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Provision of Mental Health Services in Operation Iraqi Freedom 05-07

Chapter 9

PROVISION OF MENTAL HEALTH 

SERVICES IN OPERATION IRAQI 

FREEDOM 05-07

MARC A. COOPER, MD*; SHARON M. NEWTON, MHS†; and JEFFREY S. YARVIS, MSW, PhD‡

INTRODUCTION

CHANGING DYNAMICS OF THE CONFLICT

A More Sophisticated Enemy

More Developed Forward Operating Bases, More Developed Mental Health 

Services

Increased Multiple Deployers 

New Department of Defense Policies

Improvements in Command and Control of Echelon-Above-Division Stress 

Control Personnel

Standardization of Practices 

Quality Assurance

ROLE OF THE MEDIA 

Reporting Increase in Suicide Rates

Airing the Baghdad ER Special

Media Coverage of Civilian Deaths in Haditha 

SUMMARY

*Chief, Community Mental Health Service, Moncrief Army Community Hospital, 4500 Stuart Street, Fort Jackson, South Carolina 29207; formerly, 

Major, Medical Corps, US Army; OIF 05-07 Theater Mental Health Consultant, Task Force 30th Medical Brigade, Baghdad, Iraq

†

Lieutenant Colonel, Medical Specialist Corps , US Army; Command Inspector General, 30th Medical Command, CMR 442, APO AE 09042; formerly, 

Theater Consultant for Combat and Operational Stress Control, Iraq 

‡

Lieutenant Colonel, Medical Service Corps, US Army; Chief, Behavioral Health, Department of Psychiatry, Borden Pavilion, Walter Reed Army Medical 

Center, 6900 Georgia Avenue NW, Washington DC 20307; formerly, Director of Social Work, Uniformed Services University of the Health Sciences, 

Bethesda, Maryland
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Combat and Operational Behavioral Health

INTRODUCTION

During Operation Iraqi Freedom (OIF) 05-07, the 

third anniversary of combat operations in Iraq was 

observed. The battlefield had changed dramatically 

since US forces first invaded Iraq in March 2003. Open 

fighting along the routes into major cities had been 

replaced with door-to-door city fighting. The enemy 

had changed from a visible fighting force into a largely 

unseen guerilla force. As the battlefield transformed, 

so did the provision of mental health services. Mental health providers still supported soldiers, but this 

task evolved, resulting in the improvement of earlier 

operations, the incorporation of new missions, and an 

increased emphasis on data collection. Being in country for 3 years and utilizing the widespread availability 

of computerized technology, military mental health 

provision developed to a level of sophistication never 

before seen in a theater of operations.

This chapter will explore how duration of the conflict affected the provision of mental health services 

during OIF 05-07. It will look at factors that influenced 

the entire military that had consequences for mental 

health providers, such as facing a more sophisticated 

enemy, living on more developed bases, and implementing new Department of Defense policies. It will 

also look at ways in which mental health services 

expanded based on lessons learned from OIF-I and 

OIF-II. Finally, the length of the conflict and the increasing number of casualties amplified media interest in 

the conflict and in mental health services available to 

soldiers in combat. This chapter will discuss the influence of the media on the provision of mental health 

services during OIF 05-07.

CHANGING DYNAMICS OF THE CONFLICT

A More Sophisticated Enemy

In March 2003, the enemy was clear—the Iraqi Army 

commanded by Saddam Hussein. After Hussein’s 

troops surrendered in April 2003, defining the “enemy” 

became more complicated. Pockets of insurgent groups 

coupled with sectarian violence began producing coalition casualties through various guerilla warfare tactics. 

During the ensuing years, these tactics became more 

sophisticated, using the skills of sharpshooters and 

explosives experts. These deadly encounters with insurgents resulted in the decision by the US military that 

there had to be increased preparedness for all deployed 

soldiers. Consequently, one of the improvements 

made during OIF 05-07 was that all soldiers already 

deployed, as well as those soon to deploy, were given 

protective equipment that was normally provided only 

to combat units. In addition to the Army combat uniform and improved Kevlar helmets, all soldiers were 

also issued “hemcon” (hemorrhage control) bandages, 

which were a vast improvement over the previous field 

bandage. Soldiers received deltoid and axillary protector plates, and enhanced small arms protective insert 

plates, aimed at providing better protection. However, 

these protective measures also significantly increased 

the weight each soldier had to carry. This extra weight, 

especially in the hot summer months, was an added 

stressor for all soldiers, including the combat operational stress control providers during travel outside 

the forward operating base (FOB). 

Travel between FOBs was improved during OIF 

05-07. During the first half of OIF-I, travel was in softsided vehicles for the simple reason that there were 

no up-armored vehicles. The dangers of ground travel 

(ie, improvised explosive devices, rocket-propelled 

grenades, suicide bombers) became more common and 

deadlier, necessitating the requirement that all vehicles 

traveling outside the FOB be up-armored. In general, 

although more travel now occurs via aircraft than 

during OIF-I (where nearly all travel was by ground 

convoy), most combat stress control teams continue 

to travel by convoy. 

Another area in which there was improvement 

as the conflict continued was the standardization of 

convoy procedures. During OIF-I, depending on the 

location of the team and its higher headquarters, there 

was a wide variation in procedures. Some teams traveled by nontactical vehicle, while other teams were 

required to be in a convoy of at least three vehicles, 

with a specified number of crew-served weapons. 

Although the standardization of convoy procedures 

was developed to enhance safety, this more-involved 

process has created frustrations for the combat stress 

control teams who regularly need to leave a FOB to 

provide services to a supported unit. 

More Developed Forward Operating Bases, More 

Developed Mental Health Services

The living and working conditions improved 

considerably by OIF 05-07. During OIF-I, soldiers 

(including mental health personnel) lived and worked 

out of tents for the most part, using burnout latrines, 

field-expedient showers, and meals, ready-to-eat. 

Conditions began to improve even before the end of 

the OIF-I rotation, and the improvements continued 

through each rotation. During OIF 05-07, the majority 

of personnel lived and worked in trailers or buildings 
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Provision of Mental Health Services in Operation Iraqi Freedom 05-07

that were climate controlled and had electricity, including hygiene facilities with running water. Even the 

presence of beds instead of an Army cot contributed 

to the overall improvement in the standard of living. 

Obviously, these improvements affected the level of 

stress perceived by the supported soldiers as well as 

the mental health personnel providing the support. 

One observation of the 30th Medical Brigade (TF30 

Med) mental health personnel is that subordinate units 

seemed to be reporting more psychiatric patients than 

expected by combat operational stress control (COSC) 

doctrine. A rough comparison was made of the average monthly number of new psychiatric contacts to 

the average monthly number of new combat stress 

contacts from the Combat Operational Stress Control 

Workload Activity Reporting System (COSC-WARS) 

reports from OIF-I, OIF-II, OIF 04-06, and OIF 05-07. 

The average number of new psychiatric contacts rose 

disproportionately higher than the average number of 

new combat stress contacts from OIF-I to OIF 05-07. 

(Only a rough estimate is possible as data collection 

during the early part of the conflict was obviously not 

the priority.) The reasons for the increase are not clear. 

Among possible explanations are improved workload 

reporting procedures, an increase in the population at 

risk or the number of soldiers deploying with psychotropic medications, or providers more willing to use 

medication to treat combat stress and thus convert 

what would have traditionally been a new combat 

stress contact into a psychiatric contact. Providers 

were likely more comfortable prescribing medication 

because the living environment was more stable and 

better follow up was available; thus soldiers would not 

need to be sent out of the theater for treatment. 

There was a very clinical feel to many of the services provided during OIF 05-07. (One benefit that 

comes from a longer conflict is that better working 

conditions develop.) During OIF-I, tents were the 

norm. By OIF 05-07 the tents had been replaced by 

buildings—working in buildings instead of working 

outside the same tent where one lives lends itself to 

a more clinical feel. Additionally, more combat stress 

control (CSC) units had teams collocated with a combat support hospital (CSH) compared to OIF-I.1 These 

teams would frequently provide primarily mental 

health services. Often times, this was out of necessity, 

as they were the only mental health providers on the 

FOB, or the CSH did not have the personnel due to 

split-base operations. Sometimes this was the choice 

of the provider, the combat stress control commander, 

or the CSH commander. 

This is not to say that COSC personnel were not 

providing preventive outreach services. As alluded 

to earlier, many of the division mental health personnel had a preventive focus, as did the mental health 

personnel from echelons above division beyond those 

in the CSC units. All teams from the CSC units did 

some form of outreach through classes, consultation, 

and education, as well as regular outreach by walking 

around and talking to the supported units. 

By OIF 05-07, theater mental health assets had 

learned the basics of their jobs in a combat environment 

and began to expand their roles into more forensic 

and administrative psychiatry services, which would 

not normally be associated with combat psychiatry. 

Sanity boards and mental status evaluations are not 

even mentioned in the COSC field manual2

 or the two 

psychiatry volumes in the Textbooks of Military Medicine 

series.3,4 It is unclear if the requests for these specialty 

services had any relationship to the fact that mental 

health services were being offered in more clinical 

environments, and thus providers were more able or 

prepared to fulfill these requests. 

The fact that commanders and soldiers were requesting these services while deployed to a combat 

zone merits discussion. The Mental Health Advisory 

Team (MHAT) IV found that soldiers who had deployed to Iraq more than once were more likely to 

screen positive for depression, acute stress, anxiety, 

or other mental health problems. It also reported that 

soldiers who screened positive for a mental health 

problem were twice as likely to engage in unethical 

behavior as those who did not screen positive.5 The 

number of moral waivers for felonies given to recruits 

increased from 459 in 2003 to 1,002 in fiscal year 2006.6

Thus, whether due to a mental health problem or a 

history of illegal behavior, it appears that the longer 

this conflict continues, the greater the chances are that 

soldiers will be acting out while deployed, and there 

will be an ever-increasing need for sanity boards or 

command-directed mental health evaluations performed in theater. 

Established mental health clinics during OIF 05-07 

also managed to work out logistical problems that 

plagued clinics at the start of the conflict. One of 

the biggest improvements was the formulary, which 

now contains a broader spectrum of antidepressant 

medication and stimulants, two concerns brought 

up by providers during OIF-I.7

 The formulary was 

frequently reevaluated, as the Multi-National Force–

Iraq (MNF–I) pharmacists held quarterly meetings that 

allowed providers to make suggestions for additions 

or substitutions. 

Despite great interest in knowing how many psychotropic prescriptions were written in theater, several 

mechanisms make this data difficult to accurately 

report. First, most established psychiatric patients 

deploy with a 90-day supply of medication from their 

home duty station or soldier readiness processing 

site. The TRICARE mail-order pharmacy was also 
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Combat and Operational Behavioral Health

frequently used for established psychiatric patients 

and those stabilized on medication in theater. Theater 

pharmacies ordered their own stocks of medications 

and kept their own records of prescriptions written for 

each psychotropic. Thus, centralized order tracking 

would only reflect shipments to theater pharmacies, 

not how much of those shipments were actually being 

prescribed. 

Another advance that occurred in theater was the 

increased availability and usage of Composite Health 

Care System-Interactive Training Tool (CHCS-ITT), 

the deployment electronic medical record. Because 

CHCS-ITT is linked with the computerized medical 

record system utilized in garrison, provider notes written in the combat zone can be accessed at any military 

treatment facility in the world. This system greatly 

improved continuity of care between the Iraq Theater 

of operations and the medical facilities where soldiers 

were being treated and reduced the biggest risk of 

paper documentation—misplacement. Unfortunately, 

the only facilities that had reliable electricity, computer 

access, and CHCS-ITT trainers were the Level III CSHs 

and Level II battalion aid stations. Unless they were 

collocated in one of these facilities, the CSC teams did 

not have access to the CHCS-ITT system. 

The debate that had occurred in garrison mental 

health clinics was subsequently heard in theater. This 

debate centered on the inclusion of mental health notes 

in the general medical record and the lack of privacy 

of the computerized mental health record. The CHCSITT “sensitivity feature” was nonfunctional in theater. 

This sensitivity feature, also known as the “break the 

glass” feature, keeps record of all users accessing any 

clinical notes labeled as “sensitive.” Prior to accessing 

a sensitive note, medical providers are warned with 

a pop-up message that they are about to read sensitive data and they will be audited. For CHCS-ITT, 

in-theater providers could designate a note as sensitive, but there was no record created of who accessed 

a sensitive note and there was no warning pop-up 

message. To use the system while protecting patient 

privacy, some providers opted to keep all their records 

electronically unsigned, which kept the encounter in 

an “open” status and prevented other providers from 

being able to read the notes, but still allowed treating 

providers to write up a summary of their encounter 

with the patient and print it out. The disadvantage of 

this was that future mental health providers could not 

access these notes because they were never closed, and 

open encounters significantly downgraded the entire 

system so that all notes in all clinics on that particular 

network took longer to write. 

With more established FOBs offering more services, 

KBR (formerly Kellogg Brown & Root, the largest 

civilian contractor in Iraq at the time), and the Army 

and Air Force Exchange Service required more civilian 

employees during OIF 05-07 than in OIF-I. Problems 

arose when these employees, who were supposed to 

be psychiatrically cleared prior to their deployment, 

showed up at military mental health clinics in need of 

treatment. This put military providers in an uncomfortable position for several reasons: (a) military malpractice did not cover the care of contractors, (b) contractors 

were not eligible for care and so prescriptions would 

be difficult to fill, and (c) if the contract agency found 

out that an employee was receiving mental healthcare, 

the employee would be sent home, so when contractors presented to mental health clinics, they asked the 

providers not to report them. KBR brought its own 

employee assistance program counselors to Iraq, 

which was helpful when KBR employees were involved in a casualty-producing incident, because their 

own counselors could offer debriefings or counseling. 

However, KBR had no physicians or psychiatrists on 

staff. Because only physicians can initiate air evacuation requests, military psychiatrists were tasked with 

authorizing all KBR psychiatric emergencies requiring 

evacuation from theater.

Developed FOBs brought with them communication systems that were vastly improved from OIF-I. 

This had several implications for the mental health 

community. First, most FOBs now had widespread 

Internet access and phone centers, which enabled 

soldiers to call home more regularly. Mental health 

providers in theater considered this a mixed blessing—

soldiers could receive additional support or they could 

receive devastating news, yet they were still expected 

to perform the mission. 

Another consequence of improved communication, especially the ability to send US mail across 

FOBs fairly reliably, was that the design for MHAT 

IV could be simplified. Rather than having a team of 

researchers come into theater and travel across FOBs 

administering the surveys, the surveys were sent by 

express mail to the theater. They were then mailed to 

the mental health assets organic to the FOBs where the 

participating units were stationed. The surveys were 

administered by each unit’s mental health asset and 

then mailed back to the MNF–I surgeon’s office, where 

MHAT IV was housed. This new process allowed 

for a reduction in the number of researchers needed 

to deploy to theater. The mission now focused more 

on data analysis rather than survey administration. 

Although this expanded the mission of the theater 

mental health provider, it gave units an opportunity 

to interact with their own mental health assets, rather 

than with a group of outsiders. It also decreased the 

need for travel across FOBs by MHAT personnel, a 

process with its own inherent risks. Ultimately, there 

were delays in the mail system, so MHAT personnel 
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Provision of Mental Health Services in Operation Iraqi Freedom 05-07

did more travel than was originally planned, but this 

was still far less than previous MHAT teams.

Increased Multiple Deployers

Clearly, with each additional year of the conflict, 

the chances increase that the population of deployed 

soldiers will contain greater numbers of multiple deployers. The increased number of multiple deployers 

during OIF 05-07 was not unique to soldier patients 

seeking mental healthcare. Many healthcare providers were also affected. It is not unusual to have COSC 

providers return from a deployment only to discover 

the need to prepare for the next deployment. They 

may not have had sufficient time to recover from the 

first deployment. The very nature of providing COSC 

services in a combat theater means repeated exposure 

to stress and hearing the tragedies of those being supported. Twenty-one percent of OIF 05-07 behavioral 

health providers reported high or very high levels of 

burnout.5

 It is unclear how many of these providers 

had had multiple deployments. An area of further 

research might be to look at the long-term effect of 

multiple deployments on behavioral health providers, 

especially with little time between each one. 

Ongoing provision of mental health service would 

have resulted in rotation through Army providers 

more quickly had it not been for the US Air Force and 

Navy contributing greater mental health assets than 

in previous OIF years. The Air Force deployed its 

mental health providers for 4 months at a time. They 

were placed in CSC teams or in the Air Force hospital 

in central Iraq. The Navy deployed its mental health 

providers in support of Marine line units, but also filled 

some of the rotating reservist slots of the CSC units. 

New Department of Defense Policies

As after-action reports and other reported difficulties from OIF-I and OIF-II made their way through 

the top levels of the military, new policies made their 

way down in an attempt to make needed improvements. One such policy concerned treating victims of 

sexual assault. This policy originated as a result of an 

inquiry made by the Secretary of Defense (then Donald 

Rumsfeld) in February 2004 over concerns of sexual 

assault allegations made by soldiers deployed to Iraq 

and Kuwait.8

 A task force that was formed to investigate these allegations found inconsistency in sexual 

assault prevention programs across the services. The 

task force reported that barriers to reporting sexual 

assault were significant in the military environment 

and that without an advocate looking out for the 

victim, it was easy to overlook a victim’s rights and 

needs. Among the task force’s recommendations was 

the establishment of a Department of Defense policy 

addressing sexual assault prevention and response, 

and the creation of a task force that would oversee this 

policy. After receiving congressional approval, Department of Defense Directive 6495.01, the Sexual Assault 

Prevention and Response Program, was published in 

October 2005. It outlined the treatment and care for 

victims of sexual assault and required that provisions 

be made for theater operations. The Army published 

its policy in Army Command Policy, Army Regulation 

600-20, which was first published February 1, 2006, and 

revised June 7, 2006. 

The Sexual Assault Prevention and Response Program affected theater mental health providers because 

it potentially added further missions. First, behavioral 

health personnel were often tasked with acting as the 

unit’s victim advocates due to their demonstrated 

ability to empathize. Even if they were not victim 

advocates, however, mental health personnel had 

the potential for greater contact with sexual assault 

victims, because the new policy required immediate 

availability of mental health services for all victims 

presenting to a medical treatment facility. Alternatively, 

a mental health visit could be the first contact a sexual 

assault victim had with the medical community. Thus 

providers had to know about the new reporting options, which were restricted reporting and unrestricted 

reporting. In restricted reporting, only the treatment 

community is authorized to know the victim’s identity 

(the victim’s chain of command is never told about the 

assault). In unrestricted reporting, the victim’s chain 

of command is informed and an official Criminal Investigation Division inquiry is opened. Finally, sexual 

assault review boards were now meeting in theater and 

behavioral health chiefs were a required component 

of these boards. 

The other policy that had a significant effect on the 

mental health mission during OIF 05-07 took effect 

June 1, 2006, when the Army revised its deployment 

drug testing procedures. The main changes involved 

giving more responsibilities to deployed units.9

 This 

included medical personnel because medical review 

officer (MRO) services now had to be available in the 

deployed environment. An MRO is a physician appointed to determine if a urinalysis positive for opiates, 

barbiturates, steroids, or stimulants is the result of a 

legitimate prescription or illegitimate use.10 In garrison, 

MROs are trained through a medical command course 

and are certified after passing an examination. 

An informal survey of division surgeons and the 

CSHs indicated that there were not enough certified 

MROs in theater to handle this new tasking. Ultimately, 

the decision was made to have two MROs appointed 

at each Level III CSH, two at the multifunctional medical battalion, and additional MROs as needed in the 
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Combat and Operational Behavioral Health

divisions. The Army Forensic Drug Testing Program 

then distributed training CDs to theater. Commanders 

appointed MROs, the CDs were reviewed, and MROs 

took the certifying exam via e-mail. The majority of 

newly appointed MROs were psychiatrists, although 

some of the CSHs appointed family practice physicians. 

In addition to the MRO mission, the new drug 

testing policy also affected the mental health community by identifying more substance abusers in theater. 

Unfortunately, the Army Substance Abuse Program 

did not formally exist in theater, thus treatment and 

rehabilitation options for those identified were extremely limited. Some of the larger FOBs had Alcoholics Anonymous meetings, but for the most part, any 

drug and alcohol counseling was left to chaplains and 

the mental health community.11

Improvements in Command and Control of 

Echelon-Above-Division Stress Control Personnel

As the theater matured, so did the ability to command and control COSC personnel in the echelonabove-division units. At the start of combat operations, 

there were many changes in command structure, 

supporting units, who would support whom, and so 

forth.1 During OIF 05-07, not only was there only one 

medical headquarters in theater, but it was stationary. There was no longer a need to move north as the 

conflict progressed. 

Each rotation made improvements, and by OIF 05-

07 the medical headquarters had a firm foundation on 

which to build. The introduction of a mental health 

consultant at the Multi-National Corps–Iraq (MNC–I) 

level continued during OIF 05-07 as a dual role position with the TF30 Med mental health consultant. This 

permitted a single medical headquarters to coordinate 

plans with the divisions and other separate brigades, 

as well as ensure the MNC–I and MNF–I commanders 

and command surgeons were kept informed. The result 

was an enhanced ability for greater situational awareness and coordination of COSC/mental health needs 

and services. 

This enhanced situational awareness also assisted in 

planning for coverage. Because of improved communication systems, a stationary headquarters, and solid 

foundation from previous rotations, planning was 

able to be more deliberate and organized, obtaining 

input from multiple sources. As the theater changed, 

so did the method of estimating COSC coverage. In 

OIF-I, one CSC unit provided coverage to a specific 

division; there was one preventive team per brigade. 

By OIF 05-07, area support was the norm. COSC coverage was divided more by geographic location than 

strictly by division.

Situational Awareness

Managing and directing the COSC medical functional area in a theater of operations requires accurate 

and up-to-date situational awareness. This required 

verification of the location of COSC personnel in 

theater, by clinical specialty. Fortunately, a listing that 

included MH personnel from the divisions, KBR, the 

Air Force, the Navy, and the Marine Corps Operational 

Stress Control and Readiness (OSCAR) teams already 

existed. A database was developed, adding clinical 

specialties at each location, and updated regularly. 

This listing proved to be extremely helpful and provided the situational awareness required for optimal 

management of COSC resources. Not only did it 

help to identify the proper unit to task when specific 

missions were requested, but it also assisted in the 

planning process by ensuring minimal duplication of 

services among the various mental health resources 

on an FOB. 

Planning Process 

Even though the theater had evolved considerably 

since the start of the conflict, having the right number 

of people in the right place was always a challenge. Because planning did not have to occur as troops were on 

the move, as at the beginning, it was possible to use a 

very thorough planning process. TF30 Med developed 

a process that utilized a historical review of workload 

and operational tempo, COSC doctrine, and a staffing 

model. (The staffing model that was used was based 

very closely on one proposed by the second MHAT.12

It considered three primary categories of services: (1) 

clinical, (2) unit outreach, and (3) the restoration center. 

The clinical usage was calculated based on the average of the percentages that want help, need help, and 

use help. Some of the assumptions were corrected to 

reflect current processes, and items were modified to 

be applicable in the deployed environment.) 

This was the “science” of operational planning. The 

“art” of operational planning was then employed by 

comparing the requirements from the different methods, considering input from the CSC unit commanders, 

and applying the technical knowledge and expertise 

of the staff officer. The result was a proposed realignment plan. Mental health personnel in TF30 Med were 

always cognizant of their role as consultants, and 

not the final decision makers. Therefore, this recommended plan was presented throughout the chain of 

command and others involved in providing COSC/

mental health services. Because this process may be 

different from what is experienced by most mental 

health providers, it bears explanation. The plan was 

initially reviewed and approved within TF30 Med—
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Provision of Mental Health Services in Operation Iraqi Freedom 05-07

from clinical operations, through G3 (operations), to 

the commander/theater surgeon. It was then staffed 

through TF30 Med’s direct reporting units—the commanders, the operations officers (S3s), and of course 

the CSC unit leadership. The units being supported 

were part of the divisions, so the plan was briefed to 

the division surgeons and medical planners as well. 

Additionally, the equivalent personnel from the US 

Navy were included in the discussion. Changes were 

made at each step, based on input and needs identified. The final product was published in a fragmentary 

order. Even then, it specified only the minimal number 

of personnel at each FOB—by unit—and the location 

of the restoration centers. The CSC unit commanders 

were still responsible for determining the correct specialty and personnel to place at each location. 

Coordination and planning was continuous. Distribution of COSC personnel changed and adapted 

as situations changed or divisions made requests. 

This involved TF30 Med working in partnership with 

MNC–I mental health consultant, and coordinating 

closely with the senior mental health personnel of 

both divisions and Marine Expeditionary Forces on 

the placement of CSC units—fostering cooperation 

and minimizing duplication of services. 

As previously alluded to, provision of services involved planning and anticipating needs for the future 

as well. During OIF 05-07, this included coordinating 

with the US Air Force, which was compiling a CSC for 

a follow-on rotation. TF30 Med invited an Air Force 

representative to attend the COSC conference held 

in theater and meet other CSC commanders, discuss 

the mission, and get questions answered. The commander of the CSC unit that the Air Force team would 

be replacing also provided vital input to smooth the 

transition. After the visit, the utilization of the Air 

Force liaison officer in country proved invaluable in 

fine-tuning the coordination, planning, and preparation for the incoming team. 

Another manner in which command and control 

was improved was in the redistribution of the CSC 

units. After extensive mission analysis and communication with all involved, including the incoming 

medical headquarters, the CSC units were placed 

under the command and control of the newly formed 

provisional multifunctional medical battalion. One 

of the benefits to having all the CSC units under the 

same battalion was the enhancement of the ability to 

coordinate among all of these units. It was now easier 

to maintain situational awareness across the theater, 

task the most appropriate unit for any missions that 

arose, and simplify communication. An illustration 

of this was when the members of a specific brigade 

combat team (BCT) were told that they were going to 

be extended. The extension meant the BCT would need 

to relocate, and would involve a change in COSC team 

as well. Due to the ease in communication under one 

battalion, the efforts of each of the CSC units was wellcoordinated and they were able to ensure a minimal 

disruption of services and affect on the soldiers in the 

BCT. This also included TF30 Med coordination with 

the BCT’s organic mental health personnel. 

Challenges

As with previous rotations, the OIF 05-07 rotation 

faced several challenges. One of these was the rotation 

of the divisions midway through the tour of the combat 

stress control unit supporting them. When the new 

division arrived, it would sometimes want to change 

the number or specialty of the mental health personnel 

on different FOBs. Different mental health personnel 

may vary on how to implement COSC/mental health 

services. The challenge presented itself in that the 

CSC team had already established trust and rapport 

with the supported units. Changing COSC personnel 

would affect continuity of care. This was not a problem for the division soldiers as they were leaving, but 

the supported population included soldiers from the 

echelon-above-division units as well. It was easier to 

address this challenge because of the open lines of 

communication between the CSC units, their battalion 

headquarters, and the TF30 Med. 

Another challenge was in the coordination of who 

would provide services on a particular FOB. Because 

the method of team placement emphasized minimizing duplication of services, the only mental health support might be through the division team. This would 

often require the division mental health personnel to 

perform COSC and mental health activities to both 

echelon-above-division and division soldiers. Naturally, the reverse occurred when a CSC unit team was 

the only mental health asset at a location. 

Standardization of Practices 

The better-established theater provided the opportunity for the standardization of policies and procedures, and quality control. There are certain issues that 

seemed to be prevalent in providing COSC services, 

spanning the OIF rotations. Topics such as how to 

document contacts, how to measure workload, what is 

required to evacuate a soldier, and even interpretation 

of COSC doctrine were addressed. Standardization 

was difficult when personnel brought with them different levels of training in COSC and differing individual 

comfort levels with the prevention and outreach focus 

of COSC. COSC doctrine addressed these topics, but 

finding the answer was cumbersome at best. To alleviate this, TF30 Med simplified the search by addressing 
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these topics in the COSC annex to the operation orders 

for both TF30 and MNC–I. This annex established 

consistent policies and practices theater-wide. 

Documentation 

One of the main principles behind COSC is to maintain a nonclinical approach when managing soldiers 

with combat and operational stress reaction (COSR).2

However, COSC personnel perform interventions 

and activities not only for soldiers with COSR, but 

also those with diagnosable psychiatric conditions. 

What, constitutes appropriate documentation for a 

soldier with COSR? Does the documentation differ 

from that for mental health treatment of a psychiatric 

disorder? Where is this documentation kept, and for 

how long? Based on COSC doctrine found in Field 

Manual 4-02.51, a policy was established based on 

whether or not a soldier would be placed in a COSR 

restoration program. 

Care for a soldier participating in a restoration 

program for COSR was tracked from the initial contact until the soldier was released from the program. 

It included the COSC interventions and activities 

provided, soldier response, and a summary of COSC 

services provided. This record, or file, was kept separate from the soldier’s outpatient treatment record 

or deployment health record, and safeguarded on 

premises. As outlined by the Patient Administration 

Systems and Biostatistics Activity, this file was kept by 

the CSC unit for 5 years, and destroyed in December 

of the fifth year.13 Only a notation of the dates and the 

CSC unit providing the services was entered into the 

soldier’s official record. 

Care for soldiers with COSR, but not participating 

in a restoration program, was documented according to the level of intervention and severity of COSR. 

One level was a soldier who was experiencing normal 

stress reactions, and received only brief supportive 

“therapy,” skill acquisition, or “psychoeducation” 

to normalize the response. These contacts did not require documentation. However, the soldier who was 

experiencing a more severe, yet normal, stress reaction 

would require a notation in the outpatient treatment 

record. These reactions are described in Field Manual 

4-02.51 as “maladaptive stress behaviors.”2 Documentation was also required if the COSR was interfering 

with the soldier’s ability to function. The notation 

included the CSC unit, a statement that there were no 

safety issues, and no medication was needed. At the 

soldier’s request, the provider would document any of 

the above situations. Care for soldiers with psychiatric 

disorders was documented the same as if the care was 

provided in garrison. The standards outlined in Army 

Regulation 40-66 apply on deployment, too.14

Reporting Workload 

Keeping accurate records is important in identifying any potential trends in healthcare use, incidence 

of disease, and injury rates. Current methods in force 

health protection and healthcare include reporting 

disease nonbattle injuries, surgery hours, and hospital inpatient occupancy. The types of interventions 

and activities performed in COSC do not fit well into 

these types of reporting methods. As a result, the 

COSC-WARS was developed. Because the OIF units 

were the only ones using the COSC-WARS, permission 

was received to revise the form. During OIF 05-07, the 

COSC-WARS summary report was modified twice in 

an effort to ensure the data collected were sufficient 

to answer requests from a variety of sources. The final 

version contained data that allowed accurate responses 

to requests from the Government Accountability Office, Office of The Surgeon General consultants, and 

the command surgeons at all levels—MNF–I, MNC–I, 

and TF30. This form also provided data that proved to 

be invaluable in the planning process. It is important 

to note that this process also utilized input from the 

users of the form—the COSC personnel. The latest 

version of the COSC-WARS summary report was on a 

Microsoft Excel worksheet that was easier for the units 

to complete, and with nearly zero errors. The report 

was also easier for TF30 staff to collect and enter error 

free into the summary worksheet. Automatic totals 

made responding to inquiries and analyzing data 

almost effortless. Due to the elimination of specific 

identifying information, units could submit the report 

over nonsecured means. 

Completing the COSC-WARS summary report 

often seemed a daunting task because of the length. 

However, COSC personnel were provided with various methods of explanation that included a decision 

diagram and line-by-line explanations. The more 

problematic terms such as “walk-about” and “COSR 

contact” were also explained. 

Keeping Statistics

Psychiatric casualty statistics were frequently requested from all levels of leadership, from TF30 Med 

through MNF–I. Prior to OIF 05-07, most casualty 

statistics that were reported were based on the daily 

figures from the Level III hospitals, which included 

inpatient hospitalizations and inpatient and outpatient evacuations. This resulted in underreporting the 

number of evacuations, as outpatient evacuations also 

occurred from the divisions and Level II clinics. This 
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Provision of Mental Health Services in Operation Iraqi Freedom 05-07

realization led to the creation of a new database, the 

Mental Health Casualty Tracker for OIF (MHCTO) 

during OIF 05-07. The MHCTO utilized six sources of 

information: (1) the daily inpatient census report for 

theater, (2) the daily inpatient census report for garrison, (3) the US Transportation Command Regulating 

and Command and Control Evacuation System, (4) 

the Joint Patient Tracking Application, (5) the Command Critical Intelligence Requirements, and (6) the 

MNC–I casualty report. Combining these separate data 

sources into one database allowed for the tracking of 

all inpatient mental health admissions in theater, all 

inpatient and outpatient air evacuations, and all suicide completions and suicide attempts that resulted in 

hospitalization or air evacuation. Because all the notes 

were electronic and had to be read to fill in the data 

fields, this also served as a quality assurance measure 

for all air evacuations. 

Suicide statistics were also frequently requested. In 

addition to tracking the raw numbers, it became apparent that there was a lot of useful information available 

in the Army Suicide Event Reports (ASER) that had 

already been completed for suicide events occurring in 

Iraq. The TF30 Med mental health consultant was able 

to analyze the raw data on all ASERs submitted for the 

Iraq theater of operations. As a result of this analysis, it 

was clear that providers had different interpretations 

of certain questions, which resulted in lower quality 

data. The TF30 Med mental health consultant made 

the ASER a higher priority and took a more proactive 

stance toward completed ASER submissions for all 

suicide attempts. With the help of the MHCTO, suicide 

attempts were now easier to track, so corresponding 

mental health providers were now contacted and 

informed of the expectation that the ASER would be 

submitted. Certain providers even sent ASER drafts to 

the mental health consultant to ensure accuracy. With 

more providers submitting more accurate ASERs, the 

accuracy of the suicide statistics for OIF 05-07 was 

greatly improved over previous years. Additionally, 

in the clinical background information gathered from 

the MHCTO and the ASER it was possible to read 

about actual incidents in which buddy aid—the basis 

for Army suicide prevention programs—was successfully administered and resulted in a saved life. Every 

month, a new vignette was chosen and disseminated 

at the TF30 Med Battle Update Brief.

Quality Assurance 

Having standardized practices and theater-wide 

policies in place was the first step toward assuring 

that quality care was consistently being provided 

across theater. The next logical step was to devise 

a way to ensure these policies were available and 

understood by those to whom they applied. By OIF 

05-07 the electronic communication systems had been 

greatly improved and allowed wide dissemination of 

information. It was now possible to send the policies, 

through command channels, all the way down to the 

individual provider. Additionally, the TF30 Med chief 

of professional services held a regular teleconference 

in which the deputy chiefs of clinical services from all 

the CSHs and the multifunctional medical brigade, in 

addition to the division surgeons, were invited. The 

mental health consultant regularly disseminated new 

theater-wide mental health policies through this manner, which allowed for a dynamic discussion to take 

place prior to the implementation of new policies. 

One such policy that was initiated during OIF 05-

07 was the guidelines for psychotropic prescribing in 

theater. The purpose of the guidelines was threefold. 

First, they set a standard with which most psychiatrists 

should already be familiar, but primary care providers 

may not. Secondly, they clearly stated that psychiatrists 

and certain psychiatric advanced nurse practitioners 

were the only mental health providers credentialed 

to prescribe psychotropic medication. (Anecdotally, 

medical providers had asked social workers and psychologists to write prescriptions, unaware that this was 

not within their scope of practice.) Finally, the guidelines offered an information paper for commanders, 

who frequently asked providers which of their soldiers 

were taking psychotropic medications. There seemed 

to be a misperception that starting someone on an antidepressant would lead the soldier to be nonmission 

capable. (Also anecdotally, many soldiers reported 

feeling more mission capable once their depressive 

or anxiety symptoms were under better control from 

medication.) 

Another method used to support subordinate units 

in ensuring quality of care was the staff assistance visit 

(SAV). TF30 Med conducted SAVs to gain a first-hand 

awareness of “best practices,” make recommendations 

where indicated, and answer questions. It provided the 

valuable opportunity to get to know the combat stress 

control teams and COSC/mental health personnel, 

their locations, and so forth. A checklist was developed 

to standardize the questions asked during the visit and 

to help clarify TF30 Med’s priorities. The visit was not 

meant to be punitive, but rather to offer assistance in 

meeting expectations outlined in TF30 Med policies 

and procedures. The SAV was coordinated with the 

direct reporting unit commanders or deputy chiefs 

of clinical services, allowing a visit to each CSC unit 

headquarters and restoration center, mental health 

personnel at the CSHs, and some area support medical company mental health personnel. It also allowed 
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the headquarters to obtain input from subordinates. 

In conjunction with these visits, TF30 Med personnel 

acted as an advocate for COSC/mental health at higher 

levels. A good example of this occurred after an SAV to 

one of the CSHs. Based on input from the mental health 

personnel, the TF30 Med mental health officer could 

ensure that the need of CSH mental health personnel 

for appropriate space was heard at brigade headquarters. This included current and future facility needs. 

Toward the end of its rotation, TF30 Med decided 

to institute more regular, formalized, quality control 

through the establishment of monthly mental health 

chart reviews. Up until this point, peer reviews were inconsistently being done and most were informally conducted, usually consisting of case discussions. The first 

question to be addressed was which encounters were 

to be reviewed: COSR, psychiatric mental disorder 

(PMD), or both. Because providers were presumably 

more familiar with the behavioral health standards of 

the Joint Commission, and because there was more ambiguity in the COSR charting requirements, it seemed 

reasonable to start with chart reviews on the PMD 

charts rather than the COSR charts. The next issue was 

determining a standard for mental health charting in 

theater. The MNC–I surgeon/TF30 Med commander’s 

directive was that the standards in theater be the same 

as those for garrison. Even though the Joint Commission would never visit the combat zone, its standards 

were based on patient safety issues, which still applied 

in theater. A garrison mental health chart review was 

then e-mailed to all the CSHs and CSC commanders 

for feedback on which standards did not apply to the 

theater. After a consensus was reached, the next step 

was to determine how isolated clinics could perform 

the review. It was decided that if there was only one 

provider at a certain location, that provider was expected to have another medical provider conduct the 

chart review. This only happened on rare occasions 

because of the frequency of CSC commander SAVs. 

The results of the reviews were then e-mailed to the 

mental health consultant, who could verify to the TF30 

Med commander that they were being done.

As a result of the mental health peer review, there 

was now one standard for mental health charting in 

the combat zone. This brought up some issues that 

were previously not being addressed. First, it became 

apparent that most reserve providers were unaware of 

the requirement for cosigning the notes of their mental 

health technicians. Not having a civilian equivalent of 

an outpatient mental health technician, this was understandable. Additionally, more questions were being 

asked about what was in a specific provider’s scope 

of practice, such as whether or not a psychiatric nurse 

practitioner was able to prescribe medications. Finally, 

as mentioned previously, with more forensic psychiatry requests, there was an increased likelihood that 

psychiatric charts could be subpoenaed. Chart reviews 

indicated that this, along with limits of confidentiality, 

was not always discussed with patients. 

Another quality assurance initiative developed by 

TF30 Med involved a review of the scope of practice of 

unlicensed providers, such as medics and other health 

technicians. Upon learning that there were unlicensed 

psychologists in theater who required regular supervision, the TF30 Med commander began discussions 

with the Office of The Surgeon General and Medical 

Command about this practice. Ultimately, the decision 

was made that no further unlicensed psychologists 

would deploy to the Iraq theater of operations. The 

mental health community was not prepared for this 

policy change. In the immediate aftermath of this, 

major changes had to be made in assignments. The 

result was an acute shortage of psychologists, which 

led to psychiatrists or psychiatric nurse practitioners 

being used to fill vacant deployment psychologist 

slots. According to the director, Behavioral Health 

Proponency, Office of The Surgeon General,15 training 

for psychologists in the last year has been extended to 

2 years to prevent unlicensed psychologists from being 

assigned to deployable positions. 

ROLE OF THE MEDIA 

The quality of information provided to the media 

is important and can have widespread effect on the 

mission. To this end, the TF30 Med COSC and mental 

health consultants worked closely with the task force 

in developing a Public Affairs Office policy as it related to COSC operations in theater. This ensured the 

protection of the service members being supported, 

and provided guidelines for the providers on releasing information. This policy also covered any articles 

or research requests from providers in theater. Headquarters has a broader awareness of events across the 

theater, is in a better position to ensure the information 

is consistent with the overall mission objectives of OIF, 

and that release of this information is compliant with 

operational security requirements. By having TF30 

Med answer incoming questions, it allowed providers in the field to focus on their mission of providing 

COSC/mental health services to the force. 

Although it is impossible to determine exactly how 

much the media influenced the daily operations of 

mental health providers during OIF 05-07, there were 

headlines that commanded the attention of soldiers 

and military leadership alike. These media reports 

ultimately translated into combat mental health prac-
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Provision of Mental Health Services in Operation Iraqi Freedom 05-07

tices being more carefully scrutinized and greater accountability of mental healthcare providers, neither of 

which is necessarily a negative result. In this section a 

closer look will be taken at some of the more significant 

headlines during OIF 05-07 and how they potentially 

impacted the mental health community. 

Reporting Increase in Suicide Rates

In April 2006, the 2005 Army suicide rate was released and became widely quoted in the press, the media, and on the Internet. The Associated Press reported 

that 83 soldiers killed themselves in 2005, the greatest 

number of Army suicides since 1993.16 The following 

month, The Hartford Courant ran a series entitled “Mentally Unfit, Forced to Fight.” In an article in the series, 

titled “Potent Mixture: Zoloft and a Rifle,” the authors 

discuss case reports of soldiers prescribed medication 

in a combat zone who later committed suicide. The 

article suggested that psychotropic medications were 

being prescribed too freely in theater and were related 

to suicides.17

The release of the 2005 suicide rate generated considerable interest in the topic of suicide and, specifically, how it applied to the conflict. In “Zoloft and a 

Rifle,” the authors used the increased suicide rate to 

criticize the combat effort and point out flaws with 

military mental health. The article sent a mixed message to soldiers in theater—the authors cared about 

soldiers and wanted to honor those who committed 

suicide, yet if they were having problems, health 

providers in theater would only make them worse. 

Little attention was paid to the theater suicide prevention programs already in existence, or the power 

of buddy aid. 

As the reporting of the increase in the suicide rate 

spread throughout the media, TF30 Med and MNC–I 

received additional inquiries related to suicide statistics. By April, the MHCTO was fully operational, 

which enabled the TF30 Med to support the requests 

for information. As mentioned previously, studying 

the ASERs also provided valuable information about 

theater suicides that was frequently requested by 

mental health providers and was presented at theater 

mental health conferences. 

Although dramatic, “Zoloft and a Rifle” did bring 

up a valuable point regarding how nonpsychiatrists 

were treating mental illness. An informal survey of 

physician assistants in theater demonstrated that comfort levels with the use of psychotropics varied greatly. 

This prompted the MNC–I surgeon to commission the 

psychotropic prescribing guidelines, which came out 

as a MNC–I fragmentary order during the summer of 

2006. The guidelines were meant to assist providers in 

better understanding psychotropic prescribing in the 

combat zone and included information about monitoring laboratory reports, side effects, drug interactions, 

standard of care for treating psychiatric disorders, 

and what to tell commanders requesting information 

about their soldiers.

Airing the Baghdad ER Special

Baghdad ER is a Home Box Office special that aired 

May 21, 2006. It is a graphic and emotional account 

of the realities of combat through the experiences of 

a CSH. Yet graphic documentaries also have other 

implications. They can serve as powerful reminders 

or “triggers” for soldiers who have been exposed to 

trauma. Baghad ER is indeed a harsh reminder of the 

brutal realities of combat. 

Lieutenant General Kevin Kiley, then the Army 

Surgeon General, directed Army mental health experts to prepare for the impact of Baghdad ER. Said 

Kiley, ”This film will have a strong impact on viewers 

and may cause anxiety for some soldiers and family 

members.”18 He suggested that mental health facilities 

should extend their treatment hours and reach out to 

the troops proactively. The Army recognized that it had 

to address the near-term implication of the program 

and also recognized that the families and soldiers who 

might be traumatized by this media event might also 

have on-going psychological issues.

The theater mental health consultant wrote the 

following talking points,which were disseminated in 

theater prior to the airing of the program.

1. Most soldiers returning from deployment 

seek to avoid images and media coverage related to the global war on terrorism. Soldiers 

in theater will have limited access to the HBO 

special. The greatest impact will likely be on 

soldiers’ families, brought about by fears 

raised from direct viewing or the publicity 

afterwards.

2. Technology has significantly altered communications with the home front, with increased 

accessibility and frequency. Mental health 

providers have noticed spouses who are coping poorly can significantly affect the morale 

of their deployed soldier.

3. In the days and weeks following the program 

airing, commanders should:

	 	 •	 Check in with their soldiers to see how their

spouses are coping.

	 	 •	 Consider limiting contact immediately

before a mission or have mental health assets or chaplains available during popular 

calling periods.

	 	 •	 Be aware of common warning signs of
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increased stress, such as soldiers becoming isolated, becoming easily angered, or 

seeming distracted, and a change in work 

performance.

	 	 •	 Encourage soldiers to talk with their peers,

chaplains, or mental health providers if 

they start to feel more stressed after talking 

with family members.

4. There are assets available in stay-behind elements to assist family members coping with a 

soldier’s deployment, such as TRICARE and 

Military OneSource. Additionally, commanders should encourage active participation in 

family readiness groups, as this provides a 

unique opportunity for families with a common interest to support each other.19

Based on conversations with CSC providers, the 

aftereffects from Baghdad ER were not as intense in 

theater as was expected. Nevertheless, the event was 

a clear example of how the media influenced mental 

health providers in theater during OIF 05-07.

Media Coverage of Civilian Deaths in Haditha

In November 2005, Marines killed 24 Iraqi civilians 

in the town of Haditha, Iraq. Specifics of the story 

were not immediately available, but eventually it 

was reported that the killings were in retribution for a 

roadside bomb in which a Marine had been killed. The 

Washington Post wrote that “[t]wo US military boards 

are investigating the incident as potentially the gravest 

violation of the law of war by US forces in the 3-yearold conflict in Iraq.”20

Haditha was a complex media event because it 

lasted for months, as each new revelation had its turn 

in the media frenzy that followed. Mental health experts were often interviewed to try to make sense of 

the killings. The psychiatrist Robert Jay Lifton explains 

that “atrocity is a group activity.” Therefore, he writes 

at Editor & Publisher “[t]o attribute the likely massacre at Haditha to ‘a few bad apples’ or to ‘individual 

failures’ is poor psychology and self-serving moralism.”21 Lifton says that the Haditha incident can be 

understood as what he calls “an atrocity-producing 

situation,” which he defines as “one so structured, 

psychologically and militarily, that ordinary people, 

men or women no better or worse than you or I, can 

commit atrocities.” 

Interest in combat ethics grew substantially during OIF 05-07 as a result of the killings in Haditha. 

All subsequent war misbehavior was often presented 

in comparison to that event. MHAT-IV was commissioned by the MNF–I commander with the request to 

investigate combat ethics. The MHAT-IV accomplished 

this through survey questions and focus group discussions. The final report includes information about 

behaviors during deployment and discusses ideas for 

teaching ethics. Recommendations include incorporating battlefield ethics in all behavioral health counseling and anger management classes, especially when 

conducted in a combat zone.5

 These recommendations 

could substantially increase the scope of duties of 

deployed mental health providers.

SUMMARY

This chapter has explored how the provision of 

mental health services advanced during OIF 05-07 as 

a result of a more mature battlefield. Without having 

to worry about basic necessities or establishing new 

clinics, mental health providers were able to take 

on additional missions, such as serving as MROs or 

on sexual assault review boards, responding to the 

media, and meeting standards of care that were the 

same as garrison mental health clinics. The provision 

of mental health consultation to TF30 Med, MNC–

I, and MNF–I leadership was also able to advance 

because providers had become adept at mastering 

the basics. Although not mentioned specifically in 

this chapter, brevity, immediacy, contact, expectancy, 

proximity, and simplicity (BICEPS) remained as the 

cornerstone of mental health services in the combat 

zone during OIF 05-07. The fact that they did not 

require alterations speaks to their universality. As 

future battlefields will likely look as different from 

OIF as OIF does from World War II, it is reassuring 

to know that there will be at least one constant in the 

provision of mental health services. That constant 

is the BICEPS approach to combat and operational 

stress reactions.

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Database. Accessed December 11, 2006.

2. US Department of the Army. Combat Stress Control. Washington, DC: DA; June 6, 2006. Field Manual 4-02.51.
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Provision of Mental Health Services in Operation Iraqi Freedom 05-07

3. Jones F, Sparacino L, Wilcox V, Rothberg J, Stokes J, eds. War Psychiatry. In: Zajtchuk R, Bellamy RF, eds. Textbooks of 

Military Medicine. Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1995.

4. Jones F, Sparacino L, Wilcox V, Rothberg J, eds. Military Psychiatry: Preparing in Peace for War. In: Zajtchuk R, Bellamy 

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www.armymedicine.army.mil/reports/mhat.html. Accessed September 4, 2008.

6. Tan M. Gangs in uniform. Army Times. September 3, 2007:14.

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HQDA G-1. December 16, 2003. Available at: www.armymedicine.army.mil/reports/mhat.html. Accessed September 

4, 2008.

8. United States Department of Defense Sexual Assault Prevention and Response Web site. Available at: http://www.

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9. All Army Activity (ALARACT) Message No. 087/2006. Drug Testing During Deployments. April 26, 2006.

10. US Army Medcial Command Military MRO Information Pamphlet, May 30, 2006. 

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12. Mental Health Advisory Team (MHAT-II). Operation Iraqi Freedom (OIF-II). Report. The US Army Surgeon General. 

January 30, 2005. Available at: www.armymedicine.army.mil/reports/mhat.html. Accessed September 4, 2008.

13. Patient Administration Systems and Biostatistics Activity Memorandum. Consolidation of Deployment Medical Documentation. October 21, 2005. 

14. US Department of the Army. Medical Record Administration and Health Care Documentation. Washington, DC: DA; June 

17, 2008. Army Regulation 40-66.

15. Ritchie EC. Colonel, Medical Corps, US Army. Personal communication, February 2009.

16. Army suicides hit highest level since 1993. Associated Press. April 21, 2006. Available at: http://www.msnbc.msn.com/

id/12428185. Accessed September 9, 2008.

17. Chedekel L, Kauffman M. Potent mixture: Zoloft & a rifle. Hartford Courant. May 16, 2006:A1. 

18. Starr B. Army: HBO documentary could trigger stress disorder [transcript]. Entertainment. CNN television. May 15, 

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in Nov. 19 incident. Washington Post. May 27, 2006:A01. Available at: http://www.washingtonpost.com/wp-dyn/

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21. Lifton RJ. The psychology of atrocity. Editor and Publisher. June 4, 2006. 
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