Critical transformation requirements missing in Obama's Executive Order to improve access to mental health services for military

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Guest blog -  Col (Ret) George Patrin, CMHNetwork Advisory Council Member - Regarding President Obama’s “Executive Order to Improve Access to Mental Health Services for Veterans, Service Members, and Military Families” focused on suicide prevention, released August 31, 2012:

To resolve this National epidemic within military families, let’s not put “Old wine in a new bottle.” (Military Mental Health, September 24, 2012).

Critical transformational requirements missing in the Order are -

First - Emphasize same day access to behavioral health services within “Patient-Centered Medical Homes (PCMH),” universally screening for anxiety and depression, integrating existing behavioral health professionals in same day referral programs.  This does not require "Recruiting, hiring, and placing 1,600 mental health professionals by June 30, 2013.” The stigma associated with mental health care will remain unless we tear down this silo approach to dealing with depression, anxiety, and Post-Tramatic Stress. Start real therapy before crises occur with timely proactive comprehensive care and  safety plans addressing PTSD, TBI, depression, related mental health conditions, pain, and substance abuse for Active Duty (AD), Family Members (FM), to include returning Reserve and National Guardsmen (NG) to their civilian communities. Provide this approach in rural areas with tele-medicine teams. The "standard of care" for access to mental health (“wait times”) must be same day…even 24 hours is too long to establish a safety net. The Order, as is, will only perpetuate the same procedures we have today, “Old wine in a new bottle” as suggested by COL-Ret Cameron Ritchie in Mental Health, September 24, 2012.

Second - Examine policies that (inherently or directly) promote stigma. Recall the AF suicide reduction program in the early 2000s. “Expanding mental health professional hours beyond traditional business hours” will not decrease stigma and discrimination rampant within the military or get Service Members to access them. Address the culture of military discharge policies based on “behavioral problems" with zero tolerance for hazing and harassment of Service Members (SM) for 'acting out' and putting pressure on spouses who speak out about the lack of treatment for their SM spouse suffering from PTSD and other conditions. Address wrongful administrative discharges from military service for behavioral concerns and resultant despair over the loss of a career to serve our country.

Third - Call for the "external research portfolio review" to include examination of the "Medical Evaluation Board (MEB)" and "Physical Evaluation Board (PEB)" processes. They are too often incomplete, inaccurate, and untimely. Base them within the PCMH, not in a separate specialty processing area. Combine the DoD and VA Disability Claim processes now.

Fourth - Involve surviving FMs with insight on correcting processes that ‘pushed’ their loved one to carry out suicide. (Suicide stand-downs don’t include families, for instance.) Incorporate an informed consent form that allows communication with ‘family’ into clinic intake processes prior to crisis development. Listen for what's missing "to expand suicide prevention strategies" and to "take steps to meet the current and future demand for mental health and substance abuse treatment services for veterans, service members, and their families." Include the end-user of these services in the strategy for improvement. Track FM suicides as well. Recall AD Family Members are not able to be seen in VA facilities nor Retired FMs in some Tricare facilities. Services should be authorized for grief care for family members after a death occurs (postvention). Get data from life insurance companies paying death claims to discover a statistic that will indicate the extent of this subset “casualties of war.”

Fifth - Provide pain management, substance abuse, alcohol recovery, and drug addiction treatment services within the PCMH for Veterans, Service Members, and their Families in the suicide prevention plan with same day access right along with behavioral health. Address wrongful administrative discharges from military service for our failure to address these issues as reasons for self-treatment while trying to get continuous quality care within our clinics and referral systems.

Sixth – Truly integrate network all mental health services for veterans, service members, and their FMs. Eliminate redundancy. Focus on outreach to veterans and their families with coordination between the Departments of Veterans Affairs and Defense and the Civilian (Tricare) Networks with provision of warm handoffs, especially for patients with mental health issues. Make the new Task Force accountable for transparency and answerable only to the President!  Include visionaries from prior National Prevention Strategy Plan efforts. Empower the Task Force to hold non-profits from the past accountable for unmet outcomes fusing civilian network leaders into military efforts instead of allowing them to operate within silos. Look to civilian and military programs with the best results (I.e. Henry Ford Clinic in Detroit and the AF program in 2004) for the ‘best’ model to implement.  We don’t need to delay this with additional research looking for “pilot projects.”

Seventh – Along with “expanding the Veteran Crisis Line by 50 percent,” make sure it is peer-based with trained counselors, to include the “800 peer-to-peer Veteran Counselors” being added. Remove operation and control of the program from Federal operatives (I.e. SAHMSA). Veterans do not trust Federal programs. Fund non-profits mandated to work as an integrated National Network with 2-1-1 or 800-SUICIDE as the universal crisis line call number.

Eighth – Reconsider insisting "any new requirements are supported within existing resources" and implemented “consistent with applicable law and subject to the availability of appropriations."  The magnitude of the problem suggests there is no law dealing with the cultural problems inherent in suicide. And if “existing resources” are allocated to the same services we’ve had over the past 50 years, the desired outcomes will not be realized.

Ninth - This Order "does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person," suggesting we do not have to be accountable for our actions. Executive departments and agencies must know they are responsible to provide transparency and accountability, including the “Director of the Office of Management and Budget relating to budgetary, administrative, or legislative proposals." It is past time we look at the legal and ethical ramifications in our cultural norms that prevent a serviceman fighting for the security of our Nation to question the medical care and administrative processes they are receiving and being subjected to. Until we hold ourselves to the same standards and services we expect of civilian leaders, we will continue to lose the most creative and sensitive of our US heroes and citizens, a loss we simply can’t afford.

All said, Dr. Ritchie and I are in agreement – “this challenge is not a problem only for the military, or the Department of Veterans Affairs. It is a national problem that needs to be tackled, and solved, by the nation as a whole.”

COL-Ret George D. Patrin, MD, FAAP, FACHE
Pediatrician, Healthcare Advocate
210-833-9152
patrin.george@gmail.com

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