Identifying Soldiers for behavioral-health problems before they deploy to a combat zone, and then coordinating continuing care for those Soldiers while they are overseas, can reduce suicidal thoughts, psychiatric disorders and other problems, according to a study published in the American Journal of Psychiatry.

The study was conducted with more than 20,000 Soldiers assigned to Multinational Division-Center in Iraq during 2007 and 2008. Three brigade combat teams (BCT) of the 3rd Infantry Division were screened for behavioral-health issues during pre-deployment processing at Fort Stewart, Ga. Three brigade combat teams from other installations did not receive the same screening and provided a comparison group.

Only 2.9 percent of the screened troops presented for psychiatric or behavioral-health disorders in the first six months of deployment, compared to 13.2 percent of the comparison group. These Soldiers also had lower rates of combat operational stress reactions (15.7 percent versus 22 percent), expressing thoughts of suicide (0.4 percent versus 0.9 percent) and gestures toward suicide (0.1 percent versus 0.2 percent). Only 0.6 percent received duty restrictions for behavioral health reasons, and 0.1 percent were evacuated from the theater for those reasons, compared to 1.8 percent and 0.3 percent, respectively, in the comparison group.

The co-primary investigators for the study were Col. George N. Appenzeller, then division surgeon of the 3rd Infantry Division and now commander of the Army hospital in Alaska, and Maj. Christopher H. Warner, then the division's staff psychiatrist and now a student in the Army Command and General Staff College.

Assisting with the study were Capt. Jessica R. Parker, chief of the Warrior Restoration Center at Fort Stewart; Dr. Carolynn M. Warner, then surgeon for Fort Stewart's warrior transition unit; and retired Col. Charles W. Hoge, senior scientist at Walter Reed Army Institute of Research and The Army Surgeon General's consultant for neuropsychiatry.

Military behavioral-health screening in past wars focused on identifying Soldiers who should not deploy. This process differed in attempting to improve care for Soldiers during their deployments.

"This system shifted away from the traditional mental-health paradigm of attempting to predict future behavior or inability to cope. Rather, the purpose of this process was to ensure that we were not deploying unsafe Soldiers based on present conditions, and ensuring that we were linking those who were deploying with the in-theater assets so that they could stay in the fight. The result is an effective process that enhances Soldier and unit safety," said Warner.

Soldiers in the 3rd Infantry Division who were preparing to deploy to Iraq were evaluated by primary-care health professionals and asked about behavioral-health treatment, use of medications and suicidal or homicidal thoughts. Those who were identified as needing more screening were interviewed by a psychiatrist, psychologist or licensed clinical social worker. They were evaluated using Department of Defense guidelines established in 2006 to ensure that Soldiers under treatment for behavioral-health conditions were stable for deployment, and to facilitate ongoing care for those who required further treatment in the deployed environment. All care was coordinated through the unit health-care providers.

During the first six months of each brigade combat team's deployment, behavioral-health problems were monitored using a standard mandatory reporting and tracking system used throughout Iraq.

The most important component of this program, according to the investigators, was the coordination of care in theater.

"A unique aspect to this study was the requirement for BCT surgeons and the division psychiatrist to track and monitor all of these Soldiers during their deployment and coordinate in-theater care for those on medications and those who received waivers," said Appenzeller. "This was accomplished through medical management by the unit-assigned primary-care providers who deployed with the Soldiers, to ensure ongoing Soldier confidentiality."

Of the 10,678 Soldiers who underwent the pre-deployment screening process, the screening process identified 819 (7.7 percent) who required an evaluation with a behavioral-health professional, including 347 (3.3 percent) who were taking a medication for a sleep or behavioral-health problem. After evaluation, only 48 (less than half a percent) were unable to deploy because of a serious behavioral-health problem, 26 had their deployment delayed one to two months for behavioral-health treatment, and all of the remaining Soldiers with behavioral-health concerns deployed with ongoing support in theater. Soldiers who needed ongoing care were seen regularly by unit medical providers. The program assisted Soldiers to complete the deployment successfully.

"The study is informing ongoing revisions to pre-deployment processes and the response to new ... requirements for pre- and post-deployment mental-health assessments," said Hoge.