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The Military Pathways Program
By Paul F. Heithaus, MSW

With the completion of Operation Iraqi Freedom (2003-2010) and Operation New Dawn (2010-2011), and the winding down of Operation Enduring Freedom in Afghanistan, the ranks of young Americans who have served during wartime and identify as veterans continue to grow, as does the demand for clinicians trained and willing to focus on their specific needs. According to the Congressional Research Service’s January 2014 report on U.S. military casualties, 118,829 cases of PTSD have been officially diagnosed among service members (Fischer, 2014). The warrior culture that allows our men and women to thrive in the grueling conditions of multiple combat deployments leaves little room for help-seeking behavior, which may be perceived as weakness, attaching stigma to mental health issues. The result, according to a 2012 Blue Star Families study, is almost two-thirds of all military-related PTSD cases are undiagnosed and untreated (Greentree, Johnson, Lore, Dagher, & Taylor, 2012).

Untreated PTSD affects not only the service member or veteran, but also the family. A recent study of young veterans found that behaviors such as angry verbal outbursts, destruction of property, threatening others with violence, and engaging in dangerous behaviors (eg, driving under the influence of alcohol) were often tied to violent combat exposure (Milliken, Auchterlonie, & Hoge, 2007). These young veterans also experience higher than average levels of conflict in family and social relationships. Added stressors can result in a breakdown of the family unit, which could be the veteran’s primary support system.

Recognizing the psychosocial impact of war on those who serve, as well as those at home, the Department of Defense (DoD) has spent the past 10 years developing strategies to address the challenges the warrior culture presents to identification and treatment and therefore readiness. The combination of a resistance to seeking help and the frequency with which members of the military move means service members need a portable, private method for evaluating mental health. A 2008 study of soldiers returning from deployment found they were significantly more likely to score positive for both PTSD and depression when a screening was conducted anonymously. The study found similar results when examining the self-reported need for treatment. Researchers found that anonymity led to higher results because respondents felt comfortable being honest whereas mandatory assessments made them uncomfortable (Warner et al., 2011).

Protecting Privacy
Supported by evidence that anonymity was essential to identifying and addressing the mental health needs of today’s military, and determined to avoid the pitfalls of previous generations, the mental health community needs innovative solutions that are anonymous and easily accessible. Social workers are taught to meet clients where they are. Like most Americans in today’s fast-paced, information-at-your-fingertips culture, the military and veteran communities live online. Social media, Web chats, and e-mail allow service members and veterans to remain in contact with their families while deployed and their battle buddies when they return. While it may seem unorthodox, if this is where clients feel most comfortable, social workers must try to meet them there. The use of technology in the craft may be unsettling for some, but as long as there is evidence to back it up, the focus should be on the clients’ comfort level, not the social workers’.

The need for innovative tools to address mental health is not confined to the military and veteran communities. In 2008, the national nonprofit Screening for Mental Health sanctioned an independent evaluation of an online version of their flagship program National Depression Screening Day. The effort strives to provide the mental health community with tools similar to those of the physical health community by raising awareness of and screening people for depression and related mood and anxiety disorders. The research team specifically looked at the effectiveness of the nonprofit's online self-assessment tools in encouraging further evaluation and treatment. The 2008 evaluation was conducted as a follow up to a similar 1996 study of in-person self-assessments conducted as part of National Depression Screening Day. The results were statistically comparable. Of participants screening positive for depression, 54% in 1996 and 60% in 2008 sought treatment in a three-month follow-up (Greenfield, Reizes, Magruder, Muenz, Kopans, & Jacobs, 1997; Aseltine, 2009). The 2008 study provided evidence that an online platform is as effective as in-person tools in raising awareness and directing users to follow-up services.

Based on the Blue Star families data on undiagnosed PTSD cases, a major focus needs to be on successful screening and evaluation. The evidence supporting the validity and the success of the online platform bolsters the DoD’s use of technology in mental health programs.

Web-Based Assessments
The Military Pathways program is one of several Web-based mental health self-assessment and awareness programs provided by the DoD. Originally created as the Mental Health Self-Assessment Program in response to the 2006 National Defense Authorization Act, Military Pathways’ mission is to improve awareness of the availability of mental health services for, and warning signs about, mental health problems in members of the Armed Forces and their families. The program seeks to do the following:

• reduce any stigma associated with seeking help for a mental health problem;

• educate military families and service members about the mental health and alcohol treatment services available through military and community-based providers; and

• encourage the use of treatment services through referrals generated by free, voluntary, anonymous self-assessment tools.

Military Pathways’ main tool is its Web-based self-assessment resource, www.MilitaryMentalHealth.org. Averaging almost 250,000 visits per year, it helps the military and veteran communities in their journey to greater awareness and treatment. The journey begins with six validated mental-health self-assessments: the HANDS depression screening (Baer et al., 2000), the Alcohol Use Disorders Identification Test (Allen, Litten, Fertig, & Babor, 1997), the Carroll-Davidson Generalized Anxiety Disorder screen (Carroll & Davidson, 2000), the Primary Care PTSD screen, the Mood Disorder Questionnaire (Hirschfeld et al., 2003), and the Brief Screen for Adolescent Depression (Lucas, 2001). When each screening is completed, the user is provided with resources, including treatment and referral information, education and awareness information, mobile and Web-based treatment and maintenance tools, a comprehensive video library, and an interactive video doctor program.

Since 2006, more than 340,000 mental health screenings have been completed at MilitaryMentalHealth.org. Of these, 60,560 scored positive for depression and responded to a follow-up question measuring intent to seek further evaluation. Of these, 43,603 reported intent to seek further evaluation. While the anonymity of the program prevents Military Pathways from gathering additional data, research suggests that the majority of those who score positive seek follow-up and treatment. It seems clear that the screening program leaves the user with a better understanding of his or her wellness and readiness.

Online self-assessments are not a substitute for treatment, but they help to break through any perceived stigma and provide information about the user’s mental health. Social workers know it is difficult to help someone who is not ready to be helped; education and understanding are keys to success in treatment. Military Pathways helps service members, veterans, and their families understand that the first step need not be through the doors of a mental health clinic. Creating a safe space helps them take the next step closer to those doors. 

— Paul Heithaus, MSW, is a Military Pathways program manager.

Author’s Note: The views expressed are those of the author and do not reflect the official policy of the DoD or the U.S. Government.

References
Allen, J. P., Litten, R. Z., Fertig, J. B., & Babor, T. (1997). A review of research on the alcohol use disorders identification test (AUDIT). Alcoholism: Clinical and Experimental Research, 21(4), 613-619.

Aseltine, R. H. (2009). Evaluation of the 2008 National Depression Screening Day online screening program. Farmington, CT: University of Connecticut Health Center, Institute for Public Health.

Baer, L., Jacobs, D. G., Meszler-Reizes, J., Blais, M., Fava, M., Kessler, R., et al. (2000). Development of a brief screening instrument: the HANDS. Psychotherapy and Psychosomatics, 69(1), 35-41.

Carroll, B. J., & Davidson, J. R. T. (2000). Screening Scale for DSM-IV GAD.

Fischer, H. (2014). A Guide to U.S. Military Casualty Statistics: Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom. Retrieved June 10, 2014, from http://fas.org/sgp/crs/natsec/RS22452.pdf.

Greenfield, S. F., Reizes, J. M., Magruder, K. M., Muenz, L. R., Kopans, B., & Jacobs, D. G. (1997). Effectiveness of community-based screening for depression. The American Journal of Psychiatry, 154(10), 1391-1397.

Greentree, V., Johnson, S., Lore, C. E., Dagher, L., & Taylor, J. A. (2012). 2012 Military Family Lifestyle Survey: A Comprehensive Report. Blue Star Families, Department of Research and Policy. Retrieved from: http://bluestarfam.org/resources/military-family-lifestyle-survey.

Hirschfeld, R. M., Holzer, C., Calabrese, J. R., Weissman, M., Reed, M., Davies, M., et al. (2003). Validity of the mood disorder questionnaire: a general population study. American Journal of Psychiatry, 160(1), 178-180.

Lucas, C. P. (2001). Brief Screen for Adolescent Depression (BSAD), Parent Version. New York: Columbia DISC Development Group.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. Journal of the American Medical Association, 298(18), 2141-2148.

Warner, C. A., Appenzeller, G. N., Grieger, T., Belenkiy, S., Breitbach, J., Parker, J., et al. (2011). Importance of anonymity to encourage honest reporting in mental health screening after combat deployment. Archives of General Psychiatry, 68(10), 1065-1071.

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