A Foundation for a "Cheerful Society": The Korean War and the Rise of Psychiatry.

One of the most remarkable medical achievements of the Korean War was the development of psychiatry. During the Korean War, soldiers and prisoners of war (POWs) experienced "gross stress reaction" and manifested poor concentration and memory as well as clinical depression and social alienation. Rest and relaxation rotations served as the primary treatment for their conditions. Civilians also bore the brunt of the war's effects. Delusions of grandeur and megalomania appear to have been common among Koreans, but there were few mental health facilities to provide treatment and care. Out of the furnace of war, psychiatry emerged as a newly specialized field, and in the 1950s, Korea became the very place where military psychiatry training under the U.S. military laid the groundwork for civilian psychiatry. This essay aims to enrich the study of mental illness during and after the Korean War by providing a more detailed picture of the mental problems experienced not only by veterans and POWs, but also by civilians in Korea. Examining mental health issues from this period is challenging due to the scarcity of resources for delving into the minds of the civilians involved. Taking military psychiatry as a starting point, this essay goes beyond existing scholarship to discuss psychiatry-related responses to the Korean War, including the influence of military psychiatry on civilian psychiatry, the endeavors of medical professionals and government policies, and contemporary expressions of mental distress during and after the war.

Training Military Psychiatrists to Adapt and Overcome: How COVID-19 Highlighted the Unique Flexibility of Military Psychiatry in Training and in the Fleet.

PURPOSE OF REVIEW: Born out of necessity, military medicine continues to find itself at the forefront of medical innovation. This generation of military physicians has never previously been challenged with continuing to provide top notch medical support to servicemembers in a variety of operational settings in the midst of a global pandemic. While military medicine has always been able to uniquely meet the educational goals of residency training, COVID-19 brought new challenges to the forefront. RECENT FINDINGS: While the threat presented by COVID-19 was different from the historical battlefield threats and challenges that have given birth to military medicine, it was nevertheless ready to pivot and adjust course, focusing on how to best meet the medical needs of the military patient population in an ever-changing geopolitical environment while continuing to meet and exceed the educational standards that training programs are held to. Historically and currently, mental health remains one of the most common reasons that servicemembers are evacuated from combat zones. The COVID-19 pandemic provided an opportunity for modern military psychiatry to showcase its ability to adjust the educational focus in certain areas of residency training to prepare the next generation of military psychiatrists to be able to face the newest threat to force wellness.

Predictors of Suicide Attempt Within 30 Days After First Medically Documented Suicidal Ideation in U.S. Army Soldiers.

OBJECTIVE: The authors sought to identify predictors of imminent suicide attempt (within 30 days) among U.S. Army soldiers following their first documented suicidal ideation. METHODS: Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers, the authors identified 11,178 active-duty Regular Army enlisted soldiers (2006-2009) with medically documented suicidal ideation and no prior medically documented suicide attempts. The authors examined risk factors for suicide attempt within 30 days of first suicidal ideation using logistic regression analyses, including sociodemographic and service-related characteristics, psychiatric diagnoses, physical health care visits, injuries, and history of family violence or crime perpetration or victimization. RESULTS: Among soldiers with first documented suicidal ideation, 830 (7.4%) attempted suicide, 46.3% of whom (N=387) attempted suicide within 30 days (rate, 35.4 per 1,000 soldiers). Following a series of multivariate analyses, the final model identified females (odds ratio=1.3, 95% CI=1.0, 1.8), combat medics (odds ratio=1.6, 95% CI=1.1, 2.2), individuals with an anxiety disorder diagnosis prior to suicidal ideation (odds ratio=1.3, 95% CI=1.0, 1.6), and those who received a sleep disorder diagnosis on the same day as the recorded suicidal ideation (odds ratio=2.3, 95% CI=1.1, 4.6) as being more likely to attempt suicide within 30 days. Black soldiers (odds ratio=0.6, 95% CI=0.4, 0.9) and those who received an anxiety disorder diagnosis on the same day as suicidal ideation (odds ratio=0.7, 95% CI=0.5, 0.9) were less likely. CONCLUSIONS: Suicide attempt risk is highest in the first 30 days following ideation diagnosis and is more likely among women, combat medics, and soldiers with an anxiety disorder diagnosis before suicidal ideation and a same-day sleep disorder diagnosis. Black soldiers and those with a same-day anxiety disorder diagnosis were at decreased risk. These factors may help identify soldiers at imminent risk of suicide attempt.

Personality Disorders as a Basis for Discharge and Denial of Benefits in the Military: Logical or Abusive?

ABSTRACT: The US Department of Defense specifically states that intellectual disability and personality disorders are not diseases for compensation purposes, and disabilities from them may not be service connected absent a superimposed mental disorder. In addition, the diagnosis of a personality disorder led to the discharge of 31,000 troops during the years 2001 to 2010. I review the history of these developments, and how the Diagnostic and Statistical Manual of Mental Disorders enabled these actions. In contrast, the United Kingdom and Canada do not allow such actions. Whether our approach is logical seems highly questionable, especially given the significant problems with the DSM's definitions of personality disorders, definitions at odds with the literature.

Medication by Proxy: The Devolution of Psychiatric Power and Shared Accountability to Psychopharmaceutical Use Among Soldiers in America's Post-9/11 Wars.

With the United States military stretched thin in the "global war on terror," military officials have embraced psychopharmaceuticals in the effort to enable more troops to remain "mission-capable." Within the intimate conditions in which deployed military personnel work and live, soldiers learn to read for signs of psychopharmaceutical use by others, and consequently, may become accountable to those on medication in new ways. On convoys and in the barracks, up in the observation post and out in the motor pool, the presence and perceived volatility of psychopharmaceuticals can enlist non-medical military personnel into the surveillance and monitoring of medicated peers, in sites far beyond the clinic. Drawing on fieldwork with Army personnel and veterans, this article explores collective and relational aspects of psychopharmaceutical use among soldiers deployed post-9/11 in Iraq and Afghanistan. I theorize this social landscape as a form of "medication by proxy," both to play on the fluidity of the locus of medication administration and effects within the military corporate body, and to emphasize the material and spatial ways that proximity to psychopharmaceuticals pulls soldiers into relationships of care, concern and risk management. Cases presented here reveal a devolution and dispersal of biomedical psychiatric power that complicates mainstream narratives of mental health stigma in the US military.

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.

A Qualitative Investigation of Barriers to Seeking Treatment for Suicidal Thoughts and Behaviors Among Army Soldiers with a Deployment History.

This study aimed to identify barriers to treatment seeking and service utilization among previously deployed Army soldiers who recently experienced a suicidal crisis. Confidential interviews were conducted on a psychiatric inpatient unit with 12 Army soldiers with a deployment history following a suicidal crisis. Qualitative analysis focused on statements coded as "barriers to seeking help" and "explicit recommendations." Suicidal Army soldiers with a deployment history experienced different barriers to seeking help, including stigma and logistical challenges (e.g., long wait times for appointments). Negative and positive perceptions of support were reported for various resources - for example, family, crisis hotlines, chaplains, and command. Suicidal Army soldiers, interviewed in this study, experienced a number of challenges and frustrations associated with various helping resources. This study highlights the need for greater attention toward understanding these challenges and subsequently addressing them through appropriate resource allocation and additional training for those working directly with Army soldiers at risk for suicide.

Identifying Research Gaps and Prioritizing Psychological Health Evidence Synthesis Needs.

BACKGROUND: Evidence synthesis is key in promoting evidence-based health care, but it is resource-intense. Methods are needed to identify and prioritize evidence synthesis needs within health care systems. We describe a collaboration between an agency charged with facilitating the implementation of evidence-based research and practices across the Military Health System and a research center specializing in evidence synthesis. METHODS: Scoping searches targeted 15 sources, including the Veterans Affairs/Department of Defense Guidelines and National Defense Authorization Acts. We screened for evidence gaps in psychological health management approaches relevant to the target population. We translated gaps into potential topics for evidence maps and/or systematic reviews. Gaps amenable to evidence synthesis format provided the basis for stakeholder input. Stakeholders rated topics for their potential to inform psychological health care in the military health system. Feasibility scans determined whether topics were ready to be pursued, that is, sufficient literature exists, and duplicative efforts are avoided. RESULTS: We identified 58 intervention, 9 diagnostics, 12 outcome, 19 population, and 24 health services evidence synthesis gaps. Areas included: posttraumatic stress disorder (PTSD) (19), suicide prevention (14), depression (9), bipolar disorder (9), substance use (24), traumatic brain injury (20), anxiety (1), and cross-cutting (14) synthesis topics. Stakeholder input helped prioritize 19 potential PTSD topics and 22 other psychological health topics. To date, 46 topics have undergone feasibility scans. We document lessons learned across clinical topics and research methods. CONCLUSION: We describe a transparent and structured approach to evidence synthesis topic selection for a health care system using scoping searches, translation into evidence synthesis format, stakeholder input, and feasibility scans.

[ISRAELI MILITARY PSYCHIATRY: CHALLENGES AND ACHIEVEMENTS].

INTRODUCTION: In this article, we have attempted to summarize the achievements and the challenges of the mental health department (MHD) of the IDF Medical Core from the past four decades, since its initiation. We approach this wide scope question through the investigation of the MHD according to the perspective of its main fields of endeavor. These domains are widely arrayed. In this paper, we chose to focus on the following: the unique training of the mental health officers; the initial psychological screening of soldiers - from recruitment to discharge; the mental health treatment of soldiers and officers, and the life-time treatment of combat post traumatic (PTSD) patients; the development of combat PTSD diagnosis, treatment and prevention; the continuous prevention of soldiers' suicides; the prevention of psychiatric hospitalizations; and the participation of the MHD in research and in the development of new treatment modalities. In the writing of this paper we relied on the accumulative experience of the MHD and the historic perspective of the last four commanders of the Mental Health Department of the IDF.

Military psychologists and cultural competence: exploring implications for the manifestation and treatment of psychological trauma in the British armed forces.

This paper considers the manifestation and treatment of psychological trauma in the military. The article describes how military psychologists conceptualise psychological trauma within the culture of the Armed Forces (AF), which is reflected in the process of acquiring what has been referred to as cultural competency. Psychologists in this context acquire an understanding of the manner in which the psychological and organisational systems and culture of the military affect the presentation of psychological trauma, including post-traumatic stress disorder (PTSD). The paper outlines core psychological features of military life, including some of the ways in which the AF functions effectively as an adaptable fighting force. This highlights, for example, the potential for stigma within and between military personnel who experience mental health difficulties. The article proceeds to examine aspects of help-seeking in military mental healthcare, how symptoms can present at different stages in a deployment process, and the consequences that such problems can cause for military conduct and performance. Psychological care in the military is structured within an occupational mental health ethos, in which psychologists fulfil a range of clinical, organisational and leadership roles. These dynamics are explored with examples of care pathways and clarity on evidence-based interventions for trauma and PTSD in those experiencing military-related psychological injuries. Two vignettes are then offered to illustrate how some of these interventions can be used psychotherapeutically in addressing symptoms pertaining to hyperarousal, hypervigilance, guilt and shame.

The diathesis-stress model in the emergence of major psychiatric disorders during military service.

Existing evidence and the diathesis-stress model hypothesis suggest that stress as an environmental factor may trigger the onset of psychiatric disorders, such as psychosis spectrum disorders, mood disorders, anxiety disorders, in people with an underlying vulnerability. The purpose of this study was to determine the period of time during military service at which symptomatology of clinical significance is more often developed, considering that stress of service and adaptation to its requirements is common to all army recruits. A retrospective file study for the years 2017-2018 was conducted in order to identify male soldiers who were hospitalized in the psychiatric clinic of 414 Athens Military hospital and diagnosed as F20-29, F30-39 and F40-48 according to ICD-10. The number of hospitalizations per clinical diagnosis and the time of onset relatively to the month of military service were examined. A total of 139 cases were screened, 119 of which had disorders falling into the diagnostic categories F20-29, F30-39 and F40-48. 53% of total hospitalizations took place within the first two months of a nine-month military service. It was found that the risk of disorder onset within the first two months of military service was statistically higher (OR=0.210, p=0.001) for a schizophrenic spectrum disorder (F20-29) compared to F30-39 and F40-48 disorders. After adjusting for potential confounders, such as heritability for psychiatric disorders, urbanicity, history of substance use or age, the risk for hospitalization within the first two months continued to be significantly predicted by F20-29 disorder (OR=0.255, p=0.022) compared to other diagnoses. Individuals vulnerable in developing a psychotic disorder appear to have lower stress tolerance and may manifest an earlier disease onset, when exposed to the stress of military service compared to subjects predisposed to develop mood or anxiety disorders. Stress during military service is of major importance for the emergence of the whole psychopathology spectrum, particularly in vulnerable individuals. The development of prevention and early intervention strategies is considered to be of particular importance to conscripts. The findings of the present study are in agreement with the diathesis-stress model and moreover suggest that people who subsequently develop a psychotic spectrum disorder have greater vulnerability to stress exposure.

History of military psychology.

Military psychology is a specialist discipline within applied psychology. It entails the application of psychological science to military operations, systems and personnel. The specialty was formally founded during World War I in the UK and the USA, and it was integral to many early concepts and interventions for psychological and neuropsychological trauma. It also established a fundamental basis for the psychological assessment and selection of military personnel. During and after World War II, military psychology continued to make significant contributions to aviation psychology, cognitive testing, rehabilitation psychology and many models of psychotherapy. Military psychology now consists of several subspecialties, including clinical, research and occupational psychology, with the latter often referred to in the USA as industrial/organisational psychology. This article will provide an overview of the origins, history and current composition of military psychology in the UK, with select international illustrations also being offered.

Neuropsychology and clinical health psychology in the UK Ministry of Defence.

Neuropsychological testing has been used in a wide range of applications across military settings, including the selection of personnel to engage in covert operations, battlefield assessment and rehabilitation following blast exposure, traumatic brain injury, other neurological conditions and assessment of malingering. Over recent decades, military psychologists have helped to shape the advances in assessing and remediating the psychological sequela that is associated with operationally related neurological and other physical injuries. This paper will present an overview of some of the neuropsychological and related services within the UK Armed Forces, which are provided to service personnel with traumatic brain and other physical injuries.

Leadership in 21st century military healthcare: what did clinical psychologists ever do for us?

Psychology is integral to the concepts and practice of leadership. Leadership models often have their roots in psychological paradigms, making it intrinsically easy for psychologists to grasp and apply them alongside clinical models. Psychologists' 'second-order' skills have been used to good effect in the changing landscape of military mental healthcare: modelling adaptive responses to change, understanding the non-conscious aspects of relationships in hierarchical organisations, working with systems, the ability to diagnose situational requirements and act accordingly, drawing on a range of psychological theories and leadership styles. The clinical psychologist as a professional who can help others 'reframe' a situation or experience is key to their leadership role within healthcare settings, 'enabling others to achieve shared purpose in the face of uncertainty'. The contribution that clinical psychology has made to leadership in Defence over the past 20 years will be illustrated by personal accounts from 'experts by experience'.

175 Years of Progress in PTSD Therapeutics: Learning From the Past.

Traumatic stressors have always been a part of the human experience. What is now referred to as posttraumatic stress disorder (PTSD) was first studied in the context of military trauma during the Civil War and World War I but most extensively in World War II. Much of what we know about the medical and psychological management of PTSD has its origins in military psychiatric approaches, and a review of these practices reveals important tenets that should be applied in current treatment for both military and nonmilitary PTSD. These practices include intervention as soon as possible after the traumatic exposure, provision for a safe and supportive therapeutic milieu designed for an individual's relatively rapid return to his or her responsibilities and normal activities, and using a combination of pharmacotherapy and psychotherapy (especially exposure to the traumatic memory). A review of current guidelines for treatment of PTSD reveals that few treatments are endorsed with great certainty, owing in large part to a paucity of clinical trials, particularly of pharmacotherapy. This shortcoming must be addressed to enable translation of promising discoveries in the neuroscience of fear into the therapeutic advances patients need and deserve. [AJP at 175: Remembering Our Past As We Envision Our Future March 1947: Psychiatric Experience in the War, 1941-1946 Brig. General William C. Menninger "Another observation which can be made as a result of our experience, is that if intensive treatment was provided early, in an environment in which the expectation of recovery prevailed, remarkable results were obtained." (Am J Psychiatry 1947; 103:577-586 )].

Hippocampal gray matter increases following multimodal psychological treatment for combat-related post-traumatic stress disorder.

Introduction: Smaller hippocampal volumes are one of the most consistent findings in neuroimaging studies of post-traumatic stress disorder (PTSD). However, very few prospective studies have assessed changes in hippocampal gray matter prior to and following therapy for PTSD, and no neuroimaging studies to date have longitudinally assessed military populations. Methods: A pilot study was conducted, assessing patients with combat-related PTSD with structural MRI. Participants were then assigned either to a treatment group or waiting-list control group. After the treatment group received multimodal psychological therapy for approximately 6 weeks, both groups completed a second neuroimaging assessment. Results: Region-of-interest analysis was used to measure gray matter volume in the hippocampus and amygdala. There was a group by time interaction; the therapy group (n = 6) showed a significant increase in hippocampal volume and a nonsignificant trend toward an increase in amygdala volume following therapy, while no change was observed in the waiting-list group (n = 9). Conclusions: This study provides initial evidence for increases in gray matter volume in the hippocampus in response to therapy for combat-related PTSD.

Burnout Among US Military Behavioral Health Providers.

The present study investigated the prevalence of burnout among US military behavioral health providers (BHPs) and tested a mechanism of developing burnout in a job demands-resources model. Surveys were sent to BHPs working with US military populations globally (T1). Six months after, surveys were collected again at T2. In total, 271 providers completed T1, and 116 completed T2. The job demands-resources model showed that T1 burnout self-efficacy and support predicted T2 burnout and work engagement. T1 job demands predicted T2 burnout. To provide a deeper comparison of our findings, we included a meta-analysis, which indicated burnout among BHPs working on a military installation was equivalent with other professions. Providers working with military clients within the community reported lower burnout than other professionals. Findings suggest BHPs working on a military installation might be at greater risk of developing burnout. Burnout might be preventable by increasing job resources and decreasing job demands.

What's Changed? A Comparison of Army Suicide Surveillance Data to Cases from 1975 to 1982.

US Army suicide rates increased significantly in the last decade and have remained high. To inform future research hypotheses, Army suicide surveillance data (2012-2014) were compared to similar Army data for suicides from 1975 to 1982. Preliminary data suggest that suicide rates increased across most demographic groups, but may have decreased among divorced soldiers. Mental health utilization increased over time. Legal problems and physical health problems were identified in a higher percentage of cases in the recent data relative to the 1975-1982 era. Potential implications for suicide prevention are discussed.