Learn more about women’s issues, suicide, and PTSD in the military.
Psychiatric Times® had the opportunity to sit down with Elspeth Ritchie, MD—the chair of psychiatry at MedStar Washington Hospital Center—at the 2023 APA Annual Meeting. Check out our conversation on 3 important military issues here.
PT: Tell us a bit about yourself.
Elspeth Ritchie, MD: I retired from the army a few years ago as a colonel. I spent the last of my time developing policy at the office of the army surgeon general. But although I have retired, I have kept in touch with a number of military issues. On Friday, for example, I was at the Society for uniformed services psychiatry, which is a military district branch, and we talked about some of the same things that I talked about when I was on active duty. Now, a couple areas I can talk about here: one is an interest in health of active-duty women, another is suicide prevention, and another would be treatment of posttraumatic stress disorder (PTSD).
PT: Let's start with suicide in the military.
Ritchie: Suicide, both in the military and in the civilian world, has often been looked at as a mental health problem. What we have found is, most of the time, it is not a mental health issue. Suicides in the military—and I studied this when I was there—are often related to financial problems, frustration at work, humiliation, and other parts of life that have nothing to do with mental health diagnoses. Yet there is an expectation that the way to solve the suicide problem is by getting more people into mental health and by screening, screening, screening, screening. The providers in the military feel like all this screening is taking away from their time with their patients, as well as having low value because it requires self-report. People in the military are worried that if they say “Yes, I am feeling suicidal,” they will be sent to the hospital and their job will be taken away from them, etc.
This translates over to the civilian world, where again there is a lot of emphasis on screeners, such as the Columbia Suicide Severity Rating Scale (C-SSRS), which is now being widely implemented. Again, the C-SSRS depends on self-report. This is just an example of a screening tool. Often patients do not like these because they feel every time they come in, they are being asked the same questions. And, to go back to suicide as not necessarily a mental health issue, if it is an issue of quality of life, or finances, or frustration, then the solution is not necessarily to have more psychiatrists and more mental health treatment, but rather to try to understand the causes. I think we do that pretty well.
PT: What about interventions that address the causes?
Ritchie: It is somewhat similar to the argument about gun violence where one faction says the problem has mental health issues, and the other faction say the problem with guns. Sure, there are some gun owners with mental health issues, but the point is, it is not just a mental health issue. There are a lot of other factors involved.
We have come up with lots of recommendations that often have to do with manpower and lowering the stress. A lot of times, suicide is people just feel overworked and under stress. Having more psychiatrist is not a bad thing, I am not saying it is, but it is not the solution. Then people point to psychiatrists and say, “Oh, it is your fault that we have had a suicide.”
PT: Let’s talk next about women in the military.
Ritchie: When I was on active duty, I deployed to a number of remote locations including Somalia and Iraq, and I was in the field quite a bit when I was in Korea. One of the challenges I see is that the army and the military are still mainly men, and so mainly think of health needs of males. For years, for example, the military was worried about trench foot. Men were in the jungles of Vietnam in the swamp, and their feet were rotting and wet, so the military enacted a lot of preventive programs to prevent trench foot.
For women, the military has not yet done as good a job, though I think they have gotten better. But the thing that first got me interested in this subject was the amount of urinary tract infections. People would go to a place where the bathrooms were often scarce, or porta potties, and you did not want to sit down. When we went into Iraq, for example, they were driving from Kuwait to Baghdad, and there was not a place to pee by the side of the road. If you got out, you would either be shot or bombed and blown up. Women would restrict and that led to urinary tract infections. Even if you got to a porta potty, often there was not sanitation there. I do not know if you have ever had a urinary tract infection, but if you have, you will know that you are not at the top of your game when you have one. So, this became my first area of interest on women's health issues, which by and large are fixable if you pay attention to them.
I published a book with Oxford in 2015 called Women at War.1 One of my concerns was I had been talking about these issues for a long time, and there had been a lot of attention paid to them, and then 911 happened and we went to war. The research that had been done on that area went into cessation. My colleague, Anne L. Naclerio, and I published the book in 2015. She had gone to Afghanistan, and I have been to Iraq, as part of the Women's Task Force. She looked at the circumstances, and 20 years after we have been talking about them, things were still very primitive in the field environment.
Now there are a lot of other health issues for women. Women are mainly of reproductive age when they join, so there are issues around pregnancy and breastfeeding. Right now, the question of course is if abortion is no longer acceptable. Where does a person go in order to have a safe abortion if that is the choice she is making? Then, as I mentioned, breastfeeding is one thing; you do not deploy right after you have given birth. You can wait either 6 months or a year before you deploy, but it can be a challenge, if you have got a job where you are going out to the field, and you are trying to breastfeed. I will say that I think the military is not ignoring these issues. They have made great strides. I congratulate the Navy in this area. They are now using long-acting contraception much more readily and they teach about it right when people come into basic training. It used to be a very taboo subject and now there is more recognition, but there is still a long way to go.
I was struck by this and am thinking of 2 articles in The Washington Post.2,3 One was on how the equipment used still does not fit women very well. By equipment, I mean helmet and rucksack. They have had some years to make it adapt to women's bodies, and they are still having problems. The other article covers how women who have served in Afghanistan, who have served in combat, they come back and the VA or other providers still think “Oh, you are a female, you cannot have been in combat.” Instead of bringing them a diagnosis of PTSD, they are more likely to give it an adjustment disorder, which has a lot of consequences for disability benefits. It is very frustrating because in this particular case, women were on the frontlines in Afghanistan working, interpreting, helping out, and then they get back and they go, “Well, you have never been in combat, you are female.”
PT: You mentioned PTSD. Let’s talk more about that.
Ritchie: I have also spent a lot of time thinking, talking, and writing about PTSD—and this will not be new to providers. But what I would like to do is take it up in the context of school shootings. You all know that PTSD is a diagnosis that came after the end of the Vietnam War. In retrospect, we have realized that it has been out there for a long time after every conflict. But after Vietnam was when we really began finding the problems associated with it, and then having it be in the DSM-III and updated a few times. Now one of the questions is, what does PTSD from school shootings look like and how is it similar or different and more important? How is the treatment similar or different?
I think one of the differences that you have is that soldiers who go into battle know they are going into battle. They are trained, they are equipped, and they have their colleagues. It is traumatic, but by and large, they should have a sense of, “I know what I am here for.” Now, if we want to talk about Ukraine and the conflict there for the soldiers, that is different, so I am going to talk about specifically US soldiers. When I went into Iraq, I knew I was going into Iraq. I was a decent shot, and I only had a pistol. I had it, but I had enlisted guys around me with bigger weapons. But in a school shooting or another mass shooting, if you are unprepared, you do not have colleagues who are going to protect you. You do not know what is going to happen next. And you do not have, in general, the same kind of supportive return to military life.
I think this is an area that deserves some more attention. What is the best way to support victims, either direct victims or indirect? What we do know a lot about is how to respond in early intervention following mass violence. Right before 911, we were putting together a conference on the topic. The concern back then was critical incident stress debriefing (CISD). CISD is where after an event, people sit and talk about what happened. The concern was that it made things worse. The military, the Department of Justice, the Red Cross, the National Institute of Mental Health, and the VA, put together a conference where we asked, what is the best thing we could do after mass violence? There have been reiterations and some talks given here today on the same topic.
The important thing is to start with improving the sense of safety and security. For example, 1) letting people know where their family are is critically important, and 2) making sure that there is some kind of security paid to the family members so that the media does not rush in and retraumatize them—no offense to the media. There are good things about the media, but when a TV reporter goes in and says, “How does it feel to have your best friend's girl get killed?” That is not necessarily the right thing. You want to have a perimeter. After 911, we set that up at the Pentagon with a Family Assistance Center, and then provided information. It is very, very important to get relevant information, even if there is no new information to share. At least say, “We are doing everything we can to update you.”
Then you move into sort of a hierarchy about what happens next. Triage is important. There are some people that will need a higher level of care, but that is usually not the thing to do right away within the first 24 or 48 hours. We pretty much said, “No, do not do CISDs,” except in selective cases, such as when it is a fire department unit or police unit, where they know and trust each other.
I think what we need to be doing is looking at what is happening in terms of the coordinated response to school shootings. I think we have come a long way since 911 and there is a lot less of the knee jerk reaction of CISD. I guess the final thing I will say is that you should do an assessment of the needs before you do an intervention. Too often people just want to throw in the intervention without knowing what the needs are.
PT: What advice would you give to your fellow clinicians who might work with members of the military?
Ritchie: The advice that I would give to psychiatrists who are working with all military members is learn as much as you can, understand as much as you can, go to bases, and talk to folks. This is such a complicated subject, though. There are some key differences in treating military members. One is that you do not want to put them on a lot of meditations because that will impact their ability to do their job and they may not be able to deploy, so you need to be careful. For example, we should not put a military member on an antipsychotic without a lot of discussion about whether they really need it, because that may cause them to lose their job, as they cannot deploy.
I would say also, for both sexes, respect the military member and their choice. We are an all-volunteer military. It is not like what happened years ago people were drafted. Do not treat the person as a victim; treat them as a proud service member who feels very good about their service to their country, their family, and the world. In terms of women's issues, it is a double-edged sword. Women in the military do not really like to be singled out for being female. They do not want to be seen as weaker than anybody else, or as somehow inferior or needing special care or coddling. You want to respect their ability to do their job. But know, there are going to be specific challenges, and the biggest challenges are about reproductive issues. How are you going to be a mother with young children and deploy? How are you going to maintain breastfeeding, if that is what you want to do? How do you take care of elderly parents at home? Of course, women are still traditionally the sandwich between the kids and the elderly parents, and I think that is underappreciated as an issue, as it is in the civilian world.
With the military, it is either harder or easier when you are on the other side of the world. With my first posting in Korea, it was before the internet, so you did not know how things were going at home. Now with internet, you're getting the “Come back, we miss you!” There are pros and cons; it’s a multifaceted set of issues.
PT: Thank you so much!
Dr Ritchie is the chair of psychiatry at MedStar Washington Hospital Center. She retired from the Army in 2010, after holding numerous leadership positions within Army Medicine, to including Psychiatry Consultant. She is a professor of psychiatry at the Uniformed Services University of the Health Sciences and at Georgetown University.
1. Ritchie EC, Naclerio AL. Women at War. Oxford University Press; 2015.
2. Kamen A. Military body armor not a good fit for women. The Washington Post. May 21, 2012. Accessed May 24, 2023. https://www.washingtonpost.com/politics/military-body-armor-not-a-good-fit-for-women/2012/05/17/gIQAwyG7eU_story.html
3. Seck HH. These women survived combat. Then they had to fight for health care. The Washington Post. March 27, 2023. Accessed May 24, 2023. https://www.washingtonpost.com/national-security/2023/03/27/jax-act-women-combat/