We have tried pen-and-paper screenings for 100 years, literally, since World War I, and what we’ve found is that generally, they don’t work. Again, these are based on self-report. If somebody fills out a piece of paper that asks about suicidal ideation, if the person wants to get into the military, they’re not going to answer that. And the military doesn’t have access to previous records unless the person chooses to offer them.
Let me add to that, the best screen is basic training. So, remember when a recruit comes in, they have 8 to 13 weeks, depending on the service, of very intense interaction with other recruits, and with the drill sergeants, and about 8% of troops actually wash out of basic training. What we’ve tried over and over to do is to develop a paper-and-pencil screen, but it either isn’t sensitive or isn’t specific enough.
Question: What about "checkpoint" screenings that you do periodically after some time in the service?
Dr. Ritchie: As people come back from deployment, they are screened, and 3 to 6 months later, they have a postdeployment reassessment because we realized that people weren’t going to tell the truth as they were coming back home because they just wanted to go home. So, we asked them again. And, there is a yearly assessment done, but again, a lot of what this relies on is the soldier’s willingness to share what’s really going on. There are questions for depression, and suicidal ideation, and posttraumatic stress disorder as part of the whole assessment process.
Question: But will they answer truthfully at all times, regardless of how they feel about deployment, because they are afraid of being stigmatized?
Dr. Ritchie: Remember that this is an all-volunteer army, and we’ve been at war since 9/11/2001, so troops who have been in the service know they’re going to be deployed and want to be deployed. And with the difficult economy, they want to stay in the service and they want to be promoted. So, they are concerned if they answer "yes" to a mental health question, they will be made to see a psychiatrist, which might have an impact on their career, or they won’t be allowed to deploy. So, there is a lot of motivation to minimize symptoms.
Now, that’s true of people who want to make the military a career. I have also seen that people who have decided to leave the military, or the military has decided that the person shouldn’t stay, then there is often a lot of incentive to answer yes to all the mental and physical health symptoms. For example, on your retirement physical, you’re told, "Make sure you put down every condition you’ve got because you want to have access to the VA" and maybe you’ll get disability or get compensated. So you’ll often see underreporting if a soldier wants to stay on active duty, and perhaps there’s some embellishment of symptoms as they’re going out the door.
Question: What about therapies that are said to address other physical symptoms, like acupuncture, but which are actually addressing the mental health aspect as well?
Dr. Ritchie: There are two main types of evidence-based therapies for PTSD. There’s the cognitive-behavioral therapy, which has cognitive processing therapy as part of it, and there is exposure-based therapy, as evidence-based psychotherapies. And then there are medications – the selective serotonin reuptake inhibitors for PTSD – as well. However, many, many service members don’t want to take medication, and/or they don’t want to go and talk to someone about their trauma. In most cases, these are young men, and young men often don’t want to talk about anything, much less their feelings or a traumatic experience where perhaps one of their friends was killed or wounded. So, I have gotten very interested in the various forms of integrative medicine – such as acupuncture, yoga, mindfulness – which many of our troops really enjoy doing. They probably don’t treat the PTSD by themselves, but they provide a bridge to treatment.
And, perhaps they do treat the symptoms themselves. Certainly, service members have reported vast improvements from acupuncture, from stellate ganglion block, from yoga. They say: "It cools my brain so I can concentrate on other things."
Question: Please explain to us how stellate ganglion block, which is an anesthesia, is used to treat PTSD.
Dr. Ritchie: It is an anesthetic technique used for pain, where lidocaine is injected into the stellate ganglion by an anesthesiologist. It has been seen to dramatically reduce PTSD symptoms in some. There is not yet a robust body of literature, but there are certainly a lot of very promising case studies and anecdotal reports on it.