Spotlight on Research and Development
Mental health screening at temporary military health clinics in low-income Hispanic communities within the Rio Grande Valley of Texas
By Col. Robert Morecook, PhD, Col. James L. Greenstone, EdD, JD, and Lt. Col. J. Ray Hays, PhD, JD
Welcome to the Spotlight on Research and Development (R&D) column. This column showcases research activities and projects underway in many of the R&D Laboratories within the U. S. Department of Defense, partnering organizations, and the academic and practitioner community in military psychology. Research featured in the column includes a wide variety of studies and programs, ranging from preliminary findings on single studies to more substantive summaries of programmatic efforts on targeted research topics. Research described in the column is inclusive of all disciplines relevant to military psychology — spanning the entire spectrum of psychology, including clinical and experimental as well as basic and applied. If you would like your work to be showcased in this column, please contact Krista Ratwani at (202) 552-6127.
This edition of the newsletter highlights work conducted to understand the need for mental health screening as part of Operation Lone Star (OLS). OLS, conducted for two weeks each year, provides free medical clinics and other health-related services for all who arrive. It is conducted by the Texas Military Forces, in conjunction with the Texas Department of State Health Services and local county health services. Understanding the need for mental health screening as part of this exercise is necessary to ensure that the highest quality care is provided.
Behavioral and mental health problems are not always considered in temporary medical clinics, and instruments are not readily available to provide medical practitioners in those settings with information relevant to mental health conditions. This study provided preliminary data on the utility of the Mini Mental Screen in temporary military medical clinics in the Texas Rio Grande Valley. This instrument was administered to individuals who may have behavioral or mental health problems. In a sample of mostly Hispanic patients (N = 75) seen at a temporary military medical clinic, 12 percent were at significant risk of mental health problems, with an additional 9 percent at moderate risk using published cutoff scores for the risk of such problems. The results for each patient were provided to a medical practitioner who further evaluated the risk, treated the problem, or made a referral. When asked, three of four medical practitioners found that screening data were helpful in their work with patients. One practitioner was concerned that the screening instrument might have too high a false positive rate to be useful. Cultural issues of openness about mental health and behavioral problems need to be considered in such settings.
Problem to Solve
For two weeks each year in the Texas Rio Grande Valley, Texas Military Forces, in conjunction with the Texas Department of State Health Services and local county health services, provide free medical clinics and other health-related services on a walk-in basis in eight locations for all who arrive. This service is designated as Operation Lone Star (OLS), and its primary goal is to provide a full range of medical services to the indigent population on the southern border of Texas. These services include medical and behavioral health care, the latter of which has often been ignored or marginalized. OLS is also a training mission for Texas Military Forces, as it provides training in the organization and operation of medical clinics after disaster situations such as hurricanes. This exercise is one of the primary mandates for the Texas State Guard, which is one of the three branches of the Texas Military Forces.
OLS medical clinics have not always provided behavioral health or mental health services, and the actual need for such services in these clinics is not well understood. Before 2010, mental health services were sometimes available at OLS on a referral basis from clinic physicians and were occasionally used. At OLS in 2008, preliminary data were collected by the authors that suggested that mental health services were warranted and should be regularly provided as part of the general medical services offered at OLS. However, additional data were needed to further understand how the quality of the overall health services provided by OLS clinics could be improved.
Solution and Approach
As a follow-up to the work conducted in 2008, in 2010, a convenience sample of clinic patients was screened using the Modified Mini Screen (MMS), which was developed by the New York State Office of Alcoholism and Substance Abuse Services (2001). That screening was conducted to determine whether or not mental health screening and mental health services should be provided at OLS as a regular part of the clinics. All adults who arrived one afternoon and those arriving the following morning were selected and asked to answer the MMS items while they waited to see a physician or nurse practitioner. All patients were told that the results of the screen would be provided to the medical practitioner so the patient could then be provided with the best medical care during his or her visit. All but two persons completed the questionnaires and returned them to the examiner (N = 75). The screens were scored, and the results were placed with the patient's medical chart generated at the clinic.
The MMS is a 22-item pencil and paper instrument that takes about 15 min to answer and screens for mental health problems in three areas: mood disorders, anxiety disorders, and psychotic disorders. The MMS is available in two languages: English and Spanish. The items are based in a straightforward manner on Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) diagnoses. Many patients at OLS clinics speak little or no English, and having an instrument that was available in both languages was an advantage of the MMS. In fact, 68 of the 75 patients decided to complete the Spanish version of the MMS.
The MMS was scored according to the guidelines in the manual. The manual recommends that persons receiving 6-9 points be considered as having a moderate likelihood of having a mental illness and that persons receiving a score of 10 points or higher be considered as having a high likelihood of having a mental illness. In addition, several individual items deserved special attention due to their importance. Item 4 was inspected by the behavioral health researcher and physician because it indicates the possibility of suicide. Items 14 and 15 were inspected together for the presence of posttraumatic stress disorder. Because the wording of many items is based straightforwardly on DSM-IV-TR diagnostic criteria, the examiner occasionally suggested additional diagnoses to the medical clinician on a rule-out basis.
There were four physicians or nurse practitioners who saw patients in the clinic after screenings were performed for various physical medical conditions. Just prior to the patient's visit to the medical clinician, the results of the each patient's MMS protocol were provided for inclusion in the diagnostic interview. The screener provided an English translation of the protocol along with mental health diagnoses for the medical clinician to consider and rule out.
Of the 75 completed forms, nine (12 percent of the total) had scores of 10 or greater, suggesting the patient was at high risk for a mental illness. Seven (9.3 percent of the total) had scores between 6 and 9, suggesting a moderate risk that the patient suffered from a mental illness. Of the 59 protocols in the low-risk category, one scored positive on suicide risk, and five more appeared worthy of follow-up assessment because of endorsement of items suggesting the presence of mood disorders, panic attacks, or psychotic features for those patients. On 10 (13.3 percent) of the protocols, patients endorsed Item 4 ("In the past month, did you ever think that you would be better off dead, or wish that you were dead?"), suggesting a possible suicide risk. Altogether, 22 protocols were identified as either elevated or risky, suggesting that 29.3 percent of the total number of patients surveyed should receive a further mental health assessment.
At the conclusion of the study, the four medical practitioners in the clinic were interviewed regarding the utility of the MMS as a screening instrument for use during OLS. One clinician found the hypotheses generated very useful and firmly endorsed its use. Two others were positive about its usefulness. Furthermore, one of those clinicians approached the screener during the study and asked that an adolescent be given the instrument, despite the lack of normative data for adolescents, thus showing further confidence in this type of screening. The remaining clinician stated that the instrument generated many false positives and that patients routinely denied items that they had just previously endorsed.
Given the opinion of the screening held by this last clinician, the screener later discovered that the clinician was seeing more than twice as many patients per treatment day as other clinicians and thus may have not built the rapport necessary for full disclosure of mental health issues. A Hispanic health provider who was on site provided additional insight, indicating that Hispanics, especially men, are often unwilling to discuss mental health issues with health providers. Such information suggested the need for greater patience and cultural sensitivity by clinicians when interviewing for mental health problems in this population.
Results of the MMS screening procedure were shared with Brian R. Smith, MD, MPH, who was both the Incident Commander of OLS and the local Public Health Authority. On the basis of the procedure used and the results obtained, Smith expressed a clear desire that mental health screening be continued as part of OLS in future years, either using the MMS or similar mental health instrument. Further, he stated that mental health personnel should be provided for follow-up interviews to the screenings as an adjunct to medical clinicians. Including the MMS and a diagnosis of mental health during OLS is important because those presenting for physical problems may also be experiencing emotional distress as well. Additionally, there may be a relationship between the medical reason for which they presented and emotional and behavioral health issues that they also may be experiencing. Physical symptoms may be one half of the overall personal equation; mental health is the other half. Therefore, as suggested by this research, it is important that clinics assess both physical and mental health to determine the overall health of patients. The MMS provides a viable option for assessing the latter in an efficient manner while providing valuable information to health care professionals.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
Morecook, R., Greenstone, J. L., & Hays, J. R. (2011). Mental health screening at temporary military health clinics in low income Hispanic communities within the Rio Grande Valley of Texas. International Journal of Emergency Mental Health, 13(1), 27-29.
New York State Office of Alcoholism and Substance Abuse Services. (2001). Screening for co-occurring disorders user guide for the Modified Mini Screen (MMS). Albany, NY: New York City Department of Mental Health and Mental Hygiene Quality Impact Initiative.
Data collection occurred during Operation Lone Star 2010, an annual training exercise of the Texas Department of State Health Services, the Texas Military Forces, including the Texas State Guard, the Texas Army National Guard, and the Texas Air National Guard, along with local health groups in the Rio Grande Valley of Texas.
This research was originally published by Morecook, Greenstone, and Hays (2011) in the International Journal of Emergency Mental Health (complete reference provided in the reference list).
Point of Contact Information
For further information about this research effort, please contact the following POCs:
Col. Robert Morecook, PhD
Professor of Psychology
Houston Community College and Commander of the Houston Medical Response Group, Texas State Guard
Col. James L. Greenstone, EdD, JD
Professor of Psychology and Human Services at Capella University and Deputy Commander of the Texas Medical Brigade, Texas State Guard
Lt. Col. J. Ray Hays, PhD, JD
Professor of Psychiatry and Behavioral Sciences
Baylor College of Medicine, Houston, Texas, and a member of the Texas State Guard