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Abstract
Objective To determine Canadian service members’ level of adherence to a recommendation for mental health services follow-up that was assigned by clinicians during postdeployment screening.
Design Retrospective cohort study.
Setting Canadian military population.
Participants The cohort consisted of personnel (n=28 460) with a deployment within the 2009–2014 time frame. A stratified random sample (n=3004) was selected for medical chart review. However, we restricted our analysis to individuals whose completed screening resulted in a recommendation for mental health services follow-up (sample n=316 (weighted n=2034) or 11.2% of screenings.
Interventions Postdeployment health screening.
Primary outcome measure The outcome was adherence to a screening-indicated mental health services follow-up recommendation, assessed within 90 days, a preferred delay, and within 365 days, a delay considered partially associated with the screening recommendation.
Results Adherence within 90 days of screening was 71.1% (95% CI 59.7% to 82.5%) for individuals with ‘major’ mental health concerns, 36.1% (95% CI 23.9% to 48.4%) for those with ‘minor’ mental health concerns, and 46.8% (95% CI 18.6% to 75.0%), for those with psychosocial mental health concerns; the respective 365-day adherence fractions were 85.3% (95% CI 76.1% to 94.5%), 55.7% (95% CI 42.0% to 69.4%) and 48.6% (95% CI 20.4% to 76.9%). Logistic regression indicated that a 90-day adherence among those with a ‘major’ mental health concern was higher among those screening after 2012 (adjusted OR (AOR) 5.45 (95% CI 1.08 to 27.45)) and lower, with marginal significance, among those with deployment durations greater than 180 days (AOR 0.35 (95% CI 0.11 to 1.06)).
Conclusions On an individual level, screening has the potential to identify when a care need is present and a follow-up assessment can be recommended; however, we found that adherence to this recommendation is not absolute, suggesting that administrative checks and possibly, process refinements would be beneficial to ensure that care-seeking barriers are minimised.
- mental health
- occupational & industrial medicine
- epidemiology
- psychiatry
- health services administration & management
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- mental health
- occupational & industrial medicine
- epidemiology
- psychiatry
- health services administration & management
STRENGTHS AND LIMITATIONS OF THIS STUDY
The study used a clearly defined population with clear definitions for the exposure, a postdeployment mental health screening indicated follow-up recommendation, and the outcome, adherence to the follow-up care recommendation.
Information on the discussion that occurred at the screening interview was limited to situations where notes were available. This unknown information may have provided further insight into the factors that influenced service members’ likelihood of following through with screening indicated recommendations for mental health services follow-up.
A mental health follow-up recommendation was assigned at screening for all in the analysis but their intended follow-up was unspecified. As such, the study’s criteria for adherence, although very general, may have been imprecise for some situations.
The study analysis was restricted to individuals with a mental health follow-up recommendation and then further stratified by mental health concern. This resulted in low numbers for some covariate attributes and their associated adherence levels, ultimately influencing the variability of point estimates and the statistical power to detect associations.
Introduction
Military personnel encounter unique experiences during their service, experiences that can contribute to their risk of developing mental health problems.1–5 Research has identified a number of barriers to treatment seeking among military personnel with a potential mental healthcare need.6–8 ⇓ In recognition of these care-seeking barriers, many countries have reinforced their military mental health systems and implemented interventions to assist their personnel.9–11 The Canadian Armed Forces (CAF) expanded its outpatient mental health system in an effort to reduce physical barriers to care10 and it introduced a resilience and mental health training programme to promote recognition of a potential mental health services need, treatment seeking and stigma reduction.12 Postdeployment screening programmes have also been implemented by some countries in order to facilitate care-seeking in the context of the high prevalence of postdeployment mental health problems.7 13 The goal of this screening is to facilitate early detection and care-seeking for service members with a potential need for services following their deployment.1 2 6–9 Moreover, recent research has observed that postdeployment screening in the CAF resulted in a shorter delay to care among those who, subsequent to their deployment return, had been diagnosed with a mental disorder that was assessed to be deployment related.14
There are a number of potential benefits to postdeployment screening. Some studies on the association of mental disorder prognosis relative to the timing of care suggest that earlier treatment after deployment return is associated with a greater likelihood of symptom improvement15–17 and a more favourable occupational outcome.18 In addition, there is potentially a cost benefit associated with earlier treatment; for example, annual health services costs can be significantly lower for patients using early intervention services compared with non-users. 19 Moreover, one of the leading barriers to accessing mental healthcare in military populations is a failure to perceive a need for care and this can be offset with screening.20 This is especially true when a large fraction of military personnel with a probable mental disorder do not seek help7 21 22 or symptomatic individuals delay seeking care.23 Postdeployment mental health screening may be an important link to both offset any lack in perceived need for mental healthcare and expediting care-seeking.
In contrast, a systematic review of the available evidence on postdeployment screening highlights the potential disadvantages to such screening.24 As indicated in their systematic review, the authors24 indicate how a successful screening process is reliant on: (1) truthful reporting on screening tools that have good sensitivity and specificity for the conditions being measured, (2) appropriate follow through and adherence to recommended services, (3) effective treatment services for the identified concerns and (4) a beneficial opportunity cost for the investments in screening. Moreover, for a given screening programme each of these identified attributes may be present to greater or lesser degrees which can lead to less effective screening.
As indicated, the effectiveness of screening is reliant on a series of processes occurring consistently and as planned, processes that lead to the accurate identification of those who may require professional mental healthcare and ensuring that evidence-based care is delivered in a timely manner.24 25 Ultimately, effective screening can be realised only if the individuals identified with a potential issue get the follow-up care that screening indicates they may require. Moreover, after a review of the available research, the US Preventive Services Task Force has recommended screening for anxiety, depression and suicide risk in adults but with the implementation caveat that it requires adequate systems that can ensure accurate diagnosis, effective treatment and appropriate follow-up.25–27 As such, adherence to the recommended follow-up care is one of the key processes to be assessed when evaluating the effectiveness of a screening programme, as it leads to the targeted outcome of a shortened delay to care.24 25
The available research, although limited, indicates that many military members do not receive their recommended follow-up care that was identified at screening. One US study reported that 61% of service members were adherent to their referral for care, assessed as a mental health visit within 90 days of screening over the 2005–2006 period,28 while another indicated that 73% of those who screened positive had a mental health visit during the 2004–2006 study period.29 Conversely, a randomised controlled study in the UK that assessed screening among its personnel over 2011–2014 observed that only 33% of positive screeners reported any past-year mental health services use when assessed at follow-up and similarly, 36% of those who would have screened positive in the study’s comparator group reported this services use.30 However, none of these studies fully delve into factors that might provide some insight into how postdeployment screening processes might be augmented to improve adherence and we do not have comparable information on the CAFs screening programme. Given the importance of the processes leading from the identification of those who may require professional mental healthcare to the realised outcomes, this further stresses the need for such research on adherence to screening-indicated care in Canada.
This study was designed to assess this follow-through component of the CAFs postdeployment screening programme. The primary objective was to determine service members’ adherence to a recommendation for mental health services follow-up that was assigned by clinicians during screening and to assess predictors of this outcome.
Methods
Postdeployment screening in the CAF
Postdeployment screening was introduced in the CAF in 2002. Service members who deploy for 60 days or longer are required to complete a postdeployment screening within 90–180 days of their return. The screening process begins with an orientation briefing of the screening’s purpose, confidentiality and the associated follow-up. The service member is then asked to complete a questionnaire that contains questions on sociodemographic and military characteristics, deployment experiences and health problems that are assessed using standardised instruments to assess for health concerns: the 36 item Short Form Health Survey (SF-36), a general health status measure with an emphasis on functioning31; portions of the Patient Health Questionnaire assessing physical symptoms, depression, suicidality, panic disorder and generalised anxiety disorder32; the civilian version of the post traumatic stress disorder checklist (PCL-C)33; the 10-item Alcohol Use Disorder Identification Test34; a 30-item combat exposure scale35 and the Brief Traumatic Brain Injury Screen.36 These screening instruments were chosen to provide an indication of any concern in nine areas: (1) military-related PTSD (post traumatic stress disorder) symptoms, (2) civilian-related PTSD symptoms, (3) depressive symptoms, (4) anxiety symptoms, (5) substance use, (6) postconcussive symptoms, (7) other physical health issues, (8) family/marital problems and (9) workplace conflict. The responses from these instruments are scored as indicated by the questionnaire guidelines and concerns are identified using either the recommended cut-offs or ones that were slightly adjusted for the CAF population.
After the questionnaire is completed, the responses and indicated concerns are then reviewed by a mental health professional who subsequently conducts a semistructured interview during which potential concerns are reviewed with the member. This interview can occur on the same day as the questionnaire was administered or up to approximately 2 weeks later. Following this interview with the service member, the mental health professional may recommend the member for follow-up care and this recommendation, along with the identified concerns, is documented on a screening disposition form that is retained in the member’s medical record. Follow-up care categories include primary care, mental health, Canadian Forces Member Assistance Programme (ie, short-term counselling) or ‘other’ to be specified care. Depending on the concerns identified, the screened individual with a recommendation for mental health follow-up care may be referred to general mental health (psychiatry/psychology/addictions), psychosocial or primary care services.
Study population and sampling
This study used a retrospective cohort study design. The cohort consisted of CAF personnel (n=28 460) with a deployment during the 1 January 2009 to 31 December 2014 time frame. A stratified random sample (n=3004) was selected for medical chart review. Seven sampling strata were defined by administrative data that indicated increasing amounts of postdeployment mental health services use in order to guide oversampling of those who would likely have a mental disorder: six strata categorised any specialty mental health services use (ie, 0, 1–3, ≥4 psychiatrist or psychologist appointments) among those with and those without an indicated screening-associated appointment and a seventh stratum included those with no identified mental health services use in the administrative data. The study was powered to discern a 50-day delay to care differential between screened and non-screened individuals with 85% power when using a log-rank test; however, while this was the primary objective of the overarching study it holds some relevance to the analyses of the current paper. The strata sample sizes were determined using a Neymann optimal allocation approach.37 Medical records for 2997 individuals in the sample were reviewed and 7 were inaccessible.
The current study analyses were restricted to sampled individuals with a completed postdeployment screening that resulted in a recommendation for mental health services follow-up (sample n=339, weighted n=2103; 11.4% (95% CI 9.5% to 13.3%) of screenings). However, we excluded 23 screenings (weighted n=69) for individuals who had a diagnostic assessment that resulted in a diagnosed mental disorder prior to screening. Thus, the analysis was limited to 316 (weighted n=2034) or 11.2% (95% CI 9.3% to 13.2%) of screenings.
Data collection
Deployment details came from deployment tasking (extract date: 30 March 2016), deployment-related pay (extract date: 30 March 2016) and human resources (extract date: 1 August 2017) administrative databases. Mental health diagnostic assessment data, including diagnoses, assessment date, other health services use and mental disorder history, were abstracted from medical records over the period of 6 February 2017 to 1 May 2018. Screening data were obtained from the medical record and this was supplemented with electronic data from the screening programme to offset any missing information. Additional data on sociodemographic and military characteristics came from human resources administrative data (extract date: 1 August 2017).
Outcome measure
The outcome was adherence to a mental health follow-up recommendation that was indicated at postdeployment screening within 90 days of the recommendation, a preferred delay that has been reported by other researchers,28 and within 365 days, a delay where follow-up could still be considered partially associated with the screening recommendation. The criteria for adherence being achieved were stratified by screening-indicated mental health concern and this was implemented using the screening disposition form. As mentioned earlier, the screening disposition form is completed by a mental health professional at the end of the interview where a service member’s responses on the standardised questionnaires are reviewed with the member. This form records the mental health professional’s impression of a member’s mental health concerns and the recommended follow-up. Although there can be some subjectivity in the mental health professional’s interpretation, they are generally advised to indicate a ‘major’ concern for PTSD, anxiety, depressive or substance use/abuse symptoms when the standardised questionnaires indicate the likely presence of a disorder or problem; a ‘minor’ concern is to be indicated when a member has some symptoms in the concern area but the questionnaire scores are below the cut-off levels. However, follow-up services can be recommended for those with either a ‘minor’ or ‘major’ concern in the problem areas. In addition, the screening disposition form also records mental health concerns that are only psychosocial in nature (eg, family/marital, workplace, sleep, anger concerns) and the recommended follow-up. These psychosocial concerns are revealed during the discourse at the interview with the mental health professional as there are a few questions in this domain that interviewers are to ask.
When either a ‘major’ or ‘minor’ mental health concern was indicated (ie, PTSD, anxiety, depressive or substance use/abuse symptom concerns) on the screening disposition form, subsequent care that included any combination of a comprehensive mental health diagnostic assessment conducted by a psychiatrist or clinical psychologist, a discussion of mental health concerns in primary care, or an assessment of psychosocial functioning conducted by a social worker or mental health nurse was considered adherent to the recommended care. Alternatively, when the mental health concern was indicated to be only psychosocial (eg, family/marital, workplace, sleep, anger concerns), the sufficiency criteria were the same but with the addition that the provision of supportive or other psychosocial services were also considered sufficient.
In addition, individuals who were already in some form of care, and had still received a mental health follow-up recommendation at screening, were also assessed on this adherence, as early supportive care is sometimes provided that may or may not be sufficient for the concern; however, as outlined earlier, those with a prescreening mental disorder diagnosis were excluded.
Covariates of interest
Covariates that previous research have found to be associated with postdeployment mental health problems or delays to accessing care were considered for possibly influencing the outcome.22 38–42 The military and sociodemographic covariates included: sex; age (19–34 or 35–60); service (Army, Navy or Air Force); component (Regular or Reserve Force); rank category (junior non-commissioned member, senior NCM or officer); combat arms military trade/occupation; years of service (<10 or ≥10; marital status (married/common law, divorced/separated/widowed or single—never married); first official language (English or French); and indications in the medical record of a past mental disorder diagnosis. Deployment length (≤180 days, >180 days) was also assessed but deployment location (Afghanistan or ‘other’), although considered, had insufficient numbers for the ‘other’ location. The screening-related covariates included: screening year (2009–2011, 2012–2016); urgency of the recommendation for mental health services follow-up (emergent: follow-up within 48 hours, urgent: follow-up within 14 days, routine: follow-up >14 days); and indications that the service member was already receiving some form of support or care for their mental health concern. Variable categorisations were based on the data’s distribution and previous work with this population.
In addition, the time-varying covariates for age, rank, combat arms occupation and years of military service were assessed relative to individuals’ screening date while marital status was assessed relative to the human resources administrative data extract date, the only option.
Statistical analysis
The data were predominantly analysed using SAS for Windows, V.9.4 (SAS Institute); however, marginal effect estimates and final logistic regression results were obtained using Stata for Windows, release V.14 (StataCorp). Sample design weights were applied for all statistics and Taylor series linearisation43 was used to generate SE estimates and 95% CIs. There were no missing values among the assessed covariates. The primary unit of analysis was a completed screening and, as it was possible to have more than one deployment, the design specification incorporated individuals as clusters in order to adjust the standard errors for repeated measures.44
Logistic regression assessed 90-day adherence to the screening-indicated mental health follow-up recommendation separately for those with a ‘minor’ and ‘major’ mental health concern, as determined at screening. The results were expressed as adjusted ORs (AORs) and their 95% CIs. Initially, each covariate’s association with adherence was assessed and those with a Wald χ2 test p≤0.25 were retained for the multivariable regression.
A marginal standardisation approach was used to estimate the proportion of screenings that, based on the final logistic regression model, would be expected to be adherent had they had the characteristic of interest. This approach operates by statistically forcing the total population to have the characteristic of interest while other covariates retain their observed value.45 Expected marginal adherence difference estimates were computed and a z-test assessed their statistical significance.45
Patient and public involvement
CAF service members, patients and/or the public were not involved in developing the research question, the study design or in the conduct of the study. The findings from this study and the larger research project will be shared with CAF service members and other interested stakeholders through targeted conference venues, CAF community newsletters or communiques and other venues.
Results
Study population characteristics
Table 1 summarises the study population’s sociodemographic, military and screening characteristics among the 11.2% (95% CI 9.3% to 13.2%) of screenings that resulted in a mental health services follow-up recommendation. Characteristics are summarised by mental health concern identified at screening, ‘major’ mental health concern (39.3% (95% CI 30.4% to 48.2%)), ‘minor’ mental health concern (47.2% (95% CI 37.9% to 56.5%) and psychosocial or ‘other’ mental health concern (13.5% (95% CI 6.4% to 20.5%)). Individuals were predominantly married, male, English in first official language, Regular Force members, in the JNCM ranks, in Army service, had an Afghanistan deployment location and did not have a past mental health problem. At screening, a majority screened in 2011 or earlier were less than 35 years old and had less than 10 years of military service. The screening indicated urgency for mental health follow-up and the fraction indicated to already be in supportive, possibly interim, or definitive care for their identified concern varied by identified mental health concern.
Distribution of sociodemograhic, military and screening characteristics by mental health concern identified at screening
Adherence to mental health follow-up recommendation
Table 2 summarises the mental health follow-up care that occurred within 90 and 365 days of screening, which could include a comprehensive mental health diagnostic assessment, a discussion of mental health concerns in primary care, an assessment of psychosocial functioning and/or the provision of supportive or other psychosocial services. Adherence to the screening-indicated mental health follow-up recommendation for either a ‘major’ or ‘minor’ mental health concern was considered achieved if any of the mental health follow-up care options had occurred within the specified time frame, with the exception that provision of supportive or other psychosocial services alone was insufficient. However, if mental health concerns were only psychosocial then the provision of supportive or other psychosocial services alone were sufficient to meet the adherence definition. Adherence was generally higher among those with more severe mental health concerns. The 365-day adherence fractions were 85.3% among those with major mental health concerns, 55.7% among those with minor mental health concerns and 48.6% among those with psychosocial mental health concerns; the respective 90-day adherence fractions were 71.1%, 36.1% and 46.8%.
Mental health assessments that occurred subsequent to screening by mental health concern identified at screening
As might be expected, the fraction receiving a diagnostic assessment within 365 days followed the adherence pattern, highest for those with a ‘major’ mental health concern at 62.6%, 27.3% for those with a ‘minor’ concern, and 14.3% for those with only psychosocial concerns; the respective fractions with a diagnostic assessment within 90 days were 37.3%, 9.9% and 9.9%. The degree to which the screening-indicated concerns and follow-up recommendation were suggestive of underlying disorders is reflected in the fraction of individuals who had a diagnostic assessment that resulted in a mental disorder being diagnosed (table 2). Among individuals with a diagnostic assessment within 365 days, a mental disorder was diagnosed among 89.8% of those with a ‘major’ concern, 88.7% of those with a ‘minor’ concern and 30.8% of those with only psychosocial concerns. In addition, these fractions increased when also considering diagnostic assessments that occurred more than 365 days after screening. As such, non-adherence or even delayed adherence to the mental health follow-up recommendation represents a concern for the organisation and the individual as it potentially impacts the performance and quality of life of individuals with an untreated mental health problem.
Table 3 and online supplemental table 1 summarise the unadjusted associations between a number of sociodemographic and military characteristics with 90-day adherence. Among individuals with a ‘major’ mental health concern (table 3), and using p values as a guide, there was some indication that 90-day adherence was lower for younger individuals, individuals whose first-language was French, lower ranks, military service of less than 10 years, combat arms occupations, longer deployments and less recent screening year. In addition, the number of individuals with an ‘other’ deployment location was not large but this category had 100% adherence within 90 days; this covariate was not handled in the logistic regression. Among individuals with a ‘minor’ mental health concern (online supplemental table 1), there was some indication that 90-day adherence was lower for younger individuals, males, individuals whose first-language was English, single marital status, military service of less than 10 years, Reserve Force members, Army or Navy service, combat arms occupations, and individuals not already in some form of care related to their concern at screening. One unexpected similarity for 90-day adherence between ‘major’ and ‘minor’ mental health concerns was the lack of an association between the urgency of the follow-up recommendation and adherence.
Supplemental material
The 90-day adherence to a mental health follow-up recommendation by various covariates among those with a ‘major’ mental health concern that was identified on screening
Logistic regression
Logistic regression assessed the predictors of adherence to the mental health follow-up recommendation within 90 days of screening. As presented in tables 4 and 5, the multivariable regressions were restricted to covariates whose p value from a Wald χ2 test of association with adherence was ≤0.25 (ie, see table 3). In addition, tables 4 and 5 also contain the marginal differences in adherence associated with each covariate category, after adjusting for the influence of the other covariates in the regression (ie, marginal adherence differences).
Logistic regression results and the associated marginal effect estimates for a 90-day adherence to a mental health follow-up recommendation for ‘major’ mental health concerns that were identified at postdeployment screening
Logistic regression results and the associated marginal effect estimates for a 90-day adherence to a mental health follow-up recommendation for ‘minor’ mental health concerns that were identified at postdeployment screening
Among those with a ‘major’ mental health concern (table 4), the odds of a 90-day adherence to follow-up recommendation were higher for individuals who screened in 2012–2016 relative to 2009–2011 (AOR 5.45 (95% CI 1.08 to 27.45)), with an associated marginal adherence difference of 22.9%, and lower with marginal significance (ie, 0.05≤p≤0.10) for those with a deployment duration of 180 days or longer (AOR, 0.35 (95% CI 0.11 to 1.06)), which represented a marginal adherence difference of 16.0%.
Among those with a ‘minor’ mental health concern (table 5), the odds of a 90-day adherence to follow-up recommendation were lower among members in the combat arms occupation (AOR, 0.11 (95% CI 0.03 to 0.37)), which represented a marginal adherence difference of 39.6%, and additionally, there were a number of marginally significant associations. These marginally significant associations (ie, 0.05≤p≤0.10) included a 90-day adherence odds that was higher among those with a French first language (AOR, 2.54 (95% CI, 0.90 to 7.16)) with a marginal adherence difference of 14.9%, lower for Reservists (AOR 0.25 (95% CI 0.06 to 1.01)) with a marginal adherence difference of 19.7% and relative to married or common law marital status, higher among individuals in the divorced, separated or widowed category (AOR 3.82 (95% CI 0.99 to 14.79)) with a marginal adherence difference of 21.6% but comparable for the single marital status category. Moreover, some of the marginal adherence difference estimates achieved significance at a p<0.05 level when the AOR was only marginally significant (ie, 0.05≤p≤0.10) and notably, Navy members had a significant 24.6% lower 90-day adherence relative to Army members when the AOR was non-significant with a p=0.103.
Discussion
Key findings
The primary objective of this study was to assess the level of adherence to a screening-indicated recommendation for mental health services follow-up relative to concern level and to assess for predictors. We found that adherence within 365 days of screening occurred among 85.3% of individuals with major mental health concern, 55.7% of those with minor mental health concerns and 48.6% of those with psychosocial mental health concerns; the respective 90-day adherence fractions were 71.1%, 36.1% and 46.8%. The increase in adherence from 90 to 365 days, an increase of 14.2% for ‘major’ and 19.6% for ‘minor’ mental health concerns, suggests a margin of improvement that is potentially reachable if we assume that any adherence after 90 days, and at least to 365 days, was attributable to modifiable care-seeking barriers.
The factors that had the most influence on a lower 90-day adherence among those with a ‘major’ mental health concern at screening were screening prior to 2012 and deployment durations greater than 180 days. With only two covariates identified as influential on 90-day adherence, it is difficult to surmise what might be assisting or hindering. It is possible that greater facilitation of follow-up, making follow-up easier, might be beneficial for those who were away on longer deployments and likely have more diverse needs or demands on their time. In contrast, the factors that had the most influence on a lower 90-day adherence among those with a ‘minor’ mental health concern at screening were English first-language, Reserve Force component, Navy and to some degree, Army service, married or single marital status, and combat arms occupations. Generally, this tends to suggest that there is a greater inclination among some subgroups to avoid or delay care-seeking, or possibly self-manage concerns, when mental health problems are ‘minor’. Again, it’s possible that greater follow-up facilitation could assist, especially if delays are related to competing demands that make it easier to avoid scheduling follow-up care. Moreover, the urgency of the mental health services follow-up recommendation did not appear to have a significant association with the outcome in any of the analyses which was an unexpected finding.
Comparison with other research
There has been limited research into service members’ adherence to a recommendation for mental health services following screening and that which is available largely emanates from the USA. Screening in the US Army consists of an initial assessment within 30 days of a deployment’s end and a second one that occurs 90–180 days postdeployment46; the latter assessment is similar to screening in Canada. One US study assessed service members’ care-seeking over 2005 and 2006 following their second screening assessment.28 The authors reported that 61% of recommended individuals had used mental health services within 90 days of screening. We observed a similar services use percentage among those with a recommended follow-up, 71.7% for those with a ‘major’ mental health concern, 41.9% for those with a ‘minor’ one and 46.8% for those with only psychosocial mental health concerns. However, it should be noted that our definition of adherence among individuals with ‘major’ or ‘minor’ mental health concerns was slightly more restrictive (ie, 71.1% and 36.1%, respectively), as they excluded psychosocial services receipt when it was the sole follow-up care.
A few other studies have assessed mental health services use following a postdeployment screening but are less comparable. For example, one US study assessed a population of service members who released from service after 11 September 2001 and sought care over 2004–2006.28 The authors reported that while only 45% underwent screening, 73% of those who screened positive for a mental health concern had completed a mental health appointment during the study period (24% had done so within 90 days of their screening). In addition, a UK study assessed screening among Royal Marines and Army personnel who returned from an Afghanistan deployment over 2011–2014.29 The authors reported that 33% of participants who screened positive for mental health concerns, and who received tailored help-seeking advice, reported having had a past-year mental health services use when assessed at a postscreening follow-up. A similar service use fraction (36%) was reported among the study’s comparator group, participants who received only general health advice and who would have screened positive. However, the screening methods of this study were not directly comparable to screening in Canada.
Limitations
The primary limitation of our study relates to it being retrospective and reliant on information that was available. For instance, although a mental health follow-up recommendation was assigned at screening, it was unspecified what the intended ideal follow-up should be. However, it could be assumed that a comprehensive mental health diagnostic assessment was intended for those with a ‘major’, and likely for a majority of those with a ‘minor’, mental health concern and a precursor of either a primary care clinician visit for concern management and/or a referral for further assessment or a detailed psychosocial assessment would be considered sufficient. In addition, in some instances where the discussion of mental health concerns with a primary care clinician was deemed adherent to the follow-up recommendation, the summary primary care note read as though the discussion occurred independent of the screening recommendation, suggesting a weaker level of adherence. However, while this pathway may be less direct it ultimately led to mental health concerns being assessed and follow-up occurring, and this was possibly associated with the individual being primed at screening to be aware of their mental health issues.
Another study limitation relates to our restricting the analysis to individuals with a mental health follow-up recommendation and then further stratifying the analysis by mental health concern. This resulted in low numbers for some covariate attributes and their associated adherence levels. This ultimately had an influence on the variability of point estimates and the statistical power to detect associations. However, there was an indication that some covariate associations differed by mental health concern level which warranted this stratification analysis and we used a conservative approach when interpreting our results in an attempt to minimise this limitation.
Interpretation
The CAFs postdeployment screening programme was initiated to reduce barriers to care, aid the identification of health concerns, and facilitate earlier care provision in those with a perceived need.12 While effective postdeployment screening is reliant on a sequence of steps operating as intended,24 25 a key element is that individuals recommended for further assessment and treatment get the care they may require. The clinicians who conduct screening interviews determine whether a mental health follow-up recommendation is indicated, informing the member and when feasible, assists in arranging follow-up care. Logically, non-adherence can be attributed to service members’ hesitancy to follow-through with the service recommendation, perhaps because of a care-seeking barrier or the presence of systemic issues that delays follow-through (eg, long wait times, competing home/ work demands, or interference from an imminent position change or training) or in some situations, the concerns may resolve with non-clinical supports and services. While our observations indicated that, as expected, the screening-indicated concern level contributed to adherence levels (ie, higher with higher concern level), they also suggest that some care-seeking barriers may be present. We observed that when screening-identified mental health problems were less severe, some subgroups, English first-language speakers, Reservists, married or single individuals, those in combat arms occupations, and Navy service, were less likely to seek recommended care within 90days. Yet, among those with more severe screening-indicated mental health problems, there were fewer subgroups who were less likely to seek recommended care within 90days (ie, individuals who underwent screening prior to 2012 and those with longer deployment durations). In addition, in some cases, documentation was available that indicated care-seeking delays were associated with an initial refusal of care or imminent courses or postings to a new location, after which care-seeking was to occur but ultimately became further delayed. Therefore, it is possible that the lower adherence to recommended care associated with some military characteristics suggests that possibly career-concerns, stigma, physical access or other care-seeking barriers were present.47 48
The CAF screening programme includes a postscreening step that was designed to foster participant adherence with recommended follow-up. Approximately 6–8 weeks after screening, clinic staff are directed to assess whether recommended follow-up occurred and, when lacking, to contact the service member and determine whether further care still appears to be needed. While the level of clinic staff’s adherence to this direction is unknown, our results highlight its importance as a means to confirm non-adherence because of a resolved need and conversely, to assist those who are experiencing a care-seeking barrier that may benefit from this additional contact. This is especially true given that we observed a noteworthy fraction with a delayed follow-up who eventually had a mental disorder diagnosed. In addition, the importance of this step is reinforced further when considering our observation that the urgency of the follow-up recommendation had a non-significant influence on adherence. It appears that the relevance of this urgency identifier is lost in the transition from a completed screening to recommended follow-up care being scheduled. While this would suggest that further instruction to clinic staff on this postscreening contact is warranted, a number of automated checks have recently been implemented that prompt the screening clinician with recurring notices when mental health services follow-up was recommended and is overdue.
Overall, the mental health services follow-up recommendations that emanate from the CAF postdeployment screening programme appear to have a moderately high level of adherence. Our findings suggest that adherence can potentially be further increased with minor process refinements that ensure it is operating optimally and as intended.
Conclusion
A number of military organisations have invested in postdeployment screening programmes to assist their service members. On an individual level, these programmes can identify when an apparent need is present and recommend a follow-up assessment; however, while perfect adherence is not expected, administrative checks and possibly, process refinements would be beneficial to ensure that all steps in this process run as intended and that care-seeking barriers are minimised.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Advarra IRB Services,372 Hollandview Trail, Suite 300, Aurora, Ontario, Canada (Continuing Review Approval/ REB Attestation #: CR00301039). Historic administrative data and chart review data were used for this study. As it was considered an occupational health study that anonymises individuals in the final reports, institutional privacy and ethics reviews permitted the data access for the specific study purpose.
Acknowledgments
We thank Julie Lanouette for her assistance with the data collection from patient medical records. We also thank Dylan Johnson and Peter Believeau for their assistance with the initial data cleaning for this project. Additionally, we thank Dr Mark Zamorski, Dr Minh Do, and Dr Corneliu Rusu for their participation in the initial design and implementation of the overarching study.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors DB had full access to all data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis. DB is the guarantor and principal investigator of the study. DB wrote the initial draft of the manuscript and both DB and BG contributed to the interpretation of the results as well as the writing and revising of the manuscript. DB and BG have read and agree with the manuscript’s final content.
Funding This work was supported by funding from the Canadian Armed Forces Surgeon General’s Health Research Program.
Disclaimer This funding source had no role in study design, data collection, data analysis, data interpretation, writing of the scientific article, or the decision to submit the paper for publication.
Competing interests Both authors were employees of the Canadian Department of National Defence while the manuscript was being written and funding support for this research came from this federal government department; no additional financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.