Mental Health Issues and Military Personnel Returning from Combat Operations: Current Knowledge, Research and Community

1. Mental Health Issues and Military Personnel Returning from Combat Operations: Current Knowledge, Research and Community Opportunities Presented to The Frederick County Legislative Breakfast November 6, 2009 Robert A. Mays, Jr., Ph.D., MSW Colonel, U.S. Army (Retired) Chief, Office of Rural Mental Health Research National Institute of Mental Health National Institutes of Health Department of Health and Human Services

2. Attribution Statement: The comments which follow are my own and are in no way intended to reflect official policy of the United States Federal Government, other than those related to my functions and official duties as an employee of the United States Federal Government. Financial Disclosure Statement: I am not receiving any type of compensation for this activity, other than my compensation as an employee of the United States Federal Government.

3. Overview Purpose and Process Definition of Terms Process Desired Outcomes Questions/Comments

4. Purpose Disseminate information about mental health issues in the five stage model of deployment for combat operations; Gather information pertinent to the mission of NIMH; and Stimulate the collaborative relationship between NIMH and the community partners of Frederick County, Maryland ============================================= Improve the Quality Of Life (QOL) of the Nation’s Total Military Family -

5. Desired Outcomes: • The dissemination of information about mental health issues in the stages of deployment for combat operations which contribute to high quality local service delivery; • The receipt of data and information which helps NIMH refine it’s research portfolio and produce meaningful findings; • An enhanced collaborative relationship between NIMH and the community partners of Frederick County, Maryland ============================================= Actions which improve the Quality Of Life of the Nation’s Total Military Family

6. Definition of Terms Mental Health: a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and cope with adversity. Mental Health Problems: instances where the negative signs and symptoms of mental function are of insignificant intensity or duration to meet the diagnostic criteria of any mental disorder. Mental Disorders: health conditions that are characterized by alterations in thinking, mood, or behaviors (or combinations thereof), over as specified period of time. Mental Illness: a term that refers collectively to all diagnosable mental disorders. (Mental Health: A Report of the Surgeon General,1999, pp., 4-5)

7. Definition of Terms (Cont’d) Behavioral Health: pertaining to mental health or substance abuse. “The self-actuated activities which prevent, reduce, mitigate, or eliminate negative health outcomes.” (Mays) Disparities: conditions or a fact of being unequal, as in age, rank, or degree. Synonyms are inequality, unlikeness, disproportionate and difference. The term is often associated with “equity”. Issues: “The act or an instance of flowing, passing, or giving out” (in this instance, on matters pertaining to military service in general and combat operations, specifically).

8. Stages of Deployment – “Time” • Pre-deployment (varies) • Deployment (1st month) • Sustainment (months 2 thru ??) • Re-deployment (last month of assignment) • Post-deployment (3-6 months after deployment)

9. Mental and Behavioral Health Themes/Issues Based on my military clinical practice and leadership education, deployment experiences, and literature review I note that there are topics or issues which throughout history appear to be recurring themes presented by military personnel returning “home” from combat operations. • These “themes” or issues can be categorized as a “hierarchy of needs” and they could serve as a guide for services providers. • Using Maslow’s paradigm as a model the themes are arrayed with the bottom “need” requiring satisfaction before proceeding up to the next level.

11. IssuesAfter the Homecoming Event “Returning” Reunion Re-entry Reintegration Remorse Regret Reflection Reconditioning Reconstitution RESILIENCY Re-enlistment Reconciliation Respect Rehabilitation Recovery Revenge Restitution Replacement REDEPLOYMENT

13. U.S. Army Mental Health Support Doctrine

14. Overview of Stress Management The prevention of war related stress traces its roots to antiquity and it has been addressed in numerous ways by a variety of cultures. The practitioners, students, and casualties of war have noted that during the activities of war: Stress causes physiological and behavioral responses. Humans react differently when exposed to the same situation. Distress/fear in the face of a threat-to-life situation is normal. Repeated prolonged exposure to threat-to-life situations appear to produce debilitating physical and emotional conditions. Certain pre-exposure activities that are introspective or altered states of consciousness (e.g. prayer, chanting, drugs, and establishing resolve and camaraderie), appear to mitigate the effects of stress during a threat-to-life event for some unspecified period of time.

16. Buy-In and Traction of Combat Stress Prevention American Civil War – fierce intermittent battles (Soldier’s Disease) WWI – periods of prolonged bombardment (Shell Shock) Fitness for Duty (psychiatric screening, aptitude testing, and separations) WWII - fierce intermittent battles, sustained contact, with major civilian casualties; with evacuation in echelons of care (Battle Fatigue) (NIMH established in 1946) UN Police Action – Korea fierce intermittent battles, sustained contact, and major civilian casualties; with evacuation in echelons of care (Battle Fatigue/Combat Fatigue)

17. Buy-In and Traction of Combat Stress Prevention (Cont’d) Viet Nam – fierce intermittent battles; hyper-vigilance for surprise attacks, ambushes, lethal and maiming booby traps; psychological warfare with addictive drugs to induce apathy/unit dissention; evacuation in echelons of care (PTSD). ============================================================ Introduction of Combat Stress Control Doctrine (1990) Operations Desert/ Desert Storm (Gulf War Syndrome ??) 1990-1991 Operation Joint Endeavor (Bosnia) December1995 Operation Enduring Freedom (OEF-A, P, HOA, and TS) – GWOT OCT 2001 Operation Iraqi Freedom (OIF) March 2003

18. Organizational Climate Change Affecting Reduction of Mental Health Stigma : 1960s - 1970s National Focus on Civil Rights and Equal Rights; 1970s - 1980s VOLAR (recruit soldiers and retain families) Deglamorization of Alcohol Suicide Prevention Prevention of Family Violence 1980s - 1990s Congressional Legislation and DoD Directives on Equal Rights (Mental Health Evaluations; Whistle-Blower Protection; POSH; Fraternization; Women in Combat; Don’t Ask Don’t Tell; Victim Assistance) Shift from Forward Military Presence to Force Projection (Modularity) (i.e. drug interdictions, peacekeeping, humanitarian missions, and disaster relief) (Modularity): Right amount of assets in the right place at the right time; with the remainder of the unit ready to reinforce or deploy to another location

19. Buy-In and Traction of Combat Stress Prevention To be deployed on an operation: the unit must be mission essential, self-contained and self-sufficient, light in weight, with few personnel Rationale: Combat Stress Control Doctrine (during a military operation conserve the fighting strength and be a force multiplier through): 1. Command Consultation/Liaison (preventive advice, education, screening, surveys, return to duty coordination, staff planning, area presence for immediate response ). 2. Reconstitution Support (restore well-being, integrate replacements) 3. Neuropsychiatric Triage (sort fatigue and NP) using BICEPS/PIES 4. Restoration (1-3 days) 5. Reconditioning (7-21 days) 6. Stabilization (to duty or evacuation)

20. Combat Stress Control Approval Process (Traction) Chief of Staff Army (Approve/Disapprove) CG, Training & Doctrine CG, Logistics Center The Surgeon General General Officer Steering Committee Council of Colonels System Integration Panel Systems Panel (Functional User Input)

21. Original Army Active Duty Medical Detachments (CS) 83rd MED DET (CSC) Fort Campbell 84th MED DET (CSC) Fort Carson 85th MED DET (CSC) Fort Hood 98th MED DET (CSC) Fort Lewis 528th MED DET (CSC) Fort Bragg 616th MED Co (CSC) Fort Gordon

22. The Lineage of Veteran’s Issue

23. The practice of war-time military bonuses began in 1776, as payment for the difference between what a soldier earned and what he could have earned had he not enlisted. • Before World War One, the soldier's military service bonus (adjusted for rank) was land and money — a Continental Army private received 100 acres and $80.00 at war's end while a Maj. Gen. received 1,100 acres. • In 1855, Congress increased the land-grant minimum to 160 acres and reduced the eligibility requirements to fourteen days of military service, or one battle; and the bonus also applied to veterans of any Indian war. • Breaking with tradition, the veterans of the Spanish-American War did not receive a bonus. • After World War One, not receiving a military service bonus became a political matter when WWI veterans received only a $60 bonus. • In 1919, the American Legion was created, and led a political movement for an additional bonus.

24. Lineage (Cont’d) • In 1924, over-riding the President’s veto, Congress legislated compensation for veterans to recognize their war-time service: with a dollar for each day of domestic service, to a maximum of $500; and $1.25 for each day of overseas service, to a maximum of $625. • Amounts owed of $50 or less were immediately paid; greater sums were issued as certificates of service maturing in 20 years (1945). • The Veterans Administration, also called the VA, is established July 21, 1930, to consolidate and coordinate government activities affecting war veterans.

25. Lineage (Cont’d) • Approximately 3,662,374 military service certificates were issued, with a face value of $3.638 billion. • Congress established a trust fund to receive 20 annual payments of $112 million that, with interest, would finance the $3.638 billion dollars owed to the veterans in 1945. • Meanwhile, veterans could borrow up to 22.5% of the certificate's face value from the fund. In 1931, because of the Great Depression, Congress increased the loan value to 50 per cent of the certificate's face value; yet, by April 1932, loans amounting to $1.248 billion dollars had been paid, leaving a $2.36-billion-dollar deficit. • Although there was Congressional support for the immediate redemption (payment) of the military service certificates, there was also opposition because it would negatively affect the Federal Government's budget and Depression-relief programs. • Meanwhile, veterans organizations pressed the Federal Government to allow the early redemption of their military service certificates and rallied as a “Bonus Army” in Washington D.C., to express their concern.

26. Lineage (Cont’d) • The “Bonus Army” massed at the United States Capitol on June 17 , 1932 as the U.S. Senate voted on the Patman Bonus Bill, which would have moved forward the date when World War I veterans received a cash bonus. • Most of the Bonus Army camped in a Hooverville on the Anacostia Flats, then a swampy, muddy area across the Anacostia River from the federal core of Washington. The camps, built from materials scavenged from a nearby rubbish dump, were tightly controlled by the veterans with streets laid out, sanitation facilities built and parades held daily. • To live in the camps, veterans were required to register and prove they had been honorably discharged. The protesters had hoped that they could convince Congress to make payments that would be granted to veterans immediately, which would have provided relief for the marchers who were unemployed due to the Depression. • The bill passed the House of Representatives (211 to 176) on June 15, 1932 , but was blocked in the Senate by a vote of 62 to 16.

27. Lineage (Cont’d) • Some veterans accepted an offer of free transportation home while others remained to press their case, and tension continued to escalate. • On 28 July, 1932, the Attorney General ordered the police evacuation of the Bonus Army veterans, who resisted by throwing objects and injuring several police; the police shot at them, and killed two Bonus Army members. • When told of the killings, the President Hoover ordered the U.S. Army to effect the evacuation of the Bonus Army from Washington, D.C., without use of lethal force. • At 4:45 p.m., commanded by MG. Douglas MacArthur, the 12th Infantry Regiment, Fort Howard, Maryland, and the 3rd Cavalry Regiment, supported by six battle tanks commanded by Maj. George S. Patton, Fort Myer, Virginia, formed on Pennsylvania Avenue and began the expulsion.

28. Lineage (Cont’d) • After the cavalry charge, infantry, with fixed bayonets and adamsite gas, entered the Bonus Army camps, evicting veterans, families, and camp followers. The veterans fled across the Anacostia River, to their largest camp. • The President ordered the Army assault stopped, however, Gen. MacArthur—believing the assembly was a Communist attempt at overthrowing the U.S. Government—ignored the President and ordered an advance across the 11st Street bridge to the camp on the Anacostia Flats where three people were killed 54 people injured and 135 arrested.

29. Lineage (Con’t) • Following his election, President Franklin D. Roosevelt also did not want to pay the bonus early because of the impact on the U.S. Treasury. In March 1933, he issued an Executive Order allowing the enrollment of 25,000 veterans into the Civilian Conservation Corps, for work in forests. • When the veterans marched on Washington again in May 1933, the First Lady met with the veterans and she purportedly persuaded many of them to sign up for jobs making a roadway to the Florida Keys, which was to become the Overseas Highway, the southernmost portion of U.S. Route 1. • Unfortunately, the third-strongest hurricane ever measured, the September 2, 1935 Labor Day hurricane, occurred and the storm surge killed 258 veterans who were working on the Highway. • It is believed that newsreels of veterans giving their lives for a government that had taken them for granted, influenced public sentiment to the point that Congress could no longer afford to ignore it in an election year (1936). The President’s veto was overridden, making the bonus a reality.

30. Lineage (Cont’d) • Please visit www.vba.va.gov/VBA/ to obtain information on the following additional educational benefit programs administered by the VA:  • The Post-9/1l GI Bill • Montgomery GI Bill- Active Duty (MGIB-AD) • Montgomery GI Bill- Selected Reserve (MGIB-SR) • Reserve Educational Assistance Program (REAP) • Veterans Educational Assistance Program (VEAP) • Educational Assistance Test Program (Section 901) • Survivors' and Dependents' Educational Assistance Program (DEA) • National Call to Service Program

31. Lineage (Cont’d) • As a result of the Post 9/11 Veterans Educational Assistance Act of 2008 (Post 9/11 GI Bill), passed into law June 30, 2008, new educational benefits are available to employees who are veterans or dependents of active duty service members. The new bill, which went into effect on August 1, 2009, is the most comprehensive educational benefit package since the original GI Bill was signed into law in 1944. • Veterans and dependents of service members on active duty can avail themselves to educational opportunities and funding offered by the Department of Veterans Affairs (VA) to develop skills and knowledge that will benefit both the individual and the Department of Health and Human Services (HHS). With these benefits, veterans and eligible dependents may enroll in programs offered at colleges and universities, private career schools, and other institutions of learning without any direct cost to HHS. • The Post 9/11 GI Bill encompasses three general components that enhance education benefits for service members and veterans.

32. Lineage (Cont’d) The bill: • Creates a new veterans education benefits program for service members on active duty on or after September 10, 2001; • Increases veterans education benefits under the preexisting Montgomery GI Bill; and • Authorizes the Department of Defense (DoD) to develop a program that allows active duty service members to transfer education benefits to their dependents.   • The DoD administers transferability of GI benefits from service members on active duty to their dependents. Dependents of service members may visit the DoD website for further information. 

33. Lineage (cont’d) • On 25 October 1988, President Reagan signed legislation creating a new federal Cabinet-level Department of Veterans Affairs to replace the Veterans Administration effective 15 March 1989. • My internet research indicates that “in both its old and new forms, the VA drew its mission statement from an extract of President Abraham Lincoln'ssecond inaugural address: "...to care for him who shall have borne the battle, and for his widow and his orphan."

34. How is NIMH Addressing the Mental Health Issues of Returning Service Members?

35. Related Mission Focus: Research: Conduct mental health research that improves the quality of life across the continuum of the military life cycle for the diverse populations that comprise the total military family.

36. Examples of NIMH Targeted Research Content Posttraumatic Stress Disorder – the effects of trauma and threat-to-life events on military personnel, family members, and caregivers Suicide and suicide prevention - signs, symptoms and the validity/reliability of assessments Risk-taking and understanding, protective factors, and resiliency

37. Related Mission Focus (Cont’d) Capacity Building: • Educate and train today’s mental health researchers • Contribute to the knowledge base and create novel tools and instruments which meet the special needs of the military community • Assist in the preparation of the next generation of mental health investigators

38. Military PTSD and TBI NIH Staff Training in Extramural Programs Forum (12/2008) Lisa Jaycox, Ph.D., Rand Corp Terry Keane, Ph.D., NC-PTSD Dennis Charney, M.D., Dean Medical School Mt. Sinai Dean Kilpatrick, Ph.D., Medical School South Carolina Joel Scholten, M.D.,VA Poly-trauma Center, Tampa, FL Telepsychiatry and eMental Healthcare Meetings to: • Increase Access to Care • Improve Continuity of Care • Ensure Culturally Appropriate Care

39. Related Mission Focus: (Cont’d) Outreach and Dissemination: • Establish collaborative partnerships which produce efficient and effective mental health related products for the military community and which may also benefit the general public. • Provide valid, reliable, and useful information which addresses the mental health needs of the total military family. • Stimulate the rapid uptake of research-based information.

40. Recent Projects Related to Service Members and Veterans Research: • “Addressing the Mental Health Needs of Returning Combat Veterans in the Community “ (R01) • “Collaborative Study of Suicidality and Mental Health in the U.S. Army” Capacity Building: • 2nd Annual Trauma Spectrum Disorder Meeting: DCoE, VA, NIH (12/2009) • PTSD and TBI Forum for NIH Extramural Staff Training, NIH (12/2008) • Telemedicine to Increase Access to Specialized Mental Healthcare - Meetings Outreach & Dissemination: • Mental Health Courts and Incarceration issues (with former U.S. Surgeon General David Satcher and Judge Steven Leifman, 11th Judicial District, FL) • PTSD in Women Returning from Combat Mental Health Meeting (12/2008) (Society for Women’s Health Research, DoD, VA, NIMH & others)

41. Outreach and Dissemination Activities (Cont’d) Federal Collaboration on Health Disparities Research • Mental Health Science Group (Draft Action Plan) • (NIMH and SAMHSA Staff Co-Leads) National Partnership for Action to End Health Disparities (OMH, OS, DHHS and Federal Interagency Management Team) Department of Veteran Affairs (VA) Advisory Committee on Minority Veterans Meeting, November 2, 2006 “Mental Health Issues of Returning Veterans” - Legislative Breakfast hosted by Mental Health Association of Frederick County, Maryland November 6, 2009

42. Direct ORMHR and Military Related Partnerships Defense Center of Excellence for PTSD and TBI BG Lorre Sutton and staff Department of Veteran Affairs Lucretia McClenney Laurent Lehmann Joel Scholten National Center for Post Traumatic Stress Disorder Matthew Friedman and staff Uniformed Services University of the Health Sciences – Department of Psychiatry Bob Ursano and staff Walter Reed Army Medical Center – Dept of Social Work National Naval Medical Center – Behavioral Health Care Dept

43. Closing Comments

44. Clinical Considerations When Discussing Re-deployment Issues (Organizational Climate) Victimization of self or others: • Bullying, Hazing, or Harassment • Assault • Actual or perceived bias and discrimination • Abuse of Policies Resulting in “Unfairness” • Use of prescribed and unprescribed “medications”

45. What Can You Do ? • Acknowledge the service-members contribution • Welcome service members new to your community • Don’t confuse the service-member’s performance of duty with national policy • Be aware of referral points for support services , particularly for those veterans and families who are remote from military installations • Don’t forget the veterans from previous combat operations…

46. On-line Information Sources http://www.nlm.nih.gov/medlineplus/veteransandmilitaryhealth.html#cat26 http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-easy-to-read/index.shtml • Post-Traumatic Stress Disorder • What is post-traumatic stress disorder, or PTSD? • Who gets PTSD? • What causes PTSD? • How do I know if I have PTSD? • When does PTSD start? • How can I get better? • How PTSD Can Happen: Janet's Story • Facts About PTSD • Don't Hurt Yourself • Contact us to find out more about PTSD.

47. Summary Practice, Policy, or Research • What is the service-member’s need? • What “return” issue is the Service-member addressing?

48. IssuesAfter the Homecoming Event “Returning” Reunion Re-entry Reintegration Remorse Regret Reflection Reconditioning Reconstitution RESILIENCY Re-enlistment Reconciliation Respect Rehabilitation Recovery Revenge Restitution Replacement REDEPLOYMENT

49. Acknowledgements and NIMH Points of Contact: Thomas R. Insel, M.D. Director, NIMH Phillip S. Wang, M.D., PH.D Deputy Director, NIMH Robert Heinssen, Ph.D., ABPP Acting Director, DSIR, NIMH Pamela Y. Collins, M.D., M.P.H. Associate Director for Special Populations and Director OSP, ORMHR, and OGMH, NIMH -------------------------------------------------------------------------------------------------- Additional Acknowledgement (Brenda Mays, HOME)

50. Thank You Mental Health Association of Frederick County Maryland