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Running head: FIGHTING MAD: MENTAL HEALTH IN THE COMBAT ZONE

Fighting Mad: Mental Health in the Combat Zone

Zachariah E. Bingham

Bon Secours Memorial College of Nursing

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FIGHTING MAD: MENTAL HEALTH IN THE COMBAT ZONE
The official termination of combat missions for Operation Enduring Freedom (OEF) and

Operation Iraqi Freedom (OIF) brought an end to our nations longest sustained military

operation. During this time 2 million service members deployed in support of OEF and OIF.

(Pickett, 2015) A large amount of these deployed service members were exposed and

experienced direct combat and sustained threats. (Wangelin, 2014) The tactics used by our

enemies included gorilla style combat, roadside bombs (IEDs), and rocket propelled attacks.

This style of combat can result in high mortalities, increased risks for traumatic brain injury, and

posttraumatic stress (PTSD). Attacks like these can occur on a routine basis, causing constant

and increasing stress on combat troops. These risk factors cause mental health problems, which

lead to acute attacks or suicide. Understanding how mental healthcare and support benefits at

risk combat operators, may reduce the occurrence of mental health cases, and minimize the

amount of suicides within the AOR.

Mental health problems among military personnel and veterans are quickly becoming an

increased problem. OIF and OEF veterans account for 1.9 million new personnel eligible for

care from the Department of Veterans Affairs (VA). Of this 1.9 million, 57.2% received at

least a provisional mental health diagnosis, with the most common conditions being PTSD,

depressive disorders, and anxiety disorders. (Pickett, 2015) Even more alarming is Army data

showing suicide rates in combat zones have increased; as of 2007 30% Army suicides and 17%

of Marine suicides occurred in deployed settings. (Bryan, 2010) Suicides in the combat zone

have been credited to untreated mental illness, insomnia, substance abuse and the availability of

means. In an area where nearly all have access to firearms, 93% of suicides in combat zones are

from firearms, compared this to 52% of death by firearms while not deployed, shows how

means can increase suicide rates. (Bryan, 2010)

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FIGHTING MAD: MENTAL HEALTH IN THE COMBAT ZONE
Research has showed that many of these mental health issues develop in the combat zone

or are pre-existing in the member prior to deployment to a combat zone. Furthermore a Navy

Bureau of Medicine and Surgery study found deployed personnel who receive in-theater

treatment for mental health problems were at high risk for post deployment mental disorders.

(Conway, 2016). This begs the question of what kind of care are they service members

receiving while in the area of operation (AOR), and who is tracking their care while deployed

and once returned home? Deployed service members have limited access to mental health

facilities, medications and behavioral health specialists. In combat zones, specialized services

such as substance abuse treatment, inpatient psychiatric units, and family therapy simply do not

exist.(Bryan, 2010) Combat service members may not have the facilities to successfully fill

their needed medications, and in some cases the medications they need (sedatives) cannot be

taken due to the altered mental status the cause.(Bryan, 2010) Group therapy has show to be a

good option, as it targets a larger amount of at risk members. However group therapy models,

which benefit the patient after multiple sessions, can have limited effectiveness in the combat

zones due to the difficulty of getting off work. Trouble getting time off to seek and attend

therapeutic groups were cited by many deployed service members. (Bryan, 2010) Even if these

members are able to access therapeutic groups or medications, the member then returns to

combat and stressful situations, exposing them to higher risks of experiencing additional

traumatic events than if medically discharged (in a non combat setting). (Wangelin, 2014)

One positive service in its early stages of development is called Prolonged Exposure (PE)

therapy. Accessed via telehealth, PE is regarded as the most widely used and evaluated protocol

for military members with PTSD. (Wangelin, 2014) According to Dr. Bethany Wangelin, a staff

psychologist on the PTSD Clinical Team, PE includes four major components:

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FIGHTING MAD: MENTAL HEALTH IN THE COMBAT ZONE
psychoeducation, repeated in vivo exposure to safe situations that are avoided due to distress,

repeated and prolonged imaginable exposure involving vividly revisiting the traumatic event in

memory, and processing of exposure activities, in which memories and meaning of the event are

discussed with the therapist. Research shows the positive impact of PE on veterans seeking care

back home, and military health officials are confidant PE telehealth technology could become a

valuable mechanism for providing treatment for deployed military members. (Wangelin, 2014)

When compared to the services and requirements established by Healthy People 2020

(HP2020) the Department of Defenses (DOD) programs in combat theaters is lacking in some

areas. Mental Health and Mental Disorder (MHMD) 5 requires that of primary care facilities

that provide mental health treatment onsite. (MHMD, 2016) Currently there are only select

bases in the combat theater that have mental health facilities. In most cases members assessed

for being at risk for mental health problems or suicide are sent o Combat Support Hospitals

(CSH). These are not inpatient psychiatric units, rather a place where the member can be kept

safe awaiting his or her transport out of the AOR. These CSHs do not have the resources or

manning to meet adequate standards for inpatient psychiatric care. (Bryan, 2010)

Answering the call to reduce suicide rates, in line with MHMD 1, the DOD has began to

look into the effects on insomnia, agitation and nightmares occurring in combat members. By

better understanding how to treat these symptoms, the DOD feels they can use and adapt

evidence-based interventions to reduce the suicide rates down range. One concept they have

adopted is the idea of belongingness. Instituting social responsibly paradigm that capitalizes

on taking care of one another, the DODs wingman or battle buddy concept creates a sense

of unity and reducing the feelings of decreased belongingness, which is associated with suicide

ideation and attempts. (Bryan, 2010)

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FIGHTING MAD: MENTAL HEALTH IN THE COMBAT ZONE
Once military members have sought treatment, and received care they are then assessed

and returned to their respective units. This is a major change, in an effort to fight the stigma

associated with mental health in the military. Inline with MHMD 8 the military no longer sends

those at risk to treatment, followed by a medical discharge. The DOD now uses a Unit Watch

program to allow commanders and clinicians to use social support net works to manage

members during crisis and after recovery. (Bryan, 2010) There is no longer any punitive actions

or terminations as a result of a mental health illness. These strategies minimize stigmas, and

match the MHMD 8 that requires an increase the proportion of persons with serious mental

illness who are employed.

The World Health Orginzations (WHO) Comprehensive Mental Health Action Plan

(CMHAP) provides the world with numerous mental health objectives for countries to use as

templates to design mental health plans for their respected countries. The DOD has many

programs and initiatives that meet and mirror those established by the WHO. Objective 3 of

the WHO CMHAP implements strategies for promotion and prevention in mental health. The

DOD has been successful in creating programs to allow for promotion and prevention of mental

health. Although the mental health programs in combat zones are not as efficient as the DOD

would like, home station programs can be effective when targeting members getting ready to

deploy. The Navy Bureau of Medicine and Surgery found pre-deployment mental health

screening may prevent the deployment of many individuals with the highest risk of ongoing

adjustment problems. (Conway, 2016) This data is what drives the DOD to implement

strategies to prevent these members from going into combat, allowing them to remain at their

home station to seek treatment and recovery.

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FIGHTING MAD: MENTAL HEALTH IN THE COMBAT ZONE
The WHO action plan contains six cross cutting principles and approaches towards

mental health around the globe. WHO asks that evidence-based practice: Mental health

strategies and interventions for treatment, prevention and promotion need to be based on

scientific evidence and/or best practice, taking cultural considerations into account. Using

independent studies, and those conducted by the VA and DOD, initiatives and preventions have

been made to reduce mental health disparities and suicides. One such implementation is the use

of telehealth PE in the combat zone. Evidence based practice shows the impact PE has on

veterans suffering from PTSD at home station and within the VA. Offering services to combat

troops provides a source of recovery for all, with no regard to culture, beliefs or location in

theater.

One important WHO action plan that the DOD will have difficulty measuring up to is the

reduction of access to means of suicide. According to the WHO the major means are

pesticides, firearms, certain medications. (Suicide, 2016) The DOD understands this measure

to be extremely difficult to overcome. The Journal of Military Medicine states The difficulty

in limiting access to firearms and other potentially lethal method for suicide is arguably one of

the most significant barriers to suicide prevention in combat zones. (Bryan, 2010) Due to this

case, suicidal ideations and expressions are not taken lightly, and commanders are given

explicate rights to medically evacuate serves members from the combat zone to maintain safety.

Managing mental health and suicides in the combat zone allows combat operators to

focus on their mission and safety of their peers. Clinical adjustments must be made along with

more services for operators in recovery and those who may become risks. Without adjusting

our current policies, members will remain at risk for mental illnesses, and suicides will continue

to occur.
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References

Bryan, C., Kanzler, K., Durham, T., West, C., Greene, E. (2010) Challenges and considerations

for managing suicide risk in combat zones. Military Medicine, 175(10), 713-718. doi:

http://dx.doi.org/10.7205/MILMED-D-09-00248

Conway, T., Schmisel, E., Larson, G., Galameau, M. (2016) Treatment of mental or physical

health problems in a combat zone: Comparisons of postdeployment mental health and

early separation from service. Journal of Traumatic Stress, 29(2), 149-157.

doi:10.1002/jts.22091

Mental Health and Mental Disorders. (2016, November 3). Retrieved November 12, 2016, from

https://www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental-

disorders

Prickett, T., Rothman, D., Brancu, Crawford. (2015) Mental health among military personnel

and veterans. North Carolina Medical Journal, 76(5), 299-306. doi:

10.18043/ncm.76.5.299

Suicide. (2016, September). Retrieved November 12, 2016, from

http://www.who.int/mediacentre/factsheets/fs398/en/

Wangelin, B., Tuerk, P. (2014). PTSD in active combat soldiers: To treat or not to treat?

Journal of Law, Medicine & Ethics, 42(2), 161-168. doi:10.1111/jlme.12132

World Health Organization: Sixty-Fifth World Health Assembly [Resolutions and Decisions

Annexes]. (2012, May). Geneva. http://dx.doi.org/10.7205/MILMED-D-15-00039

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