This paper reviews two separate case studies involving post-traumatic stress disorder in military members. Both studies used military members that had served in Iraq or Afghanistan. When assessing for PTSD or depression, the military along with the Department of Defense (DoD) have assessment measures that are more detailed to the service members. Further study would be needed to increase the validity of the findings.
The military has realized a need for mental health, especially following exposure to traumatic events. As of 2009, an estimated 300,000 military members have returned with a metal health condition such as depression or posttraumatic stress disorder after being deployed as part of Operation Enduring Freedom or Operation Iraqi Freedom (McCarthy, Thompson, & Knox, 2012). The Department of Defense now requires military members to take the Post-Deployment Health Assessment upon return from deployment. In addition, the Post-Deployment Health Reassessment (PDHRA), a web based questionnaire administered 90 to 180 days latter (McCarthy, Thompson, & Knox, 2012). The military also has a version of PTSD checklist (military version) known as the PCL-M that is used to measure severity of symptoms.
The PCL-M is a PTSD checklist (military version) that allows individuals to rate the severity of 17 DSM-IV symptoms from 1 (not at all) to 5 (extreme) (McCarthy, Thompson, & Knox, 2012). Scores can range from 17 to 85, but to meet the "strict" criteria for PTSD according to the PCL-M a score of 50 or higher needs to be annotated (McCarthy, Thompson, & Knox, 2012). The PCL-M was used as the primary source of measurement in the article Development and Testing of Virtual Reality Exposure Therapy for Post-Traumatic Stress Disorder in Active Duty Service Members who served in Iraq and Afghanistan.
Depression is common among many. According to Sarin, Abel, and Auerbach (2005), most individuals experience depressive symptoms during their lifetime. Fortunately, not all of those that experience symptoms go on to be debilitating or long-term. Depression can take place immediately following an event or linger on for years. Assessing for depression may be difficult, especially if the individual is not forthcoming with his/her feelings. The symptoms of depression could be the result of another condition, so medical testing would need to be conducted. According to WebMD, (online, 2012), doctors can usually determine if a person has depression during a physical exam and through a series of questions. Most tests will consist of a series of questions.
McLay et, al. (2012) used an open label treatment-development study where active duty Soldiers or Marines who had an existing diagnosis of chronic PTSD related to combat operations in Iraq or Afghanistan. The initial assessment included medical records, psychotic interview, and self-reported measures of symptom severity (McLay et al., 2012). A clinician administered PTSD scale (CAPS) and PCL-M. In addition to those two, participants were given the patient health questionnaire -9 (PHQ-9) and beck anxiety inventory (BAI). Twenty participants completed the entire study and 15 (75%) no longer met the diagnostic criteria for PTSD on the PCL-M assessment and all improved at least 50% (McLay et al., 2012). The PCL-M scores were compared using separate paired t-tests. The average PCL-M scores were 54.4 (SD 9.7) for pretreatment and 35.6 (SD 17.4) post treatment. PCL-M scores were compared using separate t-test, with scores of 57.5 (SD 10.6) for pretreatment and 44.7 (SD 17.3) for post-treatment (McLay et al., 2012). The difference is significant enough that 45% of the participants no longer met the criteria for PTSD on the PCL-M scale (McLay et al., 2012).
McCarthy, Thompson, and Knox focused their study on Airmen who completed the PDHRA between January and December of 2008. The primary purpose is to identify individuals who have physical or behavior health issues after deployment. Airmen that score positive on the PDHRAs are called or immediately referred to a medical provider. The Airmen that tested positive for behavior health concerns were ask to complete the PCL-M and the Patient Heath Questionnaire (measuring for depression). McCarthy, Thompson, and Knox (2012) attempted to evaluate the PDRHA's effectiveness in identifying military members for depression and PTSD through sensitivity and specificity.
The Cronbach's a for the PDHRA was used to screen for the PCL-M was within an acceptable range for nomothetic research (0.76) and the Cronbach for the PHQ-9 was high enough to serve as a guide for clinical decision-making (McCarthy, Thompson, & Knox, 2012). The PHQ-9 had a mean of 2.1 and a standard deviant of 9.37, within 1 standard deviation of the clinical range of 5 suggesting mild concern and 10 suggesting moderate concern (McCarthy, Thompson, & Knox, 2012). The study results suggested that the PDHRA may help in identifying patients that would benefit from early intervention. The PCL-M mean score was more than 3 standard deviations below the clinical cutoff level of 50, suggesting that the PDHRA trauma-related screening is too inclusive (McCarthy, Thompson, & Knox, 2012). The outcome of this study determined depression diagnoses were more common among individuals with PDHRA scores positive for behavior health concerns and positive PDHRA scores where more than 4 times as likely to be diagnosed with depression and 5 times as likely to be diagnosed with PTSD (McCarthy, Thompson, & Knox, 2012).
"The two most common ways to assess the clinical value of a test are to determine its sensitivity and specificity" (McCarthy, Thompson, & Knox, 2012, p S62). Sensitivity is accurately calculating the positive results and specificity is correctly identifying the negative. McCarthy, Thompson, & Knox (2012), test results reported the PDHRA's sensitivity for depression was 0.704 and its specificity for PTSD was 0.744; the lack of sensitivity for depression was 0.296 and lack of specificity was 0.349; and for PTSD there was a lack of sensitivity of 0.256 and lack of specificity of 0.350 (McCarthy, Thompson, & Knox, 2012). Specificity is related to Type I errors of measure, equating too few false positives and sensitivity is related to the Type II error of measure, where there are fewer false negatives (McCarthy, Thompson, & Knox, 2012).
There have been no scaling or testing of the assessments since the PDHRA was implemented, therefore reliability and validity have not been fully established. The validity is "a judgment or estimate of how well a test measures its purports to measure in a particular context" (Cohen & Swerdlik, 2010, p 172). The validity of a test lets people know how frequently the test measures what it is supposed to measure. Validity and reliability are important aspects of testing. Reliability comes from getting the same results over and over within the same test. Everyone wants their weight scale at home to be reliable, tests should be the same.
The military has made advancements in assessing for the psychological needs of its members; however, further research should be conducted. The ability to correctly determine an individual's problem directly relates to the care he/she can receive. It does not do any good to treat a person for depression when that person isn't depressed. The validity of tests is important in determining assessments and diagnosis. Testing tools such as the PDHRA and PCL-M are the first indication that an individual may need help. If these tools are not reliable then individuals may never get the help they need.