Col. Elspeth Cameron Ritchie, M.C., psychiatry consultant to the U.S.
Army surgeon general, addresses the mental health needs of members of the
military during the annual Mental Illness Awareness Week symposium sponsored
by APA and NAMI last month in Washington, D.C.
A continuing critical shortage of psychiatrists and psychologists in the
armed forces and access to quality mental health care for veterans in rural
areas are issues that must be addressed now, mental health leaders told
members of Congress and their staffs last month.
Military and veterans officials and others identified key concerns in the
treatment of mental illness during the 2007 Mental Illness Awareness Week
Congressional Symposium, jointly sponsored by APA and the National Alliance on
Mental Illness (NAMI). The Capitol Hill briefing described the progress made
in identifying and treating mental illness among active-duty and veterans
groups, as well as thesignificant work that remains (see also VA Told to
Establish Multiple Prevention Programs).
"We have to be realistic that when we send men and women to war
zones, we are placing them at great risk for developing psychiatric
disorders," said Daniel Blazer, M.D., Ph.D., a psychiatrist and member
of the Department of Defense Mental Health Task Force, which recently
concluded its work with the release of a report on the need to improve mental
health services for members of the military and their families
(Psychiatric News, August 3). "If we don't pay attention to
their mental health, then we are closing our eyes to the real-life cost of
sending them to war."
The risk of developing mental illness as a result of combat exposure is as
real as the risk of incurring physical injuries, and the government needs to
be ready for that eventuality, he said. At this point the military is falling
short of that commitment to provide sufficient care.
Blazer and others cited a shortage of psychiatrists and psychologists in
the armed forces as the leading obstacle to effective mental illness detection
and treatment for those who serve in the Iraq and Afghanistan war zones.
His conclusion echoed the leading finding in the task force's report:"
The Military Health System lacks the fiscal resources and the
fully-trained personnel to fulfill its mission to support psychological health
in peacetime or fulfill the enhanced requirements imposed during times of
conflict." The task force urged more funding to retain existing
personnel and to add more, so members of the military would have greater
access to care.
This proposal will require not a one-time infusion of additional funding,
Blazer said, but "sustained increased funding to shore up mental health
care for our soldiers."
One way the military has attempted to increase access with limited
personnel is to increase the use of telemedicine, including in Europe.
However, technological limitations have restricted its use in Afghanistan and
Iraq, according to Col. Elspeth Ritchie, M.C., psychiatric consultant to the
Army surgeon general.
Access obstacles also limit the mental health services that the Department
of Veterans Affairs (VA) is able to provide, according to several speakers.
However, veterans' access problems were attributed more to geography than to
Ira Katz, M.D., deputy chief of patient care services officer for mental
health in the VA, said, however, that the 200,000 VA employees—including
2,000 psychiatrists—have been able to meet most of the mental health
care needs of U.S. veterans, fewer than 12 percent of whom require treatment
for PTSD or other mental health problems. The hiring of 3,600 more"
mental health professionals" in the last three years has allowed
the VA system to offer increased treatment sought by recent veterans of the
wars in Iraq and Afghanistan, who are much more likely than older veterans to
seek mental health care. Thirty-six percent of the 250,000 Iraq and
Afghanistan veterans who have sought care in the VA system were treated for
mental health problems.
Katz stressed, however, that "no matter how much the VA expands
access, there will continue to be challenges in providing care, especially in
One way to address rural access is for the VA to partner with state and
local health care systems in rural areas that lack VA mental health
professionals, said Frederick Frese, Ph.D., a member of the NAMI board of
directors and a consumer advocate.
Legislation (S 38 and HR 2689) to authorize the VA to contract with
community health centers and "other qualified entities" to provide
mental health services in areas not adequately served by VA facilities has
been introduced in Congress, but has not yet advanced.
Another barrier to mental health care for members of the military is their
fear that treatment for psychiatric problems will hurt future chances to
advance in rank or get jobs once they leave the military. "Stigma has
not gone away," Ritchie emphasized.
The branches of the military have tried to lessen stigma by making
psychiatrists and mental health professionals readily accessible to frontline
troops, including the assignment of more than 200 Army clinicians to Iraq and
Afghanistan, at any given time.
Another way to address stigma, according to Gail Wilensky, Ph.D., a member
of the President's Commission on Care for America's Returning Wounded
Warriors, is to challenge the belief that treatment blocks career advancement.
She encouraged the armed services to have young officers who have received
treatment and subsequent promotions share their experiences with other members
of the military.
Leaders in each service branch have begun programs to educate their members
about mental illness and encourage them to urge their buddies who display the
warning signs of mental health problems to seek treatment. Several military
installations, such as Fort Bragg in North Carolina, have begun to embed"
mental health workers" in their general medical units, which
allows soldiers to seek care in a less-obtrusive way.
Another challenge facing military and veterans health care providers is the
elevated suicide risk their patient populations face. The VA response to
increased suicides by veterans has included the assignment of a full-time
suicide prevention coordinator to each VA medical center and launching a
national suicide prevention hotline (Psychiatric News, September
Other challenges with which the military and VA mental health systems are
wrestling include better understanding of posttraumatic stress disorder and
traumatic brain injury and the best treatments for those conditions.
In addition to the many usual war-related mental health problems, mental
health professionals are struggling to understand the best way to treat the
effects of repeated concussive injuries and how those interact with PTSD,
The text of the Veterans Mental Health Outreach and Access Act can
be accessed at<http://thomas.loc.gov>
by searching on bill number, S 38. The report of the DoD Task Force on Mental
Health is posted at<www.ha.osd.mil/dhb/mhtf/MHTF-Report-Final.pdf>.▪