For Veterans Day...

Solving the Mystery of Military Mental Health: A Call to Action

In the wake of the recent Veterans’ Day observances (November 11, 2018), I had a strangely disquieting feeling. At first, I attributed it to binge-watching too many war movies that had been broadcast for the occasion (including All Quiet on the Western Front, Saving Private Ryan, Platoon, Patton). But there was also the fact that the holiday coincided with the 100th anniversary of the Armistice of WWI, the “Great War,” punctuated by the indignity of our POTUS being deterred by the weather from attending the ceremonies at the French cemetery where US soldiers were buried. But then, in a burst of insight, I realized what so upset me was when George C. Scott slaps the soldier with PTSD in Patton and calls him a “yellow-bellied coward.” This iconic scene resonates with the historic and continued ambivalence of the military toward the psychological wounds of war. It is the military equivalent to the stigma of mental illness that pervades our society—but on steroids.Because of this stubborn aversion to the reality of psychic injuries in the military, active duty and veteran military personnel have been denied effective mental health care, and limited progress has been made in understanding the pathological basis of psychologic trauma and developing more effective treatments. Consequently, our active and veteran military personnel suffer and die unnecessarily.

Military trauma

More than 2 million troops have already been deployed to the wars in Iraq and Afghanistan with no end in sight. Almost a third of all service-persons in these ongoing conflicts suffer from some clinically significant mental condition, the poster child for which is PTSD, and their complications of suicide, addiction and domestic or other-directed violence.1,2 The shocking statistics indicate that our veterans are more than twice as likely to commit suicide than their peers in the civilian population.3The reasons for the burgeoning rates of mental health problems among military personnel deployed to the Middle East—more than in any other war—are as yet undetermined. The possibilities include the asymmetric type of warfare, repeated tours of duty, lack of clearly defined mission. But then the rates had begun to rise during Vietnam when the army was conscripted and possibly beforehand and gone unnoticed. Regardless, the unique psychological dangers faced by our military personnel take their toll and make re-entry into civilian life difficult.The mental health consequences of military trauma are often distressing, disabling and persistent unless there are timely interventions. Symptoms of PTSD include re-experiencing the traumatic event, avoidance of thoughts of the traumatic event and people, places, or other stimuli that evoke the trauma; changes in cognitions regarding the world and one’s self; hypervigilance; hyperarousal (including irritability, concentration difficulties, and disrupted sleep); and increases in disturbing thoughts and negative feelings. PTSD is commonly associated with functional impairment, substance abuse, suicidal ideation, impulsivity and violence, as well as increased utilization of medical care.

Treatments: too few, too late, and not good enough

Despite treatment with the available psychotherapies and pharmacotherapies, PTSD never fully remits in more than half of patients. Meta-analyses of psychotherapy for PTSD has found short-term improvements compared with baseline only in about 50% to 60% of patients, with the majority continuing to have substantial residual symptoms.4-7 The efficacy of medication in PTSD is also sub-optimal, with few patients experiencing a complete remission following pharmacotherapy.7 Moreover, there is a lack of psychopharmacologic advances in its treatment.

Because early symptoms of combat-related mental problems are a reliable predictor of chronicity and impaired social and occupational functioning, early treatment is most advantageous. Early intervention can increase functional capacity, rapid symptom recovery, prevention of maladaptive coping behaviors, and prevention of chronic PTSD and other psychopathology, including complicated grief.8,9Unfortunately, while models of early intervention have been

tested in non-military populations, they have rarely been implemented in military personnel.

Coming home: reconnecting and reintegrating

Research indicates that as many as 50% of veterans experience significant difficulty acclimating with a third developing mental health problems including PTSD, anxiety disorders and depression.10,11Reconnecting with loved ones after repeated exposure to traumatic events and combat stress, coping with physical injuries sustained during combat, and renegotiating roles as civilians in the midst political, social, and economic crises can present an emotionally challenging experience for service members and their family members. If the psychopathology causing these problems goes untreated, chronicity develops that leads to significant social impairment, marital dysfunction, job instability, suicide, substance abuse, and violent behavior.

To compound the problem, there is an acute shortage of services, trained clinicians, and lack of expertise in evidence-based treatments, which limits the care of large numbers of redeployed veterans and their families. Moreover, the quality of services and the effectiveness of treatments are not optimal and limited federal funding has impeded much needed progress that could derive from psychobiological research on the effects of physical and psychological trauma on the brain.12-15Indeed, current treatments for trauma-related mental health disorders, such as PTSD, suicidality, and traumatic brain injury, have yet to be proven effective for large populations of war veterans.16

The lack of available quality mental health care is compounded by the fact that active duty personnel and veterans are too often reluctant, indeed overtly deterred from seeking mental health care because of shame, stigma, and adverse career impact. For those who do seek help, a variety of logistical, cultural, and professional barriers may interfere with care access and delivery.17,18 To add insult to injury, family members of military personnel are not eligible for mental health care in VA settings. Ignoring the needs of these populations is both unfair, given their great sacrifices, and unwise, as family support is critically important for optimal adjustment of returning veterans.

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