Mental Disorders in the Armed Forces

“In 2011, mental disorders accounted for more hospitalizations of U.S. service members than any other diagnostic category.” – Armed Forces Health Surveillance Center Medical Surveillance Monthly Report, June 2012

Recently, my daughter Elizabeth told me about a friend who stopped in to see her at the mall where she works while attending college.  Like her, he’s in his early twenties.  They worked together at a toy store a few years ago, and she hadn’t seen him since then.

He had enlisted in the army.  He was deployed overseas twice, and served a tour in a war zone.  He sustained a minor physical injury, now healed, while serving.

She said that he seemed a little down in the dumps when she saw him.  He told her that he is having trouble with his relationships since his return, but doesn’t think there’s anything wrong with him.  He’s pretty sure he doesn’t have PTSD, and sees no reason to seek counseling or other mental health supports.

Instead, he mostly keeps to himself and drinks a little more than he thinks he should.

Elizabeth is concerned about him, and should be.

Nearly one million (936,283 to be exact) active duty service members were diagnosed with at least one mental disorder from 2000 to 2011.

And, according to the most recent Armed Forces Health Surveillance Center Medical Surveillance Monthly Report, both the numbers and rates of service members diagnosed with mental disorders increased by 65% during the same period.

These just count active duty military personnel who are diagnosed with a mental disorder.  They don’t include either veterans or the young people who – like Elizabeth’s friend – have no formal diagnosis.

Mental disorders now account for more hospitalizations among U.S. service members than any other diagnostic category.  Suicide is the second leading cause of death among active service members (behind combat injuries), and mental disorders are the third most common reason for ambulatory care visits, behind musculoskeletal disorders and routine health care.  

Between 2003 and 2011, the rates of certain mental disorders with a significant environmental component soared as our involvement in Iraq and Afghanistan deepened.

• The rates of depression and adjustment disorders doubled.
• The anxiety rate tripled.
• The PTSD rate went up six-fold.

On the other hand, the combined rate of alcohol and substance abuse and dependence remained nearly the same (alcohol dependence was lower; other substance dependence was higher), as did the rates of schizophrenia and other psychoses. 

Just as worrisome is that the rates of the more environmentally-influenced mental disorders have not gone down as we’ve wound down our combat roles.  Between 2009 and 2011:

• The depression rate was about the same.
• The rate of adjustment disorders was 10% greater.
• The PTSD rate was 12% greater.
• The anxiety rate was 23% greater.

The surveillance report noted that all these numbers should be viewed in a broader context – that one in two adults will meet the criteria for a mental disorder at some point in their lifetimes.

Here’s the problem with that comparison.  There are only about 3 million total OEF/OIF (Iraq and Afghanistan) veterans and active duty personnel combined.  So the “lifetime” prevalence of mental disorders among the still mostly young people in these groups is already at least 30% - and could already be much higher.

As Elizabeth pointed out, “If they don’t get help today, where will they be ten years from now?”

Good question. 

So what should we do?

For one thing, we need to beef up mental health services to both active duty personnel and veterans, including planning the transition to from military to civilian life much more carefully than we have done in the past. 

We might also consider a couple of prevention strategies.  Adjustment disorders are twice as common in active duty teenagers as in any other military age group.  If we were to increase the age of recruitment by a year or two, we could prevent a lot of these.  In addition, anxiety and depression both peak when active duty personnel are in their late twenties.  If we restricted multiple deployments and limited separation from growing families, we might curtail these, too.

We also need to improve adult mental health services in general.  There are still too many policy leaders who avoid tackling this problem by pretending that mental disorders are personality weaknesses. 

But when they effectively paint at least 30% of brave, young active duty military personnel and veterans with this sloppy old brush, the real weaknesses are the policymakers’—most notably their own denial of reality.  

You can read more about service gaps in meeting the needs of veterans by clicking on the names of each of the following columns: Answering the Call, Veterans and Mental Illness, Veterans Dazed Not Dazzled by Mental Health Care, and Iraq and Back.

Answering the Call

It is worth noting on this “traditional” Memorial Day of May 30^th that over 6,400 service people have lost their lives so far while fighting our two most recent wars.

Unless we put more money into health and mental health care, many thousands more will eventually lose their lives fighting the physical and mental effects of these wars.

This past weekend, we learned that 45% of returning Iraq and Afghanistan War veterans are seeking compensation for service-related injuries. 

The challenge of finding the billions of dollars needed to treat these men and women will test us as a nation. 

It will likely stoke the fires of yet another protracted battle about “public option” health care in America.

This fight is about to take place because of two reasons.

The first is that the percentage of veterans seeking compensation is twice what it was in past wars.  “Invisible” injuries with behavioral manifestations, like PTSD and traumatic brain injury, account for much of the difference.

The second is that the VA system has too little capacity to meet the needs of even the lower percentages of those who have survived past wars and made similar claims for assistance.

This usually means that we begin by denying the existence of injuries we don’t easily see. 

I remember a Memorial Day parade I attended when I was a youngster in Middletown, Connecticut.  Then, as it still does today, Middletown closed its mile-long Main Street to traffic as a collection of high school and middle school bands, children’s sports teams, public safety officers, public officials, and groups escorted war veterans past cheering crowds.

The particular parade I recall featured two of Middletown’s earliest returning Vietnam veterans.  I remember standing on the roof of a two-story building watching them as they rode in a convertible down the parade route.  They were impressive in their dress uniforms, waving to the crowd.  One, as I recall, had lost a leg in battle.  The other, an arm and an eye.

Their injuries were undeniable.

The thing about parades, though, is that once one float passes by, we always turn our heads to see what comes next. 

And with Vietnam veterans, what injuries came next weren’t always so easy to see.  Agent Orange affected thousands, addiction affected tens of thousands, and PTSD affected hundreds of thousands.  As a matter of public policy, we ignored all of these for years as the Vietnam War’s real death toll mounted. 

The ongoing lack of capacity to serve the health and mental health needs of veterans is an even bigger threat to the well-being of veterans today.

A March 2012 Gulf War Veterans’ Illnesses Task Force Report provided some recent, statistical insight into this.  It noted that of the over 500,000 service members who served in Operation Desert Shield, 152,126 filed successful service-connected disability claims.  But only half – 79,415 – received VA healthcare.  The same was true of the almost 600,000 Desert Storm service members.  165,596 filed successful service-connected disability claims, but only 87,612 received VA healthcare.

There are three times as many Iraq and Afghanistan veterans as there were Desert Shield or Desert Storm veterans.  By percentage, twice as many returning Iraq and Afghanistan service veterans are filing claims as did Gulf War-era veterans. 

Based on the current numbers of claims being filed, over 750,000 may ultimately file successful claims, and at least 400,000 already need treatment for mental illnesses.  The VA system has the capacity to provide health and mental health care to only a fraction of them.

These are wars for which most of the rest of us have been called on to make no sacrifice by public officials who dishonor the sacrifices of brave veterans when they cower in fear at the word “taxes.” 

This may seem harsh, but we were asked to pay no new taxes for these wars, in spite of the billions of dollars we spent on them and the thousands of lives we sacrificed.  Does that seem right?

We would say that we meant it when we honored the sacrifices of veterans – especially those who have died fighting our wars – when we flew our flags, visited our cemeteries, and attended our parades this week.

So here’s our choice.  Will we answer the call when asked to sacrifice more tax dollars for health and mental health care for all? 

Or will we turn our backs on our veterans once the parades have passed us by?