Mental Health Advisory Team (MHAT) IV Operation lraqi Freedom 05--=07 FINAL REPORT November 2336 Office of the Surgeon Multinational Force-Iraq ane 0. "ice of The Surgeon General Unitee Statee Array Cornrnane TABLE OF CONTENTS I. EXECUTIVE SUMMARY ..3 II. BACKGROUND ..6 SOLDIER 3; MARINE MENTAL HEALTH AND IV. BATTLEFIELD ETHICS ..3-4 V. MILITARY TRANSITION TEAMS MENTAL HEALTH AND WELL-BEING ..43 VI. BEHAVIORAL HEALTH CARE SYSTEM VII. SUICIDE PREVENTION PROGRAM REVIEW "66 STATUS OF MHAT RECOMMENDATIONS ..74 IX. DISCUSSION "76 X. CONSOLIDATED RECOMMENDATIONS "82 XI. REFERENCES "37 XII. BATTLEMIND TRAINING SYSTEM "39 APPENDICES EXECUTIVE SU MMARY Introduction The Mental Health Aclyieery Team (MHAT) IV wae eetalqlieheq by the Gfiiee ef the US. Army Surgeen General at the requeet ef the Ge-mmanding General, Multi--Natiena| Fe-ree--lraq The ef MHAT IV wae te Seldier and Marine mental health and (I3) examine the qeliyery ef behayieral health eare in G-peratien lraqi Freeqem (OIF), and preyiele fer euetainment and impreyement te eemmantzl. The MHAT IV the mental health ef the qepleyetzl feree frem 28 AUG ta 3 OCT 06. are baeecl en finqinge frem anenymeue Selclier (N 1,320) and Marine (N 44?) euryeye, and en behayieral health, primary eare and unit minietry team euryeye; feeue greup interyiewe with Seleliere and Marinee, ae well ae interyiewe and feeue greupe with Army and Nayy lqehayieral health pereennel; yarieue and pereenal elqeeryatiene lay team membere. Central Findings 1. Net all Selcliere and Marinee czlepleyecl te Iraq are at equal riek fer eereening peeitiye fer a mental health prelqlem. The leyel ef eemlqat ie the main tzleterminant ef a er Marine'e mental health etatue. 2. Far Selcliere, elepleyment length and family eeparatiene were the tap nen-eemlqat (czlepleyment) clue te eherter elepleyment Iengthe, Marinee had fewer nan- eemlqat c:lepleyment eeneerne. 3. Only ef Selcliere reperteczl taking in--theatre Reet El Relaxatien (REE), eyen theugh the ayerage time elepleyecl wae 9 menthe. 4. Selcliere and Marinee reperted general abeut the ereatien and enfereement ef rulee in a eembat enyirenment. 5. Selclier merale wae Iewer than Marine merale but wae eimilar te OIF Selczlier merale. 6. Oyerall, Seltzliere had higher ratee ef mental health prelqleme than Marinee. VVhen matehetzl fer tzlepleyment length and tzlepleyment hietery, Seltzliere' mental health ratee were eimilar te ef Marinee. Multiple elepleyere reperteczl higher aeute than firet-time elepleyere. Depleyment length wae relatetzl te higher ratee ef mental health prelqleme and marital prebleme. 8. Geed NCO leaderehip wae the key te euetaining Seldier and Marine mental health and well--being. 9. Marital eeneerne were higher than in OIF 04-06, and eeneerne were related te depleyment length. 10. Altheugh demegraphie exiete between the depleyed OIF Seldiere and the Army pepulatien, 2003-2000 OIF ratee are higher than the average Army rate, 10.1 ye. 11.6 Seldier per year per 100,000. 11. The eurrent preyentien training ie net deeigned fer a eemleatfdepleyed enyirenment. 12. Appretarimately 10% ef Seldiere and ltflarinee repert mietreating (damagedfdeetreyed lragi preperty when net er hitfkieked a nen-- eemleatant when net Seldiere that haye high leyele ef anger, experieneed high leyele ef eembat er eereened peeitiye fer a mental health prelelem were nearly twiee ae likely te mietreat nen--eembatante ae whe had lew leyele ef anger er eemleat er eereened negatiye fer a mental health prelelem. 13. Traneitien Team memleere have lewer ratee ef mental health preleleme eempared te Brigade Cemleat Team Seldiere, altheugh there wae an unmet behayieral health eare need. 1-4. Behayieral health preyidere reguire additienal Cemleat and Operatienal Centrel ((3030) training prier te depleying te lrag; yery few attended the Army lvledieal Department Center 0 Seheel (AIVIEDD C03) (3030 Ceuree. 15. There ie ne etandardized jeint reperting eyetem fer menitering mental health etatue and euryeillanee ef eeryiee memleere in a eembatfdepleyed enyirenment. Key Recommendations The lieted Ieelew enly a partial lieting ef the eentained in thie repert. A eemplete liet ef ean lee feund in the Ceneelidated Pre-Depfeymenr 1. Te prepare Seldiere and lvlarinee fer handling the ef eembat and depleyment, mandate all Seldiere and lylarinee attend emal|--greLip P'RE--depleyment Battlemind Training. (FORSCOMIHQIUICJ . Deyelep Battlefield Ethiee training baeed en the Army Chief ef Staffe "Se|diere' Rulee," ueing OlF--baeed ed that Se-ldiere and lvlarinee knew exaetly what ie expeeted ef them in terme ef battlefield ethiee and the fer reperting yielatiene. (TRADOCITECOM) . Reyiee the preyentien bregram with elemente epeeifie te the OIF area ef eperatiene, ueing training that en buddy-aid and leader aetiene. (Army Deployment 4. Re--etrLietLire the in--theatre REE peliey te eneure that Seldiere (and Marinee) whe primarily werk euteide the in--theatre REE, te inelude redueing the aetual travel time te and frem the RER eite. J--3 31 J--1) . Share mental health infermatien with eemmandere in the eame manner and detail ae infermatien abeut a weunded ie ehared. Preyide a behayieral health medieal prefile detailing the extent ef the mental health injury, pregneeie, and any reetrietieneflimitatiene en what the ean and eannet de. (IUIEDCOIWOPNAV D93) . Deyeleb etandardized fer eendueting Battlemind Peyehelegieal Debriefinge to replace Critieal Eyent Debriefinge and Critieal lneident Debriefinge felle-wing deathe, eerieue injuriee and ether eignifieant eyente. (lUll\lF--| Surgeen fit IUIRIUICIOPNAV E: NIUIRC) . Feeue behayieral health eutreaeh en unite that haye been in theatre lenger than eix menthe. (Lead: 3" MEDCOM: Surgeen) Pear rafnm em' 8. Te faeilitate Seldiere and lvlarinee reintegrating with their familiee and traneitiening heme, mandate all Se-ldiere and lylarinee emall greup POST--depleyment Battlemind Training. (FORSCOIWHQIVIC) . Edueate and train junier and effieere in the impertant rele they play in maintaining mental health and well--being by ineluding behayieral health training in ALL junier leader deyelepment beginning with the Warrier Leader (Degree and OBIS. (TRADOCITECOIUI) 1D. Extend the interval between depleymente te 18-36 menthe er deereaee depleyment length to allew additienal time fer Seldiere te re--eet fellewing a ene--year eembat teur. (HQ DAIHQMC) the eptimal time fer Seldiereflvlarinee te their mental health and well-being. (HQ DAIHQIVIC fit IVIEDCOIWIVIRIUIC) BACKGROUND Thie repert represents the findinge frem the feurth Mental Health Adyieery Team (MHAT IV) be-ndueted einee the beginning ef Operatien Iraqi Freedem (OIF) Operatien Iraqi Freedem Mental Health Adyieery Team Repert, Mental Health Adyieery Team II Repert frem Operatien Iraqi Freedem II, Mental Health Adyieery Team Operatien Iraq Freedem D4436, 2DD6). The and bf aetiyitiee ef the MHAT IV were appreyed by the Cemmandinq General (CG), Multinatienal -- Iraq (see Appendix A). The MHAT IV membere were aeeigned te the MNF--I and werked direetly under the euperyieien and eentrel ef the Cemmand Surgeen, MIRIF-I. The MHAT IV etatement: IV Seldier and Marine mental health and well--being; examinee the deliyery ef behayieral health bare in analyzee infermatien ebtained; preyidee fer euetainment and impreyement te eemmand." The MHAT IV bf aetiyitiee included the felleyying: 1. the mental health and ef the depleyed feree, building an the findinge frem preyieue Feeue en three pepulatienez Seldiere, Marinee, and Military Traneitien Teame. Thie ie the firet MHAT te the mental health and well- being ef Marinee and Military Traneitien Teame. 2. ethieal faeed by Seldiere and Marinee te enhanee future battlefield ethiee training. Thie aetiyity wae ineluded at the epeeifie requeet ef the CG, MNF-I. Thie ie the firet time that the tepie ef Battlefield Ethiee hae been eyetematieally in a eembat enyirenment einee War II Steuffer, et al. 1949). 3. Cempare findinge frem eurrent OIF eperatiene te preyieue MHAT findinge. 4. Review behayieral health pregrame, etrueture and te eneure eptimal inteqratienrutilizatien, en preyentien efferte. 5. Review the etatue ef the implementatien ef ef preyieue preyiding where SOLDIER 8: MARINE MENTAL HEALTH AND WELL-BEING The IVIHAT IV Soldier and Marine VVel|--being Suryey, whioh wae adapted from the Land Combat Study of the Walter Reed Army lnetitute of (Caetro Hoge, 2DD2) was eimilar in range and eoope to the eunreye ueed in all preyioue with two notable exoeptione. The IVIHAT IV Soldier and Marine VVe||--being Sunrey inoluded an of Battlefield Ethioe and oombat leader behayiore, whioh wae the firet time areae were by an IVIHAT. Soldier and Marine Combat 3. Well-Being Model The areae ooyered in the IVIHAT IV euryey inoludedz (1) Environmental Riel: Faotore, euoh ae oombat and deployment experienoee, and unit and oharaoterietioe, euoh ae branoh of eeryioe Soldiere or lVlarinee), multiple deploymente and deployment length; (2) Proteotiye Faotore, euoh ae training and leaderehip; and (3) Behavioral Health Statue and VVe|l--being, inoluding morale, mental health (inoluding aoute (PTSD), anxiety, and anger) and marital well-being Figure 1). I if -. - a rel' 'ta1,133 :r.g_1 51'-45.I- II-. nil'.- . . .. svir$t5*- . .. 2-lit; . . :21 my. fir; afiyifiyart fat - . - 2--. -as .. 2 Figure 1. Soldier and Marine Combat 3: Well-Being Model {Adapted from Elieae E: Caetro, 2003}. Ae appropriately noted in the IVIHAT report, the baeio underlying aeeumption of thie model ie that the behavioral health and vve|l--being of Soldiere and lvlarinee ie determined by both environmental and individual level oharaoterietioe. lt'e impoeeible to underetand the ourrent mental health etatue of the deployed foroe vvithout of the oombat environment and the individual oharaoterietioe of the Soldiere and lvlarinee operating in that environment. 'v"v'Ithin thie oontext, important gueetione in the IUIHAT report inolude: Doee the mental health etatue of multiple deployere differ from firet--time deployere'? le deployment length related to mental health and Ie the mental health etatue of Soldiere different from that of lvlarinee'? Further, the IVIHAT e>::pande on thie baeio approaoh by inoluding faotore vvhioh have been ehovvn to proteot or attenuate the Soldier and lvlarine from potentially adveree riek faotore. Speoifioally, IVIHAT the role of leaderehip and training in euetaining the mental health of the deployed foroe. Soldier 8. Marine Sample and Methods Table 1 ehovve unite that vvere in the IUIHAT unite either had Soldiere or lvlarinee oomplete the behavior health (BH), primary oare (PC) or unit minietry team eurveye. Eaoh of eurveye oan be found in Appendioee B, C, D, E, reepeotively. In addition, eeleoted unite aleo provided Soldiere or lvlarinee to partioipate in fooue group intervievve. The intervievv eohedule and eummary of the fooue groupe oan be found in Appendioee G. The IUIHAT of Soldiere and lvlarinee on line oompaniee, primarily Soldiere from brigade oombat teame and lvlarinee from Regimental Combat Teame The IVIHAT aleo inoluded Soldiere and lvlarinee from eupport unite at the oorpe and divieion level. To eneure a eample, Soldiere and lvlarinee from all lragi regione vvere inoluded vvhere eignifioant LJ.S. ground foroee lvlap 1). JSC 130b] Table 1. Unite in the Soldier and Marine Well-Being Survey by operational region. USC There were demographic between the Seldiere and lylarinee yyhe eempleted the Wel|--Being Suryey that paralleled the demegraphiee ef Seldiere and lvlarinee aeeigned te brigadefregimental eemldat teame Tablee 2 and 3). The Seldiere euryeyed were elder, mere eenier ranking, mere likelyte haye eempleted eeme eellege, mere likely te be married, and mere likely te haye ehildren eempared te the lvlarinee euryeyed. On ayerage, Seldiere were alee depleyed lenger than the lylarinee at the time they eempleted the euryey, 9 menthe yereue 6 menthe. There were ne eignifieant between the Seldier and Marine eamplee in terme ef ethnieityfraee, eeryiee eempenent (Aetiye er er preyieue depleymente te lrad. Overall, the eLirrent Seldier eample ie demegraphieally eimilar te the Seldier eamplee ef previeue l'v'lHATe. Ae neted previeuely, thie ie the firet time that Nlarinee have been ine|Lided in a IVIHAT ee ne eemparieen eample exiete. Table 2. Eiemegraphiee ef DIF Seldiere that eempleted the Seldier and Marine Well-Being Survey. Gender: Female 14% 133} - Male 36% 11113} Serviee Cempenent. AC RC 3% Age 1e--1e av. 43} NB 13% 25-24 49% ifn=545}i E5-29 24%if =312ji - - - - . EH39 19% Median yea re in military. 3 veare 45+ 5% ifn= Pereent married: 51% (n =565} Igrhnicitw flrlifite Am Median yea re married 3 years ace: iean- n= Hiepanie 15% 195} with $311? child ren: 45% (n 535) Rank: Jr. Enlieted (n=T12} 71% in 393) MED - ,3 at Hm, Multiple 29:4': in -- 354} 5% Average Menth_e Edueatien: H.e.ieEe deployed (median): 9 Seme College 39% {n=532} Elegr ifn=EJI2]i Elaehe|er"e 3% ifn=1lIl5} 1% ifn=14]i Table 3. Demographics of OIF Wlarines that completed the Soldier and Well-Being Suryey. Gender: Female nt: AC 900,? Male 93% {n_4fl3} eryice ompone Age 13-19 115% ifn= 20-24 55% +fr'I=239} Median yea rs in military: 2 years 25-29 13% ifn=5E|ji sees ear =25} 4i;i+ mag. 31: 3} Percent married 33% (n =136) Median yea rs married 2 years Ethnicity! White 69% Race: Nrififin-firm 5% 25} Marines with HIEPEIHIE (FF 7'5} children: 17% (n 69} Asian 13} Ether 15} Deployments to Iraq: 1" Time (n 2T3) Rank: Jr. Enlisted 35% {n=3i3T'} Multipie 33% in 135} Nco 12% {n=52} Sr. s1% {n=3]i Averfl ge Months Dfficenwfl I 9} deployed (median): 6 Education: 61% {n=2Ei2ji Some Edlege 26% {n=112} Assoc. Degree 5% ifn=21} Bachelors 4% ifn=1E} s1% ifn=2]i Comparison Samples (OF I, OIF and CHF D4-06) Whenever appropriate, findings from IUIHAT IV were compared to the findings from previous in order to identify emerging trends or patterns relating to the Ioehayioral health and we||--Ioeing of Soldiers. It should be noted that IUIHAT I and MHAT ll included Soldiers deployed to both Iraq and Kuwait in their analyses. In contrast, IUIHAT Ill and IVIHAT IV did not include Soldiers deployed to Kuwait; thussamples, only Soldiers deployed to Iraq are included in the comparatiye analyses. CHF In total, Soldiers deployed to Iraq completed the Soldier Well-Being Suryey during IVIHAT I. Despite the relatively small sample size, the demographic profile of the OIF I sample is similar to the sample in IVIHAT IV (N 1,320) and to the other IVIHAT samples. The only significant differences in the demographic rnal::tra missidns er details ta Saldiersilyiarines. Eshibit and reasdnable aetidn under stress. Shaw faydritismta eertain members in the unit. Treat all members ef the unitfairly. Are edneerned abdutthe safety bf Ensure that arines dd net assume HSHS when edndueting missidns. Will tell the unit has been giyen tee many tasks. I Nlarines Preteetthe unit frem many tasi~:ings. F'reyide elear guidanee an hawtashs and missiens are ta be aeedmblished. Seldiers ritre yieyyed by the as haying bhysieal edurage. xitre yiewed by the Seldiersfiirlarines as haying meral eeurage. 30 100 Percent Errten and Always Figure 12. Seldier and Marine pereeptieris ef Hen-eemmissiened Offieer Leadership during DIF 05-07. 28 Clffieere in my unit: Tell Seldiereflvl arinee when they have dene a deed jeb. 41 Embarraee Seldierallvl arinee infrent ef ether 112 ref ri e. 1 Try te deed te higher--Libe by aeeigning extra Exhibit CIE ar thinlti ng and reaeijnable ai:tii:in under etrese 41 Shevv fave riti em te ee rtain me mbere in th Linitfell rlv, 4 3 are eeneerned abetit the eafety ef Seldiereflvl erinee. . 5? Ensure that Seldiereflvl arinee de net aeetime LlEtl El TI 3. 5' vvill tell higher--Libevvhen the unit has been given tee many 25 El 3 HS . I F'retei::t th Linit frem re eeivi ng tee ma ny taeltinge. 33 I ma F'revide elear guidance en hevvtaelte and are te ll 3 CD lj . 15.5.5 are viewed by the Seldiererlvlarinee ae having bhyeieal 43 Eflldielvs CD ra Are viewed by the Seldie reflvl arinee as having me ral 44 eetiragePercent Dften and Always Figure 13. Seldier and Marine pereeptieria ef Orffieer Leaderahip during OIF 05-07. Gender and Behavieral Health Status The IUIHAT eamble eeneieted ef 183 female Seldiere and 39 female lvlarinee. Duete the email eamble eize ef female lvlarinee, all enly ineluded female Seldiere. Overall, there were ne eignifieant between male and female Seldiere in terms ef eereening beeitive fer anxiety versus (37% vereue er aeute (PTSD) (19.5% vereue Hevvever, when the level ef eembat vvae eeneidered. gender did emerge between male and female Seldiere. Whereas. enly 9% ef male Seldiere eereened beeitive fer any mental health breblem in the Levv Cembat eenditien. ef female Seldiere eereened beeitive fer any mental health breblem in the Levv Cembat eenditien -4.32. .93). A brea kdevvn by the three mental health eategeriee fer the Levv Cembat eenditien revealed marginally eignifieant differences between male and female Seldiere fer anxiety vereue XE (419) 3.31, versus X3 (419) 3.11, .93). and aeute (PTSD) vereue 12%; XE (419) 2.39. :1 .13). with female Seldiere mere likely te eereen beeitive fer all three mental health eategeriee eempared te male Seldiere. Fer the lvledium Cembat eenditien, altheugh female Seldiere differed frem male Seldiere fer aetite (PTSD) (13% vereue these vvere net eignifieant (XE (-419) .95. .22). Neither anxiety vereue ner verede rates differed between male and female Seldiere in the Medium Cembat eenditien. Due 29 te the emall number ef female Seldiere (n 11) reperting e:~:perieneing high Ieyele ef eembat, we were unable te determine if gender in mental health etatue exiete under high eembat. Marita! Stability Oyerall, marital eatiefaetien ie high, yet there ie a dewnwarde trend einee OIF1. Fer example, in reepenee te the gueetien regarding, haye a geed marriage," there wae a 10% drep frem OIF I te OIF 05-0? in the number ef Seldiere whe agree er etrengly agree with that etatement. Similar deelinee were ebeeryed fer the ether marital eatiefaetien iteme Figure 14). I haye a deed marrlaele I DIFHSE Malriltee My relatieriehip with my epeuee makes me happy Seltllere filly relatienehip with my epeuee El DIFMW Ie yery etable I really feel like a part ef a team with my epeuee 51} 1111} Pe1*ee11t..4g1*ee er Agree Figure 14. Fereent ef married DIF I, DIF 04-06 and OIF 05-0? Seldiere and Marines whe agree er etrengly agree with etatemente refleeting marital eatiefaetieri. Figure 15 ehewe the pereent ef married OIF l, OIF 04-06 and OIF 05-0? Seldiere and lylarinee whe reperted infidelity ae a preblem er reperted that they are planning a eeparatienfdiyeree. Ae ene ean a higher pereentage ef OIF 05-0? Seldiere reperted marital prebleme than OIF I and OIF 04-06 Seldiere and OIF 05-0? Marinee. Fer inetanee, 20% ef OIF 05-0? Seldiere reperted that they er their epeuee were eurrently planning a diyereefeeparatien, while enly 15% ef OIF 04-06 Seldiere and 13% ef Nlarinee reperted that they er their epeuee were planning a diyereefeeparatien. Net eurprieingly, depleyment length wae related te marital prebleme, with 31% ef Seldiere depleyed fer mere than eix menthe reperting marital eeneerne eempared te 10% ef Seldiere depleyed fer menthe er (XE (E336) 0.61, 4 .01). Speeifieally, eyer 22% ef Seldiere depleyed fer mere than menthe reperted that they er their epeuee were planning a diyereefeeparatien eempared te 14% ef Seldiere depleyed fer eix menthe er (X (635) 5.13, 4 .02). Depleyment length wae alee related te 30 Soldier reporte of infidelity being a problem, with 113% of Soldiere deployed for than eix monthe reporting infidelity being a problem oompared to of Soldiere deployed for eix monthe or more 10.77', e: .005). There were no differenoee between Soldiere who were firet--time deployere and multiple deployere for either Soldier or Spouee ourrently planning to get a diyoroe or eeparation (19.5% yereue 19.1%) or infidelity being a problem during the deployment (15.5% yereue Howeyer, many Soldiere reported that they had eignifioant eyente (anniyereariee, ohildren'e birthdaye, eto.) due to being deployed or being away from home training for deploymente. For Nlarinee, it wae not poeeible to determine the impaot of deployment length on marital oonoerne due to there being an ineuffioient number of Nlarinee euryeyed who hae been deployed for ab: monthe or more. It wae poeeible, however, to the impaot of multiple deploymente on marital oonoerne. Similar to Soldiere, there were no differenoee between Nlarinee who were firet--time deployere and multiple deployere for either Soldier or Spouee ourrently planning to get a diyoroe or eeparation (13.2% yereue 13.5%) or infidelity being a problem during the deployment (14.5% yereue EIDIFI -- 41! - '3 eltlierr: I 115-1I11fiu:lelit.y :1 p1*olJle111 oldie 1* 1:po11r1e .1111}: P1*ol.1le111 1:111 1111 1111.'; en He 11 fly 111111111111 11 e11 t. dive ree Figure 15. Feroerit of married OIF I, OIF 04-06 and OIF U5-UT Soldiers and Mfll'iI'IE5 reporting infidelity problems or plane to aepaate or diyoroe. Summary of Findings Combat experienoee for Soldiere and lylarinee in OIF remain high. Mental health aleo remain a oonoern. However, not all Soldiere and Marinee are at equal riek for eoreening poeitiye for a mental health problem. Soldiere and lylarinee experienoing high leyele of oombat are three timee ae likely to eoreen poeitiye for a mental health 31 problem compared to Soldiers and Marines who experience relatively low levels of combat. Not surprisingly, deployment length and multiple deployments to Iraq were related to Soldier mental health and well--being, with Soldiers deployed longer than six months and Soldiers on their second deployment to Iraq more likely to screen positive for a mental health problem than Soldiers who were deployed less than six months or on their first deployment. Longer deployments were also associated with marital problems. Soldiers and lvlarines still report considerable difficulties accessing mental health care, particularly in getting time off from duty to receive treatment. 'very few Soldiers received in--theatre Overall Soldier and Marine morale remains relatively low. Soldiers and lvlarines expressed frustration, anger andr'or resentment at the creation of basecamp rules and policies with no apparent linkage to maintaining combat readiness. Notably, good leadership positive leader behaviors) plays an important role in maintaining Soldier and lvlarine mental health and well--being. Recommendations: Soldier 3. Marine Mental Health and Well-Being 1. Mandate all Soldiers and Marines attend small-group PRE-deployment Battlemind Training. 2. Mandate all Soldiers and Marines receive small group PDST-deployment Battlemind Training. 3 Educate and train junior and officers in the important role they play in maintaining mental health and well-being by including behavioral health awareness training in ALL junior leader development courses, beginning with the Warrior Leader Course (WLC) and the E:-fficer Basic Course (CJBC). (TRADDCIT ECCJM) 4. Revise the combat experiences scale to include "sniper attacks." (WRAlRlFuture NIHP-.Ts) 5. Extend the interval between deployments to 13-36 months or decrease deployment length to allow additional time for Soldiers to re-set following a one- year combat tour. (HC1 DAIHEIMC) Assess the optimal time for to "reset" their mental health and well-being. (HE: DAIHEIMC E: 6. Re-evaluate the in-theatre policy to ensure that Soldiers (and Marines) who work primarily outside the basecam receive in-theatre to include reducing the actual travel time to and from the site. J-3 3; J-1) 7. Develop standardized procedures for conducting Battlemind Debriefings to replace Critical Event Debriefings and Critical Incident Stress Debriefings following deaths, serious injuries and other significant events. (MNF-I Surgeon 3; MRMCIDPNAV 3; 32 3. Develop intewentiena te reduce the impact ef combat and deployment length en the mental health and well-being ef Selclieraiwlarinea. (MNF-I Surgeon 3. 3; NMRC) 9. Standardize baaecamp and FCJB rules to eliminate theae rulea that clen't pertain te eembat reaclineaa, avoiding the eatabliahment ef garriaen-like atanclarcla. (MNF-I 03M) 112}. Pu bliah a peliey that enaurea Seldieraiwlarinea are able te mental health care during the duty clay. 33 BATTLE FIELD ETHICS At the requeet ef GEN Caeey, CG, Multinatienal the MHAT IV deyeleped euryey iteme and feeue greup intenriew queetiene that epeeifieally the ef battlefield ethiee and the adequaey ef battlefield ethieal training fer preparing Seldiere and Marinee eendueting eembat eperatiene in Iraq. Thie ie the firet time that MHAT hae the ef ethiee, and te eur knewledge, the LLB. iethe firet eeuntry te eyetemieally thie in Iraq, altheugh the ef ethiee hae been explered by the Canadian Defenee (CDF) (Themeen, Adame 3: Sarteri, 2005). A review ef the eeientifie literature failed te identify ethieal queetiene er eealee euitable fer en a euryey in a eembat enyirenment. Thue, the MHAT IV membere and ether military eubjeet matter experts deyeleped a eet ef euryey queetiene that are unique net enly te thie MHAT but te the entire field ef battlefield ethiee. uniquely deyeleped ethiee queetiene feur areae: (1) Attitudee Regarding Treatment ef Ineurgente and (2) Battlefield Ethieal Aetiene and (3), Reperting Ethiee Vielatiene and (-4) Battlefield Ethiee Training. Seldier and Marine Attitudea Regarding the Treatment ef In-au rgente and Hen- Cem batanta wae ueing 5 queetiene, en a fiye--peint eeale ranging frem Strengly Dieagree (1) te Neither Agree er Dieagree (3) te Strengly Agree eample iteme ineluded, "All nen--eembatante eheuld be treated with dignity and reepeet" and "Terture eheuld be allewed in erder te gain impertant infermatien abeut ineurgente." Battlefield Ethieal Aetiene and wae ueing 5 queetiene deeigned te hew eften a Seldier er Marine engaged in epeeifie aetiene en the battlefield; were en a eeale frem Meyer, One Time, Twe Timee, Three er Feur Timee te Fiye er Mere Timee; eample iteme ineluded, "lneulted andfer eureed nen- eembata nte in their and the brutalityfmietreatment ef a nen- eembatant by a unit member." Reperting Ethiee Vielatiene wae ueing 6 queetiene en a fiye--peint eeale ranging frem Strengly Dieagree (1) te Neither Agree er Dieagree (3) te Strengly Agree eample iteme ineluded, weuld repert a unit member fer the mietreatment ef a nen-eembatant" and weuld repert a unit member fer net fellewing General Ordere." Battlefield Ethiea Training wae ueing 5 queetiene regarding hew well the Seldier er Marine felt trained in battlefield ethiee, ueing a er reepenee; eample iteme ueed ineluded, "The training I in the preper (ethieal) treatment ef nen-eembatante wae adequate" and eneeuntered ethieal eituatiene in Iraq in whieh I didn't knew hew te reepend." Again, it muet be kept in mind that thie ie the firet time euryey queetiene have been ueed, thue it ie te eempare the findinge frem thie MHAT IV ef Seldiere and Marinee with any ether greup ef military pereennel. Rather, findinge muet be ae a etarting peint, a enapehet, fer hew Seldiere and Marinee VIEW Iraqi ineurgente and nen-eembatante, hew yiewe tranelate inte battlefield ethieal aetiene, and hew yielatiene ef ethiee are reperted. VVith thie infermatien, battlefield ethioe training oan be developed that epeoifioally ta rgete ethioal dilemmae that Soldiere and lvlarinee faoe on the ground in Iraq. Figure 16 ehowe Soldier and Marine attitudee towarde the treatment of non--oombatante and ineurgente. Soldiere and lylarinee are fairly eimilar in their attitudee towarde the treatment of non-oombatante and ineurgente. Only of Soldiere and only 33% of lylarinee agreed that non-oombata nte ehould be treated with dignity and reepeot. Well oyer a third of Soldiere and lvlarinee reported torture ehould be allowed, whether to the life of a fellow Soldier or Marine and reepeotiyely) or to obtain important information about ineurgente (36% and 39%, reepeotiyely). All non-oombatanta ahould be treated with dignity fl'Id reapeot 47 All non-oombatanta ahould be treated as insurgents I 4154]? Ma ri nee Torture should be allowed if it will save 44 the life of a 41 a Torture should be allowed in order to gather important info about i [1 51] rg rant 5 I would risk my own safety to help a non-o ombatant in danger 1} 11} 41} lift!) Per-r e11t. Agree Figure 16. Soldier and Marine attitudes towards the treatment of insurgents and non-oombatanta. Figure ehowe findinge from the battlefield ethioe behayiore eoale for both the mietreatment of non-oombatante and following the ROE. The moet oommon behayior Soldiers and lylarinee reported engaging in wae oureing andfor ineulting lragi non- oombatante in their with 23% of Soldiere and 30% of lylarinee reporting doing thie. Far fewer Soldiere and lylarinee reported damaging or deetroying lragi property when it wae not Qft?a and 12%, reepeotiyely; or hitting or kioking a non- oombatant when it was not 4% and reepeotiyely. When it oomee to Rulee of Engagement (ROE), juet than of Soldiers and lylarinee reported that their unit modifiee the ROE to the importantly, Soldiere and lylarinee who reported better offioer leaderehip were more likely to follow the ROE than thoee Soldiere and lylarinee who reported poorer offioer leaderehip (X2 4.21, e" I35) and (X3 (314) 5.34, EUR1.05) reepeotiyely. 35 lnsultedfcursed at ncn-ccmbatants in their presence Damaged I Iraqi prcperty when it was net necessary I _fl5'D? Mannes Physically hit I kicked ncn-ccmbatant when it was net necessary a 05.0? Scldiers Members cf unit mcdify ROEs in crder tc the missicn Members cf unit igncre RflEs in crder tc the missicn 1} st} 41} as st} 1111} E1 11-? c1' Ii.-Icre Times Figure Scldier and Marine battlefield ethical behayicrs. Figure 18 Scldiers' and Marines' yiews cn repcrting battlefield ethics yiclaticns. The likely battlefield ethics yiclaticn that Scldiers and Marines wculd rebcrt included a unit member injuring cr killing an innccent ncn--c-embatant, with 55% cf Scldiers agreeing that they wc-uld repcrt a unit member and 40% cf Marines agreeing that they wc-uld repcrt a fellcw Marine. Sc-ldiers and Marines were least likely tc repcrt a unit member unnecessarily cr damaging private prcperty, with 43% cf Scldiers indicating that they wculd repcrt a unit member and 30% cf Marines indicating that they wculd dc sc. Less than half cf Scldiers and Marines wculd rebcrt a team member fer an unethical behayicr, with the Marines being less likely tc rebcrt a fellcw Marine than Scldiers repcrting a fellcw Scldier. 36 I weuld repert a unit member fer: injuring er killing an innecent nen- cembatant stealing frem a nen-cembatant mistreatment ef a nen-cembatant net fellewing general erders .3543? Seldiers vielating ROEs unnecessarily destreying private preperty 1} sir we Pe'rce;nr. Agree er 5 Ireligljr Ages Figure 13. Seldier and Illiarine reperting ef battlefield ethics vielatiens. A large majerity ef Seldiers and Marines reperted that they received training in hew they sheuld treat nen--cembatants (see Figure 19), yet a third ef Ivlarines and ever a quarter ef Seldiers did net agree that their N?30s and Officers made it clear net te mistreat nen-- cembatants. Further, ever a quarter ef beth Seldiers and Marines reperted facing ethical situatiens in which they didn't knew hew te resbend. Received training that made it clear new I sheuld behave teward nen-cembatants. Received training in the preper treatment ef nen-cembatants. I ere-s41: Training in preper treatment ef nen-cembatants was adequate. ere-1541: NCOs and Officers in my unit made it clear net te mistreat nen-eembatants Enceuntered ethical situatiens in Iraq in which I did net knew new te respendl3'erce11r. Agree er Agree Figure 19. Seldier and Illiarine attitudes tewards battlefield ethics training. 3? While there are undoubtedly many eituatiene that might lead te the mietreatment ef a nen--eembatant, ene ebyieue eituatien in Whieh unethieal behayiere might ie when the Seldier er Marine ie angry. Figure 20 ehewe the relatienehib ef Se-ldiere' and l'v'larinee' anger leyele te the mietreatment ef lragi nen--eembatante. Ae ean be eaeily Seldiere and Marinee are mere likely te rebert engaging in the mietreatment ef lragi nen-eembatante when they are angry. Fer all the behayiere under etudy, Seldiere and Nlarinee when had high leyele ef angerwere twiee ae likely te engage in unethieal behayiere en the battlefield eempared te Seldiere and Nlarinee whe had lew leyele ef anger ,3'l4) 35.24, 4' .01) and (X2 (433) 14.40, 4' reepeetiyely. lneultedfeureed at nen-eembatante in their Damaged andfer deetreyed Iraqi private Angfir preperty when it wae net IHigh Anger Fhyeieally hit I kieked nen-eembatant when fil] Pe1*ee11r. E.e11e1*Ii11g Ellie er Tinraee Figure 20. The effeete ef anger en the mietreatment ef Iraqi nen-eembatante. Figure 21 ehewe the relatienehib ef mental health etatue and unethieal behayiere en the battlefield. Se-ldiere whe eereened peeitiye fer a mental health preblem (anxiety, er aeute were twiee ae likely te engage in unethieal behayier eempared te Seldiere whe did net eereen peeitiye. Thie relatienehip between mental health and unethieal behayier helde eyen when eentrelling fer anger. findinge indieate the need te inelude Battlefield Ethiee in all mental health eeuneeling and anger management (X2 (640) 0.04, 4 .01) (X3 3.53, 4 .05) reepeetiyely. 33 lneultedleureed at nen-eembatante in their 25 presence 4g El Eereenetl Damaged andfer deetreved Iraqi private Megan" prepertv when it wae net 1'5 El Eereentl Peeitive Fhveieallv hit I kieked nen-eembatant 13 when 1-1-1 Pereent Reperting Cine er Mere Tirnee Figure 21. The effeete ef mental health {eereering peeitive er negative fer an:-tietv, and aeute en 3e|diere' mietreatment ef Iraqi nen-eembatante. Cembat ex were alee related te the mietreatment ef nen--eembata nte. Ae ehewn in Figure 22a, Seldiere whe had a member ef their unit a were mere likely te engage in ineulting er eureing at nen--eembatante in their (X3 16.06, .01) and rebert damaging er deetreving Iraqi breberty when it was net 9.55, e" .01) than Seldiere whe did net have a member ef their unit a Having a member ef veur unit a Ne er 'fee. lneultedlleureed at nen-eembatante in their Damaged I deetreved Iraqi prepertv when . Seldi ere - Me It W35 net Seldiere - 'fee Fhveieallv hit I kieked nen-eembatant when it wae net [1 2t} 40 fit} St} 1flIJ Percent Reperting Cine er Mere Timee Figure 22a. The pereentage ef Seldiere with Medium er High Cembat reperting mietreatment ef nen-eembatante ae a funetien ef whether they did {Yea} er did net {Ne} have a member ef their unit a 39 Figure 22b shews that Seldiers whe handled dead Ieedies er human remains were alse mere likely te haye insultedreursed at nen--eembatants in their presenee (X9 (868) 25.23, D1), damaged er destreyed lrag preieerty when it was net 31.56, .81) er iehysieal hit er kiek a nen-eemleatant (X3 (868) 15.34, .01) when it was net eempared te Seldiers whe did net handle dead bedies er human remains. lnsultedreursed at nen-eembatants in their presenee Damaged I destreyed Iraqi preperty when it was net Fhysieally hit I kieked nen-eembatant when it was net Handling dead bedies er human remains: Ne er Yes. 43 Seldiers - Ne Seldiers - Yes 21;} El] Efl F'ereent Reperting Cine er Mere Times 1flfl Figure 22b. The pereentage ef Seldiers with er High Cembat e:-tperienees reperting mistreatment ef nen-eembatants as a funetien ef whether they did {Yes} er did net {Ne} handle dead bedies er human remains. As shewn in Figure 23a, similar te Seldiers, Marines whe had a member ef their unit a easualty were mere likely te engage in insulting er eursing at in their presenee s" .01) er repert damaging er destreying lragi iereperty when it was net (X2 (256) 35?, 135) eempared te Marines whe did net handle dead Ieedies er human remains. Figure 23b, shews that similar te Seldiers, Marines whe handled dead leedies er human remains were alse mere likely te haye insultedreursed at nen-eemleatants in their ieresenee (X2 (252) 85?, damaged er destreyed lrag preperty when it was net s" .01) er ehysieal hit er kiek a nen-eemleatant (XE (252) 579, ,e J31) when it was net eemieared te Marines whe did net handle dead Ieedies er human remains. Having a member ef yeur unit a casualty: Ne er Yea. lnaultedfeureed at nen-eembatanta in their Damaged I deatreyed Iraqi preperty when it waa net - Ne Matinee -'fee Fhyaieally hit I kieked nen-eemleatant when it waa net [1 fit} ED 113!) F'ereent Cine er Mere Timee Figure 23a. The pereentage ef with Medium er High Ceml:-at reperting miatreatment ef nen-eembatanta aa a funetien ef whether they did {Yea} er did net {Ne} have a member ef their unit a Handling dead leediea er human remains: Ne er Yea lneultedleureed at nen-eembatante in their hi did dl rt amage ea reye raql prepe yw en -I..I..I liflannea-Yea Fhyeieally hit I kieked nen-eemleatant when 1111] F'ereent Cine er Mere Timee Figure 23b. The pereentage ef Nlarinea with Medium er High Cembat reperting miatreatment ef nen-eembatanta aa a funetien ef whether they did {Yea} er did net {Ne} handle dead bediea er human remains. Summary of Findings Seldier and lvlarine Battlefield Ethice vvae ueing eurvey iteme and fecue greup dueetiene develeped by the IUIHAT membere per the redueet ef the CG, Feur Battlefield Ethice areae vvere attitudee, behavic-re, reperting and training. than half ef Seldiere and lvlarinee believed that nc-n--cc-mbatante eheuld be treated vvith dignity and reepect and vvell ever a third believed that terture eheuld be allevved te eave the life ef a fellevv team member. Abeut ef Seldiere and lvlarinee reperted mietreating an Iraqi nen--cembatant vvhen it vvaen't either by deetreying their private preperty er by hitting er kicking them. than half ef Seldiere er lvlarinee vveuld repert a team member fer unethical behavier, inetead preferring te handle it at the team level. Altheugh reperting receiving ethical training, nearly a ef Sc-ldiere and lvlarinee reperted enceuntering ethical eituatiene in Iraq in vvhich t'iey didn't knevv hevv te reepend. Having a unit member beceme a caeualty er handling cead bediee and human remaine vvere vvith in the mietreatment ef lrad nen-cembatante. High levele ef anger and ecreening peeitive fer a mental health preblem vvere alee vvith the mietreatment ef Iraqi nen--cembata nte. Recommendations.' Battlefield Ethics 1. Develop Battlefield Ethice Training baeed en the "Seldiere' Ftulee," ueing GIF- baeed ecenariee ac Seldiere and Marines knevv exactly vvhat behaviere are acceptable en the battlefield and the exact preceduree fer reperting vielatiene. (TRADCICIT 2. lncerperate battlefield ethics in all behavioral health ceuneeling, especially ceuneeling cenducted in a cem bat theatre. 3. CIPNAV D93) 3. Include battlefield ethics in all anger management eepecially training conducted in a cembat theatre. (MNF-I 3; DPNAV D33) 4. adherence te the Seldiere' Rulee during Actien Revievve fellevving critical evente. (MNF-I) MILITARY TRANSITION TEAMS MENTAL HEALTH AND WELL-BEING IUIHAT IV suryeyed 113 Soldiers from Military Transition Teams (ly'liTTs), Border Transition Teams (BTTs) and National F'olioe Transition Teams This assessment represents the first time Transition Team Soldiers have been inoluded in a MHAT assessment. Not surprisingly, the demographio make--up of the Transition Teams is quite different than that of Soldiers from Brigade Combat Teams (BCTs) (see Table Soldiers on Transition Teams are more predominately male, oompared to for Soldiers in a BCT. Soldiers on a Transition Team are also older, more senior in rank (more time in the military, years yersus 3 years), and are more likely to haye a oollege degree. Transition Team members are more likely to be married and haye ohildren. There are no differenoes between Soldiers on Transition Teams and Soldiers in BCTs in terms of previous deployments and median years married. In terms of mental health and well--being, Transition Team Soldiers haye higher personal morale (31% yersus 19%) and unit morale (19% yersus oompared to BCT Soldiers. Transition Team Soldiers also have lower rates of self-reported mental health problems yersus and are less likely to soreen positiye for a mental health problem (13% yersus Although the oyerall mental health and well--being of Transition Team Soldiers is high oompared to Soldiers in BCTs, there is a signifioant peroentage in need of mental health support Relying on Combat Stress Control (CSC) Detaohments and mental health assets to provide mental health treatment at the plaoes these teams pass through for logistioal support is ineffeotiye as it does not give Transition Team Soldiers seeking help the time needed to aooess and reoeiye oare. As is often the ease, when a Transition Team Soldier wants help, hefshe has to soramble to find someone or (as is usually the ease) hefshe must suok it up and driye on. Instead, eaoh team should be assigned a CSC or NIH team that routinely yisits eaoh Transition Team oonduots behavioral health oare outreaoh) to ensure eaoh Soldier's mental health needs are met. Gender: Fem" Primary Component: 50 lvlale 1oe} RC 15% Age 1e-1e 2% 2:1 NG 17% 25-24 15% 25-25 25% {n=2Ei]i - - - - . SD39 35% Median years In military. 10 years 45+ 24% ifn= Percent married 55%ii1 W"'itE' 79% Median yea rs married 3 vears Race: ifltirican-Am 15% 11} Hispanic 12% 15} smdiers with Asian 5} - .3199-' .35 Dther 3} children. :3 in 1 . Deplovm ents to Iraq: Rank: Jr. Enlisted 15% [i'i=1El} 1st Bgoffi (H 24% {n=2Tji It. I 32%, 33 sr. Nos 15% 9 '31" 3 Dfficeriviifl 41% ifn=45} Average WliIiI'i1Il'i_S Education: 14% {n=15} d9P'D'.i'9d 5 Some College 25% {n=2Ei]i Assoc. Degree 15% {n=15} Bachelor "s 55% {n=4iIi} lvlaster'siF'h.Ei. 13% {n=14} Table 7. Demographics of the Transition Team members. Summary of Findings Overall, the mental health of the Military Transition Teams is high. Hovvever, there are approximately 13% of transition team members requiring mental health support. Hovvever, often these transition team members go vvithout help due to their geographical isolation from basecamps vvere mental health personnel are located. Recommendations: Transition Teams Mentai Heaith and Weii- Being 1. Provide far-forvvard behavioral health care outreach at the location ofthe Transition Team. (3rd Teams) 4-4 BEHAVIORAL HEALTH CARE SYSTEM ASSESSMENT Behaviorai Heaith Staffing and Distribution The overall ratio of BH pereonnel to Soldiere during OIF 85-8? fell within the range of ratioe for previous OIF deploymente. The ratio of BH pereonnel to Soldiere ranged from 1:888 (OIF I) to 1:88? (OIF II), with the raljo for OIF D4-D8 being 1:448 and OIF 85-8? being 1:888. When looked at by operational regione (see Table 8), the ratio and dietribl tion of BH ereonnel improved over time ae the number of BH oereonnel inoreaeed. Table 8. The Distribution of BH Personnel 8 Ratio of BH Personnel to Soldiers by Operational Regions [2803-2885}. IRAQ TICJTAL 118888 1:888 215 1:38? 288 188188 1:448 Note: Number of Soldiers from reporte and ie rounded. Compared to OIF 84-88, the overall number of OIF 85-8? BH pereonnel deolined, while the number of Soldiere deployed to Iraq inoreaeed resulting in a alight inoreaee in the ratio of BH pereonnel to Soldiere, 1:448 to 1:888. Moat importantly, the range in the ratioe of BH personnel to Soldiere inoreaeed eionifioanthi Table 81. 45 Table 9. The Dietributien ef EH Fereennel E: Retie ef EH Fereennel te Selcliere {end Nierinee} by Operetienel Regiene U1 0 IRAQ TCJTAL Teblee and 11 eentein edditienel infermetien ebeut the BH epeeieltiee by OIF eperetien and unit type ef Table 10. Eehavieral Health Fereenriel Specialty by OIF Dperatien. Peyehiatriet Peyeh Nurse 12 21 12 See Work 2? 3D 23 Peyehalegiet 1? 21 14 Wledie 5 Ci 5 OT Teeh 5 12 MH Sp-eeialiet 123 120 5 4 TOTAL 215 230 174 U.S. Navy Peyehiatriet - - Peyehalegiet - - Peyeh Teeh - TOTAL - - 13 U.S. Air Farce Saeial Werl-{er - Peyehelegiet TDTAL 3 IRAQ THEATRE TDTAL 23'" 190 Table 11. OIF Eelmviural Health Personnel by Unit and Unit Type. Urit Tutal EDW ESA Army Total 1T4 USNIUSMC 13 4 2 USAF 3 2 1 THEATRE TOTAL 190 Methods The following desoribes the methods used to oolleot data from Behavioral Health (BH) providers, Primary Care (PC) providers, and Unit lvlinistry Teams (UNIT). Data were oolleoted through written surveys of BH, PC and UNIT personnel, and struotured foous group and individual interviews with Behavioral Health personnel (see Appendioes C-E). NIHAT used very similar anonymous questionnaires as NIHAT Ill and NIHAT ll. BH personnel surveyed inoluded Army, Navy, and Air Foroe psyohiatrists, therapists, psyohiatrio nurses, sooial workers, olinioal psyohologists, therapy speoialists, and mental health teohnioians. The PC personnel surveyed inoluded Army and Navy primary oare dootors, nurse praotitioners, physioian assistants, and mediosfoorpsman. UNIT personnel surveyed inoluded Army and Navy Chaplains and Chaplain Assistants (see Table 12). Survey guestions fooused on demographios, standards of praotioe, of servioes, BH servioes provided, skills and training in relation to BH servioes, peroeived stigma and barriers to mental health oare, methods to address Soldier BH needs, and personal wel|--being. Where possible, questions were standardized aoross the three groups of providers. Psyohiatrio medioations were assessed on the BH and PC surveys and were oompleted by oredentialed providers (NIDs, PA, El Nurse Praotitioners) only. BH and UNIT personnel were asked who they thought was the best group and whioh groups should be allowed to partioipate in Battlefield Ethios training. Spaoe was provided for partioipants to make oomments regarding eguipmentfsupplies needed to better perform their BH mission, as well as any additional oomments. Demographics A sample of 123 BH, 2613 PC, and UNIT surveys was oolleoted. Table 12 depiots the military speoialtyfarea of oonoentration (MOSIAOC) of the BH, PC, fit Ulv'|T staff. In addition, the region where BH personnel were assigned is presented in Table 13. Specialty Frequency Valid Percent ef Sample Eiehavieral Health 8 7' (8 Army, 3 Navy) Oseupatienal Therapist 7' 8 Nurse 8 7' Sesial Werker 13 11 Clinical 12 18 (8 Army, 3 Navy, 1 Air Ferse) OT Specialist 7' 8 Mental Health Specialists' 88 48 Oerpsman (54 Army, 8 Navy) Other 8 5 Missing 1 - TOTAL 123 Primary Care l'v"lDs 58 (48 Army, 11 23 Navy) Nurses 3 1 Physician Assistants 2? 11 l'v"leelieslOerpsman 123 (84 Army, 38 48 Navy) Other 41 (33 Army, 8 1? Navy) Missing 8 -- TOTAL 288 Unit Minis try Teams Chaplains 41 53 Army, 4 Navy) Chaplain Assistants 34 44 (31 Army, 3 Navy) Other 2 (2 Navy) 3 Missing 1 - TOTAL Table 12. Oeeupatienal Specialties ef behauieral health and primary eare previders and unit ministry teams. USC 130|::v] 50 Occ Therapist Nurse Social Worker Clinical OT Specialist NIH Tech Other TDTAL USC 130b] Table 13. Region in Iraq where behavioral health care personnel were located. Demographics for 8H, PC and UNIT personnel are shovvn in Table 14. All three groups were predominately male, active duty, Army personnel. On average, providers were older than the Soldiers they support with UNIT members being the eldest. The majority of BH and PC personnel were enlisted Soldiers while a slight majority of UNIT personnel vvere officers. Each BH team supported an average of 5,888 Soldiers located on four FOBs. The OIF 85-8? BH teams traveled an average of two hours to perform outreach support. Age Gender Rank Days Branch of Component (Median) Deployed Service Behavioral 88-88 58% 2?4 88% Army, 82% Active Health years old males enlisted (mean) 18% Navy, Duty -41% AF Primary 38-38 82% 83% 2?4 Army, 82% Active Ca re years old male enlisted (Nlea n) 23% Navy, Duty -41% AF Unit 48 or older 88% 48% 288 88% Army, 77% Active Ministry male enlisted (mean) '1 1 Navy Duty Teams Table 14. Demographics of behavioral health care and primary care providers and unit ministry team personnel. Standards of Clinical Care Figure 24 shovv'sra1J'ngs of the standards of care by both BH and PC providers across C-IF 84-88 and OIF 85-8?. Ratings of standards are similar or more positive across the board for 8H providers during DIF 85-8? compared to OIF 84-88. Although a higher percentage of BH providers in OIF 85-8? reported that the standards of behavioral healthcare in the theatrer'area of operations were clear (82% vs. 53'% in OIF 84-88), the difference is not statistically significant. A significantly higher percentage of BH 51 providers in OIF reported that the standards for olinioal documentation in the theatrefarea of operations were olear (55% vs. 39'% in OIF D4435 (X2 (225): 3.53, Fortv--one peroent of OIF BH personnel indioated that medioal reoords management in the theatrefarea of operations was olear versus 31% in OIF D4- 05 (X3 (226): 4.24, s" .05). A higher peroentage of BH providers in C-IF 05-0? reported that the standards for the transfer of olinioal BH information between levels of oare were olear oompared to 21% of providers in D4-D5. Ratings of standards among PC providers are similar in OIF 05-0? and OIF 04-05; the lone exoeption being standards of behavioral health oare in the theatre of operations. A higher peroentage of PC providers reported that the standards for behavioral healthoare in the area of operations (A0) were olear. peroent of PC providers in OIF 05-0? reported that the standards of behavioral healthoare were olear. This is higher than OIF D4435, where 53% of the PC providers reported that the standards were olear (XE (430) 6.24, .05). However, a similar peroentage of PC providers reported that standards for olinioal dooumentation were olear (59% in OIF 05-0? vs. in OIF 04-05); standards for reoords management (49% in OIF 05-0? vs. 53% in OIF 04-05); and standards for transfer of olinioal information between levels of oare in the theatrefarea of operations (33% in OIF 05-0? vs. 35% in OIF D4435). Finally, there are no signifioant differenoes between OIF BH and PC providers on any of the ratings of olinioal standards. The standards of mental health oare are olear The standards for elinieal doeumentation are olear 55 DIF 114.115 5 E9 I DIF flfi-II]? The standards for reeord management are olear 41 3 EH El 04-05 The standards for transfer of elinieal behavioral health I information between levels of oare are el ear pg Chi square is signifioant at .01 2'3 4'3 5'3 1:33 Chi square is signifioant at .05 Percent agree agree Figure 24. Fereentage of behavioral health and primary oare providers who agree the standards of behavioral health oare are olear. Coordination and Support 52 Seventy six peroent of OIF 05-0? BH providers reported their BH aotivities with PC providers and with UNIT members in their area of operations. These peroentages are similar to OIF 04-06 when of providers reported they their BH aotivities with PC providers and 58% with UNIT members. PC providers rated their and support of behavioral servioes similar to OIF 04- 06 ratings. Fifty-eight peroent of PC providers reported they their BH aotivities with BH personnel oompared to 51% in OIF 04-06. Likewise, forty peroent of PC providers reported they their aotivities with UNIT members oompared to 51% in OIF of PC providers reported that BH personnel provide information about where to refer servioe members with mental health problems in OIF 04-05), and 77% indioated that BH staff provide information about the mental health servioes provided to servioe members in OIF 04-05). Resources from Command A higher peroent of BH providers in OIF 05-0? reported that their higher headquarters provided them with the resouroes needed to do their mission, 53% oompared to in OIF (XE (220) -4.60 ps .05) (see Figure 25). In oontrast, of UNIT staff reported that their oommand provided them with the appropriate resouroes to oonduot UNIT aotivities, oompared to 81% in OIF 04-06; this differenoe, however, is not signifioant. "My higher HQ provides us with the resources required in to oonduot our n1'ssionEr.' '3 ozros oso? ocros oso? El. Behavioral Health Providers Unit lvtinistry Teams Figure 25. Feroent of Behavioral Health providers and Unit Ministry team members reporting reoeiving support from their oommand. Behavioral Health Outreach Work The freguenoy of oonduoting behavioral health work is shown in Figure 25. Fifty peroent of the BH providers indioated they oonduoted outreaoh servioes to servioe members "several times a week" oompared to 58% in OIF 04-06. The BH providers 53 stated that they oonsulted with unit leaders "several times a week or more" (41% oompared to in OIF 04-05). Forty--two peroent of BH providers reported that they oonduoted psyohologioal debriefings at least "onoe a month" oompared to 54% in OIF 04-06 (X2 (224) 4.44 ps .55). A lower peroentage of OIF BH (35% vs. 54% in OIF D4436) providers oonduoted systematio unit needs assessment at least onoe every 2-3 months (X3 (224) 8.?4 psi .01). Behavioral health providers eondueted outreaeh {at least several times per weelt} Behavioral health providers met with unit leaders DIF {I4-flfi {at least several times per EH Behavioral health providers eondueted psyehologieal debriefings {at least onoe a month} I DIF flfi-fl?' Behavioral health providers eonduet systematie urit EH needs assessment {at least onoe every 2-3 months} ad 1121121 Peroent reporting Figure 26. Mental health servioes provided by behavioral health eare providers. With regard to PC providers oonduoting BH oare, 43% of PC providers indioated that they referred servioe members with mental health problems to BH providers at least onoe a month oompared to 48% in OIF D4436. Twenty--five of PC providers reported helping servioe members with mental health problems at least onoe a week oompared to 19% in OIF D4436 (see Figure 54 Primary eare referred Seldiers with mental health preblems {at least eneeimenth} DIF I14-flfi PC: Primary eare preiriders helped Beldiers with mental I health preblems {at least eneeiweeld 2e 4e as as we Pereent reperting Figure Primary eare rele in behayieral health eare. UMT inveivement in Suicide Prevention and Behavierai Heaithcare Figure 23 shews that UNIT staff members eentinue te be the primary persennel eendueting suieide preyentien training. Ninety-fiye pereent ef UNIT members eendueted suieide preyentien training "at least enee during this dep|eyment" eempared te 03% in OIF 04-06. Eighty--ene percent ef UNIT members reperted identifying seryiee members at risk fer Battle Fatigue "at least enee during this depleyment" eempareel te 33% in OIF 04-06. UNIT members played a large rele in psyehelegieal debriefings with 31 stating they had eendueted elebriefings "at least enee a menth", eempared te in OIF 04-06. Fifty--three pereent ef UNIT members eensulted with unit leaders "several times a week" eempared te 53% in OIF 0-4-06. pereent ef UNIT members afferded sewiee members the eppertunity te diseuss their eembat experienees "several times a week," eempared te 60% in OIF 04-06. 55 Cenduet suieide preventien training {at least 93 enee} 95 Identify Seldiers at risk fer battle fatigue {at least 3313 enee} ED Frevlde Seldlers eppertunltles te dlseuss eembat 51 El DIF D4- {at least several times a vveel-.2} 115 UNIT 59 Censult with unit leaders {several times per vveelt} 53 37,- UlvTl' Cenduet psyehelegieal debriefings sueh as CED 31 and CISD {at least several times per week} - - - - - 2121 4121 an an we Pereent reperting Figure 23. Unit ministry team {um} rale in behavieral health eare. Cenfidenee in Skills and Training BH previders remain eenfident in their ability te treat eembat and eperatienal stress reaetiens ameng serviee members. Ninety--eight pereent en' the BH previders reperted eenfidenee in their skills te help serviee members adapt te the stressers ef eembat depleyment (93% in OIF 94-96); 93% reperted eenfidenee te evaluate and treat suieidal behavier (93% in OIF 94-96); and 96% reperted eenfidenee in treating all eembat and eperatienal stress reaetiens (93% in OIF 94-96). pereent reperted eenfidenee in their ability te evaluate and treat aeute stress diserder er PTSD eempared te 65% in OIF 94--96. pereent en' the BH previders reperted eenfidenee in their ability te evaluate and treat vietims ef sexual assault vvhieh vvas similar te BH previder reperts in OIF 94-96 Finally, 65% ef BH previders reperted eenfidenee in being able te evaluate and treat service members vvith substance abuse er dependence in OIF 95-9? eempared te 61% in OIF 94-96. Nene ef these differenees vvere statistically signifiea nt. Seventy--five per-sent ef PC previders reperted having eenfidenee te help serviee members vvith mental health issues during the depleyment eempared te 69% in OIF 94- 96. Ferty--seven pereent en' the PC previders reperted eenfidenee in their ability te treat and evaluate serviee members vvith su bsta nee abuse preblems eempared te 61% in OIF 94-96 (X2 (426) 7'.66, 4 .91). Fifty--nine pereent vvere eenfident in their ability te treat eembat and eperatienal stress reaetiens eempared ta in OIF 94-96 (X3 (426) 9.11, 4 .91). Ferty--nine pereent ef the PC previders reperted having eenfidenee in their ability te evaluate and treat aeute stress disc:-rder er PTSD versus 55% OIF 94-96. Fifty-ene pereent en' PC previders reperted having eenfidenee in their ability te evaluate and treat vietims ef sexual assault eempared te 46% in OIF 94-96. Neither ef the last twe differenees is statistieally significant 56 Figure 20 shovvs BH and PC providers' reports of oonfidenoe in their ability to evaluate and treat Soldiers vvith oombat and operational stress reaotions aoross OIF 04-06 and OIF 05-07'. As noted previously, the differenoe betvveen OIF 04-06 and OIF 05-07' for PC providers represents a signifioant deoline. 4. '30 CI (II 45- IE- Peroent Reporting Confidence IE- 04-06 05-0? 04-06 05-0? Behavioral Health Providers Primary Care Providers Figure 20. Fereent of behavioral health and primary eare providers reporting eonfidenee in ability to treat oombat an operational stress reaetions. members reported similar levels of oonfidenoe in their ability to help servioe members oope vvith operationa stress. Ninety-tvvo peroent of LJIVIT members reported having oonfidenoe in 1I"iEll' ability to oonduot suioide prevention olasses or training oompared to in OI 3 04-06. Ninety-tvvo peroent of UNIT members reported having oonfidenoe in 1I"iEll' skills to help servioe members adapt to stress of oombat versus 05% in OIF 04-06. peroent of UNIT members reported having oonfidenoe in their abilities to identify oombat and operational stress reaotions versus 03% in OIF 04-06. Provider Web'-Being and Burnout Only 3% of BH providers reported that their ability to perform theirjob vvas impaired by the stressors of oombat deployment oompa red to 0% in OIF 04-06. Tvventy-one peroent of BH providers reported their burnout level as high or very high. We vvere unable to oompare OIF 05-0? burnout to OIF 04-06 due to it being measured differently. More PC providers reported that their ability to perform their job vvas impaired by the stressors of deploymentfoombat than in OIF 04-06 (X2 (430) 4.15, .05). Hovvever, a similar peroentage of PC providers reported their burnout level as high or very high oompared to C-IF 04-06 5? Tvvelve peroent of the UNIT members reported that the ability to do their job had been impaired by the stressors of oombat deployment as oompared to 5% in OIF $34-$36. Tvventy-five peroent of LJl'v'lT members reported their burnout level as high or very high oompared to in OIF $34-$35. Neither of these differenoes is statistieally signifioant. Systematic Unit Needs Assessment BH providers reported using a variety of methods for assessing the BH needs of serviee members. Figure 3$3 presents a number of methods BH providers used in assessing the needs of serviee members and units. There vvere signifioant ditferenoes betvveen OIF and OIF in vvhether BH providers talked informally to servioe members (X2 (225) EH33, talked vvith unit oommanders (X2 (223) 4.34, and using validated survey instruments (X2 (xx) 8.81, vvith OIF being lovver. Talked infonnally to Soldiers Talked to Chaplains Talked to unit oommanders Talked with unit medioal personnel Conduoted foous groups EH Used validated surveys I 054}? Used looally developed surveys EH ED El] 1$3$3 Figure 313. Methods behavioral health oare providers used to assess the behavioral health needs of Soldiers. Provider Perception of Barriers to and Stigma oonoerning BH Care Provider survey results shovv a lovver pereentage of BH providers report that oommanders vveloome baok servioe members vvho have reoeived BH servioes oompared to OIF $34-$35. Figure 31 shovvs provider peroeptions of the degree to vvhioh oommanders vveloome bask servioe members vvho reoeive behavioral healthoare. The differenoe between reported by OIF $34-$35 providers and 58% reported by OIF $35- BH providers vvas statistioally signifioant (X3 (225) 972, ps A signifieantly higher number of OIF BH providers report that there is inadequate oommunioation betvveen BH personnel and supported units oompared to OIF $34-$36 (X9 (222) 4.14, pa In addition, only 44% of BH providers for OIF $34- $36) report that oommanders respeot patient oonfidentiality vvhen it oomes to mental health. During an outbrief of IVIHAT survey findings, a oommand sergeant major 58 eemmented that leadere ean net help Seldiere if they de net knew what mental health their Seldiere haye er if they are even a BH preyider fer a mental health preblem. He further eemmented that "yeu ean't aek ue te treat mental health like any ether medieal preblem if yeu den't tell ue what their preblem ie when ene ef eur Seldiere te mental health. I ean eall the dee when my Seldier ie ehet and find eut hew he'e deng, hew eeyere the weund ie and when he ean eeme baek te werk. Mental health wen't even tell me when ene ef my guye te them." Clearly, in-theatre need te be eetabliehed identifying what type ef mental health infermatien eheuld be reutinely ehared with unit leadere in erderte balanee eenfidentiality with eperatienal neede. When Seldiereflylarinee mental health in theatre, then leadere need te a mental health prefile eimilar in detail te a medieal prefile detailing the extent ef the mental health injury, pregneeie, and any reetrietieneflimitatiene en what they ean and eannet de. There wae a eignifieantly lewer number ef PC preyidere in C-IF 05-0? whe reperted that eemmandere weleeme baek eeryiee membere whe behayieral healtheare eempared te OIF 0-4-86 (X2 (430) pe. D5). The differenee between 57% and 43% reperted by UNIT membere ie net eignifieant. 'l|ClE| ee . 57 El..I Pereent reperting yes . . . . . . . . . . . .- . . . . . . . . . . . . ....I Behayieral Primary Ca re Unit Mnietry Health Preyidere Teame Preyidere Figure 31. Fereent ef behayieral health and primary eare preyidere and unit minietry teame that repert Cemmander weleeme baek Seldiere whe have behayieral health eare Ethics Fer the firet time, battlefield ethieal behayier and training in Seldiereflylarinee wae ln additien, we aeked behayieral health (BH) eare preyidere and unit minietry team (LJIUIT) membere whe they theught wae the meet apprepriate teaeher ef ethiee en the battlefield. Figure 32 ehewe that BH preyidere think that NCO and effieer leadere in the unit are the meet apprepriate teaehere ef battlefield ethiee. Chaplaine eyerwhelmingly think that they are the meet apprepriate teaehere ef battlefield ethiee. 59 NCOs in unit 32 12 Dfficers in unit 16 31 I o|F 05.07 BH 14 Other El DIF O5-D7 UNIT 12 Chaplains 2 53 lillental Health 2D -40 Figure 32. Percent cf behavicral health prcviders and unit n1inistr3rtean1 {um} repcrting was the mast instructcr cf battlefield ethics. We alsc asked BH and UNIT they thcught shculd participate in battlefield ethics (see Figure 33). The majcrity cf in grcups NCO-s and cfficers in the unit participating in ethics training, with BH and LJIUIT repcrting similar rates mental health participating in ethics training. Hcwever, a much higher percent cf Chaplains fellcw Chaplains being participants in battlefield ethics training than did BH (X2 (1 96) 31.93, ps. UB1). 60 NCOs in unit Offioers in unit IOIF BH Other IZIOIF Chaplains Figure 33. Percent of behavioral health providers and unit ministry team {um} reporting who should participate in Eiattlefield Ethics Tra'riirig. Medications Tvvelve percent of Soldiers and 5% of Marines reported taking medication for a mental health, combat stress. or sleep problem during the deployment. iviost medications were for sleep problems. depression. or acute stress (PTSD). and nurse practitioners are the only behavioral health (BH) care providers who may prescribe medications in Iraq. In our sample. we did not have any nurse practitioners so we could only ask the about medications in theatre. Four of nine reported on the survey that the procedures for ordering and replenishing medications in the theatreiarea of operations are clear compared to three of five in OIF D4-D6. Seven of eight (1 did not respond) stated that there is generally adequate availability of medications compared to all five in OIF 04-06. There is a similar pattern for availability of medications at the different levels of medical care. Four of six said there is adequate availability at level Battalion Aid Stations compared to all five in OIF five of six at level II Fon-vard support medical companies (three of five in OIF seven of eight at level Combat Support Hospitals (OIF 04-06 was five of five). All nine reported that they had never practiced outside the scope of their privileges. A Standing Operating Procedure (SOP) was published by the Ivlulti National Corps -- Iraq (IUINO-I) behavioral health consultant establishing uniform guidelines for the prescription of medications in the Iraq Theatre of Operations. It contains several appendices: 1) responsibilities and procedures for 61 prescribing, 2) information for preeoribere, 3) an information paper for oommandere giying guidelinee on how to approaoh mental health while reepeoting Soldiere' right to oonfidentiality, 4) detailed medioation information, and 5) freguently aeked gueetione. The following druge were reported ae being needed but not available (or) during thie deployment: eleep aide -- Luneeta, Ambien, Sonata, and Strattera; -- Zyban, Wellbutrin, Parril, Zoloft, and Seleotiye Serotonin Reuptake lnhibitore that would work guioker; atypioal antipeyohotioe -- Seroguil; ADHD treatment -- Adderall; alooholidrug treatment -- hlaltrexone and antabuee; and emoking -- Niootine patohee. Combat and Operational Stress Controi (0030) Training A oommon theme during moet fooue groupe wae that proyidere, partioularly therapiete and mental health epeoialiete felt they were not prepared for oombat and operational oontrol (COSC) work. Thie wae a major for oomponent proyidere who work in an unrelated field in their oiyilian poeitione. For example, the therapiet who worke in a oiyilian hoepital hand olinio and the mental health epeoialiet who ie a oiyilian meohanio were unprepared for the funotional areae and ekille reguired ae a member of a oombat oontrol unit. Some of proyidere reported eearohing the internet when they arrived in Iraq in order to aoguaint or re--fa miliarize themeelyee with mental health dieordere and treatment modalitiee. than 5% of all Combat Control (CSC) and BH pereonnel reported they had attended the COSC oouree at the Army lvledioal Department Center 3; Sohool (ANIEDD C35). Many felt thie ehould be a reguirement before deploying. lyloet proyidere reoeiyed the training oonduoted by the Combat Operational Control lylobile Training Teame (COSC MTT). All reported thie training wae yaluable but many reported a need andior deeire for more COSC training. A few proyidere raieed the of who ie the primary proyider when CSC unite are looated on the eame FO Be with brigade rrental health COSC dootrine ourrently etatee that all COSC and BH pereonnel are required to perform all areae of COSC, inoluding BH treatment. Thie may "territorial" when CSC unite allow brigade Soldiere to oare in their olinioe. Some and brigade BH pereonnel have been able to work together by eharing information and by BH pereonnel underetanding that CSC unite oannot turn away eenrioe membere in need. Another poeeible eolution offered by one CSC proyider wae to haye COSC dootrine epeoify that brigade BH and CSH pereonnel haye BH treatment ae their primary and CSC teame fooue on preyention and outreaoh. During behavioral health (BH) interyiewe and fooue groupe, we aeked proyidere "What additional iteme would you like to haye to enable you to do yourjob better?" The BH euryey aleo had a gueetion that aeked whioh eguipmentieuppliee would haye improyed the BH team'e ability to oomplete their BH on general 62 equipment euoh ae more or improved oomputere, printere, oopiere, projeotore phonee, offioe epaoe, and offioe euppliee. Combat and Operational Control (CBC) unite reported that the M64 eyetem wae not adequately dietributed or trained. in addition, proyidere deeired peyohology manuale and booke ae well ae up--to--date peyohologioal teeting equipment and euppliee. Many reported they paid for peyohology booke and equipment out of their own pookete. Finally, many proyidere reported laoking traneportation and deeiring their own yehiole in order to be able to reaoh unite they euppon. Command Inepeotion Program During fooue groupe, eome BH proyidere reported or demonetrated a laok of knowledge about ourrent COSC dootrine; inoluding not knowing that the new (3030 manual wae publiehed. In addition, only 41 "lb of BH proyidere reported that the polioy on tranefer of BH reoorde in the theatrefarea of operatione wae olear. To eneure that unite have all relevant BH referenoee on hand, are familiar with thoee referenoee, and are adhering to the guidelinee in thoee referenoee, the BH ooneultant developed a oommand inepeotion program Appendix M). Thie program proyidee taeke, oonditione and etandarde for mental health, and oombat and operational oontrol interyentione 3: aotiyitiee in the theatre of operatione. The etated purpoee of the program ie "to eneure CBC unite have eetabliehed and are maintaining a oombat and operational oontrol program; NIH pereonnel in non--CSC unite are providing (DOSES interyentione and aotiyitiee ae applioable; all NIH pereonnel are performing NIH aotiyitiee that meet etandarde of oare." The inepeotion whether BH pereonnel are properly dooumenting BH oare, ueing COSGWARS, euperyieing proyidere who require eupenrieion, and oonduoting ohart reyiewe, outreaoh, ourrent preyention training, and unit neede During OIF GS-81 the Medioal Brigade ueed the oommand inepeotion form to oonduot "oommand noe yieite". information derived from yieite wae ueed to eduoate BH unite on waye to improve their delivery of BH oare but wae aleo briefed up the ohain of oommand. le it important for future BH ooneultante to olearly etate whether they are oonduoting oommand or oommand inepeotione. If only doing oommand yieite, findinge ehould not be reported up the ohain of oommand. Summary of Findings The behavioral health oare eyetem in Iraq ie robuet, with at leaet one behavioral health oereon per TDD mili1:ary pereonnel.m}E Combat and Operational Control ((3086) training remaine a key oonoern, with many proyidere reporting not being prepared priorto deployment. Behavioral health pereonnel did not the reoently deyeloped unit mental health neede to determine unit or behavioral health neede, inetead they relied on a variety of uneyetematio and random approaohee, leaving many Soldiere and larlarinee without eupport. Mental health dooumentation oontinuee to be problematio in Iraq, with a majority of proyidere interyiewed reporting to be uneure what mental health information neede to be 63 dccumented, and What fcrme ehculd be ueed. There appeared tc be very little cvereight and cf vvae being implemented, eepeciallv at the brigade mental health level. Operaticnal leadere extreme dieeatiefacticn vvith behavicral health perecnnel in the amcunt cf that ie ehared regarding the mental health cf their Scldiere. Recemmendatlens: Behavioral Health Care 1. Establish a eccpe cf practice pclicy far all CSC peracnnel and delineating the levels cf preventicn, treatment and interventicn activitiee fer each epecialty. (Lead: AMEDD Educarlcn and Ccmmandj 2. Ensure at least cne behavicral health perecn (cfficer cr enliated} per aervice membere. "fig (Lead: MED Sdrgecn) 3. Fccua behavicral health cutreach tc unite that have been in theatre lcnger than eix (Lead: Sdrgecn) 4. Develcp and execute a behavicral health care cutreach plan tc enau re all traneiticn team mem bera receive care. Ccneider dedicating BH aeaete that prcvide BH at the tranaiticn team'a lccaticn. (Lead: Sdrgecn) 5. Eneure all behavicral health peracnnel and chaplaina cf eervice) are prcficient in bat by mandating thatthey the AMEDD bat and Dperaticnal Streae Ccuree pricr tc deplcying tc the CIIF theatre. Thia training ahculd be required teams and perecnnel. (Lead: C-TSG 3. AMEDDKOPNAVGQE BUMED) 6. Revise the Unit Mental Health Need-a tc prcvide epecific acticne fer behavicral health perecnnel tc take baeed en the unit needa tc the mental health cfthe unit. (Lead: MRMC) 7. Include training in ueing the Unit Mental Health Need-a in the reviaed CSO Ccurae. (Lead: AMEDD 133.3) 3. CD30-WARS training intc the CS0 ccurae. (Lead: AMEDD 9. Develcp a user friendly data analyeea rcutine repcrting CD30-WARS findinge. (Lead: AMEDD (343.3) Immediate: Mandate all (330 and DivieicnlElrigade BH perecnnel CD30-WAR repcrta. (Lead: Sdrgecn) Lcng-term: Develcp a jcint theatre- 6-fill wide mental health and suicide surveillance system fer Scldiers, Marines, Sailcrs, and Airman (pcssildly include Deli) civilians). (Daily 11. Establish a central repesitery fer all CD30-WARS data ccllected. (Lead: 12. Implement an in-theatre BH Chart Review prc-cess. (Lead: MNF- ifidrgeenl 13. Ccnduct pericdic in-theatre training seminars (bi-annual} tc ensure BH best practices and tc identifyidiscuss sclutiens to emerging BH issues. Include 91)-is in these training seminars. (Lead: MEDCOM) 14. Establish and maintain a web-site as a means tc cbtain reference and training material (especially fer 91)(s serving in a deplcyed envircnment). (Lead: AMEDD C-&SfNavai iliedicai Eddcaricn and Training Ccmmand) 15. Execute a BH Cemmand lnspecticn (see Appendix (Lead: Sdrgeen) 16. Share Scldieriwlarine mental health with cemmanders in the same manner and detail as abcut a weunded Scldieriwlarine is shared. Prcvide a medical prcfile detailing the extent cf the mental health injury, and any restricticnsilimitaticns en what the Scldieriwlarine can and cannct dc. D93) 17. Target BH fer Scldiersiwlarines with relaticnship ccncerns mid-tcur leave and pricrtc re-depleying heme. (CSCiBrigade Mental Health) 65 SUICIDE PREVENTION PROGRAM REVIEW All the previoue l'v'lHATe have revievved the etatue of the C-IF theatre'e prevention and eurveillanoe program, inoluding an analveie of oompleted The of oompleted vvae of partioular intereet during IVIHAT l, due to an unantioipated inoreaee in the rate of in OIF I oompared to the LJ.S. Army norm, vvith tvvo eignifioant "outbreake" in the monthe of July and Ootober Tablee '15 3: and Figure 3-4). The IUIHAT oonduoted a eimilar revievv of prevention and eurveillanoe program and a detailed analveie of oompleted Suicide Prevention Committee The Command Surgeon of lvll\lF--l eervee ae the ohair of the lvll\lF--l Suioide Prevention Committee. The oharter of thie oommittee ie to revievv and prooeduree vvithin trende in and behaviore vvithin theatre, and adviee Commandere and leadere in the prevention of to inolude training and eduoation. Thie oommittee vvae formed in AUG 2006, and the firet prevention oommittee eetabliehed in OIF. Army Suicide Event Report (A SER) The Army Suioide Event Report (ASER) ie the reporting and traoking meohaniem for oompleted and non--letha| evente that reeult in hoepitalization andior evaouation. The ASER vvae developed, and initial validation oonduoted by the LJ.S. Army lvledioal LJnit--Europe, ae a meane to traok in near, real time and behaviore of Army pereonnel vvithin the LJ.S. Army, Europe (LJSARELJR) (Dolan, Sohroeder, Wright, Thomae, 3: 2003). Follovving the reoommendation of the lvlental Health Advieorv Team (IUIHAT) I, the LJ.S. Army lvledioal Command a poliov direoting that the ASER be ueed throughout the Iraqi theatre of operatione. The Suioide Riel: lvlanagement 3: Surveillanoe Offioe (SRMSO) looated at Fort Levvie, Waehington hae operational overeight of the ASER, oonduote routine data and publiehee reporte of findinge. The SRMSO aleo hae reeponeibilitv for updating ohangee to the ASER, vvith the lateet update in Deoember 2005. The SRMSO guidanoe for vvhen an ASER ie to be oompleted pereonal oommunioation, September E5, 2006). are to be oompleted if they meet ALL of the oriteria belovvz 1) The pereon ie in the Army and oomponent 2) The Soldier oompleted vvae hoepitalized or evaouated 3) The method ueed vvae lethal or believed by the pereon to be lethal 4) The So|dier'e intent vvae to die 66 Te eneure that all required within the OIF theatre ef eperatiene are eempleted eyery menth, the lVll\lF--l BH Ceneultant reade the theatre medieal eyaeuatiene ueing the Regulating and Cemmand and Centrel Eyaeuatien Syetem (TRAC2ES) and all theatre in--patient reperte; the IUINF-I BH Ceneultant then eentaete the preyider handling the te eneure the ASER ie eubmitted. te SRMSO, frem 1 JAN 2666 te 31 AUG 2666, there were 66 eubmitted fer C-IF 65-6?, 46 ef the were fer attempte and 12 were fer eempleted The SRNISO yalidatee all eubmitted fer a eempleted with the Armed Medieal Examiner (AFNIE). Llnfertunately, the SRMSO hae ne meehaniem te eneure the aeeuraey ef eubmitted fer attempte. The BH Ceneultant neted that multiple are frequently eubmitted fer the eame Seldier and that ASERE. are eften eubmitted when they den't meet the eriteria eutlined preyieuely. Fer example, in a review ef the eubmitted fer OIF 65-6? (frem 1 JAN -- 36 JUN 2666), the BH Ceneultant wae enly able te yalidate 26 ef 39 ASERS with 6 being duplieatee and 7' failing te meet the eriteria fer eempleting an ASER preyieuely eited eriteria). Ae neted earlier, the ASER wae initially deyeleped fer in garrieen; and altheugh the ASER hae been eubeeguently medified fer use in a depleyed enyirenment, additienal reyieiene Firet and feremeet, the ASER muet inelude gueetiene that will maximize the implementatien ef petential interyentiene in a depleyed enyirenment. While the ASER eentaine general gueetiene abeut the depleyment, queetiene regarding the relatienehip ef the er attempt te key depleyment are mieeing. Fer example, the ASER eentaine ne gueetiene regarding whether the Seldier returned frem mid--teur leaye. Currently, all Seldiere leaying fer mid--teur leaye muet a ehaplain brief. If it eeuld be demenetrated that er attempte are mere likely te fellewing mid--teur leaye, then it might be eeneible te reguire Seldiere te preyentien training upen returning frem mid--teur leave. The lKilF.lF--| ie a mu|ti--eeryiee headguartere and therefere the Surgeen reguiree a eunreillanee eyetem eapable ef menitering and behayiere all (Army, Navy, Nlarinee, Air Feree, and Ceaet Guard). The ASER ie an Army eyetem, and therefere are eurrently enly being eempleted fer Seldiere. A mu|ti--eeryiee euryeillanee eyetem ie urgently needed te faeilitate jeint intereperability ef traeking and reperting. Suicide Statistics Sinee the beginning ef OIF there haye been T2 eenfirmed Seldier in Iraq. Frem 1 JAN te 1 OCT 2666, the Armed Nledieal Examiner (AFME) eenfirmed 1-4 eempleted Seldier in the OIF area ef eperatiene, with ene death pending The majerity ef deathe inyelyed eingle, white, male, junier enlieted Seldiere, with the ef death fer all Seldiere being a eelf--inf|ieted gunehet weund Table 15 6 16). Thie prefile ef 2666 OIF Seldier ie eeneietent with 6? OIF Soldier profilee end with the 2005 Army profile. When all OIF (2003-2006) are ooneidered, there doee appear to be more OIF deethe reeulting from gunehot wounde then the 2005 Army profile we. ee well 06 Soldiere being younger (83% we. 60%) end likely to be married we. There were eleo two oonfirmed 2006 OIF lvlerine whioh metohee the Army demogrephio end method profile. Table Table 15. Summary of Dem ographioe of Confirmed 2003. 2004. CHF 2005. CHF 2006 (thru 31 AUG 06) and Army 2005 Suioidee 2006 2005 2004 20% 2005 Army Army Army Army GIF Army Suicideg Suioidee Suioidee Suioidee Suioidee Suicide by 100% 05% 100% 06% firearmfgunehot Male 06% 86% 80% 100% 02% Age 30 or younger 60% 03% 68% 80% E-4 or below 61% 86% 63% Married 21% 32% 11% 38% Minority (non-whiteTable 16. Prefile ef Cenfirmed CIIF 2006 Seldier Suieidee (As ef 1 en Date efsuieide Age Rank MUS Gender |"ii'Ifll'itflI liilethed Table 17. Prefile ef Cenfirmed 2006 Marine Suieidee. (As ef 1 en Date Age Rank M03 Centp Gender liilarital liilethed The Seldier ratee fer OIF fren1 2003 (MAR) te 2006 (AUG) are ehevvn in Table 18. The Seldier rates in 2003 and 2005 vvere eignifieantlv higher than the LJ.S. Army ten--year average rate Table 10). Lieing the dietributien fer rare evente eenfirmed thie Fer OIF 2003 and OIF 2005, the ratee vvere 18.8 and 10.0 per 100,000 Seldiereiyear, reebeetively, eempared te the LJ.S. Arn1v'eten--year average ef11.6 per100,000i'year. There vvae ne eignifieant differenee between the rate fer OIF 2004 and the LJ.S. Arn1y'e ten- year average (10.5 ve. 11.6 ber100,000 Seldiereivear). 69 The current, adjueted euicide rate OIF 2006 ie 10.1 euicidee per 100,000 Scldiere the firet eight cf 2000, vvhich ie eignificantly different than the LJ.S. Army'e 10-year average euicide rate. Hcvvever, the adjueted annualized euicide rate OIF 2000 ie 10.3 euicidee per 100,000 Scldierefyear, vvhich ie marginally eignificant (Pcieecn, .055). Thue, three cut cf the fcur yeare, Scldier OIF euicide ratee are higher than the U5. Army'e 10-year average euicide rate. Table 13. 0lF Scldiersuicidea: 2003-2006. SUICIDE 2003 2004 2005 2006 UPDATE OIF Ccnfirmed 25 11 22 14 OIF Pending 0 0 0 0 Oil: C0l'lfll'lTlEE3l 133* 9.6 199* 15.1 Adjueted Rate 1 3505} *F'cieecn, .01 Table 10. U.S. Army Suicide Ratea: Ten Year Average (1006-2005) Calendar Year Rate per 100,000 1000 12.4 100? 10.0 1003 12.0 1000 13.1 2000 12.1 2001 0.1 2002 11.1 2003 12.3 2004 11.0 2005 12.3 Average 1006-2005 11.5 U.3. Average 12.31" fttrude, ccnaervative U.S. pcpulaticn rate {Eatcn et al., 2006} Figure 3-4 ehcvve the number cf Scldier euicidee by 2003 -- 2000. Ae can readily be there vvere three in vvhich the number cf euicidee "ebiked," vvith 5 euicidee in NOV 2003 and 0 euicidee each in July 2003 and Octcber 2005. All three cf a eignificant ebike in euicidee (Pcieecn, [3 c: .05). In fact, each year (2003, 2005 and 2000) in vvhich there vvae an increaee in the C-IF Scldier euicide rate ccmpared tc the US. Army euicide rate, there vvae at leaet cne in vvhich 3 euicidee In 2003 there vvere in vvhich at leaet 3 euicidee there vvere 5 euicidee in July and Ncvember 2003. In 2005 ?0 there were three menthe in whieh there were at leaet 3 there were 3 in beth May and July, and 6 in Oeteber The enly year in whieh there wae net at a menth when three wae 2DD4, the enly year in OIF where the C-IF rate wae net higher than the US. Arn1y1?i--yearayerage etiieiple rate. Further, fer yeare when the OIF ratee plipl differ frem the LJ.S. Army rate, there appear te be a eix-menth "elLietering" effeet, beginning with the firet menth in whieh at leaet three Fer inetanee, 16 ef the 22 that in 20% happened frem May (the firet menth there were at leaet three etiieiclee) Lintil C-eteber, ef all fer the year. A eimilar pattern ie alee fer 2DD3 where 18 ef 26 ef all teek plaee between July and It ie tee early te eenduet thie analyeie fer 2DD6, but it eheuld be neted that February wae the first menth in whieh at leaet three Ne preyieue l'v'lHATe haye preyiplepl any inplieatere ef Selplier trenple. One appreaeh wetild be te meniter fer any menth in whieh three ae thie likely eignifiee a year in whieh ratee will the 1D--year Army ayerageJan Feb Mar Apr May Jun Jul Aug Sep Oct Hey Dee 2003 I 2004 2005 2006* "'FreI'rI 1 JAN -- 1 OCT 20136 Figure 34. OIF Selclier Suieiclee fer 2003- 2005. Summary of findings Since the beginning ef OIF (lvlarch 203), there have been T2 cenfirmed Soldier suicides in Iraq. The has an active Suicide Prevention Committee that is chaired by the Command Surgeon. The current suicide training program being used vvas develeped fer a garrisen Army and lacks relevance fer a depleyed (combat) environment. The Army Suicide Event Report (ASER) is being vvidely used in the theatre by both Army and lvlarine behavioral health care providers, but only fer suicidesisuicidal gestures by Army personnel. Hevvever, there is confusion over vvhen an ASER should be completed, and concern over the relevance of the ASER in a combat environment. Although there are numereus service--specific mental health tracking systems, there is net a single, jeint tracking system capable of monitoring suicides, mental health evacuations, and use of mental healthicembat stress centrel services in a combat environment. Recommendations.' Suicide Prevention Program 1. Sustain the NINF-I Suicide Prevention Committee, chaired by the seniortheatre medical officer. (Lead: Surgeon) 2. Expand the MNF-I Suicide Prevention Committee to include operational commanders and senior l*~lCCis. (Lead: Surgeon) 3. Revise and field suicide avvareness and prevention training so that it focuses on specific actions Soldiersillilarines (self-aid and buddy aid) and leaders can take in helping fellovv unit members. Use real-vvorld examples from a combat environm ent. (Lead Army 4. Provide a detailed instruction manual for completing the ASER. (Lead: SRMSO) 5. Establish an in-theatre revievv process of all ASERs before submitting to to ensure that an ASER is required, and that the ASER is accurate. (Lead: Surgeon) 6. Updateimodify the so that it meets the needs of a deployed force. Ensure that the ASER committee members have practical and recent deployment experience. Ensure all modifications to the ASEFE facilitate the development of prevention activities in both a garrison and deployed environment. (Lead: SRMSO) 7. Establish a joint tracking system forthe deployed environment to monitor suicides, mental health evacuations and the use of mental healthiCSC services. (Lead: T2 3. Establish a quality eentrel that enaurea beth internal he duplieatea) and external (eempleted suicides in the ASER databaae match these in the AFME data validity. (Lead: SRMSO) ?3 STATUS OF MHAT RECOMMENDATIONS The lvlHAT Report contained general recommendations for improving the delivery of BH care in OIF. The recommendations and the implementation status of each are discussed below. 1. Implement a MNF-I BH Policy. A draft FRAGO outlining a comprehensive behavioral health policy to be incorporated into the Command Policies and Procedures has been written and is expected to be published by the end of 2iZi?iE3. 2. Designate a MNF-I BH Consultant to serve as the principal staff officer to the MNF-I Surgeon in conjunction with duties as the MNC-I BH Consultant. Designate Regional Behavioral Health Consultants to address issues throughout the area of operations. The Command Surgeon has designated the senior BH officer within the ad" lvledical Brigadel3"j ivieocoivi asthe lvll~lF-| BH Consultant. No regional BH Consultants have been appointed. However, this role has fallen to the senior BH officer in the region, typically the division BH officer. 3. Continue to emphasize the reduction of stigma and barriers to behavioral healthcare for Soldiers and increase emphasis on suicide and deployment stress training. This is a major area of focus of the Suicide Prevention Program. 4. Implement the standardized Unit Behavioral Health Needs Assessment Survey (UBHNAS) fielded by MHAT for use by all combat stress control detachments and BCT organic BH personnel. The Unit Behavioral Health Needs Assessment was fielded by MHAT to a single CSC. To date, no other CSC or BCT organic BH personnel have been trained result, the fielding of the is incomplete and its use remains sporadic. 5. Continue to Integrate Behavioral Health staff with Primary Care providers to help reduce stigma and barriers to behavioral healthcare for Soldiers. The location of BH personnel within CSCs and BCTs is in accordance with current and Army polices. 6. Continue research targeted at enhancing Soldier well-being with a particular focus on Soldiers who have deployed multiple times. No progress has been made for this recommendation. 7. Provide theatre suicide surveillance through service-specific suicide event reports to include the Army Suicide Event Report (ASER) for Soldiers. This recommendation has been successfully implemented. 3. Establish policy forthe transfer of behavioral health information between providers. No policy for the transfer of behavioral health information between providers has been published. 7'-fill 9. Ensure elietributien ef behavieral health eeneietent with unit requirementa. Ferthe meet part, the elietributien ef behavieral health ie aeleguate. 'hm 1121. Eatabliah a theatre-vvicle behavieral health perfermanee imprevement breg ram. The BH Ceneultant ie eurrentlv develebing a 1heatre--vvide behavieral health berfermanee imbrevement bregram. Several elemente ef thie bregram have been elevelepeel, eueh ae mental health ehart revievve and guielelinee fer peyehetrepie medieatiene. Hevvever, ne evidenee vvae feund that riek management revievve vvere being eendueted fer previder (effieer and enlietecl) edueatien and training. 11. that the prepenent fer Army Suieicle Preventien Training the requirementa fer a preventien preg ram with elementa apeeifie te the CIIF area ef eberatiena. The implementatien ef thie ie in Thie ie a majer area ef feeue ef the Suieicle Preventien Pregram ehaired by the Cemmand Surgeen. ?5 DISCUSSION The war in Iraq ie eften ae "a war witheut frente," implying that all depleyed military (and eiyilian) pereennel are at equal riek fer being injured er killed. Yet, net all Seldierer'Marinee depleyed te Iraq are at equal riek fer eereening peeitiye fer a mental health preblem. lnetead, it ie Seldiere whe epend a eignifieant ameunt ef their time euteide ef the mp er ferwa rd eperating baee (FOB) that are at the meet riek fer eereening peeitiye fer a mental health preblem. Thirty pereent ef Seldiere in the High Cembat eenditien eereened peeitiye fer a mental health preblem eempared te fer the Medium Cembat eenditien and 11% fer the Lew Cembat eenditien, with Seldiere frem the High Cembat epending 56 heure a week euteide the eempared te appreximately 35 heure a week fer Seldiere in the Medium Cembat eenditien and 12 heure fer Seldiere in the Lew Cembat eenditien. Thue, inetead ef the war in Iraq ae "a war witheut frente," a mere aeeurate and ueeful ie that the frent in Iraq ie any plaee net en a er FOB. Stated differently, anytime Seldiere er Marinee ge euteide "the wire" they are at the frent. The finding that a Seldier er Marine ie at the frent in lrag anytime hefehe leaves the er FOB hae impertant implieatiene fer euetaining their mental health and well- being. Altheugh, it hae leng been that mental health breakdewn after prelenged eembat expeeure Grinker Spiegel, 19-45; Swank 3: Marehand, 1946), a eeneiderable number ef Seldiere and Marinee are eendueting eembat eperatiene eyeryday ef the week, 10-12 heure per day eeyen daye a week fer menthe en end. At ne time in eur military hietery have Seldiere er Marinee been reguired te eerye en the frent line in any warfer a peried ef menthe, let alene year, witheut a eignifieant break in erder te frem the phyeieal, peyehelegieal, and emetienal demande that eneue frem eembat. During Werld War II, entire unite were withdrawn frem the line fer menthe at a time in erder te reet and refurbieh. Even during Vietnam, week--|eng eembat patrele in the field were fellewed by eeyeral daye ef reet and reeu peratien at the Yet, in Iraq neither Seldiere ner Marinee experieneing high leyele ef eembat eignifieant in--theatre periede ef Clearly, the twe week mid--teur leaye ie ineuffieient te reetere the Seldier'e peyehelegieal and emetienal we|l--being ae eyideneed by the faet that the mental health etatue ef Seldiere, whe mid--teur leaye ie ne different than Marinee whe did net. Furthermere, enly abeut 5% ef Seldiere in- theatre RSR. Arguing that the inteneity ef the eembat eperatiene in Iraq ie net eemparable te ef preyieue ware eueh ae Werld War II and Vietnam and therefere periede are demenetratee a laek ef appreeiatien ef what eenetitutee eembat in general, and igneranee ae te the level ef eembat Seldiere and Marinee are experieneing in Iraq. Being in mertal danger fer heure en end, every day ef the week fer menthe at a time ie at beet phyeieally exhaueting and mentally draining Campbell, Seeing firet-hand a unit member being eerieuely injured er killed and realizing that it eeuld have eaeily been yeu reveal a vulnerability few ether elieit. Underetanding aepeete ef what eembat ie like in lrag, ene ean ?6 then begin te that there ie little dietinctien between the impact that cembat hae en the mental health ef Seldiere and lvlarinee in Iraq and that ef ether vvare the LJ.S. hae feught What thie meane iethat Seldiere and lvlarinee experiencing high levele ef cembat in Iraq need periede te recever, juet like in every ether vvar. Cencretely, Seldiere and lvlarinee experiencing high levele ef cembat eheuld receive ene menth ef in-theatre recevery fer every 3 menthe ef cembat duty. Fer lvlarinee, vvhe depley fer eeven menthe te lrag, thie vveuld mean a ene menth in-theatre recevery peried. Fer Seldiere, vvhe depley fer 12 menthe, thie vveuld mean tvve te three ene--menth in-theatre recevery periede. Ideally, in-theatre recevery periede vveuld eccur at the cempany er battalien level. It neede te be kept in mind that vve are enly recemmending in-theatre recevery periede fer Seldiere and lvlarinee experiencing high levele ef cembat. Fer Seldiere and lvlarinee experiencing medium levele ef cembat, eherter recever periede ef in- theatre recevery are Fer Seldiere and lvlarinee experiencing levv levele ef cembat, ne in-theatre recevery We knevv frem findinge frem the Walter Reed Army lnetitute ef (WRAIR) Land Cembat Study that the mental health etatue ef Seldiere hae net "re--eet" after returning frem cembat duty in Iraq befere they are depleyed again te |rac| (Caetre 31 Hege, 2805). Tvventy--ene ef OIF 05-0? Seldiere depleying te |rac| fer a eecend time ecreened peeitive fer a mental health preblem (anxiety, er PTSD) cempared te 9% ef Seldiere frem the eame BOT that vvere depleying fer the firet time. Te be eure, there vvere imperta nt demegraphic differencee betvveen eecend--time and firet--time depleyere. The eecend--time depleyere vvere elder, mere eenier ranking, mere educated, and mere likely te be married cempared te firet--time depleyere; factere generally feund te be pretective er reeterative ef ene'e mental health, making the ebeerved difference in the mental health rate between firet-- and eecend--time depleyere even mere dieturbing. The findinge frem thie IVIHAT and IVIHAT ehevved eignificant differencee in mental health etatue betvveen multiple depleyere (primarily eecend--time depleyere) and firet- time depleyere. Specifically, thie IVIHAT feund that ef multiple depleyere ecreened peeitive fer any mental health preblem cempared te fer firet--time depleyere. In a cemparieen between the findinge frem IVIHAT IV and the findinge frem the WRAIR Land Cembat Study, it can be that the percentage ef Seldiere ecreening peeitive fer a mental health preblem increaeed fer beth firet--time depleyere and multiple depleyere. Fer firet--time depleyere there vvae an increaee, frem 9% te fer multiple depleyere there vvae a 6% increaee, frem 21% te That the increaee in the percentage ef multiple depleyere that ecreened peeitive fer a mental health preblem ie eimilar te the increaee in firet--time depleyere vereue euggeete that previeue depleyment experience per ee net "ineculate" Seldiere againet further in mental health Thue, training fecueed eelely en "expeeure" te the ef cembat ie unlikely te be beneficial in pretecting Seldiere er lvlarinee. lnetead, training muet fecue en the develepment ef Seldier and lvlarine mental health reeiliency ekille, akin te the Battlemind Training pregram. Findinge frem the WRAIR Land Cembat Study indieate that depleyment length ie related te mental health etatue. When Seldiere were three menthe pe-et--dep|eyment, Seldiere depleyed te OIF I far 8 menthe were likely te eereen peeitiye fer and PTSD eempared te Se-ldiere depleyed te OIF far 12 menthe. Thie IUIHAT alee the impaet ef depleyment length en the mental health etatue ef the depleyed feree, and feund that Seldiere depleyed far 6 menthe er were likely te eereen peeitiye fer anxiety and aeute (PTSD) eempared te Seldiere depleyed lenger than 6 me-nthe Figure 8). Tegether, findinge indieate that baeed eelely en a mental health perepeetiye, depleyment lengthe ef menthe weuld be ideal; that ie, depleyment lengthe eimilar te that adapted by the Wlarinee, the Air Feree, and the LJ.S. Speeial lntereetingly, altheugh Marine Regimente depley fer eixreeyen menthe, the Marine Expeditienary Feree Headguartere depleye far 12 menthe. Thie an impertant gueetien ae te whether the Army eeuld adept a eimilar depleyment length etrategy whereby maneuyer unite (battaliene and belew) depley far 6 me-nthe, with headguartere unite depleying anywhere frem 12-18 menthe. Given the dramatieally different eembat re-le ef maneuver and headguartere unite, thie etrategy might eerye te beth euetain the mental health and well--being ef the feree, while at the eame time preyide greater eentinuity in military eperatiene at the eperatienal and etrategie leyel. Heweyer, befere eueh a etrategy ie undertaken, a eyetematie ef the mental health and well- being ef headguartere pereennel at the brigade level and abeye eheuld be eendueted, te include a ef the leave and pregram. Findinge frem thie IUIHAT elearly ehew that familiee are under a great deal ef with ef married Seldiere reperting that they are haying marital prebleme, either infidelity being a preblem andrer a diyeree er eeparatien being planned Of the twe OPTENIPO meaeuree during thie MHAT (depleyment length er multiple depleymente), enly depleyment length wae eignifieantly related te marital prebleme, with Seldiere depleyed fer mere than menthe reperting mere marital prebleme than Se-ldiere depleyed fer ei>: menthe er Net eurprieingly, fer lylarinee that typieally depley fer ei>c: er eeyen menthe, ne relatienehip wae feund between depleyment length and marital relatienehip. Thue, frem the perepeetiye ef keeping marriagee tegether, findinge alee euppert the eeneept redueing the depleyment length. ef the mental health and well--being ef female Seldiere reyealed twe main findinge. Firet, we feund ne eyidenee that female Seldiere are able than male Seldiere te eepe with the and ehallengee ef eerying in eembat. See-end, we feund ne eyidenee that female Seldiere have unique er unmeant mental health neede that differ frem ef male Seldiere. findinge are eeneietent with ef preyieue l'u'lHATe in ehewing that female Seldiere are ne mere yulnerable than male Seldiere in hew eembat ean affeet their mental health and well--being. ln faet, a etreng ean be made that female Seldiere are at riek te the demande ef eembat than are male Se-ldiere. Recall that when eembat were lew, female Seldiere were mere likely te eereen peeitiye fer a mental health preblem than male Seldiere; ?8 hewever, under medium eembat there were ne between male and female Seldiere, demenetrating that eembat hae a greater impaet en the mental health etatue ef male Seldiere than it en female Seldiere. When the rele ef the female Seldier in eembat, the feeue neede te meve away frem ene ef and vulnerability, te ene ef etrength and Every IUIHAT hae eendueted an ef OIF 'With the exeeptien ef IVIHAT ll, all previeue l'v'lHATe have feund an inereaee in the everall OIF Se-ldier ratee eempared te the Army ten--year average rate. Determining the ef Seldier C-IF ef eeuree, ie ef the multidimeneienal aepeet ef and the rarity ef The ef OIF Seldier ie further eempeunded by the faet that many impertant demegraphie between the OIF Seldier pepulatien and the Army pepulatien are te eentrel fer in therefere, making etraight ferewerd eemparieene unattainable. lmpreving the OIF preventien training pre-gram ee that it hae relevanee te a eembat and depleyed envirenment wae by IVIHAT Ill, ae well ae by the NIHAT. Twe aepeete ef thie prepeeal eheuld be kept in mind. Firet, we are net that additienal preventien training be eendueted. lnetead, we are prepeeing that the exieting preventien training be eignifieantly medified ee that it ie en aetiene that Se-ldiere, buddiee, and leadere ean take in a eembat envirenment when they believe that a fellew unit member might be at riek ef harming themeelvee er ethere. there ie ne evidenee that preventien training alene will eignifieantly reduee the everall rate ef Thie net mean, hewever, that breventien training ie rather, it highlighte the need te eentinueuely impreve the preventien training effert ee that it ie mere and relevant te meet the ebjeetivee ef the pepulatien the training. Utilizing a garriee-n--baeed preventien pregram ae ie eurrently being dene in OIF faile te meet the neede ef a feree e-berating in a eembat envirenment. Thie wae the firet IUIHAT te explere the rele that leadere play in influeneing the mental health and well--being ef Seldiere and lvlarinee, with the explieit te identity hew leader behaviere might be develeped in erder te euetain and impreve the mental health ef the depleyed feree. Keep in mind that we are talking abeut junier leader behaviere that are imbertant in a eembat zene frem the berebeetive ef the euberdinatee. Net eurprieingly, Seldiere whe reberted that they had geed junier NCO leaderehip reperted higher merale and fewer mental health ee-neerne. Geed junier effieer leaderehip wae alee with Se-ldiere and lvlarinee fellevving the Rulee ef Engagement (ROE). Clearly if there ie a banaeea, a eilver bullet fer euetaining the mental health and well- being ef the depleyed feree, it liee with develeping junier leadere that the impertant rele that they play in maintaining and euetaining the merale and mental well- being ef their Seldiere. leader behaviere that have been ehewn te be effeetive fer euetaining merale, vve|l--being, and mental health in eembat need te be taught at every ?9 level ef leader develepment, beginning vvith the Warrier Leader Ceuree and the effieer baeie The etudy ef Seldier and lvlarine Battlefield Ethiee vvae undertaken at the regueet ef the Cemmanding General, Ae neted brevieuely, te thie taek vve develebed unigue eurvey and feeue greup intervievv gueetiene. We en feur areae ef Battlefield Ethiee: attitudee, behaviere, reberting, and training. The reeulte are eaeily eummarized. In terme ef attitudee, than half ef Seldiere and lvlarinee agreed that nen--eembatante eheuld be treated vvith dignity and vvith vvell ever a third ef all Seldiere and lvlarinee believing that tenure eheuld be allevved te eave the life ef a fellevv Seldier er lvlarine er te ebtain imbertant intelligenee. In terme ef behaviere, Seldiere and lvlarinee did rebert engaging in the mietreatment ef lragi nen--eembatante, vvith 4"x'Ea and ef Seldiere and lvlarinee, reepeetively reperting that they hit er kieked a nen--eembatant vvhen it vvaen't Further, 9% and 12% ef Seldiere and lvlarinee, reebeetively, admitted te damaging er deetreying lragi breberty vvhen it vvaen't By far, the meet eemmen behavier reperted by Seldiere and lvlarinee vvae ineulting er eureing at nen--eembatante, 28% and 38%, reebeetively. In terme ef reperting, than a half ef Seldiere and lvlarinee vveuld reieert a team member fer unethieal behavier. In terme ef training, altheugh Seldiere and lvlarinee reieerted adeguate battlefield ethiee training, ever ene guarter reieerted eneeuntering eituatiene in vvhieh they didn't knevv hevv te reepend. Tegether, findinge indieate the need fer the Army and the lvlarine Cerbe te eelleetively develep Battlefield Ethiee training that vvill enable Seldiere and lvlarinee te knevv vvhat behaviere are ieermieeible and vvhat behaviere are net bermieeible vvhen interaeting vvith eembatante and nen--eembatante. There eheuld be a eingle eelutienfappreaeh fer all when it eemee te Battlefield ethiee. lvlarinee, fer example, eheu|dn't treat nen--eembatante ene vvay, vvhile the Army treate them anether. It ie alee te eetablieh a elear eet ef fer reperting Battlefield Ethiee vielatiene, and then eneure Seldiere and lvlarinee are trained en While every Seldier and lvlarine knevve te use the ehain--ef--eemmand te rebert vielatiene, there ie uneertainty ae te vvhat behaviere muet be reperted, and vvhat behaviere ean be handled "eff--|ine" by talking te the Seldierilvlarine in gueetien. Further, there ie even mere uneertainty ae te vvhat aetiene a Seldier er lvlarine eheuld take if their ehain--ef-- eemmand faile te aet er net take euffieient aetien. The eurrent "Cere 'v"v'arrier 'valuee Training" faile te brevide Cembat partieularly leeing a team member, vvere related te an inereaee in ethieal vielatiene. Battlemind peyehelegieal debriefinge eendueted after the ef a team member eheuld inelude explieit ef the tendeney tevvarde inereaeed anger and heetility direeted at lragi nen--eembatante. Anger and mental health etatue vvere alee linked te Battlefield Ethiee. Seldiere and lvlarinee vvhe had high levele ef anger vvere mere than tvviee ae likely te engage in unethieal behavier en the battlefield eempared te Seldiere and lvlarinee vvhe had levv levele ef anger. And Seldiereflvlarinee vvith mental health prebleme vvere mere likelyte mietreat nen-- eembatante, even when eentrelling fer anger. Ae neted abeve, a praetieal abpreaeh te Bi} addressing these findings is te immediately inelude battlefield ethies awareness diseussiens in all mental health eeunseling and anger management eeurses. Further, leaders at all levels need te ensure that Seldiers that are having diffieulty eentrelling their anger immediate eerreetive training. This MHAT was the first te assess the mental health and well-being ef Marines. When adjusting fer depleyment length and eembat experienees, the mental health status ef Marines and Seldiers were similar. Fer example, Marines experieneing high levels ef eembat were just as likely te sereen pesitive fer a mental health preblem as were Seldiers experieneing high levels ef eembat, versus 30%. Likewise, the mental health status ef Seldiers whe had been depleyed fer less than 6 menths was similar te the mental health status ef Marines whe had been depleyed fer less than 6 menths. These findings are impertant beeause they suggest that efferts te sustain er impreve the mental health ef the depleyed feree sheuld feeus en beth Seldiers and Marines. We believe that the eentained in this repert are equally applieable te beth. While there are undeubtedly eulture differenees between the twe serviees, these differenees were net feund te be ef suffieient magnitude te argue fer the depleyment ef independent mental health efferts te ensure that the mental health needs ef Seldiers and Marines are met. Instead, the findings suggest a jeint effert is preferable, espeeially as mental health suppert in the future is likely te be previded by mental health eare prefessienals frem military serviees different than the units being supperted. Currently in Iraq, fer example, Navy mental health prefessienals previde suppert te beth Marines and Seldiers, with Air Feree mental health prefessienals previding suppert te predeminately Army units. The key te previding eress--serviee mental health suppert is te that there are differenees in eulture, and net te let these differenees a barrier te serviee members seeking eare. This means we must train as we fight. Navy, Army, and Air Feree mental health persennel must begin immediately training with and supperting military persennel frem all the serviees. Fer example, Seldiers sheuld net eneeunter Air Feree mental health persennel fer the first time en the battlefield. Likewise, mental health suppert te Marines sheu|dn't be previded by Army mental health prefessienals en the battlefield witheut first familiarizing the Marines with Army mental health, and familiarizing Army mental health prefessienals with the Marine eulture. Sueh a shift in thinking and behavier will require suppert and direetien frem the highest levels within eaeh ef the serviees, eur Seldiers, Marines, Sailers and Airmen deserve ne less. 81 CONSOLIDATED RECOMMENDATIONS FROM MHAT IV Note that eome recommendations may appear in more than one phaee of the deployment oyole. Pre-Depfoymenr 1. Mandate all Soldiere and Marinee attend emall--group F'RE--deployment Battlemind Training. 2. Develop Battlefield ethioe training baeed on the 'Soldiers' Rulee," ueing OIF-baeed eoenarioe eo Soldiere and Marinee know e:~:aotly what behayiore are aooeptable on the battlefield and the exaot prooeduree for reporting yiolatione. (TRADOCETECOM) 3. Eneure all behayioral health pereonnel and ohaplaine of eeryioe) are profioient in Combat Dootrine by mandating that they oomplete the AMEDD Combat and Operational Control Couree prior to deploying to the OIF theatre. Thie training ehould be required for CSCICJSCAR teame and diyieionfbrigade pereonnel. (Lead: OTSG 3: Ai'ylEDDfOPNfil/ 093 BUMED) 4. Reyiee and field and preyention training eo that it on epeoifio aotione Soldiereflylarinee (eelf-aid and buddy aid) and leadere oan take in helping felloyy unit membere. Llee real--yyorld examplee from a oombat enyironment. (Lead army G-THBUPERS) Deployment 5. Re--eyaluate the in--theatre RSR polioy to eneure that Soldiere (and Marinee) who work primarily outeide the reoeiye in--theatre RSR, to inolude reduoing the aotual trayel time to and from the RSR eite. (MNF-I J-3 J-1) 6. Develop etandardized prooeduree for oonduoting Battlemind Peyohologioal Debriefinge to replaoe Critioal Eyent Debriefinge and Critioal lnoident Debriefinge following deathe, eerioue injuriee and other eignifioant eyente. Surgeon 3: NMRC) Deyelop interyentione to reduoe the impaot of oombat and deployment length on the mental health and yue|l--being of Soldiererlylarinee. Surgeon fit MRMCIOPNAV NMRC) 8. Standardize and FOB rulee to eliminate thoee rulee that don't pertain to oombat ayoiding the eetabliehment of garrieon-like etandarde. (MNF-I CSM) 82 9. Publish a pclicy that ensures are able tc access mental health care during the duty day. Surgecn) 1D. battlefield ethics in all behavicral health ccunseling, especially ccunseling ccnducted in a ccmbat theatre. 3: D93) 11. Include battlefield ethics in all anger management classes, especially training ccnducted in a ccmbat theatre. SurgecnfIvIEDCOIvI fit D93) 12. Stress adherence tc the $c|diers' Rules during After Acticn Revievvs (AARs) critical events. 13. Prcvide behavicral health care cutreach at the Iccaticn cf the Transiticn Team. (3rd NIEDCOIWCSC Teams) 14. Establish a sccpe cf practice pclicv all CBC and mcnitcr delineating the levels cf preventicn, treatment and interventicn activities each specialty. (Lead: AMEDD C&Sx'NavaI ftfiedfcaf Eddcaffcn and Training Ccmmand) 15. Ensure at least cne behavicral health (EH) perscn (cfficer cr enlisted) per service members. ibmg (Lead: 3 fvfEDCOfvf; Sdrgecn) 16. Fccus behavicral health cutreach tc units that have been in theatre Icnger than six (Lead: fvIEDCOfvf; MNF-I Sdrgecn) Develcp and execute a behavicral health care cutreach plan tc ensure all transiticn team members receive care. Ccnsider dedicating BH assets that prcvide BH at the transiticn team's Iccaticn. (Lead: MNF-I Sdrgecn) 18. Immediate: Ivlandate all CBC and BH COBO- WAR (Lead: fvWF--f Sdrgecn) Lcng--term: Develcp a jcint theatre--vvide mental health and suicide surveillance system Scldiers, Marines, Sailcrs, and Airman (pcssiblv include civilians). 19. Implement an in--theatre BH Chart Revievv prccess. (Lead: 3" Sdrgecn) 20. Ccnduct pericdic in--theatre training seminars (bi--annua|) tc ensure BH best practices and tc identifvfdiscuss emerging BH issues. Include 91Xs in these training seminars. (Lead: MEDCOM) 21. Execute a BH Ccmmand Inspecticn (see Appendix Ivl). (Lead: 3" fl/iNF--I Sdrgecn) 83 22. Share mental health infermatien with commanders in the eame manner and detail ae infermatien abeut a weunded ie ehared. Preyide a medieal prefile detailing the extent at the mental health injury, pregneeie, and any reetrietieneflimitatiene en what the ean and eannet de. (IUIEDCOIWOPNAV D93) 23. Target BH euppert fer Seldierefldlarinee with relatienehip eeneerne fellewing mid-teur leave and prier te re-depleying heme. (CS(3!Brigade Mental Health) 2-4. Suetain the Suieide Preyentien Cemmittee, ehaired by the eenier theatre medieal effieer. (Lead: IVWF-I Surgeen) 25. Expand the Suieide Preyentien Ce-mmittee te inelude eperatienal eemmandere and eenier l'~lCOe. (Lead: fL=lNF--f Surgeen) 26. Eetablieh an in--theatre reyiew at all befere eubmitting te SRIUISO te eneure that an ASER ie required, and that the ASER ie aeeurate. (Lead: 3" MNF4 Surgeen) Eetahlieh a jeint traeking eyetem fer the depleyed enyirenment te meniter mental health eyaeuatiene and the ef mental (Lead: Defll) Pear Depieym 28. Mandate all Seldiere and lylarinee emall greup POST--depleyment Battlemind Training. (FORSCOIWHQIUIC) 29. Deyelep intenrentiene te reduee the impact at eembat and depleyment length en the mental health and ef Seldiereflvlarinee. Surgeen fit 3: NMRC) SD. Publieh a pe-liey that eneuree Seldierefldlarinee are able te mental health eare during the duty day. 31. Share mental health infermatien with eemmandere in the eame manner and detail ae infermatien abeut a weunded ie ehared. Preyide a medieal prefile detailing the extent at the mental health injury, pregneeie, and any reetrietieneflimitatiene en what the ean and eannet de. (IUIEDCOIWOPNAV D93) Susrafnm em' 32. Edueate and train junier and effieere in the impertant rele they play in maintaining mental health and well--being by ineluding behayieral health 8-fill training in ALL junior leader development beginning with the Warrior Leader Couree (WLC) and the Offioer Baeio Couree (C-BC). (TRADOCETECOIVI) 33. Reviee the oombat experienoee eoale to inolude "eniper attaoke." MHATQ 3-ll. Extend the interval between deploymente to 18-36 monthe or deoreaee deployment length to allow additional time for Soldiere to re--eet following a one--year oombat tour. (HQ DAIHQMC) the optimal time for Soldiereflvlarinee to their mental health and well--being. (HQ DAIHQMC IVIEDCOIWIUIRIVIC) 35. Publieh a polioy that eneuree Soldiereflvlarinee are able to mental health oare during the duty day. 36. lnoorporate battlefield ethioe in all behavioral health oouneeling. (lvlEDCC-lvl 3: OPNAV D93) lnolude battlefield ethioe in all anger management eepeoially training. (l'vlEDCOl'v'l 3; OPNAV 093) Due oute from LTG Kiley inoluded: 1) providing epeoifioe on poeitive I negative leader behaviore and thie information to NCO leaderehip, 2) reviewing I revamping the C36 Combat and Operational Control ((3030) Couree ourrioulum, 3) building real world eoenarioe and vignettee from deployed environment into prevention training, 4) eetabliehing plan for expaneion of Battlemind training Army--wide, and 5) providing detaile on the rolee that therapiete play on CD50 teame. 38. Eetablieh a eoope of praotjoe polioy for all CSO pereonnel and monitor for oomplianoe, delineating the levele of prevention, treatment and intervention aotivitiee for eaoh epeoialty. (Lead: flu'vfEDD C&Sx'Navaf fvfedfoal Eduoaffon and Training Command) 39. Reviee the Unit lvlental Health Neede to provide epeoifio aotione for behavioral health pereonnel to take baeed on the unit neede to improve the mental health of the unit. (Lead: MEMO) lnolude training in ueing the Unit lvlental Health Neede in the revieed CBC Couree. (Lead: (ES) 41. lnoorporate COSQWARS training into the CSC oouree. (Lead: fiu'vfEDD cites) 42. Develop a ueerfriendly data routine for reporting COSGWARS findinge. (Lead: flufvfEDD 43. Immediate: lvlandate all CBC and Divieionr'Brigade BH pereonnel oomplete COBO- WAR reporte. (Lead: MNF-I Surgeon) Long--term: Develop a joint theatre--wide mental health and eurveillanoe eyetem for Soldiere, lvlarinee, Sailore, and Airman (poeeibly inolude oiviliane). 85 44. Eetablieh a oentral repoeitory for all COSQWARS data oolleoted. (Lead: 45. Eetablieh and maintain a C030 ae a meane to obtain referenoe and training material (eepeoially important for 91>