ARLINGTON, Va. — Military health officials are trying to figure out how to reduce the stigma for troops seeking mental health care, but concede they’re fighting an uphill battle.

“Stigma is a real problem. It’s a societal issue, but it is much more pronounced in the military,” said Col. Thomas Burke, one of the Pentagon’s top psychiatrists and the director of mental health policy for the Defense Department.

“There is a perception among the troops that seeking mental health care means you’re weak or a coward and frankly, we in the military kind of foster that attitude,” said Burke. “We give medals to the soldiers who charge the hill, but don’t really recognize the day-to-day heroism of soldiers who take care of themselves — doing simple things like changing their socks and cleaning their weapons — doing whatever it takes to keep themselves in condition to do the mission.”

A recent Defense Department study looking at combat troops returning from Iraq found that soldiers and Marines who need counseling the most are least likely to seek it. As many as 16 percent of the troops questioned admitted to symptoms of severe depression, Post Combat Stress Disorder and other problems.

Of those, six out of 10 questioned felt their leaders would treat them differently and that fellow troops would lose confidence in them. As many as 65 percent said they’d “be seen as weak.”

Army psychiatrist Col. Charles Hoge, lead author of the study, said, “Our most important finding was this concern about stigma and barriers to care, that is, the number of soldiers who have mental health issues who don’t seek care.”

Troops returning from combat soon will undergo two mandatory mental health assessments — one right away, one three to five months later — to make sure they aren’t suffering long-term trauma, Department of Defense officials announced in January.

But self-indentifying and pursuing further help might still be difficult for some.

Hoge, who is head of psychiatry at Walter Reed Army Institute of Research in Silver Spring, Md., said the key to reducing that stigma is “making mental health care more routine. If the troops view mental health care as routine as getting an X-ray, they’ll be more likely to get it.”

“What soldiers need to understand is that stress reactions — difficulty sleeping, reliving incidents in your mind, feeling emotionally detached — these kinds of reactions are very common and really expected after combat,” said Hoge.

Wherever they go, they should remember that what they’re feeling “is normal and it’s nothing to be ashamed of.”

The war on labels

But even in the combat zone, officials have made a conscious effort not to call troops seeking mental heath care “patients.”

“It’s a hotly debated decision within the mental health community,” said Burke, “and it cuts the very heart of the stigma issue.”

On one hand, he said, calling those troops “patients” in the long run could help reduce the sense that problems coping with the horrors of combat are no different than bleeding from a gunshot wound.

On the other hand, studies have shown that the more troops are treated as sick — rather than simply experiencing normal reactions — the more likely they are to wrestle with mental health problems over time.

The biggest barrier to reducing stigma in the military, he said, is confidentiality.

“The military is in an ugly situation. In the civilian world, confidentiality is pretty strict,” said Burke.

Firm laws are in place protecting patient privacy, “but all those provisions make exceptions for the military.

“You’re never going to have complete confidentiality in the military system,” said Burke. “That doesn’t mean we open our books to anyone who wants to look — we are indeed very, very careful to safeguard privacy as much as possible — but the truth is, there is a big hole in the wall of confidentiality that will never close.”

To ease those concerns, last year military officials opened up limited confidential counseling outside of the military health care system through its One Source program with civilian providers. And last week, officials announced they would add a second round of mental health screening a few months after troops return from combat.

Officials are also in early discussions to replicate the National Institute for Mental Health’s recent “Real Men, Real Depression” public awareness campaign within the military.

For any program to work, said Burke, troops and military leaders need to understand “mental illness is not the kind of unsolvable problem that it once was.” The message he tries to ram home is that usually it’s not a matter of “problem soldiers, but soldiers with problems.”

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