The Intractable Problem of Mental Health and Military Service

It's not what you think.

My roommate in flight school tried to kill himself. He swallowed a lethal dose of prescription pills. Fortunately we found him and got him to the hospital quickly enough for him to receive treatment to stop the effects. I picked him up from the inpatient facility a few days later. He was still wearing a shirt covered in the charcoal they used to pump his stomach.

“Well…this is awkward.” he said and then burst out laughing.

He was, and still is I imagine, a funny guy. He had a dry sense of humor and straight faced delivery that made it a bit like living with Stephen Wright. At 23, I’d never known anyone that tried to kill themselves. I’d certainly never picked anyone up from the hospital and drove home to our apartment who had tried. In the months living with him afterward we talked about it more than you might think. We weren’t close friends. But we were friends enough. The way he described what happened has stuck with me as something that’s been helpful to me in understanding how depression and suicide works. He told me that the sadness he had always been prone to started to not go away. And that it eventually started to take his physical energy. First he didn’t feel like doing anything. Then he didn’t do anything. And then he couldn’t get out of bed. Eventually he felt so physically exhausted that he couldn’t go on.

There was no conscious trade off about how this would hurt his mother or his girlfriend or the people that cared for him. There wasn’t any rational thought at all. It had consumed it. He was the singularity in a black hole of depression. And the only thought he had left was that he wanted it to stop. So he tried to stop it.

The thing I didn’t understand before his description was that it wasn’t something happening in his mind, at least not the way we think of one’s mind being born of thought. He wasn’t thinking one way or another. He was just spent physically. Or at least that’s how he felt. I’ve read suicide notes that loved ones have shared with the public. Oftentimes they refer to the fact that they’d lost the battle. And through that lens, it’s easy to understand this is more a physical manifestation of depression than a logical or rational choice. And that has made it easier for me to understand. But actually harder to handle. It’s heartbreaking.

My roommate’s trigger? Who can say for sure. But some part was almost certainly the loneliness and relative slowness of life after we left Annapolis. How can someone living with roommates they got along with and a loving, caring girlfriend be lonely? Pretty easily actually. We were a few months removed from graduation. At the Naval Academy we lived with people who were closer to family than friends. We shared one experience together. And we never had nothing to do. We may have complained that life at Annapolis behind the walls was boring. But what we really meant was tedious. Boring implies some sort of slow pace and personal loneliness that Annapolis never allowed. In the transition afterwards, we were living our own lives for the first time.

He was prone to bouts of sadness before but never really considered himself depressed. But he fell into depression in the quiet, slow and lonely times after. Closer to the other pole of the human condition, I considered myself a bit hyperactive and prone to worry. I never thought that I suffered from anxiety. But the quiet, slow and lonely times after found me riddled with it. The pattern there is important.

My wife interned at the Veterans Village of San Diego when she was completing the clinical course work for her counseling program. Veterans Village is a place where homeless vets can come to be cared for and receive drug and alcohol counseling if they find themselves on the streets. She told me that the common bond between these folks wasn’t the invisible wounds of war time trauma. In fact most were not combat vets at all. What was really going on was that these were people who all had some kind of pre-existing condition before entering service. Be it anxiety, depression, ADHD or bipolar disorder or something else. The structure and “family” of service and the high demand lifestyle of training and deploying enabled them to function somewhat well. But once removed from it, they came undone.

The misconception about the military is that it creates disciplined humans. It doesn’t. It creates humans that can survive rigorous circumstances and structure. Discipline implies some choice that doesn’t exist. The military sharpens the fight or flight in us. But it doesn’t do well with the space between. People with undiagnosed pre-existing mental health issues enter the service and then go on to live in a world that punishes diagnoses and help. It’s better than it used to be. But you’re not finding the captain of a ship or a SEAL Team that was diagnosed in his 20s with anxiety and then went on to serve the next 20 years on prozac. They don’t let you do that. Not without leaving your job in some way that will eventually impact your career. What they do let you do is slam yourself face first into the wood chipper of deployments and work ups. There’s a sort of self medication of service.

To be clear, the DOD understands that it has a problem. They’ve invested a significant amount into the mental health of their service members. There is no shortage of education and resources aimed at helping service members identify the patterns of mental health issues or processes to notify the right people. Or to seek help. From experience though, I’m not sure that’s the sort of thing that matters as much as changing the culture of the organizations that make up the institution. And I don’t mean the well meaning de-stigmitization of seeking help. I mean great policies like this on whether you can enlist if you’re on antidepressants:

Or…this on whether or not you can fly a plane on antidepressants:

Or….this on whether you can enlist while on ADHD:

An IEP after the age of 14 is disqualifying? Who thinks there’s no kids with ADHD or learning disabilities showing up in the U.S. Military today? This is the stuff that pops up when you start to google what you can and can’t have when you join the military. Some of it has changed or will change. But there is still a limitation on what sorts of mental issues one can have and serve in the most desired and rewarded types of service. Which means that two things are true:

1-There are tens of thousands of people actually self medicating their mental health issues with their military service. I don’t mean self medicating with drugs and alcohol. I mean actually with their service, the structure and pace of what they do for a living.

2-The approach to treatment for the most acute cases of mental health problems ends the careers, permanently, of the people who suffer from them.

If you take those two facts together, you start to wonder how the problem isn’t bigger. And I can tell you, the problem is bigger. It’s much bigger. And it’s not the 22 suicides a day veterans that you hear about. That number has all kinds of context problems including that the average age of vets in that study is about 60 years old. The real problem is what happens to vets when they get out before they end up killing themselves 30 years later. And what happens when they come home from deployment or when they leave a more stringent and rigorous role and go to one that slows down. If you want to see the real mess, look there.

Here’s the thing that people really really really don’t like to talk about. Americans feel some comfort in thinking that it’s the stress of service that causes the prevalence of mental health issues for service members. That these things are just part of the sacrifice. PTSD diagnosis and payments from the VA have ballooned over the last decade. And so we sweep the issue into that bucket. But the truly intractable problem is that the DOD is one of the institutions (law enforcement, first responders, etc) that does not allow its workforce to separate the physical and mental health outcomes from their career outcomes. As long as that’s the case, the DOD will have suboptimal mental health outcomes for service members. You can give them all the “see something say something” videos you want. You can teach them the “signs” of suicide risk. But the truth is that there’s ZERO incentive to raise one’s hand and get help. And by help I mean actual durable psychotherapy, pharmacological or psychedelic interventions that we know help without throwing away your career.

I know the argument against this is that we don’t really want people with mental health issues having these critically important national security related roles. But I’ve got news for you. They already do. And they always will. Ignoring that reality costs people their lives.

I lost another teammate this week; found dead in his home. I don’t know what happened yet. But, I hope it was an accident is a hell of a thought to have to have. I’ve had it more times than you’d think. And I don’t want to have it again.