COMMENTARY

Addressing Military Mental Health: A Proposed Solution

Jeffrey A. Lieberman, MD

Disclosures

December 13, 2018

Hello. This is Dr Jeffrey Lieberman of Columbia University, speaking to you today for Medscape.

I want to comment on my thoughts in the aftermath of Veterans Day, which we celebrate on November 11th. The title of my comments could be, "Solving the Mystery of Military Mental Health."

After watching the Veterans Day observances, I really felt upset. At first, I thought maybe I'd binge-watched too many war movies that had been broadcast for the occasion, including All Quiet on the Western Front, Saving Private Ryan, Platoon, and Patton. There was also the fact that Veterans Day marked the 100th anniversary of the Armistice of World War I—the Great War—and, unfortunately, was also punctuated by the indignity of our President being deterred by the weather from attending ceremonies at the French cemetery where our US soldiers were buried.

Then it hit me. What really upset me was in Patton, when George C. Scott slaps the soldier with post-traumatic stress disorder (PTSD) and calls him a yellow-bellied coward. This iconic scene captures the historic and continuing ambivalence of the military toward the psychological wounds of war. It's the military equivalent of what mental illness faces in our society, which is pervasive stigma, but in the case of the military, it is a stigma on steroids.

It is because of this stubborn aversion to the reality of the psychic injuries in the military that active-duty and veteran military personnel continue to be denied effective mental healthcare, and limited progress has been made in understanding the pathology of psychological trauma and has impeded the development of effective treatments.

More than 2 million troops have already been deployed in the Middle East—Afghanistan, Iraq, Syria—with no end in sight. Almost one third of all the service-persons in these ongoing conflicts suffer some clinically significant mental condition. The poster child for these is PTSD, along with its complications of suicide, addiction, and violence. It is shocking when you see a statistic that veterans are twice as likely to commit suicide as their peers—nonveteran citizens in the general population. At one point, active-duty military personnel were dying from suicide at a rate that was greater than from enemy combatants. There is no reason for this.

It has long been known that the psychological effects of military service and combat can produce psychological injuries that are distressing, disabling, and persistent. Before the term "PTSD" was coined and codified in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-3) after the Vietnam War, it was called by other names, including "soldier's heart" in the Civil War, "shell shock" in World War I, and "battle fatigue" and "combat neurosis" in World War II and the Korean War. Yet, efforts to develop effective treatments have really been limited.

Current treatments are useful, but they are only partially effective at best. Furthermore, there are very limited prospects for advances based on the current research. There is a desperate need for treatments that can be administered at different stages of what military personnel go through, in terms of their risk of sustaining injury, psychic or physical, or when they actually sustain it.

You see that soldiers, when they go into the theater of war, have body armor to prevent injury, and if they are wounded, there's emergency treatment. There should also be preventive and symptomatic treatments for psychic trauma. Preventive treatments could potentially immunize persons going into harm's way. If they do sustain trauma, the latter could be administered in the field as soon as possible after traumatic exposures.

The military has already demonstrated its capacity to make extraordinary advances in the medical care of soldiers. [Over 80% of the severely wounded combatants in World War I died.] Now, in the Middle East, over 80% survive.

Whereas wounded soldiers writhed in pain and died of infection and exsanguination in World War I, medics now are able to stabilize soldiers in theater, air-evacuate them to field hospitals where they undergo surgery and, when stable, can be airlifted to military hospitals in Germany for more intensive treatment. When they recover, if they need further treatment, they can be transported to the United States and admitted to the Walter Reed National Military Medical Center.

Research has indicated that as many as 50% of veterans discharged from active duty experienced significant difficulty of a psychological nature associated with acclimating. One third of these individuals develop mental health problems that meet the DSM criteria for PTSD, anxiety disorders, or depression. Reconnecting with loved ones after repeated exposure to combat stress; coping with physical injuries they've sustained during combat, including amputations or traumatic brain injury; and renegotiating their lives as civilians and returning can be emotionally overwhelming for these personnel and their family members.

[These overwhelming experiences] can lead to significant social impairment; marital discord; job instability; and, even worse, suicide, substance abuse, and violent behavior. To make matters worse, there's an acute shortage of mental health services available to veterans. Trained clinicians often are lacking in number and expertise of the evidence-based treatments that are currently available. This limits the ability to care for the large numbers of redeployed veterans and their families.

Moreover, the quality of the services and the effectiveness of the treatments are not optimal. They are effective, but they are not good enough. There has been limited federal funding to devote to improving our understanding and the effectiveness of treatments. Much progress could be achieved by a more intensive effort to focus on psychobiological research related to the effects of psychological trauma on the brain.

The lack of mental health services is compounded by the fact that active-duty and veteran military personnel are often reluctant to or overtly deterred from seeking mental healthcare because of the shame and stigma associated with it and the fear that it could adversely affect their career. To add insult to injury, family members of military personnel are not eligible for mental healthcare in Veterans Affairs (VA) settings. Ignoring the needs of these populations is both unfair and, given their great sacrifices, unwise, because family support for veterans is critical for their optimal adjustment after returning from active duty and tours of duty.

Given the scope of mental health problems among military personnel, better and more mental health services must be developed. Evidence-based treatments are needed in multiple settings, including basic training, on the battlefield, in theater, following injury, and upon and after discharge. Special efforts must be made to address the deterrence of shame and stigma by at least ensuring that all personnel—active duty, then after discharge—are encouraged to obtain mental health services if needed.

Why hasn't more been done? Why hasn't this been addressed in a more effective way to manage the psychological wounds of war and its sequelae? I believe there are three reasons why little progress has been made in addressing this problem.

First, the idea of psychological weakness is antithetical to military culture and its ethos of strength and invulnerability. Therefore, military leaders were disinclined to accept the possibility of, much less recognize, psychic injury. As a result, many soldiers were accused of cowardice and punished, and some were even executed for their infirmity.

Second, mental disorders are not tangible. There are no physical signs or diagnostic tests to confirm them; hence, they're not seen as real and are minimized. You do not get a Purple Heart for PTSD.

Third, because PTSD was considered a military problem, the responsibility for figuring it out and developing treatments was left to the Department of Defense (DoD) and the Veterans Administration. The National Institutes of Health (NIH) did not see it as within the scope of their research missions by and large, and did not engage the best and the brightest biomedical researchers at our medical institutions in the country to study PTSD.

Consequently, talented investigators who might have pursued this line of research could not get funding. I personally know of two National Academy of Science-level researchers who, because of their own interests for developments in their labs, submitted applications that seemed to be incredibly innovative and potentially important to DoD for funding. The applications were scored highly but not funded.

There are flaws in this scenario. First, just because there is no physical lesion associated with psychic injuries of war does not mean that it isn't a pathologic consequence that is distressing and disabling.

Second, psychological trauma does not only occur in the military. It is more common and more concentrated in the military because of the fact that they're engaged in active combat, but psychological trauma also occurs in the civilian population—for example, mugging, natural disasters, fires, and auto accidents. Therefore, this should be considered a medical problem that is of importance in this country, which extends from the civilian population to the military. The NIH and the biomedical research community should be engaged and make this a priority.

There is another reason why the measured response of our government to address military mental health is so unwise and unfortunate. Of the 265 disorders described in the DSM-5, only two have known etiologies and can be readily studied in animal models: substance abuse and PTSD. The biology of PTSD can be studied in the laboratory through fear conditioning paradigms and therapeutic approaches developed to alleviate symptoms and potentially prevent or immunize people against these effects.

What is needed is a Manhattan Project to elucidate the pathophysiology and develop effective treatments for psychic injuries of military experience and combat. Although this is a formidable scientific challenge, it is eminently achievable. The first step is for the administration and Congress to empanel a task force of leading scientists to develop a strategic plan for research on the pathologic basis of PTSD and development of effective treatments.

Next, Congress must allocate funding to support this research so that it is not taken away from research being done in other disease areas under the auspices of the NIH. This should be done in partnership with the VA and with the DoD.

The NIH director's office should be charged with the responsibility of monitoring progress and reporting to the President and Congress. This effort would be sustained until sufficient progress has been made to the missions accomplished. The final step would entail establishing a network of medical centers to work with the VA hospitals to provide specialized mental health services for veterans and to have mechanisms to reimburse care at non-VA institutions.

It's time for us to ask our government to right this historic wrong. Amidst the political gridlock in Washington and polarized opinions of the electorate, this is one thing on which everyone agrees—it is our respect and concern for US military personnel. Images and statistics of returning veterans with lost limbs, injured brains, and traumatized psyches have seared the public consciousness and evoked an outpouring of compassion. Thankfully, we are light-years away from the Vietnam-era vilification of the military.

Let us pledge that not another Veterans Day shall pass without our government, biomedical research, and medical communities committing to solve the mystery of psychological trauma and to remove this scourge from those who placed themselves in harm's way to defend us and our freedoms.

Thank you for listening. This is Dr Jeffrey Lieberman of Columbia University, speaking to you today for Medscape.

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