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Provider’s Perspective: Veteran Mental Health and the Invisible Wounds of War

Provider's Perspective: Veteran Mental Health and the Invisible Wounds of War

November 4, 2022
Teressa Carter – LCSW

This post was written by Teressa Carter, a therapist at Heading Health with extensive experience serving and treating active-duty service members and their families


In celebrating Veteran’s Day, I am honored to create a space to salute all who have served, and the sacrifices made by members of the U.S. armed forces and their families to preserve our freedom. This day is very personal for me as my family, and I celebrate the service and sacrifice of both my maternal and paternal grandfather, as well as my father, who all served in the United States Army. My six-year-old son is reminded that his father is a hero, having served in the United States Marine Corps. Aside from my familial connections to the military, I have had the privilege and the honor of providing mental health services to active-duty service members and their families of all branches.

A Military Mental Health Crisis

Veteran’s Day allows us to explore and assess how we can better support our veterans, especially when navigating their mental health. Recent research suggests 11 to 20 percent of veterans experience post-traumatic stress disorder (PTSD) in a given year. Suicide rates of military service members and veterans are also at an all-time high, with deaths by suicide having increased by 25% during 2020.


Despite the prevalence of mental health needs, veterans often struggle to find and stick with care. One study found that among the veterans with mental health needs, 55 percent did not seek treatment from Veterans Affairs. Some of the more commonly cited reasons for avoiding or not continuing with treatment include:


Given all of this, it’s vital that veterans have the tools to receive and stick with effective care and that clinicians know how to reach out and provide support to service members in need.

Advice for Veterans in Need of Mental Health Care

If you are a Veteran in need of mental health treatment, you are not alone, and great support is out there. I strongly encourage veterans to reach out to someone, whether your medical provider, your VA liaison, family, or friends, who can support and assist them in finding the right mental health treatment for their needs. Here are some other tips:


  • Look for clinicians that have either military experience or experience training to treat military-related issues.
  • The VA or Military OneSource are great resources for finding treatment options.
  • Prepare for your first intake. There will be a lot of information gathering. This is also where you have the opportunity to interview the therapist to make sure this is a good fit for you and that you feel comfortable.
  • Remember, mental health treatment is a process and should not be rushed. Prepare for this by viewing your treatment as a journey.
  • Share your feelings, hesitations, limitations, and boundaries with your therapist.
  • Always remember that getting help is a sign of strength and resilience.

Tips For Therapists Treating Veterans

There are several steps mental health professionals can take to ensure they are effectively reaching out to veterans in need and providing them with adequate care. 

Market Your Services to Veterans

The civilian mental health community should ensure they are marketing services to the veteran population. Here are some suggestions.


  • Add any military experience or previous work with the veteran population or armed services to your professional online profile.
  • Highlight if you have specialized training to treat conditions prevalent among veterans, such as PTSD, anxiety, depression, and addiction-related issues.
  • Advertise your services to agencies that cater to the veteran community, such as your local Veterans Affairs office, TRICARE, or Military OneSource. Make your services known and available through the base coordinator that assists Active-Duty service members transitioning to veteran status.
Build Rapport

In my career working with active-duty service members and veterans, I found building an initial rapport centered around trust, understanding, and respect was an absolute must. Here are 10 simple strategies I use to build rapport and develop a strong relationship with service members and veterans.


  1. Always thank the service members for their sacrifices.
  2. Share your background and personal experience with the military.
  3. Be honest about where your gaps in knowledge or understanding of the military lifestyle are.
  4. Emphasize your willingness to learn.
  5. Be curious. Inquire about their branch of service, rank, years of sacrifice, and duty stations.
  6. Explain that you are trying to obtain a deeper understanding of their unique service and experience.
  7. Create a safe space. Make sure your clinical area is quiet, private, and free from sudden noises or distractions that could trigger PTSD symptoms. Invite your veteran clients to share as much or as little of their military experience as they are comfortable disclosing.
  8. Allow veterans to speak freely and at their own pace.
  9. Never say, “I understand.” This could trigger the veteran client to be upset if you do not have military experience, especially direct combat experience.
  10. Refrain from using a lot of clinical jargon and acronyms. Veterans are used to clear, concise, and direct communication because of their military experience. Too much clinical jargon may create space for miscommunication and confusion.
Utilize Available Resources

An important aspect of providing mental health treatment to veterans is to have a working knowledge of available resources in the community and helping clients get connected to them. Here are some resources that may be helpful:


Address Family Needs 

Mental health providers will also need to address family needs when working with veterans, as families have also served and sacrificed. Additionally, the family is transitioning with their service members. For example, families may be transferring medical, educational, and social services from on-base providers to civilian providers. As a result, they must adapt to new doctors and mental health providers. They may also be moving to new homes in new neighborhoods, meaning the children will be transferring schools and making new friends. Adjusting to these changes can be challenging and added support can be helpful.  


As we gather to celebrate this upcoming holiday, please take a moment to acknowledge and honor the sacrifices of our veterans and active-duty service members. Please be an advocate in your community, workspace, and even your organization for increased support and resources for the veteran community. When you see a veteran, thank them for their sacrifice. Thank you to all who have served and the families that served along with them. 


If you know a veteran who may be experiencing mental health issues, please help them get care. You can do this by enrolling in their local VA and requesting mental health services. If you feel a veteran is experiencing a crisis, please call the national suicide hotline (988).

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The Problem of Delayed Treatment for Mental Health Conditions

The Problem of Delayed Treatment for Mental Health Conditions

October 9, 2022

From recognizing one needs treatment to finding an in-network provider to scheduling an appointment, getting help for one’s mental health can be a time-consuming and disheartening process. One study found that since 2000, individuals with schizophrenia, mood, and anxiety disorders have taken nearly 32 months on average to receive their first treatment. 

Aside from the immediate harm of suffering from the symptoms of a mental illness, a delay in treatment is associated with a range of negative outcomes, highlighting the importance of prompt access to rapidly effective interventions. 


Here are some key findings: 

Rates of Treatment Response and Remission

When examining the impact of the duration of untreated illness (DUI) on mental health outcomes, much research has focused on rates of response (i.e., at least a 50 percent reduction in symptoms) and remission (i.e., a full recovery). A meta-analysis, which compiled data from several studies on the topic found some striking results. In particular, they found that:


  • Patients with a DUI shorter than eight weeks after their first episode of depression have a 70 percent greater probability of achieving a response
  • Patients with a DUI shorter than eight weeks after their first episode of depression have a 65 percent greater probability of achieving remission


Response to Antidepressants

Researchers looked specifically at the response to antidepressants and found similar results. For example, studies have found that:


  • Patients with obsessive-compulsive disorder who did not receive treatment within the first 24 months were 28 percent less likely to respond to SSRIs (selective-serotonin-reuptake inhibitors)
  • Subjects with major depressive disorder who did not receive a first-line antidepressant until  six months or more after their depression started were 13 percent less likely to experience remission
  • Longer DUI was associated with a lower response to antipsychotics and a higher rate of relapse in individuals with schizophrenia



Mental illness can bring about feelings of hopelessness and despair which can cause patients to think about or attempt to commit suicide. Several studies have found that a longer DUI is associated with more suicidal thoughts and attempts for a range of conditions. For example, studies have found that:


  • Bipolar patients with a longer DUI showed a higher number of suicide attempts during a five-year follow-up
  • In patients with schizophrenia, suicidal plans or attempts were significantly higher in subjects from communities without an early detection program relative to those from early detection communities
  • Depressed patients with a longer DUI also showed an increase in the number of hospitalizations and suicide attempts


Cognitive Performance

Deficits in cognitive performance (e.g., in tasks involving memory, attention, verbal abilities, etc.) have become one of the core features of mood disorders and are significantly associated with DUI. A 2020 study found that:


  • Over half of the subjects diagnosed with major depressive or bipolar disorder showed mild cognitive impairment.
  • Those with major depressive disorder who showed cognitive impairment had a six month longer DUI on average
  • Remission was associated with improvements in memory, executive function, and attention, but not in visuospatial abilities or verbal fluency


Physiological Changes in the Brain

Researchers have found that as mental health conditions go untreated, they can produce a range of physiological changes in the brain. For example, one meta-analysis found that:


  • Long durations of untreated illness are associated with brain changes in individuals who have schizophrenia, bipolar disorder, major depressive disorder, panic disorder, and obsessive-compulsive disorder 
  • In schizophrenia, significant changes can occur within the first year
  • Some brain changes may be associated with poor treatment response


Associations with other Chronic Conditions

Mental illness is associated with various other chronic health conditions, such as heart disease and diabetes. Again, a longer DUI is associated with worse outcomes regarding many of these conditions. A 2022 study found that:


  • Subjects with depressive and bipolar disorders with DUIs longer than one and two years, respectively, were nearly 30 percent more likely to have physical comorbidities
  • Longer DUIs were significantly associated with higher BMIs, which can cause or exacerbate other physical conditions

These findings highlight two general takeaways. First, there is an obvious need to shorten the time it takes for patients to receive treatment. Given the wide range of adverse outcomes that become more prevalent as DUI increases across several mental health conditions, individuals dealing with mental illness must receive treatment as soon as possible. 


Second, there is a need for novel treatments. Even when patients can see a physician, first-line treatments can take several weeks to months to work. For a sizable subset of these individuals, these solutions may not be effective, even when their illness is recent. Additionally, longer DUIs are associated with physiological changes in the brain, which may be why standard treatments tend to be less effective over time. As a result, solutions working in different ways targeting different parts of the brain, like ketamine, TMS, or other emerging interventions, may prove critical for treating individuals who do not respond to first-line treatments.


At Heading Health, we utilize a multi-pronged approach to combat these issues. First, we offer an integrated team of specialists who work together to provide prompt care tailored to each patient’s individual needs. In most cases, we can see patients within 24-48 hours. To support this approach, we use cutting-edge treatments with rapid and sustained responses, meaning patients get in and get better quickly.


Talk with your doctor to determine whether these treatments are right for you, or schedule an appointment with one of our psychiatrists or therapists to advise you on any other potential treatments for depression, including ketamine, Spravato, and TMS. Call us at 805-204-2502 or request an appointment here.

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Interview with an Expert: Should Ketamine Be Combined with Psychotherapy?

Interview with an Expert: Should Ketamine Be Combined with Psychotherapy?

October 7, 2022

With evidence mounting in support of ketamine’s therapeutic effect on depression and other mental health conditions, clinics and physicians are increasingly prescribing it as a standalone solution. While ketamine has clear benefits on its own, experts are beginning to explore the role psychotherapy plays in enhancing or extending its effects.


In a recent edition of The Peter Attia Drive, Professor of Psychopharmacology and leading ketamine scholar Celia Morgan addresses this topic, among several others related to ketamine’s use in treating depression and other mental health conditions. 


Her take? Psychotherapy is critical to obtaining a lasting effect from ketamine. Here’s why.


Ketamine Increases Neural Plasticity

One of the key reasons Professor Morgan believes ketamine is most effective when combined with psychotherapy is its mechanism of action (i.e., how it changes the brain to produce its therapeutic effects).


When ketamine enters the brain, it attaches to N-methyl-D-aspartate (NMDA) receptors, causing a release of glutamate (a chemical messenger in the brain) and brain-derived neurotrophic factor (BDNF). The result is that neurons (tiny cells in the brain that send and receive information from each other) have an increased ability to grow, reorganize, and rewire themselves in response to new experiences, a phenomenon known as neural plasticity.


Among other things, neural plasticity enables us to learn and acquire new habits, including our cognitive and emotional tendencies. Professor Morgan argues that because many psychological therapies target these mental habits, they may be more effective when used after ketamine treatments. She states:


We know that what we’re asking people to do in psychological therapy is to think differently about things and learn new ways of thinking about old problems. [Neural plasticity] seems to me like an intuitively appealing mechanism.


Professor Morgan goes on to suggest that not only might therapy be beneficial but that its precise timing after a ketamine treatment may be especially critical, stating:


I think the idea you know for me as a psychologist is that you could time your psychological therapy when your brain is most plastic. […] We know from animal studies this might be starting four hours following the ketamine days peaking about 24 hours.


Ultimately, more research needs to be done to determine when ketamine causes the greatest increase in neural plasticity in humans. Professor Morgan notes that:


We want to be doing some work at the moment to sort of chart the time course of that in humans by looking at EEGs […] and trying to target the window of this synaptic plasticity


Experimental Participants Receiving Therapy Maintain Therapeutic Benefits for Longer

Ketamine’s impact on neural plasticity suggests that ketamine should enhance the effects of psychotherapy in theory, but how does this pan out in practice?


In a recent study on the effectiveness of ketamine in the treatment of alcohol use disorder, Professor Morgan compared the effects of ketamine used on its own and when combined with psychotherapy. They found the greatest reductions in drinking and abstinence in the group that received ketamine alongside psychological therapy. 


What’s particularly shocking is that 86 percent of the ketamine therapy subjects remained abstinent for six months after three ketamine infusions. Given the small number of treatments, the six-month benefit patients experienced further suggests therapy had a positive impact. As professor Morgan highlights, studies show the antidepressant effects of a single IV ketamine infusion typically last from three days to a week, though repeated administrations can extend this effect.



While more research is needed to confirm and clarify therapy’s role in enhancing and extending the effects of ketamine on depression and other mental health conditions, these early results suggest the two therapeutic solutions work synergistically to deliver an optimal outcome.


Talk with your doctor to determine whether this treatment is right for you or schedule an appointment with one of our psychiatrists or therapists to advise you on this or any other potential treatments for depression, including ketamine, Spravato, and TMS. Call us at 805-204-2502 or request an appointment here.

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