Half of Veterans who have undergone psychological assessments have clinically high levels of suicidal ideation, according to research from the Texas Tech University Department of Psychological Sciences. Paul Ingram, an assistant professor in counseling psychology, is looking to improve the diagnosis and treatment of Veterans’ mental health. Since he began his research in 2012, Ingram’s findings have revealed that nearly 50% of Veterans have clinically high levels of suicidal ideation, which includes suicidal thoughts, consideration and planning.
“When you look across the board, clinical levels of suicidal ideation are astronomically high in Veterans,” Ingram said. “Forty-five to 50% endorse suicidal ideation. It doesn’t matter where we’re assessing them. It could be a primary care clinic, a post-traumatic stress disorder (PTSD) clinic, psychiatric rehabilitation, traumatic brain injury clinic – it’s everywhere. The rates of suicidal ideation are huge. That says we need to be getting good assessments so we can link Veterans with the services they need.”
Ingram’s research focuses on improving diagnoses so the needs of individuals can be met with accuracy and in a timely manner. His solution for improving diagnoses is improving mental health assessments for Veterans, using the Minnesota Multiphasic Personality Inventory (MMPI).
In 2019, he published a number of articles documenting the findings of his research over the past eight years, including a seven-year sample that explains how to expand and improve the mental health of Veterans and explores different health settings in Veteran Affairs (VA).
Background and passion for psychology
Ingram came to Texas Tech in 2017 after finishing his doctoral internship at the Eastern Kansas Veteran Affair Medical Center. Ingram said he was attracted to Texas Tech because of the research opportunities and the possibilities associated with an expanding community VA clinic.
“I’ve always been interested and passionate about psychology,” Ingram said. “A big part of psychology and mental health is the diagnosis because it tells us how things are causing problems in everyday life. To me, the idea that we can come up with good ways to figure out what’s going on with people so we can figure out what they need, is big. My goal is to bring resources to those needs.”
Most Veterans have significant mental health needs, Ingram said, and the best way to meet those needs is with diagnoses and mental health assessments, which can pinpoint the correct treatment for any given individual based on those different diagnostic needs.
To conduct his research, Ingram uses the MMPI, a personality inventory used to measure psychopathology. Psychopathology, the study of mental health disorders, is used to achieve a mental health diagnosis, including substance use, suicide, depression, antisocial behaviors, thoughts related to paranoia, schizophrenia and average experiences. Ingram described the MMPI as a “comprehensive battery” of an individual’s psychopathology which assesses all these areas of need.
Ingram began using the MMPI after its last revision in 2008, but has been working specifically conducting assessments and improving diagnoses for Veterans and active-duty personnel since 2012. He is working on the newest version of the MMPI, slated to be released later this year.
“This new instrument came out, and it was a serendipitous way for me to dip my toe into research,” Ingram said. “I had run into problems finding good assessments before. It was really intended as a side project, and I fell in love with the idea that if I’m asking a question well, and I have a good way to measure it, I get a better answer.”
The MMPI is an assessment in the form of true/false questions. Ingram said it’s not that different from sitting down and conducting an interview, except the assessment gives psychologists a standard way questions are asked and answered, so scales can be created to represent the information. The quantitative data gives psychologists comparative ways to think about diagnoses.
“Veterans are one of the most severely impacted groups for many diagnoses,” Ingram said. “Improving our diagnostic process for them has great potential to improve their treatment. There’s a lot of room for improvement because there’s a lot they’re dealing with. The more problems someone has and the more diagnoses they hold, the more difficult it is to figure out what they need.
“That’s where the MMPI comes in. It’s kind of like taking your car to the shop: it’s like undergoing a comprehensive checkup to see what the problem is so it can get taken care of. It’s looking at behavior patterns, thought patterns and emotional patterns that may be making their lives harder. Anything you would traditionally think of as a mental health problem is measured on the MMPI.”
Although Ingram has been working with the MMPI since 2012, he’s begun publishing extensively on the MMPI only in the past four years because of how long it takes to build databases for clinical populations. In his research, Ingram looks for mechanistic ways to diagnose people by creating instruments that can reliably predict problems and outcomes.
“One of the things I’ve been able to do in my research is point to where we need to be concerned,” Ingram said. “Fifty percent of Veterans endorsing suicidal ideation is insane. That’s one in two Veterans at risk. And with those kinds of odds, our assessments need to be as good as they can be. Instruments like the MMPI are traditionally better predictors of outcomes than clinical interviews where we just ask the client. When we use mental health assessments, we get better outcomes. My goal is in line with the historic precedent of continuing to improve those assessments.”
Challenges in Veteran mental health care
One of the greatest challenges involved with providing mental health care for Veterans is the stigma surrounding mental health. Ingram said that while there’s a culture of asking for help within the VA, there’s a prescriptive element to it that can be damaging. Telling someone they need help with their PTSD without a thorough diagnosis and a culture of engaging in therapy implies they have PTSD and encourages them to hold on to all the problems that come along with it.
“It becomes part of who they are,” Ingram said.
Sometimes getting Veterans into a doctor’s office is only the first step, as many aren’t willing to verbalize their struggles.
“It’s not as simple as asking questions, because people don’t always want to verbalize what’s going on,” Ingram said. “It’s hard for people to talk about suicidal ideations because they’re concerned that people will think less of them or that they’ll be locked up. With substance use, people are worried about getting into legal trouble. A lot of it comes down to stigma. So they suffer alone.”
Hopes for the future
Much of Ingram’s work is with the creator of the MMPI and he hopes their efforts will contribute to refinements and improvements moving forward. He currently conducting several studies on the next version of the instrument, which will be released in the later part of this year.
In addition to contributing to revisions to the MMPI, Ingram hopes to help physicians and mental health care providers adapt their practices to better address Veterans’ needs.
“Identifying the correct diagnoses means having the ability to offer the most impactful treatments and being able to predict who will drop out and who will be successful,” Ingram said. “It also means being aware of who may need additional support while getting those therapies. I’m working with several treatment clinics around the country to do this.”
To learn more about Ingram’s research, visit his lab website.