BY ELAINE BRUNER, MSN, CMGT-BC
(The opinions and content expressed here are the author’s and do not represent those of the United States government, the Department of Defense, or the United States Navy.)
Active-duty service members (ADSM) face unique issues related to social determinants of mental health (SDoMH). Military service can be considered a social determinant of health (SDoH), influencing health and wellness where people live, work and play. Being a military member is an unusual occupation; less than 2% of Americans serve or have served, and their circumstances lead to lifelong consequences impacting them and their families. Exposure to violence, conflict and war results in psychosocial hardships driving divorce, suicide, domestic violence, unnecessary ED visits plus a myriad of challenges related to stigma and discrimination. SDoMH impact may not be immediate but reveal itself in a crisis such as unexpected deployment or a pandemic.
Transdisciplinary case management teams are well-positioned to address mental health challenges in military populations. To remain resilient and thrive, we cannot isolate physical and mental health care for our ADSM. Integrating SDoMH queries during our assessments, combined with knowledge of military culture, produces effective interventions to support these individuals, their families and caregivers.
C.W. White describes military service as an SDoH. “Military service has direct control over the people on a military base, providing them with housing, food, education and employment. The military base also has control of all the environmental factors within that base community” (White, 2021). Individuals may choose military service to escape chaotic, dysfunctional situations resulting in vulnerability to chronic social stressors. Consider the power and influence active-duty service has over its population. The worksite or duty station is a physical SDoH, and prescribed norms are regulated by the Department of Defense.
What is a social determinant of mental health (SDoMH)? Let’s begin with a definition of SDoH:
“Social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” – Healthy People 2030
Adding mental health considerations to the person’s environment, plus the social and socioeconomic factors result in significant mental health disparities or SDoMH. The pandemic cost the equivalent of 90% of our gross domestic product (Cutler and Summers, 2020), while alcohol sales and opioid-related mortality increased in 41 states (Czeisler, et al., 2020). Our ADSM was affected proportionately to the civilian population by the pandemic. This additional stress combined with military duty, and its SDoH, resulted in mental health crises, untoward events and negative outcomes for our military members, their families and caregivers.
Overview of ADSM and SDoMH
In their 2021 annual survey, the Wounded Warrior Project poll included what injury or health issue is most common. The top 10 injuries and health problems:
- Sleep: 78%
- PTSD: 75%
- Anxiety: 74%
- Depression: 72%
- Musculoskeletal Injury: 66%
- Hearing loss/Tinnitus: 65%
- Migraines/Headaches: 52%
- Traumatic Brain Injury: 32%
- Nerve Injury: 31%
- Spinal Cord Injury: 15%
Case managers working with ADSM won’t be surprised by these results; civilian case managers may be. The “invisible wounds” of the past 21 years of conflict have received increased media attention but weren’t as graphic as a multi-limb amputation or spinal cord injury.
Recognizing that military service is an SDoH, let’s continue exploring SDoMH. There are a few similar SDoMH to the civilian population such as adverse childhood experiences (ACEs). Additional elements impacting military life are:
- Operational tempo with toxic exposures
- Food Insecurity
- Transition to civilian life
A full discussion of ACEs is beyond the scope of this article; however, acknowledging that these traumatic events before age 17 are linked to chronic physical and mental health issues as well as substance abuse disorders is critical. This harms education, job opportunities and earning potential. Toxic stress changes brain development and how individuals respond to stress. Is an ACE the reason individuals choose military service? Perhaps…
Operational temp and SDoMH are real. Combat exposure in the first two years of military service was associated with higher rates of mental health diagnosis when compared with deployment, no combat exposure and no deployment (Campbell, O’Gallagher, Smolenski, et al, 2021). This highlights the need for case managers to have awareness of ADSM deployment history as it relates to SDoMH and risk factors for behavioral or mental health issues.
Toxic exposures are linked to physical illness and mental health issues. ADSM deploy healthy yet return with progressive illnesses and worsening symptoms. Recent legislation, the Promise to Address Comprehensive Toxics (PACT) Act, expands VA benefits and services for 11 respiratory-related conditions as well as several types of cancer including melanoma and glioblastoma. Why mention toxic exposures with SDoMH? Consider the connection between chronic illness and mental health such as depression and anxiety. It is a well-studied issue and is certainly present in our ADSM. Case managers focus on person-centered care promoting quality of life and cost-effective outcomes. The 2022 CMSA Standards of Practice of Case Management outlines guiding principles which include an approach that integrates medical, behavioral, social, psychological, functional and other needs. To fully support, advocate and educate ADSM on toxic exposures and their potential outcomes, case managers must have current knowledge and tools. More on this in a later section.
Sixteen percent of ADSM live with food insecurity. Surprised? Food insecurity can be defined as a lack of consistent access to enough food for an active, healthy life. How is it that steady employment with guaranteed pay results in food insecurity? Several reasons:
- Low income in junior ranks
- Second income limitations
- Not eligible for Supplemental Nutrition Assistance Program (SNAP); pay + Basic Allowance for Housing (BAH) + special pays=over-income
- Rents are astronomical in town and the cost of living is higher in certain areas, i.e., San Diego and Seattle
Recent escalating food prices have added to the burden of offering nutritious meals to military families. All of the above elements and food insecurity results in serious implications on mental health. Reduced calories, inadequate vitamins, minerals or lower value food choices, i.e., junk food increase obesity, hypertension and diabetes. The psychological stress of not being able to feed yourself or your family may impact mental health. A 2020 meta-analysis found that food insecurity increased the risk of depressive symptoms (Pourmotabbed et al., 2020). The Department of Defense has recognized the impact of food insecurity on not just physical and mental health but also military readiness. An ADSM worried about their family having enough to eat is not focused on their job or mission. What’s the answer? A Basic Needs Allowance (BNA) has been proposed; this is estimated to be a $400 per month stipend, and ten thousand junior enlisted service members would be eligible. Another proposal is to exclude BAH from SNAP eligibility. Other strategies include assistance for military spouses to secure and sustain employment. Child care needs to be affordable and accessible; it is the primary reason that an ADSM spouse is not working. No service member or their family should be hungry in service to their country.
Finally, making the transition to civilian life is a journey with actual and potential challenges. Many of these challenges include behavioral and mental health. The Pew Research Center explored the transition to civilian life and found that post-9/11 veterans experience more difficult transitions than WWII, Korea or Vietnam veterans. Veterans who say that they had an emotionally traumatic experience while serving or had suffered a service-related injury were significantly more likely to report problems with re-entry (2021). Factors influencing transition or re-entry:
- Officer vs. enlisted
- Marriage; can be a protective factor
- Faith/religiosity for post-9/11
- Education; those with a high school diploma experienced more difficulties than those with a college degree
- Having a clear understanding of missions results in easier re-entry
ADSM separate or retire every year; it’s an opportunity for case managers to offer resources that prepare them for success. Bridge programs with internships may ease concerns regarding a transferable skill set. Open discussions on what’s next need to begin sooner than six months before the ADSM leaves service. Multiple decisions face military families during the transition to civilian life and require considerable thought plus planning. Each change can be a stressor which in turn may be a crisis. Support and advocacy from case managers can mitigate the stress and lessen the anxiety, thus offering a successful journey to civilian life.
Take a look at the American flag at the beginning of this article. It’s a distressed flag; a metaphor for what our ADSM are experiencing with SDoMH. What’s our way forward?
Aware; Assess; Act
Considering the consequences and impact on readiness, recruitment, attrition and national security, this is a case manager “all hands.” Be aware of the protective and risk factors with each ADSM. Transdisciplinary teams matter: Physical therapy will have information other team members may not be aware of. The ADSM will share in the gym what they can’t say in an office or clinic.
The 2022 CMSA Standards of Practice of Case Management outlines a client-centered assessment including physical, psychological, social, environmental and spiritual domains. Assessment is a dynamic process and happens in every interaction. Case managers may engage the ADSM in other settings where additional data is offered. You can learn a lot in the chow line or walking across the base. The “walk and talk” approach is more casual than a structured meeting and offers a relaxed setting for sensitive information. Primary care managers may ask about personal safety and interpersonal violence. What about food insecurity? Be familiar with these two food insecurity statements:
- Within the past 12 months, we worried whether our food would run out before we had money to buy more.
- Within the past 12 months, the food we bought just didn’t last and we didn’t have money to buy more.
Choices are Often True; Sometimes True; Never True. Those who respond Often or Sometimes True are at risk for food insecurity. Be prepared to offer food resources in a way that doesn’t reinforce stigma and shame.
Action is needed now. Implement one action; a small step forward. Review the ADSM exposure documentation. Encourage completing the VA Airborne and Burn Pit Registry. Advocacy is essential; act in the ADSM’s best interest by offering the best information relevant to their health situation. You may be the only voice raising a concern but be that voice. Explore community collaboration and partnerships for mental health support. Needs may not be met through military treatment facilities so be familiar with the community network. What will be the robust, successful intervention from your case management team? If not now, when? If not us, who?
White, CW (2021). Professional case management and military service as a social determinant of health. Professional Case Management, 26(1) 46-49.
Cutler, D. and Simmons, L. (2020). The COVID-19 Pandemic and the $16 Trillion Virus. https://news.harvard.edu/gazette/story/2020/11/what-might-covid-cost-the-u-s-experts-eye-16-trillion/
Czeisler, M.E., Lane, R.I. & Petrosky (2020) Mental health, substance abuse, and suicidal ideation during the COVID-19 pandemic-United States, Jun 24-30, 2020. MMWR, 1049-1057. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm
Wounded Warrior Project (2021). Annual warrior survey. https://www.woundedwarriorproject.org/mission/annual-warrior-survey/past-wwp-annual-warrior-surveys
Campbell, M., O’Gallagher, K., Smolenski, D., et al. (2021). Longitudinal relationship of combat exposure with mental health diagnosis in the military health system. Military Medicine Jan 25;186(Suppl 1):160-166.
Case Management Society of America (2022) Standards of Practice for Case Management. Brentwood, TN https://cmsa.org/sop22/
Pourmotabbed, A., Moradi, S., Babaei, A. et al. (2020). Food insecurity and mental health: a systematic review and meta-analysis. https://pubmed.ncbi.nlm.nih.gov/32174292/
Pew Research Center (2011). The difficult transition from military to civilian life. December 8. Author: Same. https://www.pewresearch.org/social-trends/2011/12/08/the-difficult-transition-from-military-to-civilian-life/
Centers for Disease Control (2020). ACEs Adverse Childhood Experiences, fast facts. https://www.cdc.gov/violenceprevention/aces/fastfact.html
Cronk, T. (2021). Defense official says food insecurity is a national security issue. July 27, DOD News. https://www.defense.gov/News/News-Stories/Article/Article/2709598/defense-official-says-food-insecurity-is-a-readiness-national-security-issue
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Lutz, J. & Welsh, C. (2022). Solving food insecurity among U.S. veterans and military families. June 1. https://www.csis.org/analysis/solving-food-insecurity-among-us-veterans-and-military-families
Ndugga, N. & Artiga, S. (2021). Disparities in health and health care: 5 questions and answers, Kaiser Family Foundation. www.kff.org/report-section/disparities-in-health-and-health-care-5-key-questions-and-answers-issue-brief/
PACT Act (2022) FACT SHEET: PACT Act delivers on President Biden’s promise to America’s Veterans. The White House. August 2. https://www.whitehouse.gov/briefing-room/statements-releases/2022/08/02/fact-sheet-pact-act-delivers-on-president-bidens-promise-to-americas-veterans/
Welsh, C. (2021). Food Insecurity among U.S. Veterans and Military Families. https://www.csis.org/analysis/food-insecurity-among-us-veterans-and-military-families
Elaine Bruner, MSN, CMGT-BC, is an experienced nurse, case manager and educator. She completed her undergraduate studies with the State University of New York at Plattsburgh, followed by her graduate work with the University of Virginia. Prior to entering case management practice, Elaine worked in diverse settings including oncology, nutrition support, home health, and traumatic brain injury rehabilitation. Case management offered Elaine opportunities to join transdisciplinary teams in cardiology, critical care, and ambulatory care. Since 2008, she has been associated with American Nurses Credentialing Commission, contributing to the Nursing Case Management (NCM) certification review products. She co-authored the 4th edition of the NCM Review and Resource Manual, with Peggy Leonard, and was the faculty for live workshops and webinar presentations. Elaine embraces her educator role, authoring manuscripts in CMSA Today, offering continuing education presentations, and coaching case managers to certification success. Elaine’s current role, with US Navy, offers daily challenges, keeps her skills sharp and a smooth transition to retirement.