A Mixed Message about Stigma in Military Mental Health Care

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Adm. Mike Mullen, chairman of the Joint Chiefs of Staff, heralds the opening of a new mental-health clinic at Fort Drum, N.Y., in 2009 / Dod photo by Chad McNeeley

The military keeps talking about eliminating stigma related to seeking mental health treatment. Then why don’t they change the policies that promote it?

To decrease stigma, the Army now uses the term “behavioral health.” The Defense Department – of which the Army is a part — prefers “psychological health.”  They have developed numerous training regimes for Post-Traumatic Stress Disorder, suicide prevention and the importance of seeking treatment.  They have substantially increased access to mental-health providers and are involving primary-care teams and other care agencies in the efforts.

Nonetheless, there are numerous policies that have a very mixed message. One of the major ones is the Deployment Limiting Psychiatric Conditions policy, issued in November of 2006.

It’s a well-intentioned policy, meant to avoid service members being plucked from psychiatric hospitals and sent to the battlefield. However it has numerous negative unintended consequences.

The policy requires that service members be stable for three months on their medication before deploying. Otherwise they need a waiver from Central Command (CENTCOM). It sounds good, but leads troops to avoid seeking mental-health treatment.

Remember in this era of high unemployment, service members want to keep their jobs, and deployment is part of keeping your job and getting promoted.  Staying behind for three months because you have had your sertraline (Zoloft) switched to fluoxetine (Prozac) —both very safe and common antidepressants, also used for the treatment of PTSD—is not good for unit cohesion, or promotion.

There are many other policies that discourage treatment. In the Navy, if you are on antidepressants, you need flag (eg. the Navy equivalent of an Army general) officer approval before you can hold a firearm.  Who wants to have a very high-ranking officer sign off on your ability to go to the firing range?

Security clearances are another major issue. Although officially the dreaded Question 21 has been revised so that you do not have to report mental-health issues that happen in the combat theater, anecdotally there is still an incredible lag if you report any psychological issues while the security folks investigate.

I could go on and on about policies and procedures that keep service members from walking into the mental-health clinic, or even worse, the substance-abuse clinic. Why are these clinics in separate buildings, where if you are in the waiting room, everybody knows you have a “problem”?

Again there are some excellent efforts to overcome these barriers, including the Respect-mil program, where the primary-care medical team screens and provides treatment. But there is still the barrier to deployment, whether a regular doc or psychiatrist does the prescribing.

Regular Mental Health Advisory Teams (MHAT) that survey troops on the front lines and report back trace the success of such efforts.  The most recent MHAT-7, released May 24, shows stigma and barriers to care in the theater of war remain essentially unchanged.

Yet there is good news. Soldiers reported better training in suicide prevention and other psychological issues in MHAT 7. The suicide rate among active duty troops has finally started to flatten, although it continues to rise among National Guard troops.

But the bottom line is that the military cannot simply do public service announcements about getting treatment and expect our troops to salute and do as they are told. There needs to be a thorough and transparent assessment of military policies that stigmatize troops and keep them from getting the help they need.