Operation lraqi Freedom (01F-11) 

Mental Health Advisory Team (MHAT-II) 

REPORT 

30 January 2005 

Chartered by: 

The U.S. Army Surgeon General 

The views expressed in this report are those of the Operation lraqi Freedom 

Mental Health Advisory Team members and do not necessarily represent the 

official policy or position of the Department of Defense, the U.S. Army, or the 

Office of The Surgeon General. 
TABLE OF CONTENTS 


Page 

OPERATION IRAQI FREEDOM (01F-11) MENTAL HEALTH ADVISORY TEAM 

EXECUTIVE SUMMARY ............................................................................................3 


OPERATION IRAQI FREEDOM (01F-11) MENTAL HEALTH ADVISORY TEAM 

REPORT .....................................................................................................................7 


APPENDIX 1: MENTAL HEALTH ADVISORY TEAM CHARTER ...........................26 


ANNEX A: MENTAL HEALTH AND WELL-BEING OF SOLDIERS ......................A-I 


ANNEX B: BEHAVIORAL HEALTHCARE SYSTEM ASSESSMENT .....................B-1 


ANNEX C: EVACUATION ASSESSMENT ..............................................................C-I 


ANNEX D: SUICIDE ................................................................................................D-I 


ANNEX E: INTERNMENT FACILITY SOLDIER ASSESSMENT ............................E-I 


ANNEX F: INTERNMENT FACILITY DETAINEE ASSESSMENT ..........................F-1 


ANNEX G: MENTAL HEALTH ADVISORY TEAM (MHAT-I) ISSUES AND 

RECOMMENDATIONS MATRIX ..............................................................................G-I 


ANNEX H: MENTAL HEALTH ADVISORY TEAM SUPPORTING 

DOCUMENTS ...........................................................................................................H-I 


APPENDIX 1: MENTAL HEALTH ADVISORY TEAM MEMBERSHIP .........H-3 


APPENDIX 2: MENTAL HEALTH ADVISORY TEAM ITINERARY ..............H-4 


APPENDIX 3: GLOSSARY OF TERMS AND ACRONYMS .........................H-5 

OPERATION IRAQI FREEDOM (01F-Ill 

MENTAL HEALTH ADVISORY TEAM 

EXECUTIVE SUMMARY 

INTRODUCTION 

The Office of The Surgeon General (OTSG) established the Operation Iraqi Freedom 

(OIF-ll) Mental Health Advisory Team (MHAT) in July 2004 to follow up on the OIF-I 

Mental Health Advisory Team, to assess OIF-ll related mental health (MH) issues, and 

to provide recommendations. The MHAT-II conducted a comprehensive assessment of 

the OIF-ll behavioral healthcare (BH) system, focusing its assessment and 

recommendations on three broad areas and the OIF-ll Suicide Prevention Program (see 

below). 

(1) The BH needs assessment of the OIF-ll area of operations (AO) 

(2) The BH delivery system of the OIF-ll area of operations 

(3) The BH training requirements of the OIF-ll area of operations 

(4) Implementation of the MHAT-I recommendations for the OIF-ll area of 

operation Suicide Prevention Program 

FINDINGS 

The MHAT-II found that like OIF-I Soldiers, OIF-ll Soldiers are experiencing numerous 

combat stressors. However, noncombat deployment stressors related to quality of life 

have shown considerable improvement since OIF-I. Deployment length remains a top 

concern for OIF-ll Soldiers. Fifty-four percent of OIF-ll Soldiers reported their unit 

morale as low or very low. However, unit morale was significantly higher in OIF-ll 

compared with OIF-I, when 72% of Soldiers reported low or very low unit morale. 

Mental health and well-being improved from OIF-I to OIF-ll, reflected by a lower 

percentage of Soldiers who screened positive for a MH problem in OIF-ll compared with 

OIF-I (1 3% vs. 18%, respectively). Acute or posttraumatic stress symptoms remain the 

top MH concern, affecting at least 10% of OIF-ll Soldiers. Soldiers in transportation and 

nonmedical combat service support (CSS) National Guard and Reserve units had 

significantly higher rates of MH problems and lower perceptions of combat readiness 

and training than Soldiers in other units. 

The OIF-ll behavioral healthcare system has improved compared with OIF-I. Most BH 

personnel in theater report conducting outreach on a regular basis. Coordination is 

occurring between BH personnel, Unit Ministry Teams (UMTs), and primary care 

providers (PCPs). The BH return-to-duty (RTD) rates are high and comparable to 

OIF-I. Both the number of BH personnel in theater and the ratio of BH personnel to 

Soldiers are higher in OIF-ll than in OIF-I. Behavioral health personnel are more evenly 

distributed in OIF-ll than in OIF-I. Combat stress control (CSC) units, medical 
companies with MH sections, and combat support hospitals (CSHs) can manage 

routine and surge period demands for holding Soldiers with BH problems. 

Forty percent of Soldiers with MH problems reported receiving professional help during 

the deployment. This was significantly higher than the 29% of Soldiers with MH 

problems who received professional help in OIF-I. Stigma and organizational barriers 

to receiving care remain concerns for Soldiers. Forty-one percent of Soldiers surveyed 

reported that they had received adequate training in handling the stressors of 

deployment. This was significantly higher than the 29% of Soldiers who reported 

receiving adequate training during OIF-I. 

There was no significant difference between the prevalence of BH disorders among 

Soldiers in custodial positions in detainee operations and those of other Soldiers 

surveyed in OIF-ll. Custodial staff members shared stressors in common with OIF-ll 

peers. Behavioral health care was conducted in accordance with combat and 

operational stress control (COSC) doctrine. Insufficient training in correctional BH 

diminished optimal support for custodial staff. 

The majority of OIF-I Mental Health Advisory Team recommendations has been 

implemented or is in the process of being implemented. Opportunities for improvement 

still exist in the OIF-ll behavioral healthcare system. While coordination between BH 

care personnel, UMTs, and PCPs is good, coordination could increase between these 

three professional groups. Significant challenges remain in providing BH care. Two 

thirds of Soldiers reported receiving training in handling the stresses of deployment 

andlor combat, and less than half reported the training in managing the stress of 

deployment was adequate. Most BH personnel received pre-deployment refresher 

training in BHICOSC tactics, techniques, and procedures, but reported additional 

training is needed. Standards of care, documentation management, and statistical 

reporting methods were unclear to some BH personnel. Behavioral health care 

personnel are using multiple methods to assess the BHICOSC needs of Soldiers and 

units; a standardized needs assessment process needs to be implemented. 

For the same 7-month period (1 March-30 September 2004), 23% fewer Soldiers were 

evacuated for BH problems in 2004 than those evacuated in 2003. Evacuation 

procedures and policies have matured as evidenced by written standing operating 

procedures (SOPS), increased accountability, efficient information tracking, and 

improved transmission of clinical information between levels of care. 

The community-based Army Suicide Prevention Program (ASPP) objectives have been 

adapted and a unit Suicide Prevention Program is evident at all OIF major commands 

of the combat units in Iraq as recommended. The January-December 2004 suicide rate 

for Soldiers deployed in OIF-ll was 8.5 per 100,000, which is lower than Calendar Year 

(CY) 2003 and recent Army historical rates. 
RECOMMENDATIONS 

Continue to improve awareness of MH issues, access to care, and efforts to 

reduce stigma. Considerations include: 

a) Emphasizing the role of leaders at all levels in facilitating recognition of 

MH concerns, training in handling the stresses of deployment, and encouraging 

the use of available resources. 

b) Assuring that there is accessible MH support to all units throughout the 

theater. 

c) Where feasible, integrating MH care with primary care in troop medical 

clinicslbattalion aid stations (BASS) so that MH care becomes routine in these 

settings. 

Develop and assess the effectiveness of standardized training modules to 

prepare Soldiers to handle the psychological demands of deployment and 

combat-related stressors throughout the deployment cycle. Establishlmaintain 

deployment policies that support Soldier morale and well-being across various 

forward operating bases (FOBS). Improve Soldier and leadership training in BH 

issues. 

Continue to support BH services to Soldiers by: 

Continuing forward-deployed outreach to facilitate Soldier access to BH 

services. 

Ensuring all BH personnel can provide (with supervision and medical 

support) the full range of BH services. 

Completing the development and fielding of a Unit Needs Assessment 

Program and Survey Tool. 

Utilizing an empirically derived staffing model for BH personnel allocation 

and distribution. 

Publishing the updated field manual (FM). 

Completing the development of the Behavioral Health COSC Course. 

Researching and developing a program for burnout and compassion 

fatigue. 

Continue BH services to Soldiers in Detainee Operations in accordance with COSC 

doctrine and MHAT-II staffing recommendations. Supplement COSC doctrine with 
training in specific stressors unique to corrections and in best practices to provide care 

to custodial staff. Consider parallel BH programs for Soldiers and detainees. 

Continuously assess how well the BH needs of families are being met in the rear. 

Continue existing (community-based) objectives of the ASPP for OlF Soldiers and units 

during pre-deployment, deployment, and re-deployment. Continue monitoring and 

reporting of completed suicides and serious suicide attempts with the Army Suicide 

Events Report (ASER). 

Continue the appointment of a TheaterIArea of Operation BH consultant to advise 

The Surgeon on BH issues. 
OPERATION IRAQI FREEDOM (01F-Ill 

MENTAL HEALTH ADVISORY TEAM 

REPORT 

INTRODUCTION 

The Office of The Surgeon General (OTSG) established the Operation Iraqi Freedom 

(OIF-ll) Mental Health Advisory Team (MHAT) in July 2004 to follow up on the OIF-I 

Mental Health Advisory Team, to assess OIF-ll related mental health (MH) issues, and 

to provide recommendations. The MHAT-II conducted a comprehensive assessment of 

the OIF-I behavioral healthcare (BH) system, focusing its assessment and 

recommendations on three broad areas and the OIF-ll Suicide Prevention Program (see 

below). 

(1) The BH needs assessment of the OIF-ll area of operations (AO) 

(2) The BH delivery system of the OIF-ll area of operations 

(3) The BH training requirements of the OIF-ll area of operations 

(4) Implementation of the MHAT-I recommendations for the OIF-ll area of 

operation Suicide Prevention Program 

This report contains the MHAT-ll's key findings and its recommendations. 

This report consists of three major parts: 1) the OIF-ll Mental Health Advisory Team 

Executive Summary, 2) the OIF Mental Health Advisory Team Report, and 3) the 

Annexes to the OIF-ll Mental Health Advisory Team Report. The annexes contain the 

assessment methodologies, results, and recommedations for the BH system. 

CONVENTIONS 

The OIF-ll Mental Health Advisory Team referred to the BH system when discussing its 

findings. The BH continuum of care encompasses not only traditional mental health 

(MH) care efforts but also many efforts of a primary and secondary prevention nature 

that have traditionally not been counted as MH services. To avoid confusion, the MHAT 

will designate all of these services as BH services. 

Also, many preventive interventions are referred to as combat stress control (CSC) 

services. Recently, the three services (Army, Navy, and Air Force) agreed to refer to 

these services as combat and operational stress control (COSC) services. The units 

are still referred to as CSC units; however, the services are COSC services. The MHAT 

also referred to behavioral healthcare providers. Table 1 defines those military 

personnel considered BH care providers. 
1 Table 1: Behavioral Healthcare Providers bv AOCIMOS 1

60W Psvchiatrists 

1 I I 65A 1 Occupational Therapists 

1 66C 1 Psvchiatric Nurses 

1 73A 1 Social Workers 

1 73B 1 Clinical Psychologists

1 91W191WN3 1 Health Care Specialists 

91X 1 Mental Health Soecialists 

OPERATION IRAQI FREEDOM (01F-11) MENTAL HEALTH ADVISORY TEAM 

REPORT 

REASON FOR THE MENTAL HEALTH ADVISORY TEAM (MHAT-11) 

At the request of the Multi-National Corps-Iraq (MNC-I) senior leadership, the Office of 

The Surgeon General (OTSG) established the OIF-ll Mental Health Advisory Team in 

July 2004 to follow up on the OIF-I Mental Health Advisory Team, to assess OIF-ll 

related MH issues, and to provide recommendations (See the Charter at Appendix 1). 

Specifically, the MHAT was directed to focus its assessment and recommendations on 

three broad areas and the OIF II Suicide Prevention Program (see below). 

(1) The BH needs assessment of the OIF II area of operations (AO) 

(2) The BH delivery system of the OIF II area of operations 

(3) The BH training requirements of the OIF II area of operations 

(4) Implementation of the MHAT-I recommendations for the OIF-ll area of 

operation Suicide Prevention Program 

For each of these factors, the MHAT assessed challenges associated with: 

(a) Command and Control. 

(b) Communications. 

(c) Resource Support. 

(d) Policies. 

THE MENTAL HEALTH ADVISORY TEAM ANALYSIS OF OBJECTIVES 

To consult with the BH leaders in OIF-ll and in the evacuation chain, the MHAT traveled 

to Kuwait, Iraq, and Landstuhl Regional Medical Center (LRMC) in Landstuhl, Germany. 
The MHAT left the Continental United States (CONUS) Replacement Center at Fort 

Bliss, Texas on 27 August 2004, and stayed in Kuwait and Iraq from 28 August until 18 

October 2004. 

In Kuwait, the MHAT consulted with the leadership of the Coalition Forces Land 

Component Command (CFLCC), thmedical Brigade, and combat units (see Table 

1>. 

Table 1: CFLCC lnterviews 

Medical 

MHAT consulted with the leadership of the Multi-National Corps-Iraq (MNCBrigade, and combat units (See Table 2). 

Table 2: NINC-I Interviews 

The team also collected data, with the help of researchers from United States Army 

Research Unit-Europe (USARU-E), from LRMC, Germany from 13-1 7 October. The 

team consulted with relevant local MH personnel and Army Medical Department 

(AMEDD) leadership. 
The MHAT approached this mission as an opportunity to reassess the Army BH system 

in an active combat campaign. The MHAT-II again used the Soldier Well-being Survey 

developed by the Walter Reed Army Institute of Research (WRAIR) under a research 

protocol, using established scales for which there are comparative data from other units 

(See Annex E, Appendix 6). 

The MHAT-II also assessed the BH system. The MHAT surveyed and interviewed BH 

providers, PCPs, Unit Ministry Teams (UMTs), and the command group's senior leaders 

in sampled units (see Tables 1 and 2). The instruments used in assessing the BH 

system are found in Annex B. The MHAT-II assessed the OIF-ll behavioral health care 

resources, services provided, training, coordination, application of CSC doctrine, 

medical evacuation system, and other factors. In addition, the 

MHAT-II assessed the status of OIF-ll suicide prevention efforts. 

The MHAT also examined systemic issues relative to the BH system. Particular focus 

was given to command and control of BH units, their ability to communicate horizontally 

and vertically, the adequacy of their resource support, and existing policies. 

FINDINGS 

FINDING #I. Like Olf-I Soldiers, Olf-11 Soldiers are experiencing numerous 

combat stressors. However, noncombat deployment stressors related to quality 

of life have shown considerable improvement since Olf-I. Deployment length 

remains a top concern for Olf-11 Soldiers. fifty-four percent of Olf-11 Soldiers 

reported their unit morale as low or very low. However, unit morale was 

significantly higher in Olf-11 compared with Olf-I, when 72% of Soldiers reported 

low or very low unit morale. 

Combat Stressors 

Operation Iraqi Freedom (OIF-ll) Soldiers reported higher rates of incoming 

rocket and mortar attacks than OIF-I Soldiers, and OIF-ll Soldiers also experienced the 

escalation of improvised explosive device (IED) attacks. However, combat experiences 

thought to be more likely to be associated with MH problems, such as seeing dead or 

seriously injured Americans, handling human remains, or killing an enemy combatant 

were all somewhat higher during the initial ground combat in OIF-I than in OIF-ll. 

Non-deployment Stressors 

The most frequently reported noncombat stressor in OIF-I was uncertain redeployment date, with 87% of Soldiers reporting high or very high trouble or concern. In 

OIF-ll, this item was endorsed at that level by only 41% of Soldiers. Many quality of life 

concerns such as lack of privacy, lack of personal space, and difficulties communicating 

back home were reported much less frequently in OIF-ll than in OIF-I. 
Deployment Length 

Long deployment length was the most commonly reported noncombat stressor in 

OIF-ll; 52% of Soldiers reported high or very high concern about this issue, 16% 

reported moderate concern, and 32% reported low or very low concern. 

Unit and Personal Morale 

The percent of Soldiers reporting low or very low unit morale was 54%, with 9% 

reporting high or very high unit morale, and the remainder reporting at the medium level. 

Although 54% of Soldiers reported their unit morale as low or very low, this was 

improved from the OIF-I survey, when 72% of Soldiers reported low or very low unit 

morale. The percent of Soldiers reporting low or very low personal morale decreased 

from 52% in OIF-I to 36% in OIF-ll 

FrNDrNG #2, Mental health and well-being improved from Olf-I to Olf-11, reflected by 

a lower percentage of Soldiers who screened positive for a MH problem in 

Olf-11 compared with Olf -1 (13% vs. 18%, respectively). Acute or posttraumatic 

stress symptoms remain the top MH concern, affecting at least 10% of Olf-11 

Soldiers. Soldiers in transportation and nonmedical combat service support 

(CSS) National Guard and Reserve units had significantly higher rates of MH 

problems and lower perceptions of combat readiness and training than Soldiers 

in other units. 

Soldiers Who Screened Positive for a MH Problem 

A lower prevalence of MH problems was reported by OIF-ll Soldiers compared 

with OIF-I Soldiers. In OIF-ll, 17% of Soldiers reported currently experiencing a 

moderate or severe stress, emotional, alcohol, or family problem, compared with 23% in 

OIF-I (pc.001) and 14% (pc.001) in a pre-deployment sample. Thirteen percent of OIFII Soldiers screened positive for acute stress/posttraumatic stress disorder (PTSD), 

depression, or anxiety compared with 18% in OIF-I (pc.001). 

Acute or Posttraumatic Stress Symptoms 

Acute stresdPTSD was the most prevalent condition (10%) compared with 15% 

in OIF-I (pc. 001). The distribution of diagnoses differed somewhat, with only 7% of 

Soldiers in Kuwait reporting acute stresdPTSD compared with 1 1 % in Iraq. 

Transportation and Nonmedical CSS Mental Health Rates 

A higher rate of screening positive for depression, anxiety, or acute 

stress/PTSD was observed among the transportation and support personnel (e.g. 

Forward Support Battalion (FSB) and Corps Support (CSB) units) compared with 

Soldiers in combat and other units. Overall, 17% of Soldiers from transportation and 

support units screened positive for one of these conditions compared with 13-14% of 
Soldiers from combat arms units, and 8% of all other unit types (pe.002). In lraq, 

transportation and support units had a prevalence rate of acute stresslPTSD of 19% 

compared with 11 % in combat units and 7% in other unit types. 

FINDING #3. The OIF-11 behavioral healthcare system has improved compared with 

OIF-I. Most BH personnel in theater report conducting outreach on a regular basis. 

Coordination is occurring between BH personnel, UMTs, and PCPs. Behavioral health 

return-to-duty (RTD) rates are high and comparable to OIF-I. Both the number of BH 

personnel in theater and the ratio of BH personnel to Soldiers are higher in OIF-11 than 

OIF-I. Behavioral health personnel are more evenly distributed in OIF-11 than OIF-I. 

Combat stress control units, medical companies with MHsections, and Combat Support 

Hospitals (CSHs) can manage routine and surge period demands for holding Soldiers 

with BH problems. 

Behavioral health personnel are conducting outreach services. 

Sixty-nine percent of BH personnel surveyed reported that they were conducting 

COSC outreach services either weekly or several times a week, and 71 % reported 

consulting with unit leaders once a week or more. Behavioral healthcare personnel 

reported they were actively involved in conducting educational classes, psychological 

debriefings, and suicide prevention training. They also indicated they were providing 

services at the Soldiers' worksite as well as their own. 

There is coordination between BH care personnel, UNITS, and PCPs. 

Seventy-eight percent of the PCPs reported on their survey that BH personnel 

had given them information about where to refer Soldiers for MH problems, and 76% 

reported they had received information about the services offered by BH personnel for 

Soldiers. Many chaplains (83%) reported they had received information from BH 

personnel on where to refer Soldiers for MH problems, and 88% reported that they had 

been educated on the services provided by BH personnel for Soldiers. 

Behavioral health RTD rates are high and comparable to 01F-1. 

All forward-deployed BH assets in OIF-11 lraq had high RTD rates (>95%, see 

Table 1, Annex B). The BH units (CSC units, Area Support Medical Battalions 

(ASMBs), Area Support Medical Companies (ASMCs), and CSHs) subordinate to them 

Medical Brigade in Iraq returned 86% of the diagnosed psychiatric outpatient and 

inpatient Soldiers to duty. 

Both the number of BH personnel in theater and the ratio of BH personnel 

to Soldiers are higher in 01F-11 than 01F-1. 

Last year (OIF-I), the overall ratio of BH personnel to Soldiers was 11851. As of 

1 October 2004, 232 BH personnel (see Table 1) are providing services to an estimated 

94,500 Soldiers in Kuwait and lraq, for a ratio of 11407-a ratio over twice that of OIF-I. 
Behavioral health personnel are more evenly distributed in 01F-11 than 01F-1. 

The OIF-ll ratios varied from 11160 to 11888 (with a standard deviation of 227), 

while the OIF-I ratio of BH personnel to Soldiers varied from zero (no BH personnel) to 

113,292 by region (with a standard deviation of 1,038). Further, 76% of Soldiers live on 

Forward Operating Bases (FOBS) where BH personnel are collocated. In general, as 

the size of the FOB population decreased, the number of BH personnel to Soldiers also 

decreased, and the variance in the distribution of BH personnel within each size 

category increased. 

Combat stress control units, medical companies with NIH sections, and 

CSHs can manage routine and surge period demands for holding Soldiers with 

BH problems. 

On both routine and on an emergent basis, "holding capacity" is available at CSC 

units and at brigade, division, and ASMCs. Each of the CSH slices are able to 

holdladmit Soldiers with BH problems on the intermediate care wards. Theater BH 

personnel interviewed indicated that, in general, a Soldier deemed to require an 

inpatient level of care is only held long enough to be stabilized, evaluated, and prepared 

for evacuation out of theater. All of the CSHs have partnered with CSC units to provide 

synergistic BH treatment services. 

FINDING #Q: forty percent of Soldiers with MH problems reported receiving 

professional help during the deployment. This was significantly higher than the 

29% of Soldiers with MH problems who received professional help in Olf-I. 

Stigma and organizational barriers to receiving care remain concerns for 

Soldiers. forty-one percent of Soldiers surveyed reported that they had received 

adequate training in handling the stressors of deployment. This was significantly 

higher than the 29% of Soldiers who reported receiving adequate training during 

Olf-1. 

Soldiers Receiving Professional Help during the Deployment 

Although there was an increase in use of MH services among Soldiers with MH 

problems from OIF-I to OIF-ll, there was no evidence of changes in perceptions of 

stigma and other barriers among these Soldiers between OIF-I and OIF-ll. Among 

Soldiers who screened positive for depression, anxiety, or PTSD, 53% reported that 

their unit leadership might treat them differently, and 54% reported that they would be 

seen as weak. Organizational barriers to care, which leaders can potentially influence, 

included concerns that it would be too difficult to get to the location of BH services, 

reported by 20% of Soldiers with MH problems, difficulty getting time off from work 

(39%), and not knowing where to go for help (22%). These findings were almost 

identical to findings from OIF-I. 
Soldier Training in Handling Stress and Suicide Awareness 

Overall, 77% of Soldiers in OIF-ll reported that they had received suicide 

prevention training in the past year, and 69% reported that they had received training in 

handling the stresses of deployment and/or combat. Forty-eight percent of OIF-ll 

Soldiers surveyed reported that the training in identifying Soldiers at risk for suicide was 

sufficient (not different from the 45% who endorsed this in OIF-I). Although only 41 % of 

Soldiers reported that the training in managing the stress of deployment was adequate, 

this rate was higher than the rate of 29% reported by OIF-I Soldiers (p<.001). 

FINDING #5: There was no significant difference between the prevalence of BH 

disorders among Soldiers in custodial positions and those of other Soldiers 

surveyed in Olf-11. Custodial staff members shared stressors in common with 

Olf-11 peers. Behavioral health care was conducted in accordance with COSC 

doctrine. lnsufficient training in correctional BH diminished optimal support for 

custodial staff. 

Soldier Stress Levels and Prevalence of Behavioral Health Disorders 

The Soldier Health and Well-being Survey revealed that positive screenings for 

PTSD, anxiety, and depressive disorders among military police (MP) officers (and 

Soldiers in other military occupational specialties (MOSs) sewing as custodial staff) 

were equivalent to those for other Soldier MOSs in OIF-ll (see Annex A, Finding #4 and 

Figure 3 for further details). In focused group interviews, custodial staff reported 

comparable stressors to those of their OIF-ll peers. 

Behavioral Health Care Delivery 

Interviews with senior BH providers indicated that appropriate functional 

areas of COSC doctrine were implemented for Soldiers at the internment 

facilities. Custodial and medical staff descriptions of BH services confirmed 

sufficient adherence to COSC doctrine and availability of services. 

Training in Correctional Behavioral Healthcare 

lnsufficient training in correctional behavioral healthcare delayed providers in 

providing support as they familiarized themselves with correction's unique stressors, 

procedures, philosophies, and situations. 

FINDING #6: The majority of Olf-I Mental Health Advisory Team 

recommendations has been implemented or is in the process of being 

implemented. The Olf-11 behavioral healthcare system has improved (see finding 

#3). Opportunities for improvement still exist in the Olf-11 behavioral healthcare 

system. While coordination between BH personnel, UMTs, and PCPs is good, 

coordination could increase between these three professional groups. 

Significant challenges remain in providing BH care. Two thirds of Soldiers 
reported receiving training in handling the stresses of deployment and/or combat, 

and less than half reported the training in managing the stress of deployment was 

adequate. Most BH personnel received pre-deployment refresher training in 

BHKOSC tactics, techniques, and procedures, but reported additional training is 

needed. Standards of care, documentation management, and statistical reporting 

methods were unclear to some BH personnel. Behavioral health personnel are 

using multiple methods to assess the BH/COSC needs of Soldiers and units. A 

standardized needs assessment process needs to be implemented. 

Coordination between BH personnel, UNITS, and PCPs is valuable. 

All three groups are valuable resources for each other and together represent a 

force multiplier for Soldier support. Although the great majority of respondents indicated 

they were informed of where to refer Soldiers for BH care, increased coordination would 

further capitalize on the strengths of these three professional groups. 

Significant challenges remain in providing BH care. 

Forty percent of the BH personnel surveyed agreed that there was inadequate 

transportation to conduct outreach activities, 30% agreed that there was inadequate 

communication between BHICOSC and supported units, and 27% reported traveling to 

supported units was too dangerous. Although 40% felt that arranging convoys to 

supported units was not difficult, 21% reported having to cancel missions due to the 

inability to arrange convoys. 

Less than half of Soldiers trained in handling the stresses of deployment 

reported the training was adequate. 

Sixty-nine percent of the Soldiers reported they had received training in handling 

the stresses of deployment and/or combat, and 41 % reported that the training in 

managing the stress of deployment was adequate. (This rate was higher than the rate 

of 29% reported by OIF-I Soldiers (p< .001)). Twenty-three percent reported not 

receiving suicide training in the last year. Such training is vital given that a fellow 

Soldier is often turned to for support. 

Training of BH Personnel 

Behavioral health personnel were more confident in their training this year (OIF11) due to the pre-deployment refresher training they received, but there were still areas 

of identified need. Identified areas included cross-cultural (Iraqi) evaluation and 

treatment, Combat and Operational Stress Control Workload and Recording System 

(COSC-WARS), and sexual assault and substance abuse evaluation and treatment. 

Standards of Care, Documentation Management, and Statistical 

Reporting Methods 
Behavioral health personnel report a lack of clarity on clinical and 

administrative requirements. Fifty-seven percent of the BH personnel agreed 

that the standards of BH care in theater were clear. Just over half (53%) agreed 

that COSC service standards were clear. Of the BH personnel surveyed, only 

41% agreed that standards for clinical documentation were clear; 33% felt that 

the standards for records management were clear, and 35% that the transfer of 

clinical BH information between levels of care was clear. 

Standardized Needs Assessment Process 

Although BH personnel report talking informally to Soldiers (92%), medical 

personnel (77%), unit commanders (71%), and chaplains (71%) to gather data for a 

needs assessment, less than half use instruments of any kind. Forty-two percent 

conduct focus groups or locally developed surveys. Thirty-nine percent use validated 

surveys/instruments. 

FINDING #7. for the same 7-month period (I March- 30 September), 25% fewer 

Soldiers were evacuated for BH problems in 2004 than those evacuated in 2003. 

Similarly, evacuations for all medical-surgical problems fell 12.1% in the same 

time frame. Evacuation procedures and policies have matured as evidenced by 

written standing operating procedures (SOPs), increased accountability, efficient 

information tracking, and improved transmission of clinical information between 

levels of care. 

For the same 7-month period (1 March-30 September), 25% fewer Soldiers 

were evacuated for BH problems in 2004 than in 2003. 

Behavioral health accounted for only 6.1 % of all OIF-ll Army medical-surgical 

evacuations, falling from 7.1% from OIF-I. When compared with other medical-surgical 

specialties, BH was the fourth leading reason for evacuation in OIF-ll, falling from third 

in the year before. 

Evacuation procedures and policies have matured. 

The LRMC has made marked improvements in the evacuation procedures since 

the MHAT-I visit. The Deployed Warrior Medical Management Center (DWMMC) has 

completed its critical SOPs. Transmission of clinical information from OIF-ll to LRMC 

substantially improved from OIF-I (83.5% v. 44.8%). The BH records at LRMC were 

assembled in accordance with hospital SOPs. Clinical documentation at LRMC was 

forwarded to the next level of care in 92.7% of cases. Interviews with evacuees 

indicated that they were very satisfied with their care during the evacuation process. 

FINDING #8: The community-based Army Suicide Prevention Program (ASPP) 

objectives have been adapted, and a unit Suicide Prevention Program is evident 

at all OIf major commands of the combat units in Iraq as recommended. 
Surveillance of completed suicides with use of the standardized suicide event 

reporting has been implemented. The January-December 2004 suicide rate for 

Soldiers deployed in OIF was 8.5 per 100,000, which is lower than CY 2003 and 

recent Army historical rates. 

The community-based ASPP objectives have been adapted, and a unit 

Suicide Prevention Program is evident at all OIF major commands of the combat 

units in lraq as recommended. 

All major commands of the combat units surveyed in lraq indicated that they 

have a designated proponent to manage the suicide prevention program and had leader 

and Soldier suicide awareness training in the past year. 

Surveillance of Completed Suicides 

Army Suicide Event Reports (ASERs) for completed suicides for OIF-ll have 

been submitted as required, according to the ASER program manager. 

January-December 2004 Suicide Rate for Soldiers Deployed in Operation 

Iraqi Freedom 

The OIF 2004 confirmed suicide rate was 8.5 per 100,000 Soldiers. This rate is 

lower than the 2003 OIF rate of 18.0 per 100,000 and the Army average annual rate for 

the 9-year period 1995-2003 of 12 per 100,000. 
RECOMMENDATIONS 

Immediate Implementation 

1. Continue to improve awareness of MH issues, access to care, and 

efforts to reduce stigma. Considerations include: 

a) Emphasizing the role of leaders at all levels in facilitating 

recognition of MH concerns, training in handling the stresses of 

deployment, and encouraging the use of available resources. 
Leaders have a critical role in fostering unit morale and cohesion, and assuring 

that Soldiers have the equipment and training needed for mission success, sufficient 

recovery time, and training in how to best cope with the deployment stressors. Soldiers 

and leaders need training in how to recognize signs of operational stress and 

posttraumatic stress, and how they can receive help when needed, to include buddy aid, 

and medic, chaplain, and MH professional support, etc. Training should also include the 

fact that increased use of alcohol is associated with PTSD symptoms, which can lead to 

alcohol-related adverse behaviors. Leaders also play an important role in reducing 

organizational barriers to care, such as assuring that Soldiers get the needed time and 

have the means to get to a MH appointment. They may also be able to effect 

perceptions of stigma, although there is no research yet to support this. 

b) Assuring that there is accessible and visible NIH support to all units 

throughout the theater. 

This requires adequate equipment for division MH personnel and CSC teams 

to conduct outreach, establish predictable MH services at battalion levels, and provide 

adequate supervision to 91X mental health specialists or noncommissioned officers 

(NCOs) working remotely (e.g. availability of up-armored vehicles, communication), and 

location of personnel to assure that Soldiers have regular and predictable access to MH 

professionals. 

c) Where feasible, integrating NIH care with primary care in troop medical 

clinicslbattalion aid stations (BASS) so that NIH care becomes routine in these 

settings. 

Mental health care should become as routine as all other primary care. 

Considerations to facilitate this include utilizing the same facilities, entrances, and 

waiting areas that are used for routine medical care, as well as the same record keeping 

system used by PCPs, limiting the details of the MH notes to those necessary to assure 

continuity of clinical care and safety. It is also important to assure robust collaboration 

between MH professionals, chaplains, PCPs, and unit leaders. 

2. Develop and assess the effectiveness of standardized training modules to 

prepare Soldiers to handle the psychological demands of deployment and 

combat-related stressors throughout the deployment cycle. Establishlmaintain 

deployment policies that support Soldier morale and well-being across various 

FOBS. Improve Soldier and leadership training in BH issues. 

Standardized Training Modules 

Training Soldiers in suicide awareness and in dealing with the stresses of 

deployment has many potential benefits. Standardized training materials need to be 

further developed and applied before, during, and after deployment that teaches these 

skills to Soldiers and leaders. A particular emphasis should be given to educating 

Soldiers and leaders about the likelihood of posttraumatic stress symptoms following 
combat experiences, normalizing these symptoms, and providing education about the 

benefits of earlier treatment, the methods available, and information on how to access 

services if the symptoms are causing functional impairment. 

Soldier and Leadership Training in BH Issues 

Train Soldiers and leaders in how to crisis manage BH issues-suicidal ideation, 

homicidal ideation, recognition of combat and operational stress reactions, depression, 

hyper-anxiety, and PTSD. This training should be incorporated into officer and enlisted 

schools, ongoing officer and NCO development programs, and during pre-deployment 

and post-deployment briefings. Most importantly, this training must be skill-based and 

performance-focused. 

Deployment Policies and Soldier Morale and VVell-being 

Focus group data, consistently voiced throughout the theater, provided some 

insight into concerns that Soldiers have that might contribute to low perceptions of unit 

morale. Some things for leaders to consider to improve the morale related to issues 

that Soldiers raised in focus groups include: 

1) Uniform policies that are consistent, not overly restrictive, and meet the 

"common sense" test are important to Soldiers. 

2) Leaders should ensure that Soldiers are adequately informed, that policies are 

clearly expressed, that rumors are addressed, that Soldiers receive positive feedback, 

and that subordinates are allowed to seek clarification of orders or policies without their 

leaders responding defensively or considering the Soldiers disloyal. 

3) Leaders should emphasize the importance of not scheduling additional duties 

during downtime and should assure that Soldiers get sufficient rest to maintain optimal 

cognitive acuity (generally 7-8 hours sleep per 24-hour period). 

4) Leaders should assure that clear and consistent family emergency leave 

policies are communicated to Soldiers. 

3. Continue to support BH services to Soldiers by: continuing forward-deployed 

outreach to facilitate Soldier access to BH services, ensuring all BH personnel 

can provide (with supervision and medical support) the full range of BH services, 

completing the development and fielding of the Unit Needs Assessment Program 

and Survey Tool, utilizing an empirically-derived staffing model for BH personnel 

allocation and distribution, publishing the updated field manual (FNI), completing 

the development of the BH Combat and Operational Stress Control Course, and 

researching and developing a program for burnout and compassion fatigue. 

Forward Deployed Outreach 
Aggressive outreach may be one of the reasons for the increase in utilization of 

BH services (from 29% to 40% from OIF-I), and it should continue. Behavioral health 

personnel are better distributed in OIF-11 than in OIF-I. 

Behavioral Health Personnel Providing the Full Range of BH Services 

Personnel who conduct outreach at the unit level or are the sole provider at a 

particular location should be able to provide the range of services to include clinical 

evaluation and treatment, triage, referral to the next level of care, prevention, 

consultation, and education. Likewise, clinical staff at large FOBs (at CSHs, restoration 

units, etc.) should be able to provide outreach routinely. 

Needs Assessment Program and Survey Tool 

Last year, the MHAT recommended that a standardized needs assessment 

program and tool be developed and fielded to all BH assets. This need was recognized 

again this year. Walter Reed Army Institute of Research is in the process of completing 

development of such a tool. It is recommended that this tool be transitioned rapidly for 

widespread use. 

Empirically Derived Staffing Model 

Future staffing decisions need to take into consideration the operational 

environment in theater, the overall Army OPTEMPO, and other factors. Military 

planners need to tailor the BH force package based on the size of the force, the 

distribution of the force (number of FOBs), the amountltype of services desired in 

theater (see Annex B, Appendix 5, Tab A for full discussion of the staffing model), and 

the availability of personnel and resources to provide this staffing level. 

Publication of the Updated COSC Field Manual 

It is important that the CSC field manual (FM 8-51) be rewritten to reflect the 

many changes in Army and COSC practice and evolving doctrine noted in the OIF-I 

Mental Health AdvisoryTeam report. Those changes have been drafted by the MHAT 

for incorporation into the programmed successor to FM 8-51, FM 4-02.51. Changes 

noted in doctrine from this report should also be integrated into the draft and then 

published as quickly as possible. 

The BH Combat and Operational Stress Control Course 

The MHAT recommends the creation of an "all disciplines" COSC course. This 

Army Medical Department Center and School (AMEDDC&S) course will serve as a 

foundation course for all BH disciplines in combat and battlefield BH doctrine and 

practice. This course should be a requirement of all new BH officers within their first 

year of service. Further, all BH officers should be required to attend this course upon 

accepting a table of organization and equipment (TO&E) or professional filler system 
(PROFIS) assignment. A refresherlupdate course should also be created for those who 

have attended. 

Burnout and Compassion Fatigue 

Thirty-three percent of BH personnel reported high burnout, 27% reported low 

motivation, and 22% reported low morale. Fifteen percent agreed that the stressors of 

deployment impaired their BH job. If our providers are impaired, our ability to intervene 

early and assist Soldiers with their problems may be degraded. It is vital to understand 

the processes of provider burnout and compassion fatigue in order to prevent and 

intervene in order to preserve the care in our caregivers. 

4. Continue BH care services to Soldiers in detainee operations in accordance 

with COSC doctrine and NIHAT-II staffing recommendations. Supplement COSC 

doctrine with training in specific stressors unique to corrections and in best 

practices to provide care to custodial staff. Consider parallel BH care programs 

for Soldiers and detainees. If adopted, keep staff member participation in both 

programs at the same time to a minimum to prevent any perception of ethical 

conflicts. 

Behavioral Health Care in Accordance with Supplemented COSC Doctrine 

Combat and operational stress control doctrine provides a generic model for BH 

care and effectively anticipates the common stressors and emotional reactions of 

Soldiers in military operations. Additional training can prepare BH providers to 

anticipate the stressors inherent in the correctional setting and implement the best 

practices to support custodial staff (see Annex F, Appendix 10, Tab D). 

Parallel BH Care Programs 

Correctional literature advocates for independent BH programs to encourage 

custodial personnel to access care. Traditionally, custodial staff members underutilize 

BH care when staff or services are shared. Perceived conflicts in advocacy and 

confidentiality prevent staff members from seeking care. 

5. Continuously assess how well the BH needs of families are being met in the 

rear. 

The well-being of military families is essential to the health of Soldiers deployed 

to OIF. Soldiers continue to express many concerns about the ability of rear 

detachment commanders and family readiness groups (FRGs) to adequately support 

families, a finding also identified in surveys conducted among spouses of Soldiers 

deployed to OIFIOperation Enduring Freedom (OEF). The data suggest the Army 

needs to establish permanent clinical social work support at least at the brigade level to 

support FRGs, to consult with rear detachment commanders, to help families cope with 

the deployment stressors, and to ensure families receive needed services. 
6. Continue existing (community-based) objectives of the ASPP for OIF Soldiers 

and units during pre-deployment, deployment, and re-deployment. Continue 

monitoring and reporting of completed suicides and serious suicide attempts 

with the Army Suicide Events Report (ASER). 
Continue existing objectives of the ASPP for OIF Soldiers and units during 

pre-deployment, deployment, and re-deployment. 

Strategies of the ASPP should be applied to the OlF force through actions in the 

following five areas: Proponency, Awareness, Training, Surveillance, and Help-Seeking 

Behavior. See the MHAT-I report for detailed descriptions of these five areas. 

Continue monitoring and reporting of completed suicides and serious 

suicide attempts with the ASER. 

Enough precedence exists to support the strategy of reducing suicide occurrence 

by reducing the occurrence of serious suicide attempts (leading to hospitalizations and 

evacuations). A critical component of this strategy is the monitoring of suicide attempts 

as an outcome metric for suicide prevention actions. Serious suicide attempts (that 

result in hospitalizations or evacuations) should be included within Army medical 

surveillance as reportable medical events analogous to communicable disease and 

other reportable events. See the MHAT-I report for rationale for use of the ASER as a 

means of data collection. 

7. Continue the appointment of a theaterlarea of operation BH consultant to 

advise The Surgeon on BH issues. 

The OIF-11 Behavioral Health Consultant has been instrumental in advising The 

Surgeon on distribution of BH assets in theater for the delivery of BH care in the area of 

responsibility (AOR), coordinating training and providing BH personnel consultation 

support; and consulting with The Surgeon on BH matters. Having a BH consultant to 

oversee the planning, coordination, and integration of BH assets in theater will help to 

ensure continuity of BH services delivery in theater during OIF-Ill. 

Future Implementation 

1. Identify the scientifically valid key leadership behaviors that facilitate Soldier 

morale, cohesion, and unit performance in a hostile environment. 

Leadership at the local level is critical for maintaining high Soldier morale, unit 

cohesion, and unit performance. Identifying and training those specific leader behaviors 

that have been associated with optimal Soldier and unit performance needs to be a top 

priority for future research efforts and leader development. 

2. Develop and assess the effectiveness of training programs for Soldiers and 

leaders to improve coping with operational stresses, to improve understanding of 

NIH issues, and to improve access to services. Assess the effectiveness of new 
programs to reduce the stigma of MH problems. Determine the effectiveness of 

critical incident stress debriefing (CISD) and other interventions to prevent PTSD. 

Given that a significant number of Soldiers screened positive on the PTSD scale, it 

is imperative that the military determine the most efficacious early intervention strategy 

for attenuating or preventing the onset of PTSD. This includes efforts to improve 

resiliency of Soldiers through new training materials, to reduce the stigma of MH care, 

and to improve access to services. In addition, it is important to determine the 

effectiveness of interventions that are being used, but do not have a strong evidence 

base to support their use, such as CISD. The CISD model is the most widely used 

methodology applied to groups exposed to traumatic events, although its effectiveness 

has not been proved. Walter Reed Army Institute of Research has a scientifically 

approved research protocol to assess the effectiveness of CISD in ameliorating the 

adverse MH effects of Soldiers exposed to combat. 

3. Study the feasibility of developing a tactical and strategic evacuation tracking 

system for efficient clinical and administrative information flow. 

Medical Command (MEDCOM) should establish a joint process action team (PAT) to 

study the feasibility of an evacuation database system capable of clinical, tracking, and 

analytical functions. It must be readily available, secure, and tailored to the needs of 

line commanders, medical personnel, medical regulating planners, and medical 

planners. 

4. Establish a Correctional BH Care Fellowship Training Program. Integrate a 

Correctional BH Care Track into the Force Health Protection Conference. 

Correctional BH Care Fellowship 

Given the paucity of Army BH providers with experience in correctional care, it is 

important to develop and maintain clinical and administrative program expertise as it 

applies to internment facility operations. The Army Medical Department (AMEDD) 

should consider supporting a prior proposal for a Correctional BH Care Fellowship 

Training Program at the U.S. Detention Barracks in Fort Leavenworth. 

Correctional BH Care Track in the Force Health Protection Conference 

To develop a basic understanding of correctional principles and practices, Force 

Health Protection Conference organizers may consider adding a Correctional BH Care 

track to the program. 
Page Intentionally Left Blank 
APPENDIX 1 

MENTAL HEALTH ADVISORY TEAM CHARTER 

(See next three pages.) 
DASG-ZB 29 July 2004 

SUBJECT: Charter for Consultation Proposal for Operation Iraqi Freedom II 

(OlF-11)-Related Behavioral Health 

Issues 

1. ESTABLISHMENT, PURPOSE, MEMBERSHIP, AND SCOPE OF ACTIVITIES 

a. ESTABLISHMENT. At the request of the Multi-National Corps-Iraq (MNC-I) 

senior leadership, the Office of The Surgeon General (OTSG) established the mental 

health advisory team (MHAT) for assessing OIF Il-related behavioral health (BH) issues 

and providing recommendations for improvement. This Charter delineates the OIF II 

MHAT's purpose, membership, and scope of activities. 

b. PURPOSE. The OIF II MHAT will consult to the relevant medical and line leaders 

of BH units and their corresponding headquarters in the OIF II area of operations and in 

the evacuation chain, to include Landstuhl Army Medical Center. 

This consultation will focus its assessment and recommendations on three broad areas 

and the OIF II suicide prevention program: 

(1) The BH needs assessment of the OIF II area of operations; 

(2) The BH delivery system of the OIF II area of operations; and 

(3) The BH training requirements of the OIF II area of operations. 

(4) Implementation of MHAT-I recommendations for the OIF II area of operation 

Suicide Prevention Program. 

c. MEMBERSHIP 

(1) The MHAT will consist of the following members: 

(a) Team Leader, BH Consultant, MEDCOM 

(b) Combat Stress Control Subject Matter Expert (SME) 

(c) Senior Army Psychologist 

(d) Senior Army Psychiatrist 

(e) Senior Army Occupational Therapist 

(f) WRAlR BH Researchers 
DASG-ZB 29 July 2004 

SUBJECT: Charter for Consultation Proposal for Operation Iraqi Freedom II 

(OlF-11)-Related Behavioral Health 

(g) Representative from U.S. Army Chief of Chaplains 

(h) Representative from MNC-I Surgeon 

(i) Other representativeslsubject matter experts as deemed appropriate by 

OTSG 

(2) The MHAT will interface and coordinate with the appropriate line and medical 

leaders within the OlF 11 area of operations, as well as other echelons of relevant line 

and policy leaders to accomplish the stated Purpose and Scope of Activity above. 

d. SCOPE OF ACTIVITY. The MHAT will assess BH challenges associated with: 

(1) Command and Control -clarity and adequacy of communication feedback to 

resolve emerging BH challenges. 

(2) Communications - sufficiency of extant communications capabilities (e.g. 

radio, phone, fax and e-mail) to support efficient and safe preventive outreach to units, 

to support referrals within the area of operations, and to convey adequate clinical 

information for Soldiers within the evacuation chain. 

(3) Resource Support -adequacy of 1) BH provider base, 2) holding capacity 

and treatment initiatives for Soldiers in the evacuation chain, 3) geographic allocation of 

BH assets, and 4) psychotropic medication availability. 

(4) Policies -adequacy of current OIF 11 and Army policies to meet the BH needs 

of Soldiers, units and families. 

2. PROCEDURES. 

a. The MHAT will initiate these efforts on the date of this Charter's approval, and will 

visit designated sites in the OlF 11 area of operations, beginning in August 2004 for a 

period of approximately 30 days and not to exceed 60 days in order to collect data to 

satisfy Purpose and Scope of Activity objectives. 

b. The MHAT will conduct an in-brief to Division and echelons above Division MH 

units and supported units' linelmedical leaders on the first day of each site visit. 

Likewise, the MHAT will conduct an out-brief to the local linelmedical leaders at the 

conclusion of the site visit, and will provide preliminary findings and recommendations. 
DASG-ZB 29 July 2004 

SUBJECT: Charter for Consultation Proposal for Operation Iraqi Freedom II 

(OlF-11)-Related Behavioral Health 

c. The MHAT will request access to relevant local and central data sources (e.g. BH 

personnel and BH patient flow data) as needed. 

d. The MHAT will conduct interviews with relevant unitlmedical leaders at each site, 

and with line and policy leaders at higher echelons as appropriate. 

e. The MHAT will conduct surveys needed to assess the morale of the troops, 

determine the availability and effectiveness of BH services and review significant trends 

as needed (i.e. suicides, MH admissions, evacuations from theater). 

3. DELIVERABLES. 

a. The MHAT will prepare a preliminary report of its findings and recommendations 

(after review to ensure that no protected information is inadvertently released) for the 

Commander, MNC-I and Multi-National Force-Iraq prior to departure from lraq. The 

final report will be due to the Commander, MNC-I within 120 days after departure from 

lraq. The final report's submission date is contingent on completion of any relevant data 

analyses. 

b. The MHAT will conduct subsequent briefings of its final findings and 

recommendations to all appropriate echelons as directed by OTSG. 

c. The MHAT members will not communicate with the media without approval of 

The Surgeon General or his designee prior to release of the MHAT report. 

FOR THE SURGEON GENERAL: 

JOSEPH G. WEBB, JR. 

Major General 

Deputy Surgeon General 
ANNEX A 


WALTER REED ARMY INSTITUTE OF RESEARCH (WRAIR) REPORT ON THE 

MENTAL HEALTH AND WELL-BEING OF SOLDIERS IN OPERATION IRAQI 

FREEDOM (OIF-II) 

Data for this report were collected as part of the Mental Health Advisory Team 

(MHAT-II) Mission to lraq and Kuwait, August through October 2004. The data 

were collected under an approved protocol of the Walter Reed Army Institute of 

Research (WRAIR), Medical Research and Materiel Command, Washington D.C. 

30 January 2005 

Chartered by: 

The US. Army Surgeon General 

This is an annex to the Operation Iraqi Freedom (OIF-11) MHAT-11 Report 

addressing the mental health and well-being of Soldiers deployed to OIF-11. The 

findings were obtained by means of a survey (Soldier Health and Well-being 

Survey) and focus group interviews with junior enlisted, noncommissioned 

officers (NCOs), and officers conducted throughout lraq and Kuwait. 

The views expressed in this report are those of the authors and do not necessarily 

represent the official policy or position of the Department of Defense (DoD), the U.S. 

Army, or the Office of The Surgeon General (OTSG). 
ANNEX A 

TABLE OF CONTENTS 

EXECUTIVE SUMMARY ............................................................................................A-4 


Key Findings ...................................................................................................... A-4 


Key Recommendations ..................................................................................... A-5 


SURVEY METHODS ................................................................................................... A-6 


Quality Control of Data ..................................................................................... A-6 


Comparison Populations .................................................................................. A-6 


Study Sample .................................................................................................. A-7 


Sample SizelAnalysislStatistics....................................................................... A-7 


SURVEY RESULTS .................................................................................................... A-7 


Combat Stressors ........................................................................................ A-7 


Noncombat Deployment StressorslQuality of Life Measures ......................A-8 
 .

ADDITIONAL DATA FROM FOCUS GROUPS PERTAINING TO MORALE ..........A-13 


DISCUSSION ............................................................................................................ A-14 


RECOMMENDATIONS............................................................................................. A-I 7 


OPERATIONAL RESEARCH NEEDS .....................................................................A-20 


TABLES AND FIGURES SUPPORTING FINDINGS ...............................................A-22 


Table 1: Units Surveyed ............................................................................A-22 


Table 2: Survey Locations ........................................................................... A-22 


Table 3: Types of Units Surveyed ...............................................................A-23 .. Table 4: Demographics of Study Populations ............................................. A-23 


Figure 1. Important combat and noncombat deployment stressors. 

OIF-I compared with OIF-11 among survey participants ....... A-24 


Figure 2 . Graph shows percent of Soldiers who screened positive for 

depression. generalized anxiety. or acute stresslPTSD 

and endorsed high symptom severity or impairment in 

worklinterpersonal functioning in the past month ...............A-25 


Figure 3. Prevalence of depression. anxiety. or acutelPTSD by 

unit type ................................................................................... A-25 


Table 5: Prevalence of Acute StresslPTSD by Component and Unit 

Type .......................................................................................... A-26 

ANNEX A 

TABLE OF CONTENTS 

(Continued) 

Table 6: Perceptions of Readiness by Component and Unit 

(Percent Who Agreed) ............................................................
 A-26 

APPENDIX 1: SUMMARY OF SOLDIER HEALTH AND WELL-BEING 

SURVEY ................................................................................... A-27 


Combat and Deployment Stressors ...............................................................A-27 


Morale and Unit Cohesion .............................................................................. A-27 


Readiness........................................................................................................ A-27 


Mental Health Status ....................................................................................... A-28 


Stigma and Barriers to Behavioral Health Care ............................................A-28 


Marital Satisfaction and Family Support ....................................................... A-28 


Mental Health Training .................................................................................... A-28 

Rating of Survey .............................................................................................A-29 


APPENDIX 2: FOCUS GROUP INTERVIEWS .......................................................A-30 


ThemeslQuestions .....................................................................................A-30 ..... Procedures....................................................................................................... A-30 


Findings.....................................................................................................A-30 ......

APPENDIX 3: REFERENCESIACKNOWLEDGEMENTS ....................................... A-31 


References....................................................................................................... A-31 


Acknowledgements ....................................................................................A-31 

EXECUTIVE SUMMARY 

The objective of the Soldier Survey was to assess the health and well-being of Soldiers 

(junior enlisted, noncommissioned officers (NCOs), and officers) deployed to Kuwait 

and lraq during Operation Iraqi Freedom (OIF-11). A standardized survey instrument 

was administered to 2,064 Soldiers stationed at various base camps throughout Kuwait 

and lraq from August through October 2004. The data from this survey were compared 

with data collected using a similar theatre-wide survey conducted under the same 

protocol during the same months in 2003 (see the Mental Health Advisory Team 

(MHAT) 2003 report). In addition, the survey was supplemented by focus group 

interviews. Initial findings from this study were provided to the Multi-National Corps-Iraq 

(MNC-I), Multi-National Force-Iraq (MNF-I), and Combined Forces Land Combat 

Command (CFLCC) leadership mid-October 2004. 

Key Findings 

1. Like OIF-I Soldiers, OIF-ll Soldiers are experiencing numerous combat stressors. 

However, noncombat deployment stressors related to quality of life have shown 

considerable improvement since OIF-I. Deployment length remains a top concern for 

OIF-ll Soldiers. 

2. Fifty-four percent of OIF-ll Soldiers reported their unit morale as low or very low. 

However, unit morale was significantly higher in OIF-ll compared with OIF-I, when 72% 

of Soldiers reported low or very low unit morale. 

3. Mental health and well-being improved from OIF-I to OIF-ll, reflected by a lower 

percentage of Soldiers who screened positive for a mental health problem in OIF-ll 

compared with OIF-I (13% vs. 18%, respectively). Acute or posttraumatic stress 

symptoms remain the top mental health concern, affecting at least 10% of OIF-ll 

Soldiers. 

4. Soldiers in transportation and nonmedical combat service support (CSS) National 

Guard and Reserve units had significantly higher rates of mental health problems and 

lower perceptions of combat readiness and training than Soldiers in other units. 

5. Forty percent of Soldiers with mental health problems reported receiving professional 

help during the deployment. This was significantly higher than the 29% of Soldiers with 

mental health problems who received professional help in OIF-I. 

6. Stigma and organizational barriers to receiving care remain concerns for Soldiers. 

Fifty-three percent of Soldiers with mental health problems perceived that their leaders 

would treat them differently, 54% that they would be seen as weak, 39% that it would be 

difficult getting time off work, and 20% that it was too difficult to get to the mental health 

specialist's location. 
7. Forty-one percent of Soldiers surveyed reported that they had received adequate 

training in handling the stressors of deployment. This was significantly higher than the 

29% percent of Soldiers who reported receiving adequate training during OIF-I. 

8. Marital issues, family separation, and support of families remain top concerns for OIF 

Soldiers. 

Key Recommendations 

1. Continue to improve awareness of mental health issues, access to care, and efforts 

to reduce stigma. Considerations include: 

a. Emphasize the role of leaders at all levels in facilitating recognition of mental 

health concerns, training in handling the stresses of deployment, and encouraging the 

use of available resources. 

b. Assure that there is accessible mental health support to all units throughout the 

theater. 

c. Where feasible, integrate mental health care with primary care in troop medical 

clinicslbattalion aid stations so that mental health care becomes routine in these 

settings. 

2. Develop and assess the effectiveness of standardized training modules to prepare 

Soldiers to handle the psychological demands of deployment and combat-related 

stressors throughout the deployment cycle. Train leaders and Soldiers that stress 

symptoms and other mental health problems are common and expected reactions to 

combat, that mental health interventions are best applied as early as possible, and that 

the Soldiers are informed early of the ways in which they can get help when they need 

it. 

3. Continuously assess how well the behavioral health needs of families are being met 

in the rear. Establish clinical behavioral health support to family readiness groups 

(FRGs) and rear detachment commanders at least at the brigade level to address family 

issues and help coordinatelfacilitate access to resources. 

4. Reevaluate if levels of combat skills training are sufficient for transportation and 

support personnel from National Guard and Reserve units in the current operational 

environment, since confidence in combat skills likely builds resiliency to the negative 

effects of combat stressors. 

5. Establishlmaintain deployment policies that support Soldier morale and well-being 

across various forward operating bases (FOBS). 
SURVEY METHODS 

The OIF-ll Soldier Health and Well-being Survey was conducted for MHAT--11 under an 

approved protocol of the Walter Reed Arm Institute of Research (WRAIR) 

LTq"1 b)(6)-2 (PIS: COLk"'B)-'and Walter Reed Army Institute of Research, 

Silver Spring, MD . The survey is part of a larger effort involving pre- and postdeployment surveys of Soldiers from XVlll ABN Corps, USASOC, and Marine 

Expeditionary Forces (see Hoge, et. al., New England Journal of Medicine, 2004). The 

survey was designed as a rapid assessment of the health and well-being of the Soldiers 

deployed during OIF-ll. Details of the survey instrument are included in Appendix 1. 

The MHAT traveled throughout Kuwait (CFLCC) and lraq (MNC-I) and administered 

surveys and conducted focus groups between 27 August and 3 October 2004. 

In Iraq, line units from brigade combat teams (BCTs) and other units were targeted for 

assessment at various base camps1FOBs throughout the country. In Kuwait the survey 

also targeted battalion level units more likely to experience combat and operational 

stress, including transportation, infantry, signal, and other units. Sampling included 

combat arms, combat support, and CSS personnel. Combat support hospitals (CSHs) 

were included in both lraq and Kuwait. Samples of approximately 20 to 25 Soldiers 

were drawn at the company level, based on mission availability for list of unit, locations, 

and types of units sampled (see Tables 1 through 3.). Signed informed consent was 

obtained from all participants prior to survey administration per the WRAIR protocol. 

Participants were briefed on the purpose of the survey and the fact that participation 

was voluntary. The surveys were conducted anonymously. More than 99% of the 

Soldiers briefed agreed to complete the survey. 

Quality Control of Data 

Scanning, data entry, and quality control of the data were conducted in Iraq. Data from 

the surveys were scanned into a database using the Scantools program. A complete 

quality assurance check was conducted on a random selection of approximately 5% of 

all surveys. Out of 2,064 surveys collected, 107 were quality checked. All 328 

variables on these surveys were directly compared between the electronic database 

and the paper surveys (35,096 fields examined). Results revealed that there were a 

total of 85 errors in the 35,096 fields, in no particular pattern (overall error rate 

0.2422%). Of those errors, 0.0513% were subject errors (e.g. double marks, marks too 

light), 0.1225% were scanner errors, and 0.0684% were hand entry errors (for fields 

where hand entry was required). 

Comparison Populations 

Cross-sectional data collected in lraq and Kuwait during OIF-I (August-September 

2003) (n=756) under the same WRAIR protocol were included for comparison (see 

MHAT report, 2003). Baseline data collected before deployment (n=2,530) were also 

included in some comparisons. These pre-deployment data were obtained from a 
brigade of them~ivision justprior to deployment to OIF-l (Hoge, et. al. 

2004). 

Study Sample 

Participants were 2,064 U.S. Army Soldiers from different units serving in OIF-ll (see 

Tables 1 through 3). The OIF-ll sample was very similar to the OIF-I sample except that 

there was a higher proportion of National Guard and Reserve Soldiers resulting in a 

somewhat older sample (Table 4). The demographic distribution of the OIF-ll sample 

differed somewhat from the demographics of the OIF theater in general (Table 4). 

Reserve and National Guard units and women were over-sampled, which assured 

adequate representation for subgroup analyses. 

Sample Size/AnalysislStatistics 

Based on the size of the U.S. Army population serving in OIF-ll, a sample size of 2,000 

is more than adequate to detect most conditions that occur at a predicted prevalence of 

5-1 0% (for example the prevalence of screening positive for depression or 

posttraumatic stress disorder (PTSD). For example, 202 is the minimum number of 

completed surveys necessary to detect a condition with a prevalence of 5% (range no 

more than 2-8%) at the 95% confidence level. The 2,064 surveys, therefore, provide 

ample numbers to look at important subgroups within the population, for example by 

component (Active, Reserve, and National Guard), as well as males and females, 

Kuwait and Iraq, and even to a limited extent within unit types (e.g. support units 

compared with combat units). Analysis of data was conducted with SPSS version 12. 

Chi-squares and ANOVAs were used to test for significance, where relevant. 

SURVEY RESULTS 

FINDING #I: Like OIF-I Soldiers, OIF-11 Soldiers are experiencing numerous 

combat stressors. However, noncombat deployment stressors related to quality 

of life have shown considerable improvement since OIF-I. Deployment length 

remains a top concern for OIF-11 Soldiers. 

Combat Stressors 

Operation lraqi Freedom (OIF-ll) Soldiers reported experiencing numerous combat 

stressors. Selected experiences are shown in Figure 1. Operation lraqi Freedom 

(OIF-ll) Soldiers reported higher rates of incoming rocket and mortar attacks than OIF-I 

Soldiers. Operation lraqi Freedom (OIF-ll) Soldiers also experienced the escalation of 

IED attacks, a question that was not asked on the OIF-I survey. However, combat 

experiences thought to be more likely to be associated with mental health problems, 

such as seeing dead or seriously injured Americans, handling human remains, or killing 

an enemy combatant were all somewhat higher during the initial ground combat in OIF-I 

than in OIF-ll. Among Soldiers who experienced firefights, the frequency was greater in 
OIF-I than during OIF-ll (median number of firefights during deployment that OIF-I 

Soldiers reported was 3 compared with 2 for OIF-Il Soldiers). 

Active, Reserve, and National Guard Soldiers, overall, had comparable levels of combat 

experiences in OIF-ll. For example, during OIF-ll the percent of Soldiers surveyed in 

lraq who reported receiving small arms fire was 60% for Active Component Soldiers, 

48% for Reserve Soldiers, and 54% for National Guard Soldiers. The percent of 

Soldiers surveyed in lraq in OIF-ll who reported receiving incoming rocket, artillery, or 

mortar fire was 93% for Active Component Soldiers, 96% for Reserve Soldiers, and 

89% for National Guard Soldiers. The percent of Soldiers surveyed in lraq in OIF-ll who 

reported having a team member become a casualty was 57% for Active Component 

Soldiers, 58% for Reserve Soldiers, and 47% for National Guard Soldiers. 

Noncombat Deployment StressorslQuality of Life Measures 

Many of the concerns that were endorsed at a high rate during OIF-I showed 

considerable reductions during OIF-ll (Figure 1). In OIF-I, the most frequently reported 

noncombat stressor was uncertain re-deployment date, with 87% of Soldiers reporting 

high or very high trouble or concern. In OIF-ll, this item was endorsed at that level by 

only 41% of Soldiers. Many quality of life concerns such as lack of privacy, lack of 

personal space, and difficulties communicating back home were reported much less 

frequently in OIF-ll than in OIF-I. There was also a decrease in the percent of Soldiers 

reporting not having adequate equipment or repair parts. Long deployment length was 

the most commonly reported noncombat stressor; 52% of Soldiers reported high or very 

high concern about this issue, 16% reported moderate concern, and 32% reported low 

or very low concern. See also the section on morale, next page, for information 

obtained from focus groups. 

FINDING #2: Fifty-four percent of OIF-11 Soldiers reported their unit morale as low 

or very low. However, unit morale was significantly higher in OIF-I1 compared 

with OIF-I, when 72% of Soldiers reported low or very low unit morale. 

Soldiers were asked to rate their personal and unit morale on a five-point scale from 

very low (score 1) to very high (score 5). The percent of Soldiers reporting low or very 

low unit morale was 54'10, with 9% reporting high or very high unit morale, and the 

remainder reporting at the medium level; although 54% of Soldiers reported their unit 

morale as low or very low this was improved from the OIF-I survey, when 72% of 

Soldiers reported low or very low unit morale. The percent of Soldiers reporting low or 

very low personal morale decreased from 52% in OIF-I to 36% in OIF-ll. Mean personal 

morale increased from 2.41 to 2.78 (p<.001) and unit morale increased from 1.95 to 

2.32 (p<.001). There are very limited normative data on these morale indices for a 

sustained combat environment. Mean cohesion scores remained largely unchanged 

between OIF-I and OIF-ll (2.98 and 3.10, respectively). Focus group data provided 

additional information relevant to Soldier and unit morale (see pages A1 1-A12). 

FINDING #3: Mental health and well-being improved from OIF-I to OIF-11, reflected 

by a lower percentage of Soldiers who screened positive for a mental health 
problem in OIF-11 compared with OIF-I (13% vs. 18%, respectively). Acute or 

posttraumatic stress symptoms remain the top mental health concern, affecting 

at least 10% of OIF-11 Soldiers. 

Mental health concerns are prevalent among OIF-ll Soldiers in the combat zone, 

particularly symptoms of acute stress/PTSD resulting from combat experiences (also 

see Hoge, et. al, New England J of Medicine, 2004). An encouraging finding is that 

OIF-ll Soldiers reported a lower prevalence of mental health problems compared with 

OIF-I Soldiers. 

In OIF-ll, 17% of Soldiers reported currently experiencing a moderate or severe stress, 

emotional, alcohol, or family problem, compared with 23% in OIF-I (p<.001) and 14% 

(pc.001) in a pre-deployment sample. Overall, 11% of OIF-ll Soldiers reported on the 

anonymous survey that they were interested in receiving help for a stress, emotional, 

alcohol, or family problem, compared with 15% in OIF-I and 9% pre-deployment. 

Using standardized clinical screening instruments, 13% of OIF-ll Soldiers screened 

positive for acute stress/PTSD, depression, or anxiety (Figure 1) using a clinical 

definition that required the subjects to meet the Diagnostic and Statistic Manual for 

Psychiatric Disorders (DSM)-4 criteria report a high number of symptoms or 

impairment in occupational or social functioning (see Hoge, et. al., N Engl J Med 2004 

for details of the study design and scales used). The 13% in OIF-ll compared with 18% 

in OIF-I (p<.001). Acute stresslPTSD was the most prevalent condition (10%) 

compared with 15% in OIF-I (p<.001). Differences in rates of depression and anxiety for 

OIF-I and OIF-ll were not statistically significant. Note that the National Center for 

PTSD checklist was used to measure PTSD symptoms, but in the combat zone, these 

symptoms would frequently be considered part of an acute stress or combat stress 

reaction. Overall, there were no statistically significant differences in rates of screening 

positive by component (Active, Reserve, or National Guard); 13% of Active Component 

Soldiers screened positive for a mental health problem compared with 12% of National 

Guard Soldiers and 15% of Reserve Soldiers. There were also no significant 

differences in the rates of mental health problems between male and female Soldiers 

(13% for males, 12% for females for any mental health problem). Soldiers in Kuwait 

had slightly lower rates of any mental health problem than Soldiers in Iraq (1 1 % vs. 13% 

respectively). However, the distribution of diagnoses differed somewhat, with only 7% 

of Soldiers in Kuwait reporting acute stress/PTSD compared with 11% in Iraq, likely a 

reflection of the less hostile environment in Kuwait than in Iraq. 

Since the OIF-I and OIF-ll samples differed in terms of unit type, component, age, and 

the proportion of the sample that was surveyed in Kuwait, the prevalence rates of any 

mental health problem and acute stress1 PTSD in the OIF-ll sample were adjusted to 

reflect the distribution of these factors seen in the OIF-I sample. Separate adjusted 

rates were calculated for Kuwait and Iraq, as well as both together. (No adjustment was 

necessary for gender, since rates of mental health problems were comparable between 

males and females.) This analysis showed that there were minimal effects in adjusting 

the rates. For example, the unadjusted prevalence of any mental health problem in the 
entire OIF-ll sample was 12.6%. After adjusting this to the distribution of the units 

sampled during OIF-I, the prevalence was 12.2%. Adjusting for age changed the rate to 

12.8, and adjusting for component (Active, Reserve, National Guard) changed the rate 

to 13.0. Separate adjustments for Kuwait and lraq also did not result in appreciable 

changes in the prevalence rates. These analyses supported the conclusion that the 

observed differences in the prevalence of mental health problems between OIF-I and 

OIF-ll were not due to sampling biases. 

It is not completely understood why mental health concerns showed improvement in 

OIF-ll compared with OIF-I. Factors that may have contributed to the observed 

improvements in OIF-ll include less frequent or intense combat experiences, markedly 

improved quality of life (MWR, air-conditioning, communication home, food, showers, 

etc.), increased access to mental health services, or improved training in handling the 

stresses of deployment. See discussion section of this annex for further comment on 

this topic. 

FINDING #4: Soldiers in transportation and nonmedical CSS National Guard and 

Reserve units had significantly higher rates of mental health problems and lower 

perceptions of combat readiness and training than Soldiers in other units. 

Comparisons of rates of mental health problems by the type of unit revealed some 

important differences (see Figure 3 for rates overall in the entire Iraq-Kuwait theater). 

Overall, for the entire survey sample, a higher rate of screening positive for depression, 

anxiety, or acute stress/PTSD was observed among the transportation and support 

personnel (e.g. Forward Support Battalion, Combat Support Battalion units) compared 

with Soldiers in combat and other units; 17% of Soldiers from transportation and support 

units screened positive for one of these conditions compared with 13-14% of Soldiers 

from combat arms units, and 8% of all other unit types (p=.002). 

Further analysis was conducted using only the lraq sample, which was at higher risk for 

combat-related mental health problems than the Kuwait sample. Overall in the lraq 

sample, transportation and support units had a prevalence rate of any mental health 

problem of 20% compared with 13% for combat units (p=.01) and 9% for other unit 

types (p<.001). These differences were largely due to differences in the prevalence of 

acute stress1PTSD; the prevalence of acute stress1PTSD was 19% for transportation 

and support units compared with 11% for combat units (p=.002), and 7% for other unit 

types (p<.001). The higher rate of acute stress/PTSD among support units compared 

with other unit types was limited to National Guard and Reserve units (see Table 5). 

National Guard support personnel experienced twice the rate of PTSD as personnel 

from National Guard combat units. Reserve support personnel also had significantly 

higher rates than other reserve units or active component support units. 

Although support and transport units had significantly higher rates of PTSD than combat 

arms units overall, they reported significantly lower rates of most combat experiences, 

suggesting that there may be differences in resilience to combat stressors among the 

support units. There were no significant differences in the levels of adverse childhood 
experiences or non-deployment related traumatic experiences to explain the difference 

in prevalence rates. The survey also asked Soldiers general questions about their 

perceptions of combat readiness, including confidence in their unit's ability to perform 

the mission, whether their unit would doldid an excellent job in combat, and an 

assessment of level of training. An important finding was that support personnel and 

transporters reported significantly lower ratings in all these areas compared with other 

all other Soldiers in the sample. For the entire Iraq and Kuwait sample, among Soldiers 

from transportation and support units, 55% reported confidence in the unit's ability to 

perform the mission, compared with 62% of all other units (p=.01); 38% of Soldiers from 

transportation and support units agreed that their unit would doldid an excellent job in 

combat compared with 55% of Soldiers from other units (p<.001); 35% from 

transportation and support units agreed that the level of training was high compared 

with 47% from other units (p<.001). These differences were particularly pronounced in 

National Guard units in Iraq, especially for the question pertaining to perception of level 

of combat training (Table 6). Lower ratings of confidence, combat readiness, and 

training were all statistically correlated with higher rates of screening positive for mental 

health problems, particularly acute stressIPTSD, suggesting that perceptions of training, 

confidence, and combat readiness may buffer the effects of combat stressors. 

FINDING #5. Forty percent of Soldiers with mental health problems reported receiving 

professional help during the deployment. This was significantly higher than the 29% of 

Soldiers with mental health problems who received professional help in OIF-I. 

Among the Soldiers who screened positive for depression, anxiety, or PTSD, 40% 

reported receiving help at any time during the deployment from a mental healthlcombat 

stress control professional, general medical doctor, or chaplain. However, this 

represented an increase from OIF-I, when only 29% of Soldiers with mental health 

problems received treatment, and was statistically significant (p=.03). Increases were 

observed in receiving services from all types of professionals, with chaplains most 

frequently consulted. Twenty-two percent of Soldiers who screened positive for a 

mental health problem in OIF-I sought help from chaplains compared with 28% in OIF-11. 

The figures for a mental healthlcombat stress professional was 12% for OIF-I and 19% 

for OIF-11, GMO or medic 9% for OIF-I and 13% for OIF-11. Among those who received 

mental health services, 69% reported being satisfied with the treatment, and 31% 

reported being dissatisfied. (There was no neutral category to this question, and 

Soldiers who marked "NA were excluded.) 

FINDING #6: Stigma and organizational barriers to receiving care remain 

concerns for Soldiers; 53% of Soldiers with mental health problems perceived 

that they would be treated differently by their leaders and 54% that they would be 

seen as weak; 39% of Soldiers with mental health problems reported that it would 

be difficult getting time off work, and 20% that it was too difficult to get to the 

mental health specialist's location. 

Stigma and organizational barriers to care remain a concern for Soldiers in need of 

mental health services. Although there was an increase in use of mental health 

services among Soldiers with mental health problems from OIF-I to OIF-11, there was no 

A-I I 
evidence of changes in perceptions of stigma and other barriers among these Soldiers 

between OIF-I and OIF-ll. Among Soldiers who screened positive for depression, 

anxiety, or PTSD, 53% reported that their unit leadership might treat them differently, 

and 54% reported that they would be seen as weak. Organizational barriers to care, 

which leaders can potentially influence, included concerns that it would be too difficult to 

get to the location of behavioral health services, reported by 20% of Soldiers with 

mental health problems, difficulty getting time off from work (39%), and not knowing 

where to go for help (22%). These findings were almost identical to findings from OIF-I. 

FINDING #7. Forty-one percent of Soldiers surveyed reported that they had 

received adequate training in handling the stressors of deployment. However, 

this was significantly higher than the 29% percent of Soldiers who reported 

receiving adequate training during OIF-I. 

Overall, 77% of Soldiers in OIF-ll reported that they had received suicide prevention 

training in the past year, and 69% reported that they had received training in handling 

the stresses of deployment and/or combat. Forty-eight percent of OIF-ll Soldiers 

surveyed reported that the training in identifying Soldiers at risk for suicide was 

sufficient (not different from the 45% who endorsed this in OIF-I). Although only 41% of 

Soldiers reported that the training in managing the stress of deployment was adequate, 

this rate was higher than the rate of 29% reported by OIF-l Soldiers (p<.001). Soldiers 

who indicated that they had received adequate training in handling the stresses of 

deployment reported significantly higher confidence in their ability to help Soldiers get 

assistance for a mental health problem (p<.001). Overall, 27% of all Soldiers surveyed 

in OIF-Il indicated that they had helped a fellow Soldier get professional help for a 

mental health problem, a question that was not asked in a comparable manner during 

the OIF-I evaluation. 

FINDING #8. Marital issues, family separation, and support of families remain top 

concerns for OIF Soldiers. 

Nearly 50% of OIF-ll Soldiers reported that being separated from family was a major 

stressor. Operation Iraqi Freedom (OIF-ll) Soldiers who were married reported high 

marital satisfaction; 76-78% reported that they had a good and stable marriage; and 

14% reported plans to separate or divorce, which is higher than the rate reported in a 

pre-deployment comparison group of 9% and the rate reported on the survey during 

OIF-I of 11%. Only 21% of married Soldiers reported being satisfied with the reardetachment support of their families (compared with 18% in OIF-I); only 24% of married 

Soldiers reported that they were satisfied with the FRG support (vs. 15% in OIF-I). 

ADDITIONAL DATA FROM FOCUS GROUPS PERTAINING TO MORALE 

Focus groups provided Soldiers with an opportunity to express their views about their 

deployment experiences and assess if there were any areas not adequately covered on 

the survey. Below is a summary of the most common concerns that Soldiers identified 

during focus groups. 
a. "Garrison" rules applied in a war zone vary across base camps1 FOBS, even 

within the same camps, and rules change frequently. Soldiers, who are "outside the 

wire" every day risking their lives, particularly resent seemingly "petty" rules when they 

return from patrol or criticism for things they perceive as being trivial in the context of 

what they have had to do on patrol or in combat. Examples include not being able to 

wear PT clothes to the dining facilities (DFACs) on some camps; not being able to carry 

small backpacks into the DFAC, despite having to walk long distances on some camps; 

not being allowed to wear a tiny penlight on the shirt pocket despite the convenience of 

this for using portable latrines at night or getting around on posts at night, etc. 

b. Leadershiplcornmunication concerns exist, particularly the perception that there 

is poor information flow about the purpose of missions and lack of information about 

critical events, such as a Soldier being injured. Common complaints that Soldiers 

expressed included rapidly changing missions, "micromanagement" by higher 

leadership, frequent "pointless details" that cut into the already limited time for recovery 

after missions, perceived favoritism, and lack of positive feedback. 

c. Soldiers also spoke frequently about the personal nature of casualties, loss of 

unit members, the constant threat of serious harm or death, frequent mortar attacks, the 

sense of anticipation, of never knowing when or where something bad would happen, 

feeling like "sitting ducks" on patrol "outside the wire" with frequent IED attacks, not 

being able to fight back at times due to rules of engagement, and the perception that 

there is often no clearly identified enemy. 

d. Long deployment length, back-to-back deployments, and separation from family 

were also prominent concerns for Soldiers. Most Soldiers felt that they could 

comfortably manage a 6-month deployment, but the year-long deployment was very 

stressful. There were also concerns about back-to-back deployments for some Army 

units. Members of National Guard units were particularly distressed by what they 

perceived as an unduly long and poorly organized training period prior to deployment 

(up to 6 months with very limited leave time) prior to the year-long "boots on the 

ground." 

e. High OPTEMPO, lack of downlfree time, and lack of personal space were all 

issues that Soldiers reported commonly. 

f. Some Soldiers expressed considerable anger at the Army's stop-loss policies that 

prevented them from leaving service at the end of their obligation, and led some to 

express feelings that the Army had broken its "contract" with the Soldier. 

g. Some Soldiers perceived that there were unclear policies regarding family 

emergency leave. Some Soldiers felt that their leadership did not take sufficiently 

seriously some family emergencies, or that there was inequity in the decisions about 

which types of emergencies would result in sending a Soldier home and for how long 
h. Another concern that Soldiers voiced frequently that was not covered on the 

survey involved the unique factors inherent in working with and training new Iraqi 

security forces, including lack of equipment and supplies, communication problems, and 

concerns about infiltration from insurgents. 

Soldiers also reported beneficiallpositive aspects of deployment, including friendships, 

satisfaction with the job they were doing, improved confidence, cohesion, demonstrating 

success in missions, and pay. Many felt that improved DFACs, living conditions, MWR 

facilities, and R&R programs improved morale. Soldiers said they were satisfied with 

the lottery system that some units established to assure fairness regarding R&R trips 

back home. 

DISCUSSION 

This study of over 2,000 OIF-ll Soldiers surveyed throughout lraq and Kuwait used the 

same survey instruments as were used in a theater-wide assessment in OIF-I and in a 

study of Soldiers from combat units surveyed 3 to 4 months after returning from OIF-I 

reported in a prominent medical journal (see 2003 MHAT report, and Hoge, et. al. N 

Engl J of Med; July 1, 2004). Although the study enrollment did not use a random 

sampling design, the sample is very likely to be representative of most combat and 

support units serving in OIF-ll. Operational factors largely determined which Soldiers 

were available to participate, and Soldiers were surveyed in their company or battalion 

areas at multiple FOBS throughout lraq and Kuwait. The survey over-sampled Reserve 

and National Guard units, that made up about half of the sample compared to 36% of all 

Soldiers serving in OIF-ll at the time. In addition, the survey somewhat over-sampled 

female Soldiers; 14% of the sample were female Soldiers compared with 10% overall in 

the OIF-ll theater. This assured that adequate comparisons could be made by 

component and gender. Although the sample demographics differed somewhat from 

the theater at large, the comparability in rates by component and gender supports the 

generalizability of the survey rates to the larger theater population. 

While mental health problems remain a leading health problem for Soldiers deployed to 

lraq and Kuwait, there were significant decreases observed in the prevalence rates of 

mental health concerns between Soldiers during OIF-ll compared with OIF-I. It is 

unlikely that differences in sampling strategy or population demographics accounted for 

the lower rates of mental health problems in OIF-ll compared with OIF-I. These two 

samples were obtained at almost the identical timeframe (end of August to early 

October) in 2003 and 2004. The OIF-I and OIF-ll samples were very similar in terms of 

country where surveyed (IraqIKuwait), gender, rank, marital status, and duration that the 

Soldiers had been deployed at the time of the survey. The OIF-ll sample had a higher 

percentage of Reserve and National Guard Soldiers than the OIF-I sample, resulting in 

a somewhat older population. This partly mirrored the changes in the overall theater 

population, primarily due to National Guard infantry units serving in a much greater 

capacity in OIF-ll than in OIF-I. Analysis showed that there were no significant 

differences in the rates of mental health problems by component, so the fact that the 

OIF-ll sample had a higher proportion of National Guard Soldiers than the OIF-I sample 
is not likely to account for any observed differences in prevalence rates between the 

OIF-I and OIF-ll samples. In addition, adjusting the prevalence rates for OIF-ll to the 

distribution of unit types seen in OIF-I or by demographic differences in the population 

(component and age) did not result in any appreciable changes in the reported rates, 

lending support to the conclusion that the differences in prevalence rates observed 

among OIF-I Soldiers and OIF-ll Soldiers were not due to differences in the types of 

units or demographics of the units that were sampled. 

There are several possible explanations for why the mental health prevalence rates 

were lower among the OIF-ll Soldiers than the OIF-I Soldiers. 

a. Although there were similar rates of many combat experiences, certain 

experiences thought to be more closely related to PTSD symptoms (body handling, 

being responsible for the death of an enemy combatant) were more prevalent during 

OIF-I than in OIF-ll and combat frequency, as measured by number of firefights was 

also higher in OIF-I. 

b. There have been substantial improvements made in the quality of life in theater, 

particularly access to air conditioned sleeping quarters, better facilities (bathrooms, 

showers, MWR facilities, etc.), better food and DFACs, and improved communication 

home through telephone and e-mail. These likely help buffer the negative effects of 

combat. 

c. Evidence from the survey suggests that there have been improvements in 

training Soldiers in handling the stresses of deployment. 

d. There have also been an increased number of mental health professionals and 

improved distribution of mental health professionals. 

Regarding combat experiences, clearly the nature, frequency, and intensity of the 

combat experiences are the most important predictors of acute or posttraumatic stress 

disorders. There have been changes in the types of combat operations from OIF-I to 

OIF-ll. Operation lraqi Freedom (OIF-I) Soldiers experienced very intense sustained 

ground combat during the initial operations, with large numbers of lraqi military and 

civilian casualties. Also, there were the constant threat of chemical or biological attack 

and the added stress of having to work in protective suits for extended periods during 

OIF-I. On the other hand, OIF-Il Soldiers have had to deal with the increased 

rocketlmortar attacks and increased threat of improvised explosive devices (IEDs) and 

vehicle borne improvised explosive devices ("VBIED"), changing rules of engagement 

that emphasize continuous patrols in urban areas, security, and rebuilding missions, as 

well as a new government and increased collaboration with lraqi security forces. 

Further research is needed to understand which types of combatldeployment 

experiences will be more predictive of long-term mental health sequelae. 

Between OIF-I and OIF-ll, there have been significant improvements in quality of life 

that likely contribute to improved morale. Compared with OIF-I Soldiers, OIF-ll Soldiers 
have much greater access to air-conditioned sleeping areas, food cafeterias, MWR 

facilities, better bathroom/shower facilities, and markedly improved communication 

home. Although the relationship between morale and the prevalence of mental health 

problems is very complex, it is highly likely that improved quality of life and improved 

morale buffer the effects of ongoing combat operational stressors. 

Regarding training, the survey suggested that more Soldiers are receiving training in 

handling the stresses of deployment and that this training has a beneficial effect in 

building confidence and helping Soldiers get assistance when they need it. A high 

percentage of Soldiers reported helping a fellow Soldier access professional help. It is 

not fully understood what types of training programs are most effective in building 

resiliency to operational stress; this is an area that needs much, additional research. 

Key elements of any training program include information about what leaders can do to 

improve morale and cohesion, what leaders and Soldiers can do to better cope with 

stress, what types of mental health problems are most likely following combat, and how 

Soldiers can get help when needed. 

Regarding access to mental health professionals, there are ample data collected in the 

other annexes of this report that shows that there have been considerable increases in 

the number of mental health professionals in theater and increased emphasis on 

outreach efforts in OIF-ll compared with OIF-I. The Soldier Health and Well-being 

Survey confirmed that Soldiers who screened positive for a mental health problem were 

significantly more likely to access a chaplain or other mental health professional in 

OIF-ll than in OIF-I. Among Soldiers who screened positive for a mental health 

problem, 40% reported that they had received help from a chaplain, mental health 

professional, or medical professional, compared with 29% of OIF-I Soldiers. While this 

may be because of improved mental health care delivery and outreach, it also may be 

related to theater maturation and greater stability of Soldiers on individual bases, or 

improved coordination between primary care professionals, chaplains, and mental 

health professionals. Among Soldiers who had returned from OIF-I deployment who 

screened positive for a mental health problem, 40% reported receiving help identical to 

the figure reported in theater in OIF-ll. 

Although the comparisons between prevalence rates in OIF-I and OIF-ll are 

encouraging, it is important to bear in mind that over 12% of Soldiers in OIF-ll are still 

experiencing significant acute or posttraumatic stress symptoms or symptoms of 

depression or generalized anxiety. Especially concerning is the markedly higher rate 

among transportation and support (FSB, CSB) personnel from National Guard and 

Reserve units, who are experiencing rates in excess of 20%, reflecting the fact that in 

the current operational environment support, personnel may be just as exposed to 

serious combat stressors as Soldiers from combat arms units. Although preliminary, the 

data indicate that the high rates of mental health problems in support units are 

correlated with lower ratings of combat readiness, training, and confidence in their unit's 

ability to perform the mission. It is unclear if the perceptions that these Soldiers 

reported accurately reflect their levels of combat readiness, and if improved training 
would adequately buffer against negative mental health outcomes, but the data suggest 

that further assessment of this is warranted. 

RECOMMENDATIONS 

1. Continue to improve awareness of mental health issues, access to care, and 

efforts to reduce stigma. Considerations include: 

a. Emphasizing the role of leaders at all levels in facilitating recognition of 

mental health concerns, training in handling the stresses of deployment, and 

encouraging the use of available resources. 

b. Assuring that there is accessible mental health support to all units 

throughout the theater. 

c. Where feasible, integrating mental health care with primary care in troop 

medical clinics/battalion aid stations so that mental health care becomes routine 

in these settings. 

Overall, more mental health professionals have been working in Iraq and Kuwait during 

OIF-ll than in OIF-I. A significantly higher percentage of Soldiers with mental health 

problems in OIF-ll accessed mental health services than in OIF-I, although still over half 

of the Soldiers who screened positive for mental health problems reported not receiving 

services. Challenges remain in providing services in this combat environment and 

reducing the stigma and barriers to care which Soldiers perceive. Considerations to 

reduce these barriers to care include: 

a. Emphasizing the role of leaders at all levels in facilitating recognition of mental 

health concerns, training in handling the stresses of deployment, and encouraging 

access to services. Soldiers and leaders should be educated about the predictable 

stresses of deployment, including PTSD. Leaders have a critical role in fostering unit 

morale and cohesion, and assuring that Soldiers have the equipment and training 

needed for mission success, sufficient recovery time, and training in how to best cope 

with the deployment stressors. Soldiers and leaders need training in how to recognize 

signs of operational stress and posttraumatic stress, and how they can receive help 

when needed, to include buddy aid, medic, chaplain, mental health professionals, and 

other forms of support. Training should also include the fact that increased use of 

alcohol is associated with PTSD symptoms, which can lead to alcohol-related adverse 

behaviors. Leaders also play an important role in reducing organizational barriers to 

care, such as assuring that Soldiers get the needed time and have the means to get to 

a mental health appointment. They may also be able to effect perceptions of stigma, 

although there is no research yet to support this. 

b. Assuring that there is accessible and visible mental health support to all units 

throughout the theater. This requires adequate equipment for division mental health 

personnel and combat stress control teams to conduct outreach, establish predictable 
mental health services at battalion levels, and provide adequate supervision to mental 

health personnel working remotely (e.g. availability of up-armored vehicles, 

communication), and location of personnel to assure that Soldiers have regular and 

predictable access to mental health professionals. 

c. Where feasible, integrating mental health care with primary care in troop medical 

clinics/battalion aid stations. Mental health care should become as routine as all other 

primary care services. Considerations to facilitate this include using the same facilities, 

entrances, and waiting areas that are used for routine medical care, as well as the same 

record keeping system that primary care providers use, limiting the details of the mental 

health notes to those necessary to assure continuity of clinical care and safety. It is 

also important to assure robust collaboration between mental health professionals, 

chaplains, primary care providers, and unit leaders, which is the subject of another 

annex of this report. 

2. Develop and assess the effectiveness of standardized training modules to 

prepare Soldiers to handle the psychological demands of deployment and 

combat-related stressors throughout the deployment cycle. Train leaders and 

Soldiers that stress symptoms and other mental health problems are common 

and expected reactions to combat, that mental health interventions are best 

applied as early as possible, and the ways in which Soldiers can get help when 

they need it. 

The data suggest that training Soldiers in suicide awareness and in dealing with the 

stresses of deployment has many potential benefits. Standardized training materials 

need to be further developed and applied before, during, and after deployment that 

teaches these skills to Soldiers and leaders. A particular emphasis should be given to 

educating Soldiers and leaders about the likelihood of posttraumatic stress symptoms 

following combat experiences, normalizing these symptoms, providing education about 

the benefits of earlier treatment, and the methods available, and information on how to 

access services if the symptoms are causing functional impairment. 

3. Continuously assess how well the behavioral health needs of families are 

being met in the rear. Establish clinical behavioral health support to FRGs and 

rear detachment commanders at least at the brigade level to address family 

issues and help coordinate/facilitate access to resources. 

The well-being of military families is essential to the health of Soldiers deployed to OIF. 

Many family members live on posts where there is limited availability of TRICARE 
providers in the community to address their mental health needs and those of their 

children. At Fort Bragg, for example, much of mental health care that spouses received 

was through the primary care medical clinics on post, because of the lack of availability 

of appointments for family members at the military treatment facility or in the community. 

Soldiers continue to express many concerns about the ability of rear detachment 

commanders and FRGs to adequately support families, a finding also identified in 

surveys conducted among spouses of Soldiers deployed to OIFIOEF. The data 

suggest that the Army needs to establish permanent clinical social work support at least 

at the brigade level to support FRGs, to consult with rear detachment commanders, to 

help families cope with the deployment stressors, and to ensure families receive needed 

services. Leaders can assure that family problems are addressed in a timely manner. 

4. Reevaluate if levels of combat skills training are sufficient for transportation 

and support personnel from National Guard and Reserve units in the current 

operational environment, since confidence in combat skills likely builds 

resiliency to the negative effects of combat stressors. 

Data from this report show that lower perceptions of combat readiness, levels of 

training, and confidence in the unit's ability to perform the mission are strongly 

correlated with higher rates of mental health problems. While overall, National Guard 

and Reserve Soldiers had similar rates of mental health concerns, there were marked 

differences observed by unit type among National Guard and Reserve Soldiers. 

Soldiers in transport and support units from National Guard and Reserve units 

experienced increased levels of mental health problems compared with Soldiers in other 

units, and they reported lower levels of readiness, combat skills training, and 

confidence. Furthermore, in the current operational environment, these units may be at 

as high a risk of being attacked as combat arms units. It is unclear if these perceptions 

reflect accurately on actual combat skills training, or if there are other differences 

between support and combat arms Soldiers that could explain the findings. However, 

the data suggest that there should be further assessment to determine if the level of 

combat skills training is sufficient for transporters and support personnel in the current 

operational environment. 

5. Establish/maintain deployment policies that support Soldier morale and wellbeing across various FOBs. 

Focus group data consistently voiced throughout the theater provided some insight into 

concerns that Soldiers have that may contribute to low perceptions of unit morale. 

Soldiers are sensitive to perceived inequities in policies between units on the same FOB 

or between FOBs. Some things for leaders to consider for improved morale related to 

issues that Soldiers raised in focus groups include: 

a. Soldiers perceive many uniform policies in theater to be unnecessary 

inconveniences that do not relate to operational effectiveness, readiness, or safety. 

Uniform policies that are not overly restrictive, consistent, and meet the "common 

sense" test are important to Soldiers. Examples that Soldiers gave include allowing a 
small penlight to be worn on a DCU button (very useful in portable toilets at night), sewn 

on names on hats, PT uniform in the DFAC, backpacks in the DFAC, pouch wallet 

around the neck on PT or DCU uniforms, weapons in the DFAC, etc. It is important to 

note that on many bases Soldiers have to walk long distances to get to locations like the 

DFAC or MWR facilities, and with little downtime between missions, it may be overly 

restrictive to have to change the uniform they are wearing or secure a backpack or 

weapon before eating. 

b. Soldiers frequently voiced concerns about not receiving adequate 

information/explanation pertaining to missions (particularly when missions changed), 

unit policies, or critical events (such as status of wounded unit members). Soldiers also 

frequently complained that they received very little or no positive feedback for their 

efforts or lived in a climate where they often received negative feedback or threats of 

UCMJ action. Leaders should ensure that Soldiers are adequately informed, that 

policies are clearly expressed, that rumors are addressed, that Soldiers receive positive 

feedback, and that subordinates are allowed to seek clarification of orders or policies 

without their leaders responding defensively or considering the Soldier disloyal. 

c. Soldiers also complained frequently about not having sufficient recovery time 

between missions. Leaders should emphasize the importance of not scheduling 

additional duties during downtime, and should assure that Soldiers get sufficient rest 

(generally 7 to 8 hours of sleep per 24-hour period) to maintain optimal cognitive acuity. 

d. Leaders should assure that clear and consistent family emergency leave policies 

are communicated to Soldiers. 

OPERATIONAL RESEARCH NEEDS 

1 Field a unit needs assessment measure that behavioral health professionals in 

theater can use to assess their units and assure that Soldiers receive adequate 

services. 

It is important for mental health professionals in theater to have the tools to conduct 

systematic needs assessments of their units to identify any unique needs and assure 

that Soldiers are receiving adequate care. This tool should include an assessment of 

levels of stress, mental health status, unit climate, and level of training in behavioral 

health issues. In addition, there should be an assessment of availability, access, and 

acceptability of counseling services provided according to the latest standards of care. 

The commander, chaplains, and mental health professionals would use the findings 

from this behavioral health assessment to target specific action plans, including 

behavioral health prevention and early intervention efforts and distribution of resources. 

A prototype instrument that WRAlR developed is ready for initial fielding. 
2. Identify the scientifically valid key leadership behaviors that facilitate Soldier 

morale, cohesion, and unit performance in a hostile environment. 

Leadership at the local level is critical for maintaining high Soldier moral, unit cohesion, 

and unit performance. Identifying and training those specific leader behaviors that have 

been associated with optimal Soldier and unit performance need to be top priorities for 

future research efforts and leader development. 

3. Develop and assess the effectiveness of training programs for Soldiers and 

leaders to improve coping with operational stresses, understanding of mental 

health issues, and access to services. Assess the effectiveness of new programs 

to reduce the stigma of mental health problems. Determine the effectiveness of 

critical incident stress debriefing (CISD) and other interventions to prevent PTSD. 

Given that a significant number of Soldiers screened positive on the PTSD scale, it is 

imperative that the military determine the most efficacious early intervention strategy for 

attenuating or preventing the onset of PTSD. This includes efforts to improve resiliency of 

Soldiers through new training materials, and efforts to reduce the stigma of mental health 

care and improve access to services. In addition, it is important to determine the 

effectiveness of interventions that are being used, but do not have a strong evidence 

base to support their use, such as CISD. The CISD model is the most widely used 

methodology applied to groups exposed to traumatic events, although its effectiveness 

has not been proved. The WRAlR has a scientifically approved research protocol to 

assess the effectiveness of CISD in ameliorating the adverse mental health effects of 

Soldiers exposed to combat. 
TABLES AND FIGURES SUPPORTING FINDINGS 

Table 1: Units Surveyed 

I 

Transporters Combat Arms Support Siqnal Medical 

(b)(2)-2 

Table 2: Survey Locations 

I

ljb)(2)-2 Location 1 KI~wn~t 118 l(b)(2)-2 Ilracl 1 

# of Surveys 

84 

I 

I 

A 

I I ' I 

I Iraq 

85 

26 

91 

p)-Z 

b)(2)-2 

p(2)-2 

llraq 

Iraq 

I 

1 

115 

3 6 

32 

1 

1 

Iraq 45 Fb)(2)-2 25 

1 lraa 6 llraa 30 I 
1 

Table 3: Tvoes a, of Units Surveved -


Unit Type #. (%) of Surveys # (%) of Surveys 

OlFl OIF2 

I 

j 

Combat (IN. CAV, FA, ADA, AR) 

support (FSB, CSB. Ma~nt, etc.) 

I 

1 

383 (51) 

42 (6) ~ 

81 8 (40) 

347 (17) 

Transportation 72(10) 131 (6) 

i 

Eng~neerslEOD 

M~litary Pol~ce* 

Civil Affairs i 27 (4) 

50 (7) 

35 (5) 

i 

1 

45 (2) 

176 (9) 

152 (7) 

1 

I 

OtherlNot Listed 

Signal 

Medical from CSHs and FHs 

1 

1 

10 (1) 

12 (2) 

125(17) 

1 

1 

30 (2) 

120 (6) 

245 (12) 

Total 756 2,064 

* This category includes MPs and other personnel (e.g. FA Soldiers) workin; 

as MPs in Detainee Ooerations at Abu Ghraib and Bucca. 

Table 4: Demoaraohics of Studv Pooulations 

Total OIF-ll Army 

Population (n=99,883) 

30 Sep 2004 

Percent Only 

Kuwait 

Component 

AC 

NG 

RC* 

Grade 

E7-E9 

OfficerslWarrant Officers 

Age 

18-24 Not 

25-29 Available 

30-39 

40 or older 

Gender 

Male 

Female 

No. (%) Single Never Married ~ Not 

No. (%) Married Available 

Living with spouse/geogr. apart 

Married but separated 

No. (%) Divorced 

No. (%) with Children Not Available 

Months in Theater, Median 6 months 7 months 

(Interquartile Range) (5-7 months) (6-7 months) Not Available 

'01F-I RC includes 7 AGR (I%), and 01 I RC includes 40 AGR (2%). 
Figure 1. Important combat and noncombat deployment stressors, OIF-I 

compared with OIF-ll among survey participants. 

Combat: 

Receiving incoming artillery, rocket, mortar 

Receiving small arms fire 

Knew someone seriously injured or killed 

Having a member of your own unit 

become a casualty 

Seeing dead or seriously injured Americans 

Handling or uncovering human remains 

Being directly responsible for the death 

of an enemy combatant 

lEDl booby trap exploded near you 

40 60

least once durmg this 

Deployment StressorslQuality of Life Measures: 

Uncertain re-deployment date 

Long Deployment Length 

Being separated from family 

Lack of privacy or personal space 

Boring or repetitive work 

Difficulties communicating back home 

Not having right equipment or repair 

parts 

Lack of time off for personal time 

0 20 40 60 80 100 

Pcrcent rcporting high or wry high conccrn 
Figure 2. Graph shows percent of Soldiers who screened positive for 

depression, generalized anxiety, or acute stresslPTSD and endorsed high 

symptom severity or impairment in worklinterpersonal functioning in the past 

month. 

Pre-deployment Ed OIF-I OIF-ll 

Depression Anxiety Acute Any Mental Health 

StresslPTSD Problem 

Figure 3. Prevalence of depression, anxiety, or acute stresslPTSD by unit type. 

3 0 

25 - Any Mental Health Problem 
Active Component 

Support Units 11% 13% 

Combat Units 14% 16% 

Other Unit Types 7% 8% 

National Guard 

Support Units 20%* 22%* 

Combat Units 8% 11% 

Other Unit Types 7% 8% 

Army Reserves 

Support Units 34%** 34%"" 

Other Unit Types 9% 10% 

Support units include transportation, forwardlcombat support, maintenance, and DISCOM Soldiers. Any 

mental health problem includes screening positive for acute stresslPTSD, depression, or generalized 

anxiety. 

* p<.01 for comparison between NG support units and NG combat units 

**p=.001 for comparison between RC support unit and AC support unit; p<.001 for comparison between 

RC support units and RC other units 

Other comparisons not significant 

Active Component 1 1 1 

Su~~ort Units 63% 48%* 50% 

~okbatUnits 67% 68% 58% 

Other Unit Types 1 68% 55% 43% 

National Guard 

Support Units 

Combat Units 

Other Unit Types 

1 

1 

1 

55% 

65% 

57% 

41%" 

62% 

47% 

28%* 

51% 

33% 

Army Reserves 1 1 

Support Units 54% 48% 29% 

Other Unit Types 51% 44% 39% 

Responses to the three statements above ranged on a 5-point scale from strongly disagree to strongly 

agree. "Agree" and "strongly agree" were scored as positive. Support units include transportation, 

forwardlcombat support, maintenance, and DISCOM Soldiers. 

* p<.001 for comparison between support units and combat units within Component 
APPENDIX 1 

SUMMARY OF SOLDIER HEALTH AND WELL-BEING SURVEY 

The Soldier Health and Well-being Survey is a specially adapted version of a 

questionnaire that WRAlR uses in an ongoing protocol to assess the effects of 

OPTEMPO, combat exposure, and mental and physical health variables on Soldiers 

and Marines, as well as family members. Data from other samples that WRAlR 

collected previously are used as comparison data in this report. The findings from 

scales and items in the survey that are presented in this report include: 

Combat and Deployment Stressors 

Combat and deployment stressors were examined using two scales. 

Combat Exposure: The frequency of exposure to various combat events was 

examined, and participants were asked to rate the number of times they felt they were 

in serious danger of being injured or killed (four-point scale). Example questions 

include: "being attacked or ambushed," "receiving small arms fire," "seeing dead bodies 

or human remains," "clearinglsearching homes or buildings," and "being responsible for 

the death of an enemy combatant." 

De~lovment Stressors and Qualitv of Life Measures: Participants also rated their 

concern about various other stressors along a five-point scale. Deployment stressors 

included: "being separated from family," "uncertain redeployment date," "duration of 

deployment," "lack of privacy," "boring and repetitive work," "difficulties communicating 

back home (e.g. telephone calls, e-mail, mail)," and "lack of privacy or personal space." 

Morale and Unit Cohesion 

Participants were asked to rate both their personal morale and the morale in their unit 

on a five-point scale from "very low" to "very high." Unit cohesion was measured as an 

average of participants' agreement or disagreement to the following three questions: 

"The members of my unit are cooperative with each other," "The members of my unit 

know that they can depend on each other," and "The members of my unit stand up for 

each other." (Castro, 2000) 

Readiness 

General perceptions of readiness were measured with three items that asked 

participants to rate on a five-point scale from "strongly disagree" to "strongly agree" their 

assessment that the unit would doldid an excellent job in combat, that the level of 

training in the unit is high, and that there is high confidence in the unit's ability to 

perform its mission. 
Mental Health Status 

Participants were asked a number of questions about their current mental health 

functioning in the areas of depression, generalized anxiety, and PTSD. In order to 

score positive for one of these three areas, the participant had to endorse items on each 

scale according to established clinical guidelines at "more than half the days" 

(depressionlanxiety scales), or "moderate" level (PTSD scale) AND endorse a high 

number of symptoms (PTSD scale) or mark that the problem caused functional 

impairment (depression and anxiety scales). The functional impairment question for 

depression and anxiety was based on a single question asking the respondent to rate 

how difficult the symptoms had made it to do hislher work or get along with other 

people. "Very difficult" or "extremely difficult" was scored positive. For the PTSD scale, 

a positive score required both meeting the DSM criteria at the moderate level and 

having a total score of at least 50 on a scale of 17 to 85. This established a 

conservative estimate of those at high risk for a possible mental disorder. (Spitzer, 

1999; Blanchard, 1996; Hoge, 2004) 

Stigma and Barriers to Behavioral Health Care 

Stigma and barriers to receiving mental health care were assessed by asking each 

participant to agree or disagree (on a five-point scale) with a series of 17 questions. 

Organizational barrier questions included, "I don't know where to get help," "It is difficult 

to get an appointment," and "It is too difficult to get to the location where the mental 

health specialist is." Stigma questions included "I don't trust mental health 

professionals," "My leadership would treat me differently," "My leaders would blame me 

for the problem," and "I would be seen as weak." (Hoge, et. al. 2004; Britt 2000) 

Marital Satisfaction and Family Support 

A number of factors were examined about marriages and how families were supported 

at the home station. 

Marital Satisfaction: Measured by the average response to four questions ("I have a 

good marriage," "My relationship with my spouse is very stable," "My relationship with 

my spouse makes me happy," and "I really feel like a part of a team with my spouse."). 

In addition, participants were asked whether or not they (or their spouses) intended to 

separate or divorce. 

Familv Suggort Durina Deglovment: Participants were asked to rate their 

satisfaction of their unit rear detachment's support of their families, and their satisfaction 

with their unit FRG's support of their families. 

Mental Health Training 

Soldiers were asked if they agreed on a five-point scale from "strongly disagree" to 

"strongly agree" if training in suicide prevention was adequate, if training for identifying 

Soldiers at risk for suicide was sufficient, and if training in handling the stresses of 
deployment was adequate. Soldiers were also asked their confidence in their ability to 

identify Soldiers with depressive symptoms, at risk for suicide, and whether they had 

attended training in suicide prevention or stress education using "yes-no" questions. 

Rating of Survey 

Soldiers were asked to rate on a five-point scale ("strongly disagree" to "strongly agree") 

their satisfaction with the survey in three areas: survey worthwhile, content 

appropriatelimportant, and survey covered the keylmain issues. Ratings were very 

high. Only 16% disagreed with the statement that the survey was worthwhile, 10% 

disagreed that the survey content was appropriatelimportant, and only 9% disagreed 

that the survey covered the keylmain issues. 
APPENDIX 2 

FOCUS GROUP INTERVIEWS 

Seventy-three small group interviews from CFLCC A0 (Kuwait) (n=8 groups) and 

MNC-I (Iraq) (n = 65 groups) with junior enlisted (N = 29 groups), NCOs (N =I5 groups), 

officers (N=6 groups) and mixed officer, NCO and enlisted (N=23 groups) were 

conducted to obtain Soldiers' perspectives on the operational/combat stressors they 

encountered. A total of 177 junior enlisted Soldiers, 128 NCOs, and 28 officers were 

included in the groups. Of the 323 service members who were involved, 48 were 

women. 

The Mental Health Advisory Team (MHAT) members conducted all interviews among 

Soldiers who had just completed the Soldier Health and Well-being Survey at the same 

locations throughout Kuwait and Iraq where the survey was administered. 

All groups were asked the same questions. Below are the specific questions for all 

focus groups. 

Questions: (1) Was there anything not covered on the survey that is important for us to 

know about your experience during the deployment? (2) What has been the most 

positive aspect of this deployment? (3) What has been the most negative aspect of this 

deployment? (4) What has been the most stressfui/challenging aspect of the 

deployment? (5) How available are behavioral health services if you need them? (6) 

Please tell us about your experience with Rest and Relaxation (R & R) or the 

Environmental Leave (EML) program? 

Procedures 

All interviews began with members of the MHAT interview team introducing themselves 

and describing the purpose and objective of the interview. Confidentiality and 

anonymity were guaranteed in order to encourage candid and honest discussion. Thus, 

no names of any of the group members were recorded. Interviews lasted approximately 

15 to 30 minutes. 

Findings 

The key themes identified in the focus group interviews are summarized earlier in this 

Annex. In addition, Soldiers were asked about whether there were any areas not well 

covered on the survey. In general, Soldiers were complimentary of the questionnaire. 

Suggestions for improvement included adding questions on leadership and chain of 

command (particularly officer level), questions on the impact of stop loss, and more 

questions specific to the medical units that were surveyed. 
APPENDIX 3 

REFERENCESIACKNOWLEDGEMENTS 

References 

Blanchard EB, Jones-Alexander J, et. al. Psychometric properties of the PTSD checklist 

(PCL). Behaviour Research and Therapy 1996 34:669-73. 

Britt TW. The stigma of psychological problems in a work environment: evidence from 

the screening of service members returning from Bosnia. J Applied Social Psychology 

2000:30: 1599-1 618, 

Castro, C.A., Bienvenu, R.V., Huffman, A. H. & Adler, A. B. (2000). Soldier Dimensions 

and operational readiness in U.S. Army Forces Deployed to Kosovo, International 

Review of the Armed Forces Medical Services, 73, 191-200. 

Hoge CW, Castro CA, Messer SC, McGurk D, Cotting Dl, Koffman RL. Combat duty in 

Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004, 

July 1, 2004; 351 :I3-21. 

Operation Iraqi Freedom Mental Health Advisory Team (MHAT) report: chartered by 

U.S. Army Surgeon General and HQDA G-I. December 16, 2003. Available at 

www.armymedicine.armv.mil ("news and media" link) 

Spitzer RL, Kroenke K, Williams JB. Validation and utility of self-report version of the 

PRIME-MD: the PHQ primary care study. JAMA 1999;282:1734-44. 

Acknowledgements 

The data in this report were collected under a Walter Reed Army Institute of Research 

(WRAIR) protocol (principal investigators COL(b)(6)-2 L T C We are ~ 

indebted to the Ira survey data collection 

COLl(b)(6-2 

MAJ (b)(6)-2 Cp~(b)(6)-2 1 SFC (b)(6)-2 

SPC (b)(6)-2 

COf -1
ANNEX B 

BEHAVIORAL HEALTHCARE SYSTEM ASSESSMENT 

Operation lraqi Freedom (OIF-ll) 

Mental Health Advisory Team (MHAT-II) 

30 January 2005 

Chartered by: 

The U.S. Army Surgeon General 

This is an annex to the Operation lraqi Freedom (OIF-ll) Mental Health Advisory 

Team (MHAT-ll) Report addressing the Behavioral Healthcare System in OIF-11, 

including Kuwait and Iraq. The findings were obtained via direct observation, 

interviews, surveys, and data calls. 

The views expressed in this report are those of the authors and do not necessarily 

represent the official policy or position of the Department of Defense (DoD), the U.S. 

Army, or the Office of The Surgeon General (OTSG). 
TABLE OF CONTENTS 


INTRODUCTION......................................................................................................... B-4 


FINDINGS ................................................................................................................... B-4 


RECOMMENDATIONS............................................................................................. B-10 


APPENDIX 1 ............................................................................................................. B-14 


SUMMARY OF BEHAVIORAL HEALTH (BH) SURVEY ........................................ B-14 


INTRODUCTION .................................................................................................................. B-I4 


FINDINGS............................................................................................................................. B-74 


BACKGROUND .................................................................................................................... B-79 


TAB A: Behavioral Health (BH) Survey ................................................................................ B-21 


APPENDIX 2 ............................................................................................................. B-26 


SUMMARY OF PRIMARY CARE (PC) SURVEY ...................................................... B-26 


INTRODUCTION .................................................................................................................. B-26 


FINDINGS............................................................................................................................. B-26 


BACKGROUND .................................................................................................................... B-27 


TAB A: Primary Care (PC) Survey ....................................................................................... B-30 


APPENDIX 3 ............................................................................................................. B-34 


SUMMARY OF UNIT MINISTRY TEAM (UMT) SURVEY .......................................... B-34 


INTRODUCTION .................................................................................................................. B-34 


FINDINGS............................................................................................................................. B-34 


RECOMMENDATIONS......................................................................................................... B-36 


BACKGROUND .................................................................................................................... B-36 


TAB A: Unit Ministry Team (UMT) Survey ............................................................................ B-39 


APPENDIX 4 ............................................................................................................. B-43 


SUMMARY OF BEHAVIORAL HEALTH INTERVIEWS ........................................ B-43 

INTRODUCTION .................................................................................................................. 6-43 


APPROACH ......................................................................................................................... .B-43 

RESULTS ............................................................................................................................. 6-44 


TAB A: Behavioral Health Interview/Focus Group Schedule ................................................ 6-49 


APPENDIX 5 ............................................................................................................. B-50 


DISTRIBUTION OF BEHAVIORAL HEALTH SERVICES ........................................ B-50 


INTRODUCTION .................................................................................................................. 6-50 


FINDINGS............................................................................................................................. 6-50 


RECOMMENDATIONS......................................................................................................... 8-52 


TAB A: Behavioral Healthcare Staffing Model ......................................................................8-58 


APPENDIX 6 ............................................................................................................. B-69 


BEHAVIORAL HEALTH RETURN-TO-DUTY AND WORKLOAD DATA ................. B-69 


INTRODUCTION .................................................................................................................. 8-69 


FINDINGS............................................................................................................................. 6-69 


RECOMMENDATIONS......................................................................................................... 6-72 


BACKGROUND .................................................................................................................... 8-73 


TAB A: Definition of COSC-WARS Preventive Outreach and Intervention Terms ................ 6-75 


TAB 6 : Definitions of Contributing Factors to Soldiers' Stress Reactions ............................. 6-76 


TAB C: Electronic Data Matrix .............................................................................................. 6-77 


TAB D: Standard COSC-WARS Summary Report (SR) Data Fields .................................... 6-83 


APPENDIX 7 ............................................................................................................. B-86 


REFERENCES.......................................................................................................... B-86 

INTRODUCTION 

One objective of the Operation Iraqi Freedom (OIF-ll) Mental Health Advisory Team 

(MHAT-II) was to conduct an assessment of the Army behavioral healthcare system in 

Kuwait and Iraq. The focus was to assess Army-wide policies, procedures, and 

resource requirements affecting behavioral health (BH) services in theater and to 

provide recommendations to address potential organizational and resource limitations. 

To accomplish this goal, MHAT-II gathered information by using three written 

anonymous surveys (one for behavioral healthcare providers, one for unit ministry 

teams (UMTs), and another for primary medical care providers), an interview schedule 

for behavioral healthcare providers, and a series of data calls from BH units. 

Within the annex, the overall findings and recommendations for the OIF-ll behavioral 

health system are presented first. These overall findings and recommendations draw 

from the findings and recommendations of the BH, primary care (PC), and UMT 

surveys, interviews with BH personnel, and various data calls found within the 

appendices. 

FINDINGS 

Finding #I: As reported in Annex A, Soldiers are experiencing numerous combat 

stressors; however, noncombat deployment stressors related to quality of life 

and Soldier mental health (MH) and well-being have shown improvement since 

OIF-I. 

Although OIF-ll Soldiers are experiencing numerous combat stressors and the majority 

(54%) rates their morale as low or very low, the noncombat deployment stressors have 

improved considerably since OIF-I, and the morale and MH have also improved. Mental 

health and well-being improved from OIF-I to OIF-ll, reflected by a lower percentage of 

Soldiers who screened positive for a MH problem in OIF-ll compared with OIF-I (13% 

vs. 18% respectively). In addition, 40% of Soldiers with MH problems reported 

receiving professional help during the OIF-ll deployment, significantly higher than the 

29% of Soldiers with MH problems who received professional help in OIF-I. Stigma and 

organizational barriers to receiving care are still problems. Fifty-three percent of 

Soldiers with MH problems perceived that their leaders would treat them differently, 

39% reported that it would be difficult getting time off work, and 20% reported that it was 

too difficult to get to the location of the MH specialist (see Annex A). Other indicators of 

improvement include lower evacuation rates (see Annex C) and lower suicide rates 

(from 18 per 100,000 down to 8.5 per 100,000-see Annex D). 

Finding #2: The OIF-11 behavioral healthcare system is improving. 

As noted in Annex G, many of the MHAT recommendations from OIF-I have been or are 

being implemented. Examples include the appointment of a BH consultant to the MultiNational Corps-Iraq (MNC-I) Corps Surgeons cell, the adoption of Army Suicide Event 

Reports (ASERs) to track data surrounding completed suicides, improvement in 
Soldier access to care (from 29% to 40°h), the 23% reduction in the BH evacuation 

rates, and the improvement of Soldier training in handling the stresses of 

combatloperational stress (from 29% to 41 %). The following findings support the fact 

that the BH system is improving: 

Supportive Finding #2a: Most BH personnel in theater report conducting 

outreach on a regular basis, despite challenges of working in the operational 

environment. 

Sixty-nine percent of BH personnel surveyed reported that they were conducting 

combat and operational stress control (COSC) outreach services either weekly or 

several times a week, and 71 % reported consulting with unit leaders once a week or 

more. Behavioral healthcare personnel reported they were actively involved in 

conducting educational classes, psychological debriefings, and suicide prevention 

training. They also indicated they were providing services at the Soldiers' worksites as 

well as their own. 

In addition, COSC principles were more readily accepted in OIF-ll than in OIF-I. In 

OIF-ll, 78% of those surveyed disagreed with the statement, "Behavioral health1COSC 

personnel don't think preventive outreach activities are effective," and only 5% agreed 

with this same statement. Further, 74% disagreed with the statement that providers 

don't like to perform outreach. These rates show a more positive acceptance to 

outreach activities when compared to two questions, of a similar nature, that were 

asked during OIF-I. Operation Iraqi Freedom (OIF-I) providers were asked, "How 

relevant is COSC doctrine to current operations?" Forty-four percent of the junior 

enlisted, 35% of the noncommissioned officers (NCOs), and 45% of the officers agreed 

that it was relevant. Also, fewer people (57%) of the BH personnel in OIF-I agreed 

COSC was the best method of early intervention. 

Supportive Finding #2b: Coordination is occurring between BH personnel, 

UMTs, and PC providers, and over 75% of the UMTs and PC providers reported 

receiving information on BH services and guidance on how to refer Soldiers to 

BH personnel. 

Seventy-eight percent of the PC providers reported on their survey that BH personnel 

had given them information about where to refer Soldiers for MH problems, and 76% 

reported they had received information about the services offered by BH personnel for 

Soldiers. Many chaplains (83%) reported they had received information from BH 

personnel on where to refer Soldiers for MH problems, and 88% reported that they had 

been educated on the services provided by BH personnel for Soldiers. 

Supportive Finding #2c: Behavioral health return-to-duty (RTD) rates are 

high and comparable to OIF-I. 

All forward-deployed BH assets in OIF-ll Iraq had high RTD rates. One separate 

brigade BH team returned 100% of the Soldierslpatients evaluated by its Division 
Mental Health Section (DMHS). The two DMHS's and another separate brigade's rates 

were above 96%. The one combat stress control (CSC) company, while deployed at 15 

forward operating bases (FOBs) throughout Iraq, returned 95% of the Soldiers it 

evaluated. The Air Force's two operational stress teams in Kuwait had RTD rates 

(97%) comparable to the Army's forward-deployed BH units. A combat support hospital 

(CSH) returned 80% of the psychiatric patients it evaluated and treated. 

Supportive Finding #2d: Both the number of BH personnel in theater and the 

ratio of BH personnel to Soldiers are higher in OIF-/I than in OIF-I. 

Last year (OlF-I), 163 BH personnel (psychiatrists, psychologists, social workers, 

occupational therapists, psychiatric nurses, enlisted MH specialists, and occupational 

therapy (OT) technicians) provided services for an estimated 138,000 Soldiers in Kuwait 

and lraq in September 2003. The overall ratio of BH personnel to Soldiers was 11851. 

As of 1 October 2004, 232 BH personnel (see Table I) are providing services to an 

estimated 94,500 Soldiers in Kuwait and Iraq, for a ratio of 11407-a ratio over twice 

that of OIF-I. Last year's MHAT (OIF-I) concluded that the overall number of BH 

personnel was sufficient to provide coverage throughout the OIF Theater. However, the 

distribution of BH personnel was uneven; some areas lacked adequate coverage. 

In Kuwait, Navy and Air Force personnel were providing most BH coverage. Other than 

a few Army staff members px2)-2 

Navy personnel performed the bulk of the primary medical care, andb,(2,2Air Force 

combat stress teams (CSTs) performed all of the BH prevention and early intervention 

(See Tables 2 and 3). Based on Soldier population, there are fewer BH personnel in 

Kuwait (11656 overall) than in lraq (11388) where the need is greater due to operational 

stressors. 

Supportive Finding #2e: Behavioral health personnel are more evenly 

distributed in OIF-11 than in OIF-I. 

Behavioral health personnel are more evenly distributed in OIF-ll than in OIF-I. The 

OIF-ll ratios varied from 11160 to 11888 (with a standard deviation of 227), while the 

OIF-I ratio of BH personnel to Soldiers varied from zero (no BH personnel) to 113,292 by 

region (with a standard deviation of 1,038). Further, 76% of Soldiers live on FOBs 

where BH personnel are collocated (Note: For simplicity, "FOB'' includes base camps, 

logistical support areas, ranges, etc., in Kuwait and Iraq). In general, as the size of the 

FOB population decreased, the number of BH personnel to Soldiers also decreased, 

and the variance in the distribution of BH personnel within each size category 

increased. 

Forward operating bases that did not have on-site BH personnel may have received 

services from BH personnel at neighboring FOBs. Data from the Soldier Health and 

Well-being Survey showed that overall, Soldiers on smaller FOBs reported nearly 

identical rates of utilization of MH services as Soldiers on larger FOBs. On FOBs with 

Soldier populations less than or equal to 1.000 in size, 11 % of Soldiers saw a MH or 
CSC professional during the deployment, compared with 9% of Soldiers on FOBS that 

had a population of 1,001 -3,000, and 11 % on FOBS over 3,000. 

Supportive Finding #2f: Combat stress control units, medical companies 

with MH sections, and CSHs can manage routine and surge period demands for 

holding Soldiers with BH problems. 

On both routine and on an emergent basis, "holding capacity" is available at CSC units 

and at brigade, division, and area support medical companies (ASMCs). The CSC units 

have the capability to set up many more Level II cots for stress and psychiatric 

casualties if needed. Each CSH slice is able to admit Soldiers with BH problems on the 

intermediate care wards. Theater BH personnel interviewed indicated that, in general, a 

Soldier deemed to require an inpatient level of care is only held long enough to be 

stabilized, evaluated, and prepared for evacuation out of theater. All of the CSHs have 

partnered with CSC units to provide synergistic BH treatment and holding services. 

Finding #3: The majority of OIF-I Mental Health Advisory Team recommendations 

has been implemented or is in the process of being implemented. Opportunities 

for improvement still exist in the OIF-11 behavioral health system. 

Examples include irregular submission of ASERs on nonlethal suicide attempts, need 

for a standardized unit BH needs assessment program, need for research on early 

psychological interventions for traumatic stress exposures, and the improved tracking 

systems for evacuations (see Annex C). The following findings identify areas where the 

BH system can improve. 

Supportive Finding #3a: While coordination between BH personnel, UMTs, and PC 

providers is good, coordination could increase between these three professional groups. 

Fifty-four percent of the BH personnel reported that they coordinatedlintegrated 

BHICOSC activities with the UMTs, and 62% of the PC providers and 61% of the 

chaplains (58% chaplain assistants), in turn, reported coordinating their MH activities 

with BH personnel. All three groups are valuable resources for each other and together 

represent a force multiplier for Soldiers' support. Although the great majority of 

respondents indicated they were informed of where to refer Soldiers for BH care, 

increased coordination would further capitalize on the strengths of these three 

professional groups. 

Supportive Finding #3b: Significant challenges remain in providing BH 

care. 

Forty percent of the BH personnel surveyed agreed that there was inadequate 

transportation to conduct outreach activities, 30% agreed that there was inadequate 

communication between BHICOSC and supported units, and 27% reported traveling to 

supported units was too dangerous. Although 40% felt that arranging convoys to 

supported units was not difficult, 21% reported having to cancel missions due to the 

inability to arrange convoys. 
Supportive Finding #3c: Two thirds of Soldiers reported receiving training 

in handling the stresses of deployment and/or combat, and less than half 

reported the training in managing the stress of deployment was adequate. 

Sixty-nine percent of the Soldiers reported they had received training in handling the 

stresses of deployment and/or combat, and 41% reported that the training in managing 

the stress of deployment was adequate (This rate was higher than the rate of 29% 

reported by OIF-I Soldiers (p< ,001)). Twenty-three percent reported not receiving 

suicide training in the last year. Such training is vital given that a fellow Soldier is often 

turned to for support. Fourteen percent of all Soldiers stated that they turned to another 

Soldier in their units for "counselingIMH services for a stress, emotional, alcohol, or 

family problem." This percentage increased to 26% among those Soldiers who 

screened positive for MH symptoms (depression, anxiety, or posttraumatic stress 

disorder (PTSD)). 

Supportive Finding #3d: Most BH personnel received pre-deployment 

refresher training in BH/COSC tactics, techniques, and procedures, but reported 

additional training is needed. 

Behavioral health personnel were more confident in their training this year (OIF-ll) due 

to the pre-deployment refresher training they received, but there were still areas of 

identified need. Survey and focus group data revealed four key areas that BH 

personnel perceive the need for further training: 

Cross-cultural (IraaiJ Evaluation and Treatment. One in five BH personnel 

felt confident in their ability to evaluate or treat an Iraqi individual. Given the potential to 

become involved in detainee or humanitarian operations, this is a vital skill that needs to 

be addressed. 

Combat and Operational Stress Control Workload and Reporlina Svstem 

(COSC-WARS). Forty-seven percent of the BH personnel reported they were confident 

in their ability to use this system. 

Sexual Assault Evaluation and Treatment. Sixty-three percent of BH 

personnel felt confident in evaluating and/or treating a victim of sexual assault. 

Substance Abuse Evaluation and Treatment. Seventy percent reported 

they were confident in their ability to evaluate and/or treat substance abuse disorders; 

30% did not endorse confidence in this ability. 

Supportive Finding #3e: Standards of care, documentation management, 

and statistical reporting methods were unclear to some BH personnel. 

Behavioral health personnel report a lack of clarity on clinical and administrative 

requirements. Fifty-seven percent of the BH personnel agreed that the standards of BH 

care in theater were clear. Just over half (53%) agreed that COSC service standards 

were clear. 
Documentation management in the theater was clear for less than half of the BH 

personnel surveyed. Of the BH personnel surveyed, 41 % agreed that standards for 

clinical documentation were clear; 33% reported the standards for records management 

were clear: and 35% reported the transfer of clinical BH information between levels of 

care was clear. 

Supportive Finding #3f: Behavioral health personnel are using multiple 

methods to assess the BHKOSC needs of Soldiers and units. A standardized 

needs assessment process, undergoing development as a result of the OIF-I 

Mental Health Advisory Team, needs to be implemented. 

Although BH personnel report talking informally to Soldiers (92%), medical personnel 

(77%), unit commanders (71 %), and chaplains (71%) to gather data for a needs 

assessment, less than half use instruments of any kind. Forty-two percent conduct 

focus groups or locally developed surveys. Thirty-nine percent use validated 

surveyslinstruments. There continues to be a need to provide BH personnel with a 

standardized Soldier and unit needs assessment tool that can objectively quantify BH 

needs in order to better plan tailored BH interventions for each unit. 

Supportive Finding #3g: Some BH, UMT, and PC personnel are reporting 

compassion fatigue and burnout. 

Thirty-three percent of BH personnel reported high burnout, 27% reported low 

motivation, and 22% reported low morale. Fifteen percent agreed that the stressors of 

deployment impaired their BH job; in addition. 12% felt that their sensitivity to the needs 

of the Soldier had been adversely affected. 

Thirty-seven percent of PC personnel reported high burnout, 35% reported low 

motivation, and 35% reported low morale. Fifteen percent agreed that the stressors of 

deployment had impaired their medical job, and 14% indicated they had become less 

sensitive to the needs of Soldiers during this deployment. 

Sixteen percent of UMT personnel agreed or strongly agreed that the stressors of the 

deployment and combat impaired their job. They also reported low or very low personal 

energy (28%), personal motivation (23%), personal morale (18%), and high or very high 

personal burnout (33%). Some also reported having their mental (1 3%) or spiritual 

(15%) well-being adversely affected by combat or deployment stressors. 

Table 1 presents the percentages of officers and enlisted members of the three various 

groups (BH, PC: and UMT) who report adverse effects of deployment andlor low 

morale. Primary care personnel have significantly lower morale (p<.001) and lower 

personal motivation (p1.002) than BH and UMT personnel. Primary care personnel also 

reported significantly less sensitivity to the needs of Soldiers than UMT personnel 

(p1.002). Pooled together, the officers reported significantly less adverse effects from 

the deployment: higher morale, and lower burnout than enlisted providers (all p<.001). 
Table #I: Comparison of Compassion Fatigue and Burnout Among Provider Types 

" 

Spiritual well-being adversely affected 9.6 17.5 17.7 

Less sensitive to Soldiers' religiousispiritual needs 21.9 18.6 9.5 

Ability to do job is impaired by listening to combat experiences 10.9 7.2 6.0 

Personal morale (Low or Very Low) 25.7 48.5 24.4 

Energy level (Low or Very Low) 28.4 38.6 32.5 

Level of burnout (High or Very High) 38.3 53.7 41.2 

Motivation (Low or Very Low) 36.9 55.6 29.1 

RECOMMENDATIONS 

Recommendation #I: Continue forward-deployed outreach to facilitate Soldier 

access to BH services. 

Aggressive outreach may be one of the reasons for the increase in utilization of BH 

services (from 29% to 40% from OIF-I), and it should continue. Behavioral health 

personnel are better distributed in OIF-ll than in OIF-I. 

Recommendation #2: Ensure all BH personnel can provide (with supervision and 

medical support) the full range of BH services. 

It is important to maintain strong coordination amongst the various BH personnel in 

theater (whether from division, CSC units, CSH, etc.) to assure that Soldiers have 

access to BH services when needed. Personnel who conduct outreach at the unit level 

or are the sole provider at a particular location should be able to provide the range of 

services to include clinical evaluation and treatment: triage, facilitation of restoration in 

local medical companies, referral to the next level of care, prevention, consultation, and 

education. Likewise, clinical staff at large FOBS (at CSHs, CSC restoration facilities, 

etc.) should be able to provide outreach routinely. While existing COSC doctrine 

(FM 8-51, 1998) has traditionally divided tasks into prevention, restoration, and 

treatment, BH personnel need to be able to do all of these functions. 
Recommendation #3: Improve Soldier and leadership training in BH Issues. 

Since Soldiers turn to their peers for help in crises under combat conditions, it is 

imperative that Soldiers and leaders be trained in how to provide support andlor refer 

their peers and subordinates with BH issues to BH personnel. The BH personnel in 

theater provide this training during outreach. It should be enhanced in officer and 

enlisted schools, ongoing officer and NCO development programs, and during predeployment and post-deployment briefings. 

Recommendation #4: Develop and field an automated BH preventive and clinical 

documentation and reporting system for use in theater. 

Theater leadership should set policy requiring a single format for documenting and 

reporting all BH preventive and clinical services. Assess if an existing system (such as 

COSC-WARS) meets the requirements and ensure that whatever system is approved is 

implemented theater-wide. 

Recommendation #5: Complete development and fielding of a unit needs 

assessment program and survey tool. 

Last year, the MHAT recommended that a standardized needs assessment program 

and tool be developed and fielded to all BH assets. This need was recognized again 

this year. The United States Army Medical Research and Materiel Command 

(USAMRMC) should be tasked to complete and field this programltool. 

Recommendation #6: Utilize an empirically derived staffing model for BH 

personnel allocation and distribution. 

Last year's MHAT (OIF-I) concluded that the overall number of BH personnel was 

sufficient to provide coverage throughout the OIF Theater, providing a ratio of 1 :851 BH 

personnel to Soldiers. However, the distribution of BH personnel was uneven; some 

areas lacked adequate coverage. The ratio of BH personnel to Soldiers in OIF-ll is 

1:407, substantially different than last year. 

Future staffing decisions need to take into consideration the operational environment in 

theater, the overall Army operations tempo (OPTEMPO), and other factors. Military 

planners need to tailor the BH force package based on the size of the force, the 

distribution of the force (number of FOBS), the amountltype of services desired in 

theater (see Appendix 5, TAB A for full discussion of staffing model), and the availability 

of personnel and resources to provide this staffing level. 

Utilizing the methodology in Appendix 5, TAB A, the MHAT is proposing the use of a 

theater-wide staffing model to improve BH personnel utilization and enhance coverage 

of the theater. However, regardless of the model used, it should be needs based and 

empirically grounded. 
Recommendation #7: Finish publication of updated field manual (FM). 

The 1994 CSC field manual (FM 8-51), with minor updating in 1999 for the Medical 

Reengineering Initiative, has not kept up with the vast shifts in doctrine since entering 

the Global War on Terror. Because it remains the "official" doctrine-sometimes in 

opposition to last year's MHAT findings and recommendations, BH personnel in the field 

are confused as to which "doctrine" to follow. It is imperative that the FM be rewritten to 

reflect the many changes in Army and COSC practice and evolving doctrine noted in the 

OIF-I Mental Health Advisory Team report. 

Those changes have been drafted by the MHAT for incorporation into the programmed 

successor to FM 8-51, FM 4-02.51. Changes noted in doctrine from this report should 

also be integrated into the draft and then published as quickly as possible. 

Recommendation #8: Complete development of behavioral health COSC course. 

As recommended by last year's MHAT, and as part of the indoctrination and preparation 

of BH personnel-both active and reserve-is the creation of an "all disciplines" COSC 

course. This 2-week Army Medical Department Center and School (AMEDDC&S) 

course will serve as a foundation course for all BH disciplines in combat and battlefield 

BH doctrine and practice. This course should be a requirement of all new BH officers 

within their first year of service. Further, all BH officers should be required to attend this 

course upon accepting a table(s) of organization and equipment (TO&E) or Professional 

Filler System (PROFIS) assignment. A I-week refresherlupdate course should also be 

created for those who have attended the basic COSC course and need an update prior 

to a TO&E assignment andlor deployment. 

Recommendation #9: Publish a compendium of best practices. 

Another OIF-I Mental Health Advisory Team recommendation that was revalidated this 

year is the need for a "compendium of best practices" from the field. This compendium 

could reside at the Center for Army Lessons Learned at the AMEDDC&S and at the 

United States Army Center for Health Promotion and Preventive Medicine 

(USACHPPM) or another appropriate site available to all BH personnel. 

Recommendation #lo: Web-based BH prep for deployment (OIF Newcomers 

Orientation Training) 

Computer access in theater is improved, and most BH personnel in OIF and Operation 

Enduring Freedom (OEF) have access to a computer with Internet linkup. Given the 

disperse nature of both BH personnel in the continental United States (CONUS) prior to 

deployment, and the disperse nature of the teams in theater during deployment, ondemand, web-based training may be the best way to reach the vast majority of BH 

personnel. For those unable to access web-based training, printed materials or CDROM formats should also be made available. Behavioral health personnel could access 

Programs of instruction (Pols) throughout the entire deployment cycle (prior to 
mobilization, during mobilization, during deployment, and during post-deployment and 

de-mobilization). Changes in doctrine, techniques, and policy could be centralized for 

on-demand retrieval. Further, core course work could be programmed with feedback to 

commanders, BH consultants, and other leadership to ensure that those officers and 

enlisted members under their jurisdiction have completed the courses as required. 

These core courses could be particularly helpful for the reserve physicians who rotate in 

for only 90 days. They must be able to 'get up to speed" very quickly. A short hour, 

web-based POI would cover the medical and BH policies and procedures currently in 

place: familiarize them with the theater (in general, unclassified, terms), etc. 

Recommendation #I?: Research and implement a program for burnout and 

compassion fatigue. 

As noted in the findings above, a third of BH, medical, and pastoral counseling 

personnel are experiencing burnout, compassion fatigue, and other professional 

impairments since being deployed. If one third of our providers are impaired, our ability 

to intervene early and assist Soldiers with their problems may be degraded. 

In addition to studying Soldiers to better understand the products and processes of 

combat-induced trauma and deployment deprivation, it is vital to understand the 

processes of provider burnout in order to prevent and intervene in order to preserve the 

care in our caregivers. 

Recommendation #12: Continue to appoint a BH consultant to the area of 

responsibility (AOR) Surgeons cell to advise the Surgeon on BH issues. 

The OIF-ll behavioral health consultant has been instrumental in advising the Surgeon 

on distribution of BH assets in theater for the delivery of BH care in the AOR; 

coordinating training and providing BH personnel consultation support; and consulting 

with the Surgeon on BH matters. Having a BH consultant to oversee the planning, 

coordination, and integration of BH assets in theater will help to ensure continuity of BH 

services delivery in theater during OIF-Ill. 
APPENDIX 1 

SUMMARY OF BEHAVIORAL HEALTH (BH) SURVEY 

INTRODUCTION 

The objective of the BH Survey was to gather data to assess the BH care services 

being rendered during OIF-ll and provide recommendations based on the findings. 

Behavioral health personnel is defined in this section as officer and enlisted personnel 

who provide BH services to Soldiers. 

FINDINGS 

Finding #I: Standards of care for BH and COSC services and standards for 

documentation, records management, and transfer of clinical BH information are 

clear for most BH personnel. However, about one third of the BH personnel are 

unclear on documentation policies. 

Behavioral health personnel were asked how clear the standards of BHICOSC services 

and documentation were to them. Fifty-seven percent agreed the standards of BH care 

in theater were clear, while 23% disagreed (20% were neutral). The standards of 

COSC services were clear for 53% and unclear for 23% of the BH personnel surveyed. 

Documentation management in the theater was not clear for over one third of those 

surveyed. Behavioral health personnel agreed that standards for clinical 

documentation (41 %), records management (33%), and transfer of clinical BH 

information between levels of care (35%) were clear. However, 33% indicated 

documentation standards were not clear, 39% reported records management was not 

clear, and 31 % believed the standards for transfer of clinical BH information between 

levels of care in theater were not clear. 

This finding indicates the need to provide training for deploying BH personnel on 

standards of care and documentation management. In some instances, Theater, the 

Army Medical Department (AMEDD), the Army, or the Department of Defense (DoD) 

may need to clarify policies. 

Finding #2: Coordination is ongoing between BH personnel, UMTs, and PC providers. 

Fifty-four percent of the BH personnel agreed they coordinatedlintegrated BHICOSC 

activities with the UMTs, and 73% coordinatedlintegrated their activities with PC 

providers. Sixty-two percent of the PC providers and 61 % of the chaplains (58% 

chaplain assistants), in turn, reported coordinating MH activities with BH personnel. 

Results indicate coordination between these three groups is underutilized. All three 

groups are valuable resources for each other and together represent a force multiplier 

for Soldier support. 
Seventy-eight percent of the PC providers reported on their survey that BH personnel 

had given them information about where to refer Soldiers for MH problems, and 76% 

reported they had received information about the services BH personnel had offered for 

Soldiers. Chaplains (83%) reported that BH personnel provided them with information 

on where to refer Soldiers for MH problems, and 88% had been educated on the 

services that BH personnel provided for Soldiers. Although the great majority of 

respondents indicated they were informed of where to refer Soldiers for BH care, further 

coordination would capitalize on the strengths of these three professional groups. 

Finding #3: Many BH providers reported inadequate coordination with their 

higher headquarters. 

Thirty-nine percent of BH personnel reported their higher headquarters (HHQ) did not 

encourage them to provide feedbacklcomments regarding theater BHICOSC policies; 

34% reported their HHQ did encourage feedback. Thirty-one percent agreed their HHQ 

provided resources required to conduct the BHICOSC mission, while 46% disagreed. 

Two questions addressed medical leadership and line leadership in support of 

BHICOSC activities. Seventy-six percent of respondents believed medical leadership 

supports BHICOSC activities; 7% disagreed. Sixty-nine percent felt the leadership of 

the units they worked with supported BHICOSC activities; 11% disagreed. 

Finding #4: Most BH personnel in theater report conducting outreach on a 

regular basis, despite challenges of working in the operational environment. 

Behavioral health personnel were asked how frequently they provided services listed in 

Table 1. Sixty-nine percent were conducting COSC outreach services either weekly or 

several times a week, and 71% reported consulting with unit leaders once a week or 

more. Behavioral health personnel reported they were actively involved in conducting 

educational classes: psychological debriefings, and suicide prevention training. They 

also indicated they were providing services at the Soldiers' worksites as well as their 

own. 
Table 1: Provider Responses to Questions on Frequency of Service Delivery 

The numbers in the columns below (1 throuah 7) ., , are Dercentaae rates of the remonse for each 

quest~ona. through 1. Below the chart IS the definltlon' key for each numeral 1-7.' 

BHlCOSC Services (% of Respondents] 

During this deployment, how frequently did you: 1234567 

a. Provide COSC outreach services? 6 2 6 6 10 13 56 

b. Conduct educat~onal classes7 10 1 5 11 9 17 47 

c. Consult with unit leaders? 6 3 3 7 112249 

d Conduct psychological debriefmgs (CEDICISD)7 22 10 14 11 29 9 6 

e. Conduct systemat~c un~tneeds assessments? 36 11 14 17 14 5 4 

f. Conduct Suicide Prevention Trainina7 - 34 12 17 12 15 8 4

g. Provide one-to-one BH counseling with Soldiers at their worksite? 23 3 11 10 11 13 30 

h. Provide one-to-one COSC services with Soldiers at their worksite? 23 5 9 8 10 14 31 

i. Provide one-to-one BH counseling with Soldiers at your worksite? 9 2 4 4 5 11 65 

j. Provide one-to-one COSC services with Soldiers at your worksite? 12 3 4 4 8 12 57 

1 = Never; 2 = Only once; 3 = Once every 2-3 months; 4 = Once a month; 

5 = Two to three times a month; 6 = Once a week; 7 = Several times a week 

Seventy-eight percent of those surveyed disagreed with the statement, "Behavioral 

healthlCOSC personnel don't think preventive outreach activities are effective" while 5% 

agreed with this statement. Seventy-four percent disagreed with the statement that 

providers don't like to perform outreach. These rates show a more positive acceptance 

to outreach activities when compared to two questions, of a similar nature, that were 

asked during the MHAT-I survey. Operation Iraqi Freedom (OIF-I) providers were 

asked, "How relevant is COSC doctrine to current operations?" Only 44% of the junior 

enlisted, 35% of the NCOs, and 45% of the officers agreed that it was relevant. Also, 

57% of the BH personnel in OIF-I agreed COSC was the best method of early 

intervention. 

It is important to note that 50% of the BH personnel in OIF-I reported they had not 

received adequate training in COSC, prior to deploying. Driven by these findings, the 

combat stress control BH consultant ensured units supporting OIF-ll received "just in 

time training," prior to their deployment. Training teams were dispatched to the units' 

locations for 2 to 3 days of intensive COSC instruction. A portion of this training 

emphasized the importance for outreach. 

Significant challenges remain that impact the BH providers' ability to provide care. Forty 

percent of the BH personnel agreed that there was inadequate transportation to conduct 

outreach activities, 30% agreed that there was inadequate communication between 

BHICOSC and supported units, and 27% reported traveling to supported units was too 

dangerous. Forty percent felt that arranging convoys to supported units was not 

difficult; however, 21% reported having to cancel missions due to the inability to arrange 

convoys. 
Finding #5: Behavioral health personnel are confident in their ability to treat 

Soldiers with combat stress, suicidal thoughts/behaviors, or PTSD. They are not 

as confident to treat Soldiers with substance abuse/dependence, victims of 

sexual assault, or lraqi people. 

Behavioral health personnel expressed varying degrees of confidence in their ability to 

treat the following conditions listed in Table 2. These questions began with the phrase, 

"I feel confident in my ability to ..." followed by each of the statements listed below. 

Table 2: Confidence to Treat Varvina Conditions 

, , 

Evaluate and manage Soldiers with suicidal thoughtslbehaviors. 94% 1% 

Evaluate and treat Soldiers with substance abuseldependence. 70% 9% 

Evaluate and treat combat and o~erational stress reaction. 94% 2% 

Evaluate and treat acute stress disorder1PTSD. 91% 3% 

Evaluate and treat victims of sexual assault. 63% 10% 

Perform clinical evaluation and treatment of Iraqi civilians. 20% 44% 

Perform clinical evaluation and treatment of detainees. 23% 42% 

Perform clinical evaluation and treatment of Iraqi security force personnel. 22% 61% 

It is evident that further training is needed to prepare BH personnel to manage Soldiers 

experiencing substance abuseldependence, PTSD, and sexual assault. 

Finding #6: Psychiatric medications in OIF-I1 were more readily available than 

they were during OIF-I at each level of care, but Levels I and I1 continue to have 

limited availability of psychiatric medications for those who are credentialed to 

prescribe. 

Seventy-seven percent of the psychiatrists and nurses who had prescriptive authority 

reported adequate availability of appropriate psychiatric medications. Twenty-three 

percent disagreed. During OIF-I, only 36% of the psychiatrists and nurses felt that there 

was an adequate supply of psychiatric medication, an improvement from last year. 

Levels I and II continue to be perceived by some as problematic. The higher the level of 

care, the more available the medication became as 47% reported adequate availability 

of psychiatric medication at Level I (the battalion aid stations (BASS)); 78% reported 

adequate availability at Level II (the forward support medical company (FSMC)); and 

94% reported adequate availability at Level Ill (CSHs). Providers were asked to list the 

medications that Soldiers needed at each level of care; the longest list was with Level I 

(there were a total of 14 medications listed). Of these 14 medications, only three were 

repeated twice on the list, Effexor, Zyban, and Zyprexa. For the medications listed, see 

Table 3. Level II had eight listed with only one medication, Olanzapine. which was 

listed twice. Level Ill had only one medication listed. 
Olanzapine, Prazosin, Remeron, Seroquel, Strattera, Trazadone* 

Wellbutrin XR**, Zyban, Nicoderm patch 

Concerta, Lexapro, Paxil*, Prazosin, Remeron, Seroquel, Sonata, Level II Olanzapine 

* Approved for the medical equipment set at Level I, May 2004 

** Approved for the medical equipment set at Level 11, May 2004 

During this past year, a process action team (PAT) of psychiatrists recommended 

additions to the psychiatric medication formulary in the medical equipment set's (MES's) 

sick call (Level I), patient holding (Level II), and the CSH pharmacy. The Directorate of 

Combat and Doctrine Development's (DCDD's) combat casualty care integrated 

concept team approved the additions in May 2004, and the MESS will be updated to 

incorporate these changes. Also added were Celexa at Level I and Prozac and Zoloft at 

Level II. Space available for basic loads of medications at Levels I and II is very limited, 

while special medications can be supplied on request from a CSH or through Medical 

Logistics. The theater BH consultants (Kuwait and Iraq) are working with the pharmacy 

officer in the Corps Surgeon's office on a theater-wide formulary, following data 

collected from providers in theater. 

Finding #7: A quarter (25%) of the BH personnel surveyed reported a lack of 

confidence in their ability to use the COSC-WARS. 

Forty-seven percent of the BH personnel reported they were confident in their ability to 

use the COSC-WARS. Twenty-eight percent neither agreed nor disagreed. 

Finding #8: Behavioral health personnel are using multiple methods to assess 

the BHKOSC needs of Soldiers and units. Thirty-nine percent are using validated 

surveys/instruments. 

Behavioral health personnel were asked how they assessed the BHICOSC needs of the 

units and the Soldiers they support. Ninety-two percent reported they talk informally to 

Soldiers; 77% talk to unit medical personnel; 72% talk with unit commanders; 71% talk 

to chaplains; 42% conduct focus groups; 42% use locally developed surveys; and 39% 

use validated surveys/instruments. These are effective methods, but there continues to 

be a need to provide BH personnel with a standardized Soldier and unit needs 

assessment tool that can objectively quantify BH needs and needs of the Commander. 

Finding #9: One third of BH personnel are experiencing burnout. 

Thirty-three percent of BH personnel reported high burnout, 27% reported low 

motivation, and 22% reported low morale. Fifteen percent agreed that the stressors of 

deployment impaired their BH job; in addition, 12% felt that their sensitivity to the needs 

of the Soldiers had been adversely affected. 
BACKGROUND 

Survey Methods and Procedures 

The OIF-ll Mental Health Advisory Team (MHAT-II) designed the BH survey. The 

questions were devised by consensus of the team members to gather data on a variety 

of topics of interest to the MHAT-II mission, such as standards of practice, provision and 

coordination of services, skills and training in relation to compliance and understanding 

of COSC doctrine, involvement in suicide prevention, perceived stigma and barriers to 

MH care, and resource deficits. A copy of the instrument can be found at TAB A. 

The MHAT-II traveled throughout the Kuwait Combined Forces Land Combat Command 

(CFLCC) and the lraq MNC-I operational theaters and administered surveys and 

conducted interviews with BH personnel between 28 August and 30 September 2004. 

All BH personnel who the MHAT-II contacted were asked to complete the survey 

regardless of their current work assignment or unit. Participants were briefed on the 

mission and informed that the survey was both anonymous and voluntary. All BH 

personnel asked to complete the survey chose to participate. 

Quality Control of Data 

The MHAT-II collected a total of 137 surveys from BH personnel throughout Kuwait and 

lraq and hand-entered the data into a Microsoft (MS) Access database. A 10% quality 

control (QC) was performed on the dataset to check for entry errors. Each and every 

one of the survey fields was read aloud by one staff member, while another staff 

member checked the hand-entered MS Access database. 

Fifteen (1 5) out of 137 surveys were quality checked. Each survey contained 97 fields, 

for a denominator of 1455. Results revealed a total of 1 error (in the comment field). 

The error rate for all mistakes was 111455 or .069%, well within the acceptable 0.2% 

limit. 

Comparison Populations 

Data from the OIF-I behavioral health survey, conducted between 29 August and 

30 September 2003, are included in this report when comparisons of similar questions 

can be made. Most of the behavioral health OIF-ll survey questions were altered to 

better quantify the participants' response and to also capture the changes made in the 

BH system between 2003 and 2004. 

Study Sample 

A convenience sample of 137 (59%) of the 232 (as of 1 October 2004) lraq and Kuwait 

BH providers and enlisted MH specialists completed the survey at 17 locations around 

theater. Sixty-three percent of the survey respondents were age 30 or more. The rank 

distribution is as follows: junior enlisted Soldiers 28%, NCOs 27%, and officers 46%. 

Thirty-nine percent of all surveyed were active component, 52% Army Reserve, and 9% 
National Guard. Ninety-six percent of the participants were Army, 2% were Navy, and 

2% were Air Force. Sixty-five percent of the sample was male. 

Participants had been deployed an average of 21 0 days (7 months) over the past 2 

years; 25% said 1 year. Ninety-five percent of those surveyed reported currently 

working in their BH job. Table 4 shows the types of personnel represented in the 

survey. 
TAB A: Behavioral Health (BH) Survev 

Behavioral HealthlCombat and Operational Stress Control 

Personnel Survey 

This survey is being conducted under the auspices of The Army Surgeon General's OIF Mental Health 

Advisory Team (MHAT). The purpose of this questionnaire is to gather data about the current mental 

well-being of Soldiers and behavioral health personnel in theater and the functioning of the mental health 

system in OIFIOEF. Your responses will not be linked to you as an individual. 

Definitions: In this survey, Combat and Operational Stress Control (COSC) is used synonymously with 

preventive, educational and outreach services, and the management of combat and operational stress 

reactions (COSRs) as described in FM 8-51. Behavioral health (BH) is used synonymously with clinical 

care for behavioral health disorders (i.e.. evaluation and treatment). 

Today's Date: 

Age: Gender: Primary Component: 

1 = 18-20 1 = Male 1 = Active Component 

2 = 21-24 2 = Female 2 = Reserve (USAR) 

3 = 25-29 3 = National Guard 

4 = 30-39 4 =AGR 

5 = 40 or older 5 = Individual Ready Reserve (IRR) 

1 6 = WOI-WO5 

MOS/AOC; Which region best describes where you For THIS deployment, please 

I= Psychiatrist (60W) are currently serving? indicate the MONTH/YEAR you 

2 = Occ Therapist (65A) I= Northern lraq (Mosul area) arrived in theater: 

3 = Psych Nurse (66C) 2 = North East lraq (Kirkuk area) 

4 = Social Worker (73A) 3 = North Central lraq (TikritIBalad area) 

5 = Clin Psychologist (73B) 4 = Central lraq (Baghdad area) How long (MONTHS) should a 

6 = OT Specialist (91WN3) 5 = South Central lraq (Karbala to Nasiriyah) deployment last? 

7 = MH Specialist (91X) 6 = South lraq (Basra area) 

8 = Other: 7 = North Kuwait (Udairi. Virginia. etc.) 

8 = South Kuwait (Doha. Arifjan, etc.) 

I 


9 = Other: 

How many TOTAL DAYS have you been deployed (combat or peacekeeping) in the past 2 1 

years? 

How many MONTHS have you been assigned to your current unit? 

How many MONTHS has your current unit been deployed to IraqIKuwait? 

Are you currently working in my BHICOSC job? Yes INo 
Please circle the number indicatina - the dearee - to which vou aaree - or disaaree with - the statements below. 

I= Strongly D~sagree. 2 = D~sagree.3 = Ne~theragree nor disagree, 4 =Agree, 5 = Strongly Agree 

6.STANDARDS 

1 The standards of BH care ~n thls theaterlArea of Operat~ons are clear. 12345 

2 The standards of COSC services in thls theater1Area of Operations are clear. 12345 

3 The standards for clinical documentation in th~s theateriArea of Operations are 12345 clear 

4 The standards for records management In th~s theater1Area of Operat~ons are 12345 PIPST 

u,u-,. I 

5. The standards for transfer of clinical BH information between levels of care in 12345 this theateriArea of Operations are clear. 

C. COORDINATION 

1. My higher headquarters provides us with the resources required to conduct our 12345 BHICOSC mission. 

2. My higher headquarters encourages us to provide feedbacklcomments to 12345 theaterlArea of Operations BHICOSC policies. 

3. We coordinateiintegrate our BHICOSC activities with the Unit Ministry Teams in 12345 our Area of Operations. 

4. We coordinateiintegrate our BHICOSC activities with primary care medical 12345 personnel in the battalion aid stationsimedical companies. 

Please circle the number indicatins the deqree to which vou aqree or disasree with the statements below. 

I = Never: 2 = Only once: 3 = Once everv 2-3 months: 4 = Once a month: 

5 = Two to three times a month: 6 = Once a week: 7 = Several times a week 

I support (including preparation time)? 
Please circle the number indicating the degree to which you agree or disagree with the statements below. 

Please circle the number indicating the degree to which you agree or disagree with the statements below. 
Please circle the number indicatina - the dearee - to which vou aaree - or disaaree with - the statements below. 

1 = Never, 2 = Seldom, 3 = Frequently. 4 =Always 

G. SOLDIER NEEDS 

1 How do you assess the BHICOSC needs of the units you support? 

a. Talk informally to the Soldiers 1234 

b. Conduct focus groups with Soldiers 1234 

c. Talk with the chaplams 1234 

d. Talk with the unit's commander 1234 

e Talk with the unit's medical personnel 1234 

f. Use validated surveysl~nstruments 1234 

g. Use locally developed surveyslinstruments 1234 

h. Develop a BHICOSC unit prevention and early intervention plan 1234 

I. Conduct Command Consultation 1234 

Please clrcle the number indlcatlng the degree to whlch you agree or dlsagree wlth the statements below. 

1 = Strongly Disagree, 2 = Disagree, 3 = Neither agree nor disagree, 4 = Agree, 5 = Strongly Agree 

H. PERSONAL WELL-BEING 

1 My ability to do my behaworal health job is impaired by the stressors of 12345 deploymentlcombat 

2 My mental well-being has been adversely affected by the events I have 12345 witnessed on thls deployment. 

3 My spiritual well-being has been adversely affected by the events I have 12345 witnessed on this deployment 

4 Since this deployment. I have become less sensitlve to the needs of the Soldiers 

l servelsupport 

5 My abillty to do my job is lmpalred by listening to the combat experiences of 12345 Soldlers I've talked with whlle performing my BHICOSC misslon. 

Please circle the number indicating the degree to which you agree or disagree with the statements below. 

1 6 Please rate the following: 

I = Very low, 2 = Low, 3 = High, 4 = Very high 

a. Your personal morale 1234 

b. Your energy level 1234 

c. Your level of burnout 

d Your motivation 

The following equipment/supplies would have improved my team's ability to complete our BHICOSC 

mission: 
Please circle the number indicating the degree to which you agree or disagree with the statements below. 

= Sfronalv Disaaree: 2 = ~isaaree:3; Neither aaree nor-disaaree: 4-= Aaree: 5 = Stronalv Aaree I. < .Psy.-c.HIAT-RiC .ibNL.v PS~y-c.HiATRI-s-TSjN-".R.s-. ...... I _ .-..- -

PRACTITIONNERSIPAs) 

1. The procedures for orderinalre~lenishina Dsvchiatric medications in this - . -. * 

theaterl~rea of Operations are clear. 

2. In general, there has been adequate availability of appropriate psychiatric 

medications in the area of operations. Yes I No 

3. There has been adequate availability of appropriate psychiatric medication 

at these levels of care: 

a. Level I (Battalion Aid Station) Yes 1 No 

b. Level II (Forward Support Medical Company) Yes 1 No 

c. Level Ill (Combat Support Hospital) Yes INo 

4. What medications were needed by Soldiers during this deployment, but were not 

available to prescribe? 

Please provide any additional comments below. 

Thank you for completing this survey! 
APPENDIX 2 

SUMMARY OF PRIMARY CARE (PC) SURVEY 

INTRODUCTION 

Primary care is frequently a BH referral source for Soldiers with MH problems. Some 

PC providers prescribe medication for mental disorders in addition to monitoring and 

refilling previously prescribed psychotropic medications. A part of the OIF-ll Mental 

Health Advisory Team's (MHAT-11's) mission was to evaluate the working relationship 

between PC providers and BH personnel rendered in theater. The MHAT-II devised an 

anonymous questionnaire for primary medical care personnel. These personnel were 

doctors, physician assistants (PAS), nurses, and medics serving in BASS, FSMCs, and 

CSHs. Behavioral healthcare personnel is defined in this appendix as officer and 

enlisted personnel who provide BH services to Soldiers. 

FINDINGS 

Finding #I: Coordination is ongoing between PC personnel, BH personnel, and 

UMTs. 

Over three quarters of the PC providers surveyed (78%) reported BH personnel had 

provided them information about where to refer Soldiers for MH problems, and 76% 

reported BH personnel had educated them on BHICOSC services available for Soldiers. 

Forty-seven percent of the PC providers reported they coordinatedlintegrated their MH 

activities with UMTs, and 62% coordinatedlintegrated MH activities with BH personnel. 

Finding #2: Primary care providers are helping Soldiers with MH problems, and 

they are referring Soldiers with MH problems to BH services. 

Primary care providers were asked how frequently they provided services listed on the 

next page in Table 1. Twenty-four percent of the respondents reported helping Soldiers 

with MH problems either once or several times a week. Of this 24%, 14% referred 

Soldiers to BH personnel. While 78% of PC respondents indicated they had received 

information on where to refer Soldiers for MH services, 23% had not referred any 

Soldiers with MH problems to BH personnel; 8% had referred once; 22% had referred 

once every 2 to 3 months, and 47% had referred once a month or more. 
Table 1: Provider Responses to Questions on Frequency of Service Delivery 

The numbers in the columns below (1 throuah ., 71,are Dercentaae rates of the resDonse for each auestion ' 

In the left column. Below the chart I; the defln~t~on ke; for each numeral 1-7. 

PC Provider Provision of Mental Health Services (% of Respondents) 

During this deployment, how frequently did you: 1 2 3 4 5 6 7 

Help Sold~ers for a mental health problem? 15 10 16 13 22 13 11 

Conduct educational (stress management) classes? 68 11 10 6 3 1 1 

Consult with unit leaders regarding mental health issues? 41 13 21 10 10 5 2 

Refer Soldiers with mental health problems to the Chaplain? 140 14 22 10 10 3 2 

Refer Soldiers with problems to the mental health personnel? 123 8 22 13 20 9 5 

1 = Never; 2 = only once; 3 = Once every 2-3 months; 4 = Once a month; 5 = Two to three times a month; 6 

= Once a week; 7 = Several times a week 

Finding #3: Almost three fourths of the PC providers feel confident in their ability 

to help Soldiers face MH issues, but are less confident to treat Soldiers with 

PTSD, substance abuse, or sexual assault. 

While 73% of the PC providers reported they felt confident in helping Soldiers face MH 

issues during this deployment, 47% were confident in treating Soldiers with substance 

abuseldependence; 58% were confident in treating Soldiers with combat and 

operational stress reaction (COSR); 64% were confident in treating acute stress 

disorderlPTSD; and 39% were confident in treating victims of sexual assault. 

Finding #4: Primary care personnel do not believe many commanders will 

welcome back their Soldiers with BH problems. 

Thirty-two percent of the PC providers believed commanders would welcome back 

Soldiers who received MH services, 22% agreed that commanders would welcome 

back Soldiers who displayed suicidal thoughtslbehaviors, and 18% agreed that 

commanders would welcome back Soldiers with homicidal thoughtslbehaviors. 

Finding #5: Just over one third of PC personnel are experiencing burnout. 

Thirty-seven percent of PC providers reported high burnout, 35% reported low 

motivation, and 35% reported low morale. Fifteen percent agreed that the stressors of 

deployment had impaired their medical job, and 14% indicated they had become less 

sensitive to the needs of Soldiers during this deployment. 

BACKGROUND 

Survey Methods and Procedures 

The MHAT-II designed the PC survey. No standardized questions were used, though 

most of the questions were devised by consensus of the team members. Where 

possible, questions were standardized across the BH, PC, and UMT surveys. The 

questions ranged on a variety of topics of interest to the MHAT-II mission, such as 

standards of practice, provision and coordination of services, skills and training in 

relation to compliance and understanding of BH services, perceived stigma and barriers 
to MH care, and general personal well-being. A copy of the instrument can be found at 

TAB A. 

The MHAT traveled throughout the Kuwait (CFLCC) and lraq (MNC-I) operational 

theaters and administered surveys and conducted interviews with PC providers 

between 28 August and 30 September 2004. All PC providers who the MHAT-II 

contacted were asked to complete the survey regardless of their current work 

assignment or unit. Participants were briefed on the mission and informed that the 

survey was both anonymous and voluntary. All PC providers, which were asked to 

complete the survey, elected to participate. 

Quality Control of Data 

A total of 242 surveys were collected and the data entered into MS Access. A 10% QC 

was performed on the dataset to check for entry errors. Each and every one of the 

survey fields was read aloud by one staff member, while another staff member checked 

the hand-entered MS Access database. 

Twenty-five (25) out of 242 surveys were quality checked. Each survey contained 68 

fields, for a denominator of 1,700. Results revealed a total of 2 errors in 2 different 

fields. The error rate for all mistakes was 211,700 or .I18%, below the accepted 0.2% 

error rate standard. 

Study Sample 

A convenience sample of 242 PC surveys was collected in 24 different locations around 

lraq and Kuwait. (See Table 2 for professions represented.) Sixty-five percent of the 

surveyed respondents were age 30 or more. The rank distribution is as follows: junior 

enlisted Soldiers 20%, NCOs 22%, and officers 58%. Seventy-two percent of all 

surveyed were active component, 4% Army Reserve, and 23% National Guard. Ninetyfive percent of the participants were Army, 4% were Navy, and 1% was Air Force. 

Seventy-two percent of the sample was male. 

Participants had been deployed an average of 229 days (7.6 months) over the past 2 

years, and 89% of those surveyed reported currently working in their PC job. Table 2 

shows the types of professionals represented in the survey. 
Physician Assistant 47 20% 

Family Practice 28 15% 

Nurse 10 4% 

Emergency Medicine 9 4% 

Flight Surgeon 7 3% 

General Medical Officer 4 2% 

Other (Internal Medicine, Surgeon, 

51 21% 

midwife, etc.) 
TAB A: Primarv Care (PC1 Survev 

Primary Care (BASIMedical) 

Personnel Survey 

This survey is being conducted under the auspices of The Army Surgeon General's OIF Mental Health 

Advisory Team (MHAT). The purpose of this questionnaire is to gather data about the current mental 

well-being of Soldiers in theater and the functioning of the mental health system in OIFIOEF. Your 

responses will not be linked to you as an individual. 

Definition: Mental health care is the clinical care of Soldiers with mental health problems or combat and 

operational stress reactions. 

Today's Date: 

Age: Gender; Primary Component: 

1 = 18-20 I= Male 1 = Active Component 

2 = 21-24 2 = Female 2 = Reserve (USAR) 

3 = 25-29 3 = National Guard 

4 = 30-39 4 =AGR 

5 = 40 or older 5 = Individual Ready Reserve (IRR) 

I 1 6 = WOI-W05

MOS/AOC; Which region best describes where you For THIS deployment, please 

1 = Emerg Med (618) are currently serving? indicate the MONTH/YEAR you 

2 = Family Practice (61H) I= Northern lraq (Mosul area) arrived in theater: 

3 = Flight Surgeon (61N) 2 = North East lraq (Kirkuk area) 

4 = GMO (62B) 3 = North Central lraq (TikritIBalad area) 

5 = PA (65D) 4 = Central lraq (Baghdad area) How long (MONTHS) should a 

6 = Nurse (66B) 5 = South Central lraq (Karbala to Nasiriyah) deployment last? 

7 = Med Specialist (91W) 6 = South lraq (Basra area) 

8 = Other: 7 = North Kuwait (Udairi. Virginia, etc.) 

8 = South Kuwait (Doha. Arifjan, etc.) 

I 


9 = Other:

How many TOTAL DAYS have you been deployed (combat or peacekeeping) in the past 2 

years? 

How many MONTHS have you been assigned to your current unit? 

How many MONTHS has your current unit been deployed to IraqIKuwait? 

Are you currently working in my medical job? YesiNo 
I 

Please circle the number indicating the degree to which you agree or disagree with the statements below. 

= Sfrongly Disagree; 2 = Disagree: 3 = Neither agree nor disagree; 4 = Agree; 5 = Strongly Agree 

B. STANDARDS 

1 The standards of inedlcal care ~n thls IheateliArea of O~eratlons ale clear 12345 

2. The standards of mental health care in this theaterlArea of Operations are clear. 12345 

3. The standards for clinical documentation in this theaterlArea of Operations are 

clear. 12345 

4. The standards for records management in this theaterlArea of Operations are 

clear. ~ ~~~ 

12345 

5. The standards for transfer of clinical mental health information between levels of 

care in this theaterlArea of Operations are clear. 12345 

C. COORDINATION 

1 We coordinatelintegrate our mental health activ~t~es with the Unit M~nistry Teams 

In our Area of Operat~ons. 12345 

2 We coordinatelintegrate our mental health activ~ties with mental health 

personnel In our Area of Operations. 12345 

3 Mental health personnel have provided us informat~on about where to refer 

Sold~ers for mental health problems. 12345 

4 Mental health personnel have provided us informat~on about the servlces they 

prov~deto Sold~ers. 12345 

Please circle the number indicating the degree to which you agree or disagree with the statements below. 

I = Never: 2 = Only once: 3 = Once every 2-3 months: 4 = Once a month; 

5 = Two to three times a month: 6 = Once a week: 7 = Several times a week 

D. COMBAT AND OPERATIONAL STRESS CONTROL AND MENTAL HEALTH 

SERVICES 

1 Durina this dedovment. how freauentlv did vou: 

c. Consult with unit leaders regarding mental health issues? 1234567 

d. Refer Soldiers with mental health problems to the Chaplain? 1234567 

e. Refer Soldiers with Droblems to the mental health ~ersonnel? 1234567 

2. Approximately how many Soldiers does your team support? 

Please circle the number indicating the degree to which you agree or disagree with the statements below. 

1 = Stro~lgly Disagree. 2 = Disagree 3 = Neither aglee nor disaglee. 4 = Aglee. 5 = St~ongly Agree ............................................................... E...SKliiS..AND.T.RAiN.lNG- ................................. -


......................... -


1. I feel confident in my ability to: 

a. Help Soldiers face mental health issues during the deployment. 12345 

b. Evaluate and treat Soldiers with substance abuseldependence. 12345 

c. Evaluate and treat Combat and Operational Stress Reaction. 12345 

d. Help Soldiers face BHICOSC issues during the deployment. 12345 

e. Evaluate and treat Acute Stress DisorderlPosttraumatic Stress Disorder. 12345 

f. Evaluate and treat victims of sexual assault. 12345 

g. Perform clinical evaluation and treatment of Iraqi civilians. 12345 

h. Perform clinical evaluation and treatment of detainees. 12345 

i. Perform clinical evaluation and treatment of Iraqi Security Force personnel. 12345 
Please circle the number indicating the degree to which you agree or disagree with the statements below. 

1 = Strongly Disagree; 2 = Disagree; 3 = Neither agree nor disagree; 4 = Agree; 5 = Strongly Agree 

F. STIGMA AND BARRIERS TO MENTAL HEALTH CARE 

I 1. Commanders welcome back Soldiers who have received mental health services 

from my team. 

I . - - . - 12343 I 

2. Commanders welcome back Soldiers who have been assessed for suicidal 

thoughts/behaviors and returned to duty. 12345 

3. Commanders welcome back Soldiers who have been assessed for homicidal 

thoughtslbehaviors and returned to duty. 12345 

Please circle the number indicating the degree to which you agree or disagree with the statements below. 

1 = Stronalv Disaaree: 2 = Disaaree: 3 = Neither aaree nor disaaree: 4 = Aaree: 5 = Stronalv Aaree 

1. My ability to do my medical job is impaired by the stressors of 12345 deploymentlcombat. 

2. My mental well-being has been adversely affected by the events I have 12345 witnessed on this deployment. 

3. My spiritual well-being has been adversely affected by the events I have 12345 witnessed on this deployment. 

4. Since this deployment. I have become less sensitive to the needs of the Soldiers 12345 I servelsupport. 

5. My ability to do my job is impaired by listening to the combat experiences of 12345 Soldiers I've talked with while performing my BHICOSC mission. 

Please circle the number indicating the degree to which you agree or disagree with the statements below. 

I = Very low, 2 = Low, 3 = High, 4 = Very high 

Please rate the following: 1 6 

a. Your personal morale 1234 

b. Your energy level 1234 

c. Your level of burnout 1234 

d. Your motivation 1234 

I The following equipmentisupplies would have improved my team's ability to complete our medical 

mission: 
I 

Please circle the number indicating the degree to which you agree or disagree with the statements below. 

= Stronalv Disaaree: 2 = Disaaree: 3 = Neither aaree nor disaaree: 4 = Aaree: 5 = Stronalv Aaree _ .-.-<.-- --.. 

PSYC.H,*TRi-C ICA.TIO.i (ON.L.v. P".YS.jCIA~S,NUkSEN.".R~E~ -< ..%.... .

PRACTlTlONERSIPAs) 

1. The procedures for orderinalre~lenishina Dsvchiatric medications in this 

3. There has been adequate availability of appropriate psychiatric medicatio 

-. -.... . ,--. . . . . -. . . ... -. . . .-. . . --. . .. 

b. Level II (Forward Support Medical Company) YesiNo 

c. Level Ill (Combat Support Hospital) YesiNo 

Please circle the number indicating the degree to which you agree or disagree with the statements below. 

I = Never: 2 = Onlv once: 3 = Once everv 2-3 months: 4 = Once a month; 

5 = Two to three times a month; 6 = ~~~~~~a week; 7 = several times week 

4. During this deployment, how frequently did you prescribe medication for: 

a. Sleep problems? 

b. Depression? 

c. Anxiety? 

5. What medications did Soldiers need during this deployment, but were not 

available to prescribe? 

Please provide any additional comments below. 

Thank you for completing this survey! 
APPENDIX 3 

SUMMARY OF UNIT MINISTRY TEAM (UMT) SURVEY 

INTRODUCTION 

The Unit Ministry Team (UMT) survey was administered to gather data regarding the 

UMT's pastoral support of deployed troops, how well they interface with BH assets 

during OIF-ll, and to provide recommendations from the identified findings. The UMT 

personnel are defined as both chaplains and chaplain assistants and are included in all 

analyses below: except where otherwise noted. 

Prior to their deployment to theater, the MHAT members constructed the survey. The 

UMT survey from last year's MHAT-I focused on UMTs and suicide prevention. This 

survey focused on combat stress and UMT's interface with the BH system in theater. 

Standardized questions were used in conjunction with BH and PC formats and devised 

by consensus of the team members. The questions covered a variety of topics of 

interest to the MHAT mission, such as coordination with BH assets for CSC, UMT 

religious and pastoral care activities, skills and training, perceived stigma and barriers to 

care, Soldiers' needs, personal well-being of the UMT member, and what UMT 

members perceive as the major issues impacting Soldiers. Space was provided for 

participants to make comment regarding equipment needed, and any additional 

comments regarding the deployment. 

FINDINGS 

Finding #I: Most UMT personnel are providing suicide prevention training. 

Eighty-five percent of UMT personnel (91% of chaplains) report that they have 

conducted suicide prevention training at least once during the deployment. Just over 

half (51 %) conduct suicide prevention training monthly or more often. 

Finding #2: Most chaplains are conducting critical event debriefing (CED) 

sessions. 

Seventy-six percent report conducting at least one CEDICritical Incident Stress 

Debriefing (CISD) session during the deployment; 25% conduct CEDICISDs monthly or 

more often. 

Finding #3: Unit ministry team personnel regularly identify Soldiers at risk for 

battle fatigue. 

Twenty-five percent of UMT personnel (82% of chaplains) report having identified at 

least one Soldier at risk for battle fatigue, and nearly half (49%) report identifying a 

Soldier once a month or more often. Fifteen percent identify a Soldier at risk once a 

week or more often. (Note: Army Chaplain Corps doctrine still uses the term "battle 
fatigue" for what joint medical doctrine now refers to as "combat and operational stress 

reactions (COSRs).") 

Finding #4: Unit ministry team personnel report receiving good coordination 

from BH personnel. Most chaplains report coordinating/integrating their UMT 

religious activities with the BH/COSC team(s) and PC personnel in their Area of 

Operations (AO). 

Eighty-three percent of UMT personnel agreed that BH personnel had provided 

them with information about MH services that were provided, and where to refer 

soldiers with MH problems. Fifty-eight percent of UMT personnel (61% of the 

chaplains) acknowledged coordinatinglintegrating their UMT activities with BH 

personnel. Sixty-three percent (75% of chaplains) coordinatedlintegrated 

services with PC personnel in their AO. 

Finding #5: Most UMT personnel report high morale, energy, and motivation. 

Most also report that their mental and spiritual well-being and their ability to do 

theirjob have not been impaired by deployment/combat stressors. However, 

there were some UMT personnel who reported problems with burnout. 

A great majority of UMT personnel indicated high levels of morale, energy, and 

motivation. Seventy-six percent reported that morale was high or very high. 

Seventy-two percent indicated that their energy level was either high or very high. 

Eighty-five percent reported high or very high levels of motivation. Sixty-two percent 

reported that their level of burnout was low or very low. 

Most UMT personnel reported that their mental well-being was not adversely affected by 

their role as providers. Sixty-nine percent of the UMTs surveyed disagreed or strongly 

disagreed that their mental well-being was adversely affected by listening to the combat 

experiences of Soldiers. Further, 79% of UMT personnel surveyed disagreed or 

strongly disagreed that the stressors of deployment and combat impair their job. 

Although most are doing well, 16% of UMT personnel agreed or strongly agreed that the 

stressors of the deployment and combat impaired their job. They also reported low or 

very low personal energy (28%), personal motivation (23%), personal morale (18%), 

and high or very high personal burnout (33%). Some also reported having their mental 

(13%) or spiritual (15%) well-being adversely affected by combat or deployment 

stressors. 
RECOMMENDATIONS 

Recommendation #I:Ensure UMT personnel understand COSC principles. 

Field Manual (FM) 1-05 states that "the Unit Ministry Team works closely with the unit's 

leaders and medical personnel to care for battle fatigue cases through religious support 

and comfort." Survey data revealed that UMT personnel regularly identify Soldiers with 

combat and operational stress and that they regularly provide CEDlCISDs within 

their units. Working together, BH and UMT personnel can provide reinforced vigilance 

and intervention to Soldiers who might not otherwise seek or receive care. 

Recommendation #2: Research burnout and develop/implement a program to 

prevent or reduce it. 

Although the vast majority of chaplains and chaplain assistants are doing very well, a 

small, but significant portion (15-30%) are experiencing combatldeployment-induced 

problems that may affect their ability to care for Soldiers. Further research into the 

causes, effects, and mitigating factors involved in the burnout process is needed. Once 

these factors are better understood, prevention and/or intervention programs should be 

devised to assist UMT personnel. 

BACKGROUND 

Procedures 

The MHAT traveled throughout the Kuwait (CFLCC) and Iraq (MNC-I) operational 

theaters, and administered surveys to UMT personnel between 29 August and 

8 October 2004. Surveys were administered to combat: combat support, and combat 

service support units. The UMTs were surveyed as part of these units that the MHAT 

surveyed. 

The MHAT personnel administered the surveys. All participants were briefed on the 

mission of the MHAT and informed that the survey was both anonymous and voluntary. 

All UMT personnel asked to complete the survey did so. 

Quality Control of Data 

Data collected from the surveys were entered into a MS Access database. A 10% 

quality check was performed on the first 150 surveys entered into the dataset to check 

for entry errors. Each and every one of the survey fields was read aloud by one staff 

member, while another staff member checked the hand-entered MS Access database. 

Fifteen out of 150 surveys were quality checked; 80 fields in each survey. Results 

revealed a total of 9 errors among the 1200 (80 x 15) fields checked. The error rate for 

all hand-entry mistakes was 0.75%. 
Comparison of Data to OIF-I Mental Health Advisory Team 

Due to changes in the survey, The OIF-I and OIF-ll Unit Ministry Team surveys only 

have one question in common. The focus of the OIF-I Unit Ministry Team survey was 

suicide prevention, while the OIF-ll UMT survey covered a wider variety of topics. 

Study Sample 

A convenience sample of 86 Army and 3 Air Force chaplains, and 74 Army, 2 Navy, and 

4 Air Force chaplain assistants completed the survey between 29 August and 8 October 

2004 at 21 locations in Kuwait and Iraq. Because UMT members were also canvassed 

during routine UMT training meetings in both Kuwait and Iraq, more than 21 locations 

are actually represented. More than 70% of the chaplains and chaplain assistants in 

Iraq were surveyed. 

Of the commissioned chaplains, 46% were field grade officers, and of the enlisted 

chaplain assistants, 51 % were NCOs. Of all the respondents, 57% were Active 

Component, 27% were National Guard, and 15% were Army Reserve Soldiers. 

Seventy-three percent of the chaplains were age 40 or older, while 77% of the chaplain 

assistants were under age 40. Two chaplains and seven chaplain assistants were 

female. The UMT personnel had been deployed a median 240 days in the last 2 years 

(may include other deployments than the current one), and 99% reported that they were 

performing UMT duties while in theater. 

Table 1 shows the types of units the respondents supported in theater. Table 2 is a 

breakdown by percentage of Section C of the UMT Religious Activities that responders 

reported. 

Table 1: Types of Units the UMT Respondents Supported 

Description Percent of Respondents 

Combat Arms Un~ts 36% 

Combat Support Un~ts 27% 

Combat Service Support Un~ts 21% 

Medical 6% 

Unknown or Unmarked 10% 
Table 2: The UMT Religious Activities that Respondents Reported 

The numbers in the columns below (1 throuah 71 are Dercentaae rates of the resDonse for each auestion a 

a. Provide ministry of presence? 

b. Conduct suicide prevention training? 

c. Conduct religious services? 6 21 2 42858 

d. Conduct memorial services? 

e. Identify Soldiers at risk for battle fatigue? - 1 25 8 19 16 17 8 7

f. Provide crisis intervention management? - 1 18 10 19 17 15 12 9

g. Conduct educational classes (stress management, etc.)? 131 12 27 9 11 7 4 

1 h. Consult with unit leaders? 4 1 4 61223511 

i. Conduct psychological debriefings (CEDICISD)? 36 12 25 13 7 3 3 

1 i. Conduct svstematic unit reliaious needs assessments? 26 25 18 149 4 5 1 

1 k. Conduct arief facilitation and h0~e counselina? 1 27 5 16 11 17 13 11 I 

1 I. Reinforce Soldiers' faith and ho~e? 3 1 2 5 817641 

m. Provide Soldiers opportunities to discuss their combat experiences? 6 4 6 7 14 19 43 

n. Provide one-to-one pastoral counseling with Soldiers at their worksite. 14 2 2 5 7 16 54 

o. Provide one-to-one pastoral counseling with Soldiers at the UMT worksite? 14 1 2 5 8 12 57 

1 = Never; 2 = Only once; 3 = Once every 2-3 months; 4 = Once a month; 5 = Two to three times a month; 

6 = Once a week; 7 = Several times a week 
TAB A: Unit Ministrv Team (UMTJ Survev 

Unit Ministry Team (UMT) 

Personnel Survey 

This survey is being conducted under the auspices of The Army Surgeon General's OIF Mental Health 

Advisory Team (MHAT). The purpose of this questionnaire is to gather data about the current 

mentallspiritual well-being of Soldiers and chaplains in theater and the functioning of the mental health 

system in OIFIOEF. Your responses will not be linked to you as an individual. 

Definitions: In this survey, Combat and Operational Stress Control (COSC) is used synonymously with 

preventive, educational and outreach services, and the management of combat and operational stress 

reactions. Behavioral Health (BH) is used synonymously with clinical care for behavioral health disorders 

(i.e., evaluation and treatment). 

Today's Date: 

Age: Gender: Primary Component: 

1 = 18-20 1 = Male 1 = Active Component 

2 = 21-24 2 = Female 2 = Reserve (USAR) 

3 = 25-29 3 = E7-E9 3 = National Guard 

4 = 30-39 4 = 01-03 4 =AGR 

5 = 40 or older 5 = 04-06 5 = Individual Ready Reserve (IRR) 

6 = W01-WO5 

MOS/AOC; Which region best describes where you For THIS deployment, please 

I= Chaplain (56A) are currently serving? indicate the MONTH/YEAR you 

2 = Chaplain Assist. (56M) I= Northern Iraq (Mosul area) arrived in theater: 

3 = Other: 2 = North East lraq (Kirkuk area) 

3 = North Central lraq (TikritIBalad area) 

4 = Central lraq (Baghdad area) What type of unit do you How long (MONTHS) should a 

5 = South Central lraq (Karbala to Nasiriyah) support? deployment last? 

6 = South lraq (Basra area) I= Combat (IN. AR. FA) 7 = North Kuwait (Udairi. Virginia. etc.) 2 = Combat Support 8 = South Kuwait (Doha. Arifjan, etc.) 3 = Combat Svc Support 9 = Other: 

4 = Medical 

5 = Other: I 

How many TOTAL DAYS have you been deployed (combat or peacekeeping) in the past 2 1 

vears? 1 
Please circle the number indicatina - the dearee - to which vou aaree - or disaaree with - the statements below. 

I= Strongly D~sagree. 2 = D~sagree.3 = Ne~theragree nor disagree, 4 =Agree, 5 = Strongly Agree 

6. COORDINATION 

1 My command prov~des us with the resources requ~red to conduct our UMT 12345 rehglous act~vit~es. 

2 My chaplain chain of command prov~des us w~th the resources requ~red to 12345 conduct our UMT rehglous act~v~ties. 

3 We coordinatel~ntegrate our UMT religious act~v~t~es with the BHICOSC team(s) 12345 In our Area of Operat~ons (AO). 

4 We coordinatelintegrate our UMT religious actwities with prlmary care medical 12345 personnel in the battalion aid station(s)lmedical company(s) in our A0 

5 Mental health personnel have prov~ded us information about where to refer 

Sold~ers for mental health problems. 12345 

6 Mental health personnel have prov~ded us mformat~on about the servlces they 12345 provide to Sold~ers. 

Please circle the number indicating the degree to which you agree or disagree with the statements below. 

I = Never: 2 = Only once; 3 = Once every 2-3 monfhs: 4 = Once a monfh; 

5 = Two to three times a month; 6 = Once a week; 7 = Several times a week 

, , 

n. Provide one-to-one pastoral counseling with Soldiers at their worksite? 1234567 

o. Provide one-to-one pastoral counseling with Soldiers at the UMT worksite? 1 2 3 4 5 6 7 

2. Approximately how many Soldiers does your team support? 

3. How many locations (base campslFOBs) does your UMT support? 

4. On average, how many hours does it take to convoy to the base camps you 

support (including preparation time)? 
Please circle the number indicatina - the dearee - to which vou aaree - or disaaree with - the statements below. 

I= Strongly D~sagree. 2 = Disagree. 3 = Ne~theragree nor disagree, 4 =Agree, 5 = Strongly Agree 

D. SKILLS AND TRAINING 

1 l feel confident in my ability to: 

a. Conduct pastoral counseling 12345 

b. Conduct suicide prevention classesltraining for Soldiers. 12345 

c. ldent~fy and ass~st Soldiers wlth sulc~dal thoughts/behav~ors. 12345 

d. Help Soldiers adapt to the stressors of combatldeployment. 12345 

e. Identify Soldiers with substance abuseldependence. 12345 

f. Assist Soldiers with sexual harassment issues. 12345 

g. Identify Soldiers with Combat and Operational Stress Reactions. 12345 

h. Perform clinical evaluation and treatment of detainees. 12345 

Please circle the number indicatina the dearee to which vou aaree or disaaree with the statements below. 

1 = Strongly Disagr.ee: 2 = Disagree. 3 = ieither- agr-ee ,;or dis&r-ee: 4 = igr-ee: 5 = Stror,gly Agree 

E. STIGMA AND BARRIERS TO CARE 

1. Commanders welcome back Soldiers who have received ~nental health selvices. 12345 

2. Commanders welcome back Soldiers who have been assessed for suicidal 

thoughts/behaviors and returned to duty. 12345 

3. Commanders welcome back Soldiers who have been assessed for homicidal 

thoughts/behaviors and returned to duty. 12345 

4. The leadership doesn't support pastoral counseling activities. 12345 

5. There is inadequate transportation to conduct UMT religious activities. 12345 

6. Soldiers feel uncomfortable talking to UMT personnel about their problems. 12345 

7. Traveling to supported units is too dangerous. 12345 

8. Arranging convoys to supported units is too difficult. 12345 

Please circle the number indicating the degree to which you agree or disagree with the statements below. 

1 = Nevet 2 = Seldo~n3 = Fteqcrently 4=Always 

1 How do you assess the religiouslspiritual needs 

F. SOLDIER 

of 

NEEDS 

the units you support? -

a. Talk informally to the Sold~ers 1234 

b. Conduct focus groups with Soldiers 1234 

c Talk with the BHICOSC personnel 1234 

d. Talk wlth the un~t's commander 1234 

e. Talk with the unit's medical personnel 1234 

f. Use val~dated surveyslinstruments 1234 

g. Use locally developed surveys/~nstruments 1234 

h. Develop a religious support plan 1234 
Please circle the number indicating the degree to which you agree or disagree with the statements below. 

1 = Strongly Disagree; 2 = Disagree; 3 = Neither agree nor disagree; 4 = Agree; 5 = Strongly Agree 

G. PERSONAL WELL-BEING 

1 My ability to do my UMT job is impaired by the stressors of deploymentlcombat 12345 

2 My mental well-being has been adversely affected by the events I have 

witnessed on this deployment 12345 

3 My spiritual well-bemg has been adversely affected by the events I have 

witnessed on th~s deployment 12345 

4 Since this deployment. I have become less sensitwe to the religiouslspiritual 

needs of the Sold~ers Iservelsupport. 12345 

5 My ability to do my job is impaired by listening to the combat experiences of 

Sold~ers I've talked with whde performing my BHICOSC miss~on. 12345 

Please circle the number indicat~ng the degree to which you agree or disagree w~th the statements below 

I = Very low, 2 = Low, 3 = High, 4 = Very high 

6 Please rate the following: 

a. Your personal morale 1234 

b. Your energy level 1234 

c Your level of burnout 1234 

d. Your rnotwat~on 1234 

The following equipment/supplies would have improved my team's ability to complete our UMT mission: 

Please provide any additional comments on the back. 

Thank you for completing this survey! 
APPENDIX 4 

SUMMARY OF BEHAVIORAL HEALTH INTERVIEWS 

INTRODUCTION 

Face-to-face interviews with BH personnel in Kuwait and lraq were conducted to obtain 

level of perspectives on the delivery, resources, and problems encountered providing 

MHIBH care in a combat operational theater. All BH specialties were represented and 

were the following: Psychiatrists, psychologists, social workers, occupational therapists, 

psychiatric clinical nurse specialistslpsychiatric nurses, MH specialists, and OT 

assistants. 

APPROACH 

Face-to-Face Interviews 

Members of the MHAT conducted all interviews on an interview schedule (see TAB A). 

Forty-two individual or group interviews were conducted at 12 different locations 

throughout Kuwait and lraq with the following composition: 

RANK PARTICIPANTS 1 % OF TOTAL 

I Field Grade 1 20 I 24% I 

Company Grade 20 24% 

NCO 15 18% 

Junior Enlisted 27 34% 

TOTAL 82 100% 

ThemeslQuestions 

Prior to all interviews: key themes and specific questions were determined that every 

MHAT interviewer would attempt to address. All individuals were asked the same 

questions. Interview questions were: (1) What can you tell us about your experience 

that we didn't ask on the survey? (2) What challenges or obstacles to providing care 

have you faced during the deployment? (3) What additional training would you benefit 

from prior to deployment, if any? 

Procedures 

All interviews began with a member of the MHAT introducing himselflherself and 

describing the purpose and objective of the interview. Confidentiality and anonymity 

were guaranteed in order to encourage candid and honest discussion. Thus, no names 

of any of the interviewees' were recorded. Interviews lasted approximately 20 to 60 

minutes. 
RESULTS 

Behavioral Health Personnel in Kuwait 

Participants were four enlisted and eight officers at three separate unit locations in 

Kuwait. Several issues surfaced that were not asked on the BH survey that were 

discussed during the interview: 

Behavioral Health System Concerns: 

1. There were limited drug and alcohol treatment programs, but Alcoholics 

Anonymous (AA) was available for Soldiers. 

2. Some BH personnel were assigned to do other jobs, such as psychiatric 

registered nurses (RNs) who were asked to work in Medicinelsurgery areas. 

3. It would have been helpful to know prior to deployment what was available, 

and what was needed for clinical practice in theater such as reference books, because 

procuring equipment in theater was challenging. 

4. There were limited computers and lack of private space to work with Soldiers. 

5. Getting out to other FOBS was challenging due to poor roadways 

6. The concept of operations for the United States Air Force (USAF) teams was 

not defined regarding how much should be Army-type CSC prevention versus clinical 

care outreach or stationary clinic. 

7. The Navy team defined its mission as solely clinical care, staffed clinics, and 

established an "Intensified Outpatient Program" on the Navy's model in a minimally 

furnished building, but then dropped the Diagnostic and Statistical Manual of Mental 

Disorders (DSM) diagnoses and lumped the admissions into "combat stress reactions" 

and "operational stress reactions," as in Army restoration programs. 

8. There was confusion about the concept of operations with an Army medical 

headquarters directing two USAF and one Navy team, but not defining it as a joint 

command. 

9. It was unclear to the Air Force BH personnel what the support relationship 

was; they solicited essential equipment from the U.S. Air Force EMED (hospital) with 

whom they had no defined relationship. 
Suaaested additional trainina that would benefit staff before de~lovment 

included: 

1. Drug and Alcohol Program Adviser (DAPA)/Substance Abuse Rehabilitation 

Program (SARP) training and perhaps Adams classes (alcohol/substance abuse 

awareness) for all staff such as the Navy is doing presently. 

2. Cross-training service members from sister services on cultural issues, etc 

3. Critical Incident Stress Debriefing, Cognitive Behavioral Therapy, PTSD 

treatment training, and Sexual Assault Victim Intervention training. 

Behavioral Health Personnel in lraq 

Thirty-two officers and 38 enlisted BH personnel at ten different locations throughout 

lraq shared common concerns and experiences that were not captured on the BH 

survey. Many of the themes below were reported more than once, but are listed only 

once for this report. 

0 The Behavioral Health Svstem: 

1. Overall, felt well prepared to perform the mission. The mutual 

support of providers helped tremendously. 

2. Difficulty fitting in when cross-leveled to an established unit. Integrating 75% 

of personnel who were cross-leveled to a unit was challenging, especially with 

leadership and chain of command. 

3. Challenges for teams to get life support when they arrive at a FOB. Need 

prior communication with the Area Support Groups (ASGs) to find out what units are in 

the FOBS and their point of contact (POC). It is best to have the CSC Detachment (or 

teams) collocate with an ASG and cover its area of operations. Teams may have to be 

tasked out and attached under operational control for support. They should send an 

advanced liaison to set it up. Behavioral health personnel need further training in 

operational details (like fragmentary orders (FRAGOs), etc.). Better coordination 

between outgoing and incoming BH personnel would also smooth transitions. 

4. Differing tour lengths (3, 6, and 12 months) between the different services 

hurt BH morale. The rapid turnover of psychiatrists (60Ws) disrupted continuity of care 

and decreased morale of the CSC team. High personnel tempo (PERSTEMPO) may 

lead to reduced retention for some BH personnel-particularly among early- and midcareer personnel. 

5. A road map for deployment for U.S. Army Reserves (USAR) and Army 

National Guard (ARNG) Soldiers would be helpful. 
6. Separate (National Guard) brigades are not authorized a BH officer, and one 

is needed. 

7. The limited range of types of patients during deployment may cause providers 

to lose skills. Stop-loss has been tough on professionals, especially since some 

professionals rotate out in 90 to 180 days. 

8. Each battalion should have specified BH staff who support them as a means 

to assist with building relationships with the medical and UMT personnel assigned to 

each battalion. 

9. Operating forward is essential to improving soldier access and lower stigma. 

Chaplain support is essential to effectiveness; developing rapport with the chaplain has 

really helped with BH mission accomplishment. 

10. In some cases, enlisted MH personnel (91Xs) were needed to contribute to 

the BH mission; therefore, they were pulled away from BH work. 

11. Personal stressors (long hours with no time off, trying to please everyone, 

time away from family, weather and heat, transition from medical center (MEDCEN) to 

TO&E unit) take a toll on BH personnel. 

12. Tighten pre-deployment screening, for medical illness as well as 

mentallbehavioral ones. Civilian PAS did most of the screening; they need more 

information about the Theater-its limited resources, the harsh environment, the 

consequences of decompensation, and options for deferring deployment. It would be 

best to assign providers who have been here to do redeployment screening. Consider 

pre-deployment psychological testing of Soldiers who are already on psychotropic meds 

in the soldier readiness processing (SRP) before going on to other screening to 

decrease inappropriate deployment. 

Administrative Issues: 

1. Some personnel actions (promotions, etc.) are being held up because BH 

personnel were not correctly told to bring their personnel (201) files with them to theater. 

2. Lack of replacements for the unit members sent home degrades the mission 

capability of the unit. 

3. Training on useful military forms, unit movement, supplies, Form Flow, 

lessons learned, and standing operating procedures (SOPS) on administrativellogistics 

coordination in a "Smart Book would be very helpful. Also knowing the administrative 

skills of the S1, S2, and S3 would be helpful. Training for writing an Operational Needs 

Assessment (with examples) and conducting one's own unit Needs Assessment would 

be helpful before deploying. Know how to do command referralslevaluations, 
regulations (format, requirements on the electronic version), and when to do clinical 

documentation vs. COSR documentation before you deploy. 

4. Be prepared to use the COSC-WARS before deploying, 

5. Identify and resolve credentialing early (best before activation/mobilization). 

6. Completing the continuing medical education requirement while in Theater is 

hard to do; this is a reason for having 6-month rotations instead of I -year rotations. 

Internet education could meet some needs. 

7. Have more on CSC in Command & General Staff College, Officer Candidate 

School (OCS), etc. 

8. Have references available for military BH law, ethics, and regulations. 

Loaistical/Eaui~ment Issues: 

1. Very difficult to communicate within own unit as well as with other units. For 

example, one unit reported having only one single-channel ground and airborne radio 

systems (SINCGARS) radio, but having teams at 18 locations all over Iraq. The digital 

nonsecure voice terminal (DNVT) phones were often down, too. Some reported no 

computer equipment and lack of supplies. One unit acquired Thuriya cell phones by 

negotiation and Iraqi commercial cell phones by purchase, in order to maintain 

communications and to accomplish the mission. Some unit members received training 

in the use and maintenance of the DNVT and other Army communication, which 

enabled some successful troubleshooting. 

2. Limited space for work and lack of privacy in the workspace for working with 

Soldiers 

3. Psychological testing kit materials were outdated; updated ones are needed. 

4. More training was needed on how to obtain logistical support from the line 

units. 

Trainina Needs: 

1. 1. Refresher training on COSC, critical incident stress management (CISM) 

training, mini-course for 60Ws with a CSC perspective. Teach area of concentration 

specifics so all staff can know each other's strengths. 

2. More training for 91Xs before deployment. The 91Xs could use more 

clinical training since many do not work in the field in their civilian life, e.g. training on 

interviewing and counseling. More training on personality disorders would be helpful to 

the staff. One 91X reported: "My AIT had no clinical experience, and I went straight to 
my division just before deployment. They let me work a little in Community MH to get 

my skill level up." 

3. Provide clinical training for USAR and National Guard BH personnel on drill 

weekends with real patients (e.g. at VA, Univ. Hospital, etc.). 

4. Lack of skills in dealing with real medical emergencies by many BH staff. The 

91X Soldiers should also complete 91 W training to prepare for combat emergencies. 

5. Training on how to interact with commands; Iraq country skills. Training on 

awards, efficiency reports, etc. 

6. Reduce unnecessary training in 91X school and devote more training time on 

crisis intervention, suicide preventionlintervention, COSC, anger management, battle 

fatigue, life saving skills, CED training, home front issues, solutions to soldier based 

issues, and family crisis intervention. 

7. Training in pharmacological management of Soldiers in theater 

8. Training in managing vicarious trauma, burnout, and compassion fatigue. 

Also training in team building and conflict negotiation. Important to set up help for 

helpers at each location-providing an outlet for providers. Awareness and buddy aid 

for providers. Behavioral health personnel should not skip BH-topic briefings on the 

assumption that they know it. 

9. Updated training on the VAlDoD clinical guidelines for PTSD 

10. For military training, more field and combat environment training, and more 

training on soldiering skills such as: convoy techniques (convoy operations training 

much more realistic in Kuwait than at the mobilization site in CONUS), survival skills 

training; battle drills; command liaisonlconsultation etiquette; and how to get life support 

in theater 
TAB A: Behavioral Health Interview/Focus Group Schedule 

Behavioral HealthICOSC Personnel lnterviewlFocus Groups 

"This information is anonymous and will not be linked to your unit. The information will 

be combined with that of other units to reflect the nature of BHlCOSC units in OIF-11." 

Interviewer: 

Notes Taken By (if other than interviewer): 

Date: 

Location: 

Number in Group: 

Group Type (Circle): Jr. Enlisted (El-E4) NCOs (E-5 +) Officers 

Mixed 

Ranks: -El-E4; -E5-E6; -E7-E9; -01 -03; -04-06 

Gender: -Males; -Females 

Unit: 

1. What can you tell us about your experience that we didn't ask on the surveys? 

2. What challenges have you faced during this deployment? 

3. What additional training would you benefit from prior to deployment, if any? 
APPENDIX 5 

DISTRIBUTION OF BEHAVIORAL HEALTH SERVICES 

INTRODUCTION 

Assessment of staffing and distribution were key parts of the OIF-ll Mental Health 

Advisory Team's (MHAT's) mission to evaluate the BH care in the OIF Theater. Three 

particular questions that were addressed were: (1) Are there enough BH personnel in 

theater to successfully accomplish the BH mission? (2) Are the BH personnellunits 

adequately distributed throughout theater to successfully execute the BH service 

mission? (3) What are appropriate levels of BH staffing for future similar deployments? 

In order to answer these three questions, the MHAT generated a layout of the BH 

resources in theater (as of 1 October 2004) and examined a number of possible 

methods for estimating the need for and positioning of BH personnel. 

The data gathered for this analysis came from reports, maps, and interviews with BH 

personnel, cartographers, and divisionlcorps personnel officers. The validity of parts of 

this analysis is time limited due to the constant changing battlefield and concomitant 

shifts in personnel. For convenience, 1 October 2004 was chosen as a cross-sectional 

target date. Changes made after 1 October 2004 are not reflected in this analysis. 

Although there are no data to support this, a key assumption is that on-site BH 

personnel will help to reduce barriers to BH care. 

This analysis only includes Army Soldier populations, Army BH personnel, and those 

Navy and Air Force BH personnel who are primarily serving Army Soldiers. Special 

Forces personnel and FOBS with a population of less than 25 U.S. Army Soldiers were 

also excluded from this analysis. 

FINDINGS 

Finding #I: The ratio of BH personnel to Soldiers is greater this year (OIF-/I) than 

last year (OIF-I). 

Last year (OlF-I), 163 BH personnel (psychiatrists, psychologists, social workers, 

occupational therapists, psychiatric nurses, enlisted MH specialists, and OT 

technicians) provided services for an estimated 138,000 Soldiers in Kuwait and Iraq in 

September 2003. The overall ratio of BH personnel to Soldiers was 11851. As of 1 

October 2004, 232 BH personnel (see Table I) are providing services to an estimated 

94,500 Soldiers in Kuwait and Iraq, for a ratio of 11407-a ratio over twice that of OIF-I. 

Last year's MHAT (OIF-I) concluded that the overall number of BH personnel was 

sufficient to provide coverage throughout the OIF Theater. However, the distribution of 

BH personnel was uneven; some areas lacked adequate coverage. 
In Kuwait, Navy and Air Force personnel were providing most BH coverage. Other than 

a few Armv staff member$)(2)-2 

the bulk oithe primary mebica~ care was performed by Navy personnel, and all of the I 

BH prevention and early intervention was performed by lb)o1Air Force Operational 

Stress Teams (OSTs) (See Tables 2 and 3). Based on Soldier population, there are 

fewer BH personnel in Kuwait (11656 overall) than in lraq (11388) where the need is 

greater due to operational stressors. 

Finding #2: Behavioral health personnel are more evenly distributed in OIF-11 

than in OIF-I. 

The OIF-Il ratios varied from 11160 to 11888 (with a standard deviation of 227). The 

OIF-I ratio of BH personnel to Soldiers varied from zero (no BH personnel) to 113,292 by 

region (with a standard deviation of 1,038). 

Finding #3: Forward operating bases with higher Soldierpopulations tend to 

have more on-site BH personnel. There were some FOBs in all size categories 

without on-site BH personnel located on them. These FOBs may receive BH 

services from neighboring FOBs. 

Seventy-six percent (76%) of Soldiers live on FOBs where BH personnel are collocated. 

(NOTE: For simplicity, "FOB" includes base camps, logistical support areas, ranges, 

etc., in Kuwait and Iraq). In general, as the size of the FOB population decreased, the 

number of BH personnel to Soldiers also decreased, and the variance in the distribution 

of BH personnel within each size category increased (see Table 4). Almost all FOBs 

with more than 1,000 Soldiers had a BH professional on site. One FOB in lraq with over 

3,000 Soldiers and two FOBs with 1,000-3,000 Soldiers had no on-site BH personnel. 

The MHAT visits to, and interviews with, PC and UMT personnel at some sites without 

on-site BH personnel indicated that BH personnel were not regularly visiting some of 

these FOBs. However, data from the Soldier Health and Well-being Survey showed 

that Soldiers on smaller FOBs reported nearly identical rates of utilization of MH 

services as Soldiers on larger FOBs. On FOBs with Soldier populations less than or 

equal to 1,000 in size, 11 % of Soldiers saw a MH or CSC professional during the 

deployment, compared with 9% of Soldiers on FOBs that had a population of 1,001- 

3,000, and 1 1 % on FOBs over 3,000. 

Finding #4: Psychiatrists, psychiatric nurses, and occupational therapists-who 

specialize in medical management and restorationlreconstitution services-were 

generally located at larger FOBs, while social workers and clinical psychologists were 

located farther forward (smaller FOBs) to provide more outreach services. 

Table 5 shows the distribution of BH specialties by FOB size 
Finding #5: There is adequate BH holding capacity in theater. 

On an emergent basis, "holding capacity" is available at CSC units. medical companies, 

and at CSHs. The CSC units have the capability to set up many more Level II cots for 

stress and psychiatric casualties if needed. Each of the CSH slices are able to admit 

Soldiers with BH problems; however, none of the Army CSH slices in theater is staffed 

to host a psychiatric treatment ward which is appropriate given the current theater 

evacuation policy (see Table 6). 

Theater BH personnel interviewed indicated that, in general, a Soldier deemed to 

require an inpatient level of care is only held long enough to be stabilized, evaluated, 

and prepared for evacuation out of theater. All of the CSHs have partnered with CSC 

units to provide BH treatment services (see Finding #6 below). 

Finding #6: The CSC restoration programs are located near CSH slices and often 

share resources. 

Like last year's MHAT, the MHAT this year noted that the four CSC restoration 

programs are located on the same FOBS as the CSHs (see Table 7). Collocating the 

CSC fitness teams with the CSHs has been im~lemented in various ways, often 

synergistically. The lb"2)-2 provides the classes and 

treatment services to those psychiatrically admitted to \ h e m Patients sleep on 

the ward in the CSH at night, but are transported to the CSC for a day treatment 

program. At bothp2)-2 1 psychiatrists assigned to the CSC teams 

have admitting privileges and provide the needed BH specialty services at the local 

CSH. 

Finding #7: There is one CSC reconditioning program in theater. 

In addition to a restoration program, the CSC company element in Baghdad has a 

structured program for holding Soldiers with psychiatric mental disorders and good 

prognosis for RTD for up to 3 weeks. The program combines milieu therapy: OT, 

psychotherapy, and medication (as needed). 

RECOMMENDATIONS 

Recommendation #I:Use an empirically derived staffing model for BH personnel 

allocation and distribution. 

Last year's MHAT (OIF-I) concluded that the overall number of BH personnel was 

sufficient to provide coverage throughout the OIF Theater, providing a ratio of 1 :851 BH 

personnel to Soldiers. However, the distribution of BH personnel was uneven; some 

areas lacked adequate coverage. The ratio of BH personnel to Soldiers in OIF-ll is 

1:407, substantially different than last year. 

Future staffing decisions for OIF and similar stabilitylsupport operations need to take 

into consideration the operational environment in theater, the OPTEMPO, 
and other factors. Military planners need to tailor the BH force package based on the 

size of the force, the distribution of the force (number of FOBs), the amountltype of 

services desired in theater (see TAB A for a full discussion of a staffing model), and the 

availability of personnel and resources to provide this staffing level. 

Based on the BH consultants to The Army Surgeon General, Human Resources 

Command, and MEDCOM Operations, there are significant concerns about being able 

to sustain current staffing levels of BH assets in theater with the existing AMEDD 

infrastructure. In addition, there are no data that demonstrate what the optimal number 

of BH professionals in theater should be. For many BH issues, leadership, training, unit 

cohesion, morale, and quality of life are probably as important as the number of BH 

personnel available. 

The methodology in TAB A of this appendix provides a general model for determining 

staffing levels. It is intended to be a guide, not the definitive answer on what the optimal 

staffing level should be. Any model that is used should be needs based, empirical, and 

driven by operational requirements and Army doctrine. 

Recommendation #2: Continue forward-deployed outreach to ensure Soldiers 

can access BH services. 

Recommendation #3: Ensure all BH personnel can provide (with supervision and 

medical support) the full range of BH services. 

It is important to maintain strong coordination amongst the various BH personnel in 

theater (whether from division, CSC, CSH, etc.) to assure that Soldiers have access to 

BH services when needed. Personnel who conduct outreach at the unit level or are the 

sole provider at a particular location should be able to provide the full range of services 

to include clinical evaluation and treatment, triage, referral, prevention, consultation, and 

education. Likewise, clinical staff at large FOBs (at CSHs, restoration units, etc.) should 

be able to provide outreach routinely. 

Recommendation #4: Develop and implement a plan to assure that there will be 

adequate BH resources to sustain the BH mission over the next several years. 

The current BH infrastructure was not designed for the OPTEMPO of the Global War on 

Terrorism. The increase in PERSTEMPO is leading to high levels of attrition of BH 

personnel and impacting other healthcare and professional training missions. Medical 

operation and military personnel planners should develop and coordinate a plan to 

allocate resources based on desired service levels and ensure that there are enough 

personnel to sustain current and future operations. 
I 

I OIF-I (SEP 2003) I 

REGION I BH SOLDIERS RATIO I BH SOLDIERS 

IRAQ TOTAL 1 140 1 116000 1 830 1 215 1 83200 1 387 

KUWAIT TOTAL 1 23 1 22000 1 943 1 17 1 11250 1 662 

GRAND TOTAL 1 163 1 138000 1 851 1 232 1 94450 407 

Note: Number of Soldiers is rou~ided for Operations Security (OPSEC). 

Table 2: OIF-11 Behavioral Health Personnel by Service 
Table 3: OIF-11 Behavioral Health Pe 

Fbj(21-2 

b)(2)~2 
Table 4: Behavioral Health Personnel Ratios By Forward Operating Base Size 

1 TOTAL WITH BH PERSONNEL I I 

Size # of 

FOBS 

# of 

Soldiers 

# of 

BH 

Ratio 

(1:X) 

# of FOBS 

with BH 

# of 

Soldiers 

I W/O BH P 

:t w-2

IRAQ 

-

All Iraq 64 83350 215 388 28 65650 215 305 36 

:i>?-

KUWAIT 

THEATER 

AllKuwait I 

All Theater 1 

10 

74 

1 

1 

11150 

94500 

/

/ 

17 

232 

/

/ 

656 

407 

1 

1 

2 

30 

1 

1 

6150 

71800 

1 

1 

17 

232 

/

1 

362 

309 

1 

1 

8 

44 

Note Number of Soldrers rs rounded for OPSEC 

Table 5: Behavioral Health MOS bv Forward . O~eratina - Base Size 

AOR FOB Sue #of 

FOBS 

Total 

#of 

BH 

#of 

Psychiatrlsts 

#Of 

Psychologrsts 

#of Soc 

Workers 

#of 

OTs 

# of 

Psych 

Nurses 

#of 

MH 

EMS 

#of 

OT 

EMS 

(b)(2)-2 

IRAQ 
Table 6: Disposition of Inpatient MH Assets as of 1 October 2004 

AOR FOB UNIT Staff Psychiatrists Nurses Psych Psychologists Social MH 

EMS 

[0)(2)-2 

1 KUWAIT Fb)(2)-2 I 

Table 7: Disposition of Restoration Assets as of 1 October 2004 

AOR FOB UNIT 

:b)(2)-2 
TAB A: Behavioral Healthcare Staffing Model 

Last year's MHAT Report (Office of The U.S. Army Surgeon General, 2003) discussed 

several methods for evaluating BH personnel strength in OIF-I (Kuwait and Iraq). Those 

methods included Unit Basis of Allocation (in accordance with FM 8-55) and BH 

personnel to Soldier ratios. Last year's MHAT concluded that a ratio of one BH 

personnel for every 851 Soldiers was sufficient to provide needed coverage. This year, 

the ratio has increased to one to 407 Soldiers because of an increase in BH personnel 

in theater and an overall decrease in the Soldier population. 

This analysis includes only Army Soldier populations, Army BH personnel, and those 

Navy and Air Force BH personnel who are primarily serving Army Soldiers. 

Staffing Models 

Faulkner and Goldman (1997) posited five approaches to estimating the number of BH 

personnel needed to staff a civilian MH system. Most of these look at the existing 

number of BH personnel and try to determine if they can meet the needs of the service 

population. However, as Elisha, Levinson, and Grinshpoon (2004) point out, 

approaches that are based on the existing number of BH personnel "tend to perpetuate 

distortions in staffing patterns, give little weight to clients' needs, and lack a conceptual 

rational" (p. 325). 

One of Faulkner and Goldman's (1997) approaches begins with an estimate of the 

population needs and demands. Calculations are based on three variables: 

1. The number of individuals who need services as determined by a populationbased psychiatric morbidity survey. 

2. The percent of individuals likely to demand BH services as determined by 

records or estimates of service utilization. 

3. The amount of timeleffort BH providers have to put forth to provide the 

services needed as determined by workload efficiency data. 

In addition to these three variables, Faulkner (2003) and Elisha, et al. (2004) parse the 

need into those tasks that a psychiatrist must perform, and those any other MH 

professional can perform. For this analysis, we will parse the need into officers and 

enlisted, assuming that a further analysis will need to take place amongst the officer 

corps to determine the appropriate mix of areas of concentration (AOCs) in theater. 

Staffing Model Assumptions 

This analysis makes a number of assumptions that may not remain valid under differing 

circumstances in the theater of operation. Any use of this model requires careful 

analysis of each assumption, and the overall product must be weighed against 
METT-TC (Mission, Enemy, Terrain and weather, Troops and support available, Time 

available, Civil considerations). 

For this report, the following assumptions have been made: 

1. Approximately 11% of the population will receive BH care during the course of the 

deplovment. This is based on multiple sources of data. As noted above, we examined 

three variables: those who want help, those who need help, and those who usually use 

help. 

a. Want help. On the OIF-ll survey, 11 % of all Soldiers reported a desire to get 

help for a stress, emotional, alcohol, or family problem (see Annex A). 

b. Need help. Regarding estimated treatment need, 13% of OIF-ll Soldiers who 

were surveyed screened positive for depression, anxiety, or PTSD. 

c. Normallv use help. Data from the Walter Reed Army Institute of Research 

(WRAIR) Land Combat Study indicated that 7-1 1 % of Soldiers surveyed 3-4 months 

after returning from OIF-I used BH services in the past year (this includes the deployed 

period). In the current OIF-ll survey, 9% of Soldiers reported that they had seen a BH 

provider at least once during the deployment. (Soldiers were surveyed on average 7 

months into the deployment, but this cannot be directly extrapolated to a year 

deployment since Soldiers do not seek care uniformly throughout the year.) These 

rates are very similar to Army-wide ambulatory BH service utilization. Overall, eight 

percent of the Soldiers reported that they had seen a MH professional within the last 

year according to the most recent DoD Survey of Health Related Behaviors Among 

Military Personnel (Bray et al., 2003). 

2. Soldiers who receive BH care will have, on average, three clinical visits. Available 

DoD healthcare utilization data indicate that the median number of visits is 2: however. 

high utilizers may drive the mean higher than this. Therefore, we chose a conservative 

estimate of three visits per Soldier receiving care. 

3. On average, BH providers will he able to provide individual outpatient clinical support 

to up to six Soldier visits a dav, 6 davs a week (or 36 visits/weeWprovider). These 

numbers include both initial appointment and follow-up visits; they also include both 

diagnosed patients and Soldiers who are experiencing combat and operational stress 

symptoms and require intervention. The MHAT members determined the ratio 

(36lweeklprovider) based on their collective clinical experience and observations in 

theater. 

4. All FOBs with Soldier populations over 1,000 will need a BH officer. Although there 

may be FOBs with over 1,000 Soldiers who can be adequately covered by neighboring 

FOBs, or staffed by BH NCOs instead of officers, for this planning model, we assumed 

the need for a BH officer at each FOB over 1,000. For each FOB over 1,000 Soldiers: 

there would be at least 1 officer and 1 MH specialist (91X) providing clinical services 
and outreach (see #5 below). Larger FOBs would require additional BH professionals 

to provide clinical andlor outreach to the additional population. bb)(')~' 1 

(bIW2 

5. Behavioral health outreach, consultation, prevention, and education services 

provided at the unit-level will require approximatelv 8 hours (I dutv-dav) per battalionsize unit per week. This time allows for travel time and coordination. It is expected that 

some battalions will require substantially more time than this (e.g. travel timelwaiting for 

convoys, etc), while others that are collocated on the same FOB with the BH 

professionals will require less time for these services. For planning purposes, BH 

enlisted Soldiers provide these services under the supervision of the officer on the same 

FOB, although they may switch responsibilities as needed. 

6. The averaqe restoration unit will hold about 4 Soldiers at a time; the reconditioninq 

units will hold about 8. Based on observations from OIF-I and OIF-ll, the MHAT noted 

that the restoration units in theater rarely held more than 4 Soldiers at a time. 

Calculations on the number of BH personnel needed for these missions are based on 

Tables 3 and 4. below. 

7. Combat Support Hospitals (CSHs) will deplov with their doctrinal 4 BH personnel (2 

officers and 2 enlisted). The BH personnel are included in the calculations as providing 

basic clinical support on large FOBs. 

8. Behavioral health officers have differinq capabilities, but can provide a full ranqe of 

care, qiven proper supervision and consultation. Although communication types and 

sophistication levels vary from FOB to FOB, in general, communications have improved 

significantly since last year (OIF-I). Given the improvement in the telephone and e-mail 

systems, and the availability of psychotropic medication support from a PC 

physicianlPA, most BH officers should be able to provide the full range of BH services 

2417. In addition, enlisted BH personnel can provide BH services given proper 

consultation, staffing, and supervision. For purposes of this analysis, all officer 

specialties are assumed to be interchangeable. Further analysis is required to 

differentiate which specific specialties are needed for a given operation. 

9. Some BH personnel are required to fill command, control, and staff functions in 

addition to those needed for clinical and outreach services. Because BH officers and 

NCOs hold staff positions within medical brigades, and command and leadership 

positions within CSC units and other units, additional time (resources) must be factored 

into the model. For this model, we have chosen a ratio of one leaderlstaff officer for 

every fifteen BH personnel (1:15). This ratio would provide the equivalent of three 

fulltime leadership personnel in a CSC unit. 
Further Discussion of Assumptions Underlying the Model 

The nature of combat and the combat environment requires staffing redundancy and 

flexibility not needed in CONUS, peacetime, or civilian staffing models. These 

intangible factors include efforts to secure basic life support and supplies, efforts to 

arrange for and conduct convoy operations to remote locations, personnel surges on 

the battlefield (due to unit rotations or local battle concentrations), mass casualty 

events, and possible loss of BH personnel due to casualties, emergency leave, etc. 

As critical events and battle concentrations occur in differing areas. additional BH 

personnel may be temporarily needed to augment certain areaslunits. Whether sent as 

individuals or "quick reaction teams," the flexibility to surge BH personnel from one 

battlefield area to another requires sufficient resources be in theater to continue 

universal minimal services while staffing such missions. 

To address these considerations, this staffing model builds in flexibility to allow the BH 

care system to respond to these types of factors. 

1. The total number of BH care visits among Soldiers who access care was 

assumed to be 3, whereas the average, based on all available data, is 2. Thus, 

estimated actual clinic utilization is likely to be lower than predicted by the model. 

2. Outreach at the battalion level is assumed to take 1 entire day for each 

battalion, visited once every week. Some battalions may need more time than this, 

particularly given the difficulties with travel. However, some battalions may need to be 

visited less frequently, based on the outcome of an individualized unit needs 

assessment. It may not take an entire day to conduct outreach to a battalion collocated 

with the BH professional. 

3. All bases with more than 1,000 Soldiers were assumed to have at least 1 BH 

officer and 1 BH enlisted professional on-site, whereas Soldiers on the smaller bases 

(bW-2 are assumed to receive services either through 

BH outreach at the battalion level (staffed for the whole theater) or through Soldiers 

traveling to the location of the BH professionals (also staffed for the whole theater). 

4. Behavioral health professionals could work more than 6 days a week if 

necessary. Also, they may provide one-on-one BH care to more than six Soldiers per 

day. 

5. Personnel at the CSHs are not considered in the calculations. This provides, 

on average, 2 additional BH personnel on each of the FOBS where a CSH slice is 

located. These individuals can provide some of the FOB outpatient clinical work or they 

can be used for outreach to units on the local FOB, contingent on the workload at the 

CSH. 
6. The current staffing is based on calculations for the entire theater with the 

same level of staffing for Kuwait as in Iraq. Based on the data from the Soldier Health 

and Well-being Survey, the MH care needs are greater in lraq than in Kuwait. While 

theoretically resources from Kuwait could be shifted to support lraq bases, in practice 

this is problematic given the different commands. 

In addition, it is assumed that there will be flexible utilization of BH personnel. For 

planning purposes for this model, BH officers were identified as the primary 

professionals (as credentialed professionals) responsible for clinical care and enlisted 

BH personnel as the primary personnel for conducting outreach services. However, in 

practice this is highly flexible, with officers frequently providing outreach and education 

and enlisted personnel providing clinical services. The staffing model is designed to 

allow for this flexibility. The model only generates an estimate of the total number of 

personnel that may be needed in theater. Operational and medical leaders, guided by 

the tacticalloperational situation and Army doctrine, determine how these personnel are 

allocated and used. 

Behavioral health personnel are currently assigned to, and deploy with, DivisionlBrigade 

Mental Health Sections, CSC units, CSHs, Area Support Medical Battalions (ASMBs), 

Area Support Medical Companies (ASMCs), etc. Nothing in this staffing model is meant 

to detract from the current organization tables or methods of personnel deployment; 

however, medical planners may use this staffing model to determine how many units or 

unit slices to deploy. This model provides an estimate of the number of BH personnel 

needed to provide care, outreach, etc.; it does not assume or restrict where that support 

should come from (Division Mental Health Sections, CSC units, or individual 

augmentees). 

Staffing Model Calculations 

Using these assumptions, we calculated three increasing "components" of care, each 

built upon the previous one. These components can be stacked up as need, command 

support, and resources allow. 

The first of these is a clinical services component. It provides for clinic-based outpatient 

care on all FOBS with a Soldier population larger than 1.000. It also provides some 

inpatient care capability by using CSH behavioral health assets. The calculations for 

this component are based on population estimates of psychiatric morbidity (need), 

desire for care, and past patterns of utilization. 

The second service component provides unit outreach. These additional BH personnel 

extend the clinical mission by adding preventive counseling, command consultation, unit 

needs assessment. Soldier classes, coordination with UMTs and PC providers, etc. 

The calculations for this component are based on the number of battalion-size units 

needing outreach, and the frequency of that need. With this model, officer and enlisted 

staff members located on each FOB could switch off duties as needed to provide clinical 

and outreach services. 
The third service component adds additional personnel to staff regional restoration units 

that provide a location and up to a 3-day program as an intermediate care facility. This 

component also provides for a reconditioning unit in theater to provide longer-term 

restoration and reconditioning services (up to 21 days) to Soldiers from all over theater. 

These calculations are based on a new restoration/reconditioning unit staffing model 

found at the end of this TAB. 

Table 1 presents an estimate of the BH staffing levels for each component of care 

based on OIF-ll data as of 1 October 2004. In addition to the number of officers and 

enlisted for each component, the table shows the "running totals" and "running ratios" 

(ratio of 1 BH personnel to the number of Soldiers). The data used for this table will 

likely change for OIF-Ill and thus require a new staffing calculation. 

Table I: Operation Iraqi Freedom Behavioral Health Functional Components Staffinq Model 

I I 

Unit Outreach 10 3 2 2 3 4 1 102 929 

3 Rest11 Recond Units (Avg 4-8 pts) 10 10 1 

TOTAL 42 74 7 

Using the assumptions noted in the sections above, the staffing projection for the OIF 

(Kuwait and Iraq) population (as of 1 October 2004) is 123 BH personnel (42 officers, 74 

enlisted, and 7 leaders-a mix of officers and senior NCOs). This would provide one 

BH personnel for every 770 Soldiers in theater-a ratio in between the current level of 

staffing, and that of OIF-I. 

The model allows for differing assumptions. For example, it may not be reasonable to 

lump lraq and Kuwait together since they have different needs and different command 

structures. If one wishes to only look at lraq (assume lraq data is that of 1 October 

2004-see Annex B, Table 4), wants to ensure that there are 2 officer providers on 

each FOB larger than 1,000 (plus additional enlisted BH staff), and thinks that outreach 

to each battalion-sized unit will take 2 days on average instead of 1 day, then new 

staffing levels can be calculated. These new parameters would result in 183 BH 

personnel (58 officers, 11 4 enlisted, and 11 leaders-a mix of officers and senior 

NCOs). This would provide one BH personnel for every 456 Soldiers in lraq (see 

Table 2). 
Table 2: Operation Iraqi Freedom Behavioral Health Functional Components Staffing Model 

(Based on Irao-Onlv Soldier Po~ulation of 84.000. 1 October 2004. Two Providers on 

FOBS >1000, and 2.0utreach ~&s per week per att tali on) 

BASIC COMPONENTS Ldrs TOTAL Running Running 

Ratio (1 :X) 

I Clinical Services (FOBS>1000) 1 48 48 6 102 1 102 1 81 5 1 

Unit Outreach 0 56 4 60 162 51 5 

3 Rest 1 1 Recond Units (Avg 4-8 pts) 10 10 1 21 183 456 

TOTAL 58 114 11 183 

The model can thus be used for a range of situations, depending on the facts one has 

and the assumptions one makes at the time of the estimate. If further redundancy is 

desired, the planner may choose to increment the numbers by an additional percentage 

(add a "fudge factor"). 

Additional Information on Staffing Model Calculations 

Clinical Services Component 

1. The estimated number of Soldiers needing help was determined by multiplying the 

Soldier population by the average of the percent of Soldiers wanting help (1 1 %), 

needing help (13%), and usually using help (10%). The result was 10,500. 

[Soldiersserve]= [Soldier population] * ([%WantHelp]+ [%NeedHelp] + [UseHelp]) 1 3 

2. The estimated total number of visits for a deployment year is 31,500 (1 0,500 times 

the number of visits per Soldier, 3). 

[TotalVisits] = [SoldiersSewe] * 3 

3. 31,500 visits require 17 officer providers seeing six Soldiers per day, 6 days a week. 

[Providers] = ([TotalVisits]I(365*617)) 16 

4. However, 17 providers will not provide adequate coverage for all 23 FOBs with 

populations~1,000 Soldiers. Therefore, one must have at least 23 (one for each FOB) 

plus an additional 9 for FOBs with large populations (over 3,500) in order to cover the 

required clinical workload. This results in a total of 32 clinical providers. This was 

increased for Table 2, above, to assure at least 2 officers (and two enlisted) could be 

placed on each FOB over 1,000. 

[ClinProviders]= The Greater of ([Providers] OR ([NumFOBs~1000] + [NumFOBs > 35001) 

5. To support and extend the clinical mission, 32 enlisted soldiers (one for each officer 

provider) will deploy as well. This results in a total of 64 BH personnel to provide clinical 
coverage at the 23 FOBS throughout theater with Soldier populations greater than 1,000 

(see Table 1, above). 

[Enlisted] = [ClinProviders] 

6. In addition to clinical providers, for every 15 BH personnel, one additional person (or 

''full time equivalent") is added to the model to allow for command, control, and staff 

functions. This adds 4 additional personnel (could be any combination of additional 

officers or senior enlisted personnel), for a total of 68 BH personnel. 

[Total] = [ClinProviders] + [Enlisted] + (([ClinProviders] + [Enlisted]) l 15) 

Unit Outreach Component 

7. Outreach staffing numbers are based upon a BH officer or enlisted member 

spending 1 day each week with each battalion-sized element in theater. This time can 

be used doing need assessments, command consultation, liaison with chaplains and 

PC providers, providing on-the-spot interventions, classes, setting up and training the 

battalions' Soldiers in a train-the-trainer mode, etc. We did not have the exact number 

of battalions in theater, but estimated it by taking the total Soldier population and 

dividing it by 500 (approximately 500 Soldiers in a battalion). This resulted in the need 

for 189 person-days per week. This was divided by 6 (the number of work days per 

week), resulting in the need for 32 additional personnel. For our analysis, we assumed 

that this work could be done in large part by 91Xs under the supervision of the BH 

officer at the FOB or on a nearby FOB. This resulted in the need for 32 additional 

enlisted BH personnel. For Table 2 this was changed to assume that it would take 2 

days for each battalion. 

[OutreachPeople] = ([NumBNs] * [NumDaysOutreachPerBN])16 

8. The additional personnel also require one leader for every 15 personnel, so 2 additional 

leaders are needed. 

[Total] = [OutreachPeople] + ([OutreachPeople] 1 15) 

Regional Restoration and Theater Reconditioning Component 

9. The number of personnel needed to staff a regional restoration program or a theaterwide reconditioning program was drawn from the Staffing Model below. We assumed 

that restoration programs in OIF and comparable scenarios would not hold more than 4 

Soldiers on average, and that a reconditioning program would not hold more than 8 

Soldiers on average. Restoration programs required 2 officers and 2 enlisted staff to 

serve a 1:4 ratio. Since there are three regional restoration programs, this resulted in 6 

additional officers and 6 additional enlisted personnel. 

10. From the staffing guidelines below, a reconditioning program needs 4 officers and 4 

enlisted personnel to support a 1 :8 ratio. 
11. Adding these together results in the need for 10 more officers and 10 more enlisted 

personnel to support 3 regional restoration programs and one theater-reconditioning 

program. 

12. Finally, one must add one additional leader (or "full time equivalent") for the 20 BH 

personnel performing restorationlreconditioning services; this results in a total of 21 BH 

personnel to conduct restoration and reconditioning in theater. 

Combat Stress Control Restoration and Reconstitution Staff Models 

The MHAT noted that some CSC restoration programs had more personnel than they 

needed to care for the Soldiers being referred to them. The theater BH consultant 

stated that some of these personnel are used as rapid reaction teams for surges and 

psychological mass casualties (MASCALs). Current base tables of organization and 

equipment (BTOEs) implies incorrectly that a restoration or fitness section works as 

(and only as) a single entity. However, current teaching and the rewritten draft COSC 

field manual clearly state that all CSC teams, and especially fitness teams, must 

routinely split into smaller, dispersed elements, as needed to fulfill specific missions. 

The Army Transformation CSC unit will be composed of 3-person mobile teams that can 

provide outreach services or can be assembled to provide restoration or reconditioning. 

This will provide planners and leaders with more flexibility and freedom to adapt to 

mission requirements. As noted above, certain specialties (like OT) are needed at 

restoration units. However, any persons andlor time not fully used in providing 

restorationlreconditioning care should be shifted to provide preventive outreach to units 

on the local FOB. 

Behavioral health inpatient wards have developed staffing-to-patient models, but 

restoration units and prevention teams have not yet identified such models. In actual 

practice, the independent capability level of any particular BH team or unit is based on 

two critical aspects: (1) The licensurelregulatory limitations imposed and the 

experience of the team members, and (2) The capabilitylcapacity of the BH teamlunit to 

hold and treat Soldierslpatients. Behavioral health teams with the appropriate capability 

ratings should be matched (and not over-matched) with mission needs. 

Table 3 describes the various capability levels that a BH provider or team may assume 

based on the specialized capabilities of its member(s). Table 4 describes the levels 

each BH provider or unit may assume based on ability to provide holding capacity. 

Using Table 4, each proposed restoration program should be able to gauge the 

appropriate number and mix of personnel needed to care for a given number of 

Soldiers. For example, if a unit is providing care for 1 to 4 Soldiers, they will need two 

full-time 91Xs, an OT or OT technician, and a social work or clinical psychology officer. 

If the number of Soldiers in restoration is increased to eight, the unit would need 3 

fulltime 91Xs, 2 OTs or OT technicians, and one social work or clinical psychology 

officer. These tables and ratios are meant to be guidelines; leaders must take into 
consideration operational and environmental factors when staffing units on the 

battlefield 

+ Full 

Assessment; 

Outpt 

management; 

Outpt treatment 

OT officers may 

be used if a 

licensed BH 

clinician's 

telephoneie-mail 

support is 

available 2417. 

COSC-WARS 

Outpt cases - BH chart 

notes; BH 

note in pt 

outpt records 

Ity Capability Levels 

BH Officer wlCmdDirected Eval 

Capability IAW ROD 

6490.1 

+ Self-contamed 

evaluat~ons of 

command-d~rected 

evaluat~ons In nonemergent environs 

Non-PhD BH officers 

can evaluate Cmddirected cases in 

emergent conditions 

They can evaluate 

routme Cmd-directed 

cases ~f PhD-level BH 

clin~cian telephonelemail support IS 

ava~lable 2417 and 

the case is reviewed 

and countersigned 

when a PhD Drovider 

is available. 

COSC-WARS 

Outpt cases - BH 

chart notes; BH 

note in pt outpt 

records 

Cmd-directed 

cases - cmddirected forms 

BH Officer wl 

Prescribing 

Privileges 

+ On-site medication 

management 

Non-prescribing BH 

officers should use 

available PA/ 

physician support for 

basic medical 

management. Polypharm andior 

potentially 

complicated medical 

management cases 

must have available 

psychiatrist 

tele~honele-mail 

support 2417. 

COSC-WARS 

Outpt cases - BH 

chart notes; BH 

note in pt outpt 

records 

Cmd-directed 

cases -cmddirected forms 
4Rs; Monitoring; 

Stabilization 

1-3 days 

91 X + supervision 

91X-1:4 

91 W - per med 

unit's staffing 

SOP 

Medical officer 

supervision - per 

med unit's 

staffing SOP 

wlother med patients 

Soldier in Holding 

COSC-WARS 

Brief BH note in 

outpt record 

2b + OT Assessment 

1-3 days 

CAP I b + OT191 WN3 

91X-1 + 1.4 

OTl91 WN3 - 1 16 

CAP 1b Off- 1.12 

Occ Milieu 

Soldier in Holding 

COSC-WARS 

Brief BH summary 

in outpt record 

I 

91 WN3= Enlisted Occupational Therapy Technic I 

L. I . , 

PN = Psychiatric Nurse: SOP = standing Operating Procedures 

2c + OT Program 

4+ Days 

CAPId+OT+PN 

91X-1 + 114 

91WN3-1.6 

OT- 1:12 

PN-1.12 

CAPIbOff-1.12 

CAP Id Off - 1.30 

PsychlOcc Milieu 

Soldier in Recovery 

COSC-WARS 

Full notes in BH 

chart 

Summary BH note 

in outpt record 

,ns; OT = Occupations 

Secure 

environment 

Stabilization 

Medication 

Management 

As needed 

CAP Id + PN 

Based on BH 

inpatient ward staffing 

model used by the 

particular hospital, 

augmented if 

necessary by CSC 

unit 

Psychiatric Milieu 

Patient 

Full inpt medical 

chart 

Admission and 

disposition notes 

in out~t chart 

Therapist: 
--- 

--- 

APPENDIX 6 

BEHAVIORAL HEALTH RETURN-TO-DUTY AND WORKLOAD DATA 

INTRODUCTION 

As part of the MHAT mission, electronic workload, evacuation, and RTD data were 

collected from various BH units. These units included: CSC detachments; a CSC 

company; division, brigade and area support medical company MH sections; CSH 

psychiatric sections; and USAF teams that supported primarily U.S. Army troop 

populations. Many units did not respond to the data call, and in other cases: the data 

received were difficult to standardize for comparison. However, the usable data 

provided by some units allowed us to arrive at some findings and recommendations. 

FINDINGS 

Finding #I: Behavioral health assets had high RTD rates. 

All forward-deployed BH assets in OIF-ll Iraq had high RTD rates (See Table 1). One 

separate brigade BH team with two each organic officers and 91 Xs returned 100% of 

the Soldierslpatients that its DMHS evaluated. The two DMHS's and another separate 

brigade's rates were above 96%. The one CSC Company, deployed for a time at 15 

separate FOBS throughout Iraq, returned 95% of the Soldiers provided I-on-I 

preclinical or clinical care. The Air Force' operational stress teams in Kuwait had 

RTD rates (97%) comparable to the BH units. 

Table 1: OIF-I and OIF-11 Return to Duty By Type of BH Team/Unit 

% RTD Type of Unit Dates QIF-ll I OIF-I 

Division MH Sections Apr-Aug 04 97% 1 97% 

I Separate Brigade MH Sections* I Apr-Aug 04 1 99% 1 1 

I Combat Stress Control Unit I Aug-Sep 04 1 95% 1 96% 1 

I USAF Combat Stress Teams I JunAug 04 1 97% 1 96% 1 

I CSH (with CSC RIR)** I Apr-Aug 04 1 80% 1 69% 1 

I CSH (Psych Inpatients only)* I Apr-Aug 04 1 4% 1 1 

Regional Medical Center (Germany) Mar-Sep 04 3% *** 4Oh 

*No data from a Gompafable unit in MHAT-1 Report 

** R/R = Restoration/Reconditioning Program 

*** LRMC OIF-I1 RTD was 0% for inpatients, 3.7% for outpatients. 

Soldiers returned to duty from divisions, separate brigades, and CSC units included 

both non-inpatient "psychiatric" and "combatloperational stress reactions." 

Non-inpatient RTD rates in the high nineties suggest that forward-deployed BH 

personnel are retuning almost all Soldiers they helpltreat for both stress and mental 

problems immediately to their units. 
The CSC reconditioning program treats selected Soldiers with diagnosed mental 

disorders who have not responded to outpatient treatment or a 3-day restoration 

program, but who were still judged to have worthwhile RTD potential. Since many units 

(particularly reserve units) do not receive replacements during the I-year deployment, a 

program that can treat Soldiers and return them to duty is a force multiplier. The 

program's RTD rate from reconditioning could not be reliably calculated from the 

records available to the MHAT-II. Continual analysis is required to judge whether the 

BH personnel involved in treating the reconditioning cases would have greater impact 

on overall combat effectiveness and soldier well-being if they were employed further 

forward for outreach and outpatient interventions. 

The OIF-I combat support hospital had its own small psychiatric ward and additional 

staff. The OIF-ll combat support hospital could only admit psychiatric casualties on an 

intermediate medical care ward. However, the OIF-ll combat support hospital worked 

closely with the CSC unit's restorationlreconditioning program. Soldiers admitted to one 

unit were often treated andlor quartered by the other. In general, Soldiers were seen at 

the CSHs in either an outpatient or inpatient mode. Soldiers seen as outpatients 

(including those who were temporary residents in the neighboring CSC unit restoration 

program) had a much higher RTD rate (80%) than did those Soldiers who were 

admitted as inpatients to the intermediate care ward (4.3%). This lower 4.3% RTD rate 

reflects the severity and poor prognosis of their conditions in the psychiatrist's clinical 

judgment. Less severe cases with better prognosis were admitted to the nearby CSC 

facility, which also has psychiatry, psychiatric nursing, and OT capabilities focused on 

RTD. 

Finding #2: A tracking system for CSC preventive and preclinical individual 

contact activities has not yet been universally implemented in the OIF Theater. 

The attempt to gather and compare data from various units in OIF-ll clearly 

demonstrated a need to both standardize and enforce mandatory reporting of common 

data. Although the CSCIBH units under the Medical Brigade and the two divisions in 

OIF-ll use the COSC-WARS summary report, some units use it differently. Some users 

made variations in the line formats or misinterpreted what data to enter into certain 

fields, thus making comprehensive compilation and analysis impossible. 

The CHPPM's automated version of COSC-WARS is one option that AMEDD Combat 

Developments is using as the test-bed for developing contract specifications for the 

COSC functional area in the Theater Medical Information Program (TMIP). Automated 

COSC-WARS is developing the capability to capture the data at the single-event level, 

generate summary reports, enable temporary archiving in theater for local use, and 

permanently archive the initial data and reports in CHPPM's secure, searchable 

surveillance database, which can respond to inquiries from Theater. The program 

operates on laptops and handheld and desktop computers, with electronic 

synchronization and transmission. Coordination has begun to add COSC-WARS 

capabilities to the medical communications for combat casualty care (MC4) system. 
- - 

Further assessment and coordination is needed to ensure that the existing system 

(COSC-WARS) meets BH and theater requirements. 

Finding #3: Combat Stress Control (CSC) units contribute to outreach efforts. 

Table 2 demonstrates the types and quantity of outreach and early intervention that one 

CSC Company accomplished in a 7-month timeframe. This workload represents the 

equivalent of 52 debriefings, 198 classes, 1,160 unit visits, and 274 command 

consultations per month. Organic BH assets also do outreach, but through 

augmentation, CSC behavioral health personnel can greatly assist organic outreach 

(and other BH service) efforts. TAB A contains definitions for workload categories noted 

in Table 2. 

Table 2: Preventive Outreach Activities of a CSC Unit in OIF-11, 

March-Sentember 2004 /Summinu Weeklv COSC-SRs)* 

I # Critical Events I 178 I 

# Participants 2587 

Other Debriefings 91 

# Participants 1746 

Health Protection Classes 1097 

# Participants - 8405 

Mission-focused Classes 290 

# Partici~ants 5295 

I Unit Surveys 29 I # Questionnaires Received 1 1122 1 

Command Consults (Not case related) 1921 

*The company had approximately 80 personnel to conduct preventive 

activities, about 68 of them clinically trained. From March to June, the 

summary reports (SRs) came weekly to the CSC Company HQ from )b)(2)~2 

b)W2 

Based on these statistics, the CSC Company provided an average of two CED sessions 

for each critical event they responded to, with an average 7 Soldiers in each debriefing. 

This is consistent with training guidelines. There were fewer "Other debriefings;" these 

averaged 19 participants per session. 

Approximately 8 Soldiers attended the health protection classes on average. Examples 

of these classes included individual Soldiers attending anger management or tobacco 

cessation classes. Mission focused classes, on the other hand, averaged 18 

participants per session; most likely these were coordinated with specific units for 

members of that unit. 
Finding #4: Behavioral health providers rated "relational factors" as the 

predominant contributing factor to Soldiers' chief complaint. 

Table 3, below, reports what BH personnel in a DMHS recorded as the primary 

stressors or contributing factors in the COSR and psychiatric cases they interviewed 

and aidedttreated. Their evaluations integrated the chief complaints of the individual 

Soldiers with their own knowledge and experience in the etiology of emotional distress 

and mental disorders. They perceived relational issues as the major factor in the 

majority of cases (58%). Of these relational issues, problems in relationships on the 

home front were considered the most common, followed by problems with peers in the 

unit, then leadership conflicts. Individual causes were perceived as the next highest 

contributor to the symptoms (26%); these causes included preexisting disorders, 

"conditional" ("I'll get better only if you send me home"), and character traits. 

Olserational exDosures, includina traumatic events, were lserceived as lsrimary causes in 

Ii%.See TAB B for definitionsif the below contr/buting'factors. 

Table 3: Contributina Factors to Soldiers' Stress Reactions 

(From a DMHS' weekly COSC-SR; Jan - Aug 2004) 

Conditional 72 3% 

Number of Soldier Visifs = 1,575. 

Behavioral health personnel could record up to 3 factors/case. 

RECOMMENDATIONS 

Recommendation #I:All BHKSC personnel use a single standard format for 

documenting preventive encounters and interventions. 

Theater BH assets should use an identical format for recording their COSC-type 

activities and cases. The teams may use different portions of the format, and report 

only what higher headquarters specifies in the SOP. The documentation must merge 

within the BHICSC teams to produce the unit's weekly summary, and by higher 

headquarters to combine the summary reports across units and over time for ongoing 

trend analysis, resource redistribution, and follow-up assessment. 
The CHPPM's automated version of COSC-WARS is one option. The AMEDD Combat 

Developments is using COSC-WARS as the test bed for developing contract 

specifications for the COSC functional area in the TMIP. Automated COSC-WARS has 

the baseline capability to capture the data at the single-event level, generate summary 

reports, enable temporary archiving in theater for local use, and permanently archive 

the initial data and reports in CHPPM's secure, searchable surveillance database, which 

can respond to inquiries from theater. The program operates on laptops and handheld 

and desktop computers, with electronic synchronization and transmission. 

Recommendation #2: Cooperation and synchronization of effort between organic 

MH sections and augmenting CSC teams should be fostered through task 

organization and clear command and control relationships. 

The advent of the CSC units in 1993 added BH personnel to the deployed force, but 

experience has found that organic (division and brigade) and augmenting CSC 

personnel, teams, and units often have difficulty integrating within a single area of 

operations. Because CSC units (and their BH personnel) are corps-level assets, the 

corps medical brigade usually controls them. Further, the corps medical brigade 

commander may or may not be the Corps Surgeon, creating distinct chains of command 

for divisional BH personnel and CSC personnel. This split can result in different 

reporting formats, differential service standards, and most apparently, in overlaps and 

gaps in BH services in theater. 

Logistics support of CSC units is another noted problem that has been raised through 

BH interviews and focus groups in both OIF-I and OIF-ll. Because CSC units are a 

corps asset and often (as small teams) lack inherent supply, communication, and other 

necessary survival capabilities, coordination must be done when placed in a forward 

location to ensure adequate logistical support. 

BACKGROUND 

Study Sample 

The units for which adequate workload and RTD data were obtained in time for this 

report are listed in Table 5. Some units provided data that were incomplete: 

inconsistent, or difficult to interpret. These units are also listed in Table 5. 

Table 5: Units Contributing Data to the Data Call Appendix 

Unit Data Used in Analyses Unit Data Not Included in Analyses* LC - ? 

I I1 

*Data not used because data was inconsistent. incomplete, or difficult to interpret within the time 

available 
Procedures 

All major BH units and sections were queried via telephone and e-mail andlor in person 

between 9 September and 9 October 2004. Although some small, forward-located 

teams were not canvassed, their parent organizations were. A data matrix was emailed to the maior units in September 2004 and again to non-responders a week or so 

later. ~dditionaliv, COSC-WARS summary reportscompiled over time were received 

rb)oKuwait. 

The electronic data call form is at TAB C. The standard data fi numbered lines) of 

the manually recorded COSC-WARS Summary Report that th a

b)W2

ed Bde used is at 

TAB D. The MHAT archived the electronic data from the forms and of the e-messages 

related to the data used in this appendix in the Department of Military Psychiatry, Walter 

Reed Army Institute of Research (WRAIR), Silver Spring, MD. 
TAB A: Definition of COSC-WARS Preventive Outreach and Intervention Terms 

# of Critical Event Debriefing (CED)* Sessions 

Number of debriefing sessions for Soldiers, leaders, others who were part of a critical 

incident 

A Critical Event Debriefing (CED) is a form of psychological debriefing conducted by 

BHICOSC personnel at the request of units following a critical event (CE) for the 

purpose of clarifying the event, facilitating the team members' support for each other, 

and regaining unit cohesion and readiness for further action. 

Total # of Attending CEDs 

The total number of participants in all of the CEDs performed during the reporting period 

# of Critical Events** 

This is the number of all critical (combat and noncombat) events that has occurred 

within the reporting unit's area of responsibility during the time covered by the report 

A CE is an event that involves death, injury, or imminent risk thereof, and has high 

potential to produce emotionslcognitions of intense fear, horror, 

helplessness/hopelessness,guilt, etc., in some survivors and rescuers. 

# of Other Debriefing Sessions 

The number of debriefing sessions for Soldiers for reasons other than the aftermath of a 

critical event (for example, end of tour debriefings) 

# of Force Health Protection (FHP) Classes 

The number of classes given on FHP topics that are not related to a current deployment 

or deployment-phase. For example, FHP classes would include smoking cessation, 

anger management, stress management, suicide prevention, etc. Reunion classes are 

FHP classes if given generically, and not as part of a current deployment. 

Total # of Attending FHP Classes 

Total number of participants attending all FHP classes lead by the reporting unit during 

the reporting timeframe 

# of Mission-Focused Classes 

Mission-focused classes include those classes, courses, and briefings related to a 

current or pending deploymentlmission. Pre-deployment briefings and re-deployment 

briefings (to Soldiers andlor family members, etc.) are mission-focused classes. Other 

examples include classes on: Continuous Operations; Psychological Aspects of 

Nuclear, Biological, and Chemical (NBC) Operations; Peacekeeping Operations, etc. 

# Consultations to Command or Other Med Pros 

The number of nonclinical (i.e.. not about an individual) command consultations or 

consultations to other medical professionals 
TAB B: Definitions of Contributinq Factors to Soldiers' Stress Reactions 

# of Combat Exposure 

The number of COSC contacts where the primary problem was attributed to direct 

combat exposure (lethal weapons used with deadly intent in the immediate vicinity, 

direct exposure to casualties, front-line action, etc.) 

# Noncombat Severe Event 

The number of COSC contacts where the primary problem was attributed to a 

critical incident other than direct combat (suicide in unit, fatal accident, exposure to 

mass suffering or dead bodies, great danger, etc.) 

# PeerlUnit 

The number of COSC contacts where the primary problem was attributed to a 

conflict with the unit or with a peer in the unit 

# Leadership 

The number of COSC contacts where the primary problem was attributed to a 

conflict with or between leaders in the unit or to perceived poor leadership within the 

unit or at higher echelons of command 

# Home Front 

The number of COSC contacts where the primary problem was attributed to an 

issue at home, conflict with family member, etc. 

# Environmental Factors* 

The number of COSC contacts where the primary problem was attributed to 

environmental causes (living conditions, specific mission requirements, high 

operations tempo (OPTEMPO), sleep loss, continuous operations, mission-oriented 

protective posture (MOPP), resupply delay, etc.) 

#Other Individual Factors* 

The number of COSC contacts where the primary problem was attributed to 

individual causes (personality, malingering, expectation of secondary gain, etc.) 

* The COSC-WARS Summary Report format (See TAB D) provided data entry fields for dividing 

Environmental Factors into two subcategories and Other Individual Factors into three subcategories. 
TAB C: Electronic Data Matrix 

Estimated Distance Estimated Time Unit (in miles) (in hours) 

5. Approximately how many Soldiers are in your sector? 
. I 

20. Does your unit have access to Motorola Walkie-Talkies? I 

22. Does your unit have access to satellite phones? 
3 23. Did V) you bring psychotropic medication for the 

purpose of distributing to Soldierslpatients? 4 

F 

3
 24. How far away is the nearest pharmacy to refill 3. your medication supplies? 2 

25. How many psychological tests have been $ 

3
 performed from 1April to 30 August 2004? P


-, 

26. How do you order laboratory tests? i? 

27. How do you get laboratory test results? 

31. Do you have a Behavioral Health Casualty i? 


Estimate Model? Ifyes, please attach a copy to this 4 

completed worksheet. F 

TAB D: Standard COSC-WARS Summary Report (SRJ Data Fields 

The COSC-WARS, as a data collection system for COSC surveillance and monitoring, 

has three standard data entry formats: one for summarizing aspects of each preventive 

contact; one for summarizing aspects of each individual preclinical or clinical contact; 

and one periodic summary report of selected, rolled-up data from both the preventive 

and individual contacts. The original Prevention Contacts and Individual Contact forms 

were not used in OIF-ll. 

In field operations without COSC-WARS being automated, it is often impractical to fill 

out each prevention and individual contact form, then transcribe the data from each 

event sheet into a computer, and do the computations to produce the summary report. 

Therefore, the COSC-Summary Report form was also designed to be a data collection 

worksheet for recording and summing the Summary Report data. Immediately after 

each event, the provider puts a tick mark or Arabic numeral in the space in the row to 

the right of each relevant data field title. At the end of each reporting period, the tick 

marks or numerals are summed to give the totals in the far right columns, and the totals 

for each line (row) from all the providers are summed to give the unit's totals at the end 

of each reporting period. As with automated roll-down menus in an automated system, 

only the rows (data fields) that are relevant to the event are used. 

The Summary Report form, beginning on the age, is the one that alm~edical 

Brigade units in OIF-ll used. It is the form that bW)-2 TT 
Medical Brigade was using at the 

end of OIF-I, in which they had added 7 lines regarding degrees of suicidal and 

homicidal behaviors to the original 52-line version. The mental health sections of the 

Corp's divisions and brigades received the original 52-line version, but some then 

added or deleted data fields without preserving the original line sequence. 

COSC-SUMMARYREPORT- (COSC-SR) - MODIFIED 

B-83 
I 1 Unit and Team(s): I I 

1 

2 Report Dates: 

Location (andlor BCT 

SUDDO~~~~): 

From: 

Thru: 

4 # of Critical Event Debr~ef~ng Sess~ons 

5 Total # Attending CEDs 

6 # of Critical Events 

7 # of Other Debr~ef~ng Sessions 

8 Total #Attending Other Debriefings 

# of Preventive Educational 

Classes Enter Sum frorn Line 10 and Line 12 

10 #of Force Health Protection (FHP) Classes 

11 Total # Attending FHP Classes 

12 # of Mlssion-Focused Classes 

14 # Sensing Sessions/Walkabouts/Focus Groups 

15 Total # Participants/Contributors 

16 # Unit Surveys (Different Units Surveyed) 

17 #Questionnaires (Total Returned in Unit Surveys) 

18 # of Individuals Screened for Pre-/Post-Deployment 

19 # of Individuals Further Screened in Person 

20 # of Individuals Requiring Further Intervention 

25 


26 

-

27

-

28 

29 

30 

31 

Operational Causes 

Relational Causes 

Environmental Factors 

Other Individual Causes 

# Combat Exposure 

# Noncombat Critical Event 

# PeerIUnit 

# Leadership 

# Home Front 

# PhysicalIEnvironmental Exposure 

# Other Mission Requirements 

# Characterological Factors 

# Conditional 

# Preexistina Condition 
32 # of PsychiatriciMental Enter Sum from Line 33 and Line 34 

Disorder Contacts 

33 # of New Cases (First-time Contacts) 

34 #of Follow-up Contacts 

Comments (significant findings and trends, to include those related to Lines 53-59): 
APPENDIX 7 

REFERENCES 

Bray, R. M., Hourani, L. L., Rae, K. L., Dever, J. A,, Brown, J. M., Vincus, A. A. et al. 

(2003).2002Department of Defense survey of health related behaviors among 

military personnel. http://www.tricare.osd.mil/main/news/2002WWFinalReport.pdf 

[On-line]. 

Elisha, D.: Levinson, D., & Grinshpoon, A. (2004).A need-based model for determining 

staffing needs for the public sector outpatient mental health service system. 

Journal of Behavioral Health Services & Research, 31, 324-333. 

Faulkner. L. R. & Goldman, C. R. (1997).Estimating psychiatric manpower 

requirements based on patients' needs. Psychiatric Services, 48, 666-670 

Faulkner, L. R. (2003).Implications of a Needs-Based Approach to Estimating 

Psychiatric Workforce Requirements. Academic Psychiatry, 27, 241-246. 

Field Manual 8-51,Combat Stress Control in a Theater of Operations: Tactics, 

Techniques, and Procedures. 20January 1998. 

Field Manual 8-55,Planning for Health Service Support, 9September 1994 

Office of The U.S. Army Surgeon General (2003).Operation Iraqi Freedom Mental 

Health Advisory Team report. 

htt~:/lwww.qIobaIsecuritv.orq/miIitarv/librarv/re~ort/2004/mhat.htm[On-line]. 
ANNEX C 

EVACUATION ASSESSMENT 

OPERATION IRAQI FREEDOM (OIF-Ill 

MENTAL HEALTH ADVISORY TEAM IMHAT-II] 

30 January 2005 

Chartered by 

The U.S. Army Surgeon General 

This is an annex to the Operation Iraqi Freedom (OIF-ll) Mental Health Advisory 

Team (MHAT-Il) Report addressing the behavioral health evacuation system in 

OIF-11 (including Kuwait and Iraq). The findings were obtained from many sources 

to include interviews, record reviews, and Department of Defense- (DoD-) 

supported databases. 

The views expressed in this report are those of the authors and do not necessarily 

represent the official policy or position of the Department of Defense (DoD), the U.S 

Army, or the Office of The Surgeon General (OTSG). 
ANNEX C 

TABLE OF CONTENTS 

(See note on the last page (C-5) of the Table of Contents.) 

INTRODUCTION.........................................................................................................C-6 


FINDINGS ................................................................................................................... C-6 

Table 1: Comparison of Army Evacuations1100. 000 Soldiers .........................C-6 


Table 2: Behavioral Health Evacuation Rates in Previous Military 

Operations* ..................................................................................... C-7 

RECOMMENDATIONS............................................................................................... C-7 


Immediate Implementation .................................................................................. C-7 


Future Implementation .....................................................................................C-7 


METHODS .................................................................................................................. C-8 

I. Evacuation Rates ............................................................................................. C-8 

Source of Data ........................................................................................ C-8 


Inclusion Criteria for OIF-ll Army Evacuations ....................................... C-8 


Inclusion Criteria for Behavioral Health Evacuations ............................C-8 


Evacuation Rate per 100. 000 Soldiers ..................................................... C-8 


II. Evacuee Chart Review .................................................................................... C-9 


Source of Data ........................................................................................... C-9 


Method of Analysis .................................................................................C-9 


Ill. Behavioral Health Interviews ......................................................................C-9 


Instrument Development .......................................................................... C-9 


Interview Method .......................................................................................C-9 


Analysis of Surveys and Interviews ........................................................C-9 


RESULTS .............................................................................................................C-10 


I. Evacuation Rates ...................................................................................... C-10 


Total Army OIF-ll Evacuations ............................................................... C-10 


Table 3: Total Army OIF-ll Evacuations ..........................................C-10 


Table 4: Army Evacuations per 100. 000 Soldiers by 

Month (March-September) ...........................................C-10 


Chart I:Army Evacuations per 100. 000 Soldiers .......................... C-11 


Behavioral Health Evacuations ............................................................. C-I I 


Table 5: Army OIF-ll Behavioral Health Evacuations ..................... C-I I 

ANNEX C 

TABLE OF CONTENTS 

(Continued) 

Table 6: Army Evacuations per 100. 000 Soldiers by 

Month (March-September) ........................................................ C-12 


Chart 2: Army Behavioral Health Evacuations per 100. 000 Soldiers ......... C-12 


Table 7: Behavioral Health Evacuees Given a Non-Psychiatry 

Designator .................................................................................. C-13 


Table 8: Evacuations by Medical Surgical Specialty 

(I March-26 September 2004) ................................................... C-14 


Chart 3: All Army OIF-ll Evacuations per 100. 000 Soldiers by Month 

Compared with Behavioral Health Evacuations per 

100. 000 Soldiers ......................................................................... C-15 


II. Evacuee Chart Review .................................................................................... C-15 


LRMC Chart Review ................................................................................... C-15 


Table 9: Demographics ....................................................................... C-16 


Table 10: Behavioral Health Disorders in OIF-ll ................................ C-17 


Table 11 : Behavioral Health Disorders at Discharge from LRMC ... C-17 


Table 12: Percent Change in Diagnoses from OIF-I to OIF-ll ........... C-17 


Table 13: OIF-ll Diagnoses Remaining Unchanged at LRMC ........... C-18 


Table 14: Expanded List of Behavioral Health Disorders ................ C-19 


Table 15: Medication Prescribed in OIF-ll and LRMC ....................... C-20 


Table 16: Return-to-Duty Rates .......................................................... C-21 


Table 17: Documentation in LRMC Charts ........................................ C-21 


Ill. Evacuation Policy ........................................................................................... C-22 


IV. LRMC Behavioral Health Interviews and Evacuation Procedures ............. C-22 


Arrival ......................................................................................................... C-22 


Triane .......................................................................................................... C-22 


Duration of Stay ......................................................................................... C-22 


Outpatient................................................................................................... C-22 


Standards of Care ...................................................................................... C-23 


Treatment Initiatives .................................................................................. C-23 


Evacuee Accountability ............................................................................. C-23 


Documentation from OIF-ll ........................................................................ C-23 


Command Notification of Evacuation Pronress ...................................... C-24 


Suicides and Uniform Code of Militarv Justice (UCMJ) Issues ............. C-24 


Alcohol Use bv Evacuees ......................................................................... C-24 


LRMC Recommendations for Improved Evacuations ............................. C-24 


V. LRMC Evacuee Interviews .............................................................................. C-25 

ANNEX C 

TABLE OF CONTENTS 

(Continued) 

APPENDIX 1: DESCRIPTION OF DEPARTMENT OF DEFENSE-SUPPORTED 

DATABASES............................................................................ C-27 


Transportation Command Regulating Command and Control 

Evacuation System (TRAC2ES) ................................................................ C-27 


Patient Accounting and Reporting Real-Time Tracking System 

(PARRTS).................................................................................................... C-27 


Medical Occupational Data System (MODS) ................................................. C-27 


APPENDIX 2: THE MHAT-II LANDSTUHL REGIONAL MEDICAL 

CENTER VISIT ........................................................................... C-28 


Purpose............................................................................................................ C-28 


Personnel.......................................................................................................... C-28 


Command and Control .................................................................................... C-28 


Method............................................................................................................. C-29 


Step 1: Preparation for MHAT-II Visit ...................................................... C-29 


In-Brief ..................................................................................... C-29 


Behavioral Health Provider Interviews .................................. C-29 


Behavioral Health Evacuee Interviews .................................. C-29 


Behavioral Health Evacuee Record Review .......................... C-29 


Miscellaneous Evacuation Records ...................................... C-30 


Out-Brief .................................................................................. C-30 


Step 2: In-Brief .......................................................................................... C-30 


Step 3: Sub-Team Tasks .......................................................................... C-30 


Sub-Team 1........................................................................... C-30 


Behavioral Health Provider Interviews ........................ C-30 


Behavioral Health Evacuee Interviews ........................ C-31 


Miscellaneous Evacuation Records ............................ C-31 


Sub-Team 2 .......................................................................... C-32 


Behavioral Health Evacuee Record Review ............... C-32 


Step 4: Out-Brief ........................................................................................ C-32 


TAB A: The LRMC Behavioral Health Provider Interview ...............C-33 


LRMC Behavioral Health Provider Interview Questions ......... C-33 


I. EVACUEE ARRIVAL ...............................................................C-33 


I/. PATIENT CARE ................................................................C-35 ..... 111. EVACUEE DEPARTURE ......................................................C-37 


I V. TRAC2ES...............................................................................C-38 


V. ESCORTS...............................................................................C-39 

ANNEX C 

TABLE OF CONTENTS 

(Continued) 

TAB B: The LRMC Behavioral Health Evacuee Interview ............... C-40 

LRMC Army OIF-11 Behavioral Health Evacuee Interview 

Questions ............................................................................. C-40 

Customer Satisfaction ............................................................... C-40 

TAB C: The MHA T-I1 In-Brief Powerpoint Presentation ................. C-4 1 

NOTE: For the purpose of brevity, the following acronyms may be used (instead of 

spelling out the words) in this Table of Contents. 

LRMC: Landstuhl Regional Medical Center 

MHA T: Mental Health Advisory Team 

OIF: Operation Iraqi Freedom 

TRAC2ES: Transportation Command Regulating Command and Control 

Evacuation System (TRAC2ES) 
INTRODUCTION 

The Mental Health Advisory Team (MHAT-II) charter called for an examination of Army 

behavioral health (BH) evacuations from Operation Iraqi Freedom (OIF-11). This report 

focuses on the relative evacuation rates for medical-surgical specialties, evacuee 

demographics and diagnoses, and clinical/administrative procedures. These findings 

are compared with those identified in the MHAT-I report. 

In keeping with the MHAT-II charter, this report focuses on BH relevant aspects of the 

medical evacuation process. It does not explore other clinical, logistical, or 

administrative issues (e.g., delays in evacuation; standing operating procedures (SOPS) 

by tactical and strategic medical evacuation flight teams; and clinical services in flight). 

FINDINGS 

1. For the same 7-month period (1 March-30 September), 25% fewer Soldiers 

were evacuated for BH problems in 2004 than those evacuated in 2003. 

Similarly, evacuations for all medical-surgical problems fell 12.1% in the 

same time frame. 

OIF-I1 Evacuations (2004) 4152 4288 -12.1% 

OIF-I Behavioral Health Evacuations (2003) 527 347 

Behavioral health accounted for only 6.0% of all OIF-ll Army medical-surgical 

evacuations, falling from 7.1 % from OIF-I. When compared with other medical-surgical 

specialties, BH was the fourth leading evacuator from OIF-ll, falling from third in the 

year before. 
Put into a historical perspective, the percentage of OIF-ll behavioral health to all 

evacuations fell within the parameters of past military operations (see Table 2). 

OIF-I (Mar-Sep 03) 

Afghanistan (2003) 

Kosovo/Bosn~a**

*Provlded by the ANEDD Center 

** The number of physical baffle 

of behavioral heakh evacua 

2. Evacuation procedures and policies have matured as evidenced by written 

SOPs, increased accountability, efficient information tracking, and improved 

transmission of clinical information between levels of care. 

Landstuhl Regional Medical Center (LRMC) has made marked improvements in the 

evacuation procedures since MHAT-1's visit. The Deployed Warrior Medical 

Management Center (DWMMC) has completed its critical SOPs. Transmission of 

clinical information from OIF-ll to LRMC substantially improved from OIF-I (83.5% v. 

44.8%). Landstuhl Regional Medical Center BH records were assembled in accordance 

with hospital SOPs. Landstuhl Regional Medical Center clinical documentation was 

forwarded to the next level of care in 92.7% of cases. Interviews with evacuees 

indicated that they were very satisfied with their care during the evacuation process. 

The Office of The Surgeon General (OTSG) Evacuation database sufficiently tracked 

patients evacuated from theater. Landstuhl Regional Medical Center's BH providers 

report that Transportation Command Regulating Command and Control Evacuation 

System (TRAC2ES)IPatient Movement Record's (PMR's) clinical utility continues to 

improve. 

RECOMMENDATIONS 

Immediate lmplementation 

1. Develop performance improvement data entry procedures to improve the 

clinical utility of TRACZESIPMR. 

Future lmplementation 

1. Study the feasibility of developing a tactical and strategic evacuation tracking 

system for efficient clinical and administrative information flow. 
Medical Command (MEDCOM) should establish a joint process action team (PAT) to 

study the feasibility of an evacuation database system capable of clinical, tracking, and 

analytical functions. It must be readily available, secure, and tailored to the needs of 

line commanders, medical personnel, medical regulating planners, and medical 

planners. 

METHODS 

I. Evacuation Rates 

Source of Data: As in the MHAT-I analysis, MHAT-II relied on the OTSG Evacuation 

database, ' which combined information from other Department of Defense (DoD) 

databases: TRAC2ES, PARRTS, and Medical Occupational Data System (MODS) (see 

Appendix 1 for further details on each database). 

Inclusion Criteria for OIF-ll Army Evacuations: To prepare the OTSG Evacuation 

database for analysis. MHAT-II subjected all entries to specific inclusion criteria. To be 

included in the OIF-ll Army Evacuation database, entries had to satisfy the following 

inclusion criteria: 1) must have Army as the branch designator; 2) must have Iraq as 

the operational event designator; and 3) must have a date between 1 March and 

26 September 2004 as the date designator. The MHAT-II eliminated any updated 

entries that did not satisfy the inclusion criteria. Remaining blank entries were assumed 

to fulfill the inclusion criteria. The final database contained all OIF-ll Army Evacuations 

from 1 March to 26 September 2004. 

Inclusion Criteria for Behavioral Health Evacuations: To prepare the OIF-ll Army 

Evacuee database for BH evacuation analysis, MHAT-II subjected all entries to 

inclusion criteria. To be included in the OIF-ll Army Behavioral Health Evacuee 

database, all entries must have satisfied either of the following inclusion criteria: 1) 

must have psychiatry as the medical-surgical specialty designator; or 2) must have a 

history highlighting BH reasons for evacuation (e.g., intentionally self-inflicted wounds, 

overdose, or psychiatric diagnosis). The MHAT-II members reviewed the histories of 

those entries without a psychiatry medical-surgical designator for inclusion in the 

database. The MHAT-II reviewed all entries with a psychiatry designator, and included 

only those with a history consistent with a BH condition. The final database contained 

all Army OIF-ll Behavioral Health Evacuees between 1 March and 26 September 2004. 

Evacuation Rate per 100,000 Soldiers: To determine the evacuation rate per 100,000 

Soldiers, the number of evacuations was divided by the average force population in 

OIF-ll from 1 March to 30 September 2004, and then multiplied by 100,000. 

' MHAT-II considered using Deployed Warrior Medical Management Center's Patient Information Application (PIA). 

However, it followed only LRMC OIF-ll evacuees, unlike the OTSG database, which tracked all evacuees regardless 

of their destination. MHAT-II also considered using TRAC2ES database itself, but opted for the OTSG Evacuation 

database given that it contained TRAC2ES data as well as information from other medical databases (e.g. PARRTS 

and MODS). 
To determine the evacuation rate per 100,000 Soldiers by month, evacuations with 

known dates were sorted by month, divided by the force population during that 

respective month. and then multiplied by 100,000. 

Because evacuees were not systematically given a Reserve Component (RC) or Active 

Component (AC) in the database, it was not possible to compare the rates of these two 

groups. 

II. Evacuee Chart Review 

Source of Data: The MHAT -11 developed a plan for evacuee chart review at LRMC 

(see Appendix 1 for details). The LRMC team consisted of three researchers from 

WRAlR (Europe) and the former psychology consultant to The Surgeon General (TSG). 

This team conducted the protocol over a I-week period, and submitted data to MHAT-II 

for use in this report. 

The MHAT-II used the OTSG evacuee database to identify Army BH evacuees who 

were transferred from OIF-ll to LRMC from 1 March to 30 September 2004. For each 

identified evacuee, MHAT requested hislher patient records for review. The LRMC 

team reviewed the charts for information identified in the research protocol and entered 

this information into a Microsoft Access file or Word document. 

Method of Analysis: Analysis of the LRMC Chart Review database used tools in 

Microsoft Access and Excel. Sorting results were compared to the total number of 

database entries for the purpose of generating a ratio or percent value. 

Ill. Behavioral Health lnterviews 

Instrument Development: The MHAT-II developed interview instruments for BH 

providers and BH evacuees at LRMC. Questions focused on evacuation procedures, 

clinical services, and command and control. The interview questions for BH providers 

are available for review in Appendix 2; questions for evacuees are in Appendix 3. 

Unstructured interviews were conducted with Multi-National Corps-Iraq (MNC-I) and 

Combined Forces Land Combat Command (CFLCC) surgeons and their staffs to elicit 

information regarding evacuation policies and procedures. 

lnterview Method: Structured interviews were conducted in small groups, comprised of 

three to five BH personnel. The former psychology consultant to TSG conducted the 

interviews. lnterviews required approximately 1 to 1% hours to complete. Limits of 

confidentiality were reviewed with interview participants. Interview notes were taken 

during the session, and later these notes were entered into a database for analysis. 

Analysis of Surveys and Interviews: Tool in Microsoft Access was used to analyze 

the surveys and interview database. Results were compared to the raw number of 

database entries for the purpose of generating a ratio or percent value. 
RESULTS 

I. Evacuation Rates 

Total Army OIF-ll Evacuations: The Army OIF-ll Evacuee database contained entries 

for 4,152 Soldiers evacuated from OIF-ll from 1 March to 26 September 2004 (210 

days; approximately 7 months). On the average, 19.8 evacuees were evacuated per 

day, and 593 evacuees were evacuated per month. 

In comparison with OIF-I, evacuation rates were 12.1% lower in OIF-ll. Table 3 

compares total number of evacuations, average monthly and daily evacuations, and 

evacuations per 100,000 Soldiers. 

Table 3: Total Army OIF-ll Evacuations I 

Average Average Evacuations per Total Evacuations Evacbations per 100.000 Evacuations per Month Day Soldiers 

OIF-I (1 Mar - 30 Sep 03) 7415 1059 34.6 4877 

OIF-ll (1 Mar - 26 Sep 04) 41 52 593.1 19.8 4288 I 

Table 4 compares Army evacuations per 100,000 Soldier by month (March through 

September) for OIF-I and OIF-ll. Chart 1 shows this same information graphically. 
Behavioral Health Evacuations: There were 251 Army OIF-ll behavioral health 

evacuations from 1 March to 26 September 2004 (210 days; approximately 7 months) 

On the average, 19.8 evacuees were evacuated per day, and 593 evacuees were 

evacuated per month. The rate of BH evacuations per 100,000 Soldiers was 260.2. 

Table 5 compares BH evacuations in OIF-I with OIF-ll. 

Table 5: Army OIF-ll Behavioral Health Evacuations 

OIF-I (1 Mar - 30 Sep 03) 527 75 2.5 346.6 

OIF-ll (1 Mar - 26 Sep 04) 251 36 1.2 260.2 

I 
I 

Table 6 compares BH evacuations per 100,000Soldiers by month (March through 

September) for OIF-I and OIF-ll. Chart 2 shows this same information graphically. 

ITable 6: Army Evacuations per 100,000 Soldiers by Month (MarchSeptember) 

art 2: Army Behavioral Health Evacuations per 100,000 Soldiers 

Army Behavioral Health Evacuations per 100K Soldiers 

Mar Jun Jul 

Month 
Of all Army OIF-ll behavioral health evacuations, 232 Soldiers were designated as 

psychiatry evacuations (i.e., entries with the psychiatry medical-surgical specialty 

designator). Of the 232 psychiatry evacuations, 3 were eliminated because their 

histories were not consistent with a BH issue. Review of the history fields from the 

3,920 medical-surgical specialty-designated evacuations revealed that 22 entries were 

related to BH issues (see Table 7); these entries were included in the final dataset, 

bringing the total number of entries to 251. 

Table 7: Behavioral Health Evacuees Given A Non-Psychiatry Designator 

Number of MedicalSurgical Spcscialty Behavioral Health Issue Evacuations 

Adjustment Disouder 1 

Gastrointestinal Depression 

I 

1 I 

Depression 1 

General Surgery Self-inflicted Gun Shot Wound 5 

Neurology Various psychiatric disorders 6 

Overdose 1 

Neurosurgery Psychological factors 1 

Psychosis 1 

Orthopedic PTSDIAlcohol Dependence 1 

Podiatry Self-Inflicted Gunshot Wound 1 

Overdose 1 

Pulmonary Adjustment Disorder 1 

Panic Attack 1 

I Total 

I I 

22 I 

I 
Comparisons of evacuations by medical-surgical specialty are shown in Table 8. In 

comparison with 1 March30 September 2003, BH moved from the third leading 

evacuating medical-surgical specialty to fourth in 1 March-26 September 2004. 

Neurosurgery rose from the fifth to third leading evacuating specialty; however, its 

evacuations only exceed BH by one. Of note, general surgery experienced the greatest 

increase in evacuations (60%) when compared to other specialties. 

Table 8: Evacuations bv MedicalSuraical Saecialtv .I1 . March-26 Seatember 2004) 

Psychiatry 

(Behavioral 232 (251) 5.6% (6.0%) 240 (260) -29% (-25%) 

Health\ 

Cardiac 224 5.4% 231 18% 

Internal Medicine I 221 5.3% 228 29% 

Urology 186 4.5% 192 6% 

Neurology 175 4.2% 181 -44% 

Ear Nose Throat 120 2.9% 124 -1 2% 

Gastrointestinal 97 2.3% 100 -36% 

Ophthalmology 96 2.3% 99 -1 2% 

Pulmonary 96 2.3% 99 -40% 

GYN 85 2.0% 88 -56% 

Oncology 53 1.3% 55 -1 4% 

Dermatology 45 1.1% 46 -63% 

Burn Surgery 42 1 .O% 43 -26% 

Oral Suraerv - , 35 0.8% 36 96% 

Renal 24 0.6% 25 -35% 

Infectious Disease 2 1 0.5% 22 -52% 

Obstetrics 19 0.5% 20 -74% 

Podiatry 19 0.5% 20 -32% 

Endocrine 14 0.3% 14 -57% 

Rheumatology 14 0.3% 14 -37% 

Dental 9 0.2% 9 -66% 

Thoracic 9 0.2% 9 102% 

Maxofacial Surgery 8 0.2% 8 -1 0% 

Audiology 7 0.2% 7 -65% 

Hematology 7 0.2% 7 -61% 

Vascular Surgery 4 0.1% 4 0% 

Metabolic 1 0.0% 1 -98% 

Unknown 

Total Evacuation I 

1 

41 52 

0 .O0A 

100.0% 

1 

4288 

-93% 

-12.1% 
Chart 3 compares Army OIF-ll evacuations per 100,000 Soldiers by month with BH 

evacuations per 100,000 Soldiers during 1 March-26 September 2004. This chart 

shows the relationship between the two curves graphically. As all evacuations rise or 

fall, BH evacuations reflect these changes as well. 

Chart 3: All Armv OIF-ll Evacuations Der 100.000 Soldiers bv Month ComDared with Behavioral 

Health ~vacuations per 100,000 ~old/ers 

All Army OIF-ll Evacuations per 100K by Month Compared with Army OIF-ll 

Behavioral Health Evacuations per 100K 

1 - 60 

Be 700 -

- 50 ha 

VIO 

All 600 - ral 

Ar He 

- 40 alt 

500 h 

ac EV 

Ue 400 - 30 tz es 

es 

300 

- 20 

200 

- 10 

100 

Month 

II. Evacuee Chart Review 

Landstuhl Regional Medical Center Chart Review: Landstuhl Regional Medical 

Center provided 273 OIF-ll evacuee BH charts for review (82 inpatient; 189 outpatient; 

and 2 both in- and outpatient charts). Thirty-five of these charts (13%) belonged to 

evacuees who were originally transferred out of OIF-ll for nonbehavioral health reasons 

The Behavioral Health Service maintained Landstuhl Regional Medical Center's charts. 

Each record was comprised of various administrative and clinical documents, and 

maintained like those of other patients. 
Tables 9, 10, and 11 summarize the demographic characteristics; diagnosed BH 

disorders in OIF-ll; and diagnosed BH disorder at discharge from LRMC. Operation 

Iraqi Freedom (OIF-ll) demographics were comparable to OIF-I. Table 12 shows that 

the percentage of Adjustment Disorders diagnosed at LRMC fell nearly 14% (i.e., from 

I Table 9: Demographics 

Officer 12 4.4% 

Warrant Officer 8 2.9% 

Unknown 6 2.2% 

IFemale 36 13.2% 

I

Reserve Component 99 36.3% 

Unknown Component 7 2.6% 
I 

ITable 10: Behavioral Health Disorders in OF-ll 

Category 

nxiety Disorders 

djustment Disorders 

Personality Disorders 

Substance Abuse Disorders 

V Codes 

No Diagnosis 

t4 O/O 

88 32.23% 

66 24.18% 

42 15.38% 

37 13.55% 

13 4.76% 

4.03% 

2.93% 

2.56% 

0.37% 

0 0.00% 

able 11 : Behavioral Health Disorders at Discharge 

justment Disorders 70 25.64% 

Psychotic Disorders 

Personality Disorders 

Substance Abuse Disorders 

22 

11 

10 

9 

9 

8.06% 

4.03% 

3.66% 

3.30% 

3.30% 

2 0.73% 
Table 13 reveals many diagnoses in OIF-ll did not change by time of discharge at 

LRMC. Over 80% of Adjustment Disorders diagnosed in theater remained the same by 

the time the evacuees left LRMC. 

Table 13: OIF-ll Diagnoses Remaining Unchanged at I 

85.71% 

nxiety Disorders 80.95% 

65.91% 

61.54% 

Personality Disorders 11 6 54.55% 

Other 8 2 25.00% 

V Codes 1 0 0.00% 
Table 14 shows all BH diagnoses given at LRMC and their corresponding percentages. 

Table 14: Expanded List of Behavioral Health Disorders 

Diagnosis # % 

I Adjustment Disorders I 

70 

I 

25.64% 

Mood Disorders 81 29.67% 

Bipolar Disorder (1 9) (6.96%) 

Depressive Disorder NOS (1 7) (6.23%) 

Dysthymic Disorder (1) (0.37%) 

Major Depressive Disorder (42) (15.38%) 

Mood Disorder NOS (2) (0.73%) 

Anxiety Disorders 55 20.15% 

Acute Stress Disorder (1 9) (6.96%) 

Anxiety Disorder NOS (9) (3.30%) 

Generalized Anxiety Disorder (6) (2.20%) 

OCD (2) (0.73%) 

Panic Disorder (5) (1.83%) 

PTSD (1 3) (4.76%) 

Simple Phobia (1) (.037%) 

Other Disorders 10 3.66% 

ADHD (1) (0.37%) 

Cognitive Disorder NOS (1) (0.37%) 

Conversion Disorder (3) (1 .I 0%) 

Dissociative Disorder (1) (0.37%) 

Intermittent Explosive Disorder (1) (0.37%) 

Sleep Disorder NOS (1) (0.37%) 

Somatoform Disorder NOS (2) (0.73%) 

I Personality Disorders I 

12 

I 

4.40% 

Psychotic Disorders 6 4.03% 

Brief Psychotic Disorder (3) (1 .I 0%) 

Psychotic Disorder NOS (6) (2.20%) 

Schizoaffective Disorder (1) (0.37%) 

Schizophreniform Disorder (1) (0.37%) 

Substance Disorders 9 3.30% 

Alcohol Dependence (4) (1.47%) 

Benzodiazepine Abuse (1) (0.37%) 

Inhalant Abuse (1) (0.37%) 

Substance Abuse (3) (1 .I 0%) 
Table 15 indicates how many evacuees were prescribed psychotropic medications in 

OIF-ll and at LRMC. In comparison with OIF-I, OIF-ll saw a 21% increase in evacuees 

who were prescribed medication (39.07% to 60.44%). Evacuees who received 

medication throughout evacuation increased from 29.39% in OIF-I (82 evacuees out of 

279) to 58.57% in OIF-Il (147 evacuees out of 251). 

Those evacuees not receiving any medication during their evacuation dropped from 

25.8 % in OIF-I (i.e., 72 evacuees without prescriptions out of 279) to 10.7% in OIF-ll 

(i.e., 27 evacuees without prescriptions out of 251). 

Table 15: Medication Prescribed in OIF-ll and LRMC 

nknown 16 4 6 
Table 16 shows the return-to-duty rates from LRMC to OIF-ll by inpatientloutpatient 

status, and by diagnosis. Only 7 (2.56%) evacuees were returned to duty from 1 March 

to 30 September 2004. In contrast, OIF-I returned 10 (3.58%) evacuees to duty from 

1 March to 30 September 2003. 

Table 17 shows the documentation found on evacuee BH inpatient and outpatient 

charts at LRMC. Transmission of OIF-ll clinical documentation increased from 44.8% in 

OIF-I (125 charts out of 279) to 83.5% in OIF-ll (228 charts out of 251). Either OIF-ll 

clinical or TRAC2ES documentation was on 96.4% of LRMC charts. 

I Table 17: Documentation in LRMC Charts I 

OIF-ll Clinical # % 

Documentation 

Yes 228 83 5% 
Ill. Evacuation Policy 

Evacuation Policy of CFLCC and MNC-I: Discussions with Corps Surgeons at 

CFLCC and MNC-I revealed that there was no change in the evacuation policy of 7 

days. An extended evacuation policy was considered impractical because it would 

require additional medical assets in theater. Instead, BH cases were given the flexibility 

to extend beyond the 7-day window, based on the clinician's assessment of return-toduty potential. 

During the Combat and Operational Stress Control Conference held in September 

2004. BH providers reported adherence to the theater evacuation policy. Evacuations 

out of theater were made only after 1) a good faith effort to address the issue in theater 

failed; 2) if Soldiers were unable to adequately contribute to the mission; or 3) if they 

were dangerous to self or others. Behavioral health providers indicated that they kept 

patients in theater beyond the 7-day evacuation window on a case-by-case basis, and 

reported that this arrangement had worked well. 

IV. Landstuhl Regional Medical Center Behavioral Health Interviews and 

Evacuation Procedures 

Arrival: All evacuees arrive at Ramstein Air Force Base (AFB) in accordance with the 

United States Air Force (USAF) medical evacuation procedures. Ambulatory evacuees 

are transported by bus or ambulance as required. All evacuees arrive at the emergency 

room or, based on their condition, may go directly to the appropriate ward. During duty 

hours, personnel evacuated due to a BH issue are directed to report to the Outpatient 

Psychiatry Service, Division of Behavioral Health, where an initial assessment is 

conducted within 1 to 2 hours of arrival based on the number of evacuees. Operation 

Iraqi Freedom (OIF-ll) evacuees have first priority in the walk-in clinic. After duty hours, 

the BH provider on-call is contacted and comes to the emergency room to conduct the 

assessment. 

Triaae: All evacuees are triaged and evaluated by the doctoral-level behavioral 

healthcare provider. The criteria for hospitalization are identical to those applied to all 

BH assessments. These criteria hinge on the degree of dangerousness to self or others. 

Additional criteria are employed on a case-by-case basis such as any unique medical 

issues requiring inpatient management. Admission procedures for the BH evacuee are 

essentially identical to those for other admissions. As with all patients who exhibit 

suicidal or homicidal behavior, the OIF-ll evacuee who exhibits these behaviors is 

hospitalized and evacuated consistent with USAF regulations for patients in this status. 

Duration of Stav: Hospital stays vary from 4 to 6 days based on the availability of 

evacuation aircraft. 

Outpatient: Outpatient evacuees are housed at Kleber Kaserne, located approximately 

30 minutes from LRMC. The facility is a converted administrative and housing unit with 

a maximum capacity of 400 persons. The census is usually 200 to 250. The population 

consists of all ambulatory evacuees to include those with psychiatric diagnoses. 
Command and control consists of a detachment commander, first sergeant, and 

operations noncommissioned officer (NCO). Daily formations are at 0600, and Soldiers 

are required to have a pass to proceed outside the immediate KaiserslauternlLandstuhl 

area. 

Additional control measures include the use of unit liaisons. These are individuals from 

the evacuees' unit who meet the arriving bus and are responsible along with the 

Deployed Warrior Medical Management Center (DWMMC) for monitoring the evacuee's 

progress through the medical system. 

Overall responsibility for the Kleber facility and monitoring all evacuees is the DWMMC. 

The DWMMC maintains the Patient Information Application (PIA) database, which 

tracks the evacuee from date of arrival to date of departure, and provides status 

updates to the command while the evacuee is at LRMC. The PIA is accessible by 

providers, DWMMC personnel, and unit liaisons on the LRMC intranet. 

All BH outpatient evacuees receive a memorandum (attached) from the Chief, 

Department of Psychiatry, providing instructions concerning contacting their unit liaison, 

leave requirements, and the prohibition of the consumption of alcoholic beverages. 

Standards of Care: In all areas, the evacuee standards of care are identical to those 

provided to non-OIF-ll patients. With respect to access to care, the OIF-ll evacuees' 

access is superior in that they receive immediate attention upon arrival and are not 

appointed for a later date. Evacuee charts are subject to existing quality improvement 

SOPS and are not evaluated separately. 

Treatment Initiatives: The relative brief stay of most evacuees (4-6 days) does not 

permit the development of initiatives requiring extensive follow-up. However, three 

areas of care are subject to immediate intervention and monitoring. Patient safety 

issues are assessed immediately following arrival at LRMC, and a determination of 

inpatient versus outpatient status is made. In addition, patients often arrive with sleep 

disturbance and anxiety symptoms. Immediate medical management has been highly 

effective in the amelioration of these symptoms. 

Evacuee Accountability: The DWMMC has responsibility for all patient evaluation, 

treatment, disposition, and accountability while at LRMC. The DWMMC also maintains 

a PIA on the LRMC intranet. This PIA provides a wealth of data on each patient to 

include date of arrival, current medical status, and projected departure date. 

Documentation from OIF-ll: The evacuees arrive with a TRAC2ESIPMR, which 

details the circumstances that prompted the evacuation. Although the majority of these 

reports are thorough, there have been occasions where patients arrived with little or no 

information. Because of this lack of information, it is difficult to provide feedback to 

these providers. 
Although not strictly medical information, the PMR is very helpful to have information 

from the Soldier's command concerning his performance and expectations concerning 

return to duty. Also e-mail addresses and other access points for the referring provider 

are helpful in planning dispositions and providing any requested feedback from the 

referring provider. 

Feedback is not routinely provided to the referring provider due to lack of contact 

information. 

According to LRMC staff, the clinical utility of TRAC2ESlPMR data is improving, and 

this facilitates disposition of an evacuee. The range for both inpatients and outpatients 

is 4 to 6 days. 

In the absence of clinical documentation from the referring unit, an effort is made to 

contact the unit and determine the reason for evacuation. Without this information, the 

information provided by the evacuee determines the management. In cases where it is 

considered that no psychiatric condition is present which warrants evacuation, the 

recommendation is that the Soldier returns to duty. These cases without psychiatric 

documentation usually occur in patients evacuated due to medical reasons other than 

psychiatric. 

Command Notification of Evacuation Prowess: The unit liaison is aware of 

disposition, and where contact information exists, both the CONUS receiving facility and 

the OIF-ll referring facility are notified. Behavioral health does not provide disposition 

back to the OIF-ll command. 

Suicides and Uniform Code of Military Justice IUCMJ) Issues: No evacuee has 

committed suicide and no assaults have been reported. One BH evacuee is under 

investigation for violation of the no movement policies and other possible UCMJ actions. 

Alcohol Use bv Evacuees: All BH evacuees are directed via memorandum from the 

Chief, Department of Psychiatry, to abstain from the use of alcohol. Incidents of misuse 

or abuse are reported to the Soldier's command and addressed clinically as required. 

LRMC Recommendations for Improved Evacuations: LRMC personnel proposed 

making changes in two areas that might enhance the quality of care for evacuees. 

Unstructured interviews with LRMC Command, BH providers, medical personnel, and 

chaplains indicated that Landstuhl Regional Medical Center personnel were directly 

impacted by the ongoing care demands of OIF-ll evacuees. Landstuhl Regional 

Medical Center Command considers this issue important and requests that the MHAT-II 

consider the following recommendations. 

1) Provide two BH providers with specialized expertise in the care and management of 

healthcare provider stress. 
LRMC Rationale for I). The LRMC staff is comprised of both active and United States 

Army Reserve (USAR) component personnel. These individuals provide care for many 

seriously injured personnel from all services. lnterviews with BH providers, 

medicallsurgical providers, chaplains, and LRMC leadership confirm the stress 

attendant to these duties. Landstuhl Regional Medical Center receives three to six 

buses of injured service members each day. Implementation of a "therapy by walking 

around" model, as was accomplished by Operation Solace, could assist the providers in 

managing this stressful duty. Additionally, these augmentees could enhance the 

Department of Psychiatry consultation liaison services for the intensive care unit (ICU) 

and medical and surgical patients. 

2) Recommend that MHAT-II address this need for increased psychiatric inpatient 

capacity at LRMC. 

LRMC Rationale for 2). LRMC serves a catchment area of 400,000 beneficiaries. It 

has an 18-bed inpatient psychiatry capacity. A proposed increase to a 26-bed unit is 

pending funding by MEDCOM. As active duty admissions surge due to periodic OIF-ll 

requirements, care for family members becomes an issue as these beneficiaries must 

be hospitalized in German medical treatment facilities (MTFs). 

V. Landstuhl Regional Medical Center Evacuee lnterviews 

Two BH evacuees were interviewed. One was an inpatient who had arrived on the day 

of this interview. The other was an outpatient who had arrived two days prior to this 

interview. Responses to the specific questions are summarized below. Although the 

interviews were conducted separately, the responses are consolidated for the purpose 

of this report. Both evacuees were informed concerning the purpose of this interview, 

the MHAT-II charter, and right to decline participation. Each evacuee was assured that 

only hislher responses to the questions and no identifying information would be included 

in the report. Both evacuees were cooperative and freely participated in the interviews. 

Both evacuees described their care as excellent during all stages of their evacuation. 

Each complimented the care received through combat stress control (CSC) units. The 

evacuees described themselves as reluctant to leave the theater, but described their 

care in positive terms. 

Both described support from caregivers and their duty units during the initial stages of 

the evaluation. One evacuee noted that his battalion commander came to the CSC unit 

to check on him prior to evacuation. They both noted that medical personnel ensured 

accountability for all ambulatory evacuees throughout the process. 

Neither evacuee had any recommendations to improve his experience. However, one 

did note somewhat humorously that a "hot in-flight meal" would have been preferable to 

a meal-ready-to-eat (MRE). 
One evacuee returned with an escort. This evacuee described the escort as very 

helpful. Both evacuees described the reception processing at Ramstein and LRMC as 

efficient. Neither required specialized medical care. However, one stated that had it 

been necessary: she was confident that it would have been provided. This evacuee 

stated that, throughout the flight, nursing staff regularly checked on their status and 

offered assistance. 
APPENDIX 1 

DESCRIPTION OF DEPARTMENT OF DEFENSE-SUPPORTED DATABASES 

Transportation Command Regulating Command and Control Evacuation System 

(TRACZES) 

Transportation Command Regulating Command and Control Evacuation System 

(TRACZES) is a web tool that tracks and manages casualty evacuations and patient 

movement. The present system was deployed nearly 2 years ago to monitor the 

movement of casualties out of a combat zone. The Transportation Command took over 

the responsibility for TRAC2ES in 1993; the casualty-evacuation management software 

was developed in response to widespread complaints following the 1991 Persian Gulf 

War that it was difficult to track and locate wounded service members being treated at 

military care centers and hospitals. Typical scenarios for the applicability for TRACZES, 

commanders on the ground determine that casualties need to be evacuated and 

transported to a medical facility. The command will contact the so-called "patient 

movement requirement center," a facility set up to support a specific conflict. The 

center, in turn, will request the aircraft and crews to transport those patients. 

Although TRACZES was designed to track evacuees like cargo shipments, healthcare 

providers have relied on its clinical data entries whenever medicallBH records did not 

accompany the evacuee. 

Patient Accounting and Reporting Real-Time Tracking System (PARRTS) 

The purpose of the PARRTS is to report special interest patients as required by 

MEDCOM Regulation 40-7, Reporting of Special Interest Personnel. It is an interactive 

web-based data entry system used by Army MTFs and deployed medical assets. 

Manually, data are inputted via the U. S. Army Patient Administration Systems and 

Biostatistics Activity (PASBA) Restricted Web Site. Users of the PARRTS are senior 

staff members of the OTSG and MEDCOM, patient administration personnel at MTFs, 

and PASBA Input Sections. 

Medical Occupational Data System (MODS) 

The Medical Occupational Data System (MODS) is a database that helps personnel 

managers, special pay clerks, Professional Filler System (PROFIS) managers, 

manpower managers, and medical readiness managers make operational data simpler. 

The MODS provides Army Medical Department (AMEDD) human resource and soldier 

readiness processing (SRP) site managers with a responsive and reliable information 

management data system for all categories of military and Department of Army (DA) 

civilian medical support personnel. The data that are the basis for MODS are pulled 

from 18 different major Army and DoD databases. 
APPENDIX 2 

THE MENTAL HEALTH ADVISORY TEAM (MHAT-11) LANDSTLJHL REGIONAL 

MEDICAL CENTER (LRMC) VISIT 

Purpose 

To provide structure and method to collect LRMC's Army Operation lraqi Freedom 

(OIF-ll) behavioral health (BH) evacuation data for the MHAT-II report. 

Personnel 

The MHAT-II, that will collect BH evacuation data at LRMC, is comprised of the 

following two sub-teams: 

Sub-team 1, consisting of one senior Army BH clinician, will conduct the 

Behavioral Health Provider Interviews and Behavioral Health Evacuee Interviews, and 

will request Miscellaneous Evacuation-Related Records. The Sub-team 1 leader is also 

designated as the Senior Team Leader and will oversee the MHAT-II Landstuhl 

Regional Medical Center visit. 

Sub-team 2, consisting of three U.S. Army Research Unit-Europe (USAMRU-E) 

personnel, will conduct the Behavioral Health Evacuee Record Review. 

Command and Control 

Each sub-team has a designated team leader who reports to the Senior Team Leader. 

The designated Senior Team Leader oversees the MHAT-II visit, liaisons with LRMC 

leadership, and reports to ~olonelFb"6'2through daily situation reports (SITREPs). 

Instruments to be used during the collection of LRMC's Army OIF-ll behavioral 

health data are: 

The Europe Regional Medical Command (ERMC) Clinician: 

Behavioral Health Provider Interview (TAB A). 

Behavioral Health Evacuee Interview (TAB B), 

Request for Miscellaneous Evacuation Related Records 

The MHAT-II In-Brief Powerpoint Presentation (TAB C) 

The Behavioral Health Evacuee Record Review (see TAB C, slide 8) 

The Operation lraqi Freedom (OIF-ll) MHAT-II Charter (Appendix 1 to Report) 
Method 

0 Step 1 : Preparation for the MHAT-II Visit 

~olonel~will contact the LRMC command to arrange visit date, 

time. and dace. In this contact. team members hi^. method of data collection. sources 

of data, aAd logistical support are identified (see visit Preparation worksheet). 

Specifically, Colonel (b)(6)-2 lwill arrange the following events and corresponding 

details: 

In-Brief: Date, time, place, and point of contact for the Senior 

Team Leader's in-brief with the LRMC Commander, DCCS, DCA, DCN, and other key 

personnel designated by the Commander. Estimated duration: 1 hour 

Behavioral Health Provider Interviews: Date, time, place, and 

point of contact for Sub-team 1's individual interviews or group interview-depending on 

staff availability-with the following BH personnel: 

Chief, Department of Psychiatry. 

Chief, Psychology Service. 

Chief, Social Work Service. 

Chief, Patient Administration Division. 

Chief, In-Patient Psychiatry. 

Chief, Outpatient Psychiatry. 

Chief, Deployed Warrior Medical Management Center. 

Estimated duration: 1-112 hour per interview 

Behavioral Health Evacuee Interviews: Date, time, place, and 

point of contact for Sub-Team 1's individual interviews with two Army OIF-ll behavioral 

health evacuees. Estimated duration: 30 minutes per interview 

Behavioral Health Evacuee Record Review 

Point(s) of contact (POCs) for collection of BH inpatient and 

outpatient records 

Identification and collection of all Army OIF-ll behavioral 

health inpatient and outpatient records from 1 March through 30 September 2004 for 

review 

Point of contact for spacelcomputerltelephone logistical support 

Date, times, and place for Sub-team 2's Army OIF-ll 

behavioral health patient record review. Estimated duration: 5 days 

Miscellaneous Evacuation Records 
The POC for the DWMMC and an electronic copy of its 

standing operating procedures (SOPS). Estimated duration: 30 minutes 

Point(s) of contact for BH evacuee tracking databases 

unique to LRMC, and electronic copies (if available). Estimated duration: 30 minutes 

Out-Brief: Date, time, place, and point of contact for the 

Senior Team Leader's in-brief with the LRMC Commander, DCCS, DCA, DCN, and 

other key personnel designated by the Commander. Estimated duration: 1 hour 

~olonel~will provide LRMC leaders copies of MHAT's Patient 

Record Review instruments, Behavioral Health Provider lnterview instruments, and 

Behavioral Health Evacuee lnterview instruments on request. 

(b)(W colonelwill provide the completed Visit Preparation Worksheet 

to the Senior Team Leader prior to the visit. 

The Senior Team Leader will confirm arrangements with points of contact 

prior to the team's arrival date. 

Step 2: In-Brief 

The Senior Team Leader will meet with the LRMC Commander, DCCS, 

DCA, DCN, and other key personnel designated by the Commander. Other MHAT-II 

members may be present at the discretion of the Senior Team Leader. 

0 In the briefing, the Senior Team Leader will discuss the MHAT-11's charter; 

proponent; purpose for visiting LRMC; team membership; requested data sources; each 

sub-team's data collection methods; use of data to develop the MHAT-II report for the 

OTSG; visit timeline; team contact numbers; and request to out-brief LRMC leadership 

at the mission's completion (see TAB C. MHAT-II In-Brief PowerPoint presentation). 

Step 3: Sub-Team Tasks 

Sub-Team I 

Behavioral Health Provider Interviews 

Sub-team 1 will meet with BH providers as previously 

arranged. Individual and/or group interviews are permitted. 

Before asking questions from the Behavioral Health 

Provider lnterview Worksheet, the interviewer will review the following information with 

the interviewee: MHAT-11's charter; proponent; purpose for visiting LRMC; purpose of 

the interview; limits of confidentiality regarding information; use of interview data to 
develop the MHAT-II report for the OTSG; and the right to refuse participation in the 

interview. 

lnterview questions are listed in the Behavioral Health 

Provider lnterview Worksheet (see TAB A). Interviewers should write interviewee 

responses verbatim, whenever possible, in the space provided on the worksheet. 

After the interview, written responses will be typed into 

the electronic Behavioral Health Provider lnterview Worksheet. A completed electronic 

copy will be given to the Senior Team Leader for final transmission to 

C~lonel~~)(~)-~ 

Behavioral Health Evacuee Interviews 

Sub-team 1 will meet with BH evacuees as previously 

arranged. To maintain privacy, only individual interviews are permitted. 

Before asking questions from the Behavioral Health 

Evacuee lnterview Worksheet, the interviewer will review the following information with 

the interviewee: MHAT-ll's charter; proponent; purpose for visiting LRMC; purpose of 

the interview; lack of confidentiality regarding information provided by interviewee (note: 

no patient identifying data will be documented); use of interview data to develop the 

MHAT-II report for the OTSG; and the right to refuse participation in the interview. 

lnterview questions are listed in the Behavioral Health 

Evacuee lnterview Worksheet (see TAB B). Interviewers should write interviewee 

responses verbatim, whenever possible, in the space provided on the worksheet. 

After the interview, written responses will be typed into the 

electronic Behavioral Health Evacuee lnterview Worksheet. A completed electronic 

copy will be given to the Senior Team Leader for final transmission to 

Colonel Patterson. 

Miscellaneous Evacuation Records 

Sub-team 1 will coordinate with the point of contact of the 

DWMMC and will collect an electronic copy of its SOPS. This electronic copy will be 

given to the Senior Team Leader for final transmission to colonel7 

Sub-team 1 will coordinate with the POC(s) for any BH 

evacuee tracking databases unique to LRMC, and will collect an electronic copy of the 

databases. Electronic copies will be given to the Senior Team Leader for final 

transmission to Colonel (b)(6'-2 

Sub-Team 2 
Behavioral Health Evacuee Record Review 

Sub-team 2 will confirm arrangements with the point(s) of 

contact for patient record collection and with the point of contact for 

spacelcomputerltelephone logistical support after the In-Brief. 

Sub-team 2 members will use the Microsoft Access file, 

LRMC Evacuee Record Review, to record data collected from each BH evacuee's 

inpatient andlor outpatient record (see TAB C, slide 8, for LRMC Database Fields). 

Each Sub-team 2 member will have a copy of this 

Microsoft Access file saved on hislher laptop computer. The copy will be named in 

accordance with this format: "Name of reviewer - LRMC Evacuee Record Review - 

Date." For example: "Leavitt - LRMC Evacuee Record Review - 30 Sep 04." 

After completing the record review, an electronic copy of 

each reviewer's Microsoft Access file will be given to the Senior Team Leader for final 

transmission to Colonel ""-21 

Step 4: Out-Brief 

The Senior Team Leader will discuss preliminary findings and 

observations with ~olonel~~rior to the out-brief. All collected electronic files 

and documents will be forwarded to Colonel (b"6'-2 for review. Out-briefing content 

will be coordinated with Colonel 

The Senior Team Leader will meet with the LRMC Commander, DCCS. 

DCA, DCN, and other key personnel designated by the Commander. Other MHAT-II 

members may be present at the discretion of the Senior Team Leader. 

In the briefing, the Senior Team Leader will thank LRMC leadership 

support for the MHAT-II mission; discuss preliminary findings in accordance with 

~olonelcb"6'2~uidance; rovide contact information to follow up with team 

members and/or Colonel*; and answer questions. 
TAB A: THE Mental Health Advisory Team (MHAT-11) Landstuhl Reaional Medical 

Center (LRMC) Visit Behavioral Health Provider lnterview Questions Handout 

LRMC Behavioral Health Provider Interview Questions 

Date: Location: Interviewer: 

Interviewee(s): 

Group Number: 

AOCs: 

I. EVACUEE ARRIVAL 

1. Where do evacuees arrive in Germany? When do they typically arrive? How do 

they arrive (e.g., bus: ambulance, or other)? 

2. How are evacuees transported to LRMC? Who transports them? 

3. When is the initial BH assessment conducted? How many hours after the 

evacuees' arrival? Who conducts the assessment? How long does a typical 

assessment last? Where is the assessment conducted? 

4. How is inpatient and outpatient status determined? What are the criteria? Who 

makes this decision? 

5. Do the procedures for admitting a BH evacuee differ from a "routine" BH 

admission? How soon after admission is a treatment plan developed? 
6. Where are outpatient evacuees housed? How are they monitored? Who 

supervises them? Are there any safety considerations for these outpatients? For 

example, is access to alcohol limited; is their movement controlled, etc.? How is 

accountability maintained? 

7. What medical records should arrive with the OIF-ll evacuee? Are the medical 

records or documentation arriving with the patient from the OIF-ll Theater? 

8. What medical information is helpful in managing your mental health patient? 

9. Is the evacuee's clinical documentation valuable to you during the evaluation 

phase? 

10. Do you provide input and feedback to the sending BH provider regarding the 

value, accuracy, and integrity and transported clinical documentation? 

11. Is the evacuee's TRAC2ES documentation valuable to you during the 

evaluation phase? 
II. PATIENT CARE 

1. What is the typical length of stay for inpatients? Outpatients? Who decides how 

long these patients stay at LRMC? 

2. When an OIF-ll patient escalates with suicidal andlor homicidal behavior, how 

does that impact the management of the patient throughout the evacuation process? 

3. Has any evacuee in LRMC's care committed suicide, assaulted others, or broken 

the law? 

4. How do you manage patients who do not have a clear reason for evacuation 

(e.g., no clinical documentation, no Axis I diagnosis, malingering)? 

5. Who alerts the OIF-ll command about the disposition plan? How is the patient 

notified? Do you alert the next higher level of care? 

6. What types of behavior have occurred that have warranted the Uniform Code of 

Military Justice (UCMJ)? Who has administrative control of the evacuees and is it 

enforced? 

7. What additional resources or staffing do you need to provide care to evacuees? 

8. Do the outpatient evacuee standards of care approximate those of partial or 

outpatient in general? 

9. How many BH providers deliver care to the OIF evacuees? 
10. How do you know if your treatment initiatives for OIF-ll evacuees are effective? 

What are the measurable outcomes for these findings? 

11. What criteria are used to determine if evacuation to a higher level of care is 

needed? Who makes the decision? 

12. Are there specific treatment initiatives for evacuees? Inpatients? Outpatients? 

13. Are there SOPS for BH evacuee evaluation, treatment, disposition, and 

accountability processes? 

14. What is the policy concerning alcohol use? How has it compromised clinical 

status of OIF-ll evacuees? 

15. How is the final evacuation disposition determined? 

16. How do you determine whether an evacuee should return to OIF-ll? Do you 

have a SOP or policy? If so, may we receive an electronic copy? 
Ill. EVACUEE DEPARTURE 

1. Has LRMC developed any specific forms to be used for evaluation and treatment 

of OIF evacuees? If so, may we receive an electronic copy of these forms? 

2. How do you decide where to evacuate a patient? Who decides this? 

3. How is the evacuee sent from LRMC to CONUSIOCONUS? Who manages the 

administrative process? Who manages the medical process? From where does the 

evacuee depart? 

4. What medical records should be sent with the patient upon further evacuation 

from LRMC? 

5. Do you have e-mail addresses and telephone numbers for points of contact for 

BH providers in OIF-ll? OCONUS? CONUS? If so, may we receive a copy of your 

list@)? 

6. Do you notify the rear detachment before initiating the patient's evacuation to the 

next level of care? The final MTF destination? Deployment Cycle Support care 

managers? 

7. Do you provide input to the receiving BH provider regarding the value, accuracy, 

and integrity of the patient's transported clinical documentation? 
IV. TRACZES 

1. Has the PAD established a quality improvement process to minimize errors in 

TRAC2ES data entry? 

2. Do you monitor the quality, accuracy, and value of TRAC2ES information? 

3. Is there a quality improvement program for evacuee charts? If so, may we have 

a copy of the SOP? 

4. Is there a quality improvement program for the implementation of LRMC evacuee 

policy and procedures? If so, may we have a copy of the SOP? 

5. What information in TRAC2ES needs to be included for it to be useful? 

6. What factors lead you to this conclusion about TRAC2ES documentation? 

7. How would you rate the value and quality of the documents accompanying OIFIl evacuees? 

8. What factors lead you to this conclusion about evacuee documentation? 
V. ESCORTS 

1. How are escorts managed (e.g., fed, housed, accounted for) once they arrive at 

LRMC? Arelis there a policy andlor SOP governing escort management at LRMC? 

2. How is it decided whether or not to send an escort? How are escorts selected? 

What training is provided to the escorts (specifically regarding safety)? 

3. What do escorts do if there is a problem (e.g., who are their POCs if a problem 

arises)? What accommodations are escorts given? 

4. Are there problems with the escort system? Do you have a SOP that is applied 

to the responsibility of escorts; if so, may we have a copy of the SOP? 
TAB B: The Mental Health Advisorv Team (MHAT-11) Landstuhl Reqional Medical 

Center (LRMC) Visit Behavioral Health Evacuee lnterview Questions Handout 

LRMC Army OIF-ll Behavioral Health Evacuee lnterview Questions 

Date: 

Location: 

Interviewer: 

Interviewee(s): 

Group Number: 

PositionsTTitles: 

AOCs: 

Customer Satisfaction: 

1. Were you satisfied with the care received during the evacuation process (at origin, 

during travel, at destination)? 

2. What factors led you to this conclusion? 

3. What would have made your experience better? 

4. What kinds of treatment did you receive during the evacuation process? 
TAB C: THE Mental Health Advisory Team (MHAT-11) In-Brief Powerpoint 

Presentation 
ANNEX D 

ASSESSMENT OF SOLDIER SUICIDE PREVENTION PROGRAM 

AND 


REPORT ON COMPLETED SUICIDES 

IN 

OPERATIONIRA~FREEDOMIOIF-11) 

MENTAL HEALTH ADVISORY TEAM IMHAT-Ill 

30 January 2005 

Chartered by: 

The U.S. Army Surgeon General 

This is an annex to the Operation Iraqi Freedom (OIF-ll) Mental Health Advisory 

Team (MHA T-ll) Report addressing suicide prevention activities and suicides 

among soldiers deployed to OIF, including Kuwait and Iraq. 

The views expressed in this report are those of the authors and do not necessarily 

represent the official policy or position of the Department of Defense (DoD), the U.S. 

Army, or the Office of The Surgeon General (OTSG). 
ANNEX D 

TABLE OF CONTENTS 

INTRODUCTION......................................................................................................... D-3 


FINDINGS................................................................................................................... D-3 


RECOMMENDATIONS............................................................................................... D-4 


DISCUSSION.............................................................................................................. D-4 


Table 1: Monthly OIF Suicides for 2003-2004 ................................................... D-5 


Table 2: Summary of Demographics on OIF 2003. OIF 2004. 

and Army 2003 Suicides ................................................................ D-6 


APPENDIX 1: TABLES ............................................................................................. D-8 


TAB A: U.S. Army Suicide Rates: 1995-2004 ................................................... D-8 


TAB B: OIF Suicides: 2003-2004 ....................................................................... D-8 


TAB C: Profile of Confirmed OIF 2003 Suicides ............................................... D-9 


TAB D: Profile of Confirmed OIF 2004 Suicides 

(as of 12 December 2004) .............................................................. D-10 


APPENDIX 2: METHODS AND PROCEDURES ..................................................... D-11 


APPENDIX 3: REFERENCES ................................................................................. D-12 

INTRODUCTION 

As part of its charter, the Operation Iraqi Freedom (OIF-I) Mental Health Advisory Team 

(MHAT-I) was directed to determine whether the July 2003 suicides represented a 

burgeoning suicide rate among OIF soldiers. The MHAT-ll's charter included an 

assessment of implementation of the MHAT-I recommendation for a Suicide Prevention 

Program in OIF II. In addition to suicide prevention activities, a comparison of suicide 

rates for calendar year (CY) 2003 and CY 2004 for the OIF theater was conducted and 

is reported in this annex. 

This report provides an analysis of Army suicides occurring in lraq and Kuwait between 

January and December 2003 and January 2004 and December 2004 by male and 

female Active and Reserve Component (RC) soldiers. The OIF suicide rates for 2003 

and 2004 were compared to other relevant suicide rates, and the characteristics of OIF 

suicides were studied to determine whether there are increased risks for suicide 

associated with OIF deployment. Findings and recommendations are presented first, 

followed by discussion, tables, summary of methods, and references. 

FINDINGS 

FINDING #I: The community-based Army Suicide Prevention Program (ASPP) 

objectives have been adapted and a unit Suicide Prevention Program is evident at 

aN OIF major commands of the combat units in lraq as recommended. 

All major commands of the combat units surveyed in lraq indicated that they have 

designated proponent(s) to manage the Suicide Prevention Program. All major 

commands of the combat units surveyed indicated that they had leader and soldier 

suicide awareness training in the past year. 

FINDING #2: Surveillance of completed suicides with use of the standardized 

suicide event reporting has been implemented. 

Army Suicide Event Reports (ASERs) for completed suicides for OIF-ll have been 

submitted as required, according to the ASER program manager. 

FINDING #3: The January-December 2003 suicide rate for soldiers deployed in 

OIF was 18.0 per 100,000 soldiers. The January-December 2004 suicide rate for 

soldiers deployed in OIF was 8.5 per 100,000 which is lower than 2003 and recent 

Army historical rates. 

Although in July and November 2003 OIF suicides rose to 5 each month, there was no 

confirmed trend of rising suicides in OIF in 2003 and the rate for other months remained 

lower at 2 each month, which is consistent with Army historical rates. The OIF 2004 

confirmed suicide rate was 8.5 per 100,000 soldiers for suicides occurring between 

January-December 2004. This rate is lower than the 2003 OIF rate of 18.0 per 100,000 
and the average annual rate of 12 per 100,000 for the 9-year period 1995-2003 (range 

9.1 - 14.8). 

RECOMMENDATIONS 

1. Continue existing (community-based) objectives of the ASPP for OIF soldiers 

and units during pre-deployment, deployment, and re-deployment. 

2. Continue monitoring and reporting of completed suicides and serious suicide 

attempts with the ASER. 

3. Develop and implement an assessment process to track suicide prevention 

training for all soldiers in accordance with AR 600-63 and DA PAM 600-24 during 

pre-deployment, deployment, and re-deployment. 

DISCUSSION 

FINDING #I: The community-based ASPP objectives have been adapted and a 

unit Suicide Prevention Program is evident at all OIF major commands of the 

combat units in lraq as recommended. 

All major commands of the combat units surveyed in lraq indicated that they have a 

designated proponent to manage the Suicide Prevention Program. All major commands 

of the combat units surveyed indicated that they had leader and soldier suicide 

awareness training in the past year. 

Two BCT brigades of the combat units indicated they have had key unit personnel 

trained in providing crisis intervention (e.g. Applied Suicide Intervention Skills Training 

(ASIST)). Mental Health Advisory Team (OIF-ll) member contacts with Unit Ministry 

Teams (UMTs) and commands confirm the above and indicate most UMTs have had 

ASIST. 

There is evidence of a command climate that encourages appropriate helpseeking behavior by distressed soldiers. The Soldier Health and Well-being 

Survey responses indicated that 77% of soldiers surveyed reported they received 

suicide prevention training in the past year, and 59% of soldiers surveyed 

indicated they felt confident in their ability to identify Soldiers at risk for suicide. 

Ninety percent of UMTs surveyed reported that they provided suicide prevention 

training in the past year ranging from 2 to 3 times per month to several times a 

week to their various units. 

FINDING #2: Surveillance of completed suicides with use of the standardized 

suicide event reporting has been implemented. 

Army Suicide Event Reports for completed suicides for OIF-ll have been submitted as 

required, according to the ASER program manager. Data have been compiled and 
distributed on these cases. However, ASERs on nonlethal, serious suicide attempts 

have not been submitted consistently. This requires improved compliance to make the 

ASER Program a viable data source for future study. 

FINDING #3: The January-December 2003 suicide rate for soldiers deployed in 

OIF was 18.0 per 100,000 soldiers. The January-December 2004 suicide rate for 

soldiers deployed in OIF was 8.5 per 700,000, which is lower than CY 2003 and 

recent Army historical rates. 

Although in July and November 2003 OIF suicides rose to 5 each month, there was no 

confirmed trend of rising suicide in OIF in 2003 and the number of suicides for other 

months remained lower at 2 each month, which is consistent with Army historical rates. 

The OIF 2004 confirmed suicide rate was 8.5 per 100,000 soldiers. This rate is lower 

than the 2003 OIF rate of 18.0 per 100,000. The average annual rate for the 9-year 

period 1995-2003 was 12 per 100,000 (range 9.1 - 14.8) (Appendix 1, Tab A). The rate 

of 8.5 per 100,000 was based on 9 January-December 2004 Army deaths occurring 

within Iraq or Kuwait that the Office of the Armed Forces Medical Examiner (OAFME) 

classified as suicides (Appendix 1, Tab D). 

Table 1 displays monthly OIF suicides for 2003 and 2004. When comparing numbers of 

suicides each month in 2003 and 2004, there were increases in suicides in July and 

November 2003. There were no spikes in the number of suicides in 2004 and no 

indication that any of the suicides were related to each other. There were no suicides in 

OIF in January, February, June, September, November, and December 2004; two 

suicides in March, April, and August 2004; and one suicide in May, July, and October 

2004. 

Table 1: Monthly OIF Suicides for 2003-2004 

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 

02003 2004 
Firearms were the only confirmed method of suicide for OIF soldiers in 2003 and 2004 

with the exception of one drug overdose case in 2003. Suicides were committed 

predominately by young males: a group that is typically high risk for suicide. The 

frequency of firearm suicide during OIF was much higher when compared to firearm 

suicide for the Army and U.S. populations in previous years. The deployed force is 

comprised of a large number of young males who are a group with high suicide risk in 

the U.S. population. 

Table 2 compares demographic characteristics of CY 2003 and CY 2004 OIF Soldiersuicides to Army suicides in 2003. The OIF suicide cohort is comprised of young males 

(a group that is high risk for suicide in the U.S. population with twice the national rate of 

suicide in 2002 (ages 25-34)). The OIF 2003 and 2004 cohort is more junior in rank to 

the 2003 Army suicides with no females in 2004 and fewer minorities in 2004 than 2003. 

Table 2: Summary of Demographics on OIF 2003, OIF 2004, 

and Army 2003 Suicides 

2004 Army 

As of 12 Dec 2004 OIF 

Suicides 

2003 Army OIF 

Suicides 

2003 Army 

Suicides 

Suicide by 100% 96% 71% 

firearmlgunshot 

Male 100% 92% 94% 

Age 30 or younger 89% 79% 72% 

E-4 or below 78% 71% 56% 

Married 11% 38% 53% 

Minority (non-white) 22% 42% 22% 

RECOMMENDATION #I: Continue existing (community-based) objectives of the 

ASPP for OIF soldiers and units during pre-deployment, deployment, and redeployment. 

Strategies of the ASPP should be applied to the OIF force through actions in the 

following five areas: proponency, awareness, training, surveillance, and help-seeking 

behavior. See the MHAT-I report for detailed descriptions of these five areas. 

RECOMMENDATION #2: Insure monitoring of serious suicide attempts with the 

ASER. 

Enough precedence exists to support the strategy of reducing suicide occurrence by 

reducing the occurrence of serious suicide attempts (leading to hospitalizations and 

evacuations). A critical component of this strategy is the monitoring of suicide attempts 

as an outcome metric for suicide prevention actions. Serious suicide attempts (that 

result in hospitalizations or evacuations) should be included as reportable medical 
events analogous to communicable disease and other reportable events. See the 

MHAT-I report for rationale for use of the ASER as a means of data collection. 

RECOMMENDATION #3. Develop and implement an assessment process to track 

suicide prevention training for all soldiers in accordance with AR 600-63 and 

DA PAM 600-24 during pre-deployment, deployment, and re-deployment. 

Limited data were available on suicide prevention training during pre-deployment, 

deployment, and re-deployment. 
APPENDIX 1 


TABLES 

TAB A: U.S. Army Suicide Rates: 1995-2004 


Calendar Year Rate per 100,000 

1995 14.8 

1996 12.4 

2004 


Averaqe 1995-2003 


TAB B: OIF Suicides: 2003-2004 


SUICIDE UPDATE 2003 2004 


OIF Confirmed 24 9 


OIF Pending 0 3 


OIF Confirmed Rate 18.0 8.5 (As of EOM: Dec 2004) 
TAB C: Profile of Confirmed OIF 2003 Suicides 

Date of Suicide Aae Rank MOS Com~ Gender RaceIEthnicitv Married Method 
TAB D: Profile of Confirmed OIF 2004 Suicides (as of 12 December 2004) 

Date of Suicide Age Rank MOS Comp Gender RaceIEthnicity Married Method 
APPENDIX 2 

METHODS AND PROCEDURES 

1. Operation Iraqi Freedom suicides were defined as those Army Active or RC deaths 

for which the fatal self-inflicted injury occurred in lraq or Kuwait between 1January 2003 

and 31 December 2004, and for which the OAFME determined the manner of death to 

be suicide. 

2. Information about the soldiers from the suicide cohort was obtained from casualty 

reports, personnel records: CID reports, and the medical examiner records. There were 

no psychological autopsies or other reports from behavioral health personnel for the 

suicides occurring in lraq or Kuwait. 

3. Suicide rates are reported by convention as the number of suicides per 100,000 

persons. Monthly suicide rates were calculated by multiplying the number of suicides 

each month by 100,000 and dividing by the number of soldiers in the OIF theater. The 

denominators used were force strength numbers at the end of each month, January 

2003 though December 2004, for male and female active and RC soldiers assigned to 

Kuwait and Iraq. 
APPENDIX 3 


REFERENCES 

1. Mental Health Advisory Team (MHAT-I) Report from Operation Iraqi Freedom, 

chartered by The U.S. Army Surgeon General and HQDA G-1, December 16, 2003, 

available on www.armvmedicine.armv.mil 

2. Crow, BC. Ft. Lewis Suicide Prevention 1998-2003, the Quest for Best Practices. 

6th Annual Force Health Protection Conference, Albuquerque, New Mexico, 14 August 

2003. sponsored by the U.S. Army Center for Health Promotion and Preventive 

Medicine, Edgewood. MD. 

3. Other Military References: 

DA PAM 600-24, Suicide Prevention and Psychological Autopsy 

AR 600-63, Army Health Promotion 

Army Suicide Prevention: A Guide for Installations and Units (Draft) 

AR 600-5, Health Promotion 

AR 190-40, Serious Incident Reporting 

DoD Suicide Prevention and Risk Reduction Committee Charter 
ANNEX E 

INTERNMENT FACILITY SOLDIER ASSESSMENT 

OPERATION IRAQI FREEDOM (OIF-Ill 

MENTAL HEALTH ADVISORY TEAM (MHAT-II) 

30 January 2005 

Chartered by: 

The U.S. Army Surgeon General 

This is an annex to the Operation Iraqi Freedom (OIF-ll) Mental Health Advisory 

Team (MHAT-Il) Report addressing the behavioral health services in OIF-11 

internment facilities. The findings were obtained from many sources to include 

surveys, interviews, Department of Defense- (DoD-) supported databases, and 

behavioral health record reviews. 

The views expressed in this report are those of the authors and do not necessarily 

represent the official policy or position of the Department of Defense (DoD), the U.S. 

Army, or the Office of The Surgeon General (OTSG). 

E-I 
ANNEX E 

TABLE OF CONTENTS 

INTRODUCTION.......................................................................................................... E-3 


MISSION CONSIDERATIONS ..................................................................................... E-3 


MISSION OBJECTIVES .............................................................................................. E-4 


FINDINGS.................................................................................................................... E-5 


RECOMMENDATIONS................................................................................................ E-5 


Immediate Implementation ................................................................................... E-5 


Future Implementation .......................................................................................... E-6 


DISCUSSION............................................................................................................... E-6 


Stress and Prevalence .......................................................................................... E-6 


Soldier Care Services and Resources ................................................................ E-7 


METHODS ................................................................................................................... E-7 


Sources of Data ..................................................................................................... E-7 


Data Collection ...................................................................................................... E-7 


Method of Analysis ............................................................................................... E-8 


RESULTS .................................................................................................................... E-8 


Custodial Staff Interviews .................................................................................... E-8 


Behavioral Health Provider Interviews ................................................................ E-9 

INTRODUCTION 

The Multi-National Corps-Iraq (MNC-I) requested the Mental Health Advisory Team 

(MHAT) to assess the behavioral health care at two Army internment facilities (Camp 

Bucca and Abu Ghraib), to offer recommendations to improve the current level of care, 

and to develop an Army Medical Department (AMEDD) behavioral health care model for 

detainees and Soldiers in future internment facility operations. 

This report addresses Soldier behavioral health issues. The behavioral health care of 

detainees is addressed in Annex F. 

Multi-National Corps-Iraq leadership requested an assessment of behavioral health care 

resources for Soldiers working at internment facilities in view of reports of custodial staff 

misconduct at Abu ~hraib' and inadequate medical resources for detainees.* MultiNational Corps-Iraq sought answers to the following questions: 

1. Were the stressors greater for custodial staff members than for other Soldiers in 

Operation Iraqi Freedom (OIF-ll)? 

2. Was the prevalence of behavioral health disorders higher among custodial staff than 

for other Soldiers in OIF-ll? 

3. Should custodial staff and detainees share behavioral health services or should they 

be separate? 

MISSION CONSIDERATIONS 

To accomplish this assessment, the MHAT assembled a special forensic team (i.e., 

MHAT-FT) consisting of the Psychiatry Consultant to The Army Surgeon General, the 

Forensic Psychiatry Consultant to The Surgeon General, a forensic psychiatrist (who 

served on the MHAT 2003 mission), and a Sergeant First Class with previous 

correctional behavioral health experience. 

When planning for this assessment, the MHAT-FT relied on previous inspection reports 

of Abu Ghraib and Camp Bucca for background inf~rmation.~ Soldier-related stressors 

identified in these reports included: heat and dust exposure, 12-hour work shifts, and 

low staff-to-inmate ratio^.^ Unlike Camp Bucca. Abu Ghraib faced additional stressors: 

'See Annex F, Appendices 1-3 for further details. 

A detailed overview of each internment facility can be found in Annex F 

Large sub-compounds ranged in size from 200 to 300 detainees 

3 
frequent mortar attacks, improvised explosive device ambushes, and increased public 

scrutiny due to alleged misconduct. The road between Abu Ghraib and the airport was 

notoriously dangerous due to frequent ambushes, thereby, slowing supply shipments to 

the camp. 

Air-conditioned living quarters, internetltelephone access, and other morale, welfare, 

and recreation (MWR) functions offset these stressors. Likewise, improved dining 

facility infrastructure and food quality, and exercise facilities had improved quality of life 

(more details of internment facility operations appear in Annex F). 

A review of the professional literature highlighted common stressors that impact 

correctional staff in the civilian setting: understaffing, overtime, rotating shift work, 

supervisor demands, role conflict, role ambiguity, threats of violence, inmate demands 

and manipulation, conflicts with coworkers, poor public image, and low pay.5 Stress can 

result in significant problems for custodial personnel: physical i~lnesses,~ b~rnout,~ 

substance abuse,a excessive disability retirementqg and interpersonal problems with 

family and coworker^.'^ It is recognized that the effects of stress on civilian correctional 

personnel can compromise institutional safety, cost money, and create stress for other 

staff members. 

MISSION OBJECTIVES 

With these considerations in mind, MHAT-FT selected the following objectives for this 

assessment: 

1. To determine whether current behavioral health care for Soldiers was in accordance 

with combat and operational stress control (COSC) doctrine. 

2. To assess the behavioral health care needs of the Soldiers working at internment 

facilities via survey and interview techniques. 

3. To make recommendations for improved Soldier behavioral health care at internment 

facilities. 

Addressing Correctional Officer Stress: Programs and Strategies. 2000. Peter Finn. US Department of Justice. 

'Woodruff. "Occupational Stress for Correctional Personnel": and Cheek, F.E.. and M.D. Miller. "New 

Look at Officers' Role Ambiguity." in Correctional Officers-Power. Pressure and Responsibility, ed. JN 

Tucker. Laurel. Maryland: American Correctional Association. 1983. 

Cornelius. G.. Stressed Out: Strategies for Living and Working with Stress in Corrections. Laurel, Maryland: 

American Correctional Association. 1994. 

Addressing Correctional Officer Stress: Programs and Strategies. 2000. Peter Finn. US Department of Justice. 

"bid 

Van Fleet. F.. ''Correctional Officers and Their Families: Dealing with Stress." in The Effective Correctional Officer. 

Laurel. Maryland: American Correctional Association. 1992. 

10 
Finding #I: There was no significant difference between the prevalence of 

behavioral health disorders among Soldiers in custodial positions and those of 

other Soldiers surveyed in OIF-11. Custodial staff members shared stressors in 

common with OIF-11 peers. 

The Soldier Health and Well-being Survey revealed that positive screenings for 

posttraumatic stress disorder (PTSD), anxiety, and depressive disorders among 

custodial staff members" were equivalent to those for other Soldier MOSs in OIF-ll (see 

Annex A, Finding #4 and Figure 3 for further details). 

In focused group interviews, custodial staff members reported comparable stressors to 

those of their OIF-ll peers. They indicated that increased scrutiny of Army internment 

operations had increased their likelihood to "second guess" their decisions and felt that 

their hard work had been stained by the misconduct of a few. All in all, custodial staff 

members believed they were coping well with stressors. 

Finding #2. Behavioral health care was conducted in accordance with COSC 

doctrine. lnsufficient training in correctional behavioral health care diminished 

optimal support for custodial staff. 

Interviews with senior behavioral health providers indicated that appropriate functional 

areas of COSC doctrine were implemented for Soldiers at the internment facilities. 

Custodial and medical staff descriptions of behavioral health services confirmed 

sufficient adherence to COSC doctrine and availability of services. Insufficient training 

in correctional behavioral healthcare delayed providers in providing support as they 

familiarized themselves with correction's unique stressors, procedures, philosophies, 

and situations. 

RECOMMENDATIONS 

Immediate Implementation 

1.Continue behavioral health care services in accordance with COSC doctrine 

and MHAT-11 staffing recommendations. Supplement COSC doctrine with training 

in specific stressors unique to corrections and in best practices to provide care 

to custodial staff. 

While COSC doctrine provides a generic model for behavioral health care and 

effectively anticipates the common stressors and emotional reactions of Soldiers in 

military operations, further refinement is necessary to adapt it to unique needs of units 

Custodial staff members were military police and Soldiers with other MOSs serving in custodial 

positions. 

11 
andlor Soldiers. Additional training in accordance with the proposed Detainee 

Behavioral Health Care Program Model (see Annex F, Appendix 10, Tab D) can 

prepare behavioral health providers to anticipate the stressors inherent in the 

correctional setting, and implement the best practices to support the custodial staff. 

Annex B provides further behavioral health staffing guidance. 

2. Consider parallel behavioral health care programs for Soldiers and detainees. 

If adopted, keep staff member participation in both programs at the same time to 

a minimum to prevent any perception of ethical conflicts. 

Correctional literature advocates for independent behavioral health programs to 

encourage custodial personnel to access care.'' Traditionally, custodial staff members 

underutilize behavioral health care when staff or services are shared.13 Perceived 

conflicts in advocacy and confidentiality prevent staff members from seeking care. 

Future Implementation 

1. Establish a Correctional Behavioral Health Care Fellowship Training Program. 

Given the paucity of Army behavioral health providers with experience in correctional 

care, it is important to develop and maintain clinical and administrative program 

expertise as it applies to internment facility operations. The AMEDD should consider 

supporting a prior proposal for a Correctional Behavioral Health Care Fellowship 

Training Program at the U.S. Detention Barracks in Fort Leavenworth. 

2. Integrate a Correctional Behavioral Health Care Track into the Force Health 

Protection Conference. 

To develop a basic understanding of correctional principles and practices, Force Health 

Protection Conference organizers may consider adding a Correctional Behavioral 

Health Care track to the program. 

DISCUSSION 

Stress and Prevalence 

This analysis shows no significant difference between the prevalence of behavioral 

health disorders of Soldiers in custodial positions and those of Soldiers surveyed in 

'' Staffing Considerations (Chapter VI). B. Jaye Anno. Correctional Health Care: Guidelines for the Management of 

an Adequate Delivery System (2001) US Department of Justice. 

Behavioral health programs for staff members fall into one of three basic structures: in-house programs. 

independent contracted services. and hybrid arrangements. In-house programs offer custodial staff and inmates the 

same serviceslbehavioral health as staff members. Independent contracted services offer custodial staff members a 

seDarate behavioral health team and services. 

13 
OIF-ll. 

In Annex A, the results of the Soldier Health and Well-being Survey revealed that a 

percentage of military police officers (and Soldiers in other MOSs serving as custodial 

staff) who screened positive for PTSD, anxiety, and depressive disorders was not 

statistically different from those for other Soldier MOSs in OIF-ll. This analysis is fully 

described in Annex A (i.e., Finding #4 and Figure 3), and is not repeated here. 

Custodial staff members who participated in focused group interviews reported 

stressors commonly shared by their OIF-ll peers. Separation from family, deployment 

length, and lack of privacy were frequently identified as noncombat stressors. Reports 

of combat stressors differed between the Abu Ghraib and Camp Bucca custodial staff. 

By virtue of its location, Abu Ghraib presents a convenient target for insurgents, whose 

nightly mortar attacks have forced Soldiers to live within fortified prison cells and to wear 

body armor and Kevlar when outside their living quarters. In contrast, Camp Bucca's 

remote location has shielded it from enemy attacks. 

Soldier Care Services and Resources 

lnterviews with senior behavioral health providers indicated that appropriate functional 

areas of COSC doctrine were implemented for Soldiers at the internment facilities. 

Custodial staff descriptions of behavioral health services confirmed sufficient adherence 

to COSC doctrine and availability of services. Insufficient training in correctional 

behavioral healthcare delayed providers in providing support as they familiarized 

themselves with correction's unique stressors, procedures, philosophies, and situations. 

In this assessment, the MHAT-FT relied on results from the Soldier Health and Wellbeing Survey and focused group interviews with military police officers, other Soldiers 

serving in custodial positions, and senior behavioral health providers. 

Sources of Data 

The MHAT-FT interviewed military police officers, other Soldiers serving in custodial 

positions, and senior behavioral health providers. 

Data Collection 

lnterviews were conducted in small groups, comprised of 1 to 4 persons. Participants 

were asked questions relating to the following themes: 1) stressors for Soldiers at the 

internment facility; 2) perception of the behavioral health needs in the Soldier 

population; 3) stigma and barriers to behavioral health care; 4) satisfaction with 

behavioral health services; and 5) perception of risks to personal safety. 

lnterviews were conducted by 1 or 2 MHAT-FT personnel, and required approximately 1 

to 1% hours to complete. Interviewers informed participants about the purpose of this 
study, and that the interview would be used in the final report. Interviewers emphasized 

that no statements would be attributed to a specific interviewee in the report. The 

MHAT-FT personnel took interview notes during the session: and these notes were later 

transcribed into a Microsoft Word document. 

Method of Analysis 

The MHAT-FT members reviewed interview documents, identified themes, and grouped 

similar statements together. Interview synopses are presented in this report. 

RESULTS 

Custodial Staff Interviews 

Soldiers with custodial responsibilities were interviewed at both facilities (i.e., 4 

personnel at Camp Bucca, and 8 at Abu Ghraib). These Soldiers reported being aware 

of behavioral health resources for themselves and for the detainee population. 

Custodial staff members reported stressors commonly shared by their OIF-ll peers (see 

Annex A, Appendix 2). Some Soldiers complained about leaders imposing seemingly 

arbitrary rules; "micromanagement" by leaders; and perceived busywork. Others 

identified separation from family, deployment length, and lack of privacy as persisting 

stressors. 

Reports of combat-related stressors differed between Abu Ghraib and Camp Bucca 

custodial staff. By virtue of its location, Abu Ghraib presents a convenient target for 

insurgents, whose nightly mortar attacks have forced Soldiers to live within fortified 

prison cells and to wear body armor and Kevlar when outside their living quarters. 

Likewise, the risk of ambush is high for convoys coming to or leaving Abu Ghraib. In 

contrast, Camp Bucca's remote location has largely shielded it from enemy attacks. 

Participants reported coping well with the stressors of deployment and custodial work. 

They felt their peers were coping equally well. All were familiar with the buddy system 

for mutual support. Morale, welfare, and recreation activities were considered key to 

coping with stress. Participants were aware of chaplain and COSCIbehavioral health 

services, and felt that services had been appropriate for Soldier needs. Soldiers 

indicated that consultation, education, counseling, evaluations, treatment, and crisis 

interventions had been available through the CSC Prevention Team at Abu Ghraib, and 

the behavioral health team at Camp Bucca. 

Nonmilitary police staff members identified additional stress from adapting to their 

custodial roles. These Soldiers regarded cross training as key to improving their 

confidence and efficiency. 

Participants reported that the negative publicity of the Abu Ghraib misconduct had 

added to their stress level. They indicated that they were more likely to "second guess" 
their decisions, and felt that their hard work had been stained by the misconduct of a 

few. 

Behavioral Health Provider Interviews 

The MHAT-FT interviewed the senior behavioral health providers at each internment 

facility. Each provider led their respective teams, and had arrived in Iraq only within the 

last 2 months. 

These providers reported little to no experience in correctional settings, and indicated 

that their staff members were equally inexperienced. Both expressed confidence 

providing clinical interventions to Soldiers. They were familiar with COSC doctrine, and 

described services consistent with the COSC functional areas. They saw their 

unfamiliarity with Iraqi, Islamic, and Arabic cultures as a formidable obstacle to detainee 

patient care delivery. 

Camp Bucca had one social work officer and one mental health specialist (91 X) to 

provide behavioral health care to 400 soldiers14 and 2,600 detainees.lS The social 

worker indicated thamhad focusedrb,nbehavioral health efforts on Soldier 

preventive and clinical services, and had recently initiated detainee interventions (see 

Annex F for details)jTbelieved that behavioral health resources were adequate for 

Soldier care, but additional personnel were necessary to expand detainee services. 

Abu Ghraib had a ten-person team comprised of a psychiatrist, psychologist, four 

nurses, and four mental health specialists (91X). Prior to the Abu Ghraib team's arrival 

in 2004, a combat stress control company provided Soldier care through regular visits to 

the camp. The psychiatrist described plans to provide parallel behavioral health 

services for the camp's 900 soldiersI6 and 2,600 detainees.I7lb,c6,held the view that= 

team's staffing level was sufficient to satisfy Soldier care needs, but additional 

personnel would be necessary as detainee services expanded. 

14 This number approximates the MNC-I Soldier census on 15 Sep 2004 (derived from the MNC-I Gl's 

Joint Personnel Statistics). 

15 Department of the Army Inspector General Detainee Operations Inspection (2004). 

16 This number approximates the MNC-I Soldier census on 15 Sep 2004 (derived from the Gl's Joint 

Personnel Statistics). 

li Department of the Army Inspector General Detainee Operations Inspection (2004). 
ANNEX G 

CURRENT STATUS 

ISSUES 

AND 


RECOMMENDATIONS 

OPERATION IRAQI FREEDOM (OIF-Ill 

MENTAL HEALTH ADVISORY TEAM IMHAT-II] 

30 January 2005 

Chartered by: 

The U.S. Army Surgeon General 

This is an annex to the Operation Iraqi Freedom (OIF-ll) Mental Health Advisory 

Team (MHAT-Il) Report addressing the Behavioral Healthcare System in the OIF 

Theater of Operation (Kuwait and Iraq). The findings were obtained via direct 

observation, interviews, surveys, and data calls. 

The views expressed in this report are those of the authors and do not necessarily 

represent the official policy or position of the Department of Defense (DoD), the U.S. 

Army, or the Office of The Surgeon General (OTSG). 
ANNEX G 

TABLE OF CONTENTS 

INTRODUCTION......................................................................................................... G-3 


FINDINGS ................................................................................................................... G-4 


DISCUSSION............................................................................................................ G-12 

INTRODUCTION 

In December 2003, The Army Surgeon General's Mental Health Advisory Team 

(MHAT-I) identified a number of issues to improve behavioral health (BH) services 

throughout the Operation Iraqi Freedom (OIF-I) Theater. In August-October 2004, the 

MHAT-II collected data to evaluate the progress being made in addressing the OIF-I 

MHAT issues-both within the OIF Theater and in Germanylcontinental United States 

(CONUS). The MHAT-I recommendations are the starting point for discussing the 

issues, but this is not intended as an assessment of "compliance." The decision makers 

in OIF-ll may have implemented other actions to fix an identified problem. 

The data supporting the findings that follow this page were garnished from the OIF-I 

MHAT Report, portions of this (OIF-ll MHAT) report, or were collected during the 

months of August through December 2004. Findings are summarized on the following 

pages. Sources of data for each finding listed below are located in various annexes of 

the MHAT-II Report. Status of MHAT-I issues as of December 2004 is described as 

GREEN, AMBER, or RED. GREEN indicates that substantial progress or completion 

has been achieved in addressing this issue based on data collected in MHAT-II. 

AMBER indicates that some significant progress has been achieved in addressing this 

issue. RED indicates that little or no progress has been made on this issue. Some 

issues were described as "Future"; therefore, it may be premature to expect progress to 

be made in only 1 year. 
FINDINGS 

OIF-I MHAT ISSUES STATUS OIF-ll MHAT FINDING 

1. A. Appoint a Theater/Area of Operation BH 

consultant to advise the Surgeon on BH GREEN ~olonel[b)(W' bas appointed the OIF TheateriArea of Operation BH 

issues. consultant and arrived in theater in April 2004. 

1. B. Execute an aggressive BH outreach 

program. Ensure that BH personnel have a GREEN Most Soldiers in the 01F-ll Theater have access to BH resources, and 79% of BH 

regular, far-fotward consultation program at professionals indicate they provided combat and operational stress control 

the small-unit level. (COSC) outreach services once each week or more. Seventy-six percent of OIF-ll 

Soldiers live on a Forward Operating Base (FOB) that has resident BH care. 

There are presently 232 BH personnel either present on site or visiting FOBs and 

sites where Soldiers are serving. Suggest continued evaluation of placement of 

resources in order to best meet the BH needs of the Soldiers in theater. 

1. C. Area of responsibility (AOR) BH 

consultants need to distribute BH assets AMBER Seventy-six percent of OIF-ll Soldiers live on a FOB that has resident BH care. 

appropriately. Some FOBs had no resident BH services but may be provided services presently 

by BH professionals from other FOBs. Some gaps remain. Operation Iraqi 

Freedom (OIF-ll) BH planners implemented and are widely advertising a "Help 4 

U" web site and a 24 hourstday telephone point of contact through which any 

leader or service member can learn how to contact the nearest providers to 

coordinate access. 

1. D. Field a simple, standardized needs 

assessment tool for Soldiers and units. AMBER Walter Reed Army Institute of Research (WRAIR) has developed a needs 

assessment tool for use by BH personnel in theater that is ready for initial fielding. 

While BH personnel in theater conduct needs assessments, recommendation 

remains to field a standardized tool to allow for research opportunities, better 

communications between providers, etc. 
1. E. Train Soldiers in meeting the demands of 

deployment/combat-related stressors. AMBER The MHAT-II Soldier Health and Well-being Survey data indicate Soldiers 

reported higher levels of training in handling the stresses of deployment compared 

with Soldiers in OIF-I. The Center for Health Promotion and Preventive Medicine 

(CHPPM) and MHAT developed five Tip Cards that were distributed by MultiNational Corps-Iraq (MNC-I) in October 2004 in spite of logistical problems. 

Efforts are underway to provide these cards and instructions to units for internal 

training before they leave CONUS or while in staging areas in Kuwait. Additional 

work needs to be done to standardize, implement, and assess training materials. 

1. F. lmprove the ability to hold Soldiers in 

theater closer to their own units. Create a BH GREEN O~erationlraai Freedom [OlF-ll) Theater BH has increased the abilitv to hold 

Reconditioning Program. soldiers in the'ater and BH fitness teams to further assess 

Restoration programs were found in[b)(2)-2 I 

Soldier and staff reports and return-to- duty rates are favorable on these 

programs. There is no shortage of combat stress control (CSC) and medical 

company cots to hold Soldiers in theater during Restoration or Reconditioning. 

The table(s) of organization and equipment (TOE) capabilities of the CSC fitness 

teams now deployed were designed for stress casualty rates predicted in a major 

theater with possible use of weapons of mass destruction. 

1. G. lmprove the quality of behavioral 

healthcare services for Soldiers during GREEN The quality of behavioral healthcare services for Soldiers during evacuation has 

evacuation. improved based on revised standing operating procedures (SOPS), better 

command and control, and better transmission of clinical data from theater to 

Lanstuhl and from Lanstuhl to other medical treatment facilities (MTFs). In spite 

of these improvements, no specific BH initiatives have been developed. 

2. A. Area of responsibility BH consultants 

should establish quarterly BH training 

meetings. 

GREEN Area of responsibility BH Consultant, Colonel Fb)(6)-2 lestablished a 

quarterly BH training meeting schedule; meetings took place 6 June 2004 and 

15 September 2004. Attendance has been excellent with representatives of 

MNC-I staff, Multi-National Force-Iraq (MNF-I) staff, combat brigades, combat 

support hospitals (CSHs), CSC units, and division mental health (MH) staff. 
- - OIF-I MHAT ISSUES STATUS QIF-II MHAT FINDING 

2. B. Conduct COSC training for BH personnel, 

both Active ComponentiReserve Component GREEN Training was conducted for all deploying CSC units during Calendar Year (CY) 

(ACIRC), preparing to deploy. 2004. A team of COSC specialists from Medical Command (MEDCOMI, Arrnv 

at 

to 

National Guard (ARNG) MH personnel in(bl(21-2 

and to pre-deploying Army 

J~uture 

training for deploying units will be scheduled as units are alerted and preparing to 

deploy and cosc subject matter experts (SMEs) have been recruited to-conduct 

training sessions as requirements are identified. Medical Command staff members 

are coordinating this effort presently. 

2. C. Conduct COSC research in key areas to 

ensure that the best prevention and early Walter Reed Army Institute of Research (WRAIR) has an approved research 

intervention methodologies are AMBER protocol to assess the validity of COSC critical event debriefing (CED) intervention 

established/validated. methods. Implementation is scheduled for 2005. As of 26 October 2004, the 

Deputy Assistant Secretary of Defense for Clinical and Program Policy tasked the 

Armed Forces Epidemiological Board to explore further OIF mental health issues 

and support research activities. There was an initial planning session on 

30 November and 1 December 2004 to examine future research questions 

involving all of the armed services. A multi-service cooperative effort should 

develop to further study combat stress issues. 

3. Plan for the upcoming battle-handover. 

Planning sessions did take place at MEDCOM, and BH services and personnel 

GREEN were expanded in OIF-ll to meet growing demands and OPTEMPO. Operation 

Iraqi Freedom (OIF-Ill) and -IV planning sessions took place at MEDCOM in 
4. A. Designate proponents to manage the The existing community-based Army Suicide Prevention Program has been 

Coalition Forces Land Component Command AMBER adapted to OIF Soldiers and units. A survey of the brigades in theater 

(CFLCC) and Coalition Joint Task Force-7 revealed that all brigades identified a suicide prevention program in their 

(CJTF-7) Suicide Prevention Programs. AOR. They all indicated that they have a designated proponent to manage 

the suicide prevention program. MHAT-II learned that most Unit Ministry 

Teams (UMTs) have completed Applied Suicide Intervention Skills Training 

(ASIST), but more effort is required to ensure the Suicide Prevention Program is 

fully implemented during pre-deployment, deployment, and post- deployment. 

4. B. Maintain vigilance by leaders and 

Soldier-peers to ensure Soldiers at risk for GREEN Soldiers who indicated they received adequate training in handling the stresses of 

suicide receive appropriate support. deployment and/or combat in OIF-ll reported significantly higher confidence in 

their ability to help Soldiers get assistance for a MH problem. Twenty-seven 

percent indicated they actually helped a fellow Soldier get professional help for a 

MH problem. Suicide rates in OIF-ll are significantly lower than in OIF-I. 

4. C. Conduct training that provides crisis 

intervention skills to designated Soldiers with a AMBER Soldiers in OIF-ll reported higher levels of training in handling the stresses of 

goal of one trained Soldier per company. deployment com -I. Crisis intervention skill training was 

conducted in the ~heo(2)-2~~~ Unit began "in theater" 

training in training throughout theater are 

being explored. Response by combat divisions to the crisis intervention skills 

training thus far has been very positive. 

4. D. Implement surveillance of completed 

suicides and serious suicide attempts with AMBER The AMEDD Suicide Events Report (ASER) reporting process implemented with 

standardized suicide event reporting by BH submissions on completed suicides for 2004. Serious suicide attempts reporting 

personnel. is not occurring consistently in theater presently. This requires emphasis by 

Office of The Surgeon General (OTSG) and Army Medical Department (AMEDD) 

commanders and staff. 
4. E. Establish a command climate that 

encourages appropriate help-seeking behavior The MHAT-II Soldier Health and Well-being Survey found that the percent of 

by distressed Soldiers. Behavioral health care AMBER Soldiers with MH problems that accessed professional services increased from 

should be delivered as far forward as possible 29% in OIF-I to 40% in OIF-ll. However, there were no appreciable differences 

to maximize the likelihood of successfully between the perceptions that OIF-I Soldiers had compared with OIF-Il Soldiers 

returning Soldiers to duty. that they would be stigmatized by their unit or leadership if they received help. A 

review of BH staff located in theater indicated providers were far forward in most 

instances and the return-to-duty rate for those seen far fotward was over 95% and 

over 90% by the division and brigade BH teams. 

Future Implementation 

Behavioral health consultants are developing a proposal for a CSC course 

1. A. Direct The Surgeon General (TSG) BH AMBER presently that will provide training for all BH specialties with priority for those in 

consultants to develop and implement a COSC duty positions. 

multidisciplinary COSC course to teach COSC 

doctrine, tactics, and procedures to all 

BHICOSC personnel. 

1. B. Direct TSG behavioral health consultants 

to charter multidisciplinary PATS to develop the AMBER Behavioral health consultants are developing a proposal for a CSC course 

key elements for inclusion in the course. presently. 

1. C. Direct TSG behavioral health consultants 

to reorient the AMEDD officer and enlisted Behavioral health consultants are developing a proposal for a CSC course 

military education systems to integrate AMBER presently. 

collective blocks of instruction in COSC, 

disaster BH, and battlefield professional 

practice. 

1. D. Direct CHPPM and TSG behavioral 

health consultants to ensure that a COSCIBH A BH track was incorporated in the annual FHP Conference during 2003 and 

track is incorporated into the annual Force GREEN 2004 and is planned for 2005. 

Health protection (FHP) Conference. 
2. A. Medical Command should review the 

COSC Workload and Activity Reporting AMBER The MH teams under MNC-I and the medical units under the Medical Brigade 

System (COSC-WARS) for sufficiency and used the COSC-WARS Summary Report (SR), with hand entry of data. Problems 

then automate it. were identified with standardization, training, and written instructions. The SR 

format needs to record additional variables. The COSC-WARS Preventive 

Contacts (PC) and Individual Contacts (IC) data entry formats (never used for 

routine manual entry) have been automated by CHPPM for data entry into 

handheld and laptop computers. A pre-pilot, debugging trial of the software and 

hardware began in October 2004 in two CSC units in Iraq. The CHPPM is 

incorporating lessons learned. Combat stress control units and MH sections 

mobilizing for OIF-Ill are receiving the software and training. With Command 

approval, a pilot test could be conducted in OIF-Ill. 

2. B. Medical Command should integrate 

COSC prevention efforts into existing and AMBER The automated PC and IC programs will generate the periodic SRs, and can be 

emerging theater medical databases. programmed to generate the DiseaseINonbattle Injury (DNBI) Report and other 

report formats. The Army Medical Department Center and School (AMEDDC&S) 

and potential users are evaluating the integration of COSC-WARS and the 

Medical Communications for Combat Casualty Care (MC4) system. The COSCWARS is the AMEDD Combat Developments and CHPPM test-bed for developing 

precise contract requirements for the COSC component of the totally automated 

Theater Medical Information Program of the Future Force. 

3. Medical Command should establish a joint 

process action committee to work on an No effort to change the evacuation database has been put forth as of this time. 

evacuation database system capable of 

clinical, tracking, and analytical functions. It 

must be readily available, secure, and tailored 

to the needs of line commanders, medical 

personnel, medical regulating planners, and 

medical ~lanners. 
4. A. Develop a peer-mentoring program using 

mid-grade Soldiers to facilitate the early 

identification and intervention of psychosocial 

problems at the company level. AMBER 

4. B. Improve BH support for rear-detachment 

commanders and Family Readiness Groups 

(FRGs). One possible solution would be to AMBER 

have social workers fulfill this mission. 

The WRAIR behavioral health staff has a proposal for this program and has 

presented it to the Deployment Cycle Support Program Manager and WRAIR for 

consideration and implementation. It has similarity to the British model focused 

on traumatic risk assessment and management. ~helb)(2)-21in OIF-ll is testing an 

adaptation of the British Traumatic Risk Management (TRM) Program. A peermentoring training program taught to noncommissioned officers (NCOs), has also 

been developed, and theP(2,.4~~~ Unit in Iraq is field testing it presently. No 

officially sanctioned peer-mentoring program has been approved or fielded as of 

now. Additional training for medics, battalion and company commanders, first 

sergeants (ISGs), and platoon leaders in stress management training and BH 

issues is recommended, with COSC personnel among the trainers. This will 

shore up the existing infrastructure rather than introduce a new program that line 

or medical leadership may not support. 

Some AR, ARNG, and Army AC commands are now using Army Community 

Service (ACS) family program coordinators or social workers and in some cases 

activated Behavioral Health Officers (e.g.m~egional Readiness Command 

(RRC)) to assist families during pre-deployment, deployment, and postdeployment. In addition, Army One Source has been established to assist 

Soldiers or family members by referring them to local resources to address issues 

of concern and paying for six counseling sessions to help resolve issues of 

concern. The following other resources have been established to address BH 

support for rear-detachment commanders and FRGs: 

Care Manager Program. 

Disabled Soldiers Support System (DS3). 

Extended TRICARE Benefits. 

The Army Deployment Cycle Support Program managers (DCSPER-G-1 staff) are 

presently exploring alternatives to ensure the referral and availability of needed 

services for Soldiers and family members. Medical Command will be involved in 

ensuring the successful implementation of BH support and was solicited in 

November 2004 to provide input to the DCSPER-G-I staff to design the 

programs. 
attempts within Army medical surveillance The ASERs for completed suicides for OIF have been submitted as required, and 

systems. Task CHPPM and the BH data have been compiled and distributed on these cases. The ASERs on suicide 

consultants to develop capability for monitoring AMBER behaviors resulting in hospitalization and evacuation, but not death, have not 

serious suicide attempts at the installation, been submitted consistently. Behavioral health leadership in theater must 

operational, and Army-wide levels. The pilot continue to emphasize submission to improve data collection rates. 

version of the ASER is a promising tool for 

reporting suicide attempts. 
DRAFT 


DISCUSSION 

As is evident from the report above, many of the MHAT-I recommendations have been 

implemented in the past 12 months. More BH staff is present in theater in OIF-ll. The 

overall ratio of BH personnel to Soldiers has increased from 1:846 in OIF-I to 1:407 in 

OIF-ll. The number of BH personnel in theater now is sufficient to provide coverage 

throughout the OIF area of responsibility, a very great accomplishment. 

As far as the 16 immediate recommendations from MHAT-I, there is evidence that 8, or 

50%. have been fully implemented presently and that 8. or 50%. are at a minimum 

partially completed. Overall, 100% of MHAT-I recommendations have either been 

implemented fully or at least partially as of October 2004. This is a substantial step in 

meeting the needs of Soldiers in theater, and for this, staff should be commended. 

As far as the 10 future recommendations from MHAT-I, 1 is fully implemented and 8 are 

partially implemented giving a total of 9 of 10 or 90% in place or in process. The other 

long-term recommendation should be the focus of efforts now in order to ensure the 

very best of care and outcomes for our Soldiers and their families in the future. 

Recommendations for action plans are developed in this report and will be emphasized 

to leadership. Without doubt, our Soldiers and their families will be well-served due to 

the extensive commitment and actions of BH staff and their actions on behalf of our 

force. All involved should be commended for their actions, and leadership should also 

be commended for their willingness to explore BH needs and the actions that have 

followed MHAT-I activities. 
(MHAT-Ill 

(OIF-ll) 

(OIF-ll) 

(MHAT-ll) 

(DoD), 

H-I 

ANNEX H 


MENTAL HEALTH ADVISORY TEAM 
 SUPPORTING DOCUMENTS 

Operation lraqi Freedom 

Mental Health Advisory Team (MHAT-II) 

30 January 2005 

Chartered by: 


The U.S. Army Surgeon General 


This is an annex to the Operation lraqi Freedom Mental Health Advisory 

Team Report providing supporting documentation for the MHAT 

mission. 

The views expressed in this report are those of the authors and do not necessarily 

represent the official policy or position of the Department of Defense the U.S. 

Army, or the Office of The Surgeon General. 
1: 

................................................................................ 

...................... 

ANNEX H 

TABLE OF CONTENTS 

APPENDIX MENTAL HEALTH ADVISORY TEAM (MHAT-II) 

MEMBERSHIP............................................................................. 

APPENDIX 2: MENTAL HEALTH ADVISORY TEAM (MHAT-II) 

ITINERARY 

APPENDIX 3: GLOSSARY OF TERMS USED BY THE 

MENTAL HEALTH ADVISORY TEAM (MHAT-II) 

H-3 

H-4 

H-5 
(MHAT-II) 

1 

1 ~fficer,rb)(~)~~ 

COL 'MA, (b)(fi)-2 MSS,OTR: p(6)-2 

(b)(fi)-z 1 

COL (b)(6)~2 

Psy~holoa$)(~)-~ 

COL (b)(6)~2 1 

(b)(fi)-2 1 

COL 

COL (b)(W2 

(b)(W2 

LTC p)(6)-2 1 

(b)(6)-2 

LTC b)(fi)-2 1 M.D.: 

'b)(6)~2 

APPENDIX 1 

MENTAL HEALTH ADVISORY TEAM MEMBERSHIP 

Social Work Consultant to 

the Surgeon General; MHAT Team Chief. 

M D: Combat Stress Control Program 

Occupational Therapy Consultant to the 

Surgeon General. 

M.D., 

Sciences, 

Ph. D.: Reserve Component Psychology Consultant, 

Department of 

M.D., Psychiatry Consultant to The Surgeon General, 

Psychiatric Nurse Consultant to The Surgeon General, 

Chief, Department of Psychiatry and Behavioral 

Behaviora Heat Consultant to OIF, Baghdad, Iraq 


Forensic Psychiatric Consultant to The Surgeon General, 


Chief, Operation Solace, Pentagon Stress 

Management Team, 
SPC P2 1 

(b)[6)-2 

Mental Health Specialists, Department of Psychiatry and 

Behavioral Sciences, 
CONUS 

Iraq 

briefedm~ed 

briefeaed 

APPENDIX 2 

MENTAL HEALTLH ADVISORY TEAM (MHAT-II) ITINERARY 

July 2004: MHAT-II mission defined and tasked to U.S. Army MEDCOM 


July 2004: MHAT-II team formed 


July-August 2004: Initial MHAT-II planning via audio conferences 


6-12 August 2004: MHAT-II meets at the U.S. Army Force Health Protection 


Conference, Albuquerque, New Mexico. 


22-27 August 2004: MHAT-II is at the 
 Replacement Center (CRC), Ft. Bliss, 


Texas. 


28 August-3 September, 22-26 September 2004: MHAT-II activities in Kuwait 


3 September-9 October 2004: MHAT-II Activities in 


MHAT-II exit 
 Bde, MNC-I, and MNF-I leadership on 6, 7, and 9 October 

2004. 

9-18 October 2004: MHAT-II Activities in Kuwait. MHAT exit Bde and 


CFLCC leadership on 13 October 2004. 


19-21 October 2004: MHAT-II at CRC, Ft. Bliss, Texas 


22 October-5 December 2004: MHAT-II analyzes data and writes draft report. 


6-17 December 2004: MHAT-II meets at WRAIR, Washington, D.C. to finalize drafts of 


report. 


30 January 2005: MHAT-II report submitted to OTSG, CENTCOM, MNC-I, and MNF-I 

for final review. 
(MHAT-Ill 

DoD 

miIldoctrineljel1doddictl 

person(s) andlor andlor 

(DoD) andlor 

(DoD) and/or 

(DoD) 

(DoD) 

APPENDIX 3 


GLOSSARYOFTERMS 

USED BY THE MENTAL HEALTH ADVISORY TEAM 

Dictionary of Military Terms 

As amended through 5 June 2003 

http:llwww.dtic. 

accident 

An unplanned event that results in injury (including death) or occupational illness to 

damage to property, exclusive of injury damage caused by 

action of an enemy or hostile force. (AR 310-5) 

brigade 

A unit usually smaller than a division to which are attached groups 

battalions and smaller units tailored to meet anticipated requirements. Also called BDE 

and bde. 

combat and operational stress 

The expected and predictable emotional, intellectual, physical, behavioral 

reactions of Service members who have been exposed to stressful events in war or 

military operations other than war. Combat stress reactions vary in quality and severity 

as a function of operational conditions, such as intensity, duration, rules of engagement, 

leadership, effective communication, unit morale, unit cohesion, and perceived 

importance of the mission. 

combat service support 

The essential capabilities, functions, activities, and tasks necessary to sustain all 

elements of operating forces in theater at all levels of war. Within the national and 

theater logistic systems, it includes but is not limited to that support rendered by service 

forces in ensuring the aspects of supply, maintenance, transportation, health services, 

and other services required by aviation and ground combat troops to permit those units 

to accomplish their missions in combat. Combat service support encompasses those 

activities at all levels of war that produce sustainment to all operating forces on the 

battlefield. Also called CSS. See also combat support. 

combat support 

Fire support and operational assistance provided to combat elements. Also 

called CS. See also combat service support. 
(DoD) 

(DoD) CONPLAN. 

(DoD, 

regimentlbrigade 

(DoD 

(DoD) andlor 

(DoD) 

communications zone 

Rear part of a theater of war or theater of operations (behind but contiguous to 

the combat zone) which contains the lines of communications, establishments for 

supply and evacuation, and other agencies required for the immediate support and 

maintenance of the field forces. Also called COMMZ. See also combat zone; line of 

communications; rear area; theater of operations; theater of war. 

concept plan 

An operation plan in concept format. Also called See also operation 

plan. 

division 

NATO) 1. A tactical unitlformation as follows: a. A major administrative and 

tactical unitlformation which combines in itself the necessary arms and services 

required for sustained combat, larger than a and smaller than a corps. 

b. A number of naval vessels of similar type grouped together for operational and 

administrative command, or a tactical unit of a naval aircraft squadron, consisting of two 

or more sections. c. An air division is an air combat organization normally consisting of 

two or more wings with appropriate service units. The combat wings of an air division 

will normally contain similar type units. 2. An organizational part of a headquarters that 

handles military matters of a particular nature, such as personnel, intelligence, plans, 

and training, or supply and evacuation. 3. only) A number of personnel of a ship's 

complement grouped together for tactical and administrative control. 

evacuation 

1. The process of moving any person who is wounded, injured, or ill to 

between medical treatment facilities. 2. The clearance of personnel, animals, or 

materiel from a given locality. 3. The controlled process of collecting, classifying, and 

shipping unserviceable or abandoned materiel, U.S. or foreign, to appropriate 

reclamation, maintenance, technical intelligence, or disposal facilities. 4. The ordered 

or authorized departure of noncombatants from a specific area by Department of State, 

Department of Defense, or appropriate military commander. This refers to the 

movement from one area to another in the same or different countries. The evacuation 

is caused by unusual or emergency circumstances and applies equally to command or 

non-command sponsored family members. See also evacuee; noncombatant 

evacuation operations. 

evacuation policy 

1. Command decision establishing the maximum number of days that patients 

may be held within the command for treatment. Patients who, in the opinion of 

responsible medical officers, cannot be returned to a duty status within the period 

prescribed are evacuated by the first available means, provided the travel involved will 

not aggravate their disabilities. 2. A command decision concerning the movement of 
(DoD) andlor 

~eritage~ 

(DoD) 

CONPLAN 

OPLANs 

CONPLAN 

CONPLAN CONPLAN 

CONPLAN 

CONPLAN. 

civilians from the proximity of military operations for security and safety reasons and 

involving the need to arrange for movement, reception, care, and control of such 

individuals. 3. Command policy concerning the evacuation of unserviceable or 

abandoned materiel and including designation of channels and destinations for 

evacuated materiel, the establishment of controls and procedures, and the 

dissemination of condition standards and disposition instructions. See also evacuation; 

patient. 

medical treatment facility 

A facility established for the purpose of furnishing medical dental care to 

eligible individuals. 

morale 

discipline, and willingness to perform assigned tasks. (The American 

Dictionary of the English Language: Fourth Edition. 2000.) 

The state of the spirits of a person or group as exhibited by confidence, cheerfulness. 

operation plan 

Any plan, except for the Single Integrated Operational Plan: for the conduct of 

military operations. Plans are prepared by combatant commanders in response to 

requirements established by the Chairman of the Joint Chiefs of Staff and by 

commanders of subordinate commands in response to requirements tasked by the 

establishing unified commander. Operation plans are prepared in either a complete 

format (OPLAN) or as a concept plan (CONPLAN). The can be published 

with or without a time-phased force and deployment data (TPFDD) file. a. OPLAN-An 

operation plan for the conduct of joint operations that can be used as a basis for 

development of an operation order (OPORD). An OPLAN identifies the forces and 

supplies required to execute the combatant commander's strategic concept and a 

movement schedule of these resources to the theater of operations. The forces and 

supplies are identified in TPFDD files. will include all phases of the tasked 

operation. The plan is prepared with the appropriate annexes, appendixes, and TPFDD 

files as described in the Joint Operation Planning and Execution System manuals 

containing planning policies, procedures, and formats. Also called OPLAN. 

b. CONPLAN-An operation plan in an abbreviated format that would require 

considerable expansion or alteration to convert it into an OPLAN or OPORD. A 

contains the combatant commander's strategic concept and those annexes 

and appendixes deemed necessary by the combatant commander to complete 

planning. Generally, detailed support requirements are not calculated and TPFDD files 

are not prepared. c. with TPFDD-A with TPFDD is the same 

as a except that it requires more detailed planning for phased deployment of 

forces. Also called See also operation order; time-phased force and 

deployment data. 
(DoD) 

suicide> 

http://www.dtic.milldoctrine/jelldoddict/acronym~index.html 

ASlST 

CONPLAN 

CONPLAN 

squadron 

1. An organization consisting of two or more divisions of ships, or two or more 

divisions (Navy) or flights of aircraft. It is normally but not necessarily composed of 

ships or aircraft of the same type. 2. The basic administrative aviation unit of the Army, 

Navy, Marine Corps, and Air Force. 3. Battalion-sized ground or aviation units in U.S. 

Army cavalry regiments. 

suicide 

1 a: the act or an instance of taking one's own life voluntarily and intentionally 

especially by a person of years of discretion and of sound mind b: ruin of one's own 

interests <political 

2: one that commits or attempts suicide. (Merriam-Webster's Online Dictionary) 

Joint Acronyms and Abbreviations 

AFME Armed Forces medical examiner 

Applied Suicide Intervention Skills Training 

ASMC Area Support Medical Company 

BAMC Brooke Army Medical Center 

Concept Of Operation Plan 

Contingency Plan 

CSH combat support hospital 

DMHS Division Mental Health Section 

EAMC Eisenhower Army Medical Center 

FSMC Forward Support Medical Company 

LRMC Landstuhl Regional Medical Center 

LRMC Landstuhl Regional Medical Center (U.S. Army) 

MODS Major Operations Data System 

MODS Medical Occupational Data System 
NIPRNET 

SIPRNET 

ADHA 

MTF medical treatment facility 

Non-Secure Internet Protocol Router Network 

OTSG Office of The Surgeon General 

PARRTS Patient Accounting and Reporting Real-Time Tracking System 

Secure Internet Protocol Router Network 

TRACZES TRANSCOM Regulating And Command and Control Evacuation System 

Additional Acronyms and Abbreviations 

AC Active Component 

ACA American Correctional Association 

attention deficit hyperactivity disorder 

AFB Air Force Base 

AMEDD Army Medical Department 

AOC area of concentration 

AOR area of responsibility 

APA American Psychiatry Association 

AR Army regulation 

ASD acute stress disorder 

ASER Army Suicide Event Report 

ASPP Army Suicide Prevention Program 

ASR acute stress reaction 

BATS Biometric Automatic Toolset System 

BH behavioral health 

CFLCC Coalition Forces Land Component Command 
CI 

CONUS 

CSCICOSC 

DAlG 

DNBl 

Ill Ill) 

gynocology 

civilian internee 

continental United States 

CP collection point 

combat stress controllcombat and operational stress control 

CY calendar year 

DA Department of the Army 

Department of the Army Inspector General 

DCA Deputy Commander for Administration 

DCCS Deputy Commander for Clinical Services 

DCN Deputy Commander for Nursing 

DCS deployment cycle support 

DNA deoxyribonucleic acid 

disease and non-battle injury 

DO disorder 

DWMMC Deployed Warrior Medical Management Center 

EPW enemy prisoner of war 

ERMC European Regional Medical Command 

FOB forward operating base 

GC Geneva Convention 

GPW Geneva Convention Relative to the Treatment of Prisons of War (Also known as 

Geneva Convention (GC 

GTMO Guantanamo Bay U.S. Naval Base, Cuba 

GYN 

HIV human immunodeficiency virus 
ICRC 

IIR 

NCOlNCOlC 

HQDA Headquarters, Department of the Army 

International Committee of the Red Cross 

ICU intensive care unit 

internmentlretention 

ISN internment serial number 

MEDCOM U.S. Army Medical Command 

METL mission essential task list 

MH mental health 

MHAT-FT Mental Health Advisory Team-Forensic Team 

MNC-I Multi-National Corps-Iraq 

MNF-I Multi-National Force-Iraq 

MP military police 

MRE meals, ready-to-eat 

noncommissioned officerlnoncommissioned officer in charge 

NDRS National Detainee Reporting System 

NIC National Institute of Corrections 

NOS not otherwise specified 

OCD obsessive-compulsive disorder 

OEF Operation Enduring Freedom 

OT occupational therapist 

PA physician assistant 

PAT process action team 

PCP primary care provider 
PIES 

PROFIS 

PWlC 

SElU 

SITREP 

WRAlR 

91X 

PIA patient information application 

proximity, immediacy, expectancy, and simplicity 

PIR priority intelligence requirements 

PMR patient movement record 

professional filler system 

PTSD posttraumatic stress disorder 

Prisoner of War Information Center 

RC Reserve Component 

RP retained personnel 

Service Employees International Union 

SF 881600 Special Form 881600 

situation report 

SOP standing operating procedures 

TSG The Surgeon General 

UCMJ Uniform Code of Military Justice 

UMT Unit Ministry Team 

UN United Nations 

USAF United States Air Force 

USAMRU-E U.S. Army Research Unit-Europe 

Walter Reed Army Institute of Research 

enlisted MOS code for Mental Health Specialists