Human Capital: Additional Actions Needed to Enhance DOD's Efforts to Address Mental Health Care Stigma
What GAO Found
Military servicemembers' perceive that a stigma exists with seeking mental health care, but little information is known about Department of Defense (DOD) deployed civilian perceptions. GAO's analysis of the most recently available data from a DOD-wide survey found that about 37 percent of active duty servicemembers in 2011 and 39 percent of reservists in the 2010/2011 timeframe responded that they thought seeking mental health care through the military would probably or definitely damage a person's career. Military service-sponsored surveys and comments from all 26 of GAO's focus groups with servicemembers and with civilian employees of DOD who have deployed or were preparing to deploy also indicated that stigma is a concern. GAO's review of DOD-wide surveys found that none of them measure deployed civilians' perceptions of mental health care, including stigma. As of February 2016, DOD did not have a functional mechanism to identify the population of deployed civilians. DOD officials are taking actions to improve the accuracy of their data on deployed civilians, in response to a prior GAO recommendation in June 2009. Once these data are available, DOD should be in a better position to collect information and monitor deployed civilians perceptions about mental health care. Without this information, DOD cannot fully assess the organizational climate of its total workforce.
DOD has efforts underway to improve perceptions about mental health care for servicemembers and, to a comparably limited extent, deployed civilians, but has not clarified or updated certain policy provisions that may contribute to mental health care stigma. DOD officials and health care providers said that certain policies are unclear or out-of-date and limit career opportunities for individuals who have sought mental health care. A 2014 RAND Corporation report identified 203 DOD policies that may contribute to stigma. For example, an Army policy requires verification that a soldier has no record of emotional or mental instability to be eligible for recruiting duty. This policy is unclear as to what diagnoses constitute instability, and whether a servicemember responding well to treatment would be prohibited from this opportunity. Without clarifications and updates to policies, DOD will be hampered in meeting its policy goal of reducing stigma.
DOD is not well positioned to measure the progress of its mental health care stigma reduction efforts for several reasons. First, DOD has not clearly defined the barriers to care it generally understands as “mental health care stigma” and does not have related goals or performance measures to track progress. Second, GAO's review found that multiple DOD- and service-sponsored surveys that contain questions to gauge stigma use inconsistent methods, which precludes the analysis of trends over time in order to determine effectiveness of stigma reduction efforts. Finally, GAO found that responsibilities for mental health care stigma reduction are dispersed among various organizations within DOD and the services, and some information sharing is hampered. No single entity is coordinating department-wide efforts to reduce stigma. Without a clear definition for “mental healthcare stigma” with goals and measures, along with a coordinating entity to oversee program and policy efforts and data collection and analysis, DOD does not have assurance that its efforts are effective and that resources are most efficiently allocated.
Why GAO Did This Study
A 2010 DOD task force on suicide prevention concluded that stigma—the negative attitudes and beliefs about mental illness and related care—interferes with willingness to seek mental health care in the military. In August 2012, the President identified mental health care for servicemembers as a high priority. The National Defense Authorization Act for Fiscal Year 2015 included a provision for GAO to assess the perception of the impact of mental health care stigma. This report examines (1) military servicemembers' and deployed civilians' reported perceptions about mental health care stigma; and the extent to which DOD (2) has policies and related efforts to address mental health care stigma and (3) is positioned to measure the progress of its efforts to reduce mental health care stigma.
GAO analyzed program documentation and DOD-wide and service-specific survey results; conducted 23 non-generalizable focus groups with servicemembers and 3 with deployed civilians at six locations representing distinct and dispersed populations; and interviewed DOD and service officials.
GAO is making 7 recommendations, including that DOD collect and monitor deployed civilians' perceptions of mental health care; clarify and update policies contributing to stigma; clearly define barriers to care understood as “stigma,” and establish related goals and measures; and designate an entity to coordinate stigma reduction efforts. In written comments on a draft of this report, DOD generally agreed with all 7 recommendations.
Recommendations for Executive Action
|Department of Defense||The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to collect and monitor deployed civilians' perceptions related to mental health care.||
DOD concurred with this recommendation. In 2018, DOD officials told us the Defense Manpower Data Center (DMDC) launched a new Civilian Deployment file in September 2016 as a central means for tracking DOD civilians who are deployed. It also serves as the means to identify contacts to participate in surveys. In June 2019, DOD issued its updated Instruction 6490.03-Deployment Health which requires DOD civilians to complete deployment related surveys which include an assessment of mental health needs. It explains that various health assessments for service members and DOD civilians are conducted at specific intervals throughout the deployment cycle and the deployment mental health assessment, specifically, is scheduled to be given three times between 90 days and 30 months after an individual returns from deployment. The mental health assessment survey includes questions related to the individual's assessment of their mental health conditions, concerns and the need for any additional information, professional or community assistance or support, as necessary. Responses to this and the other deployment health surveys are collected in the Defense Medical Surveillance System and, according to DOD directive 6200.04, each military department is to perform routine, continuous, integrated, and comprehensive surveillance of all military populations including deployed civilians whether at home or abroad. Because DOD has an updated, documented requirement to monitor deployed civilians' health and well-being, to include mental health issues, at periodic, defined time frames in a systematic method, we believe DOD's actions will allow it to collect and use this health surveillance data and information to better track and respond to the concerns of this workforce. We believe this recommendation should be closed as implemented.
|Department of Defense||The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to leverage recommendations made by the RAND Corporation in its 2014 report on mental health stigma in the military to update and clarify policies as needed to remove stigmatizing provisions, such as career restrictions that may be too limiting for individuals who have received mental health care.||
DOD concurred with this recommendation. In June 2018, officials from the Psychological Health Center of Excellence (PHCoE) completed a review of over 400 DOD and service specific policies including confirming policies cited in the 2014 RAND study and performed an additional policy review examining policies from January 2013 to November 2016. PHCoE officials recommended policy language changes, as 264 policies were found to contain potentially stigmatizing language. Their recommended policy changes are currently assigned to the services or agencies who own the respective policies for approval and execution. Therefore, this action meets the intent of this recommendation.
|Department of Defense||The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to establish a clear, consistent definition of those barriers to care generally understood by DOD as "mental health care stigma," to include explanations of its causes or contributing risk factors and ways that stigma is apparent in behaviors and policies.||
DOD concurred with this recommendation. We found that DOD and the services apply variations on the concept of stigma in terms of a definition, proxy measures, and the manners in which stigma is manifested within the department. Officials from the Psychological Health Center of Excellence (PHCoE) told us that in April 2017 they briefed new definition of mental health care stigma to the Psychological Health and Readiness Council (PHRC) which consists of members from DOD, Joint Staff, each of the military departments along with Reserve and National Guard representatives. At this April 2017 meeting, the Council approved the definition. With a clear definition of mental health care stigma, DOD should be able to develop specific and related goals and measures with which to evaluate its progress toward reducing stigma. As such, this recommendation should be closed as implemented.
|Department of Defense||The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to establish goals for efforts to address barriers to care generally understood by DOD as "stigma reduction efforts," and performance measures that link to these goals.||
DOD concurred with this recommendation. We reported that DOD has not defined their goal of stigma reduction, increasing access to care, and reducing barriers to care with any specificity in measurable forms. Additionally, DOD did not have performance measures that link to these goals. The Defense Health Agency's (DHA) Psychological Health Center of Excellence (PHCoE) conducted a data call in June 2018 asking each of the military services to identify stigma reduction efforts and associated goals/metrics in response to this recommendation. PHCoE synthesized the results of this data call task to identify broad stigma reduction performance measures with associated goals. A total of six goals were identified, tied to specific lines of effort. For each of these goals, PHCoE worked with the services to craft performance measures and benchmarks for improving stigma-reducing efforts in each area. In February 2020, it provided the results of this effort, discussing the six goals and the detailed performance measures and benchmarks to be used to guide and assess the department's mental health care stigma reduction efforts. Given the development of these goals, performance measures and benchmarks as GAO recommended, this recommendation should be closed as implemented.
|Department of Defense||The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to develop a method to collect and analyze information on barriers to seeking mental health care, including stigma, so that reliable data may be gathered and used to measure the effectiveness of stigma reduction efforts over time.||
DOD concurred with this recommendation. We reported that Psychological Health Defense Center of Excellence (PHCoE) officials acknowledged the limitations they face in trying to track changes in the prevalence of stigma over time and relate them to the effectiveness of departmental stigma-reduction initiatives. In July 2018, PHCoE officials said that an "item bank" of survey questions developed by RAND was reviewed by PHCoE leadership in May 2017 and approved for implementation by the Psychological Health and Readiness Council (PHRC) in June 2018 to collect information to be analyzed and used to measure the effectiveness of stigma reduction efforts. With the development of this method to collect reliable data, DOD will be able to track barriers to care across DOD and can be conducted longitudinally by suing the 2017 RAND item bank and will have the needed information to assess the prevalence of stigma and analyze trends over time. As such, DOD's actions meet the intent of this recommendation which should be closed as implemented.
|Department of Defense||The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to designate an entity to coordinate efforts to reduce mental health care stigma, among other barriers to care.||
DOD concurred with this recommendation. In December 2016, the Principal Deputy, Performing the Duties of the Assistant Secretary of Defense for Health Affairs and the Principal Deputy Secretary of Defense for Readiness approved the charter for the Psychological Health and Readiness Council which was designated as the coordinating entity to reduce mental health stigma, among other barriers to care. With this office designated as the coordinating entity within DOD to collect and use information on mental health care stigma, DOD will be in a better position to monitor the prevalence of stigma and measure stigma reduction efforts across the department. Therefore, this recommendation which should be closed as implemented.
|Department of Defense||The Secretary of Defense should direct the Under Secretary of Defense for Intelligence to reissue consolidated guidance, incorporating subsequent updates for the denial or suspension of access to classified information and for assignment to sensitive duties based solely on information about mental health care.||
DOD concurred with this recommendation. We reported that since 2008 DOD has issued a series of memoranda clarifying for the military services and other DOD components that certain types of counseling should not be disclosed by applicants in their response to the security clearance application question on mental health and explaining what adjudicative personnel consider in reviewing any reported mental health information. However, we found that some of these memoranda are not readily available and had not yet been incorporated into an administrative reissuance of DOD's manual on the personnel security program, which was last updated February 23, 1996. In April, 2017, the Office of the Under Secretary of Defense for Intelligence reissued that manual, DOD Manual 5200.02 Procedures for the DOD personnel Security Program. With the reissuance of an updated manual, DOD will have reasonable assurance that such decision by commanders and civilian supervisors are made consistently and in accordance with existing policy and goals. Therefore, this recommendation should be closed as implemented.