Identifying and managing posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) occurs in an estimated 8% of men and 20% of women who are exposed to traumatic events. PTSD is a trauma- and stress-related disorder associated with significant psychosocial morbidity, substance abuse, and other negative physical health outcomes. The hallmarks of PTSD include exposure to a traumatic event; reexperiencing the event or intrusion symptoms; avoidance of people, places, or things that serve as a reminder of the trauma; negative mood and thoughts associated with the trauma; and chronic hyperarousal symptoms. Self-report questionnaires can assist clinicians in identifying anxiety problems associated with traumatic events. For patients who meet criteria for PTSD, trauma-focused psychotherapy and pharmacotherapy improve symptoms. Benzodiazepines and atypical antipsychotics are not recommended because studies have shown that adverse effects outweigh potential health benefits. Primary care physicians should monitor patients with PTSD for comorbid conditions such as substance abuse, mood disorders, and suicidality, and should refer patients to behavioral health specialists and support groups when appropriate.

Importance of anonymity to encourage honest reporting in mental health screening after combat deployment.

CONTEXT: US soldiers are required to undergo screening for depression, posttraumatic stress disorder (PTSD), and other mental health problems on return from service in Iraq or Afghanistan as part of routine postdeployment health assessments. OBJECTIVE: To assess the influence of the anonymity of screening processes on willingness of soldiers to report mental health problems after combat deployment. DESIGN: Anonymous and nonanonymous surveys. SETTING: US military. PATIENTS: US infantry soldiers' reporting of mental health problems on the routine Post-Deployment Health Assessment was compared with their reporting on an anonymous survey administered simultaneously. MAIN OUTCOME MEASURES: The Primary Care PTSD Screen, the Patient Health Questionnaire-2 (modified), the suicidal ideation question from the Patient Health Questionnaire-9, and several other questions related to mental health were used on both surveys. Soldiers were also asked on the anonymous survey about perceptions of stigma and willingness to report honestly. RESULTS: Of 3502 US Army soldiers from one infantry brigade combat team undergoing the routine Post-Deployment Health Assessment in 2008, a total of 2500 were invited to complete the anonymous survey, and 1712 of these participated (response rate, 68.5%). Reporting of depression, PTSD, suicidal ideation, and interest in receiving care were 2-fold to 4-fold higher on the anonymous survey compared with the routine Post-Deployment Health Assessment. Overall, 20.3% of soldiers who screened positive for depression or PTSD reported that they were uncomfortable reporting their answers honestly on the routine postdeployment screening. CONCLUSIONS: Current postdeployment mental health screening tools are dependent on soldiers honestly reporting their symptoms. This study indicates that the Post-Deployment Health Assessment screening process misses most soldiers with significant mental health problems. Further efforts are required to reduce the stigma of reporting and improve willingness to receive care for mental health problems.

Effectiveness of battlefield-ethics training during combat deployment: a programme assessment.

BACKGROUND: Breakdowns in the ethical conduct of soldiers towards non-combatants on the battlefield are of grave concern in war. Evidence-based training approaches to prevent unethical conduct are scarce. We assessed the effectiveness of battlefield-ethics training and factors associated with unethical battlefield conduct. METHODS: The training package, based on movie vignettes and leader-led discussions, was administered 7 to 8 months into a 15-month high-intensity combat deployment in Iraq, between Dec 11, 2007, and Jan 30, 2008. Soldiers from an infantry brigade combat team (total population about 3500) were randomly selected, on the basis of company and the last four digits of each soldier's social security number, and invited to complete an anonymous survey 3 months after completion of the training. Reports of unethical behaviour and attitudes in this sample were compared with a randomly selected pre-training sample from the same brigade. The response patterns for ethical behaviour and reporting of ethical violations were analysed with chi-square analyses. We developed two logistic regression models using self-reported unethical behaviours as dependent variables. Factors associated with unethical conduct, including combat experiences and post-traumatic stress disorder (PTSD), were assessed with validated scales. FINDINGS: Of 500 randomly selected soldiers 421 agreed to participate in the anonymous post-training survey. A total of 397 soldiers of the same brigade completed the pre-training survey. Training was associated with significantly lower rates of unethical conduct of soldiers and greater willingness to report and address misconduct than in those before training. For example, reports of unnecessary damage or destruction of private property decreased from 13·6% (54 of 397; 95% CI 10·2-17·0) before training to 5·0% (21 of 421; 2·9-7·1) after training (percent difference -63·2%; p<0·0001), and willingness to report a unit member for mistreatment of a non-combatant increased from 36·0% (143 of 397; 31·3-40·7) to 58·9% (248 of 421; 54·2-63·6; percent difference 63·6; p<0·0001). Nearly all participants (410 [97%]) reported that training made it clear how to respond towards non-combatants. Combat frequency and intensity was the strongest predictor of unethical behaviour; PTSD was not a significant predictor of unethical behaviour after controlling for combat experiences. INTERPRETATION: Leader-led battlefield ethics training positively influenced soldiers' understanding of how to interact with and treat non-combatants, and reduced reports of ethical misconduct. Unethical battlefield conduct was associated with high-intensity combat but not with PTSD. FUNDING: None.

Suicide prevention in a deployed military unit.

OBJECTIVE: Military suicide and parasuicidal behaviors have been increasing over the last several years, with rates highest in the deployed environment. This article presents a deployment cycle-specific suicide prevention plan utilized during one U.S. Army division's 15-month deployment to Iraq. METHODS: Education, identification, and intervention programs were implemented at each phase of the deployment cycle based on the specific unit activities and predicted stressors. RESULTS: During the deployment, there was an annual suicide rate of 16/100,000 within the trial cohort, compared to a theater rate of 24/100,000. Peaks in suicidal ideation and behaviors occurred during months two, six, and twelve of deployment. CONCLUSIONS: A deployment cycle prevention program may decrease rates of suicide in the combat environment. This program may serve as a model for other suicide prevention programs.

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.

Ethical considerations in military psychiatry.

Military psychiatrists are faced with multiple, difficult questions that shape the context for ethical patient care. These questions are difficult to answer and future efforts, including policy and evidence-based treatment practices, should aim at reducing the ambiguity faced by military psychiatrists. New research should focus on issues as diverse as optimal approaches to informed consent, evidence-derived approaches to protecting confidentiality, outcomes of care for individuals in widely varying military roles, and medication use in the field. Training for mental health care providers who deal with military patients should be provided not only in military graduate medical education but also in job-specific courses and in ethics. This should include specific training for personnel who will be dealing with specific populations, such as the US Army's current "Dealing with Detainee course" and the Army Medical Department's "Combat Operational Stress Course" for deploying military psychiatrists and psychologists.

Soldier attitudes toward mental health screening and seeking care upon return from combat.

OBJECTIVE: This study examined soldier attitudes about postdeployment mental health screening, treatment, barriers to care, strategies for overcoming barriers, and settings, personnel and timing for conducting postdeployment mental health screening. METHODS: Deploying soldiers participated in a voluntary anonymous survey. RESULTS: Of 3,294 soldiers, 2,678 (81.3%) responded to the survey. When the three most endorsed perceived barriers to mental health care (negative perception by unit members, negative perception by leaders, and being viewed as weak) were examined, approximately 15% fewer soldiers endorsed the perceptions, compared with a previous study conducted at the beginning of the war. Receipt of training focused on managing psychological problems associated with increased agreement to seek treatment. Participants endorsed surveys, interviews, and unit providers as preferred instruments and providers for postdeployment screening. Soldiers endorsed encouragement from family members and friends as the preferred approach to reducing barriers to mental health care. CONCLUSION: Extensive educational programs seemed to have reduced the stigma related to receiving mental health care. Programs that focus on friend and family member encouragement of soldiers to seek mental health assistance should continue. Postdeployment screening should be conducted under conditions in which soldiers are most likely to report problems honestly.

Military family physician attitudes toward treating obesity.

OBJECTIVE: The goal was to examine current knowledge, attitudes, and treatment practices of family practitioners regarding obesity. METHODS: A cross-sectional, anonymous, self-report survey of active members of the Uniformed Services Chapter of the American Academy of Family Physicians was performed. Measures included demographic information, attitudes toward obese patients, knowledge of associated health risks, and treatment recommendations, rated on a 5-point Likert scale. Results were compared with previous similar studies, and associations between demographic variables, physician body mass index, and attitudes and behaviors were examined by using multivariate regression analysis. RESULTS: Of the 1,186 members invited to participate, 477 (40.2%) responded. Compared with previous studies, there was increased awareness of obesity-associated health risks and physicians' sense of obligation to counsel patients. There were minimal changes in physician comfort and gratification with obesity counseling. Stereotypical attitudes of physicians toward obese patients were increased. Treatment recommendations were increased in all fields, including exercise, diet/nutrition counseling, and behavioral modification, but the most notable increases were seen in the use of prescription medications, diet center programs, and surgical referrals. Age, physician gender, physician weight status, practice location, and current training status were each associated with some aspect of physician attitudes and treatment practices. CONCLUSION: Physicians are better able to identify obesity and its associated health risks, but some negative stereotypical attitudes persist. These attitudes affect current treatment practices. Increased awareness, training, and study are required to combat the continuing increase in obesity rates.

Postdeployment Health Reassessment: a sustainable method for brigade combat teams.

OBJECTIVE: The Postdeployment Health Reassessment (PDHRA) was mandated in 2006 and the 3rd Infantry Division was the first unit to perform a large-scale implementation. This article outlines a reproducible model for conducting PDHRA using only existing resources. METHODS: The PDHRA (DD 2900) screening and referral processes are reviewed and data on positive screens are reported. RESULTS: Of the 12,817 soldiers who participated in the mass screening, 1,460 (11.4%) were referred for behavioral health, 815 (6.4%) for primary care, 71 (0.01%) for specialty services, and 9 (0.001%) for emergency services. Consult requests were higher in maneuver brigades than in support units (12.1% versus 8.6% for behavioral health and 6.9% versus 4.4% for primary care referrals). All (1,460, 100%) of the behavioral health consults were completed on-site and the unit incurred no additional financial cost in conducting this process. CONCLUSIONS: This method for performing a large-scale implementation of the PDHRA provides a flexible, efficient, and cost-effective process that could be implemented at the brigade combat team level without difficulty and in most locations without significant impact on other medical demands.

Division mental health in the new brigade combat team structure: part I. Predeployment and deployment.

OBJECTIVE: Recent Army transformation has led to significant changes in roles and demands for division mental health (DMH) staff members. This article focuses on predeployment and deployment. METHODS: Surveillance of Combat and Operational Stress Reactions data, review of DMH implementation plans, and observations by staff members, providers, and soldiers were reviewed. RESULTS: During the course of the deployment, the Task Force Baghdad DMH unit had >22,000 soldier encounters with 5,542 clinical encounters. The duration of the deployment and increased levels of threat later in the deployment resulted in increased stress problems but not a substantial or sustained increase in mental health casualties. CONCLUSIONS: Predeployment education and communication probably eliminated some problems during deployment, and communication among mental health and command units during deployment resolved most problems encountered.

Division mental health in the new brigade combat team structure: part II. Redeployment and postdeployment.

OBJECTIVE: Recent Army transformation has led to significant changes in roles and demands for division mental health staff members. This article focuses on redeployment and postdeployment. METHODS: The postdeployment health assessment behavioral health screening and referral process and redeployment plan are reviewed, and data on postdeployment rates of negative events are reported. RESULTS: All soldiers and many of their families participated in an aggressive education program. Of the 19,500 soldiers screened, 2,170 (11.1%) were referred for behavioral health consultation; of those referred, 219 (10.1%) were found to be at moderate or high risk for mental health issues (1.1% of total screened). Of the moderate/highrisk soldiers, 146 (71.9%) accepted follow-up mental health treatment upon return to home station. Fewer cases of driving under the influence, positive drug screens, suicidal gestures/ attempts, crimes, and acts of domestic violence were seen, in comparison with rates seen after an earlier deployment of this unit to Iraq. CONCLUSIONS: A formalized approach with command support and coordination can have a positive impact on successful referral and treatment and reduce negative postdeployment events.

The evolving role of the division psychiatrist.

With the recent restructuring of Army infantry divisions in the new brigade combat team model, division psychiatrists are facing new and unique demands. This article outlines the varying perspectives of the position and the duties and responsibilities of a division psychiatrist. It provides guidance on how to negotiate the myriad of challenges unique to the position. Discussion includes planning and supervision, providing command consultation, educational efforts, fulfilling the roles of an officer and leader, and future directions for the position.

Injury patterns in peacekeeping missions: the Kosovo experience.

Proper medical deployment planning requires projecting injuries. For this reason, the injury patterns and mechanism of injury were reviewed for an 18-month period in Kosovo, and injury rates and mechanisms were extracted for review. Overall, there were 404 trauma patients treated during the study period. Isolated head and neck injuries accounted for 29.5% (119) of injuries, chest wounds 5.7% (23), abdominal wounds 4.5% (18), and extremities 33.4% (135). Multiply injured patients accounted for the remaining 27.0% (109). When subdivided by mechanism, penetrating injury made up 36.9% (149), whereas blunt trauma accounted for 63.1% (255). Motor vehicle accidents made up the majority of blunt trauma (72.2%). Of penetrating injuries, gunshot wounds accounted for 55%, blast wounds 38%, and stabbings 6.7%. The data clearly demonstrate that humanitarian and peacekeeping missions require preparation for a wide variety of mechanisms of injury beyond the typical penetrating trauma of combat situations.