Reducing Stigma of Mental Illnesses Could Reduce Suicides
By Staff Sgt. Kathleen T. Rhem, USA
American Forces Press Service
ARLINGTON, Va., May 8, 2000 The continuing social stigma attached to mental illness is the biggest obstacle mental health experts face in helping patients, reducing suicide rates -- and in the military, improving the fighting force.
"I think there's no question that the main impediment to psychiatric care is the stigma," Johns Hopkins University psychiatrist Dr. Kay Redfield Jamison said May 2. "We have good treatments for the major psychiatric illnesses. What's difficult is getting people to recognize that they have a problem ... and to set aside the stigma or work around it."
The Baltimore professor put the spotlight on mental health as the latest speaker in a year-long women's health seminar series co-sponsored by the Women in Military Service to America Memorial Foundation, DoD and the Department of Veterans Affairs. The monthly noontime brown-bag lunch presentations are held at the Women in Military Service to America Memorial at Arlington National Cemetery here.
Jamison said she draws insight from her own experiences as a military "brat." Her father was an Air Force scientist and pilot who struggled with manic-depression.
"The major way [mental illness] was treated was to go to the Officers Club and drink. Alcohol was very heavily subsidized by the Air Force," she said. "At that time, had he sought treatment, there is no question he would have been out of the service."
Mental illness is of particular concern to the military because the military population is statistically younger than the general population. "Mental illness is a disease of youth. That's why suicide is such a problem among young people," Jamison said. "Major psychiatric illnesses tend to kick in around the time of puberty and escalate after that. The average age of bipolar disorder to kick in is 17 or 18. Depression has a slightly later onset ... the early 20s."
Depression is at least twice as common in women as in men, she noted, but men and women are equally likely to suffer from bipolar disorder.
"Nearly one person in five will suffer a major depressive disorder," said Jamison, who recalled her personal battle with bi-polar disorder for the audience. She stressed mental illness is highly treatable and that, while things aren't fully enlightened, they've changed a lot since her father's military days.
"The tragedy of having mental illness go untreated doesn't have to happen any more," she said.
Dr. (Army Lt. Col.) E. Cameron Ritchie agreed. She's the director of mental health policy and women's issues for the Office of the Assistant Secretary of Defense for Health Affairs and was at Arlington, too.
"We have been trying very hard in the military and in the civilian world to destigmatize mental health," she said. "One way to do this would be to have people who have struggled with depression and bipolar disease come forward, but that's very hard to do.
"I have a number of patients who are very successful in the military, but would I ask any of them to come forward and tell their story? No. Not if they're hoping to get another job; not if they're hoping to be promoted," Ritchie said. "Perhaps if they've recently retired. There is still such a stigma about the treatment of mental illnesses."
She said the suicide rate in the United States is about 20 per 100,000 people every year. The suicide rate in DoD is somewhat lower -- about 12 to 14 per 100,000, she noted.
Both experts praised the Air Force's suicide prevention program and an underlying premise: If you need mental health treatment, you're more courageous to seek it than avoid it, she said.
Jamison said the Air Force treats suicide and mental illness as servicewide command problems as well as medical ones. She said the service took recommendations for suicide prevention from the Centers for Disease Control and put them into effect and established a central database to determine the circumstances of suicide attempts and suicides.
"In addition, the top military personnel in the Air Force sent an e-mail out to everyone saying the really courageous thing to do and the correct thing to do if you suffer from any type of psychiatric disorder is to reach out and get help," she added.
Ritchie pointed to the Air Force's focus on suicide and mental health treatment command- and four-star-level issues. "They've worked with their community services, their alcohol and drug control programs and their chaplains, so there's better communication," she said. "They've also put a high emphasis on confidentiality of mental health records, so people can be seen without worrying about who's going to find out about it."
The Air Force has the lowest suicide rate of the services, and that fact hasn't escaped DoD's attention. A working group is looking at ways to reduce suicides throughout the department and it's drawing from the Air Force's success.
One of the issues the working group is studying is record keeping. "Traditionally, we keep data on those who commit suicide but not those who attempt suicide. But we know an attempted suicide is a high risk factor for suicide," Ritchie said. "After a completed suicide there's supposed to be a 'psychological autopsy.' But even in the Army, which took the lead in psychological autopsies, they were only being completed in about 50 percent of the cases."
Among other things, a psychological autopsy seeks to determine individuals' state of mind before they died. "We need data about why people commit suicide so we can take it back and look at our prevention programs," she explained.
Efforts are also under way to improve confidentiality of mental health records. Ritchie said the Navy and Air Force post mental health entries into members' main medical records, while the Army maintains them in separate records. Either way, commanders technically can request access to the records, and this makes many service members apprehensive about seeking treatment, she said.
In reality, service members might not need to worry about this too much. "I've never had a commander request records," Ritchie said.
DoD is also trying to keep pace with changes in civilian medical policies. In October 1999, President Clinton signed an executive regulation limiting release of medical records. The new regulation "prevents doctors, hospitals, health plans and other covered entities from releasing identifiable health information without a patient's written consent for purposes unrelated to treatment, payment, or priorities like public health."
"Every American has a right to know that his or her medical records are protected at all times from falling into the wrong hands," Clinton said Oct. 29. "These standards represent an unprecedented step toward putting all Americans back in control of their own medical records."
Ritchie said this has changed one important thing in the military system. "If there's a court-martial pending and people needs treatment, they can go seek treatment and not fear that those records are going to be used against them," she said.
Privacy walks a fine line in the military. The command has a valid need to know if a service member is dangerous to himself or others or to unit readiness or security, but these are extreme circumstances, Ritchie said. "Usually, at that point, the person is admitted to the hospital and the command knows that," she said.
"The problem is, the average person doesn't know what they can come talk about without it being revealed," she said. "Then one of three things can happen. They'll go downtown instead of the military [medical] system, they'll go see a chaplain, or they won't see anybody. Sometimes suicide is the result."
Ritchie said she emphasizes to service members that mental health professionals are discreet, and that it's in their own best interest to seek treatment before a situation becomes critical.
"If it's a self-referral, nobody else needs to know," she said. "If, however, the situation worsens to the extent it affects their job or personal life and it comes to the commander's attention through a [police] report, their job is a lot more in jeopardy."