The U.S. armed services must immediately improve access to mental health
care for all their members and their families, but doing so will take more
money, more psychiatrists and mental health professionals, and better
attitudes about the psychological health of service members, Navy Surgeon
General Vice Admiral Donald Arthur told a congressional hearing on July
Arthur is co-chair of the Department of Defense Task Force on Mental
Health, whose recommendations are now being considered by the Pentagon. A
reply, along with plans for action, is due from the secretary of defense on
The absence of sustained combat operations in the 30 years after the end of
the Vietnam War left the military health system understaffed and equipped to
handle only the peacetime needs of its troops, Arthur told the House Armed
Services Subcommittee on Military Personnel.
The onset of wars in Afghanistan and Iraq and the consequent sudden
increase in the need for mental health services have revealed a system in need
of money and additional personnel. The shortcomings of the present system were
exposed but not caused by the current conflicts, Arthur noted.
"This is a leadership issue," he said. "We can change by
focusing officers and noncoms on the psychological health of service members,
just as they do on physical health."
"We need to get to the point where asking for help is seen not as a
sign of weakness but as a sign of integrity, and overcoming that initial
reluctance is a mark of leadership," said S. Ward Cascells, M.D.,
assistant secretary of defense for health affairs. Many military personnel
fear that asking for help or reporting symptoms of stress or other mental
health problems will stigmatize them and harm their careers.
The focus on psychological health should extend from recruitment to
retirement. Incoming troops should be evaluated, and those whose prior life
experiences made them vulnerable to severe stress reactions should be guided
to jobs, like repairing aircraft engines, that are less stressful than
patrolling roads in Iraq, said Arthur.
The Pentagon task force found significant gaps in the numbers of
psychiatrists and mental health professionals in uniform, added the other
co-chair, Shelley MacDermid, Ph.D., director of the Center for Families at
Purdue University and co-director of the Military Family Research
Military health leaders would prefer to rely on mental health clinicians in
the military rather than depending on clinicians who are civilian contractors
for two reasons. First, troops feel more comfortable talking to someone who
understands first hand the demands of military service. In addition, current
Pentagon policy involves placing mental health personnel as close to the
frontlines as possible, a situation that is inappropriate for civilians. But
recruiting and retaining these mental health care providers has become more
difficult recently and may call for additional incentives, said MacDermid.
"Having fewer providers means more deployments for the ones who stay
in the service," she told Psychiatric News in an interview."
Even those who want to stay are tired of repeated deployments and
separation from their families."
Outside the combat zones or military bases, the TRICARE system of civilian
medical contractors presents problems for troops and their families when they
seek mental health services, MacDermid pointed out. Many mental health
services for military families are not reimbursable, including counseling for
domestic abuse, bereavement, or marital problems. TRICARE prohibits individual
outpatient substance abuse treatment. Reimbursement rates are lower compared
with other major payors, there is no consistent standard of care, and mental
health providers must meet more extensive certification requirements than
other professionals to be included on the TRICARE roster, she said. In
addition, certain mental health services are either not available, require
out-of-state travel, or direct patients to inpatient services rather than
closer-to-home outpatient or day-treatment settings.
National Guard and Reserve troops face "daunting" additional
difficulties, MacDermid noted. They seek care in their own communities but
often find that local clinicians don't know about the military experience and
best practices for treating combat-related psychiatric conditions.
Subcommittee chair Rep. Susan Davis (D-Calif.) asked panel members how many
new providers the services needed and what the costs might be for more
personnel and changes in procedures. The task force did not provide those
figures although its report did offer a list of 94 recommendations for
improving the military's mental health response.
"We did not have the financial expertise to determine funding, so we
thought it best to articulate a clear vision of what is needed," said
Arthur. The task force recommends a risk-adjusted, population-based model,
which each service would develop independently. Features common to all
services, however, included embedding mental health personnel in operations
units, placing psychologists in primary care settings to give easy access and
reduce stigma, and broadening the idea of "provider" to cover a
broad range from a psychiatrist to the school nurse.
"We recommend access everywhere," said Arthur. ▪