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Mental Health & The Military: A Psychiatrist’s Perspective

I met Dr. Harding at a press conference announcing the expansion of the Give an Hour initiative and really enjoyed our candid conversation about the unmet mental health needs of veterans of the war in Iraq and Afghanistan. It is sobering to know that many hundreds of thousands of soldiers are returning to the U.S. with traumatic brain injuries and post traumatic stress disorder. They volunteered to give up their lives for us, will we volunteer to care for them?

An interview with Richard K. Harding, M.D., professor and chair of the Department of Neuropsychiatry and Behavioral Science and an adjunct professor of pediatrics at the University of South Carolina School of Medicine.

Dr. Val: You mentioned that this quote means a lot to you: “One does not escape war by leaving the war zone.” Can you explain what you mean by that?

Dr. Harding: I was referring to my own experience with children rescued from Vietnam and transported to the U.S. Here, 6000 miles away and in a perfectly safe place with lots of support and food, they were still dealing with the trauma of the war zone. And I’ve seen this all along in my career, especially taking care of the National Guard folks in South Carolina. I’ve seen people become depressed and anxious and use substances to try to deal with the recurring thoughts provoked by combat experiences. They have profound changes in how they see the world. These are healthy people who were doing well in their jobs and family life. And then when they come back, they have a considerable amount of anxiety and worry and a loss of optimism about the future. In a way, the war follows them home.

Dr. Val: How do you help your patients to gain maximal recovery?

Dr. Harding: The best treatment begins with an accurate diagnosis and good access to care. There have been some major road blocks in terms of dependents trying to use TRICARE insurance, so access has been limited for family members who need services.

A good diagnostic workup by someone who knows what he’s doing is really important. Military personnel need to see a therapist who has had experience with PTSD [post-traumatic stress disorder] and other combat-related mental health issues.And they also need to get into a good treatment program that is tailored to their needs. Some people need psychotherapy, and others need psychotherapy plus medications. Some may be so severely depressed that they need to be in the hospital temporarily.

Dr. Val: There have been reports of different rates of mental health disorders in different arms of the military. For example, 50 percent of National Guard personnel report mental health issues, whereas only a third of Marines report the same. What’s that about?

Dr. Harding: Well we don’t know why, but I can speculate. If you are a trained military infantry combat soldier, you’ve been through a lot of training. You are camping out in the woods, you’ve been shot at, you’ve been through all kinds of simulations. You also belong to a tight group of individuals with whom you’ve been working for a long time, and your family has support at the military base in which you live.

That’s a lot different than a National Guard outfit composed of citizen soldiers. They’re suddenly asked to come in — not just one or two weeks out of the year — but to deploy to Afghanistan for 15 months. These people are lawyers, doctors and so forth, but they are often put on frontline assignments as soldiers. Unfortunately, they don’t have the same training and experience as the professional soldiers, so they’re more subject to emotional trauma. In addition, their families back home are scattered all over the state and don’t have the same backup and support that a family on a base would have. Spouses are often isolated when their partner is deployed.

Finally, the stigma associated with mental illness makes the military personnel less likely to get help early on because they’re worried that it will limit their opportunity for promotion.

Dr. Val: I heard that the question about mental health treatment was recently removed from the security clearance questionnaire. Is that evidence of the Army’s attempt to embrace and normalize mental health treatment?

Dr. Harding: It’s a very important symbolic victory. There is still a problem with stigma, but the Army is responding to this concern. There’s a tendency to think of mental health issues as a sign of weakness. Tough Army guys aren’t supposed to have emotional problems. They feel that they’re letting down other people if they admit to problems. You’re supposed to be able to pull yourself up by the proverbial “bootstraps.”

Dr. Val: It strikes me as somewhat adaptive, though, to choose that kind of attitude in a combat situation.

Dr. Harding: Yes, it may be. Seventy-five percent of military personnel make it through without mental health problems. They show amazing resiliency when you think about it. I’d like to think that I’d have that kind of resiliency too, but I don’t know. You don’t know until you’re in the situation. When good people try to do tough things, some will inevitably fall into the injury category. What we have to do is get recovery going and the “physical therapy” in the mental sense started as early as possible to help them get back to full capacity.

Dr. Val: What’s the most important message that you’d like to relay to a general public audience about mental health services and veterans returning from Iraq and Afghanistan?

Dr. Harding: Services are available, but you have to ask for them. You have to raise your hand and admit that you have difficulties and need help. It’s also important to do this early on before you leave military service because you won’t necessarily get the same amount of care once you’re back in the workforce.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Give an Hour: Improving Access To Mental Health Services For Our Military

I had the chance to attend a recent press conference announcing the expansion of a nationwide effort to help U.S. veterans. The American Psychiatric Foundation, the Lilly Foundation, and Give an Hour Foundation joined forces to provide free mental health care for Iraq and Afghanistan war veterans and their families.

This innovative program allows mental health professionals to donate at least one hour a week of their professional time to serve the needs of the military. Collectively, this donated time adds up to a large improvement in access to services beyond the current reach for many of our nation’s heroes.

I am also hoping that the Give an Hour Foundation will join forces with Revolution Health to provide a therapeutic online community for military personnel and families who need support.

An interview with Barbara V. Romberg, Ph.D., founder and president of the Give an Hour Foundation

Dr. Val: Tell me about the Give an Hour initiative. Who came up with the idea, what does it involve, and how is the concept being promoted?

Dr. Romberg: I grew up in the post-Vietnam era and watched my brother’s friends go to war and they either never came back or they returned as completely different people. So about three years ago, I was watching the Iraq war unfold and I became more and more aware that people were returning home with some very significant mental health issues. I began worrying about whether there were enough mental health services available to meet their needs, and I wondered if we in the mental health community should step up to provide additional services.

The thing that really pushed me to do something about this, as a busy private practitioner, was when I was driving in Bethesda [Md.] with my 9-year-old daughter. We passed a homeless veteran on the street and she said to me, “Mom, how can we?” It was the use of the word “we” that touched me. “How can we let this happen to these men and women who serve our country?”

And I thought, I can’t let her grow up and look to me and say, “Why didn’t your profession do something?” So I said, “OK, I’ve got to do this.” And that was the beginning of the Give an Hour initiative.

The Give an Hour initiative is a national network of mental health professionals —  psychiatrists, psychologists, social workers, licensed counselors and therapists — who volunteer an hour of their time per week to serve the needs of the military. Participants are collected in an online database. Military personnel can come to our website at www.giveanhour.org, and enter their ZIP code and the services they seek, and we’ll return a list of providers available in their area. If there is no one listed in the database in the search area, we offer phone support.

Dr. Val: In your opinion, how is the health care system failing Iraq and Afghanistan war veterans who need mental health services?

Dr. Romberg: I’m not sure that it’s failing so much as it’s just being overwhelmed. The Department of Defense and the VA [Veterans Administration] are working really hard, but they’re just overwhelmed. It’s our duty, honor and opportunity to step up as mental health professionals and give back to the military. Regardless of what you think of the war, it’s a wonderful opportunity for our country to heal. The work is also therapeutic for the therapist.

Dr. Val: In terms of access to mental health services, where are the largest shortcomings: 1. Access to psychiatrists? 2. Access to psychologists? 3. Access to affordable therapies? 4. Community support?

Dr. Romberg: Yes. [Laughing.] All of the above. Many of the National Guard and Army Reserves staff return to rural communities after their tours of duty. There often aren’t providers who accept TRICARE [military health care insurance] in rural communities, so access to mental health services is limited. The VA is doing a lot of good work, but there are long waits and not enough therapists for regular ongoing visits. Continuity of care really suffers.

Dr. Val: What’s the most important message that you’d like to relay to a general public audience about mental health services and veterans returning from Iraq and Afghanistan?

Dr. Romberg: These men and women are put in situations that are sometimes horrific and excruciatingly stressful for long periods of time. If you put any of us into those situations, it would affect how we experience ourselves and the world. What we want to do is educate the public so that they understand this and know how to talk to their neighbors and co-workers. When people don’t understand an illness, they can become uncomfortable and fearful that they may say the wrong thing. But by normalizing mental health issues through public education efforts, we can reduce the associated stigma of mental illness.

Military personnel need to be comfortable in accessing services when they need them. For starters, they can visit the Give an Hour website. We’re also affiliated with many other Veterans Affairs associations like the Wounded Warriors program, National Military Family Association, and TAPS. These organizations can offer assistance or put people in touch with us as needed.

*See a continuation of this conference reporting here.*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

CBS News: Marine Survives Battle, Dies of Misdiagnosis?

Tonight (Jan 31, 2008) the CBS evening news will be airing a segment about a tragic case of a young Marine who died of melanoma. According to the news transcript, an unusual mole was diagnosed as a melanoma in 1997, but no follow up was scheduled, and no explanation given to the young man about his diagnosis or treatment plan. Eight years later in Iraq he complained to medical personnel of the mole growing larger and he was told it was a wart which would be treated once he returned to US soil. He slipped through the cracks somehow, and tragically died in 2008 of stage IV melanoma.

One interesting issue raised in the segment is that the Marine was not eligible to to sue for negligence in his case.  There is a law, the Feres Doctrine, that denies military personnel the right to sue the government in cases of perceived or real medical malpractice. The rule was established in 1950 after a case was brought to the U.S. Supreme Court (Feres v. United States) in which servicemen who picked up highly radioactive weapons fragments from a crashed airplane were not permitted to recover damages from the government.

While I do understand (in theory) the purpose of this law – if every battle injury allowed soldiers to sue the government, we’d bankrupt our country in the span of a year – it does seem to be over-reaching in this case. The Marine was not injured in battle, but his life was indeed compromised by sloppy medical follow up. In my opinion, the doctor who correctly diagnosed him in 1997 should be held accountable for lack of follow up (if that’s indeed what happened). As for the military personnel who thought the Marine’s advanced melanoma was a wart, that is a tragic misdiagnosis, but hard to say that there was malpractice at play. With limited access to diagnostic pathology services, it is difficult (in the field) to be sure of the diagnosis of a skin lesion. And yes, I can imagine that an advanced melanoma could look wart-like. This is a tragic shame, but since the young man had the melanoma for 8 years prior to the misdiagnosis of the “wart,” in the end I doubt that a correct diagnosis at that point would have changed his terminal outcome.

But I wonder if the Feres Doctrine should be modified to allow for more accountability amongst military physicians in caring for diseases and conditions unrelated to military service? Although I am not pro-lawsuit, it does seem unfair that this Marine was denied the opportunity to pursue justice in his case. What do you think? Check out the segment with Katie Couric tonight and let’s discuss.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Fly The Ball

I had lunch with an extraordinary physician today. She came to the US from Pakistan 30 years ago with a medical degree, a little girl and a baby on the way. Since she was a foreign medical grad, she had to accept a position at a less competitive residency program in New York’s inner city (even more violent and dangerous then than now). She made it through, with several near muggings and death threats but longed to work at a hospital where she and her girls could be safe.

One day she came upon a large, clean naval hospital and on a whim decided to join the military so she could work there. She served for two decades as a navy physician, and learned many life lessons along the way.

As I hung on her every word, my friend told me about her experience with navy pilots. She said that one of the scariest maneuvers is landing a plane on a dark aircraft carrier on a rolling sea. The pilots dreaded these drills, and truth be told, the officers were more worried about losing a 3.2 million dollar jet to the ocean waves than the life of one of the pilots. “There will always be another pilot. They’re not in short supply. But the planes are expensive.” This was the attitude drilled into the young aviators.

In order to land the plane in the dark, the pilot had to learn to trust completely in his optical landing system. It more or less consists of a pin icon with a ball on top, and a series of red, yellow, and green lights. The goal is to keep the ball well centered so that it remains green for landing. Achieving this is called “flying the ball.” In total darkness with crashing waves and a rolling deck, a successful arrested landing is difficult and perilous.

As I looked at my friend, a petite and beautiful woman, I tried to imagine what life was like for her as a young Pakistani resident – pregnant and alone in a concrete jungle filled with graffiti, trash, and drug addicts. Her life has been an incredible journey with ups and downs, and amazing success against all odds.

“How did you do it?” I asked her, shaking my head. “How did you get where you are today through all that adversity?”

She paused for a moment, then grinned slowly as she replied: “I learned how to fly the ball.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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