It’s a leadership job to make sure that people understand that when they do have a problem, that they can get help and that it’s OK to do that.

— Secretary of the Air Force Frank Kendall

Source: Greg Hadley, “Air Force to Announce Working Group to Study Resilience, Mental Health,” Air & Space Forces Magazine, January 6, 2022

On November 1, 2021, my life changed forever. I was sitting in the base emergency operations center less than one hour into my shift as the director, when I received a phone call from one of my flight commanders.

“Sir, we had a suicide last night,” he said.

My mind raced. Those are the words every commander hopes they never hear, but, unfortunately, these words are far too common in the military. Air Force Chief of Staff General Charles Q. Brown Jr. stated, “we can never stop working to find ways to combat suicide and take care of our Airmen and their families.”¹ Unless the military decides to invest properly in the mental health of its members, suicides will continue to increase.

The Mental Health Problem

 Whether a new Airman fresh out of high school or an experienced senior noncommissioned officer, people from every rank, race, religion, and gender struggle with mental health issues. In fact, the world is struggling with mental health. According to Mental Health America, 20 percent of American adults, approximately 50 million people, experience a mental illness, and 5 percent experience a severe mental illness.² The military is facing similar issues; it is estimated that 30,177 active-duty personnel and veterans who served in the military after 9/11 died by suicide.³

Rarely did a day in my command go by without a discussion about one of our Airmen going through a mental health struggle. The military is a stressful occupation. Military service means living and working in isolating and lonely circumstances, and servicemembers are sometimes placed in life-or-death situations. These stressful moments often add up and contribute to anxiety, depression, and much more. The Substance Abuse and Mental Health Services Administration estimated that individuals in high-stress jobs, such as military and first responders, are 10 percent more likely to develop behavioral conditions than the general population.⁴

Furthermore, the recent COVID-19 pandemic has placed additional and new stressors on people. Social distancing measures and requirements for isolation and quarantine altered the daily lives of servicemembers and citizens worldwide.⁵ These factors put military members at a greater risk for mental health-related issues.⁶

With the demand for mental health support at an all-time high, the US military, including the Air Force, is struggling to provide enough mental health professionals. For servicemembers, it is difficult to obtain an appointment with a mental health provider in a timely manner. A 2020 DoD Inspector General report indicated 7 of 13 military treatment facilities evaluated did not meet the specialty mental health access-to-care standard of 28 days in any month from December 2018 to June 2019.⁷ To overcome the shortage of mental health providers, military treatment facilities often must triage patients and send people with lesser symptoms to nonmedical counselors or supervisors for support. 

Invest in Your Greatest Resource

Military leaders often refer to their personnel as their greatest resource. Leaders frequently talk about the importance of keeping and retaining talent. This is especially important today because each service struggles to meet its recruiting and retention goals. For example, for the first time in a decade, the Air Force had to increase its recruiting bonuses two separate times in 2022 to meet its recruiting goals for its active duty members.⁸  While the service met its goals for active duty members in 2022, it fell short in the Reserve and Guard by 1,500-2,000 Airmen in each component.⁹ To take care of its greatest resource and to keep and retain talent, the military must rethink the way it addresses mental health. It must start the mental health process before the individual joins the military and increase its investment in resources to support the warfighter after they join.

The Air Force needs to implement a more rigorous mental health screening process before allowing recruits to join. On numerous occasions, I encountered young Airmen who joined the military with preexisting mental health issues ranging from self-injury or cutting to severe anxiety. The member either did not report their issues, or they did but were still allowed to join the service because the issues were not deemed severe enough.

This is dangerous because active duty members with previous suicide attempts are more likely to experience more intense suicidal ideation than those who have no such history, even when controlling for many suicide risk factors, including depression, hopelessness, gender, and personality traits.¹⁰ Allowing these individuals to join the military is not beneficial to them or to the unit’s readiness.

The military’s mental health screenings prior to enlistment are subjective and rely largely on recruits to self-report mental health issues. Specifically, no access to pre-application civilian medical data creates challenges for a thorough review and often result in an incomplete analysis.¹¹ Implementing a thorough review of medical records and conducting additional mental health screening will help reduce the number of military members joining with severe preexisting conditions.

One potential solution is to implement a program initiated by the Army. The Army uses preventative screenings for several negative outcomes (e.g., suicide, violence, sexual assault) with high prevalence in the early years of an Army career. The screenings have predicted potential negative outcomes with a high degree of certainty. For example, 40.5 percent of suicide attempts occurred among the 10 percent of new Soldiers with the highest predicted risk of suicide.¹² Similar preventative screenings in all the military branches can help identify members not predisposed to military service.

There are instances when preventing Airmen with preexisting mental health conditions from serving is too restrictive. Potential recruits with a preexisting condition should have an in-depth evaluation performed by a medical board to determine if they are fit to serve. Those who make it through the screening process should then be assigned to bases where there are resources and capacity to meet their needs, similar to the Exceptional Family Member Program. The screening process will ensure members with mental health issues are given the proper care, including teaching them how to manage stress and build other skills to cope effectively with their mental health diagnosis.¹³

Another way to help the Air Force take care of its members and support positive mental health is to provide each unit with a licensed clinical social worker and a mental health technician. These embedded mental health teams should focus on unit circulation, education, and counseling to promote resilient and help-seeking behavior. The goal of the mental health team is to encourage and enable early intervention for members struggling with mental health issues. The Air Force tested this recommendation in 2020 in a program called Task Force True North at four active duty bases with resounding success.

The embedded mental health care teams work because military members are generally guarded and untrusting of people outside their unit. Servicemembers with mental health issues are more likely to reach out to peers than healthcare professionals.¹⁴ Embedding a licensed clinical social worker and mental health technician within the unit helps them overcome this unfounded stigma. Trust is key for the providers to connect with the military members. Additionally, units are foundational structures of the military. Highly functioning units are associated with a lower likelihood of suicidal ideation, and strong bonds reduce vulnerability to depression.¹⁵

A 2020 RAND report found Task Force True North’s embedded mental health teams gained the trust of Airmen and leaders.¹⁶ As the embedded health teams gained trust with unit members, they created a safe space where Airmen received the mental health help they needed. More importantly, the trusted relationships resulted in more Air Force members seeking help, destigmatizing the perception that servicemembers will receive negative repercussions if they seek mental health treatment. The unit’s mental health teams helped foster a culture of help-seeking behavior and let everyone know there is no shame in asking for help when needed.

Embedded mental health care teams also have a positive impact on the unit’s overall morale and welfare. The mental health professionals interact with the unit daily in intimate situations. These interactions give them a true sense of the morale, disciplinary issues, and unit’s struggles. Interactions on these topics are important because a core driver of suicide among military members is financial problems due to loss of pay or rank because of misconduct.¹⁷ Knowing these intimate details allows the mental health team to advise the command teams on areas of improvement for the unit and develop specific ways to create a culture where people feel valued and secure to share their struggles with others.

Conclusion

Implementing a more rigorous mental health screening process and embedding mental health teams in Air Force units comes at a significant monetary cost. The cost associated with these recommendations is worth it if the military can help improve the mental health of its personnel. Increased investment in military mental health will improve the resilience and well-being of servicemembers and, more importantly, increase retention and effectiveness of the country’s fighting force. It is time for the Air Force to truly invest in its greatest resource—its people.

The views and opinions expressed or implied herein are those of the authors and should not be construed as carrying the official sanction of the Department of Defense, the Department of the Air Force, Air Education and Training Command, Air University, or other agencies or departments of the US government.