Hoge, Charles, Carl A. Castro,

Hoge, Charles, Carl a. Castro, Stephen C. Messer, Dennis McGurk, Dave I. Cotting, & Robert

L. Koffman. (2004). Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. Originally published in the New England Journal of Medicine, 351:13-22.

The physical injuries caused by military combat are all too obvious. However, the 2004 article by Hoge (et al.) from the New England Journal of Medicine attempts to bring to light the often invisible mental health problems generated by combat. To better understand and treat the mental health problems suffered by veterans, investigators studied a population selected from three Army units and a Marine Corps unit. The reason for selecting three Army units and one Marine unit and the decision to exclude Navy or Air Force combat forces was to ensure a focus on ground combat units. The Army units were demographically similar; the Marine unit was slightly younger and contained more unmarried individuals (Hoge 2004, p.10). The researchers used an anonymous survey to ensure confidentiality and candor. Hogue (et al.) also notes that the survey generated a very high response rate due to the anonymous nature of the inquiry and to the fact that participants were given time by their units to complete the 45-minute survey (Hoge 2004, p.9).

The survey was administered to 2,530 subjects before their deployment to Iraq and to 3,671 subjects 3 to 4 months after their return from combat duty in Iraq or Afghanistan. The complaints studied included major depression, generalized anxiety, and posttraumatic stress disorder (PTSD). All were evaluated on the basis of standardized, self-administered screening instruments. The units "whose members responded to the survey were also involved in hazardous security duties" and of those deployed to Iraq, nearly 90% reported handling dead bodies and receiving direct fire (Hoge 2004, p.7; 12).

Self-screening can be problematic for mood disorders like major depression and PSTD, given that quite often the subject's loved ones may be more apt to spot changes in the individual's normal behavior. Additionally, given the timing of the study, problems may have yet to manifest themselves in an obvious fashion. However, this was partially the purpose of the study: "very few studies have examined a broad range of mental health outcomes near to the time of subjects' deployment" and shortly afterward (Hoge 2004, p.7). Still, the subjects might still be so inculcated in the military mindset of not revealing weaknesses they could be less willing to admit mental problems. However, despite the possible tendencies to underestimate mental health stressors, the study still found significant mental distress amongst all former combatants. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq than after tours of duty in Afghanistan and much higher in subjects who had been wounded or injured (Hoge 20004, p.12). Greater frequency and intensity of combat experiences in Iraq was seen as the reason for the discrepancy.

The research was conducted through the auspices of the U.S. military and the response rate was 98%. Unit leaders assembled the soldiers and the investigators then briefed them and obtained their written consent. It should be noted that the researchers were themselves military personnel and thus were likely relatable figures for the study's members, and could 'speak the language' of the subjects (Hoge 2004, p.8). Major depression and generalized anxiety were measured with the use of a patient health questionnaire developed for a general population group while the presence or absence of PTSD was evaluated with the use of the 17-item National Center for PTSD Checklist of the Department of Veterans Affairs. Thus the instruments combined both civilian and military psychological inventories. The relatively brief survey took 45 minutes to complete and focused on current symptoms. There were also two questions regarding alcohol 'misuse' and questions about the severity of stress, emotional problems, and family problems experienced by the respondents. Participants were then asked whether they were interested in receiving help and asked about their past use of mental health services and perceived barriers to treatment such as stigmatization. Overall, it was found that 9% of soldiers were deemed to be at risk for mental disorders before combat deployment, and as many as 11% to 17% were at risk for such disorders 3 to 4 months after their return. Only 38% to 45% indicated an interest in receiving mental health services, and only 23% to 40% reported having received professional help in the past year (Hoge 2004, p.12).