Good afternoon, everyone, and welcome. I'm Terri Brister, the National Director of Research, Support, and Education at NAMI, the National Alliance on Mental Illness, and also the SMI Advisor Patient and Family Engagement Expert. It's my pleasure to have you joining us this afternoon for today's SMI Advisor webinar, The Cultural Intersection of Depression, Trauma, and Suicide Risk Among Veterans and Service Members. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for all those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to help you care for your patients. Today's webinar has been designated for one AMA PRA category one credit for physicians, one continuing education credit for psychologists, and one continuing education credit for social workers. Content for participating in today's webinar will be available until July 3rd of 2021. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link and you'll be able to download the PDF while you watch the presentation. We want you to feel free to submit your questions throughout the presentation by typing them into the question area, also found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A, so please submit your questions there. And now it gives me great pleasure to introduce you to you today, the faculty for our webinar, Sherman Gilliams Jr., who I'm also proud to say is a colleague of mine at NAMI. Sherman is a retired U.S. Marine officer and former senior executive at Paralyzed Veterans of America and AMVETS, two of the largest congressionally chartered veteran service organizations in the country. For 17 years, he has fought to remove barriers to timely access to quality care and work to reduce unemployment and suicide among the nation's most vulnerable veterans, as well as military families and caregivers. He has testified on Capitol Hill, engaged at the White House on a host of issues, appeared on major networks such as CNN, Fox News, NPR, and C-SPAN, and in national print media as an influential voice on policy and government accountability. He was selected by Hill Vets as among the 100 most influential persons in 2016 and one of the mighty 25 military influencers by We Are the Mighty in 2020. Sherman currently serves as the chief strategy and operations officer at NAMI, the National Alliance on Mental Illness. Sherman, we want to thank you for leading today's webinar, and we're looking forward to your presentation. Thank you, Dr. Bristol, for that introduction. And I want to thank all of the attendees here for your interest in a topic that's not only near and dear to me, but has implications for the national security of our country. And I'll start with declaring that I have no financial relationships or conflicts of interest. And what you're seeing is a link to a video that will be available in the recording. I added here only to draw your attention to testimony I'd given in 2019 on the topic of how best to address the epidemic of veteran suicide. And a lot of the focus had a lot more to do with what the community at large can do than what the government can do, because what we've been doing up to that point hadn't been working. So a lot of what we'll talk about today draws from some of the work I did on Capitol Hill and at the White House, as Dr. Bristol mentioned, in trying to raise alarms about what we can do and what we had to do differently in terms of saving veterans, in many cases from themselves, but from the epidemic that suicide is right now. And I'm going to click past this only because this will be available to you, and I encourage you to watch it when the presentation is available online. During this presentation, I will focus on three critical aspects of military mental health that are central to the issues that many of you will face as you engage and treat those who served in uniform. One, we will closely examine what happens at the entry stage when these young men and women join the military, as well as why it's important to include what happened before they joined, particularly during childhood, and even what led to the decision to join the military service. You'll hear me use the term socio-military within that context, which I'll explain shortly. Two, we'll look at aspects of mental health and illness in service members that commonly get missed because of the esoteric nature of systems designed to ensure military readiness that have health implications but don't necessarily prioritize health and wellness among those who serve. And then lastly, we're living at a time when we have veterans from six different wartime eras, including peacetime. For the first time in our history, while they're all connected by military service, their needs do vastly differ as reflections of how the nature of warfare, society, medicine, and research have evolved over time. And by the end of this presentation, I hope that you'll come away with a better understanding of what makes veterans unique as a patient population, notwithstanding their fairly common diagnoses, depression being chief among them. I'll start with this concept of socio-military and why I use that term. It generally refers to the systemic study of the military as a social group rather than just a hierarchical organization with a traditional rank structure. But for this discussion, the term also involves the examination of civil-military relations or civil society as a whole and the military organization established to protect it. I find this important to consider given the tensions that often lie between youth mental health, how we recruit youth to serve, the social and military incentives to serve, the images we build around those who serve, and what happens when that identity breaks down. And that can all be traced to how society and our military, and this is my term, how it conspires to start and repeat a process that will predictably not end well for many. The term socio-military is a construct in reference to how we view and idealize the connection between individuals who join the military and society prior to their enlistment. Here's a photograph of me where I'm serving as a drill instructor, but this experience includes life as a recruit before I got to this point. And I bring that up because I've seen both sides of the hardship. The stress of military training is precisely intended to expose vulnerabilities that challenge and then ideally build adaptive defensive strategies in individuals who previously were not experiencing active symptoms of depression. While recruits with elevated rates of depression can develop adaptive strategies and experience symptom reduction through the course of basic training, this doesn't mean that those symptoms hide forever. They sometimes wait for the right moment to begin to show themselves and manifest. I'll point to one aspect of the problem that I'm going to constantly bring up throughout this presentation. Gathering data on the history of abuse in previous mental health treatment may be a useful adjunct for depression screening in primary care settings, particularly since it's often like looking for a needle in a haystack until one gets stuck with it. Many recruits, often with the prodding of their recruiters trying to make a quota, a training quota, may elect to omit information that could potentially bar these recruits from entering the military, which is why it's best to rely on screenings performed during basic training instead of those prior to induction, where we assume it's the most accurate information. Because boot camp was designed to be a process to weed out the weakest among them and push those who made it through to the front lines to defend our country. The change for them doesn't take place in combat, though. When they get inducted, they lose a few things well before that, a few of them being empathy, because that's what's required to have the emotional numbness to do their job in many cases, but also comfort and the penalties that come along with asking for help. So I want to begin with a conception here. Again, we're talking about socio-military conceptions. What is a veteran? Most people assume a veteran is simply someone who serve in uniform and or in combat. But there is a legal definition that's relevant to care providers because it often dictates access to health services. It also provides clues on what could be several socioeconomic factors that impact well-being for those under your care. A veteran is a former service member who was formally discharged from active duty with one of five types of discharges. Three of them are considered administrative. Two of them are considered punitive, being bad conduct and dishonorable. Now, why are those important? Because the type of discharge will determine whether a veteran meets the statutory definition of veteran. For example, a veteran could have many photos of himself in Afghanistan in combat decoration, but doesn't meet the statutory definition because he received a bad conduct discharge, for example, illicit substance abuse. Because he's not entitled to benefits by virtue of this discharge, he won't receive the level of treatment he needs, which may contribute to homelessness, joblessness, relationship problems, and unfortunately, suicide in too many cases. In fact, this veteran, quote-unquote veteran, won't even rate a military burial because that entitlement requires an honorable discharge. There are an estimated half a million former service members in this country with other than honorable or lesser discharges that impact their entitlement to benefits. It is their entitlement to benefits that determine whether or not they meet the definition of a veteran, not their actual service. This is a very important distinction for you to consider whenever you encounter someone who served in the military. Again, another socio-military conception plays a role in how we idealize those who serve as the most healthy individuals in our society, sound in both mind and body, because that's the requirement to serve, at least on paper. The problem with that general perception of veterans begins with whom our society and government believes joins the military. Those ideals fuel the prevailing notion of a, as seen on the slide here, presumption of soundness at the time of induction. In other words, the 17 to 20-somethings are considered by law 100% intact without defect in most cases as a measure of socioeconomic viability and the most mentally and physically fit citizens in our country who are most likely able to withstand the rigors of service. So, so much so that even they believe there's nothing wrong, when I say they, I'm talking about the individuals themselves, when problems surface. But after their service concludes and they apply for benefits, the government presumes that every individual who joined was sound at the time of entry and as a measure of his or her state of health at the time of application against their entry-level self at the time when they were considered 100% intact to determine whether they're entitled to what's called service connection or aspects of their less-than-sound service that have a nexus to their military service that created injuries, disabilities, and things like that. But there's one very important thing that often gets overlooked, the entirety of the life of a service member before he or she joined. All the experiences that influenced the choice to serve range from family legacy and desire to go to college to escaping abuse or seeking a new identity after surviving trauma. These are all factors that are part of their mental wellness. I want to point to a study of the psychological well-being of entry-level soldiers in the Army during basic training where it was noted that a majority of the soldiers scored within the average range on a mental health screening for a primary care setting. What that study did not include was an assessment of psychiatric history or predisposing factors. And my feeling is this is the norm rather than the exception based on my experience as a trainer in the recruit training environment. And what gets factored into that are the recruiting tactics that, again, have more to do with making quota than ensuring we have the most fit and sound individuals joining our military. I'd go as far as to say that a lot of this, again, based on the responsibility I had to push through a lot of the young men in my case, there's a bit of a plausible deniability that factors into this because we know that some of these individuals have problems when we read their case histories and their narratives. But again, we're not there to determine whether they're fit. We're there to assume that they're fit and to make them successful in terms of getting through the boot camp experience. However, another study on inductees after the first Army study where the indicators of psychiatric concerns such as family history revealed that depression was more likely to occur among those who had those problems. This isn't exactly rocket science for somebody like me, but it was certainly eye-opening when you consider what this study may have done to undermine the presumption of soundness that I just talked about. The problem is the military often does not account for what it does not cause. So if a young person comes into the military with deficiencies, the individual may not receive benefits to compensate for how the military may have exacerbated the condition. In fact, the condition could very well be the reason the person is prematurely or punitively discharged. This creates disincentives for revealing psychiatric issues prior to and upon entry into the military. More importantly, it creates gaps in medical histories that could hide the true and relevant extent of a psychiatric or psychological condition. So when we consider who tends to join a military, why they join, and the systemic incentives that make it more likely they'll be considered sound upon entry, one could argue the reason we see higher rates of suicide among veterans are not all that hard to figure out. Now, I'm not saying that most who join or even many who join are not sound or are likely to die by suicide, but when we talk about the prevalence of conditions such as depression and the elevated risk of suicide among veterans, which is estimated around 20 a day, it's these upstream contributaries that cannot be overlooked if we're serious about curbing veteran suicide. And with that in mind, I want to point to the largest study of mental health and resilience ever conducted among military personnel that found men and women who joined the military are more likely to have endured difficult childhoods, including emotional and sexual abuse. In other words, they were sound enough to pass the screening at that time, but far from sound as persons who could handle the rigors of service without becoming part of the downstream statistics like veteran suicide that we end up spending billions of dollars trying to curb. When we talk about depression, which is what we're here to focus on, in itself is a part of military life. Everyone experiences some level of it while they're serving, whether it's situational, atypical, seasonal, or any other variation. Genetics and other biological factors do play a role, but subjecting one's body to poor sleep, diet, stress, hardship, uncertainty, and what I call intentional trauma and abuse is often part of the experience when we talk about things like combat and interpersonal conflict training. The rate of depression, I want to give you a statistic here, is five times higher among soldiers as civilians, five times higher major depression. Intermittent explosive disorder, which results in episodes of extreme anger, is six times as high, and post-traumatic stress is nearly 15 times higher than among civilians that the study found. And while there are certain cultural traditions in place to mitigate the depressive effects of military service, when we talk about things like shared hardship and esprit de corps, building esprit de corps in a unit, what that does to our brain chemistry, though, is a little regard for military leaders. So the depression just sits there, hidden behind behaviors that help us simply blend in until we can no longer hide it. And then on top of that, stigma persists, and the stigmas are why so many wait so long to get help before the depression becomes severe. As I mentioned at the outset, we're living in a time when more veterans from different eras are alive and may end up in front of you for treatment. Despite their differences, veterans of all eras experience mental health disorders, things like substance abuse, post-traumatic stress, and traumatic brain injury at disproportionate rates when compared to their civilian counterparts. Just a few era-specific stats. First and second World Wars saw shell shock and combat fatigue instead of PTSD that most believe stem from concussive effects of bombardment or were more about a matter of exhaustion. And so the systemic efforts to diagnose and treat post-traumatic stress didn't come until decades later. So if you see an older veteran from a previous conflict, that person is likely not to have even received treatment until later on in life when many of the effects have taken root. Even today, the mental health consequences of war remain poorly defined with these ever-shifting diagnostic categories and uncertain theoretical foundations and a lack of consensus on the relative contribution of predisposing factors. Recognizing that a majority of individuals with early symptoms of mental illness would not attend specialists, physicians, or psychiatrists, I've got a reference to a Dr. Selman who suggested that all practitioners should be educated in principles of psychiatry to improve their skills in treating veterans, and he emphasized the importance of holistic or patient-centered health care. And again, this is back in World War I when the need was first identified. So let's talk about the changing gender of the military. There are more women serving in the military than in times past, and this shift in composition has less to do with the sheer number of women serving and more to do with the fact that the older male veteran population is dying off. So we see that shift for those reasons, but these women are also moving up in rank. their roles and assignments that offer greater equity involve combat service and in terms of getting promotions and things like that. But this happens even as stigmas and discriminatory behaviors persist. And this has implications in terms of mental health and its intersection with combat roles, women and units that were previously all-male, and a cohort of veterans that were more likely to be exposed to trauma and abuse during childhood are the same people that are ending up in these roles, which leads to a higher incidence and intensity of mental health conditions when combined with the hardships of military service. So that's something to keep in mind whenever you have women who had served in uniform presented before you, that the story is often a lot greater and involves more than the military service. As far as the military as a whole is concerned, the demographic characteristics of veterans have varied across service periods, as one might guess. In addition to the demographical trends noted on the slide, post-911 veterans, those who served after the attacks on 9-11, were less likely to be married when compared against their former-era counterparts, but less likely to have been incarcerated. And maybe that has a lot more to do with the less likelihood that someone will be institutionalized or criminalized for having a mental illness. And they're more likely to be educated and gainfully employed and appear more socially integrated, largely because they have the advantage of technology. They're also the youngest cohort among all those veterans, of course, because they came later on, but the median age is 37 years old. The diversity of experiences also span the various service branches and experiences, as well as the wartime eras, health-specific issues associated with those eras that make each both similar and unique, including Agent Orange and things like race tensions in Vietnam after Martin Luther King was assassinated, versus armpits for the current era, and the race tensions after George Floyd was killed, and that incident cinemized for the nation to watch. And at the same time, they're differentiated for various reasons that are typical of their era, and this could have implications in mental health and treatment. In 2018, which is what this references, this slide, post-911 veterans were the most racially and ethnically diverse group. More than one-third of post-911 veterans were some other race and ethnicity than non-Hispanic white, which is significantly more than veterans even from the recent era of Gulf War, which is when I served up until 9-11, or peacetime, since the period began in 1975. And as you can see, over the next 20 years, this goes out to 2044, veterans of color will make up a higher percentage of the demographic as a whole, with Hispanic service members gaining the most share and African-American service members remaining steady. This is important to consider in terms of the future of greater diversity and research, as sample populations reflect the diversity of the military. So I'll be curious to watch how research evolves with these trends. Greater intersectional diversity among veterans also increasingly shows up across what we call vulnerable populations. Whenever we talk about vulnerable populations, many of us are not inclined to characterize veterans that way, because of our, again, our socio-military conditioning. You know, we cheer these people on at sporting events and, and parades and things like that. But like other marginalized groups, the vulnerability of these individuals is exacerbated by race, ethnicity, age, sex, and other factors such as income, insurance coverage, or lack thereof, in the absence of usual sources of care. Now what binds them, what binds all these veterans, these 18 million, and there are more than that, but this is in reference to the average, is the induction process, going to boot camp, a sense of belonging based on the uniform that gives them an identity, and then their transition of service, they all have that in common. And while veterans do evolve with a distinct culture that includes, but is not limited to, things like selfless duty and codes of conduct and obedience to orders, this population is also, again, racially and ethnically diverse and includes more women and individuals from what we call vulnerable subpopulations, such as those who identify as lesbian, gay, bisexual, and even transgender in greater numbers than any other time in our history. So this chart provides an example of a list of groups in the U.S. I just point out that many veterans fall into many of these groups, so even though we look at them as one cohort and perhaps vulnerable, they often are rendered more vulnerable because they fall in several groups, for example, poor, or formerly incarcerated, or even obese in many cases, and drug and alcohol dependent, so that doesn't allow us to sit comfortably with the idea that veterans are this group of people who are the strongest and therefore require the least help. In fact, they may require more help than the average person in these vulnerable populations. And so by the time they get to you, this is what you're looking at. It wasn't simply a sniper's bullet or an IED or, in far too many cases, a rape that happened in the barracks that started the downward spiral of the thing that may have helped push them off the edge, could have been whatever each was running from that made them join the military to pursue a new identity, which comes at a price. And what makes this group unique is the fact that you rarely, if ever, know what's behind the mask until you find a way to get them to lift it, which will be tough because of the many disincentives to not lift it, and we'll cover a few of those a little bit later. As far as depression goes, many of you as clinical professionals know that there's not a single event or factor that's the cause of someone's depression. It's instead a variety of interactive variables that contribute to the development and maintenance of depression. This iceberg shows beneath the surface a lot of the things that could conspire against someone's wellness that aren't obvious. Some linked to service, some not linked to service, some part and parcel of the consequences of service. Then we add to that military cultural factors that influence the manifestation of symptoms, making it less evident that a service member or veteran is experiencing depressive symptoms. An example is as part of their training, they learn to hide their true emotions, even in therapy sessions in order to avoid being stigmatized. And the reason for that is pretty simple. When you lose a leg, when you're paralyzed, injuries to the body garner sympathy. But if the brain or psychology is injured, you don't get a purple heart for depression or post-traumatic stress or mental illness, or even things that could be life threatening and lead to serious injury and death. So it's not rewarded, therefore, it's not invited in terms of being a part of someone's identity who may carry the burden of those conditions. Depression is among one of the most common conditions that veterans experience who return from conflicts in Iraq and Afghanistan with estimates as the slide shows from 13 to 15%. And depressive disorders themselves accounting for about 17% of all orders diagnosed. Veterans are more likely to develop major depressive disorder when compared against the general population. And among those who are most susceptible are women who are younger in age and lower in rank, which also happens to be among those who are most stigmatized and sexually harassed in the military. And when you consider the number of women service members who come into the military with a history of abuse and trauma, this probably comes as no surprise to most of you. And I personally believe that the military has a lot more work to do in protecting victims of assault who report and then get harassed or experience systemic retaliation when they do report. Surprisingly, another study also found that being unmarried was associated with resilience to depression, which might be explained by a lack of a relationship and a lack of family stress while deployed that has shown to be a contributor to depression in military population. Just doing a quick time check here to make sure we're on time. Research suggests that people with PTSD are more likely to have depression. And likewise, individuals with depressive mood disorders are also more likely to experience more anxiety and stress, which I can, I can personally attest to that as somebody who lives with the consequences of service in the form of post-traumatic stress and anxiety. And I share that with about 19% of cases of service members who return from Iraq and Afghanistan. Comorbidity between post-traumatic stress and major depressive disorder is common with approximately half of those with PTSD also having a diagnosis of major depressive disorders across diverse epidemiological samples. The question about how and why they co-occur has significant implications for treatment, depending on whether symptoms overlap or not, and the imprecise nature of categorizing each or some aspect of psychopathology following trauma exposure, such as personality type or substance abuse, or prominent risk factors that I'm going to constantly raise, such as childhood adversity and abuse. The U.S. Department of Veterans Affairs reported about a quarter of OEF-OIF veterans who sought care from the VA had some kind of substance abuse disorder, such as alcohol, cannabis, which is important to consider as we talk about the expansion of medical marijuana and even legalized marijuana, and dependence on other substances, including tobacco, nicotine, and in this case, cocaine. Heavy and problematic use of alcohol and other drugs is a major barrier to care received among the general population. In studies of the OEF-OIF veterans, those who reported alcohol misuse also reported low rates of substance use treatment engagement. They tended not to seek treatment. Focus groups and interviews with active duty service members offered some insight into why they avoid treatment, and some of it was attributed to perceived negative attitudes from their commanding officers and peers, which can exacerbate fears of career repercussions and stigma, of course. And some just believe they can handle it themselves, and they handle a problem on their own, self-medication or hiding it. Many veterans who use alcohol or other substances do it to self-medicate and may be hesitant to seek care for post-traumatic stress because many facilities require, and in many cases, demand abstinence from substances even before treatment can begin. And giving up alcohol and other substances, at least in their experience, can intensify symptoms of post-traumatic stress, and many treatment centers are not always equipped to provide care for both conditions. And there are story after story of veterans who were discharged from programs because they couldn't stop the addiction for which they were seeking treatment in many cases. So it's not a good conundrum to be in as a care provider. Let's talk about accelerated aging. I don't hear a lot of talk about that in the mental health context, but it does have implications. Some studies suggest that military service may contribute to accelerated aging as a result of health-damaging exposures, such as combat injury and environmental contaminants, although there are other unmeasured factors that could also explain why that happens. Psychosocial factors, such as lifetime trauma, childhood sexual trauma. And again, I want to bring back this notion of presumption of soundness. In addition to negative beliefs about aging are independently associated with accelerated aging, particularly when you see cases of diabetes, hypertension, and body mass index. These are all correlates of accelerated aging. And we can point to complimentary lines of research that collectively provide evidence that mental illness is associated with accelerated aging. And this is reflected in an array of metrics ranging from genetics to physical health diagnoses. How this accelerated aging process affects the mental wellness of service members is an area ripe for research, I believe, particularly given its impact on life expectancy. Let's turn now to treatment resistant depression. A Janssen study presented at the Psych Congress in 2018 highlighted the substantial economic burden among US veterans living with treatment resistant depression. These are people who have been treated, but it hadn't responded to two or more antidepressant medications. And it affects nearly a third of those living with depression in the United States. While approximately 13% of Americans will experience depression during their lifetime, nearly three times as many US veterans will be affected by this illness, which may be due to again, the exposure to traumatic experiences and separation from family during deployment or military training. So accuracy and timely diagnosis is important. For another reason, though, what we know is nearly 40% of US veterans will experience depression in their lifetime, three times the rate of the general population. Yet there is limited research to date to understand the impact of treatment resistant depression in particular among veterans. And as a result, here's a reference to healthcare utilization and costs that are exponentially higher for these veterans. I'll just say from my own experience as an advocate that anytime costs becomes a key driver in VA healthcare, it often supersedes outcomes and wellness. It's not a criticism or meant to disparage any particular individuals. It's just a consequence when, you know, when we demand costs to go down, a lot of times health outcomes take a backseat to that when checking the boxes become more important. Here's a chart that compares veterans who have major depressive disorder versus those who don't. When we're talking about treatment resistant depression, I'll leave that there for you to take in. We can look at things like PTSD, which spans both groups, but there are definitely actually those compare about the same but but you can see the differences when we talk about treatment resistant depression being a part of it. Now, in light of the prevalence of major depressive disorder, co-occurring substance abuses and post traumatic stress that we've talked about, as well as concerns over accelerated aging and treatment resistant depression, closing treatment gaps is the one thing we can control and it's critical. Although treatment options are available to service members, a large portion of them with depression do not access mental health services. One study showed or highlighted the association between the use of measurement tools and treatment gaps, estimating that treatment gaps were larger when depressed patients were identified by screening tools instead of diagnostic interviews. And there are likely multiple reasons for this gap, a substantial number of depressed service members may lack the mental health literacy skills required to self recognize the need for their care. Over 80% of them who met diagnostic criteria for a past year mental health disorder, but had not received mental health counseling or medication in the previous 12 months, reported no perceived need for mental health care. Among depressed service members who recognize the need for mental health care, things like structural barriers, difficulty scheduling an appointment or getting time off work, were the offsider reasons for not receiving treatment. In addition to the fear of negative career repercussions, things like the inability to deploy with your unit or having your security clearance stripped, were factors in decisions not to seek care. And then of course, you've got the negative attitudes toward mental health treatment, such as just a mere belief that it's ineffective and as a former service as a service member, who carry that weight, I can speak firsthand on the validity of that concern. I'm going to bring up personality disorder for a reason, although it's not necessarily associated with depression. I'll get to the point of all of it in a second, I just want to point to trends in personality disorders and some of the things that we note in terms of ethnic differences in the pathology in terms of how it's diagnosed among male combat veterans. One study indicated higher rates of personality disorder among African American veterans, with the difference potentially attributable to higher rates of ethnic discrimination. Hispanic males were included in that as well. There's also a higher prevalence of PTSD among women as a rule. So the comorbidity of PTSD and personality disorders and the increasing number of women in the military, particularly women of color, make it important to understand the relationships among these factors so that treatment can be identified and appropriate psychiatric services provided. Here's just a statement about the incidence of personality disorder among patients with major depressive disorder. Now I'm going to get to the point because this is not real obvious to many people. Recruits who have a severe pre-existing illness like a personality disorder are not allowed to pass the rigorous screening process and accepted for military service. But among those who do make it through and are physically and psychologically fit, before they get deployed to Iraq and Afghanistan, personality disorders become a problem when they get diagnosed later on down the line. They pass the screening, they make it through boot camp, they were fit to deploy, but there are far too many and when we talk about the trends among African Americans, Hispanic Americans, women, this is a problem because the consequences of having a personality disorder as a basis for discharge is pretty severe. It's a pre-existing condition. So a soldier or a Marine who's discharged with a personality disorder as a basis for being unfit for service cannot collect disability benefits. They cannot receive long-term medical care like other wounded soldiers and this is even if they have an injury in many cases, a psychological injury in many cases. And in some cases they have to give back their signing bonuses. This was a problem for Vietnam era veterans because many veterans of color were being discharged due to a personality disorder, therefore ineligible for benefits on that basis, despite having served, despite bearing the scars of service after serving in Vietnam and things like that. So this is not a, this is not a situation we can ignore. Even today, um, the department discharged over 22,000 service members with personality disorders between 2002 and 2007. And as a result, on the day of discharge, many of them find out at that point that they're having to give back their your signing bonuses. Um, estimated losses are between $5 billion and $20 billion in lost lifetime and other medical benefits that they would have collected had they been given the benefit of this service, notwithstanding a personality discharge. And again, I want to take us back to how we define who is sound, soundness, uh, in terms of this presumption that we have about service members. I was going to talk about the case of Corporal Tate Ohu, but because she's been released and there are legal implications for her case, I'm not going to bring that up here. But I do encourage you when you, uh, get a chance to hit the hyperlink and read about her case. It's a case study in how mental health and the failure to manage it the right way with an eye toward what happened pre service during service systems to help address issues that come up when it goes terribly wrong. Uh, it's, it happens the way it did for Corporal Ohu, who did not have a good experience. And today she still deals with the consequences of a system that failed her. So I'm gonna move past that only because there is an ongoing review going and I was involved in her case. Let's turn on a veteran suicide. Um, the Pentagon released a report that listed the total number of suicides for 2018. There's a reason why there's this two year gap that they don't, they don't look at the suicides or study the cases during the year, even a year after there's this two year leap. So we're oftentimes looking at retrospective information. Why is that important? Because we won't learn about the impact of COVID-19 until probably 2022 in terms of suicides and things like that. So have that context in mind as I talk about suicide deaths in 2018 in the, in the military. Um, the 325 suicide deaths recorded for that year, 2018 represented an increase of 40% when compared to the previous year, most of them were army and Marine Corps deaths. And that's just the nature of service for those two branches. Um, less than half of service members who died by suicide had at least one current or past mental health diagnosis. The two most common diagnoses were adjustment disorder, clinically significant stress or impairment in response to a stressor. The second one was substance use disorder, which is the misuse or abuse of mood altering substances. Enlisted males who are under 30 in the active component were found to be at higher risk compared to the population average. Um, here's an interesting angle though, that not a lot of folks realize. Suicides aren't necessarily correlated with combat service, contrary to popular belief. Um, and I'll just point to history. Um, suicide rates slowly rose from the end of World War II to the start of the Korean war, then dropped significantly, uh, as combat operations increased. And, uh, and more research, uh, more recent research has shown that suicide among individuals who serve in Iraq and Afghanistan were not higher for troops or veterans who saw combat than those who did not. When you hear about a veteran suicide, in most cases, you're talking about somebody who did not serve in combat, did not deploy is very early in his or her career. So there, there's no strong correlation, although that's, that's counterintuitive, but there is not a strong correlation between combat service and suicide. What is strongly correlated, however, is loneliness. Um, when veterans who have survived suicide attempts were asked to describe what led them to that action. One of the top three reasons given is feeling alone. It's a, it's a known risk factor for suicide and the prevalence of suicidal thoughts appear to increase with the degree of loneliness, which is part and parcel of, again, serving in the military. Um, you know, 2014 national health and resilience in veteran study, 44% of veterans report of feeling lonely at some point, um, and factors such as older age difficulties with activities of daily living, lifetime traumas, depression, PTSD. These were all factors that were associated, uh, with loneliness. And so, um, healthcare initiatives that take the unique needs of the veteran population into account, um, and, and seek to reduce military suicides must also include tailored interventions that address loneliness among other issues. And this is especially critical when you consider how loneliness has contributed, uh, actually how the pandemic has contributed to the likelihood that more people veterans among them will be lonely. Some of you may or may not recognize this, but it references a parable that I like to invoke whenever I talk about how our government, uh, has handled, uh, the study of suicide to this point. Um, I have a great respect for the work that many researchers do, but I oftentimes compare it to the six blind men, uh, feeling an elephant, uh, one grabs a leg and thinks it's a tree. The other touches a side of things. It's a wall. Uh, one thinks the tusk is a snake. The tail is a rope, the ear is a fan, and they all have a piece of this puzzle. A perceived truth is, is what they're looking at, but none of it is completely correct. Um, we all report on the piece of that anatomy. We expect to find if we're these researchers and we reject any manifestations of that that make us feel uncomfortable. And so when we talk about things like, um, evidence-based medicine, there is a place for that, but it's not the only thing that saves lives. And I referenced that in my testimony before Congress, we have to expand our understanding of what keeps veterans alive. It's a, it's a multifaceted therapeutic evidence-based, but also peer-based approach that in my experience, 17 years post-military has saved more lives than any one of those alone. So I just want to have that image burned in your head with respect to how we study these problems and why we miss things in many cases. I have to talk about the impact on the family. Anytime we talk about mental illness in service members and veterans, families are a part of that because they're extensions of these men and women. So what happens to the service member and veteran often impacts the family and vice versa. So some of these statistics give you an indication of, uh, of the impact that many of these, um, conditions have on the family. Some of the more interesting were, um, admissions that depression was likely to result in domestic violence in many cases and service members with depression were also more likely to report that their children were afraid of them or lack warmth towards them. So these are things to think about for this population. This talks about military spouses in particular. Um, this is a research from the Anxiety and Depression Association of America. They found a number of factors increased major depressive disorder in military spouses. Um, many of the things that, uh, the unique situations involve geographic separation, uh, unpredictable training cycles. You know, they come home and find out that their loved one is going to be gone for six weeks, frequent relocation, the deployments, um, and in many cases, the spouse and family have to deploy with the service member to Germany and to then Japan and places like that while the service member deploys further to Iraq and Afghanistan. Uh, and they themselves then have to experience frequent job rotations and other things. So the, the prevalence of major depressive disorder among military spouses, uh, is, uh, something to explore. Um, strong indicators of the increased risk for MDD or major depressive disorder include gender, which is, uh, uh, mainly female being less than 30, having combat deployments, having post-traumatic stress, alcoholism, and the service members branch of service. And again, I point to the Army and Marine Corps as, uh, some of the more intense branches in terms of the, their purpose, their inherent purpose in the grand scheme of, uh, of the military. Again, I'm just going to let you take this in. Uh, when we talk about kids, um, as opposed to the spouses, results show that children were exposed to deployment between one sixth and one fifth of their lives across all the ages studied. And, uh, if there's zero to five, they're not going to see as much of an issue. A lot of that is because of the, um, you know, it's common sense that if they're younger, they're not going to know a lot about what's going on. But once they hit that three to five year range, generalized anxiety is, is found. And when they're six to 10, um, start to see more problems in school and things like that. And I've got some experiences with service members who have kids that are a little bit older, that has some real issues. And we're going to speed up here just a little bit, um, to keep on time. Again, just some comparisons between all youth and youth of military personnel with respect to major depressive disorder. Um, and, and, and, and cultural competency. This is important to me. Um, at NAMI, we talk a lot about the importance of being able to speak the language in, in, in building a relationship with people that you're going to treat, um, little things like not referring to women who serve in the military as female soldiers or female Marines, or, or not calling a soldier or a Marine, a soldier, um, that that shouldn't matter, but it does. And having a sense of how that helps you build bridges to the people you're treating who may have served, um, is helpful. So having these resources available to, uh, help you speak the language might make your engagement with some of these men and women more effective as you treat them. There are research going on that, uh, focuses on family interventions. One of the, my criticisms of the VA for a long time has been, they don't treat the family. So when you have a service member in an office being treated, a lot of times some of the, what needs to be fixed is, is between, uh, is between the members of the family, the relationships, and some of the issues that the service member or veteran experiences has to do with what's happening with a spouse or a loved one. So it's important to include the family in a lot of this. This website, it's, uh, I think it's mentalhealth.va.gov is a place to go to find provider toolkits that help you speak the language or, or at least have a deeper understanding of, uh, what's happening with, uh, veterans when you, um, when, when you're talking about cultural competence. And these are, again, you can see this in the, in the, uh, recording when you go back, these are some of the government resources that offer, um, toolkits and other advice on how to do that military culture course modules and things like that. Uh, the VA is pretty proud of its research. It does a lot for, uh, not just veterans and service members, but also the broader community with some of the breakthroughs. And these are some of the bigger milestones that have happened since 2006 relative to depression. I'm really excited about the, uh, the million veterans program, uh, which is looking to go beneath the surface, looking to the DNA and look for ways to make medicine treatment therapy more efficacious by understanding the predispositions to certain conditions, such as depression and others like PTSD and heart attack and things like that. So the million veterans program, uh, it came about a few years ago. There's still some, some work to do in terms of getting more veterans to participate. Uh, but it is, uh, an opportunity for the VA to lead, uh, in the effort to better understand depression and other conditions. And I'm going to stop here. Um, because that's the end of the presentation, but I will mention that this last video, uh, does show me as I talk about, uh, veteran suicide and, and our responsibility to do more for the men and women who serve. Um, I myself took that journey back in 2002 when I was injured in service as a Marine, 29 years old. Uh, I'm proud to say I'm here today because I had some great doctors, some great mental health professionals who helped me get through it. Uh, I saw the screening tools, received the medications and therapies. And again, the peer engagement was a cherry on a Sunday. Um, so I want to thank you all for what you do. It's important to me personally, but you're going to be the reason why we're going to save lives in the future going forward. Thank you Sherman for the presentation. And I've had the privilege of watching that video and it is extremely powerful. So encourage all of you when you download and go to the link after this is over and post it on the SMI advisor site to, to watch that. So before we shift to the Q and a, uh, what I'd like to do is take just a minute to let you know that the SMI advisor is now accessible from your mobile device and you can use the SMI advisor app to access resources, education, and upcoming events like this webinar to complete mental health rating scales and even submit questions directly to our team of SMI experts. And you can download it at SMIadvisor.org backslash apps. So we've got time for just a couple of questions, Sherman. And the first one that came through was how has the pandemic affected the mental health of service members? Are you aware of any comparisons between service members and veterans and the civilian population? For example, I know you said that some of the suicide data lags two years behind, but curious what you might have heard. Yeah, this is, I want to give context. So if you were last year told you had to wear a mask and, and that was to prevent death from a, a, a, a lung attacking virus, that's one thing that's bad enough. But if you are a veteran who had already gone through the experience of being told gas, gas, gas, put your gas mask on, you have to put this mask on, or this, the Syrian gas is going to kill you in Iraq. It can, it can do a lot to you mentally and the isolation being sitting on a post when you feel like you're alone and make an attack, you can revisit a lot of that. If you're sitting in your home being told that, you know, you have to socially distance and all these other things. So I think having, having that, that experience revisited upon us as a whole was bad enough, but a lot of veterans had to deal with that. As far as the active duty, my daughter's at the Naval Academy right now. I think they were pretty isolated. They did have COVID cases that did happen. And I think that's probably going to, we're going to have to see down the line what the consequences of that are, because there will be physical and mental consequences down the line. And I think we're still too early to know exactly how that happened, but we need to watch for it. It's a very good answer to a complicated question, because I think that's true with, with all populations. We have to wait and see. Here's a question, Sherman, about whether or not you're aware of any diagnostic tools that might be under development by the armed forces to ethically screen for those pre-existing or underlying psychiatric conditions. Specific tools are being developed constantly. I know that the VA is trying a lot of different things. They're even more open to industry than in times past. And so you're going to hear about corporations that have apps, right? Apps that help you, you know, identify or apps for family members. I've talked about things like suicide first aid and what we can do to help increase the likelihood that we'll do a better job of flagging someone. But specific evidence-based tools, we're going to have to, you know, I'm going to have to have you turn to the research portals on the VA website to get the latest and greatest. But I am aware of a lot of technologies that are being worked on that help us do that a lot better. Perfect. So there are a couple of other questions, but I know we're almost out of time, but I'm going to kind of lump them together and ask you what recommendations, Sherman, would you have or what guidance would you offer to clinicians that are on this call? Maybe nurses, maybe therapists, maybe social workers to better engage the service members and veterans they're working with or who come to them for services. We know so many people come in and something turns them off and they go away, especially if the provider doesn't have military experience themselves. Any words of wisdom that you could share? Any veterans events, especially ones that allow veterans with disabling conditions to do adaptive sports, please volunteer. I love it when I hear about a psychologist, a psychiatrist, social worker, because it's a human thing and you're going to have plenty of time to be doctors and clinicians, but meeting them on a human level during these volunteer opportunities is the best way to learn about what makes them tick, to disarm them so that they tell you more about why they do what they do. And it'll also give you some insights into the culture so you can speak the language. Meet them where they are. And that's one of the things that we preach at NAMI, but also something that's promoted through SMI advisor when working with individuals and families. And what I hear you saying, Sherman, is that's especially true with this population as well. So I again want to thank you for the presentation today, Sherman. And if we can go to the next slide, please. We'd like to let you know that if you have a consultation, whether it's related to mental illness and service members and veteran populations or their families, if it's something specific related to today's presentation or any other topic related to evidence-based care for SMI, our clinical experts are available for online consultations. And these are free of charge. Any mental health clinician can submit a question and receive a response from one of our SMI experts. Again, these consultations are free and they are confidential. Next slide, please. I think my video is playing in the background, so you're probably going to hear. That's okay. SMI advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We encourage each of you to explore the variety of resources that are available on the Mental Health Addiction Prevention TTCs, as well as the National Center for Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance can take up to five minutes, and you'll then be able to select Next to advance and complete the program evaluation before you claim your credit. We invite you to join us next week on June 11, 2021, as Dr. Joseph Ceremele with the University of Washington presents Bipolar Disorder and Measurement-Based Care. Again, this free webinar will be June 11, 2021, from 12 to 1 p.m. Eastern time. Thank you for joining us. Thank you for your presentation, Sherman, and until next time, take care.

webinar

Terri Bristor

Sherman Gilliams Jr.

NAMI

mental illness

veterans

service members

depression

trauma

suicide risk