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?

Iraq and Back: Veterans Experience Tragic Delays in Obtaining Mental Health Care

A newly released report found that hundreds of thousands of veterans experience excessive delays in trying to obtain mental health services from the Veterans Administration (VA).  This is especially sad to consider today, both because May is Mental Health Month and the President has just renewed our troop commitment to Afghanistan.

William Hamilton was a 26 year old Iraq veteran when he died in May 2010.

One of five siblings, he joined the army when he was nineteen.

He experienced his first symptoms of mental illness while serving a tour in Iraq in 2005. He was diagnosed with PTSD and an anxiety disorder. 

He was discharged honorably later that year and sought treatment at a VA Center.

For four years, as his condition worsened, Hamilton bounced from one VA treatment setting to another. 

In 2006, he was diagnosed with major depressive disorder.  Chemical dependency complicated his treatment.  He was hospitalized at the VA on several occasions over the next two years, and had several unsuccessful VA transitional housing placements.

In 2009, he was diagnosed with schizoaffective disorder.  He had two extended stays at the VA hospital and another at a rehabilitation center. 

In 2010, he was also diagnosed with psychosis, and by then it seemed to his parents that the VA didn’t want to see him anymore. 

Three times in 2010, his parents contended, Hamilton was denied admission to a VA medical center. 

The first was early in the year after he was found running in and out of traffic and hospitalized in a community hospital.   The second was after he was hospitalized a month later after being found walking the streets naked.  

In both instances, hospital personnel documented that the VA center reported that there were no beds available those days. 

The third was a few days before he died in May.  Community hospital personnel said that when they spoke by phone with the VA center at 4:20 p.m. they were told that the VA did not accept transfers that late in the day.  So they found a Department of Defense hospital to admit him.  His parents expected him to be transferred to the VA center from there, but instead he was released three days later. 

His parents said that he was unstable.  He died four hours later when he stepped in front of a train.

Did the VA center’s failure to accept and treat William Hamilton contribute to his death that day?

His parents thought so, and the Office of the Inspector General of the Department of Veterans Affairs agreed to investigate.  It released the report of its findings a little over a month ago.

It determined that the VA center did have beds available on the first two dates in question, and should have admitted him.  However, it could not determine whether he had been denied admission in May, too. 

That’s because when it tried to verify the 4:20 pm phone call, the VA center records showed that “no outgoing calls were recorded from any VAMC extension to anywhere on the subject day.” No one could say why, but the OIG suggested that “it would not be plausible” that no outgoing calls were made during that entire day.

This tragic case is an exclamation point on a bigger story.

According to a new reportissued by the OIG just last week, hundreds of thousands of veterans experience delays in obtaining mental health evaluations and care from the VA.

The VA mandates that all initial mental health evaluations for veterans seeking mental health care from the VA for the first time be completed within fourteen days.

Over 373,000 veterans sought such care in FY2011.  Only 49% had their mental health evaluations completed within 14 days.   An estimated 28,000 evaluations were never completed at all.

The VA also mandates that patients new to a specific mental health clinic be granted appointments within fourteen days of when the veteran wants to be seen.

Out of 262,000 appointments, only 64% met this deadline.  94,000 veterans waited longer.

In Denver CO, the average wait was 19 days.  In Milwaukee WI, it was 28 days.  In Spokane WA, it was 80 days, and in Salisbury NC, it was 86. 

One of the things that jumps out at me about William Hamilton’s tragedy is that as his symptoms of mental illness became more and more serious, his treatment never seemed to catch up with his disease.

And what jumps out at me about the VA data is that where veterans’ mental health is concerned, playing catch-up seems to be the norm.

Comments are welcome on this and other columns.  If you have questions about this column or would like to receive an email notifying you when new OHPM columns are published, please email gionfriddopaul@gmail.com.

The Top Health Policy Stories of 2011, Part One

Public policy attacks on public health and mental health, intrusions in doctor/patient privacy, the continuing fight over the Affordable Care Act, and our collective loss of faith in private health insurance were among the top health policy story lines of 2011.

This year, eight stories make my short list.  Not all of these stories made big headlines during the year.  But they have had, or will have, an outsized impact on our lives.

I’ll begin the countdown this week with four that capture and continue some of the major trends of the recent past.   Next week, I’ll offer four more that hint at where health policy may go in the future.

8.  The Shooting of a Congresswoman.  In January, the first big health policy story of the year was about violence and mental illness – the horrible wounding of a member of Congress, and the murder of several people around her.  As the media struggled to make sense of this, it raised once again the relationship between mental illness and violence.  What it failed to do was to report that, while this particular shooter seemed mentally imbalanced, most perpetrators of violence are not, and many victims of violence either already have mental illness, or will develop it as a result.

The continuing trend – Our jails are our nation’s largest mental health institutions, and will remain so until we invest more in prevention and treatment of mental illness.   

7.  The End of the Iraq War.  The War in Iraq may have ended this month, but its health effects will be with us and our veterans for many years to come.   A GAO report released in Octobergot little mainstream media attention, but was blunt in its description of the effects of this war and others on veterans’ mental health.  The 2.1 million unique veterans who received mental health treatment in the five year period between 2006 and 2010 represented over 30% of the veterans who received any type of health care.  The fastest-growing groups of veterans receiving mental health treatment during this period were the 213,000 Iraq and Afghanistan veterans with mental health needs.  And 38% of all Iraq/Afghanistan veterans who received health care during that time required mental health care. 

The continuing trend – So long as we remain at war, veterans’ health and mental health services will need to be expanded significantly throughout the foreseeable future, and, as taxpayers, we will need to pay for them.

6.  The Death of the CLASS Act.  What does it say when the first major provision of health reform to be killed off in a bipartisan way was the one provision that had enjoyed bipartisan support for a generation?  There are at least two things about long term care most of us don’t want to face.  The first is that most of us will need it someday.  The second is that practically none of us can afford it on our own.    Rather than coming up with a meaningful public/private partnership to pay for it after almost thirty years of trying, the Administration and Congress quietly killed CLASS in October, choosing once again to keep the current, broken system in place.  This is the one where we first impoverish people when they get old and sick, and then let government pay the whole bill.

The continuing trend – Medicaid will remain the default payer for long term care.  Costs will continue to skyrocket, we’ll all continue to complain, and long term care insurance won’t gain a greater foothold in the market any time soon.   

5.  Low PCIP Enrollment Numbers.  The most compelling evidence in 2011 that we may have finally lost our faith in private insurance was found in the late summer reports of the low enrollment in the Pre-Existing Condition Insurance Program (PCIP).  This is a program that eligible uninsured people were supposed to embrace, because it pretty much guaranteed that it would pay out far more for their health care than it collected in premiums, saving each of them lots of money.  But when only 30,000 of the 4 million eligible people enrolled as of July, most of the rest seemed to be saying that they would rather take their chances on permanent financial ruin than insurance.  Or that they were already so impoverished by illness that they no longer had anything to lose.

The continuing trend – If the health insurance industry cannot restore our trust, even the people who need it most will opt out, relying only on safety net government funding.

Next week:  The final Our Health Policy Matters column of the year looks at four more big stories of the year, and their implications for the future.