Another sad story in the press. There have been four more suicides at Fort Hood, Texas. Military suicide numbers keep climbing. The rates of depression, PTSD and suicide are reaching startling proportions among soldiers and veterans. New programs begun by the Department of Defense and the Veterans Administration are said to be designed to expand mental health care, and to make it more effective, palatable, and accessible to soldiers and veterans. They don't. As a psychiatrist employed by the VA who sees these broken soldiers on a daily basis, I find it infuriating and heartbreaking.
The new Mental Health programs, referred to by the Department of Defense as the acronym RESPECT-mil, and by the Veterans Administration as TIDES, are based on the Hamburger Helper model of health care. That is, if real care is too expensive, then dilute it with cheap care, fluff it up, advertise it well and make it look there is more there than there actually is. This brilliant new idea of the Veterans Administration and Department of Defense is intended to direct the psychiatric care of patients away from the people actually trained to provide this care, i.e., psychiatrists, psychologists, psychotherapists, and psychiatric nurse practitioners, and to place their care in the hands of less expensive people with weeks rather than years of training in mental health. This perspective includes the notion that mental health care is best provided away from stigma in the primary care setting, and that soldiers can be managed by primary care doctors helped by nurses with eight weekends of training to become what are called, "Champions."
The U.S. Government website says: "Welcome to the RESPECT-Mil Program. RESPECT-Mil stands for Re-Engineering Systems of Primary Care Treatment in the Military. It's a system of primary care designed to enhance the recognition and high-quality management of Post-Traumatic Stress Disorder (PTSD) and depression." It is in this opening statement that the intention to focus the treatment of mental health issues in primary care rather than the mental health clinic is noted.
The website goes on to state: "RESPECT-Mil is a treatment model designed by the United States Department of Defenses' Deployment Health Clinical Center (DHCC) to screen, assess and treat active duty Soldiers with depression and/or PTSD. This program is modeled directly after a program that's proven effective in treating civilian patients with depression."
Unfortunately, the evidence for this type of program being effective is some of the weakest data I have ever seen in my professional life. The evidence is derived almost entirely from a 2006 paper by psychologist Simon Gilbody and associates titled, "Collaborative Care for Depression" (Archives of Internal Medicine 166:2314-2312, 2006). This paper reviewed a series of studies of what is referred to in the "civilian" literature as the Collaborative Care for Depression Model. In this model, nurses are trained in roughly eight weekend training sessions to become "Depression Care Managers" or, in the military's more Pollyannaish term, "Champions." These Champions call regularly, report back to the primary care doctor, and if necessary, inform the primary care doctor that things are not going well and more help is needed. Admittedly, these are all good things. I was, however, astonished to hear at a Veterans Administration conference for the related TIDES program, that these Champions are also expected to advise the doctors as to when and if medication should be adjusted.
In Gilbody's paper, 35 studies in which the Collaborative Care model was compared against "standard care" in the primary care setting were reviewed. What is so disturbing and completely unacceptable about these studies, and Gilbody's paper, is that "standard care" in the primary care setting was never described. In fact, it was admitted that "standard care" varied from place to place, from fairly good care in some sites to virtually no care in other clinics. In Gilbody's meta analysis, the Collaborative Care model faired quite well against "standard care." Unfortunately, due to the lack of definition of "standard care," all that can really be said about the Collaborative Care model that the Department of Defense and the Veterans Administration has sunk it's hopes and resources into, is that it is almost certainly better than nothing!
The Collaborative Care model has not been compared against the mental health care provided by trained mental health professionals in mental health clinics. I do believe that contact and communication from "Champions" can be very supportive and beneficial to soldiers and veterans. However, this would be if it were in addition to competent mental health care, not in lieu of it! I have heard the argument that "specialty" behavioral health, i.e., real mental health professionals, is still available in the system. However, I believe that if the money being devoted to RESPECT-mil and TIDES were diverted to hiring real mental health professionals, there might be a better chance of actually improving things.
Finally, the addition of the new, highly touted, "Resiliency Training" as a method to avert depression, PTSD and suicide completes the recipe for inadequacy, incompetence, and disaster in the treatment of mentally ill soldiers and veterans. The 10 hour course on resiliency is taught by "Master Trainers" who themselves are soldiers who have had 10 days of training to become skilled enough to encourage resiliency and strength, and to prevent suicide in their charges. What are these people thinking?
The Department of Defense and the Veterans Administration need to take steps now to hire a sufficient number of competent, well trained mental health professionals, not Champions or cheerleaders, to treat the soldiers and veterans now suffering from military related illnesses. These must include psychiatrists, psychologists, psychotherapists and psychiatric nurse practitioners. There are no shortcuts. As a psychiatrist who sees and treats our veterans of World War II, Korea, and Vietnam on a daily basis, I can guarantee you that this problem will not go away any time soon.