Pentagon Acknowledges Need for More MH Services, Clinicians

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 12.

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 September 12.

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 Institute.

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. ▪