VOLUME 172OCTOBER 2007NUMBER 10
Authors alone are responsible for opinions expressed in the contribution and for its clearance through
their federal health agency, if required.
MILITARY MEDICINE, 172, 10:1017, 2007
Postdeployment Health Reassessment: A Sustainable Method
for Brigade Combat Teams
Guarantor: MAJ Christopher H. Warner, MC USA
Contributors: LTC George N. Appenzeller, MC USA*; MAJ Christopher H. Warner, MC USA†;
CAPT Thomas Grieger, MC USN‡
Objective: The Postdeployment Health Reassessment (PDHRA)
was mandated in 2006 and the 3rd Infantry Division was the
first unit to perform a large-scale implementation. This article
outlines a reproducible model for conducting PDHRA using
only existing resources. Methods: The PDHRA (DD 2900)
screening and referral processes are reviewed and data on
positive screens are reported. Results: Of the 12,817 soldiers
who participated in the mass screening, 1,460 (11.4%) were
referred for behavioral health, 815 (6.4%) for primary care, 71
(0.01%) for specialty services, and 9 (0.001%) for emergency
services. Consult requests were higher in maneuver brigades
than in support units (12.1% versus 8.6% for behavioral health
and 6.9% versus 4.4% for primary care referrals). All (1,460,
100%) of the behavioral health consults were completed on-
site and the unit incurred no additional financial cost in con-
ducting this process. Conclusions: This method for perform-
ing a large-scale implementation of the PDHRA provides a
flexible, efficient, and cost-effective process that could be im-
plemented at the brigade combat team level without difficulty
and in most locations without significant impact on other
datory in 1997.1,2Shortly thereafter, the Army introduced the
Postdeployment Health Assessment which screened soldiers for
physical and mental health problems upon return from deploy-
ment. It was seen as a method for early identification of prob-
lems and possibly decreasing the stigma associated with behav-
ioral health care. However, few studies have looked at validating
the postdeployment screening instrument against other mea-
sures or functional outcome.3,4Furthermore, experiences from
other samples of returning soldiers indicate that rates of re-
ported deployment-related symptoms can increase with time
after returning from deployment.5–7
This information led the Assistant Secretary of Defense for
Health Affairs to direct an extension of the existing Postdeploy-
ment Health Assessment program to include a re-evaluation at
3 to 6 months after return from a combat zone.8This new
screen, called the Postdeployment Health Reassessment
(PDHRA), is a global health screen, but it places specific empha-
sis on behavioral health issues. It was pilot tested at several
locations in late 2005 and was required for Army-wide imple-
mentation in 2006.
In January 2006, the 3rd Infantry Division (3ID) returned
from Iraq and began planning for the first large-scale implemen-
tation of the PDHRA. Several unique challenges included (1) the
need to develop a large-scale implementation plan for nearly
15,000 soldiers in a short time period, (2) coordinating with a
smaller medical treatment facility that was already performing
postdeployment assessment for several large returning reserve
units, (3) dealing with ongoing financial restraints at both the
3ID and the local medical treatment facility, and (4) a planned
additional deployment of 3ID units during the PDHRA time line.
The 3ID determined that the division medical assets would take
ostdeployment psychological screening has been growing in
importance since Operation Desert Storm and became man-
*Division Surgeon, Third Infantry Division, Building 620, Fort Stewart, GA 31314.
†Division Psychiatrist, Third Infantry Division, Building 601E, Fort Stewart, GA
‡Associate Professor, Department of Psychiatry, Uniformed Services University of
the Health Sciences, Bethesda, MD 20814.
Presented at the 2006 U.S. Army Force Health Protection Conference, August,
2006, 7–11,/Albuquerque, NM.
The work herein was part of our employment with the federal government and is
therefore in the public domain. The stated views are those of the authors and do not
represent the views or the policy of the Department of Defense. No industry grants or
financial support were used in this project.
This manuscript was received for review in November 2006. The revised manu-
script was accepted for publication in June 2007.
Reprint & Copyright © by Association of Military Surgeons of U.S., 2007.
Military Medicine, Vol. 172, October 2007
ownership of the PDHRA process and perform the screening at
the brigade level using internal assets.
The purpose of this article was to outline division actions to
complete the PDHRA process using only existing resources and
provide a potential road map to other units with limited re-
sources or limited external support.
The implementation plan included several key points: (1) all
screenings would be conducted by division medical and mental
health personnel, the majority of whom had deployed with the
soldiers or would do so in future; (2) unit commanders would be
prebriefed on the PDHRA as an opportunity for soldier educa-
tion as well as an assessment; (3) commanders would be pro-
vided monthly unit updates to emphasize the importance of the
process; (4) PDHRA would be built into brigade combat team
(BCT) training schedules to maximize participation and limit
time away from other requirements; (5) battlemind training
would be included to enhance soldier awareness of the behav-
ioral health problems that may be encountered postdeployment;
(6) division mental health consult teams would provide on-site
consults to maximize completion, minimize stigma of behavioral
health care, and limit time away from training; and (7) screening
would require no additional cost or equipment.
The PDHRA screening for the five brigades at Fort Stewart/
Hunter Army Airfield would be completed from March to August
2006. Command emphasis would be provided from the Division
Commander to lower levels of command and the PDHRA would
be emphasized as a forum for soldier preventive education as
well as an opportunity for health assessment. Each BCT would
assume responsibility for the screening and work with com-
mands to link PDHRA to the training calendar. They would
coordinate their own location within the BCT area and utilize
only their internal resources to eliminate any additional costs
for facilities or equipment. Individual BCTs could elect to also
incorporate medical record screening and immunization up-
dates to optimize the use of time and facilities.
The 3ID PDHRA process is outlined in Figure 1. Soldiers
completed the PDHRA Form (DD 2900) with an Internet-based
data entry system within 3 days before arrival at the screening
site. On arrival soldiers were briefed and received battlemind
training.9Battlemind training is an Army-sponsored educa-
tional program that includes suggested postdeployment coping
skills, awareness of concerning symptoms or patterns of behav-
ior, and suggestions of sources of support or possible mental
health treatment for those who need it. The education and train-
ing were facilitated by the BCT behavioral health officer or the
enlisted behavioral health specialist. If the BCT chose to do so,
soldiers then underwent a medical record screening and immu-
nization station to update soldier medical readiness. Soldiers
then received a face-to-face interview with a divisional primary
care provider in which each of their responses on the DD 2900
were reviewed from the online database.
Content and Scoring of the PDHRA Instrument
and Follow-On Questions
The PDHRA DD 2900 includes a 16-question survey of soldier
exposures during deployment and current physical and mental
health symptoms at the time of screening. The responses to
these questions which relate to the possible need for mental
health care, were previously examined in soldiers returning
from deployment and compared response patterns against cli-
nician interviews to determine optimal thresholds for determin-
ing whether a mental health referral would be beneficial.3In
most instances, the threshold is based on maximizing sensitiv-
ity and specificity. In areas of safety (such as self harm), sensi-
tivity is maximized at the expense of specificity are included in
Fig. 1. PDHRA implementation plan. TMC, Troop medical clinic. BHO, Behavioral health officer.
Military Medicine, Vol. 172, October 2007
1018PDHRA Reassessment for TO&E Units
Soldiers were asked, “Since your return from deployment,
have you had serious conflicts with your spouse, family mem-
bers, close friends, or at work that continue to cause you worry
or concern?” Responses were “yes,” “no,” or “unsure.” Re-
sponses of yes or unsure would generate a mental health refer-
ral (established sensitivity, 0.68; specificity, 0.81).
Post-Traumatic Stress Disorder (PTSD)
Soldiers were asked four questions about PTSD symptoms
using the Primary Care PTSD Screen.10Questions involve: (1)
nightmares/re-experiencing, (2) avoidance of thoughts or situ-
ations that are reminders, (3) vigilance and startle, and (4) feel-
ing numb or detached from others/activities/surroundings. Re-
sponses were “yes” or “no.” Two positive responses would
generate a mental health referral (established sensitivity, 0.79;
Possible Alcohol Use Problems
The survey included the two-item conjoint screen for alcohol
problems.11Soldiers were asked whether during the past month
they “used more alcohol than they meant to” and if they felt the
need or want to “cut down on your drinking.” Responses were
“yes” or “no.” Two yes responses generated a mental health
referral (established sensitivity, 0.73; specificity, 0.86).
The survey included the two screening questions from the
Patient Health Questionnaire 2.12The questions addressed
“little interest or pleasure in doing things” and “feeling down,
depressed, or hopeless” over the past month. Response choices
included “not at all,” “few or several days,” “more than half the
days,” and “nearly every day.” A response of “more than half the
days” or “nearly every day” to either question would generate a
mental health referral (established sensitivity, 0.73; specificity,
Interest in Receiving Treatment or Counseling
Four questions asked soldiers whether they had an interest
in (1) seeing a health care provider to discuss concerns; (2)
receiving information or assistance with stress, emotional, or
alcohol concerns; (3) getting assistance for a family or rela-
REFERRAL CRITERIA FOR BEHAVIORAL HEALTH QUESTIONS ON DD 2900
All “yes and unsure”
0.81Since return from your deployment, have you had serious conflicts
with your spouse, family members, close friends, or at work
that continue to cause you worry or concern?
Have you ever had any experience that was so frightening, horrible,
or upsetting that, IN THE PAST MONTH, you:
a. Have had any nightmares about it or thought about it when
you did not want to?
b. Tried hard not to think about it or went out of your way to
avoid situations that remind you of it?
c. Were constantly on guard, watchful, or easily startled?
d. Felt numb or detached from others, activities, or your
In the PAST MONTH did you:
a. Use alcohol more than you meant to?
b. Felt that you wanted to or needed to cut down on your
Over the LAST 2 WEEKS, how often have you been bothered by any
of the following problems?
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
Answer options were (not at all, few or several days, more than half
the days, or nearly every day)
If you checked off any problems or concerns on this questionnaire,
how difficult have these problems made it for you to do your
work, take care of things at home, or get along with other
Answer options were (not, somewhat, very, extremely)
Would you like to schedule a visit with a health care provider to
further discuss your health concerns?
Are you currently interested in receiving information or assistance
for a stress, emotional, or alcohol concern?
Are you currently interested in receiving assistance for a family or
Over the PAST MONTH, have you been bothered by thoughts that
you would be better off dead or hurting yourself in some way?
Refer if “yes” to 2 or more0.790.78
Refer if “yes” to both 0.73 0.86
Refer if “more than one-
half the days or nearly
every day” to either
Refer if “very or extremely” N/AN/A
Refer all “yes”N/A N/A
Refer all “yes” N/A N/A
Refer all “yes” N/AN/A
Refer all “yes” N/A N/A
N/A, not applicable.
Military Medicine, Vol. 172, October 2007
1019 PDHRA Reassessment for TO&E Units
tionship concern; and (4) having a visit with a chaplain or
community support counselor. Response choices were “yes”
or “no.” A “yes” response to any of the four questions would
generate a mental health referral (sensitivity and specificity
PDHRA face-to-face evaluations were conducted by physi-
cians and physician assistants assigned to the soldier’s units.
Soldier’s responses to the screening form were reviewed, con-
cerns were discussed, and two additional behavioral health
questions were asked. The two behavioral health questions in-
clude item 9 of the 9-item Patient Health Questionnaire 9 to
evaluate for potential suicidal ideations.
whether in the past month they had thought that they “would be
better off dead or hurting yourself in some way.” Positive re-
sponse choices were “very few days,” “more than half of the
time,” or “nearly every day.” A similarly structured question was
used to evaluate for potential harm to others: “Have you had
thoughts or concerns that you might hurt or lose control with
someone?” Response choices were “yes,” “no,” and “unsure.” A
positive response to either question would be carefully explored
by the primary care provider who would make a clinical assess-
ment of whether the soldier was at risk of self-harm or harm to
others (sensitivity and specificity not previously established).
13Soldiers were asked
In addition to the criteria outlined above, providers could refer
any soldier they felt should be seen by behavioral health regard-
less of their responses. All soldiers requiring a behavioral health
consult were directed to the on-site behavioral health team
consisting of a provider (psychiatrist, psychologist, or social
worker) and an enlisted behavioral health specialist. This team
completed all of the behavioral health consults on-site and pro-
vided soldiers with resource and educational materials. In gen-
eral, the soldiers were seen first by the enlisted technicians who
then staffed the results with the behavioral health officer before
releasing the soldier. The officer discussed the evaluation, pro-
vided education, and developed a treatment plan before the
Soldiers requiring behavioral health or primary care follow-up
appointments were provided with appointment slips before de-
parture from the PDHRA site. Soldiers with emergent concerns,
such as suicidal thoughts, were evaluated by the division psy-
chiatrist immediately. Brigade surgeons tracked all soldiers re-
ferred for primary care consults to ensure completion, while the
local medical treatment facility tracked all specialty referrals for
completion. Brigade behavioral health officers tracked all sol-
diers who were seen for behavioral health consults to encourage
enrollment in ongoing services.
From April to August 2006, the five 3ID BCTs at Fort Stewart/
Hunter Army Airfield completed the PDHRA using only existing
brigade and division assets. Additionally, mental health care
access standards (wait times for appointments) were main-
tained at both the troop medical clinic and the division mental
health clinic throughout the process.
In all, 12,817 soldiers participated in the screening process.
This represents ?90% of those who were eligible for the PDHRA.
The majority of those who missed the PDHRA were attending
training schools, on leave, or on other official travel away from
their units. Three of the five brigades chose to incorporate med-
ical record screening, updates, and immunization review into
the PDHRA. As a consequence, division medical readiness im-
proved ?30% during this process.
All soldiers received the facilitated battlemind training and
many anecdotally reported that they found the training benefi-
cial and relevant. All face-to-face interviews were completed by
brigade medical providers, many of whom were very familiar
with the ongoing medical issues of the soldiers who presented
for PDHRA. Typically, the screening sites were staffed with four
to five providers and screened 300 to 400 soldiers daily. The
average time spent in the face-to-face interview was roughly 8 to
Figure 2 outlines the consult rates for the PDHRA screening.
As expected, the majority of the referrals were for behavioral
health matters. The overall percentage of soldiers referred for
consults was as follows: 1,460 (11.4%) for behavioral health,
815 (6.4%) for primary care, 71 (0.01%) for other specialty ser-
vices, and 9 (0.001%) for emergency services. Referrals were
higher in maneuver brigades compared to support units (12.1%
versus 8.6% for behavioral health and 6.9% versus 4.4% for
primary care referrals).
One hundred percent of behavioral health consults were com-
pleted on-site by the division mental health personnel. Average
time spent in consultation with a behavioral health provider was
25 to 30 minutes. The assessments focused on the reported prob-
lems that had resulted in the soldier being referred. Soldiers were
assessed for safety and educated on all behavioral health re-
sources available to them including division mental health, Mili-
tary One Source, chaplains, and Army Community Services. Sol-
diers with confirmed mental health problems were scheduled for
follow-up in the division mental health clinic both for individual
mental health providers and military family life consultants. More
than 80% of those referred to behavioral health during the screen-
division mental health clinic.
An informal exit survey of 100 soldiers who completed the 3ID
PDHRA was conducted to assess perceptions of privacy during
the evaluation process. The majority (92, 92%) reported that
they did not have concerns about their privacy during the pro-
Fig. 2. PDHRA consult rates (N ? 12,817).
Military Medicine, Vol. 172, October 2007
1020PDHRA Reassessment for TO&E Units
cess. More than three-quarters (33 of 43, 76.7%) of those who
completed the survey and were referred to behavioral health
agreed that they did not have privacy concerns. Additionally,
several soldiers made comments to the organizers that they
preferred to “go see mental health with my unit here as they
already know that I have been having problems.”
The outlined model presents a functional method for conduct-
ing PDHRA in a timely and economical fashion in deployable
units with limited resources. There are several advantages to
this approach for physical and mental health screening includ-
ing (1) command ownership and accountability, (2) cost effec-
tiveness, (3) behavioral health on-site consultation, and (4) co-
located medical record and immunization updates.
Command Ownership and Accountability
In a report from pilot sites given at the 2006 Force Health
Protection Conference, soldier compliance and participation
were noted as a problem. Medical personnel reported that as a
“medical” screening program, they did not have the support of
the local commanders. In contrast, the 3ID process was truly a
commander’s program. The commander took ownership and the
screening process became a standard element of unit training
schedules. The location and required resources were coordi-
nated with the local unit commanders, with local unit providers
performing the screening.
Given the current operational tempo of maneuver units, this
process has provided significant savings in a unit’s most valu-
able commodity, training time. Units were scheduled for partic-
ipation in the PDHRA in company units (200–250 soldiers). A
full battalion (750–1,000 soldiers) could complete the education
and screening process in a period of 2 to 3 days. Average time
spent by any soldier/company at the PDHRA site was ?4 hours.
With education, screening, medical records updates, immuni-
zations, and behavioral health consults completed on-site, unit
commanders received either a soldier who was “medically fit” or
one who was already scheduled for treatment while losing less
than half a day from training. Commanders received “real-time”
reports on rates of medical readiness and completion rates for
the postdeployment training in the same fashion they receive
feedback on the status of equipment and logistical readiness.
Compliance would not have approached 90% had this not been
an issue of command interest.
The Army Chief of Staff’s guidance for the PDHRA process was
to maximize the use of existing resources and this process em-
braces that concept. Using internal resources created a greater
sense of ownership, but it also meant no additional costs for
hiring outside personnel or purchasing new equipment. The
process provided flexibility in management of the medical clinics
and the PDHRA sites ensuring that neither was overwhelmed
and both were maintaining accessible medical care. This flexi-
bility would not have been possible with external personnel.
Furthermore, use of local resources not only minimized the cost,
but allowed for ongoing team building and relationship building
between medical providers and unit command personnel.
Behavioral Health On-Site Consultation
Both the pre- and postdeployment screening programs have
been criticized in recent years for identifying behavioral health
issues that were never addressed by a behavioral health spe-
cialist.14By placing the resources on-site, it ensured that all
soldiers who required evaluation were seen immediately. This
limited the potential for a soldier “being lost to follow-up.” Fur-
thermore, it ensured that all soldiers with ongoing behavioral
health issues received safety screening before being released
from the PDHRA site. Other units have adopted a policy that all
soldiers will be evaluated by behavioral health providers regard-
less of their responses. That approach seems to ignore the use of
a screening approach to assign soldiers to high- or low-risk
groups and requires either extensive outside resources or di-
lutes the amount of provider time available to soldiers who
endorse potential mental health problems or desire further
mental health assistance. It is unclear at this time which
method is the more effective in capturing the soldiers who re-
quire services. For a unit with limited resources, the 3ID process
is clearly a more cost-effective method.
The behavioral health evaluation focused on evaluating for
safety and educating soldiers about resources available in con-
trast to performing complete formal intakes on the first evalua-
tion. By focusing on education first, the process assisted sol-
diers in understanding whether their symptoms or behaviors
should be areas of concern possibly requiring future treatment.
The educational program provided encouragement to seek help
through any of the several available service delivery systems.
This educational approach likely played a significant role in the
large number of soldiers who were willing to seek follow-up care.
Further studies are indicated to determine how many of these
soldiers remain engaged in care, receive pharmacologic treat-
ment, and remain on duty.
This design could be effective for other units in the military
which have assigned medical and behavioral health assets,
whether they were located at a facility with a large medical
center or with only a medical clinic. One of the 3ID brigades is
located at a different installation within the state. At the time
PDHRA was required, the brigade medical providers were short
staffed in terms of primary care providers. The brigade surgeon
contacted the local medical facility and performed PDHRA using
providers from that facility. Similarly, the combat aviation bri-
gade is located at a separate installation and has no internal
behavioral health assets. They were able to conduct the PDHRA
using a combination of behavioral health personnel from within
the division and personnel from their local medical clinic. This
type of flexibility makes the program easily adaptable to almost
Challenges and Future Considerations
Although successful in its first application, several challenges
must be addressed in future applications of the 3ID model. They
include (1) education and assessment of soldiers who missed
the mass screening, (2) maintaining privacy, (3) consultation
rates, and (4) conversion from mass to maintenance screening.
There were multiple reasons for soldiers not participating in
the process, including temporary duty away from home station,
leave, and attending military schooling. Soldiers who did not
participate in the mass screening were tracked by the BCT
Military Medicine, Vol. 172, October 2007
1021PDHRA Reassessment for TO&E Units