Improve Veteran Mental Health

"Increasing numbers of Veterans are being diagnosed with mental health conditions, often coexisting with other medical problems.  More than 1.5 million of the 5.5 million Veterans seen last year had a mental health diagnosis.  This concept paper identifies how to address the following three areas:

1. Identify and test new comprehensive approaches to improve mental health through prevention, diagnosis and treatment.
2. Identify specific measures to track their effectiveness so we can allocate resources more efficiently.
3. Develop and test new treatment models to remove stigma associated with admitting problems and seeking help." (reference VA 13 challenges)

Challenge/Problem Understanding

War and terrorist interdictions have a devastating effect on the psyche of the military soldier. There are no predictable patterns to rely upon and random events occur from hidden explosives to sniper attacks to hostile suicides that put the soldier at harm's way.  Such fear and anxiety provoking stress produce ideal conditions for creating human psychopathology.  When people know the direction of their threat and can predict its occurrence, little if any neurotic or psychotic behavior typically develops.  Since this is not what happens especially in a war against terrorist where unpredictability and randomness are common, it is not surprising that over 20% of the military are diagnosed with mental health problems.

Also, seeing trauma first hand (e.g., one losing a limb, or experiencing others losing parts of their body, or others dying on the field) causes acute emotional trauma which if not adequately addressed will quickly evolve into a variety of post traumatic mental health problems.  Every human being seeks to adapt in order to survive.  When normal coping strategies fail to reduce their emotional pain, human beings revert to anything that lowers their pain.  Often this evolves into aberrant coping strategies that normal people would consider quite bizarre.  These bizarre behaviors are nothing more than a person attempting to stay alive and cope, albeit atypically, in which society recognizes as a mental health issue.  To the inflicted soldier, the maladaptive coping strategy is a life vest, one in which is very difficult to unravel once in place.

The RAND report "Invisible Wounds of War," April 2008, notes that psychological and cognitive injuries are extremely pervasive, with traumatic brain injury (TBI) and post traumatic stress disorder (PTSD) being widespread and not yet fully understood: "These invisible wounds of war require special attention and high priority. An exceptional effort will be needed to ensure that they are appropriately recognized and treated."  The Rand report further elaborates four recommendations that need to be standardized within both DoD and VA as well as extended into the community-based civilian sector:

1. Increase the cadre of providers who are trained and certified to deliver proven (evidenced-based) care, so that the capacity is adequate for current and future needs
2. Change policies to encourage active duty personnel and veterans to see needed care
3. Deliver proven, evidence-based care to service members and veterans whenever or wherever services are provided
4. Invest in research to close information gaps and plan effectively

Key Issues

There are several key issues that need to be explored regarding soldier mental well being.  To begin with, we need to look at this problem holistically, systemically and from a systems view point.   We need to understand that many of our soldiers are still very young and vulnerable and do not have the wisdom of experience to rely on to counter such traumatic events.   Prevention, early diagnosis and treatment cannot be dealt with without considering psychological, sociological and cultural factors and interventions associated with the individual soldier, his/her immediate family, and close friends.  To do less is to treat only part of the solution. We need to view the problem through the lens of systems thinking employing casual loop diagramming so as to unravel the true nature of the complexity facing the affected soldier.  Mitigating the potential problem before it occurs is the number one issue – this requires preparing the soldier and his extended social network to cope better with the impeding scenarios that the soldier will face.  Simulations, sage discussions with veterans, systematic calming techniques, and personal sensitivity training on personal emotional resilience factors of self-control, self-regulation and self-motivation are all needed.  Early diagnosis is the next issue which if done effectively will head off having to deal with the chronic nature of the illness and attack the issue while still in the acute stage where habits are not yet well ingrained.  The other remaining issue involves selecting the most robust and effective treatment modality once treatment is required.

The RAND report indicates the increased numbers of trained and certified professionals are needed to provide high-quality (evidenced-based, patient centered, efficient, equitable and timely care) in all sectors, both military and civilian serving previously deployed personnel.  Hiring and retaining such mental health providers is quite a challenge as will be determining the exact number of providers based on demand projections over time.  Although the precise number of newly trained providers is not yet known, it is likely to be in the thousands.  Additional training in evidenced-based treatment for trauma will also be required for tens of thousands of existing providers

Solution Approach

The RAND report recommends the following seven key strategies to employ:

1. Adjusting financial reimbursement for providers to offer appropriate compensation and incentives to attract and retain highly qualified professionals and ensure motivation for delivering quality care.
2. Developing a certification process to document the clinical qualifications of providers.  Providers would also be required to demonstrate requisite knowledge of unique military culture, military employment, and issues relevant to veterans.
3. Expanding existing training programs for psychiatrists, psychologists, social workers. Marriage and family therapists and other counselors to include in their curricula and practice settings training in specific therapies related to trauma and military culture.
4. Establishing regional training centers for joint training of DoD, VA, and civilian providers in evidenced-based care for PTSD and major depression.  The centers should be funded, federally, possibly outside of DoD and VA budgets
5. Linking certification to training to ensure that providers not only receive required training but also are supervised and monitored to verify that quality standards are met and maintained over time.
6. Retraining or expanding the number of existing providers within DoD and the VA (e.g., military community-service-program counselors) to include delivery or support of evidenced-based care.
7. Evaluating training efforts as they are rolled out, so that we understand how much training is needed and of what type, thereby delivery of effective care.

The VA is deeply concerned with finding creative ways to address the three areas of concern in Task 5.  Most of the areas address the seven key strategies, especially 2, 3, 5,6, and 7.

Phase/Idea 1:Identify and test new comprehensive approaches to improve mental health through prevention, diagnosis and treatment.

We will develop an experimental design using parametric and nonparametric statistical techniques to evaluate different approaches to prevention, diagnosis, and treatment where control groups are employed.  As aforementioned, a social forum of soldier and his/her connected family are to be involved prior to deployment in building a comprehensive set of coping capabilities.  Behavioral interviews will be developed and modeled for the immediate soldier's leader to be able to quickly diagnose an impending mental health problem.  An array of treatment strategies will be developed by an interdisciplinary mental health team composed of a psychologist, psychiatrist, and social worker to support the soldier and extended family needs.  If the soldier is physically impaired, the interdisciplinary team will be extended to include health/nutritionist, occupation and physical therapist, and neurologist.  A follow-on career team composed of a set of occupational counselors will be provided for career reintegration.

Phase/Idea 2:Identify specific measures to track their effectiveness so we can allocate resources more efficiently.

We will employ a resource allocation system to methodologically maximize the allocation of resources to various prevention, diagnosis and treatment programs.  Decision support is available to facilitate resource allocation.   Through pareto-optimization techniques we will be able to maximize distribution of funding across multiple program areas.

To track and measure progress of treatment programs we will employ a constellation measure of life reintegration effectiveness composed of career, social, and personal factors associated with happiness, legacy, significance and achievement.  These measures will be qualitative in nature and be judged by the perspective soldier's interdisciplinary team.  Prevention measure will entail reducing the number of soldiers diagnosed with mental health problems.  Diagnosis measures will entail how quickly they are identified by the soldier's immediate leader and to the extent the diagnosis is comprehensive in nature.

Phase/Idea 3:Develop and test new treatment models to remove stigma associated with admitting problems and seeking help.

We will employ a wellness concept that builds mental well being and treats all facets of the soldier's life – spiritually, professionally, socially, and personally.  Success will be defined in terms of positive mental health rather than psychopathology where self-worth, self-esteem and self-motivation will be emphasized.  We will emphasize adult development and deal with the soldier holistically rather than treating only the specific issue.