24 January 2011

The future of the Army's suicide & PTSD problems

Part II: Where do we go from here?

A few days ago I told you what the Army's latest data says. Now I will tell you some things that people are looking at, what those things mean, and some options for getting the suicide and PTSD epidemics under control.

The first, most important piece of this puzzle, is a study out this month that assessed the effectiveness of mental health screening prior to their Iraq deployment. Screenings were conducted on three brigades, and three unscreened brigades served as the controls. There were 10,678 soldiers in the screened brigade, of those 347 were taking a psychiatric medication at the time of their screening.1 Of those on medications 74 (0.7%) were not cleared to deploy immediately and 96 (0.9%) received waivers to deploy on time. Among those not cleared for immediate deployment, 26 were delayed for 1-2 months to allow their medications to stabilize, 32 were not cleared for deployment because they were unlikely to stabilize quickly, and 16 were not cleared for deployment because of a psychotic or bipolar disorder diagnosis.

It is unfortunate that the catalogued mental health symptoms are not reported more granularly, for instance the demographic data of those who received care is not available. What is reported though is very promising. Screened brigades had 28.5% fewer soldiers presenting with 'combat operational stress reactions', 78.2% fewer with 'psychiatric-behavioral health disorders', 54.1% fewer with suicidal ideation, and had 68.7% fewer occupational duty restrictions (these results all had a p < 0.001). Screened brigades also had 55% fewer air evacuations for behavioral health reasons (p < 0.05) and 46.7% fewer presentations of parasuicidal behavior (though p > 0.05 due to very low instance rate). These results are nothing short of astounding. Let me explain what happened in addition to the initial screening I talked about above.

Beyond the 347 soldiers who were on medications at the time of the screening an additional 472 were, or had recently been, under the care of a behavioral health provider. These soldiers, as well as those who deployed with a mental health prescription, had their predeployment care coordinated and (more closely) surveilled. This included drawing up care management plans with their primary doctor and/or mental health provider prior to deployment, which allowed for much greater coordination with in-theater resources. It's worth noting in light of last week's data that none of these units included National Guard or Army Reserve soldiers.

Moving on, there are some other indications that better tactics are being developed for dealing with psychological stresses and traumas. After taking over command of Fort Carson in late 2007 Gen. Mark Graham (Gen. James Doty is now in command of Fort Carson) commissioned a study on the epidemiology of homicides at his post. He transferred the head chaplain, who blamed witches for the rising suicide rates, to Germany. He instituted training in relaxation and stress management techniques for all soldiers under his command. Most importantly he has solved one of the Army's key detection problems:
“That might be the single most important intervention Col. George did,” Kopp, [a] psychologist, said. “Anyone can bring a soldier to me for an evaluation, but one of the critical things to know is how a soldier has changed. With the command in place longer, there are people who can tell me that.”

The staggered replacement of commanders is also the key to breaking the mental health screening code of silence, George said.

Instead of relying only on soldiers to self-report ill effects of combat stress, the brigade devised a system that asks sergeants and other immediate commanders about their soldiers, too.

“If a captain knows one of his guys lost a friend or went through something hard, he can refer him for help,” George said.
These changes are getting results:
Since the 4th Brigade came home this spring, the Army has been tracking it and comparing it with a similar brigade at Fort Carson to see if the changes are effective. Carson officials won’t say which brigade is the comparison, but researchers at the Walter Reed Army Institute of Research say it is the 3rd Brigade, 4th Infantry Division, which spent 15 months in Iraq in 2007 and 2009.

The 4th Brigade had a higher number of casualties — 39 soldiers killed in action, versus 12 in the comparison brigade. The intense combat would seem to suggest more suicides and violent crimes. But that is not what the brigade is seeing.

The 4th Brigade had 50 percent more soldiers who screened positive for some kind of behavioral health issue, Fort Carson said, but 60 percent fewer soldiers who were treated in the local psychiatric hospital, Cedar Springs Hospital, for having suicidal or homicidal thoughts. That suggests more soldiers got help early, so fewer reached the point of desperation.
More plainly:
Fort Carson's acting commander, Brig. Gen. James Doty, said Wednesday the post's suicide rate was 31 per 100,000 in 2010, down from 49 per 100,000 in 2009.

In 2008, Fort Carson's rate was 66 per 100,000.
That is some of the stuff that is being done. Now lets talk about what more we can do.

As I brought up in my post about Canadian snipers and PTSD it seems likely that the Canadians are doing an excellent job selecting those most resistent to PTSD for service in their sniper units. PTSD (and other disorders attendant to psychological trauma) tend to affect a (sizeable) minority of soldiers, one study estimated the rate among OIF/OEF veterans to be between 6 and 13%. Perhaps we can find a way to detect this at-risk population ahead of time.

There is a growing amount of research into the physiology of PTSD. A lot of it requires expensive equipment and/or quite a bit of time to detect. Among measures like hippocampal volume or quantitating someone's startle response, there has been a long posited link between PTSD and the immune system. In short, it seems that people with PTSD have reduced immune function. Twenty years ago some researchers linked having a greater number of lymphocyte glucocorticoid receptors to an increased incidence of PTSD. A new paper goes one step further and finds higher receptor levels before deployment among soldiers who went on to suffer PTSD.

While this data is all correlative, any utility it may provide identifying those predisposed to PTSD (or other conditions) is worth musing on. Imagine this (early, prospective) data were to bear fruit: it would provide at least one way of identifying those most susceptible to psychological trauma. Combining a test that identifies a risk factor with ones similar to those in Canadian sniper selection would allow the Army to, at best, select the most resilient soldiers to carry the heaviest load and, at worst, allow those with substantially greater risk to serve in capacities that do not risk their future mental health.

Toward this end the Army Study To Assess Risk and Resillience in Service members (STARRS) study that began in 2008 will identify risk and protective factors related to soldier mental health. Unfortunately it won't be done until 2014. However, there is still plenty of room for success in the interim.

While these bright spots are certainly encouraging, things aren't rosy everywhere. Fort Hood just suffered its worst year for suicides and led the Army (it's also the largest Army post). The success I talked about at Fort Carson lets us make a broad comparison. While the Army has put a task force in place to try and stem the tide, Fort Carson's success was due in large part to Gen. Graham (one of whose sons died by suicide). Beyond funding studies and learning about PTSD, the Army task force needs to be scouring its posts for strategies that have shown promise and pushing their adoption, or at least developing methods to test them more rigorously. I understand that juggling the personnel rotation schedules as Gen. Graham did has its costs, but an informed decision needs to be made on whether the status quo should remain; sticking with the status quo is a decision, but it's not being made on an informed basis presently. Not to over dramatacize it, but the status quo has seen the Army suicide rate double in less than a decade.

There are small changes that can be made in every unit from a squad or a platoon to a battalion or brigade. The Army has had a long tradition of telling its soldiers what to do and letting them figure out the best way to do so. Unfortunately the nature of this particular problem doesn't lend to those fixes being apparent from the outside. I know that the good ship buracracy takes awhile to change course, which is why many of the solutions to this problem need to come from the bottom up. For instance the doctrinaire insistence that serious incident reports (SIRs) be submitted to command within two hours of the incident. Here's C.J. Grisham on his own experience:
When Soldiers are feeling suicidal and have the good sense to reach out for help, leaders have to understand that they may NOT be the ones they reach out to. Commands need to adjust their SOPs to account for this. Some leaders think that if a Soldier doesn’t call his squad leader or section leader at such a time of crisis first, the problem rests either with the Soldier or the leader. They will say that a good leader would have such a great and wonderful relationship with his troops that they would call them first when contemplating suicide or any other personal problem. It just doesn’t work that way.
Every saved soldier represents an opportunity for the entire Army to learn a lesson. Even if that lesson is simply understanding what it is like to be one of the suffering.

1 266 used antidepressants (mostly SSRIs), 108 used medications for chronic insomnia or sleep disturbances, 43 used stimulants for ADD/ADHD, 23 used benzodiazepines for chronic anxiety symptoms, 7 were on antipsychotics for psychotic disorders, 17 were on mood stabilizers for conditions other than bipolar disorder, and 9 used mood stabilizers for bipolar disorder. A total of 114 had prescriptions for two or more psycho- tropic medications.

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