Evaluation of Data Obtained from Military Disability Medical Administrative Databases for Service Members with Schizophrenia or Bipolar Disorder

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1 MILITARY MEDICINE, 172, 10:1032, 2007 Evlution of Dt Otined from Militry Disility Medicl Administrtive Dtses for Service Memers with Schizophreni or Bipolr Disorder Gurntor: MAJ Amy M. Millikn, MC USA Contriutors: MAJ Amy M. Millikn, MC USA*; Ntly S. Weer, MD MPH*; LTC(P) Dvid W. Nieuhr, MC USA*; E. Fuller Torrey, MD ; Dvid N. Cown, PhD MPH*; Yunzhng Li, PhD*; Brend Kminski, MPH PA-C* Ojective: We re studying ssocitions etween selected iomrkers nd schizophreni or ipolr disorder mong militry personnel. To ssess potentil dignostic misclssifiction nd to estimte the dte of illness onset, we reviewed medicl records for suset of cses. Methods: Two psychitrists independently reviewed 182 service medicl records retrieved from the Deprtment of Veterns Affirs. Dt were evluted for dignostic concordnce etween dtse dignoses nd reviewers. Interreviewer vriility ws mesured y using proportion of greement nd the sttistic. Dt were strcted to estimte dte of onset. Results: High levels of greement existed etween dtse dignoses nd reviewers (proportion, 94.7%; 0.88) nd etween reviewers (proportion, 92.3%; 0.87). The medin time etween illness onset nd initition of medicl dischrge ws 1.6 nd 1.1 yers for schizophreni nd ipolr disorder, respectively. Conclusions: High levels of greement etween investigtors nd dtse dignoses indicte tht dignostic misclssifiction is unlikely. Dischrge procedure initition dte provides suitle surrogte for disese onset. Introduction he Militry New-Onset Psychosis Project (MNOPP) is series T of nested cse-control studies of potentil ssocitions of selected iomrkers with schizophreni nd ipolr disorder mong militry personnel receiving medicl dischrges. Cses were identified vi Physicl Disility Agency (PDA) dministrtive dtses mintined y ech of the three services (Army, Air Force, nd Nvy/Mrine Corps). The mission of the PDA is to develop nd to implement policies, procedures, nd progrms tht pply to the physicl disility system nd to mnge the physicl evlution ords (PEBs). 1 In ccordnce with PDA procedures, militry medicl dischrges re rendered fter two thorough medicl reviews. First, n exhustive clinicl review process, referred to s medicl evlution ord (MEB), is conducted. During the *Deprtment of Epidemiology, Division of Preventive Medicine, Wlter Reed Army Institute of Reserch, Silver Spring, MD Stnley Medicl Reserch Institute, Chevy Chse, MD Division of Physicin Assistnt Studies, Shenndoh University, Winchester, VA Portions of this work were presented t the Force Helth Protection Conference, August 7 11, 2006, Aluquerque, NM. The views expressed re those of the uthors nd should not e construed to represent the positions of the Deprtment of the Army or the Deprtment of Defense. Reprints: MAJ Amy M. Millikn, Wlter Reed Army Institute of Reserch, 503 Roert Grnt Avenue, Silver Spring, MD This mnuscript ws received for review in Novemer The revised mnuscript ws ccepted for puliction in June MEB process, t lest two nd usully three physicins independently review the clinicl history nd medicl dt nd gree upon the dignosis. If the condition under review involves mentl illness, then one of the physicins must e psychitrist. A forml nrrtive summry of their findings is produced, providing detiled informtion regrding history, physicl exmintion nd lortory findings, nd other documenttion in support of the dignosis. 2 For individuls who do not meet retention stndrds, the nrrtive summry is forwrded for fitness-for-duty evlution, referred to s PEB. This review is conducted y two nonmedicl officers nd one physicin to determine whether the individul is fit for duty, sed on the findings of the MEB nd the individul s other militry occuptionl requirements, medicl history, rnk, nd pst militry performnce. The PEB then recommends the individul for dischrge or return to duty, s pproprite. 2 Although there re differences in detils etween the processes used y the different militry services, the overll methods re very similr. 3 Sujects eligile for inclusion in this study received oth MEB nd PEB reviews nd were determined to e unfit for duty. Militry medicl dischrges re ctegorized y using the Veterns Administrtion Schedule for Rting Disilities (VASRD) coding system, 4 which does not exctly mtch either the Dignostic nd Sttisticl Mnul of Mentl Disorders, Fourth Edition (DSM-IV), system or the Interntionl Clssifiction of Diseses, Ninth Revision, system. The PDA dtses contin, mong other dt, dignostic codes, mount of disility wrded, nd other dministrtive dt pertining to when forml medicl nd dministrtive evlutions were initited nd concluded for the dignosis leding to service dischrge. 2,3 The reliility of the PDA electronic dtse dignoses hs not een formlly exmined. 5 In ddition, reliility etween psychitrists concerning dignoses of mentl disorders hs long een questioned. 6,7 The degree of reliility vries on the sis of the method of dignostic evlution, level of interviewer/reviewer trining, mentl disorder under considertion, nd type of psychitric service. A few studies hve explored these issues y exmining the dignostic reliility for psychitric conditions using different methods of mentl helth evlution For instnce, the Structured Clinicl Interview for the Psychotic Spectrum ws reported to significntly discriminte sujects with ny psychitric dignosis from control individuls nd sujects with from sujects without psychotic disorders. 15 However, compred with the Structured Clinicl Interview for DSM-IV (SCID), semistructured interview more relily supported ipolr disorder clinicl dignosis. 8,9 1032

2 Evlution of Militry Disility Dt The highest interrter reliility for ipolr disorder nd schizophreni ws reched when dignostic interviews nd susequent reviews were conducted y experienced psychitrists. 12,16 Additionlly, semi-structured interviews performed y clinicins more relily predicted mood disorders, compred with fully structured interviews completed y nonclinicins. 17,18 When psychitric record reviews nd postmortem fmily interviews were conducted, higher concordnce ws found for schizophreni (Cohen s 0.94), compred with ipolr disorder ( 0.58). 10 Better greement etween the psychitric dignoses mde under indirect supervision nd the dignoses otined through the SCID ws found for schizophreni in the emergency service (80%), compred with inptient (55%) nd outptient (44%) services. 11 The interrter reliility of the DSM-IV criteri ws highly unstisfctory for dignosing schizoffective disorder ( 0.22), compred with mnic ( 0.71) nd mjor depressive ( 0.82) episodes. 13 Overll, dignostic reliility studies vry gretly in design nd predominntly involve structured nd semistructured interviews. There re two widely ccepted sttisticl methods used for this type of reserch, i.e., proportion of greement nd the sttistic. 8 14,16 However, there is little literture on the design of clinicl record review studies nd lck of stndrds for reporting results. 19,20 The primry gol of this review ws to ssess the potentil impct of dignostic misclssifiction incurred y identifying cses for inclusion in the MNOPP studies vi dignostic codes found in the PDA dtses. The secondry gol ws to collect dt llowing investigtors to estimte the dte of illness onset from the informtion provided in the PDA dtse. To determine whether the individuls selected for record review were typicl, we lso compred the demogrphic chrcteristics of those individuls with those of the study popultion eing used in the MNOPP. This project ws reviewed nd pproved y the institutionl review ord t the Wlter Reed Army Institute of Reserch (WRAIR). Methods 1033 Study Popultion A totl of 3,105 individuls who were dischrged from militry service etween 1992 nd 2001 with dignosis of ipolr disorder (n 1,814) or schizophreni (n 1,291) were identified from tri-service PDA dtses for possile inclusion in the MNOPP studies. VASRD codes for ipolr disorder (codes 9432 nd 9206) nd schizophrenic spectrum disorders (codes nd 9211) were used to select cses for this nlysis (Tle I). Supplementl demogrphic dt were otined from the Defense Mnpower Dt Center. There were 277 records with ipolr disorder nd 118 records with schizophrenic spectrum disorders tht were retrieved nd reviewed. Record Retrievl When n individul is dischrged from militry service, hrd copy of the service medicl record is trnsferred to the Deprtment of Veterns Affirs Veterns Benefits Administrtion (VBA). Under reserch protocol, investigtors provided the VBA centrl office with the list of individuls identified y the PDAs. The VBA then queried its dtses to determine the service medicl record loction. Record loction ws identified for 1,236 (68%) ipolr disorder nd 733 (57%) schizophreni records. Investigtors trveled to severl VBA loctions to copy selected portions of the records nd to trnsport them ck to WRAIR for review. When ville, MEB nrrtive summries, PEB documenttion, dischrge summries from psychitric hospitliztions, psychitric consulttion notes, nd other relevnt clinicl notes were identified nd copied. Copies of records were lso miled from two of the VBA loctions to WRAIR. Investigtors ttempted to otin 15% of the totl records with known loctions for oth schizophreni nd ipolr disorder study sujects to complete 10% record review for ech dignostic ctegory. Becuse of discrepncies etween records identified s ville in electronic dtses nd ctully retriev- TABLE I COMPARISON OF RECORD REVIEW CATEGORIES WITH VETERANS ADMINISTRATION SCHEDULE FOR RATING DISABILITIES (VASRD) & DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS-IV (DSM-IV) CODES Record Review Dignostic Ctegory VASRD Description (Code) DSM-IV Code Mood disorder spectrum Bipolr disorder I Bipolr disorder (9432 or 9206) ; Bipolr disorder II Other mood disorder ; ; Schizophreni spectrum Schizophreni Schizophreni, disorgnized type (9201) Schizophreni, cttonic type (9202) Schizophreni, prnoid type (9203) Schizophreni, undifferentited (9204) Schizophreni, residul (9205) Schizoffective Schizoffective (9211) Psychotic disorder NOS ; NOS, not otherwise specified.

3 1034 Evlution of Militry Disility Dt le t the vrious loctions, totl of 395 records (277 from ipolr disorder sujects nd 118 from schizophreni sujects) were otined, representing 15% nd 9%, respectively, of sujects in the lrger study. All records were ssigned unique study identifiction numer nd stored in locked file cinets t WRAIR. Review Process nd Dt Astrction A record dt strction form tht included list of items sed on the criteri of the DSM-IV for schizophrenic nd mood disorder spectrum dignoses ws developed y the investigtors. Reviewers were sked to recognize nd to confirm the presence of disorder-relevnt criteri in the medicl records y nswering the questions nd using them s guidnce for mking finl dignoses. For the dignostic criteri for schizophrenic spectrum nd ipolr disorders, ll of the chrcteristic symptoms presented in the DSM-IV were included on the form. The form lso contined dignostic criteri such s durtion of illness (for schizophreni), presence of t lest one episode of cute mni/hypomni (for ipolr disorders), socil nd occuptionl dysfunction, nd sustnce-relted or other medicl condition exclusions. Records were independently reviewed nd pertinent dt were strcted y two psychitrists (reviewer 1 nd reviewer 2). All 395 records were evluted y reviewer 1, with suset of 182 records (46%) lso exmined y reviewer 2. Twentysix records were identified y t lest one reviewer s requiring ressessment nd discussion. A consensus dignosis ws reched for ech of those records. Inter-reviewer comprisons were restricted to the 182 records reviewed y oth reviewers; the entire set of 395 records ws used for ll other nlyses. Verifiction of Dignoses The full set of records (n 395) ws sorted into two rod ctegories of dignosis (mood disorders nd schizophrenic spectrum disorders) sed on VASRD codes. There were 277 mood disorder records nd 118 schizophrenic spectrum records. The specific VASRD codes nd est-mtched DSM-IV codes used for this ctegoriztion re detiled in Tle I. If record contined only outptient notes without nrrtive summry or VASRD dignosis with symptoms mentioned ut without detiled description, the informtion ws considered indequte for verifiction purposes. Exclusion of these records ensured more rigorous ssessment of the verifiction of VASRD dignoses. Interreviewer greement on dignosis ws estimted t two levels of grnulrity for the 182 records reviewed y oth reviewers. The finer level included seven ctegories, nmely, schizophreni, schizoffective disorder, psychotic disorder not otherwise specified (NOS), ipolr disorder I, ipolr disorder II, mood disorder NOS, nd insufficient informtion to evlute the ssigned dignosis. The lower level of grnulrity included three dignostic ctegories, nmely, schizophrenic spectrum disorders (schizophreni, schizoffective disorder, nd psychotic disorder NOS), mood disorders (ipolr disorders I nd II nd mood disorder NOS), nd insufficient informtion. A suset of records ws sujected to consensus review y oth psychitrists, in which they discussed the ville informtion nd greed on dignosis. Either reviewer could request consensus review, even if the other reviewer hd ssigned dignosis. In generl, if discordnt dignoses were ssigned to record, then oth reviewers dignoses were compred with the VASRD code. If either dignosis ws consistent with the ssigned VASRD code, then the dignosis ws considered verified. The exception to this pproch ws when record went through consensus review. In these instnces, if the initil dignosis of one reviewer mtched the VASRD dignosis ut the consensus dignosis did not, then the dignosis ws not considered verified. Records tht were found to hve indequte dt were excluded from these nlyses. Estimtion of Illness Onset The yer of disese onset ws defined s the erliest yer in which either the ptient or clinicin reported in the medicl record psychitric signs or symptoms consistent with schizophreni or ipolr disorder. The dtes of the MEB nd PEB were lso cptured. No comprison etween reviewers ws conducted; when there ws disgreement, the erliest dte ws ccepted. Sttisticl Anlyses All nlyses were conducted with SAS 9.0 softwre (SAS Institute, Cry, North Crolin). To estimte whether the ipolr disorder nd schizophreni records selected for review were representtive of the study popultions of sujects with ipolr disorder nd schizophreni, respectively, we used the 2 test nd Student s t test. 21 The 2 method ws used to compre the distriution of ctegoricl demogrphic chrcteristics such s gender, rce, nd militry rnch, nd the t test ws used to nlyze ge s continuous vrile. Student s t test ws lso pplied to ssess differences in the durtions of time etween estimted symptom-onset dte nd MEB/PEB initition dtes, s well s etween MEB nd PEB dtes, mong sujects with schizophreni vs. ipolr disorder. Comprisons etween reviewers were mde with Cohen s nd percentge greement. Results Demogrphic Chrcteristics There were more thn twice s mny sujects with ipolr disorders (n 277), compred with schizophrenic spectrum disorders (n 118). The demogrphic chrcteristics of the individuls whose records were reviewed (n 395) were similr to those of ll MNOPP study sujects (n 3,105), with no significnt differences found except for the rnch of service for oth disorder ctegories ( 2 test, p ) nd the ge t service dischrge distriution for ipolr disorder ( 2 test, p 0.04; Tle II). Army nd Mrine Corps sujects were comprtively underrepresented mong sujects whose records were reviewed, wheres Air Force nd Nvy sujects were overrepresented. The mjority of sujects were Cucsin, followed y Africn Americn nd other. The other rce ctegory includes ll except Africn Americn nd Cucsin. The proportion of

4 Evlution of Militry Disility Dt 1035 TABLE II DEMOGRAPHICS OF RECORD REVIEW SUBJECTS COMPARED WITH ALL STUDY SUBJECTS Chrcteristic n 277 n 1814 n 118 n 1291 Bipolr Records (%), Bipolr Sujects (%), Schizophreni Records (%), Schizophreni Sujects (%), Sex Mle Femle Age t dischrge (yers) c Rce d Cucsin Africn Americn Other Brnch of militry e Army Air Force Mrines Nvy Percentges my not totl 100 due to missing dt items on some sujects. The gender distriution in sujects with records compred with ll the sujects. 2 test: p 0.08 for ipolr disorders nd p 0.63 for schizophrenic spectrum disorders. c The medin ge t service dischrge of sujects with records vs. ll the sujects for ipolr disorders (27.5 vs. 29.0, p 0.04) nd schizophrenic spectrum disorders (28.0 vs. 26.0, p 0.14); significnce of the difference in ge distriution etween the popultions clculted using 2 test. d The rce distriution in sujects with records compred with ll the sujects. 2 test: p 0.08 for ipolr disorders nd p 0.66 for schizophrenic spectrum disorders. e The service distriution in sujects with records compred with ll the sujects. 2 test: p for ipolr disorders nd p for schizophrenic spectrum disorders. Cucsin individuls ws higher in the ipolr disorder ctegory (74 78%) thn in the schizophrenic spectrum ctegory (53%). Interreviewer Agreement There were 40 records (10.1%) with insufficient informtion, s scertined y t lest one reviewer (reviewer 1 identified 19 records, reviewer 2 identified 25 records, nd 18 records were identified y oth). Approximtely 80% of the records contined t lest one nrrtive summry; therefore, the overll qulity of the medicl records otined ws considered stisfctory. During consensus reviews, three records previously evluted s insufficient y one reviewer were reevluted s sufficient for t lest the ctegoricl verifiction of dignoses. The remining 355 records were used for further nlyses, including VASRD verifiction nd estimtion of onset of disese. Tle III presents counts for dignoses, compring reviewer 1 with reviewer 2. The totl percentge greement etween reviewers for the more grnulr dignostic ctegories ws 80%, nd the totl simple coefficient ws 0.74 (95% confidence intervl, ; two-sided p ). As shown in Tle IV, oth mesures of reviewers concordnce were higher for the less-grnulr dignostic ctegories, with percentge greement etween reviewers of 92.3% nd simple of 0.87 (95% confidence intervl, ; two-sided p ). VASRD Verifiction The coefficient for the overll concordnce etween reviewers nd VASRD dignoses ws 0.88 (95% confidence intervl, ; two-sided p ; Tle V). Becuse the suctegories of mood nd schizophrenic spectrum disorders did not correspond to the VASRD suctegories, the overll coefficient ws the only coefficient tht could e clculted. The percentge greement for ll records comined (n 355) ws 94.7%, nd results were similr for mood disorders nd schizophrenic spectrum disorders. The percentge verifiction of VASRD dignoses could not e clculted for mood disorder suctegories (ipolr disorders I nd II nd mood disorder NOS) ecuse the VASRD system uses single ctegory for ipolr disorder. For schizophrenic spectrum disorder suctegories, the percentge greement ws highest for schizophreni, intermedite for psychotic disorder NOS, nd lowest for schizoffective disorder. Onset of Symptoms Becuse of missing MEB dtes in 40 records, 339 records (95.5%) were used to clculte the difference etween MEB nd PEB dtes. An dditionl nine cses were dropped from nlysis ecuse of lck of informtion concerning the dte of onset; therefore, the difference etween the erliest yer of onset nd the MEB dte ws found for 330 cses.

5 1036 Evlution of Militry Disility Dt TABLE III INTERREVIEWER AGREEMENT: SUBCATEGORIES BY DIAGNOSIS Schizophreni Schizoffective Disorder Psychotic Disorder NOS Reviewer 2 Bipolr Disorder I Bipolr Disorder II Other Mood Disorder Insufficient Reviewer 1 Schizophreni Schizoffective disorder Psychotic disorder NOS Bipolr disorder I Bipolr disorder II Other mood disorder Insufficient Numer of records reviewed y oth 182/395, 46% of totl records ville for review, simple coefficient 0.74, totl percent greement 79.7%. NOS, not otherwise specified. TABLE IV INTERREVIEWER AGREEMENT: MOOD DISORDER VS. SCHIZOPHRENIA SPECTRUM Mood Disorder Reviewer 2 Schizophreni Spectrum Insufficient Reviewer 1 Mood disorder Schizophreni spectrum c Insufficient Numer of records reviewed y oth 182/395, 46% of totl records ville for review, simple coefficient 0.87, totl percent greement 92.3%. Mood disorder spectrum ctegory includes ipolr disorder I, ipolr disorder II, other mood disorders. c Schizophreni spectrum ctegory includes schizophreni, schizoffective disorder, psychotic disorder NOS. TABLE V PERCENT VERIFICATION OF DIAGNOSES. (VETERANS ADMINISTRATION SCHEDULE FOR RATING DISABILITIES (VASRD) DIAGNOSES VERIFIED BY AT LEAST ONE REVIEWER) Dignostic Ctegory % Agreement Mood disorder 94.7 Schizophreni spectrum 94.6 Schizophreni 78.4 Schizoffective 45.0 Psychotic disorder NOS c 66.7 Numer of records reviewed records with sufficient informtion were used for verifiction. Overll percent verifiction in the ctegoricl comprison 94.7, overll coefficient Percent greement is 94.7 for ll suctegories of mood disorder since there re only two VASRD codes nd they re oth for ipolr disorder (9432 nd 9206). c NOS, not otherwise specified. The medin time etween the estimted symptom-onset dte nd the MEB initition dte ws 1.1 yers (25th percentile, 0.3 yers; 75th percentile, 3.5 yers) for mood disorders nd 1.6 yers (25th percentile, 0.5 yers; 75th percentile, 3.8 yers) for schizophrenic spectrum disorders (t test, p 0.88). The medin for the difference etween MEB nd PEB dtes ws 0.33 yers (25th percentile, 0.21 yers; 75th percentile, 2.11 yers) for ipolr disorder cses nd 0.35 yers (25th percentile, 0.21 yers; 75th percentile, 0.86 yers) for schizophreni cses (t test, p 0.09). Discussion We found high levels of greement etween the two reviewers nd etween the reviewers nd the PDA dignoses. The levels of greement were highest when roder dignostic ctegories were considered. The medin period from initil psychitric symptoms to the dte of the initil MEB ws 1.1 yers for mood disorders nd 1.6 yers for schizophrenic spectrum disorders, ut times were 3.5 yers for 25% of oth groups. The verge time from MEB disese dignosis to militry dischrge ws 4 months for oth groups. The finding tht the numer of sujects with ipolr disorders previled over the numer of those with schizophrenic spectrum disorders is consistent with previous reserch. 22 The most likely reson is tht the erlier ge of schizophreni onset precludes individuls from militry enlistment. Recruits with schizophreni lso could e more esily screened out, ecuse of the higher visiility of their symptoms. Becuse mentl disorders re not completely discrete entities with solute oundries, 23 some discordnce etween reviewers ws expected. As nticipted, reltively greter discordnce etween reviewers ws detected for records with poorly defined clinicl pictures nd less detiled informtion. The discordnce ws lso expected to increse s function of the increse in the specificity of the dignostic criteri (i.e., ddition of sutypes nd specifiers to the mjor dignostic codes). 24 The gretest discordnce etween VASRD dignoses nd reviewers ws found for schizoffective disorder. Such discordnce ws nticipted for t lest two resons, tht is, the oundries of schizoffective disorder lck trnsprency, ecuse the disorder represents n intermedite dignostic ctegory etween mood disorder with psychotic fetures nd schizo-

6 Evlution of Militry Disility Dt phreni with mood fetures, nd there is poor dignostic stility over time, long with lck of cross-sectionl dignostic reliility. 25 The medin time etween the erliest dte of onset nd the MEB initition dte ws 1 yer for cses with mood disorders nd 1.5 yers for cses with schizophrenic spectrum disorders. This finding suggests tht the MEB initition dte cn e used in the lrger study s surrogte dte for disese onset. The medin period from disese onset to dischrge dte for individuls with dignosis of ipolr disorder or schizophreni ws 0.3 yers. Our study hs the following strengths. A gret mjority of the records hd stisfctory qulity, in terms of providing sufficient informtion. The record review ws performed y two independent psychitrists, using stndrdized strction form. A high level of VASRD dignosis verifiction demonstrted these dignoses s vlid nd relile. Therefore, mentl helth dischrge dignoses cn e used to mesure outcomes in future studies without significnt misclssifiction. There re severl limittions to the current study. The records did not exhustively cover the entire course of illness, for t lest two resons. First, the inptient nd outptient mentl helth records could e incomplete while the ptient ws in the militry. Second, records covered mentl helth during militry service nd not efore entering or fter leving the service. Another wekness of the study ws n imprecision of direct correspondence etween VASRD codes nd DSM-IV codes, s detiled in Tle I. The correspondence of VASRD codes with DSM-IV codes hs not een externlly vlidted. In ddition, the results of the study could hve een different if the psychitrists hd the opportunity to interview ptients nd to dignose psychitric disorders, rther thn to verify dignoses sed on medicl nd dministrtive records. The SCID or telephone interview ws not fesile ecuse of difficulties in finding sujects dischrged from the militry nd in otining pproprite informed consent from ptients with schizophreni nd ipolr disorders. In our nlysis to determine whether the smple of records dequtely represented the lrger study popultion, we chose two mesures of ssocition, nmely, the 2 test nd Student s t test. Although the 2 test does not indicte the directionlity or mgnitude of oserved differences, our primry intent ws to scertin whether demogrphic differences exist cross the ctegoricl vriles of interest. Our results indicted tht Army nd Mrine Corps sujects were under-represented in the record review, likely for two primry resons. First, the lck of Mrines mong sujects with records cn e explined y the smll proportion of Mrines present mong ll study sujects (5 6%). Second, we sought to otin 10% smple of ll sujects in the two rod dignostic ctegories, schizophreni nd ipolr disorder spectrum disorders, nd did not strtify the smple ccording to service. We hve no reson to think tht individuls with these disorders differ ccording to service. Conclusions Cse identifiction using the VASRD dignostic codes from the PDA records ppers to e vlid method, without evidence of significnt misclssifiction error. This supports the use of VASRD codes for cse identifiction in the MNOPP study. The onset of psychosis s estimted from the MEB initition is lso supported y this review. As result, the MNOPP study will hve ccess to lrge numer of sujects to study potentil ssocitions etween selected iomrkers nd schizophreni or ipolr disorder nd to contriute to the understnding of their etiology. Acknowledgments We thnk Mry Brundge, MLS, for her dt mngement support. This effort ws funded y the Stnley Medicl Reserch Institute (Bethesd, Mrylnd) nd the Deprtment of the Army. 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7 1038 Evlution of Militry Disility Dt 19. Worster A, Hines T: Advnced sttistics: understnding medicl record review (MRR) studies. Acd Emerg Med 2004; 11: Shrout PE: Mesurement reliility nd greement in psychitry. Stt Methods Med Res 1998; 7: Fleiss JL: Sttisticl Methods for Rtes nd Proportions, Ed 2. New York, Wiley, Herrell R, Henter ID, Mojti R, et l: First psychitric hospitliztions in the U.S. militry: the Ntionl Collortive Study of Erly Psychosis nd Suicide (NCSEPS). Psychol Med 2006; 36: Americn Psychitric Assocition: Dignostic nd Sttisticl Mnul of Mentl Disorders, Ed 4, p xxxi. Arlington, VA, Americn Psychitric Assocition, McCormick LM, Flum M: Dignosing schizophreni circ 2005: how nd why? Curr Psychitry Rep 2005; 7: Kempf L, Hussin N, Potsh JB: Mood disorder with psychotic fetures, schizoffective disorder, nd schizophreni with mood fetures: troule t the orders. Int Rev Psychitry 2005; 17: Letters to the Editor To the Editor The GUEST EDITORIAL [(Milit Med 2007; 172: ii-iv)] y Cpt Terush, et. l. proposing the trining of Joint Expeditionry Medicine Specilist (JEMS) is intriguing. However, I m concerned whether most Mster of Pulic Helth (MPH) progrms will e sufficiently le to contriute to the desired results. Mny of these progrms hve hevily refocused upon the development of specific preventive, occuptionl, or erospce medicine cpilities, downplying the core integrtive ttriutes of pulic helth prctice. The current dete regrding providing pulic helth certifiction for non-medicl professionls otining n MPH degree further dds to the identity crisis. Mny of these MPH grdutes spend most of their creers ssigned to specilized ctegoricl progrm, often performing nrrow function. The pulic helth skills or cpilities to e certified re uncler. The JEMS opertionl skill set descried y the uthors genericlly does not differ significntly thn tht required y medicl specilists who prctice community pulic helth. As I descrie in my soon to e pulished ook, De-Spmming Helth - Reforming the Helth System from the Bottom Up., the domestic demnd for such prctitioners hs plummeted while the need for them hs never een greter. The resons re multiple, including scientific nd system growth nd frgmenttion. If the uthors re convinced the militry commnd structure will optimlly utilize such specilists, there will still e chllenge to ssure they receive pproprite pulic helth trining. Jmes D. Felsen, M.D., MPH, Cpt, USPHS (retired)