A factor that makes Appalachian veterans especially susceptible is the region’s struggles with addiction. Veterans who were prescribed the highest possible doses of opioids were more than twice as likely to die by suicide compared to individuals receiving the lowest doses.

“You work for someone [in the military] who’s your boss, and you work with other people. Everyone needs something different,” said “Frank,” a veteran originally from Sistersville, West Virginia, who worked in the Navy’s visual communications team on an aircraft carrier. “Sometimes [worry] can follow you your entire life; you wonder, Have I done something wrong?

Military service, whether in combat or not, can lead to mental health complications for veterans. Frank (name has been changed to protect his privacy), now resides in Daytona Beach, Florida, and has been to see two therapists through the U.S. Department of Veteran Affairs (VA) network. In his appointments, he discusses how his work in the military caused him to suffer partial deafness, and he talks about his overall time in the Navy. But whether visiting the VA for physical issues relating to his hearing loss or visiting for mental health, Frank overwhelmingly prefers the services in Florida to those in his former home in Appalachia; he believes the quality of care is better.

In the massive region of Appalachia, which includes parts of 13 states and spans from New York to Mississippi, most forms of care straggle behind the rest of the nation. An August 2017 report from the Foundation for a Healthy Kentucky concluded that, when comparing 41 different major health indicators, Appalachia’s performance falls below standard in 33 categories. The region records some of the lowest numbers relating to life expectancy while rates of deaths relating to drug overdose and poisoning soar 37 percent higher than the rest of the country.

Transportation barriers and availability issues limit Appalachians’ access to mental health care, including potentially life-saving care for veterans. Appalachia’s lack of resources has taken a toll on its population’s mental health. The region reports one of the nation’s highest suicide rates, averaging numbers 17 percent higher than anywhere else in the country.

Appalachia’s lack of resources to combat major health-care issues means that vulnerable populations face the greatest risks. Veterans fall into this classification because, in many circumstances, the conditions they sustained while serving, such as PTSD or anxiety caused by extended absences from home, require them to receive highly specified care. The resources veterans need are often unavailable in Appalachian communities with about 35 percent fewer mental health-care providers than the national average.

Veteran populations in Appalachia have seen suicide rates drastically increase. Nationally, veteran suicide rates rose by nearly a third between 2001 and 2016. And a 2017 study by the VA concluded that veteran suicides occur more often in rural areas with high levels of social isolation. While the data does not imply that simply living in rural communities will make veterans more susceptible to suicidal thoughts and actions, other systemic issues that plague these regions can help explain why these deaths occur more often in rural spaces.

Veteran suicides are most common in the western part of the United States, but states in Appalachia that have strong rural populations, including West Virginia and Kentucky, also have staggeringly high suicide numbers. According to Denver-based magazine 5280, these high levels of suicide could partially be attributed to “rural isolation, high gun ownership and a rugged sense of individualism,” factors that could also be used to describe Appalachia, with its gun culture and long tradition of self-reliance.

Military personnel may be more reluctant to vocalize their mental health struggles or suicidal thoughts because the topics still remain highly stigmatized in Appalachia. According to a study published in 2015 by the Journal of Pediatric Psychology, this stigma surrounding mental health is socialized in Appalachian children at a young age. The study concluded that “greater perceived stigma was related to less willingness to seek services in a mental/behavioral health center or in schools,” but the study also determined that there were some instances where stigma was not a factor at all, or only present in some children. This suggests that the stigma against mental health and treatment begins early in Appalachia: at home with parents and families.

Lauren Winebrenner, who works as a public affairs specialist and community outreach program coordinator at the Martinsburg VA Medical Center in eastern West Virginia, believes this to be a strong factor in why more veterans do not report mental health concerns. “I think the more we talk about it and the more we open up and are kinder, that will help society destigmatize mental health.”

Dr. Mark Mann, chief of mental health services at the Martinsburg VA center and an Air Force veteran, believes suicide prevention should be one of the center’s top priorities. “As a group, suicide prevention in this hospital is everybody’s problem,” he said. “Anyone who talks to a veteran should think, is this veteran in need of better care? Is there something I could do to help them?”

Mann also believes in providing veterans with the tools they need to feel comfortable managing their mental health issues on their own, so that, upon returning to civilian life, they are empowered to regain as much normalcy as possible. “Veterans don’t want to think they’re going to be tethered to the VA for the rest of their life for mental health care,” he said.

But numerous veterans are not receiving the help they need. According to Mikey Allen, a veteran from Wheeling, West Virginia, who served as a broadcast journalist with the National Guard out of his home state’s capital and then as a cameraman and documentarian in Afghanistan, this is because many military members simply do not report their needs to the VA.

Allen said he is more likely to talk with his fellow veterans, and he has never contacted the VA for mental health resources. “We prefer to confide in each other because we aren’t trying to fix each other,” he wrote in an email to Rewire.News.

An additional factor that makes Appalachian veterans especially susceptible to suicidal thoughts and actions is the region’s overall struggles with addiction. A  2016 VA study found a correlation between high-dosage opioid prescriptions and suicide risk. The study reported that veterans who were prescribed the highest possible doses of opioids were more than twice as likely to die by suicide compared to individuals receiving the lowest doses.

Since 2012, VA-authorized opioid prescriptions have decreased. Veterans are being prescribed these drugs at a 41 percent lower rate than earlier this decade. However, with fewer opioid prescriptions being issued to veterans who may have been receiving the drugs for years, severe issues such as opioid withdrawalmay arise. This, in turn, has been linked to increased veteran suicide and overdose, while also inadvertently encouraging veterans to turn to less safe street drugs to self-medicate and manage their pain and symptoms.

Allen, the National Guardsman, stressed the inherent comfort that comes from connecting with fellow veterans who understand: “There is no fixing us,” he said. “There is only dealing moment to moment. And the whole listening, sharing, understanding with people you already know, love, and trust—with no pressure to solve something—is just most comforting.”

Frank, who served in the Navy, believes increasing discussions about mental health among veteran populations is one of the most powerful actions mental health-care professionals and veterans’ friends and family could take. “For veterans, it’s a different situation because they reach out and nobody takes their hand,” he said. “That’s what turns the clock.”

Veterans who would like to have confidential conversations with trained medical professionals may call the Veterans Crisis Line or visit its website. To find local support, veterans may also visit Make the Connection.

This article was originally published by Rewire.News.

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