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Pre-deployment screening for vulnerability to Post Traumatic Stress Disorder
- Ferhal Utku, Ken Checinski (14 November 2006)
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Too broad a conclusion.
- Matthew P Newton Ede, Su-Wen Goh (14 November 2006)
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Difficulties in predicting PTSD
- Prakash B Shivashankaraiah (15 November 2006)
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Clinical assessment may be the way forward.
- Suryanarayana Kakkilaya (15 November 2006)
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Ferhal Utku, Research SHO in Psychiatry St George's, University of London, SW17 0RE, Ken Checinski
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Rona et al (BMJ 2006;333:991-4) have conducted an important study of UK military personnel with a large, statistically powerful cohort. Editorially, Hyams (BMJ 2006;333:979-80) correctly points out the confounding “healthy warrior” effect. This, together with the marked differences between conscripted and volunteer groups, makes it difficult to extrapolate findings from the First and Second World Wars to the modern era. Nevertheless, there is a powerful message that PTSD (and other mental disorders) are difficult to predict, with the implication that ex-service personnel are likely to present to civilian mental health services with such conditions. As a substance misuse service, we have seen PTSD with drug/alcohol misuse as the index symptom in a number of such people and have found “Combat Stress” (based in Leatherhead, Surrey) a very useful organisation, not least because of the ability to tap into the “healthy warrior” effect through group and individual therapies, allowing us to treat the addictive behaviours in context. Post-trauma debriefing is possibly harmful (1), so service personnel need vigilant monitoring for mental disorder after the fact. This is particularly important when they leave the protective group environment provided by military life. More attention should be paid to the transitional and demobilised phases to allow early detection of PTSD emerging from a dormant phase. Often, on discharge, ex-service personnel feel abandoned, adding to the sense of anomie experienced by those suffering from PTSD. There is a case for all mental health services to receive training in helping them accept generic treatment and access more specialised input, where indicated. 1 Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Systematic Review, 2002. Competing interests: None declared |
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Matthew P Newton Ede, Regimental Medical Officer and Specialist Registar 207 Field Hospital (V), Manchester and North Manchester General Hospital, M8 5RB, Su-Wen Goh
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We read with interest the article of Rona et al. “Mental health screening in the armed forces before the Iraq War and prevention of subsequent psychological morbidity: Follow-up study”. We must however disagree with the conclusion that pre-deployment screening would not have reduced morbidity from common mental illnesses. This is too broad a conclusion. All that may be concluded is that the screening tools employed by the researchers did not predict morbidity. Indeed when looking at the three main scores used (GHQ-12, SF-36 and PCL-C), it is clear that these tools were designed for a “snapshot screen” in time. None were designed as a predictor of future mental illness (1,2,3). Military deployment occupies a unique position in that it will almost invariably expose individuals to significant psychological insult. The concept of pre-deployment screening therefore poses the unique question: what predisposes an individual to mental illness given an imminent, predictable insult? To our knowledge, there is no assessment tool that is designed to answer this question. We share the authors’ disappointment that the commonly used mental health screening tools have not proved useful in predicting illness. However we advise caution against a broad statement that screening for common mental disorders before deployment does not reduce morbidity. We must not discourage future researchers from devising more appropriate predictive tests for these debilitating diseases in this unique group of individuals. 1. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther. 1996 Aug;34(8):669-73. 2. Goldberg D, Williams P. A user’s guide to the general health questionnaire. NFER-Nelson:Windsor, 1988. 3. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36® Health Survey Manual and Interpretation Guide. Boston, MA: New England Medical Center, The Health Institute, 1993. Competing interests: None declared |
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Prakash B Shivashankaraiah, SHO Psychiatry University Hospital Aintree, Liverpool, L9 7AL
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Study conducted by Roberto J Rona et al has revealed that pre deployment screening is not effective in predicting the mental health problems that may subsequently arise. Studies have demonstrated that perceived threat to life1 and dissociative responses that occur at the time of a trauma2 are major risk factors for development of a probable posttraumatic stress disorder. The magnitude of a traumatic epicentre and its outer reverberations that an individual may experience can not be predicted. This might offer an explanation for the outcome of this study. 1.Holbrook-TL, Hoyt-DB, Stein-MB, Sieber-WJ, Hoff-W, Rozycki-G, Maxsin-T, Schermer-C, Hawkins-M, Mendelson-J. Perceived threat to life predicts posttraumatic stress disorder after major trauma: risk factors and functional outcome. Journal of Trauma, 2001 Aug, vol. 51, no. 2, p. 287-93, (32 ref), ISSN: 0022-5282 2. Briere-J, Scott-C, Weathers-F. Peritraumatic and persistent dissociation in the presumed etiology of PTSD. American Journal of Psychiatry {AM-J-PSYCHIATRY}, 2005, Vol/Iss/Pg. 162/12 (2295-2301), ISSN: 0002-953X. Competing interests: None declared |
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Suryanarayana Kakkilaya, Staff Grade Psychiatrist Peasley Cross Resource centre, 5 Boroughs Partnership NHS Trust, St Helens WA9 3DA
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Study conducted by Roberto J Rona et al1 has raised uncertainties on the effectiveness of pre deployment screening for post war PTSD and other psychological problems. The study uses GHQ and PCL- C as screening tools, but these tools are not specific to detect risk of developing PTSD. GHQ and PCL-C are good indicators of psychological distress and symptoms of PTSD respectively. This study does not take in to account other determinants including sets of cognitive factors2, background and childhood factors3 and pre- and post-date service related experiences4. It is important to screen for mental health problems as a part of general health screening to reduce the impact of subsequent psychological morbidity which might compound the physical injuries. The tools used in this study are not sensitive enough to predict the future risk of developing post traumatic psychological problems and there are no other standardised tools available. Clinical assessment of armed forces prior to deployment may be one of the ways forward. 1. Rona RJ, Hooper R, Jones M, Hull L, Browne T, Horn O, et al. Mental Health screening in armed forces before the Iraq war and prevention of subsequent psychological morbidity: follow-up study. BMJ 2006, doi:10.1136/bmj.38985.610949.55 2. Ehring-T, Ehlers-A, Glucksman-E. Contribution of cognitive factors to the prediction of post-traumatic stress disorder, phobia and depression after motor vehicle accidents. Behaviour Research and Therapy {BEHAV-RES-THER}, 2006, Vol/Iss/Pg. 44 /12 (1699-1716), ISSN: 0005-7967. 3. Koenen-Karestan-C, Moffitt-Terrie-E, Poulton-Richie, Martin-Judith, Caspi-Avshalom. Early childhood factors associated with the development of post-traumatic stress disorder: results from a longitudinal birth cohort. Psychological Medicine, {Psychol-Med}, 20 Oct 2006 (epub: 20 Oct 2006) , p. 1-12, ISSN: 0033-2917. 4. Maguen-Shira, Suvak-Michael, Litz-Brett-T. Predictors and Prevalence of Posttraumatic Stress Disorder among Military Veterans. Military life: The psychology of serving in peace and combat (Vol. 2): Operational Stress, (Operational Stress), 2006, p. 141-169, pp. xi + 255, ISBN: 0-275-98302-1 (hardcover). Publisher: Praeger Security International, Westport, C Competing interests: None declared |
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