Military Needs to Build 'Culture of Support'

The U.S. armed forces are unable to meet the mental health needs of service members today and are not likely to do much better in the future without additional funding and staff, according to a draft report issued by the Department of Defense Task Force on Mental Health in May.

“The challenges are enormous, and the consequences of nonperformance are significant,” said the report.

The task force is a joint military-civilian body, authorized by Congress, which conducted inquiries for a year before delivering the report to the secretary of defense.

A separate study, the Army Surgeon General's Mental Health Advisory Team IV (MHAT IV), surveyed 1,767 soldiers and Marines serving in Iraq and found that, among numerous factors, the level of combat, family separation, and multiple deployments placed the greatest stress on the troops' mental health. MHAT IV was established by the Office of the U.S. Army Surgeon General at the request of the commanding general of the multinational force in Iraq and supervised by its command surgeon.

The task force acknowledged existing work by the military services toward psychological health, but added that these efforts were falling short of the need. Task force members consulted experts, visited 38 military bases around the world, and listened to public testimony. The military health system lacks the resources and fully trained staff to meet peacetime needs for troops and their families, much less the increased demands posed by the fighting in Iraq and Afghanistan, they said.

Stigma remains a significant barrier to care, and current psychological screening procedures do not overcome the bias against seeking mental health services. There are also gaps in what services are available, where they are offered, and who receives them, said the report. Family members have poor access to services, and the myriad military organizations dealing with mental health are poorly coordinated and fall under different chains of command. Moreover, there are not enough active duty mental health professionals, and there will be fewer in the future without “substantial intervention.”

Quality of treatment is not up to standard, either.

“There do not appear to be sufficient mechanisms in place to assure the use of evidence-based treatments or the monitoring of treatment effectiveness,” said the report.

The task force recommended that the Department of Defense build a“ culture of support for psychological health” by updating knowledge, improving access, increasing funding and training, and incorporating education about mental health in every phase of military life.

Finally, the task force noted that, as in civilian life, the medical and mental health systems place too much emphasis on short-term treatment models and not enough on long-term management of chronic disorders.

The MHAT IV evaluated the mental health of troops in Iraq from August 28-October 3, 2006. Its report was completed in November 2006, but was released only last month. The study was based on anonymous surveys filled out by troops and on information gathered from behavioral health and primary care personnel and others. Troops surveyed included 79 percent from active component forces, 8 percent from the Reserves, and 13 percent from the National Guard, although results were not broken down by service component.

Among the troops, combat exposure and the length of deployment had the greatest impact on mental health status, according to the report. Troops facing high levels of combat were two to three times more likely to screen positive for anxiety, depression, acute stress, or any mental health problem. For instance, 30 percent of troops who spent at least 56 hours a week patrolling outside their base camps screened positive for mental health problems, compared with 11 percent who spent 12 hours a week “outside the wire.”

The more times troops were sent to Iraq and the longer they served there, the higher their rates of mental health and marital problems. About 27 percent of those returning to Iraq screened positive, compared with 17 percent of those on their first tour of duty there.

That indicates, said the report, that “previous deployment experience per se does not 'inoculate' soldiers against further increases in mental health issues.”

The 2003-06 average annual suicide rate among troops in Iraq was 16.1 per 100,000, higher than the average Army rate of 11.6. Existing suicide prevention training was not designed for application in a combat zone, said the MHAT IV.

For the first time, MHAT IV asked troops questions about battlefield ethics. Only 38 percent of Marines and 47 percent of Army soldiers said that noncombatants should be treated with dignity and respect. Rates were higher among troops who had high combat exposure or screened positive for mental health problems. The report recommended improved battlefield ethics training to better prepare for encounters with civilians and to know how to report violations.

The MHAT IV found that very few military mental health care providers had been trained in combat and operational stress control. This training should be required before they ship out to Iraq, according to the report. Also recommended was more extensive mental health awareness training for troops, noncomissioned officers, and junior officers before, during, and after deployment. Allowing troops to remain at home for 18 to 36 months between deployments would allow them to recover their mental health more fully.

A summary of the Department of Defense Task Force on Mental Health's report is posted at<www.ha.osd.mil/dhb/meetings/2007-05/media/MHTF-Report_%20DRAFT_Executive_Summary_02MAY07.pdf>.“ Mental Health Advisory Team IV Operation Iraqi Freedom Final Report” is posted at<www.armymedicine.army.mil/news/mhat/mhat_iv/MHAT_IV_Report_17NOV06.pdf>.▪