Transformation of Mental Health Care for U.S. Soldiers and Families During the Iraq and Afghanistan Wars: Where Science and Politics Intersect.

The cumulative strain of 14 years of war on service members, veterans, and their families, together with continuing global threats and the unique stresses of military service, are likely to be felt for years to come. Scientific as well as political factors have influenced how the military has addressed the mental health needs resulting from these wars. Two important differences between mental health care delivered during the Iraq and Afghanistan wars and previous wars are the degree to which research has directly informed care and the consolidated management of services. The U.S. Army Medical Command implemented programmatic changes to ensure delivery of high-quality standardized mental health services, including centralized workload management; consolidation of psychiatry, psychology, psychiatric nursing, and social work services under integrated behavioral health departments; creation of satellite mental health clinics embedded within brigade work areas; incorporation of mental health providers into primary care; routine mental health screening throughout soldiers' careers; standardization of clinical outcome measures; and improved services for family members. This transformation has been accompanied by reduction in psychiatric hospitalizations and improved continuity of care. Challenges remain, however, including continued underutilization of services by those most in need, problems with treatment of substance use disorders, overuse of opioid medications, concerns with the structure of care for chronic postdeployment (including postconcussion) symptoms, and ongoing questions concerning the causes of historically high suicide rates, efficacy of resilience training initiatives, and research priorities. It is critical to ensure that remaining gaps are addressed and that knowledge gained during these wars is retained and further evolved.

The occupational burden of mental disorders in theU.S. military: psychiatric hospitalizations, involuntary separations, and disability.

OBJECTIVE: A recent study showed that among U.S. military personnel, mental disorders were the leading medical correlate of separation from military service. The reasons for this association have not been determined. The purpose of this study was to characterize the risk and reasons for service separation for soldiers hospitalized with mental disorders compared with those hospitalized for other illnesses. METHOD: Population-based electronic health care data were linked with data on separations and disability. The authors constructed a cohort of 13,971 U.S. Army soldiers first hospitalized in 1998 and followed them for up to 2 years following this first hospitalization. RESULTS: The rate of service separation 6 months after first hospitalization was 45% among personnel whose primary hospital discharge diagnosis was a mental disorder, 27% among those with a secondary mental disorder discharge diagnosis, and 11% among those hospitalized for all other medical conditions. Separation from military service due to medical disability, misconduct and other legal problems, unauthorized work absences, behavior related to personality disorders, and alcohol rehabilitation failure was significantly more common following hospitalization for a mental disorder than for other medical conditions. Mental disorders were also significantly associated with medical separations in which there was evidence that the condition existed prior to service. CONCLUSIONS: In the military, the occupational impact of mental disorders compared with other medical conditions appears to be mediated not only by greater disease chronicity and severity but also by a variety of behavioral problems including misconduct, legal problems, unauthorized absences, and alcohol/drug-related problems. The study also points to the difficulties inherent in screening for mental disorders prior to entry into military service.

Soldier peer mentoring care and support: bringing psychological awareness to the front.

Since the Persian Gulf War of 1990-1991, the operational tempo for soldiers has steadily increased, whereas the numbers of soldiers available to fulfill these missions has decreased. As a result, soldiers and their families are experiencing increased levels of stress that continue to manifest in ways that can often be destructive for the soldiers, their families, and the Army community. Current mitigation and identification support systems such as the Chain of Command, noncommissioned officer leadership, chaplains, and family support systems have all provided critical services, but may not be expected to optimally perform necessary early risk management assessment. Behavioral health care as a self-referral system is often still perceived as career ending, shameful, or even culturally unacceptable. Our allies have also experienced similar family, operational, and combat concerns. In 1996, at the direction of their Commandant General, the British Royal Marines developed and instituted a peer-driven risk management and support system that has experienced a high degree of success and acceptance among its forces-enough so that the Royal Navy is now in the process of implementing a similar program. The Soldier Peer Mentoring and Support program, as part of the proposed deployment Cycle Support Program, is a model for peer group assessment based on the British Royal Marines psychological risk management and support system. This article presents and describes this project, which has been considered for use within the U.S. Army, as a potential augmenter of existing behavioral health support assets as a culturally acceptable, company-level support program in deployment and home stations.

Mental disorders among U.S. military personnel in the 1990s: association with high levels of health care utilization and early military attrition.

OBJECTIVE: Epidemiological studies have shown that mental disorders are associated with reduced health-related quality of life, high levels of health care utilization, and work absenteeism. However, measurement of the burden of mental disorders by using population-based methods in large working populations, such as the U.S. military, has been limited. METHOD: Analysis of hospitalizations among all active-duty military personnel (16.4 million person-years) from 1990 to 1999 and ambulatory visits from 1996 to 1999 was conducted by using the Defense Medical Surveillance System. Rates of hospitalization, ambulatory visits, and attrition from military service were compared for persons with mental disorder diagnoses and those with diagnoses in 15 other ICD-9 disease categories. RESULTS: Mental disorders was the leading category of discharge diagnoses among men and the second leading category among women; 13% of all hospitalizations and 23% of all inpatient bed days were attributed to mental disorders. Six percent of the military population received ambulatory services for mental disorders annually in 1998 and 1999. Among a 1-year cohort of personnel, 47% of those hospitalized for the first time for a mental disorder left military service within 6 months. This attrition rate was significantly different from the rate of only 12% after hospitalization for any of the 15 other disease categories (range=11%-18%) (relative risk=4.04, 95% confidence interval=3.91-4.17). The difference remained significant after controlling for effects of age, gender, and duration of service. CONCLUSIONS: Mental disorders appear to represent the most important source of medical and occupational morbidity among active-duty U.S. military personnel. These findings provide new population-based evidence that mental disorders are common, disabling, and costly to society.

Priorities for psychiatric research in the U.S. military: an epidemiological approach.

Among the 1.4 million active duty U.S. military service members, 6% receive outpatient treatment for a mental disorder each year. Over 25% of these service members leave military service within 6 months, a rate that is more than two times higher than the rate following treatment for any other illness category. There is clearly a need to define psychiatric research priorities and an unprecedented opportunity to enhance the field of psychiatric research in general using the well-characterized military population. The first priority is to better define the burden of mental disorders in terms of incidence, prevalence, severity, risk factors, and health care use. The impact of mental disorders on occupational functioning, particularly among new recruits, needs to be better characterized. Suicide research should include efforts to validate mortality data, define the normal level of rate variability, and establish surveillance for clusters. The highly structured occupational environment of the military lends itself to studies of preventive interventions designed to reduce disability or occupational attrition resulting from mental/behavioral problems.

Operation Solace: overview of the mental health intervention following the September 11, 2001 Pentagon attack.

At the direction of the Army Surgeon General, the Army behavioral health consultants in psychiatry, psychology, and social work assembled in Washington, DC immediately after the September 11, 2001 attack to plan and implement a proactive behavioral health response to the Pentagon attack. The goal was to minimize the short- and long-term adverse behavioral health and related medical effects predicted to emerge based on past U.S. mass casualty scenarios. This article summarizes the goals, methods, and rationale used to develop the plan, as well as the key elements of the behavioral health intervention developed in response to the attack.

Principles guiding implementation of the Operation Solace plan: "Pieces of PIES," therapy by walking around, and care management.

Operation Solace is the name given to a post-September 11, 2002 plan directed by the Army Surgeon General to proactively address the predictable behavioral health distress/disorders and related somatic phenomenon expected to occur among the Pentagon employees, family members, and Department of Defense beneficiaries located in the National Capitol Region affected by the terrorist attack. Using well-known and also relatively novel preventive population-based methodologies for minimizing the post-attack behavioral health-related morbidity resulted in the evolution of simplified principles ("Pieces of PIES") and methods (Therapy by Walking around and Care Management), which are briefly elaborated in this article.

Development of a brief questionnaire to measure mental health outcomes among Pentagon employees following the September 11, 2001 attack.

In the aftermath of the terrorist action at the Pentagon there was a critical operational need to understand and document the extent of injuries, illnesses, and exposures sustained by Service members and civilian employees at the Pentagon. It was decided to develop and administer a brief questionnaire to the Pentagon employees that would contain questions about exposures, new or worsening injuries or illnesses, mental health, and factors suggested by the literature to increase risk or be protective for these outcomes. This report describes the development the mental health portion of this questionnaire. Most mental health instruments are very lengthy, limiting their usefulness as rapid public health assessment tools. This brief instrument was designed to cover four main symptom domains, as well as key risk/protective factors, thought to be most important following the terrorist attack. The symptom domains were: acute and post-traumatic stress symptoms, depression, anxiety/panic attacks, and alcohol abuse. Further analyses will assess the usefulness of this questionnaire as a public health tool for rapid assessment of mental health symptoms following the attack.