Transformation of Mental Health Care for U.S. Soldiers and Families During the Iraq and Afghanistan Wars: Where Science and Politics Intersect

Abstract

The cumulative strain of 14 years of war on service members, veterans, and their families, together with continuing global threats and the unique stresses of military service, are likely to be felt for years to come. Scientific as well as political factors have influenced how the military has addressed the mental health needs resulting from these wars. Two important differences between mental health care delivered during the Iraq and Afghanistan wars and previous wars are the degree to which research has directly informed care and the consolidated management of services. The U.S. Army Medical Command implemented programmatic changes to ensure delivery of high-quality standardized mental health services, including centralized workload management; consolidation of psychiatry, psychology, psychiatric nursing, and social work services under integrated behavioral health departments; creation of satellite mental health clinics embedded within brigade work areas; incorporation of mental health providers into primary care; routine mental health screening throughout soldiers' careers; standardization of clinical outcome measures; and improved services for family members. This transformation has been accompanied by reduction in psychiatric hospitalizations and improved continuity of care. Challenges remain, however, including continued underutilization of services by those most in need, problems with treatment of substance use disorders, overuse of opioid medications, concerns with the structure of care for chronic postdeployment (including postconcussion) symptoms, and ongoing questions concerning the causes of historically high suicide rates, efficacy of resilience training initiatives, and research priorities. It is critical to ensure that remaining gaps are addressed and that knowledge gained during these wars is retained and further evolved.

Delivering Clinical Practice Guideline–Concordant Care for PTSD and Major Depression in Military Treatment Facilities

“…Army providers saw a greater proportion of their patients in primary care settings than did Air Force and Navy providers. This finding may be attributable to extensive Army efforts to increase integration of PH and primary care (Hoge et al, 2015). Army providers' caseloads had more patients with PTSD, consistent with research showing that members of the Army are more likely than members of the Air Force and Navy to develop PTSD (Schell and Marshall, 2008).…”

“…We also provide an overview of how psychological care services are configured within the service branches. We do not describe the organization of PH care across the MHS in detail; this was not the focus of our project and has been addressed elsewhere (Department of Defense, 2014;Hoge et al, 2015;Quaadgras, Glasmeier, and Kaplan, 2016).…”

“…However, in 2010, the Army reorganized its staffing structure to deliver what it perceived to be more sustainable, cost-effective, standardized care to soldiers and their dependents. Army PH care is now provided through 12 structured programs with an integrated mix of PH personnel from diverse disciplinary backgrounds, including psychology, psychiatry, psychiatric nursing, and social work (Hoge et al, 2015). 1 At the installation level, each integrated PH department is supervised by a clinical chief.…”

“…The Army has undertaken the most extensive of these efforts. In Army primary care clinics, licensed PH providers provide support through expert consultations, clinical assessments, triage, and brief cognitive behavioral interventions (Hoge et al, 2015). Integrating PH in this way has improved access and continuity of care, as well as enhanced communication among primary care providers, PH providers, and unit leaders (Hoge et al, 2015).…”

Bridging Gaps in Mental Health Care: Lessons Learned from the Welcome Back Veterans Initiative

“…Given ongoing global threats and military activities, the stress of more than a decade of war, and long-standing issues with underutilization of mental health care, projections suggest that mental health care needs across these populations are likely to continue to increase in the coming years (Hoge et al, 2015). The current need for mental health care among these groups is well documented, and research continues to explore the complexities of these issues.…”