The Battle At Home

Photo of Navy Cmdr. Eric Pauli
November 09, 2018

A national opioid epidemic, semi-regular mass shootings and high-profile celebrity suicides have drawn Americans’ attention to mental health. Media outlets ranging from CNN to Cosmopolitan are educating their audiences on mental health using the same tone and terms they would to address other health issues. On social media, users share photos of their scars from cutting, count the number of days they’ve been sober and search #mentalhealth to find and offer support. All these things help normalize conversations about mental health.

But what happens when patients who seek professional care? Too often, it’s a waiting list, a long drive or practitioners who aren’t trained to manage mental illness. Experts agree the health care workforce simply does not include enough mental and behavioral health care providers to meet demand. Even as the need has grown, the pool of psychiatrists working with public sector and insured populations declined by 10 percent from 2003-2013, according to a 2017 report from the National Council for Behavioral Health (National Council).

Due to the shortage of psychiatric care providers, the vast majority of antidepressants are prescribed by primary care providers, according to Dr. Jess Calohan, an assistant professor at GW Nursing.

The military is a microcosm of these issues seen in the broader population. Thanks to medical advances, troops are now surviving physical wounds that would have killed them in previous conflicts. All wars result in trauma, but the “signature wounds” of recent conflicts are traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD), the military and the Department of Veterans Affairs (VA) face a particularly acute mental health crisis. “In previous wars, folks would not have survived some of the things they’re surviving now, which is part of why we’re seeing higher rates [of TBI and PTSD] now,” said Navy Cmdr. Eric Pauli, an assistant professor in the Psychiatric Mental Health Nurse Practitioner (PMHNP) program at the Uniformed Services University in Bethesda, Maryland.

To deal with the crisis, military and veteran care providers are reinventing how care is delivered to better treat veterans and those still in the armed forces.

Combat exposure and cumulative deployment time are among the strongest predictors associated with having a mental health need, according to “An Evaluation of the Department of Veterans Affairs Mental Health Services” published earlier this year by the National Academies of Sciences, Engineering, and Medicine. Of the 4.2 million veterans from recent conflicts (Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn, 41 percent of those have a potential need for mental services.

Yet many of them do not perceive a need for mental health services.

More than half of veterans surveyed who had sought mental health care from the VA described the process as burdensome. One-third said that they had other concerns about seeking care, including taking time off work, harming their careers, being denied a security clearance and losing the confidence and respect of their co-workers and supervisors.

For veterans and others, treating people where they are, better preparing practitioners to manage mental health and educating veterans to become practitioners comprise a multipronged approach to better mental health care.


Better preparing primary care practitioners

The National Alliance on Mental Illness addresses the mental health concerns of veterans and active-duty troops on its website, listing a hotline, primary care providers and behavioral health specialists as sources of help. This is all good advice, but while primary care providers are prepared to identify mental health issues, they are not necessarily prepared to manage them.

“Nationally, we have a shortage of providers, especially in rural areas. Nursing can play a much bigger role in prevention and education. We need to be empowering nurses as much as possible because we’re going to have to look at solutions,” Dr. Pauli said.

The National Council’s report recommends removing barriers in state and federal law that restrict Physician Assistant (PA) and Advanced Practice Registered Nurses (APRNs)  from providing psychiatric care consistent with their education and experience and expanding the use of other providers, such as APRNs, who prescribe psychiatric medications.  “APRNs ... bring unique skills to these behavioral health settings and can complement the team-based approach to many patients with complex comorbid medical and behavioral health problems,” according to the report.

To rise to this challenge, primary care providers need to be better equipped, said Carol Braungart, director of the family nurse practitioner (FNP) and adult-gerontology primary care nurse practitioner (AGPCNP) program options at GW Nursing.

“There’s this big knowledge gap when it comes to behavioral and mental health disorders,” Dr. Braungart said. “With the increase in behavioral health problems in our communities, we need to better equip our NP students with a vast skill set that allows them to manage a broader foundation of issues,” she said.

At GW Nursing, primary care nurse educators collaborate with psychiatric mental health experts to integrate that content into the FNP and AGPCNP curriculums.

“Students have a foundation of what mental health disorders are, but they don’t delve into some of the other issues, like actually managing obsessive-compulsive disorder or when somebody is particularly at risk for suicidal or homicidal ideation. How do you recognize and deal with that? And where do you go with that?” Dr. Braungart said.

When crafting the curriculum, faculty also consult with a pharmacist who specializes in managing medications for those seeking mental health care to provide additional resources and knowledge. This perspective helps ensure NP students are skilled in identifying the needs of their client base, Dr. Braungart said.

In addition to incorporating lecture series into the didactic curriculum, educators are creating workshops and simulation scenarios for students during their on-campus experiences. This past spring, GW Nursing incorporated a simulated learning experience with an anxiety and depression component into students’ on-campus learning activities.

Truly specializing in psychiatric care is also an option for APRNs. In GW Nursing’s Psychiatric Mental Health Nurse Practitioner Certificate, students learn neuropsychopharmacology, interprofessional collaborative practice, crisis intervention, trauma-informed care, psychotherapy, group therapy, care of vulnerable populations, promotion of mental health and prevention of mental illness, substance use and co-occurring disorders, and other mental illnesses across the lifespan.



Providers now have access to much more sophisticated technologies to deploy in treating those who need care. The Defense Health Agency has even collaborated with developers to create a whole host of apps available to both patients and providers.

Jess Calohan, an assistant professor at GW Nursing, developed telehealth services in Iraq for the Army starting in 2011.

“With telehealth, we could provide services to guys at the remote bases,” he said. “It improved access for sure.”

Dr. Calohan saw telehealth expanded stateside in the Army too, because bases in remote areas like Fort Irwin in the Mojave Desert and Fort Wainwright in Alaska lacked psychiatric services. While these bases might have social workers, Dr. Calohan said they had no prescribing psychiatric providers and some of the cases were too much for primary care providers to manage.

Now a civilian, Dr. Calohan has carried the principles he first implemented for the Army into his practice. He works at GW Nursing in the D.C. area while maintaining a clinical mental telehealth practice for a hospital system on the West Coast. Whereas the no-show rates at most community mental health centers hover around 20 percent, Dr. Calohan said his telehealth practice has a no-show rate of about 10 percent.

Mental health visits to the hospital system’s emergency room are also down about 25 percent since he started seeing patients virtually 18 months ago, according to Dr. Calohan.

A 2012 study published in Psychiatric Services was the first large-scale assessment of telemental health services and found that psychiatric admissions of telemental health patients decreased by an average of 24.2 percent, and the patients' days of hospitalization decreased by an average of 26.6 percent.

Telehealth can make an especially positive impact on patients in rural areas. Providing specialty services using telehealth is easier than staffing rural facilities with specialist providers, according to the Rural Health Information Hub.

In terms of providing care to veterans, expanding telehealth in rural areas could have a major impact. Almost one-quarter of U.S. veterans age 18 years and older lived in rural areas between 2011 and 2015, according to the U.S. Census Bureau.

A new generation of providers and patients grew up in an online world and are open to receiving care. Of the veterans surveyed for the National Academies evaluation, 45 percent from recent conflicts said they would likely use the internet and 44 percent would likely use the phone to receive mental health care, with younger veterans tending to be more open to seeking mental health care using the internet.

“To me, you can’t put a price on that convenience for the patient,” Dr. Pauli said. The Pentagon is now supporting telehealth—even pushing for it—because the benefits are clear, he said.

Telehealth also offers a big opportunity for interprofessional teams to see patients, Dr. Pauli said.

By allowing specialists to consult services from afar, telemedicine has the potential to increase access to medicines and concurrent therapy for those suffering from opioid use disorders in underserved, remote and rural areas, according to a study led by GW Nursing Professor Tony Yang.


Alternative / Integrative Treatments

Mental health issues are an especially complicated issue for military mental health providers. Because of the military’s unique mission, troops must maintain operational readiness. Providers grapple with issues like the side effects of medication, for their patients more than most civilian mental health providers. 

“Every single decision we make affects their readiness and ability to deploy. If I prescribe a medication they can’t deploy for 90 days,” said Dr. Calohan. 

Because of these issues, the military and VA have been exploring integrative treatments for the last decade. 

“We’re the support for the line community [for the Navy, all the ships and Marines], so it’s more advantageous to use treatments that don’t have side effects or other downsides,” said Dr. Pauli. 

Substance abuse is integrally tied to mental health issues. More than one in four adults living with serious mental health problems also has a substance use problem, according to An awareness of opioid abuse has turned the spotlight on the use and overuse of substances to cope with stress and other health issues. 

Dr. Pauli began his mental health career in the Navy around 2000. “Even when I started, I felt somewhat isolated. But because of the national crisis, we see much more willingness to talk about mental health,” he said. 

Substance use is an issue in the military and one that clearly impacts readiness. Because it’s a crisis nationwide not unique to the military, there is a general willingness to have the conversation surrounding treatment, said Dr. Pauli. 

“Of course, opioids get a lot of attention, but we still haven’t addressed that nicotine use kills more people than opioids. Alcohol use kills more people than opioids,” he said. “We need to make sure we don’t say it’s just this one particular drug; there’s an overarching dilemma, but also it’s also an opportunity to make sure we’re addressing broader substance abuse issues,” Dr. Pauli said. 

Military members and veterans are sometimes concerned about traditional treatment methods (medication) for TBI/ PTSD because of known side effects such as substance dependence so he’s seen a dramatic shift toward not only accepting mental health care but also openness to integrative treatments, including yoga and acupuncture, over the last decade, Dr. Pauli said. 

“Just as a generation of new providers can’t imagine a world without the internet, we see the same thing with integrative treatments; there’s a willingness to consider them both in and out of the military. In 2000, someone on my base was practicing acupuncture and I heard a lot of jokes,” he said. “Now younger folks that come in are very open minded,” Dr. Pauli said. 


Educating veterans to become practitioners

Nursing educators are working to turn veterans, who understand military personnel’s medical experience first-hand, into practitioners themselves. Through a HRSA grant, GW Nursing over the past five years created a BSN veterans option to efficiently transition military veterans into nursing careers. Although the initiative started as a way to match veterans in need of civilian careers with a profession facing severe shortages, it has the added benefit that veterans will increasingly see providers who have a deeper understanding of their experience.

“I think there is some credibility amongst veterans if you’re a veteran provider,” Dr. Calohan said. “One thing we have in common is that combat patch on our right shoulders. It’s not that I’ve been through the same experience as them but we do have a common language and that builds credibility,” he said.


Bringing it all together

Experts see nurses playing a key role as the nation moves forward in the treatment of mental health. APRNs are part of the frontline of primary care providers who routinely see patients with mental health needs, and their education should reflect this reality. Telemedicine breaks down barriers between providers and patients, so all providers should be trained in effectively using tools to make this possible. A small but growing cadre of nurses and APRNs who are veterans themselves bring their personal experience and expertise to the care of those who have served.

“Nursing can play a much larger role in prevention and education, all of which could be rolled out via telehealth,” Pauli said. “We need to be forward-thinking in how we do that and make sure we have nurses working within their best scope of practice.”