Military personnel seeking mental health care outside of the military

A new article in Military Medicine, published by Oxford University Press, indicates that military personnel are making extensive use of outside mental health services, suggesting that military health and mental health services do not meet the needs of active duty service members.

The study aimed were to determine the personal characteristics of military personnel who receive care from a civilian network of volunteer professionals; to ascertain the mental health diagnoses of these military personnel; to analyze the characteristics most closely associated with mental health disorders, and suicidal thoughts; and to clarify the experiences that led military personnel to seek care outside military institutions.

Professionals working as volunteers in the Civilian Medical Resources Network received referrals of active duty GIs from the GI Rights Hotline, staffed by members of peace and faith-based organizations. A research team based at the University of New Mexico, Albuquerque, as well as in Texas, Oregon, and Massachusetts, collected quantitative and qualitative data for 233 clients between 2013 and 2016. Military clients were located throughout the United States and also in Afghanistan, South Korea, and Germany.

Clients showed very high rates of psychiatric disorders. Almost half, forty-eight percent, reported suicidal thoughts. Seventy-two percent of clients met criteria for major depression, 62% post-traumatic stress disorder, 20% generalized anxiety disorder, 25% panic disorder, and 27% alcohol use disorder. Thirty-eight percent of clients reported mistrust that their command would meet their needs. Twenty-four percent gave a history of pre-military mental health treatment.

Many clients related a history of pre-military (46%) and military (73%) trauma. Of those with military trauma, 52% gave accounts of combat related trauma while 59% reported non-combat related trauma, e.g., physical or sexual assault.

During recent years approximately 80% of referrals to Civilian Medical Resources Network involved mental health problems and 20% physical health problems, with an overlap of mental and physical problems in about 10% of cases. The majority of the clients were male (82%) and between 18 and 26 years of age (58%). Sixty-two percent identified themselves as White, 16% Black, 15% Hispanic, 2% Native American, and 4% Asian/Pacific Islander. Most clients were in the Army (64%), were of lower rank (82%), and had completed high school or some college (78%).

Several themes emerged in clients' intake interviews as reasons for seeking civilian services. Clients reported lack of accessible and trustworthy services, as well as feeling afraid of peers. Multiple clients reported that they could not afford the services they needed. Guilt about killing or injuring others were common experiences. The most frequent themes arising in client narratives were insufficient and unresponsive services (93%), fear of reprisal for seeking services (56%), mistrust of command (48%), pre-existing mental health disorders (22%), military sexual trauma (22%), and cost as a barrier to receiving health care (19%).

The mental health consequences of military service show themselves most dramatically in high rates of suicide, recently averaging 20 per day among veterans and over 1 per day among active duty military personnel. During recent wars in Iraq, Afghanistan, and elsewhere, more active duty personnel have been dying from suicide than from combat.

The article indicates that military health and mental health professionals must balance obligations both to patients and to the military command and argues that ethical problems of trust and confidentiality become barriers to care. Other barriers include stigma, a negative impact of seeking care on one's career, beliefs that care would not be effective, and lack of appropriate services.

"Current wars have led to a devastating public health epidemic of suicide and mental health problems among veterans and active duty GIs," said the study's coordinator, Dr. Howard Waitzkin, distinguished professor emeritus at the University of New Mexico. "The military should encourage and support GIs' use of civilian-sector services that do not involve the ethical conflicts inherent in military medicine and mental health care. Such civilian services should be based in not-for-profit organizations that do not benefit financially by restricting their services."