Psychological Screening Validation with Soldiers Returning from Combat

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Paul D. BLIESE, Kathleen M. WRIGHT, Amy B. ADLER1, and Jeffrey L. THOMAS Walter Reed Army Institute of Research

Note: The views expressed in this abstract are those of the authors and do not reflect the official policy or position of the US Department of the Army or Department of Defense.

Abstract. Soldiers returning from combat military operations are at risk for developing a range of psychological problems. One way to facilitate the identification of these at-risk soldiers is to have them complete a psychological screening survey. Such a survey can be used to link soldiers reporting psychological problems with appropriate mental health services. The challenge of developing such a screen is to ensure that it is valid, short, and easy to administer. The US Army Medical Research Unit-Europe has been at the forefront of developing a valid psychological screen for use with soldiers at post-deployment. Research conducted prior to 2004 showed that screening needed to include five domains: post-traumatic stress disorder, depression, alcohol problems, anger, and relationship problems. Blind validation studies conducted in 2004 led to the selection of scale items and cut-offs for each domain resulting in an effective short screen with good sensitivity and specificity values. Finally, the question of when to conduct psychological screening at post-deployment has also been addressed through a comparison of prevalence estimates at immediate reintegration and three months post-deployment. Future research will examine scale refinement and the use of sleep problem questions in subsequent screening efforts.

Keywords: Combat stress, posttraumatic stress disorder, mental health screening, deployment health

1. Psychological Screening Validation with Soldiers Returning from Combat

Psychological screening in the US military provides service members with the opportunity to identify themselves as needing mental health support. While various mechanisms for screening exist, the U.S. Army Medical Research Unit-Europe (USARMU-E), an overseas activity of the Walter Reed Army Institute of Research, is engaged in developing a short, easily-administered and validated screening procedure for use with military personnel pre-

Corresponding Author: LTC Paul Bliese. Commander US Army Medical Research Unit-Europe. Nachrichten Kaserne, Karlsruher Str. 144, 69126 Heidelberg, Germany. Telephone: ++49-6221-17-2626, email: [email protected].

and post-deployment. The goal of such screening is not selection, nor is it an effort to identify which individuals are fit to join the military and which should be excluded. Rather, psychological screening is a pro-active attempt to bring military mental health support to service members. The procedure is also transparent. The screen is designed to be straightforward, and service members know the purpose of the screen and the consequence of endorsing symptoms (e.g., that they will potentially be referred for further mental health evaluation).

2. Background

Originally, psychological screening was mandated by the Office of the Secretary of Defense for Health Affairs in 1996 for U.S. service members deployed for more than 30 days to the Bosnia Area of Operations. The scales selected for inclusion in the original screening program were primarily scales published in the open literature and validated on civilian populations. The degree to which these scales and their associated cut-offs were valid for the military population, however, was not known. After the screening program in Bosnia was concluded in 1999, psychological screening continued to be requested by commanders for other operations (for a review of the program, see Wright et al. [1]. Thus, screening remained an important component of the health support provided to military personnel across the deployment cycle.

In 2003, a mandated screening program was implemented with service members returning from combat operations in Iraq and Afghanistan (Department of Defense Form 2796). This newly mandated program underscores the continued importance that psychological screening has as part of the US military's health program for deploying military personnel.

Throughout the implementation and development of the psychological screening program, USAMRU-E has analyzed screening data and published several reports [2-3, 1-4, 5]. In total, USAMRU-E has processed screening data on over 100,000 Soldiers. Across a range of screening contexts, 15-28% of Soldiers have scored positive on the primary screening survey and 2 to 12% were recommended for a follow-up evaluation based on a brief clinical interview. Less than 1% of those screened were found to need immediate services because of threat to self or others.

3. Screening Validation Research

In 2002, USAMRU-E research on psychological screening shifted to focus on assessing the validity of the scales and cut-offs used on the primary screening survey. At that time, a series of USAMRU-E studies developed the groundwork for systematically validating the psychological screening program [4].

The first in this series of studies involved the screening of US Soldiers preparing to deploy on a peacekeeping operation. This study was designed to assess the content validity of the screen. In all, 885 Soldiers were interviewed and 864 consented to have their data analyzed for research purposes. From this study [4], five content areas were identified as targets for screening: (1) traumatic stress, (2) depression, (3) relationship problems, (4) alcohol problems, and (5) anger problems. In addition, the screening survey also included selected background questions such as demographic information and clinical and personal history items. These additional questions were included because previous research had found them to be useful variables in predicting those who required follow-up services [1, 6].

Although the optimal content areas were identified, the scales that were used to screen for these clinical dimensions were lengthy. In addition, the scoring on some of the scales tended to be complicated. The scales were also a combination of those selected from the literature and had not been specifically validated with military personnel. Thus, there was a need to develop shorter, validated scales that could be used in a quick screening procedure.

The subsequent USAMRU-E validation studies have focused on reducing the number of scale items and improving the sensitivity and specificity of the clinical scales. In each of the three studies conducted so far, a specific validation procedure was used. The procedure began with the administration of the psychological screening survey. All of those Soldiers exceeding previously established criteria on the clinical scales were interviewed as were a random selection of 20-30% those not exceeding established criteria. Those clinicians conducting the interview were blind to the individual's status on the screening survey. A determination was then made based on the structured clinical interview as to whether follow-up clinical evaluation and/or services were needed. A flowchart describing the process is presented in Figure 1.

Figure 1. Flowchart for psychological screening research procedures.

This screening procedure was used twice in 2004. First, 732 US Soldiers stationed in Germany preparing to deploy to Iraq for a year were screened. In all, 356 were interviewed. Results from the pre-deployment screening study found that 75 (10.2%) Soldiers were referred for follow-up evaluation based on a brief clinical interview. Second, 1,568 US Soldiers recently returned from a year in Iraq were screened, and 592 were interviewed. Results from the post-deployment screening study found that 106 (6.8%) were referred for follow-up based on a brief clinical interview.

Note that although these two studies included a pre-deployment and post-deployment sample, these were two very different units located in two different countries. A third study, conducted in 2005, involved post-deployment screening of those Soldiers who had participated in the 2004 pre-deployment data collection. Data presented here are taken from the 2004 studies only. Complete reports on these data are available [7-8].

4. Screening Results

Sensitivity and specificity analysis compared the scores on the primary screening surveys with results from the structured clinical interviews (in part adapted from the MiniInternational Neuropsychiatry Interview [M.I.N.I., 9]. Bliese, Wright, Adler, Thomas [7] provided a detailed review of the sensitivity and specificity associated with each of the five clinical domains compared to the structured clinical interview results. For the purposes of the present brief report, we primarily review the results from the analysis assessing posttraumatic stress disorder. Post-traumatic stress disorder and trauma-related symptoms were the most common reason for referral to follow-up mental health services in the post-deployment sample. Thus, this clinical domain seems particularly relevant to Soldiers' post-deployment psychological health.

In predicting traumatic stress referrals we evaluated two measures: (1) the 17-item Post-Traumatic Stress Checklist [10], and (2) the 4-item Primary Care - Post-Traumatic Stress Disorder screen (PC-PTSD) which is also used in the DD Form 2796, the mandated Department of Defense screening form. The stem question on the PC-PTSD was "Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you..." (1) Have had any nightmares about it or thought about it when you did not want to? (2) Tried hard not to think about it or went out of your way to avoid situations that remind you of it? (3) Were constantly on guard, watchful, or easily startled? (4) Felt numb or detached from others, activities, or your surroundings? Response options were no and yes.

Table 1 shows how various cut-off values on the PC-PTSD correspond to clinical providers' ratings as a result of the brief clinical interview based on the PTSD Module from the M.I.N.I. When the cut-off value was set at one, the primary screen identified 32 of the 37 Soldiers who were identified as positive by the clinical providers. This resulted in a sensitivity value of 0.86. At the same time, however, the criterion of requiring only one of the four items to be endorsed produced 148 false positives for a specificity value of 0.73.

Table 1: PC-PTSD survey scores compared with provider referrals for post-traumatic stress symptoms

Primary Screen with 1 or More

Clinical Provider



Negative Positive

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