Brought to you by the Depression Is Real Coalition, The Down & Up Show is dedicated to the reality of depression. Our hosts will talk with some of the world's top experts on depression, as well as people who have been impacted by this illness. The reality of depression is that it is a debilitating and potentially deadly medical condition that affects more than 15 million Americans every year. The other reality of depression is that there is hope.

Down & Up Show #04: Depression & Military Service

IAN VO DOWN & UP INTRO

The Down & Up Show on Depression Is Real.org. A talk show dedicated entirely to the subject of depression, and the reality that there is hope for people dealing with this disease. Now, your host, Dr. Ellen Frank.

DR. ELLEN FRANK INTROS COLONEL BOB IRELAND, PROGRAM DIRECTOR FOR MENTAL HEALTH POLICY, OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE

Welcome to the Down and Up Show on Depressionisreal.org. This week's episode is Depression in the Military. As the wars in Iraq and Afghanistan continue, more and more attention is being focused on the toll deployment may be taking on America's service members.

About 1.5 million troops have served in Iraq or Afghanistan. And some estimates say that 17 to 33 percent of those returning have mental health problems, such as post traumatic stress disorder or depression. Today we'll speak with Colonel Bob Ireland, Program Director for Mental Health Policy in the Office of the Assistant Secretary of Defense for Health Affairs.

Colonel Ireland will talk about how the military is addressing concerns about mental health of our men and women in uniform. His duties include coordination of Department of Defense mental health policy initiatives, chairing the DOD suicide prevention and risk reduction committee and co-chairing the Veterans Administration DOD Mental Health Work Group.

We're pleased to have him as our guest today to learn more about an issue that affects so many of our listeners, their families, and their communities.

DR. ELLEN FRANK / COLONEL BOB IRELAND

ELLEN FRANK QUESTION:
There continues to be criticism about mental health treatment in the military, especially for our returning veterans. In fact, last year at the Mental Health Task Force hearings you said that some senior leadership didn't consider treating emotional problems as priorities.

And in the report issued May 3rd, the Mental Health Task Force found that a significant stigma in which soldiers believed that they would be ridiculed or their careers would be damaged if they were to acknowledge having problems still existed. What is the military doing to change these attitudes?
BOB IRELAND ANSWER:
Well, clearly this has to be addressed on multiple levels. For most I would say professional education for military leaders, certainly choosing political leaders and appointees that are concerned about the mental health of folks is important. And also then integrating into professional military education at all levels for enlisted and officers modules that help them understand how to recognize and appreciate the significance of behavioral health symptoms that could reflect mental health conditions or disorders.

ELLEN FRANK QUESTION:
So what programs are in place to help military personnel recognize that they might have a problem and then receive treatment?

BOB IRELAND ANSWER:
The most pervasive program right now would probably be the suicide prevention initiatives that are undertaken by each of the branches, most of them go by similar initiatives, initiatives do include changing culture and making sure that leadership is aware of the things they can do and how they can take the lead and work with their component leaders to express in an unqualified way their support for folks taking care of themselves and always being in a state of readiness both physically and psychologically.

That's I think the key initiative. After that everything else follows, including things like briefings and these can be focused at various levels to senior leadership and then to the lowest level of enlisted folks coming in. It can be part of the integration of initial training into military culture. That's often done in the form of buddy care or wingman days.

It can be done in leadership training that's available not just in terms of what you go through let's say to be a senior NCO, but things like leaders guides for personnel in distress. And there's some excellent examples of those on the internet for the various branches. And these actually will go into such detail as they'll look at multiple types of scenarios where personnel in distress may manifest behaviors that should be of concern.

And so you'll go under let's say something like death in the family or legal problem or emergency family problem or abuse situation or victim of a crime, this type of thing and it will show the various behavioral, various behaviors that a leader might be concerned about what to be thinking about if they see those and the kinds of questions to ask and at what point to make a referral for more help and some sense of what level of help to whom to refer folks.

So those leaders guides for those who forget maybe what they learned in earlier training, whether it's at the service academies or in their initial in processing training and orientations or professional military education, if they forget it, a lot of this is right at their finger tips on CDs, even some branches have produced booklets of it or web based products that are always available.

So if they wake up in the middle of the night and there's a particular stressful situation they can go to the guide that sort of gives an example of that situation and tells the leader what to look out for, the supervisor, what to be aware of, what's important to do at each point and what's important to clarify, and what level of care to get based upon what they're seeing at the time.

ELLEN FRANK QUESTION:
Well, you know we find that even primary care doctors, internists, who are health professionals often have difficulty making a referral for mental health care. Why would we think that military leaders would be able to do this when physicians often can't do it?

BOB IRELAND ANSWER:
Physicians often can't do it because of the spectrum of time they have with a patient, you know if you're in a RVU (ph.) regulated environment inside or outside a health professional organization or if you have a high paced clinic and you have ten minutes with someone who comes in and has a focused problem let's say, then the opportunity for picking those up is not very good, is it?

But if you're living with someone eight to twelve to sixteen hours a day and you come to know them and their families that makes a difference. In fact, we've rolled out this spring a front line supervisor's course that talks about how to improve your ability to be a sensor for people in distress.

And one of the emphases made in that is that supervisors as opposed to spending most of their time in tracking spread sheets and technical details need to spend about 50 percent of their time getting to know their people and that you don't do that by not walking around asking the right kinds of questions, being sensitive to their responses and building a relationship.

So that's important and it enables us I think, at least within the structure of the lay structure to be much more sensitive sometimes in a brief encounter in the clinic, although our level of integration of mental health into primary care is increasing and we've had some success with that.
ELLEN FRANK QUESTION:
As we mentioned earlier the Military Task Force on Mental Health released a preliminary report earlier this month and it indicates that already strained troops are at greater risk of mental health problems because of repeated deployments to Iraq and Afghanistan. You were part of hearings that were held in support of the Task Force's work, are there concrete next steps for moving forward and improving care for veterans?

BOB IRELAND ANSWER:
Are you talking about people without DOD entitlements?

ELLEN FRANK QUESTION:
I guess we're talking primarily about people with DOD entitlements.

BOB IRELAND ANSWER:
Okay, then I'll talk about service members or let's say inactivated reserve or guard who still have six months of entitlements prior to having, yeah, they can use entitlements as soon as they're de-activated in the VA or with DOD for six months or VA without service connection for two years.

So it's sometimes important to be careful what we're talking about because if they're not living anywhere near a DOD facility then we have to talk about tri care and tri care remote, which takes care of folks who don't have folks in a network near them but still have specialists available. So if we're talking about folks who are still let's say active duty maybe, a regular in the military what do we do?

Okay. You're probably aware of some of the processes we have in terms of the post deployment cycle, five days before folks are returning, it used to be five days before or after, but five days before they return from theater they do go through a post deployment health assessment process.

This process involves a number of briefings on all kinds of matters related to their health and mental health. And it includes also an assessment form that has some É they're really more clinical screenings kinds of tools, but it has tools that we're applying to a population that's been exposed to potential traumatic events that we'll screen for various types of mental health symptoms and of varying sensitivity in terms of you know how many may end up with a final diagnosis.

But the bottom line is what it does is it enables everyone who will then be managed by a health care provider face to face, in private, an opportunity to review those things, those concerns that they've shared about their physical or mental health condition and then they provider will focus in on those things, they're checked off, and do a number of things.

They'll probably ask more questions related to what they checked and make a functional assessment as well and then make a decision on at what level of further evaluation or evaluation and treatment they should be aimed and referred. For some it may be that they don't have a lot of functional impairment or they really don't want to pursue further care, but rather treat it conservatively or see what happens when they get home, get better rested, get reconnected or they may want to talk to their chaplain or even local minister when they get home, this type of thing.

So there's sort of a dialogue that occurs with the health care provider, meeting every single person alone, in private, face to face, 100 percent of the folks coming out, to go over that and make a decision about how they'll proceed and when they'll proceed and under what basis they'll get further care if indicated.

Well, you know my own research, my own first research actually focused on post traumatic stress disorder, and so I've done a fair amount of reading about it, and it seems to me that each war in the 20th Century and now in the 21st has had its own form of post traumatic stress disorder that depending on the context of the battles we've seen different kinds of PTSD.

ELLEN FRANK QUESTION:
I know from my own practice that deployment can have a very large impact on family members left behind as well. Can you describe some of the resources that are available for spouses and children who might be suffering from depression or anxiety during a deployment?

BOB IRELAND ANSWER:
The Mental Health Self Assessment Program has recently added a new component, called the Signs of Suicide Program for Department of Defense schools. And this is a combination of some mental health training for kids and youth and duty middle and high schools. And it has some educational materials for parents and teachers to assist them, recognizing when folks are getting into trouble.

So that is one program that recently rolled out. There are other resources to tap on military one source. And I don't know if you've had a chance to play with that website, a lot of it's open without having to sign in as a military person, but there's a great deal of educational material, a great deal of material on working with kids and youth.

ELLEN FRANK QUESTION:
Could you tell our listeners again exactly what that website is?

BOB IRELAND ANSWER:
It's just type out www.militaryonesource.com.

ELLEN FRANK QUESTION:
Okay. Is there anything else you'd like our listeners who may be concerned about their loved ones serving in the military to know about their care?

BOB IRELAND ANSWER QUESTION:
Well, they're deployed most have embedded assets with them or nearby rotating to visit units on a regular basis. So there's a fair number of assets from all branches over there and there's joint efforts to cover areas that may be under-resourced. And so there's been a lot of adjustment as a result of some of the mental health advisory team reports to distribute adequate levels of mental health support care in theater.

So in terms of concerns of family and children members those kind of support systems are there, and fairly robust support including psychiatric support. There are increasing ways of being in touch with family members through e-mail and other mechanisms and more robust phone access. That is often helpful. And some would say it also sets up the dilemma where each could be experiencing the other's problems in a way that is unprecedented, which could in fact cause more of a stress on either side.

So there's certainly pluses and minuses to that, but I'm not sure anyone would ever propose detracting from the amount of communication that's occurring today.

ELLEN FRANK QUESTION:
No. Colonel Ireland thank you so much for speaking with us today. We want all of our listeners to know that mental health is as important as physical health and there is help available, including help for service members and their families.

ELLEN FRANK THANKS COLONEL BOB IRELAND AND WELCOMES CONGRESSMAN PATRICK KENNEDY BACK TO THE PROGRAM

Thank you Colonel Ireland. On Capitol Hill there is legislation pending on providing mental health benefits at the same level as benefits for physical care. Congressman Patrick Kennedy gives us an update.

PATRICK KENNEDY ANSWER:
We've got legislation for our veterans who are in the Guard and Reserve so that they have up to five years, not the initial two, to qualify for Post-Traumatic Stress Disorder. You know, frankly, I'd like to see it haÑbe open-ended. They ought to be able to qualify for as long as possible.

But, you know, initially it'sÑthe initial five years is what we've initially targeted, but we'd like to open it up further. But that's a first step and that's a bill we need to pass. And within that we also have included face-to-face interviews with every soldier in the Guard and Reserve coming back from Iraq because these soldiers, unlike the standing military, don't get the time to get debriefed adequately before they go back into civilian life.

And, hence, they don't reallyÑthey fill out these forms and a lot of em don't check off, you know, suffering from PTSD or something because they don't wanna be stigmatized or they know if they do, they'll be held back in the military, which means they're not gonna be able to go see their spouse and child who they've been held off from seeing for 13 months because Bush has over-extended their deployments four times.

We're working on a Psychological Kevlar Bill which is trying to get our soldiers in boot camp to understand that their mental resilience is as importance as their physical resilience.

And so that de-stigmatizes PTSD early on so that they know thatÑthatÑthat when they come home, that they don't have to feel ashamed of having these problems and try to not getÑseek treatment for them. Because we know that if they seek treatment early, they're better off in the long run.

So we've got a lot of issues that we're working on.

ELLEN FRANK RESPONSE:
It certainly sounds that way. I think every person in the United States who suffers from a mental illness, who has a family member that suffers from a mental illness, and every person who works in the mental health field is fortunate to have you in our Congress.

The stories of your personal experiences are invaluable and your efforts to relieve stigma and attachÑand achieve parity are greatly appreciated by every one of us.

DR. ELLEN FRANK OUTRO (Music up half way through)

For the Depression is Real Coalition, I'm Ellen Frank. Join us next week for another episode of the Down & Up Show on depressionisreal.org. [music]

IAN VO CLOSE

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