Psychiatry's impact on Military Missions

I may not have chosen this as a career were it not for setting and the mission value I had begun to realize. My service in the Marine Corps and then training in a military medical school had done a good job solidifying my military identify. Psychiatry brought a military relevance to medicine that helped foster that exact military identify for me. My readings on this topic during this time helped to cement in my mind the value of psychiatry to military missions. There is a cyclical nature to the recruitment efforts in psychiatry in the USA. There is evidence that the historical upswings in psychiatry being favored as a career choice occurred after major military conflicts [4]. During World War II, the military psychiatrists helped take psychiatric practice, which for the most part entailed psychodynamic approaches and something previously for the privileged, and delivered it to the common masses [1]. The symbiotic nature of the marriage between American psychiatry and the military is well recognized. The military has had to struggle with the emotional costs of battle and its impact on the mission. Meanwhile, the American psychiatry can trace its approach to diagnosing mental illness to the nomenclature developed by US Army after World War II [5]. This organization of labels used to identify different presentations of psychiatric illness allowed disability evaluation and diagnostic uniformity. The DSM is currently in its 5th edition, but it can trace its roots to phenomenological and phenotypical observations made by military psychiatrists. Military psychiatry’s contribution are numerous and during my medical school years, its impact became increasingly clear to me regarding missions related to GWOT.

Historically, infections and respiratory illnesses were leading cause of morbidity and loss of a soldier from the battlefield. Psychiatric causes were lower on the list. Between WWII and Korean War to Vietnam, mental illness jumped from 11th to 8th place as the leading cause of taking out troops from the battle zone [6]. Psychiatric illness rose to greater significant in more recent conflicts edging up to the fourth place in the British Army during their Bosnian operations [7]. The data from GWOT is similarly dramatic. A study looked at medical evacuations from Iraq and Afghanistan between 2004 and 2007 and noted over 34,000 troops brought to higher echelon out of the combat theater [8]. Only 14 % of the patients in this study were due to combat injuries. Psychiatric diagnoses led to the evacuation of 9 % of these troops. The most interesting findings were that psychiatric patients had the lowest return to duty rates [8]. It highlights both the breadth and depth of the impact that mental illness has on military operations, readiness and retention of talent. The next question that helped me understand the impact of a military psychiatrist during GWOT helped me see the value of the profession directly impacting frontline mission. Let’s consider the data from Cohen’s research above of those 9 % evacuated from theater. These 9 % being the numerator, then how did the denominator do? These would be all the soldiers coming in contact with mental health in the combat theater. How many were able to be returned to duty and kept in the fight? The answer to this question would help us understand the impact of military psychiatry towards the mission and motto of Army Medical Corps: To Conserve Fighting Strength. Data about forward clinical contacts and outcomes is scarce. There is only a single estimate early on during GWOT where the Army Medical Department reported that 97 % of forward deployed soldiers treated by mental health returned to duty and presumably stayed in the fight [9]. This figure plummets when the evaluations occur farther out from the battlefield. Only 11 % returned to duty when they were seen in Kuwait, 3.8 % when this was done at Landstuhl Regional Medical Center in Germany [9] and virtually no chance when the patient is sent to a place like Walter Reed in the USA [10]. These facts and impressive return-to-duty rate on the battlefield are enough to warrant mental health professionals close to frontlines. There are probably numerous factors for these declining figures but one obvious one is that patients medically evacuated out to the USA probably had greater severity of psychiatric illness. These were the patients that colored my experiential lenses as a resident at Walter Reed as I learned the science and art of psychiatry. These are the soldiers that require the advanced care that garrison treatment facilities offer. It is indeed the role of garrison medicine at places like Walter Reed to meet the promise of caring for our wounded, veterans and their families.

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