To combat stigma and ensure appropriate care, behavioral health providers need to listen more attentively to service members with mild traumatic brain injuries, also known as concussions, when discussing their mental health, according to new research from the Defense and Veterans Brain Injury Center, a division of the Defense Health Agency Research and Development Directorate.

In the study, DVBIC and University of Washington researchers found soldiers often do not overtly express their feelings of depression, but the signs for mental health challenges are still there if providers "read the language" accurately for indications of illness. Psychological issues like depression and anger are common among service members who have experienced TBIs and combat trauma. However, the military culture has traditionally emphasized personal endurance when faced with adversity, which may account for soldiers' reluctance to characterize their emotional states using terms such as depression.

For the analysis, the researchers relied on recorded transcripts from a University of Washington-based study that tested whether telephone-based problem-solving interventions could improve the mental health symptoms of service members with combat-sustained TBI. In a clinical trial, the study population was divided into two groups. One group received 12 educational brochures in the mail with advice on how to manage common TBI issues and concerns; the other group received the same literature and a bi-weekly phone call from a counselor. All participants completed questionnaires to assess their mental health.

In the study published in the journal Military Psychology, the researchers focused on a subset of 25 participants who had participated in the recorded telephone intervention. Based on their responses to the questionnaires, these 25 service members appeared to fit the model of clinical depression. In the recorded transcripts, however, few used the word "depression" to describe their feelings. They claimed to be "frustrated" and had a "loss of control" in their lives.

Their frustration manifested through irritability and anger: "I feel like I am ready to snap . . . I'm angry, very angry, and I do not know why," said one respondent. Anger was also tied to an inability to function: "It's not that I don't want to work, it's just that with my concentration and focus and irritability and anger." Even when they had a diagnosis like PTSD, they were still frustrated and blamed themselves for difficulties maintaining relationships with friends and family; as another participant said, "I'm a bad apple that no one is going to want."

The fact these service members did not use the word "depression," or similar terms, is important in both treatment and policy development within the Military Health System.

"If you have people who are rating themselves as depressed but are not reporting that they are depressed, where is the mismatch and what are the implications for intervention?" said Wesley Cole, a neuropsychologist and the senior research director at DVBIC's Fort Bragg site when the study was conducted.

Because the subjects consistently reported anger and irritability, Cole suggested many of these service members might have been treated for anger management. Not only does this fail to address the root cause of their problem, but it also may contribute to the stigma associated with mental illness. Cole added, "If you send someone to anger management who doesn't really need it, then that contributes to the stigma because I am now getting treatment that does not fit what I am experiencing. I am more disenfranchised from the medical system."

These findings underscore that providers need to be sensitive to psychological conditions when treating TBI patients. Although TBI patients may focus on the physical attributes of their illnesses, providers should also consider mental health as a factor in recovery.

"It's not just what shows up on a CAT scan or an MRI; there are so many other things that can affect service members, and being aware of those other conditions, like mental health conditions, is fundamental," said Army veteran Maj. (Dr.) Daniel José Correa. As a TBI patient and a physician who specializes in neurology, Correa can see both sides as he recounts in the video from the A Head for the Future education initiative.

If providers become more sensitive to these issues, then they can direct patients to appropriate resources. DVBIC has produced a fact sheet on changes in behavior, personality, or mood following a concussion. It offers concrete steps when confronting these psychological changes—such as working on stress management and using the mobile application Mood Tracker designed by Connected Health to identify triggers. Additional resources on depression and anger are available through the Real Warriors Campaign, which encourages the military community to reach out for help when dealing with mental health concerns.