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Severe Psychiatric Illness in the Military Healthcare System

Chapter 27

SEVERE PSYCHIATRIC ILLNESS IN THE 

MILITARY HEALTHCARE SYSTEm

GEOFFREY GRAMMER, MD*

INTRODUCTION

BRIEF PSYCHOTIC DISORDER, SCHIZOPHRENIFORM, AND SCHIZOPHRENIA

SUBSTANCE-INDUCED PSYCHOSIS

BIPOLAR DISORDER

MAJOR DEPRESSIVE DISORDER

POSTTRAUMATIC STRESS DISORDER

REMOTE SITE TREATMENT CONSIDERATIONS

AIR EVACUATION

SUMMARY

*Lieutenant Colonel, Medical Corps, US Army; Chief, Inpatient Psychiatry, Department of Psychiatry, Walter Reed Army Medical Center, 6900 Georgia 

Avenue NW, Washington, DC 20307 
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INTRODUCTION

New military recruits with psychiatric illness often will have their first contact with mental health 

professionals within the military healthcare system. 

Demographics, personal development, and life circumstances contribute to first-presentation illness 

that manifests only after active duty entry. Medical 

standards for enlistment or commission and retention 

effectively select out service members with recurrent or 

chronic mental illness. Providers who care for military 

service members are thus afforded a unique opportunity to set the tone for therapeutic alliances with patients 

unfamiliar with mental healthcare. Providers must also 

contend with patients struggling with insight and acceptance of newly diagnosed mental illness.

Several assumptions are made in this discussion 

of severe psychiatric illness in the military. Diagnoses 

elaborated in this chapter are based on the 4th edition 

of the Diagnostic and Statistical Manual (DSM-IV-TR) of 

the American Psychiatric Association. Combat zones 

are considered to be outside the continental United 

States. Severe mental illnesses include, but are not 

limited to, the diagnoses of brief psychotic disorder, 

schizophreniform disorder, schizophrenia, schizoaffective disorder, delusional disorder, major depressive 

disorder–severe, and bipolar disorder types I and II. 

And finally, the use of antidepressants and neuroleptics requires 4 to 6 weeks before efficacy can be fully 

realized.

Almost 90% of new recruits enlist in the Army 

before the age of 25, thus falling within the window 

of the average age of onset for many psychiatric illnesses.1

 Schizophrenia will begin earlier in men than 

women, but excepting less distinct prodomes, the 

average age of onset falls well within this window. 

Bipolar disorder is considered to have a bimodal peak 

onset, both in early adulthood and again later in life 

(around age 50), a time when many are ending their 

military careers. Depression can begin at any age, but 

the average age of onset is 25, falling well within the 

new-recruit age range. 

Entering into military service is not a decision that 

most take lightly. It requires geographic separation 

from friends and family, changes in daily activities, 

loss of some flexibility enjoyed by civilians, and the 

potential for hazardous deployments. A decision to join 

can challenge one’s existential and phase-of-life development and presents service members with stressors rarely found in the civilian workforce. Drastic life 

changes can be accompanied by destabilizing anxiety, 

a precipitate of psychiatric illness.

Some new recruits enter military service to bring a 

change of direction to their lives. Although most often 

this is a personal developmental milestone followed 

by a successful career, it can sometimes be the result of 

premilitary failings resulting from subclinical or fully 

developed mental illnesses. Obligations required of 

soldiers and the stringent fitness for duty requirements 

may be unknown to those who see military service as 

a chance to bring about a change in their lives. At its 

extreme, recruits may join the military with preexisting 

severe mental illness, often stopping pharmacologic 

treatment shortly before entering basic training to 

facilitate acceptance into service. 

The military operates in environments ranging from 

remote locales with few to no medical facilities through 

major academic medical centers. Soldiers may find 

themselves in garrison, peacetime missions, training 

exercises, or combat zones. Each of these environments 

presents its own unique challenges to new onset or 

recurrence of major psychiatric symptoms. Resources 

at each locale are utilized to control symptoms and 

agitation until definitive care can be administered, 

often within the confines of continental United States 

military medical facilities.

Military mental health professionals provide care 

within the context of the physical disability system 

and military regulations. Providers must often comply with the actions of the physical evaluation board 

(which will determine fitness for duty and potential 

disability ratings), while simultaneously attempting 

to maximize clinical improvement. These competing 

agendas and potential conflicting interests can add 

an unwelcome complexity to patient management. 

Patients undergoing fitness-for-duty and disability 

determination may have a financial or administrative 

disincentive for improvement or accurate reporting of 

decline in their clinical status due to varying degrees 

of conscious and unconscious secondary gain. 

BRIEF PSYCHOTIC DISORDER, SCHIZOPHRENIFORM, AND SCHIZOPHRENIA

The spectrum of primary thought disorders described in the DSM-IV-TR may present uniquely in 

a military community. Though predominately distinguished by length of symptoms, brief psychotic 

disorder may terminate in non-thought-disorder 

diagnoses such as adjustment disorders.2

 Differentiating true schizophreniform disorder (as defined by 

complete resolution of symptoms within 6 months 

of onset) from first-break schizophrenia (which has 

the same symptoms as schizophreniform disorder 
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Severe Psychiatric Illness in the Military Healthcare System

but lasts for a lifetime) may be possible only after 

clinical observation. Often the clinician will need 

to wait to see if the symptoms persist over time; it 

is estimated that 25% of these cases will resolve.3

Unfortunately for many patients, both brief psychotic disorder and schizophreniform disorder may 

serve only as place markers in the timeline of new 

onset schizophrenia, most commonly a chronic and 

disabling disease. 

A detriment to clinical accuracy can occur with such 

early presentation of primary thought disorders. It is 

common for psychotic symptoms to not be fully developed leading to ambiguous perceptual disturbances, 

delusional beliefs, or executive functioning that may 

make diagnosis more difficult. Premature diagnoses 

of delusional disorder and psychosis not otherwise 

specified may underestimate the severity of illness and 

long-term functional implications if the true disorder is 

schizophrenia. Military providers should consider this 

phenomenon when applying diagnoses and determining treatments and disposition management.

Presentation of psychotic illness is different than 

that seen in the general community. Closer scrutiny 

and command oversight can result in a greater interpersonal immersion than in the civilian workplace. 

Command-directed evaluations can require service 

members to undergo evaluation with a level of dysfunction that may not have reached threshold criteria 

in a civilian healthcare system. Early referral may be 

beneficial, as symptoms may be present for shorter 

periods before presentation to mental healthcare and 

thus offer an opportunity to positively effect long-term 

outcome through early treatment.4,5 Ensuring compliance during initial treatment may enhance outcomes 

and slow declines in function seen in naturalistic studies.6

 Service members undergoing a medical evaluation 

board often wait for months, if not more than a year, 

before adjudication, which offers an opportune time 

for close monitoring of compliance and subsequent 

clinical status.

Pharmacologic management of primary thought 

disorder extends beyond the scope of this chapter. 

Long-term metabolic and extrapyramidal side effects 

should be weighed against proven efficacy for positive 

and negative symptoms and receptor profiles.7 When 

psychosis arises in remote locations, choice of an antipsychotic agent is often more dictated by availability 

than the previously described variables. This may be 

problematic if efficacy is achieved despite long-term 

issues of toxicity.

SUBSTANCE-INDUCED PSYCHOSIS

Intentional and unintentional ingestions of supplements, medications, or illicit substances can result in 

mental status changes that may mimic severe thought 

disorders. History, physical examination, and laboratory testing sometimes detect a particular agent, but 

history may be difficult to obtain from an acutely 

agitated patient. Furthermore, not all substances are 

readily detected in drug screens or routine laboratory 

tests, or laboratory testing may not be possible in some 

field environments. 

Illicit substances and novel ways of utilizing 

items not intended for consumption have their own 

usage trends in the community. Illicit substance use 

has its own variations in popularity depending on 

street costs, accessibility, and cultural acceptance. 

Knowing which items are “in style” can assist with 

more rapid diagnosis of sudden changes in mental 

status. In addition, novel ways of ingesting or inhaling routine items, such as pressurized air, solvents, 

or even brake fluid, can alter mental status. Familiarity with these substances may allow for more 

rapid detection of their use and intervention for 

the potentially life-threatening complications that 

may develop. Collateral history from fellow service 

members, barracks health and welfare inspections, 

and prior substance abuse history may help providers determine if a particular agent is associated with 

behavioral change. 

Withdrawal from substance dependence can not 

only result in an acute change in mental status indistinguishable from primary mental illness, but it may 

also be associated with life-threatening complications. 

Military service with controlled environments—weekend drills, field exercises, combat deployments, and 

military training schools—can interrupt accessibility to 

drugs or alcohol for a chronic substance-using service 

member. Healthcare providers should remain vigilant 

for, and be prepared to treat, such events.

BIPOLAR DISORDER

Bipolar disorder presents diagnostic and management considerations for service members presenting 

with current or past histories of mania. With a bimodal 

onset, it can affect new recruits in their second decade 

or those getting ready to retire in their fifth decade.8

Both are associated with significant adjustments, as 

younger patients will have to contend with management of an indefinite mental illness, and those in 
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mid-life have retirement and generational phase-of-life 

development potentially derailed with a new-onset 

mental illness. 

Bipolar disorder type I can present with frank 

psychosis, making diagnosis more difficult. Acutely 

agitated patients with grandiose delusions may be indistinguishable from those with agitated schizophrenia 

without collateral history to suggest prior and current 

mood criteria. Misdiagnosis may be more common in 

certain ethnic groups and thus caution should be taken 

when suggesting diagnoses in minority populations.9

Bipolar type II can be less dramatic in its presentations with hypomania. A decreased need for sleep, 

narcissism, and increased goal-directed activity can 

be adaptive for noncommissioned and commissioned 

officers. Presentation for care can commonly occur under times of marked duress, such as a combat deployment, when defenses used in a hypomanic state are 

overwhelmed (leading to decompensation) or during 

depressed mood episodes. Traditional antidepressant 

medications can cause destabilization and thus a careful collateral history is needed for any service member 

presenting with depression, to ensure there have not 

been prior manic symptoms.

Bipolar disorder has a high likelihood of recurrent 

mood episodes and providers should give strong consideration for initiation of a medical evaluation board.10

Environmental changes, lack of access to laboratory 

monitoring, and sleep-cycle changes can destabilize 

this condition, and conversely, early treatment, avoidance of illicit drug and alcohol use, and lifestyle management can improve long-term prognosis.11 Military 

mental healthcare providers are in a unique position 

to affect the course of this illness long after patients 

have separated from the service.

Choice of pharmacologic agents should account 

for likely indefinite treatment and potential long-term 

side effects, such as metabolic impact and tolerance. 

Practice guidelines continue to push the envelope of 

evidenced-based treatments and extend beyond the 

scope of this chapter. Providers, however, should seek 

these resources to remain abreast of agents with the 

most evidence-based efficacy while mitigating potential side effects.12

MAJOR DEPRESSIVE DISORDER

Depression is a common disorder affecting service members of all ages.13 The effect of this illness 

on performance can be more variable than seen 

with primary thought disorders or bipolar disorder, 

ranging between little to no impact on performance 

to marked decrement with potential harm to self or 

others. Remote locales, variable pharmacologic and 

psychotherapeutic resources, command support, and 

psychosocial stressors all can affect treatment decisions 

and disposition.

The DSM-IV-TR does not distinguish between exogenous or endogenous depression. Although many 

cases have some components of external influences 

and endogenous predispositions, unique military 

environments can bring about extraordinary levels of 

environmental stress that challenge the most resilient 

of personalities. Geographic separation from friends 

and family, combat exposure, obligated tours of duty, 

scrutiny from command, loss of privacy, and physical 

demands are some of the unique military stressors 

than can help precipitate a depressed mood. Because 

service members are often unable to change their 

occupations or duty assignments and thus avoid an 

unpleasant stressor, hopelessness may ensue, leading 

to suicidal and/or homicidal thoughts. Even though 

meeting criteria for major depressive disorder, many 

of these service members will have rapid resolution 

of symptoms if medically removed from the situation, 

such as through evacuation, more fitting the intent of 

the diagnosis of adjustment disorder despite being 

incorrect by criteria.14

Whereas overt behavior associated with mania 

and psychosis will garner the attention of peers and 

commanders, isolation associated with a worsening 

depression may go unnoticed. Deployment to areas far 

from mental health resources, stigma associated with 

accessing care, and unwarranted fear of career damage 

if treated may delay entry into care. Ongoing military 

efforts to raise awareness and ease access cannot completely negate these effects. Unfortunately, ready access 

to firearms and heavy machinery make self-injurious 

behavior lethal in a military with a predominately 

younger male population, which has tended to prefer 

this mechanism for suicide.

Fortunately, mild to moderate depression can be 

treated with relative ease using both therapy and psychopharmacology, with medical assets allowing care 

in almost all austere locations. Providers who choose 

to use medications in their treatment of mild to moderate depression should consider agents less likely to 

cause sedation, ataxia, weight gain, or anticholinergic 

side effects because all of these can impair a soldier’s 

performance. Antidepressants with shorter half-lives 

and associated withdrawal phenomenon should also 

be avoided because compliance is not always accommodated by operational tempos. 

Severe depression may be associated with marked 

performance decrement, reality testing impairment, 
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Severe Psychiatric Illness in the Military Healthcare System

or injurious behavior, and should be managed at fixed 

facilities removed from active military operations. 

Diagnostic clarity often requires inpatient observation 

to rule out a depressive episode of bipolar disorder, 

or the presence of a primary thought disorder such as 

schizoaffective disorder, especially if there are comorbid psychotic symptoms. Treatments will likely require 

antidepressant and antipsychotic administration, with 

electroconvulsant therapy (ECT) as an option for those 

refractory to medication, unable to tolerate medication, 

or those with life-threatening severity, such as imminent suicidality or catatonia. Single episode severe 

depression with psychosis warrants strong consideration for a medical board.

POSTTRAUMATIC STRESS DISORDER

Combat-related posttraumatic stress disorder 

(PTSD) may account for up to 20% of inpatient admission to CONUS medical facilities through the 

aeromedical evacuation system.15 Often the symptoms 

of PTSD alone do not lead to inpatient treatment, but 

rather comorbid psychiatric conditions (with or without illicit substance use) manifest potentially dangerous clinic states that necessitate inpatient psychiatric 

treatment. With increased awareness of the phenomenon of PTSD and possible financial disability compensation, patients may find PTSD symptoms easier to 

discuss with providers, thereby masking another major 

psychiatric illness. Providers should remain vigilant 

for confounding illness present in patients who arrive 

with severe disability or safety concerns and insist on 

a sole diagnosis of PTSD. Further discussion of PTSD 

is covered elsewhere and readers are referred to those 

relevant sections of this book.

REMOTE SITE TREATMENT CONSIDERATIONS

Any mental health facility must be prepared to 

handle agitated and violent patients no matter how 

remote the location. Treatment teams need to construct 

contingency plans utilizing whatever resources they 

have available to secure a violent or agitated patient, 

including using restraint and emergency pharmacologic management. For smaller teams, other personnel 

may need to be enlisted to train and potentially assist 

with a restraint. Potential personnel resources may 

include medics, other unit members, military police, 

and battalion aid station staff. Soft-point restraints are 

a Joint Commission standard, but not always available 

on site. Providers may have to use locking ties typically 

reserved for detainees until appropriate restraint can 

be obtained. Pharmacologic treatment of agitation may 

require intramuscular injections that do not require 

refrigeration. 

Pharmacologic options may be limited, particularly 

in immature operational areas. Providers should be 

aware of what medications are available to them and, 

when possible, assist with deciding which medications 

to pack at the start of a mission. Availability of medical 

supplies and utilizing surrounding medical facilities 

can help expand medication options.

If troop movements are ongoing, medical facilities may find themselves occupied with tasks of unit 

relocation and thereby have less capability to provide 

resource intensive care. The threshold for evacuation 

will need to change to accommodate operational 

tempo in these situations. Skill sets of providers may 

also dictate what is feasible, as does patient availability. Expectations of patients to follow up weekly in an 

active combat environment may not be appropriate 

if traveling to and from the medical site is a hazard 

itself. Attending line unit battle update briefings will 

help with accurate intelligence acquisition for ongoing 

operations as well as foster a collaborative relationship 

with commands. 

While awaiting air evacuation, patients should be 

kept in a quiet room with minimal distractions. Patients who suffer from psychosis can misunderstand 

the most basic voice inflection, so providers should interact with these patients in a neutral tone and focus on 

factual information, such as current location, plan for 

evacuation, dosing of medications, and formal names 

of the people who are involved in the patient’s care. A 

patient who is psychotic at a combat stress center can 

be disruptive to soldiers recovering from mood and 

anxiety conditions. Providers should educate other 

patients at the facility about differing disease presentations in an effort to minimize pathologic identification 

for those for whom this would be a concern.

AIR EVACUATION

The international deployment of military forces 

creates a unique situation where patients may be 

evacuated across continents at the beginning of their 

mental healthcare. Although hospitalization alone can 

be an adjustment, time-zone changes, layover in medical facilities, and long evacuation flights may affect 
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the presentation of patients as they move through the 

system.16 Exposing patients to this process is justified 

by the need to get them to a fixed medical facility for 

definitive treatment and fitness-for-duty determination.17 Given the risks of symptom exacerbation and 

subsequent agitation, a low threshold for pharmacologic treatment and possible physical restraint should 

be considered. 

Another consequence of medical evacuation is 

evolution of clinical state when service members reach 

rear-echelon medical facilities. There may be numerous 

reasons for such an occurrence. Once removed from 

whatever stressor may have precipitated or aggravated 

their condition, some service members will reconstitute quickly en route. Other patients may have time to 

reflect on consequences of admitting to delusional belief systems or to the presence of hallucinatory events, 

and thus began to recant their stories given the reaction 

of those to whom they had confided. Some service 

members may admit to severe psychiatric symptoms 

with secondary gain as a motivator and, upon seemingly realizing their objective, begin to report a rapid 

recovery to escape the mental healthcare system. Treatments instituted at the lower echelon of care may have 

a rapid effect leading to genuine symptom improvement. The end result is that patients diagnosed with 

severe psychiatric disorders at lower echelons of care 

may look different and much less ill when arriving at 

a tertiary treatment facility. 

Providers should not dismiss collateral and observed behavior noted downrange. Underestimation 

of severity of illness can have consequences to both 

patient care and unit readiness. Upon arrival at the 

definitive care facility, medical records should be 

reviewed and collateral contacts made with medical 

personnel involved in the care of the patient prior 

to that point. Existence of electronic record systems 

should facilitate continuity of care, but austere environments may not allow for such a convenience and 

physical records may not survive extensive evacuation routes. Providers should make concerted efforts 

at overcoming inherent obstacles to continuity that 

military operations may create.

Command should be notified of the patient’s arrival at each step along an evacuation route. It is 

not uncommon for patients to be evacuated from an 

operational area with such efficiency as to outpace 

command notification. In addition, commands can 

provide invaluable collateral data on history of presentation, premorbid functioning, known interpersonal 

and social stressors, environmental exposures, and 

actions that may be subject to the Uniform Code of 

Military Justice. 

Patients should receive a thorough medicalpsychiatric assessment upon arrival at definitive 

treatment facilities. Lower echelons of care may not 

have resources available to meet practice guideline 

recommendations for medical workup of the psychiatric patient. The receiving facility should ensure 

that psychiatric symptoms do not have a medical or 

substance-induced cause. Operational environments 

downrange may also have competing priorities, such 

as ongoing combat operations, that prevent providers 

from completing a thorough assessment. In some cases, 

an expeditious evaluation may have been formed to 

determine appropriateness for evacuation and initial 

management. Some patients may require tests, such 

as a positron emission tomography scan, magnetic 

resonance imaging, or electroencephalography, that can 

only be performed at higher echelon facilities. Finally, 

case load downrange may not lend itself to a thorough 

psychiatric assessment that can be performed at a major 

medical facility with subspecialty consultations and 

graduate medical education programs.

SUMMARY

Severe psychiatric illness represents an important 

component of military mental healthcare. Unique 

aspects of military service and operations may impact presentation and disease processes. Military 

mental health providers should be familiar with 

the management of severe psychiatric illness and 

the nuances of its treatment in an operational environment. 

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