A UCSF assistant professor of medicine is co-directing an innovative, new clinic to promote the prevention and treatment of mental health problems among new veterans affected by their service in Afghanistan and Iraq.

The clinic is one of only three organizations in the country to integrate primary care treatment with mental health and social work services to treat combat-related problems such as post-traumatic stress disorder (PTSD -- see sidebar.)

This integration is crucial to overcome the stigma that is still attached to mental health care in the minds of many veterans.

Karen Seal, MD, MPH, a staff physician at the UCSF-affiliated San Francisco Veteran Affairs Medical Center (SFVAMC), established the clinic with co-director Rina Shah, MD, the center's director of medical practice. It opened in April 2007.

Overcoming the Stigma

The clinic makes it easy and less stigmatizing for veterans to learn about and obtain treatment for mental health problems, said Dawn Lawhon, PhD, staff psychologist for the clinic and the center's PTSD clinical team. Lawhon also conducts substance abuse research as a postdoctoral fellow in UCSF's Department of Psychiatry.

Before the clinic's establishment, Seal says, veterans' primary care physicians referred them to the center's mental health clinics in another building for an appointment at a later date. Often, veterans did not visit the mental health clinic because of the stigma associated with such services or because they felt conflicted about asking for help.

Joe's Story

Joe, 24, is a retired marine and typical for the type of patient Dr. Seal and her colleagues are trying to reach. Joe feels he should be strong enough to deal with his problems himself. After witnessing the deaths of several close comrades in Iraq, he is depressed, angry, and irritable. He doesn't sleep well and is plagued by intrusive thoughts related to combat. He also suffered a head injury from an explosion.

At the new clinic, Joe can be treated for his head injury and his depression, without suffering from any stigma. The clinic combines physical and mental health assessments on the same day at the same place, and it "demystifies and normalizes mental health services," Lawhon says.

Veterans are provided free treatment at VA Medical Centers for two years from the date they return home from service. When OEF/OIF* veterans have their initial appointment in the primary care clinic, mental health and social services are included in that appointment for everyone. Mental health care is presented as part of standard, holistic care, as treating the whole person.

Combat Stress Specialists

After a physical health assessment by Seal or one of the clinic's three nurse practitioners, Melanie Bragin, Kristen Weaver, or Cheryl Wenell, the veteran is accompanied across the hall to see one of four "combat stress specialists". These specialists are psychologists Lawhon, Shira Maguen, Eunie Jung and Mark Stalnaker.

"We tell the veteran that combat is stressful, and that it is normal to have a stress reaction," Lawhon said. Examples of such reactions are irritability, insomnia, or sudden panic. Veterans may not realize that their irritability, for example, may stem from combat-induced stress.

"Sometimes they get relief just from talking to one of us during their first visit," Lawhon said.

Visiting a "combat stress specialist" may be less stigmatizing and intimidating than having to make a separate appointment at the mental health clinic, Lawhon said. Psychologists also inform veterans that the clinic offers individual, group, couples and family therapy.

After visiting the psychologist, the veteran is taken to meet one of four "combat case managers", or social workers: Polly Rose, Kathleen Zalecki, Karen Xavier, or Nancy Herzoff. The social workers help veterans optimize their use of VA services and benefits, and they help veterans overcome barriers to obtaining treatment, such as lack of transportation or child care.

Integrate Overall Care

Another advantage of the clinic is that it expedites veterans' overall care. Mental health problems such as PTSD often manifest as physical symptoms, like headaches or gastrointestinal problems. Lawhon can facilitate the treatment of these issues by communicating directly with a patient's primary caregiver months before the patient's next scheduled primary care appointment.

The clinic's professionals also meet twice a month to address patients' needs synergistically.

*OEF = Operation Enduring Freedom (Afghanistan)
*OIF = Operation Iraqi Freedom