Brain injury
According to the RAND report, 19% of those surveyed (320,000 service members) reported that they experienced a possible TBI while deployed. As many as 7% reported both a TBI and current symptoms of PTSD or major depression, Jaycox said.
“What we don’t know yet is how many people are suffering from some long-term impairment related to those injuries, since we found that fewer than half [43%] had been evaluated by a doctor for that concussion or brain injury,” she said.
In her lecture, Ritchie urged psychiatrists and others to ask about TBIs. Individuals who have experienced mild TBI, she added, can have problems with behavior, attention, and concentration, and “we really need to be able to identify soldiers who are having symptoms of it.” Individuals exposed to a TBI, she warned, are more at risk for getting another TBI, and are, therefore, more at risk for permanent injury.
While screening tests are available for TBI, “no single test tells you definitively whether somebody has a head injury,” she said. The Military Acute Concussion Evaluation is used in theater, and the Automated Neuropsychological Assessment Metrics is used predeployment and after someone has an injury.
Treatment gaps
For those with PTSD/depression, RAND researchers found significant treatment gaps. Only 53% had seen a physician or mental health provider to seek help for a mental health problem in the past 12 months, and of those who sought care, roughly half received minimally adequate treatment.
“If PTSD and depression go untreated or are undertreated, there is a cascading set of consequences,” Jaycox said in a press statement. “Drug use, suicide, marital problems, and unemployment are some of the consequences.”
Societal costs of PTSD and depression for 2 years after deployment range from about $6000 to more than $25,000 per case, the RAND report indicated. Estimates of total society costs for the same period ranged from $4 billion to $6.2 billion, depending on whether the economic cost of suicide was includ-ed. If everyone needing care received evidence-based treatment, the savings could be as much as $1.7 billion.
Numerous recommendations were listed in the 492-page RAND report, including better organization of the array of mental health programs provided by the DoD and VA; monitoring service quality with widespread adoption of treatment guidelines for depression and PTSD and identification of screening tools and effective treatments for TBI; intensification of efforts to reduce stigma and barriers to care; and enrollment of the civilian sector in providing care that is evidence-based, that is sensitive to the unique aspects of military life and deployment, and that is adequately reimbursed.
“We need more psychiatrists in the Army,” Colonel Ritchie told APA attendees. There are some 120 psychiatrists in the active Army, serving about half a million active Army soldiers, she explained. Colonel Ritchie also encouraged mental health professionals to familiarize themselves with TRICARE and become providers. TRICARE is the health care program serving active duty service members, National Guard and Reserve members, retirees, their families, and others. It brings together the health care resources of the uniformed services and supplements them with networks of civilian health care professionals, institutions, and other providers.
The issue of stigma
Yet, even when treatment is available, service members often do not seek treatment, fearing it might damage their career or cause their peers to lose confidence in them.
New efforts to reduce stigma are under way, according to Jaycox and Ritchie. In May, DoD announced revisions to question 21 on the Questionnaire for National Security Positions, which asks if in the last 7 years, the respondent has consulted with a health care professional regarding an emotional or mental health condition or was hospitalized for such a condition. Currently, the person can answer no if the counseling was strictly related to adjustments related to service in a military combat environment.
Other steps to reduce stigma and encourage treatment cited by Ritchie include the Army’s chain-teaching program to educate soldiers how to recognize and respond to PTSD; combat stress control teams to bring front-line assistance to soldiers; Battlemind training to prepare soldiers for the stresses they face in combat and when returning home; and Military One Source, a 24-hour, toll-free hotline to enable soldiers or their families to arrange for civilian mental health counseling without charge.
