Mental Health Evaluations for Military Recruits

August, 2015

Prepared By

The Military REACH Team

The Center for Research and Outreach (REACH)

The University of Minnesota

Author:

Benjamin Butler

Military REACH Team:

Lynne M. Borden, PhD

Benjamin Butler

Michelle D. Sherman, Ph.D.

For additional information, please contact:

Lynne M. Borden, PhD

Department of Family Social Science

The University of Minnesota

lmborden@umn.edu

(612) 625-4227

Introduction

Risks associated with the emergence of mental health problems among military personnel are complex, multifaceted, and inter-related. Although considerable amounts of recent research have focused on correlates of combat deployment to war zones, deployment-related factors are not the sole cause of the development of mental conditions among military personnel. Pre-existing mental health conditions may resurface during high stress situations that are sometimes encountered in the military. The potential consequences of pre-existing mental health problems on job performance are a concern for the military and have implications for their screening and recruitment process. All recruits, regardless of branch of service or job assignment, go through the same screening process before enlistment. Current screening methods rely on recruits’ self-report of past mental health diagnoses and symptoms that could affect his/her qualification and readiness for military service (Niebuhr, Gubata, Oetting, Weber, Feng & Cowan, 2013).

Exposure to a war zone and combat deployment can increase a Service member’s risk for numerous mental health problems (McAndrew et al., 2013). Research has shown that there have been sharp increases in certain mental health problems among Service members serving in Iraq and Afghanistan (Institute of Medicine, 2014). Throughout the duration of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) (2001-2011), there was a 62% increase in Active Duty Service members being diagnosed with a mental health problem. A general population epidemiological study shows that most lifetime mental disorders have childhood-adolescence onsets between the ages of 12-14 that are initially too mild to cause rejection from military service, even if they may predict more severe subsequent episodes (Kessler, Heeringa, Stein, Colpe, Fullerton, Hwang & Ursano. 2014).

The Diathesis Stress Model (Zubin & Spring, 1977) can lay the theoretical framework for considering the emergence of mental health problems under stress. Diathesis is a hereditary predisposition to a disorder. Mental health problems can emerge when there is an interaction between a diathesis (vulnerable predisposition) and stress (environmental influences). This model may be useful in considering mental health problems among Service members where a genetic predisposition interacts with environmental or life stressors (e.g. combat deployment, war zone atmosphere) to trigger psychological problems.

Consideration and the understanding of family history, current screening methods and implications of improved screeners are necessary to understand the rationale behind implementing new standards and strategies for screening military recruits. With room to improve the current military’s screening process, the ability to evade (i.e. knowingly withhold information about mental health problems) the standards, laws, and qualifications associated with military accession (i.e., enlistment, joining the military) is a problem that may have programmatic and policy implications. Currently, mental health professionals are not involved in the recruiting process for the United States Military; rather, screens are performed by nurses and physicians. This review will describe the rationale for implementing psychological screening of

all recruits, the current strategies used during the recruitment process, challenges the military currently faces with regards to mental health, and implications for future policies and action.

Rationale for Screening

Implementing new and improved mental health screeners may have positive effects on the health and success of our Service members and military. It is possible that mental health screenings might provide an opportunity for early mental health intervention, shape job placement, reduce defense spending on healthcare costs, and possibly reduce more distal outcomes such as suicide rates.

Financial implications

The Department of Defense (DoD) and Veterans Health Administration (VHA) health care systems have received billions of dollars to provide treatment for those wounded in war (Burnam, Meredith, Tanielian & Jaycox, 2009). The financial cost of the increasing number of mental health cases in Service members is a major economic issue for the United States. Research conducted by RAND Corporation developed microsimulation models to estimate costs of traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), and depression-related injuries. On a per-case basis, two year costs associated with major depression are estimated to reach $12,427 to $16, 884 (RAND, 2008). Using further analysis and microsimulation models, the study translated these costs into a total-dollar amount predicting two-year costs for approximately 1.6 million troops affected by mental health problems who have been deployed since 2001. PTSD related and major depression related costs could cost the U.S. up to $6.2 billion over two years. These figures exclude the potential costs resulting from these mental health problems; if left untreated or undertreated, these conditions could worsen and adversely affect other domains of functioning, including physical health, social and family relationships, homelessness, and school and occupational functioning. It is possible that strengthening mental health evaluations during the recruitment process may lead to lower overall mental health care costs.

Suicide

Although the military suicide rate has historically been lower than that of civilians, suicide rates have exceeded the demographically matched civilian rate since the beginning of the wars in Iraq and Afghanistan (Schoenbaum, Kessler, Gilman, Colpe, Heeringa, Stein & Cox, 2014). In recent years, even with access to health care services, mandatory suicide prevention training, and other preventative efforts, suicide among Service members has established itself as a leading cause of death in the U.S. military (LeardMann et al., 2013). Specifically, beginning in 2005 the United States military saw an increase in suicide rates from the baseline rate of 10.3 to 11.3 deaths per 100,000 persons to a rate of 16.3 per 100,000 persons in 2008, peaking amongst Marine and Army Service members with rates of 19.9 and 19.3 per 100,000 persons, respectively. These statistics offer further evidence that evaluating recruits prior to enlistment may lower the increasing suicide rates within the military.

In a study conducted by the Army STARRS program, lifetime prevalence estimates of suicidal ideation, planning and attempts among soldiers are 13.9%, 5.3% and 2.4%, respectively (Nock, Stein, Heeringa, Ursano, Colpe, Fullerton & Kessler, 2014). A majority of reported suicide cases had pre-enlistment symptoms (e.g. anxiety, low self-esteem), and close to one-third of post enlistment suicide attempts were associated with pre-enlistment mental problems. Service members who struggle with mental health problems and/or suicidal ideation prior to enlistment may be a high risk group and warrant specialized screening during the recruitment process. Exposure to war zones and combat may exacerbate pre-existing conditions and render the Service member unable to be a productive member of his/her unit. These results highlight the importance of pre-enlistment mental health evaluation and intervention to help decrease mental health problems and suicidal ideation and behavior among U.S. Service members.

Opportunity for early intervention

With advanced screening methods, early detection of mental health problems could lead to better allocation of mental health resources. The military is a unique occupational environment. Contrary to civilian workplace, the military has extensive behavioral health care protocols and systems in place to manage and rehabilitate Service members dealing with mental health problems (Hoge, Toboni, Messer, Bell, Amoroso & Orman, 2005). The military has a strong infrastructure of supports to help military personnel with mental disorders; it strives to rehabilitate Service members before considering a medical separation. However, Hoge (2005) suggests there is evidence implicating that Service members mental health problems existed prior to enlistment. This research states that certain instances have occurred where medical conditions, that would normally have a Service member disqualified, are not detected at the entry medical evaluations but are later discovered during the first 6 months of service. These disqualifications were significantly higher among Service members dealing with mental disorders (8%) than Service members being disqualified for any other condition (e.g. eyesight, heart condition) (<1%). Such statistics may justify earlier and improved mental health evaluations in order to cut back on attrition and disqualification rates.

The U.S. government allocates substantial resources to providing mental health services for Service members battling mental health problems. Research has associated deployment and combat exposure with increased risk in PTSD, major depression, substance abuse, and functional impairment in social and occupational settings (Hoge, Auchterlonie & Milliken, 2006). Whether or not these problems existed prior to enlisting, improved screening tactics may help with safer, more productive job placement as well as more efficient utilization of mental health resources.

Current Screening Techniques

Currently, the military utilizes three screening approaches during the accession (i.e. process of applying to enter the military) of applicants (Cardona & Ritchie, 2007). The aptitude test, otherwise known as the Armed Services Vocational Aptitude Battery (ASVAB), was established in 1976. Four of the 10 ASVAB subtests are grouped into another assessment called the Armed Forces Qualification test (AFQT) score; this test estimates the recruit’s intelligence capacity.

Scores from this approach are also used to place recruits in occupations where they might be more likely to excel.

The second component of the existing screening is a review of educational achievement (e.g. high school diploma, GED). The U.S. Congress devised accession standards in relation to the Department of Defense’s mathematical model for attrition rates. This model associates educational achievement, aptitude test scores and recruiting resources to job performance. The third screening measure is a review of medical screening forms which are filled out by the recruits themselves and a gross mental health evaluation (i.e. whether the recruit believes he/she has experienced mental health problems in their lifetime) conducted by a physician, physician assistant, or nurse. There are no specific measures of psychological health prior to accession into service.

One potentially useful approach for assessing mental health fitness pre-enlistment that is being administered at select Army Military Entrance Processing Stations (MEPS) is the Tailored Adaptive Personality Assessment System (TAPAS). This measure is a computerized adaptive testing (CAT) tool that assesses the relationship between a recruit’s personality characteristics rooted in the Big Five (i.e. extraversion, agreeableness, conscientiousness, neuroticism, openness) and a ‘will-do’ mentality (Stark, Chernyshenko, Drasgow, Nye, White, Heffner & Farmer 2014). A dimension assessing physical fitness was also added to TAPAS due to its relevancy in occupational placement. TAPAS utilizes multidimensional pairwise preference items composed of statements that reflect on different dimensions of personality. In each question, two statements that are specifically chosen with similar social desirability and extremity are given to help avoid faking an answer. Currently two longitudinal studies are being conducted on the screening measure, assessing whether the tool is a predictor of service longevity and MOS placement.

Although no research has been conducted on the mental health evaluation process done by the recruiters themselves, it is possible that a substantial amount of the mental health screening is conducted by recruiters. While trained in assessing what qualities a healthy and worthy applicant should possess, a recruiter is not a qualified mental health professional. These recruitment interviews are often unstructured assessments based largely on personal opinions and feel (i.e. the recruiter’s ability to recognize and pry on a certain topic if he/she sees fit to do so) (Personal communication, Staff Sergeant Veines, U.S. Marine Corp, July 2015).

Challenges for Mental Health Evaluation

Although implementing new mental health evaluation may provide benefits, doing so is not without challenges, such as increased surrounding mental health care, financial implications, and limited effectiveness of mental health screeners.

Stigma

All U.S. soldiers are required to undergo mental health screening for PTSD, depression and other mental health problems upon return from combat deployment to Iraq or Afghanistan. Despite the mandatory nature of this screening process, stigma surrounding mental health issues remains

high in today’s military. Some examples of stigma regarding Service members seeking mental healthcare in previous studies included “My unit leadership might have less confidence in me,” “Members of my unit might view me differently,” and “It would harm my career.” Stigma may deter help-seeking (Warner, Appenzeller, Grieger, Belenkiy, Breitbach, Parker & Hoge, 2011).

A study was designed to assess barriers to mental health care; of the Soldiers and Marines who met the criteria for mental health issues, only 38% to 45% showed any interest in receiving mental health care (Greene-Shortridge, Britt & Castro, 2007). Further, within the year prior, only 23%-40% reported actually utilizing professional mental health resources. The Service members who scored positively for mental health problems were twice as likely to report fears of stigmatization as other troops.

Although conjecture, it is possible that recruits may also worry about negative consequences, including stigma, of revealing mental health concerns during the accession process. This may pose a challenge to mental health evaluations due to the ramifications of being honest and forthcoming during the proposed screening process.

Finances

Instituting mandatory mental health evaluations for recruits would require a time and financial investment, both of which may be barriers to implementing this screening approach for recruits. In order to recruit sufficient Service members to keep the military functioning at its current capacity, each branch of service is allocated considerable budgets for recruiting). Efficiency regarding allocation of funds for recruiting efforts is a top priority of each military service command. Budget components such as screenings, advertising, and special target incentives have had significant impacts on enlistment. Additionally, recruiting budgets and allocation of funds may vary due to the condition and fluctuations in the labor market (e.g. unemployment rate, military pay relative to civilian wage) as well as current recruitment goals (Sohn, 1996)

The military’s budget calls for precise allocation of funds and resources. Requiring mental health screening procedures would require dedicated time and resources, both of which could be challenges to implementation.

Other barriers

Another challenge to implementing mandatory screening is that available mental health screeners have limitations, including imprecision in their ability to identify and predict mental health problems (Jones, Hyams & Wessely, 2003). Research has documented a large array of predictors of mental health problems including but not limited to past psychiatric history, socioeconomic status, family history and child abuse. Currently there is no variable or combination of variables that have proven to accurately identify vulnerability to certain mental health problems. Therefore, the selection appropriate mental health measures would require a considerable commitment and allocation of resources. .

Being able to positively predict the existence of a mental health problem is highly dependent on the recognition and identification of symptoms (Hoge, Auchterlonie & Milliken, 2006). Predictive power is expected to be lower for screening tests applied prior to the onset of a

Service member’s symptom. This basic assumption proposes the need for our recruits to be assessed prior to enlisting, before he/she may become exposed to certain mental health triggers (e.g. war zone combat).

Implications

Findings presented throughout this brief have outlined numerous considerations regarding the implementation of mental health evaluations as part of the recruitment process. Several considerations for future programming and policy may be useful to consider.

- New recruiting command policy could incorporate a brief validated self-report questionnaire regarding current mental health symptoms which would be administrated at the military entrance processing station.

- Resources could be allocated to the development of improved mental health screeners and longitudinal research, assessing the screeners’ ability to predict mental health problems, job (MOS) performance, and retention in the military.

- Incoming Service members with known risk factors (including pre-existing mental health conditions) could be offered mental health services to promote well-being and hopefully deter the emergence of mental health problems.

- Multifaceted public awareness campaigns could be instituted to reduce the stigma surrounding seeking mental health treatment.

Summary

Although the military recruitment process requires comprehensive physical fitness screening, no such mental health evaluation is required. Despite sustained effort to improve screening, assessment, and treatment capacity, many military personnel are struggling in the aftermath of the wars in Iraq and Afghanistan.

Policy efforts may continue to address the problem of mental health stigma and other foreseeable barriers to seeking mental health services within the military and the civilian society. The health and prosperity of current, future, and veteran Service members are vital to the success and efficiency of military operations. Mental health evaluations for recruits could strengthen the U.S. military’s ability to select high quality recruits, and potentially minimize the costs and negative consequences of serious mental health problems on Service members, their coworkers, and the military more broadly.

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