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Col. Charles Engel, M.P.H., M.D Headshot

Military Mental Health Care: One Size Does Not Fit All

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In his recent Huffington Post blog, psychiatrist Scott Mendelson, M.D. unfairly characterized the Army's RESPECT-Mil program. RESPECT-Mil is a state of the science approach to early primary care recognition and management of PTSD and depression. Although it is suggested that the program lacks an appropriate scientific basis, the collaborative care management method it employs is endorsed for depression by the strict standards of the U.S. Preventive Services Task Force. The goal of RESPECT-Mil is simply to afford service members and their doctors with yet another means of reaching out to soldiers in need. It is not a panacea, and it is not a substitute for competent, high-quality mental health care delivered by skilled specialists.

In the mental health care world, we have long known that mental health specialists alone are inadequate to meet our nation's diverse mental health needs. Indeed, it has now been over 30 years since psychiatrist Darrel Regier estimated that 60 percent of mental health care is delivered by primary care providers, famously describing primary care as America's "de facto mental health service system."

We have learned that access and staffing, while important, are only two factors among many that contribute to the de facto system. For example, many with depression and anxiety experience painful physical symptoms and they may not realize the mental health nature of their difficulties. Others may avoid mental health care for fear that they will be viewed as weak or crazy. A recent army study found that about half of soldiers returning from Iraq with depression or anxiety problems believed that seeking mental health services would harm their career. Furthermore, many soldiers reported lack of confidence in mental health treatment or lack of trust in mental health specialists.

These findings tell us that, "one size does not fit all" when it comes to mental health care. They suggest that readiness to obtain mental health assistance is a process and not a given, a process that is a bit different for everyone. They also reinforce that mental health problems are life-threatening and must be taken very seriously. In a shocking finding, one high-quality study of Americans with PTSD found that the average length of time it took to seek initial care was 12 years! In the U.S. military we cannot wait that long to identify and assist those soldiers with mental health needs.

But what can we do to reach soldiers sooner? What can we do to reach them on their own terms? If we push service members into mental health care against their will, we may win the short-term battle by addressing the immediate problem, but lose the longer term war by permanently alienating them from the mental health specialists they will need most in the future.

The RESPECT-Mil Program ensures specially trained registered nurses are available at every participating primary care clinic. These nurses, called care facilitators, assist primary care providers and bolster the mental health safety net. Care facilitators help primary care providers stay connected to the mental health needs of participating soldiers. They monitor for symptom improvement, treatment adherence and side effects using scientifically valid assessments and serve as a consistent source of support for soldiers. Facilitators familiarize themselves with soldier preferences regarding medicines, psychotherapies, treatment settings, and personal and career goals.

Care facilitators meet weekly with a psychiatrist and discuss all soldiers they are following. Psychiatrists use these meetings to provide written feedback to the primary care doctor on optimal care for their patient. If patients do not show at least some response within six to eight weeks, then this team -- consisting of patient, primary care provider, care facilitator and psychiatrist -- will reassess, coordinate and adjust the treatment plan and setting.

RESPECT-Mil is not for every service member with combat related mental health problems. Since the program was initiated, we have observed large growth in the numbers of psychologists and social workers who are now working side-by-side with RESPECT-Mil nurses in about two-thirds of participating Army clinics. More specialists are still needed and on the way. Indeed, the Navy, Army and Air Force are all transitioning to a new patient-centered medical home concept, which will call for both RESPECT-Mil style nurse care facilitators, as well as mental health professionals, in nearly every primary care clinic.

As the director of the RESPECT-Mil program since it started as a single clinic pilot project at Fort Bragg in 2004, I am very proud of the program's accomplishments. The program was expanded to 42 clinics beginning in 2007 and will add 53 more primary care clinics by next summer. Participating clinics have so far screened over 750,000 visits for PTSD and depression. The rate of successful screening has risen to 80 to 85 percent of visits from a pre-program baseline of two to five percent. Over 6,000 of these visits led to the detection of suicidal tendencies, and over 1,500 of these soldier visits resulted in a primary care provider rating of intermediate or high suicide risk and definitive treatment under the care of a skilled mental health specialist.

RESPECT-Mil is sympathetic to Dr. Mendelson's concerns and would be most honored if he would join us on one or more of our site visits. I am certain that he will find that we are indeed dealing with the world of invisible soldier wounds as they are, and in so doing we are defining new ways to improve the range of settings and treatments we can offer.

Army Col. Charles Engel, M.P.H., M.D. Director of the Deployment Health Clinical Center. Col. Engel has served as the director for the past 13 years.