The Mindfield: Navigating Veterans Mental Health Policy

In Beltway politics, no issues have brought elected officials together, at least publicly, in the past two years. An oasis of debate is materializing out of the partisan desert of “unconscionable” and “embarrassing” legislative branch inaction, however, but at the other end of Pennsylvania Avenue White House officials familiar with the policy content say the President will announce a new direction for veterans’ affairs on August 26th, building off its current platform and incorporating the recent 16 billion VA bill signed by the President on August 7^th. However, little of the discussion has addressed a crucial niche within veterans’ medical policy: cognitive and affective, or emotional, health. It would appear that lawmakers are allowing the recent scandal over substandard hygiene and physical infrastructure at medical centers like Walter Reed to linger on without addressing all of war fighters’ post-combat needs.

Despite the 6 billion USD spent between 2002-2010 by the VA on Post Traumatic Stress Disorder (PTSD) and its rival as the leading cause in veteran suicide, Traumatic Brain Injury (TBI), a staggering 1,900 service members took their lives in the first three months of 2014 alone. With Congress dispassionate on the issue, concerned stakeholders can turn to a mid-2013 study “Treatment-Seeking Barriers for Veterans of the Iraq and Afghanistan Conflicts Who Screen Positive for PTSD” conducted by medical professionals and approved by the Dartmouth Committee for the Protection of Human Subjects. In the study, the researchers examine the reasons for neglect of post-combat mental health, finding that veterans “have reported obstacles in interacting with the VA, such as hassles with scheduling, waiting times…and navigating the health care system in general.”

This research is unique because circumstances generally make it difficult to gather together those likely to benefit from PTSD treatment for a variety of reasons. Over 2000 combat veterans have admitted to suicidal ideations, but few seize treatment opportunities because of lingering stigmatization and negative views of mental health assistance.

Participants were screened for the study using the MINI, the PCL, and the Physicians Health Questionnaire, which identified treatment avoidance symptoms. The tests assessed patients’ neuropsychiatric state and symptom severity—whether they were likely to contemplate suicide and the intensity of these feelings, respectively. None of the participants had ever received treatment for PTSD.

From a pool of 300 veterans exhibiting PTSD or related TBI symptoms, the investigators proceeded to elicit “beliefs about PTSD treatment” in one-on-one intervention sessions. During the conversation participants were briefly introduced to cognitive-behavioral therapy (CBT), a “theory suggesting… that thoughts about certain situations influence behavior. Because thoughts are modifiable… changing thoughts about situations may change behavior in those situations.” CBT acted as the experimental treatment, so as to determine if veterans with PTSD benefited from a new way to think about seeking attention from mental health professionals.

Investigators addressed a maximum of three beliefs held by participants and then ask them to self-evaluate.  “For example, the thought… ‘I am drinking a lot to avoid thinking, so maybe treatment could help me deal with my memories better’” would be posed to the participant, who would then respond.  Investigators would record answers and use content analysis to systematically identify and group themes, which were later coded and categorized for analysis.

Analysis demonstrated two results, the first of which was expected: demographically, participants were mostly male, from nearly every state in the Union (48 of 50), and scored moderate to severe on the PCL, as well as depressive symptoms on the PHQ-9.

Unexpectedly, treatment misperceptions were frequently reported as an impediment to addressing PTSD, indicating that the National Center for PTSD may not be having its intended impact. Information about medication, emotional readiness, and future job and security-clearance prospects was also widely misunderstood, often leading service members to self-medicate or cope with drugs or alcohol. Investigators also discovered that stigma was the third most common reason for not seeking treatment, leading them to speculate that the campaigns targeting stigma have had some positive impact.

The VA might be doing better than supposed, then. It’s equally likely that the long tradition of “fire and maneuver” shared across service branches—battlefield adaptation thinking employed to identify and solve a challenge—has leaped from military training into military society; service members might be addressing the social stigma of treatment because they support one another. While this is difficult to determine, the research discussed here has made the first step in identifying that this de-stigmatization is even taking place.

As the VA scandal continues on the Hill, it behooves policymakers to examine the goals and outcomes of this and similar research motivated by the health obstacles of veterans themselves, rather than who is in charge of care and where it takes place. Leadership and infrastructure is essential—something the DOD knows better than any Federal entity—but armed service members also understand the value of not just working hard but also working smart, a mantra Congress has yet to adopt. This research suggests policies that dim spotlights from center stage, headline-grabbing Obama administration efforts, the House Committee on VA Honesty Project, and the VA, and brings focus back to vets. It’s time their leadership by example was taken to heart.

Article Source: Stecker T, Shiner B, Watts BV, Jones M, Conner KR (2013), “Treatment-seeking barriers for Veterans of the Iraq and Afghanistan conflicts who screen positive for PTSD”, Psychiatric Services, 64(3):280–283.

Feature Photo: cc/(Armando G Alanso)