took the soldier to a hospital, Molina said.
Only about 20 percent to 25 percent of soldiers suffering from PTSD will achieve complete remission of symptoms while they are in the program, although many will see less severe symptoms following treatment, Engel said.
However, studies show it is best to start treating the problems early, and that is something that the screening program will help facilitate, he said.
Early treatment for soldiers suffering from mental health problems reduces the cost of dealing with related symptoms such as back pain, accidents and emergency room visits from hazardous drinking, he said.
Data from the program also shows that the more patients interact with the nurses, the more improvement they show in their PTSD and depression symptoms, Engel said.
The Army expects to expand availability of the program to include all family members in the military health system over the next year, he said.