USUHS: Since January, 2012 I have had the privilege of serving on the faculty of the Uniformed Services University of the Health Sciences (USUHS) and have been very impressed by the professionalism and dedication of the graduate students and faculty in nursing and psychology. The Psychology Department hosts a weekly seminar exposing the broader university community to a wide range of behavioral expertise. Steven Brewer's report: "Combat and Behavioral Health – The USUHS Medical and Clinical Psychology Department provided another informative seminar recently. This time the topic was the behavioral health of soldiers and marines after a decade of combat. The presenter was renowned military researcher Carl Castro, U.S. Army Colonel and the current director of the Military Operational Medicine Research Program at Fort Detrick, Maryland. To provide perspective for his discussion, Col. Castro began by discussing the context of combat-related PTSD and how it differs from other types, perhaps due to the extensive training provided prior to deployment. This prior training makes the traumatic event expected and not unanticipated. The prior training may also allow reaction to occur 'automatically' and allow the person to not freeze. The symptoms themselves may also be beneficial in the combat environment for survival of self and protection of others, especially when the environment will provide repeated exposure to the traumatic events, rather than a single instance.
"The key points of Col. Castro's presentation were made through the Lessons Learned from a decade of combat. The first Lesson Learned is 'Combat impacts the mental health and well-being of Soldiers and Marines.' Service members in a Brigade Combat Team assessed at three months after returning from a year in Iraq had a three-fold increase of PTSD. The risk increased proportionately with the increase of combat engagement and even perceived danger. Even 12 months post-deployment saw a significant increase in angry and aggressive behaviors. The second Lesson Learned is 'Not all Soldiers are at equal risk for mental health problems.' The risk is greatest for those serving in direct combat, such as Infantry units, compared to those who serve in combat support (CS) or combat service support (CSS), such as Signal units. While it is important to note that the CS and CSS service members do still see an increase in symptoms and mental health disorders during deployments, the risk increases directly with combat exposure. Those who served in high combat were most likely to show symptoms of anxiety, depression, PTSD, and other mental health disorders.
"The third Lesson Learned is 'Leadership is important for maintaining Soldier mental health.' Soldiers with high perceptions of leadership were less likely to screen positive for a mental health problem compared to those with low perceptions of leadership. In fact, the percentage of positive mental health problems was lower in High Combat/ High Leadership groups (17%) than it was in Low Combat/ Low Leadership groups (20%), indicating the importance of good leadership to mental health. The fourth Lesson Learned is 'Mental health training works.' For instance, Battlemind Training (BMT) is an evidence-based skill development model that uses examples relevant to service members, has a team focus, and builds on existing strengths. Those who received BMT reported significantly fewer PTSD symptoms at three months post-deployment compared to those who received the standard stress education training.
"The fifth Lesson Learned is 'Mental health 'resetting' following a year-long combat tour takes more than 12 months.' Many units that deploy for 12 months are then authorized a 12-month 'dwell time' to reset before possibly deploying again. However, the evidence shows that symptoms of depression, anxiety, and PTSD often increase over the 12-month period. Service members have little time to deal with their mental health issues, as the dwell time includes many deployment related activities, including training and preparation for the next deployment. The sixth Lesson Learned is 'Longer and multiple deployments are likely to lead to more mental health issues.' Intuitively, it makes sense that symptoms do not get better by multiplying the trauma which caused the symptoms. The evidence bears out this thought, for both 12- and 6-month deployments. The last Lesson Learned is 'Every combat Soldier and Marine will face moral and ethical challenges.' The combat arena is a difficult one for people to understand unless they have been there, and the decisions that must be made can be challenging to an individual's personal code of ethics. The findings indicate Soldiers who screened positive for a mental health problem or who had high levels of anger were twice as likely to engage in unethical behavior on the battlefield compared to those Soldiers who screened negative or who had low levels of anger. Soldiers with high levels of combat were more likely to engage in unethical behaviors than Soldiers with low levels of combat.
"The next step is to use the Lessons Learned to improve the mental health of those who serve. The primary means appears to be focusing on the junior leadership, including non-commissioned and commissioned officers. We must also work on the recovery and return-to-duty both after and when mental health issues arise. Relationship building among peers, mental health providers, and leaders is critical to improve the facilitation of mental health services. Finally, the transition from the combat arena to home is difficult. Some service members return to an active duty post; others, such as the Reservists, are transitioned to their civilian life with little time to make the conversion. Families often suffer from confusion and a sense of helplessness when mental health symptoms appear. As we move into the future, we must ensure we are providing the best care we can to those who have served 'in harm's way.'"
"Retirement": Prior to USUHS, I served with the late-U.S. Senator Daniel K. Inouye for 38+ years, retiring as his chief of staff. One of the most interesting initiatives was the directive by the conferees on the Fiscal Year 1989 Appropriations bill that DoD establish a "demonstration pilot training project under which military psychologists may be trained and authorized to issue appropriate psychotropic medications under certain circumstances." Morgan Sammons and John Sexton (both U.S. Navy) were the first to graduate from this program at the June 17, 1994 ceremony held at Walter Reed, attended by then APA President Bob Resnick. These two trailblazing colleagues unequivocally demonstrated that psychologists can learn to safely and cost-effectively provide high quality psychopharmacological care. Military psychologists should be proud of their historical accomplishment and now also affirmatively assist other colleagues in obtaining this important clinical responsibility within the VA, and throughout the civilian sector.
The Civilian Sector: During the past year significant progress has been made in two of our larger states. In New Jersey, Bob McGrath reports: "The New Jersey RxP bill passed our Assembly on April 29, 2013 despite strong opposition from several of the medical societies. Though they fielded five lobbyists on the day of the vote, they had no argument against the bill other than the usual claims that the training is insufficient and patients would be 'harmed,' without presenting a shred of data to support their position. Next we move on to the Senate. It's a remarkably expensive undertaking, and we can use any help we can get."
In Illinois, Beth Rom-Rymer: "We have had a remarkable 14 months. On March 6, 2012, the Illinois State Senate Public Health Committee passed our RxP bill out of Committee by a vote of 6-4. With our lobbyists, we made the critical decision to spend the next 12 months educating our psychologists and legislators around the state on RxP issues; training Illinois psychologists in becoming effective advocates for RxP; and reaching out to mental health associations, social service organizations, law enforcement agencies, hospitals, mental health centers, physician groups, etc. to educate about, and advocate for, RxP. We have been very fortunate to work with strongly committed and dedicated legislative chief sponsors, including the Senate President ProTem Don Harmon. On March 12, 2013, our RxP legislation passed out of the Senate Public Health Committee by the unanimous vote of 8-0 with one abstention. On April 25th, we overwhelmingly passed out of the Senate by a vote of 37-10 with 4 abstentions. On May 7th, our Senate bill was placed in the House Executive Committee. Over the next several days, we were continually conferring with our lobbyists over the advisability of calling our bill. We made the strategic decision that we wanted to take more time to work with our Representatives so that the vote would reflect an informed understanding of the issues. We will be working very closely, over the next several months, with our legislators and all of our third party groups around the state. We are very fortunate that although this legislative session has concluded on May 31st, we are in the first year of a two year sequence. We are, therefore, able to build on all of our terrific accomplishments, to date, and focus on the House. We are also in productive discussions with the Governor's Office. We are looking toward achieving passage during our next legislative session in the spring of 2014." From the littlest of Acorns, those with vision see mighty Oaks. Aloha,
Pat DeLeon, former APA President – Division19 – June, 2013
