Things have come a long way in the military’s approach to mental health issues since Gen. George Patton slapped a “shell-shocked” soldier at the height of World War II – an act not in keeping with official policy even then, of course, and for which Patton was punished. Nearly three-quarters of a century later, one of the most difficult obstacles to dealing with mental health issues is the stigma many feel attached to admitting they have a problem and the fear that such an admission and subsequent treatment will damage – if not end – their military careers. The Department of Defense (DoD) and the individual services are combating that with a flood of new directives from top commanders, Web-based information, brochures, training, informational briefings, videos, and applying new technologies – such as virtual reality (VR) – to both patient treatment and provider training.

Perhaps partly as a result, there has been an increase in reported rates of depression, substance abuse, suicide/suicidal thoughts, and post-traumatic stress disorder (PTSD – which incorporates previous generation terms such as shell shock, battle fatigue, gross stress reaction, post-Vietnam syndrome, and even, during the Civil War, “Soldier’s Heart”).

“There has been significant effort in the past four years-plus to expand mental health care services in both the VA and DoD, including more mental health workers and enhanced services that have been shown to be effective for PTSD, specifically. And that might impact the prevalence and indicate an increase in cases,” noted Dr. Bradley E. Karlin, a psychologist serving as national mental health director for Psychotherapy and Psychogeriatrics within the VA Office of Mental Health Services. “At the same time, we now have an important new opportunity for treatments of PTSD beyond what we have had previously and we are working hard to make those available to veterans.”

Major efforts by both the VA and DoD to identify, diagnose, and properly treat PTSD and other mental health issues have made what appears to be significant progress during the past decade of war in Southwest Asia. That ranges from examining the relationship between physical injuries, such as traumatic brain injury (TBI), and mental health problems to developing treatment procedures warfighters – young and old – are more likely to accept.

These efforts have been hampered by a lack of coherent data from the past, when mental health problems were hidden by those involved, subject to misdiagnosis, or misreported in an effort to protect the patient and not catalogued by military service, age, gender, job, deployment – especially to combat theaters – and so on. Even now, not all of those factors are being reported in real-time to a central coordinating agency compiling information across all four active duty services, the National Guard, Reserves, and veterans, although a number of studies and “prototype” approaches are under way.

And some of the results to date have been surprising.

“We have information showing most military suicides have never deployed, so it does not seem to be a problem tied directly to deployment, which runs counter to popular perception,” according to Gregory A. Gahm, director of the National Center for Telehealth & Technology.

The National Center for Telehealth & Technology, or T2, as it is commonly known, is one of six Defense Centers of Excellence (DCoE) for psychological health and TBI, established in 2007 to assess, validate, oversee, facilitate, and integrate DoD prevention, resilience, identification, treatment, outreach, and rehabilitation programs.

“The DCoEs were formed specifically to bring together expertise from across the military services and other levels of DoD. And the center I direct to bring to bear new and better technological solutions to help address those problems for service members, veterans, and their families,” Gahm explained.

“We have a very strong relationship with the VA and our partners, with most of our work involving some level of collaboration. It has been a nice bridging of shared minds and similar populations and problems to make sure we are not building something that only addresses a small part of the population.”

While some may see technology as a cold approach to such an intimate topic as mental health, Gahm said today’s military personnel have come to accept and rely on technology in every aspect of their jobs, including enhanced survivability in combat, all of which makes them better attuned to its use in medical care.

“In addition to serving those looking for and comfortable with receiving mental health care, technology is appealing and familiar to the younger population, representing an up-and-coming approach they might be more interested in exploring and not just the old style,” he said.

“And because it is available 24/7 through online applications and much of our care is available anonymously, which is intentional, they can really sample them in a very safe environment without any concerns. Part of what much of our online treatment programs and services do is help normalize what they are experiencing and see if this approach might help them.”

Although fears that admitting to and seeking treatment for any type of mental health problem might hurt their military careers is not a concern for veterans, the VA has found there remains a societal stigma – especially for those who still see themselves as warriors and mental health problems as a weakness.

“The best data we have – and there is no single definitive source of information about the prevalence of PTSD in the veteran community – show about 15 percent are affected. Estimates for depression are at least as high as PTSD. And in addition to those and other mental health problems, some veterans are having readjustment problems at work, in their home life, or at school,” reported Dr. Paula Schnurr, a psychologist and deputy executive director of the VA’s National Center for PTSD.

“Data from civilian studies show substance abuse may predispose individuals to develop traumatic stress because of reckless behavior, putting themselves in harm’s way. And people with pre-existing mental disorders are at risk of developing PTSD if they experience combat.”

Shortly before 9/11, the VA and DoD, in partnership with civilian researchers, began the Millennium Cohort Study to evaluate the long-term health effects of military service, including deployments. Proclaimed the largest prospective health project in military history, it was a response to what the DoD deemed a critical need following the first Gulf War in 1991. The decade-long second war in Southwest Asia both heightened those concerns and provided a massive new cadre from which to draw data.

Now based at the Center for Deployed Health Research, another of the DCoEs, Millennium Cohort involves nearly 150,000 participants. According to its mission statement, “As force health protection continues to be a priority for the future of the United States military, the Millennium Cohort Study will be providing critical information towards enhancing the long-term health of future generations of military members.”

“There has been speculation that an increase we have seen in the prevalence of PTSD might be due to so many people having been deployed multiple times. One thing we do know is the likelihood of PTSD increases with multiple deployments, although a significant emphasis on delivering good care may attenuate that prevalence,” Schnurr said, but added other factors also are being investigated. “It’s a complicated question because staying in the military may be a reflection that they are doing OK – if you are healthy, that may cause a selection bias.

“But we also know, from the current war, the more times people are deployed, the more likely they are to have PTSD. And in the majority of studies, it appears the longer you serve, the more likely you are to have PTSD or other problems. But it is very important to remember, if people have a choice and are struggling, they are less likely to re-enlist, so you may wind up with healthier people staying in.”

Despite a long list of questions still to be resolved about PTSD, the medical community has had an opportunity to test multiple treatment approaches – and now is beginning to apply advanced technologies with which those who have served in the past 20 years or so may be familiar from their training programs.

“There are several treatments considered effective for PTSD, one of the best of which is exposure therapy,” Greg Reger, acting chief of T2’s Innovative Technology Applications Division, reported. “The concept is simple – when we do things that make us anxious, the more we do them, the easier it gets. As that relates to PTSD, we ask service members to confront the memory of the traumatic event or events. Historically, they sit down with a provider, close their eyes, revisit that memory, and then tell it. When they finish the story, they do it again, ideally for 10 to 12 sessions.

“The first time, it is an uncomfortable thing because they are revisiting probably the worst thing that has ever happened to them. But once they have done that over and over again, the discomfort associated with that memory, the anxiety, decreases. That’s how we are wired as humans – when we do something for long periods of time and are not harmed by it, the fear associated with it decreases.”

However, Reger, a former active duty Army psychologist who deployed to Iraq with a combat stress control unit, said further studies showed individuals with combat-related PTSD did not benefit as much from that treatment as those with other forms of trauma, such as sexual attack or a car accident. And the major explanation is something families of those returning from combat have witnessed for centuries, something Reger experienced in Iraq.

“When guys go downrange, whether in a low- or high-stress deployment, to get through it you have to emotionally detach, disengage. You can’t feel the depth of each experience moment-to-moment and do very well during a long deployment. But as a result, they can come home with that emotional disengagement still in place and, when talking about their PTSD trauma, tell it with no emotional involvement,” he explained. “Research has shown when those with a high degree of emotional involvement tell their story, they are anxious and benefit more from exposure therapy than those who are emotionally disengaged.

“So we help them emotionally engage with that memory, using virtual reality. With multi-sensory VR, involving sights, sounds, even scents relevant to the event while they are telling their story, we hypothesize we may get a higher degree of emotional engagement and, as a result, a high degree of outcome. The system we use was developed by the Institute for Creative Technologies at USC. It is grounded in really solid research on exposure therapy and, based on preliminary results, we have started treating patients in daily clinical practice and seen many improved in clinically meaningful ways.”

T2 is halfway through a four-year randomized clinical trial, comparing VR treatment to the prolonged exposure imaginal approach. Even if VR does prove more effective, however, whether it eventually becomes DoD’s treatment of choice for PTSD will depend on a number of factors.

“If you are going to ask the government to spend money on specialized computers and other hardware, it will need to be significantly better,” Reger acknowledged. “But even if it is just equally effective, more important is whether it is more appealing and less stigmatizing than traditional talk therapy. So the real return on investment may be servicemembers being more willing to use the VR treatment, which we believe they will.

“Exposure therapy is effective for a number of anxiety disorders, such as obsessive-compulsive. So the key question is: What are the capabilities of VR with respect to the clinical needs for a given disorder and what is the potential fit? There also are applications, for example, in the area of assessment, so we are partnering on a look at using VR as a cognitive assessment tool.”

Currently, if a servicemember is sent to a clinician to determine fitness for a certain type of duty, he or she is given a pencil-and-paper test in a very quiet, controlled environment. The results then are compared against the general population.

“That’s fine, but individuals react to stress differently and the impact of TBI on the ability to focus in a combat environment may not be best tested in that manner. So we are exploring the ability of VR to deliver cognitive assessment in a manner that tests reactions in an operational environment,” Reger said.

“So you might have an individual walking around a combat environment in VR and asked a realistic requirement they would be asked on a mission, involving cognitive skills that might be impacted by an injury. For example, in a pre-mission briefing, they are asked to attend to a list of items, then go into a combat area and are asked to recall and identify that list of threats.”

The future of such advanced technologies in mental health care – and more broadly across a spectrum of military and veteran services – is dependent not only on how those technologies evolve, the cost of implementing them, and clinical evidence that they work, but on the acceptance of health care providers.

“I can imagine, in 10 to 15 years, there will be a new generation of providers who look to innovative tools like VR as a much more commonplace part of their toolkit,” he said. “And that is likely due to a couple of factors – a growing body of evidence about effectiveness and, second, as we see from our soldiers today, they are a young and technologically savvy group who have integrated technology into their lives in ways older individuals have not. So I think the next generation of providers will look to these tools to incorporate into various treatment modalities.”

While it has gained considerable public attention in recent years, PTSD is only one of many mental health issues confronting DoD and the VA, with suicide ranking high on that list. As a result, the two agencies are working closely to improve early identification and treatment of those with suicidal tendencies and to more fully understand the actual prevalence within the military, what factors may lead a service member to commit suicide, and how the military compares to similar demographics of age, gender, and job stress in the civilian population.

“We are very interested in improving the transition between DoD and the VA in terms of medical care,” noted Nancy A. Skopp, a research psychologist and project manager in T2’s Research, Outcomes, Surveillance, and Evaluation Division. “We have data on actual suicides and on three classes of self-harm behaviors from 2004-2010 and are proposing to conduct a feasibility study with MIRECC [the VA’s Mental Illness Research Education and Clinical Centers] to establish a mechanism though which the VA can access this self-harm data. The primary goal is an attempt to match records, with the ultimate goal being to share the data.

“A history of suicidal behavior and attempts is one of the strongest predictors of future suicides, so if the VA has a history of previous self-harm behavior, that would be very helpful in flagging high-risk cases and facilitating treatment. Ultimately, we hope this project will lead to identification and clinician safety planning for high-risk veterans and reduce health care costs related to suicidal behavior through early management. It also should improve care for veterans seeking help through VA out-care clinics.”

T2 manages the DoD Suicide Event Report (DoDSER), a surveillance process and tool designed in collaboration with the services to automate data collection from all services worldwide for a comprehensive annual report. DoDSERs are required for all active duty and activated Guard and Reserve suicides, but the Army also collects data on unsuccessful suicide attempts and non-fatal events, such as self-harm without intent to die.

The joint DoD/VA Clinician Access to Soldier Suicide Information (CASSI) project links DoDSER nonfatal events to cases that later show up in the VA behavioral health system.

“Phase 2 of CASSI will characterize suicides and suicide attempts by age, gender, ethnicity, period of enlistment, MOS, rank at discharge, whether the individual had combat service – and, if so, when and where,” Skopp said. “From there, we hope to exploit the possibility of using the system to share data to help the VA identify high-risk veterans.”

In addition, a grant awarded to T2 by the U.S. Military Operational Medicine Research Program (MOMRP) Suicide Prevention and Counseling Research (SPCR) office involves an epidemiological study of suicide among the Operation Iraqi Freedom/Operation Enduring Freedom military cohort. The principal goals are to examine deployment as a risk factor and compare suicide rates across the services, Guard, Reserve, and among veterans.

“By capturing data across several years, we also will have information on veterans, from 2001 to present, as well as those people who did not deploy,” she added. “The majority of military suicides occur in the U.S., so one of the primary goals of the study we are about to conduct will look at whether deployment in and of itself impacts suicide rates – if there is a higher rate among those who did versus those who did not deploy.”

While current reports indicate the military suicide rate now may be close to the civilian rate, having previously been considered much lower than civilians, they also show both groups share a number of characteristics, with military suicides predominantly being younger, lower ranking, enlisted white males.

“The most difficult year to be in the Army is the first year – 60 percent of suicides occur in first-term soldiers,” according to Army Vice Chief of Staff Gen. Peter W. Chiarelli, who headed a task force on Army suicides, which he said has refocused the military on making the health of the force a priority. “I think our commanders are understanding that now. As we get deeper and deeper in this, the realization has come.”

The task force recommended increased resilience training for new recruits during basic training, tighter enlistment standards, establishing health promotion councils at each installation, expanding behavioral health screenings, and recruiting additional behavioral health counselors and chaplains. It also noted high-risk behaviors stemming from the stress and strain of almost a decade of persistent conflict – and gaps in identifying and dealing with those as leaders focused primarily on preparing for and engaging in combat.

“It’s hard to really know what is driving this increasing suicide rate, which is why there is a lot of DoD effort at every level and across all the services to address this issue and try to get a grasp on the scope of the problem, actively pursuing answers and putting preventative measures in place,” Skopp said.

“Deaths of undetermined intent is one of the questions we will study, looking at the numbers of those among both civilians and military. We suspect there are more among civilians, because two of the most common methods of suicide in the military are pretty clear-cut – firearms and hanging. So we expect it is more definite to identify a military suicide than in the civilian population.”

Meanwhile, DoD and the VA also are coordinating the results of routine mental health screenings performed by the military and, in some cases, by the VA. Those include a periodic annual health assessment, pre-deployment and post-deployment health assessments, and a post-deployment health re-assessment conducted 90 to 180 days after return. The last are where the VA has the most interface with the National Guard and Reserves, using positive results for mental health problems to immediately refer them into VA care.

The VA also has partnered with the National Institutes of Health to award $6 million in grants for research examining the link between substance abuse, military deployments, and combat-related trauma. A variety of studies will be conducted by academia and VA centers, examining when and why some veterans ask for help and others don’t, which treatment therapies seem most effective among both veterans and active duty personnel, if early intervention can improve outcomes, and how those returning from war readjust to work and family life.

“These research projects will give us important information about the ways that combat stress and substance abuse affect returning military personnel and their families,” Dr. Nora Volkow, director of the National Institute on Drug Abuse, said. “This knowledge will be used to improve our prevention and treatment approaches, which we hope will reduce the burden of combat-related trauma. Working cooperatively with VA and other partners will help in finding solutions for this shared concern.”

This article was first published in The Year in Veterans Affairs and Military Medicine: 2010-2011 Edition.