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SAMHSA’s Award-Winning Newsletter
September/October 2008, Volume 16, Number 5 

Returning Veterans and Behavioral Health

Major General Mark Graham and his wife Carol Graham knew their son Kevin had received treatment for depression. A senior ROTC cadet, Kevin had always been a top student in good physical condition. “In hindsight, we didn’t see the warning signs—we thought he would just get over it,” said Mrs. Graham.

Without a doctor’s guidance, however, Kevin had stopped taking his medication because he feared being stigmatized at an ROTC summer camp he was selected to attend. With his depression untreated, he never arrived at the camp. Instead, he took his own life in his college apartment. (To read the Graham family’s story, see Commitment to Suicide Prevention, Mental Health.)

General and Mrs. Graham spoke at the opening plenary session of “Paving the Road Home,” SAMHSA’s Second National Behavioral Health Conference on Returning Veterans and Their Families, in Bethesda, MD, on August 11.

General Graham, who commands the Army’s Division West and Fort Carson in Colorado, and Mrs. Graham, who works at the national level to raise suicide awareness, brought their message to a capacity audience of 500 behavioral health care providers, officials at all levels of Government, and veterans’ organization representatives from across the country.

In addition, at more than 50 Internet conference sites, a nationwide audience simultaneously watched via Webcast.

General Graham said that depression is insufficiently recognized, a factor that contributed to Kevin’s death. He warned that the same lack of recognition could endanger many of the 800,000 veterans who have returned home from Iraq and Afghanistan, as well as service members on active duty. Why? Because depression and other behavioral health issues—including post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), substance abuse, and suicide—are risks to all who serve in combat zones.

The need to recognize and help veterans recover from these “unseen wounds” that they may have suffered during their service was the major theme of “Paving the Road Home.”

Aiming at Change

“We need to put psychological injuries on par with physical injuries, a task that requires transforming the culture of the military,” said Brigadier General Loree Sutton, M.D., Special Assistant to the Assistant Secretary of Defense for Health Affairs.

Of the more than 325,000 returned Iraq and Afghanistan veterans who have been seen at U.S. Department of Veterans Affairs (VA) health facilities, 39 percent have mental health diagnoses, including nearly 68,000 with PTSD and an equal number with TBI, said Ira Katz, M.D., Ph.D., Deputy Chief Patient Care Services Officer for the Mental Health Office at the VA.

In 2007, furthermore, about 2,000 active duty service members attempted suicide and 121 succeeded in taking their own lives, the highest number since tracking began in 1980, according to A. Kathryn Power, M.Ed., Director of SAMHSA’s Center for Mental Health Services.

Educating About Trauma

In the conference keynote address, Ms. Power emphasized the importance of educating both the military and civilian communities, as well as providers, about the true nature and effects of trauma. “The experience of trauma is not a disease but a public health issue,” she explained.

In recent years, SAMHSA has worked to elevate the visibility of trauma and is providing tools for understanding and dealing with its effects, she added, noting that many more models for trauma care exist now than even 10 years ago. The need for trauma awareness and trauma-informed care, which incorporate knowledge about trauma and minimize retraumatization, is especially central in dealing with today’s veterans, Ms. Power said.

The long and repeated deployments to conflict areas lacking clear front lines expose service members to trauma and extreme stress, and exacerbate the risk of mental health and adjustment issues among both service members and returning veterans. Service members may also suffer military sexual trauma arising from violence and harassment. Ms. Power added that between 13 and 30 percent of female service members suffered rape, which often goes unreported.

Normal reactions to trauma vary widely among individuals, Ms. Power said. Many people show resilience, but responses such as PTSD, depression, anxiety, and suicidal thoughts are common. These are not signs of underlying mental illness, Ms. Power emphasized, but rather results of traumatic experience. A third of the 1.64 million individuals who have deployed in the current conflicts have suffered from depression, PTSD, or TBI, she noted. Substance abuse is highly comorbid with these conditions.

“The range of efforts underway to help shows that assisting veterans as they return home involves preparing our communities to do more than have parades and release confetti. We must not only celebrate service but facilitate reintegration,” said H. Westley Clark, M.D., J.D., M.P.H., Director of SAMHSA’s Center for Substance Abuse Treatment (CSAT).

Recovery is not only possible, but highly likely with appropriate help, Dr. Clark said. Treatment for trauma’s effects is improving, and large clinical trials are coming that will evaluate treatment methods.

Although many individuals experience post-traumatic growth as positive changes take hold, he said, only half of service members or veterans who need help actually obtain it.

Building Partnerships

In addition to raising awareness, another conference goal was to build partnerships among the broad range of agencies and organizations serving veterans. One example, cited by Dr. Katz, is the SAMHSA–VA collaboration on the veterans suicide helpline, which has received over 60,000 calls, 30,000 of them from veterans themselves, since its launch in July 2007 (see SAMHSA News online, July/August 2008). “It’s a major success,” Dr. Katz said.

Dr. Katz mentioned a new Uniform Mental Health Services Handbook projected for publication by the end of 2009. The VA handbook will define which services must be provided and will give guidance on methods of addressing service gaps caused by distance and other factors, he said. Approaches include increased use of both telemental health and community services.

The U.S. Department of Defense (DoD) will also, as part of its transformation initiative, soon launch a major public information campaign on mental health emphasizing recovery and reintegration, General Sutton said.

Building on Strength

“Service members have a very strong identification with strength,” said plenary speaker Marine Sergeant Dan Taslitz, who suffered accidental brain injury in Iraq from carbon monoxide after Marine combat and reconnaissance service. “My identity was shattered. I was no longer a strong athlete and leader,” Mr. Taslitz explained. But resilience was a strong element in his recovery. “It opens the door to support,” he added.

“The Army’s new guidance is to make it a sign of strength, not weakness, to come forward to seek mental health care,” General Graham said.

He is working with his officers and noncommissioned officers at Fort Carson to create a healthy climate where soldiers will seek help without fear that it could hurt their careers. The number of individuals at Fort Carson coming forward for help has increased, he said. “We believe we are on the right track.”

Policy Academy Convenes

Following the public conference day, SAMHSA convened a 2-day Policy Academy for teams from nine states and one territory.

By invitation after a brief competition nationwide, those included Florida, Massachusetts, New Hampshire, New York, North Carolina, Oklahoma, South Carolina, Utah, and Washington, as well as American Samoa.

Team members represented state governments, mental health and substance abuse providers, veterans and faith-based organizations, and family members.

Their goal? A seamless system of care for returning veterans and their families in their home states. A list of challenges to helping veterans included plans for employment, universal health coverage, community coalitions, and support for children and families.

Recommendations from the Policy Academy will be available within 60 days. State plans will be reviewed by SAMHSA, the DoD, and the VA.

For more information as it becomes available on the Policy Academy. For a comprehensive list of resources for returning veterans and their families, see Resources for Veterans.


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SAMHSA recently announced grant awards for programs related to children's mental health, suicide, drug-free communities, and others.

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