Military Psychiatry

The wars in Afghanistan and Iraq are historically significant for many reasons; most conspicuously, this marks the longest war in U.S. history. Its duration, and the nature of combat in the Iraqi and Afghan theaters, have subjected the nation’s all-volunteer military to its biggest test. Often called upon for multiple deployments for more than a decade, service members and their families have been challenged by the deployment related stress.

Early studies and surveys of warfighters in Iraq and Afghanistan revealed that about 5-9 percent had mental health symptoms before deploying; after deploying, this percentage increased to as much as 20 percent. Many have suffered from symptoms of post-traumatic stress and/or depression, and in recent years, young veterans returning from the Middle East are more likely to commit suicide than the civilian population, according to a 2011 study.

Over the past two decades, the Military Psychiatry Branch has emphasized research to improve service member psychological functioning, to reduce the impact of mental disorders, and to enhance psychological resilience.

Over the past two decades, the Military Psychiatry Branch has emphasized research to improve service member psychological functioning, to reduce the impact of mental disorders, and to enhance psychological resilience.

Over the course of much of the Iraq and Afghanistan conflicts, studies led by Dr. Charles Hoge, (Col., U.S. Army, Ret.), revealed that symptomatically, “post-concussive syndrome” following an mTBI and PTSD were much alike – so much so that it was possible, even likely, that a person suffering from PTSD and depression might be diagnosed with “post-concussive syndrome.” This was an important observation for tens of thousands of service members with mTBI diagnoses, as there was not – and still is not – a known evidence-based treatment for mTBI. Hoge’s studies suggested that service members with a “post-concussive syndrome” diagnosis could benefit from proven cognitive therapies for PTSD and depression.

The Center for Military Psychiatry and Neuroscience’s most widely cited epidemiological study of the mental health impact of the wars in Iraq and Afghanistan is the WRAIR Land Combat Study conducted by the Military Psychiatry Branch. Since its inception in 2003, approximately 100,000 service members have been studied across the deployment cycle as part of the Land Combat Study. One of the most visible components of the Land Combat Study is the Mental Health Advisory Team missions. The first MHAT was conducted in 2003, in response to the concerns of Lt. Gen. James Peake, the Surgeon General of the Army, about the mental health and increasing suicide rate of soldiers. The first MHAT deployed in 2003 to Iraq and included Lt. Col. Carl Castro and Lt. Col. Tony Cox, who were then WRAIR’s chief and deputy chief of military psychiatry.

The MHATs, which have deployed periodically to Iraq and Afghanistan over the past decade, constitute the first comprehensive effort to collect behavioral health care data from and about soldiers in a theater of operations. Rather than rely on limited focus groups, they are a systematic attempt to survey soldiers about their behavioral health needs – and just as important, to assess the obstacles soldiers face in seeking and receiving quality mental health care.

The MHATs have become a milestone in military medicine: They have been critically important in collecting information about troops’ anxiety, depression, and post-traumatic stress symptoms, and have documented the challenges soldiers face in seeking and receiving mental health care – including the warrior’s stigma against seeking help, a shortage of clinicians, and the influence of leaders at different command levels.

The emphasis on these comprehensive surveys, said Bliese, evolved rapidly. By 2006, when MHAT IV was deployed to Iraq, WRAIR had become the lead organization for the teams. “That was just the right time, in terms of technology,” he said, “to allow us to deploy in theater with scanners, so that we could go in and collect the data, scan the data, run the statistical analyses, conduct an outreach to commanders, and write the entire report within a short period of time. This became a way of providing behavioral health information back to operational commanders in near real time.” Since 2009, the teams have applied greater scientific rigor to their sampling methods, achieving a randomized sample that allows valid comparisons of results from survey to survey.

The MHATs have become a milestone in military medicine: They have been critically important in collecting information about troops’ anxiety, depression, and post-traumatic stress symptoms, and have documented the challenges soldiers face in seeking and receiving mental health care – including the warrior’s stigma against seeking help, a shortage of clinicians, and the influence of leaders at different command levels.

The teams have also helped shape operational doctrine and policy, according to Bliese. “The teams have brought about some very concrete results,” he said. “For instance, back in 2009, when the team went into theater, they estimated the rate of the mental health problems, and they also evaluated the number of behavioral health providers in theater. And they found, essentially, that there weren’t enough providers, given the rate of mental health problems they were seeing on the surveys. So we made a recommendation to go to what we call the dual provider model: We said each brigade combat team should have, organic to that combat team, two behavioral health providers, because this would allow one to go out and kind of do rounds for the units that might be spread out, and another one could stay there, at these large forward operating bases. The MHAT survey wasn’t the only piece of information to lead to the implementation of the dual provider model – others were saying similar things – but it was a key piece of information.”

In addition to the MHATs, the Land Combat Study has collected data across the deployment cycle and has made important contributions that have informed policy and programs. For example, the development of Battlemind Training was informed by findings from the Land Combat Study. Battlemind training is, essentially, the Army’s version of cognitive reframing: First, it recognizes the courage, leadership, camaraderie, mental toughness, and maturity it takes to succeed in theater, and then teaches soldiers how to reapply those skills to family and workaday life – and perhaps to apply them to resolving problems with anxiety, depression, or PTSD. “Carl [Castro]’s idea,” said Bliese, “was to help soldiers who had been over there for a year, who were having trouble with the transition, to reframe the way they thought about it, in a more positive way.”

“It sounds easy, and there is nothing scientifically complicated about the idea of validating a training program,” said Bliese. “But it’s complicated to actually pull it off. The group working with the soldiers has been very good at designing and conducting randomized trials of intervention programs, with the idea that if we can develop and deliver this low-cost, simple intervention to soldiers returning from combat, and if we can show efficacy with this program three or four months later, then that’s a real win. And that group has had a number of real wins.”

Battlemind, typically consisting of succinct post-deployment debriefing and training sessions, seems like a common-sense idea, but it has also proven repeatedly to be an intervention that works for returning soldiers. The first randomized trials to assess the efficacy of post-deployment Battlemind training, an element now integrated into the Army’s Comprehensive Soldier Fitness resilience training program, were conducted by USAMRU-E and WRAIR researchers in 2007. In a 2009 study, Bliese and other WRAIR researchers surveyed more than 1,000 soldiers; those who received Battlemind debriefing and training reported, four months afterward, fewer symptoms of post-traumatic stress, lower levels of help-seeking stigma, fewer depression systems, and fewer sleep problems.

“It sounds easy, and there is nothing scientifically complicated about the idea of validating a training program,” said Bliese. “But it’s complicated to actually pull it off. The group working with the soldiers has been very good at designing and conducting randomized trials of intervention programs, with the idea that if we can develop and deliver this low-cost, simple intervention to soldiers returning from combat, and if we can show efficacy with this program three or four months later, then that’s a real win. And that group has had a number of real wins.”

The Military Psychiatry Branch has continued to leverage the skills required to conduct group randomized trials of intervention programs and most recently launched a group randomized trial, “Social Fitness Training Strategies at Post-Deployment” with members of the California National Guard in 2013. This longitudinal study assessed social fitness training, defined as the existence of healthy social networks that support optimal performance and well being, at the platoon level for post-deployment behavioral health and resilience across four different phases.

The Military Psychiatry Branch has continued to leverage the skills required to conduct group randomized trials of intervention programs and most recently launched a group randomized trial.

Today, the Military Psychiatry Branch has expanded its perspectives to include examination of the Army’s behavioral healthcare system. This work has provided a snapshot of routine challenges faced in the delivery of behavioral health care to include access to care, stigma, and provider use of best clinical practices.  In addition, the Military Psychiatry Branch has started to examine neurocognitive assessments of anxiety and anger in order to compliment the survey based methodology in hopes of developing computer-based tools to mitigate the effects of combat in service members.