Data Highlight How Depression, Migraine Lead to Lost Military Productivity

A practice gap exists for treatment of comorbid depression in military personnel presenting with headache and migraine, while depression strongly correlates with productivity loss in the armed forces, according to a study published in the Journal of Headache and Pain.

“Within the military, headache accounts for greater than 50% of outpatient neurology encounters,” the authors wrote. “It is a cause for medical attention in 4% of all service members, placing significant demands on the healthcare system.”

Researchers implemented a quality improvement project as part of the first study to present the relationship of migraine, depression, and traumatic brain injury on lost productivity and resource utilization. Data was collected from 237 patients presenting to the neurology clinic at Walter Reed National Military Medical Center (WRNMMC) between August 2018 and June 2019.

According to authors, migraineurs are 2 to 4 times more likely to develop major depressive disorder, while “mood disorders, environment and traumatic brain injury are common in patients with headache, and have been shown to influence clinical course, treatment response and outcome.”

Results from the Headache Impact Score (HIT-6), Patient Depression Questionnaire (PHQ-9), and screening for presence of traumatic brain injury were collected to determine if patients were offered a referral for mental health care and a multidisciplinary headache education course. Lost productivity was determined via required reporting of medically related duty limitations among participants.

Of 247 patients, 77% were active duty or retired military personnel and the population averaged 16 headache days per month. In addition, average headache duration was 15 hours and headache impact score averaged 64 points, “indicating a severe impact on patient life.” One hundred and eighty patients had severely disabling headaches. Throughout the course of the study, the population accounted for 146 emergency department visits for acute treatment of headache or migraine.

Data revealed:

• PHQ-9 scores were positive for depression in 65% of screened patients presenting for a primary headache disorder.
• 15% of patients met criteria for severe depression.
• Depression was more likely in patients who had a history of prior mild traumatic brain injury, with a prevalence of 81%.
• Duty restrictions placed as a result of headache or migraine occurred in 3.8% of patients who did not meet criteria for depression and in 29% of patients with depression.
• Of all patients undergoing a medical board or limited duty restrictions for headaches, 94% had a PHQ-9 score consistent with a diagnosis of depression.

Researchers noted that “medical boards within our cohort accounted for at least $31 million of resource utilization and lost productivity.” Furthermore, “of service members who screened positive for depression, nearly 30% were facing duty restrictions or medical separation from the military.”

They also found that military duty restrictions and lost productivity greater correlate with depression than headache impact scores, despite the fact patients initially presented at the clinic for headache complaints.

“Treatment of comorbid psychiatric conditions may have considerable financial implications in the headache population, especially within the United States military population,” the authors concluded.

One study limitation is the lack of information collected on anxiety, which also correlates with migraine and headaches. Results also may not be generalizable to the US population as a whole, due to the fact that military personnel have been exposed to unique environmental and physical factors. These include inconsistent schedules and higher frequency of traumatic brain injuries, which have been shown to affect headaches and migraines, potentially predisposing subjects to higher PHQ-9 or HIT-6 scores.

“Recognition and treatment were more likely if patients met criteria for severe depression. Even in this subgroup, nearly one-third were without a formal diagnosis or engaged with mental health,” the authors noted. “This practice gap presents an opportunity for neurologists to improve patient safety, quality of life, and productivity.”

Reference

Baker VB, Sowers CB, Hack NK. Lost productivity associated with headache and depression: a quality improvement project identifying a patient population at risk. J Headache Pain. 2020;21(50). doi:10.1186/s10194-020-01107-4