Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH.

A supplement recently published in Military Medicine seeks to examine how the Defense Department meets the medical needs of its women warriors. Called “Combat: Framing the Issues of Health and Health Research for America’s Servicewomen,” the articles go a long way toward shining a light on an important issue.

Several of the articles in the supplement highlight mental health issues for women in the military. They include the pieces about sexual harassment, the many faces of military families, alcohol use, and the corrosive effects of ostracism.

One of the articles by Kate McGraw, Ph.D., of the Deployment Health Clinical Center, Silver Spring, Md., focuses on the mental well-being of servicewomen and sexual trauma. Underlying the supplement is the recognition that the most robust mental health research repeatedly conducted in Afghanistan, for example, did not include a single woman because of the sampling methodology. A dedicated group addressing service women’s health and inclusion in health research would have prevented this oversight.

The health of female service members has long been an interest of mine, partly because I was in the Army for 28 years and deployed to a lot of austere environments. They included the rice fields of Camp Edwards, near the DMZ in Korea; Mogadishu and other “cities” in Somalia; and various Forward Operating Bases in Iraq.

Many years ago, I published an article on health concerns of deployed women. That focused on concerns about how to avoid urinary tract infections (UTIs) while in the field – where bathrooms are often scarce and dirty – and other seemingly mundane issues.

Mundane unless you have a UTI, or are trying to figure out how to manage your menses with no tampons or places to wash your hands.

Since then the literature has grown. For example, I published a volume called “Women at War” (Oxford University Press, 2015) last spring. This recent supplement advances those discussions, including articles on avoiding anemia and stress fractures.

But the way forward has been spotty. Many political issues delay an open discussion, especially on reproductive concerns. Further, there is no driving function within the Department of Defense that focuses on funding research in support of service women and reporting back to the department and civilian leadership.

For example: Female service members have a rate of unintended pregnancy twice that of the civilian world. This leads to early attrition from the military, and in turn, to young female veterans with children who are homeless.

Some have said, highlighting these concerns, that females should not be in the military because our presence is a risk to operational readiness. However, this is not an issue without tested solutions.

Taking this one issue further, consider that all service women are included in the Military Health System and have access to a variety of forms of birth control. If female service members can be put on oral contraceptives, that would both suppress their menses and avoid unwanted pregnancies. However, longer lasting methods of birth control would enable service women to enjoy decreased menses, avoid unwanted pregnancies, and avoid access issues during deployment.

The supplement contains numerous health policy and research recommendations as well as a detailed look at the unique health and lifestyle challenges of service women. Other issues include: the reproductive health of women in austere environments, nutritional factors, avoiding musculoskeletal injuries, combat-related injuries, designing military equipment (including uniforms) for optimal performance, and the role of leadership. It concludes with 20 research gaps and accompanying recommendations.

The number of women serving in the military is increasing, while all jobs, particularly those in the ground combat element, are now open to women. The time is now to focus on establishing and tracking health and well-being issues to ensure the success of this population – and the Military Medicine special issue is just a first step.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Services in Bethesda, Md., and at Georgetown University in Washington. She helped write one of the articles in the supplement with Dr. McGraw and Tracey Perez Koehlmoos, Ph.D., an associate professor with the Uniformed Services University.

A supplement recently published in Military Medicine seeks to examine how the Defense Department meets the medical needs of its women warriors. Called “Combat: Framing the Issues of Health and Health Research for America’s Servicewomen,” the articles go a long way toward shining a light on an important issue.

Several of the articles in the supplement highlight mental health issues for women in the military. They include the pieces about sexual harassment, the many faces of military families, alcohol use, and the corrosive effects of ostracism.

One of the articles by Kate McGraw, Ph.D., of the Deployment Health Clinical Center, Silver Spring, Md., focuses on the mental well-being of servicewomen and sexual trauma. Underlying the supplement is the recognition that the most robust mental health research repeatedly conducted in Afghanistan, for example, did not include a single woman because of the sampling methodology. A dedicated group addressing service women’s health and inclusion in health research would have prevented this oversight.

The health of female service members has long been an interest of mine, partly because I was in the Army for 28 years and deployed to a lot of austere environments. They included the rice fields of Camp Edwards, near the DMZ in Korea; Mogadishu and other “cities” in Somalia; and various Forward Operating Bases in Iraq.

Many years ago, I published an article on health concerns of deployed women. That focused on concerns about how to avoid urinary tract infections (UTIs) while in the field – where bathrooms are often scarce and dirty – and other seemingly mundane issues.

Mundane unless you have a UTI, or are trying to figure out how to manage your menses with no tampons or places to wash your hands.

Since then the literature has grown. For example, I published a volume called “Women at War” (Oxford University Press, 2015) last spring. This recent supplement advances those discussions, including articles on avoiding anemia and stress fractures.

But the way forward has been spotty. Many political issues delay an open discussion, especially on reproductive concerns. Further, there is no driving function within the Department of Defense that focuses on funding research in support of service women and reporting back to the department and civilian leadership.

For example: Female service members have a rate of unintended pregnancy twice that of the civilian world. This leads to early attrition from the military, and in turn, to young female veterans with children who are homeless.

Some have said, highlighting these concerns, that females should not be in the military because our presence is a risk to operational readiness. However, this is not an issue without tested solutions.

Taking this one issue further, consider that all service women are included in the Military Health System and have access to a variety of forms of birth control. If female service members can be put on oral contraceptives, that would both suppress their menses and avoid unwanted pregnancies. However, longer lasting methods of birth control would enable service women to enjoy decreased menses, avoid unwanted pregnancies, and avoid access issues during deployment.

The supplement contains numerous health policy and research recommendations as well as a detailed look at the unique health and lifestyle challenges of service women. Other issues include: the reproductive health of women in austere environments, nutritional factors, avoiding musculoskeletal injuries, combat-related injuries, designing military equipment (including uniforms) for optimal performance, and the role of leadership. It concludes with 20 research gaps and accompanying recommendations.

The number of women serving in the military is increasing, while all jobs, particularly those in the ground combat element, are now open to women. The time is now to focus on establishing and tracking health and well-being issues to ensure the success of this population – and the Military Medicine special issue is just a first step.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Services in Bethesda, Md., and at Georgetown University in Washington. She helped write one of the articles in the supplement with Dr. McGraw and Tracey Perez Koehlmoos, Ph.D., an associate professor with the Uniformed Services University.

A supplement recently published in Military Medicine seeks to examine how the Defense Department meets the medical needs of its women warriors. Called “Combat: Framing the Issues of Health and Health Research for America’s Servicewomen,” the articles go a long way toward shining a light on an important issue.

Several of the articles in the supplement highlight mental health issues for women in the military. They include the pieces about sexual harassment, the many faces of military families, alcohol use, and the corrosive effects of ostracism.

One of the articles by Kate McGraw, Ph.D., of the Deployment Health Clinical Center, Silver Spring, Md., focuses on the mental well-being of servicewomen and sexual trauma. Underlying the supplement is the recognition that the most robust mental health research repeatedly conducted in Afghanistan, for example, did not include a single woman because of the sampling methodology. A dedicated group addressing service women’s health and inclusion in health research would have prevented this oversight.

The health of female service members has long been an interest of mine, partly because I was in the Army for 28 years and deployed to a lot of austere environments. They included the rice fields of Camp Edwards, near the DMZ in Korea; Mogadishu and other “cities” in Somalia; and various Forward Operating Bases in Iraq.

Many years ago, I published an article on health concerns of deployed women. That focused on concerns about how to avoid urinary tract infections (UTIs) while in the field – where bathrooms are often scarce and dirty – and other seemingly mundane issues.

Mundane unless you have a UTI, or are trying to figure out how to manage your menses with no tampons or places to wash your hands.

Since then the literature has grown. For example, I published a volume called “Women at War” (Oxford University Press, 2015) last spring. This recent supplement advances those discussions, including articles on avoiding anemia and stress fractures.

But the way forward has been spotty. Many political issues delay an open discussion, especially on reproductive concerns. Further, there is no driving function within the Department of Defense that focuses on funding research in support of service women and reporting back to the department and civilian leadership.

For example: Female service members have a rate of unintended pregnancy twice that of the civilian world. This leads to early attrition from the military, and in turn, to young female veterans with children who are homeless.

Some have said, highlighting these concerns, that females should not be in the military because our presence is a risk to operational readiness. However, this is not an issue without tested solutions.

Taking this one issue further, consider that all service women are included in the Military Health System and have access to a variety of forms of birth control. If female service members can be put on oral contraceptives, that would both suppress their menses and avoid unwanted pregnancies. However, longer lasting methods of birth control would enable service women to enjoy decreased menses, avoid unwanted pregnancies, and avoid access issues during deployment.

The supplement contains numerous health policy and research recommendations as well as a detailed look at the unique health and lifestyle challenges of service women. Other issues include: the reproductive health of women in austere environments, nutritional factors, avoiding musculoskeletal injuries, combat-related injuries, designing military equipment (including uniforms) for optimal performance, and the role of leadership. It concludes with 20 research gaps and accompanying recommendations.

The number of women serving in the military is increasing, while all jobs, particularly those in the ground combat element, are now open to women. The time is now to focus on establishing and tracking health and well-being issues to ensure the success of this population – and the Military Medicine special issue is just a first step.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Services in Bethesda, Md., and at Georgetown University in Washington. She helped write one of the articles in the supplement with Dr. McGraw and Tracey Perez Koehlmoos, Ph.D., an associate professor with the Uniformed Services University.

“Afterwar” is not a light book to read for an escapist afternoon. The subject – the return to civilian life after war – is heavy. The writing is thoughtful and serious. Most daunting, or exciting, are the philosophical questions raised.

Nancy Sherman, Ph.D., is professor of philosophy at Georgetown University in Washington. The philosophical lens, which she focuses on our returning service members, helps to frame the current difficulties many have in reintegrating into civilian society. Dr. Sherman seeks to bring the war back home to us through the in-depth stories of several who have served and whom she has come to know well through extensive interviews. She often ties their stories to those told by the Greek tragedians and philosophers. Sophocles, one of the greatest Greek tragedians, was himself a Greek general, and his plays written after he returned from the Peloponnesian War, like “Ajax” and “Philoctetes,” shed light on our own current homecomings.

About 2.5 million service members have served in the conflicts in Iraq and Afghanistan. That number, however, represents only about 1% of the U.S. population. There are currently deep cultural divides between the military and civilian populations in America, a theme repeated often in “Afterwar.”

Post-traumatic stress disorder (PTSD), suicide, and traumatic brain injury (TBI) have been headline news for many years. There is increasing focus on “moral injury.” The question of moral injury is the central theme of this book.

What does the term mean? Usually, moral injury refers to a sense of shame and guilt. Shame at not being able to save a battle buddy. Guilt that one has survived and one’s buddies have not. It also may encompass a sense of having been betrayed by the government or military in which the service member has invested his or her whole life. Literally

This is an important concept, in the context of the seemingly never-ending wars in Iraq and Afghanistan. It also illuminates other troubled conflicts, especially the Vietnam War. Parenthetically, that war began 50 years ago, but the disability claims from Vietnam veterans were the highest ever last year.

About 15% of the military is female. The stories of women in the service are just beginning to be told. Women who join the military are often unconventional. Dr. Sherman articulates their voices in this volume.

Why should psychiatrists read “Afterwar”? For all kinds of reasons.

Again, 2.5 million service members have served in the conflicts since Sept. 11, 2001. The vast majority have returned home and separated from the military. About half will get care through the Veterans Health Administration. Some of these, plus the other half, will also go to the plethora of civilian providers, through school or work, or the public mental health systems. So civilian psychiatrists will see veterans.

This book does not outline treatment regiments for PTSD or TBI, but it does offer a way to talk to veterans about their military service and the moral injury they may be struggling with. And, hopefully, that should reduce the alarmingly high suicide rate.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington. She also is coeditor of “Women at War” (New York: Oxford University Press, 2015).

“Afterwar” is not a light book to read for an escapist afternoon. The subject – the return to civilian life after war – is heavy. The writing is thoughtful and serious. Most daunting, or exciting, are the philosophical questions raised.

Nancy Sherman, Ph.D., is professor of philosophy at Georgetown University in Washington. The philosophical lens, which she focuses on our returning service members, helps to frame the current difficulties many have in reintegrating into civilian society. Dr. Sherman seeks to bring the war back home to us through the in-depth stories of several who have served and whom she has come to know well through extensive interviews. She often ties their stories to those told by the Greek tragedians and philosophers. Sophocles, one of the greatest Greek tragedians, was himself a Greek general, and his plays written after he returned from the Peloponnesian War, like “Ajax” and “Philoctetes,” shed light on our own current homecomings.

About 2.5 million service members have served in the conflicts in Iraq and Afghanistan. That number, however, represents only about 1% of the U.S. population. There are currently deep cultural divides between the military and civilian populations in America, a theme repeated often in “Afterwar.”

Post-traumatic stress disorder (PTSD), suicide, and traumatic brain injury (TBI) have been headline news for many years. There is increasing focus on “moral injury.” The question of moral injury is the central theme of this book.

What does the term mean? Usually, moral injury refers to a sense of shame and guilt. Shame at not being able to save a battle buddy. Guilt that one has survived and one’s buddies have not. It also may encompass a sense of having been betrayed by the government or military in which the service member has invested his or her whole life. Literally

This is an important concept, in the context of the seemingly never-ending wars in Iraq and Afghanistan. It also illuminates other troubled conflicts, especially the Vietnam War. Parenthetically, that war began 50 years ago, but the disability claims from Vietnam veterans were the highest ever last year.

About 15% of the military is female. The stories of women in the service are just beginning to be told. Women who join the military are often unconventional. Dr. Sherman articulates their voices in this volume.

Why should psychiatrists read “Afterwar”? For all kinds of reasons.

Again, 2.5 million service members have served in the conflicts since Sept. 11, 2001. The vast majority have returned home and separated from the military. About half will get care through the Veterans Health Administration. Some of these, plus the other half, will also go to the plethora of civilian providers, through school or work, or the public mental health systems. So civilian psychiatrists will see veterans.

This book does not outline treatment regiments for PTSD or TBI, but it does offer a way to talk to veterans about their military service and the moral injury they may be struggling with. And, hopefully, that should reduce the alarmingly high suicide rate.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington. She also is coeditor of “Women at War” (New York: Oxford University Press, 2015).

“Afterwar” is not a light book to read for an escapist afternoon. The subject – the return to civilian life after war – is heavy. The writing is thoughtful and serious. Most daunting, or exciting, are the philosophical questions raised.

Nancy Sherman, Ph.D., is professor of philosophy at Georgetown University in Washington. The philosophical lens, which she focuses on our returning service members, helps to frame the current difficulties many have in reintegrating into civilian society. Dr. Sherman seeks to bring the war back home to us through the in-depth stories of several who have served and whom she has come to know well through extensive interviews. She often ties their stories to those told by the Greek tragedians and philosophers. Sophocles, one of the greatest Greek tragedians, was himself a Greek general, and his plays written after he returned from the Peloponnesian War, like “Ajax” and “Philoctetes,” shed light on our own current homecomings.

About 2.5 million service members have served in the conflicts in Iraq and Afghanistan. That number, however, represents only about 1% of the U.S. population. There are currently deep cultural divides between the military and civilian populations in America, a theme repeated often in “Afterwar.”

Post-traumatic stress disorder (PTSD), suicide, and traumatic brain injury (TBI) have been headline news for many years. There is increasing focus on “moral injury.” The question of moral injury is the central theme of this book.

What does the term mean? Usually, moral injury refers to a sense of shame and guilt. Shame at not being able to save a battle buddy. Guilt that one has survived and one’s buddies have not. It also may encompass a sense of having been betrayed by the government or military in which the service member has invested his or her whole life. Literally

This is an important concept, in the context of the seemingly never-ending wars in Iraq and Afghanistan. It also illuminates other troubled conflicts, especially the Vietnam War. Parenthetically, that war began 50 years ago, but the disability claims from Vietnam veterans were the highest ever last year.

About 15% of the military is female. The stories of women in the service are just beginning to be told. Women who join the military are often unconventional. Dr. Sherman articulates their voices in this volume.

Why should psychiatrists read “Afterwar”? For all kinds of reasons.

Again, 2.5 million service members have served in the conflicts since Sept. 11, 2001. The vast majority have returned home and separated from the military. About half will get care through the Veterans Health Administration. Some of these, plus the other half, will also go to the plethora of civilian providers, through school or work, or the public mental health systems. So civilian psychiatrists will see veterans.

This book does not outline treatment regiments for PTSD or TBI, but it does offer a way to talk to veterans about their military service and the moral injury they may be struggling with. And, hopefully, that should reduce the alarmingly high suicide rate.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington. She also is coeditor of “Women at War” (New York: Oxford University Press, 2015).

Problems with access to care at the Department of Veterans Affairs have been the source of front-page headlines for at least a year. Some of us are asked: Can the VA and military health care system do it all? My answer: Of course not.

More than 2.5 million American combat veterans have fought in longest war in our history, the wars in Afghanistan and Iraq. Thousands of physically and psychologically wounded active duty troops overflow military hospitals. The VHA (Veterans Health Administration), the medical arm of VA, is caring for millions of these recent veterans. But it also treats veterans from many other wars, including those from World War II, Korea, and Vietnam.

As those men and women age, their need for medical care will only increase. So just take into account the older veterans, and then add the recent combat veterans with posttraumatic stress disorder, traumatic brain injury, and physical injuries from the conflicts in Iraq and Afghanistan.

So, to me, “of course not” is an obvious answer to whether the military health care system and VA can do it all.

This should be no surprise. Back in 2007, my former boss, the Army surgeon general, was fired when Walter Reed National Military Medical Center got overwhelmed with the wounded. A consistent theme of overwhelmed military and veterans facilities has emerged.

Yet, I still get asked the question “Is the military and the VA doing enough to take care of wounded veterans?” whenever I do a media interview about PTSD and suicides in soldiers. The reporters tend to ask with a kind of “gotcha” attitude, as if the VA’s struggle to keep up is a secret.

My answer is “They are doing all they can. They are stretched very thin.”

I recently served on an Institute of Medicine committee looking at how well the Department of Defense and the VA delivered care for PTSD. The short answer? It varies. Some VA hospitals deliver stellar care, others not so much. Being swamped was a common theme.

Rather than ragging on the struggling VA, the more productive direction, it seems to me, is to ensure that the civilian health care system is capable of recognizing and treating the psychological injuries of war.

Why involve civilians? For many reasons. A lot of veterans choose not go to the VA, because they receive health care via their workplace or school insurance. Some veterans are too low a priority to be seen. Even for those eligible to receive treatment there, when too full, the VA refers many veterans to the civilian sector.

Fortunately, there have been a lot of efforts to teach psychiatrists about caring for the psychological wounds of war, including:

• The military track at the American Psychiatric Association meeting in Toronto, on its 5th year.

• Webinars and conferences developed by public and private organizations, such as the Substance Abuse and Mental Health Services Administration, and the Massachusetts General Hospital Home Base program.

• Many books and articles by experts in the area of veterans health, for example see Once a Warrior – Always a Warriorb y Col. (Ret.) Charles W. Hoge, M.D., (Guilford, Conn.: Lyons Press, 2010), or my forthcoming book, Women at War (Oxford University Press, 2015).

• Numerous websites, such as that of the National Center for PTSD,the Borden Institute,and the Center for Deployment Psychology.

• The developing medical school curriculum on veteran’s health, spurred by the White House’s Joining Forces initiative.

• An action paper to be presented at this year’s APA Assembly, recommending that all providers inquire about the military status of their patients.

Of course, there is lots of room for everybody – not just health care providers – to join in the mission. As we enter year 14th year of the long war, we all need to help.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington.

Problems with access to care at the Department of Veterans Affairs have been the source of front-page headlines for at least a year. Some of us are asked: Can the VA and military health care system do it all? My answer: Of course not.

More than 2.5 million American combat veterans have fought in longest war in our history, the wars in Afghanistan and Iraq. Thousands of physically and psychologically wounded active duty troops overflow military hospitals. The VHA (Veterans Health Administration), the medical arm of VA, is caring for millions of these recent veterans. But it also treats veterans from many other wars, including those from World War II, Korea, and Vietnam.

As those men and women age, their need for medical care will only increase. So just take into account the older veterans, and then add the recent combat veterans with posttraumatic stress disorder, traumatic brain injury, and physical injuries from the conflicts in Iraq and Afghanistan.

So, to me, “of course not” is an obvious answer to whether the military health care system and VA can do it all.

This should be no surprise. Back in 2007, my former boss, the Army surgeon general, was fired when Walter Reed National Military Medical Center got overwhelmed with the wounded. A consistent theme of overwhelmed military and veterans facilities has emerged.

Yet, I still get asked the question “Is the military and the VA doing enough to take care of wounded veterans?” whenever I do a media interview about PTSD and suicides in soldiers. The reporters tend to ask with a kind of “gotcha” attitude, as if the VA’s struggle to keep up is a secret.

My answer is “They are doing all they can. They are stretched very thin.”

I recently served on an Institute of Medicine committee looking at how well the Department of Defense and the VA delivered care for PTSD. The short answer? It varies. Some VA hospitals deliver stellar care, others not so much. Being swamped was a common theme.

Rather than ragging on the struggling VA, the more productive direction, it seems to me, is to ensure that the civilian health care system is capable of recognizing and treating the psychological injuries of war.

Why involve civilians? For many reasons. A lot of veterans choose not go to the VA, because they receive health care via their workplace or school insurance. Some veterans are too low a priority to be seen. Even for those eligible to receive treatment there, when too full, the VA refers many veterans to the civilian sector.

Fortunately, there have been a lot of efforts to teach psychiatrists about caring for the psychological wounds of war, including:

• The military track at the American Psychiatric Association meeting in Toronto, on its 5th year.

• Webinars and conferences developed by public and private organizations, such as the Substance Abuse and Mental Health Services Administration, and the Massachusetts General Hospital Home Base program.

• Many books and articles by experts in the area of veterans health, for example see Once a Warrior – Always a Warriorb y Col. (Ret.) Charles W. Hoge, M.D., (Guilford, Conn.: Lyons Press, 2010), or my forthcoming book, Women at War (Oxford University Press, 2015).

• Numerous websites, such as that of the National Center for PTSD,the Borden Institute,and the Center for Deployment Psychology.

• The developing medical school curriculum on veteran’s health, spurred by the White House’s Joining Forces initiative.

• An action paper to be presented at this year’s APA Assembly, recommending that all providers inquire about the military status of their patients.

Of course, there is lots of room for everybody – not just health care providers – to join in the mission. As we enter year 14th year of the long war, we all need to help.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington.

Problems with access to care at the Department of Veterans Affairs have been the source of front-page headlines for at least a year. Some of us are asked: Can the VA and military health care system do it all? My answer: Of course not.

More than 2.5 million American combat veterans have fought in longest war in our history, the wars in Afghanistan and Iraq. Thousands of physically and psychologically wounded active duty troops overflow military hospitals. The VHA (Veterans Health Administration), the medical arm of VA, is caring for millions of these recent veterans. But it also treats veterans from many other wars, including those from World War II, Korea, and Vietnam.

As those men and women age, their need for medical care will only increase. So just take into account the older veterans, and then add the recent combat veterans with posttraumatic stress disorder, traumatic brain injury, and physical injuries from the conflicts in Iraq and Afghanistan.

So, to me, “of course not” is an obvious answer to whether the military health care system and VA can do it all.

This should be no surprise. Back in 2007, my former boss, the Army surgeon general, was fired when Walter Reed National Military Medical Center got overwhelmed with the wounded. A consistent theme of overwhelmed military and veterans facilities has emerged.

Yet, I still get asked the question “Is the military and the VA doing enough to take care of wounded veterans?” whenever I do a media interview about PTSD and suicides in soldiers. The reporters tend to ask with a kind of “gotcha” attitude, as if the VA’s struggle to keep up is a secret.

My answer is “They are doing all they can. They are stretched very thin.”

I recently served on an Institute of Medicine committee looking at how well the Department of Defense and the VA delivered care for PTSD. The short answer? It varies. Some VA hospitals deliver stellar care, others not so much. Being swamped was a common theme.

Rather than ragging on the struggling VA, the more productive direction, it seems to me, is to ensure that the civilian health care system is capable of recognizing and treating the psychological injuries of war.

Why involve civilians? For many reasons. A lot of veterans choose not go to the VA, because they receive health care via their workplace or school insurance. Some veterans are too low a priority to be seen. Even for those eligible to receive treatment there, when too full, the VA refers many veterans to the civilian sector.

Fortunately, there have been a lot of efforts to teach psychiatrists about caring for the psychological wounds of war, including:

• The military track at the American Psychiatric Association meeting in Toronto, on its 5th year.

• Webinars and conferences developed by public and private organizations, such as the Substance Abuse and Mental Health Services Administration, and the Massachusetts General Hospital Home Base program.

• Many books and articles by experts in the area of veterans health, for example see Once a Warrior – Always a Warriorb y Col. (Ret.) Charles W. Hoge, M.D., (Guilford, Conn.: Lyons Press, 2010), or my forthcoming book, Women at War (Oxford University Press, 2015).

• Numerous websites, such as that of the National Center for PTSD,the Borden Institute,and the Center for Deployment Psychology.

• The developing medical school curriculum on veteran’s health, spurred by the White House’s Joining Forces initiative.

• An action paper to be presented at this year’s APA Assembly, recommending that all providers inquire about the military status of their patients.

Of course, there is lots of room for everybody – not just health care providers – to join in the mission. As we enter year 14th year of the long war, we all need to help.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington.

“It is all in your head.” Patients hate to hear that. I am not sure why physicians still say it.

Lots of “real disease” is in your head: multiple sclerosis, strokes, pain, and depression. That does not mean that there is not organic pathology.

The report from the evidence-heavy Institute of Medicine (IOM) validates what so many patients have known all along: Chronic fatigue syndrome is a valid diagnosis.

No, we do not have laboratory or radiologic markers of the disease. Of course, there are not biomarkers of many other diseases, including posttraumatic stress disorder, pain, and depression.

What is tremendously important about this report is that it scientifically validates the experiences of so many patients – patients who previously have been dismissed by their physicians, thereby adding to their misery.

To reiterate the conclusions of the report:

“Myalgic encephalomyelitis/chronic fatigue syndrome – commonly referred to as ME/CFS – is a legitimate, serious, and complex systemic disease that frequently and dramatically limits the activities of affected individuals.” In the report, the IOM developed new diagnostic criteria for the disorder that include five main symptoms. In addition, it recommended that the disorder be renamed “systemic exertion intolerance disease” and be assigned a new code in the International Classification of Diseases, Tenth Edition.

The report goes on to say that between 836,000 and 2.5 million Americans suffer from ME/CFS, and an estimated 84%-91% of people with ME/CFS are not diagnosed. The disease’s symptoms can be treated, even though a cure does not exist. Its cause remains unknown, although in some cases symptoms have been triggered by an infection.

Less than one-third of medical schools include ME/CFS-specific information in the curriculum. Most patients (67%-77%) said that it took more than a year to receive a diagnosis – about 29% of these patients said it took more than 5 years. The direct and indirect economic costs of ME/CFS to society have been estimated at $17 billion to $24 billion annually, $9.1 billion of which has been attributed to lost household and job productivity.

Clearly, it is a disorder that physicians should take seriously. Especially psychiatrists, who know many diseases are “all in the head.”

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry.

“It is all in your head.” Patients hate to hear that. I am not sure why physicians still say it.

Lots of “real disease” is in your head: multiple sclerosis, strokes, pain, and depression. That does not mean that there is not organic pathology.

The report from the evidence-heavy Institute of Medicine (IOM) validates what so many patients have known all along: Chronic fatigue syndrome is a valid diagnosis.

No, we do not have laboratory or radiologic markers of the disease. Of course, there are not biomarkers of many other diseases, including posttraumatic stress disorder, pain, and depression.

What is tremendously important about this report is that it scientifically validates the experiences of so many patients – patients who previously have been dismissed by their physicians, thereby adding to their misery.

To reiterate the conclusions of the report:

“Myalgic encephalomyelitis/chronic fatigue syndrome – commonly referred to as ME/CFS – is a legitimate, serious, and complex systemic disease that frequently and dramatically limits the activities of affected individuals.” In the report, the IOM developed new diagnostic criteria for the disorder that include five main symptoms. In addition, it recommended that the disorder be renamed “systemic exertion intolerance disease” and be assigned a new code in the International Classification of Diseases, Tenth Edition.

The report goes on to say that between 836,000 and 2.5 million Americans suffer from ME/CFS, and an estimated 84%-91% of people with ME/CFS are not diagnosed. The disease’s symptoms can be treated, even though a cure does not exist. Its cause remains unknown, although in some cases symptoms have been triggered by an infection.

Less than one-third of medical schools include ME/CFS-specific information in the curriculum. Most patients (67%-77%) said that it took more than a year to receive a diagnosis – about 29% of these patients said it took more than 5 years. The direct and indirect economic costs of ME/CFS to society have been estimated at $17 billion to $24 billion annually, $9.1 billion of which has been attributed to lost household and job productivity.

Clearly, it is a disorder that physicians should take seriously. Especially psychiatrists, who know many diseases are “all in the head.”

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry.

“It is all in your head.” Patients hate to hear that. I am not sure why physicians still say it.

Lots of “real disease” is in your head: multiple sclerosis, strokes, pain, and depression. That does not mean that there is not organic pathology.

The report from the evidence-heavy Institute of Medicine (IOM) validates what so many patients have known all along: Chronic fatigue syndrome is a valid diagnosis.

No, we do not have laboratory or radiologic markers of the disease. Of course, there are not biomarkers of many other diseases, including posttraumatic stress disorder, pain, and depression.

What is tremendously important about this report is that it scientifically validates the experiences of so many patients – patients who previously have been dismissed by their physicians, thereby adding to their misery.

To reiterate the conclusions of the report:

“Myalgic encephalomyelitis/chronic fatigue syndrome – commonly referred to as ME/CFS – is a legitimate, serious, and complex systemic disease that frequently and dramatically limits the activities of affected individuals.” In the report, the IOM developed new diagnostic criteria for the disorder that include five main symptoms. In addition, it recommended that the disorder be renamed “systemic exertion intolerance disease” and be assigned a new code in the International Classification of Diseases, Tenth Edition.

The report goes on to say that between 836,000 and 2.5 million Americans suffer from ME/CFS, and an estimated 84%-91% of people with ME/CFS are not diagnosed. The disease’s symptoms can be treated, even though a cure does not exist. Its cause remains unknown, although in some cases symptoms have been triggered by an infection.

Less than one-third of medical schools include ME/CFS-specific information in the curriculum. Most patients (67%-77%) said that it took more than a year to receive a diagnosis – about 29% of these patients said it took more than 5 years. The direct and indirect economic costs of ME/CFS to society have been estimated at $17 billion to $24 billion annually, $9.1 billion of which has been attributed to lost household and job productivity.

Clearly, it is a disorder that physicians should take seriously. Especially psychiatrists, who know many diseases are “all in the head.”

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry.