Dr. Hoge and Colleagues Reply

To the Editor: Regarding the letter by Dr. Staudenmeier and Dr. David Brown, we agree that military ambulatory data systems (like other medical data collected for administrative purposes) have limitations, and to the extent that only primary diagnoses are reported, the prevalence rates of alcohol and substance-related comorbidity are underestimated.

Although Dr. George Brown has practiced as a military psychiatrist researcher, his letter unfortunately illustrates commonly held misconceptions regarding the generalizability of findings from studies in military populations. Certainly, caution is warranted, but our research suggests that there are more similarities than differences between military and civilian populations (1). For example, the rates of inpatient and ambulatory mental health care use that we reported are similar when demographically adjusted to civilian data from statistics from the National Center for Health Statistics. Adjusted suicide rates are virtually identical (2). The association of high attrition among service members diagnosed with mental disorders extends the findings in nonmilitary populations that disorders such as major depression are on par with diabetes and other chronic medical conditions in their occupational and social impact (3). Regarding attrition, currently approximately one-third of all soldiers who enlist in the military services fail to complete their first term of service, a rate comparable to the college dropout rate in the United States. Our study begins to define the relationship between mental disorders and the risk of occupational attrition in an important segment of the young adult population.

We do not agree that “discrimination” explains the differences in attrition that we reported, although we acknowledge that there are unique interfaces in the military between mental and behavioral problems, occupational requirements, administrative practices, and the mental health care system. For example, behaviors related to a personality disorder or alcohol abuse that can lead to rapid termination from a civilian job may instead lead to mental heath referral, counseling, and rehabilitation efforts before administrative separation procedures are initiated. Failure to adjust to a new civilian job setting may lead to resignation, but in the military, the process of separation sometimes affords care that may yield an adjustment disorder diagnosis. These examples do not reflect discriminatory practices or differences in protections afforded to civilian Americans with psychiatric disorders compared with military service members. One could even argue that military service members have higher levels of protection.

In today’s military, the average service member can expect to be deployed overseas several times in his or her career, and there are no occupations (including clerical, secretarial, or medical technical) that are exempt. It is true that service members taking mood stabilizers such as lithium are usually not considered deployable and may be medically separated (often with disability benefits if the condition started while they were on active duty); however, bipolar disorders account for only 2% of the diagnoses of mental disorders. Regulations regarding medical separations for nonpsychotic mood or anxiety disorders are based on the severity and persistence of symptoms that interfere with duty (4), not on the use of psychotropic medications per se, and many service members with these conditions remain on active duty. Psychotropic medications, particularly the newer antidepressants, are now routinely used, even in deployed environments, as long as they do not require blood-level monitoring and have wide safety margins.

We agree with Dr. George Brown that service use does not equate with treatment need. The Epidemiologic Catchment Area Survey (5) and the National Comorbidity Survey (6) have shown that in the general population only 25%–30% of people with diagnosable mental disorders receive professional help. This figure is probably lower in the military, given the stigma and the predominantly male population. Additional research is needed to understand the reasons for attrition related to mental disorders in the military and to design prevention and intervention strategies that will reduce the barriers to care for patients, encourage earlier treatment, and reduce the occupational impact of these disorders.

Finally, research on veterans’ health issues has been widely published and accepted, even though the population is highly selected and the health care system is unique. Just as we have learned from veterans about trauma, health, and aging, we believe the military offers a rich and largely untapped environment for achieving new insights into the epidemiology of mental disorders and their impact on occupational functioning in younger adults.

The views expressed are those of the authors and do not reflect the official position of the Department of Defense or the Department of the Army.