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Provision of Behavioral Health Services During Operation Iraqi Freedom One

Appendix 1

PROVISION OF BEHAVIORAL HEALTH 

SERVICES DURING OPERATION IRAQI 

FREEDOM ONE

ROBERT D. FORSTEN, DO*; BRETT J. SCHNEIDER, MD†; SHARETTE KIRSTEN GRAY, MD‡; COLIN 

DANIELS, MD§; and GARY J. DROUILLARD, MD¥

INTRODUCTION

ECHELONS OF TREATMENT IN THE COMBAT THEATER

ARRIVING IN KUWAIT

COMBAT SUPPORT HOSPITALS

COMBAT STRESS CONTROL UNITS

DIVISION MENTAL HEALTH SECTIONS

SUMMARY

*Lieutenant Colonel (P), Medical Corps, US Army; Command Psychiatrist, US Army Special Operations Command (AOMD), 2929 Desert Storm 

Drive (Stop A), Fort Bragg, North Carolina 28310-9110; formerly, Staff Psychiatrist, Department of Psychiatry, Walter Reed Army Medical Center, 

Washington, DC

†

Lieutenant Colonel, Medical Corps, US Army; Deputy Chief, Department of Psychiatry, Building 61, Child and Adolescent Psychiatry Clinic, Walter 

Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307

‡

Lieutenant Colonel, Medical Corps, US Army; Chief, Hospital and Administrative Psychiatry Services, Department of Behavioral Health, Building 

36000, Darnall Loop, Carl R. Darnall Army Medical Center, Fort Hood, Texas 76544; formerly, Division Psychiatrist, 4th Infantry Division, Fort 

Hood, Texas 

§

Lieutenant Colonel, Medical Corps, US Army; Psychiatrist, Department of Psychiatry, Madigan Army Medical Center, 9040 Fitzsimmons Drive, 7BLM, 

Tacoma, Washington 98431; formerly, Chief, Behavioral Health Services, 28th Combat Support Hospital, Operation Iraqi Freedom 2003

¥

Lieutenant Colonel, Medical Corps, US Army; Chief, Chemical Addiction Treatment Service, Department of Psychiatry, 1 Jarrett White Road, Tripler 

Army Medical Center, Honolulu, Hawaii 96859; formerly, Chief, Consultation Liaison Psychiatry, Tripler Army Medical Center, Honolulu, Hawaii
752

Combat and Operational Behavioral Health

INTRODUCTION

In 2003, the US Army deployed four different 

medical units with behavioral health assets during 

Operation Iraqi Freedom One (OIF I). Each of these 

units provided varying levels or echelons of healthcare 

throughout the war zone. A review of care echelons 

and each behavioral health unit is discussed later in 

this appendix. The primary mission of these behavioral 

health units was to provide evaluation and treatment 

for all behavioral health disorders and operational 

stress issues, in addition to administrative psychiatric 

support services. The structure of each unit and how 

it delivered its services varied markedly, depending 

on numerous factors, including the unit supported, 

location, command, logistic support, and assigned 

personnel. Behavioral health assets were located 

throughout Iraq at the combat stress control (CSC) 

detachment or company, division mental health section (DMHS), combat support hospital (CSH), and area 

support medical battalion/company. Of these different 

types of behavioral health assets, two are medical units 

(CSH and area support medical battalion), and two 

are assigned directly to the combat units (DMHS and 

CSC). The area support medical battalion/company’s 

behavioral health capability was phased out in 2007 

and will not be discussed in this appendix; also, the 

forward support medical company (FSMC), as part of 

the forward support medical battalion (FSMB), may 

have had behavioral health assets assigned to it but 

this organizational structure will be phased out. Only 

the CSC company and detachment, DMHS, and CSH 

will be discussed. 

Although many other resources on medical topics 

and military operations exist, this appendix focuses 

on helping behavioral health providers understand 

the challenges identified during the conventional 

ground phase of OIF I (2003), amid highly uncertain 

conditions characteristic of the early stages of combat 

operations, as well as potential differences between 

behavioral health operations during future deployments or campaigns.

During peacetime, US Army physicians, nurses, 

medical administrators, and enlisted medical personnel primarily work in post hospitals and clinics. The 

aforementioned behavioral health units have key personnel assigned to them at all times to operate the unit 

in garrison. During war or contingency operations, 

these personnel may receive activation orders to augment medical units through the Army’s Professional 

Officer Filler Information System (PROFIS). PROFIS 

assigns personnel working in hospitals and clinics to 

deploying Forces Command (FORSCOM) units. 

The Army attempts to assign behavioral health 

officers (psychiatrists, psychologists, social workers, psychiatric nurses, occupational therapists, 

and behavioral health specialists [formerly military 

occupational specialty 91X, now 68X]) who are geographically located close to their PROFIS unit (in many 

cases the personnel are located on the same base as 

the unit), so these personnel can train or coordinate 

with the unit in garrison. However, some personnel 

assigned to units as PROFIS providers have duty 

stations hundreds (and in some cases thousands) of 

miles away from their FORSCOM unit’s home station 

or garrison. In addition, Reserve component medical 

and behavioral health units also participated in OIF I, 

with some active duty PROFIS personnel augmentees 

filling Reserve vacancies. 

Most PROFIS personnel who met the deployment 

challenge—coming together to comprise the treatment 

aspect of the medical and behavioral health units—

had never met prior to deployment, in contrast to 

FORSCOM units (combat arms, combat support, and 

combat service support branches) that train for wartime missions continuously in garrison, and US Army 

medical branches that perform “real life” missions on 

a daily basis. However, moving into a battlefield setting to treat medical and behavioral health casualties 

presents different challenges, such as the logistics of 

patient care in the austere or hazardous environment, 

compared to the more complex and heavier case loads 

typically managed in garrison medical organizations. 

Despite the challenges, most professional personnel 

adapted to their new environment and completed the 

medical mission admirably. 

ECHELONS OF TREATMENT IN THE COMBAT THEATER

Every behavioral health unit in a theater of combat operations provides different treatment options, 

increasing with the treatment echelon (level) of care. 

There are five echelons of care, with echelon 5 possessing the most comprehensive or definitive options 

(similar to a medical center in the continental United 

States [CONUS]) and echelon 1 composed of self-aid, 

aid from other unit members (buddy aid), and care 

from combat medics. As the echelon increases, so does 

the evaluation capability and medical care provided. 

In terms of behavioral health assets, each unit at the 

battalion level—echelon 1—was assigned an enlisted 

behavioral health specialist whose activities were 

coordinated by the DMHS. 
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Provision of Behavioral Health Services During Operation Iraqi Freedom One

Each behavioral health specialist is an enlisted soldier or noncommissioned officer (NCO) with varying 

degrees of experience in the diagnosis, treatment, and 

management of behavioral disorders. Starting at the 

brigade level—echelon 2—a CSC detachment (also 

assigned at corps or echelons-above-brigade [EAB] 

level) focuses on interventions to prevent combat 

operational stress response casualties through critical incident debriefings, stress management classes, 

“walk-about” marketing contacts, and some restoration/fitness programs resembling brief day-treatment 

programs, as well as providing conventional clinicbased behavioral health evaluation and treatment. 

Each brigade also has an organically assigned 

behavioral health officer—usually a psychologist 

or social worker—who may conduct evaluations of 

brigade soldiers or facilitate command liaisons with 

area CSC/CSH elements. Echelon 3 consists of CSC 

companies providing fitness or restoration units, the 

CSH (which is typically assigned at corps-level EAB), 

and the DMHS, if the theater organization utilizes 

conventional division structure instead of modular 

independent brigades. On a linear battlefield, echelons 

of care also show predictable positions relative to the 

forward line of troops, but a nonlinear battlefield obscures this relationship, with many behavioral health 

resources (units or detached slices/elements) located 

across large areas, such as a forward operating bases 

(FOBs) or logistic support areas (LSAs). However, 

some behavioral health resources may support small 

camps or outposts with small elements positioned 

locally or rotating out from FOBs, depending on local 

needs, resources, distances, transportation/logistics, 

and expected travel-related hazards. 

Prior to wartime deployment, all units (augmented 

with their PROFIS personnel) complete tasks such 

as medical screening; legal documents (wills, powers of attorney); weapons qualification; training in 

unexploded ordinance; CBRNE (chemical, biological, 

radiological, nuclear, and explosive) hazards; and 

all other training required by unit readiness training 

matrices. PROFIS personnel join the unit for this specified “train-up” period to ensure they are familiar with 

the standard operating procedures, mission essential 

task list, and internal workings of the host unit. Many 

PROFIS personnel may lack prior experience with the 

specific unit or its chain of command and may never 

have met face-to-face with any of the unit’s members. 

The exception is DMHS, which operates in garrison 

with most of the personnel required during deployment, but may be augmented with PROFIS personnel 

depending on wartime mission requirements. 

Garrison division mental health personnel will 

need to train all the personnel within the behavioral 

health section with whom they will be deploying. At 

a minimum, this training should consist of setting up 

standard operating procedures related to evaluation, 

diagnosis, treatment, clinic management, and prevention techniques. The training also gives the unit leaders 

an assessment of each team member’s technical proficiency and experience, and the extent to which that 

provider is able to function independently. Supervision 

may be required depending on training, licensure, and 

credentialing levels.

ARRIVING IN KUWAIT

Prior to entering Iraq, most units from OIF I 

landed in Kuwait at the SPOD/APOD (sea [for equipment]/aerial [for personnel] point of embarkation/

debarkation). Many units had expected to arrive at 

another SPOD/APOD in Turkey and approach from 

the north but received last-minute redirection to the 

overcrowded Kuwait staging area due to diplomatic 

issues. From the APOD, most units moved to a “cabal,” 

or tactical assembly area, where they reassembled 

their operating capability and prepositioned while 

awaiting movement north into Iraq. These cabals were 

small base camps with minimal infrastructure located 

in the remote Kuwaiti desert. The majority of OIF I 

soldiers then convoyed into Iraq from Kuwait, loaded 

into high mobility multipurpose wheeled vehicles 

(HMMWVs or Humvees), family of medium tactical 

vehicles (FMTVs) or the older M939 series 2.5 (“deuceand-a-half”) vehicles, and 5-ton trucks. These convoys 

often took up to 3 days to complete because anytime a 

vehicle broke down, the entire convoy waited until the 

vehicle was remobilized or recovered. Furthermore, 

early-phase convoys also contended with nearby combat or threatened engagement by Iraqi Army forces. 

Additionally, the early unit convoys faced challenges 

related to unlabeled and undeveloped routes through 

an unmapped country with minimal signage and 

many roads that were inadequate for large and heavy 

military vehicles. While some units possessed globalpositioning-satellite capability, many navigated with 

uncertain means in a landscape with few reliable visual 

landmarks during a season where large dust storms 

could completely obstruct visibility and stifle breathing 

for extended periods (soldiers deploying to OIF now 

fly directly into Iraq via the nearest air strip to where 

they will assume mission responsibility). 

Units typically resided in tents, although some 

moved into dirty, decrepit, abandoned masonry structures. Tent space became very limited in both Kuwait 
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Combat and Operational Behavioral Health

and Iraq during OIF I; many personnel were fortunate 

to have 2 linear feet of space on either side of the cot on 

which they slept and stored all their gear. Many lessfortunate soldiers, especially in combat arms units, did 

not have either a cot or a tent and slept on the ground 

or on their vehicles, in extremely variable stifling heat 

or bitter cold. Overcrowded tents, stress, and close living proximity accelerated viral spread and increased 

the frequency of infectious illnesses. Anecdotally, the 

average weight loss per soldier during the first month 

was 5 to 10 lb; many infantry soldiers lost 20 to 40 lb 

during the conventional ground combat phase due to 

limited food consumption, along with irregular and 

continuous combat operations. However, most soldiers 

within these units adjusted physically and behaviorally, bonding into a cohesive team and unit. During this 

period, officers had to avoid complaining, especially 

around the enlisted soldiers, who tended to lose respect 

for officers they heard complaining. However, among 

some officers, complaining, mostly through humor, 

was a helpful way to vent frustration, improving 

overall officer morale, mood, and bonding. 

The largest stressor in Kuwait was not the Scud 

missile alerts and subsequent donning of the missionoriented protective posture (MOPP) 4 suits (thick, 

carbon-based chemical weapons protection suits), or 

joint-service lightweight integrated suit technology 

(JSLIST) equipment, but boredom coupled with overcrowding and the austere environment, which tended 

to fuel gossip behaviors and interpersonal conflicts. 

Additionally, soldiers experienced emotional stress 

from a perceived conspicuous absence of information 

on each unit’s specific mission, leading to speculation 

on justifications for deployment, chain-of-command 

motives, and when each unit would actually move 

forward to begin operations in Iraq. In most cases, unit 

equipment arrived in port (SPOD) after unit personnel 

had been flown into the APOD, causing personnel to 

wait in the cabals for their equipment while residing 

in overcrowded tents with minimal infrastructure or 

recreational opportunities. 

Units with responsive and competent commanders 

who fostered group cohesiveness and subordinate 

communication, keeping their soldiers busy with mission-focused operational training, appeared to have 

less disruptive drama and stress-related behavioral 

health issues or conduct problems. These leaders effectively implemented the primary preventive actions 

to control and reduce the stressors known to increase 

combat and operational stress reactions, validating 

the basic precepts of combat psychiatry, as per Field 

Manual (FM) 4-02.51 (formerly FM 8-51), Combat and 

Operational Stress Control.

Most soldiers seen by medical personnel on the cabals 

were not “emergent,” but rather had interpersonal problems with supervisors, were homesick or had home-front 

problems, or did not adjust well to the high operation 

tempo the deployment could demand. The first two 

stressors (unit/command problems and home-front 

worries) emerged as the top two most common stressors of deployed service members, as shown in the first 

and subsequent Mental Health Advisory Team (MHAT) 

reports. Each cabal had a small clinic set up for seeing 

medical emergencies and sick call, but these battalion 

aid station equivalents did not have behavioral health 

assets unless augmented individually by providers in 

units temporarily assembling at a particular base. 

Privacy became an issue while evaluating patients 

on the cabals because no structures approximating 

“clinical space” had been set up, nor was there a 

mechanism for medical recordkeeping. Despite this, 

commanders knew where the medical units were located on the cabals and sent their personnel to “walk 

in” for evaluations. Soldiers were often evaluated by 

medical personnel who sat down with them on the 

sand, in the shade of a vehicle or tent. Documentation 

remained an unresolved issue without any means of 

copying files, and no soldier had a medical record 

to review or document care. Most of the medical 

notes completed during OIF I were handwritten on 

SF600 forms, and soldiers typically lost these notes. 

Records kept at facilities would not follow soldiers 

through their care at different locations. The Armed 

Forces Health Longitudinal Technology Application 

(AHLTA) or the Composite Healthcare System (CHCS)

electronic medical records did not become operational 

until later rotations (approximately 2006–2007). The 

role of the behavioral health professional on the cabal 

during OIF I was primarily evaluation to determine 

which soldiers were safe and could move north to 

Iraq and which soldiers needed to be evacuated from 

theater for further evaluation, treatment, or administrative separation. Some soldiers had unexpected 

panic responses to the MOPP-4 protective mask. This 

required either prompt successful desensitization 

(sometimes with benzodiazepine-induced relaxation) 

to learn to tolerate the mask or evacuation from theater. Behavioral health emergency patients had to join 

a convoy to the hospital in Kuwait, which was staffed 

by one psychiatrist.

COMBAT SUPPORT HOSPITALS

Two combat support hospitals—the 21st and 28th 

CSHs—were at cabals in Kuwait by March 2003, preparing to deploy their hospitals north to Iraq after 

initiation of the ground invasion. Because the 21st CSH 
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Provision of Behavioral Health Services During Operation Iraqi Freedom One

was an early Medical Reengineering Initiative (MRI) 

CSH, it did not have a neuropsychiatric group as the 

28th CSH had. The primary mission of the new MRI 

CSH was to perform split operations in two locations, 

separating into two smaller hospitals, both capable of 

operating independently but with the same chain of 

command. Campaign evolution soon demonstrated 

the need for smaller hospital organizations that maintained similar capability levels but provided more 

geographically dispersed support, prompting the 28th 

CSH to perform a split operation as well, as did all 

subsequent CSH units. The lack of a neuropsychiatric 

group meant that the behavioral health section of the 

21st CSH brought no equipment such as bedding, tentage, or cots, and only a limited number of behavioral 

health personnel: a psychiatrist, a psychiatric nurse, 

and two behavioral health specialists. In contrast, the 

28th CSH had a psychiatrist, a social work officer, three 

psychiatric nurses, and approximately six enlisted 

behavioral health specialists. The 28th CSH did not 

operate a separate neuropsychiatric ward and planned 

to use only one or two beds from the medical–surgical 

ward to house psychiatric patients. They also did not 

plan to operate an outpatient clinic or behavioral health 

holding capability (resembling a fitness program at a 

CSC). 

Once operations commenced, the number of psychiatrically hospitalized patients exceeded the number 

of medical patients on the ward. Additionally, units 

often packed a ground evacuation vehicle with soldiers requiring behavioral health evaluations. These 

convoys would go directly to the CSH, bypassing 

other echelons and flooding the CSH with outpatient 

evaluations. Some units also sought to “medicalize” 

the behavioral problems within their unit and send 

misconduct cases to the CSH for presumed evacuation instead of administering disciplinary action and 

initiating administrative returns. These numerous outpatient evaluations resulted in many soldiers who did 

not require hospitalization or evacuation but needed 

several days of observation before returning to duty. 

Furthermore, delays in transportation also increased 

needs for a holding requirement and some supervision 

by behavioral health staff.

Once the 21st CSH split, a professional provider and 

a behavioral health specialist went with each hospital 

slice. As an MRI CSH, the 21st was composed of three 

companies: A Company (CO), B CO, and Headquarters 

CO. As stated above, the primary mission of the new 

MRI CSH was to perform split operations so that one 

slice could set up and operate independently of the 

other. B CO left approximately 5 days before A CO in 

mid-April and was located in Mosul, Iraq, approximately 160 miles north of A CO, which was located on 

a large airfield in Balad, Iraq, about 40 miles north of 

Baghdad. The 28th CSH set up its main unit initially 

in Camp Dogwood, a patch of desert near Baghdad, 

and subsequently packed up the tent hospital to move 

into a fixed facility (Ibn Sina) in Baghdad, maintaining 

a smaller slice in Tikrit.

One of the earliest goals of the CSH was to set up 

the emergency room (ER) and operating rooms (ORs) 

within 48 hours or less to be ready to accept patients. 

Once this “main line” is set up, the remainder of the 

CSH is then built adjoining it. There is no set procedure 

on how or where to put clinics, wards, and so forth, 

so the hospital is usually arranged by the experience 

within the command. For example, the 21st CSH in 

Balad had a section of tents between the ER and the 

OR that acted as an “exchange,” so patients could 

overflow if needed into this area. The exchange made 

coordination of patients easier for mass casualty 

events, air evacuation, and movement to and from 

the ER, OR, and radiology. The 21st CSH set up an 

outpatient clinic in addition to inpatient services. In 

this case, the psychiatrist worked in both settings seeing routine outpatients as well as inpatients usually 

admitted through the emergency room. The outpatient 

service was located in the “specialty clinic” area of the 

hospital in an “office” consisting of half of one of the 

sections in the eight-section tent, with a field desk and 

two chairs. The 28th CSH had a similar arrangement, 

except that the behavioral health “clinic” was located at 

the other end of the hospital tent complex, away from 

any other clinics and next to the chaplain’s “office.” 

The clinic space also consisted of a small tent section, 

with patient interviews often conducted in hallways 

during busy periods.

As soon as the 21st CSH arrived at Balad, behavioral health consultations began. Because the 21st was 

the first medical treatment facility on the base, the 

psychiatrist and behavioral health specialist quickly 

started seeing patients. Initially, behavioral health 

patients were seen on an outpatient basis because the 

hospital ran sick call for the base from the specialty 

clinic. Three fourths of the behavioral health referrals at sick call were sent by the chain of command to 

rule out danger to self or others. These were soldiers 

who had threatened to hurt themselves or others. The 

other 25% needed medication refills because they did 

not deploy with enough medication or were close to 

running out after being in Kuwait for several months 

before moving forward into Iraq. The 28th CSH saw 

a similar preponderance of danger evaluations and 

medication refills. Units also sent numerous evaluations for chapter separation, conscientious objection, 

or other administrative issues. Army Reserve and 

Army National Guard units seemed to have a disproportionate number of chapter evaluations, as the 

active duty deployment gave these Reserve units an 
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unanticipated opportunity to evaluate actual duty 

performance and separate those incapable of meeting 

mission requirements. However, the main active duty 

unit supported by the 28th CSH, the 3rd Infantry Division (ID), appeared to supply most of the malingering 

and misconduct cases seen at this CSH.

The 21st CSH pharmacy section deployed with a 

small supply of paroxetine and fluoxetine, but these 

drugs were quickly depleted within the first week after 

the hospital was set up. However, the CSH was collocated next to a medical logistics battalion that was able 

to coordinate future medication supplies. After 6 to 8 

weeks, the pharmacy stocked up on oral medications, 

including several selective serotonin reuptake inhibitors, second-generation antidepressants, stimulants, 

atypical antipsychotics, benzodiazapines, and sleep 

medications. The 28th CSH pharmacy also deployed 

with a minimal supply of medications, forcing providers to dispense medications in 1-week increments to 

delay or minimize stock-outs, which still occurred. In 

contrast to the 21st CSH, the 28th CSH did not have 

logistics support and sustained operations with the 

limited drug supplies the psychiatrists personally 

carried into theater. In addition, behavioral health 

specialists from the 28th CSH who went to Landstuhl Regional Medical Center (LRMC) in Germany 

on medevac escort missions requested and obtained 

medication resupply from the psychiatrists there to 

bring back into theater. For future reference, any psychiatrist deploying to an immature theater should have 

a lockbox (or several) of medications and coordinate 

as soon as possible with the medical logistics battalion 

and pharmacist for resupply. 

The dynamics of a deployed CSH were such that it 

took a physician with a great deal of military experience as well as an approachable, healthy personality to 

function as the deputy commander for clinical services 

(DCCS). The DCCS is particularly helpful in organizing the physicians into a tight-knit team. The DCCS 

acts as a buffer between providers and along the chain 

of command, engaging in the medical administrative 

battles to allow other physicians to focus on their 

medical mission, and to ensure that their junior rank 

did not result in others ignoring or overruling their 

expert recommendations based on rank alone. The 

DCCS also mentors junior medical officers by arranging training—military and nonmilitary—as well as 

normalizing the deployment experience.

Many referrals to the CSHs were soldiers requiring 

dispositions from outlying behavioral health units. 

Early in OIF I, if a soldier was evacuated to a hospital 

remote from the referring unit, that soldier usually 

ended up being evacuated out of theater to Kuwait and 

then to Germany. Discussing cases with commanders 

and behavioral health teams during the early phases 

of OIF I was often difficult due to limitations in communication lines, which were down at least half the 

time. It was also not uncommon for all convoys to be 

halted for several days at a time secondary to increased 

fighting. This frequent lack of any communication 

abilities with commands, via either telephone line 

or in person, discouraged providers, overburdened 

holding capabilities, and led to medical evacuation of 

soldiers who might otherwise have returned to duty. 

The division psychiatrist had multiple examples of 

soldiers being dropped off at the DMHS clinic for an 

evaluation, and the unit then convoyed for hours back 

to their assigned FOB prior to contacting the DMHS. 

Although most of these soldiers received fit-for-duty 

dispositions, they remained at the DMHS for several 

weeks because no one could contact their command, 

and it could take 2 weeks or so for the referring unit to 

convoy back and pick up the soldier. At the 21st CSH, 

providers usually admitted soldiers for observation 

and safety to the medical–surgical intermediate care 

ward (and later, the five-bed neuropsychiatric unit 

of the 28th CSH). However, a theater policy to admit 

patients to a CSH for no more than 7 days resulted in 

evacuations to a higher level of care where return to 

duty (RTD) became even more difficult and improbable. Most unit commanders supported providers 

who recommended patient evacuation, but on some 

occasions they objected to evacuation and wanted 

their soldiers returned to them. A chain-of-command 

representative (the commander, first sergeant, or senior 

NCO) then came to the CSH or CSC to pick up the 

soldier in person.

The 21st CSH did not have neuropsychiatry assets 

to establish an inpatient milieu; behavioral health patients admitted to this CSH did not have the benefit of 

a psychiatric ward setting with groups, confidentiality, 

or a multidisciplinary approach to treatment. However, the milieu remained very limited and public at 

the 28th CSH as well. Patients had a few groups run 

by psychiatric nurses but shared the ward with medical and surgical patients. Nursing care was generally 

delivered to these patients by a psychiatric nurse; 

however, medical and surgical nurses also contributed 

to nursing care of psychiatric patients due to staffing 

necessities. While some staff sought to increase privacy 

by hanging blankets as dividers around a psychiatric 

patient’s bed, this effectively identified them as a psychiatric patients and increased interest in them when 

they stepped out from behind the hanging blanket. 

Open space anonymity provided better confidentiality 

because other patients would not know why another 

patient had been hospitalized. 

Very few psychiatric cases evacuated from Iraq 
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Provision of Behavioral Health Services During Operation Iraqi Freedom One

returned to Iraq. Once soldiers were evacuated to the 

47th CSH in Kuwait, the psychiatrist assigned to the 

47th noted that:

most soldiers sent to Kuwait markedly improve as 

they “move Westward” and most of what is sent here 

for air evacuation to Germany (Landstuhl Regional 

Medical Center) is not battle fatigue and not severe 

behavioral illness but rather a failure to adapt to the 

deployment due to occupational stress and problems 

back home. Because of this, more soldiers were sent 

back to their commands with recommendations for 

administrative separation. However, many were 

transported out of the theater on a medical evacuation because they were “conditionally suicidal” but 

we still recommend for a chapter separation. 

Some behavioral health providers were unwilling 

to make the recommendation for a chapter separation. 

One of the psychologists in a reserve CSC unit stated, 

“I’m just not comfortable making a decision like that 

that will have such an impact on someone’s life,” 

meaning that this provider thought a separation would 

affect a soldier’s career in civilian life. However, these 

administrative duties remain an integral part of the 

job for military behavioral health providers, either in 

garrison or on deployment. During OIF I, the chief of 

psychiatry at LRMC stated that, “it helps Landstuhl 

tremendously to have recommendations like these 

because these soldiers look fine when they get there 

and we don’t get to see them when they are in Iraq, 

when they have mentally decompensated.” Such was 

the case in the CSHs in Iraq when soldiers were sent 

for evaluation from smaller behavioral health units 

(DMHS, CSC, chaplain, behavioral health technicians) 

or battalion surgeons embedded within combat units. 

These soldiers usually improved quickly but also 

decompensated quickly when told they were being 

sent back to their unit. Providers at the CSH would 

then spend extensive time trying to reach the unit at 

a distant location for collateral information via primitive telephonic infrastructure to make the necessary 

determinations. Without collateral information providers would often not know the relevant conditions 

and observed behaviors of the soldier. However, some 

units became more available for discussion when they 

received notification from the patient administrative 

section or the CSH patient administrative section that 

their soldier was in RTD status and needed pick-up 

for transportation back to the unit.

As stated, the policy of the CSH was to evacuate 

any soldier admitted for more than 7 days. Usually, 

units off the base could not be reached in this period 

of time and these soldiers were sent to Germany via 

the 47th CSH in Kuwait. However, the 28th CSH accumulated a large holding population awaiting RTD, 

sometimes exceeding the 7-day hospitalization policy 

if RTD appeared probable. Extensive holding populations entailed some risk and caused some concern to 

the hospital command, but the command then used 

its resources and influence to achieve contact with 

the original unit and arrange transportation. Some of 

the psychiatric patients at 28th CSH needed evacuation and went to LRMC, which facilitated pharmacy 

resupply, as already discussed. However, these evacuations presented another issue as it typically took 2 to 

3 weeks for a behavioral health specialist who escorted 

the patient to return to the CSH for routine duties. 

Sometimes the CSH sent other nursing personnel on 

these missions, but that depleted other sections of their 

nursing or enlisted medical personnel. The poor lines 

of communication to units and limited treatment options presented challenges that the CSH units handled 

differently; the 21st CSH usually evacuated these soldiers from theater, whereas the 28th CSH held them for 

RTD to prevent personnel depletion (at the CSH and 

sending unit). Early in OIF I, when commanders were 

able to locate their soldiers and call or visit the CSH 

to see how they were doing, the commanders were 

occasionally angry that they had “lost” their soldiers 

to the medical evacuation system. Getting soldiers to 

agree to commit themselves to maintaining personal 

safety and return to their units was sometimes very 

difficult with only supportive therapy and “three hots 

and a cot,” especially if the soldier had the expectation 

of release from theater.

Soldiers’ mood and affect usually brightened when 

they were away from the stress of their unit; had some 

rest, a shower, and three meals; and were in an airconditioned hospital. Many soldiers evaluated in this 

setting stated they had joined the Army for “college 

money” and “never thought [they] would deploy”; 

they often acted out when told they were going back 

to their units. This situation became an ethical dilemma 

for psychiatrists sending soldiers back to combat 

knowing they might be killed, injured, or deteriorate 

behaviorally, but these issues applied to any soldier 

ordered into a combat environment.

After the end of the major combat offensive, roughly 

the end of April 2003, it was not considered very 

dangerous for units to convoy to hospitals or clinics, although sporadic attacks with small arms and 

rocket-propelled grenades continued. However, after 

the insurgency became more organized, these ground 

convoys decreased in frequency as improvised explosive devices (IEDs) hidden around roadways became 

the primary weapon against coalition forces. Camps 

received regular mortar (indirect) fire after early July 

2003, and the roadside IEDs and rocket indirect fire 
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Combat and Operational Behavioral Health

attacks also increased dramatically. For example, the 

Balad (Arabic for “in the country or countryside”) 

airfield (aka Camp Anaconda), a huge, sprawling airbase of many square miles, received multiple mortar 

attacks from July 3 to September 26, 2003. Most of 

these mortar attacks occurred in the quadrant of the 

base containing the CSH. 

Commanders reported difficulty in referring soldiers to DMHS or CSC units where they would normally have been seen for evaluation and treatment. Because CSHs were located on large LSAs, units brought 

their soldiers to the CSHs when they convoyed to the 

LSA to pick up supplies. A very small percentage of 

cases seen involved florid psychosis or mania; most 

referrals were lower-ranking enlisted personnel with 

adjustment disorders. However, the behavioral, logistical, and combat stressors of OIF I affected all ranks 

and branches. For example the psychiatrist of the 21st 

CSH evacuated two aviators due to panic attacks and 

anxiety that affected their flying, caused in each case 

by “brown out” situations (caused by sand and dust 

from the rotor wash during landings). This resulted 

in such significant anxiety about future recurrences 

that it impaired overall mission capability. Other cases 

were more serious and involved stress confronted by 

higher level commanders. 

Case Study A1-1: A 40-year-old combat arms battalion 

commander with 19 years active duty presented as a selfreferral for worsening depressed mood with suicidal thoughts 

to shoot himself in the head with his 9-mm pistol. His brigade 

commander described him as “the strongest and most reliable 

battalion commander in the brigade.” His depression centered 

on the lack of control he felt over the lives of his troopers 

and the lack of training his men had been given for “extra 

duties” such as security and patrols. While on a patrol two of 

his soldiers had been killed by insurgents. After admission 

to the hospital for 5 days followed by 3 weeks of outpatient 

treatment consisting of counseling and medication, his mood 

and suicidal thoughts continued to worsen. He was evacuated 

from theater for more intensive treatment. In follow-up, he was 

noted to be doing well and still on active duty.

Another factor that led to referrals to behavioral 

health was the guilt associated with killing enemy 

combatants or the sheer terror of seeing friends killed 

by insurgent attacks. Many soldiers did not confront 

these stressors until seen by a behavioral health provider. Many would break into tears when asked the 

simple question of whether or not they had killed anyone in combat. Another common source of guilt came 

(correctly or incorrectly) from whether one’s actions 

or inactions led to a negative outcome for a friend, 

civilian noncombatant, or fellow soldier. 

Case Study A1-2: A 22-year-old enlisted soldier presented to the CSH, referred by his unit for depressed and 

psychotic symptoms. He blamed himself for the death of his 

commander. His commander had reached up to catch a line 

that was falling on top of the Bradley fighting vehicle that the 

commander was on top of. It electrocuted the commander. 

The presenting soldier had been the gunner but was inside 

the vehicle at the time of the electrocution. He felt guilty and 

demonstrated severe depression with psychotic features, 

hearing voices telling him he was a “poor soldier” and that he 

“should have done something to help his commander,” with 

whom he had a good working relationship. In reality, there 

was nothing he could have done to save his commander, yet 

he believed it was his fault that his commander died. Traumatic event management with the soldier and unit proved 

helpful in this case, and his psychotic symptoms improved 

significantly with an antidepressant and low-dose atypical 

antipsychotic medication, allowing him to return to duty.

One behavioral health unit referred a soldier to the 

CSH for medevac to LRMC for a “sleep study to rule 

out sleepwalking.” While conceptually it was easy 

to send this soldier back to the unit for observation, 

the increase in mortar and rocket attacks made his 

return more complicated and potentially hazardous. 

The provider admitted this soldier instead, observing 

him at the CSH before sending him back to his unit. 

In most cases, sleepwalking referrals were returned 

to the unit after brief medical work-up to avoid an 

epidemic of sleepwalking “evacuation syndrome” in 

these units.

During the period in late 2003 when insurgent attacks increased, word began to spread that most units 

would remain deployed for a year rather than the 6 

months many had expected. From May to June 2003, 

there were six suspected cases of self-inflicted gunshot 

wounds to the foot seen at the 21st CSH in Balad and 

several at the 28th CSH at Camp Dogwood. The psychiatrist at the 21st consulted for the surgical team to 

evaluate one of these cases that appeared suspicious. 

Case Study A1-3: An orthopaedic surgeon consulted 

psychiatry to evaluate an enlisted soldier in his mid-20s to 

determine whether the soldier’s injury was accidental or 

self-inflicted, and to assess the soldier’s risk of self-harm. 

The soldier stated that he shot his foot by accident. During 

the initial evaluation he reported depressed mood “ever 

since I’ve been deployed,” and noted that he wanted to go 

home. He also complained of having interpersonal problems 

with his chain of command. He reported poor sleep, guilt 

about the deployment, anergia, and poor concentration 

since being deployed. He denied having these symptoms 

prior to deployment and felt they would “go away if he were 

home.” He expressed surprise that the orthopaedic surgeon 

would send him back to duty, even though his foot had a 

clean injury without any fractures. He commented that, “I 

might as well shoot myself intentionally in order to leave if 

I have go back there.” The provider also noted that during 

the initial evaluation the soldier stated that his first concern 
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Provision of Behavioral Health Services During Operation Iraqi Freedom One

was where he would be “sent from here,” expecting “that it 

would be Germany.” 

Initial psychiatric evaluation recommended that after 

sufficient orthopaedic recovery, he follow up with a CSC 

unit near his unit duty location with a stress management 

group. In the following days, his unit started a line-of-duty 

investigation, which contributed to his stress. The hospital 

chaplain then consulted psychiatry 3 days later when the 

soldier hinted that he would display violent behavior if he 

returned to the unit. When questioned about suicide or homicide, he stated, “I don’t know what will happen if I go back 

to my unit.” He still insisted that the initial incident was an 

accident. He denied pulling the trigger and could not come 

up with a reason for the weapon discharging. Ten days after 

the second evaluation, his chain of command contacted the 

hospital and informed the medical team that they wanted to 

court-martial the soldier. However, the line-of-duty investigation remained incomplete and would take 2 to 3 more weeks 

to complete. The CSH informed the unit that the soldier’s 

foot had healed sufficiently for discharge from the hospital, 

but because of the unit’s remote location and lack of medical facilities to change his foot dressings, he would need air 

evacuation to LRMC in Germany. When the soldier learned 

of this decision, his affect and mood brightened to euthymic 

and he reported, “I expected that.” He appeared happy that 

he would be getting out of the Army, stating, “Any way is 

good.” He reported feeling “glad that I’m not going back to 

my unit with a loaded weapon.” 

After the soldier had been at the CSH for approximately 

6 weeks, due to the nature of his injury, the line-of-duty 

investigation, and the poor communication with his unit, he 

was sent to Kuwait for evacuation to Germany. However, his 

unit intercepted him in Kuwait and told him he was returning 

to Iraq for a court-martial, at which point it required several 

personnel to restrain him. He was nonetheless eventually 

evacuated from Kuwait to an Army hospital in Germany due 

to his combative behavior. 

From June to July 2003, a suicide cluster occurred, 

with each case likely having had multiple contributing factors, but ultimately leading each individual to 

feel hopelessness and intolerable depression. These 

soldiers may have felt trapped in a situation with no 

clear departure or end date (unprecedented in this 

generation of deployed soldiers). Additionally, all 

soldiers carried their weapons and ammunition at all 

times. Added deployment stressors were the following: separation from family and loved ones; receiving 

“dear John/Jane” letters ending relationships; no lines 

of communication home; threat of being killed or injured; high temperatures; perceived harassment from 

chain of command; and poor sleep, latrines, hygiene, 

and food. Behavioral health planners and commanders discussed relocating the 113th CSC fitness teams 

from Mosul and Baghdad to the 21st CSH in Balad 

to start a neuropsychiatric unit after these suicides. 

This collocation never occurred, but a CSC fitness or 

restoration unit should collocate with an MRI CSH to 

share resources, treatment, and evaluation of soldiers, 

since the post-MRI CSH has limited behavioral health 

assets. (This arrangement worked very well during 

subsequent deployment rotations observed in the authors’ subsequent deployments, including the 1908th 

CSC and 10th CSH in 2006 in Baghdad, and the 47th 

CSH and the 528th CSC at COB Speicher, in 2009.) 

Such collocation could improve RTD rates, as well as 

reduce evacuations from theater. At the 21st CSH in 

Mosul, the 98th CSC ran an outpatient clinic next to 

the hospital with two CSC psychiatrists (who admitted 

patients to the hospital if needed), a social worker, and 

five behavioral health specialists.

COMBAT STRESS CONTROL UNITS

The US Army’s behavioral health community has 

long recognized the impact of acute and chronic stressors, as well as traumatic events, on the functioning 

of individual soldiers and military units. The Army 

currently maintains two types of CSC units: (1) CSC 

companies and (2) CSC detachments. The former are 

primarily staffed by reservists and contain 80 personnel of various disciplines, including psychiatrists, 

psychologists, psychiatric social workers, psychiatric 

advanced practice nurses, general psychiatric nurses, 

a medical-surgical nurse, numerous psychiatric technicians, and administrative support staff (eg, a cook, 

mechanics, and so forth), so they can function as selfsustaining units in a deployed environment. The active 

duty component CSC detachments grew 50% larger 

after the introduction of MRI units and are approximately half the size of a CSC company, but with fewer 

psychiatrists. Also, they do not contain the same mix 

of personnel as pre-MRI units or CSC companies.

CSC units are designated primarily as units tasked 

to perform preventative activities. As such, personnel 

in a CSC usually are configured into teams, known as 

prevention teams, consisting of one professional and 

two paraprofessionals (behavioral health specialists). 

These teams are usually assigned to specific units for 

which they provide primary and secondary prevention for combat-stress–related issues. Specifically, these 

teams present psychoeducational briefings focusing 

on suicide prevention, stress management, identification of combat fatigue or depression, and briefings 

preparing soldiers to reconnect with their families 

near the end of their deployment. At the beginning 

of OIF, military doctrine recommended critical event 

debriefing as the preferred intervention for traumatic 

events experienced by groups of soldiers. However, 

concurrent studies, both in the military and in civilian 
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Combat and Operational Behavioral Health

settings, questioned the efficacy of these critical event 

debriefings. 

Even more important to the practitioner, some 

studies reported that critical event debriefings had the 

potential to actually harm some participants, possibly 

through reexperiencing the trauma or by overwhelming the psychological defense mechanisms that had 

otherwise been allowing the soldier to manage the 

trauma without intervention. Furthermore, many providers had not attended courses certifying proficiency 

in conducting critical event debriefings. These factors 

contributed to a wide variation in the utilization of 

the debriefings and the consistency of responses to 

potentially traumatizing events. The military behavioral health community had previously promoted the 

utility of critical event debriefing to Army leaders 

during the years leading up to OIF, which resulted in 

commanders requesting a debriefing for their soldiers 

anytime any adverse event happened. The following 

case study describes some of the issues involved in 

this process.

Case Study A1-4: A military chaplain phoned a local 

CSC unit after a fire had broken out in a hangar that served 

as the “barracks” for a military unit. The chaplain said that 

the unit’s commander had requested a critical event debriefing. The chaplain asked for the assistance of the CSC unit 

inasmuch as the chaplain was inexperienced in performing 

such a debriefing and because the large unit would require 

multiple group debriefings (debriefings are usually limited 

to 20 people). 

The consulted behavioral health officer evaluated the 

situation and determined that no one’s life had been threatened by the fire, only property was lost, and that finding 

new housing was the unit’s most immediate concern. The 

CSC staff discussed the situation with the chain of command and decided that instead of critical event debriefings 

(where everyone participated in groups discussing their 

experience, both factual and emotional), they would take a 

different approach with this particular event. This approach 

consisted of a meeting with the whole unit at once. The unit’s 

commander spoke first to reassure his unit that new housing 

was in process and expected imminently. Furthermore, the 

Army would help the soldiers replace items lost in the fire. 

The behavioral health staff then gave an educational briefing 

about stress management and coping skills to the assembled 

soldiers along with specific contact information if any soldier 

wanted individual meetings. 

Adaptive doctrine allows these CSC teams more 

flexibility to evaluate and treat soldiers with combat 

fatigue and behavioral health disorders. The teams also 

engage in traumatic event management and critical 

event debriefings, providing evaluation and appropriate intervention for involved units. The teams provide 

consultation to military commanders, both in ways to 

help the whole unit prevent combat-stress–related dysfunction and also by performing command-directed 

behavioral health evaluations on individuals when 

commanders are concerned about their safety and 

reliability. Finally, the teams provide assessment and 

treatment for soldiers who self-refer for evaluation of 

their own distress. 

These functions require that the prevention teams 

live with units and travel within the operational area 

of the units for which they provide support services. 

Due to the travel hazards in the evolving Iraqi theater 

and in any nonlinear battlefield, routine travel plans 

decreased somewhat during OIF I. These prevention 

teams are “assigned” to cover the unit, but are not 

actually organic to the unit, so living and integrating 

with the host unit becomes imperative to develop 

trust from the unit’s leaders and soldiers. Without 

developing these strong relationships, including being 

perceived as available and “useful” to the commander 

and soldiers, a prevention team would not accomplish 

its defined mission; not due to lack of skill or personnel, but due to an inability to earn credibility and trust 

with their customers. Without the credibility, barriers 

inevitably arise and limit the prevention team’s access 

to the soldiers who need their care. 

Despite the task of prevention and the doctrinal 

mission of psychoeducation classes, this pivotal underlying mission of relationship-building conveys a 

similarity with marketing functions. Although philosophically debatable, a unit’s referral rate from the first 

sergeant or sergeant major provides a useful practical 

indirect metric of a prevention team’s effectiveness, 

as these NCO leaders keep their fingers on the metaphorical pulse of the unit and will only refer when their 

skeptical trust has been earned. Some CSC units sought 

to justify their existence by optimistically counting social and coincidental contacts as “prevention” (marketing) contacts to report as statistics, but these contacts 

provide minimal actual care. Genuine individual or 

small-group sessions, usually with credentialed providers, not initiated by CSC staff, constitute substantive 

care and adverse outcome prevention. 

In contrast to the established doctrine promoting 

team travel, some observations provide insights requiring diligent consideration to optimally balance benefits 

with costs. Travel tended to increase breadth of contact, but greatly decreased the depth of intervention. 

Soldiers needing behavioral health services tend to get 

directed to nearby behavioral health components perceived as helpful and competent, and whose personnel 

accumulate into provider panels. These panels quickly 

evaporate when disrupted by travel, as soldiers move 

on instead of establishing a perceived new relationship 

with another provider. Command elements directing 

behavioral health activities often do not appreciate the 
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Provision of Behavioral Health Services During Operation Iraqi Freedom One

differences inherent in behavioral health relationships 

and expect a comparable portability from behavioral 

health as they might expect from other medical providers, such as sick call or dental or surgical services. 

New locations established after travel rarely yield a 

client/patient panel to match the size of the panel at 

the previous location. 

Professional providers practicing in the best interest 

of beneficiaries maintain some degree of skepticism 

towards disruptive relocations that do not appear 

warranted or logical on clinical grounds. Directed activities may serve as perceived requirements or even 

a beneficial bullet in someone’s reports or evaluations 

that actually detracts from collective soldier care. For 

example, an author questioned an ill-advised tasking 

that appeared more politically motivated than caredriven because the decision makers did not permit 

any merit discussion or consult actual subject matter 

experts. This particular tasking decimated a robust 

panel at a large base with ten to twelve substantive 

appointments per day while yielding two to three 

appointments per day after relocation. After returning in 8 weeks, the panel required another 8 to 12 

weeks of rebuilding before approaching its previous 

productivity level.

CSC units also had a second type of function—

restoration—with the restoration (formerly known as 

fitness) team. This team had more personnel assigned 

and usually operated from a stationary location, unlike 

the prevention teams. In addition to providing marketing activities similar to those provided by prevention 

teams, the restoration team also served as a treatment 

alternative for the prevention teams, commanders, or 

other nonbehavioral health providers, for soldiers who 

needed an evaluation and may have benefited from 

a spectrum of intervention activities ranging from 

prescriptions with interval aftercare to an intensive 

outpatient/partial hospitalization program equivalent 

to daytime groups and self-care quarters. By doctrine 

(specifically FM 4-02.51), restoration teams were meant 

to provide a stable place, somewhat removed from the 

front lines, where a soldier could be “restored” through 

the basic principles of the acronym BICEPS (brevity, 

immediacy, contact, expectancy, proximity, and simplicity). (PIES—proximity, immediacy, expectancy, and 

simplicity—was the previous acronym, used in FM 

8-51.) Nonetheless, these treatment concepts led to the 

practice of “three hots and a cot,” with the belief that 

the majority of combat stress casualties could be reconstituted in a short time, usually 1 to 3 days with close 

attention, to avoid accumulating large numbers or 

permitting extended care (> 3–4 day), which decreased 

the soldier’s expectation of RTD, possibly prompting 

symptom sustainment to delay RTD and maximize 

reprieve at the relatively comfortable CSC. In concept, referrals managed with BICEPS would adapt 

better in the long run if returned to their units than if 

“medicalized” and evacuated. Doctrine also discourages labeling these soldiers as “patients,” since labels 

also shape expectations (this appendix uses the term 

“patient” in the CSC context for consistency to denote 

a beneficiary receiving services, without intending to 

imply any particular treatment/intervention model or 

outcome expectation). In practical settings, care often 

transitioned fluidly across environments dictated by 

external circumstances (eg, care could occur at the 

CSC for one encounter, then a dining facility table, and 

then a CSH clinic office, with various combinations 

of pharmacological, psychological, educational, and 

behavioral interventions). 

During OIF I, most restoration teams were based in 

camps that also housed a soldier’s unit headquarters 

and that sometimes took frequent indirect fire. Thus, 

providers observed little difference between, or benefit 

from, quartering soldiers in the CSC versus leaving 

them with their host unit. While providing a respite 

from the immediate unit environment and command 

interactions may provide some benefit for certain cases, 

it may also adversely affect soldiers’ perceived proximity to their unit and expectation for prompt RTD. 

Typically, documentation given to unit commanders 

recommended environmental and behavioral modifications as part of the treatment/restoration program, 

including the expected CSC aftercare. Anecdotally, 

by not keeping soldiers separated from their peers, 

commanders reduced the general unit perception that 

the soldier was “mental” or “crazy,” thus reducing the 

stigma of care within these units. As discussed, restoration teams often functioned like community behavioral 

health clinics, providing psychiatric evaluation and 

treatment of ambulatory patients. This function also 

provided a referral resource for nonpsychiatric clinicians and the prevention teams. 

The most common complaint from soldiers presenting to the CSC, consistent with the CSH, was for 

evaluation of “home-front issues,” such as difficulties 

with significant others or family members at the home 

station or elsewhere in the United States or Germany. 

Depressed mood, insomnia, and anxiety, most commonly in the form of panic attacks, hypervigilance, 

or “jumpiness,” remained prevalent symptom complaints, but frank posttraumatic stress disorder (PTSD) 

was very rarely diagnosed among soldiers during their 

deployment. 

With the chief complaints listed above, most practicing psychiatrists would recognize that targeted 

psychopharmacologic interventions would have an important role in helping to alleviate symptoms. As previ-
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ously mentioned, military doctrine for CSC was written 

to support a linear Cold-War–style combat campaign. 

Linear battlefields with conventional mobility warfare 

feature a rapidly moving, fluid battlefield requiring 

more prevention and triage than formal diagnoses, treatment, and aftercare plans. Doctrine writers appeared to 

conceive definitive psychiatric care (permitting RTD) 

as a separate activity to occur in rear areas after CSC 

doctrinal interventions failed to achieve prompt RTD, 

or after the rapidly moving campaign concluded. Thus, 

no provisions in FM 8-51, the doctrine at the beginning 

of OIF I, detailed how a CSC should obtain or store 

medications or a recommended formulary. Since the 

beginning of OIF I, the Army recognized this change 

in underlying assumptions and the consequent need 

to revise CSC doctrine in OIF II (2004). Of note, treatments with potentially sedating medications, especially 

atypical antipsychotics for insomnia or anxiety and benzodiazepines for anxiety, received increasing scrutiny. 

Media coverage of the issue and command concern understandably arose about ensuring that soldiers remain 

alert during missions. Providers must use these options 

responsibly to alleviate symptoms while recognizing 

that soldiers may display less optimal performance or 

alertness if their symptoms remain unaddressed. Benzodiazepines demonstrated good efficacy in overcoming 

or desensitizing acute stressors, but these drugs require 

vigilance, responsible prescribing, and commensurate 

psychological interventions. Without this attention, 

escalating use occurred frequently, leading to habituation and perpetuation of anxiety symptoms after return 

to CONUS.

DIVISION MENTAL HEALTH SECTIONS

During OIF I, combat forces deployed as entire 

divisions, under the organizational structure of the 

“Operational Force” (all divisions except the 4th and 

25th IDs) or “Force XXI” (the 4th and 25th IDs had 

changed to Force XXI by the beginning of OIF I). This 

organization differed from the new “modular” organizational structure now in place due to the Army’s 

transformation after OIF I. This appendix relates 

specifically to the DMHS assets during OIF I, prior 

to the Army’s transformation to the current modular 

organizational structure and operation.

The organically assigned DMHS assets belong 

specifically to the division, as permanent and integral parts of the division in peacetime and wartime. 

During a deployment, the DMHS can occasionally 

receive supplemental behavioral health PROFIS personnel if there is a shortage of assigned but needed 

personnel. In contrast to the DMHS, CSH and CSCtype units have few organic medical assets and receive most of their medical personnel from PROFIS. 

DMHS personnel operate within the division, both 

in garrison and in a deployed environment, as the 

primary behavioral health resources for the division. 

They evaluate and treat division soldiers, liaison 

with chain of command, and provide command 

consultation services for the various units within 

the division.

In garrison, the DMHS usually operates from one 

location as a full behavioral health section, generally 

located near other division medical assets. If division brigades are located in different geographical 

areas, such as Germany or Korea, then the DMHS 

will have more than one operating clinic. DMHS staff 

provide the full range of behavioral health services, 

including

	 •	 evaluation for all behavioral health disorders

(whether self-referrals, command referrals, or 

medical referrals);

	 •	 treatment, including individual therapy,

group therapy, and medication management; 

and

	 •	 prevention services (usually via command

consultation and liaison).

In divisions structured in either the Operational 

or Force XXI structure, the DMHS generally has one 

division psychiatrist, one division psychologist, one 

division social worker, and six to eight behavioral 

health specialists (military occupational specialty 68Xs, 

previously designated as 91Xs). Depending on the 

organizational structure of the division (ie, Operational vs Force XXI), DMHS personnel were either all 

assigned to the main support battalion (as part of the 

division support command brigade) or to a specific 

support battalion within the division. 

In an Operational structured division (eg, the 101st 

Airborne [Air Assault] Division), all DMHS personnel 

were assigned to the main support battalion. However, 

in a Force XXI structured division (eg, the 4th ID), the 

DMHS operated together in garrison but were actually 

assigned to the various support battalions. In these 

divisions, the division psychiatrist and noncommissioned officer-in-charge (NCOIC) were assigned to the 

division support battalion. The other DMHS personnel were assigned to the FSMCs, part of the forward 

support battalions, designated to support a specific 

brigade combat team during deployment. Under this 

structure, usually one behavioral health officer (either 

the division social worker or division psychologist) 

along with one or two behavioral health specialists 
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Provision of Behavioral Health Services During Operation Iraqi Freedom One

were assigned to each of the FSMCs. However, with 

three FSMCs but only two available behavioral health 

officers (ie, a social worker and a psychologist), one 

FSMC would have a team of only behavioral health 

specialists assigned to it, with no assigned officer.

According to linear battlefield doctrine, the division psychiatrist provided behavioral health service 

support to division personnel evacuated from the 

maneuver brigades, as well as to personnel assigned or 

attached to units collocated with the division support 

units and division headquarters. However, as stated 

previously in this appendix, OIF I did not develop 

according to a “linear” battlefield model, particularly 

with the various maneuver brigades and brigade combat teams located on different FOBs throughout Iraq, 

with nonlinear patterns of enemy engagements or orientation of combat forces. Therefore, patients from the 

various maneuver brigades could be routed directly 

to the division or main support battalion according to 

doctrine, or directly to a nearby higher echelon of care 

(eg, CSC or CSH). Proximity became more important 

as travel hazards increased and soldiers understandably presented to the closest asset with the capability 

to adequately evaluate the problem and minimize 

overall risk. 

Once receiving deployment orders, the DMHS 

shifted operations from the garrison mission to the 

deployment or operational mission. This included 

screening for and identifying division soldiers whose 

behavioral health conditions made them unsuitable 

for deployment, transferring their care to the garrison 

hospital behavioral health assets, and processing recommendations for medical separations (via Medical 

Evaluation Board) or administrative separations (ie, 

AR 635-200, Chapter 5-13/5-17), as indicated. Reserve 

component units frequently referred soldiers for 

evaluation prior to deploying, but sometimes these 

referrals occurred after arrival in theater when medical 

screening revealed that the soldier was taking mood 

stabilizers or antipsychotic medications for the treatment of bipolar disorder or psychotic disorders that 

the Reserve unit did not fully recognize. Subsequent 

screening processes became more comprehensive and 

prevented deployment of these vulnerable soldiers in 

later rotations. As expected, other routine referrals to 

behavioral health included cases of existing depression, anxiety disorders, or substance-use disorders. 

Case Study A1-5: A 44-year-old E-8 reservist with over 

25 years in service was referred for anxiety and alcohol 

dependence. He had been drinking one half of a fifth of 

whiskey in Kuwait every other day. Prior to deployment he 

drank a case of beer from Friday night to Sunday night, with 

an occasional beer on the weekdays. The soldier initially 

presented prior to deployment, secondary to increasing 

anxiety and depression related to recent activation to active 

duty and occupational difficulties. He minimized his alcohol 

use at this time. He was assigned as his unit’s first sergeant 

but did not feel he could handle the position’s responsibility. 

In addition to symptoms of anxiety, he also reported uncontrollable crying spells, poor concentration, fatigue, and 

decreased appetite. The initial CONUS provider diagnosed 

him with an adjustment disorder with anxious and depressed 

mood, starting him on citalopram, clonazepam, and zolpidem. 

He was found fit to deploy but directed to seek behavioral 

health services once he arrived in theater. He returned for 

aftercare 2 weeks later while still in CONUS and reported 

that his symptoms had improved and that he had stopped 

the prescribed medications. 

After deploying to theater, his symptoms of anxiety returned and he sought help at the CSH in Kuwait. His provider 

restarted him on his previous medications but he stopped 

these again after 4 weeks. He subsequently presented 

again in relation to pending Uniform Code of Military Justice 

charges due to his alcohol consumption while deployed, a 

violation of General Order Number 1. He did not feel that he 

could go on with his job and was evacuated from theater for 

treatment of his alcohol dependence and anxiety. 

As preparations for deployment continued, all 

garrison DMHS operations were shut down and 

the care of soldiers remaining behind transferred 

to the garrison hospital behavioral health assets, 

while the DMHS focused on equipment readiness, 

packing, and training for the upcoming deployment 

missions. Packing followed existing up-to-date load 

plans and focused on identifying what supplies and 

equipment would be needed in theater. Packing 

included inventory, assessment, and loading the 

equipment already “owned” by the DMHS, per the 

Table of Organization and Equipment (tents, light 

sets, field desks, chairs, cots, and vehicles). It also 

included assessing the need for and acquiring other 

anticipated useful supplies necessary to conduct 

the mission (eg, supplies for writing patient notes, 

maintaining charts, performing command referrals, 

writing mental status evaluations, useful templates, 

prescription pads, and any important resources such 

as textbooks or field manuals). 

Of note, supplies of psychotropic medications were 

not obtained prior to leaving the garrison environment. Once deployed and OIF I began, the absence 

of pharmaceutical supplies quickly became apparent, 

with poor availability in theater and lengthy delays to 

establish dependable supply chains. By approximately 

midsummer 2003, a dependable supply chain had 

developed and medications became readily accessible 

through the division’s own supply chains or at the 

various CSH units.

Maneuver brigades and their supporting units 

convoyed from Kuwait into Iraq during the initial 
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Combat and Operational Behavioral Health

assault that began OIF I. Some combat units, such as 

the 101st Airborne (Air Assault) Division, that were 

directly involved in the initial assault “jumped” 

from one location to the next. This occurred from 

the beginning of formal combat operations until approximately May 2003, as units repositioned with 

a northerly movement direction and support units 

completed their convoys afterwards. As the mission 

evolved, permanent FOBs became established, with 

designated units operating out of a given location. 

During the previous “jumping” phase, conducting 

behavioral health and support operations had the 

unique challenge of operating in temporary environments without the stability, infrastructure, or luxuries 

of an established base. Prior to arriving and setting 

up at their permanent FOBs, the various maneuver 

brigades and supporting units (main and forward 

support battalions) remained in one location for only 

a few days to weeks, conducting operations from 

tents and makeshift buildings. Conditions remained 

austere for all units during this time, and did not 

provide ideal conditions for conducting sustainable 

operations. Fortunately the behavioral health mission 

did not have significant equipment requirements, 

and the DMHS teams experienced limited adverse 

effects because they required only a pen and paper to 

document encounters and a location to see patients. 

Providers could see patients in any safe, convenient, 

and relatively comfortable place. Providers utilized 

their ingenuity to create clinical spaces, for instance, 

in the small DMHS tent, in the back of a HMMWV, or 

in any “field-expedient” location providing a minimal 

amount of privacy for soldiers. Once established in 

the permanent FOBs, units dedicated more time and 

resources to setting up tents for permanent operations 

or occupying and improving old, abandoned Iraqi 

buildings on the FOB premises, converting them for 

living and working accommodations.

As previously mentioned, in a deployed environment, the DMHS section was divided into small 

two- to three-person teams (usually composed of a 

behavioral health officer—psychiatrist, psychologist, 

or social worker—and one or two behavioral health 

specialists) integrally located with the support battalion. Therefore, these were small operations, usually 

working out of a small tent or other accommodations, 

available 24 hours a day to accommodate soldiers who 

could present at any time (because soldiers presented 

unexpectedly day or night after convoying several 

hours from another FOB that lacked behavioral health 

assets). These DMHS teams were able to provide a 

range of behavioral health services and support to 

all the soldiers in the supported brigade and in their 

vicinity or catchment area. They were responsible for 

direct behavioral health patient care, as in garrison, 

with services that included

	 •	 evaluation of acute behavioral health issues

whether presented via self-referral or command referral;

	 •	 command consultation; and

	 •	 treatment, including brief supportive therapy

and medication management, if required. 

In terms of the types of cases presenting for treatment to DMHS, the whole spectrum of behavioral 

health concerns was represented, from significant Axis 

I disorders to subthreshold symptoms consistent with 

adjustment disorders related to situational stressors 

(occupational, home-front, or other operational stressors, classified, per Army doctrine, as “combat and 

operational stress reactions”) to misconduct stress 

behaviors. The most common cases presenting were 

those not meeting the threshold for actual significant 

Axis I disorders but rather were more consistent with 

misconduct stress behaviors (eg, substance abuse, 

fighting) or combat and operational stress reactions—

problems that might formerly have been diagnosed, 

per the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, terminology, as occupational problems, adjustment disorders, or even partner-relational 

problems. Soldiers were presenting with symptoms of 

stress related to the “operational” stress of functioning 

in an austere environment with extreme temperatures, 

extended separation from home and family, lack of privacy, and increased behavioral and physical demands. 

There was significant occupational stress from difficulties with peers or superiors; home-front stress from 

family, partner-relational, or financial concerns; or just 

frustration with the environment and the cumulative 

effect of the various stressors. 

Soldiers also presented with symptoms of actual 

Axis I depressive disorders, anxiety disorders, bipolar 

illness, psychosis, and attention deficit hyperactivity 

disorder (ADHD), either newly presenting or with 

diagnoses present prior to deployment (the latter cases 

needing continued treatment and routine medication 

management, particularly for depression, ADHD, or 

anxiety). A significant number of soldiers also presented with substance use issues, usually related to 

alcohol or other drugs (such as “Iraqi valium,” which 

they acquired illegally from Iraqis). The presentation of 

soldiers with acute stress disorder (ASD) or PTSD-type 

symptoms related to traumatic combat experiences 

was rarer at the beginning of OIF I prior to the maturation of the insurgency. However, by approximately 

August 2003, after the increase in insurgent attacks 

(eg, IEDs, rocket-propelled grenades, mortar attacks), 
765

Provision of Behavioral Health Services During Operation Iraqi Freedom One

the number of soldiers presenting with ASD/PTSD 

symptoms notably increased. Overall, the ratio was 

approximately 6 to 4 for soldiers presenting with 

either “misconduct stress behaviors” (eg, substance 

abuse, assault on other soldiers) or subthreshold 

symptoms classified in Army parlance as “combat 

and operational stress reactions” to those presenting 

with significant Axis I disorders.

The number of patients presenting to DMHS usually ranged from eight to twelve soldiers per day. 

Soldiers generally presented as walk-ins (either as 

self-referrals or as command referrals). Most presentations were patients with an acute crisis; those who 

presented for routine treatment (ie, medication refills 

or follow-up) usually came whenever their operational 

mission would allow or, if located on another base, 

whenever they could “hop” a ride on a convoy that 

was traveling to the FOB where DMHS was located. 

Command referrals were usually acute (ie, for soldiers 

with imminent risk issues) but were also occasionally 

for routine, nonacute concerns.

In addition to evaluation and treatment of both 

acute and routine issues, DMHS teams accomplished 

other associated behavioral health activities, similar to 

those in a garrison-type environment. These included 

behavioral health evaluations, as required, for administrative separations (Chapters 13 and 14 separations) 

and recommendations to command for Chapter 5-13 

or 5-17 administrative separation for soldiers whose 

conditions clearly indicated unsuitability for continued 

service. Sanity boards were also conducted for soldiers 

undergoing court-martial. In addition, evaluations 

were done occasionally for soldiers planning to attend 

drill sergeant or recruiting school upon redeployment. 

The DMHS staff also provided consultation on a regular basis to commanders, first sergeants, chaplains, 

other medical personnel, and Judge Advocate General 

personnel, to ensure the safest, most appropriate, and 

most efficient dispositions for soldiers.

Examples of cases that presented to DMHS included 

the following: 

	 •	 soldiers who “locked and loaded” their weapon against their unit members; there were 

several cases a month of significant soldier 

versus soldier violence.

	 •	 soldiers in acute suicidal crises, including soldiers of all ranks, who had locked and loaded 

their weapon and held it to their head; 

	 •	 a soldier with a past history of clinical depression who had been barred from convoys/

patrols by his unit because he had been taking 

“pot shots” at local Iraqis;

	 •	 a soldier involved in “horseplay” with two

other soldiers that “got out of hand” when the 

soldier pulled out his bayonet, which caused 

the threatened soldier to pull out his 9-mm 

pistol;

	 •	 single or married soldiers presenting in recurrent suicidal crises after learning that soldiers 

with whom they were sexually involved were, 

simultaneously, sexually involved with other 

soldiers in the unit; 

	 •	 cases of soldiers who consumed alcohol and

became belligerent, suicidal, and/or homicidal, and occasionally assaulted other soldiers, 

or held their squad at gunpoint while intoxicated (two cases occurred on one FOB); 

	 •	 soldiers who made suicide attempts by overdose or who had unintentionally overdosed 

on “Iraqi valium” obtained from local Iraqis 

(with prolonged sedated, amnestic periods);

	 •	 multiple soldiers who “head-butted” brick

or concrete walls (or fractured hands from 

punching walls) due to anger involving 

NCOs, coworkers, or home-front issues;

	 •	 a sergeant major with anxiety, panic attacks,

and nightmares of death after being accidentally electrocuted by another soldier; 

	 •	 soldiers with acute manic or psychotic presentations (although rarer); and

	 •	 soldiers with notable ASD- and PTSD-type

anxiety symptoms resulting from involvement 

in combat operations. 

The 4th ID DMHS psychiatrist/NCOIC team was 

collocated with a CSC restoration team on the same 

FOB, which was very helpful for soldiers who presented acutely and who could benefit from a brief 

period of restoration away from their acute stressors. 

Soldiers who required evacuation to higher echelons 

of care, including out of theater, were evacuated to 

the closest CSH.

From April 2003 to November 2003, the 4th ID 

psychiatrist and DMHS NCOIC at the 4th ID DSB, 

located at FOB Speicher in Tikrit, Iraq, evaluated over 

600 soldiers. Of this number, 22 were referred to the 

CSC restoration program (due to operational stress 

reactions that made them temporarily nonmission 

capable), and 12 were evacuated to higher echelons 

of medical care (including some out of theater), resulting in an RTD rate of a minimum of 94.4%. This 

rate improved later in the year when the same team 

(although with a new division psychiatrist) saw an 

additional 480 soldiers from mid-November 2003 

until March 2004, when the 4th ID redeployed stateside, with only three soldiers requiring evacuation 

out of theater.
766

Combat and Operational Behavioral Health

SUMMARY

Over the past 8 years, behavioral health issues 

in the Army and the Department of Defense have 

changed greatly and continue to do so. This appendix is historical in nature. It may be used as a 

training tool for military residents and fellows (for 

example, in a military psychiatry seminar) or to 

assist in preparation of future providers deploying 

to an immature theater. The case studies may be 

used for discussions about varying stressors and 

other conditions that might be encountered during 

deployments. Regardless of the use of this material, 

the discussion of each major unit during OIF I and 

the challenges faced should be considered in future 

operations.

REcommended READING

 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM 

IV-TR). Arlington, Va: APA; 2008. 

 US Department of the Army. Mental Health Advisory Team (MHAT) Reports I-VI. Available at: http://www.behavioralhealth.army.mil/research/index.html. Accessed November 23, 2010.

 US Department of the Army. Combat Stress Control in a Theater of Operations. Washington, DC: DA; 29 September 1994. 

Field Manual 8-51.

 US Department of the Army. Combat and Operational Stress Control. Washington, DC: DA; July 2006. Field Manual 

4-02.51.

 US Department of the Army. Active Duty Enlisted Administrative Separations. Washington, DC: DA; April 27, 2010. AR 

635-200.

 Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes JW, eds. War Psychiatry. In: Zajtchuk R, Bellamy RF, eds. 

Textbooks of Military Medicine. Washington, DC: DA, Office of The Surgeon General, Borden Institute; 1995.