APA, Military Brainstorm on Ways to Pool Expertise

APA leaders met in March at APA headquarters with military mental health officers to discuss ways they might cooperate in expanding services to members of the U.S. armed forces.

Among the participants were Nada Stotland, M.D., M.P.H., APA president; Carolyn Robinowitz, M.D., immediate past president; Darrell Regier, M.D., M.P.H.; head of APA's Office of Research and the American Psychiatric Institute for Research and Education; James H. Scully Jr., M.D., APA medical director; and other APA staff. The military services were represented by Brig. Gen. Loree Sutton, M.D., a psychiatrist and APA member who heads the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury; members of her staff; and representatives of Army, Navy, and Air Force health branches.

Col. Elspeth Cameron Ritchie, a psychiatrist and director of the Army's Proponency of Behavioral Health program, delineated several issues hampering provision of services to troops.

One such issue is the insufficient number of mental health professionals available to help members of the armed services and their families. The military services want to hire more clinicians to address the multiple mental health needs of these individuals but are in competition with the civilian market and each other in that quest.

A serious hurdle facing the military in contracting with additional civilian clinicians, however, is that TRICARE, the health care program for service members and their families, imposes obstacles such as slow credentialing, delayed service approval, and low payments, discouraging many providers from participating in the system.

In addition, civilian psychiatrists who want to help are often unfamiliar with military culture, just as troops are often uncomfortable discussing their experiences with civilian clinicians. At least part of that cultural barrier could be overcome with additional continuing medical education for nonmilitary psychiatrists, suggested Stotland.

To that end, Sutton, Ritchie, and two Navy psychiatrists, Capt. Paul Hammer and Capt. Ed Simmer, have put together a session for APA's annual meeting next month to address the myriad mental health issues engendered by the stresses of the current wars and the strains they have placed on troops and their families. The session, which will be held Wednesday, May 20, from 9 a.m. to 11 a.m., will explain the preventive measures taken by the armed services and both old and new challenges facing individuals and clinicans, including suicide, posttraumatic stress disorder, traumatic brain injury, and pain management.

Civilian psychiatrists who treat service members must also be aware of military protocols on medications, some of which, although in common civilian use, are prohibited for troops in theaters of war.

The officers at the joint meeting also wanted more collaboration with psychiatrists on pain management. At present, 12,000 service members are in transition units while under treatment for their wounds, they noted.

“These are mostly orthopedic cases but many have comorbid psychiatric problems too,” said Ritchie. Many of these troops are taking opioids or anti-seizure medications, and Ritchie asked for APA's help in developing best-practice guidelines for comorbid pain management and depression.

Suicide continues to concern officials (see Military Brass Address Suicide Crisis and Strategies to Cure It). Military suicides are statistically associated with relationship, financial, and legal problems, many of which are in turn connected to extended and repeated deployments. The services wanted more help with suicide risk assessment to add to existing measures.

Another issue discussed at the meeting was how the military deals with substance abuse, which is now the responsibility of the military personnel structure, not its medical branches, said Ritchie. Soldiers fear that if they are found using illicit substances, everything they've worked for will be in jeopardy.

“The focus now is on screening and is seen as punitive, but we have moved forward in our ability to treat addiction,” she said.

As a result, confidentiality is a major concern. “The troops want more, but the commanders want to know” about their troops' mental status, said Ritchie.

Another major challenge facing military medical personnel is “the overlap between psychiatric problems and blast, concussion, or orthopedic injury,” said Brig. Gen. (Ret.) Steven Xenakis, a psychiatrist and consultant to the Pentagon. “There is an increase in complaints about headaches, sleep problems, irritability, and cracked teeth. We need to go back to a neuropsychiatric medical model and rethink the psychiatrist's role and training.”

Other suggestions discussed at the joint meeting included creating a neuropsychiatric fellowship at the Uniformed Services University of the Health Sciences, developing incentives to recruit psychiatry residents, encouraging APA members to take a refresher CME course on suicidality and depression, and creating a list of military speakers who can present educational programs at APA district branch meetings.

“The symptoms of our troops and their families have helped to legitimize psychiatry and have touched our hearts,” said Stotland.“ Now, through APA, we can help both personally and as an organization.”

Contacts between APA and the armed services will continue, the participants agreed. ▪