Upon return from their second 12 month deployment to Iraq in early 2006, all members of the deployed unit completed a Department of Defense mandated Post-Deployment Health Assessment. Among them was a 24 year old, single, Caucasian male who endorsed having experiences which replayed as nightmares, feeling numb or detached from others, and constantly being on guard within the past month. As a result of his answers, he was asked to meet with a primary care provider. During this meeting, he cited three incidents in which he and his unit members were engaged by the enemy including two improvised explosive devices and one small arms ambush. During those engagements, two of his fellow unit members were wounded and one close friend was killed. The soldier was given a referral to speak with a behavioral health provider who conducted an evaluation the next day. He was found to meet DSM-IV-TR criteria for posttraumatic stress disorder (PTSD). The soldier was then enrolled into the installation medical facility’s behavioral health service and underwent treatment with a course of trauma-focused psychotherapy. After 6 months of treatment, the soldier’s symptoms were significantly improved and the soldier continued to successfully serve in the military.

Conversely, a second soldier from the same unit denied any difficulties or mental health symptoms during his post-deployment screening process. By 6 months following his return home, this previously even-tempered married soldier with no history of disciplinary problems had ongoing marital problems, was under investigation for domestic violence against his wife, and was cited by local police for driving under the influence of alcohol. Ultimately, he was administratively discharged from the military for patterns of misconduct, an outcome which could have likely been prevented.

Maintenance of medical readiness is a top priority for all commanding officers in the military . Medical readiness is a shared responsibility of military commanders, military medical personnel, and individual service members. They should work in an integrated manner to ensure that our military personnel are ready to fight and win our nation’s wars while taking all practical measures to minimize the risk of harm to indivdiuals and to the mission. Over the 14 year course of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), both commanders and the military health system (MHS) have primarily focused on treatment of symptoms and injuries following return from deployment , pre-deployment screening, and post-deployment screening . From a military mental health standpoint, common difficulties for service members have included PTSD H, depression, traumatic brain injury, and substance misuse. OEF/OIF has involved unprecedented numbers of repeat deployments by service members and combat deployments by Guard and Reserve serve members; as these conflicts have continued, the impact on maintaining readiness has steadily increased [1–3]. The US Army alone has provided well over 1.5 million troop-years to OIF/OEF between 2001 and 2011, more than all other US services combined [3]. Since 2008, the cumulative amount of time an individual soldier has spent deployed increased by an average of 28 % [3]. The US Navy, Air Force, and Marine Corps have contributed 333,000, 309,000, and 280,000 troop-years to OIF/OEF from 2001 to 2011, respectively [3].

Epidemiologic studies estimate the current or 1-year prevalence of PTSD to be 3.5–5 % for the general population over 12 months, 4–31 % overall for military personnel returning from deployment , 13 % for infantry personnel returning from deployment, and upwards of 30 % for those seeking behavioral health care [4–9]. Rates of depression in similar populations have ranged from 3–25 % [10, 11] and traumatic brain injury has been identified in 19 % of the returning military personnel [12]. Service members with multiple combat deployments are at a higher risk of developing mental health problems than those deployed only once. Per the Office of the US Army Surgeon General, approximately 11.9 % of the individuals returning from their first deployment will have mental health problems [13]. This number climbs to 18.5 % with a second deployment, and 27.2 % with a third or fourth deployment [13]. National Guard and Reserve personnel also appear to be at higher risk of mental health problems when compared to active-duty peers. Longitudinal assessment by Miliken et al found that 35.5 % of the Guard and Reserve troops were at mental health risk 6 months after deployment compared with 27.1 % of the active-duty soldiers [14].

From these statistics, it appears the majority of service members exposed to trauma do not develop PTSD. Additionally, many service members who develop PTSD are able to pass screenings and deploy repeatedly, suggesting that the natural course of PTSD is to improve over time, even without treatment. Studies which have followed PTSD over time have come to similar conclusions [15]. Those that do not improve over time, even with treatment, have a poorer prognosis; a general trend among long-term PTSD trajectory and medication studies is that individuals with greater chronicity of symptoms demonstrate lower responses to treatment than those treated early following the index trauma [6, 16–28]. It is for this reason that screening is so vital; those treated earlier after onset of symptoms are much more likely to be returned to duty while those caught late are far more likely to require medical retirement or significant limitations in duty. Essentially, the primary purpose of screening service members for PTSD is to catch the small percentage of service members who are more likely to be treatment-refractory and get them help before symptoms become chronic.

Many veterans receive care from the Veterans Administration (VA) at some point in their careers. Relatively few of these individuals receive VA care due to retirement from active duty after serving 20 years or more or being medically retired due to one or more chronic medical conditions [29]. The majority of veterans seeks out care after serving one or two tours of duty [30, 31]. Of these, a substantial portion do not access, delay to access, or fail to complete an adequate course of treatment while on active duty [31, 32]. All Veterans of OIF/OEF have been entitled to 2 years of free health care through the VA since 2001, and this was raised to 5 years of free care in the 2008 National Defense Authorization Act (NDAA) [33]. As of 2008, 40 % of all the OIF/OEF veterans had enrolled with the VA [34] and 238,098 veterans received care through the VA [35]. Of these, 84,972 received new mental health diagnoses; 49,425 were new diagnoses of PTSD [35]. Given the impact of chronicity on treatment response for PTSD, it is clear that the VA faces a very difficult mission. VA treatment populations are comprised predominately of male veterans with chronic, treatment-refractory PTSD and a high percentage of comorbid conditions such as substance misuse [36]. Many experts feel that previously held distinctions between treatment response for men versus women and combat-trauma versus other traumas is better accounted for chronicity of symptoms in predominately male VA populations as opposed to anything unique about response to combat-trauma [36]. Unfortunately, no studies currently exist looking at these factors. Screening is less of a priority in this setting, though still important due to the proportion of service members who never seek out or receive treatment prior to enrolling with the VA.

In 1991 , nearly a quarter million US service members redeployed from Southwest Asia after participating in the Operation Desert Shield/Storm. At the time of their return they appeared healthy, but over the coming months to years reports emerged of illnesses and somatic complaints. This led to the development of large-scale epidemiological screening and special clinical programs to determine potential associated or causative factors; however, the lack of available deployment and post-deployment surveillance data served as a significant limitation to these efforts. In the wake of joint efforts by the Department of Defense, Department of Veteran’s Affairs, and the Institute of Medicine, new guidelines were developed for post-deployment monitoring and management. In 1998, as part of the enactment of that protocol, the first Post-Deployment Health Assessment (PDHA) was introduced which included both a survey and a face-to-face interview and evaluation with a primary care provider [37].

Of note, the first PDHA contained a total of six questions of which only one focused on mental health (During this deployment have you sought, or intend to seek, counseling or care for your mental health?) [38]. Over the next 3 years, assessments conducted on personnel deploying to the Balkans allowed for refinement of the process and in 2001, the PDHA first included screening tools for depression (Patient Health Questionnaire-2) and PTSD (Primary Care-PTSD) [39, 40]. This process remained in place until 2006 when a second screening, called the Post-Deployment Health Re-assessment (PDHRA) was instituted.

The PDHRA, mandated as part of the 2005 National Defense Authorization Act, is required for all service members to complete 90–180 days after returning from a deployment [41]. This modification was based on initial studies in Afghanistan and Iraq veterans which showed that rates of service members with symptoms of PTSD increased after 90 days home [10, 14]. These studies also identified various barriers to care and stigmas about seeking mental health care which further influenced other mental health initiatives throughout the military and VA . During this time, multiple other initiatives and changes were considered to the process to include having all returning service members complete a face-to-face evaluation with a behavioral health provider or undergo a full behavioral health intake evaluation, but studies did not support the anticipated benefit of those initiatives and the general process of completing the initial questionnaire and reviewing with a primary care provider has remained intact [42]. The one augmentation that most post-deployment screening stations did add was the presence of on-site or tele-available mental health providers to allow for initial completion of mental health referrals if indicated, though this was not a Department of Defense requirement [43].

In conjunction with the post-deployment screening, the prolonged requirements in Iraq and Afghanistan placed a demand on the all volunteer military for service members to participate in repeated deployments to combat zones. This led to concerns over deploying service members with mental health conditions and led to the creation of minimum mental health standards for deployment. Specifically, these standards required at least 90 days of treatment (usually medication) stabilization before deployment and specified medications which precluded deployment regardless of duration of treatment (e.g., lithium, antipsychotics, and tricyclic antidepressants). When coupled with a coordination of care process, these standards were shown to be effective in reducing the incidence of mental health complications [44].

Even with the myriad of changes as well as the addition of questions on drug/alcohol abuse and family violence, many service members with PTSD were not identified prompting Congress to require additional screening. In the 2012 NDAA, lawmakers increased the frequency of screening to the current schedule of 120 days before deployment, upon return from deployment, 90–180 days after deployment , 180–365 days after deployment, and 18–30 months after deployment [45]. Additional screenings are also conducted on entry into the VA health-care system and prior to separation from the military.

In conjunction with the post-deployment screening process, the US Army also implemented a primary care PTSD and depression screening process called Re-engineering Systems of Primary Care for PTSD and depression in the military known as (RESPECT-Mil) [46, 47]. As part of this process, which is now being adopted by Department of Defense widely, service members were routinely screened for depression and PTSD at each of their primary care patient encounters. If the service member screened positive, then they were assigned a nurse case manager who helped both to establish and maintain consultative communication between primary care and mental health services, and also monitor the service member compliance and health status. More recently, this process now includes the presence of a licensed behavioral health provider working directly in the primary care clinic to provide supportive counseling needs and assist in the care coordination. Those receiving treatment through these programs or receiving treatment in a traditional behavioral health setting are screened periodically to gauge progress (see Basic Epidemiology and Important Limitations of all Screening Instruments for more about the problems associated with using screening instruments as outcome measures) [46, 47].

Most recently, the Department of Defense has introduced the Behavioral Health Data Portal (BHDP). This automated system contains multiple screening protocols which service members complete when attending their mental health appointments. The advantage of this system is that it is integrated throughout the military allowing for both a historical record of symptom scores and potential severity monitoring and it provides a standardized mechanism for assessment throughout the large, widespread military healthcare network. Through BHDP, patients complete screening questionnaires at each visit, which are immediately scored and saved. Data acquired through widespread use of this program may enable development of better instruments capable of being validated for repeated administration/gauging of symptoms over time [48].