A.D. Heymann et al. • Vol 9 • February 2007 90 Screening for physical and psychological health in the armed forces has a long history. No instrument that can accurately assess psychological vulnerability has yet been identified. There is a high incidence of false positive and false negative identification and a lack of cooperation of the target population who may not wish to share concerns with a medical officer [1,2]. There have been many efforts to identify recruits who may be at risk for psychiatric illness, such as the SHIP questionnaire from the United States Navy [3,4]. Several variables were significantly predictive for psychiatric hospitalization: female gender, low education level, history of abuse, and tobacco smoking. It may be that psychological surveillance and not screening may be the most appropriate tool to identify soldiers suffering from emotional distress. Results from psychologi- cal surveillance programs in Bosnia and Kosovo have shown that it is possible to monitor changes in mental health status of soldiers and that those at risk can then be referred [5]. However, this surveillance tool provides a snapshot of the soldiers’ psychological state and is not ongoing. In our study we hypothesized that the information that accumulates in the electronic medical record could serve as an indicator to identify soldiers who might be suffering from mental distress. It should be noted that the background rate of stress in the civilian population is high and under-diagnosis is common. A World Health Organization study conducted in 14 countries indicated that among people who visited their primary care physician 24% were suffering from mental distress. Of these visits 10.4% were primarily for depression, 7.9% were for anxiety, and 2.7% for substance abuse disorders [6]. According to the WHO five of the ten most common reasons for work absenteeism are emotional problems [7]. Most patients suffering from mental distress visit their family doctor [8], while the majority remains undiagnosed [9,10]. The U.S. Preventive Services Task Force recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up [11]. We could not find examples of a large healthcare organization that has successfully implemented such screening. Thus the challenge for civilian and military primary care remains. Recent publications in popular journals claim that about 15% of the soldiers recruited for compulsory service in the Israel Defense Forces are discharged during their first year of their service, and that suicide is one of the leading causes of military mortality [12,13]. In July 2004, an Israeli parliamentary committee learned that in 2003 a total of 43 soldiers committed suicide; only 20% of them were known to the IDF mental health services [12,13]. In addition, it is claimed that 70% of the reasons for early discharge of conscript soldiers are for mental disorders [12]. Mental distress can cause reduced efficiency among soldiers, can negatively affect morale, and may burden the military healthcare framework. A recent survey of Turkish conscripts found a prevalence of depression as high as 30% [14]. Depression can be accompanied by somatic symptoms. Up to 66% of depression presentations were with exclusively physical Abstract Background: In 2003 a total of 43 soldiers in the Israel Defense Forces committed suicide; only 20% of them were known to the IDF mental health services. Somatic symptoms are often the only presentation of emotional distress during the primary care visit and may be the key to early identifcation and treatment. Objectives: To examine whether the information in the medical records of soldiers can be used to identify those suffering from anxiety, affective or somatoform disorder. Methods: We conducted a case-control study using the information in the electronic medical records of soldiers who during their 3 year service developed affective disorder, anxiety, or somatoform disorder. A control group was matched for recruitment date, type of unit and occupation in the service, and the Performance Prediction Score. The number and reasons for physician visits were collated. Results: The fles of 285 soldiers were examined: 155 cases and 130 controls. The numbers of visits (mean ± SD) during the 3 and 6 month periods in the case and control groups were 4.7 ± 3.3 and 7.1 ± 5.0, and 4.1 ± 2.9 and 5.9 ± 4.6 respectively. The difference was statistically signifcant only for the 6 month period (P < 0.05). The variables that remained signifcant, after stepwise multivariate regression were the Performance Prediction Score and the presenting complaints of back pain and diarrhea. Conclusions: These fndings may spur the development of a computer-generated warning for the primary care physician who will then be able to interview his or her patient appropriately and identify mental distress earlier. IMAJ 2007;9:90–93 Differences between Soldiers, with and without Emotional Distress, in Number of Primary Care Medical Visits and Type of Presenting Complaints Anthony D. Heymann MB BS MHA 1,2 , Yaniv Shilo MD 3 , Amir Tirosh MD 4 , Liora Valinsky MPH 1 and Shlomo Vinker MD 2,3 1 Medical Division, Maccabi Healthcare Services, Tel Aviv, Israel 2 Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel 3 Department of Urology, Assaf Harofeh Medical Center, Holon, Israel 4 Department of Family Medicine, Medical Corps, Israel Defense Forces, Israel Key words: emotional distress, medical officer, primary care, somatic complaints IDF = Israel Defense Forces Original Articles