Christopher M Palmer M.D.

Post-Traumatic Stress Disorder

The crisis in veterans' mental health and new solutions, veteran suicides increase 10-fold from 2006 to 2020..

Posted November 10, 2023 | Reviewed by Davia Sills

  • What Is PTSD?
  • Find a therapist to heal from trauma
  • Veterans suffer from high rates of mental health conditions, including PTSD, depression, and substance use.
  • Suicides among veterans increased 10-fold from 2006 to 2020.
  • New treatment strategies are desperately needed.
  • Addressing mental and metabolic health simultaneously may lead to better outcomes.

Source: John Gomez/Shutterstock

Every year on Veterans Day, we celebrate the brave individuals who have served our country. The mental health challenges that veterans face are both unique and profound. As they transition from service to civilian life, many carry the weight of experiences that significantly impact their well-being. Conventional treatment approaches for conditions such as PTSD , anxiety , depression , and substance abuse are invaluable, yet some veterans continue to struggle with symptoms.

A recent research study published in JAMA Neurology has unearthed a deeply troubling trend: a greater than 10-fold increase in suicide rates among U.S. veterans from 2006 to 2020. Clearly, our current treatment strategies are failing far too many veterans. This is where innovative perspectives, such as the brain energy theory of mental illness, offer fresh hope and understanding.

The brain energy theory, as outlined in this post , posits that mental health conditions are intricately linked with the brain's energy dynamics. A brain with balanced and optimal energy is crucial for mental wellness. For veterans, whose brains are often taxed by the rigors of service and the scars of trauma , ensuring adequate brain energy could be particularly transformative.

Brain energy is, in essence, the currency that powers every thought, emotion , and reaction. This energy stems from the complex interplay of nutrients, hormones , neurotransmitters, and mitochondrial function. For veterans, exposure to stressful environments, trauma, sleep disruption, and physical exertion can lead to a mismatch in energy supply and demand within the brain, potentially exacerbating mental health symptoms.

Research has demonstrated that PTSD, for example, is not just a manifestation of psychological distress but may also be linked to altered metabolism . This can affect the way the brain processes information and responds to stress. By targeting these metabolic processes, we might be able to offer veterans more effective interventions.

How, then, can the brain energy theory guide novel treatment strategies?

  • Nutritional Interventions: Tailored nutritional counseling aimed at optimizing brain energy production can be a powerful addition to veterans' treatment plans.
  • Exercise and Stress Reduction: Interventions such as targeted exercise regimens may not only enhance overall energy but also improve brain plasticity, resilience , and the regulation of stress hormones. Mind-body practices like yoga and meditation could further aid in rebalancing the brain's energy utilization and emotion regulation mechanisms.
  • Specialized Brain Energy Interventions: One promising area is the exploration of supplements, medications, and even light therapy that specifically support mitochondrial function and, consequently, brain energy. While still in the early stages of research, these interventions may offer relief for veterans whose mental health symptoms have been resistant to other treatments. One example is the application of red or near-infrared light to the scalp (transcranial photobiomodulation). In a pilot trial , this intervention was found to improve brain metabolism and reduce symptoms of traumatic brain injury and PTSD.
  • Enhanced Psychotherapy : Integrating brain energy optimization into behavioral therapies could amplify their effectiveness. By ensuring the brain is energetically equipped to engage with and benefit from therapy, we can enhance learning, neural growth, and the consolidation of therapeutic gains.
  • Comprehensive Care Teams: Coordinated care teams can ensure that veterans receive holistic support, addressing both mental and metabolic health.

The journey toward healing and mental wellness for veterans is both a collective and individual endeavor. By harnessing the principles of brain energy, we can open new avenues for treatment that honor the complexity of the brain and the diversity of experiences among veterans. With continued research and clinical application, this perspective holds the promise of not only alleviating symptoms but also restoring a sense of vitality and hope to those who have served.

As we move forward, it is essential to continue advocating for and investing in research that elucidates the intricate connections between metabolism and mental health. By doing so, we not only pay homage to the sacrifices of our veterans but also elevate our approach to mental health care for all.

Christopher M Palmer M.D.

Christopher M. Palmer, M.D. , is a Harvard psychiatrist and researcher working at the interface of metabolism and mental health. He is the director of the Department of Postgraduate and Continuing Education at McLean Hospital and an Assistant Professor of Psychiatry at Harvard Medical School.

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Veteran and Military Mental Health Issues

Affiliations.

  • 1 1st Special Operations Medical Group
  • 2 Uniformed Services University of the Health Sciences
  • 3 Hurlburt Field Air Force Base
  • 4 Uniformed Services University
  • 5 University of Texas Health Science Center at San Antonio
  • PMID: 34283458
  • Bookshelf ID: NBK572092

As the United States endures 2 decades of ongoing warfare, both the media and individuals with personal military connections have raised significant public and professional concerns about the mental health of veterans and service members. The most widely publicized mental health challenges veterans and service members encounter are posttraumatic stress disorder (PTSD) and depression. Research indicates that approximately 14% to 16% of the US service members deployed to Afghanistan and Iraq have been affected by PTSD or depression. Although these mental health concerns are prominently highlighted, it is crucial to acknowledge that other issues, such as suicide, traumatic brain injury (TBI), substance use disorder (SUD), and interpersonal violence, can be equally detrimental in this population. These challenges can have far-reaching consequences, significantly affecting service members and their families. Although combat and deployments are known to be associated with increased risks for these mental health conditions, general military service can also give rise to challenges. The presentation of these mental health concerns may not follow a specific timeline. However, there are particularly stressful periods for individuals and families, especially during periods of close proximity to combat or when transitioning from active military service.

As per the recent reports released by the U.S. Census Bureau, there are around 18 million veterans and 2.1 million active-duty and reserve service members (https://www.census.gov/newsroom/press-releases/2020/veterans-report.html) in the United States. Since September 11, 2001, the deployment of 2.8 million active-duty American military personnel to Iraq, Afghanistan, and other areas has resulted in a growing number of combat veterans within the population. Over 6% of the US population has served or is currently serving in the military. Notably, this number also does not consider the significant number of relatives affected by military service. Healthcare providers can enhance the quality of care they provide patients and potentially save their lives by comprehending the relationship between military service and a patient's physical and mental well-being.

Posttraumatic Stress Disorder

PTSD was officially recognized and codified in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-3 in 1980, driven partly by the sociopolitical aftermath of the Vietnam War. However, its manifestations have been alluded to in different forms throughout history, with terms such as "soldier's heart" during the Civil War, "shell shock" in the First World War, and "combat fatigue" around the Vietnam War. The DSM criteria have remained primarily unchanged until the latest update in 2013. However, there is still ongoing debate regarding its classification. As a complex and constantly evolving combination of biological, psychological, and social factors, studying and diagnosing PTSD poses significant challenges. Although PTSD is commonly studied in individuals who have experienced war or natural disasters, its impact is not limited to specific groups and can affect anyone, including children. This disorder is commonly observed in individuals who have survived violent events such as assaults, disasters, terror attacks, and war. However, even secondhand exposure, such as learning that a close friend or family member experienced a violent threat or accident, can also lead to PTSD. Although many individuals may experience transient numbness or heightened emotions, nightmares, anxiety, and hypervigilance after exposure to trauma, these symptoms resolve within 1 month. However, in approximately 10% to 20% of cases, the symptoms may worsen and become persistent, causing significant impairment. PTSD is characterized by intrusive thoughts, flashbacks, and nightmares related to past trauma, leading to avoidance of reminders, hypervigilance, and sleep difficulties. Frequently, reliving the event can evoke a sense of threat as intense as the original trauma. PTSD symptoms can significantly disrupt interpersonal and occupational functioning and manifest in various ways, affecting psychological, emotional, physical, behavioral, and cognitive aspects. Military personnel can be exposed to an array of potentially traumatizing experiences. Military personnel deployed during wartime may witness severe injuries or violent deaths, which can occur suddenly and unpredictably. These events can impact not only intended targets but also others in the vicinity. Active-duty military members risk non-military-related traumas beyond the challenging deployment environment, such as interpersonal violence and physical or sexual abuse. Symptoms related to these traumas may be exacerbated in the deployed environment.

As a result of 2 decades of ongoing warfare in Afghanistan, there is a rising population of veterans seeking mental health treatment, with a significant portion having experienced combat and deployment. While caring for veterans, healthcare providers should consider the physical injuries they may have sustained during their service period and the emotional wounds they may be experiencing presently, including PTSD, acute stress disorder, and depression. Although depression does not garner the same level of attention as PTSD, this condition remains a prevalent mental health condition in the military. Research shows that depression is responsible for up to 9% of all ambulatory military health network appointments. The military environment can serve as a catalyst for the development and progression of depression. Factors such as separation from loved ones and support systems, the stressors of combat, and the experience of witnessing oneself and others in harm's way all contribute to an increased risk of depression in both active-duty and veteran populations. After deployments to Iraq or Afghanistan, military medical facilities witnessed an increase in diagnosed depression cases, rising from a baseline of 11.4% of members to a rate of 15%. Given this high prevalence, providers have a critical responsibility to identify active-duty and veteran patients who may be suffering from depression.

Major depression manifests through various symptoms, encompassing a depressed mood, loss of interest in activities, insomnia, weight loss or gain, psychomotor retardation, fatigue, reduced ability to concentrate, feelings of worthlessness, and thoughts of suicide. These symptoms dramatically affect the patient's capacity to operate at full potential. Although the array of symptoms is evident on paper, a patient's presentation can often be ambiguous. Surprisingly, it has been found that half of all patients suffering from depression are not correctly diagnosed by their general practitioner. Therefore, accurate screening, identifying, and following through with appropriate treatments is paramount, especially in the active-duty and veteran military population.

Veteran suicide rates have reached their highest level in recorded history, with over 6000 veterans dying by suicide annually. Furthermore, overall suicide rates within the United States have increased by 30% between 1999 and 2016. According to a study conducted in 27 US states, it was estimated that veterans committed 17.8% of reported suicide cases. Data published by the U.S. Department of Veterans Affairs (VA) in 2016 indicated that veteran suicide rates were 1.5 times higher than those of non-veterans. Research has shown that veterans are at significantly increased risk of suicide during their first year after leaving the military service. In 2018, a Presidential Executive Order was signed to improve suicide prevention services for veterans during their transition to civilian life. Moreover, the Department of Defense (DoD) and VA have placed significant emphasis on suicide prevention due to the observed rise in fatal and non-fatal suicide attempts during the wars in Iraq and Afghanistan. The suicide rates in the U.S. Armed Forces doubled between 2000 and 2012. However, since then, there has not been any significant change in the annual rate of suicides, with approximately 19.74 deaths per 100,000 service members occurring each year.

Substance Use Disorders

Despite receiving public attention over recent decades, SUDs, including alcohol use, continue to be a problem among veterans and military members. In these populations, alcohol use is prevalent and is frequently utilized for stress relief and socializing. SUDs are associated with significant adverse medical, psychiatric, interpersonal, and occupational outcomes. A study conducted on military personnel revealed that approximately 30% of completed suicides and around 20% of deaths resulting from high-risk behavior were attributed to alcohol or drug use. In the general US population, alcohol is the fourth leading cause of preventable death, contributing to 31% of driving-related fatalities involving alcohol intoxication. According to the DSM-5, SUD is a group of behaviors that involve compulsive drug-seeking, which includes impaired control over drug use, dysfunctional social functioning due to drug use, and physiological changes resulting from drug consumption. Addiction represents the most severe stage of SUD in individuals, characterized by a loss of self-control that leads to compulsive drug-seeking behavior despite a desire to quit. Substances encompass various categories, including legal drugs such as caffeine, nicotine, and alcohol; prescription medications such as opioids, sedatives or hypnotics, and stimulants; and illicit drugs such as marijuana, cocaine, methamphetamines, heroin, hallucinogens, and inhalants.

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Veterans’ Transition Out of the Military and Knowledge of Mental Health Disorders

  • Savanna Taylor
  • Meghnaa Tallapragada
  • Melissa Vogel
  • Meghnaa Tallapragada , Temple University, United States ORCID Dr. Meghnaa Tallapragada is an assistant professor in the Department of Advertising and Public Relations at Temple University. She earned her Ph.D. in Communication from Cornell University and her research focuses on assessing and improving public perceptions on controversial issues, particularly in the areas of science, health, and risk communication.
  • Melissa Vogel , Clemson University, United States Dr. Melissa Vogel is a Professor of Anthropology at Clemson University, where she is Director of the Business Anthropology Program and Graduate Coordinator for the M.S. in Social Science. She has 25 years of mixed methods research experience in the U.S. and Latin America, currently focused on improving corporate approaches to qualitative research and training applied social science researchers.

There is a need for research to understand veteran’s mental health and how they use resources, like the Veteran’s Affairs and non-profit organizations. This study serves to further our understanding about veterans’ knowledge on this subject. This study adds to the literature by conducting semi-structured interviews with 15 veterans who had deployed on either United States military bases or ships, or peace-keeping missions, overseas after 9/11. The interviews were audio-recorded, transcribed, and thoroughly analyzed using a narrative approach. Five important themes emerged from the interviews: prevalence of mental health disorders, knowledge of disorders and resources, barriers to seeking help, types of resources available, and motivations to seek help. Although this study aimed to explicitly understand knowledge, the inductive research process produced four other themes that became pivotal in understanding why veterans were skeptical to seek help.

  • Page/Article: 85–95
  • DOI: 10.21061/jvs.v6i1.131
  • Accepted on 30 Dec 2019
  • Published on 31 Jan 2020
  • Peer Reviewed

Military Veterans’ Mental Health Needs

The topic of the study concerns the mental health needs of veterans who suffer different types of disorders as the result of their military service. This issue has a significant influence on my practice because this population constitutes a relatively large number of people in the USA. Many individuals encounter such difficulties as mental disorders, substance abuse, “homelessness, and involvement in the criminal justice system” (Blodgett et al., 2015, p. 163). Such a wide range of issues that need to be addressed in the psychotherapeutic context implies the importance of the investigation of the challenges this population experiences.

Despite cultural and ethnic diversity of the target population, the common psychological issues are characterized by similar symptoms. However, it is relevant to apply culture-sensitive interventions to amplify the efficacy of psychotherapy. It is essential to retrieve and use the information about the cultural particularities of a patient to help him or her deal with the issues within a comfortable spectrum of beliefs. Religious and family history background might be helpful at this point.

The community provides both private and public services to ensure veterans’ accessibility to the facilities and information. Multiple brochures, scholarly research publications, websites, and counseling advertisement are available to increase the scope of services for vets. However, there are some gaps in the addressing of the possible ways how this population might seek for help. This issue might be complicated due to the reluctance of traumatized individuals to face the problem and acknowledge their disability and attempts to resolve it on their own. To address the gaps, the ways to facilitate the accessibility of mental health institutions for veterans should be found.

To understand the needs of veterans better and to introduce effective psychotherapeutic services, it would be useful to study the scope of literature addressing the particular aspects with which they deal, such as substance use, communicational issues, depression. Also, it is important to investigate the mental health problems that veterans’ family members might experience and provide relevant services for them as well. I will need to find and study an explicit description of practical interventions applicable to this particular population.

The relevance of the research to the target population might be explained by the common occurrence of the mental health problems of veterans after their combat service. More importantly, the unresolved psychological issues in veterans might lead to severe complications in both their health conditions and their social behavior. According to Blodgett et al. (2015), about “10% of incarcerated adults (i.e., those in jail or prison) have served in the military” which includes approximately 210,000 veterans (p. 164).

Also, alcohol misuse and the behavioral threats that follow are prevalent among veterans (Osilla et al., 2018). Thus, a great number of those involved in military service have a high rate of exposure to substance abuse and criminal activities. It is vital to apply timely mental health for those who need it to prevent adverse outcomes for both, the veterans and the society.

To succeed at timely identification of a problem, it is essential to raise awareness and attract family members to therapeutic interventions. The research explicitly addressed the involvement of veterans’ families in mental health treatment. One of the most widely spread problems related to military experience is a post-traumatic stress disorder that is best treated with the participation of family members (Fisher et al., 2015). It is essential to identify the most effective interventions for veterans and their families to eliminate the threats emerging as the result of combat experience.

This research will greatly influence my practice as a psychiatric-mental health nurse practitioner (PMHNP) because it will contribute specific knowledge about the mental health needs of veterans related to their military experiences. According to American Psychological Association (n.d.), the majority of veterans returning home after their service fail to find relevant public institutions due to the lack of workforce in the field. As a result of this research, the information and its analysis will facilitate in increasing of the scope of service and providing more opportunities for the deployed military service members to find psychotherapeutic help and be adequately treated.

The particular findings of the most commonly found disorders including alcohol and drug use, criminal behavior, depression, or post-traumatic stress disorder will contribute to the practical side of my work.

Being acknowledged about the various mental health problems, it will be more useful to apply basic methodology and interventions to treat veterans. The implementation of the family-oriented method will amplify the positive outcomes of therapy for both vets and their family members who might also experience challenges in the adjustment to a non-military environment (Osilla et al., 2018). Thus, the research will broaden the scope of my theoretical and practical skills and will contribute to the efficacy of my work.

To improve care for veterans, I aim to investigate the relations between the type of service and mental health disorders. It will contribute to the understanding of the roots of problems and, from a long-term perspective, will facilitate the interventions. Also, it would be appropriate to find more information about positive therapeutic experiences in care for veterans. Such practical implications will be the basis for improvement of session interventions aimed at dealing with different mental health problems specific for this population group.

American Psychological Association. (n.d.). The mental health needs of veterans, service members and their families . Web.

Blodgett, J. C., Avoundjian, T., Finlay, A. K., Rosenthal, J., Asch, S. M., Maisel, N. C., & Midboe, A. M. (2015). Prevalence of mental health disorders among justice-involved veterans. Epidemiologic Reviews, 37 (1), 163–176.

Fischer, E. P., Sherman, M. D., McSweeney, J. C., Pyne, J. M., Owen, R. R., and Dixon, L. B. (2015). Perspectives of family and veterans on family programs to support reintegration of returning veterans with posttraumatic stress disorder. Psychological Services, 12 (3), 187-198

Osilla, K. C., Pedersen, E. R., Tolpadi, A., Howard, S. S., Phillips, J. L., and Gore, K. L. (2018). The feasibility of a web-intervention for military and veteran spouses concerned about their partner’s alcohol misuse. The Journal of Behavioral Health Services and Research, 45 (1), 57-73.

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Psychiatry Online

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Mental Illness and Homelessness Among Veterans

  • Toorjo Ghose , Ph.D., M.S.W. ,
  • Adam J. Gordon , M.D., M.P.H. ,
  • Stephen Metraux , Ph.D. , and
  • Amy C. Justice , M.D., Ph.D.

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To the Editor: Researchers have documented mental illness profiles ( 1 ), homelessness trajectories ( 2 ), and intervention outcomes ( 3 ) among homeless veterans with mental illness. Few recent studies, however, have examined the influence of mental illness on homelessness risk in a general veteran population receiving care in the Department of Veteran Affairs (VA) health care system. Although homeless veterans report a high prevalence of mental illness ( 4 ) and incidental findings of recent studies indicate that psychoses ( 1 ) and posttraumatic stress disorder (PTSD) ( 2 ) influence homelessness risk, few studies have systematically examined various mental illnesses to identify the ones that contribute most to homelessness risk.

Addressing this need, this study examined mental illness and homelessness among 6,819 VA patients in the Veterans Aging Cohort Study, an eight-site study of veterans in VA care in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh, and Washington, D.C. ( 5 ).

Homelessness was measured as lifetime homelessness, homelessness in the past month, and shelter use in the past month. Mental illness diagnoses were obtained from hospital administrative data. The effects of depression, PTSD, anxiety, and schizophrenia were assessed in our analysis. We conducted bivariate analyses and entered significant correlates into logistic regression models.

Almost 40% of the sample (N=2,693) had experienced past homelessness; 13% (N=866) reported recent homelessness, and 11% (N=714) reported recent shelter use. Almost 11% (N=780) had a diagnosis of major depressive disorder, 9% (N=603) had a PTSD diagnosis, 6% (N=378) had an anxiety disorder diagnosis, and 4% (N=271) had a diagnosis of schizophrenia. Compared with participants without depression, a significantly higher proportion of depressed veterans reported past homelessness (60%, N=468, versus 37%, N=2,234), current homelessness (24%, N=187, versus 11%, N=682), and current shelter use (22%, N=169, versus 9%, N=544; chi square test, p<.01 for all). Similarly, veterans with PTSD and schizophrenia reported significantly higher rates of past and current homelessness than veterans without these diagnoses. When the logistic regression models controlled for age, race, gender, socioeconomic status, as well as frequency of alcohol and drug use, depression emerged as one of the strongest risk factors, doubling or nearly doubling the risk across all three measures of homelessness (past homelessness, odds ratio [OR]=2.12, 95% confidence interval [CI]=1.79–2.50; current homelessness, OR=1.95, CI=1.60–2.38; and current shelter use, OR=2.08, CI=1.67–2.58). Compared with veterans without schizophrenia, those with this diagnosis were more likely to report past homelessness (OR=2.01, CI=1.52–2.64), current homelessness (OR=1.39, CI=1.01–1.92), and current shelter use (OR=1.77, CI=1.27–2.47). PTSD and anxiety were not associated with homelessness.

The results establish priorities for mental illness treatment as a potentially effective approach to preventing homelessness among veterans: depression and schizophrenia warrant treatment first, because other mental illnesses were not associated with homelessness. Researchers have found that PTSD is usually comorbid with other psychiatric illnesses among veterans ( 1 ), which may account for the fact that its bivariate association with homelessness disappeared after the analysis controlled for other mental illness.

Given the high prevalence of homelessness in this population and the contribution of mental illness to homelessness risk, a significant step toward the government's goal of eradicating homelessness among veterans is to target veterans with depression and schizophrenia who are already in VA care. Future research needs to examine how services mediate the association between mental illness and homelessness.

Acknowledgments and disclosures

The authors report no competing interests.

1 Goldstein G , Luther JF , Jacoby AM , et al. : A preliminary classification system for homeless veterans with mental illness . Psychological Services 5:36–48, 2008 Crossref ,  Google Scholar

2 O'Connell MJ , Kasprow WJ , Rosenheck RA : Rates and risk factors for homelessness after successful housing in a sample of formerly homeless veterans . Psychiatric Services 59:268–275, 2008 Link ,  Google Scholar

3 Kasprow WJ , Rosenheck RA : Outcomes of critical time intervention case management of homeless veterans after psychiatric hospitalization . Psychiatric Services 58:929–935, 2007 Link ,  Google Scholar

4 Rosenheck R , Frisman L , Ching A : The proportion of veterans among homeless men . American Journal of Public Health 84:466–469, 1994 Crossref , Medline ,  Google Scholar

5 Justice AC , Dombrowski E , Conigliaro J , et al. : Veterans aging cohort study (VACS): overview and description . Medical Care 44(suppl 2):S13–S24, 2006 Crossref , Medline ,  Google Scholar

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Psychedelics may help treat PTSD—and the VA is intrigued

Demand from veterans for psychedelic medicine is poised to explode as research suggests it might help with post-traumatic stress disorder and depression.

Last month the U.S. Department of Veterans Affairs announced it will begin studying psychedelic medicines in veterans, requesting research proposals on methylenedioxy-methamphetamine (MDMA), psilocybin (derived from certain mushrooms), and other psychedelic compounds to stem the high rates of depression, post-traumatic stress disorder, and suicide in veterans.

More than a quarter of Iraq and Afghanistan war vets have developed PTSD since their deployment and some 8,000 service members are discharged from the military each year due to the disease. That anxiety condition and depression are largely responsible for the 17 veterans who die by suicide every day .

Advocacy groups have pressed the VA for years to take a serious look at psychedelic-assisted therapy for veterans after studies of MDMA in the general population showed it can be especially beneficial , with more than two-thirds of study participants no longer having PTSD symptoms after three sessions along with accompanying psychotherapy.

Such research in veterans as well as active-duty service members is important because their PTSD often differs from that of the general public’s, says U.S. Army Major Aaron Wolfgang, a psychiatrist at Walter Reed Army Medical Center and the Yale School of Medicine.

Rather than resulting from a single incident like a car crash or sexual assault, PTSD in service members often springs from “longitudinal traumas where they are in unsafe environments over a long period of time,” Wolfgang says. Veterans may also have compounding issues including poverty or homelessness that can further complicate their condition.

For these reasons, even “gold standard” trauma-based psychotherapies such as prolonged exposure and cognitive processing therapy may be less effective in veterans.

“Our best treatments right now still leave a lot of service members and veterans suffering,” Wolfgang says.

How much money the VA will ultimately commit to psychedelic research and how quickly the studies might begin are not clear. (The VA declined National Geographic ’s request for an interview.) The agency’s research will build on a small body of science in veterans who have improved their mental health after receiving psychedelic therapy in other countries where the drugs are legal.

One veteran who made such a trip was Jesse Gould, a former Army Ranger. During a week-long retreat in Peru in 2017 he had four experiences with ayahuasca, a brew made from several plants and shrubs containing psychedelic compounds used in some indigenous South American cultures.

By the end of the retreat, “I felt noticeably changed,” says Gould, who went on to create the nonprofit Heroic Hearts Project to facilitate similar experiences for other veterans.

“The VA should be an advocate for veterans, so it makes sense for them to conduct research,” Gould says. Even if the U.S. Food and Drug Administration were to approve psychedelic medicines, the VA will want to evaluate effectiveness and risk among its own population, he says. The first new drug application, for pharmaceutical-grade MDMA—a drug known on the street as Ecstasy—was submitted by Lykos Therapeutics late last year, and the FDA recently indicated it will decide by August whether to approve it.

( When psychedelics will be legal ?)

Myriad psychedelics are being tried

Heroic Hearts has facilitated psychedelic therapy for a thousand veterans since its founding seven years ago. The group has organized and financially subsidized retreats to Peru, Mexico, Costa Rica, and Jamaica, primarily for ayahuasca but also psilocybin and ibogaine, a compound derived from the roots of the iboga plant native to central Africa. Last year the program also brought eight veterans to Oregon after that state legalized psilocybin therapy in 2020. Treatments include weeks of group therapy preparation, one or more sessions with the drug, and months of individual and group follow-up therapy.

Independent scientists have sought to assess the program’s effectiveness, although their research is observational and considered less rigorous than comparing a treatment against a placebo. A report of eight participants published in the journal Psychological Trauma concluded that after an ayahuasca retreat five of the veterans had meaningful reductions in PTSD symptoms at the three-month follow-up. An ongoing study by Imperial College London has so far documented marked symptom improvements in 40 veterans with PTSD, although results are unpublished.

Like many veterans, Gould developed his symptoms after he ended his six-year enlistment that included three tours in Afghanistan. When he returned to his former career in finance, he found himself experiencing panic attacks, brain fog, and bouts of depression. Gould functioned sufficiently at work but drank excessively on nights and weekends.

Alarmed by his behavior, Gould went to a Veterans Affairs clinic and was diagnosed with PTSD. He recalls being told at a VA hospital that antidepressant medications might blunt his symptoms but that he’d mostly have to live with the disease. (Gould subsequently additionally diagnosed himself with traumatic brain injury from the explosive weapons he discharged.)

Treatment in Peru

Gould learned about ayahuasca from a podcast and booked a retreat in Peru in 2017. He didn’t know anyone who had done this and felt it was a drastic but necessary step. “I was treading water in my life…. If I stayed on this trajectory, I knew things would get worse for me,” he says.

Unlike psychedelics like psilocybin that often yield pleasant thoughts and imagery while consuming the drug, ayahuasca generally facilitates a physical and emotional purging. Some believe this response serves to eliminate traumas from the body.

During the first two sessions one day apart, Gould vomited, sweated, and felt filled with fear and anxiety. But after the third one he experienced a profound sense of peace. By the end of the retreat, PTSD symptoms including hypervigilance and social anxiety had disappeared and he no longer felt compelled to drink excessively. This has lasted to this day.

Preliminary research on a range of psychedelics is intriguing 

Small studies in veterans raise the possibility other psychedelics might also prove helpful. One involved 86 veterans from special operations forces who visited a clinic in Mexico to take ibogaine and 5-MeO-DMT, a psychedelic compound obtained from gland secretions of certain toads. A month later, most had significantly improved their PTSD and depression and felt more satisfaction with life.

Lykos Therapeutics (formerly MAPS Public Benefit Corporation), which submitted the FDA application, is currently enrolling veterans in the Bronx to study its MDMA therapy in this group.

While all the research in veterans is preliminary, the results are encouraging, says Alan Davis, director of the Center for Psychedelic Drug Research and Education at Ohio State University who coauthored the Mexico study.

But the challenge the field faces is that the studies are small, observational, and they haven’t followed veterans for the years needed to determine if the benefits are long-lasting, Davis says. This is especially a concern with those who take the drugs during a foreign retreat.

“People are down there for a couple of days to a week and then they have to go home and be back in their same environment that they were struggling in,” they say. And while some clinics and programs, including Heroic Hearts, provide what Davis says is crucial ongoing psychological support in the months following treatment, not all do.

More research is also needed to better understand the dangers. With Ibogaine, for example, there are concerns it may harm the hearts of some users.

Urging the VA to plan for approval of psychedelic therapy

Juliana Mercer, director of the nonprofit Healing Breakthrough that has advocated for veteran access to MDMA, believes that if the FDA were to approve psychedelic therapy, demand among veterans will skyrocket.

When 21 active-duty service members and veterans with traumatic brain injuries were surveyed about their thoughts concerning this treatment, most initially expressed only moderate interest , with some believing it might trigger undesirable personality changes. But once they learned about the results of the research, many were eager to try it.

Healing Breakthrough wants the VA to begin planning for how they might administer psychedelic therapy and to whom.

“If they don’t start now to work out the logistics and start training clinicians, MDMA is going to be approved and they’re not going to be ready to implement this life-saving treatment,” says Mercer, a Marine Corp veteran who experienced MDMA therapy under a limited compassionate-use program.

( Psychedelic medicine is coming—but who’s going to guide your trip? )

Such logistics will be formidable, says Wolfgang, who has written about the challenges the VA and U.S. Department of Defense will face. For one, roughly 80 hours of professional therapy time is required for a single person to receive MDMA-assisted therapy, including the two therapists in the room for three multi-hour sessions plus introductory and follow-up psychotherapy.

Wolfgang worries that should a long waiting list eventually emerge at the VA, some veterans might turn to illegal sources of the drugs, which are often adulterated with other substances and are taken without medical oversight.

Veterans might falsely think, “I can go and improve my PTSD or depression if I take some illicit compound I get from my friend,” he says. Then, rather than possibly receiving benefits from the drug, they’d be “subjecting themselves to potential harm.”

Read This Next

When will psychedelics be legal, ketamine helps with depression. is it right for everyone, what happens to your body when you’re in love and heartbroken, 9 simple ways to boost your mental health, according to science.

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U.S. Government Accountability Office

VA Health Care: Opportunities Exist to Further Meet Student Veterans' Mental Health Needs

Research suggests that student veterans are more likely to suffer from mental health challenges, including depression and anxiety, than other students. To help, the Veterans Health Administration partners with some colleges and universities to provide campus-based mental health care and other support for student veterans.

As of October 2023, roughly a quarter of VHA's health care systems offered this program. It may be hard for additional VHA systems to learn how to implement it as VHA only provides information about it on request. We recommended that VHA regularly provide information about the program to all of its health care systems.

A person in amilitary uniform sitting across from a therapist or counselor.

What GAO Found

The Department of Veterans Affairs (VA) provides health care to veterans for mental health conditions, such as depression and substance use disorders. VA data showed that the percentage of student veterans who received mental health care at VA facilities increased from fiscal years 2017 through 2022, and at a higher rate than that of the total veteran population. (See figure.) VA data show student veterans were primarily treated for depression-related disorders, post-traumatic stress disorder, and anxiety-related disorders. VA officials said younger veterans typically seek mental health care more than older veterans, and most student veterans are younger than age 34. Further, the COVID-19 pandemic exacerbated mental health conditions for the general population, including for veterans.

Comparison of Student Veterans and All Veterans Receiving Mental Health Care at VA Facilities, Fiscal Years 2017 through 2022

Comparison of Student Veterans and All Veterans Receiving Mental Health Care at VA Facilities, Fiscal Years 2017 through 2022

Note: The percentages reflect student veterans and all veterans receiving mental health care (i.e., at least one visit for any mental health diagnosis), among student veterans and all veterans who received any health care at VA facilities, respectively. In fiscal year 2022, 261,000 student veterans and 5,966,000 veterans in total received health care at VA facilities.

VA administers the Veterans Integration to Academic Leadership program to support the mental health needs of student veterans. Under this voluntary program, VA health care systems—including medical centers and other facilities—can partner with local colleges and universities to provide campus-based mental health support to student veterans. As of October 2023, 32 of 139 health care systems have such programs. However, GAO found VA does not communicate comprehensive information to its health care systems to help them consider when and how to implement programs, such as the types of staffing needed. Instead, VA communicates information about the program upon request. By more regularly communicating comprehensive information across its health care systems, such as through guidance, VA could help ensure its systems all have the information they need to consider participating in the program. This, in turn, would help ensure VA's ability to support the mental health needs of its student veteran population.

Why GAO Did This Study

Mental health conditions have been a persistent and growing issue for the nation's veterans. Research suggests that student veterans—those pursuing a course of education using VA's educational assistance benefits—are more likely to experience anxiety, stress, depression, and suicidal ideation than their nonveteran peers.

The Support the Resiliency of Our Nation's Great Veterans Act of 2022 includes a provision for GAO to study the mental health needs of student veterans. Among other objectives, this report (1) describes what available VA data show on the use of mental health care by student veterans and (2) examines VA efforts to address the mental health needs of student veterans through its Veterans Integration to Academic Leadership program.

GAO reviewed VA documentation and data for fiscal years 2017-2022 (the most recent available) on mental health care use and diagnoses and conducted a literature search. GAO also interviewed officials from VA and a non-generalizable selection of three veterans service organizations, as well as 12 student veterans identified by one of the veterans service organizations.

Recommendations

GAO is making one recommendation to VA to communicate comprehensive information on when and how to implement a Veterans Integration to Academic Leadership program across its health care systems on a regular basis, such as by distributing guidance. VA concurred with GAO's recommendation.

Recommendations for Executive Action

Full report, gao contacts.

Alyssa M. Hundrup Director [email protected] (202) 512-7114

Office of Public Affairs

Chuck Young Managing Director [email protected] (202) 512-4800

ProPublica

How the VA Fails Veterans on Mental Health

by Kathleen McGrory and Neil Bedi

This article contains descriptions of mental illness and suicide.

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

A veteran with a known history of suicidal thoughts showed up at a St. Louis hospital before dawn one morning and was left unmonitored in an exam room for hours.

Another was deemed at risk of suicide by a hospital psychiatrist in Washington, D.C., then forcibly discharged, even as he tried to stay, by the same hospital’s emergency department.

Another still in Pittsburgh was assigned a behavioral health nurse who failed to complete thorough suicide screenings or review his suicide safety plan, and didn’t follow up when he said he wished he was dead.

In all three cases, independent inspectors documented serious failures by the Department of Veterans Affairs. And in all three cases, the veterans involved went on to kill themselves or other people.

The lapses were similar to ones examined by ProPublica last week in an investigation of the VA’s handling of two veterans with serious mental disorders. Both suffered for years with inadequate care from the same clinic in Northern California, they told reporters. Their stories ended in tragedy.

The problems appear to be systemic. Over and over, the hospitals and clinics in the VA’s sprawling health care network have fallen short when it comes to treating people with mental illness.

That conclusion emerges from a ProPublica review of all of the reports published by the VA’s inspector general since 2020. That includes 162 regular surveys of facilities and 151 investigations that were triggered by a complaint or call to the office on a wide variety of alleged health care problems.

If you or someone you know needs help:

  • Call the National Suicide Prevention Lifeline: 988
  • Text the Crisis Text Line from anywhere in the U.S. to reach a crisis counselor: 741741
  • If you are a veteran, call the Veterans Crisis Line: 988, then press 1

Issues with mental health care surfaced in half of the routine inspections. Employees botched screenings meant to assess veterans’ risk of suicide or violence; sometimes they didn’t perform the screenings at all. They missed mandatory mental health training programs and failed to follow up with patients as required by VA protocol.

One in 4 of the reports stemming from calls or complaints detailed similar breakdowns. In the most extreme cases, facilities lost track of veterans or failed to prevent suicides under their own roofs.

Sixteen veterans who received the substandard care killed either themselves or other people, the review revealed. An additional five died for reasons related to the poor care, such as a bad drug interaction that the reports say could have been prevented. Twenty-one such deaths is a meaningful count even for a health care system that has more than 9 million people enrolled, in the view of Charles Figley, a Tulane University professor and expert in military mental health. The VA has struggled with mental health care for decades, he said. “It’s a national disgrace.”

For grieving family members, it is incomprehensible. “It was never my expectation that [the VA was] going to solve his problems,” said Colin Domek, the son of the veteran in Pittsburgh. “My expectations were that someone who was saying ‘help me’ would receive some kind of help.”

The inspector general reports reviewed by ProPublica have limitations. The individual investigations can be narrow. The reports offer only broad suggestions as to whether individuals should be held accountable for breakdowns and provide little sense of whether they actually were. Even together, they don’t capture the full reality of the VA’s 1,300 health care facilities. But they do start to assemble a meaningful picture of the system’s most chronic shortcomings when it comes to treating people with mental illness.

The VA declined requests for an interview for this story. In a statement to ProPublica , VA press secretary Terrence Hayes said “there is nothing more important to VA than providing high-quality mental health care to Veterans” and that the agency was “grateful” to the inspector general’s office for its oversight. He noted that last year, more than 80% of veterans who participated in VA surveys reported being satisfied with the mental health care they received through the agency.

In a separate statement, VA Inspector General Michael Missal said, “Our reports have repeatedly illustrated that it is critical that [Veterans Health Administration] leaders remain vigilant to problems, ensure care is coordinated, and take swift, responsive actions that address root causes and promote accountability.”

The VA’s health care system is the nation’s largest. The agency operates about 170 medical centers and 1,100 outpatient sites, and it provides counseling services at some 300 facilities known as vet centers. In the last fiscal year, the VA provided mental health services to about 2 million veterans, according to agency figures.

The system has notable strengths. The VA has played an important role in developing treatments for conditions such as post-traumatic stress disorder and traumatic brain injury, and provides critical training opportunities for psychiatrists, psychologists and social workers nationwide.

But the number of suicides among veterans has remained stubbornly high, ticking up to 6,392 in 2021, the most recent year in agency statistics . And acts of violence by veterans with mental illnesses have continued making news, including two mass shootings in Atlanta last year alone.

Experts told ProPublica the failures revealed in the inspector general reports point to broad problems, including inadequate mental health staffing, outdated policies and the inability to enforce high standards across a large, decentralized health care network.

“It’s a very sad thing,” said M. David Rudd, a psychology professor at the University of Memphis for whom the Rudd Institute for Veteran and Military Suicide Prevention is named. “You can sit here today and predict with great accuracy how many deaths there are going to be over the next five years. Yet there are unlikely to be any meaningful, significant changes.”

When there are allegations of patient care issues, mistakes or policy violations inside a VA health care facility, it is often up to the agency’s independent inspector general to investigate. The office can then write a report explaining what happened and offering recommendations for improvement. Facilities typically follow the recommendations.

The inspector general’s reports don’t name the veterans or any doctors or nurses — a deliberate choice intended to protect their privacy. They obscure gender and specific dates, too. In several cases, however, ProPublica was able to match details from the reports with information contained in news stories or lawsuits and interview the veteran’s relatives.

One of those cases involved Kenneth Hagans, a 60-year-old father of four who served as a private in the Army in the early 1980s.

In September 2021, Hagans showed up at the John Cochran Veterans Hospital in St. Louis complaining of bladder problems and depression, records show. By then, he had been receiving care at the facility for more than two decades and treated for substance abuse and suicidal thoughts.

The nurse who first saw Hagans that morning determined he was not at risk of self-harm. But instead of using the computer to call up a questionaire to assess his risk of suicide, the nurse recited the questions from memory, then left Hagans unmonitored in an exam room.

The nurse claimed to have notified the on-call physician, who was “resting” on a stretcher in another exam room when Hagans arrived, according to the inspector general report on the case. But video footage did not support that claim, the report said. A second nurse alerted the physician an hour after Hagans’ arrival. But the physician was feeling the effects of a vaccine and slow to respond, the physician told investigators.

An hour after that, Hagans was found dead in the exam room. He had used a cord to take his own life.

The inspector general report, which was published in June, found that the nurse had failed to monitor Hagans and that the nurse and physician were responsible for a delay in his care. It also raised questions about the quality of the suicide screening Hagans received. (Later, when asked by investigators to recall the questions on the assessment by memory, the nurse could not, records show.)

Additionally, the report drew attention to an email sent by an emergency department leader regarding the inspector general’s investigation into Hagans’ death. “Everybody needs to know this is NOT the opportunity to air grievances,” the leader wrote to a staff physician. “The [inspector general] will be trolling for evidence of leadership and administrative malfeasance that allowed a veteran to kill himself in our [emergency department]. Appropriate responses to direct questions are: yes, no, I don’t know, and I don’t remember. BOOM!”

The inspector general recommended that the medical center standardize its processes for suicide screenings and monitoring patients — and that local leaders in St. Louis investigate the possible interference in the inspection. In a written response to the report, facility director Candace Ifabiyi did not challenge any of the inspector general’s findings and said she agreed with the recommendations.

Hagans grew up as one of eight siblings in Hammond, Louisiana. As a kid, he hopped onto trucks bound for New Orleans and hung out in the French Quarter. He saw an opportunity in the Army, his son Graie told ProPublica. But in the years that followed, he struggled with drug addiction and homelessness. He was in and out of his children’s lives.

Hagans never talked about any traumatic experiences he had while serving in the military, Graie said. But in 2017, he started getting help for post-traumatic stress disorder stemming from that period in his life. The treatment, which he got through the VA, was making a difference, Graie said. “He was learning about the impact of PTSD on his life,” he said. “Some things were making more sense about his behavior.”

Graie was stunned to learn the circumstances of his father’s death, he said. His call with a hospital official that day raised questions. Shouldn’t the VA hospital system that treated his father for psychiatric issues have been familiar with his mental health history? Shouldn’t the staff have kept an eye on him?

Hagans’ death could have and should have been prevented, Graie contended. “There’s an institutional and structural failure if what happened to my dad can happen inside a VA hospital,” he said.

In a statement to ProPublica, the VA St. Louis Health Care System expressed its “deepest condolences to Mr. Hagans’ family and friends.” The statement added that health system leaders had established standard policies for suicide screenings and monitoring patients, and initiated “appropriate personnel action” for individuals involved in the case. The health system declined to share specific details.

Hagans’ case was not an anomaly, ProPublica’s review of records found. Many of the breakdowns in care involved problems with screenings for the risk of suicide and violence.

Screenings are simple; they generally entail asking a patient a few questions about their thoughts and actions to assess their potential of self-harm or violence. But research has shown they can help save lives.

Screenings played a key role in the case of Nicholas Domek, a former Army engineer and demolition expert whose three decades in the military included serving overseas in Operation Desert Storm and in the Army Reserves.

In 2018, Domek attempted suicide and was admitted to the Pittsburgh VA’s inpatient mental health unit. He also attempted to kidnap his former domestic partner and, in early 2019, was readmitted to the mental health unit for homicidal thoughts.

The VA gave Domek a designated behavioral health nurse practitioner; the two met monthly after his second hospitalization. The nurse practitioner documented Domek’s thoughts of suicide after each of their four visits, according to the inspector general report. But there was no evidence the nurse practitioner did a thorough suicide risk assessment or reviewed Domek’s suicide safety plan as protocol dictates.

Two weeks after Domek’s last meeting with the nurse practitioner, Domek killed the former domestic partner, Mary Jo Kornick. He then killed himself.

The nurse practitioner could not remember why no risk assessment was done, the report said. The inspector general determined the nurse practitioner had copied and pasted information from prior visits throughout his records, making them difficult to follow and interpret.

Domek’s son Colin told ProPublica the nurse practitioner should have done more. He said the nurse practitioner knew about his dad’s plans; he had been in the room when his father told the nurse practitioner he intended to kill both himself and Kornick, he said.

Colin Domek described his father as a hard worker who enjoyed fishing and geocaching, a recreational activity in which participants search for hidden objects outdoors. He loved being a soldier, Colin said, and the whole family took pride in his service. One year at Christmastime, they decorated their tree with tiny paratroopers. The family was on the local news when Domek deployed to Iraq.

More recently, though, Nicholas Domek had had his left leg amputated and struggled with depression, Colin said. He’d started seeing a mental health professional and trying medications. “In his mind, the VA was going to take care of him,” Colin said. “It was never a thought to see someone outside the VA. That was never on the table.”

The tragedy ravaged a second family. Kornick was a loving mother and grandmother who worked at a home for older people, her daughter Sherry Kornick told ProPublica. She loved to laugh and play pranks. She made up songs to make people smile.

She was killed the day before Mother’s Day. “I don’t even want to celebrate Mother’s Day” anymore, Sherry said, breaking down into tears. “And I realized it’s not fair to my kids who want to celebrate me.”

In its investigation, the inspector general determined the nurse practitioner had made similar missteps with at least seven other patients and had copied and pasted “significant sections of notes” from prior evaluations in 97% of the 143 patients’ health records it reviewed.

The report on the case recommended that the VA’s Pittsburgh health system consult with its human resources and legal teams to “determine whether personnel action [was] warranted.” The facility director agreed with the recommendation but noted the nurse practitioner retired in January 2022.

In a statement to ProPublica, the Pittsburgh health system said it was “devastated when [it] learned about the challenges Mr. Domek faced and took immediate action to prevent another Veteran from having a similar experience.” That included developing a refresher training program for suicide-risk evaluation and management as well as a new template for electronic health records.

Other VA facilities missed screens, too, ProPublica’s review found. At one Arizona hospital, a social worker didn’t screen a veteran who called to reestablish mental health care, instead referring the veteran for psychological diagnostic testing. The veteran wasn’t offered treatment for a month and later died by suicide. A South Carolina hospital didn’t do a suicide risk assessment on another veteran who was being released from its inpatient mental health unit as VA policy requires. That veteran also died by suicide.

There were other cases, too, in which veterans with serious behavioral health issues were overlooked or didn’t get the help they needed.

The VA Medical Center in Houston, for example, lost track of a veteran with chronic schizophrenia who sought treatment at the facility’s emergency room in 2020 for back pain. The veteran was found off-site four days later in cardiac arrest and died the next day, according to an inspector general report . In interviews with the investigators, hospital staff said the veteran had been shuttled between departments due to possible COVID-19 symptoms and then wandered off. In a statement to ProPublica, Houston health system leaders said the situation did not “represent the quality health care southeast Texas Veterans have come to expect from Houston VA” and that they had improved their COVID screening processes and trained employees on wandering patients.

At the VA Medical Center in Washington, D.C., a psychiatrist found a veteran with drug withdrawal symptoms to be at moderate risk of suicide and recommended in-patient treatment. The psychiatrist walked the veteran to the facility’s emergency room for follow-up. But doctors there didn’t read the psychiatrist’s notes and determined the veteran should be discharged. When the veteran refused to leave, an attending physician called the VA police and was heard saying the veteran could go shoot himself. The veteran died from a self-inflicted gunshot wound six days later.

Hospital leaders agreed with the findings in the inspector general report and noted that the physician who made the insensitive remark was replaced as a contract provider. They told ProPublica in a statement that a second physician on contract had resigned from the facility.

Experts say such missteps often stem from the fact that employees are overworked and undertrained.

Demand for mental health services within the VA has been surging , and the system has long endured mental health provider shortages. A survey published by the inspector general in August found that more than three quarters of the VA’s 139 networks of hospitals and associated clinics had reported “severe” shortages of psychiatrists, psychologists or both.

Separately, a report from the Government Accountability Office from 2022 concluded that one-fifth of all large VA health care facilities failed to meet requirements that mental health providers be available within primary care settings to help assess veterans and follow up with their care. The facilities said “persistent staffing challenges” were largely to blame.

The VA is far from the only health care organization that has had difficulty filling critical behavioral health positions amid a national shortage of providers in recent years. But Carl Castro, a professor at the University of Southern California and director of its Center for Innovation and Research on Veterans and Military, said the VA in particular has struggled to compete for providers.

“The system doesn’t pay them enough money,” he said. “It works them to the bone. That’s why it is hard to recruit people.”

Indeed, in exit interviews, VA psychologists cited insufficient pay, too much work and job stress as among the top five reasons they left their positions, according to data published by the VA in October.

The VA, for its part, has steadily increased its funding for mental health over time, federal budget data shows. In 2022, the figure surpassed $13 billion, up from about $6 billion a decade earlier. In 2022, mental health was about 13% of the total health care budget. In 2012, it was about 12%.

Agency leaders have acknowledged that growing the mental health workforce is a priority. They recently announced a targeted hiring initiative intended to bring 5,000 new mental health professionals into the system over the next five years. The agency also boosted the pay range available for staff psychiatrists last year and is offering more flexible schedules to employees to help battle burnout, it said.

“We are fully engaged in a multi-faceted strategy to attract qualified candidates, leverage all flexibilities and incentives to meet the workforce needs, and monitor staffing ratios and other data regularly to help inform facility staffing priorities and decisions,” the agency said in a statement to ProPublica.

Aside from staffing issues, experts said the VA struggles with consistency across its huge system, which is broken down into 18 regional networks and dozens of smaller hospital systems, each with its own leaders and policies. “If you’ve seen one VA facility,” said Alyssa Hundrup, a director on the Government Accountability Office’s health care team, “you’ve seen only one VA facility.”

The national policies alone have generated confusion, the reports showed. According to the inspector general’s office, two of the handbooks describing the mental health policies all VA facilities must follow had been outdated for years. One was missing the agency’s most recent guidance on managing patients at risk of suicide or suffering from PTSD or major depressive order.

Dr. Sandro Galea, dean of the Boston University School of Public Health who chaired a congressionally mandated committee on the treatment of PTSD in military and veteran populations a decade ago, said the individual tragedies highlight the need for a wholesale look at the VA’s mental health care system “to identify gaps and holes.”

“That needs to happen,” Galea said. “It’s clearly time.”

Emma Dash is sure something needs to be done. Her husband, a 33-year-old Army veteran named Brieux Dash, was struggling with PTSD when he was involuntarily committed to West Palm Beach VA Medical Center in 2019. He took his own life during his stay.

Dash had been a wheeled vehicle mechanic in the Army from 2006 until 2015. He deployed to Iraq twice, his Army records show. When he returned home the second time, he was different, Emma said. He would scream in the middle of the night. Sometimes, he erupted into violence in his sleep.

Emma, who worked in the West Palm Beach VA medical center’s pharmacy department, had her husband committed to the medical center’s inpatient mental health unit once before, she said. “It got him back to being him,” Emma recalled. So when he attempted suicide at home in 2019, she followed a similar course of action.

The VA’s inspector general later found that a nursing assistant who had been assigned to do patient safety checks every 15 minutes the day Brieux Dash died had also carried out other tasks contrary to unit protocol. In addition, video cameras that were supposed to help monitor patients hadn’t worked in years.

The findings shocked Emma, who had believed the facility was the best equipped to help her husband. She sued the VA in 2022 and settled for $5.75 million last year, an amount her lawyer characterized as “historic.”

In a statement to ProPublica, the West Palm Beach VA Medical Center said it installed sensor alarms and new surveillance cameras after Dash’s death and added a new checklist to address environmental risks for patients on inpatient mental health units. “Anytime a Veteran in our care dies by suicide,” the statement said, “it is heartbreaking.”

Emma Dash had a simple message for the VA, she told ProPublica: “Do better!”

If you have information about mental health care services provided by the VA, email [email protected] .

How the VA Fails Veterans on Mental Health

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Prevention of cerebrovascular diseases and cognitive impairment in psychiatric and neurological practice: A literature review

https://doi.org/10.14412/2074-2711-2016-3-95-100

For citations:

Merkin A.G., Kazhin V.A., Komarov A.N., Fonarev A.V., Priyatel V.A., Nikiforov I.A. Prevention of cerebrovascular diseases and cognitive impairment in psychiatric and neurological practice: A literature review. Neurology, Neuropsychiatry, Psychosomatics . 2016;8(3):95-100. (In Russ.) https://doi.org/10.14412/2074-2711-2016-3-95-100

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A. G. Merkin Institute for Advanced Training, Federal Biomedical Agency of Russia, Moscow, Russia 91, Volokolamskoe Shosse, Moscow 125371 Russian Federation

V. A. Kazhin Institute for Advanced Training, Federal Biomedical Agency of Russia, Moscow, Russia 91, Volokolamskoe Shosse, Moscow 125371 Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia, Perm, Russia 26, Petropavlovskaya St., Perm 614990 Praxis Schaffhausen, Switzerland Bachstrasse 40, 8200 Schaffhausen, Switzerland Russian Federation

A. N. Komarov Clinical Hospital, Presidential Administration of the Russian Federation, Moscow, Russia 45, Losinoostrovskaya St., Moscow 107150 Russian Federation

A. V. Fonarev N.I. Pirogov Russian National Research Medical University, Ministry of Health of Russia, Moscow, Russia 1, Ostrovityanov St., Moscow 117997 Russian Federation

V. A. Priyatel Central Mental Hospital, Federal Biomedical Agency of Russia, Moscow, Russia 12, Kriulinsky Passage, Elektrostal, Moscow Region 144001 Russian Federation

I. A. Nikiforov Institute for Advanced Training, Federal Biomedical Agency of Russia, Moscow, Russia 91, Volokolamskoe Shosse, Moscow 125371 Russian Federation

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Lack of access to mental health services contributing to the high suicide rates among veterans

Ronald d. hester.

Health Care Administration, Nicole Wertheim College of Nursing & Human Services, Florida International University, Miami, FL 33199 USA

The United States has become a country that is constantly at war. This situation has created a crisis amongst our veterans. The current uneven access to appropriate mental health services that returning U.S. veterans encounter echoes the disparities in access to quality mental health services for the general population. The information presented here shows that the shortcomings of our health care system in addressing the mental health needs for our returning veterans may lead to the high suicide rates. Addressing the problem of inadequate access to quality mental health services is critical in any efforts to reforming the U.S. health care system. Our findings suggest that mental health disparities are often a leading factor to the high suicide rates among veterans who experience depression and Post-Traumatic Stress Disorder. To improve the health and well—being of our veterans who have served this nation, requires a collaboration between public and non—profit mental health providers at the State and local levels. It is imperative that we increase the availability of crisis intervention and mental health services for all veterans that have served this nation.

Many recent reports have identified that individuals enlist for many reasons, often due to patriotism, educational benefits, a family tradition of military service and financial inducements. [ 1 ].This may help explain why young adults enlist in the armed forces. Many youth often believes that they are invincible and one never thinks that they could get killed or seriously injured in a combat zone. Many recruits are high school graduates with limited job prospects and the military seems like a place to get a job and learn some skills. The reality is markedly different. Our soldiers today fight wars unlike any others who have fought. They fight a largely unseen enemy and face casualties from IEDs and suicide bombers. Many are injured and maimed by unseen foes. They fight for unclear objectives and end up coming home with limited skills and in many cases with severe physical and mental injuries. They are often separated from the military service with questionable employment prospects. A number of veterans experience depression, loss of purpose present, in some cases, an overwhelming family crisis. Their mental health difficulties profoundly touch the lives of the U.S. general public.

Recent reports documents that military personnel have experienced conditions that may have affected their mental well-being [ 2 ]. Their efforts to gain access to quality psychological health services after multiple deployments are often met significant obstacles. This lack of access to critical mental health services may led to suicidal behavior, especially among young military veterans who have completed multiple deployments to Afghanistan and Iraq. Recent data on suicide rates among Army veterans, reported by the Department of Defense (DOD), showed an increase of more than 18% from 2011 to 2014 [ 3 ]. The Department of Veteran Affairs (DVA) is now struggling to find solutions to this national crisis for our veterans.

The rate of suicidal deaths is considerably high in the veteran populations. For example, the rate of suicides among women veterans is 35 per 100,000, a rate that is much higher than their civilian counterparts [ 2 ]. Suicide in civilian populations is addressed, for example, by community-based mental health treatment providers such as Baltimore Crisis Response Inc. (BCRI), which serves the Greater Baltimore region, through a Crisis Response Hotline; mobile crisis response teams; and mental health and substance abuse treatment beds for inpatient treatment services. These and similar suicide prevention programs have proven to be successful in lowering suicide rates for the civilian population in urban communities such as Baltimore, and Boston.

These resources are not readily available at most VA Hospital and Health Systems due to the shortage of critical mental health personnel and the general lack of support in addressing crisis-intervention issues. As a result, veterans who do not rely primarily on the VA health care delivery systems to address their mental health needs once they return home from combat, do not have easy access to these critical crisis-intervention services [ 4 ].

In the civilian population, the disparities in mental health treatment often stem from the lack of mental health coverage in employment-based health insurance plans. Except for employers that sponsor health insurance plans for low-wage employees, mental health benefits are not covered under most managed care health plans provided by small businesses [ 5 ]. Many low-wage earners cannot afford a supplemental health insurance plan that would include a comprehensive mental health benefit to address crisis-intervention needs of family members who may experience depression, anxiety, and Post-Traumatic Stress Disorder (PTSD); substance abuse; and difficulties with anger management. As a result, they are not covered for crisis-intervention needs that affect many veteran families during this time of social and economic stress [ 6 ]. Consequently, when a mental health crisis occurs, these families must rely on public-supported programs funded under the State Mental Health Services Block Grant program (Table  1 ).

Table 1

Suicide rates by sex and calendar year, suicide rate (per 100,000 person—years)

Source: U.S. DVA, Office of Suicide Prevention, 2016

The rate of suicides among users of VHA services have remained relatively stable in recent years

In Florida, a new mental health law was established in 1972, called the Baker Act. This Florida Public Law was established to enable families and loved ones to gain access to emergency mental health services and temporary detention for individuals impaired because of a mental illness. This law allows the family to assist their family members, who have experienced a mental health episode to gain the help that they need in the form of mental health treatment services. This type of program is needed in other States, to address the needs of mental health patients who are veterans, and the general public.

Many members of our military have experienced mental health problems prior to entering the military that were not treated. Once these individuals enter the military, their mental health conditions are often not detected or untreated [ 7 ]. As a result, when they re-enter society as veterans these mental health conditions may have intensified due to combat stress and PTSD. Other conditions such as combat injuries, depression, unemployment, financial stress, alcoholism, and the inevitable family discord contribute to the higher rates of mental illness.

Consequently, an increasing number of our veterans are now homeless, experiencing substance abuse problems and gambling addictions, which often lead to suicide attempts and even death [ 8 ].

The Affordable Care Act does not address the issue of expanding mental health coverage and benefits for low-wage earners under the new health plans that are available to them in recent years [ 9 ]. Not requiring mental health benefits as part of the mandated health benefit package is considered one of the weaknesses of the new health care law. Mental health coverage is still a great hurdle for millions of Americans at a time when various approaches to health care reforms are being considered. Many of the reforms being considered would increase out-of-pocket cost and lower benefits for many veterans. Because of the excessive cost of providing comprehensive mental health benefits under existing employer-sponsored health plans for returning veterans, these benefits are often excluded. Thus, many Americans who experience mental health problems have no access to health insurance coverage to pay for their mental health treatment [ 10 ].

The mental health crisis is a major dilemma for a growing number of Americans. The American Mental Health Association (AMHA) reported that at least 20% of all Americans are uninsured for mental health services and must rely on public hospitals to receive mental health services to address primary-care crisis intervention needs for themselves and family members. This lack of basic mental health benefits in the general public occurs at a time of mental health crisis exacerbated by the large numbers of veterans returning home from combat and often experiencing depression, substance abuse and family crisis.

Schoembaum and Kessler [ 11 ] examined common mental health disorders among Army participants and whether the disorder developed prior to entering the Army. They found in their landmark study that the most common disorders for Army participants was ADHD and intermittent explosive disorders, both are mental health predictors for suicide and accidental death based upon the results from the Army Study to Assess Risk and Resilience in Service members (Army STARRS).

The crucial issue of mental health care for veterans is more important than ever before due to the considerable number of veterans returning from combat missions who have experienced episodes of PTSD and other mental health conditions. More than 1.5 million of the 5.5 million veterans seen in VA hospitals had a mental health diagnosis in 2016. This represents about a 31% increase since 2004 [ 12 ]. Diagnosis of PTSD is on the rise, as the changing nature of warfare increases the chance for injuries that affect mental health and as our veterans face significant challenges upon returning home [ 13 ]. The potential negative effects of mental health issues, such as homelessness and suicide, affect the more than 107,000 veterans who are homeless on any given night. Current data reports that on average at least 21 veterans die by suicide each day, which makes the response to veteran mental health needs more urgent with each and every day [ 14 ].

To address this challenge, the VA has significantly invested in our mental health care workforce, hiring more than 6000 new mental health care workers since 2005. On August 31, 2012, President Obama signed an Executive Order to direct the VA to expand health manpower resources by encouraging collaboration arrangements with nonprofit organizations to work with the VA in their communities to expand the availability of health professionals by 2013, to address the problem of suicide among veterans.

President Obama signed into law The Suicide Prevention for American Veterans Act of 2015. This law requires an independent review of all Veteran Administration and Department of Defense programs aimed at preventing suicides, creates per review support and community outreach pilot programs and forms a program to repay loans debts for psychiatry students to incentivize them to work for the Veteran Administration Health System. It also creates a website to provide veterans with information about mental health services and allows the VA Health System to collaborate with non-profit mental health organizations on suicide prevention.

The challenges facing the VA are very complex and only one-third of our veterans are in the care of VA Hospitals and Health Systems [ 6 ]. Those who are employed often choose to use their private health insurance plans rather than the VA system. Veterans who are unemployed, a percentage that was recently reported at 5%, often experience the shortcoming of our health care system, which may be a contributing factor to high suicides rates.

The Veterans Administration needs to develop a new strategy with the focus on crisis intervention prevention. The existing strategy major focus is on the development of a hot-line to allow veterans to communicated with an individual, who may not be a mental health expert to assist them to consider other options than suicide. I would suggest the following crisis intervention strategy to address this problem by the Veterans Administration and the Department of Defense:

  • Establish a 30 day exist period once they are discharged to offer the each veteran, job counseling, drug prevention education, housing support and marriage counseling;
  • Establish mental health and substance abuse treatment beds for inpatient drug treatment at each regional Veteran Medical Facility; and

This program has proven successful in Baltimore and other communities to address suicide prevention in the general community.

Conclusions

It has been widely reported that the VA needs to do a better job of developing strategies for routine mental health screening and early intervention for all service members before they return to civilian life. This effort would entail identifying the several signs and symptoms that veterans may display prior to attempting suicide: (1) depression, (2) sleeping poorly, (3) losing weight, (4) telling family members they feel like a burden on their spouse, (5) drinking, and (6) using drugs. Given that this information often provides a clearer picture of potential mental disorders and indications that a veteran may be contemplating suicide, a plan of intervention based on these signs could be the first step for a crisis intervention team to provide needed assistance and conduct a psychiatric evaluation.

With a volunteer military force, a very small segment of the general population—estimated at only 2%—participates in the military. As a society, we do not experience the brunt of the hardship of losing a loved one when a veteran has committed suicide. We must do more to reach out to the veterans who are served by the VA Medical System and those that are currently not being served by the Veterans Administration System, but by our private and public health care system, to ensure that they get the help that they need.

Acknowledgements

The author wishes to thank Mr. Alan Gold, President, US Neurosurgical Inc., for his support and comments during the development of this manuscript.

Competing interests

The author declares that he has no competing interests.

Available of data and materials

No datasets were generated during the current study.

Consent for publication

Not applicable.

Ethics approval and consent to participate

No animals were used in this study.

No outside funding for this manuscript.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Mental Health Care Services for Veterans Essay

Service delivery system, financing of policy, political, administrative, and financial feasibility.

This program is proposed as a federal service delivery system. To guarantee that this requirement is met and the policy falls within federal jurisdiction, it is essential to address four dimensions of the program. First, it is federal because outright money payments and strict control over implementation are required. Because veterans served the state, it is imperative to assure that they are treated with equal respect and provided with adequate care across the country. The federal government is the only body that has enough resources and authority to support this initiative. Second, it is a direct service delivery system, i.e. the government is the direct and only supplier of healthcare services (Sanborn, 2013). Moreover, a high level of centralization is recommended, as it is assumed that strictly centralized program control is key to its success. Finally, this initiative requires detailed actions and decisions, which are closely connected to the determination of eligibility (Birkland, 2011). Meeting these criteria would make the program a federal fall within federal jurisdiction.

Because this initiative is a federal program, the federal budget is the main source of financing. Here, the foundation for allocating resources is the Tax Code, as taxes make up the basis of the state budget, and are later redirected to funding healthcare needs (Oliver, 2014). Nevertheless, just like in the case of other federal programs, additional sources of financing are acceptable. For instance, necessary funds can be withdrawn from state and local budgets. Moreover, the role of powerful private organizations such as the American Medical Association should not be underestimated, as their donations can help fill the existing funding gaps (Barr, 2016). Another option is attracting private contributions to healthcare units constructions or seeking discounts for providing healthcare services to those, who fall within the requirements of the program (Gholipour & Rouzbehani, 2016). Even though the last two recommendations are not directly connected to financing the initiative, they are beneficial for guaranteeing its success and addressing the mental needs of veterans as well as making the program more easily accessible.

The political feasibility of a governmental program can be determined by estimating the current situation in the existing environment and identifying barriers and opportunities for introducing the change (Mason, Gardner, Outlaw, & O’Grady, 2016). As for now, the issue of veterans’ mental health is addressed by another federal program – Veteran Health Administration. Nevertheless, access to adequate care is limited. Moreover, some significant problems such as high suicide rates among veterans are not addressed on a nationwide basis (Bagalman, 2016).

As for barriers and opportunities, the focus is usually made on the perception of implementing the proposed change (Patel & Rushefsky, 2014). Bearing in mind existing problems, launching a separate program focused on mental needs is recommended and politically feasible, as it would improve the image of the government. Speaking of administrative feasibility, the primary challenge is to determine who is eligible to care. However, in this case, the program is feasible because the government already has developed frameworks for drawing appropriate conclusions. That is why carrying it to another policy is all that is needed. Finally, as for financial feasibility, this initiative is easy to implement because funds can be redirected from the currently existing unit of the Veteran Health Administration to the whole new organization. From the perspective of governmental management, it would not take much effort and resources to support this change.

Bagalman, E. (2016). Health care for veterans: Suicide prevention. Web.

Barr, D. A. (2016). Introduction to U.S. health policy: The organization, financing, and delivery of health care in America. Baltimore, MD: Hopkins University Press.

Birkland, T. A. (2011). An introduction to the policy process: Theories, concepts, and models of public policymaking. New York, NY: Routledge.

Gholipour, R., & Rouzbehani, K. (2016). Social, economic, and political perspectives on public health policy making. Hershey, PA: IGI Global.

Mason, D. J., Gardner, D. B., Outlaw, F. H., & O’Grady, E. T. (2016). Policy and politics in nursing and health care. St. Louis, MI: Elsevier.

Oliver, T. R. (2014). Guide to U.S. health and health care policy. Washington, DC: CQ Press.

Patel, K., & Rushefsky, M. E. (2014). Healthcare politics and policy in America. Armonk, NY: M. E. Sharpe.

Sanborn, C. J. (2013). Case management in mental health services. New York, NY: Routledge.

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