Many veterans suffer from mental health challenges as a result of the difficulties faced in the course of service. Luckily, there are resources to help.
Elspeth Cameron Ritchie, M.D., M.P.H.
Chair, Psychiatry, MedStar Washington Hospital Center
As a psychiatrist with a military background, you bring a unique perspective to your work. How has your experience in the military informed your approach to psychiatric care, especially in understanding and addressing the mental health challenges faced by service members and veterans?
I’ve been deployed with service members. I’ve been deployed to Somalia. I’ve had three trips to Iraq. I was in the army for 28 years. One of the things you learn is not just the vulnerabilities in the military, but the strength of the military. This is an all-volunteer army. People know what they’re getting into, they train together, and there’s a lot of effort to focus on unit cohesion, morale, and strength.
If deficiencies are identified — and that has certainly happened through the years, especially with the long wars in Iraq and Afghanistan — then they can be addressed. There are also certain limitations in behavioral healthcare as to what the military can provide. For example, there are certain medications that you’re not allowed to be on while deployed.
Your expertise extends to women’s mental health. How do you tailor your approach to address the specific mental health needs and experiences of female veterans?
One of the things I found very striking is that mental health and physical health in both sexes cannot be completely separated from each other. Certainly, people think about PTSD and females, but I like to take a wider approach. One of my bottom lines is, let’s see if we can have private and secure bathrooms out in a mature deployed environment. Because if you’re, say, in Iraq, you can’t just get out by the side of the road, because you might be shot or get blown up.
In therapy, some places will have all-female groups and others will have a mixed group; there are pros and cons to each. One of the things that concerns me quite a bit is that with so many military women’s stations and states that have more restrictive access to reproductive health care, how does that meet the needs of female active-duty service members who in many cases don’t have funds or time available to travel? I think the DoD is trying to accommodate them — they will pay for their TDY (temporary duty) expenses — but so far, according to the data, we have only a few people who have taken advantage of that. Remember, females in the military are usually of childbearing age, so reproductive health is very important.
Military service often involves exposure to high-stress and traumatic experiences, which can have long-lasting effects on mental health. How do you address the unique needs and challenges of veterans in your practice, and what resources are available to support their mental well-being?
It starts with preparation, and then there are a variety of interventions that can be done right after a traumatic event. Usually, the most important thing is making sure people are safe, and then addressing their other immediate needs. In general, service members don’t like to be singled out and sent to therapy. That has some caveats to it, but the best you can do is to focus on the unit. Support the unit as a whole.
After people are out of military service, they’re often more receptive to therapy and mental health resources.
Suicide prevention is a critical aspect of veteran mental health care. What strategies do you employ to assess and mitigate suicidal ideation among your patients, and how do you support veterans in developing coping mechanisms and accessing support networks?
There have been many, many groups that address suicide prevention. Yet, it’s still a major problem. I can’t offer an easy Band-Aid solution. I will say that we’ve looked at the stressors for suicide, and they are different stressors than for the civilian population. Everybody in the military is employed and should be getting paid, housed, and fed. That’s not true of all the civilian population. What we see when we look at military suicides is that often they’re preceded by a humiliating event — somebody’s girlfriend has gotten pregnant by somebody else, or somebody gets a DUI.
Mental illness does not play as large a part in the military as in the civilian world, because people in the military are screened for mental illness. One of the things that we try to do is develop coping mechanisms for when people are leaving the military and help them understand the different options they have available. There are a lot of veterans organizations, but you have to get people to access these support mechanisms. I think that the network of veterans out there that reaches back out to the military is great and should be continued.
PTSD can have profound effects on various aspects of a veteran’s life, including relationships, work, and daily functioning. How do you help veterans navigate these challenges and rebuild their lives in the aftermath of trauma?
Let me define that a little bit. Post-traumatic stress disorder was not recognized as a diagnosis until well after the end of the Vietnam War. However, we know that psychological reactions to war have existed for probably as long as war itself. It does impact relationships, work, and daily functioning. What can be very hard to cope with is veterans feel like people don’t understand them except perhaps other veterans, and it can be hard to relate to civilian life.
To give an example, shortly after I got back from Somalia, I had Thanksgiving dinner with my brother and his family. All they wanted to talk about was going to the mall and going shopping. I couldn’t imagine going to the crowded mall and going shopping. It just seems so irrelevant and crowded. Fourth of July, to give another example, is very difficult because of all the booms and loud noises.
Luckily, we do have good treatments for PTSD. I put treatment into three buckets: Firstly, medication, which is usually an anti-depressant medication that also treats PTSD. Secondly, there are a variety of different talking therapies. Cognitive behavioral therapy is the one that’s used most often. Finally, there’s everything else. The “everything else” is a wide array of ways that patients can self-soothe and treat themselves. This could be exercise, yoga, or working with animals. I try to do whatever the veteran wants to do, because you can prescribe exercise all you like, but if somebody doesn’t want to do it, it’s unlikely to work. I recommend doing things that come naturally, are enjoyable, and are low-stress.
The other thing that’s very important about prescribing anything is you want the veteran to want to do it. If they have individualized choices, they, in general, feel a lot better about it than somebody thrusting a whole handful of medications at them.
One other piece is that if somebody is on medications, some of them can have side effects, including sexual side effects. It’s important to tell the veteran about it, because if they have erectile dysfunction, for example, that’s not going to help their self-esteem, that’s not going to help their relationship. There can be a lot of blaming. Broken relationships are a major risk factor for suicide. I did a book a couple of years ago on sexual health in veterans. This is one of the points that I emphasize is really important. Most of our military members are young men and women, and sexual health is a very important topic for them.
Looking ahead, what do you believe are the most pressing mental health needs facing veterans today, and how do you envision the field of psychiatry evolving to better serve this population in the future?
You know, there’s so much that affects both veterans and the general population — things like climate change, which affects everybody. The VA is doing some interesting work. They’re looking at exposures to toxic exposures, whether it’s burn pits or chemical exposures. They’ve passed legislation to allow better availability for people who have mental health concerns, because of those chronic exposures. I think that’s a topic that really hasn’t been covered in the same way that blast injuries and other physical traumas have.
Veterans’ experiences differ broadly, depending on when and where they served. One thing I loved about being in uniform was that when I came back to an airport, everybody would come up to me and thank me. That certainly was not the case with Vietnam veterans. Don’t treat veterans as a homogenous group. One of the easiest things you can do is ask them about their military service. People thank us for our service, and it comes off as a little trite. However, if somebody comes up and really is interested in the service, that goes a long way.
