And other disillusioning findings from a new RAND report.
Sean Locke / Stocksy
In 2012, the Pentagon commissioned the RAND Corporation, a nonprofit think tank, to regularly evaluate the treatment that service members with post-traumatic stress disorder (PTSD) and depression receive from the Military Health System (MHS). RAND's latest analysis, which looked at the outcomes of more than 38,000 active duty members treated from 2013 to 2014, offers both good and bad news.
On the bright side, the overwhelming majority of these patients were screened for their risk of suicide and substance use during their first visit (90 percent were), and most received some amount of treatment, whether it was therapy or medication. Service members hospitalized for PTSD or depression also nearly always received follow-up care from their doctors within 30 days of being discharged (the rate was about 95 percent for both conditions).
But there were also major gaps in treatment for some of the most at-risk people. Only 25 percent of people with depression received proper follow-up care in the eight weeks after their initial diagnosis, while the same could be said of 35 percent of PTSD patients. The authors defined adequate care as at least four psychotherapy visits or two medication management visits in that eight-week period. Less than half of people were assessed for the severity of their symptoms using a standard measure, the report found.
Those identified to be at risk of suicide were often left behind, the report says: 54 percent of people with PTSD and suicidal ideation received appropriate follow-up care and only 30 percent of people with depression and suicidal ideation. In general, patients with PTSD received better care and screening than those with depression.
Not all service members with PTSD or depression received the recommended initial and follow-up treatment
The report is one of the largest evaluations of mental health care in the military, according to Kimberly Hepner, one of RAND's senior behavioral scientists and lead researcher on the study, and it indicates areas for improvement. "The military health system did quite well in screening for suicide risk," Hepner told military news service Stars and Stripes. "Where we found they could do better was how the providers responded to service members with suicide risk identified."
As she told USA Today, "The most immediate action—removal of firearms—can help to reduce risk of suicide attempts." She said suicide death by firearms is the most common method, so "the provider needs to have that discussion about access to firearms. Not only their service weapon but their access to personal weapons."
Other gaps in the system included the type of treatment service members got, with less than half receiving evidence-based forms of therapy—meaning types that research suggests will help with their condition. Forty-five percent of PTSD patients received evidence-based psychotherapy and, of the people with depression who got therapy, 30 percent received cognitive behavioral therapy, which is shown to be effective for depression.
A variety of factors influenced the quality of care patients got, like region, pay grade, age, race, and even which branch of the military they belonged to. Similarly, service members often saw upwards of a dozen different medical providers during their year of treatment, indicating that many have to wade through a confusing maze of doctors. That sort of exhaustion could in turn discourage people from sticking to their treatment plans, the report said.
The researchers also found that a third of people with PTSD received at least one prescription for benzodiazepines, a class of anti-anxiety drugs including Ativan, Xanax, and Valium. This despite the fact that clinical guidelines say they might be harmful for people with PTSD, Hepner said, and even the Department of Veterans Affairs (VA) and Department of Defense's own practice guidelines for PTSD recommend against their use. One 2015 meta-analysis found that benzodiazepines can prolong or worsen PTSD. Not only are benzos not shown to work for PTSD, but they can be habit-forming and can be lethal when mixed with alcohol or with opioid painkillers. And about half of the service members in the study were prescribed opioids. Hepner said the rates of benzo prescriptions among people with PTSD were similar to those from 2012 to 2013, aka not much progress.
The rate of mental disorders like PTSD and depression has long been shown to be higher among people in the military than their civilian peers. A 2014 study in JAMA Psychiatry, for instance, found that a quarter of non-deployed active duty soldiers fit the criteria for a mental disorder, compared to 11.6 percent in the civilian sample, and the suicide rate has continued to climb since the days of the Iraq War, in some months even eclipsing the number of deaths from combat. Last year, the VA reported that an average of 20 veterans died by suicide every day in 2014; although vets only comprised 8.5 percent of the adult population that year, they accounted for 18 percent of suicides nationwide.
For all the gloom though, the RAND report does note that service members received slightly better care from 2013 to 2014 than the previous study period. The authors also offered a detailed list of recommendations to improve the military's mental health care system, from better tracking of the medications patients are given, since more than half are prescribed four or more, to implementing an "enterprise-wide" system that can measure how well specific centers are performing in following up with their patients.
"The report findings and recommendations are being reviewed and will be used to shape our future direction to ensure we are improving patient care," Pentagon spokeswoman Laura Ochoa, told USA Today. "We remain committed to providing the best quality mental health care to our patients. We will also continue to make the necessary adjustments and improvements to help those afflicted fully recover."