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Walter Reed Army Institute of Research Contributions During Operations Iraqi Freedom and Enduring Freedom

Chapter 5

WALTER REED ARMY INSTITUTE OF 

RESEARCH CONTRIBUTIONS DURING 

OPERATIONS IRAQI FREEDOM 

AND ENDURING FREEDOM: FROM 

RESEARCH TO PUBLIC HEALTH POLICY

CHARLES W. HOGE, MD*; AMY B. ADLER, PhD†; KATHLEEN M. WRIGHT, PhD‡; PAUL D. BLIESE, PhD§; 

ANTHONY COX, MSW¥; DENNIS McGURK, PhD¶; CHARLES MILLIKEN, MD**; and CARL A. CASTRO, PhD††

INTRODUCTION

WALTER REED ARMY INSTITUTE OF RESEARCH

FROM RESEARCH TO PUBLIC HEALTH POLICY

INITIAL RESEARCH ON THE IMPACT OF MENTAL DISORDERS BEFORE 

SEPTEMBER 11, 2001

MENTAL HEALTH IMPACT OF THE PENTAGON ATTACK

RESEARCH RELATED TO OPERATIONS ENDURING FREEDOM AND IRAQI 

FREEDOM

OTHER WRAIR MENTAL HEALTH RESEARCH INITIATIVES

SUMMARY

*Colonel, US Army (Retired); formerly, Director, Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research, 503 Robert Grant 

Avenue, Silver Spring, Maryland 20910

†

Research Psychologist, US Army Research Unit—Europe, Walter Reed Army Institute of Research, CMR 442, APO AE 09042-1030

‡

Research Psychologist, US Army Medical Research-Europe, Walter Reed Army Institute of Research, CMR 442, Box 94, APO AE 09042; formerly, 

Deputy Chief, Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, Maryland

§

Colonel, Medical Service Corps, US Army; Director, Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research, 503 Grant 

Avenue, Silver Spring, Maryland 20910

¥

Lieutenant Colonel, Medical Service Corps, US Army; Social Work Consultant, Great Plains Regional Medical Command; Chief, Social Work, Brooke 

Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, Texas 78234

¶

Major, Medical Service Corps, US Army; Commander, US Army Medical Research Unit—Europe, Walter Reed Army Institute of Research, CMR 442, 

APO AE 09042-1030

**Colonel, Medical Corps, US Army; Program Director, National Capital Consortium Psychosomatic Medicine/Geriatric Psychiatry Fellowship, Walter 

Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307; formerly, Principal Investigator, Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research, 503 Grant Avenue, Silver Spring, Maryland

††Colonel, Medical Service Corps, US Army; Director, Military Operational Medicine Research Program, US Army Medical Research and Material 

Command, 504 Scott Street, Fort Detrick, Maryland 21702-5012; formerly, Chief, Department of Military Psychiatry and Chief, Soldier and Family 

Readiness, Walter Reed Army Institute of Research, Silver Spring, Maryland
76

Combat and Operational Behavioral Health

INTRODUCTION

Research examining the mental health impact of 

war has typically been conducted years (and often 

decades) after combat.1–3 Before Operation Enduring 

Freedom (OEF) and Operation Iraqi Freedom (OIF), 

researchers at Walter Reed Army Institute of Research 

(WRAIR) established an international reputation in 

deployment psychology. This experience put WRAIR 

researchers in a position to become leaders in new 

initiatives to understand the psychological impact 

of OIF and OEF. During the 1991 Persian Gulf War 

(Operations Desert Shield and Desert Storm), WRAIR 

research teams surveyed and interviewed US Army 

units in theater and postdeployment to assess the 

psychological impact of deployment to combat.4–12

WRAIR teams also conducted in-theater research with 

units deployed to Operation Just Cause in Panama in 

1989,13 Operation Restore Hope in Somalia in 1993,14

Operation Uphold Democracy in Haiti in 1994,15 and 

throughout the Balkans in the mid-1990s in support 

of Operation Provide Promise in Croatia,16 Operation 

Joint Endeavor in Bosnia,17 and Operation Joint Guardian in Kosovo.18 When troop mobilizations began for 

both OEF and OIF in 2002 and 2003, researchers at 

WRAIR developed and executed a comprehensive 

research plan to examine the psychological health 

of soldiers during combat. This program provided 

real-time data as the war was occurring that led to 

multiple health policy changes to improve the mental 

health and well-being of service members and their 

families. This chapter outlines some of the key mental 

health research initiatives by WRAIR scientists with a 

focus on efforts that directly influenced mental health 

policies, programs, and training for service members 

serving in war. 

WALTER REED ARMY INSTITUTE OF RESEARCH

WRAIR is a premier Department of Defense 

(DoD) biomedical research center that integrates 

basic research and advanced technology to protect 

and sustain military service members. The WRAIR 

mental health research program is located at two 

sites: (1) the Department of Military Psychiatry, Division of Psychiatry and Neuroscience, at the main 

institute in Silver Spring, Maryland, and (2) the US 

Army Research Unit—Europe in Heidelberg, Germany. Approximately 35 employees work at the two 

sites. The program is multidisciplinary, including 

research and clinical psychologists, psychiatrists, 

social workers, and sociologists, as well as expertise 

in clinical evaluation and management, organizational psychology, individual and unit performance, 

leadership, psychiatric epidemiology, and healthcare 

services research. In addition to military psychology 

and psychiatry research, the division includes two 

other world-class research programs, one focused 

on sustaining performance during sleep deprivation 

and the other on reducing the impact of battlefield 

head injuries. 

FROM RESEARCH TO PUBLIC HEALTH POLICY

After the events of September 11, 2001, and the 

onset of the war in Afghanistan, WRAIR researchers 

embarked on a comprehensive research program to 

measure the mental health impact of OEF and OIF 

on military service members. The program, called 

“Interventions to Enhance Warfighter Psychological 

Resilience,” was predicated on the recognition that 

few studies examined combat-related mental health 

problems, posttraumatic stress disorder (PTSD), or 

healthcare utilization proximal to the time of war. Such 

population-based health service utilization research 

had generally been impossible in previous wars, in 

part because of the lack of integrated electronic databases, which became available only after the Persian 

Gulf War.

The research program also recognized the need 

for data to guide public health policies to address 

war-related mental health problems. The research 

agenda established by WRAIR focused on three types 

of products: (1) information products identifying 

factors that predict high rates of mental disorders, 

gaps in service delivery, stigma and barriers to care, 

and the association of mental health with functional 

impairment and readiness; (2) assessment tools that 

provide effective methods of conducting psychological health screening in deployed troops; and 

(3) prevention and early interventions to support 

psychological adjustment to the demands of combat, 

prevent stress-related performance degradation, and 

improve resiliency and health. These tools are the 

cornerstones of prevention and early intervention 

efforts. The remainder of this chapter lists WRAIR’s 

significant efforts and accomplishments from this 

research program.
77

Walter Reed Army Institute of Research Contributions During Operations Iraqi Freedom and Enduring Freedom

INITIAL RESEARCH ON THE IMPACT OF MENTAL DISORDERS BEFORE SEPTEMBER 11, 2001

Using population-based healthcare data systems, 

researchers at WRAIR established baseline prevalence rates of healthcare service use for mental health 

problems before September 11, 2001.19–22 These studies, comparing major International Classification of 

Disease, 9th revision, illness categories, established 

that mental disorders were the most important 

source of occupational and medical morbidity as 

measured by use of medical services and attrition 

from service. The studies demonstrated that 12% 

of service members utilized mental health services 

each year, that mental disorders was the leading 

category of inpatient hospital bed days, and that 

mental disorders was the disease category most 

strongly correlated with attrition from military service and attrition from initial entry training. Such 

results provided a benchmark for understanding 

the importance of supporting the mental health of 

service members during the ensuing wars in Iraq 

and Afghanistan. 

MENTAL HEALTH IMPACT OF THE PENTAGON ATTACK

Immediately after the September 11th attack on 

the Pentagon, the Army Surgeon General’s Office 

established a comprehensive outreach program for 

Pentagon employees named “Operation Solace” and 

tasked the US Army Center for Health Promotion and 

Preventive Medicine to conduct a survey assessing 

the mental health effects on the employees. WRAIR, 

together with colleagues at the Center, Uniformed 

Services University of the Health Sciences, and the Office of The Army Surgeon General, rapidly developed 

and validated a brief survey instrument and provided 

descriptive data on the outreach program.23–25 This 

survey instrument, along with prototype instruments 

fielded during deployments in Bosnia and Kosovo, 

influenced the development of the Post-Deployment 

Health Assessment (PDHA) implemented by the DoD 

in 2003 to assess the population-level impact of deployment to a combat zone. 

RESEARCH RELATED TO OPERATIONS ENDURING FREEDOM AND IRAQI FREEDOM

In October 2001, the United States and coalition 

partners initiated OEF combat operations in Afghanistan, followed by OIF, the largest sustained ground 

operation since the Vietnam War, in Iraq in March 2003. 

The wars in Afghanistan and Iraq offered a unique 

opportunity to examine the mental health impact 

of combat deployment and, in turn, inform military 

health policy as the wars progressed. 

Epidemiological Consultations of Suicide and 

Homicide Clusters 

Just before OIF and OEF, WRAIR investigators 

established procedures to conduct epidemiological 

investigations of clusters of serious behavioral health 

problems, such as suicides or homicides, applying 

methodology developed for infectious disease outbreaks. Although infectious disease epidemiological 

consultations (EPICONs) were common in the military 

and in civilian public health departments, investigations of behavioral health clusters lacked well-established methodology. 

The first military behavioral health EPICON to 

establish the methodology was conducted in 2000. 

Its objective was to identify correlates of an outbreak 

of suicidal behaviors and completed suicides among 

soldiers in basic training at Fort Leonard Wood, Missouri.26 Since then, WRAIR investigators have been 

involved as part of Army Medical Department multidisciplinary teams in conducting EPICONS to address 

clusters of suicides and homicides at other posts. These 

clusters have been linked primarily to the high operational tempo of combat operations in Afghanistan and 

Iraq, as well as marital and family stressors.27–29

An EPICON that received national media attention 

pertained to a cluster of suicides and homicides at Fort 

Bragg, North Carolina, among soldiers involved in 

operations in Afghanistan.27 This investigation resulted 

in recommendations that led to the 2003 establishment 

of the Army Deployment Cycle Support Program,30 a 

comprehensive program designed to support soldiers 

and family members throughout the deployment cycle 

and assure that soldiers who return home from the 

combat environment because of serious family stressors are evaluated upon return to duty. 

Land Combat Study 

One of the most well known epidemiological surveillance studies pertaining to OIF and OEF is the 

large-scale, 5-year Land Combat Study. Initiated in 

2003, the study involves anonymous cross-sectional 
78

Combat and Operational Behavioral Health

and longitudinal surveys that assess the mental health 

and well-being of service members in combat infantry 

brigades serving in Iraq and Afghanistan. The surveys 

use validated measures to assess the mental health and 

well-being of service members at different points during their deployment cycle (before, during, and after 

deployment). Surveys have been collected from over 

50,000 service members, mostly from Army brigade 

combat teams but also from Marine Expeditionary 

Forces and Navy engineers working in ground operational units. Data have also been collected from 

military spouses. 

Data from some of the first units to return from 

OIF and OEF deployments were rapidly analyzed 

and published in the New England Journal of Medicine 

in July 2004.31 This publication provided the first 

systematic look at the mental health of soldiers and 

Marines involved in combat operations in Iraq and 

Afghanistan. The study indicated that 12% to 13% of 

soldiers and marines from combat units surveyed 3 to 

4 months after returning from deployment to Iraq met 

the screening definition of PTSD, compared with 5% 

at predeployment. In addition, 15% to 17% of those 

surveyed at postdeployment met the screening definition of PTSD, major depression, or generalized anxiety 

disorder, compared with 9% at predeployment. 

To maximize specificity for population-level prevalence estimates, investigators used stringent cut-off 

criteria to determine mental disorders in this study. 

Using more sensitive criteria widely validated in clinical care settings, the study indicated that 18% to 20% of 

soldiers returning from combat in Iraq had significant 

symptoms of PTSD, and 28% to 29% had significant 

symptoms of PTSD, depression, or anxiety. The study 

also found deployment to be associated with alcohol 

misuse: 24% to 35% of subjects reported using more 

alcohol than intended, and 20% to 29% reported wanting or needing to drink less. 

Besides establishing the prevalence of mental health 

symptoms among military personnel returning from 

combat, another critical finding identified by this 

study was the problem with stigma and barriers to 

care. The study showed that the majority of service 

members who had significant mental health problems 

did not receive care, and concerns about stigma and 

other barriers to care were pervasive. The study led 

to widespread DoD, public, media, and congressional 

interest, as well as multiple new clinical, research, and 

public health efforts throughout DoD and the Veterans 

Administration to mitigate stigma, remove barriers to 

care, and improve the screening and treatment of PTSD 

after deployment. 

A subsequent publication from the Land Combat 

Study assessed the prevalence of mental health problems 12 months postdeployment. In this sample, 17% 

of service members met the criteria for PTSD, major 

depression, and/or generalized anxiety using the stringent cut-off criteria.32 This finding confirmed that no 

decrease in symptoms occurred during the first year 

postdeployment. This 1-year period was the same 

amount of time many units had before rotating back 

to Iraq or Afghanistan for a subsequent deployment, 

suggesting that the soldiers had not recovered from 

the first deployment when they left for their second 

deployment. 

The study also demonstrated that soldiers with 

PTSD symptoms were much more likely than soldiers 

from the same deployments who did not have PTSD 

symptoms to experience lower ratings of general 

health, more missed work days, higher use of medical 

services, and higher somatic symptom levels. These 

findings were independent of being wounded or injured. The study highlighted the comorbidity of PTSD 

with physical health problems and the need to evaluate 

veterans who present with somatic concerns for PTSD. 

This study was one of several that provided data supporting the implementation of new DoD programs to 

enhance mental health screening and management in 

primary care settings.33

Mental Health Advisory Teams

Another important OIF initiative is the epidemiological assessment of the mental health and well-being 

of troops during deployment. Each year, the Army 

surgeon general deploys a team of mental health 

experts together with researchers from WRAIR to 

conduct anonymous assessments of the mental health 

of troops in Iraq. These teams use similar surveys to 

those administered as part of the WRAIR Land Combat 

Study research protocol, and also assess the adequacy 

and distribution of behavioral health resources in 

theater.34–37

Key findings from the mental health advisory team 

missions included: 

	 •	 Fifteen to twenty percent of combat troops

deployed to Iraq experience significant symptoms of acute stress, PTSD, or depression, and 

twenty percent of married service members 

experience marital concerns.

	 •	 Longer deployments, multiple deployments,

greater time away from the basecamp, and 

combat frequency and intensity all contribute to higher rates of PTSD, depression, and 

marital problems.

	 •	 Combat frequency and mental health problems are associated with ethical mistreatment 
79

Walter Reed Army Institute of Research Contributions During Operations Iraqi Freedom and Enduring Freedom

of noncombatants.

	 •	 Good unit leadership is key to sustaining

mental health and well-being among combat 

troops.34–37

As a result of these findings, the Army revised the 

combat and operational stress control doctrine and 

training,38 mandated stress control training for all 

deployment mental health professionals, and ensured 

that sufficient mental health personnel (credentialed 

providers and mental health technicians) are available 

in theater. The mental health advisory teams identified 

an optimal ratio of at least one mental health professional for every 1,000 troops, supporting the Army’s 

effort to ensure optimal distribution and access to 

services throughout theater. The findings also led to 

the inclusion of new training initiatives for soldiers and 

leaders developed by WRAIR researchers.39

Research on Deployment Mental Health Screening 

Another important WRAIR research initiative has 

focused on psychological screening. DoD-wide psychological screening began in 1996 with the deployment of US forces to Bosnia and continued as a commander’s program with the subsequent deployment 

to Kosovo.40 Psychological screening was designed to 

identify individuals in need of follow-up mental health 

services and provide a proactive way to link individuals with mental health professionals. 

The current DoD screening program was launched 

in April 2003, a month after the ground war began in 

Iraq. At that time, the DoD mandated that all service 

members complete a PDHA immediately upon return 

from any deployment using a brief screening instrument combined with a clinical interview.41 Initiated 

to meet an immediate need, the program generated 

controversy for being started before any evidence 

was available to support the effectiveness of such a 

program.42,43

The goal of WRAIR’s screening research program 

has been to validate and improve the screening for 

mental health problems associated with deployment. 

In keeping with these goals, WRAIR conducted a series of studies to identify the appropriate content for 

predeployment and postdeployment screening,44 the 

best approach to screening,45 the psychometrics of the 

screening instruments,46 and effective implementation 

strategies.47 The results of this research and subsequent 

program evaluation48 have influenced the development of the DoD psychological screening program for 

military personnel returning from Iraq. Three WRAIR 

studies were particularly notable in guiding the DoDwide postdeployment screening program. 

The first study looked at the timing of the screening process. Shortly after the PDHA was initiated, researchers at the WRAIR unit in Europe determined that 

soldiers were two to five times more likely to report 

mental health concerns 4 months after returning from 

deployment than they were immediately upon return 

from deployment.47 The data were communicated to 

DoD Health Affairs in early 2004 and led to an immediate triservice mandate to expand the PDHA program to 

include a second screen, the Post-Deployment Health 

Reassessment (PDHRA), 3 to 6 months after return 

from deployment.49

A second study included a series of analyses that 

validated the mental health questions used on the 

PDHA and PDHRA against a “gold-standard” structured diagnostic interview.46 This study demonstrated 

that the PDHA questions had acceptable sensitivity 

and specificity in identifying individuals who needed 

further evaluation or treatment and contributed to a 

better understanding of how to score the PDHA and 

PDHRA questionnaires. 

The third study, conducted in collaboration with 

the Army Medical Surveillance Activity, evaluated 

the lessons learned from the PDHA program on a 

population-wide level. The study showed that combat duty in Iraq was correlated with high utilization 

of mental health services and attrition from military 

service postdeployment.48 One third of soldiers returning from OIF utilized mental health services in medical 

treatment facilities in the year after returning home (including screening, prevention, and treatment services). 

However, the PDHA was found to have limited utility 

in predicting the level of mental health services that 

were needed postdeployment. These data highlight 

the challenges in ensuring that adequate resources are 

available to meet the mental health needs of returning 

veterans. The data also supported the DoD Health Affairs’ decision to expand the PDHA program to include 

the PDHRA 3 to 6 months postdeployment. 

Wartime Studies of Leadership and Unit Factors in 

Operational Units 

A unique feature of WRAIR research has been studies of the relationship between mental health and unit 

factors such as leadership. Studies have collected data 

from large intact units (eg, brigade combat teams), 

thereby including responses from members of the 

same subordinate units (eg, companies and platoons). 

This sampling strategy provides an opportunity to 

examine shared collective perceptions of unit members about cohesion and leadership and understand 

how these perceptions relate to mental health.50,51 The 

research has shown that variables of this nature have 
80

Combat and Operational Behavioral Health

both main-effect and moderating influences.52 In terms 

of main effects, perceptions of leadership, cohesion, 

and other aspects of the social environment have been 

shown to be directly related to mental health outcomes. 

That is, units with positive perceptions of leadership 

and cohesion also tend to report low levels of psychological problems, and this shared unit effect is often 

stronger than the effect analyzed as an individual-level 

relationship.51,53 Leadership and other unit factors have 

also been shown to interact with various stressors such 

that the negative effects of stressors are weakened 

when unit factors are positive. This finding suggests 

that leadership, cohesion, and other forms of social 

climate may serve to protect soldiers from combat 

stressors. In one example, shared perceptions of leadership provided a protective influence for soldiers 

deployed to Haiti.54 As noted, a key finding from the 

fourth mental health advisory team assessment in Iraq 

(2006) was that good unit leadership was associated 

with fewer mental health problems.37 As a result of 

these research findings, WRAIR developed training 

materials to improve leader behaviors and enhance 

the mental health of units. 

Battlemind Training

At the time that the DoD’s Deployment Cycle Support Program was initiated, no standardized combat 

and deployment stress training packages existed to 

prepare soldiers for the stressors of war, or to facilitate 

their transition home, and no integrated mental health 

training occurred across the deployment cycle. Thus, it 

was up to behavioral health professionals at each military post to come up with their own training material 

to meet the requirements of the program. 

To address this need, WRAIR researchers created a 

validated standardized mental health risk communication training program called “Battlemind.” Battlemind 

educates soldiers and leaders about

	 •	 what to expect at each phase of the deployment cycle,

	 •	 how to look out for their own mental health,

	 •	 how to help their fellow unit members, and

	 •	 resources available forthem to get help if they

need it during and after deployment.

The content of Battlemind training, based on results 

and lessons learned from studies of OIF and OEF 

combat soldiers, focuses on the strengths and skills 

that help soldiers survive in combat. 

Following the piloting of the first Battlemind products in 2005 and 2006, several new products have been 

developed and disseminated in collaboration with 

the Army Medical Department (AMEDD) Center and 

School. Several prototype Battlemind training modules 

have been developed and piloted for each phase of the 

deployment cycle. Predeployment training includes a 

module for soldiers and leaders that builds resilience 

by anticipating combat stressors and typical reactions 

while identifying actions that can be taken to meet 

these challenges. Predeployment modules have also 

been developed for behavioral health professionals 

and military spouses. 

During deployments in Iraq, mental health professionals are using two types of Battlemind psychological debriefing techniques developed by WRAIR.55

Event-driven Battlemind psychological debriefing is 

designed for use after a critical event, and time-driven 

Battlemind psychological debriefing is designed for 

use periodically over the course of a 12- or 15-month 

deployment. Both of these techniques actively integrate Battlemind concepts, using structured group 

discussion to review key issues, reinforce positive 

mental health strategies, encourage unit members to 

look out for one another, and keep individuals focused 

on professional and ethical conduct. 

The practice of psychological debriefing is controversial, and controlled research examining the efficacy 

of debriefing with at-risk cohesive occupational groups 

is lacking.56,57 WRAIR demonstrated the efficacy of 

postdeployment Battlemind psychological debriefing 

in a group randomized-control trial in which platoons 

were assigned to different types of postdeployment 

transition training.58 The debriefing techniques used 

in this study were the basis for in-theater debriefing 

models and a postdeployment Battlemind psychological debriefing model now integrated into the Combat 

Operational Stress course taught at the AMEDD Center 

and School. 

In the same study, Battlemind training conducted at 

reintegration and at 3 to 6 months postdeployment was 

also found to effectively reduce mental health symptoms over time.59 These two postdeployment training 

modules highlight combat skills that can be adapted 

to facilitate the transition home. A postdeployment 

Battlemind training module has also been developed 

for spouses. Additional Battlemind training products 

under development include a first aid module for medics, basic Battlemind during initial military training, 

and leadership development courses. Several training 

DVDs have also been developed to supplement the 

Battlemind system. 

Battlemind training is currently integrated into the 

Deployment Cycle Support Program directive and 

is part of the standard training that soldiers receive 

before and after combat deployment.30,39 Battlemind 

training offered for spouses is specifically designed to 
81

Walter Reed Army Institute of Research Contributions During Operations Iraqi Freedom and Enduring Freedom

strengthen their resilience during times of separation 

due to war. As each Battlemind product is fielded, it 

has been made available on its Web site, www.battlemind.org. Other nations including Canada, the United 

Kingdom, and Australia are also adopting Battlemind 

training.

Army Medical Department General Officers Behavioral Health Summit 

In June 2006, WRAIR hosted a general officers summit for the Army surgeon general and the commander 

of the US Army Medical Research and Materiel Command. The 2-day conference, attended by 20 AMEDD 

general officers, was conducted with three primary 

goals: (1) to arrive at a common understanding (or 

“lexicon”) of available data on the mental health 

impact of combat, (2) to evaluate best practices and 

lessons learned so that consistent approaches can be 

established across components and installations, and 

(3) to establish the AMEDD behavioral health strategy. 

The conference achieved its goals and led to the publication of a comprehensive report on Army behavioral 

healthcare strategy.60

OTHER WRAIR MENTAL HEALTH RESEARCH INITIATIVES

WRAIR researchers have been involved in a variety 

of related efforts, including assessing how adverse 

early childhood experiences affect psychological adjustment following combat,61 assessing the appropriateness of PTSD diagnostic criteria applied to combat 

veterans,62 and developing a conceptual model for understanding the stigma of mental health problems.63

The research program has also led to innovations 

in the development of tools to help unit leaders assess 

the behavioral health status of their units. WRAIR 

researchers have used their knowledge of health measures, military norms from the Land Combat Study, 

and feedback from unit commanders to develop a 

unit needs assessment program, designed for behavioral health professionals to provide consultation to 

military units. The program includes tools, scoring 

guidelines, implementation recommendations, and 

a briefing template to facilitate the behavioral health 

assessment of units. 

Given the complexities associated with analyzing large data sets collected from soldiers hierarchically nested within military units (squads, platoons, 

companies, etc), the WRAIR research program has 

also contributed to innovations in statistical software 

and statistical techniques. Many of these innovations 

have been implemented in the open-source statistical 

language R.64 For instance, the “lme4” package in R is 

designed to analyze hierarchical mixed-effects models 

containing dichotomous outcomes (eg, meeting or not 

meeting PTSD thresholds). The algorithms used in 

the lme4 package were developed by the University 

of Wisconsin and the Toyon Research Corporation 

(Goleta, Calif) in a Small Business Technology Transfer 

Program grant managed by WRAIR scientists. 

In another example, WRAIR researchers developed 

and maintain the multilevel package for R, providing 

a number of routines for determining whether group 

members significantly agree about shared concepts 

such as unit leadership or cohesion. Finally, the package “ltm” is designed to perform item response theory 

analyses on specific survey items to aid in creating 

scales with good psychometric properties. WRAIR 

scientists provided funding to expand the ltm package 

to handle multiresponse items (eg, strongly disagree, 

disagree, neither, agree, strongly agree). Each of these 

developments has contributed to the analyses of complex multilevel data sets involving health outcomes.

WRAIR researchers are active in publishing their 

work in peer-reviewed journals and other outlets. 

In 2006 the work of several WRAIR researchers was 

showcased in a four-volume book series, Military 

Life: The Psychology of Serving in Peace and Combat.

65–68

WRAIR research figures prominently throughout this 

comprehensive examination of the psychological issues facing military personnel and their families. The 

series also provides an agenda for military psychology 

research in the coming years. 

Finally, WRAIR research has been widely cited by 

medical policy makers and lawmakers, and has contributed to significant increases in funding for PTSD 

treatment and research within the DoD and Veterans 

Administration. The fiscal year 2007 Congressional 

appropriation, for example, included a total of $450 

million for research and treatment initiatives in the 

area of PTSD, and another $450 million for traumatic 

brain injury. 

SUMMARY

In keeping with its tradition of working directly 

with military units in times of conflict, WRAIR has 

been at the forefront of mental health research since 

the events of September 11, 2001. Researchers have 

conducted comprehensive analyses of the mental 

health impact of OIF/OEF, improved deployment-
82

Combat and Operational Behavioral Health

related screening initiatives, and developed interventions to improve the psychological health of US 

troops. The program has been focused on directly 

supporting operational units, deploying research 

teams into Iraq and Afghanistan, generating timely 

products relevant to current operations, and informing 

healthcare policies on an Army- and DoD-wide level. 

Future directions include the development of advanced training modalities to improve resiliency and 

mitigate the mental health effects of combat, randomized controlled trials to assess early interventions, and 

studies of the relationship between PTSD and combat 

injuries, including traumatic brain injuries. Through 

balancing scientific rigor with the behavioral health 

needs of military personnel, WRAIR researchers will 

remain focused on delivering quality information and 

training products in support of service members and 

their families. 

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