Mental Health
An Overview for Service Members

the Air Force and the Air Force Medical Service. This
Mental Health Overview provides our total force withthe basics on staying mentally healthy and provides
resources, clinical and non-clinical, to support yourmental health. Knowledge and transparency are
critical first steps in developing the trust required to bevulnerable. This overview provides both. We must allunderstand what mental health is and how each of us““

Mental health is a top priority for the Department ofplays a role in developing and sustaining a mentally
ready force. This foundation is paramount.

LIEUTENANT GENERAL ROBERT I. MILLER
AIR FORCE SURGEON GENERAL

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INTRODUCTION

CHAPTER 1
What is Mental Health?

CHAPTER 2
Staying Mentally Healthy

CHAPTER 3
Seeking Non-Clinical Mental Health Assistance

CHAPTER 4
Embedded Mental Health

CHAPTER 5
Being Evaluated for Clinical Mental Health Care

CHAPTER 6
What to Expect from Clinical Mental Health Care

CHAPTER 7
An Overview of Mental Health Standards

CONCLUSION

3INTRODUCTION

This overview is intended to help members of the Department of the Air
Force (DAF) understand the complexities of “mental health.” While stigma

Our greatest enemies, the ones
we fight most often, are within.
THOMAS PAINE

related to mental health is on the decline, there is still a lot of confusion.
This overview is designed to provide clarity. The first step is to define
mental health (Chapter 1) – a term used in a wide variety of ways withvery different meanings. The chapters thereafter follow the spectrum ofresilience – from staying mentally healthy (Chapter 2) to seeking nonclinical mental health care (Chapter 3) to utilizing embedded non-clinicalmental health resources (Chapter 4). This spectrum continues with methods
for seeking clinical mental health care (Chapter 5) and what to expect if you
are vectored into clinical mental health care (Chapter 6). Last, this overview
explains how clinical mental health can impact your ability to deploy,engage in your duties, and remain in the military (Chapter 7).

5

The following infographic is a helpful way toconceptualize all the information in this overview.
After completing each chapter, please consider
returning to this infographic to solidify yourunderstanding of mental health in the DAF.
RE
CA
P
OU
GR

All non-clinical resources can refer Service Members to other nonclinical resources: the Chaplain can recommend going to finance forfinancial worries. Similarly, non-clinical mental health resources canrefer to another clinical resource. Unless there is a safety concern,
referrals are typically voluntary.
Within the MH Clinic, most patients will receive group therapy.
Some patients may also require individual therapy and/or
medication management.

6.

Being a patient (having a clinical MH diagnosis that requires clinicalMH care) requires determining if a profile is indicated. Profiles are theprimary method MH clinicians can alert command to the fact that amember needs their support. In response to a profile a Commander
can ensure the Service Member is safe, the mission is safe, and thatcare can be completed in a timely manner.

7.

Most MH illnesses can be “cured” or go into “remission.” The MH
clinic’s goal is to help patients achieve remission as quickly as possible
so they can continue serving without a profile.

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Service Members can go anywhere for help – but might not know
which resource is best. The MH Clinic can assist using the “vectoring”
process. Vectoring you to the best resource for your situation. Those
who need clinical MH care are vectored into the MH clinic and areconsidered a patient.

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3.

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The Mental Health (MH) Clinic, Primary Care Clinic, and Primary Care
Behavioral Health (PCBH) Clinic are unique in that they can provide
clinical mental health care. Most people don’t need clinical mental
health care – so most of the support is non-clinical.

MH

PCB
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5.

6

Service Members are at the center. We all strive for resiliency, mental
and physical health, and positive relationships. With every challenge
comes an opportunity for growth. Sometimes though, Service Members
need support along the way to “stay in the green.” DAF leaders know
this is challenging and have surrounded Service Members with avariety of non-clinical mental health resources.

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7

CHAPTER 1

What is Mental Health?

9“Mental health” clearly means different things in these common examples –which can cause a lot of confusion:•

I gotta’ hit the gym and take care of my mental health.

•I’m really struggling – I think I need to go see mental health.

•Our unit has embedded mental health.

•SrA Thomas is being kicked out because of mental health.

For this overview, “mental health” will be delineated into four specific terms:•

Mental Health (generic, non-clinical)•

Clinical Mental Health / Mental Health Disorder•

Mental Health Care•

Clinical Mental Health Care

Mental Health and Clinical Mental Health are different, but can beconceptualized as two intersecting states of being [Keyes & Lopez, 2002]:•

Mental Health (MH) is defined as the “state of mind characterized byemotional well-being, good behavioral adjustment, relative freedom
from anxiety and disabling symptoms, and a capacity to establish
constructive relationships and cope with the ordinary demands andstressors of life” [American Psychological Association, 2023].

•

Clinical Mental Health, Mental Illness, or a Mental Health Disorder,
is considered “any condition characterized by cognitive and emotional
disturbances, abnormal behaviors, impaired functioning, or any
combination of these” [American Psychological Association, 2023].

Based on these two definitions one might arrive at the conclusion that weare all human and some days are better than others. Sometimes we may
exhibit optimal mental health and at other times we may struggle withmanaging the demands of daily life. While this simplification is appealing,
it is not terribly helpful. How do we determine if someone’s struggles havecrossed the threshold of being a “disorder” – of requiring clinical treatment– and potentially requiring a profile? Military MH clinicians spend many
years honing the skill of making this differentiation, but to put it simply – it is
all about horses and carts.

10

If someone is struggling to attain something they want to accomplish theymight feel tired, anxious, or worried. They might even sleep less and avoid
other aspects of their life. These are all in response to what they are striving
to achieve. The horse is in front of the cart. While it might not be healthy, it is
not a disorder. If, however, their anxiety gets in the way of their goals, it is nolonger just a response to life but impairing it. This can be easier to understandusing physical terms. Getting after it at the gym can cause muscle pain,
exhaustion and fatigue– but it’s worth it because it’s the result of working
hard. Conversely, if pain, exhaustion, or fatigue prevents someone from goingto the gym it is a problem – it’s getting in the way of their goals. So – thekey delineator between mental health and illness is evidence of clinicallysignificant distress and/or occupational / social dysfunction [DSM-5-TR, 2022]– evidence that symptoms are getting in the way of someone’s goals.

Mental Health Care and Clinical Mental Health Care follow a similar
spectrum, although Clinical Mental Health Care might utilize aspects of
Mental Health Care to facilitate treatment.
•

Mental Health Care is any effort an individual takes to maintain mental
health or, put another way, to prevent mental illness. This can be anythingfrom taking a walk before getting in their car at the end of the day, talking
to a friend about the week’s struggles, meditating, journaling, or simply
reflecting (Chapter 2). It can also include engaging with non-clinicalmental health assistance (Chapter 3) or engaging clinical mental healthclinicians embedded in their unit to provide non-clinical counseling(Chapter 4).

•

Clinical Mental Health Care is delivered by MH clinicians - Psychiatrists,
Psychologists, Licensed Clinical Social Workers, Psychiatric Nurse
Practitioners, Psychiatric Nurses, and Mental Health Technicians (or“4Cs” in the DAF). There are several ways to get clinical mental healthcare (Chapter 5). MH clinicians use carefully crafted psychotherapies
designed for specific disorders. Sometimes you use medications to
reduce symptoms – often to make it easier to engage in therapy. Whileclinicians will often use or recommend many examples of Mental HealthCare listed previously, the keys to achieving remission (“curing” a MH
disorder) are the clinical tools you are using. Some MH Disorders cango into remission with brief therapy or a short duration of psychiatric
medication, while other less common conditions are persistent or may
require life-long medication management or repeated hospitalizations.
Understanding the requirements and limitations of clinical care isimportant (Chapter 6) – to include the DAF Standards associated withclinical mental health care (Chapter 7).
CH AP T E R 1 . W H AT IS M E N TAL H E ALT H ?

11DAF STRESS CONTINUUM & RESOURCES

We’ve mentioned a few spectrums – let’s visualize them here. The top half ofthe graphic details the progression of mental health symptoms as our stresslevels increase. The bottom half lists appropriate resources and advocatesthat can best support Service Members when stress levels reach theindicated level. Moving to the right, the experiences shift from “mental health”
to “clinical mental health.” At the same time, the bottom shifts from genericMH care to clinical MH care. This graph is helpful because the transition from“mental health” to “clinical mental health” isn’t always obvious. Similarly, thetype of required care, non-clinical vs clinical, can overlap. The next chapter
reviews how to “stay in the green” – how to stay mentally healthy.

READY

REACTING

INJUREDCRITICAL | CLINICALHigh quality sleep

Decreased sleep

Disturbed sleep

Insomnia

Future oriented

Unable to plan past today

Struggle to plan out today

Hopelessness

Able to handle uncertainty

Need to be in control

Fear of losing control

Feeling out of control

Sense of gratitude

Focused on recognition

Feeling unappreciatedBlaming self/others

Able to handle complexity

At capacity

Feeling overwhelmed

Feeling trapped

Clear sense of mission

Task focused

Getting through the day (surviving)

Avoiding work

Positive sense of self

Poor sense of self

Negative sense of self

Thoughts of suicide

Outward focused

Inward focused

Strained relationships

Broken relationships

RESOURCES:RESOURCES:RESOURCES:RESOURCES:

Friends & Family

Friends & Family

Friends & Family

Primary Care

Command Team

Command Team

Command Team

Primary Care Behavioral Health

MilitaryOneSource

MilitaryOneSource

MilitaryOneSource

MH Clinic

Chaplain

Chaplain

Chaplain

If After Hours:

Embedded Mental Health

Embedded Mental Health

Embedded Mental Health

Nearest ER | Call 988

Military & Family Life Counseling

Military & Family Life Counseling

Military Crisis Line (24/7)
1-800-273-8255 (Press 1)

Primary Care
Primary Care Behavioral Health

Goal: Maintain Mental Health

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Text 838255
www.veteranscrisisline.com

Goal: Return to Mental Health
CH AP T E R 1 . W H AT IS M E N TAL H E ALT H ?

13

Maintaining one’s mental health (MH) is vital to sustaining a ready force.
While struggle and even failure are normal parts of life, there are ways toprepare and respond to these tough times to minimize the impact.
PREVENTION
Just as we prepare for physical struggles by exercising and resting(recovery day is just as important as leg day), we must invest similarly
in our mental wellness. Preventative measures are used to prepare
ourselves for times of stress. These efforts provide structure and comfort
in anticipation of our environment being chaotic. Engaging in what we are
expected to do is a critical first step. Learning the basics of our job during
training is what makes it easier to perform. Performing our best at peace
time is what prepares us to excel in a contingency environment. Self-carebefore times of stress is also essential. Research has shown that poor
sleep, poor nutrition, lack of exercise, and social isolation increase therisk of future mental health issues. Similarly, the time to develop a support
network is before one is needed. These efforts do more than just prevent
illness – these help us achieve wellness.

CHAPTER 2

Staying Mentally Healthy

RESPONSE
When stressful events do occur, the time for preparation is over and
we must decide how we will respond to them. If we have preparedsuccessfully, we should be able to utilize the same self-care efforts thatworked before the stressful event occurred. This is why people whoroutinely engage in prevention appear to have fewer stressful events – theirprevention strategies are working. Prioritizing healthy coping strategies
and relying on our support network is critical to succeeding in a stressful
situation. Our support network can also help connect us to the additional
resources and help we may need to cope, recalibrate, and return to a peaklevel of performance.
More tools to help stay mentally healthy can be found here:
https://www.resilience.af.mil/Tools-and-Guidance/

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CH AP T E R 2 . STAY IN G M E N TAL LY H E ALT H Y

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There are numerous non-clinical mental health (MH) resources available
for Service Members when they feel additional support is needed during
challenging times. In addition to the resources listed below, fellow wingmen,
supervisors, First Sergeants, and other unit leaders are often the mostaccessible supports for Service Members seeking assistance. A nonexhaustive list of non-clinical resources available to all Service Members
are listed below.
•

Chaplain Team – Offers general and spiritual non-clinical counselingservices. No referral needed.

•

Military OneSource – Non-medical counseling for a wide range ofissues via telephone/video. No referral needed. Available 24/7 here:
www.militaryonesource.com•

Military and Family Life Counseling (MFLC) – Non-medical
counseling, as outlined above. Available on-base for in-person
sessions. No referral needed.

•

Military & Family Readiness Center (M&FRC) - Offers a wide rangeof military and family services and programs contributing to the wellbeing of the military community. M&FRC’s overall goal is to ensure
Service Members and families are informed, educated, and prepared
for the unique demands of military life. No referral needed. You can findyour local M&FRC here: https://installations.militaryonesource.mil/.

•Primary Care Behavior Health (PCBH) – Integrated mental healthservices within the primary care clinic. Their coordination allows theprimary care team to work together to optimize a Service Member’s
overall health. PCBH can also provide clinical MH care to patients.
Please see Chapter 6 for more details on Clinical MH care.

CHAPTER 3

Seeking Non-Clinical
Mental Health Assistance

Still not sure which resource is best? Service Members can contact their
DAF Mental Health Clinic for assistance. DAF Mental Health Clinicians aretrained to first help determine what type of care is needed. It’s not always
easy to determine if clinical or non-clinical mental health assistance isrequired – let alone which type of non-clinical mental assistance would bebest. This process is called “vectoring”– it’s how DAF Mental Health clinics
ensure Service Members receive the best care they need for their struggles(see Chapter 6 for more details).

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CH AP T E R 3. S E E K IN G N O N - CL IN ICAL M E N TAL H E ALT H AS S ISTAN CE

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Bringing Clinical Mental Health (MH) clinicians into units, close to
warfighters and command teams, create unique opportunities to provide
agile and responsive support to missions while also helping MH clinicians
get a better understanding of the mission that Service Members aresupporting. In the DAF, most embedded care occurs under the Integrated
Operational Support (IOS) program. Despite being clinical MH clinicians,
most of the time these embedded clinicians are delivering non-clinical MH
care for Service Members with non-clinical MH concerns (see Chapter 1 fordetails). Embedded MH clinicians may engage in something called “limited
scope counseling” for low acuity concerns that are not expected to impact
readiness (see Chapter 7 for details). When an embedded MH clinician
detects elevated concerns, they will typically recommend the Service
Member go to the MH clinic for vectoring to determine what level of careis needed (see Chapter 6 for details). In addition to providing non-clinicalmental health support, embedded MH clinicians engage in commandconsultation, unit education & training, application of healthy behaviors, andmonitor trends in unit mental health.

CHAPTER 4

To reduce unanticipated or unnecessary readiness impacts, embedded
MH clinicians can assist Service Members with non-clinical MH concerns
through a service called “Limited Scope Counseling.”

Embedded Mental Health18

CH AP T E R 4. E M BE DDE D M E N TAL H E ALT H

19

CHAPTER 5

Being Evaluated forClinical Mental Health Care

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There are five basic ways that a Service Member might arrive at a Mental
Health (MH) clinic. Going to a MH clinic doesn’t necessarily mean someone
has a clinical mental health disorder or needs clinical mental health care
– so this chapter focuses solely on the logistics of getting to the clinic. The
next chapter will review more about receiving clinical mental health care.
The five most common ways a Service Member might engage their MH
clinic are:1.

Independently walk-in or call for an appointment

2.

Referral from another clinician

3.

Self-Initiated/Supervisor-Facilitated (via the Brandon Act)

4.

Command Directed Evaluation due to concerns about member’s
mental health and its potential impact on the mission

5.

As required for a clearance or special duty

INDEPENDENTLY WALK-IN OR CALL FOR AN APPOINTMENT OR REFERRAL FROMANOTHER CLINICIAN
Service Members can typically walk into the MH clinic or call the MH
clinic directly. Some MTFs require use of a central appointment line orengagement with Primary Care to obtain a referral. Sometimes otherclinics like the Alcohol and Drug Abuse Prevention and Treatment (ADAPT)Program or the Family Advocacy Program (FAP) will refer members to the
MH clinic for additional care. Regardless, upon initial contact with the MH
clinic, individuals are briefly assessed to identify their presenting concerns.
Mental Health clinics use a targeted approach to ensure Service Members
are “vectored” to the most appropriate resource(s) based on theirpresenting concerns or issues. Thus, Service Members may be vectored to
one of the non-clinical/non-medical resources listed in previous chapters if
their condition is not clinical (i.e., not a disorder).
SELF-INITIATED/SUPERVISOR-FACILITATED (VIA THE 2020 BRANDON ACT)
Service Members may request supervisor support when seeking voluntary
MH care. They start the referral process by talking to their Commanderor Supervisor (E-6 or above), who will contact the MH clinic and facilitate
scheduling a voluntary appointment for them. Once at the MH clinic, theprocess is basically the same as arriving independently, Service Members
will be vectored into clinical or non-clinical MH Care. The two differencesare (1) that the vectoring interview will include some extra questions(“triage”) with an “eyes-on” from a licensed provider and (2) if their

22

Commander/Supervisor calls the MH clinic to confirm their Service Member
attended the appointment they helped them book, the MH clinic is required
to confirm their attendance. Command notification is not otherwise required
unless there is a safety, readiness, or duty concern (which is always true
regardless of how a Service Member arrives at a MH clinic).
COMMAND DIRECTED EVALUATION DUE TO CONCERNS ABOUT MEMBER’SMENTAL HEALTH AND ITS POTENTIAL IMPACT ON THE MISSION
In accordance with DoDI 6490.04 and AFI 44-172, Service Members
may be involuntarily referred to the MH clinic by their Commander,
supervising officer, or civilian equivalent, due to a “MH concern” relatedto: (1) the safety of the Service Member or others; or (2) the Service
Member’s MH is adversely impacting mission readiness. The use of thephrase “MH concern” is intentional. Something is causing a Commander
to be concerned – Command is not making a diagnosis. Instead, they
are seeking expert help to determine if what they are concerned about
represents a clinical MH disorder that warrants additional action. When theconcern is related to safety, an “Emergency Command Directed Evaluation”(E-CDE) is executed promptly in an emergency setting. When the concern
is limited to readiness only, a “Command Directed Evaluation” (CDE) is more
appropriate and can be scheduled in the MH clinic as the next available
intake. Neither of these types of evaluations automatically indicate that aService Member has a mental health disorder – they are simply tools thatenable Commanders to refer the member for appropriate evaluation bytrained Mental Health experts. In these circumstances, a command directed
mental health evaluation has the same status as any other military order.
Additionally, although command directed evaluations are NOT voluntary,treatment is always voluntary.
AS REQUIRED FOR A CLEARANCE OR SPECIAL DUTY
Service Members may voluntarily request a psychological evaluation as partof a clearance for a variety of reasons: deployment, PCS, cross training, oran AFSC specific MH clearance outlined by the SPECAT Guide. In this casethe Service Member will complete a one-time evaluation in the MH clinic todetermine if they can participate.

CH AP T E R 5 . BE IN G E VAL UAT E D F O R CL IN ICAL M E N TAL H E ALT H CAR E

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CHAPTER 6

What to Expect From
Clinical Mental Health Care

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VECTORINGINITIATING CLINICAL CARE

Upon initial contact with the Mental Health (MH) clinic (phone call or walkin), Service Members (who are NOT yet considered a patient) are firstassessed, typically by a DAF MH technician, to understand the individual’spresenting concern. The primary goal is to determine if the concern
is clinical or non-clinical. If their concerns are non-clinical, the Service
Member is “vectored” to the optimal non-clinical resource. For example, if
someone is stressed about their finances, they will be vectored to finance.
Talking about not getting paid is less effective at reducing stress thanactually being paid.

If Service Members have symptoms that might represent a mental healthdisorder, they will be vectored into the clinic for further evaluation (alsocalled “triage”) to help determine the most appropriate next steps and to
confirm that they require clinical MH care. After this initial evaluation the next
step is to schedule an intake.

Vectoring is a critical safety net for Service Members, the mission, and the
MH clinic. It prevents normal struggles from being treated like disorders.
Just like it would be inappropriate to call a bruised knee a fracture, it is not
appropriate to call the normal struggles of life a “MH Disorder.” It would beeven more inappropriate to put screws in someone’s knee and cast them ifthey were only bruised. The same is true in Mental Health – it would not beappropriate to start a medication or dive into therapy for troubles associatedwith daily life. This approach also protects the mission. In the past decade,
80% of the Service Members who presented to DAF MH clinics didn’t
have a MH Disorder [AFMED Data Analysis, 2023]. How can this be? A
MH Disorder, requires evidence of “significant psychological distress and/or social/occupational dysfunction” [DSM-5-TR, 2023]. Most of the issues
that bring Service Members to the MH clinic do not reach these levels of
distress or dysfunction. They face real struggles – yes – but they don’t
have a MH Disorder. Overdiagnosing them would not only be unethical; itwould also result in a lot of unnecessary profiles. More importantly, it would
undermine trust in the MH clinic and compromise mission readiness. Lastly,
vectoring ensures the clinic has the space to support clinical MH patients.
If a MH clinic is going to provide clinical MH care to the 20% of Service
Members who present with a MH Disorder that requires the clinic to havetime for their clinical patients.
Service Members do not need to worry about trying to figure out if
something is clinical or not before going to the MH clinic. It can be very
challenging to figure this out – the MH clinic is expertly trained to vector
Service Members to the best resource. It’s our job!
If a Service Member who does not have a clinical MH disorder insists onbeing seen by the MH clinic versus another non-clinical helping agency,
they will not be turned away from the MH clinic, but this care will be limited
to brief non-clinical MH care. Anything longer would require re-evaluation
for a MH disorder.

26

During the intake, which can be the same day or up to a few weeks later,
depending on severity and space in the clinic’s schedule, a much morethorough evaluation will be completed. An intake requires reviewing theentire medical record and typically more than an hour of interviewing.
Upon completion, the diagnosis, treatment goals, modality of treatment(e.g., group therapy, individual therapy, couple’s therapy, family therapy,
and/or medications), and expectations for length of treatment are typically
discussed. Clinical MH treatment has a strong focus on achieving
remission – which means no longer meeting criteria for having a clinical
MH disorder. As such, treatment goals will typically include improving
functionality at home & work, fitness & suitability for service, andrehabilitating duty-impairing symptoms.
Evidence-based treatment groups will be recommended for most patients.
Group therapy is a scientifically supported stand-alone treatment toeffectively address most symptoms and conditions. Group therapy promotessocialization, enhances communication, and allows participants to develop
a sense of belonging. Whether patients are dealing with depression,anxiety, sleep issues, or any other mental health disorder, a group setting
tends to contribute to improved sense of hope and offers the patients anopportunity to learn from others in attendance. Additionally, group sessions
can help individuals learn about themselves as they hear and understandmore about other people’s struggles, which in turn helps them see thingsfrom a different perspective and therefore increases their self-awarenessand self-acceptance.
Individual treatment is typically reserved for patients who, due to their MH
disorder, are not ready for a group setting. Some patients may require
individual therapy in addition to group therapy. This will be determinedwith each patient individually. The essential item to remember is that the
primary goal of the MH clinic is to provide the best individualized care foreach patient to help them get back to health. To accomplish this goal, MH
clinicians will collaborate with patients to develop the best plan for theirneeds. Occasionally this requires individual therapy – but more often than
not it requires processing fears, frustrations, and expectations regarding apatient’s MH disorder and their treatment.

CH AP T E R 6. W H AT TO E XP E CT F R O M CL IN ICAL M E N TAL H E ALT H CAR E

27

As such, active engagement in care is vital. MH clinicians know symptoms
can make this challenging, but they will work with each patient to reduce
their symptoms to get to the core of their struggles. Treatment is acollaborative effort between each patient and their clinician, sharing
thoughts and opinions is critical. If something doesn’t make sense, patientsare empowered to ask questions.
SAFETYIn mental health, the term “safety” has a very specific meaning – threat
to self or others, to include the military mission and national security. If aService Member is having thoughts of “wanting to kill themselves” andindicates intent to act on these thoughts, the clinician is obligated to help.
Most of the time suicide risk can be effectively managed in the outpatient
clinical setting; this means developing a safety plan with the patient andtheir command. Occasionally, it involves inpatient hospitalization whenacute risk is present. If a patient threatens serious bodily harm to anotherperson, clinicians are required by law to initiate precautions to protect those
involved, to include contacting law enforcement and notifying any identified
potential victims. Action is also necessary if a patient presents withpsychiatric symptoms that make it difficult to predict behavior (e.g., hearing
or seeing things that are not really there, and/or acting in unintendedways). In this situation, clinicians would recommend hospitalization to keep
everyone safe until the patient is stabilized. It is important to understand thatthe intention of these efforts is to keep the Service Member, other people,
and the mission safe.

MENTAL HEALTH CARE FOR GUARD/RESERVE MEMBERS
Guard/Reserve Members may access Directors of Psychological Health(DPH) affiliated with the Guard/Reserve Medical Unit (GMU/RMU) for
vectoring of Mental Health concerns to ensure appropriate support ateither the non-clinical or clinical level. Guard/Reserve Members on orders
are eligible for emergency care and those on orders for 30 days or moreare eligible for routine care. If continued care is needed after orders have
expired, care will be coordinated by the treating provider and may beenhanced by the DPH at the GMU or RMU. If the condition is potentially
service related the treating provider shall coordinate with the GMU / RMU
for line of duty evaluation.

WHAT IF TREATMENT DOES NOT RESULT IN REMISSION?
A minority of patients will not be able to achieve remission within a year
(12 months). These patients will need to be reviewed for retainability. Somewill be retained; perhaps the diagnosis was complex and took months todetermine, or care was delayed due to a medical illness, etc. Some willneed to be medically retired or discharged (indicating that it is unlikely they
will get better), but this is not the norm, this is the exception. For more on
this topic see the next chapter on MH Standards.

This is what “suicidal ideation” specifically means. It’s not wanting
to disappear or to die – it’s the thought and desire to kill oneself.

1

28

CH AP T E R 6. W H AT TO E XP E CT F R O M CL IN ICAL M E N TAL H E ALT H CAR E

29This diagram provides an overview of all the steps
described in this chapter.

RETURN TO DUTYFIRST CONTACT
Phone/In Personwith BH

INITIALSCREENING(VECTORING)ENCOUNTER
More info
needed?

CASE CLOSURE

NON-CLINICALMH CAREREMISSION

VECTORED TO:

Additional triage
questions

EVIDENCE-BASEDGROUP
CLINICALMH CARE(MH CLINIC)

Unable to meettreatment goals
for > 365 days
OR
Concern thatsituation will never
be compatible with
continued service

INTAKEINDIVIDUAL
THERAPY

NO RESPONSE
TO TREATMENT

ADJUST
TREATMENT PLAN

30

MEDICALEVALUATIONBOARDSEPARATIONCH AP T E R 6. W H AT TO E XP E CT F R O M CL IN ICAL M E N TAL H E ALT H CAR E

31

CHAPTER 7

An Overview of
Mental Health Standards

33

HOW DO STANDARDS APPLY TO MENTAL HEALTH DISORDERS?

HOW ARE PROFILES COMMUNICATED TO COMMANDERS?

If a patient’s symptoms meet the criteria for a mental health (MH) disorder,
they will typically be placed on a profile and provided treatment for
their disorder with the goal of achieving remission so they can come
off the profile. A profile is also required when a patient is psychiatrically
hospitalized or attempts suicide.

The Airman and Guardian Availability Management (AGAM) system is
a communication tool between medical providers, ill or injured Service
members, and their supervisors or Commanders use to initiate andmanage a profile. This system will send a notification to the command
team indicating that one of their Service Members is on a profile, theanticipated length of the profile, and any specific mobility or duty
limitations recommended by the clinician. A Service Member’s diagnosis,
treatment plan, and other detailed information is not visible to the patient’s
command team.

A profile is a recommendation that clinicians make to a Commander tocommunicate potential risks and ways that Commanders can support
Service Members. For example, if a Service Member is struggling tofocus and forgets to correctly tighten a bolt on an airplane, people could
be injured. That’s risk. While Service Members are enrolled in treatment,
profiles can also help protect against major disruptions in treatment
caused by deployments or PCS activities. However, only Commanders
can authorize the profile – so if a profile recommendation isn’t made, it ischallenging for them to protect their member and their mission.
Some mental health conditions can be .severe enough to impact apatient’s ability to do their job, even in a non-deployed setting. Whenconditions reach this level, a mobility profile is initiated to allow the Service
Member to focus on their treatment and preserve mission capabilities.
Duty profiles can include many duties – but some commonly impacted
duties include arming, use of force, flight status, Personnel Reliability
Program, and Top-Secret clearance. Many MH patients can deploy,treatment would not be impacted by a Permanent Change of Station, andthey can do their job without difficulty. In these instances, the MH clinic willcommunicate to Commanders that the patient will require a Deployment
Waiver (DW) to deploy. This is not a profile – it’s just a pre-emptive
notification of which Service Members will need a waiver to deploy.
Specific details can be seen in the figure on page 36.
A common concern among Service Members is that seeking mental
health care will have significant or permanent impact on their career.
This is typically not the case, as most mental health disorders can beeffectively treated or “cured” (i.e., go into “remission”). For example, 92%of patients living with PTSD go into remission after completing 12 sessionsof evidence-based therapy [Galovski, 2012]. The MH clinic’s mission is tohelp patients achieve remission as quickly as possible, so they can returnto health, their profile can be removed, and they can fully return to work.
In fact, if the profile is entered appropriately and in a timely manner, it iseasier to demonstrate remission via the removal of the profile. It is much
more difficult to prove that a patient is doing better and is ready to deploy,
when their care has not been documented clearly.

34

As a best practice, clinicians will often request permission from theirpatients to talk to their patient’s Commander beyond what is accomplishedthrough ASIMS. The goal is to gather more information about the patient’s
struggles, set expectations and answer questions the Commander might
have regarding profiles, and to explain to the Commander how they
can support their member. While it’s only required that clinicians call
Commanders for specific situations regarding risk [DoDI 6490.08], thisadditional optional communication is highly encouraged as it improves theclinician’s ability to accurately understand their patient’s struggles while
also ensuring command can effectively support their Service Members.
WHAT IF TREATMENT DOES NOT RESULT IN REMISSION?
If a Service Member’s MH disorder does not go into remission after ayear of treatment, or if they experience a serious mental health event(e.g., suicide attempt, multiple hospitalizations) there is a possibility that
the Service Member may not be able to stay in the military. This is NOT
something a MH clinician determines. The clinician must first discuss thecase with a local group of independent clinicians - the Airmen Medical
Readiness Optimization (AMRO) Board. If the AMRO board determinesa Service Member likely cannot remain in the military, based on their
medical or Mental Health condition(s), their case is referred for anotherformal review to obtain a secondary objective opinion. This second
opinion results in a recommendation to the Service Member’s Commander.
Possible recommendations include that the Service Member be (1)retained in DAF, (2) medically separated, or (3) administratively separated[Additional details are available on page 36]. When a Service Member is
medically separated, a Military to Veteran’s Affairs (M2VA) representative
will contact the Service Member to ensure a smooth transition to the
Veteran’s Administration (VA) for continued mental health care.

CH AP T E R 7. AN OVE RVIE W O F M E N TAL H E ALT H STAN DAR DS

35

CAN THIS MEMBER DEPLOY/PCS? (DW POSSIBLE?)CAN THIS MEMBER FULLY DO THEIR JOB? (CODE 31)
CAN THIS MEMBER BE RETAINED? (CODE 37)
FURTHER GUIDANCE
Disorders / Situations that do not meet retention standards - retention is unlikely
QlA

Schizophrenia Spectrum and Other Psychotic Disorders as definedin the current DSM.

U

U

N

QlB

Bipolar and Related Disorders, as defined in the current DSM.

U

U

N

QlC

Mental disorder(s) requiring use of lithium, anticonvulsants, or
antipsychotics beyond 6 months.

U

U

N

Member will need to be placed on a Code 31 in AGAM by clinician. Clinician should
begin narrative summary promptly and present case to the AMRO Board. AMRO
Board will likely elevate to a Code 37. Retention is unlikely. Waiver to deploy is notpossible. Note that the 6 months are not provided as a means for trialing these
medications, but to provide time to stop unnecessary medications before a full iRILO
is indicated.

Disorders / Situations that do not meet retention standards - retention is possible
Q2A

DSM disorders causing or expected to cause duty/mobility
restrictions (see Q3B-C Criteria) for greater than 12 months.

P

P

U

Q2B

DSM disorders resulting in more than one psychiatric hospitalization.

P

P

U

Q2C

Requires care at least every 3 months from a specialty Mental
Health provider for greater than 12 months.

P

P

U

Q2D

Any suicide attempt/behavior in the past 12 months.
P

P

U*

Member will need to be placed on a Code 31 in AGAM by clinician. Clinician should
start narrative summary, and present case to the AMRO Board. If likely to improve
expect a request for an iRLIO and continued Code 31. If unlikely to improve, expect arequest for an MEB and elevation to a Code 37. If AMRO recommends a Code 37 andthe disorder is a Neurodevelopmental or a Personality Disorder, a recommendation for
Admin Sep is indicated rather than an MEB. Waiver to deploy is unlikely.
If diagnosis substance related, ADAPT will engage command directly.
In addition to the above, following any AD suicide attempt, the MTF SGH will convene
an ad hoc AMRO Board (including at least one MH provider) to determine if an iRILO
is needed. ARC members will always require a fitness for duty evaluation.
*Note: This is “strictly disqualifying” for a DW to CENTCOM.

Disorders / Situations that meet retention standards but not deployment standards - waiverto deploy is possible

Q3A

Any psychiatric hospitalization in the past 12 months.

Y

P

P*

Q3B

Concurrent use of 3 or more psychotropic medications.

Y

P

P

Q3C

Currently meeting criteria for any DSM Disorder(s) (F-Prefix) not inremission as documented in last encounter.

Member will need to be placed on Code 31 in AGAM for 3 months by clinician.
Clinician should review duty of deployment/PCS limitations with AMRO (informally).
Clinician should reevaluate with AMRO every three months. At 12 months see
guidance for Q2 criteria.

Y

P

P

*Note: PACAF requires 24 months prior to allowing PCS/Deployment.

*Note: Waiver to deploy to CENTCOM is required if remission is accomplished via
a Schedule II-IV medication (ex: Ritalin). This is because it is difficult to get these
medications to theater.

Disorders / Situations that meet retention standards and deployment standards
Q4A

Currently meeting criteria for any DSM Disorder(s) (F-Prefix) inremission for at least 3 months with treatment as documented inlast encounter.

Y

Y

P*

Q4B

History of any DSM Disorder (F-Prefix) in remission for at lest 3
months without treatment as documented in last encounter.

Y

Y

Y

Q4C

Currently meeting criteria for any Z or T-Prefix DSM Diagnosis.

Y

Y

Y

Y YES

36

P POSSIBLEU UNLIKELY

For patients on flight / special duty status, refer to flight med.
For patients on flight / special duty status, refer to flight med.

N NO

CH AP T E R 7. AN OVE RVIE W O F M E N TAL H E ALT H STAN DAR DS

37

PROJECT LEAD
Lt Col Eric Meyer
CONTRIBUTORSCONCLUSION

Lt Col Christopher “Todd” Anderson
Lt Col Christopher Button
Col Angelica EscalonaThis guide has introduced many, but not all, of thecomplexities hidden behind the simple phrase “mental
health.” Some key things to remember:••

Most Service Members who are struggling withmental health do not have a MH Disorder.
Most of the resources to help are non-clinical.

Col Jennifer Gillette
SMSgt Kody Parsons
Lt Col Jennie Sheffield
REVIEWERS
Lt Col Corey Carnes
CMSgt Tangyeniika Clemmons•

Getting help early and often prevents the need forclinical mental health care.

Lt Col Saul Freedman
Dr Elizabeth Harwood

The goal is to promote wellness behaviors and preventor mitigate mental health disorders before they occur.

Lt Col Kevin Hooker
Col Christian Smith
Lt Col Kim Sunderland
SMSgt Allen Walton
Lt Col Seth Wilson

38

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DAF SG Public Affairs

FOR MORE INFORMATION:
Please contact your local military mental health clinic.