Multiple-role dilemmas for military mental health care providers

Military psychologists and psychiatrists frequently face ethical quandaries involving boundary crossings, or extratherapy contact, and multiple relationships. A multiple relationship is defined as necessarily engaging psychotherapy patients in nonclinical roles, such as coworker, superior officer, neighbor, or friend. In contrast to their civilian counterparts, military mental health professionals must often engage patients in many different contexts and roles. In this article, we consider the distinctive features of mental health practice in the military and offer military providers several practice guidelines for avoiding harm to patients in military settings. This article is also designed to enhance sensitivity to multiple-role risks among nonpsychiatric providers.     

How communication with families can both help and hinder service members' mental health and occupational effectiveness on deployment

Communication with home can be beneficial to deployed service members' mental health, morale, and occupational effectiveness. Conversely a lack of communication with home increases the risk of developing mental health problems. Therefore it is important to ensure that communications media is both affordable and accessible while on deployment. However, contact with families can sometimes have negative effects, particularly when problems arise at either end. It can also be difficult for military personnel and their families if the level of contact is lower than they expected. Conversely, too much contact with home may have a negative impact on occupational effectiveness. More research is required to determine the optimal level of communication with home. Additional research is required to determine which types of communications media are most beneficial and whether the benefits of communication with home differ depending on the context of the deployment and the family status of the service member.     

International military leaders' survey on operational stress

Despite the importance of military leaders in moderating the impact of deployment stressors on unit members, little attention has focused on the training leaders receive in managing unit stress. As part of a NATO Research Panel (Human Factors and Medicine (HFM)-081/Research and Technology Organization Task Group (RTG)), 16 nations participated in a needs assessment survey of military leaders who had returned from an operation within the previous 2 years. Findings from 172 leaders emphasized the lack of training specifically geared for leaders to address operational stress issues for unit members and their families and the need for integrated mental health support across the deployment cycle. In general, most leaders regarded stress-related mental health problems as normal and were supportive of help-seeking. The information obtained here was used to develop a Human Factors and Medicine -081/RTG Leader's Guide on operational stress.     

The effects of mental health symptoms and organizational climate on intent to leave the military among combat veterans

Frequent deployments to Iraq and Afghanistan have placed a strain on military retention. There is a need to determine contributing factors predicting intent to leave the military. The purpose of this study was to determine to what extent soldiers' mental health symptoms and perceptions of organizational climate are associated with intent to leave the military. Participants (n = 892) were soldiers of one infantry brigade combat team stationed in the United States, anonymously surveyed approximately 6 months after returning from a combat deployment to Iraq. The survey assessed overall deployment experiences, mental health symptoms, and perceptions of organizational climate. Results showed that soldiers reporting higher perceived organizational support were significantly less likely to report intent to leave and those screening positive for anxiety were significantly more likely to report intent to leave than those not screening positive. Implications of these results for Army clinicians and career counselors are discussed.     

The psychologist's role in the Garrison mission of combat stress control units

Active duty psychologists frequently are called upon to provide services that extend beyond the model of direct patient care. Army psychologists in combat stress control teams or division mental health services, Navy psychologists deployed to surgical companies, and Air Force psychologists deployed with air-transportable hospitals or mental health rapid response teams may find themselves acting as organizational consultants as well as clinicians. Psychologists assigned to hospitals and clinics also have opportunities to make contact with their units for purposes of consultation and education. Organizational consultations that offer interventions for improving unit readiness and/or increasing combat effectiveness are often welcomed by commanders and provide a mechanism for the application of training and experience directly to military populations. Transferring skills from patient care to performance enhancement may not be a clear progression for many clinicians. This article describes the strategies and materials developed as part of a combat stress control garrison mission at Fort Lewis, Washington, as an example of one approach to working with combat units. The article also calls for the development of a formal mechanism to train psychologists for such roles and for the maintenance and dissemination of research materials to support organizational interventions.     

Women in the Gulf War: combat experience,exposures, and subsequent health care use

The expanding role of women in the military raises questions related to the military experiences of women serving in major conflicts. We assess the military experiences and postwar health care use of women who served during the Gulf War. Data from a population-based survey of military personnel serving between August 1990 and July 1991 assessing military preparedness, combat experience, occupational and other service-related exposures, and health care use were analyzed. Deployed women were more often in the Army, single, without children, college educated, and reported fewer vaccinations. Deployed men and women had similar military experiences; however, men more often participated in combat. Deployed women had more outpatient and inpatient health care use 5 years after deployment and more often received Department of Veterans Affairs compensation than men. If these important differences in exposures and health care use are confirmed in other studies, optimal training and deployment preparedness strategies should be reconsidered.     

Occupational stress and psychiatric illness in the military: investigation of the relationship between occupational stress and mental illness among military mental health patients.

OBJECTIVE: This was a pilot study aimed at gathering preliminary data on the relationship between occupational stress and mental illness among military personnel. The primary goal of this study was to determine to what extent military mental health patients report suffering from significant occupational stress. METHODS: Eighty-five active duty military mental health outpatients at the Wilford Hall U.S. Air Force Medical Center mental health clinic answered a 65-item survey that included items on the perception of occupational stress and reported life changes. Participation in this cross-sectional study was anonymous, voluntary, and random. The 85 participants represent 83% of those surveyed and approximately 10% of the clinic's total population of military mental health outpatients. The survey incorporated the 43-item Schedule of Recent Experiences (SRE). By adding the weighted values assigned to the 43 items, each respondent was given an SRE score, which is a measure of overall stress that has been shown to be predictive of future illnesses. RESULTS: A majority (60%) reported suffering from significant work stress. A majority (52%) reported that work stress was causing them significant emotional distress. Almost half (42.5%) reported that work stress was a significant contributor to the onset of their mental illness. The average SRE score for all respondents was 266, reflecting increased risk for future illnesses. Generic work stressors were endorsed more frequently than military-specific stressors. CONCLUSIONS: The results reveal that this population of military mental health clinic outpatients perceived that work stress had a strong negative effect on their emotional health. These results raise the possibility that work stress could be a significant occupational health hazard in the U.S. military, a possibility that warrants further investigation. By gathering additional data on the relationship between work stress and emotional health in the military, interventions can be planned to mitigate the effect of stress caused by the military work environment on the mental health of military personnel.     

Developing evidence-based clinical guidelines for military use: case study of smoking cessation guidelines

OBJECTIVE: To develop evidence-based clinical guidelines on smoking cessation, for use throughout the British military. METHOD: A ten-member, multiprofessional smoking cessation working group met five times between October 2000 and July 2001 to develop targeted smoking cessation guidelines for use by military health professionals in the clinical setting. The guidelines were based on the best available scientific evidence at that time, mainly systematic review of controlled trials, and individual randomised trials. RESULTS: The agreed military guidelines on smoking cessation were promulgated in July 2001. Three tiers of support were defined. Military health professionals have a key role as nonsmoking models and advocates, and should be trained to use 'brief intervention' at every clinical encounter with a military smoker. 'Intermediate support' (defined as a specialist service delivered by military health professionals who have undergone specific training and continuation training) is to be available at local level. The most heavily addicted military smokers will require referral to civilian smoking cessation clinics. Effective technologies for use at any one of the three levels of care are: nicotine skin patches, nicotine gum, nicotine lozenges and bupropion. CONCLUSIONS: These are the first ever clinical guidelines for military use which meet accepted modern quality criteria. Informal monitoring of the uptake of these guidelines between July 2001 to December 2001 suggests that they have been well received by military health professionals. An audit of their impact on smoking patterns within the UK Armed Forces will commence in 2002. The guidelines will be updated 5-yearly, or sooner.     

Military hardiness as a buffer of psychological health on return from deployment

Military hardiness, the context-specific adaptation of psychological hardiness, is explored as it relates to military occupational stressors. It was hypothesized that military hardiness would moderate the effects of deployment stressors on soldier health. In a survey study of 629 U.S. soldiers, deployment stressors, military hardiness, and psychological and physical health were assessed during a peacekeeping deployment. Health was measured again after deployment. Results of moderated regression analyses partially supported the hypotheses; military hardiness moderated the impact of deployment stressors on depression after deployment, after controlling for depression during deployment. Implications for training military hardiness and applications to other occupational settings are discussed.     

The use of unit watch or command interest profile in the management of suicide and homicide risk: rationale and guidelines for the military mental health professional

Military mental health care professionals have, for decades, recommended that commanders implement a unit watch (now called a "command interest profile" at most Army posts) as a tool for enhancing the safety of personnel in the unit when a soldier presents with suicidal or homicidal ideation. Although these procedures are used extensively in garrison and in operational settings, there exists no specific body of literature or Army publication to offer either a rationale or a set of guidelines for their use. We have successfully used unit watch protocols for years both in the deployment setting and in garrison. This article provides both a rationale and a set of guidelines for their use based on fundamental military psychiatric principles, review of the relevant literature, and anecdotal experience with this intervention. Although further research is indicated, this article provides support for the use of unit watch in military settings.     

Detecting post-deployment mental health problems in primary care

Post-deployment mental health problems are a source of potential concern for health professionals and politicians in military forces in the world; the UK Armed Forces are no exception. This article examines practical ways in which General Practitioners in Primary Care can enhance their ability to detect post-deployment mental health problems and offers suggestions on immediate management and assessment, based on contemporary evidence and clinical experience.     

Psychiatric illness and the workplace: perspectives for occupational medicine in the military.

In inpatient psychiatric wards and outpatient mental health clinics throughout the military, psychiatrists and other mental health professionals are often faced with patients suffering from emotional distress attributed to occupational stress. There has been scant research into how the routine military work environment affects the mental health status of military employees. This paper provides a review of the occupational medicine literature on the relationship between the work environment and employee mental health. There is a growing recognition that stress resulting from the workplace can provoke psychiatric illness, but the research is limited at this time. The data existing on the work force in general are examined, and the relationship of these findings to the military work environment is discussed. This review suggests that a comprehensive examination of the relationship between the military work environment and the mental health of military employees is needed. By gathering these data, interventions can be planned to mitigate the effect of stress caused by the military work environment on the mental health of its members.     

我国首批女实习舰员长远航心理健康状况调查分析

目的 了解执行"和谐使命-2010"任务女实习舰员的心理健康状况及影响因素,为更好地维护女舰员心理健康及未来女舰员的选拔提供科学依据.方法 以参加此次任务的女实习舰员、女医务人员、男舰员为调查对象,以整群抽样和分层随机抽样相结合,采用症状自评量表(SCL-90)进行4次跟踪问卷调查,同时使用自制的一般资料问卷进行访谈.结果 女实习舰员长远航期间心理健康问题总体检出率为21.8%.长远航中期各因子分超出正常的人数明显增加,长远航后期各因子分超出正常的人数略有降低.女实习舰员长远航前、早期与中、后期比较,心理健康水平差异有统计学意义(P<0.05),躯体化、抑郁、恐怖、其他因子分均显著高于中国军人常模(P<0.05),人际敏感、焦虑、偏执因子分低于中国军人常模,但差异无统计学意义.女实习舰员在航行中、晚期较同期男舰员、女医务人员心理健康状况差(P<0.05).结论 长远航明显降低女实习舰员的心理健康水平,应及时对女实习舰员的心理健康进行必要的干预.

Abstract：

Objective To investigate the mental health status of the midshipwomen involved in Mission Harmony-2010 and its influencing factors, and also to provide scientific basis for the maintenance of mental health and selection of female ship crew.Methods With midshipwomen, female medical personnel, male shipcrew as study subjects, and with cluster sampling and stratified random sampling as study methods, questionnaires were conducted 4 times by using symptom checklist (SCL-90) and routine interviews were also made during our study.Results During the prolonged seagoing deployment, the rate of detection for mental health problems among the midshipwomen was 21.8%. Scores of various factors during the mid stage of deployment were obviously higher than those of the normal people. However, in the later stage, scores of various factors were slightly lower than those of the normal people. Statistical significance was shown in the mental health status of the midshipwomen, when a comparison was made between pre-deployment,early stage of deployment and the mid and later stages of deployment(P<0.05). Scores of somatization, depression, phobia and other factors were significantly higher than those of the norms of Chinese military personnel (P<0.05). Scores of interpersonal sensitivity, anxiety and paranoia were lower than those of the norms of Chinese military personnel, but without statistical significance. During the mid and later stage of the prolonged seagoing deployment, the mental health status of midshipwomen was worse than that of the male ship crew and female medical personnel(P<0.05).Conclusions Prolonged seagoing deployment could significantly worsen the mental health status of midshipwomen. It was necessary to give in-time psychological intervention so as to ensure the mental health of midshipwomen.     

Travelers' diarrhea among United States military personnel during joint American-Egyptian armed forces exercises in Cairo, Egypt

A study was conducted of travelers' diarrhea in a United States military population on deployment in Cairo, Egypt, during July and August 1987. Acute diarrhea requiring medical attention developed in 183 (4%) of 4,500 troops. A possible etiologic agent was identified in 49% of all diarrhea cases. Enteric pathogens associated with cases of diarrhea included: Enterotoxigenic Escherichia coli (17% ST-producers, 13% LT-producers, and 3% LT/ST-producers); Shigella (9%); Campylobacter spp. (2%); Salmonella (2%); and Vibrio cholerae non-01 serogroup (2%). Other enteric pathogens isolated from one episode each of diarrhea included Aeromonas hydrophila group, Plesiomonas shigelloides, and Bacillus cereus. Yersinia enterocolitica, enteroinvasive E. coli, intoxications by Clostridium perfringens and Clostridium difficile, and pathogenic enteric parasites were not found in any of the 183 patients with diarrhea. A survey of military personnel not requesting medical care indicated that up to 40% of troops may have had diarrhea during this deployment. Acute gastroenteritis is a potential cause of substantial morbidity in U.S. military personnel deployed to Egypt.     

驻云南部队干部心理健康状况影响因素研究

目的探讨驻云南部队干部心理健康状况及其影响因素。方法随机整群抽取驻云南部队干部99人,采用：军人心理健康量表、军人情景特质应对方式量表和军人职业压力量表进行测评,并对军人职业压力、年龄、民族、文化等因素进行相关分析。结果云南部队干部的心理健康状况与军人职业压力存在显著的相关性。云南部队干部与年龄、军龄、民族、文化等因素的多元逐步回归分析结果显示,军龄、年龄及民族与心理健康状况成负相关,文化程度与心理健康状况成正相关。结论云南部队干部的心理健康状况呈现出其特殊性,应以不同的方式对待。     

军事作业疲劳的评定、机制、预防及快速恢复措施

疲劳是一个世界性难题,军人在军事作业或行动中经常发生疲劳,给完成任务带来障碍.在当今复杂的国际军事环境下,军事疲劳已受到各国军队的高度重视.本文对军事作业中疲劳的表现、评定、发生机制,以及疲劳的预防与快速恢复进行阐述,以期为我军更好地、合理地对抗军事作业或训练中出现的体力疲劳和脑力疲劳提供充足的理论依据.     

The role of chaplains in maintaining the psychological health of military personnel: an historical and contemporary perspective

For many hundred of years, military forces have included chaplains of various faiths. Although these personnel mainly concentrate on providing for the religious and spiritual needs of the armed forces, they also contribute to the mental health of service personnel. This article provides a historical overview of military chaplains, examines their contributions to the psychological health of allied forces in World War I and World War II, and offers an overview of the scope of their present and future mental health related activities. The importance of the relationship between medical officers and chaplains in diagnosing and treating mental health problems is also discussed. We conclude that chaplains are capable of contributing significantly to the mental health of armed forces personnel if they are able to do so in informal and collaborative way.     

Psychiatric diagnoses and treatment of U.S. military personnel while deployed to Iraq

Military personnel deployed in support of combat operations are at significantly higher risk for mental health problems. However, much of what we know about combat-related mental health comes from postdeployment assessments. This study describes the mental health of 1,336 treatment-seeking deployed U.S. military personnel and interventions recommended by military mental health providers in Iraq from January 2006 to January 2007. Cases were primarily young enlisted men, most of whom were on their first combat deployment. Marines made up the majority of the cases (60%), but there were also large numbers of Army and Navy personnel. The most common psychiatric diagnoses were anxiety disorders (31%, including 11% with posttraumatic stress disorder), followed by adjustment (27%) and mood disorders (25%, including 22% with depression). Medication was the most commonly prescribed treatment for patients with psychiatric diagnoses but was often combined with recommendations for psychotherapy/counseling and/or behavioral modifications. The findings illustrate the distribution of mental health conditions seen among treatment-seeking troops while actively serving in a combat environment and the interventions recommended for them. Further examination of postdeployment health outcomes may help to facilitate the development of more effective acute intervention strategies in theater.     

Psychological morbidity during the 2002 deployment to Afghanistan

Questionnaires were completed by military personnel on arrival (n=1,696) in Kabul, Afghanistan and then again on departure (n=1,134). Analysis of the 113 personnel who completed both the arrivals and departures questionnaire revealed a lower alcohol use score after deployment (AUDIT mean difference (post-deployment - pre-deployment) = -0.39, 95% confidence interval (CI) = - 1.25 - +0.47) and no significant change to mental health (GHQ mean difference = 0.55, 95% CI = -0.07 - +1.17). An increase in psychosomatic symptoms (GHQ A mean difference = 0.22, 95% CI = -0.03 - +0.47) is considered to result from the adverse conditions, but it is not supported by other mental ill health markers. In conclusion, there appeared to be no negative effect on mental health from deployment to Afghanistan.