ARTICLES

Mental Health Care in Operation Enduring

Freedom (OEF), 2001 to 2013.* #
By T. SAVOIE. U.S.A.

Tammy M. SAVOIE
Tammy M. SAVOIE, Ph.D.
EDUCATIONAL BACKGROUND
Dec. 2001: M.S., Business Administration, Touro University, Los Alamitos, CA.
Dec. 1992: Post-Doctoral Fellowship, Emory University, Atlanta, GA.
May. 1991: Ph.D., Clinical Psychology, Emory University, Atlanta, GA.
PROFESSIONAL EXPERIENCE
Feb. 1994 Present: Officer, United States Air Force; Biomedical Science Corp (BSC); Rank-LtCol.
ASSIGNMENT HISTORY:
Aug. 2013 Present: Chief, International Health, Air Force Central Command, Shaw AFB, SC.
Jan. 2012 Jul. 2013: Chief, Clinical Operations and Research / The Joint Staff, The Pentagon, Washington, DC.
Jan. 2011 Jan. 2012: Chief, Strategy Branch/ The Joint Staff, The Pentagon, Washington, DC.
Jul. 2008 Jan. 2011: Deputy Commander; Chief, Life Sciences and Human Effectiveness, European Office
of Aerospace Research & Development, Air Force Research Laboratory; London, England.
Jul. 2005 Jun. 2008: Branch Chief, Biobehavioral Performance Branch, Air Force Research Laboratory, TX
Sep. 2002 Jul. 2005: Deputy Program Manager, Theater Medical Information Program, Falls church, VA.
Jun. 1999 Aug. 2002: Deputy Sq Commander, 47th MDOS; Flight Commander, Life Skills Clinic; Laughlin AFB, TX.
Jun. 1996 Jun. 1999: Chief Psychological Services, Substance abuse Element Leader; Kadena AFB, Okinawa, Japan.
Feb. 1994 Jun. 1996: Chief, Psychological Services; Substance Abuse Program Manager; Maxwell AFB, AL.

RESUME
Prise en charge psychologique durant lopration Enduring Freedom de 2001 2013.
Au dbut des oprations de combat en Afghanistan en 2001, lempreinte oprationnelle tait lgre et la sant mentale des
troupes dployes en Afghanistan ntait pas au premier plan; il na pas sembl non plus quelle aurait d ltre. Il est apparu cependant,
la guerre se poursuivant, que la sant mentale des troupes combattantes ou de soutien devait faire partie de proccupations des chefs
aussi bien militaires que civils. Cet article passe en revue la sant mentale au cours de lopration Enduring Freedom en Afghanistan de
2001 2013 et prend en considration : les structures de consultation en sant mentale; les moyens de traitement disponibles; les
changements de politique au cours de lopration. Des changements significatifs sont intervenus au cours de cette guerre dans
les principes de prise en charge sur le terrain. Des cas concrets observs sur le terrain sont prsents ainsi que les leons tires.

KEYWORDS: Mental health, Operation Enduring Freedom, Theater mental health, Afghanistan, Medical
evacuations.

MOTS-CLS : Sant mentale, Opration Enduring Freedom, Sant mentale sur le terrain, Afghanistan, Evaluation
mdicale.

VOL.
88/4

At the beginning of combat operations in Afghanistan

(Operation Enduring Freedom: OEF), the operational
footprint was light and the mental health of troops
deploying to Afghanistan was not at the forefront of the
national consciousness, nor did it seem as if it needed to

International Review of the Armed Forces Medical Services

be. Indeed from 2000 through 2003 there was remarkable consistency in the low number of Service
Members receiving an initial mental health diagnosis1;
however, from 2004 through 2012 Service Members
with at least one mental health diagnosis steadily and

XX

Revue Internationale des Services de Sant des Forces Armes

VOL.
88/4

significantly increased: In 2012, 76% more Service

Members received an initial diagnosis of a mental disorder than in 20002. Commensurate with the rise in mental health diagnoses, a marked increase in the number
of outpatient mental health visits from 2007 to 2011
was also observed (2007: 946K; 2011: 1.9M)3.

Steady gains in the number of mental health personnel

supporting theater operations in Afghanistan from
2005 through 2010 is demonstrated; these numbers
remained steady through the summer of 20136, 7.
Beginning in 2007, a push was made to increase and
redistribute mental health personnel throughout the
theater to provide improved support to Service
Members at forward operating bases. Deploying mental health assets to forward deployed locations and
having mental health providers visit units (i.e., battlefield circulation) became and continues to be the
model of care. Indeed mental health providers prefer
battlefield circulation to reach Service Members for
individual contact6.

Mirroring the escalation in mental health diagnoses and

outpatient visits seen in active duty Service Members, the
proportion of medical evacuations for psychiatric issues
among deployed male troops to Afghanistan multiplied
from 2003 to 2012. Annual rates of medical evacuations
attributable to mental disorders more than tripled from
2003 to 2007 and remained stable but high from 2008
through 2012, while evacuation rates for musculoskeletal
and other nonbattle disorders rose from 2001 to 2007,
but then decreased through 20124.

By 2012 when the drawdown of forces began, there

was a robust system of mental health care resources
available in the Afghanistan Theater providing a vast
array of services including: Emergency psychiatric care
and evacuation; intensive psychotherapy; brief psychotherapy (to include treatment of combat stress); medication management; outreach, education and awareness training; traumatic event management (TEM); command directed evaluations; and special duty assignment
evaluations6.

Many reasons have been given for the expansion seen in

mental health diagnoses and psychiatric evacuation:
Prolonged psychological stress associated with warfighting, high operations tempo and even stress related to the
economic issues of the times. However, these increases in
part may also be attributable to efforts at reduced stigma
and easier access to mental health care. Throughout the
war period, extensive programs and resources were devoted to broadening the availability of mental health workers; reducing stigma and removing barriers to seek and
receive mental health care (5). In any case, there has been
a visible shift in the behavior of some Service Members
regarding seeking mental health treatment from the
beginning of combat operations in 2001.

These services were delivered through three separate

but integrated venues: Role 3, Combat Stress and Mental
Health Clinics; Restoration Clinics; and Organic Mental
Health Services6.

ROLE 3, COMBAT STRESS CLINICS

AND MENTAL HEALTH CLINICS

Along with the upsurge seen in mental health diagnoses, outpatient treatment and psychiatric evacuation, mental health staffing in the theater also underwent significant changes since the start of combat operations in Afghanistan in 2001. The data presented
below represent a snapshot of mental health staffing
and distribution from 2005 to 2013.

These clinics served as outpatient mental health clinics,

providing all of the aforementioned services and were
very similar to the mental health care provided in garrison. Providers in these clinics saw anyone who walked through the door; they turned no one away;
conducted both day and night call providing nonstop
24/7/365 services6.

SUMMARY OF STAFFING RATIOS

YEARS

INDEPENDENT
PRACTITIONERS (IPS)

IP TO SERVICE MEMBER
RATIO (IPR)

2005

3951

2007

15

1452

2009

21

2298

2010

58

1638

2012

57

1799

2013

57

1351

RESTORATION CLINICS
In 2009, the first mental health restoration clinic opened at
Bagram Airfield with the intent to promote proximity,
immediacy and expectancy. Treatment was provided in a
residential treatment facility and was designed to maximize restoration and return-to-duty. Services at restoration
Correspondence:
Lt.-Colonel T. SAVOIE
AFCENT/SGI
1 Gabreski Drive
Shaw AFB, SC 29152
Tammy.savoie@afcent.mil
Savoietammy95@yahoo.com
Work: 001-803-717-7100
Cell: 001-803-697-3442

(Independent practitioners are defined as psychiatrists, psychologists, psychiatric nurse practitioners, and social workers.)

These numbers include all active duty Service Members: those deployed to all theaters
of operation including Afghanistan and Iraq as well as active duty Service Members who
never deployed.

VOL.
88/4

* Presented at the 4th ICMM Pan-Arab Congress on Military Medicine,

Dead Sea, Jordan, 4-7 November 2014.

There was not a significant Mental Health footprint in Afghanistan from 2001 through 2004.

# The opinions or assertions presented herein are the private views of the author
and should not be construed as reflecting the views of the Department of
Defense, its branches, or the Defense Health Agency (DHA).

In the original source, independent practitioners also included Occupational Therapists.

However, OTs were taken out of the total count for the data presented herein because
they were not actually credentialed to practice mental health therapy independently.

International Review of the Armed Forces Medical Services

XX

Revue Internationale des Services de Sant des Forces Armes

VOL.
88/4

clinics were referral based. Reasons for referral included

occupational stress, relationship issues, sleep problems,
and difficulties dealing with anger, grief, and loss.
Restoration programs included structured 3, 5, or 7 day
skills-based intervention; referred Service Members could
not be actively suicidal, homicidal or unstable6, 8. By 2011
two other restoration clinics were opened, however, with
the drawdown all restoration centers in Afghanistan were
closed.

Resolution: Congress authorized and funded

significant expansion of mental health resources in
theater and expanded recruitment of active duty and
civilian mental health providers to conduct mental
health screens and provide care in garrison11.
3. Issue: Service Members returning from deployment who needed mental health care were not being
identified as such.
Resolution: Every Service Member receives faceto-face interview with a mental health or certified
health professional within 90 to 180 days of the Service
Members return home along with incremental follow
up evaluations12.

In spite of the availability of the restoration clinics since

2009, census data indicate low utilization rates. The
stringent referral and admissions criteria for restoration
clinics and line commanders reluctance to release relatively stable Service Members for a period of up to 7
days (plus two days of travel), were cited as reasons
contributing to low utilization rates. The Joint Mental
Health Advisory Team 8 report recommended reviewing
and revising the admissions criteria for the restorations
clinics6.

4. Issue: Line commanders were not always aware

of mental health issues or assets in garrison or in theater. They were often unaware of the mental health
issues associated with combat operational stress6.
Resolution: An effective education and awareness campaign for line commanders regarding mental
health issues and available mental health resources was
implemented; in addition, policy directing commanders
to ensure Service Members receive appropriate mental
health evaluations and to reduce stigma associated
with mental health care has been implemented13, 14.

ORGANIC MENTAL HEALTH ASSETS

By 2012 the Army mandated that each Brigade have
two mental health officers and two mental health specialists embedded in their units6. In 2011/2012 the Navy
and Marine Corp. implemented their Operational Stress
Control and Readiness (OSCAR) Teams. These teams are
also embedded within the unit and include Navy mental health providers as well as Marines trained as
OSCAR mentors and extenders. These mental health
assets provide an array of services to include outreach
and education and traditional outpatient therapy6.

5. Issue: There was poor reintegration from theater

to garrison and from active duty to civilian life for redeploying and separating Service Members. Upon redeployment and/or discharge from Active Duty, comprehensive services and follow up were not consistently
available.
Resolution: Significant resources were devoted to
the development of resiliency programs and greater
effort to prepare Service Members for re-entry to garrison or civilian life. Veterans Administration hired
more mental health professionals; State psychological
services were developed for Reserve and Guard personnel over the course of the war15, 16.

In summary by the peak of the OEF campaign, mental

health services in Afghanistan were comprehensive;
access to care was greatly improved and it became challenging to maintain an even distribution of mental
health resources across the theater in the most effective manner due to the fluidity of the situation6.
Throughout the 13 years of war and the development
of this robust in theater mental health care system
many lessons were learned, the majority of which have
been identified and addressed throughout the years.
The following is a summary of the most pressing issues
and efforts to resolve them.

Reducing stigma and providing comprehensive mental

health care for our Services Members has come a long
way since 2001. As lessons were learned, new policy
was created. By 2013 numerous new Department of
Defense, Health Affairs, Service, and Combatant
Command policies were written, and many existing
policies were revised. Of significance are new policies
which mandate pre and post deployment screening,
updated policies regarding mental health services for
National Guard and Reserve personnel, and policies to
reduce stigma to name just a few. Most recently in
Feb 2015, the Clay Hunt Suicide Prevention for
American Veterans Act17 was passed which among
other things assists veterans transitioning from active
duty in accessing mental health services. As we institutionalize our policies and rewrite our doctrine, we must
apply our lessons learned sooner rather than later in
any new operations that we may find ourselves.

1. Issue: Initially, inadequate pre-deployment screening resulted in Service Members arriving in theater
with significant preexisting mental health conditions;
these Service Members presented a significant drain on
both operational unit and mental health resources6.
Resolution: Stringent mandatory pre-deployment
criteria and screening were implemented throughout
the service components and set out in Department of
Defense, Service, and Combatant Command policy9, 10.

VOL.
88/4

2. Issue: In garrison, there was a shortage of mental

health professionals to conduct pre-deployment screening and to provide general mental health care, and
there was a shortage of resources and providers in
theater.

International Review of the Armed Forces Medical Services

ABSTRACT
At the beginning of combat operations in Afghanistan

XX

Revue Internationale des Services de Sant des Forces Armes

VOL.
88/4

in 2001, the operational footprint was light and the

mental health of troops deploying to Afghanistan was
not at the forefront nor did it seem as if it needed to
be. However, as the war progressed it became apparent
that the mental health of troops both in combat and in
support roles needed the attention of military and civilian leaders. Mental health care associated with
Operation Enduring Freedom (OEF) from 2001 through
2013 in the theater of operations in Afghanistan is
reviewed, to include: Mental health clinic structure;
available treatment and resources, and policy changes
over the course of OEF. There were significant changes
in the laydown of mental health care in theater over the
course of the war. Consistent themes observed in theater
mental health care are discussed as well as lessons learned.
REFERENCES
11. Armed Forces Health Surveillance Center, Mental
Disorders and Mental Health Problems, Active Duty
Component, U.S. Armed Forces, January 2000December 2009, Medical Surveillance Monthly Report
(MSMR). 2010 Nov; 17(11): 6-13.
12. Armed Forces Health Surveillance Center, Numbers and
proportions of U.S. military members in treatment for
mental disorders over time, active component,
January 2000-September 2013, Medical Surveillance
Monthly Report (MSMR). 2014 May; 21(5): 2-7.
13. Armed Forces Health Surveillance Center, Ambulatory
visits among members of the Active Component, U.S.
Armed Forces, 2011, Medical Surveillance Monthly Report
(MSMR). 2012 Apr; 19(4): 17-22.
14. Armed Forces Health Surveillance Center. Medical
Evacuations from Afghanistan during Operation Enduring
Freedom, Active and Reserve Component, U.S. Armed
Forces, 7 October 2001 31 December 2012, Monthly
Surveillance Medical Report (MSMR). 2013 Jun; 20 (6):2-8.
15. Armed Forces Health Surveillance Center, Wither the
Signature Wound of the War After the War: Estimates
of Incidence Rates and Proportions of TBI and PTSD
Diagnoses Attributable to Background Risk, Enhanced
Ascertainment, and Active War Zone Service, Active
Component, U.S. Armed Forces, 2003-2014, Medical
Surveillance Monthly Report (MSMR). 2015 February;
22(2): 2-11.
16. Joint Mental Health Advisory Team 8 (J-MHAT 8),
Operation Enduring Freedom 2012, Afghanistan,
12 August 2013. Office of the Surgeon General, United
States Army Medical Command; Office of the Command
Surgeon, Headquarters, US Army Central Command,
(USCENTCOM); Office of the Surgeon General, US Forces
Afghanistan (USFOR-A): 89-101; 138-139.

17. Mental Health Advisory Team 9 (MHAT 9), Operation

Enduring Freedom 2013, Afghanistan, 10 October 2013.
Office of the Surgeon General, United States Army
Medical Command; Office of the Command Surgeon,
Headquarters, US Army Central Command, (USCENTCOM);
Office of the Surgeon General, US Forces Afghanistan
(USFOR-A).
18. Joint Mental Health Advisory Team 7 (J-MHAT 7),
Operation Enduring Freedom 2010, Afghanistan,
22 February 2011. Office of the Surgeon General, United
States Army Medical Command; Office of the Command
Surgeon, HQ, USCENTCOM; Office of the Command
Surgeon, US Forces Afghanistan (USFOR-A).
19. Department of Defense Instruction 6490.03, August 11,
2006; Certified Current as of September 30, 2011;
Deployment Health.
10. Department of Defense Instruction 6490.07, February 5,
2010; Deployment Limiting Medical Conditions for Service
Members and DoD Civilian Employees.
11. Duncan Hunter National Defense Authorization Act for
Fiscal Year 2009.
12. Department of Defense Instruction 6490.12, February 26,
2013, Incorporating Change 1, Effective October 2, 2013.
Mental Health Assessments for Service Members Deployed
in Connection with a Contingency Operation.
13. Department
of
Defense
Instruction
6490.05,
November 22, 2011, Incorporating Change 1, Effective
October 2, 2013, Maintenance of Psychological Health in
Military Operations.
14. Department of Defense Instruction 6490.08, August 17,
2011, Command Notification Requirements to Dispel
Stigma in Providing Mental Health Car to Service
Members.
15. Department of Defense Instruction 6490.09, February 27,
2012, Incorporating Change 1, Effective October 2, 2013,
DoD Directors of Psychological Health.
16. Department of Defense Instruction 6490.10, March 26,
2012, Continuity of Behavioral Health Care for
Transferring and Transitioning Service Members.
17. Public Law No: 114-2 (02/12/2015); Clay Hunt Suicide
Prevention for American Veterans Act or the Clay Hunt
SAV Act; Congress/house-bill/203.

All
MSMR
reports
can
be
found
at:
http://www.afhsc.mil/ under reports and publications.
All MHAT and JMJAT reports can be found at:
http://armymedicine.mil/Pages/reports.aspx.

VOL.
88/4

VOL.
88/4

International Review of the Armed Forces Medical Services

XX

Revue Internationale des Services de Sant des Forces Armes