All right, in the interest of everybody's time, we'll get started. I'm gonna back up a little bit. Welcome and thank you all for coming and those that are listening, appreciate you too. This presentation is a bit of a work product that will be accompanied by a permanent document that the APA will publish of a similar title and information. So we're gonna talk about the impact of psychiatric diagnoses and treatments on active duty military members. Typically in our military talks, you'll hear us say this is our opinion and not official policy. While I will say that this is not policy, this is our interpretation of policy, so none of this is opinion. But I will refer you back to specific policy on occasion and then additionally, you can always ask questions to your local military treatment facility. I'm Dr. Heather Hauk. I am currently serving as the Head of Behavioral Health Services at our Naval Base in Rota, Spain. I additionally serve as the Addictions Associate Specialty Leader for the Navy. Dr. Eric Meyer is the Psychiatry Consultant to the U.S. Air Force Surgeon General. Dr. Monica Ormeno is the Navy Psychiatry Specialty Leader and Dr. Sebastian Schnellbacher is the Psychiatry Consultant to the U.S. Army Surgeon General. You will hear us talk about multiple terms across services. Some will be different and we will explain the differences between the services as well. All three of my counterparts serve in very similar roles despite being called different things, consultants versus specialty leader. During the course of the talk, we will discuss and define various military mental health standards. We'll also look at duty limiting conditions, medications and treatments. Then we will explain what all psychiatrists, civilian and military can do for patients. We'll talk about additional resources including the resource document that is pending from APA. And then we'll look at clinical scenarios and answer any questions that you guys have. I'm gonna turn it over now to Dr. Eric Meyer. All right. Last day of the conference, thank you for being here. If you're a military provider, would you mind raising your hand? All right, awesome. So we are definitely giving a sermon to the choir. And if you guys disagree with what we're saying, pop your hand up. Because one of the things that we've discovered in this process, because this has gone through CORD, we have coordinated this through the Army, through the Navy, through the Air Force, now through DHA, through TRICARE, is that there were misunderstandings, misconceptions between the services. So if this isn't the way it's happening at your clinic, these are the types of things we're trying to highlight. Because policy is intentionally written to be vague, or if you're an optimist, to be flexible. So that it can work at your location. But that also means that the rumor mill can take hold. A could becomes a should, a should becomes a must, and a way of monitoring that must becomes embedded into the culture and it kill, into the clinic, excuse me, and it kills the clinic, because it's really tedious. It's hard to unwind that. So I really do, I welcome you guys to just raise a hand and be like, wait a minute, what's that? Why are you saying it that way? So we're gonna start off with what are standards? If we want every psychiatrist to understand what standards are, we have to start with the basics. Because we use a lot of terminology and almost none of it is intuitive. We know that we're sending more and more folks to the network, so outside of our military clinics. Because our military clinics are not and our military clinics are overwhelmed. I can't speak to the other services, but in the Air Force, our number of patients has increased per year from 400,000 to 750,000. And the number of providers we have has not changed. So our clinics are hurting. We have more people coming to the clinics because they've been taught for their entire lives, go to the clinic. So if we're gonna have more support from outside of the clinics, we need to make sure that everybody understands these really important constructs. So there are types of standards. The first type of standard is an accession standard. These dictate who can join the military. Now the Medical Corps does not own these standards. They are owned by AFPC, using Air Force talk, by Personnel Command. So that's really important. We have medical accession standards, but we don't dictate them. These are the most stringent standards because we haven't trained you, we haven't paid for anything yet. So they are the strictest. They have the least amount of wiggle room. Then we have retention standards. Can someone stay in the military? Now there are administrative standards and medical standards. Command can always say, you're not meeting regs for your uniform. You're not showing up to work. And that's not a diagnosis, but we have standards for dress and appearance, we have standards for doing your job. And command can say, we're gonna remove you from the military because you're not doing your job. Now as you can imagine, especially in behavioral health, that can blur. Are they not showing up to work because they have major depressive disorder? Are they not showing up to work because they have personality disorder? So there are administrative separations within medical where we do not believe that the military has caused or exacerbated the condition. It was preexisting or inherent, kind of a dangerous word to use, goes back to the 1800s, but it's inherent to the person. Or is this an unfitting condition? The military caused it or exacerbated it and you should get some type of disability, some type of service connection. So understanding that there are three different ways you can be separated from the military and that they go by very different routes that can sometimes intermingle is really important. It requires evidence that they won't recover. This is key. So if it's a chronic mental health condition, bipolar, schizophrenia, we know diagnostically you will not achieve remission. But for every other condition to include personality disorders, there needs to be evidence we tried to get them to remission. And that either a year of trying hasn't worked or our best guess is it won't work. This is another big misconception that someone can walk in the front door and I can say, you have GAD, I'm kicking you out of the military. There has to be evidence of an effort to get them better and that it's not working. And then we have profile. So profiles are our way of communicating to command that someone can't do something or a better way of saying it is shouldn't do something. We have different words for this in the different services. In the Air Force, we use a system called ASIMS to communicate with command because command does not have HIPAA privileges. They don't just get to look at the medical record despite what Facebook says. We only send them very specific information through these systems. So the Air Force uses ASIMS, the Navy uses LIMDU and the Army uses a 3822 to communicate these limitations. And there are different types. There's duty limitations. Do we think they should be able to do their job? Do we think they should move? And that could be a permanent change of station or it could be a deployment. It could even be going on TDY. We are all on TDY, we're on a trip. Should we be allowed to go to San Francisco for a week? Should they be allowed to deploy? And then there's special duties. So should they have a top secret clearance? Should they be allowed to work with nuclear weapons, PRP? Should they be allowed to arm up, have a firearm? Should they be allowed to fly an aircraft? What type of aircraft? Flying a large aircraft where you have a co-pilot is very different than flying a small aircraft where you're the only pilot. Should you be allowed to jump out of aircraft? We have lots of special duty standards. So why do these exist? So this is the dual hat role of the military psychiatrist. It might not be safe for the military member. If someone is experiencing major depressive disorder and they're really struggling to concentrate and focus, is that the person you want tightening each bolt on the aircraft's engine to 29 pounds of torque exactly? Probably not. It's not good for the person flying that aircraft. It's not good for all the people in the aircraft. It's not good for the person working on the aircraft. So we need to be cognizant of certain diagnoses and certain treatments can influence our service members and how that could impact them, their safety, and the safety of the mission. We also don't want to deploy people or move people in the middle of treatment, right? So this is where we get a little bit lost because we don't use the word cure in psychiatry, but if you finish 12 sessions of CBT, you have a 72% remission rate, cure rate. If you finish that course of CBT, you should achieve remission. We want you to finish that before you move to a new base, before you deploy. So those mobility restrictions are really so we can execute a course of care. We also don't want someone going somewhere where we can't support them, right? Class two medications are exquisitely difficult to get into Afghanistan. The diagnosis is not that big of a deal. It's the medications, right? And if you need to see a me once a week to be your best self, that could be problematic because I don't go all the places that the military goes. Right, so we want to make sure that whatever you need to function is available wherever you might go. And then I emphasized this before, but I want to come back to it. If they can't do their job for a year, then we ask the question, can they stay in? And that's another really key thing that gets confused. People refer to MEBs, Medical Evaluation Boards, as if that ends with a period. And I wish that policy ended with a question mark. An MEB is a question. It's been a year, they haven't been able to do their job. Can they stay in? It's not a decision. The decision comes after the question. And the only requirement after one year is that the question be asked. And if the question is, you bet they can stay in, that's a local base level decision. It doesn't have to go all the way up to headquarters. So why, or excuse me, what role does military medicine have going back to that dual role? We're always considering the impact a condition might have on military duty. We're always prioritizing returning to duty as part of treatment planning. So I just talked about a bunch of things that you can put a patient on. You can put them on a profile, but you can also take them off a profile. And I'm seeing some heads going up and down, but this is probably one of the things we really need to get after in the military. If we teach military residents how to put someone on profile, it's probably more important to teach them how to take someone off profile. Because if a profile is considered as a permanent thing, then you bet it's gonna be stigmatizing. But since MDD is not a permanent thing, GAD is not a permanent thing, OCD is not a permanent thing, these can all achieve remission. They're not chronic mental health conditions. We should be communicating as such. We have great treatments for this. We have great psychotherapy for this. We have great medications for this. The goal of this profile is to finish that treatment, to see you achieve remission, and take you off that profile. Now all of a sudden being put on profile is not a career ender, it's just a necessary component of completing care, of having someone's back. But we don't communicate that nearly enough, and this process of writing this up has made that really evident to many of our senior leaders. Again, can the very due location support our patient, which isn't a typical clinical question, and their family's needs? So we are always thinking about how are we gonna take care of your kids? Because if your kids aren't taken care of, or your spouse isn't taken care of, you can't focus on your job. So you'll frequently hear conversations of is this healthcare delivery, or is this readiness? But that's really not a cogent construct. The dental care for your kiddo back home means you can focus on your mission while you're at sea, or while you're in the desert. So we're always thinking about is this location gonna be able to support the whole family? And then last but not least, everything I've mentioned this far is a recommendation. We as medical officers do not have command authority over our patients. And I think this is liberating. If you're a TRICARE provider, or you're a civilian provider, and you're listening to this, and you're like, oh, I decide where people go, I end people's careers, I take their guns away, you absolutely do not. You make a recommendation, just like we would on the consult service. This patient needs to be intubated. I'm not doing it, I'm just letting you know their airway is compromised. It is a consultative process with command. As your medical officer, this is what I recommend. And command can not follow your recommendation, because there are the commanders. So that boundary is a really important boundary, because it makes it a lot easier for us to just make our recommendation. We're not trying to guess what command wants to hear, we're telling them what we think, and letting command make its decision. My last slide, what are the implications of this dual role? Stigma and fear. Now stigma is decreasing. For 20 years, we've been telling everyone to go to behavioral health or mental health for everything and anything, and they are coming. And kids now, from day one in elementary school are taught about mindfulness, they're taught about talking about their feelings, identifying their feelings. If you're having trouble, go talk to the counselor. So they're not stigmatized from us, but this concept that there's a consequence somehow gets misconstrued as stigmatizing, which is fascinating, right? Because olanzapine has side effects, and no one ever says that those side effects are stigmatizing towards olanzapine. It's a natural consequence. And we don't start that medication lightly. We only start it if it's indicated. And it's the same with these standards. We don't put people on profile for fun, because we don't make diagnoses for fun. If you have this diagnosis, here's the profile that goes with it. It's not forever. It's until we can achieve remission. And if we can't achieve remission, and we have a whole year to do that, then we're gonna ask the question, can you stay in the military? But that is not the way standards profiles all the things I've just mentioned are typically described, especially on Facebook. Typically it's described as career enders, the military hates me, the military wouldn't give me the care I needed. And hopefully as I've walked through these basics, you can see that that is not the case. So now with this basic underpinning of what standards are, we're gonna pivot to mental health, the diagnoses and treatments and the standards that they impact. Thank you. Good morning. I want to say first that it's so nice to see my fellow military psychiatrists in the room. We have great respect for each other. But I want to say that it's even better to see non-military psychiatrists in the room. And you are welcome, and we really thank you for taking care of our soldiers. And so every single soldier that you take care of, thank you for putting in that tremendous effort that you do in doing that. But as we, the military, we are just a subculture of the larger culture. And every single thing that we see in the larger culture, we also see in the military as well. And that goes with the whole spectrum of mental health conditions. And we're going to just talk about some of those and give some thoughts and reasons why these might have impact. Mental disorders, and there's not a specific order of precedence. This is just the order that, as we were brainstorming these together, we wanted to focus on. One very common example of this might be ADHD. So these could be career-ending if the symptoms can't be resolved with simple treatment. And I frequently get the question, why, ADHD is not a big deal, why is the military focused on this? Well, if your job is to scan for a specific threat and protect everyone else around you, you need to be able to sustain that focus. It needs to be a very, it's an important qualification for you to do your job. Similarly, there are things that have to be continually monitored in the Air Force, in the Army, in the Navy, and if you're not able to sustain that focus to be able to do that, you could be putting your own or other people's lives at stake. And so, it's not necessarily a high standard of concentration that people need to go to. There are many, many people in the military that might have ADHD, for an example, but they need to at least be able to do, function at the level of doing their job. So these neurodevelopmental disorders, they're considered to have existed prior to joining the military. Lots of times, they're associated with an administrative separation at times. And as we're treating these, we have to remember that we're not always in the middle of the United States, and even in the middle of the United States, some of these medications are hard to find now, right? Given the shortages that we're seeing. But if you're all of a sudden sent to the middle of Africa, the middle of the European theater, where there's not a lot of logistical infrastructure yet, it will take time to be able to get those medications to those locations, and ideally, we will try and give them the medications before they go, but that's another element that's at play. How do we get these specific medications to these individuals that might be in the middle of a boat or a ship? I know you have specific words for those. In the middle of the Pacific Ocean, right? And there could be tremendous amounts of resources that are required to make that happen. So neurodevelopmental disorders are something that we look at. Personality disorders, okay? That's another thing that can be career-ending. There are many, many people in the military that have personality disorders that does not affect their career. There are, many of my friends have some sort of obsessive-compulsive personality disorder, and that's just kind of self-selected to where we are, and it's not impacting anything. There's definitively some narcissism that's present in the military, and self-selected, that can, it can be almost functional in a way, but it does not interfere with the job. And the military does not care about some sort of personality trait or some sort of personality disorder that does not interfere with that job. But if it does interfere with one's ability to engage in your job, or if you do have, in the case of borderline personality disorder, recurrent safety issues at play, then that will likely lead, or could lead to an administrative separation, because we don't want to put either that soldier or any other soldier at risk, and we all need to rely on each other, and we need to be able to do our mission to keep everyone else around us safe. Adjustment disorders is a fantastic topic, and in the military, we see a lot more of this diagnosis than what I've seen happening in the civilian world. And I think that there are many reasons for that, but one big reason for that is what it takes to be in the military, and that process of joining the military. So typically, the people that join the military initially are younger, they might not have a fully developed set of coping mechanisms developed yet, and then we're placing them into a very stressful situation of both training and work, and most importantly, I think a key difference between the civilian life and the military life, there are many things that military members sacrifice, but one of those things is autonomy. So in a non-military environment, if you encounter a stressor that's exceeding your coping mechanisms, you can leave that environment, right? You have other mechanisms of responding or reacting to that stressor. In the military, we have given up voluntarily a little bit of that autonomy. Every single person in this panel in front of you has given up a little bit of autonomy. And so when you have that sense of feeling overwhelmed, not having the tools to be able to deal with those stressors, but you can't leave, that can lead to a lot of stress. And what we found is there's a group of people that when you remove that stressor, those symptoms also resolve as well. And so we do see a lot of adjustment disorders in the military as people are adjusting to that different lifestyle and at that specific age with the lack of autonomy. So because these symptoms typically resolve after the stressor is eliminated, if we're not able to fully support this individual and help them and the adjustment disorder is interfering with medical service, that might be an administrative separation or if it lasts long enough to where it's a chronic adjustment disorder, potentially a medical board. And this is just because we need to have people that can adapt to the environment that they're in. And if we're putting them, if our environment is making a service member at risk, we need to take care of them and we need to take care of everyone around them. Bipolar and psychotic disorders are another, there's some differences between the military culture and the civilian culture as far as care with these diagnoses. We need every single service member to be able to function in an extremely stressful environment, in a time and a place where they might have safety concerns with people around them. So our soldiers, and they might have grenades, they will likely have weapons. And the question is, would you want this individual to be in the foxhole next to you with a loaded weapon if they're psychotic or prone, or maybe have the tendency to develop some sort of psychosis at some point in time, especially in a stressful environment. So for these reasons, these conditions, I would say are very likely, extremely likely to end a military member's career. And that's why we truly appreciate the diagnostic specificity that you have when you're evaluating our service members. Sometimes a diagnosis of bipolar disorder will end a service member's career. And so we need to be very, very careful as we're maintaining that specificity, that bipolar disorder truly is a bipolar disorder, either bipolar one or bipolar two, or a psychotic disorder. If we diagnose those, that will have impacts. But a lot of times we see the same things that you see. Depression, anxiety, PTSD, for various reasons. And we treat them. And we are very, very good at treating our service members. And these individuals frequently recover. And their careers are not impacted. In the military, in the Army specifically, if I am not able to, despite treatment, send someone to do their duty for a long period of time, or they require repetitive admissions in a more protective environment, then that would be a time where the military would feel that a non-military career might be better for a specific service member for their safety. But in general, the vast majority of people, they recover from their mental health conditions. And they resume productivity in the military. And other people have seen that. And I think that's another reason that our stigma has gone down, why so many people are coming to the military for non-behavioral health, because they see that effectiveness and that function. As we're treating all these conditions, we just have to be careful. There are specific nuances within the military treatment that are not at play in the civilian sector. So if I have a service member that's prescribed lithium, for an example, and I send them to the middle of a desert, and they're engaged in exertion, there's a greater chance for toxicity. And even not in a desert. I mean, if you're in the summer in Fort Benning and you're engaged in the training that we engage in, there could be some dehydration that's at play. So that might not be a good choice for a military service member. And typically, any of the antipsychotics or mood stabilizers, those are considered to be indicative of some sort of psychotic or bipolar disorder, which, in general, is there are significant safety concerns that are at play for having these individuals potentially carrying weapons in a high-stress environment. Also, we can prescribe almost any medication in the military. But we have a more narrow formulary. And then, just like any other healthcare system, to be able to get to specific medications, those service members might need to have met specific criteria. But also, because we're operating globally, they might not have a specific medication in the middle of the Pacific Ocean on one of your aircraft carriers. And what does it take to be able to get that to that location? So we typically have, or we prefer, a more narrow formulary that everyone has in various places just because, logistically, we know that we can serve all of our service members equally across the globe that way. What I'd ask is that you call the military treatment facilities. We are more than happy to answer any of your questions if you have a question about either a duty-limiting condition or how to potentially treat in a way that's best aligned with our formulary. We want to support you as best we can because you're supporting our service members. And then, also, because every single diagnosis can have an impact on retention, we primarily treat medical conditions. So if you have a stimulant that you're prescribing, a soldier, we would ask that it not be for performance enhancement. And also understand that as you're prescribing stimulants to our soldiers, every single, potentially any month, that soldier could get a urinalysis. And while, if you prescribe a medication to that soldier or a service member, if I say soldier by accident, airmen, guardians in the Space Force, or sailors, I mean, we all have very, very similar requirements at times. Just understand that while that, if you prescribe something, that will be okay eventually if they're taking your legitimate prescription. But that will come up as a positive urinalysis and that will add to stress. So I'd consider which stimulants are you gonna prescribe and which ones do and which ones do not come up on a UA. And so, just typically the methylphenidate will not come up on a typical urinalysis. Adderall salts will. So if you don't have a specific reason to prescribe one to a soldier compared to another, as we're talking about these stimulant medications, it might be valid to defer more towards a methylphenidate type product, just because that's going to eliminate that stress for the soldier when they have the next pee in the cup and then they're gonna have to justify it by finding their prescriptions or telling their commander, no, I'm taking this medication, that's why it was positive. So it is something that, just to enhance the confidentiality of the medications you're prescribing to your soldiers, I would make that small consideration. And with that, we're gonna transition to how you can help. Thank you. So this presentation came to be partially as a very self-serving thing, certainly, because just like Dr. Meyer talked about the Air Force, for the Navy we've gone from deferring to the network at about 1 to 2 percent to actually over 90, 95 plus percent in several of our big sites. So as has been said before, we just don't have enough psychiatrists to be able to take care of the demand. Our demand in the Navy has increased in the last 10 years by about 3,000 percent. So stigma is not something we—I would argue that we fought stigma way too well, which is a good thing because now we see that a lot of our sailors and Marines are really asking for the help that they need very early. And in doing so, of course, they end up seeing somebody who may not be as familiar with military requirements as we are. I want to also emphasize that this applies to airmen, soldiers, Marines, sailors, but also the National Guard and reservists. So I feel that a lot of times we forget to ask our patients whether they are in the National Guard or in the reserves, and that is extremely important. Because as somebody who deployed into an IA with a lot of National Guard and reservists and saw people showing up to my clinic asking for methadone, in Afghanistan it was a very complicated situation to return that National Guard or that reservist back to their hometown once they were already in country. So you can take a lot of drugs when we deploy, whether it's on a ship or if it's boots on ground in the desert. So when you're obtaining a military history, ask about their job and try to understand what that means. The best way I can explain it sometimes is imagine the worst factory that you could possibly work at. That's a ship. So ask them in their own words to explain what their job entails. Because a lot of times they may say, oh, I work in engineering. But you have an idea of what working in engineering means. Working in engineering on a ship, working on engineering in aircraft is quite different. I know that several of the managed care companies, whether it's, you know, for Tricar West or Tricar East, are also organizing trips to the bases and to the ships for our network providers in order to familiarize them with what kind of jobs, what kind of situations our sailors and Marines are living in. So if you can advocate for your, for the company that you work for to do that, we are happy to give you tours. Trust me that we, if you ask a command to give you a tour, that that's where we shine. We love to show you where we work. We love to show you what we do every day because we're very proud of it. In terms of something that has been discussed already, ask them as you're asking that history, ask them about any special duties. Are they special forces? Do they have to dive for their job? The scuba diving that somebody does in the Navy or in special forces is much different from the scuba diving that, you know, you'll be able to do if you're on a tour in the Caribbean. So, so ask about those special duties if they're, if they work with nuclear equipment, if they're on flight status. What type of security clearance do they have? That gives you an idea of what level of importance their job has in terms of secret information and, and that definitely has an implication when it comes to treatment because they have to report. First and foremost, going to mental health does not mean that their security clearance will be impacted. What, what will be impacted is if they don't disclose that they've gone to mental health. So they know, the service member, as has been said before, when we sign into the military, we sign up knowing that we have to report any change in our health status to our commanding officer because it affects our fitness for duty. So, so we know when we, if I go and see a mental health provider outside of the network that I have to report that to my command. So you wouldn't be doing something that I don't know it needs to be done. Ask about their deployments, how long they've been and, you know, if they're going on a new deployment coming up. Not just about deployments, but sometimes people forget that in the military we also go on temporary duty assignments that can be rather long. They sometimes can be three months or they can be, you know, six months. Sometimes also we need to learn about any separation from their family. Just because they didn't deploy doesn't mean that they didn't spend two years in what we call getting bachelor orders. So, so you are away from your family for two years even though it's not a deployment. Of course, ask about combat exposure, where, how long, what was their role when they went to combat. A lot of times, well not a lot of times, but sometimes what ends up happening is you may deploy not in the role that you do when, when you are actually training with your unit. Especially for enlisted personnel that happens. So they may deploy a security personnel but, you know, when they were in, in CONUS, when they were in with their unit, they were a chaplain's assistant. So that's very different from their regular job. Any history of traumatic injury and when you ask that, don't forget that domestic violence also is a huge cause of traumatic brain injury. So ask about that. Unfortunately, several of our service members, of course, have a history of that. So very important to ask about that. Any disciplinary actions and when in their career it happened, what happened, what was the punishment, and sadly, of course, something that it's often in the news, don't forget to ask about history of military sexual trauma. When you ask about it, ask if it was reported and what happened afterwards. We have a very good system that follows our, the people that report military sexual trauma, that offers that treatment, that takes them through a course of treatment, and we see great results. But I always tell patients when we diagnose them, when I diagnose them, is let's concentrate on the treatment more and your return to duty more than we concentrate on whatever we're gonna call, you know, this constellation of symptoms that you have. In the military, we definitely learn to be very conservative in our diagnosis because as it was described before, my Army colleague, several diagnoses are duty-limitating. So it is much easier for us to upgrade than it is to downgrade or take something back. So that's why we take a very conservative approach. We try to make sure that within a year, our service members are sticking to the treatment that was recommended and that we can take them through that treatment and get them back to be fit for full duty. We also avoid the use of medications of label, even if it's like for adjunctive therapy, the use of an antipsychotic would have an impact in their military status, in their fitness for duty. So we are not as able, we have to be more rigid, more black and white about whether or not if a person needs an antipsychotic to enhance an SSRI, then we have to start talking about, well, can this person be fit for duty within a year? And will they need those medications to be fit for duty and do their job in the desert, on a ship, while flying, etc. I think it's, if we've driven one point to the ground, is that anything that happens to us affects our fitness for duty. And anything that happens to us that affect our fitness for duty needs to be reported to the military. Your patient, the service member knows this. We sign a ton of paperwork when we come in and we sign a ton of paperwork when we re-enlist or when we sign for more years, acknowledging the fact that anything that affects our fitness for duty will be reported to our chain of command. So you're not violating HIPAA when you share this information with the right people in that service member's chain of command. You can always, as it's been mentioned before, you can always contact the referring provider and give them that information. Hopefully, the referring provider is somebody in the military system, and they will be able to guide you through this as well. So we know what the rules are. We know that we have to disclose any change in our health. We can't get health care without our commands knowing about it, because more often than not, we also need a referral to get health care, especially if it's, you know, going out to the network. So once again, you wouldn't be able, you're not breaking any confidentiality rules if you are sharing this information, because this is about fitness for duty. We also have some additional resources that can help you if you have any questions about, should I do this? How will this medication affect the service member that I'm seeing, etc.? So we have this coming soon document that we've been working on that will be at the APA website. We have, of course, the APA Ethics of Military and Government Agencies. We have Military OneSource, and these are all, you know, accessible on any computer. It doesn't have to be through a government computer. You don't need any type of special clearance to access this information. And if you still have questions, you can always ask for a military, the closest military treatment facility. They should always be able to receive the information of any referral, not just mental health, but any referral out to the network. They receive the information back. So your referral should go back to them. And now we're gonna go over some case applications of everything that we've discussed. Okay, you ready? Here we go. A 26-year-old male currently on active duty status in the U.S. Navy presents with concern for depression. He's diagnosed with major depressive disorder recurrent moderate without psychotic features and significant complaint of insomnia. Which of the following medications is a reasonable choice without further consideration? All right, he says A for those that can't hear. Anybody have any other thoughts? That's correct. Yeah, so yes, we talk about titration, right? But absolutely we'd start at a lower dose for sure. But this is the correct choice in this case because the others, while they can be acceptable adjunctive treatment for major depressive disorder in our system, they would make for additional duty status limitations and possible long-term implications for career. While mirtazapine is going to be something that will be much more easily managed long-term and with limited duty status limitations. So what the comment was is that if the patient presents with irritability, not in a bipolar spectrum, but irritability, that B might be a better choice. The answer is that by policy Lamotrigine is considered an anti-convulsant medication and is on the list of things that we have to limit duty status for. So while it may treat the symptom, there's policy limitations around the use of anti-convulsants. One thing I would also add, and mirtazapine is a very, very reasonable choice, especially in someone like me or someone like me 20 years ago before I put on the extra weight. Weight limitation also is a factor, especially in the Army too. So if you have an individual where you can either choose an equal weight neutral or mostly weight neutral medication compared to something that might gain weight, that's another thing to consider in our active duty population as well. Because if I just put on 15 or 20 pounds, that might be an additional stressor that just adds to the anxiety and everything else that's going on. So I love mirtazapine. It's a great medication that I use in a small subsection of my population, but I would be very, very careful about the body habitus of the service members that I was doing because we have that additional requirement. Can you use one of the microphones? So what I would probably do first if I had irritability as a chief complaint would be Pristique. I love it for irritability. I've had a lot of folks, you know, it just sort of dissipates without having to do a lot of work other than titrating up. So that's another option that would be easy to manage. And it's formulary now, at least for Army. Yeah, so the difficulty in a lot of our places, and it kind of goes back, so this is one of the things that we really have to consider a lot, is things like Desvinlafaxine. It's a great medication, but we can't get it in a lot of places. It's difficult to use. So if you're overseas, we may not be able to have that medication. For instance, I work in Spain. I can't get it. So my patients, it's not possible for me, even though people typically think about our European countries as being places where we have access to a lot of medications. Unfortunately, we just don't within our system. So I can't prescribe into the Spanish pharmacies. I have to use what's in our pharmacy, and we don't own it. So I really like that you picked the symptom of irritability, because when I was in Korea, I could not get access to Prosteq. But it also made me think, well, irritability is a really odd symptom. It shows up in two diagnoses in the DSM. It clearly is in GAD. It's also not bipolar. But it's also the most common symptom for polycystic ovarian syndrome. Most women with PCOS don't have cysts. I don't know why I got that name. 72% have irritability. So my go-to medication, if they screen positive on the Canadian screener for PCOS, is spironolactone. And there's no duty limitations with that in a healthy female. So that's some of the fun consequences of being in a constrained system, is it makes you look at situations from different perspectives. If I don't have the typical tools, what are the other options on the table? And I think that's, we mentioned this at yesterday's adjustment disorder talk, I think that's a really uncomfortable thing to say. And I just want to make space for that. That our diagnoses are contextually based can be a little terrifying. That if I had this medication, I would go with this diagnosis. That's not the way medicine works. Medication availability shouldn't influence our differential. I would say it can. What about Sertraline, just given the fact that that might be more sedating and is an SSRI? That might be my go-to? Yeah, yeah, absolutely. So we, you know, you have to pick things for multiple choice. But yes, so we would typically, or you can absolutely consider SSRIs, any of them, things that you would even, you know, paroxetine is going to be more sedating as well if you can use them. We can combine things. We do use a lot of SSRIs plus Trazodone. So those are always options as well. Get creative sometimes. Did you have anything else? Okay. All right. The next case, a 19-year-old active duty airman presents with concerns regarding attention. She reports struggling in school but never got help or any type of formal diagnosis. Review of her performance at work and home indicates a diagnosis of ADHD. You recommend that she start a stimulant medication. She reports back that she is scheduled to deploy outside of the United States in the next six months and asks if there will be any issues with her being on a stimulant. Which is the best course of action? I hear mumblings, so did I hear D? Okay, so D recommends she follow up with her military psychiatrist before starting treatment. Anybody have other thoughts? Sure, so the comment was that A, could be reasonable to recommend that her best choice is to avoid medication and use behavioral approaches. And then someone else said C, might be reasonable as well. So, all right. So D would be considered the correct answer. But C is also not unreasonable. We know that psychostimulants and medication pharmacologic management of ADHD is better than behavioral management alone. So we will typically, you can use medications, we would typically go that way for treatment. But absolutely referring back to a military psychiatrist to answer the question, particularly of duty status limitations would be helpful. But yes, you could start the medication and then discuss with the readiness component of the nearest treatment facility. Just to say, it's not like she's actually true, right? She obviously made it this long without being true. April thinks it can help, but she did not go with the final answer. I mean, what does it look like? Not necessarily. Within the year. You can get a waiver. Well, and that's why D is the best option because we don't have an expectation that every civilian provider is gonna learn Army, Navy, Air Force regs, flight regs. It's not reasonable. I don't know all the Navy regs, which is, I think seeing some of this, like, ooh, we all see a little bit differently is important for our civilian colleagues and why we highlighted option D. Because if it comes back that this is a flyer, yeah, option A is gonna be the way to go. If it comes back that, oh yeah, you can start a medication on that, I hope it's really effective. Then you're gonna be able to start that medication. The right answer, if this was a board exam, is D, because it's the safest. You're gonna get the best information for that patient. Also, as I was looking at this question, there was a sentence in there that said you recommend medication treatment. So I was making the assumption that this was, as you were making that assessment, there was a significant enough impairment that you really felt the medication was needed. I completely agree with you that there's ADHD that can be helped with behavioral approaches and that there's no concerns with that. And as you said, A, I'm like, yeah, I could easily see that. It was just that one sentence on that page that I'm like, in the hypothetical scenario, they probably would benefit from the medications. I would also use this as another opportunity to talk about which stimulants are going to come back positive on IUA and which ones might not. And I'd refer back to our addictions expert if I'm off on that, but there are differences between methylphenidate and amphetamine salts as far as what comes back. Yeah, so just to comment on that, the methylphenidate is not going to show up on a typically ordered UDS, but on our command-directed urinalyses where we're really looking for all substances, all substances absolutely will be found. So the ones that people are doing regularly scheduled within the military, they'll find any psychostimulant, but a UDS ordered by another medical person is not going to show methylphenidate. Just curious for Navy and Air Force, would something like Stratera be a problem or would they need a waiver for that? So in the Navy, you would eventually require waivers to deploy on essentially any medication, but they're relatively simple to obtain. Psychostimulants are a little quicker to obtain the waivers, honestly, because you get stable on a dose quicker. So those are a little, actually a little easier to obtain waivers for my experience. For the Navy, you would need a waiver for Stratera as well because you're still taking it in theater. Since it's not a controlled substance, would that make any difference? No, because you need a waiver for this. Either way, you'd need a waiver. Okay. In saying that C is an option, what do we do when the service member elects not to provide consent for her record to be shared? They don't have to provide consent. So HIPAA allows, there's a military exemption clause within HIPAA, and the expectation is that our service members are disclosing treatment for mental health conditions at all times, and the expectation for any clinician, even civilian clinicians, is that you are providing that information back to the command. I mean, it is absolutely not required to have consent from the patient. The key with that, though, when you look up the HIPAA law, and there is the exemption for military commands, it's minimal information, right? So that's the key word. What does this person need to know as far as fitness for duty or safety? Those are the two elements of command. Like, they don't need to know a specific diagnosis. It's just this person needs this medication or this person cannot deploy right now or this person's suicidal. Those, like a commander can know if a soldier has a safety issue, or even potentially if a soldier is depressed to the point where they can't do their job. What they can't know is that they're depressed because their father committed suicide last month, right? That's a non-needed piece of medical information that does not need to be shared. So we're just talking about, I'd refer you back to the HIPAA law itself, and it's very, very laid out. You can see it online. There is a military exemption to that HIPAA law, but also at the same time, that might be something to talk with your military patients about before the session. I think that that is something that's important because even though you are abiding by HIPAA, they might not understand that distinction themselves, and that why they don't feel like you're changing the rules of them halfway through the treatment. One of the things that we've emphasized in this document that the APA is helping us put out is that TRICARE requires that your documentation from the encounter be shared back with the referring provider within seven days. And that is a, so HIPAA law might protect you if you elect to talk directly with command, but that's gonna be a very uncomfortable conversation because unless you've had a lot of training, what should you share, what should you not share, how much do they need to know? I think a better strategy, and that's why we emphasized talk to the referring psychiatrist, talk to medical readiness, which is not command. It's a group within the military's clinic or hospital, NTF, and they're gonna know exactly what standards are not being met for your specific patient, and then what needs to be communicated to command. So while the law would protect you if you elected to talk to the member's command, you can do it. I think a safer way to execute that or meet the spirit of that law, which aligns with TRICARE policy, is to share all the medical documentation with the military physicians, the readiness office, and then they'll escalate that if needed. They might turn around and say, like, this person doesn't need to be on a profile at all. They view not necessary. In very few exceptions, it will be a two or three step process to find a medical person that your patient belongs to. For the most part, it's a one step process. So that, and when I say two, three step processes, like if they're on recruiting duty, if they are on some, you know, like going to UVA even though they're in the military, like very, very rare situations, but for the most part, your service member patient belongs to a medical person, and that medical person has every right to discuss all of the things necessary that you would discuss with another colleague. So you can talk to that person directly, and that's not gonna be as uncomfortable of a conversation as having that conversation with a commanding officer of your service member. Hi, from a civilian standpoint, you know, so this person shows up, and we know that there aren't enough, you know, active duty military psychiatrists. My challenge would be, okay, she's never had any prior diagnosis, and we know that there could be secondary gain for seeking care outside of the system as well too, especially with starting a medicine that maybe there's more barriers to getting in from active duty psychiatrists, but also without having, you know, clear neuropsychiatric testing, and then also, like, what MOS is she, you know, and then also, you know, what other things need to be considered, and whether or not this is started, and, you know, trying to make sure that, you know, I like the answer D rather than anything else, just because I think that all things considered, there might be, you know, other reasons why they want to get on this medicine, and then when you start a medicine like that, you know, typically the theory is that, you know, if they're stable on it for 90 days, then they can meet, you know, deployment criteria, but there may be other reasons why she's also wanting to get on a medicine as well too, so, and I'm not sure that that would necessarily be something that a civilian provider would be aware of. Yeah, exactly. Thank you. Yeah. I'm not gonna vote for you. So, the comment was that they're hiring at Walter Reed, and they would like for her to join. So, just to chime in on a couple things. The first thing, for any civilian providers that are taking TRICARE patients, I would refer you back to your TRICARE agreement contract, and that will have the specifics. The other, in the Army, you might not get that far by asking for the readiness office or facility in the military treatment facility. Another simple solution is just asking for their behavioral health clinic, and that will get you to someone that you can speak with, and I would also encourage you, in case you see, like, a case that seems very extreme or over the top or strange or bizarre, we are more than happy to talk about those cases and also potentially provide feedback, and just to give you an example, there was a patient just a little while ago that sought out treatment in a civilian sector and spoke about all the combat operations they were recently in, in places where we have not had any combat operations, right? So, we have a good idea of what's actually going on and when those things have occurred, and if things are, in this particular case, it hit our attention because the civilian provider was seeing descriptions of very extreme symptoms, and they just wanted to reach out just to kind of see, get an extra thought on this presentation, and as a result, we were able to clarify a lot of potential questions that that civilian provider might have had. Just one comment on semantics. I heard required medication at one point in time, I think we were talking about waivers or something like that, I don't remember who said it. For this diagnosis in the Air Force, if this medication is required for functioning in a military environment, then it becomes an unsuitable thing. I don't know if it's the same in the Navy or Army. It's technically the same, yes. I would just be careful with using required medication because if it is required for the functioning, then they meet criteria for separation. That would go back to point A. So, I don't know, you just gotta be careful with it, and I'd say it's for optimization, symptom optimization, but if someone really cannot function, then they probably shouldn't be in the military because they might be without the medication. And I would go back to what Dr. Meyer said earlier on today, not meeting retention criteria. Let's add a question mark because there's a separate system that evaluates things holistically after that point, and we have lots of people that don't meet retention criteria that have gone through that system that the military is more than happy to keep on that are taking ADHD medications, for an example. And when I say military, I should probably say Army because I'm not as clear about Air Force or Navy regulation. What you just said applies in the Navy as well. So, ADHD is probably, you know, we have way too many people with ADHD in the Navy. We would get rid of way too many sailors if we were that strict about it. But no to our colleague. I think our colleague that commented on the ADHD diagnosis, I think you are going above and beyond what we would expect from our network psychiatrist, but I think it shows your knowledge of the system. You were definitely spot on. There was a word that you mentioned that I wanted to get back to, which is stability. The reason why I want to get back to that word is because the DODI. It's the DOD instruction, the Department of Defense instruction. So, an instruction that applies to all of the Department of Defense, so for all of service members that are Navy, Air Force, Marine, Reserves or National Guard. Stability is still right now a clinical concept and we're making recommendations based on stability. So, it is very important to say that because we don't want to get into a rigid form of thinking that makes us believe that when we are starting a patient on a medication, the patient is unstable. That matters a lot, at least for Navy. I would love to hear what my Air Force and Army colleagues say about this because for us, it means that we can definitely recommend starting an SSRI today and the person sails out tomorrow. Because the assumption that starting an SSRI means that the patient is unstable is not necessarily true. So, I can start, and that's why we have embedded mental health, right? So, if I have an embedded psychiatrist in that duty station, they start an SSRI on a Thursday and they're deploying the following Monday, that's fine for us. Well, once again, it becomes a recommendation to the commanding officer and the commanding officer trusts their embedded mental health and they all sail together because that patient is not unstable. I completely agree with that concept of stability versus unstability. Where we do sometimes have some issues is even outside of the Army, there are areas that are called combatant commands. So, you might have heard the term CENTCOM in the military before, that's like everything in the Middle East area. So, those individual combatant commands are outside of the Army, Navy, Air Force structure and they have their own eligibility criteria as far as what they will take coming into theater and what they won't. It's much better now and it's much more common sense, but for many years, just the initiation of an SSRI, even in the presence of stability required a waiver and sometimes it was not granted at all. And so, that's no longer the case currently, but we do have to look and understand and this is where, once again, if you have a question, the military treatment facilities and psychiatrists, we're happy to answer that. We have better ideas of what are the current standards of these various COCOMs and also which combatant command is a soldier-like unit might be. Are they going to go to Poland or are they gonna go to Kuwait? And those are two different COCOMs and those would have two different requirements that are even outside of Army, Navy or Air Force or Space Force. Yep. So, this is a great question because I think it highlights why option D is the right answer. So, this is gonna get intensively esoteric, but we've got some military folks in the room and I think it's helpful to pull the curtain back. So, stability is not a psychiatric construct. It is not a word in the DSM. Medically, it means not changing, right? So, what is the worst mistake that a clerkship student can say? The vitals are stable instead of normal, right? And what do we all do as attending? Oh, you have three sets of vitals on this brand new patient? And not changing doesn't mean good, right? The manic patient is still manic. That would be a stable manic patient. So, the word stability comes from the FAA because in flight, stability is a very sensible construct, right? Are you in stable flight? Anyone who's had their drink service and did abruptly on a flight knows what unstable flight feels like. So, that got turned into a 2013 memo from the Defense Secretary for Health Affairs where he commented that not only should the mental health diagnosis, but the treatment should be stable. And this is how policy is super tricky. If you look at most of the service-specific policies, when they reference this 2013 memo, they reference sections 3A through E. F is where the secretary made this comment that all the doctors said, that doesn't make sense. If I switch your Zoloft from the morning to the evening because it's sedating, you can still deploy. If your medication is getting in the way of your sex life, you can still deploy. I don't understand how this medication stability became a thing. So, our solution in the Air Force with our rewrite of Air Force mental health standards is to focus on the condition. If you have an F-prefix diagnosis per the DSM, that means you have occupational or social dysfunction. And that's the whole construct behind a duty restriction. So, I'm not gonna over-diagnose you if you don't have evidence of dysfunction, not because of a military construct, because that's what the DSM says, right? I'm really happy that you have CIGICAPs, right? You have five out of seven aid criteria for MDD. That's because you're studying for an exam and you're miserable. But if the cart gets in front of the horse and now you can't study for the exam because of your symptoms, now you have dysfunction and you should be on a profile and we should do something about it. So, by right-sizing our diagnostic criteria, by going back to common sense, standards are all based off of, do you have an F-prefix diagnosis? Now, the DSM irks me because we only have remission criteria for one diagnosis and it's MDD. And that is really frustrating. We should have remission criteria for every diagnosis. You should be able to diagnose GAD in remission because we're an amazing healthcare team and we executed CBT and we started that SSRI. But focusing on the treatments is a really odd construct. So, I apologize for going down that rabbit hole, but these are all of the nuances behind these standards and policies that trap us into these diagnostic decisions. In the effort to continue, this is the last case we'll talk about. A 21-year-old active-duty Army female was emergently hospitalized while on leave, away from her home unit. She was picked up by police while running down the street in her underwear. You determined that her symptoms are consistent with Bipolar I. Collateral information from family indicates that this has never happened before and she has no significant psychiatric history. Which is the best course of action after stabilizing her condition? I'm gonna vote for Charlie. C. I vote for Echo. All of them really were trained for this. I don't know if we have any of these babies. The salty gentleman in the back, please. This is... Any trainees in the room? Oh, we didn't get any results. There's one. This is, if I had to guess, at least 10 a week at the site that I'm in, and the trainees are the ones that have to deal with it. Sometimes it's even overseas, like our sailors and marines get creative and do this in Vietnam, Thailand, while on leave in Mexico, et cetera. So one element that I just bring in this is to help you. If you're in a remote location, a person comes home for leave, becomes psychotic, informing the chain of command will probably give you additional resources that you could use for a safe discharge plan. Don't give away the answer yet. Army leads the way. We lead the way. I'll be quiet for a while and then I'll... Thank you. All right. We did hear C from the audience. Does anyone else have any thoughts? Okay. Yeah. So the correct answer is to obtain care after discharge at the primary location for the patient. But additionally, C is a good answer and going ahead and letting the command know while you have the patient is always going to be appreciated. So the reason I don't like D better than C is because these patients can be lost to follow up if there's not good communication, right? So this person no-shows that appointment, you took all the time to arrange for them. They eventually stopped their meds or maybe they immediately stopped their meds. That can cause additional delay in their care and their disposition. That's why I don't know if I like D that much. That's a great point. So by informing, and it depends on the location, but normally by informing the behavioral health clinic of the location where they're at, there is this nurse case management that will typically, intensively, and that's why I said most places... Should be. Should be. And it's really our jobs as psychiatrists is to make sure that these things are functioning as well as they can be. In my current location we have to have a stable of excellent nurse case managers that track a lot of us because we do have so much engagement with our civilian colleagues. But if, and I'm going to go back, you probably haven't heard this before, if you are in a remote location and you contact the chain of command, that chain of command will probably give you additional resources for discharge. More than likely that chain of command will fly out an NCO, potentially another individual to help make sure that this person's safe while escorting them back to their home duty of record, probably potentially to the inpatient psychiatric facility at that location, at least to the behavioral health in the military for that close follow-up. So I do think that that is an easier answer for the civilian colleagues because you're going to get the support that you need and it will really help that safe discharge plan. It goes back to the discussion we had before that it may be a more comfortable and an easier conversation to contact the medical personnel at the other side. So when we say primary care in our system, that may be that patient's medical officer that is associated with the unit and they're going to be the liaison between you and the commanding officer as that physician that's attached to the unit. The same with the psychiatry department, they may be able to provide that liaison effect for you. So I mentioned, sorry, I mentioned the residents and I, you know, I asked about if we had any residents in the audience because these are the typical phone calls that our residents get on the duty phone, on the call phone. So what ends up happening is this sailor, this Marines ends up somewhere, you know, let's say Kentucky. They're on leave, they end up there. The person that, the psychiatrist that is taking care of them knows nothing about the military. All they know is that sailor is stationed on a ship in San Diego. If they call Naval Medical Center San Diego duty psychiatry phone, which you will be able to just Google that number, that resident will be able to give you some answers and direct you in the right way of how to find who the commanding is, how to try to do some follow-up care, et cetera. It's a lot of case management at that point, but they will be able to give you as much information as possible to help that service member. Go ahead. Yes. Hi. I'm actually a 60 week skilled psychiatrist in the Army Reserves and I've been deployed four times. Every time we get deployed, we get very often, we're the only psychiatrist in theater, in whatever it is, treating up to 10,000 service members. And I felt like you actually took that out of one of the cases I saw in my first deployment, Kosovo 2012. And it was a reservist, a female soldier, which is the issue I want to bring, two things I want to bring up. One is the great challenge that we have with reserves and National Guard, because a lot of the medical care happens outside of the realm of the military and there's no communication and command never learns about it. Or even worse, sometimes they do, but there's no follow-up. Nobody's tracking the cases. I am the only psychiatrist in my brigade and I've never been consulted for any profile or anything, which I've been surprised by, but it is what it is. The second point is, and I want to go back to the lecture yesterday, which I enjoyed very much, but now that I have you all here, it would be great if there could be some training for behavioral health providers, particularly the reservists. We make a very large number of behavioral health force in the military, a very large percentage. There has never been any kind of training, concerted effort to train, reveal these policies. Many of us have learned the hard way just by reading and experience. And one thing that was said yesterday, on my last deployment in 2021, the psychiatrist that preceded me said, uh, these are the diagnosis I usually use and gave me a little cheat sheet with all Z codes. Um, and I wanted to go back to your comment yesterday because, um, then we engaged in this argument back and forth of whether to diagnose, uh, you know, some conditions that were, could be serious versus not. And his argument was, I don't want to ruin anybody's career. My argument is I want that person to be safe, uh, for themselves as well as everyone else. So there is so much here that needs to be discussed and, and, and, you know, and definitely go back to the point, please, if you can do something to get some training for all behavioral health providers, all of us, not only psychiatrists, social workers, psychologists, because it just doesn't happen, at least not in the guard and reserves. Yeah. So, um, first thank you for coming and representing the reserves. Um, I, they really are very underrepresented, especially in a lot of what we talk about. Um, but I will put in another plug for the resource resource document that is, um, very close to being finished and published. Um, it will, it actually has, um, all of the instructions and relevant publications in it, um, so that they can be referenced and then is quite extensive. What, how many pages are we at at this point? Um, of a lot of this, some, some more of it flushed out, but, uh, we'll be able to be pulled down from the APA's website and shared extensively, uh, with whoever you would like. It'll be important because that'll reach the psychiatrists, but we have a huge contingent of non-psychiatrist behavioral health, uh, staff that are still diagnosing. Um, so. Yeah. So share it freely. It will be something you can pull down and give to all your colleagues, um, but it would be nice if we had access to more people. So another, also, uh, avenue to advocate for what you're asking for, well, several actually, uh, one would be, um, the, uh, society of uniformed service, uh, psychiatrists. Uh, they have extensive training, uh, CME options, um, they're, they're a chapter of, of APA. Um, two would be, you must have a specialty there because I, I have a specialty. I have a, I have a counterpart that is the specialty leader, the consultant for the reserves of psychiatrists. And we have, um, two, uh, one annual and, and, and another one, uh, that it's more about career stuff, but, uh, we have an annual, um, meeting where we share all of the new issues, uh, regarding Navy psychiatry and they get invited to our, uh, meeting and it's, you know, eight free CMEs for them once a year. Uh, and they learn, you know, about all the new duties and all the new instructions, et cetera. Um, and then three would be to ask whoever your healthcare manager is like the, that liaison, that person that, um, that has you as a network, you know, provider. So not just for the psychiatrists, but all of the, uh, I'm, I'm guessing like you are part of a practice where there's other mental health professionals. Um, you can ask your, your, whether it's Triker East or Triker West, that representative for training. And, and that's what I was mentioning earlier about being able to go and visit ships or being able to go and visit a base. Uh, so through those connections, you, you should be able, uh, I say should, which I know it's a bad word, but, um, you should be able to get what you're asking for. It's really fun to watch a question do exactly what it was intended to do. So this question was designed so that our Tricare civilian providers would read one option as being correct. And our military providers would read another option as being correct to highlight that this is a team effort, right? We shared the MTF directory. Has anyone checked their own MTF directory? What do the civilians get when they go there? Does it take them to the appointment line or does it take them to a human? Take them to any phone number that works. So we've got lots of expectations of each other and it really takes a team effort to make this system work. Um, and then to your comments, I'm a huge fan of education and in the process of creating this, it had to go to Tricare because there's a lot of Tricare policy in this and we wanted them to take a look at their stuff and they're like, Oh, we didn't know all this other stuff. We should include this. So the Navy just released a playbook. Um, it's a fantastic PDF that covers a lot of the details of Navy mental health. The Air Force has an onboarding platform that is currently behind a DoD firewall, but it has 30 CME attached to it. So it's onboarding for all of our providers who are going to be in the clinic. But as soon as it's approved, we're looking to push that outside the clinic because you're right. I mean, the Borden Institute has free textbooks on military mental health, military psychiatry, but they're tomes, right? No one is going to sit down and read 500 pages. So if we can create these better educational tools to get everyone on the same page, I think this is going to be good for our service. And, and also to add to that, um, you know, one of my favorite training psychotherapists once told me that, uh, should statements are an indication of failed reality acceptance. Um, we, uh, we've used should, and this should happen, and this should happen in this year. And if it's not happening, then we need to actually make sure that the reality that in reality is happening. Um, one thing that you were talking about was the interaction that you had with your colleague downrange with the, uh, diagnostic differences of, of perspective, uh, with a med board, it's not optional, right? So if someone meets these specific criteria or the, the, if someone meets the criteria for, uh, or don't, uh, we'll use bipolar. Like I can't just not give that diagnosis. I still have the requirement, both ethically and, and also as a, as a physician, and also from a regulatory perspective, I, I, I need to provide that. What we're asking for is nothing more than diagnostic specificity. So, uh, I, I, I think that that's important. And if we are not quite sure what a diagnosis is, or it's still trying, we're trying to determine that. I think that, uh, because it's so hard to take back diagnosis once they've been given sometimes, and this is where billing and insurance outside the army, uh, can, can have some impact. Uh, but like the, as long as you're sure about diagnosis, you need to make, you need to call the spade a spade, and you need to take care of that service member in that way. And I just want to say that that's how we, we, we treat service members in the military, is at the, at the highest level care that we possibly can. And sometimes that's not always appreciated if someone has a, a condition that they don't want to have, uh, that might have impacts, but it's the safest thing for that service member. And that's really what it comes down to, is taking care of them. So, uh, we just are asking for diagnostic specificity, and that's it. Okay, go ahead. I just want to make one comment. So there is a redundancy, um, for the reporting thing with the last case. So, uh, from TRICARE, at least in the Air Force, uh, we do reviews for referrals. So if there's a claim that's made for an inpatient thing, we'll find out about it. Sometimes there's a little bit of a lag, and it depends on what the billing, you know, with whatever facility and how, how long they process that. Uh, but sometimes it may happen the other way, where we actually reach out to you if you're a provider in the community. Uh, sometimes it gets weird with HIPAA, because people think that I'm just some average Joe, you know, uh, officer that's calling. But understand that if we do that, it's to help negotiate some of these things. So we may actually reach out to you, um, and, you know, we can confirm who we are, uh, if you, if you need that, but, um, that, that might happen. So there is a, a TRICARE part of it, and if there's an inpatient hospitalization, we're required to report that, uh, in the Air Force. And I think it's, that's probably a DOD regulation, we report that to the commander. Um, but that we, sometimes we will find out about it without you calling us, so. Yeah. Yeah. Or if you're, if you're treating somebody as an outpatient, we might find out with that referral as well. So if it is something from a fitness for duty, we may reach out to you. And sometimes we've gotten stonewalled, uh, and if you do that, then we, if someone stonewalls us, then we can't confirm someone's fitness for duty, which will gum up that person as well. Yeah, it's always, if, it always appreciate, appreciate it if you will actually talk with us, because it's more helpful for the patient to do that. Um, okay. Any last comments? We've got one coming. Anthony Choi, I'm the, uh, psychiatrist over at Seymour Johnson. Um, the, uh, the, uh, mention of administrative separation came up a couple of times, uh, regarding personality disorders, adjustment disorders, uh, neurodevelopmental. Um, I, for, for me, the medical separation process is extremely clear. We see a condition, we refer to AMRO, that gets, uh, North Star is written, and that gets sent up. Um, for administrative separation, is there, are there guidelines on what exactly is needed by the active duty provider? Um, cause how I did it as a resident at JBSA was completely different than how I'm, uh, requested to, to do it now over at, uh, at Seymour Johnson. Dr. Choi, thank you for representing the greatest air force the earth has ever seen. Yes, sir. You're going to want to go to the KX page, go to mental health, go to readiness, go to admin set, but it's got it all listed out for you. Yes, sir. Those are the types of tools we want to get outside the DoD firewall, cause they're not secret, they're not classified. And if everyone saw how we do business, I think people would take a big breath when a clinic calls and says, do you have my member? Cause we'd like to take care of that person. Yeah. That process administratively is different across the services. So, um, the answer Dr. Meyer just gave is specific to the air force. Um, we have a separate, um, system, electronic system in the Navy where we enter those recommendations for administrative separation. Um, and then I would, uh, Dr. Schnellbarger can clarify, but I would assume that the army has a whole separate system. There are specific requirements that are set out for, uh, the current standards for administrative separation for the military or for the army as well. So really as a civilian clinician, if you're thinking that this person may meet criteria or may need to be considered for separation from service, um, we would ask that that be referred back into the military treatment facility. That will always be the answer, um, for our civilian counterparts because we will handle that. Uh, you would never submit that documentation as a civilian clinician. And as the person that bottom lines, um, half of the administrative separations for the Navy, I can tell you that that is how it's being done now for the Navy. Just, just want to say that since I've, since I separated in 1996, it's distressing to see just how far, uh, lower the number of psychiatrists and psychiatry billets that are authorized. It's a big mistake and we'll pay for it in readiness. Yes. And we, we, we are growing, um, over the last few years. We are growing. I, I don't know what branch you're separated from, but the Navy has the opposite problem. Um, we are currently at our highest number of activity psychiatrists. Uh, we have, uh, 164 billets. Uh, 40 years ago, we had 99. I appreciate your service and your thought. I just wanted to, uh, say that another element of the equation has been changed. Uh, and that is that we have, there's a night and day difference between stigma in the military now. And when I first came in, uh, 20 plus years ago, depending on how you look at it, what, when you count that start date, right? So, uh, when I was first a division psychiatrist in the 101st, people that were going to behavioral health literally on their, on their, uh, basically their chart where they are for the day, it wrote insane. That was what was one case of stigma, uh, that was at the time. Now we don't have that stigma. And as a result, a lot of the behavioral health issues that were likely at play then that were just underneath the surface, we're getting a lot more, our customer base has increased because they trust us. And so, uh, while I feel every single day, the fact that we, uh, can always use more psychiatrists and if anyone would like to join the Army, please let me know. I can easily talk to you about that. And we have a booth or we had a booth in the, in the convention hall while it was up, right? We are always looking for high quality psychiatrists. Uh, there, there is a component of, uh, people trust us more and they're willing to come and talk to us, uh, because of a change in culture. So, but, but thank you for your service in 1996. You paved the way for all of us. And, uh, I, I will close up, uh, in the interest of time, but thank you all so much for your attention and your participation. Uh, your questions and comments, uh, definitely propelled our presentation in a really great way and highlighted why this talk was so important to us. Um, so thank you again for coming.

military mental health

psychiatric diagnoses

active-duty military

diagnostic standards

fitness for duty

consultative approach

ADHD

personality disorders

mood disorders

deployment medication

civilian providers

military treatment facilities

command structures