Development of a Tool to Predict Risk of Behavioral Health Evacuation From Combat.

In the present study, we examined administrative data on 667,437 deployments of at least 30 days duration to Iraq and Afghanistan from 2011 through the end of 2016 to determine risk factors for evacuation from the combat zone for behavioral health reasons. Demographic data, military-specific data, responses on predeployment mental health assessments, and presence of previous treatment for psychiatric conditions were entered into a logistic regression based on expert determination, distinguishing the 2,133 behavioral health evacuations from those deployments that either did not end in evacuation or included evacuations for reasons other than behavioral health. The model, derived from a random half of the sample (training set), was verified on the other half (validation set). Predictor variables used in the model were calendar year; gender; age; rank; marital status; parental status; number of prior war zone deployments; branch of service; screens for symptoms of posttraumatic stress disorder, depression, and hazardous alcohol use on the predeployment mental health assessment; and prior substance- and non-substance-related behavioral health diagnoses. Odds ratios (range: 1.05-3.85) for selected variables that contributed to the model were used to assign risk scores in the Behavioral Health Evacuation Risk Tool, which can aid predicting which service members are more likely to be evacuated from combat for behavioral health reasons, thus indicating where resources can be allocated for behavioral health referrals and war zone care.

Contribuições de uma pesquisa-intervenção para a assistência de enfermagem a usuários de drogas / Aportes para una investigación-intervención para la atención de enfermería a los usuarios de drogas / Contributions to a research intervention for nursing care to drug users

Objective: Describe the professional and family contexts present in the drug user rehabilitation process in treatment in a military institution and the interventions proposed by the nursing team in this scenario. Method: This descriptive study in a military Recovery Center. Data collected from semi-structuredinter views with a script. Results: It observed that the approach of the nursing staff with the situation experienced by individuals under their care favors the creation of links and ties confidence. Conclusion: Interventions focused on drug users using motivational approaches and group therapies, lead to reducing the risks and vulnerabilities of chemical dependency.

Objetivo: Descrever os contextos profissionais e familiares presentes no processo de recuperação de usuários de drogas em tratamento numa instituição militar e as intervenções propostas pela equipe de enfermagem nesse cenário. Método: Estudo descritivo, realizado num Centro de Recuperação militar. Os dados foram coletados a partir de entrevista semi-estruturada, com um roteiro. Resultados: Evidenciou-se que a aproximação da equipe de enfermagem com o contexto vivenciado pelos indivíduos sob o seu cuidado favorece a criação de vínculos e laços de confiança. Conclusão: As intervenções junto aos usuários de drogas que utilizam abordagens motivacionais e terapias de grupo levam a redução dos riscos e vulnerabilidades da dependência química.

Objetivo: Describir los contextos profesionales y familiares presentes en el proceso de rehabilitación de usuarios de drogas en tratamiento en una institución militar y las intervenciones propuestas por el equipo de enfermería en este escenario. Método: Estudio descriptivo realizado en un Centro de Recuperación militar. Los datos se obtuvieron de entrevistas semi-estructuradas con un guión. Resultados: Se observó que el enfoque del personal de enfermería con la situación vivida por las personas bajo su cuidado favorece la creación de vínculos y lazos de confianza. Conclusión: Las intervenciones centradas en los usuarios de drogas que utilizan enfoques motivacionales y terapias de grupo conducen a riesgos y vulnerabilidades de la dependencia química reducidos.

[Military psychiatry in a theatre of operations: on mission in Mali]. / Psychiatre militaire sur un théâtre d'opérations: en mission au Mali.

The recent missions of military psychiatrists in the theatres of operation underline the reactivity of the French healthcare system, focused on the expertise of the combat unit doctor. Operation Serval in Mali illustrates in particular the methods of medical-psychological support in exceptional situations, across a vast geographical area and in very difficult climatic conditions. The concept of "forward psychiatry" has a particularly important role to play in the early screening and treatment of psychological disorders in order to preserve the operational capacity of the deployed personnel.

La formación del psiquiatra militar en el contexto de la guerra contemporánea / Training of military psychiatrists for contemporary warfare

Se opina acerca de las características de las acciones del psiquiatra militar en casos de desastres y guerras. Teniendo en cuenta las características y preparación que demandan estas situaciones excepcionales, el psiquiatra militar debe estar dotado de una preparación, que le permita atender en breve tiempo, gran cantidad de pacientes. Esta base, no está en los currículos de preparación de tiempo de paz, lo cual establece una necesidad, de forma que se empleen los escenarios de desastres, naturales o no, a fin de obtener el entrenamiento necesario para alcanzar las habilidades.

An analysis is provided of the characteristics of military psychiatry actions in disaster and war situations. Considering the features of these exceptional situations and the preparation they require, the military psychiatrist should be trained to attend to a large number of patients in a short time. Since such training is not included in peace time curricula, it is necessary to take advantage of disaster scenarios, either natural or not, to develop those abilities.

Salem VAMC-U.S. Army Fort Bragg Warrior Transition Clinic telepsychiatry collaboration: 12-month operation clinical perspective.

OBJECTIVE: To describe the clinical experience in the first Veterans Affairs (VA)-U.S. Army Warrior Transition Clinic (WTC) telepsychiatry operation (September 2008-August 2009). MATERIALS: Joint VA and U.S. Army records. METHODS: Analysis of intake, follow-up, and last visit records. RESULTS: One hundred twenty active-duty U.S. Army soldiers were seen (394 clinic visits). Ninety-eight soldiers had one or more combat tours, principally in Iraq and Afghanistan. Posttraumatic stress disorder was diagnosed in 50.0% of the cases by the WTC telepsychiatrists. The majority of the soldiers had medical comorbidities, especially chronic pain (75.0%), in addition to mental health problems. Several of the soldiers were recovering from trauma (20.8%) and/or surgery (23.3%), 11.7% exhibited traumatic brain injuries, and 17.5% had headaches. Disrupted relationships (74.2%) were notable for non-family members, especially military cohorts such as other persons in the same WTC squad or platoon. CONCLUSION: The observations in this report come from a cross-section of soldiers who were triaged to meet WTC admission criteria. As this is the prototype VA-U.S. Army telepsychiatry collaboration, there are no comparative data at this time. The nature of the medical and psychiatric problems treated in the military WTC represents an index of the more severe combat trauma treated on military bases from ongoing combat operations and may predict future VA-U.S. Army collaborative telepsychiatry clinic experiences.

Psychiatric lessons learned in Kandahar.

Not since the Korean War have the Canadian Forces engaged in combat missions like those in Afghanistan. Combat, asymmetric warfare, violent insurgency and the constant threat of improvised explosive devices all contribute to the psychological stressors experienced by Canadian soldiers. Mental health teams deployed with the soldiers and provided assessment, treatment and education. Lessons learned included refuting the myth that all psychological disorders would be related to trauma; confirming that most patients do well after exposure to trauma; confirming that treating disorders in a war zone requires flexible and creative adaptation of civilian treatment guidelines; and confirming that in a combat mission mental health practice is not limited to the clinical setting.

Effectiveness of mental health screening and coordination of in-theater care prior to deployment to Iraq: a cohort study.

OBJECTIVE: The authors assessed the effectiveness of a systematic method of predeployment mental health screening to determine whether screening decreased negative outcomes during deployment in Iraq's combat setting. METHOD: Primary care providers performed directed mental health screenings during standard predeployment medical screening. If indicated, on-site mental health providers assessed occupational functioning with unit leaders and coordinated in-theater care for those cleared for deployment. Mental health-related clinical encounters and evacuations during the first 6 months of deployment in 2007 were compared for 10,678 soldiers from three screened combat brigades and 10,353 soldiers from three comparable unscreened combat brigades. RESULTS: Of 10,678 soldiers screened, 819 (7.7%, 95% confidence interval [CI]=7.2-8.2) received further mental health evaluation; of these, 74 (9.0%, 95% CI=7.1-11.0) were not cleared to deploy and 96 (11.7%, 95% CI=9.5-13.9) were deployed with additional requirements. After 6 months, soldiers in screened brigades had significantly lower rates of clinical contacts than did those in unscreened brigades for suicidal ideation (0.4%, 95% CI=0.3-0.5, compared with 0.9%, 95% CI=0.7-1.1), for combat stress (15.7%, 95% CI=15.0-16.4, compared with 22.0%, 95% CI=21.2-22.8), and for psychiatric disorders (2.9%, 95% CI=2.6-3.2, compared with 13.2%, 95% CI=12.5-13.8), as well as lower rates of occupational impairment (0.6%, 95% CI=0.4-0.7, compared with 1.8%, 95% CI=1.5-2.1) and air evacuation for behavioral health reasons (0.1%, 95% CI=0.1-0.2, compared with 0.3%, 95% CI=0.2-0.4). CONCLUSIONS: Predeployment mental health screening was associated with significant reductions in occupationally impairing mental health problems, medical evacuations from Iraq for mental health reasons, and suicidal ideation. This predeployment screening process provides a feasible system for screening soldiers and coordinating mental health support during deployment.

Factors associated with civilian mortality in Australian Vietnam veterans three decades after the war.

A prospective cohort study of a random sample of 1,000 Australian Army Vietnam veterans analyzed risk factors for postwar mortality using information from Army records and personal interview assessments of physical and mental health measured approximately 15 years earlier. This enabled examination of the role of combat, military service, and psychiatric status including post-traumatic stress disorder (PTSD) on postwar civilian mortality. Factors predicting mortality were identified using multivariate statistical methods including logistic and Cox regression. Mortality was associated principally with age, enlistment route (regular vs. national service conscripts), and conduct while in service in the whole cohort. Additional analysis using interview data revealed that mortality was predicted by age, smoking status, chronic diabetes, bronchitis and blood diseases, and treatment for cancer and heart disease. Psychiatric status including PTSD diagnosis was not associated with mortality. Veterans' mortality risk may be reduced by attention to smoking and alcohol both in-service and postservice.

Support of marines and sailors returning from combat: a comparison of two different mental health models.

As Navy medicine continues to support the Global War on Terrorism, various approaches are used to attenuate combat stress casualties. This article examines two different mental health models, one employed at sea and one in the combat zone, used for active duty forces immediately after cessation of combat operations. Both models focus on screening, early prevention, and treatment implemented during the transition from the combat theater to garrison. Returning by sea provided the opportunity for greater education and decompression of combat stress as the service members transitioned back to garrison when compared to those who returned by air. It was also found that the Post Deployment Health Assessment (PDHA) did not capture as many individuals with mental health issues leaving combat theater, which identified 6% on both missions, compared to the capture rate with the Post Deployment Psychological Screener (PDPS), which identified 16-20%. Limitations, opportunities, and recommendations for future interventions are discussed.

Combat-related disorders: a persistent chimera.

Whilst there may be some individuals who genuinely enjoy combat, for most troops it represents many emotional challenges, such as, overcoming fear and being witness to death, suffering and mutilation, as well as having to tolerate extremes of physical discomfort. At present we lack sufficiently valid and reliable methods of screening out those personnel particularly vulnerable to adverse reactions to these challenges. The authorities should aim to provide good training, an appreciative milieu, and a working climate in which those with genuine psychopathology feel confident to admit this, without censure and stigma, and to have access to evidence-based treatments. We should also remember that military life offers much to many men and women, and that surviving physically and psychologically the unavoidable brutalities of combat can often leave a legacy of positive outcomes. We must avoid becoming preoccupied with risk and psychopathology.

[Psychology and psychiatry in the 7th Navy Hospital in the light of its 75th anniversary]. / Psychologia i psychiatria w 7 Szpitalu Marynarki Wojennej w swietle jego 75-lecia.

2007 is a year of 75 years' jubilee of VII Navy Hospital in Gdansk. Reminding of it's history seems to be important element of military psychologists and psychiatrists conference organized by hospital's personnel. SHORT HISTORY OF THE VII NAVY HOSPITAL IN GDANSK: The VII Navy Hospital came into existence in 1st May of 1932 in Gdynia Oksywie and included one hundred beds on surgery and general practice wards. In 1949 the hospital has been connected with general military hospital in Gdansk and has got it's actual place. There have been fifteen commandants since that time. Commandore Piotr Drabarek is actual commandant of this hospital. The most interesting person in a group of commandants was admiral Wieslaw Lasinski, later chancellor of Military Medical Academy in Lódz. NOWADAYS OF THE VII NAVY HOSPITAL: The hospital actually includes twelve wards. There works one professors, fifteen physicians with degree of doctor and few doctors with open doctoral dissertations. Modern equipment, highly qualified medical staff, ensure professional medical care. History of the psychology and psychiatry The VII Navy Hospital in Gdansk hadn't included psychiatry ward until seventieth years of XX century. Psychosomatic ward came to existence in 1970 and in 1975 has become psychiatry. Actual boss of the ward is doctor Alicja Furmanska. It is worth to say something about psychosomatic ward which came to existence in 2005 and is lead by Ltd. Malgorzata Zychlinska. It is professional medical base in Polish army. Four hundred patients is treated in this ward in a year on forty beds. In addition, both wards employs five doctors and five psychologists. They control 3500 patients a year. HISTORY REFLECTION: In spite of many historical, political, economical event difficulties the institution which bases on determinations, competence and personal attitude develops constantly. Psychiatry and psychology ward in the VII Navy Hospital in Gdansk are said "unsinkable".

Combat stress casualties in Iraq. Part 1: behavioral health consultation at an expeditionary medical group.

PURPOSE: We review the role of military mental health professionals in consulting with inpatient medical patients and staff at a combat hospital and aeromedical evacuation staging facility in Iraq. CONCLUSIONS: Behavioral health consultation with medical and surgical patients during hospitalization and prior to aeromedical evacuation can help identify patients with combat stress exposure that may require future mental health follow-up. PRACTICE IMPLICATIONS: Extensive use of civilian mental health practitioners including nurse psychotherapists and psychiatric nurse practitioners will be needed to provide psychiatric care for the large number of U.S. veterans who return from deployment with combat stress related disorders.

Combat stress casualties in Iraq. Part 2: psychiatric screening prior to aeromedical evacuation.

TOPIC: Exposure to combat-related trauma is a leading cause of posttraumatic stress disorder. Deployed military mental health practitioners serve important roles in the assessment, diagnosis, and aeromedical evacuation of psychiatric patients from the combat zone. PURPOSE: To review the role of military mental health professionals working with psychiatric patients at a combat hospital and aeromedical staging facility in Iraq. SOURCE OF INFORMATION: Military operating instructions, existing theoretical and research literature, and personal experiences of the authors while deployed to Iraq. CONCLUSIONS: Psychiatric screening can help reduce risk in potentially unstable mental health patients prior to aeromedical evacuation. Civilian nurse psychotherapists and advanced practice psychiatric nurses will be needed to provide psychiatric follow-up care for the large number of military veterans returning from combat.

Structured clinical interview guide for postdeployment psychological screening programs.

Brief structured clinical interviews are a key component of the Department of Defense postdeployment health reassessment program. Such interviews are critical for recommending individuals for follow-up assessment and care. To standardize the interview process, U.S. Army Medical Research Unit-Europe developed a structured interview guide, designed in response to both clinical requirements and research findings. The guide includes sections on depression, suicidality, post-traumatic stress disorder, anger, relationship problems, alcohol problems, and sleep problems. In addition, there is an open-ended section on other problems and a section for case dispositions. Data from a 2005 blinded validation study with soldiers returning from a 1-year-long combat deployment are included to demonstrate the utility of the structured interview. Guidelines and implementation considerations for the use of the structured interview are discussed.

Screening soldiers in outpatient care for mental health concerns.

Significant recent effort has been directed toward screening and describing military populations in relation to deployment. Missing from these recent efforts is information describing screened mental health symptoms for the population of active duty military that are seen for mental health services. This article presents mental health screening data for 2,882 soldiers seeking services at a military facility outpatient behavioral health clinic. Screening positive for multiple symptom domains was common, with >60% of the sample screening positive for more than one clinical symptom domain. Post-traumatic stress disorder and depression were among the most commonly identified disorders, followed by alcohol abuse. This screening data, gathered using measures similar to those used in published deployment-related screening efforts, suggest differences that exist between the clinical population and the overall military population, providing some insights into the rates of clinical symptomatology within the military health system and providing a point of comparison for population- screening efforts. Clinical implications include the importance of provider awareness to the high rates of comorbidity across symptom domains.

RESPECT-Mil: feasibility of a systems-level collaborative care approach to depression and post-traumatic stress disorder in military primary care.

BACKGROUND: U.S. military ground forces report high rates of war-related traumatic stressors, posttraumatic stress disorder (PTSD), and depression following deployment in support of recent armed conflicts in Iraq and Afghanistan. Affected service members do not receive needed mental health services in most cases, and they frequently report stigma and significant structural barriers to mental health services. Improvements in primary care may help address these issues, and evidence supports the effectiveness of a systems-level collaborative care approach. OBJECTIVE: To test the feasibility of systems-level collaborative care for PTSD and depression in military primary care. We named our collaborative care model "Re-Engineering Systems of Primary Care for PTSD and Depression in the Military" (RESPECT-Mil). METHODS: Key elements of RESPECT-Mil care include universal primary care screening for PTSD and depression, brief standardized primary care diagnostic assessment for those who screen positive, and use of a nurse "care facilitator" to ensure continuity of care for those with unmet depression and PTSD treatment needs. The care facilitator assists primary care providers with follow-up, symptom monitoring, and treatment adjustment and enhances the primary care interface with specialty mental health services. We report assessments of feasibility of RESPECT-Mil implementation in a busy primary care clinic supporting Army units undergoing frequent Iraq, Afghanistan, and other deployments. RESULTS: Thirty primary care providers (family physicians, physician assistants, and nurse practitioners) were trained in the model and in the care of depression and PTSD. The clinic screened 4,159 primary care active duty patient visits: 404 screens (9.7%) were positive for depression, PTSD, or both. Sixty-nine patients participated in collaborative care for 6 weeks or longer, and the majority of these patients experienced clinically important improvement in PTSD and depression. Even although RESPECT-Mil participation was voluntary for providers, only one refused participation. No serious adverse events were noted. CONCLUSIONS: Collaborative care is an evidence-based approach to improving the quality of primary care treatment of anxiety and depression. Our version of collaborative care for PTSD and depression, RESPECT-Mil, is feasible, safe, and acceptable to military primary care providers and patients, and participating patients frequently showed clinical improvements. Efforts to implement and evaluate collaborative care approaches for mental disorders in populations at high risk for psychiatric complications of military service are warranted.

Prevalence and epidemiology of pathological gambling at Naval Medical Center Portsmouth psychiatry clinic.

OBJECTIVE: Gambling has exploded in popularity, but pathological gambling (PG) is infrequently diagnosed. The objectives of this study were to calculate the prevalence of PG in a psychiatry clinic, to determine whether PG is underdiagnosed, and to analyze risk factors for PG. METHODS: A survey was completed by 584 outpatients presenting to the Naval Medical Center Portsmouth psychiatry clinic over 6 months. Epidemiological data, smoking status, and alcohol use were assessed, and the South Oaks Gambling Screen was administered. RESULTS: The prevalence of PG determined with the South Oaks Gambling Screen was 1.4%. The electronically documented prevalence of PG was 0.04%. Male subjects, smokers, and subjects with an alcohol problem were more likely to have a gambling problem. Active duty members did not have statistically significantly higher rates of PG. CONCLUSIONS: PG is markedly underdiagnosed. Military members are not at elevated risk for PG, relative to their dependents. Further research and greater awareness of PG are needed.

An historical account of shell shock during the First World War and reforms in mental health in Australia 1914-1939.

The study of the disorders of the mind at the turn of the twentieth century offered useful knowledge about the psyche and the First World War (FWW) provided an avalanche of case studies. Prior to the war the mentally ill were treated with disdain and the social distrust of individuals who did not present as 'normal' was high. The level of diagnostic expertise of psychiatric illness by doctors and nurses was low and as a consequence medicine and nursing was ill-equipped to deal with the phenomenon initially referred to as 'shell shock'. However, the soldiers of the FWW who endured the varied and seemingly unrelated symptoms of shell-shock were respected men - occasional heroes - who were reduced to the status of 'mentals'. There is evidence that civilian trained health professionals altered their views about mental illness during the FWW but initially, the military imperatives inherent in a global conflict perpetuated the notion that mental illness was linked with defective morality. This paper provides an historical account of changes in attitude toward the mentally ill as a consequence of the FWW. The interregnum (1918-39) was a period of advancement in the field of mental health within the civilian sector. However, the imperatives of war negated these developments and there is evidence that the management of soldiers suffering from post-traumatic stress disorders in the Second World War did not benefit from the lessons learnt in the FWW.