Operation Iraqi Freedom (OIF) 

Mental Health Advisory Team (MHAT) 

REPORT 

16 December 2003 

Chartered by: 

U.S. Army Surgeon General 

& HQDA G-1

This report is redacted to remove unit identifications, unit locations, and personal 

identity information in accordance with Army Regulation 25-55, Department of 

the Army Freedom of Information Act Program, and Army Regulation 340-21, 

The Army Privacy Program. Redacted information appears throughout this 

report blacked out, such as below. 

The views expressed in this report are those of the OIF MHAT members and do not necessarily 

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

of the Surgeon General. 
 

TABLE OF CONTENTS Page 

OIF MHAT Executive Summary 4 

 

OIF MHAT Report 8 

Appendix 1: MHAT Charter 32 

Appendix 2: OIF Mental Health Concern Information Paper 35 

Annex A: Soldier Health and Well-Being Survey A-1 

Appendix 1: Peer-Mentoring Program A-21 

Appendix 2: Summary of Soldier Health and Well-Being A-23 

Survey 

Appendix 3: Summary of Focus Group Interviews and A-26 

Procedures 

Appendix 4: References A-35 

Annex B: Behavioral Healthcare System Assessment B-1 

Appendix 1: Summary of Behavioral Health Provider B-19 

Survey 

Tab A: Behavioral Health Provider Survey B-23 

Appendix 2: Summary of Primary Care Survey B-27 

Tab A: Primary Care Survey B-29 

Appendix 3: Summary of Unit Ministry Team Survey B-32 

Tab A: Unit Ministry Team Survey B-36 

Appendix 4: Summary of Behavioral Health Provider B-37 

Interviews 

Appendix 5: Summary of Line Leaders Interviews B-49 

Appendix 6: Summary of Behavioral Health Unit Data B-52 

Calls 

Tab A: Data Matrix Questions B-54 

Appendix 7: Summary of Fort Stewart Report B-55 

Appendix 8: Distribution of BH Services B-58 

Appendix 9: Psychotropic Medication Issues B-65 

Appendix 10: Pastoral Care Assessment B-71 

Appendix 11: References B-77 

 

Annex C: Evacuation Assessment C-1 

Appendix 1: MHAT Sources of Information C-32 

Appendix 2: DoD Supported Databases C-34 

Appendix 3: LRMC Chart Review Data Points C-36 

2 
 

Annex D: Suicide D-1 

 Appendix 1: Tables D-20 

Appendix 2: Methods and Procedures D-21 

 Appendix 3: References D-22 

Appendix 4: Army Suicide Prevention – A Guide for D-23 

Installations and Units – Draft 2002 version 

Appendix 5: AMEDD Suicide Event Report (ASER), Pilot D-73 

Version 

Annex E: MHAT Supporting Documents E-1 

 Appendix 1: MHAT membership E-2 

Appendix 2: MHAT Itinerary E-3 

Appendix 3: Glossary of Terms and Acronyms used by E-5 

MHAT 

 

3 
 

Operation Iraqi Freedom (OIF) 

Mental Health Advisory Team (MHAT) 

Executive Summary 

16 December 2003 

Chartered by: 

U.S. Army Surgeon General 

& HQDA G-1

This report is redacted to remove unit identifications, unit locations, and personal 

identity information in accordance with Army Regulation 25-55, Department of 

the Army Freedom of Information Act Program, and Army Regulation 340-21, 

The Army Privacy Program. Redacted information appears throughout this 

report blacked out, such as below. 

4 
 

OPERATION IRAQI FREEDOM MENTAL HEALTH ADVISORY TEAM 

EXECUTIVE SUMMARY 

The U. S. Army Surgeon General chartered the Operation Iraqi Freedom (OIF) 

Mental Health Advisory Team (MHAT) in July 2003. Its mission was to assess 

OIF-related mental health issues, and to provide recommendations to the OIF 

medical and line commands. In addition to multiple small group interview 

sessions, the MHAT conducted surveys with 756 Soldiers—of those, 82% had 

engaged in combat. This is the first time in history Soldiers have been surveyed 

in this manner about behavioral health issues during active combat. 

The MHAT conducted a comprehensive assessment of the OIF behavioral 

healthcare (BH) system, focusing on 1) the behavioral health services for 

deployed Soldiers and units; 2) the evacuation of behavioral health patients; and 

3) the behavioral health services at one of the Army’s projection platforms, Fort 

Stewart, Georgia, home of the Army’s 3rd Infantry Division, and 4) the observed 

July 2003 increase in OIF suicides and the suicide prevention program. 

FINDINGS

The MHAT found the forward elements of the OIF behavioral healthcare system 

demonstrated great effectiveness in helping Soldiers deal with the combat and 

operational stressors, benefiting both the individual Soldier and the unit. Soldiers 

treated forward avoided the stigma linked to evacuation for a behavioral health 

illness. Nevertheless, the MHAT found there was room to improve the behavioral 

healthcare system. 

This snapshot of the behavioral health concerns of OIF Soldiers was taken at the 

height of summer heat, when living condition infrastructure was immature, and 

redeployment dates were uncertain. Although 77% of surveyed Soldiers 

reported experiencing no or mild stress, emotional, or family problem, 16% 

reported moderate and 7% reported severe levels of such stress. Additionally, 

7.3% of surveyed Soldiers screened positive for anxiety, 6.9% for depression, 

and 15.2% for traumatic stress. Conversely, 83% of surveyed Soldiers did not 

meet screening criteria for behavioral health related functional impairment. Fiftytwo percent (52%) of Soldiers reported low or very low personal morale and 72% 

reported low or very low unit morale. Soldiers who expressed a desire to receive 

help with mental health problems perceived barriers to receiving that assistance 

greater than other Soldiers surveyed. 

Although forward-deployed behavioral health units enjoyed a high return to duty 

rate (over 95%), almost half of Soldiers surveyed reported not knowing how to 

obtain their services. Moreover, of those Soldiers wanting help, only one-third 

had received any assistance. Forward-deployed behavioral health units report 

greater dissatisfaction with the availability of psychotropic medications, than units 

located in the rear. The MHAT found there was a need for improvement in the 

5 
 

consistency of implementation of behavioral health services across the theater, 

and need for a standardized behavioral health reporting and documentation 

system. 

Once a Soldier left the OIF theater for behavioral health reasons, very few were 

returned to duty. Of the 49 Soldiers evacuated to Fort Stewart, 16% failed to 

receive follow-up care and 76% received six or fewer follow-up visits. The top 

five medical-surgical reasons for evacuation demonstrated a rise in evacuation 

rates during the month of July 2003; this surge was not unique to behavioral 

health. Clinical charts were inconsistently maintained, and documentation did not 

reliably accompany patients through the evacuation chain. 

The suicide rate for Soldiers deployed to OIF January – October 2003 was higher 

than recent Army historical rates (as of 5 December 2003, 15.6/100K vs. an 8-

year (1995-2002) Army average of 11.9/100K). There was a high incidence of 

OIF suicides during July relative to other months in 2003, but it did not signify an 

escalating rate of suicide. Firearms were the predominant method of suicide for 

OIF Soldiers. Compared to historical Army suicide rates, OIF suicide rates were 

higher for Soldiers located in Iraq and lower for Soldiers in Kuwait; higher for 

Active Component Soldiers and lower for Reserve Component Soldiers; and 

higher for both males and females. 

RECOMMENDATIONS

Immediately improve the behavioral health care system by 1) appointing a 

theater/area of operation behavioral health consultant, 2) providing services to 

Soldiers who need/want them closer to the Soldier’s unit, 3) providing holding 

capability closer to the Soldier, and 4) improving the quality of behavioral 

healthcare services for Soldiers being evacuated out of the theater. 

Ensure all behavioral health providers are properly trained/educated in relevant 

combat operational stress control (COSC) doctrine, tactics, techniques and 

procedures. 

Improve the behavioral health support at the unit level. Develop a human 

resource risk management program utilizing mid-grade Soldiers to facilitate the 

early identification and intervention of psychosocial problems at the company 

level and significantly improve behavioral health support for rear-detachment 

commanders and Family Readiness Groups (FRG). 

Adapt the existing (community-based) objectives of the Army Suicide Prevention 

Program (ASPP) for OIF Soldiers and units. Strategies of the ASPP can be 

applied to a forward deployed force through actions in the following areas: 

designate proponents to manage the suicide prevention program, maintain 

vigilance by leaders and Soldier-peers, conduct training, implement a 

surveillance of completed suicides and serious suicide attempts, and establish a 

6 
 

command climate that encourages appropriate help-seeking behavior by 

distressed Soldiers. 

Implement the monitoring of serious suicide attempts within Army medical 

surveillance systems. Task the U.S. Army Center for Health Promotion and 

Preventive Medicine (CHPPM) and the behavioral health consultants to develop 

capability for monitoring serious suicide attempts at the installation, operational, 

and Army-wide levels. 

Continue to monitor the health and well-being of OIF Soldiers via survey prior to 

their re-deployment to continental United States (CONUS), and after arrival at 

home station. Begin a systematic assessment to determine the most effective 

means for early intervention of Soldiers exposed to combat. 

DISCUSSION

Behavioral health units had high return to duty (RTD) rates in Iraq yet there were 

several indicators that identified unmet needs for behavioral healthcare services: 

Soldiers reported barriers to getting help in theater; and the inconsistent quality 

of the care for Soldiers evacuated out of the theater. 

The OIF suicide rate was higher than recent Army historical rates. This reminds 

medical planners and line leaders that strategies to minimize suicide risk are a 

critical component of force sustainment during combat operations. Some suicide 

risk factors are increased in a combat zone. Vigilance of unit leaders is 

necessary to identify Soldiers at risk, and to refer them for appropriate support. 

7 
 

OPERATION IRAQI FREEDOM MENTAL HEALTH ADVISORY 

TEAM REPORT 

INTRODUCTION

The U. S. Army Surgeon General chartered the Operation Iraqi Freedom (OIF) 

Mental Health Advisory Team (MHAT) in July 2003. Its mission was to assess 

OIF-related mental health issues and provide recommendations to the OIF 

medical and line commands. In addition to multiple small group interview 

sessions, the MHAT conducted surveys with 756 Soldiers—of those, 82% had 

engaged in combat. This is the first time in history Soldiers have been surveyed 

in this manner about behavioral health issues during active combat. 

The MHAT conducted a comprehensive assessment of the OIF behavioral 

healthcare (BH) system, focusing on 1) the behavioral health services for 

deployed Soldiers and units; 2) the evacuation of behavioral health patients; and 

3) the behavioral health services at one of the Army’s projection platforms, Fort 

Stewart, Georgia, home of the Army’s 3rd Infantry Division. There were several 

possible negative outcomes when Soldiers experience extreme stress. The 

MHAT examined possible negative outcomes paying particular attention to OIF 

suicides. This report contains the MHAT’s key findings and its recommendations. 

The report consists of three major parts: 1) the OIF MHAT Executive Summary, 

2) the OIF MHAT Report, and 3) the Annexes to the OIF MHAT Report. The 

annexes contain the assessment methodologies, results and recommendations 

for the behavioral healthcare system. 

CONVENTIONS: The OIF MHAT referred to the behavioral healthcare system 

when discussing its findings. The behavioral health continuum of care 

encompasses not only traditional mental health care efforts, but many efforts of a 

primary and secondary prevention nature that have traditionally not been counted 

as mental health services. To avoid confusion, the MHAT will designate all of 

these services as behavioral healthcare services. 

Also, many preventive interventions are referred to as “combat stress control” 

(CSC) services. Recently, the three Services (Departments of the Air Force, 

Army, and Navy) agreed to refer to these services as “combat and operational 

stress control services” (COSC). The units are still referred to as CSC units; 

however, the services are COSC services. The MHAT also referred to 

“behavioral healthcare providers.” Table 1 defines those military personnel 

considered behavioral healthcare providers. 

8 
 

 

Table 1: Behavioral Healthcare Providers by AOC/MOS 

AOC/MOS Description 

65A Occupational Therapists

66C Psychiatric Nurses

60W Psychiatrists

73A Social Workers

73B Clinical Psychologists

91W/91WN3 Health Care Specialists 

91X Mental Health Specialists 

REASON FOR THE MHAT 

The Office of The Surgeon General (OTSG) established the OIF MHAT in 

cooperation with the Army’s Deputy Chief of Staff for Personnel, or HQDA G-1, in 

late July 2003 to assess OIF related mental health issues, and to provide 

recommendations (See charter at Appendix A). Specifically, MHAT was 

challenged to assess potential organizational and resource-limitation factors 

related to 1) the July 2003 increase in OIF suicides; 2) the increased behavioral 

health patient flow through Landstuhl Regional Medical Center (LRMC) from OIF 

after May 2003; 3) the stress-related issues in the Iraqi theater; and 4) 

deployment-related behavioral health issues among 3rd Infantry Division Soldiers 

at Fort Stewart, a major deployment platform. To this end, the MHAT consulted 

with relevant medical commanders, line leaders, behavioral health units, 

behavioral health headquarters, and evacuation chain support personnel at 

LRMC and Fort Stewart. 

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

(a) Command and Control, 

(b) Communications, 

(c) Resource Support, and 

(d) Policies. 

THE MHAT ANALYSIS OF OBJECTIVES: 

In order to consult with the behavioral health leaders in OIF and in the evacuation 

chain, the MHAT traveled to Kuwait, Iraq, LRMC, and Fort Stewart, Georgia. The 

MHAT left the CONUS Replacement Center in Fort Bliss, Texas on 25 August 

2003, and stayed in Kuwait and Iraq from 27 August until 

7 October 2003. 

9 
 

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

Component Command (CFLCC), the ------- Medical Brigade and Combat Service 

Support (CSS) units (see Table 2). 

Table 2: CLFCC Interviews 

Signal and 

Transportation Units 

Engineer and Military

Police Units Medical Units 

 

 

 

 

In Iraq the MHAT consulted with the leadership of the Combined Joint Task 

Force-7 (CJTF-7), the -------- Medical Brigade and Combat Arms (CA) units (See 

Table 3). 

Table 3: CJTF-7 Interviews 

1st Armored 

Division 

4th Infantry 

Division 

101st

Airborne Div 

3rd ACR ----------------------------

 

 

 

 

 

 

 

 

Four team members visited LRMC, Germany from 13 - 17 October. Five other 

team members visited Ft. Stewart, Georgia from 13 - 18 October. Both teams 

consulted with relevant local mental health personnel and Army Medical 

Department (AMEDD) leadership. (See Annex E, Appendix 2.) 

The MHAT approached the mission as a rare opportunity to assess the Army 

behavioral healthcare system in an active combat campaign. An assessment like 

this has never been undertaken in an active combat environment. The MHAT 

used an approved Soldier and theater needs assessment tool developed by the 

Walter Reed Army Institute of Research (WRAIR). The OIF WRAIR Soldier WellBeing Survey (OIF SWBS) was adapted from Soldier well-being surveys used in 

Army military operations over the last ten years (Annex A, Appendix 2). Earlier 

versions have established baseline data for units in garrison, pre-deployment and 

10 
 

post-deployment. This was the first time the instrument was used during an 

active combat campaign. 

The MHAT also assessed the behavioral healthcare system itself. The MHAT 

surveyed and interviewed behavioral health providers, primary care providers, 

Unit Ministry Teams, and command group’s senior leaders in sampled units (see 

Tables 2 & 3). The MHAT assessed the OIF mental health intervention 

strategies, application of CSC doctrine, alternative mental health interventions 

and the behavioral health medical evacuation system. In addition, the MHAT 

studied the observed spike in OIF suicides and assessed the status of OIF 

suicide preventive efforts. 

The MHAT also examined systemic issues relative to the behavioral healthcare 

system. Particular focus was given to command and control of behavioral health 

units, their ability to communicate horizontally and vertically, the adequacy of 

their resource support and existing policies. 

The MHAT was unanimously impressed with the professionalism and dedication 

of OIF leaders, Soldiers, chaplains and health care providers. It goes without 

saying that Iraq was an austere and very dangerous environment. In spite of 

high risk to themselves, they went on convoys and patrols, pulled guard duty, 

and performed other duties as required by the OIF mission. The medical 

personnel were facilitative, cooperative and extremely helpful. They performed 

their duties in a professional and exemplary manner. Many of our behavioral 

health personnel demonstrated great ingenuity and creativity in finding ways to 

take care of Soldiers despite severe resource limitations. Their examples taught 

us valuable lessons in commitment, fortitude and perseverance, and made us 

proud to be Soldiers. 

11 
 

FINDINGS

1. OIF Soldiers reported significant levels of behavioral health concerns and 

stress; and low levels of personal morale and unit cohesion. They expressed a 

desire for help with behavioral health problems, but reported barriers to receiving 

assistance. 

This assessment showed that a minority, but significant, proportion of Soldiers 

deployed to OIF experienced and reported behavioral health concerns, and that 

there was an unmet need for behavioral services. 

Distress levels and interest in receiving help. Seventy-seven 

percent of OIF Soldiers reported currently experiencing no or mild 

stress, emotional, or family problem. Sixteen percent (16%) of OIF 

Soldiers reported currently experiencing a moderate stress, 

emotional, or family problem. Seven percent (7%) reported 

currently having a severe stress, emotional, or family problem. 

Overall, 15% of Soldiers reported interest in receiving help. 

Using standardized clinical scales, 83% of Soldiers indicated mild 

problems or minimal impact on duty performance for these 

problems. Seventeen (17%) of Soldiers did screen positive for 

traumatic stress, depression, or anxiety and reported impairment in 

social or occupational functioning. 

Use of mental health services. Of the Soldiers who screened 

positive for depression, anxiety, or traumatic stress, only 27% 

reported receiving help at any time during the deployment from a 

behavioral health professional, general medical doctor, or chaplain. 

Of the Soldiers who reported interest in receiving help, only 32% 

received some form of help. 

OIF Soldiers reported low Soldier morale and unit cohesion. 

At the time of the Soldier health and well-being survey, OIF 

Soldiers reported low or very low personal and unit morale. Fiftytwo percent (52%) of Soldiers reported low or very low personal 

morale and 72% reported low or very low unit morale. Unit 

cohesion was also reported to be low. 

Multiple operational stressors were significantly correlated with morale, cohesion, 

and behavioral health problems. 

The most reported combat stressors included seeing dead bodies 

or human remains, being attacked or ambushed, and personally 

knowing someone who was seriously injured or killed. The most 

12 
 

reported deployment stressors included uncertain re-deployment 

date, long deployment, separation and lack of communication with 

family, and lack of personal privacy. These operational stressors 

were significantly correlated with low morale, low cohesion, and 

behavioral health problems. 

Barriers/obstacles impede Soldiers from obtaining behavioral health assistance. 

Soldiers most in need of behavioral health care were twice as likely 

as other Soldiers to report concerns about accessing services. 

Among Soldiers who screened positive for depression, anxiety, or 

traumatic stress, 26% reported that it would be too difficult to get to 

the location of behavioral health services. Other barriers reported 

among those who screened positive included difficulty getting time 

off from work to get help (43%), not knowing where to go for help 

(24%), or behavioral health services not being available (24%). 

Perceived stigma to care was also an important concern for OIF 

Soldiers; Soldiers reported that they might be seen as weak (59%), 

that the unit leadership would treat them differently (58%), that the 

unit would have less confidence in them (49%), or that their leaders 

would blame them for the problem (46%). 

2. The percentage of behavioral health patients returned to duty was highest 

among behavioral health units deployed forward, and was lowest among 

behavioral health units in the rear. Behavioral health outreach efforts were 

inadequate to meet the needs of Soldiers and line leaders. Although the number 

of behavioral health personnel in theater was sufficient to provide coverage 

throughout the OIF AOR, there were areas in theater that lacked behavioral 

health services. Forward-deployed behavioral health units reported greater 

dissatisfaction with the availability of psychotropic medications, than units located 

in the rear. Behavioral health units need a broader range of antidepressant and 

sleeping medications. 

The percentage of behavioral health patients returned to duty was highest among 

behavioral health units deployed forward, and was lowest among behavioral 

health units in the rear. 

The percentages of Soldiers who were treated for behavioral health 

problems and returned to duty (RTD) ranged from 97% to 4%, 

depending on the type of behavioral health unit that provided care. 

Data from the Combat and Operational Stress Control Workload 

and Activity Reporting System (COSC-WARS) was analyzed to 

calculate the Soldier RTD rate for CJTF-7 Combat Stress Control 

units. For Division Mental Health Sections (DMHS) and Combat 

Support Hospital (CSH) units, their homegrown databases were 

analyzed to calculate their Soldier RTD rates. 

13 
 

Forward-deployed behavioral health units returned to duty 97% of 

service members seen while only 11% of Soldiers treated in Kuwait 

were returned to duty and only 10 (3.6%) of behavioral health 

evacuees were returned to duty in OIF from LRMC. Of the 

evacuees whose charts were reviewed by MHAT at LRMC, 90% 

were treated as outpatients at LRMC. 

The following factors may have contributed to the low return to duty 

rates: First, patients who continued in the evacuation chain may 

have required hospitalization for severe conditions needing longterm treatment interventions. Second, the evacuation policy 

promoted the evacuation of patients, not their return to duty. For 

many behavioral health patients, even those with transitory 

conditions like adjustment disorder, treatment may require more 

days than provided for in the CJTF-7 seven-day evacuation policy. 

Third, while CJTF-7’s evacuation policy directed that evacuations 

occur “only after a good faith effort to address the issue in theater 

failed,” there were no standing operating procedures (SOP) to 

guide clinicians how or when to consider returning an evacuee to 

duty in OIF. 

In fact, several factors indicated improving behavioral health status 

in the evacuee population. First, the number of evacuees with high 

suicide risks precipitously dropped from 89 (32%) in OIF to 22 (7%) 

at LRMC. Second, there was a similar drop in the number of 

evacuees with elevated homicide risks from 25 (9%) in OIF to 7 

(3%) at LRMC. Third, nearly one-third of OIF and LRMC evacuees 

did not require psychotropic medications, suggesting that their 

conditions could be adequately addressed through 

psychotherapeutic means only. 

Behavioral health outreach efforts need to improve to better meet needs of 

Soldiers and line leaders. 

Behavioral health personnel’s perception of providing accessible 

care for Soldiers was different compared to the Soldiers who were 

surveyed. Ninety percent (90%) of the behavioral health providers 

surveyed agreed that Soldiers in their area of operation had good 

access to behavioral health services. However, only 56% of the 

Soldiers surveyed reported knowing how to obtain behavioral health 

care in theater. Twenty-six percent (26%) of Soldiers reported it 

would be too difficult to get to behavioral health services. Of the 

Soldiers who screened positive for depression, anxiety, or traumatic 

stress, 27% reported receiving help at any time during the 

deployment from a behavioral health professional, general medical 

14 
 

doctor, or chaplain. Of the Soldiers who reported interest in 

receiving help, only 32% reported receiving help during the 

deployment. Sixty percent (60%) of the respondents to the Soldier 

well being survey identified command stigma (20%), difficulties 

traveling (20%) and leader/Soldier lack of knowledge about 

behavioral health services and capabilities (20%) as the three top 

barriers to providing behavioral health care in theater. 

Although the number of behavioral health personnel in theater was 

sufficient to provide coverage throughout the OIF AOR, there were areas 

in theater that lacked behavioral health services. 

To identify the adequacy of behavioral health support, the MHAT 

calculated the behavioral health provider-to-Soldier population ratio 

for OIF and its collective areas of responsibility. The ratio was 

calculated by dividing the Soldier population of an area of 

responsibility by the number of behavioral health providers 

supporting that AOR. 

As of September 2003, the OIF ratio was one behavioral health 

provider for every 851 Soldiers. In Iraq, the ratio was one provider 

for every 830 Soldiers; and in Kuwait, the ratio was one provider for 

every 986 Soldiers. The ratios by area of responsibility ranged 

from no providers for 4,205 Soldiers, to one provider for every 673 

Soldiers. 

Forward-deployed behavioral health units report greater dissatisfaction with the 

availability of psychotropic medications than units located in the rear. 

Dissatisfaction with the availability of psychotropic medication was 

particularly high among Combat Stress Control units and Division 

Mental Health Sections (57.1 and 66.7% respectively). Unlike units 

at higher levels, these units do not have an integrated pharmacy to 

immediately dispense medication. Anecdotal reports from forwarddeployed psychiatrists indicate that filling prescriptions is 

unnecessarily complicated by forcing Soldiers and units to arrange 

at least two convoys: the first convoy is for the Soldier’s medication 

evaluation and prescription, and the second convoy is for the 

medication pick-up at the nearest pharmacy. 

15 
 

Behavioral health units need a broader range of antidepressant and sleeping 

medications. 

Fifty percent (50%) of psychiatrists identified a need for a broader 

range of antidepressant medications in the current formularies, and 

33% indicated that additional sleeping agents and stimulants would 

be helpful for treating patients. 

3. There was minimal systematic training/education in the implementation 

of CSC doctrine. There was inconsistent communication and integration 

between behavioral health providers and higher medical headquarters. 

There were ill-defined standards across the continuum of care. There was 

no standardized method to collect behavioral health workload or clinical 

information. 

Minimal CSC training in the implementation of CSC doctrine. 

More than half of the behavioral health providers interviewed 

reported either they did not know what COSC doctrine was, or did 

not support it. Fifty percent (50%) percent also reported they had 

not received adequate training in combat stress prior to 

deployment. Over 50% of the behavioral health providers 

interviewed wanted more intense training in COSC. 

There was inconsistent communication and integration between behavioral 

providers and higher medical headquarters. 

Thirty-seven percent (37%) of behavioral health personnel reported 

receiving guidance and adequate supervision from their higher 

headquarters. Thirty-four percent (34%) reported not getting 

needed mission information and intelligence. There were no 

significant differences between the active and reserve components 

on this issue. Fifty-five percent (55%) of the behavioral health

officers were dissatisfied with their perceived level of input into 

operational planning. Nineteen percent (19%) of all behavioral 

health personnel reported having input into the policies of their 

higher command. 

A need for better defined standards across the continuum of care. 

The MHAT found there were operational and doctrinal differences 

among behavioral units. Providers were divided between the 

medical and preventive models as means of delivering behavioral 

health services. The reported median time spent doing prevention 

activities was 39% compared to a reported median time of 60% for 

clinical treatment. Eighty-one percent (81%) of the psychiatrists 

16 
 

and psychiatric nurses reported spending less than half of their time 

providing prevention activities. The other behavioral health 

providers only reported spending 50% of their time doing 

prevention activities. Without instruments to assess Soldier/unit 

needs, behavioral health providers made assumptions about needs 

of the community, and relied on familiar intervention models. 

Providers with COSC training favored preventive strategies to 

promote wellness in the population – sometimes to the exclusion of 

needed clinical interventions. Providers with medical or clinical 

backgrounds resorted to the “medical model” to evaluate and treat 

behavioral health disorders in the population – to the exclusion of 

doing preventive outreach and interventions. 

No standardized behavioral data collection methodology. 

Each behavioral health unit in CJTF-7 was directed to enter their 

workload data into the COSC-WARS system and to forward this 

information to the ----- Medical Brigade. However, only the CSC 

units used COSC-WARS, the DMHSs used the disease and nonbattle injury (DNBI) database, and the CSHs used “homegrown” 

databases. More than half (53%) of the behavioral health units 

contacted in theater created and maintained their own 

“homegrown” database systems due to the reported shortfalls 

within the existing databases, including COSC-WARS. These 

unofficial database systems were used to maintain additional 

caseload information and provide additional workload and 

Soldier/patient tracking information for the providers and also their 

commands. 

4. There was a surge in all Army OIF evacuations during July 2003. This surge 

was seen in the rate of behavioral health evacuations, as well as the rates of 

other evacuating medical-surgical specialties. Clinical charts were inconsistently 

maintained, and documentation did not reliably accompany patients through the 

evacuation chain. 

There was a surge in all Army OIF evacuations during July 2003. This surge was 

seen in the rates of the top five medical-surgical reasons for evacuation. The 

surge in evacuations was not unique to the behavioral health system. 

In July 2003, the Army OIF evacuation rate per 100K troops 

increased 1.8 times (668 evacuees in June to 1225 in July). The 

top five medical-surgical reasons for evacuation demonstrated a 

similar rise in evacuation rates during the month of July. This surge 

was not unique to behavioral health. Despite this one-month surge, 

the proportion of behavioral health evacuations to all Army OIF 

evacuations remained relatively stable. 

17 
 

No single hypothesis adequately explained the surge in Army OIF evacuations 

during July 2003. 

Several hypotheses attempted to explain the surge in evacuations, 

but each failed to provide a satisfactory answer. These hypotheses 

included 1) the “backlog” hypothesis, 2) the “shrinking force” 

hypothesis, 3) the “unknown redeployment date” hypothesis, 4) the 

“home front stress” hypothesis, 5) the “trivial evacuation” 

hypothesis, and 6) the “administrative evacuation” hypothesis. 

Clinical charts were inconsistently maintained, and documentation did not reliably 

accompany patients through the evacuation chain. No Database adequately 

tracked evacuees or provided reliable clinical information 

Procedures for documenting patient visits varied among the 

behavioral health units. Procedures fluctuated with available 

resources, environmental conditions, operational tempo, type of 

behavioral health unit (e.g. DMHS, CSC, or CSH), and unit policy. 

Treatment interventions were inconsistently recorded in 

convenience files. Even at LRMC, outpatient evacuee charts were 

disorganized and stapled, contained inconsistent documents, and 

kept in an accordion file. 

Clinical documentation did not reliably arrive at the receiving facility. 

Although all OIF behavioral health providers claimed to send clinical 

documentation to the receiving facility in the evacuation chain, only 

44.8% of LRMC charts actually had OIF clinical documentation 

within the chart. Nearly 38% of reviewed charts had neither OIF 

clinical documentation, nor Patient Movement Request (TRAC2ES) 

information. In some cases, the OIF behavioral health provider 

relied upon the patient to hand-deliver his/her clinical 

documentation to the next level of care. Evidence showed that 

clinical documentation was sent to the next receiving facility for 

93% of all evacuees leaving LRMC. 

No DoD-supported or homegrown database system adequately 

tracked evacuations from OIF to CONUS to home station, thereby 

limiting usefulness in medical planning and patient-accountability. 

In lieu of receiving reliable clinical documentation from OIF, 

behavioral health providers have relied on TRAC2ES to make initial 

clinical decisions about incoming evacuees. For example, LRMC 

used the TRAC2ES in triage, deciding which patients needed 

immediate evaluation and which patients could wait until the next 

18 
 

duty day. However, TRAC2ES had many limitations: 

1) TRAC2ES could only be reached via SIPRNET connection; 

2) online TRAC2ES information was “stripped” of evacuee names 

and social security numbers; and 3) online TRAC2ES information 

only extended back 60 days. 

5. Over 80% of Army OIF evacuees with behavioral health diagnoses 

redeployed to Ft Stewart received follow-up for their conditions—most within one 

week after arrival. 

 

Although 41 (84%) of these evacuees received follow-up at Winn 

Army Community Hospital (WACH), the MHAT was concerned that 

8 (16%) evacuees were lost to follow-up. An additional 22% had 

one follow-up appointment and 75% of all evacuees had six or less 

appointments. 

Adjustment disorder was the most frequent diagnosis (33%) among 

evacuees returned to duty after follow-up, and among evacuees 

who failed to follow-up after return to home station (38%). Failure 

to closely monitor evacuees’ follow-up at home station 

unnecessarily elevated the risk for a bad clinical outcome. 

6. The suicide rate for Soldiers deployed to OIF January – October 2003 was 

higher than recent Army historical rates. There was a high incidence of OIF 

suicide during July when compared to other months but it did not signify an 

escalating rate of suicide. Not unexpected in a combat zone, firearms have 

been the predominant method of suicide for OIF Soldiers. Compared to historical 

Army suicide rates, OIF suicide rates were higher for Soldiers located in Iraq and 

lower for Soldiers in Kuwait; higher for Active Component Soldiers and lower for 

Reserve Component Soldiers; and higher for both males and females. 

The suicide rate for Soldiers deployed to OIF January – October 2003 was higher 

than recent Army historical rates. 

As of 5 December 2003, the OIF suicide rate for the period January 

– October 2003 was 15.6 suicides per 100,000 Soldiers per year 

and compares to the average annual rate of 11.9 per 100,000 for 

the eight-year period 1995-2002 (range 9.1 - 14.8). 

There were additional Army deaths that occurred between July and 

the end of October 2003 for which the manner of death was 

pending final determination; some may later be classified as 

suicide. 

There was a high incidence of OIF suicide during July 2003 when compared to 

other months, but it did not signify an escalating rate of suicide. 

19 
 

The July 2003 OIF suicides may be viewed as an increase when 

compared to the preceding and following months. There was no 

indication that any of the suicides served as a trigger for other 

suicides. 

Not unexpected in a combat zone, firearms have been the predominant method 

of suicide for OIF Soldiers. 

The frequency of OIF firearm suicide was much higher when 

compared to firearm suicide frequencies of the Army and the U.S. 

populations in previous years. The deployed force was comprised 

of a large number of young males who are a group with high 

suicide risk in the U.S. population. 

Compared to historical Army suicide rates, OIF suicide rates were higher for 

Soldiers located in Iraq and lower for Soldiers in Kuwait; higher for Active 

Component Soldiers and lower for Reserve Component Soldiers; and higher for 

both males and females. 

Compared to the average Army suicide rate of 11.9/100K Soldiers, 

the rates for OIF Soldiers assigned in Iraq and Active Component 

Soldiers were 21.2 and 17.2/100K respectively. The rates for 

Reserve Component Soldiers and Soldiers located in Kuwait were 

9.2 and 3.0 respectively. Two of the 17 OIF suicides were female 

and represent an annualized rate of 19.0/100K. This rate is higher 

than the Army historical rate of 11.9/100K, and higher than the 

4.1/100K rate of suicide among U.S. females in 2001. However, 

this rate is based on only two deaths, which does not establish a 

trend, and should not be interpreted as suggesting that there is a 

particular problem of suicides involving women. The annualized 

rate for the 15 male suicides is 15.2/100K and although higher than 

the historical Army rate, is lower than the rate of 17.6/100K for all 

U.S. males in 2001, and lower than the rate of 21.5/100K for U.S. 

males 20-34 years of age in 2000. 

20 
 

RECOMMENDATIONS

Immediate implementation. 

1. Appoint a theater/Area of Operation (AOR) behavioral health 

consultant to advise the theater Surgeon (CJTF-7 and CFLCC Surgeons) 

on behavioral health issues. Immediately improve the behavioral health 

care system by providing services to Soldiers who need/want them closer 

to the Soldier’s unit, providing holding capability closer to the Soldier’s 

unit, and improving the quality of behavioral healthcare services for 

Soldiers being evacuated out of the theater. 

Appoint a theater/Area of Operation behavioral health consultant to advise the 

Surgeon on behavioral health issues. 

In order to better allocate behavioral health personnel and to 

oversee the delivery of behavioral health care in the AOR, the 

commander should appoint a behavioral health consultant to each 

theater/AOR surgeon. This officer may be already on staff, or could 

be requested through personnel channels if a suitable choice is not 

available. Example duties of the theater/AOR behavioral health 

consultant might include: 

• Consults with the Surgeon on all behavioral health matters. 

• Conducts a theater/AOR-wide behavioral health needs 

assessment. 

• Establishes behavioral health standards and operational 

requirements plan. 

• Recommends the behavioral health theater/AOR 

evacuation policy. 

• Prepares the behavioral health portion of the medical 

operations plan. 

• Reviews all command/medical policies that affect 

behavioral health activities. 

• Evaluates the quality of behavioral health services 

rendered in the AOR. 

• Monitors the communication among levels of care during 

evacuation. 

• Plans for future behavioral health operations 

(redeployment surge, etc.). 

• Coordinates joint and combined behavioral health services 

where necessary. 

• Recommends proper distribution of behavioral health 

units/teams on the battlefield. 

• Oversees in-theater behavioral health training. 

21 
 

Execute an aggressive behavioral health outreach program. Ensure that 

behavioral health personnel have a regular, far-forward consultation program at 

the small unit level. 

A high percentage of Soldiers reported interest in receiving 

behavioral health support and/or screened positive for a behavioral 

health problem. However, data suggests that significant barriers 

are preventing Soldiers from receiving help, such as transportation 

constraints, knowing where to get help, behavioral health services 

not being perceived as available, and stigma. 

Behavioral health care providers can reduce and/or eliminate many 

of these barriers by physically going to the Soldiers who need 

and/or want help. Since the data indicated that both chaplains and 

behavioral health professionals were accessed at a similarly low 

rate, both groups need to develop and execute an aggressive 

forward-deployed behavioral health outreach program. Establishing 

a predictable, regular, and visible presence at the 

company/battalion level is essential. 

In addition to direct Soldier contacts, behavioral health personnel 

can partner with leaders, commanders, chaplains, and primary 

medical care providers to extend access to behavioral health care. 

Further, behavioral health personnel need to reach out particularly 

to leaders and other helping professionals as they often have the 

greatest direct and indirect behavioral health stressors 

AOR behavioral health consultants need to distribute behavioral health assets 

appropriately. 

The MHAT noted gaps in behavioral health services in theater. In 

particular, behavioral health personnel were not optimally 

distributed. To improve distribution problems, behavioral health 

consultants need to review their respective AORs to ensure that 

behavioral health personnel are optimally distributed and that the 

services rendered provide a consistent network of behavioral health 

services. Where gaps are noted, behavioral health units need to be 

redirected to provide the needed service. 

Field a simple, standardized needs assessment tool for Soldiers and units. 

The MHAT noted that few behavioral health personnel had 

performed a needs assessment for their AORs. Creation and 

distribution of a standardized needs assessment tool can provide 

guidance for behavioral health professionals. Such an instrument 

22 
 

should include symptoms, exposures, morale and cohesion, the 

desire for help, and barriers to care. 

Train Soldiers in meeting the demands of deployment/combat related stressors. 

The data suggest that training Soldiers in suicide awareness and in 

dealing with the stresses of deployment have many potential 

benefits. Standardized training materials need to be developed that 

teach these skills to Soldiers and leaders. 

Improve the ability to hold Soldiers in theater closer to their own units. Create a 

behavioral health reconditioning program. 

In order to facilitate behavioral health treatment and to minimize 

behavioral health evacuations out of theater, Soldiers with 

behavioral health issues should be kept in theater (Iraq or Kuwait). 

A properly placed, staffed, and operated reconditioning unit could 

successfully return to duty many Soldiers currently being evacuated 

for behavioral health reasons. The location should be in the rear 

(for those on weapons restriction), with austere conditions (to 

encourage return to duty), and co-located with combat support or 

combat service support units who could profit from the therapeutic 

work details the Soldiers would provide. 

Another limitation to optimal behavioral health services is the 

theater 7-day evacuation policy, which inhibited development of 

CSC reconditioning programs in CJTF-7 or CFLCC. Many Soldiers 

evacuated with Adjustment Disorders or Combat Stress Reactions 

may have benefited from 1-3 weeks of reconditioning in CFLCC, 

allowing their units to receive replacements while other units benefit 

from work provided by reconditioning Soldiers. 

Improve the quality of behavioral healthcare services for Soldiers during 

evacuation. 

Improve the communication between levels of care. The flow of 

clinical documentation is essential for continuity of care. MHAT 

recommends creating the following processes to ensure proper flow 

of clinical documentation and information among levels of care: 1) 

CJTF-7 and CFLCC Surgeons should jointly establish a standard 

clinical documentation packet for behavioral health evacuations, 2) 

CJTF-7 and CFLCC Surgeons should jointly establish standard 

procedures for transfer of this clinical documentation packet to the 

receiving military treatment facility, 3) the behavioral health 

consultants to the CJTF-7 and CFLCC Surgeons should develop, 

promote, and monitor administrative and clinical communication 

23 
 

among levels of care in the evacuation chain to ensure adequate 

feedback and coordination. 

Improving the data quality and utilization of TRAC2ES for tracking 

behavioral health patient evacuation. Among the tracking systems, 

TRAC2ES provides the most reliable administrative information. 

Until other methods for reliable transmission of clinical data are 

established, the MHAT recommends the following steps be taken: 

1) at each MTF, PAD/MRO should establish quality improvement 

review procedures to minimize errors in TRAC2ES data entry. 2) 

The evacuating provider should provide the evacuee’s DSM-IV 

diagnoses (in addition to ICD-9) for inclusion in the TRAC2ES 

narrative for greater clinical clarity. 3) To encourage utilization of 

TRAC2ES (and JMeWS), CJTF-7 and CFLCC Surgeons should 

improve behavioral health provider access to the SIPRNET. 4) 

Prior to deployment, all behavioral health providers should establish 

SIPRNET accounts. 5) CJTF-7 and CFLCC Surgeons should 

establish a procedure with TRAC2ES database managers at Scott 

Air Force Base to allow behavioral health providers access to data 

greater than 60 days old. 6) Behavioral Health Consultants in 

CJTF-7/CFLCC and BH Service/Department Chiefs should

develop, maintain, and monitor feedback among MTFs about the 

quality, accuracy, and value of TRAC2ES information. 

Maintain standards of care for patients during evacuation. The MHAT 

recommends the establishment of the following procedures. 

Quality Improvement: 1) Monitor the quality of evacuee charts 

throughout the evacuation chain through a locally developed and 

regulated QI program. 2) Monitor implementation of evacuation 

policy through a locally developed and regulated QI program (i.e., 

to ensure that evacuees satisfy the evacuation policy 

requirements). 3) Jointly develop CJTF-7 and CFLCC policy on 

escort utilization and responsibilities, and monitor through a QI 

program. 

Improve RTD by emphasizing treatment for evacuees: 

1) Implement a behavioral health reconditioning program for CJTF7 behavioral health evacuees with Adjustment Disorder and/or 

Combat Stress Reactions; 2) Implement treatment initiatives at 

MTFs for evacuated outpatients, particularly for Soldiers with 

Adjustment Disorder; 3) Develop SOPs for all MTFs in the 

evacuation chain to govern behavioral health evacuee evaluation, 

treatment, disposition, and accountability processes. 

24 
 

Promote treatment initiatives by extending the evacuation policy for 

behavioral health patients. 1) Extend CJTF-7 Evacuation Policy 

from 7 days to 14 days for Soldiers with Adjustment Disorders or 

Combat Stress Reactions; 2) MTF behavioral health chief should 

consider full use of available days in evacuation policy for 

treatment. 

2. Ensure all behavioral health personnel are trained/educated in COSC 

doctrine, tactics, and procedures. 

AOR behavioral health consultants should establish quarterly behavioral health 

training meetings. 

Not only did a number of behavioral health personnel state they 

were under-trained, but battlefield execution demonstrated the 

need for training in COSC doctrine, tactics, and techniques. 

Theater behavioral health consultants should establish regular 

(quarterly) training conferences to ensure that doctrine is clearly 

disseminated and problems are addressed. Training may be 

centralized, regionalized, or performed via train-the-trainer. 

Technology may also be leveraged (VTC, telephone, videotape, 

and/or CD) to accomplish this. However, tapes and talk alone will 

not suffice without some live demonstration and periodic oversight. 

Conduct COSC training for behavioral health personnel (AC/RC) preparing to 

deploy. 

MEDCOM/OTSG and the reserve medical commands should 

ensure that behavioral health personnel (both active and reserve) 

currently alerted for deployment to theater in Spring/Summer 2004 

are adequately trained. This can be accomplished by holding a 

predeployment conference or by holding regional training meetings. 

Holding a conference provides the added benefit of allowing the 

behavioral health personnel to meet each other and to begin to plan 

and network together. 

Conduct COSC research in key areas to ensure that the best prevention 

and early intervention methodologies are established/validated. 

There are several research areas that can potentially result in 

immediate and effective intervention of OIF Soldiers. These areas 

include the development of a behavioral health needs assessment 

and the validation of the COSC intervention methods (e.g., Critical 

Incident Stress Debriefing (CISD)). 

25 
 

3. Plan for the upcoming battle-handover. 

Winter/Spring 2004 will be a major upheaval as units deploy and 

redeploy. Post-deployment screening will likely require some 

behavioral health consultation (where Soldiers screen positive on 

the Post Deployment Health Assessment (PDHA) behavioral health 

questions), some units may need debriefing sessions, reunion 

classes, or other behavioral health intervention. Deploying units 

may need stress management, anger management, 

communication, suicide prevention, and other classes in 

preparation for the battlefield. 

4. Adapt the existing (community-based) objectives of the Army Suicide 

Prevention Program for OIF Soldiers and units. 

Adapt existing community-based objectives of the Army Suicide Prevention 

Program (ASPP) to OIF Soldiers and units. Strategies of the ASPP can be 

applied to a forward deployed force through actions in the following five areas: 

Designate proponents to manage the CFLCC and CJTF-7 suicide 

prevention programs. 

Maintain vigilance by leaders and Soldier-peers to ensure Soldiers 

at risk for suicide receive appropriate support. 

Conduct training that provides crisis intervention skills to designated 

Soldiers with a goal of one trained Soldier per company. 

Implement surveillance of completed suicides and serious suicide 

attempts with standardized suicide event reporting by behavioral 

health personnel. 

Establish a command climate that encourages appropriate helpseeking behavior by distressed Soldiers. Behavioral health care 

should be delivered as far forward as possible to maximize the 

likelihood of successfully returning Soldiers to duty. 

Future Implementation 

1. TSG ensures all behavioral health providers are properly trained/educated in 

relevant combat operational stress control doctrine. 

Ensure all behavioral health personnel are trained/educated in COSC doctrine, 

tactics, and procedures. 

26 
 

Direct TSG behavioral health consultants to develop and implement 

a multidisciplinary COSC Course to teach COSC doctrine, tactics, 

and procedures to all behavioral health/COSC personnel. 

Direct TSG behavioral health consultants to charter multidisciplinary 

process action teams (PAT) to develop the following key elements 

for inclusion in the course. 

• Revise/Update COSC doctrine: organize COSC around 

behavioral health capabilities supporting operational 

requirements. 

• Revise/validate the behavioral health estimate of the 

situation. 

• Develop behavioral health standards of care for the 

operational environment. 

• Develop and field tactics, techniques and procedures for 

behavioral health units and teams. 

• Develop and field standardized Soldier and unit needs 

assessment tools. 

• Develop and field a data collection methodology for 

behavioral health surveillance and outcome information. 

• Conduct research in key COSC areas to ensure best 

doctrine is trained. Areas include a) behavioral health needs 

assessment and unit climate tool for the operational 

environment, b) identify the scientifically valid key leadership 

behaviors that facilitate Soldier morale, cohesion, and unit 

performance in a hostile environment, and c) determine the 

effectiveness of COSC intervention methods (e.g., CISD). 

Direct the TSG behavioral health consultants to reorient the 

AMEDD officer and enlisted military education systems to integrate 

collective blocks of instruction in COSC, disaster behavioral health, 

and battlefield professional practice. 

Direct CHPPM and the TSG behavioral health consultants to 

ensure that a COSC/ behavioral health track is incorporated into 

the annual Force Health Protection (FHP) Conference. 

 

2. Develop & field a data collection methodology for behavioral health 

surveillance and outcome information. 

MEDCOM should review the COSC Workload and Activity 

Reporting System (COSC-WARS) for sufficiency and then 

automate it. 

27 
 

MEDCOM should integrate COSC prevention efforts into existing 

and emerging theater medical databases. 

3. Develop an automated evacuation tracking system. 

MEDCOM should establish a joint process action committee to 

work on an evacuation database system capable of clinical, 

tracking, and analytical functions. It must be readily available, 

secure and tailored to the needs of line commanders, medical 

personnel, medical regulating planners, and medical planners.

4. Improve the behavioral health support at the unit level: 

a. Soldiers are far more likely to consult fellow Soldiers for support than 

either behavioral health providers or chaplains. Therefore, develop a 

peer-mentoring program utilizing mid-grade Soldiers to facilitate the 

early identification and intervention of psychosocial problems at the 

company level. 

b. Significantly improve behavioral health support for rear-detachment 

commanders and Family Readiness Groups.

Implement a peer-mentoring program. 

Soldiers reported that they were much more willing to turn to a 

member of their unit for support than a chaplain or behavioral 

health professional. Soldiers who screened positive for behavioral 

health problems reported turning to other Soldiers for support 

(37%) much more often than they accessed care from behavioral 

health professionals (10%) or chaplains (12%). This suggests that 

developing a peer-mentoring program utilizing mid-grade NCOs 

within each company could facilitate the early identification and 

intervention of behavioral health issues at the company level. 

Improve behavioral health support for rear-detachment commanders and Family 

Readiness Groups (FRG). 

Soldiers reported being separated from the family as a major 

stressor (57% reported high/very high trouble or concern). Many 

focus groups expressed concerns that rear detachment staff and 

FRGs were not able to adequately support families. In the survey, 

55% of married Soldiers reported not being satisfied with the reardetachment support; 54% were not satisfied with the FRG support. 

This finding was also identified in prior surveys conducted among 

spouses of Soldiers deployed to OIF/OEF. The data suggest the 

Army needs to provide better support to assist families and FRGs. 

28 
 

During deployments, assistance should be given to brigade/ 

battalion rear detachments and FRGs to handle family issues. One 

possible solution would be to have social workers fulfill this mission.

5. Implement monitoring of serious suicide attempts within Army medical 

surveillance systems. Task CHPPM and the behavioral health consultants to 

develop capability for monitoring serious suicide attempts at the installation, 

operational, and Army-wide levels. 

Enough precedence exists to support the strategy of reducing 

suicide occurrence by reducing occurrence of serious suicide 

attempts (leading to hospitalizations and evacuations). A critical 

component of this strategy would be to monitor suicide attempts as 

a metric for suicide prevention actions. The pilot version of the 

AMEDD Suicide Events Report (ASER) is a promising tool for 

reporting suicide attempts. 

29 
 

DISCUSSION

The MHAT was impressed with the commitment, dedication and professionalism 

of the Soldiers serving in Operation Iraqi Freedom. Many of our behavioral 

healthcare colleagues impressed us with their creativity and originality. Given 

the austere, extremely dangerous environment of Iraq, they found ways to 

provide behavioral healthcare services to our Soldiers with outstanding results. 

With divisional DMHSs and Corps CSC units having a RTD rate in the mid to 

high 90% and the ------- CSH in Iraq having a 69% RTD, the OIF behavioral 

healthcare system demonstrated great capability to help Soldiers deal with the 

operational and combat stressors Soldiers faced in OIF. As a result of the high 

RTD, both units and Soldiers benefit. Units benefit from continued force 

sustainment. Soldiers avoid the stigma linked to evacuation for a behavioral 

health illness. 

Clearly, with positive results such as these, the OIF behavioral health system 

was working well. Nevertheless, the MHAT found room to improve the 

behavioral healthcare system. Several indicators identified unmet needs for 

behavioral healthcare services. 

Twenty-three percent (23%) of Soldiers reported moderate to severe stress, 

emotional or family problems and 15% of Soldiers reported interest in receiving 

help with their problems. Seventeen percent (17%) of Soldiers screened positive 

for traumatic stress, depression or anxiety and reported impairment in social or 

occupational functioning. Of the Soldiers who reported interest in receiving help, 

only one-third received some form of help. Of those Soldiers who screened 

positive for traumatic stress, depression or anxiety, only about one-fourth 

reported receiving help at any time during the deployment. Soldiers reported that 

there were barriers to receiving help: too difficult to get to the location of 

behavioral health services (26%), getting time off from work (43%), not knowing 

where to go for help (24%), or behavioral health services not being (24%). 

An aggressive COSC outreach program is the solution to overcoming these 

obstacles. Unlike the traditional clinical approach, COSC outreach takes the 

services to the Soldier’s worksite. Although as a theater, OIF behavioral health 

providers reported spending 40% of their time in prevention activities, several 

units had stopped outreach programs and had set up traditional behavioral health 

clinics (i.e., an office-based strategy with regular office hours). 

The MHAT also found RTD rates precipitously fell as patients moved through the 

evacuation chain. (Kuwait – 11%, LRMC – 3.6%). Given MTF de-emphasis of 

treatment of evacuees, a properly placed, staffed, and operated reconditioning 

unit may return to duty many Soldiers evacuated for transient behavioral health 

problems (e.g., combat stress reactions and Adjustment Disorder). 

30 
 

Additionally, patient documentation was inconsistently maintained and did not 

accompany the patient through the evacuation system. The flow of clinical 

documentation was essential for continuity of care. Standards for a clinical 

documentation packet for behavioral health evacuations and the transfer of the 

packet need to be established and followed immediately. Communication 

between levels of care is equally important and must be promoted. 

The July 2003 increase in OIF suicides taught a valuable lesson: suicide 

awareness and prevention programs must be proactively integrated into initial 

planning efforts, not added later in reaction to a surge in suicides. Several 

suicide risk factors for Soldiers were increased in a combat zone. Vigilance of 

unit leaders was necessary to ensure Soldiers at risk for suicide received 

appropriate support. 

The men and women of the U.S. Army in OIF are to be praised for their sacrifice 

and heroism. The MHAT’s heartfelt desire is that this report will enable our 

colleagues to better assist Soldiers as they serve in Operation Iraqi Freedom. 

The conditions of an austere, hostile environment can stress Soldiers to their 

limits. Behavioral healthcare services on the battlefield are designed to assist 

commanders maintain Soldier focus on the mission, minimize distractions and 

help Soldiers cope with the stresses of war. This report is dedicated to that end. 

31 
 

APPENDIX 1 to OIF MHAT REPORT 

 CHARTER 

21 July 2003 

Consultation Proposal for Operation Iraqi Freedom (OIF)-related MH Issues 

1. ESTABLISHMENT, PURPOSE AND SCOPE. 

 a. ESTABLISHMENT. The Office of The Surgeon General (OTSG) 

established the mental health advisory team (MHAT) for assessing and providing 

recommendations vice OIF-related mental health (MH) issues. This Charter 

delineates the OIF MHAT’s purpose, membership, and specifies the scope of 

activities. 

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

leadership of MH treatment units and their headquarters within the OIF theater 

and evacuation chain to include Landstuhl Army Medical Center (LRMC) and 

Fort Stewart – in order to assess and provide recommendations to address 

potential organizational and resource-limitation factors which may be related to 

the recent spike in OIF-related suicides, increased MH patient flow (documented 

via JMEWS) thru LRMC from OIF, recent increases in media interest in stressrelated issues in the Iraqi theater, as well as deployment-related mental health 

issues at one of our major deployment platforms-Ft. Stewart (3rd Infantry 

Division). As OIF continues to transition from combat to stabilization and support 

operations, concerns regarding the mental health services and psychological 

issues affecting the deployed OIF force are rapidly emerging. The recently noted 

increase in MH service utilization & suicides by deployed OIF Soldiers is likely 

primarily associated with: 1) a predictable clinical surge comprised of the backlog 

of MH distress cases that were on hold during the initial intense combat 

operational phase of OIF, 2) distress engendered by unavoidable uncertainties 

associated with current operational ambiguities (personal safety, redeployment 

dates, etc.), and 3) the renewed availability of communications of vulnerable 

Soldiers with distressed families at home. The MH challenges involved are 

surfacing from multiple levels: 1) MH casualty data, 2) deployed OIF MH 

providers, 3) MH providers in the patient evacuation chain at LRMC and CONUS 

MTFs, and 4) CONUS MH leadership receiving MH casualty data and sporadic 

communications from these 2 cohorts of MH colleagues. Recognizing that 

deployment-related mental health concerns for deployed service members and 

their families are not unique to the few sites delineated above, the MHAT will 

generalize its consultation to address service-wide policies, procedures, and 

resource requirements which may be constructively informed by their findings 

and recommendations. 

32 
 

 c. SCOPE OF ACTIVITY. 

 (1) The MHAT will assess MH challenges potentially associated with: 

(a) Command and Control – clarity and adequacy of communication 

feedback to resolve emerging MH challenges. 

(b) Communications – sufficiency of extant communications capabilities 

(phone, fax, e-mail) to support intra-theater referrals and 

conveyance of clinical information via evacuation chain for those 

Soldiers evacuated from theater. 

(c) Resource Support – adequacy of: 1) psychotropic medication stocks 

to minimize avoidable evacuations of Soldiers requiring 

acute/maintenance pharmaceuticals, 2) MH patient ‘holding 

capacity’ to minimize avoidable evacuations of Soldiers who are 

temporarily dysfunctional for MH reasons, 3) MH provider base – 

specifically 3rd ID MH support, 4) geographic locations of MH clinical 

assets to minimize Soldier referral travel & maximize efficiency of 

available MH clinical assets. 

(d) Policies – any needed changes in policies both in theater & 

systemically to enhance the quality of MH services provided OIFdeployed Soldiers and their families located at our deployment 

platform installations. 

2. ORGANIZATION. 

 a. The MHAT will consist of the following membership: 

- Team Leader, Behavioral Health (BH) Consultant, US Army 

Medical Command (MEDCOM) 

- Combat Stress Control policy staff officer, MEDCOM 

- Chief, Dept. of Psychology, Fort Hood 

- Project Officer – Operation Solace, Pentagon 

- Epidemiology support from WRAIR 

- Representative from U.S. Army Chief of Chaplains 

- Other representatives/SMEs as deemed appropriate by OTSG 

b. The MHAT team will interface and coordinate with the appropriate line 

and medical leadership within the OIF theater, as well as other levels of 

relevant line and policy leadership to accomplish the stated PURPOSE 

and SCOPE OF ACTIVITY above. 

33 
 

3. PROCEDURES. 

a. The MHAT will initiate their efforts to accomplish its PURPOSE effective 

the date of this CHARTER’s approval, and anticipate onsite visits to Fort 

Stewart, LRMC, and designated appropriate sites in the OIF theater - to 

commence in August 2003 for the briefest duration of time necessary to 

accomplish its PURPOSE and SCOPE of ACTIVITY. 

b. An inbrief from the MHAT will be made available to relevant line/ medical 

leadership the 1st day of each site visit. An outbrief to the local line/ 

medical leadership describing preliminary findings and recommendations 

under consideration will be provided at the conclusion of each site visit. 

c. Access to locally and centrally available relevant data sources (clinical 

personnel, MH patient flow data, etc.) will be requested. 

d. Interviews with relevant unit/medical leadership will be requested at each 

site, and at higher levels of line and policy leadership as appropriate. 

4. DELIVERABLES. 

a. A preliminary written report of the MHAT’s findings and recommendations 

(after review to ensure that no classified information is inadvertently 

released) will be completed and submitted to OTSG NLT 15 days after the 

conclusion of the last site visit. The final report’s submission date is 

contingent on completion of any relevant data analysis. 

b. Final briefings of the MHAT’s findings and recommendations to all 

appropriate levels will occur as directed by OTSG. 

c. No media communications will occur among the MHAT members without 

the approval of OTSG. 

 KENNETH L. FARMER, JR., M.D. 

 Major General 

 Deputy Surgeon General 

34 
 

APPENDIX 2 (Information Paper) to OIF MHAT REPORT 

 17 July 2003

Subject: Mental Health (MH) Concerns & Consultant Recommendations – 

Operation Iraqi Freedom (OIF)

Challenges. As OIF continues to transition from combat to stabilization and 

support operations, concerns regarding the mental health services and 

psychological issues affecting the deployed OIF force are emerging. The 

recently noted increase in MH service utilization/suicides by deployed OIF 

Soldiers is associated with: 1) a predictable clinical surge comprised of the 

backlog of MH distress cases that were on hold during the initial intense combat 

operational phase, 2) distress engendered by unavoidable uncertainties 

associated with current operational ambiguities (personal safety, redeployment 

dates, etc.), and 3) the renewed availability of communications with distressed 

families at home. The MH challenges involved are surfacing from multiple levels: 

1) MH casualty data, 2) deployed OIF MH providers, 3) MH providers in the 

patient evacuation chain at LRMC and CONUS MTFs, and 4) CONUS MH 

leadership receiving MH casualty data and sporadic communications from these 

2 cohorts of MH colleagues. The data supporting these concerns are primarily 

anecdotal and interpolated below. 

1) Command & Control – based upon reports from various deployed MH 

providers in the OIF theater and the experience of CONUS MH leadership, there 

is the perception that clear lines of authority/accountability for managing (in 

theater) MH issues are lacking; 

2) Communications – based upon reports from deployed OIF MH providers, MH 

providers in the patient evacuation chain, and efforts to sustain contact by 

CONUS MH leadership - there is inadequate communications capability made 

available to OIF MH providers. Specifically, real time access to the Internet/email/telephone is reportedly only episodic for many deployed MH providers, 

which significantly impedes clinical communications required for the safe 

transport of MH patients through the medical evacuation chain. Also, the 

MH/CSC providers often lack a directory of where the other MH providers are in 

the OIF theater, and how they can be contacted; 

3) Resource Support – based upon ongoing anecdotal reports from deployed OIF 

MH providers, 3 issues are of primary concern in their attempts to deliver clinical 

services at some Iraq locales - inadequate: 1) psychotropic medication stocks to 

minimize avoidable evacuations of Soldiers requiring acute/maintenance 

pharmaceuticals, 2) MH patient ‘holding capacity’ to minimize avoidable 

evacuations of Soldiers who are temporarily dysfunctional for MH reasons, 3) MH 

provider base – specifically regarding 3rd ID MH support; 

35 
 

4) Leadership Concerns – based upon anecdotal reports from deployed OIF MH 

providers, a few leaders have purportedly withheld Red Cross notifications from 

their enlisted subordinates for significant periods of time after receipt - 

engendering anger, resentment, loss of confidence in leadership, and in some 

cases MH/behavioral dysfunction; 

5) Expectations Management – the current lack of a well-defined theater rotation 

policy (recent media example from the 14 JUL03 issue of USA Today / AP – “3rd

ID Soldiers get longer stay in Iraq”) is negatively impacting on the psychological 

status of the OIF deployed force and their family members at home with 

predictable deleterious MH effects on vulnerable Soldiers (particularly with 

challenging relationships / financial concerns back home) and their family 

members. 

Recommendations. TSG’s MH consultants have tentatively identified (pending 

appropriate AMEDD/CJTF/CFLCC-command coordination and approval) a small 

3-4 person MH advisory team of SMEs to travel to the OIF theater to provide 

time-limited advisory consultation to the medical & MH leadership for CJTF and 

CFLCC. The MH advisory team’s purpose is to facilitate the support and 

implementation of the following recommendations which parallel the issue 

numbers per above: 

1) Command & Control: 

a. Identify a single mental health consultant in the OIF theater, whose 

primary responsibility is to address and manage with appropriate 

CJTF/CFLCC medical & line leadership approval and support - the current 

and future MH challenges in Iraq/OIF; 

b. Establish a routine communications feedback loop between the OIF 

theater MH consultant and the MH provider base dispersed throughout the 

Iraqi theater to support local MH mission problem identification and 

resolution with appropriate guidance and resources – this will likely require 

periodic MH unit site visits throughout Iraq; 

c. Establish routine communications between the OIF theater MH consultant 

and the AMEDD’s BH leadership to facilitate ongoing understanding of MH 

casualty trends and new initiatives (in theater, ERMC, CONUS) required 

to minimize MH casualties and unnecessary MH evacuations from the OIF 

theater. 

2) Communications - provide the infrastructure support and access to the Internet 

& software needed to maintain daily clinical communications with the patient 

evacuation chain in ERMC and CONUS: 

a. provide a laptop PC per stand-alone MH treatment section with 

software (TRAC2ES and PARRTS) & Internet access; 

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b. provide local MH provider training to enable utilization of available 

information systems (TRAC2ES and PARRTS); 

c. provide each stand-alone MH treatment unit with daily SATCOM phone 

access; 

d. provide a continually updated directory of MH and CSC assets and 

how to contact them. 

3) Resource Support - reassess the adequacy and expeditiously redress 

identified deficiencies in the MH provider base, MH patient holding capacity, and 

the availability of psychotropic medications in the OIF theater: 

MH provider base: 

a. cross-level MH professional/paraprofessional assets within the 

OIF theater to reflect clinical mission demand; 

b. assess whether current MH professional/paraprofessional assets 

are optimally geographically located to meet local clinical support 

& referral needs of solder populations served; 

c. if additional MH professional/paraprofessional assets are 

required after cross-leveling & geographic repositioning - 

communicate same thru CoC and via MH leadership at HQ 

MEDCOM. 

MH patient holding capacity: 

a. assess demand for temporary treatment/holding capacity needed for 

local & regional unit populations served; 

b. assess the appropriateness of the current geographic positioning of 

CSC and CSH-based MH holding capacity; 

c. maximize use of the line units themselves as the platform for 

distressed Soldier to rest and receive support from their leaders, 

teammates and chaplains, with consultation from MH or CSC 

“walkabouts” at the unit locations; 

d. if additional MH holding capacity is required - communicate same thru 

CoC and via MH leadership at HQ MEDCOM; 

e. assess OIF theater evacuation policy to insure avoidable MH A/E is 

minimized by maximal utilization of MH holding and treatment 

capabilities in theater. 

Psychotropic medications availability: 

a. survey the 60Ws deployed for a focused list of those psychotropic 

medications needed in theater to support their Soldier populations 

remaining functional and meds needed to prevent avoidable 

evacuations; 

b. compile the list of identified psychotropic meds to provide medical 

logistics to assemble push packages for expedited distribution to 

60Ws’ with such requirements. 

4) Leadership Concerns – consultation by OIF mental health consultant/medical 

leadership with senior OIF line leadership reemphasizing the importance of 

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38 

enforcing existing policy on emergency communications from home and the 

primacy of leadership integrity and trust to maintain subordinate morale; 

5) Expectations Management - DoD leadership rotation/redeployment policy is 

obviously not a MH responsibility. However, until a clearly defined policy is 

established for all Soldiers in the OIF theater, many of the MH issues affecting 

Soldiers and their families will remain unresolved. 

MH Consultants HQ, USA 

MEDCOM 

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Approved by: -----------------