WASHINGTON, DC—Despite increased efforts by VA and DoD to increase mental health awareness, the rate of suicide among servicemembers continues to rise. In December 2009, the Army reported 17 suicides of active duty servicemembers. In January, the number of confirmed or suspected suicides in the Army was 27. Legislators who have oversight over VA healthcare called the numbers “troubling and sobering.”

Two years ago, the House VA Committee held hearings that revealed the disconnect soldiers experience in mental healthcare when transferring from active duty to veteran status and how it affects their ability to receive continuous care. A similar hearing held in March shows that the disconnect, to a smaller extent, still exists. Testimony showed that military and veteran health services are not lacking in proper clinical care, but that the problem lies in making contact with those patients who need the care, getting to them early enough in the progression, and keeping them engaged and invested in the long term.

Seeking Care and Failing

Daniel Hanson joined the US Marine Corps in January 2003. His deployment with the 2nd Battalion, 4th Marines in February 2004 to Ar-Ramadi, Iraq began with the suicide of one of the Marines in his company, and progressed to a point where funerals were “a regular thing,” he told legislators. By the end of his tour in October 2004, his company had lost 35 soldiers for varying causes. He redeployed a second time to Okinawa, and left the Marines after that tour.

”After I came back, we had a few classes on how people were dealing with things, but that was it,” Hanson explained. His post-deployment health assessment consisted of himself and the other soldiers he served with sitting in a large room and being asked if they had any problems dealing with what they saw in the field, and if they did to raise their hand.

“My primary MOS wasn’t infantry,” Hanson said. “I thought, ‘If those guys aren’t raising their hands, I have no right to raise my hand,’ whether I saw something or not.”

After coming back, two Marines he served with—one his best friend—committed suicide. Hansen began drinking more, struggled with depression, and divorced in August 2007. After receiving several DUIs, he went through the Dual Diagnosis Program at the St Cloud VAMC. The program was designed to treat patients diagnosed with mental illness and a substance abuse disorders.

“The program was informative, but it wasn’t very applicable to my life. I kind of felt like a number going through a revolving door,” Hanson said. “A month after going through the program, I attempted suicide. I woke up at the St Cloud VAMC in 72-hour lock-up.

“There was no accountability. Not too long after I attempted suicide, I was doing a once a week thing at the VAMC like everything was all right. But it wasn’t all right.” His depression, drinking, and suicidal thinking continued. A month after his last DUI, he checked into Minnesota Teen Challenge, a 12-to-15 month, faith-based rehab program, from which he recently graduated.

“I know if I went through a three month, six month, or even nine month program, it wouldn’t have worked. But 15 months is what I needed to be able to not just scratch the surface, but get down to the root issues [that] I was dealing with. I would be dead or in prison right now if I didn’t go to Minnesota Teen Challenge.”

Combating the Culture

Hanson’s experience is a complex one, but contains many of the problems that officials have identified with continuity of mental healthcare in DoD and VA. Most notably are the barriers inherent in military culture to acknowledging the need for help, and the fact that treatment needs to be plotted out over the long term.

“There are 18 deaths [by suicide] per day among America’s veterans, and approximately 5 per day among those getting active treatment from VA,” explained David Rudd, PhD, University of Utah dean of the College of Social and Behavioral Sciences. “Scientifically we know that there are a number of treatments and interventions proven effective for suicidality. The effective elements of these treatments are simple and straightforward, inspiring hope and recovery in a concrete fashion. Despite the availability of effective treatment, it is important to remember that not only will many of our veterans face acute problems, they will also continue to face chronic problems.”

But the first steps in dealing with the effects of combat need to come much earlier—when the military is training and preparing soldiers, and not during post-deployment. “Prolonged and repeated exposure to combat takes a significant toll. We’re still trying to understand the [mental] health consequences of killing,” Rudd explained. Soldiers need to be told beforehand that they will experience mental fall-out from their experiences and that seeking treatment afterwards is the natural and right thing to do. The idea of post-combat adjustment and the role that mental healthcare plays in that adjustment needs to be introduced to soldiers when they are still in training.

However, reframing the conversation is necessary to help today’s soldiers get over the stigma of mental healthcare. “Traditional mental health approaches talk almost exclusively in the language of illness, which is contrary to the very core of warrior mentality. For veterans, the notion of illness and disorder is synonymous with personal weakness,” Rudd explained. “We need to move away from this traditional pathology.”

“Telling someone they have a mental illness is not necessarily a compelling reason for someone to get care if they’re raised in an environment where [this is] seen as personal weakness. I think we have to do far more on the front end when they come into basic training and we have to talk to them about resilience. We need to think differently, not necessarily on the clinical end because we know what works clinically, but about how we talk about the problem.”

And in the meantime, VA needs to position itself in places where it can be of the most help to this newest generation of veterans. “VA needs to understand that they have an image as an unyielding and inflexible bureaucracy. They need to make partnerships.”

It is expected that in the next few years 500,000 veterans will be transferring onto college campuses. “I urge VA to partner with universities,” Rudd said. “We would certainly welcome such a partnership.”

Filling in the Gaps

VA officials contend that they have filled in many of the gaps that Hanson experienced when he was seeking care a year and a half ago, but that there is much more left to do.

“We have [now required] that everyone receiving mental healthcare have a principal mental health provider,” explained VA’s Deputy Mental Health Chief Antoinette Zeiss, PhD. “If they’re receiving multiple services [as Hansen was], they would have a core person that they could feel cared about him and knew him best and was the person to turn to to get a clear sense of how to integrate different elements of healthcare.”

VA has also rolled out more intensive mental healthcare programs across their system. “These programs are at least three hours a day, at least three days a week, with an interdisciplinary team working to deliver services,” Zeiss explained. “We have been trying to bolster many of the kinds of gaps that [Hanson] described. In addition, we completely agree with statements that we need to have partnerships—that we can’t do it alone. If there’s a level of care that VA isn’t able to provide in rural or urban settings, we should look at well-tested programs.”

According to VA Undersecretary for Health Dr Gerald Cross, the suicide rate for all veterans using VA healthcare has declined continuously for the last decade, and that VA is trying to provide veterans with as many routes to mental healthcare as possible, from its suicide hotline to its Vet Centers. “Sometimes [Vet Centers] provide an alternative venue, a different kind of feel. They’re focused on combat veterans being treated by combat veterans.

“But is there more that should be done? I always think there’s more that should be done.”

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