Still In Hostile Territory: The continuing disgraceful failure of military mental health care.

Once a Warrior Always a Warrior: Navigating the Transition from Combat to Home is an excellent book (Lyon Press 2010) by Charles W. Hoge, MD. He was an Army Psychiatrist (now retired) and perhaps the most knowledgeable and reliable military expert on military mental health.  Six years ago, in the Introduction to his book he described the status of service members who have returned home from combat:

Service members and veterans often feel they’re wasting their time dealing with people who can’t relate to their perspective, and many actually feel more at home in the war zone. One infantry soldier, several months after returning from Iraq, said:

“Through all the hell and anguish I’ve experienced fighting a war, I’d still rather be fighting at war than wake up everyday to the bullshit I have to deal with and overcome here at home in what I call my job and life.”

I have heard the same sentiment from active duty soldiers and veterans more than a dozen times. They would rather deal with the constant stress of a combat environment than face the stigma and bureaucracy of the military mental health system.  They prefer to stay in the hostile territory they know and understand.

Overwhelming evidence indicates the military has made no progress at all in the last 6 years in the quality of mental health care for our military men and women. In fact, there has been no substantial progress in the last 50 years, since the disasters of Vietnam and now Iraq. However, the root causes for this miserable record of care for those who serve is slowly coming into focus.  First, let us look at recent data.

Exactly How Little Progress Have We Made?

On 18 February, 2016 USA TODAY published an article by Greg Zoroya titled “Military falls short in treating new cases of war-related stress.” [View online.]

The article simply reported the facts of a study done by the Rand Corporation:

“The Rand Corp. study of 40,000 cases, the largest ever, found that only a third of troops with PTSD and less than a quarter who  are  clinically depressed receive the minimum number of therapy sessions after being diagnosed….

The study examined treatment for a year following diagnoses in 2012. There were 8,286 diagnosed with PTSD, 24,251 with depression and 6,290 suffering with both illnesses.”

There is no telling what happened with the 60+ percentage of soldiers who were diagnosed with PTSD but did not receive timely treatment.  Did they get any treatment?

And, what about those never diagnosed because they were afraid of the stigma associated with seeking mental health care while serving in the military?

Or, those who abstain from interaction with providers because the diseases of PTSD and/or depression are manifest by avoidance?

Or, is there a failure to diagnose thousands of soldiers because the system is short of qualified professionals to diagnose and treat these disorders?

Or, how many soldiers are just turned off by the 1940s-style environment of facilities and the impersonal and dismissive tone of military mental health care?

Probably a combination of all these factors make the Rand Corporation conclusions much worse than the reported figures would indicate.

Remember, the data reported was ONLY for those in treatment for a year following diagnoses in 2012.  The numbers of affected soldiers are incredible if you consider the combat exposure of our military personnel since our war in Iraq in 2003.

Egregious Guidelines for Treatment

Further analysis of the Rand report is alarming in other ways.  The Rand investigators used the treatment guidelines of the U.S. military and the Department of Veterans Affairs as the standard of comparison. The assumption being the military and VA knew what constitutes quality of care. However, the guidelines are totally inadequate, to the point of being negligent. The military and the VA mental health systems recommend troops diagnosed with PTSD should receive at least four therapy sessions within 8 weeks.  8 weeks is a lifetime for a soldier in constant distress with the manifestations of PTSD.  While only a minority of soldiers with this diagnosis need inpatient psychiatric care, they all need an intensive level of care that includes both individual and group therapies as well as medication management.

There are known models of care where the patient is being seen every day by some level of provider, until stability is established. It was not uncommon for me to see a soldier 2 or 3 times per week, along with group therapy each week, for 3 months, and then, once stable,  I followed them once a week for over a year; if there was a crisis the frequency of visits would be increased. The Army told me they did not have enough personnel to provide this level of care. But I would have to say, Why Not? Do our service men and women not deserve the highest level of quality care?

The investigation also used the following standard:  if the patient received medication they should be seen at least twice in the eight week period to “manage newly prescribed medications.”  So, the soldier is seen once when the medication is started and then 8 weeks later?  This standard is ludicrous and dangerous.  Psychotropic medication necessarily alter brain chemistry with realistic potential to alter cognitive function, behavior and mood along with somatic or physical side effects. In service members who are already stressed and depressed, the use of such medications must be monitored very closely until the target response and stability are obtained. With the initiation of medication they should be seen at least once a week.

It is fair to say soldiers are very reluctant to enter psychiatric treatment and will be resistant and non-compliant with medication management. To get necessary trust and confidence requires high intensity follow-up.

So, not only are the standards of care inadequate, as described by the Rand report,  the percentage of service men and women adequately diagnosed is low and then only a quarter to a third of those  diagnosed receive care, which is inadequate.  This feels like, and in reality is, the definition of a circle-jerk.

Lack of Access to Treatment Results in Loss of Life

The astronomical rate of suicide in active duty military and veterans, compared to other cohorts, is  the product of this disgraceful quality of care.

Greg Zoroya, writing for USA TODAY, was quite fair in his reporting, pointing out there was some “good news in the study.” The study reported “the military has become more aggressive in treating service members after they are released from in-patient psychiatric care. About 86% of those with PTSD or depression had a follow-up session with a mental health specialist within seven days after being discharged, and the rate jumped to more than 95% for seeing a therapist within 30 days.”  However, in a reasonable health care system, the standard for follow-up after inpatient psychiatric care is 72 hours, not 7 days.  In  the military the rate of post-admission follow-up should be 100% since the Army should know where their service members are at all times, and they can and do order soldiers to show up for follow-up or be punished for dereliction of duty.

Finally, a staggering and sobering statement within the report shines a glaring light on military mental health care:

“Army research found that one of the most vulnerable periods for suicide by soldiers is during  the  year after being  released from  in-patient  psychiatric  care. The suicide rate for soldiers in this group was 264 per 100,000, far outpacing the national suicide rate of 13 per 100,000 people.” (the emphasis is mine)

Meanwhile, the abyss of military mental health care continues to get wider and deeper.  On 19 February 2016, the New York Times published a report by Dave Philipps titled “Veterans Want Past Discharges to Recognize Post-Traumatic Stress.”  The story documents the plight of soldiers who were given less than honorable discharges for behavioral dysfunction related to PTSD.  This speaks to the Army policy of commanders making decisions about soldiers without giving due consideration to mental health issues. The first post to this blog, “Life for Rent,” is the story of Stephen Akins who had severe Traumatic Brain Injuries and PTSD but was dismissed from the military without completion of a medical board and completion of a requested treatment program. Soon after Stephen committed suicide.

The New York Times article addresses the plight of veterans trying to appeal and change their less than honorable discharge on the basis of PTSD.

Many who have tried to upgrade their discharge…. Records show that the Army Review Boards Agency — the office with legal authority “to correct an error or remove an injustice” in military records — have rejected a vast majority of cases that involve PTSD in recent years.

Since 2001, more than 300,000 people, about 13 percent of all troops, have been forced out of the military with less-than-honorable discharges. Congress has recognized in recent years that some of these discharges were the fault of dysfunctional screening for PTSD and other combat injuries…. [View online.]

But the Army is very slow in correcting this form of injustice. “In 2013, the Army Board of Correction of Military Records, the supreme authority in the Army’s review agency, ruled against veterans in about 96 percent of PTSD related cases, according to an analysis done by Yale Law School’s Veterans Legal Services Clinic.”

In more recent years there has been improvement in the reviewed decisions, but this is only because of pressure from the Office of the Secretary of Defense. Meanwhile, soldiers with less that honorable discharges with service related mental health disorders are barred from veteran’s health care services, education benefits or preferential hiring and tax benefits.

“Observers say the boards are overwhelmed. And, despite a growing caseload from Iraq and Afghanistan, the staff of the Army Review Boards Agency has steadily shrunk. In 2014 it had 135 employees to process 22,500 cases, according to an agency briefing.”

Even more recently, on 30 March, 2016,  Mr. Philipps published a follow-up in the New York Times titled “Report Finds Sharp Increase in Veterans Denied V.A. Benefits.” He described the findings in a report published by the veterans advocacy group Swords to Plowshares:

Former members of the military … are being refused benefits at the highest rate since the system was created at the end of World War II…. More than 125,000 Iraq and Afghanistan veterans have what are known as “bad paper” discharges that preclude them from receiving care….

The report for the first time compared 70 years of data from the Departments of Defense and Veterans Affairs. It found that veterans who served after 2001 were nearly twice as likely as those who served during Vietnam to be barred from benefits, and four times as likely as men and women who served during World War II.

“It has gotten worse with every generation…” [View online.]

Where to Lay Blame, First and Foremost

This deplorable data can not be laid at the feet of the Veterans Administration. The VA does not make decisions about who and how servicemen and women are separated from active duty. It is the Command hierarchy who has perpetuated this trend. I avoid using the term leadership since the officer corps of the United States military are long abandoned the oath: “We take care of our own.”

The report succinctly summarizes this problem: “The rising proportion of ineligible veterans is largely due to the military’s increasing reliance on other-than-honorable discharges, which have been used as a quick way to dismiss troubled men and women who might otherwise qualify for time-consuming and expensive medical discharges.”

During my time working as a civilian psychiatrist for the Army, on numerous occasions, I had Commanders call me and scream at me because I had referred a soldier for a Medical Board when they were trying to get the soldier out because of a behavioral problem that was the direct result of military service, and in every case, related to combat exposure.  Where there was a decision to be made about concluding the Medical Board versus other-than-honorable discharge, the highest ranking officer on the base gave the final answer. So a General would almost always ignore medical information and support the administrative separation that denied or significantly impaired medical benefits.

So, who and where is the advocacy for the soldier, marine, sailor and airman?  To be fair, I must add that there are many, many dedicated officers and medical providers who fight valiantly for their servicemen and women. Admittedly the military system is not a democracy and difficult missions are not accomplished by fairness or equity. But does that mean due process and justice can not be extended to those who have served and been injured?  Or, perhaps, there is just plain discrimination toward soldiers who sustained a mental health injury, such as PTSD.

The data is overwhelming and readily available. The system to provide quality care for mental health impaired active duty soldiers and veterans is decayed beyond repair.  A list of the root causes of this disgraceful pattern of care begins at the highest levels of the military going back to World War II.

The culture of the military and the Veterans Administration, in this regard, has changed in the last 70 years only by the deterioration of service.  The compost pile of causes begins with the highest levels of command; this includes the military political minions who have occupied the chairs of the various Surgeon Generals. They masquerade as medical professionals. Unfortunately they have abdicated their ethics and integrity in order to be promoted, rather than care and protect those who serve.

Click to view larger version.
Click to view larger version.

I will refer, once again, to the statement of Major General Steve Jones, Commander, US Army Medical Department Center and School. Writing in the December 2014 issue of the United States Army Medical Department Journal, he stated:

“The Army Medical Department plays an important role in building fitness, resilience and strength, in advising commanders, and serving as a safety net for Soldiers and Families. However, the ultimate responsibility remains with the unit commander, as noted in Change 1 to Medical Field Manual 80-10, Medical Service of Field Units, dated June 28, 1946: ‘Since the majority of the factors which determine mental health troops fall within the province of command, the main job of preventive neuropsychiatry must be done by commanding officers of the line.’” (again, the emphasis is mine)

It takes some smelly load of hubris for General Jones (an Acting Surgeon General of the Army for December 2015)  to publicly write about a 70-year-old field manual directive being the standard of care for soldiers with mental health problems.  Such a ludicrous statement would be laughable were it not a true statement of operating practice in the United States Army and in general throughout the military.  This statement defines the nature and customs that direct  mental health care for our service men and women. And how are they doing?  It explains the astronomical rates of suicide, depression and substance abuse in the military.

We can hold the Congress, the Pentagon, the Chief of Staff and/or the Joint Chiefs responsible for this disgraceful record of care. But, members of Congress, the Chief of Staff, etc, etc have no knowledge or understanding of the problem and thus they can not remedy this awful situation.  After all, they take advice from the Surgeon General who is supposed to know the nature of the problems and how to solve this mess.

I lay the blame for this mess first on the Surgeon Generals because they should know better; or they know better and do not have the professional integrity to take a stand for the health of soldiers who serve and die.  They follow the idiotic directive that General Jones proclaimed: “the main job of preventive neuropsychiatry must be done by commanding officers of the line.”

The Surgeon Generals use the excuse:  the mission comes first. Thus abandoning their professional ethics and responsibilities. Their allegiance is to the command structure and not to the military service members who suffer in  service to their country.  The Surgeon Generals salute, in every way,  those above them in the hierarchy of the military command. Where does the injured soldier come in this scenario?  Unfortunately the shibboleth in the military these days goes like this: if they are broken, if they can not deploy, get rid of them as fast as you can.

The recent Surgeon General of the Army,  a nurse who retired from the Army  in December 2015, in the face of catastrophic numbers of suicides,  did absolutely nothing to improve the quality of care for soldiers with mental health disorders.  Her major initiative has been to institute the Performance Triad, that is, to enforce the nutrition, sleep and exercise of the force. All well and good, I agree, but what of the Epidemic Neurological Triad of Traumatic Brain Injuries, Posttraumatic Stress Disorder and Substance Abuse. Does she not have a responsibility to educate the Army command as to the devastating effects of these problems, along with ideas on how to prevent such disorders, and rehabilitate those service members? The Surgeon General had ready access to all the data I have quoted, and much more. She never took a stand with the Army Chief of Staff, or Congress, or the public, and said: We must not abandon those servicemen and women who have served and paid the price with injuries that will affect them and their families for the rest of their lives.

Sure, tell the Joint Chiefs there are enough healthy soldiers to carry out their battle plans. But that is just the beginning of our responsibilities to those who serve.  Young men and women volunteer to enter the military for many reasons; in many cases for purely patriotic motivations. They understand that being in the military may place them in hostile territory.  What they do not understand is if they suffer a mental illness in the course of their service, they will still be in hostile territory when they return home.

 

RELATED  publications:

Mota, N. et al.  “Late Life Exacerbations of PTSD Symptoms: Results from the National Health and Resilience in Veterans Study.”  Journal of Clinical Psychiatry; 28 March 2016. < http://www.ncbi.nlm.nih.gov/pubmed/27046308 >

Kime, Patricia. “Persian Gulf veterans still fighting for proper health care 25 years after war.” Military Times: 24 February, 2016. < http://www.militarytimes.com/story/military/benefits/veterans/2016/02/24/persian-gulf-veterans-still-fighting-proper-health-care-25-years-after-war/80850552/ >