Military doctors try to replace therapy for PTSD with 'combat cocktails.' The practice has been linked to suicide risk.

Veterans are 50% more likely to commit suicide than civilian 
adults. (Medication-Induced Suicide Prevention graphic)

Although there is no data to support the practice, many military doctors prescribe "combat cocktails" to veterans with Post- traumatic stress disorder. "The practice, known as 'polypharmacy,' can tranquilize patients to the point of numbness, cause weight gain and increase suicidal thoughts when it involves pharmaceuticals that target the central nervous system," report Shalini Ramachandran and Betsy McKay of The Wall Street Journal. Because roughly a third of military veterans live in rural areas, the post-combat treatment may have a disproportionate impact on rural families and communities.

Medical guidelines for the Department of Veterans Affairs don't recommend giving patients simultaneous mixes of psychiatric medications, and the Food and Drug Administration warns against the practice. And yet, "prescribing cocktails of such drugs is one of the VA’s most common treatments for veterans with PTSD (post-traumatic stress disorder)," the Journal reports. "And the number of veterans on multiple psychiatric drugs is a growing concern at the agency."

Polypharmacy definitions vary, but "the VA defines it as taking five or more medications at the same time," Ramachandran and McKay explain. A growing number of VA physicians and researchers believes such dosing can have disastrous results, because powerful drugs can interact with patients' nervous systems and each other in unpredictable ways.

While talk therapy is considered the best PTSD treatment, therapists are often in short supply, so medical providers have turned to medicine to treat PTSD symptoms. "Nearly 60% of VA patients with PTSD were taking two or more central nervous system drugs at the same time in 2019," the Journal reports. "The VA declined requests from The Wall Street Journal to provide more recent polypharmacy numbers for veterans in its care."

Given that suicide rates among veterans are much higher than those of civilian adults, how the VA treats PTSD is under scrutiny from Congress, advocacy groups and veterans. "Studies by VA researchers link the simultaneous use of multiple psychiatric drugs to suicide risk among veterans," Ramachandran and McKay write. "Yet the agency has been slow to mandate changes."

Rural jails lack mental health resources. Inmates can linger for weeks in tiny cells awaiting psychiatric care.

Local jails weren't build to house mentally
ill populations. (KFF Health photo)

Many rural jails lack resources to manage inmates who need mental health treatment. In Polson, a small town in northwestern Montana, "when someone accused of a crime needs mental health care, chances are they’ll be locked in a basement jail cell the size of a walk-in closet," reports Katheryn Houghton of KFF Health News. Jails across the U.S. have problems similar to Polson, where demand for inmate mental health treatment exceeds any state's capacity to provide it.

Polson's basement jail cell was intended to be a short-term solution to keep mentally altered inmates away from the rest of the jail population until a psychiatric bed opened up. Houghton writes, "Last year, a man sentenced for stealing a rifle stayed in that cell 129 days. He was waiting for a spot to open at Montana’s only state-run psychiatric hospital after a mental health evaluator deemed he needed care."

Some jailed individuals haven't been found guilty of crimes because a judge ordered mental health care completed before allowing the case to move forward. At the Grays Harbor County Jail, located in the small town of Montesano, Washington, "approximately 20-30% of the jail population is made up of inmates who are supposed to be receiving [mental health] care," reports Susannah Frame of KING-TV in Seattle. The facility's medical ward is "the size of a closet. There are no mental health professionals on staff. There is not enough staff to safely deal with a crisis."

Wyoming, Nevada and Oregon jail systems have similar struggles. "More than half of Wyoming’s 23 sheriffs told lawmakers there that they were housing people in crisis awaiting mental health care for months," Houghton reports. "Nevada has struggled despite a $500 daily fine for each jailed patient whose treatment is delayed. Disability Rights Oregon has said delays in that state continue after two people died in jail while on the state’s psychiatric waitlist."

In Polson, Vincent River has been the jail's only mental health provider for 25 years. "He said he’s not always available because he’s the only psychologist in four northwestern Montana counties evaluating whether a person in jail needs psychiatric care," Houghton writes. "River said he can’t get people into any psychiatric bed in Montana because there are too few. Instead, he tries to stabilize people while they’re jailed. . . . Some are released without care if they linger too long on the state hospital’s waitlist."

Mental Health Association launches hub dedicated to improving rural mental health access and education

Rural health includes mental health care.
(Mental Health Association photo)

The Mental Health Association launched a new hub with information and free resources to help rural residents access mental health treatment, reports Liz Carey of The Daily Yonder. The site also provides community members with tools for supporting mental health care in their area.

MHA built its hub to help address the drastic need for improved mental health treatment and education in smaller communities. Carey reports, "About 7.7 million rural adults, or about a quarter (23%) of all nonmetropolitan adults in the U.S., reported having mental illness in 2022, according to the Substance Abuse and Mental Health Services Administration. Additionally, about 1.6 million, or nearly 5%, of nonmetropolitan adults reported having serious thoughts of suicide that year."

While the hub contains many options, its conversational style and easy-to-use format make it approachable. The site's landing page features a "Get Help" drop-down list of information with links on managing a mental health crisis. The site features online mental health tests and surveys to help residents determine what kind of help might fit their situation.

America Paredes, MHA’s chief social impact officer, told Carey, "Based on an individual’s screening results, they have access to a self-guided platform that helps them navigate their mental health journey based on their experience and where they are in their journey."

Resources for communities working to help residents or families cope with mental illness are also available. Paredes told Carey, “We hope this hub serves as a first step for individuals who may feel alone in their experience and organizations looking to support these communities by providing them with free resources.”

Through the hub, MHA introduces rural residents to various care options, including telehealth, which can help them access care from mental health professionals they would otherwise have to drive long distances to see. Joy Jay, executive director of MHA-SC, told Carey, "The acceptance of telehealth has helped others in rural areas reach the help they might not have otherwise had access to."

Some rural attitudes toward mental health care are improving; access and stigma remain barriers

Ranching can be isolated, lonely work.
(Adobe Stock photo)

Farmers and ranchers must deal with mental and physical stresses that other professions don't demand. When it comes to mental health checks, both groups face isolation, social stigma that discourages asking for help, and a "frontier" legacy of being able to do it all. "This 'frontier' way symbolizes a rugged and independent way of life, characterized by the ability to survive and thrive in harsh and isolated conditions," reports Mike Watkins for Progressive Farming. "This also applies to dealing with mental health issues and the attitude that no outside help is needed."

Linnea Harvey, Rural Renewal Initiative coordinator in the Department of Agricultural Education at Oklahoma State University, explains "it's a complicated mix of barriers that play into the reluctance to seek mental health services," Watkins writes. "Harvey says many of the smaller farms she has worked with didn't have hired help. The more she got to know these farmers on a personal level, the more she saw the constant stress they were under. . . .No one talked about it, but there was a lot of loneliness, depression and anxiety."

Medical providers in more remote places often offer more integrated care that begins with a primary care doctor; however, referrals to more specialized care from psychiatrists can pose a challenge. "According to the National Alliance on Mental Illness, it's estimated that as many as 65% of rural counties do not have psychiatrists, and more than 25 million Americans living in rural areas are in a designated Mental Health Professional Shortage Area," Watkins reports. Getting to see a psychiatrist might mean traveling to another county or city, which some farmers or ranchers may not have the time to do.

The pandemic opened some opportunities for care that can specifically help rural individuals seeking mental health treatment, including telehealth. Watkins adds, "Still, in rural communities, which tend to be disproportionately older, people are often uncomfortable or unsure how to use the technology."

What are the signs that someone may need mental health support? Cate Jones-Hazledine, co-director of the Panhandle office of the Behavioral Health Education Center of Nebraska, "believes changes in someone's behavior is a big one, as is feeling or acting angry or irritable, and changes in sleep patterns and appetite, among others," Watkins explains. "Any thoughts of suicide or self-harm should be taken seriously, and help should be sought immediately."

Overcoming the mental health stigma that many rural residents have is a work in progress. Watkins writes, "Until there is a crisis, mental health care is often not a priority for most farmers and ranchers, although changes in attitude are happening." Jones-Hazledine told him: "Kids are growing up with services available at school, and this helps reduce stigma and normalize seeking help when needed. . . .Things are improving, and more resources are becoming available."

A story of hope: Rosalynn Carter's mental health advocacy 'changed journalism — and journalists'

Carter's advocacy created a framework for much of the
progress on mental illness in America. (Photo by Ric Feld, AP)

One reporter's journey to understanding the role journalism could play in improving Americans' lives began with Roslyn Carter's mental health advocacy. A condensed version of Aaron Glantz's NPR story is shared below.

"So much of who I am today is the result of receiving a Rosalynn Carter Mental Health Journalism Fellowship from The Carter Center 15 years ago.

"When I met former first lady Rosalynn Carter in Atlanta in 2008, I was accomplished — having written one book and under contract for a second — but I was also broken after three years reporting in Iraq and an equal amount of time chronicling challenges veterans faced back home. I wrote without purpose, drifting from story to story and full of rage at what I saw as the U.S. government's failure to take seriously the human consequences of the war it began.

"Mrs. Carter was the first person to ever ask me how my journalism would make an impact. It was such an obvious question that it changed my life.

"These days, the question of impact is regularly discussed in newsrooms, especially on investigative desks. But at the time, considering the purpose of one's journalism was often considered taboo. . . .Her challenge, laid out softly in her gentle Southern drawl, gave me a way to channel my trauma. I could deploy it, and the entire journalism toolbox, into making people's lives better.

"All my work since and the change it has made — the fact the VA now tracks veteran suicides in an effort to prevent them, that 500,000 fewer veterans are waiting for disability benefits, that 100,000 fewer are on government-prescribed opioids, and more — can all be traced back to Mrs. Carter and her vision that journalism should have a greater purpose, to fight stigma and make change.

"As she did with her other fellows, she watched my work closely, sending congratulatory letters when my reporting won major journalism awards. She took me seriously, which made me take myself seriously. . . . Since Carter's death, I've been crying — as I share memories with some of the more than 200 other journalists who have held the fellowship that bears her name. Even those who held the fellowship after Mrs. Carter's health began to slip when she could no longer attend in person and provide notes spoke of the impact she had on them.

"Carter was a visionary. When she established the Rosalynn Carter Mental Health Journalism Fellowship in 1996, the entire conception of mental health as a journalism beat was not well established. Screaming headlines in newspapers and chyrons on the nightly news proclaimed people to be 'crazy' or 'insane.' The idea of reporting with the expressed purpose of fighting stigma and improving conditions for people with mental illness was foreign to most editors and publishers. . . . Through deliberate work over more than two decades with hundreds of reporters; Carter changed that."