Do the Military’s Frontline Psychiatry/Combat Operational ...

Do the Military’s Frontline Psychiatry/Combat OperationalStress Control Programs Benefit Veterans? Part Two: SystematicReview of the Evidence

Mark C. Russell1 & Charles R. Figley2

Received: 24 September 2016 /Accepted: 19 December 2016 /Published online: 10 February 2017# Springer Science+Business Media New York 2017

Abstract The second of a three-part review provides the first-ever systematic investigation into the military’s claim that itscentury-old policy of preventing evacuation of psychiatric ca-sualties from war zones is beneficial to the health and well-being of individual service members and their families. Weconducted an extensive literature search for studies on themilitary’s frontline psychiatry doctrine, particularly researchcomparing the differential effects of deployed personnelreturned-to-duty (RTD) via frontline psychiatry or combatand operational stress control (COSC) and behavioral healthinterventions, as opposed to those evacuated out of war zonesas psychiatric casualties. In addition, we examined partial andindirect evidence in support of the military’s argument thatRTD and preventing psychiatric evacuations enhances post-traumatic growth and reduces adverse impact from mentalhealth stigma, shame, and guilt, as well as lowering the riskof developing PTSD or other war stress injury causing prema-ture military discharge. Results indicate support that frontlinepsychiatry benefits the war-fighting mission and goal of mil-itary medicine to prevent psychiatric attrition, with RTD ratesof 60 to 100% and severely limiting psychiatric evacuations.However, there is paucity of research on differential out-comes, with only three, small uncontrolled retrospectiveIsraeli studies from the 1982 Lebanon War reporting modestlong-term benefit, from frontline versus undefined rear hospi-tal treatment, such as lower PTSD rates. Overall, the reviewshowed insufficient and often contradictory evidence of

individual health benefits from frontline psychiatry, whichcalls for further research on military’s chief mental healthpolicy.

Keywords War stress . PTSD .Military . Veterans . Combatstress control . Forward psychiatry . Combat psychiatry .

Combat and operational stress control

The two overarching objectives of COSC (combat op-erational stress control) are to create and preserve aready force and to promote the long-term health andwell-being of individual Marines and Sailors and theirfamily members. The two objectives are interrelated andare recognized as of paramount strategic importancesince the mission of the Navy and Marine Corps is towin wars and to return good citizens to civilian life afterthose wars are fought. (Department of Navy & U.S.Marine Corps, 2010, pp. 1–2).

The second of a three-part review provides the first-eversystematic investigation into the military’s claims that its warzone mental health policies of preventing evacuation of psy-chiatric casualties are mutually beneficial to the military mis-sion as well as the health and well-being of individual servicemembers and their families. We collectively refer to the USmilitary’s combat operational stress control (COSC) and be-havioral health (BH) programs in war zones as frontline psy-chiatry (see Russell & Figley, 2016). Readers are referred toour first article for a historical and contemporary review of thedebate on frontline psychiatry that became military doctrineduring the First World War (WWI) to end mass psychiatricattrition and disability pensions threatening the military’s

* Charles R. [email protected]

1 Antioch University Seattle, Seattle, WA 98121, USA2 Tulane University, New Orleans, LA, USA

Psychol. Inj. and Law (2017) 10:24–71DOI 10.1007/s12207-016-9279-x

http://crossmark.crossref.org/dialog/?doi=10.1007/s12207-016-9279-x&domain=pdf

capacity to sustain the war effort as well as bankrupting soci-eties (Russell & Figley, 2016). Effectiveness of frontline psy-chiatry in achieving its explicit goal of conserving the fightingforce has traditionally been measured via return-to-duty(RTD) rates and restricting medical evacuations for psychiat-ric reasons (Russell & Figley, 2016). Over time, however, themilitary has increasingly justified its century-oldmental healthpolicy by messaging frontline psychiatry as mutually benefi-cial not only to the military mission through conserving thefighting force but also through enhancing the health and well-being of deployed personnel and their families (e.g.,Department of the Army, 2006; Russell & Figley, 2016). Forexample, the Pentagon’s top psychiatric advisor at the timewas quoted as stating, BIf people are treated on the front lineswith the expectation that they will go back to duty, they usu-ally recover^ (Rabasca, 2000, p. 50) and, conversely, Bif weevacuate them away from their unit, their psychiatric symp-toms tend to last^ (Rabasca, 2000, p. 50).

Periodically, the military’s claims are challenged on ethical(e.g., Camp, 2014), scientific (e.g., Jones & Wessely, 2003),and even legal grounds (McGeorge, Hughes, & Wessely, 2006;Russell, Zinn, & Figley, 2016). The most recent challenge camefrom a 2003 British High Court decision on a class action suitMultiple Claimants v. MoD (Ministry of Defense), wherebydischarged British soldiers suffering from chronic war stress in-jury, such as posttraumatic stress disorder (PTSD), allegedwrongdoing because of the MoD’s failure to ensure access topreventative frontline psychiatry services (e.g., McGeorge,Hughes, &Wessely, 2006). After extensive review of the empir-ical evidence on the efficacy of frontline psychiatry, the HighCourt dismissed the plaintiff’s claim by upholding the MoD’sargument that frontline psychiatry is generally ineffective inpreventing PTSD or other war stress injury (e.g., McGeorgeet al., 2006). The High Court even went so far as to questionthe ethics of the frontline psychiatry doctrine, echoing distantethical charges of harm from US Army psychiatrists during theVietnam War (e.g., Camp, 1994).

Purpose of the Study

The current study provides the first-ever comprehensive evi-dentiary review of the military’s claims that frontline psychi-atry is mutually beneficial to the military and its warfighters.After describing our methodology, we begin our analysis withan overview of military organizations responsible forconducting mental health-related research. This is followedby an in-depth analysis of investigations directly assessingresearch questions regarding the benefits of frontline psychi-atry to the military mission. Next, we examine studies directlyevaluating differential clinical outcomes between deployedpersonnel RTD via frontline psychiatry and those medicallyevacuated for treatment outside war zones. Lastly, we review

indirect evidence of the potential benefit of frontline psychia-try to deployed personnel and their families from multiplelines of research including related to (a) shame, guilt, andstigma caused by psychiatric evacuations and treatment as apsychiatric patient; (b) protective factors of war stress injury,like PTSD, such as unit morale, cohesion, leadership, andsocial support; (c) promoting resilience by reducing risk ofdeveloping chronic war stress injury (like PTSD); (d)preventing adverse personnel actions, including prematuremilitary discharge and loss of career; (e) posttraumatic growth(PTG); and (f) increasing positive family outcomes. Central toour analysis is the question: What is the evidence supportingthe military’s claims of improved short- and long-term out-comes for deployed individuals diagnosed and treated in thewar zones for combat stress reaction (CSR)/combat operation-al stress reaction (COSR) and/or a psychiatric condition(s) ascompared to those evacuated and treated outside of warzones?

Methodology

An extensive review of the literature was conducted on front-line psychiatry since WWI with emphasis on locating primarysources of research relating to assessing effectiveness, effica-cy, and clinical outcomes. In addition to multiple historicaltreatises on the subject (e.g., Dean, 1997; Holden, 1998;Jones, 1995a, b; Jones & Wessely, 2007; Lerner, 2003;Shepard, 2001), we reviewed current US military COSC-related publications (e.g., DOA, 2006; Department of Navy& U.S. Marine Corps, 2010; Department of Veterans Affairs& Department of Defense, 2010) and the US military’s docu-mented lessons learned for WWI (e.g., Salmon, 1917; Salmon& Fenton, 1929), Second World War (WWII; Glass, 1966),Korean War (e.g., Ritchie, 2002), Vietnam War (e.g., Camp,2014), and the Persian Gulf War (e.g., Martin & Cline, 1996),as well as independent government studies (e.g., Institute ofMedicine, 2014a; Government Accountability Office, 2016).

With regard to published scientific articles and militaryreports, an expansive key word search included relevant termsand phrases, such as forward psychiatry, war psychiatry, com-bat psychiatry, frontline psychiatry, combat stress, neuropsy-chiatry, combat stress control, combat and operational stresscontrol, acute psychiatric casualties, medical evacuation, andpreventative psychiatry, along with specific diagnostic terms(e.g., shell shock, war neuroses, battle fatigue, combat exhaus-tion, combat stress reaction, PTSD), as it pertains to treatment,prevention, resilience, and protective and risk factors.Specifically, we sought out sources cited by the US militaryas the evidentiary bases for positing the benefits of frontlinepsychiatry to service members, but also included researchfrom Australia, Canada, France, Israel, and the UK.

Psychol. Inj. and Law (2017) 10:24–71 25

Military Entities Investigating Mental Health Issues

The Department of Defense (DoD) employs multiple researchagencies whose mission involves investigating mental health-related issues including, but not limited to, the following:

In 2007, the USA dramatically increased funding for mil-itary mental health research by $1 billion for 2007 to 2013,including establishing the Psychological Health ResearchContinuum (PHRC) in 2013 to ensure that deployed personnelreceive the best evidence-based prevention, treatment, andcare possible (Castro, 2014). As depicted in Table 1, thePHRC represents just the latest in a host of military organiza-tions responsible for researching deployment issues since1893. Castro’s (2014) review of recent military mental healthresearch accomplishments includes prospective longitudinaloutcome studies after deployment, clinical trials, epidemiolog-ical studies, such as annual Mental Health Advisory Team(MHAT) surveys, as well as studies on etiology, prevention,screening, and follow-up care.

US Military Research Specific to Frontline PsychiatryOutcomes

Per the Pentagon’s top psychiatry advisor during Operation IraqiFreedom (OIF) and Operation Enduring Freedom (OEF) (Ritchie,2007), BThere is an obvious need for research regarding the effec-tiveness of our early interventions^ (p. 14). The senior advisor’sfrank admission of empirical uncertainty on the matter appears tocontradict previous assertive propositions that BIf people are treatedon the front lines with the expectation that they will go back toduty, they usually recover. But, if we evacuate them away fromtheir unit, their psychiatric symptoms tend to last^ (Rabasca, 2000,p. 50). After the past decade of protracted war, what can DoDresearchers now tell us about the present state-of-the-knowledgeof the health impact from its frontline policies?

Despite the multitude of research agencies whose shared mis-sion is to preserve or improve the mental health of military pop-ulations (see Table 1), our literature review failed to identify asingle study by the US military on the long-term clinical out-comes for deployed personnel receiving its frontline psychiatryservices, let alone any comparative analysis of war stress casual-ties evacuated out of war zones. Numerous military studies andinvestigative reports are available since WWI with regard toRTD, relapse, and evacuation rates, as well as surveys of riskand protective factors in the war zones of Iraq and Afghanistan(e.g., MHAT-I, 2003). However, overwhelmingly, those studiesaddress the benefit to the military in terms of preventing psychi-atric attrition via evacuations. In fact, the only US research ex-amining clinical outcomes from frontline psychiatry is from anonmilitary RAND group (Vaughan, Farmer, Breslau, &Burnette, 2015). Consequently, we expanded our literature re-view to any international investigations, such as by the BritishMoD and Israeli Defense Forces (IDF).

Direct Evidence That Frontline Psychiatry Benefitsthe Military Mission

Since WWI, hundreds of individual and multiple case studieshave been published with regard to the US military’s claimthat frontline psychiatry is beneficial to its mission to fight andwin wars by restricting psychiatric evacuations. Historically,the two pivotal outcome measures for directly assessing theefficacy of frontline psychiatry in reducing attrition have been(a) high RTD rate of deployed service members with warstress injury and/or behavioral health (BH) problems, coincid-ing with (b) low rate of psychiatric evacuations out of warzones.

Research on Preventing Psychiatric Attrition Priorto Current Afghanistan/Iraq Wars

Table 2 provides a comprehensive analysis of frontline psy-chiatry from WWI (1914–1918) to the First Persian Gulf War(1990–1991), representing studies by the militaries ofAustralia, Canada, Israel, France, the UK, and the USA. Inthis research, the range of RTD is 10 to 100%, with lower ratesgenerally reported by base hospitals and general hospitals far-thest from war zones. It is apparent that the reporting of RTDrates is simply a measure of administrative disposition relatedto the military’s explicit bottom line of avoiding psychiatricattrition as opposed to any kind of an assessment of the pos-sible clinical benefits to service members. The net benefit tothe military in terms of preserving manpower is notable.

Table 2 also reveals the overall poor quality of empiricalsupport underlying the military’s frontline psychiatry doctrine.The historical record is replete with published accounts bymilitary clinicians from every war reporting high RTD ratesvia frontline interventions in comparison to soldiers treated inthe rear (e.g., Noy, Levy, & Solomon, 1984), but sometimeswithout any statistical data in terms of the number of person-nel RTD (e.g., Allerton, 1969), and regularly neglecting dura-bility of intervention effects in terms of relapse rates or clinicaloutcomes (e.g., Jones & Wessely, 2003).

Research on Frontline Psychiatry in CurrentAfghanistan/Iraq Wars

Table 3 contains published reports of the US military’s front-line psychiatry programs from the current wars in Afghanistanand Iraq. With the exception of Hoyt et al. (2015), the trend ofignoring the immediate and long-term BH impact from front-line psychiatry interventions has persisted in the twenty-firstcentury. It should be mentioned, however, that Hoyt et al.(2015) do not provide any analysis of clinical outcomes spe-cific to the 467 soldiers RTD or the 46 soldiers psychiatrically

26 Psychol. Inj. and Law (2017) 10:24–71

evacuated even though assigned to the same Army unit. Thisreflects a missed opportunity to evaluate the accuracy of themilitary’s narrative of the clinical benefit of frontline psychi-atry. Nevertheless, Tables 2 and 3 provide convincing proofthat frontline psychiatry is extremely effective in conservingthe fighting force via its RTD policy.

Current Research on Psychiatric Evacuationsout of War Zones

As evident in Tables 2 and 3, for the past 100 years, frontlinepsychiatry has proven to be highly effective in ensuring lowrates of psychiatric evacuations as compared to medical

Table 1 Sample of DoD entities responsible for mental health-related research

Agency Dateoforigin

Servicebranch

Mission Reference

Walter Reed Army Institute ofResearch

1893 Army To conduct biomedical research that is responsive to theDepartment of Defense and US Army requirements anddelivers life-saving products including knowledge,technology, and medical material that sustain the combateffectiveness of the warfighter

http://wrair-www.army.mil/

59th Medical Wing 1941 Air Force To meet the needs of the Air Force through the developmentand performance of medical readiness training forexpeditionary forces

http://www.59mdw.af.mil/

U.S. Army Medical ResearchMateriel Command/MilitaryOperational Medicine Research

1943 Army Psychological health and resilience research is focused on theprevention, treatment, and recovery of soldiers’ and families’behavioral health, which are critical to force health andreadiness. Research is necessary to guide policy and ensureoptimal delivery of behavioral health training and servicesacross the continuum of care and deployment cycle.

https://momrp.amedd.army.mil/

Naval Health Research Center 1959 Navy/MarineCorps

Optimizes the operational health and readiness of our armedforces by conducting research and development to informDoD policy and practice

http://www.med.navy.mil/sites/nhrc/Pages/default.aspx

Uniformed Services University ofHealth Sciences

1972 DoD To educate, train, and prepare uniformed services healthprofessionals, officers, and leaders to directly support theMilitary Health System, the National Security and NationalDefense Strategies of the United States, and the readiness ofour Armed Forces

https://www.usuhs.edu/centers

Center for Study of Traumatic Stress 1987 DoD Develops and carries out research programs to extend ourknowledge of the medical and psychiatric consequences ofwar, deployment, trauma, disaster, and terrorism, includingweapons of mass destruction

http://www.cstsonline.org/

Congressionally Directed MedicalResearch Programs

1992 DoD To transform healthcare for Service Members and theAmerican public through innovative andimpactful research

http://cdmrp.army.mil/

Deployment Health Clinical Center 1994 DoD To advance excellence in psychological healthcare across theMilitary Health System by enhancing care quality,effectiveness, and efficiencies; facilitating the translation ofresearch to practice; and providing leadership, advocacy, andimplementation support

http://www.pdhealth.mil/

Combat Casualty Care ResearchProgram

2001 Army To drive medical innovation through the development ofknowledge and materiel solutions for the acute and earlymanagement of combat-related trauma, includingpoint-of-injury, en route, and facility-based care

https://ccc.amedd.army.mil/Pages/default.aspx

Consortium for Health and MilitaryPerformance

2006 DoD To conduct and translate basic and clinical research in militaryhuman performance, so as to inform the development ofeducational products, clinical products, clinical carepathways, operational guidelines,and health policies

https://www.usuhs.edu/mem/champ

Psychological Health/TraumaticBrain Injury Research Program

2007 DoD Establish, fund, and integrate both individual and multi-agencyresearch efforts that will lead to improved prevention,detection, and treatment of PH/TBI

http://cdmrp.army.mil/phtbi/default.shtml

Center for Rehabilitation SciencesResearch

2011 DoD To advance the rehabilitative care for service members withcombat-related injuries

http://crsr.org/#/















http://cdmrp.army.mil/











http://crsr.org/%23/

Tab

le2

Researchon

frontline

psychiatry/COSCeffectivenessin

preventin

gpsychiatricattrition

Study

War

Sample

Treatmentsettin

g%

RTD

Wiltshire(1916)

WWI

N=150UKsoldierswith

shellshock

GeneralhospitalinFrance

Nodata

Brown(1919)

WWI

N=22

UKsoldierstreatedwith

light

hypnosis

HospitalinFrancewar

zone

70–90%

overall;66%

oftreatm

entsam

plefor

amnesia(n=15)

L’eri(1919)

WWI

N=600French

soldierstreatedin

1916;N

=4000

treated1916–1919

2ndArm

yin

France

91%

100%

Russel(1919)

WWI

N=132Canadiansoldiersadmitted

tospecialty

hospitalinAugust1

917

N=1341

admitted

4monthsin

1917

CanadianStationary

hospitalinFrance

Nodata

Strecker

(1919)

WWI

N=400USmilitary

HospitalinFrancewith

inartillery

range.

4-dayaverage

65–75%

JohnsonandRow

s(1923)

WWI

N=5000

UKsoldiersadmitted

with

shellshock

NYDNCentre5thArm

yin

1917

55%

tocombatu

nits

Dillon

(1939)

WWI

N=4235

UKsoldiers

NYDNCentrefor3rdArm

yat6Statio

nary

Hospitalin1918

64%

CooperandSinclair(1942)

WWII

N=207Australiansoldiers

War

neuroses

clinicin

Tobruk

during

1941

80%

overall

–33%

(n=79)combat

–68%

(n=48)reassigned

GrinkerandSp

iegel(1943)

WWII

N=1720

USmilitary

95th

GeneralHospitalN

orth

Africain

1943

53%

overalln

=909

–Estim

ated

2%RTDcombatd

uty

Bartemeier,K

ubie,

Menninger,R

omano,

andWhitehorn

(1946)

WWII

USArm

yNodataon

samplesize

Battalio

nAideStatio

n-ClearingStatio

n-Sp

ecialty

hospitalo

utof

war

zone

-Generalpsychiatrichospital

50%

50-60%

80%

30%

Hunter(1946)

WWII

N=50

UKsoldiersin

1943

Forwardpsychiatriccenter

inItaly

<4days

30%

RTDto

combatu

nits;6

0%reassigned

Glass

(1947)

WWII

N=393USmilitary

Divisionneuropsychiatricunitduring

Apennines

Cam

paignin

1945

54%

overall

–30%

tocombatu

nits

LudwigandRanson(1947)

WWII

N=346USmilitary

random

lyselected

who

wereRTDto

combatu

nits

Forwardpsychiatriccenters

68%

returned

tocombat

HansonandRanson(1949)

WWII

N=18,255

USmilitary

admitted;

n=10,350

from

combatu

nitsand

n=7905

from

noncom

batu

nits

Mediterraneanhospitalin1945

72%

overall(n=13,175):

–81%

(n=8365)from

combat

–26%

(n=2698)combatd

uty

–55%

(n=5667)lim

itedservice


WWII

N=no

dataon

numbersof

USmilitary

referred

from

divisions

Psychiatrictreatm

entcentersfor5thArm

yItalyand7thArm

yFrance

31%

5thArm

y;24%

7thArm

y

BrillandBeebe

(1952)

WWII

N=955USmilitary:M

=13

months

activ

eduty,M

=4.1monthscombat

Forw

ardpsychiatriccenters(preservice

personality

factorsassessed)

26%

of“normal”personality

;14%

with

neurotic

traits;1

3%suggestiv

eneuroses;1

0%overt

neuroses

Gordon(1967)

Vietnam

N=1000

USmilitary

1stInfantryDivisionforw

ardpsychiatry

unit

in1967

98%

(n=976):

–91%

(n=908)

tounits

–7%

(n=68)reassigned

Allerton

(1969)

Vietnam

USArm

yNostatsreported;sum

maryof

field

reports

Arm

ydivision

psychiatry,field,and

evacuatio

nhospitals

95%

1965–1966;

97–98%

1967–1968

Strange(1969)

Vietnam

N=USmilitary

nostatistic

reported;

NavyhospitalshipoffVietnam

in1966

62%

diagnosedwith

psychiatricdiagnosis


Tab

le2

(contin

ued)

Study

War

Sample

Treatmentsettin

g%

RTD

70%

Marine

30%

Navy

78%

combatexhaustioncases

Noy

etal.(1984)

1982

Lebanon

N=no

datareported

onnumberof

Israelisoldiers

Forwardtreatm

entcom

paredto

rearward

treatm

entinIsrael

60%

RTDto

combatu

nitsfrom

forw

ard

treatm

ent

40%

RTDfrom

rearwardhospital

Holsenbeck(1996)

GulfWar

N=514USmilitary

Arm

yPsychForce

90528thMedicalCSC

in1990–1991

96%

overall(n=496)

–24%

admitted

(n=124)

–85%

ofthoseadmitted

(n=106)

Ruck(1996)

GulfWar

N=108USmilitary

18thAirborneCorps

OM

Team

in1990–1991

96%

(n=104)

–64%

n=7of

11admitted

tobase

hospital

JonesandPalm

er(2000)

Korea

N=483Canadiansoldiers

25CanadianFieldDressingStationin

Korea

50%

RTD

Ritchie(2002)

Korea

N=USmilitary;n

odatareported;

summaryof

fieldreports

Forw

ardtreatm

entinKorea

1951–1953

50–60%

(1950);9

0%(1951);6

5–90%

(1952–1953)

Study

War

%Relapse

%Evacuated

outside

thewar

zone

Psychiatrictreatm

ent

outcom

esafterevacuatio

nPo

stdeployment/long-term

outcom

esLim

itatio

ns

Wiltshire(1916)

WWI

27%

(n=41)

Nodata

Nodata

Nodata

Nocontrols

Smallsam

ple

Noobjectivemeasures

Nofollo

w-up

Brown(1919)

WWI

0.04%

(n=1)

0.04%

(n=1)

Nodata

Nodata

Missing

outcom

edataon

6of

22soldierstreatedforam

nesiaon

frontline

Smallsam

ple

Nomeasures

L’eri(1919)

WWI

Nodata

Nodata

Nodata

Nodata

Noobjectivemeasures

Nooutcom

edataotherthan

RTD

Nocontrols

Russel(1919)

WWI

73%

RTD(n=96)

–85%

shellshock

–57%

neurasthenia

27%

tobase

(n=36)

79%

RTD(n=938)

21%

(n=235)–base

10–15%

overall

evacuatedto

England

Nodata

N=39

psychogenetic

disability;M=15

months

hospitaladm

ission

prior

todischargeand

disabilitypension

Noobjectivemeasures

Smallsam

ple

Strecker

(1919)

WWI

4%Nodata

Nodata

Nodata

Noobjectivemeasures;statistical

recordslost;biasedselfreportrecall

Nofollo

w-up

JohnsonandRow

s(1923)

WWI

Nodata

Nodata

Nodata

Nodata

Noobjectivemeasures

Nooutcom

edataotherthan

RTD

Nocontrols

Dillon

(1939)

WWI

Nodata

Nodata

Nodata

Nodata

Nocontrols

Noobjectivemeasures

Nooutcom

edataotherthan

RTD


Tab

le2

(contin

ued)

Study

War

%Relapse

%Evacuated

outside

thewar

zone

Psychiatrictreatm

ent

outcom

esafterevacuatio

nPo


outcom

esLim

itatio

ns

CooperandSinclair(1942)

WWII

Nodata

23%

(n=48)

evacuatedto

base

Nodata

Nodata

Noobjectivemeasures

Noclinicaloutcom

esNofollo

w-up

GrinkerandSp

iegel(1943)

WWII

Nodata

26%

(n=450)

Nodata

Nodata

Noobjectivemeasures

Nocontrol

Nofollo

w-up

Bartemeier,K

ubie,

Menninger,R

omano,

andWhitehorn

(1946)

WWII

Nodata

5%overall

Nodata

Nodata

Nostatisticalreporting;

noobjective

measures

Nooutcom

edataotherthan

RTD

Nofollo

wup

Hunter(1946)

WWII

Nodata

<10%

Nodata

Nodata

Noobjectivemeasures

Smallsam

ple

Nofollo

w-up

Glass

(1947)

WWII

2/3ofthoserelapsingviaother

routes

(e.g.,disease,injury

ormilitary

offense)

46%

Nodata

Nodata

Nocontrols

Noobjectivemeasures

Nooutcom

edataotherthan

RTD


WWII

24%

(n=51)relapsed

aspsychiatricpatients

9.7%

(n=21)

38.6%

ofRTDperformed

well

incombat;12%

legal

misconduct;2%

KIA

;9%

WIA

;11%

reassigned

indivision;.9%

self-inflicted

wound

Nodata

Reliedon

self-report

Noobjectivemeasures

Nofollo

w-up

HansonandRanson(1949)

WWII

Nodata

28%

overall

(n=5801):

–19%

(n=1986)

combatu

nits

–39%

(n=3095)

noncom

batu

nits

Nodata

Nodata

Noobjectivemeasures

Noclinicaloutcom

esNocontrolg

roup

Nofollo

w-up


WWII

13%

5thArm

y;28%

7th

Arm

yNodata

Nodata

Nodata

Nostatisticalreporting

Noobjectivemeasures

Nooutcom

edataotherthan

RTD

BrillandBeebe

(1952)

WWII

38.5%

“normal”admitted

afterbreakdow

n;57.5%

“neurotic”;51%

“suggestive”

neuroses;

69.6%

overtn

euroses

21%

of“normal”

personality

types

Nodata

5-year

follo

w-upafter

military

treatm

ent;7%

unem

ployment;38.5%

military

dischargeafter

firsth

ospitalization;

57.5%

“neurotic”;51%

“suggestiveneuroses”;

69.6%

overtn

euroses

Selectio

nbias

insample

Retrospectiv

eassessmento

fpreservice

personality

Noclinicaloutcom

es

Gordon(1967)

Vietnam

Nodata

2.4%

(n=24)

Nodata

Nodata

Noobjectivemeasures

Noclinicaloutcom

esNofollo

w-up

Allerton

(1969)

Vietnam

Nodata

5%1965–1966;

2–3%

1967–1968

Nodata

Nodata


Noobjectivemeasures


Tab

le2

(contin

ued)

Study

War

%Relapse

%Evacuated

outside

thewar

zone

Psychiatrictreatm

ent

outcom

esafterevacuatio

nPo


outcom

esLim

itatio

ns

Nooutcom

edataotherthan

RTD

Strange(1969)

Vietnam

Nodata

38%

outo

ftheater

hospital

Nodata

Nodata


Noobjectivemeasures

Nooutcom

edataotherthan

RTD

Nonrandom

allocatio

nNoy

etal.(1984)

1982

Lebanon

Nodata

40%

evacuatedto

rearwardtreatm

ent

inIsrael

40%

tocombatu

nits

Nodata


Noobjectivemeasures

Nooutcom

edataotherthan

RTD

Nonrandom

allocatio

nNofollo

w-upundertaken

toinvestigaterelapses;p

atientsnot

categorizedby

military

role

Holsenbeck(1996)

GulfWar

Nodata

3.5%

(n=18)of

soldiersadmitted

Nodata

Nodata

Noobjectivemeasures

Nooutcom

edataotherthan

RTD

Ruck(1996)

GulfWar

Nodata

3.7%

(n=4)

Nodata

Nodata

Noobjectivemeasures

Nooutcom

edataotherthan

RTD

JonesandPalm

er(2000)

Korea

Nodata

30%

evacuatedto

Japan

Nodata

Nodata

Nocontrols

Noobjectivemeasures

Nooutcom

edataotherthan

RTD

Ritchie(2002)

Korea

5–10%

estim

ated

“repeaters”

1951–1953

n=1800

toJapanin

1950

before

frontline

psychiatry

Nodata

Nodata


Noobjectivemeasures

Nooutcom

edataotherthan

RTD


evacuations, thereby achieving the stated goal of avoidingevacuation syndromes. Table 4 summarizes contemporarystudies on psychiatric evacuations and shows that about only7–10% of all evacuations from war zones in Afghanistan andIraq are due to psychiatric reasons. The primary focus of themilitary’s evacuation research is extensively concerned withadministrative disposition, like categorical designation andRTD rates, as opposed to clinical outcomes.

For example, Rundell’s (2006) retrospective analysis of12,480 US military personnel medically evacuated toLandstuhl Germany out of Iraq and Afghanistan theaters, be-tween November 4, 2001, and July 30, 2004, revealed that1264 or 10% of evacuations were for psychiatric conditions.The most frequent psychiatric diagnostic categories were ad-justment disorders (34%), mood disorders (22%), personalitydisorders (16%), anxiety disorders (15%), no diagnosis(16%), and psychotic disorders (6%; Rundell, 2006). Afterpsychiatric hospitalization at Landstuhl, most patients (81%)were sent back to their home stations for outpatient mentalhealth treatment and 14% were transferred to other inpatientpsychiatric settings. The long-term clinical and administrative(i.e., military discharge or retention) rates are unreported(Rundell, 2006). The author emphasized that only 5% of psy-chiatric evacuees were RTD to frontline units after treatmentat Landstuhl (Rundell, 2006). No information on treatment orclinical outcomes is reported (Rundell, 2006). However,Rundell (2006) does offer possible explanations about why ameager 5% of war-stressed personnel were returned to the warzone. He noted that the assumption is that the service memberalready had Bsignificant mental health intervention^ (p. 355).He added that without providing data, evacuated service mem-bers start to Breconstitute^ in a manner preventing Bassimila-tion^ into the war theater (p. 355). In conclusion, Rundell(2006) opined, BAs in prior wars, it appears that rapid recon-stitution of psychiatric patients must be accomplished as nearto the area of operations as possible to facilitate a reasonablechance of return to combat or combat support duty^ (p. 355).The assumption is that RTD is an empirically informed mea-sure for favorable long-term clinical prognosis, while psychi-atric evacuation is generally therapeutically harmful.However, none of the studies in Table 4 describe long-termclinical outcomes of war zone psychiatric evacuees or offerany comparison with counterparts RTD via frontlinepsychiatry.

Likewise, Cohen et al. (2010) analyzed the medical reasonsand RTD rates of 34,006 US military personnel evacuated outof OIF/OEF war zones to Landsthul Germany from January2004 to December 2007. Most common categories for medi-cal evacuation were musculoskeletal and connective tissuedisorders (n = 8104 service members, 24% of total evacua-tions), combat injuries (n = 4713, 14%), neurological disor-ders (n = 3502, 10%), psychiatric diagnoses (n = 3108, 9%),and spinal pain (n = 2445, 7%; Cohen et al., 2010). The factors

most strongly associated with RTD were being a senior offi-cer, having a nonbattle-related injury or disease, and present-ing with chest or abdominal pain, a gastrointestinal disorder,or a genitourinary disorder (Cohen et al., 2010). Conversely,decreased probability of RTD was related to serving in theNavy, Coast Guard, or Marines and presenting with a combatinjury, a psychiatric disorder, musculoskeletal or connectivetissue disorder, spinal pain, or other medical wounds (Cohenet al., 2010). Nearly all (96%) of service members evacuatedfor a physical battle injury were not RTD (Cohen et al., 2010).According to Cohen et al. (2010), 9% of military personnelevacuated for psychiatric reasons were RTD to war zones,including 31 combatants previously diagnosed with TBI, 72with stress reactions, 13 with substance abuse, 67 with depres-sion or bipolar disorder, and 88 with another type of mentaldisorder. No treatment data, clinical outcomes, or long-termfollow-up were reported for either the 271 psychiatric evac-uees RTD or the 2837 service members transported to state-side treatment facilities.

Anecdotal Validation of Frontline PIE/BICEPSPrinciples

Historical overviews of managing war stress in the military’sofficial policy instructions (e.g., DOA, 2006) and medicaltextbooks (e.g., Jones, 1995a), universally refer to repeatedvalidation of frontline psychiatry principles through the unin-tended consequences of failure to learn from past war traumalessons by neglecting frontline psychiatry (e.g., Jones, 1995a;p. 16). Wartime mental health crises in the form of massivepsychiatric attrition via evacuation syndromes are regularlyattributed by the military to its initial failure in implementingfrontline psychiatry PIE (proximity, immediacy, and expec-tancy)/BICEP principles at the outset of WWI (e.g., Salmon& Fenton, 1929), WWII (e.g., Glass, 1966), Korean War(e.g., Jones, 1995a), and the 1973 Arab-Israeli Wars (e.g.,Belenky, Tyner, & Sodetz, 1983). In each periodic war, themilitary reports eventually rediscovering the validity of front-line psychiatry as confirmed by dramatic improvements inRTD rates and significant reduction in psychiatric evacuations(e.g., Belenky et al., 1983; Ritchie, 2002). For instance, duringthe Korean War, after initially evacuating 100% of war stresscasualties, frontline psychiatry was reinstituted to prevent fur-ther psychiatric attrition (Jones, 1995a, p. 16). Consequently,validation of the frontline psychiatry doctrine is reported interms of military-related versus individual clinical outcomesas in the following: BPsychiatric casualties accounted for onlyabout 5% of medical out-of-country evacuations, and some ofthese (treated in Japan) were returned to the combat zone^(Jones, 1995a, p. 16).

In sum, conclusions about the efficacy of frontline psychi-atry is in the research conducted to date mostly from the


perspective of the logistical benefits to the military and itsdesired outcome of preserving the fighting force by avoidingpsychiatric attrition (i.e., RTD). To that end, there is sufficientevidence that the military profits from frontline psychiatry. Atthe same time, none of the studies reviewed thus far remotelyaddresses questions around the health and well-being of de-ployed service members experiencing war stress injury or oth-er behavioral health disorder, who are compelled by a RTDpolicy to endure repeated war stress exposure.

Does Frontline Psychiatry Enhance the Well-Beingof Deployed Personnel and Families?

Recent arguments used to justify the military’s frontline psy-chiatry policy center around the premise that preventing psy-chiatric attrition via RTD maintains protective factors (seeRussell & Figley, 2016). Conversely, the military posits thatresearch has allegedly shown poorer administrative and clin-ical outcomes for service members psychiatrically evacuatedand treated outside the war zone (Martin & Cline, 1996, p.164). However, is there empirical support for proof of themilitary’s assertions of the health-promoting benefits fromits frontline psychiatry policies?

Direct Empirical Evidence of Frontline Psychiatry’sHealth Benefit

Table 5 contains the results from an exhaustive search of acentury-old body of frontline psychiatry literature. Inclusioncriteria for the research were related to any investigation com-paring any immediate and/or long-term outcomes (other thanRTD) of deployed personnel RTD via frontline psychiatryversus those evacuated and treated outside the war zone.Results of our search yielded only three small retrospectivestudies by the IDF comparing clinical outcomes (PTSD rates)between groups of combat veterans RTD versus those evacu-ated to Israeli hospitals during the 1982 Lebanon War. Moreaccurately, the three IDF publications represent a single lon-gitudinal study starting with the initial report (Solomon &Benbenishty, 1986) and a follow-up analyses at 1 year(Solomon, Weisenberg, Schwarzwald, & Mikulincer, 1987)and at 20 years (Solomon, Shklar, & Mikulincer, 2005).

The IDF research provides the only direct assessment of themilitary’s health benefit claims, thereby constituting the onlyknown empirical foundation for the DoD’s frontline mentalhealth policies. However, that research was conducted in acountry with a military draft and with the vital role of themilitary in the culture of the country acknowledged. In thissense, generalizations from that research to the contemporaryAmerican context must be made with caution.

IDF Research on Longitudinal Effectsfrom Frontline Psychiatry

Solomon and Benbenishty’s (1986) paper reported the RTDand PTSD rates of an unspecified number of Israeli soldierstreated for CSR 1 year after the 1982 LebanonWar (the resultsincluded only relevant percentages). The sample was dividedinto three groups: (a) veterans treated within the war zone viafrontline PIE interventions, (b) veterans evacuated and treatedat general hospitals in Israel, and (c) veterans seeking mentalhealth treatment after the war. Results indicated that beingdiagnosed with CSR was significantly related to developingPTSD regardless of treatment group. In other words, there wasno overall significant difference in clinical outcomes betweenveterans treated by frontline PIE programs or the other condi-tions. However, veterans receiving frontline psychiatry werereported to have significantly lower PTSD rates than evacuees(Solomon & Benbenishty, 1986). This finding appears to lenddirect support for the military’s health benefit claims.

However, aside from the methodological issue of unreport-ed Ns, evacuated veterans with CSR were sent to generalcivilian hospitals and not to specialized military treatment fa-cilities, and no details of treatment are provided. Therefore, itis impossible to know if higher PTSD rates in evacuees rep-resent a by-product of inadequate hospital treatment or actualevidence of the psychiatric harm caused by evacuation.Moreover, as the authors rightly point out, major methodolog-ical flaws seriously limit the weight attributed to the researchfindings aside from the obvious limitations of relying upon 1-year retrospective self-reports and nonrandomized treatmentgroup assignment. For instance, the researchers were unable toassess CSR severity levels at the time of triage leading todecisions regarding evacuation (Solomon & Benbenishty,1986). Consequently, in this study, it is entirely possible thatevacuated veterans represented a more impaired group thanthose RTD.

Reported Dose-Response Benefit from FrontlinePsychiatry PIE Principles

In Solomon and Benbenishty (1986), an effort was made toempirical test the validity of core tenets of frontline psychia-try: veterans RTD via frontline psychiatry were asked to ret-rospectively report how many of the frontline PIE principlesthey received 1 year prior. The authors found no statisticallysignificant benefit in the number of PIE principles applied, butreported a modest cumulative trend whereby lower PTSDrates were associated with more PIE principles applied. Forexample, 71% of soldiers RTD who received no PIE-relatedintervention developed PTSD within 1 year after the war, incontrast to a 40% PTSD rate if veterans RTD received all threeprinciples (Solomon & Benbenishty, 1986).


Tab

le3

Frontline

psychiatry

workloadandoutcom

edataduring

Afghanistan

andIraq

wars

Source

Deploym

ent

Totaln

umbers

receivingCOSC

/BH

Num

ber(%

)of

RTDin

war

zone

Num

ber(%

)of

relapsein

war

zone

Num

ber(%

)of

psychiatric

evacuatio

nsouto

fwar

zone

Num

ber(%

)receivingBH

treatm

entinwar

zone

Deploym

ent

outcom

esafterBH

treatm

entinwar

zone

Postdeployment

outcom

esof

personnel

RTDviafrontline

psychiatry

Postdeployment

outcom

esfor

personnelevacuated

forpsychiatric

condition

MHAT-I

(2003)

Iraq

2002–2003

3312

USmilitary

2643

(80–97%)

Nodata

n=669(20%

)n=440(13%

)excluding

Kuw

ait

Nodata

Nodata

Nodata

RTD36

of508(7%)

Nootheroutcom

edata

MHAT-II

(2005)

Iraq

Nodata

USmilitary

Nodata(80–100%

)Nodata

Nodata

Nodata

Nodata

Nodata

Nodata

Scott(2005)

Iraq

170UKsoldiers

receivingPIE

atFM

HTField

Hospital

N=123(72%

)–n=109adjustment

disorder

–n=8somatoform

disorder

–n=1generalized

anxiety

–n=1harm

ful

alcoholu

se–n=2delirium

–n=1phobia

–n=1PT

SD

N=3

N=47

(28%

)–n=23

major

depression

–n=7intentional

self-harm

–n=7adjustment

disorder

–n=4generalized

anxiety

–n=2harm

ful

alcoholu

se–n=1phobia

–n=1PT

SD–n=1dissociatio

n–n=1hypomania

Nodata

Nodata

Nodata

Nodata

Hung(2008)

Iraq

First6

months

of2008

N=49,770

Retrospectiv

ereview

ofdisposition

via

COSC

Workload

andActivity

Reportin

gSy

stem

(COSC

-WARS)

Overall,

99%

RTD

90.8%

(n=45,100)

RTDwithout

limitatio

ns;4

.4%

(n=2185)RTD

with

limitatio

ns;

3.4%

(n=1700)

“rest”(senttoa

nonm

edical

supportu

nit,

typically

farther

from

the

frontlines);0

.91%

(n=450)

“referred”

toa

higher

levelo

fmedicalcare

intheater

Nodata

n=335(0.67%

)n=5871

Psychiatric

diagnoses:

Depression

(n=1389)

Anxiety

(n=928)

Nicotineproblem

(n=1002)

ASD

/PTSD

(n=720)

Substance

abuse

(n=192)

Other

problem

(n=1640)

99.3%

Nodataon

relapseor

clinicaloutcom

es

Nodata

Nodata

Potter,Baker,

Sanders,

and

Peterson

(2009)

Iraq

War

N=57

USmilitary

personnelreferred

toa2-day

restorationcenter

inIraq

100%

RTDfor

(nodata)

treatm

ent

completers;67%

Nodata

Nodata

Nodata

Nodata

Nodata

Lackrandom

assignment;no

controls;selectio

nbias;h

igh

noncom

pleterrate


Tab

le3

(contin

ued)

Source

Deploym

ent

Totaln

umbers

receivingCOSC

/BH

Num

ber(%

)of

RTDin

war

zone

Num

ber(%

)of

relapsein

war

zone

Num

ber(%

)of

psychiatric

evacuatio

nsouto

fwar

zone

Num

ber(%

)receivingBH

treatm

entinwar

zone

Deploym

ent

outcom

esafterBH

treatm

entinwar

zone

Postdeployment

outcom

esof

personnel

RTDviafrontline

psychiatry

Postdeployment

outcom

esfor

personnelevacuated

forpsychiatric

condition

N=38

(67%

)completed

the

2-dayprogram

N=19

didnot

completeeither

RTDearly,

medically

evacuated,or

required

extended

treatm

ent

RTDfortotal

sample

Nopostdeployment

outcom

edata

beyond

RTD

status

Nocomparisonof

RTDvs.

evacuationgroup

Ogle,Bradley,

Santiago,

and

Reynolds

(2012)

Afghanistan

12months

deploy

toRegional

Com

mand

East

16,000

USmilitary

individual

appointm

entsfor

COSC

and/or

BH

Nodata(99.2%

)Nodata

(0.8%)

About

9560

individual

appointm

ents

forBH

Nodata

Nodataforpersonnel

receivingCOSC

/BH

during

deployment

Nodata

Hoytetal.

(2015)

Afghanistan

9months

deploy

with

4000

mem

ber

Arm

yStryker

Brigade

Com

bat

Team

Nodata

467(97%

)—BH

only

Nodata

46(8%)

513(13%

)97%—RTD

Nodataforpersonnel

receivingCOSC

/BH

during

deployment

719of

3284

(21%

)brigademem

bers

screened

before

returninghomeas

moderatetohigh

risk

364sought

BHcare

ingarrison

and19

admitted

psychiatric

hospitalizations—no

outcom

edata

158referred

toBHafter

positivescreeningon

90–180-day

reassessment

Nodata


However, caution is warranted in drawing conclusionsabout the efficacy of PIE principles in this research. Perhapsmost importantly, the reported trend, while generally lendingpositive support for frontline psychiatry, did not reach statis-tical significance. More than half (52%) of those RTD viafrontline psychiatry developed PTSD within a year as com-pared to 66% of soldiers evacuated to a general, nonmilitaryhospital (Solomon & Benbenishty, 1986). With regard to theprinciple of expectancy of RTD, there was no statisticallysignificant difference of PTSD rates, in that 55% to 62% ofsoldiers RTD were eventually diagnosed with PTSD(Solomon & Benbenishty, 1986). Moreover, the type andquality of hospitalized psychiatric treatment of evacuees wasnot reported, thereby limiting any conclusion about the com-parative benefit from frontline interventions and evacuees.Regardless of the study’s lack of rigor, the initial IDF findingsprovide at least tacit, provisional support for frontlinepsychiatry’s purported health benefits that would have benefit-ed had the US military conducted further research.

1987 IDF Research of Frontline Psychiatry’s HealthBenefits

The second IDF study compared outcomes from both front-line psychiatry and psychiatric evacuations and involved atotal of 470 Israeli veterans 1 year after the 1982 LebanonWar (Solomon, Weisenberg, Schwarzwald, et al., 1987). PerTable 5, 155 combat veterans who received frontline PIE treat-ment for CSR were compared to 315 veterans evacuated torear hospitals for treatment of CSR, matched to a controlgroup of 334 veterans without a diagnosed CSR (Solomon,Weisenberg, Schwarzwald, et al., 1987). Results indicated thatthere were no significant differences in clinical outcomes be-tween groups of veterans with CSR, whether treated at thefrontline or in rear hospitals. In other words, experiencingCSR significantly increased a veteran’s risk of subsequentPTSD diagnosis regardless of treatment setting. Specifically,59% (n = 255) of soldiers in the two CSR groups (frontlinepsychiatry and evacuees), as well as 16% (n = 53) of veteransin the control group, went on to develop PTSD within a yearafter the war. Identical scientific limitations exist in this studyas found in the previous IDF study, which prohibits any firmconclusions regarding frontline psychiatry efficacy.

2005 IDF 20-Year Follow-Up on Long-Term HealthBenefits from Frontline Psychiatry

The last published report on the purported health benefits fromfrontline psychiatry is a 20-year retrospective reanalysis of theprevious IDF studies (Solomon et al., 2005). Solomon et al.(2005) compared 79 veterans diagnosed with CSR who wereRTD after receiving frontline intervention with 156 veteranswith CSR who were evacuated and treated at rear hospitals,

matched to 196 veterans with no documented history of CSRin the war zone (Solomon et al., 2005). Veterans RTD viafrontline psychiatry were also asked to retrospectively recallwhether the frontline treatment they received included the PIEprinciples, replicating the authors’ 1986 study (Solomon &Benbenishty, 1986). In addition, veterans were asked to retro-spectively recall whether they felt recovered from their CSRprior to being RTD (Solomon et al., 2005). Results of theanalysis comparing veterans RTD after frontline psychiatryversus those evacuated revealed no significant differenceswith regard to PTSD diagnosis, that is, in the two targetgroups, 30% (frontline psychiatry) and 41% (evacuated) ofveterans were later diagnosed with PTSD, which are percent-ages that are significantly higher than the one for the controlgroup (Solomon et al., 2005). Interestingly, 14% of veterans inthe control group also developed PTSD (Solomon et al.,2005). Secondary analysis indicated that veterans in the front-line treatment group reported significantly more intrusion andhyperarousal symptoms than those who had been evacuated.However, there were no significant differences between front-line psychiatry and rear echelon treatment on a diverse rangeof outcomes, including avoidance symptoms, global symp-toms of distress, loneliness, perceived social support, interper-sonal functioning, and occupational functioning (Solomonet al., 2005). In their retrospective analysis of PIE principles,Solomon et al. (2005) concluded the presence of a nonsignif-icant, modest dose-response relationship between lower ratesof PTSD diagnosis and the number of PIE principles applied(Solomon & Benbenishty, 1986). For instance, a 25% PTSDrate was found when all three PIE principles were appliedcompared to 32.6% with two principles, 38.5% one principle,and 49.7% with no principles (Solomon et al., 2005). CSRcasualties who felt their RTD was premature reported 50%more PTSD symptoms than those RTD after feeling complete-ly recovered (Solomon et al., 2005). However, the researchersreiterated that the serious methodological flaws mentionedearlier prohibited any causal inferences associated with RTDand evacuation status. Furthermore, the cultural differences inthe Israeli and American military context limit generaliza-tions, as indicated.

Summary of Direct Empirical Testing of FrontlinePsychiatry Health Benefits

Despite the limitations of the IDF research for the contempo-rary American context, some implications can be consideredbecause, although methodologically flawed, the IDF researchoffers the only direct assessment of frontline psychiatry’s cen-tral tenets. In that research, a modest but nonsignificant trendwas replicated, whereby lower PTSD rates were linearly asso-ciated with the number of applied PIE principles, giving ten-tative support for frontline interventions (e.g., Solomon et al.,2005). However, two of three of the IDF’s head-to-head


Tab

le4

Current

research

ofmedicalevacuatio

nsfrom

Afghanistan

andIraq

war

zones

Study

Sampleof

medicalevacuatio

nsNum

berof

(%)

psychiatric

evacuatio

ns

Primary

psychiatric

diagnosis

Num

ber

(%)

receiving

frontline

COSC/BH

Num

ber

(%)of

relapse

after

initial

RTD

Num

ber(%

)with

know

npsychiatric

diagnosisbefore

deployment

Num

ber

(%)on

>1

deployment

Num

ber(%

)receiving

definitiv

eMH

treatm

entafter

evacuatio

n

Adm

inistrative

disposition

(e.g.,

RTD,retentio

nin

military,ormilitary

discharge)

Harman,

Hooper,and

Gackstetter

(2005)

N=11,183

USmilitary

evacuated

outo

fIraq

in2003

n=769(7%)

Nodata

Nodata

Nodata

Nodata

Nodata

Nodata

Stetz, McD

onald,

Lukey,and

Gifford

(2005)

N=12,480

USmilitary

evacuatedfrom

Iraq

andAfghanistan

n=386(7%)

73(19%

)with

psychotic

disorders

and242(63%

)with

nonpsychoticdisorders

Sixty

N=60

patients(15%

)had

DSM

-IVV-codes

orhadadeferred

diagnosispending

furtherevaluatio

n;suicidalideatio

nsand

self-injurious

behaviorsaccounted

forabout3

%of

the

cases

Nodata

Nodata

Nodata

Nodata

Nodata

Nodata

Turneretal.

(2005)

N=2009

UKmilitary

evacuatedto

UKfrom

Iraq

in2003

n=178(9%)

n=117admitted

toUKhospital

91(78%

)depression

14(12%

)anxiety

4(3%)somatic

2(2%)delusion

Nodata

48% (n

=8-

5)

37%

prior

contactw

ithmentalh

ealth

Nodata

Nodata

M=1.4days

stay

inhospital

34%

RTDn=61

Noclinical

outcom

es

Rundell(2006)

N=12,480

USmilitary

evacuated

toLandstuhl

Arm

yMedical

Centerin

Germanyfrom

OIF/OEFbetweenNovem

ber4,

2001,toJuly

30,2004

n=1264

(10%

)49%

evacuatedduring

thefirst3

months

ofdeployment,

33%

during

the

second

3months

Adjustm

entd

isorders

(34%

)Mooddisorders(22%

)Personalitydisorders

(16%

)Anxiety

disorders(15%

)ASD

(36%

)PTSD

(29%

)Psychotic

(6%)

Bipolar

disorder

(4%)or

substanceabuse

disorder

(5%)

Nodata

Nodata

Nodata

Nodata

81%

evacuated

back

tothe

USAfor

outpatient

follo

w-up

14%

evacuated

toinpatient

5%RTDto

frontline

units

Noclinical

outcom

esor

long-term

data

Peterson,B

aker,

and

McC

arthy

(2008)

Nodata

Contin

gencyAerom

edicalStaging

Facility(CASF

)atBalad

Air

Base,Iraq

Deploym

ent

N=262

52%

depressive

disorders;23%

anxiety

disorders;5%

personality

disorders;

20%

other

Nodata

Nodata

Nodata

Nodata

Nodata

Nodata


Tab

le4

(contin

ued)

Study

Sampleof

medicalevacuatio

nsNum

berof

(%)

psychiatric

evacuatio

ns

Prim

ary

psychiatric

diagnosis

Num

ber

(%)

receiving

frontline

COSC/BH

Num

ber

(%)of

relapse

after

initial

RTD

Num

ber(%

)with

know

npsychiatric

diagnosisbefore

deployment

Num

ber

(%)on

>1

deployment

Num

ber(%

)receiving

definitiv

eMH

treatm

entafter

evacuatio

n

Adm

inistrative

disposition

(e.g.,

RTD,retentio

nin

military,ormilitary

discharge)

2004

and2006

In2004,only7%

classified

asmoderatelyto

severely

ill(cat.1B);88%

categorizedas

moderately

ill(category1C

)In

2006,50%

classified

asmoderatelyto

severely

illpatients(1B);39%

asmoderatelyill

(1C)

Cohen

etal.

(2010)

N=34,046

USmilitary

medically

evacuatedouto

fOEF/OIF

January2004–D

ecem

ber2007

n=3108

(9%)

Traum

aticbraininjury

(TBI;n=218)

Substanceabuse(SA;

n=98)

Stress

reactio

ns(n=803)

Depressionor

bipolar

disorder

(n=1045)

Other

(n=814)

Nodata

Nodata

Nodata

Nodata

Nodata

RTDN=271

TBIn=31

(14%

)SAn=13

(13%

)Stress

reactio

nn=72

(9%)

Depressionor

bipolarn=67

(6%)

Other

n=88

(11%

)Noclinical

outcom

esor

long-term

data

Hauret,Taylor,

Clemmons,

Block,and

Jones(2010)

N=31,728

USmilitary

evacuated

outo

fIraq

andAfghanistan

2001–2006

(7%)

n=6 8

TBI

Nootherpsychiatric

diagnosesreported

Nodata

Nodata

Nodata

Nodata

Nodata

Nodata


comparisons between personnel RTD versus evacuationfound no significant differences in the primary clinical out-come measured (PTSD rates; Solomon, Weisenberg,Schwarzwald, et al., 1987; Solomon et al., 2005). In fact, thedominant statistical finding is that experiencing CSR by itselfis a far greater predictor of subsequent harm irrespective oftreatment setting (e.g., Solomon, Weisenberg, Schwarzwald,et al., 1987; Solomon et al., 2005).

Nevertheless, caution in interpreting the IDF’s findings iswarranted especially with regard to comparing outcomes ofevacuated veterans. For example, the military’s stated purposeof psychiatric triage is to determine whether combatants cansafely be retained in war zones with an expectancy of eventualRTD (e.g., DOA, 2006). If combatants are exhibiting signs ofsevere CSR and impairment, they will most likely be evacu-ated per military policy (e.g., DOA, 2006). Logically speak-ing, it is most likely that the groups of evacuated veterans inthe three IDF studies generally represent more severe casesthan those RTD. Although the relationship of CSR severityand PTSD was not evaluated in the aforementioned IDF stud-ies, subsequent investigations report significant association(e.g., Solomon, Benbenishti, & Mikulincer, 1988).Moreover, the nature and quality of hospitalized psychiatrictreatment IDF evacuees received is highly questionable sincesome hospitals were general or civilian in nature and not spe-cialized in treating war stress injury (e.g., Solomon &Benbenishty, 1986). Considering these factors alone, IDF re-ports of essentially equivalent treatment outcomes for evacueeand RTD groups (e.g., Solomon, Weisenberg, Schwarzwald,et al., 1987; Solomon et al., 2005) remain essentially unsup-ported and not indicative of the claimed value of frontlinepsychiatry’s health benefits.

Needed Replication of the IDF Studies in the Twenty-FirstCentury

The PIE/BICEPS principles of modern-day frontline psychia-try are relatively unchanged from WWI or WWII (e.g.,Russell & Figley, 2016). Today, the US military expects95% RTD from its frontline psychiatric policies (see Russell& Figley, 2016). Therefore, we should reasonably not expectsignificant differences in positive clinical outcomes for vet-erans RTD, consistent with the research on the IDF (e.g.,Solomon et al., 2005). However, if twenty-first century vet-erans will be evacuated to specialized centers delivering high-quality, evidence-based treatments (e.g., Department ofVeterans Affairs & Department of Defense, 2010) as opposedto the intervention technology of 1982, we should reasonablyexpect to see notable improvements from the IDF’s baselineoutcome data on evacuees, which may even eclipse that offrontline psychiatry. Better controlled research is direly need-ed on these types of questions.

Partial Evidence of Frontline Psychiatry’s HealthBenefits

The past century of frontline psychiatry has produced a highvolume of case studies, retrospective record reviews, fieldreports, and medical bulletins that offer a partial, albeit incom-plete assessment of its central tenets. Usually, the focus in thematerial is on one aspect or another (e.g., measuring outcomesof personnel RTD, but not evacuees, and vice versa). Thesefractional studies can be divided into five general lines ofinquiry: (a) outcomes of deployed personnel with CSR receiv-ing frontline intervention versus veterans without CSR (seeTable 6); (b) outcomes of deployed personnel receiving front-line psychiatry only (see Table 7); (c) outcomes of deployedpersonnel receiving a supplemental component of frontlinepsychiatry, such as resilience training (see Table 8); (d) out-comes of deployed personnel receiving BH treatment for psy-chiatric conditions in addition to PIE/BICEP interventions(see Table 8); and (d) outcomes of only deployed personnelevacuated and treated outside war zones (see Table 9). Thetables provide only a sampling of a vast literature. Importantly,all the studies reviewed, whether included or not included inthe tables, share major methodological limitations that prohib-it their utility in answering basic questions: BDo deployedpersonnel RTD via frontline psychiatry enjoy better long-term outcomes than those evacuated?^ In short, they criticallyomit necessary comparison groups and rarely provide long-term outcomes. Nevertheless, if the military’s claims of indi-vidual health benefit are generally accurate, we would expectpositive trends across most if not all five lines of investigation.In the following, we review the source material for all fiveareas to ascertain how effective is contemporary frontline psy-chiatry in the war zone with respect to outcome.

1. Outcome Research on CSR and Frontline Psychiatry

The IDF has taken the clear lead among world militarypowers in investigating the effects of CSR and frontline psy-chiatry. The clear majority of IDF studies depicted in Table 6compare a wide array of long-term outcomes of veterans treat-ed for CSR via frontline psychiatry matched with a controlgroup of veterans not diagnosed with CSR and thus not treatedby frontline psychiatry. It bears mentioning that several stud-ies in Table 6 provide unclear descriptions as to whether vet-erans referred to frontline interventions after CSR diagnosesmeans they received frontline psychiatry (e.g., Solomon &Mikulincer, 1992). Other IDF studies clearly specify that re-ferred CSR groups received frontline psychiatry services (e.g.,Solomon et al., 2005). Given the continuity in IDF researchersand methodology, it is reasonable to assume that referral andreceipt of frontline psychiatry are one in the same. Per Table 6,outcomes measured by the IDF include risk of immediate anddelayed onset of PTSD (e.g., Horesh, Solomon, Zerach, &


Tab

le5

Researchdirectly

comparing

outcom

esfordeployed

IDFpersonnelR

TDversus

evacuatio

n

Study

War

Sam

ple

Treatmentsetting

Assessm

ent

Deploym

ent

outcom

esPo


outcom

esLim

itatio

ns

%RTD

%Relapse

Solomon

and

Benbenishty

(1986)

1982

IsraeliL

ebanon

War

N=“severalhundred”

Israeli

soldiersdiagnosedand

treatedforCSR

.Sam

ple

size

unspecified,only

percentagesreported:

dividedinto

four

groups:

(1)Treated

atfrontline;(2)

treatedwith

inborder

ofwar

zone;(3)

evacuated

togeneralh

ospitalin

Israel;(4)

sought

psychiatrichelp

after

deploymentw

hileon

leave

FrontlinePIE

treatm

ent

Bygroups:

(1)=

43%

atfront

(2)=

59%

border

(3)=

21%

evacuated

(4)=

28%

onleave

151%

totalu

nexplained

ifincludingrelapses

Retrospective1year

afterwar

assessed

forPIE,R

TD,

andPTSD

Proximity:R

TDrate;frontline

treatm

entv

s.evacuatedto

rear

hospitalinIsrael

Immediacy:q

ueried

iftreatm

entreceivedwith

inhours,days,w

eek,or

after

thewar

Expectancy:

1year

after

ceasefirequeriedabout

perceptio

nsof

PIE

treatm

entg

oals

(e.g.,RTD)

93%

Nodata

Overall,

34%

ofRTDdiagnosedwith

PTSD

1year

afterthewar

vs.74%

ofthoseevacuatedto

rear

orsought

treatm

entafter

deployment

–Proxim

itydidnotsignificantly

reduce

PTSD

:52%

ofRTDafterfrontline

treatm

entd

eveloped

PTSD

vs.66%

evacuatedto

rear

–59%

ofRTDafterPIE

treatm

entat

border

developedPTSD

vs.66%

evacuatedto

rear

–Im

mediatetreatm

entsignificantly

reducedPT

SD:5

4%of

44%

soldierstreatedim

mediately

developedPTSD;7

3%of

26%

soldierstreatedwithin

1day;

56%

of29%

treatedwith

in2or

moredays;

and74%

of24%

afterthewar

Expectancydidnotsignificantly

reduce

PTSD

,but

lowered

rates:55%

of53%

soldiersRTDatallcost

developedPTSD;6

2%of

40%

RTDifcapable;and67%

of23%

not-RTD

–Trend

ofcumulativebenefito

fPIE

reported,but

notstatistically

significant:

Num

berof

PIEprinciples

/RTD%

/PTSD

%0/2

2/7

11/2

3/6

42/4

8/5

93/6

0/4

0

Nostatisticaldataexcept

%Sm

allsam

plesize

Lackrandom

izationand

controlg

roup

Severity

ofCSR

notm

easured

Samplingbias

ofpossiblemore

severe

CSR

inevacuatedgroup

Retrospectiv

estudywith

self-report

andrecallbias

Inform

al,unsystematicassessment

ofPIEprinciples

Nodataon

relapse

Measurementerror

(e.g.,all

reported%

total>

100)

Noinform

ationon

treatm

entb

yageneral,nonm

ilitary

hospital

Solomon,W

eisenberg,

Schw

arzw

ald,

etal.(1987)

1982

Lebanon

War

N=470Israelisoldierswith

CSR

:n=155received

frontline

treatm

entfor

CSR

;n=315soldiers

evacuatedto

rear

hospital

treatm

entfor

CSR

,comparedto

controlo

fn=334matched

soldiers

withoutC

SR

Frontlineuseof

PIE

principles;u

nspecified

treatm

entatrearh

ospitals

Retrospectiveassessment

1year

afterthewar

ofCSR

andPT

SD

Nodata

Nodata

Overall,

59%

(n=255)

ofsoldiers

experiencing

CSRdevelopedPT

SD1year

afterthewar

statistically

significantcom

paredto

control

N=53

(16%

)of

thecontrolg

roup

developedPTSD,but

none

sought

treatm

ent

Older

veterans

hadhigher

PTSD

ratesandmarital

status

was

notsignificant

Noreportof

significant

difference

betweenCSR

grouptreatedatfrontline

vs.evacuated

torearhospital

Retrospectiv

estudy

Self-reportand

recallbias

Nodataon

hospitaltreatment

Severity

ofCSR

orim

pairment

notassessed

Solomon

etal.(2005)

1982

Israeli

Lebanon

War

N=79

Israelisoldierswho

received

frontline

treatm

ent

FrontlinePIE

treatm

ent

andunspecifiedrear

hospitaltreatment

20-yearpostwar

assessment

ofmental,physical,

andsocialfunctio

ning

Nodata

Nodata

After

20years,soldiers

diagnosedwith

CSRand

received

frontline

treatm

ent

20-yearretrospectiveself-

reportandrecallbias


Tab

le5

(contin

ued)

Study

War

Sam

ple

Treatmentsettin

gAssessm

ent

Deploym

ent

outcom

esPo


outcom

esLim

itations

%RTD

%Relapse

forCSR

;n=156soldiers

with

CSR

evacuatedfor

treatm

entinrear

hospitals;

matched

with

n=194

soldiersnotd

iagnosed

with

CSR

IES

SCL-90R

ULS

PTSD

-IProblemsin

Social

Functioning

Score

SubjectsaskedwhatP

IEprinciples

they

received

and

levelofrecoverybeforeRTD

hadlower

ratesof

PTSD,

psychiatricsymptom

s,and

postwar

socialfunctioning

problems,butn

otstatistically

significant

Cum

ulativetrendof

PIEtreatm

ent

andPT

SDratereported,but

was

notstatistically

significant,

revealing25%

PTSD

ratewhen

allthree

PIE

principles

applied;

32.6%

with

twoprinciples;

38.5%

oneprinciple;and

49.7%

noprinciples

Nosignificantg

roup

difference

inPTSDrate,occupational

functioning

forCSRcasualties

treatedon

frontlinesor

evacuatedto

hospitals

Nostatistically

significant

outcom

esbetweenCSR

casualtiesRTD,and

those

notR

TD

50%

morePT

SDsymptom

sin

CSR

casualtieswho

felt

RTDwas

prem

aturevs.

thoseRTDwho

felt

completelyrecovered

Unableto

substantiatePIE

principles

applied

Nomeasuresof

CSR

severity

Quasi-experim

entald

esign,

lack

random

assignment;

samplingbias.S

mall

samplesize

intheanalysis

oflong-term

effectsof

frontline

treatm

entinthe

comparisongroup(n

=27),

CSR

groupreceiving

frontline

treatm

ent(n=24)

ascomparedto

theCSR

groupreceivingrear

echelontreatm

ent(n=64)

Unspecified

hospitaltreatment


Ein-Dor, 2011), multiple somatic complaints (e.g., Ginzburg& Solomon, 2011), harmful drinking (e.g., Solomon &Mikulincer, 1992), global psychiatric distress (e.g., Solomon&Mikulincer, 1988), poor physical health (e.g., Benyamini &Solomon, 2005), as well as postdeployment effects on marital(e.g., Solomon & Mikulincer, 1992), family (e.g., Zerach,Solomon, Horesh, & Ein-Dor, 2013), parenting (e.g.,Solomon, Debby-Aharonl, Zerach, & Horesh, 2011), and oc-cupational (e.g., Solomon, Mikulincer, & Kotler, 1987) func-tioning, along with secondary traumatization of militaryspouses (Solomon et al., 1992).

The research designs of studies in Table 6 permit a partialassessment of frontline psychiatry’s efficacy in preventing ad-verse health effects. Results from this line of research reveal auniversal pattern whereby CSR alone is significantly associatedwith negative impact on nearly every individual and family-related outcome measure regardless if veterans received frontlinepsychiatry or not (see Table 6). Furthermore, the cumulativeeffects of repeated CSR are reported to coincide with progres-sively poorer clinical outcomes (e.g., Solomon, Mikulincer, &Jakob, 1987; Solomon, Oppenheimer, Elizur, & Waysman,1990), which has negative implications for the military’s mentalhealth policies of repeated RTD until individuals are deemed tooimpaired or dangerous to remain inwar zones (e.g., DOA, 2006).

Solomon et al. (2005) offered the following conclusion fromtheir 20-year longitudinal study on CSR and frontline psychiatry:BAlthough persons with combat stress reactions may recover,combat stress reaction often crystallizes into chronic PTSD andplaces casualties at risk for chronic PTSD^ (p. 2312) adding that,BAs the disease evolves over time, pathological changes anddebilitating co-morbidity may become fixed and irreversible^(p. 2312). Importantly, the IDF studies reflect only the outcomesof veterans who remained in war zones after experiencing CSRwho may still do better after deployments than their evacuatedcounterparts. However, it is equally, if not more, likely that theopposite may be the case—especially if the IDF’s findings provereplicated that suffering CSR by itself may be sufficient to causenegative health outcomes.

Methodological limitations, such as the absence of ran-domization, lack of adequate control groups (e.g., no compar-ison of evacuated veterans with CSR), and inherent potentialbias from retrospective reporting (see Table 6), prevent anycausal inferences about possible benefits or adverse healtheffects from frontline psychiatry. It remains possible, however,that a control group of evacuated veterans with CSRmay haveworse outcomes than those receiving frontline psychiatry(e.g., Martin & Cline, 1996), but this remains conjecture.

2. Outcome Research on Personnel Receiving OnlyFrontline Psychiatry

Table 7 contains several uncontrolled outcome studies narrowlyfocusing on war-stressed veterans receiving only frontline

intervention. For example, a UK study (Jones, Fear, Jones,Wessely, & Greenberg, 2010) followed 825 British soldiers whoreceived frontline psychiatry/COSC during an Iraq War deploy-ment. Results indicated that 73% of soldiers RTD after frontlineintervention remained in the military 2 years following their de-ployment, but the researchers offered no comparative analysis forsoldiers evacuated outside the war zone or those not receivingfrontline psychiatry (Jones et al., 2010). Despite the inherent meth-odological limitations in this study, one can reasonably concludethat most British veterans RTD after breaking down in war zonesare not readily discharged by the MoD. It is unclear, however,whether the 73%career retention reflects the effectiveness of front-line psychiatry, per se, or the MoD’s mental health policies, orboth. For example, fundamental differences between MoD andDoD mental health policies have been reported with regard todeployment length, regulating the amount of war stress exposure,and access to definitive treatment of war stress injury (e.g., Fearet al., 2010). Therefore, it is problematic to generalize UK researchon frontline psychiatry to the US military.

US military researchers recently published a single casestudy on career retention in a deployed soldier diagnosed withacute combat-related PTSD who was RTD after successfullycompleting a 2-week COSC program in Iraq (e.g., Mattila,Crandall, & Goldman, 2011). The soldier was eventually pro-moted in rank after returning home from deployment and waspending a second deployment (e.g., Mattila et al., 2011).Therefore, there is emerging evidence that frontline psychiatrydoes not harm career standing. The absence of an evacueecomparison precludes any further interpretation. In addition,Hoyt et al. (2015) reported that 97% of 513 US soldiers de-ployed to Afghanistan were RTD after receiving frontline psy-chiatry with the remainder evacuated. The US researchers alsoreported postdeployment outcomes for the 4000-member unit,including 365 soldiers seeking mental healthcare shortly afterreturning home, 19 admitted as psychiatric inpatients, and 158members referred for BH treatment after screening positive formental health problems several months later (Hoyt et al.,2015). It is unclear, however, how many soldiers receivingpostdeployment BH treatment were of the 513 RTD via front-line psychiatry (Hoyt et al., 2015). No data were provided onthe 46 soldiers psychiatrically evacuated out of the war zone,and there was no long-term outcome data reported on thosewho received frontline psychiatry and BH services (Hoytet al., 2015). That said, the research constitutes the first USmilitary study that examines frontline psychiatry andpostdeployment adjustment.

3. Outcomes of Deployed Personnel Receiving SupplementalFrontline Psychiatry Interventions

Table 8 contains various studies on deployed personnel re-ceiving either some type of supplemental or additive frontlinepsychiatry/COSC intervention (e.g., resilience training). The


nonmilitary RAND research agency investigated the MarineCorps’ version of frontline psychiatry/COSC, calledOperational Stress Control and Readiness (OSCAR) program(Vaughan et al., 2015). In that study, the health benefits fromextensive predeployment OSCAR prevention or resilience train-ing and peer support were examined in a sample of 2523 USMarines deployed to Iraq or Afghanistan who either received thesupplemental frontline psychiatry services, or did not. A widearray of psychiatric, social, physical health, behavioral, andwork-related outcomes were assessed before and after deploy-ment (Vaughan et al., 2015). The researchers found that the onlysignificant benefit that OSCAR provided was an increase in per-sonal help-seeking (Vaughan et al., 2015). More importantly, theresearchers expressed surprise that many clinical outcomes fromthe OSCAR group were generally worse than for Marines whodid not receive the extra prevention intervention, including show-ing higher rates of PTSD, depression, and poor physical health(Vaughan et al., 2015).

In contrast, UK researchers compared the outcomes of 180British soldiers from deployed units receiving frontline peersupport training and implementation via a peer-mentored trau-ma risk management (TRiM) program and units that did notreceive TRiM training (Frappell-Cooke, Gulina, Green,Hacker Hughes, & Greenberg, 2010). Results indicated sig-nificantly reduced scores of psychological distress and anxietyreported after deployment from units receiving TRiM, butlong-term outcomes were not assessed (Frappell-Cookeet al., 2010). The major limitations of this line of researchare the absence of suitable controls or comparison groups, aswell as a lack of long-term outcomes. Thus, the mixed natureof the findings strongly raises the need for a better evidence-base underlying frontline psychiatry’s claims of individualhealth benefits (e.g., Vaughan et al., 2015).

4. Outcome Research on Behavioral Health Treatment inWar Zones

Provision of BH in war zones falls within the frontlinepsychiatry/COSC mission, with the identical expectation ofmaximizing RTD and reducing evacuation (see Russell &Figley, 2016). Referrals for BH treatment include treatmentfor both severe CSR/COSR conditions evolving into psychi-atric diagnosis like PTSD, as well as noncombat-related psy-chiatric disorders (e.g., adjustment disorder due to maritalstrain). Table 8 contains BH treatment outcome studies be-yond mere application of PIE/BICEPS frontline principlesprovided within war zones and to psychiatric evacuees receiv-ing BH treatment outside of war zones. Such an analysis iscritical in evaluating the accuracy of military claims that re-search has demonstrated that RTD is clinically beneficial forservice members versus evacuation. As reflected in Table 8,research on BH treatments in war zones consists primarily ofcase studies or retrospective record reviews. For instance,

three deployed US Marines diagnosed with acute PTSD inIraq were successfully treated with brief exposure therapy,resulting in 100% RTD and 53% PTSD symptom reduction(Cigrang, Peterson, & Schobitz, 2005). The authors reportedthat the Marines returned home with their units, but they pro-vided no postdeployment or long-term outcomes (Cigranget al., 2005). In another US study, 10 deployed personnel wereevacuated to a combat stress clinic within Iraq, at which 6received virtual reality therapy and 4 exposure therapy (e.g.,McLay, McBrien, Wiederhold, & Wiederhold, 2010). APTSD symptom reduction of 67% across both treatmentgroups was reported, along with no significant outcome dif-ferences between treatment groups, resulting in a 100% RTDrate (McLay et al., 2010). No data on relapse orpostdeployment adjustment was provided. Similarly, Mooreand Krakow (2007) reported a 100%RTD rate of 11 deployedUS personnel after receiving frontline psychiatry and BHtreatment (imagery rehearsal) for traumatic nightmares thatresulted in 64% symptom reduction. Additional treatmentstudies include Stoller, Greul, Cimini, Fowler, and Koomar(2012), who randomly assigned 80 US soldiers deployed toIraq to yoga or control groups. They reported significantlylower scores of anxiety and other symptom measures 1 weekafter training, as well as Parrish (2008) reporting that 99% of5000 US personnel deployed to Iraq were RTD after receivingboth PIE/BICEPS and BH treatment, as well as the finding ofonly 5 personnel evacuated for psychiatric treatment outsidethe war zone.

Other war zone clinical research consists of large retrospec-tive record reviews (see Table 8). For instance, Hung (2008)conducted a retrospective analysis of medical records for49,670US personnel who received frontline psychiatry duringtheir Iraq deployment, including 8262 who also received BHtreatment for a psychiatric condition. Hung (2008) reportedthat 99% of psychiatric casualties were RTD and only 355, or0.67%, evacuated outside the war zone. In addition, Schmitzet al. (2012) reported that 99% of 1167 deployed US person-nel were RTD after BH treatment for a psychiatric disorderand only 4% were evacuated outside war zones. Unlike theabove case studies, the analysis of medical records does notinclude clinical outcome data, such as symptom improvement.However, it is certainly implied that RTD coincides withsymptom resolution, with evacuation reserved for treatment-resistant cases. Therefore, on the face of it, the BH treatmentfindings appear quite impressive when significant symptomreduction is paired with reports of 99 to 100%RTD. However,none of the studies reviewed include relapse data. Also, crit-ical questions about the long-term health effects of repeatedexposure to war stress after CSR/COSR and/or having a psy-chiatric condition are ignored. Consequently, the only firmconclusion that can be reached in this line of inquiry is thatthe overwhelming majority (i.e., 97% to 100%) of servicemembers diagnosed and treated for psychiatric conditions


Tab

le6

Outcomeresearch

onCSR

andfrontline

psychiatry

Study

War

Sam

ple

Treatmentsettin

gAssessm

ent

Deploym

ento

utcomes

Postdeploym

ent/long-term

outcom

esLim

itatio

ns

%RTD

%Relapse

Solomon,

Mikulincer,

andHobfoll

(1986)

1982

Israeli

Lebanon

War

N=382Israelisoldiers

who

received

frontline

treatm

ent

forCSR;n

=334

soldiersmatched

from

thesameunit

notd

iagnosed

with

CSR

Frontline

PIE

treatm

ent

1-year

postwar

assessmento

fCSR

andperceptio

nof

socialsupportand

lonelin

ess

MCEI

Perceptio

nof

lonelin

ess

Battle

intensity

Nodata

Nodata

Lackof

socialsupportfrom

officersrelatedto

greater

feelings

oflonelin

essand

greaterlik

elihoodof

CSRin

soldiers

Lackof

socialsupportfrom

buddiesassociated

with

greaterlonelin

ess

Intensity

ofbattlewas

also

relatedto

greaterfeelings

oflonelin

essandincreased

likelihoodof

CSR

Retrospectiv

e;self-reportand

recallbias

Nodataon

frontline

treatm

entfor

CSR

Unclear

iftheCSR

groupwas

RTD

afterPIE

vs.

evacuatedor

discharged

Severity

ofCSR

not

assessed

Solomon,

Oppenhei-

mer,and

Noy

(1986)

1973

Yom

Kippur

War

and

1982

Lebanon

War

Severalh

undredsof

Israelisoldiers

diagnosedwith

CSR

during

1973

war;m

atched

with

thesamenumberof

soldiersafterthe

1973

war

Raw

datanotprovided

Noinform

ationifthe

CSR

group

received

frontline

orothertreatm

ent

9-year

postwar

assessmento

fmilitaryretentionand

relapse

Reviewof

military

health

record

profile

ratin

gs

Nodata

1%94%

ofYom

Kippurveterans

diagnosedwith

CSRwere

ratedas

combatready

before

the1973

war,but

only

42%

wereratedcombatready

before

the1982

war

−6%

oftheseveterans

were

discharged

from

military;47%

reassigned

tononcom

batroles

1%relapserateforCSR

during

the1982

war

Retrospectiv

estudy

Exclusive

relianceon

percentagesand

proportio

nsSeverity

ofCSR

not

assessed

Notreatm

entd

ata

Lackof

objective

measures

Solom

onand

Mikulincer

(1988)

1982

Israeli

Lebanon

War


who

received

frontline

treatm

ent

forCSR;n

=334

matched

soldiers

from

thesameunit

notd

iagnosed

with

CSR;control

ofn=88

soldierswho

didnotd

eploy

Frontline

PIE

treatm

ent

1-year

postwar

assessmento

fPT

SDandsocial

adjustment

PTSD-I

Problemssocial

functio

ning

scale

Prem

ilitary

social

adjustment

Battle

intensity

Nodata

Nodata

Com

batexposureby

itselfdid

notaccount

forpoor

social

functio

ning

1-year

afterthe

war

Being

diagnosedwith

both

CSR

andPTSD

andPT

SDaloneis

significantly

relatedto

poor

postwar

socialfunctio

ning

CSRaloneisnotsignificantly

relatedto

postwar

social

problems

Retrospectiv

estudy;

self-reportand

recallbias

Intensity

ofCSR

not

assessed

Noprecom

bat

assessmentofsocial

adjustment

Solomon,

Mikulincer,

andJakob

(1987)

1982

Israeli

Lebanon

War


diagnosedwith

CSR

atfrontline;

n=384matched

soldiersfrom

the

sameunitnot

diagnosedwith

CSR

CSR

groupwas

referred

for

psychiatric

interventio

nbut

noinform

ationif

treatedand

treatm

entsettin

g(frontlin

evs.

evacuated)

1-year

postwar

assessmento

fCSR

andbattleintensity

Self-report

questio

nnaire.E

ach

Israelisoldier

was

askedifhe

(1)

participated

in

Nodata

Nodata

Soldierswith

previous

CSR

episodeweresignificantly

morelik

elyto

have

another

CSR

episoderegardless

ofperceivedbattleintensity

Under

high

battleintensity,

soldierswith

outp

rior

CSR

episodeweresignificantly

less

1-year

retrospective

study

Noassessmento

flong-term

outcom

eof

repeated

CSR

episodes

Unclear

iftheCSR

groupwas

RTD

afterPIE

vs.


Tab

le6

(contin

ued)

Study

War

Sam

ple

Treatmentsettin

gAssessm

ent

Deploym

ento

utcomes

Postdeploym

ent/long-term

outcom

esLim

itatio

ns

%RTD

%Relapse

combatand

(2)had

diagnosisof

CSR

Battle

intensity

ratin

g

likelyto

have

CSR

episodein

thecurrentb

attle

Highbattleintensity

was

significantly

relatedtoCSRin

both

groups

evacuatedor

discharged

Self-reportand

recall

bias

Solomon,

Mikulincer

andKotler

(1987)

1982 Lebanon

War

N=483Israeli

soldiers:n

=285

diagnosedwith

CSR

atfrontline

and

referred

for

psychiatric

treatm

ent;n=198

soldiersfrom

the

sameunitnot

diagnosedwith

CSR

CSR

groupreferred

fortreatm

ent,but

noinform

ationif

received

frontline

PIE

orevacuated

2-year

postwar

assessmento

fCSR

andsomatic

symptom

sHealth

status

PTSD

-I

Nodata

Nodata

CSR

groupreported

significantly

moreworkabsences,alcohol

use,cigarette

use,new

medications,new

onsetchest

pain,and

digestiveproblems

CSR

groupreported

significantly

greaternumberof

somatic

complaintsvs.control

CSR

andPT

SDindependently

andcombinedpredicated

greatersomaticcomplaints

Retrospectiv

estudy

Self-reportand

recall

bias

Unclear

iftheCSR

groupreceived

frontline

treatm

ent

Noprecom

bat

measure

ofsomatic

complaints

Mikulincer,

Solomon,

and

Benbenisht-

y(1988)

1982 Lebanon

War

N=104Israeli

soldiers:d

iagnosed

with

CSRat

frontline

and

referred

for

psychiatric

treatm

ent;all

subjectswere

discharged

from

activ

eduty

afterthe

war

andnowin

reserves

Frontlin

ePIE

treatm

ent

1-year

postwar

assessmento

fCSR

symptom

sandbattle

(CE)events

Interviewscoded

PTSD

-ISC

L-90R

SEP

100%

Nodata

17psychologicaland

somatic

symptom

sof

CSR

reported

by10%

ofsample

TotalPTSD

symptom

scorrelated

with

anxietyduring

combat

CSR

notsignificantly

relatedto

problemsinsocialfunctio

ning

CSRsignificantly

associated

with

PTSD

andpsychiatric

symptom

s1-year

postwar

Veteranswith

CSRareoften

preoccupiedwith

their

breakdow

nscontributeto

postwar

adjustmentp

roblem

s

Retrospectiv

estudy

Self-reportand

recall

bias

Noprecom

bat

assessmento

foutcom

emeasures

Severity

ofCSRnot

assessed

Solomon,

Benbenisht-

i,etal.

(1988)

1982

Israeli

Lebanon

War


diagnosedwith

CSR

atthefrontline

andreferred

for

psychiatric

treatm

ent

Noinform

ationon

CSRgroup

receivingfrontline

treatm

ento

revacuated

1-year

postwar

assessmento

fPT

SD

Premilitary

and

postmilitary

adjustment,combat

experiences,andthe

extent

oftheCSR

episode

Nodata

Nodata

Extento

fCSRepisodeand

specificcombatexperiences

predictsPTSD

Psychologicalsymptom

swere

predictedmainlyby

combat

experiences,andpostwar

functio

ning

was

predicted

mainlyby

prew

arfactors

Implicationof

combat

experiencesandsoldiers’

immediatereactio

nsduring

combatinthegenesisof

subsequent

PTSD

Retrospectiv

estudy

Self-reportand

recall

bias

Smallsam

plesize


Tab

le6

(contin

ued)

Study

War

Sam

ple

Treatmentsettin

gAssessm

ent

Deploym

ento

utcomes

Postdeploym

ent/long-term

outcom

esLim

itatio

ns

%RTD

%Relapse

Solomon

and

Flum

(1988)

1982

Israeli

Lebanon

War

N=716Israeli

soldiers:C

SRgroup

(n=382)

diagnosed

andtreatedforCSR

atfrontline;

comparedton=334

non-CSR

group

Frontlin

ePIE

treatm

ent

1-year

postwar

assessmentofprew

arlifeeventsandCSR

PTSD

-IPre-war

LifeEvents

Survey

Nodata

Nodata

Nosignificantrelationbetween

CSR

andpositiv

eandnegativ

elifeeventsbefore

thewar

CSRsignificantly

relatedto

PTSD

diagnosis

PTSDseverity

correlated

with

numberof

negativ

elifeevents

PTSDsignificantly

relatedto

impaired

socialties

Retrospectiv

estudy

Self-reportand

recall

bias

Noprecom

bat

measure

ofPTSD

Severity

ofCSRnot

measured

Solomon

and

Mikulincer

(1988)

1982

Israeli

Lebanon

War

N=483Israeli

soldiers:C

SRgroup

(n=285)

diagnosed

andtreatedforCSR

atfrontline;

comparedton=198

non-CSRgroup

CSR

groupreferred

forpsychiatric

interventio

nat

frontline,but

noinform

ationif

treatm

entw

asreceived

1-and2-year

postwar

assessmento

fCSR

andPTSD

IES

PTSD

-I

Nodata

Nodata

CSRwas

significantly

relatedto

intrusive,avoidance,andother

PTSDsymptom

satboth1and

2years

Totald

istresshigherfortheCSR

groupacross

each

timeperiod

Bothgroups

reported

significantly

lower

avoidant

andintrusivesymptom

satthe

2ndyear

Retrospectiv

estudy

Self-reportand

recall

bias

Unclear

iftheCSR

groupreceived

frontline

treatm

ent

Noprecom

bat

measure

ofPTSD

Nodatatreatm

entfor

theCSRgroup

Solomon

and

Mikulincer

(1988)

1982 Lebanon

Wa r


who

received

frontline

treatm

ent

forCSR;n

=334

matched

soldiers

from

combatu

nit

notd

iagnosed

with

CSR

Frontlin

ePIE

treatm

ent

1-and2-year

postwar

assessmento

fPT

SD

symptom

sIES

PTSD

-I

Nodata

Nodata

After

1year:

59%

oftheCSR

group

diagnosedwith

PTSD

;15%

controld

iagnosed

with

PTSD

After

2years:

56%

CSR

groupand14%

controld

iagnosed

with

PTSD

CSRassociated

with

intrusion

andavoidancesymptom

sIntrusionsymptom

sdecline

morethan

avoidance

symptom

sovertim

e

Retrospectiv

estudy

Self-reportand

recall

bias

Noprecom

bat

measure

ofPTSD

Severity

ofCSRnot

assessed

Solomon,

Mikulincer,

andBleich

(1988)

1982

Israeli

Lebanon

War

N=382)

Israeli

soldiersdiagnosed

with

CSRatthe

frontlines;n=334

matched

control

frontline

soldiers

notd

iagnosed

with

CSR

Diagnosed

atfrontline

butn

oreportiftreatedat

frontline

orevacuated

1-year

postwar

assessmentv

iaPT

SD-I

SCL-90

Nodata

Nodata

CSR

groupsignificantly

more

likelyto

developPTSD

(n=228)

oftheCSRgroup

diagnosedwith

PTSD

;comparedto

n=50

ofthe

non-CSR

group

CSR

groupsignificantly

higher

clinicalseverity

onallthree

globalsymptom

measures

PTSD

diagnosissignificantly

associated

with

anxiety,

depression,hostility,and

Notreatm

entd

ata

Retrospectiv

estudy

Self-reportand

recall

bias

Severity

ofCSRnot

assessed


Tab

le6

(contin

ued)

Study

War

Sam

ple

Treatmentsettin

gAssessm

ent

Deploym

ento

utcomes

Postdeploym

ent/long-term

outcom

esLim

itatio

ns

%RTD

%Relapse

obsessive-compulsive

symptom

sSo

lomon

etal.

(1990)

1973

Yom

Kippur

War

and

1982

Lebanon

War

N=24

Israelisoldiers

who

received

frontline

treatm

ent

forCSR

inboth

1973

and1982

wars;n=39

matched

soldiers

from

thesameunit

with

firsttim

eCSR

in1982

war

only

Frontlin

ePIE

treatm

ent

3-year

post-Lebanon

War

assessed

effects

ofrepeatCSR

PTSD

-IIES

SCL-90-R

SFP

Health

status

interview

PSE

Nodata

Nodata

The

repeatCSRgroupreported

significantly

moresevere

pathologyandalowerlevelof

socialfunctio

ning

than

the

firsttim

eCSR

group

CSR

groupadjustmentand

symptom

atologywere

significantly

worse

follo

wing

thesecond

war

than

afterthe

first

Successfuladjustm

entafter

the

1stC

SRepisodedidnot

inoculateagainstsubsequent

CSR

episodes

Retrospectiv

estudy

Self-reportand

recall

bias

Smallsam

plesize

Noprecom

batd

ataon

outcom

emeasures

Solomon,

Benbenisht-

i,and

Mikulincer

(1991)

1982

Israeli

Lebanon

War

N=65

Israelisoldiers

diagnosedwith

CSR

atfrontline

and

referred

for

psychiatric

interventio

nbut

remainedin

the

military;com

pared

tomatched

control

groupof

unknow

nnumberof

veterans

with

outC

SR

Noinform

ationon

CSRgroup

receivingfrontline

treatm

ento

revacuated

1-,2-,and3-year

postwar

assessment

ofself-efficacy

Com

bat-related

perceived

self-efficacyratin

gPT

SD-I

SCL-90R

Military

record

ofprem

ilitary

adjustment

Nodata

Nodata

Self-efficacyof

theCSR

group

significantly

lower

than

the

non-CSR

controlg

roup

Psychicnumbing

andloss

ofcontrold

uringcombatw

ascorrelated

with

lower

combat-relatedself-efficacy1

and2yearsafterthewar,but

notaty

ear3

CSR

andPT

SDseverity

associated

with

lower

self-efficacy

Higherprem

ilitary

adjustment

ratin

gresultedin

higher

self-efficacyscores

across

time

Retrospectiv

estudy

Self-reportand

recall

bias

Smallsam

plesize

Noreportof

treatm

ent

fortheCSR

group

Noinform

ationon

controlg

roup

Noprecom

bat

measure

ofself-efficacy

S olomon,

Mikulincer,

etal.(1991)

1982

Israeli

Lebanon

War

N=71

Israelisoldiers

identifiedwith

delayedPT

SDgroup2yearsafter

thewar

ended,

with

outp

rior

CSR

during

thewar;

comparedto

n=73

soldiersdiagnosed

with

CSRand

immediateonset

Frontlin

ePIE

treatm

entlikely

butn

otcertainfor

immediateonset

PTSD

group

20-yearpostwar

assessmento

fsocial

supportand

coping

resourceson

PTSD

onset

MCEI

WCC

PSQ

CAQ

Nodata

Nodata

Findings

indicatedthatboth

immediateanddelayedPTSD

casualtiesreported

higher

levelsof

battlestress

than

controlsubjects

Delayed

PTSDcasualties

evincedless

personal

resourcesthan

thecontrol

groupandim

mediatePT

SDcasualtiesevincedstill

less

Retrospectiv

estudy

Self-reportand

recall

bias

Unclear

iftheCSR

groupreceived

frontline

treatm

ent

Noprecom

bat

measure

ofcoping

resourcesand

attributionalstyle


Tab

le6

(contin

ued)

Study

War

Sam

ple

Treatmentsettin

gAssessm

ent

Deploym

ento

utcomes

Postdeploym

ent/long-term

outcom

esLim

itatio

ns

%RTD

%Relapse

PTSD;m

atched

with

n=73

control

groupof

veterans

with

outC

SRor

PTSD

diagnosis

2yearsafterthe

war

personalresourcesthan

delayedPTSD

casualties

Delayed

onsetu

sedmore

problem-focused

coping

than

immediateonset

Bothim

mediateanddelayed

onsetP

TSD

reported

lower

officersupport

PTSDcasesattributed

causes

tomorestableandunpredictable

factorsthan

non-PT

SDSolom

onand

Mikulincer

(1992)

1982 Lebanon

War


diagnosedwith

CSR

andreferred

forpsychiatric

treatm

ent;n=116

matched

soldiers

from

combatu

nit

notd

iagnosed

with

CSR

CSR

groupreferred

fortreatm

ent,but

noinform

ationif

received

frontline

PIEor

evacuated

1-,2-,and3-year

postwar

assessment

ofCSR

PTSD

-IIES

SCL-90R

SFP

Health

status

Perceivedself-efficacy

Nodata

Nodata

CSRgroupreported

significantly

greaterPTSD

andpsychiatric

symptom

atologyacross

time

than

controls

Psychiatricsymptom

atologywas

stableacross

timein

theCSR

group,butn

otPT

SDsymptom

sCSR

groupreported

greaterw

ork

absences,smoking,drinking,

newonsetchest,and

back

pain,aswellasdigestive

problems

CSRissignificantly

relatedto

PTSD

CSRgroupreported

significantly

moreproblemsin

social,

marital,work,sexual,and

family

functio

ning

Retrospectiv

estudy

Self-reportand

recall

bias

Noprecom

bat

assessmento

foutcom

emeasures

Severity

ofCSR

not

assessed

Solomon,

Waysm

an,

Levy,etal.

(1992)

1982

Israeli

Lebanon

War

N=120wives

ofIsraelisoldiers

diagnosedwith

CSR;n

=85

wives

ofsoldiersnot

diagnosedwith

CSR

UncertainiftheCSR

groupreceived

frontline

orother

treatm

ent

Secondarytrauma

was

assessed

Wife’sperceptio

nsof

husband’sP T

SDWife’s

SCL-90-R

FES

SCQ

DAS

ULS

SSQ

Nodata

Nodata

CSR

andPT

SDwereboth

independently

and

cumulativelyassociated

with

significantincreasein

wife’s

psychiatricsymptom

sCSRsignificantly

relatedto

PTSD

Current

husbandPT

SDsignificantly

contributesto

wife’sim

paired

social

functio

ning,feelin

gsof

lonelin

ess,adversemaritaland

family

functio

n

Retrospectiv

estudy

Self-reportand

recall

bias

Noprecom

batd

ataon

outcom

emeasures

Severity

ofCSR

not

measured


Tab

le6

(contin

ued)

Study

War

Sam

ple

Treatmentsettin

gAssessm

ent

Deploym

ento

utcomes

Postdeploym

ent/long-term

outcom

esLim

itatio

ns

%RTD

%Relapse

Dekeletal.

(2003)

1973

Yom

Kippur

War

N=98

.decorated

heroes:received

medalsforbravery

inthe1973

Yom

KippurWar


who

received

frontline

treatm

ent

forCSR;n

=189

matched

soldiers

notd

iagnosed

with

CSR

Frontline

PIE

treatm

ent

CE

PTSD-I

SCL-90R

Nodata

Nodata

Decorated

war

heroes

reported

thehighestexposureto

battlefield

stressors;they

functio

nedbetterthan

the

other2groups

during

thewar.

Moreover,some2decades

later,they

show

edlower

rates

ofPTSDandbettergeneral

psychologicalh

ealth

than

the

CSRcasualties

CSR

grouphadthehighestrate

ofPTSDandpsychiatric

symptom

svs.decorated

veterans

andthecontrolgroup

Retrospectiv

estudy

Self-reportand

recall

bias

Severity

ofCSR

not

measured

Potentiald

emand

characteristicsof

“decorated

heroes”

Benyamini

and

Solom

on(2005)

1982

Israeli

Lebanon

War


who

received

frontline

treatm

ent

forCSR;n

=218

matched

soldiers

from

thesameunit

notd

iagnosed

with

CSR

Frontline

PIE

treatm

ent

20-yearpostwar

assessmento

fCSR

,PT

SD,lifestress,and

physicalhealth

PTSD-I

Changes

inHealth

Questionnaire

Disease

andSym

ptom

Checklist

Cum

ulativeLifeStress

Checklist

Nodata

Nodata

CSR

and,to

agreaterextent,

PTSD

,wereboth

associated

with

generalself-ratedhealth,

chronicdiseases

andphysical

symptom

s,andgreater

engagementinrisk

behaviors

CSRandPT

SDwererelatedto

greatercumulativelifestress

sincethewar.B

othnegativ

eandpositiv

elifeeventswere

independently

relatedto

most

ofthephysicalhealth

measuresbutd

idnotaccount

fortheassociations

ofCSR

andPTSD

with

poorer

health

Retrospectiv

estudy

Self-reportand

recall

bias

Noprecom

batd

ataon

outcom

emeasures

Severity

ofCSR

not

measured

Ginzburgand

Solom

on(2011)

1982

Israeli

Lebanon

War


who

received

frontline

treatm

ent

forCSR;n

=301

matched

soldiers

from

thesameunit

notd

iagnosed

with

CSR

Frontline

PIE

treatm

ent

1,2,3,and20

years

postwar

assessed

for

PTSD

,childhood

trauma,somatic

symptom

sIES

NCLES

SCL-90R

-som

atization

subscale

Nodata

Nodata

CSRresults

inhigher

initial

levelsof

intrusionand

avoidancesymptom

sanda

steeperdeclinein

symptom

sovertim

ecomparedto

control

CSRaloneresults

insignificantly

greaterlevelsof

somatization

symptom

sateach

subsequent

reassessment

CSRisamarkerforfuture

stress

reactio

nsandsomatization

symptom

sin

both

CSR

groups,indicatinglong-term

20-yearretrospective

study

Self-reportand

recall

bias

Unclear

iftheCSR

groupwas

RTD

afterPIE

vs.

evacuatedor

discharged

Severity

ofCSR

not

measured

Noprem

ilitary

measure

ofPT

SDandsomatic


Tab

le6

(contin

ued)

Study

War

Sam

ple

Treatmentsettin

gAssessm

ent

Deploym

ento

utcomes

Postdeploym

ent/long-term

outcom

esLim

itatio

ns

%RTD

%Relapse

impacton

psychological

well-being

Num

berof

adversechild

hood

eventsdidnotp

redictPTSD

andsomaticsymptom

sHoreshetal.

(2011)

1982

Israeli

Lebanon

War


who

received

frontline

treatm

ent

forCSR;n

=306

matched

soldiers

from

thesameunit

notd

iagnosed

with

CSR

Veteransweredivided

into

4groups,

accordingto

the

timeof

PTSDonset

(e.g.,1983,1984,

2002,and

noPTSD)

Frontline

PIE

treatm

ent

20-yearpostwar

assessmento

fim

mediateand

delayedonseto

fPT

SD;com

bat

exposure

(CE),

PTSD

,childhood

andpostwar

life

events

PTSD-I

IES

LEQ

NCLES

CEratin

g

Nodata

Nodata

ImmediateonsetP

TSD

significantly

relatedtoseverity

ofsubjectiv

eandobjective

levelo

fCE

CSRandCEmostp

redictive

across

alln

egativeoutcom

esfollo

wed

bysocialsupport,

homecom

ingexclusion,

family

conflictand

expressiveness

CSR

was

foundto

bethemost

powerfulp

redictor

ofPT

SDonset

Recency

effectwas

foundwith

morerecent

lifeevents

provingto

bestronger

predictorsof

PTSD

onsetthan

child

hood

events

Delayed-onsetPT

SDwas

found

amongasubstantialnum

berof

non-CSRgroup(16.5%

)

Retrospectiv

estudy

Self-reportand

recall

bias

Unclear

iftheCSR

groupwas

RTD

afterPIE

vs.

evacuatedor

discharged

Severity

ofCSR

not

assessed

Noprecom

bat

measure

ofPT

SDandsocial

adjustment

Solom

onetal.

(2011)

1982

Israeli

Lebanon

War


who

received

frontline

treatm

ent

forCSR;n

=209

matched

soldiers

from

thesameunit

notd

iagnosed

with

CSR

Frontline

PIE

treatm

ent

20-yearpostwar

assessmento

fPTSD

,maritaland

parenting

problems

PTSD-I

DAS

Parentalfunctio

ning

Lifeevents

questio

nnaire

Nodata

Nodata

60%

oftheCSR

groupand10%

controlssoughtpsychotherapy

afterthewar

CSRsignificantly

relatedto

PTSD

CSR

andPT

SDgroups

independently

and

cumulativelyreported

significantly

lower

marital

satisfactionandincreased

parentingproblemsthan

non-CSRandnon-PT

SDgroups

Emotionalsharing

moderated

PTSDseverity

andparenting

functio

ning,but

notm

arital

adjustment

Retrospectiv

eSelf-reportand

recall

bias

Noprecom

bat

measure

ofmarital

andparenting

functio

ning

Severity

ofCSR

not

assessed


Tab

le6

(contin

ued)

Study

War

Sample

Treatmentsettin

gAssessm

ent

Deploym

ento

utcomes

Postdeployment/long-term

outcom

esLim

itatio

ns

%RTD

%Relapse

Zerachetal.

(2013)

1982

Israeli

Lebanon

War

N=208Israeli

soldiers:C

SRgroup

(n=128)

diagnosed

andtreatedforCSR

atfrontline;

comparedto

n=80

non-CSR

group

Frontline

PIE

treatm

ent

1-,3-,and20-year

postwar

assessment

ofCSRandfamily

cohesion

IES

FES

Nodata

Nodata

CSRgrouphadsignificantly

greateravoidancesymptom

svs.control

Intrusiveandavoidance

symptom

sgradually

decreasedover

timein

both

groups

CSRgroupreported

significantly

lower

family

cohesion

ateach

assessmentp

eriod

CSRgroupreported

significantly

greaterPTSD

symptom

sSeverity

ofPTSD

symptom

snegativ

elyim

pacted

family

cohesion,and

lowfamily

cohesion

increasedPTSD

symptom

s

Retrospectiv

estudy

Self-reportand

recall

bias

Unclear

iftheCSR

groupreceived

frontline

treatm

ent

Noprecom

bat

measure

offamily

cohesion

andPTSD

AUDIT-C

Alcohol

Use

DisordersIdentificationTest-Consumption,CAQCausalA

ttributionQuestionnaire,D

ASDyadicAdjustm

entS

cale,F

ESFamily

EnvironmentS

cale,D

RRID

eploym

entR

iskand

Resiliency

Inventory,HPQHealth

Performance

Questionnaire,IESIm

pactof

EventsScale,LE

QLifeEventsQuestionnaire,M

CEIMilitary

Com

pany

EnvironmentInventory(socialsupport),N

CLE

SNegativeChildhood

LifeEventScale,O

Q-45OutcomeQuestionnaire-45,PBQ-SRPeritraumaticBehaviorQuestionnaire-Self-Rating,PCL-M

PTSDChecklist-Military

Version,P

HQ-2/8PatientHealth

Questionnaire2or

8items,PIS

PTSD

InventoryScale,P

SEPerceived

Self-EfficacyScale,P

SQPerceivedStressQuestionnaire,U

LSUCLALonelinessScale,SCL-90-R

Symptom

Checklist-90-Revised,

SCQSo

maticCom

plaintsQuestionnaire,SF-12Sh

ortF

orm

Health

Survey,SF

PProblemsin

SocialFunctioning

Scale,SSQSo

cialSu

pportQ

uestionnaire,W

CCWaysof

CopingChecklist


Tab

le7

Outcomeresearch

onfrontline

psychiatry

only

Study

War

Sam

ple

Treatmentsettin

gAssessm

ent

Deploym

ent

outcom

esPo


outcom

esLim

itatio

ns

% RTD

% Relapse

Jones

etal.

(2007)

WWI

N=3580

UKsoldiersadmitted

toinpatient

NYDNCentrein

France

M=25

days

inpatient

war

zone

4Stationary

Hospital

NYDNCentre

M=11.2monthsin

war

zone

before

admission

40.3%

brokedown

after6monthsCE

9%2-year

CEold

sergeants

35% reassigned

in convales-

cent

17%

RTD

n=606

20% evacuated

tobase

Ofthe

606RTD,15(2.5%)w

erereadmitted

to4Stationary

Hospitalshortly

afterdischarge

n=93

(2.6%)of

thetotalsam

pleof

3580

soldiershadtwohospitaladm

issions

Lackrandom

assignment

Onlyoutcom

emeasure

isRTD

Nocomparisonof

RTDvs.

evacuatio

ngroup

Jones

etal.

(2010)

Iraq

War

N=825Britishmilitary

personnel

deployed

toIraq

diagnosedwith

COSR

,who

received

frontline

treatm

ent(Field

MentalH

ealth

Team

s-FM

HTs)

Frontline

FMHTtreatm

entin

Iraq

usingBICEPS

FMHTrecordsreview

indicatin

gshort-term

outcom

eof

RTDor

evacuatio

nduring

deployment

Military

record

review

oflong-term

outcom

eifretained

vs.dischargedfrom

military

71.6%

RTD

with

adocument-

ed short-term

military

work

outcom

e

73.5%

ofthoseRTDhadadocumented

long-termmilitary

workoutcom

eevidentby

retentionforgreaterthan

2years

postdeployment

Adjustin

gforpotentialconfounders,a

shorter

servicelength

andremovalfrom

the

operationaltheater

wereboth

strongly

associated

with

prem

aturedischarge;

however,itw

asnotpossibletodeterm

inethe

severity

ofthepresentin

gmentalh

ealth

problem

andassess

whether

thisim

pacted

outcom

e

Retrospectiv

erecord

review

Severity

ofCOSR

notassessed

Nocomparisonof

evacuee

treatm

ento

rsoldierswith

CSRnottreated

byFM

HT

Mattila

etal.

(2011)

Iraq

N=1;

singlecase

study,

24-year-oldArm

yCorporal

with

COSRaftercombat

involvingkilling

ofinsurgents

2-weekCOSCfitness

program,consultatio

nwith

unitleaders;sleep

medication;

coping

skills;

individualsupportiv

ecounselin

g

Nodata

RTD;

completed

deployment

with

unit

1½yearsfollo

w-up,subjectw

asprom

oted

inrank,re-enlistedandpending2nd

deployment

Singlecase

study

Nopsychometrics

Nolong-term

follo

w-updata

on2nd

deployment

Hoyt

etal.

(2015)

Afghanistan

9monthsdeploymentw

ith4000

mem

berArm

yStryker

Brigade

Com

batT

eam

N=513(13%

)

COSC/BHem

bedded

with

StrykerBrigade

combat

team

Nodata

97%—RTD

467(97%

)—BHonly

46(8%)

evacuated

719of

3284

(21%

)brigademem

bersscreened

before

returninghomeas

moderateto

high

risk

364soughtBHcareingarrison

and19

admitted

psychiatrichospitalizations—no

outcom

edata

158referred

toBHafterpositiv

escreeningon

90–180-day

reassessment

Nodatafor

personnel

receiving

COSC/BH

during

deployment

Noclinical

outcom

edata


Tab

le8

Outcomeresearch

onsupplementalfrontlin

epsychiatry

andbehavioralhealth

treatm

ent

Study

Sam

ple

Treatment

setting

Researchdesign

Assessm

ent

Treatmentm

odality

Deploym

ento

utcome(e.g.,

RTD,clin

icalchanges,

relapse,evacuatio

n)

Postdeployment

outcom

es(PDO)

Lim

itatio

ns

Cigrang

etal.

(2005)

N=3USmilitary

with

acutePT

SD

Frontline

BH

treatm

entat

Iraq

Battalio

n

Multip

lecase

study

PCL

Assessedatfirst

andlastsession

Brief

exposure

therapy

4therapysessions

over

a5-week

period

100%

RTD

PTSD

symptom

sreducedby

anaverageof

56%

FinalPCLscores

with

innorm

allim

its

Nodata

Smallsam

ple

Nocontrol

Dem

and

characteristics

Nofollo

w-updata

fordeploymentor

PDO

Moore

and

Krakow

(2007)

11USsoldiersin

Iraq

with

acute

traumatic

nightm

ares

COSC/BHteam

inIraq

Multip

lecase

study

Pre-postand

1month

follo

w-up

assessments

Frequencyof

nightm

ares

Severity

ofPT

SDsymptom

sSeverity

ofinsomnia

Imageryrehearsal

therapy

4-weekly1-h

sessions

100%

RTD

64%

reported

significant

reductionin

nightm

ares,

insomnia,andPTSD

symptom

s

Nodata

Dem

and

characteristics

Nocontrol

Nolong-term,

postdeployment

follo

w-up

Nostandardized

measures

Hung(2008)

N=49,670

USmilitary

n=8,262received

BH

treatm

entfor

psychiatric

diagnosis

COSC/BH

team

sin

Iraq

Retrospectiv

ereview

ofdisposition

via

COSC

Workloadand

Activity

Reportin

gSystem

(COSC-W

AR-

S)Recordin

Iraq

during

the

first6

months

of2008

Nodata

Psychiatricdiagnoses:

Depression(n=1389)

Anxiety

(n=928)

Nicotineproblem

(n=1002)

ASD/PTSD

(n=720)

Substanceabuse

(n=192)

Other

problem

(n=1640)

BICEPS

individual

BHcounselin

g(unspecified)

Overall,

99%

RTD:9

0.8%

(n=45,100)RTDwith

out

limitatio

ns;4

.4%

(n=2185)RTDwith

limitatio

ns;3

.4%

(n=1700)“rest”(senttoa

nonm

edicalsupportu

nit,

typically

fartherfrom

the

frontlines);0

.91%

(n=450)

“refer”to

ahigher

levelo

fmedical

care

intheater

Only0.67%

(n=335)

medically

evacuatedout

oftheater

Nodata

Noclinical

outcom

esNodataon

specific

treatm

ent

modalities

Norelapsedata

NoPDO

Parrish

(2008)

Estim

ated

n=5000

BHcontactsby

US

military

Num

berof

clients

treatednotreported

Intensive

outpatient

levelII

medical

facility,

Witm

erWellness

Centerin

Iraq

Retrospectiv

eprogram

description

Nodata

Dialectical

behavior

therapy

andBICEPS

Open-ended

biweekly

individual

therapy

Group

skills

sessions

Crisisconsultatio

n

99%

RTD,onlyn=5

evacuatio

nsNoclinicaloutcom

edata

reported

Nodata

Notreatm

entd

ata

provided

Noclinical

outcom

esNosymptom

measures

Unclear

numberof

clientstreatedand

outcom

eNocontrols

N=473,964US

soldiersdischarged

Unspecified

treatm

ent

Analysisof

medicalrecords

10%

(n=1948)of

the

totalh

ospitalizations

Riskanalysisof

mental

disorders—

OEF

Iraq

(mean=137)

and112days

for

Lengthof

Tour

and

Daysto

Mental


Tab

le8

(contin

ued)

Study

Sam

ple

Treatment

setting

Researchdesign

Assessm

ent

Treatmentm

odality

Deploym

ento

utcome(e.g.,

RTD,clin

icalchanges,

relapse,evacuatio

n)

Postdeployment

outcom

es(PDO)

Lim

itatio

ns

Wojcik,Akhtar,

andHassell

(2009)

from

military

treatm

entfacilities

during

OIF

andOEF

deployment

anddatabases

ofhospital

admissions

(episodesof

care)in

both

campaigns

included

adiagnosis

ofamentald

isorder,

and6%

(n=1225)

ofthe

hospitalizations

had

aprincipalm

ental

disorder

diagnosis

Riskanalysisof

mental

disorders—

OIF

1565

soldiershad

1633

hospitalizations

inOIF,w

itha

mentald

isorder

diagnosedeither

asaprincipalo

radditio

nal

diagnosis.

Mentald

isorders

thatcontributed

tothe1633

DuringOEF,300soldiers

hadatotalo

f315

admissionswith

any

mentald

isorder.Gender,

race,and

gradewere

significantriskfactors

(TableVI)associated

with

thosehospitalizations.

Therewere34%

(n=108)

mooddisorders,28%

(n=89)adjustment

disorders,15%

(n=47)

substanceabuse-related

hospitalizations,and

13%

(n=40)anxietydisorders.

Thirty-five

percento

fthe

anxietydisorderswerethe

resultof

PTSD

thoseservingin

Afghanistan

(mean—

135)

health

admissions

The

mediantim

eto

hospitalization

with

amental

disorder

from

the

starto

fatour

was

118days

for

soldiersserving

in

Frappell-Cooke

etal.(2010)

180UKmilitary

inAfghanistan

with

posttrauma

reactio

nsArm

yinfantry

(n=86)

RoyalMarine

Com

mandos

(n=94)adopted

TRiM

Frontline

useof

TRiM

inAfghanistan

Multip

lecase

study

Predeployment

and

postdeployment

a ssessments

GeneralMentalH

ealth

Questionnaire

PCL

Traum

arisk

managem

ent

(TRiM

),apeer

supportsystem

Nodataon

RTD

TRiM

-experienced

unit

(RoyalMarines)reported

lower

levelsof

psychologicald

istress

than

theTRiM

-naive

unit

(Coldstream

Guards)both

pre-

andpostdeployment

Reduced

levelsof

anxietyin

both

groups

with

inthe

firstw

eekof

postdeployment,

comparedwith

predeploym

ent

Bothgroups

reporting

significantlevelsof

distress

wereless

likelyto

perceive

effectivesocial

supportfrom

unit

mem

bers

Nodata

Nolong-term

follo

w-up

Nooutcom

ecomparisonwith

frontline

and

evacuated

personnel

Lande,

Williams,

Francis,

Gragnani,

N=49

USmilitary

deployed

toIraq

orAfghanistan

N=22

biofeedback

Unspecified

forw

ard

deployed

intensive

outpatient

Systematic

sampling

techniquewith

random

assignmentfirst

PCL-M

ZSRD

Preandafter3-week

treatm

ent

Heartvariability

biofeedback

Twiceweeklyfor

3weeks

in20-m

insessions

RTDandrelapsenot

reported

Biofeedback

didnotproduce

ameasurable

improvem

ent.Decreasein

Nodata

Noreportof

RTD

andrelapse

NoPOD


Tab

le8

(contin

ued)

Study

Sam

ple

Treatment

setting

Researchdesign

Assessm

ent

Treatmentm

odality

Deploym

ento

utcome(e.g.,

RTD,clin

icalchanges,

relapse,evacuatio

n)

Postdeployment

outcom

es(PDO)

Lim

itatio

ns

andMorin

(2010)

N=17

control

treatm

entasusual

(TAU)

trauma

recovery

program

subjectand

alternating

assignmentto

TAUor

biofeedback

PTSDanddepression

symptom

sfrom

baselin

eto

3weeks

forboth

the

controland

treatm

ent

group

Nosignificantd

ifferencein

treatm

entand

control

McL

ayetal.

(2010)

10USmilitary

personneld

eployed

inIraq

diagnosed

with

acutecombat

PTSD

Com

batS

tress

Clin

ic,C

amp

FallujahIraq

Multip

lecase

study

Inform

edconsent

ledto

assignmentto

either

virtual

reality

therapy

(VRT;n

=6)

ortraditional

exposure

therapy(TET;

n=4)

PCL-M

Patient

Health

Questionnaire-9

BeckAnxiety

Inventory

VRT(m

ean6.5

sessions)

TET(m

ean9

sessions)

Treatmentd

uration

10days–13-

weeks

100%

RTD

Onaverage,patientsin

VR

therapyexperienceda

67%

decrease

inPTSD

symptom

sas

measuredon

thePC

L-M

.In5outo

f6

patientswho

nolonger

metcriteria,themean

change

was

74%,w

hereas

theoneremaining

individualexperienced

only

a32%

drop.

Statistically,there

was

asignificanteffectb

etween

pretreatmentand

posttreatm

ent(p<0.001)

butn

ostatistically

significanteffecto

ftreatm

entg

roup

(VRvs.

traditionalET)

Nodata

Norandom

assignment

Nocontrol

Nofollo

w-updata

Nodeploymento

rpostdeployment

outcom

edata

Schmitz

etal.

(2012)

N=1136

USmilitary

seekingBH

treatm

entinIraq

Datacollected

by19

Navy

BHproviders

servingin

Iraq

Archivald

ata

analysis

Nomeasuresreported

Psychiatricdiagnoses

includeanxiety

disorder

(n=184;

31%)PT

SD(n=152;

11%),

adjustmentd

isorder

(n=360;

27%),

mooddisorders

(n=340;

25%).8%

ASD(n=111)

Medication

Psychotherapyor

counselin

g—unspecified

Behavioral

modification

(practicecoping

skills,exercise,

sleephygiene)

96%

RTD;4

%evacuatio

n(n=54)

65%

on1std

eploym

ent

Medicationmostcom

monly

prescribed

treatm

ent

Totaln

umberBHvisitsfor

each

person

ranged

1–16,

50%

only

1visit

41%

received

treatm

entp

lan

includingmedication

35%

givenaplan

including

psychotherapyor

counselin

g(nospecifics)

34%

received

behavioral

modification

recommendatio

ns

Nodata

Nodataon

treatm

ent

effectivenessin

war

zone

Nofollo

w-updata

afterdeployment

Nooutcom

ecomparisonof

RTDand

evacuees


Tab

le8

(contin

ued)

Study

Sam

ple

Treatment

setting

Researchdesign

Assessm

ent

Treatmentm

odality

Deploym

ento

utcome(e.g.,

RTD,clin

icalchanges,

relapse,evacuatio

n)

Postdeployment

outcom

es(PDO)

Lim

itatio

ns

(practicecoping

skills,

exercise,sleep

hygiene)

21%

(n=245)

containedno

treatm

entp

lan

Medsonly:PTSD

26%

meds

alone;ASD

9%,anxiety

32%;d

epression(30%

)Stolleretal.

(2012)

N=70

USmilitary

Iraq:n

=35

received

3-week

yoga

treatm

ent;

n=35

control

groupno

treatm

ent

Forw

ard

Operatin

gBaseWarrior,

Kirkuk,Iraq

Randomized

controlledtrial

(RCT)to

evaluatethe

effectof

sensory--

enhanced

hatha

yoga

oncombat

stress,our

prim

arystudy

objective

Pretreatm

entand

1-week

posttreatm

ent

assessment

Adolescent/A

dult

SensoryProfile

STAI

Qualityof

LifeSu

rvey

Sensory-enhanced

hathayoga

classes—

treatm

entg

roup

attended

aminim

umof

2sessions/week

andaminim

umof

9sessions

for

a3-weekperiod.

Eachclasswas

75min

long

and

taught

bythe

principal

investigator

Sensory-enhanced

hatha

yoga

was

effectivein

reducing

stateandtrait

anxiety,despite

norm

alpretestscores

Treatmentp

articipants

show

edsignificantly

greaterim

provem

entthan

controlp

articipantson

16of

18mentalh

ealth

and

quality

-of-lifefactors

Sensoryseekingwas

negativ

elycorrelated

with

allm

easuresexcept

low

registratio

n,which

was

insignificant

Nodata

Dem

and

characteristics

Nodeployment

outcom

esNolong-term,

postdeployment

follo

w-up

Noindependent

raters

Jarrett(2013)

N=3456

USmilitary

completed

training

feedback

survey

98th

Com

bat

StressControl

Detachm

ent

serving

Baghdad

5-questio

nLikert

scaleon

training

satisfaction

survey

Predeploym

entW

arrior

Resiliency

Training

(WRT)combined

with

in-theater

RationalE

motive

Behavioral

Therapy

(REBT)

classes

Participantsreported

high

meanaveragein

satisfactionoverall,

includingbeingbetterable

toidentifyPTGand

PTSD;abilityto

enhance

resilienceandPTGduring

andafterdeployment

Nodata

Nodeploymento

rPD

Ooutcom

esotherthan

posttraining

satisfaction

Externalv

alidity

Nocontrol

Nomeasuresother

than

satisfaction

Vaughan

etal.

(2015)

N=2523

USMarines

deployed

toIraq

orAfghanistan:

n=1631

Marines

from

battalio

nsreceived

OSC

AR/COSC

training

toprom

ote

resilience,

comparedto

n=892Marines

Battalio

nresilience

training

before

deployment

Nonrandom

ized

design

with

matched

control

ofunitnot

receiving

OSC

AR

Assessedpre-

and

postdeployment

afterreturning

homeon

LifeEventsChecklist

Com

batE

xperience

subscaleof

DRRI

PBQ-SR

Socialsupport

Help-seeking

Unitsupport

PCL-C

PHQ-2/8

AUDIT-C

SF-12

OSCARresilience

training

andpeer

support

Nodata

Nosignificant

groupdifference

onperceptio

nof

stress

response,

unitsocial

support;unit

cohesion,

perceptio

nof

leadership

Onlysignificant

benefitfrom

Noinform

ationon

deployment

outcom

essuch

asutilizatio

nof

frontline

psychiatry,R

TD,

evacuatio

nNolong-term

clinicaloutcom

esSamplingbias


Tab

le8

(contin

ued)

Study

Sam

ple

Treatment

setting

Researchdesign

Assessm

ent

Treatmentm

odality

Deploym

ento

utcome(e.g.,

RTD,clin

icalchanges,

relapse,evacuatio

n)

Postdeployment

outcom

es(PDO)

Lim

itatio

ns

from

battalio

nsthat

didnotreceive

OSC

AR/COSC

resiliencetraining

averageof

92days

HPQ

OSC

ARwas

increased

individual

help-seeking

OSC

ARgroup

reported

worse

clinicaloutcom

esincludinghigher

levelsof

current

stress,P

TSD,

depression,and

somatic

complaints—

although

nolevel

ofsignificance

Nosignificant

difference

betweengroups

onhigh-risk

drinking

oroccupatio

nal

impairment

Baselineand

deployment

differences

whereby

mosto

ftheOSCAR

groupwas

infantry

and

controlg

roup

prim

arily

support

personnel

AUDIT-C

Alcohol

Use

DisordersIdentificationTest-Consumption,CAQCausalA

ttributionQuestionnaire,D

ASDyadicAdjustm

entS

cale,F

ESFamily

EnvironmentS

cale,D

RRID

eploym

entR

iskand

Resiliency

Inventory,HPQHealth

Performance

Questionnaire,IESIm

pactof

EventsScale,L

EQLifeEventsQuestionnaire,M

CEIMilitary

Com

pany

EnvironmentInventory(socialsupport),N

CLE

SNegativeChildhood

LifeEventScale,OQ-45OutcomeQuestionnaire-45,PBQ-SRPeritraumaticBehaviorQuestionnaire-Self-Rating,PCL-M

PTSD

Checklist-Military

Version,P

HQ-2/8PatientHealth

Questionnaire2or

8items,PIS

PTSDInventoryScale,PSE

PerceivedSelf-EfficacyScale,PSQ

PerceivedStressQuestionnaire,U

LSUCLALonelinessScale,SCL-90-R

Symptom

Checklist-90-Revised,

SCQSo

maticCom

plaintsQuestionnaire,SF-12Sh

ortF

ormHealth

Survey,SFPProblemsinSocialF

unctioning

Scale,SSQSo

cialSu

pportQ

uestionnaire,W

CCWaysof

CopingChecklist,ZS

RDSZung

Self-RatingDepressionScale


Tab

le9

Outcomeresearch

only

ondeployed

personnelevacuated

andtreatedoutsidewar

zones

Study

War

Sam

ple

Treatmentsetting

Treatment

Treatmento

utcomes

Postdeploym

ent/long-term

outcom

esLim

itations

Yealland

(1918)

Reportedin

Linden

etal.(2013)

WWI

N=196UKsoldierstreated

during

WWI1915–1919

Queen

Square

Hospitalin

London

M=71

days

Electricshock(n

=108)

Isolation(n

=12)

Physicaltreatm

ent(massage,

baths,heatetc.):n=59

Exercises

(n=35)

Persuasion

(n=2)

12%

RTDn=23

N=88

“cured”

N=84

“improved”

N=24

noim

provem

ent

Hom

eservice:n=22

Garrisonservice:n=1

Discharge,“no

furtheruse”:n

=32

Already

discharged

from

military

service:

n=21

Nodata

Nolong-term

outcom

edata

beyond

status

inthe

military

Wild

e(1942)

WWII

50UKsoldierstreatedforwar

neuroses

atbase

hospital

Basehospital

Narco-analysis

N=33

RTD

Improvem

entinsomatic,sleep,headinjury,

anxietysymptom

s

Nodata

Nofollow-updata

Nocomparisonof

frontline

RTD

Smallsam

ple

Brooke(1946)

WWII

500UKsoldiersevacuatedfor

battleexhaustion

53%

had4–6yearsmilitary

service

Specialty

inpatient

neuroses

center

inEngland

Nodataon

treatm

enttype

2weeks

to3months.Median

53days

Cum

ulativeeffectsof

stress

45%

(27/60)relapsed

from

CSC

18%

(11/60)previously

treatedin

neuroses

centers

5 .6%

military

discharge

17.6%

RTD

76.8%

reassignment

Nodata

Dem

andcharacteristics

Nocontrol

Nolong-term,

postdeployment

follo

w-up

Nostandardized

measures

Levav

etal.(1979)

1973

Yom

Kippur

War

N=35

Israelisoldierswith

CSR

evacuatedto

rear

echelon

hospital

Authorsreportcontrolg

roup

ofn=55

soldiersevacuatedand

treatedforphysicalinjuries,

notC

SR

Note.Num

bersreported

are

estim

ates

basedon

data

presentedby

theauthors

Rearecheloninpatient

hospitalo

utside

war

zone

Military

psychiatricgrading

(e.g.,diagnosis,disability

level)

Sociopsych.grading

(e.g.,level

ofeducation,intelligence,

personality

style)

Assessm

entato

nsetof

CSR

,afterhospitaltreatment

during

war,and

18months

afterwar

ended

RTDandrelapserates—

nodata

Lengthof

treatm

entcorrelatednegativ

elywith

lowerpsychiatricgrading

Upto

1weekof

treatm

ent:

35%

oftheCSRgrouphadlower

psychiatric

grading(pooroutcom

e)65%

oftheCSRgrouphad“nochange”in

grading

Nodatareported

onim

proved

grading

After“m

ore”

than

1week(unspecified

length):

70%

hadlower

grading

30%

hadno

change

Atw

ar’send,17%

oftheCSRgroup

categorizedas

temporary

orperm

anently

unfitfor

military

service.Mostlikely

received

military

discharge

Byendof

thewar:5

5%of

the

CSR

grouphadlower

psychiatricgradingthan

atthe

onseto

fhostilities

45%

“nochange”

At1

8month

follow-up:

60%

oftheCSRgrouphadlower

psychiatricgrading

40%

“nochange”

Nodataon

controlg

roup

Nocomparisonof

soldiers

with

CSR

who

werenot

evacuatedandtreatedat

rearechelon

Assessm

entand

outcom

esreported

areunclear

Nospecificreporton

RTDor

long-term

adjustment

Russell(2006)

Iraq

4USmilitary

with

combatA

SDNavyfieldhospitalin

communication

zone

during

Iraq

invasion

Eye

movem

entd

esensitization

andreprocessing

(EMDR)

NoneRTD,allstabilizedevacuatedtostateside

hospital

All4reported

significantp

re-postreductionin

PTSD

anddepression

symptom

s

Nodata

Nofollow-updata

Nocomparisonof

frontline

RTD

Smallsam

ple

Joneset

al.(2007)

WWI

N=3580

UKsoldiersadmitted

toinpatient

NYDNCentrein

France

M=25

days

inpatient

war

zone

4Stationary

Hospital

NYDNCentre

Nodataon

type

oftreatm

ent

M=11.2

monthsin

war

zone

before

admission

40.3%

brokedownafter

6-month

CE

9%2-yearCEoldsergeants

35%

reassigned

inconvalescent

17%

RTDn=606

20%

evacuatedto

base

Ofthe606RTD,15(2.5%)werereadmitted

to4Stationary

Hospitalshortlyafterd

ischarge

n=93

(2.6%)of

thetotalsam

pleof

3580

soldiershadtwohospitaladm

issions

Nodata

Lackrandom

assignment

Onlyoutcom

emeasure

isRTD

Nocomparisonof

RTDvs.

evacuatio

ngroup


during deployment are RTD, with less than 5% evacuated. Inshort, the predominant emphasis of clinically oriented studiescoming out of war zones serves to confirm the benefit to themilitary mission by conserving the fighting force, but failsentirely to address the consequential long-term health impli-cations for deployed personnel and their families.

5. Outcome Research on Personnel Evacuated from WarZones

Table 9 reviews outcomes of deployed personnel evacuatedand treated outside of war zones (e.g., Levav, Greenfeld, &Baruch, 1979), but none of the material includes comparisonwith personnel RTD via frontline psychiatry. For instance,Yealland (1918) reported that 172 of 196 (88%) shell-shocked soldiers were favorably treated with electrical shocktherapy after being evacuated to a London hospital, including12% RTD to frontline units and 142, or 72%, of soldiersretained on military service (Linden, Jones, & Lees, 2013).During WWII, Wilde (1942) reported the clinical outcomesof 50US soldiers evacuated and admitted to a base hospital forbattle exhaustion. After receiving narco-analysis, 33 (66%) ofsoldiers were RTD (Wilde, 1942). Brooke (1946) examinedthe records of 500 UK soldiers evacuated to London-basedspecialized hospitals for battle exhaustion during WWII andreported that 18% were RTD and 77% remained on activeduty (33% discharged from the military). Levav et al. (1979)reviewed medical records for 35 Israeli soldiers during the1973 Yom Kippur War evacuated to inpatient hospitals out-side the war zone for CSR, matched to 55 veterans evacuatedfor medical reasons. An 18-month follow-up record reviewwas also conducted. The CSR group had significantly poorerhealth ratings than their medical counterparts, as well as

longer duration of stay correlating with poorer outcomes(Levav et al., 1979). Specifically, 35% of veterans with CSRhad lower psychiatric grading at the time of medical dischargeand 65% were rated as unchanged (Levav et al., 1979). Thenature and type of psychiatric treatment was not specified andoutcome measures consisted only of physician grading. Atwar’s end, 17% of the CSR group were classified as unfitfor military service and likely discharged, suggesting that83% were determined to be fit for duty (Levav et al., 1979).

Table 4 contains contemporary military studies on psy-chiatric evacuations, and treatment admissions from theUK (e.g., Turner et al., 2005) and the USA (e.g., Cohenet al., 2010) all report RTD as outcome. Historically,since WWI, poor RTD rates following evacuations andhospital admission (see Tables 2, 3, and 4) have routine-ly been interpreted by the military as evidence of indi-v i d u a l h a rm ( s e e Ru s s e l l & F i g l e y, 2 0 1 6 ) .Methodologically, all studies reviewed on evacuees haveserious methodological limitations, such as the lack ofstandardized symptom measures, inadequate or lack oftreatment details, the absence of control groups, and thelack of long-term outcomes (see Table 9). In sum, theliterature on long-term outcomes of psychiatric evacueesis sparse and methodologically flawed, thus prohibitingany meaningful conclusions. That said, the available out-come data on psychiatric evacuees is mixed with somefindings supportive of the military claims (e.g., Levavet al., 1979), with others less so (e.g., Brooke, 1946).Unfortunately, what isn’t known in the twenty-first cen-tury is how might contemporary psychiatric evacueesfare if they receive high-quality evidence-based therapies(e.g., Department of Veterans Affairs & Department ofDefense, 2010) via specialized centers.

Table 10 Protective factors for US Army personnel deployed to Iraq or Afghanistan (adapted from J-MHAT, 2013)

Survey question 2005 2007 2009 2010 2012

Unit cohesion

Unit cohesion rated as medium, high, or very high 52.6 61.0 64.1 71.5 74.1

Morale

Individual morale rated as medium, high, or very high 68.4 52.5 57.5 49.9 47.0

Unit morale rated as medium, high, or very high 60.5 48.7 44.3 45.3 34.5

Leadership

Officer leadership rated as medium, high, or very high 41.9 48.8 50.2 54.5 43.9

Enlisted leadership rated as medium, high, or very high 41.9 48.4 46.1 51.5 47.1

Resilience

The training in managing the stress of deployment and/or combat was adequate No data No data No data 56.4 49.9

Posttraumatic growth

I feel pride in my accomplishments during this deployment 68.0 52.3 57.0 57.6 52.1

Deployment made me more self-confident 63.3 50.1 41.7 39.7 33.3

I deal with stress better because of this deployment 31.4 22.8 25.7 24.3 25.8


Tab

le11

Meta-analyses

andsystem

aticreview

ofrisk

factorsforcombat-relatedPTSD

Study

Design

Sample

Major

findings

Lim

itatio

ns

Kulka

etal.

(1990)

NationalV

ietnam

VeteransReadjustm

ent

Study—

natio

nalp

robabilitysampling

andinterviewresearch:p

relim

inary

valid

ation,clinicalinterviews,

andfamily

interviews

N=3016

totalinterview

s:n=344Vietnam

theatervets;

n=474spouse

interviews;n=96

Vietnam

eravets

Exposureto

war

stress

significantly

relatedto

combatP

TSD

independent

ofprecom

batp

redisposingfactors

PTSDsignificantly

higher

inVietnam

theatervs.era

vets

Prem

ilitary

child

hood

adversity

;depression,substance

abusehigher

inVietnam

theatervets

Dosageeffectof

levelo

fcombatexposureand

severity

ofpostwar

readjustmentp

roblem

sReadjustm

entp

roblem

ssignificantly

relatedto

war

stress

exposure,P

TSD

,substance

abuse,

andserviceconnecteddisability

Nonrandom

ization

Retrospectiv

eanalysis

Verificationof

reported

combat

exposure

oftheatervets

Brewin

etal.

(2000)

Meta-analysisof

risk

factors

forPT

SD

77studieson

military

(n=28)and

nonm

ilitary

populatio

nsTraum

aseverity

was

strongestriskfactor

during

andaftertraumafollo

wed

by:

Lackof

socialsupport

Posttraumalifestress

Weakeffectsforpretraum

afactors

Heterogeneity

ofstudieswith

regard

tosampling,design,

measurement,statistical

analysis,and

resulting

effects

Ozeretal.

(2003)

Meta-analysisof

studieson

predictors

ofadultP

TSD

68studiesmetinclusioncriteria,

17involvingmilitary

veterans:7

predictors:p

rior

trauma,priorpsychological

adjustment,

family

mentalh

ealth

history,

perceivedlifethreat,posttraumasocial

support,peritraumaticem

otional

response,and

peritraumatic

dissociatio

n

Allpredictorsyieldedsignificanteffectsizes

Peritraumaticdissociatio

nstrongestp

redictor

Socialsupporth

adsm

alltomedium

effect

Weakestpredictorswerefamily

history,prior

trauma,andprioradjustment

Overrelianceon

retrospective

self-report

Self-reportand

recallbias

Lackof

prospectivestudies

Variabilityin

defining

and

measuring

variables

Levelof

exposure

(com

bat)

was

notanalyzed

Zohar

etal.

(2009)

Semiprospectiv

estudyof

demographic,

prem

ilitary,precombatfactors,and

military

risk

factorsassessed

2years

priorto

military

serviceandafter

deployment

2362

Israeliw

arveterans

diagnosedwith

combatP

TSD

,matched

with

2323

veterans

notd

iagnosed

with

PTSD

Socialfunctio

ning,m

otivation,training,

pre-military/pre-traum

arisk

factorsall

foundto

beinsignificantinpredictin

gPT

SD

Ceilin

geffectfrom

stigma,Ex.

“Hidden-PT

SD”in

control

groupwhere16%

eventually

diagnosedwith

PTSD

;Com

batexposuretype,

intensity,and

duratio

nnot

assessed

Pietrzaketal.

(2009)

Retrospectiv

e,nonrandomized

mailin

gof

surveysto

1000

veterans

28.5%

response

(N=272)

from

US

OEF/OIF

veterans

1–4yearsafter

military

discharge

Resilience

scores

correlated

negativ

elytoPTSD,

depression,and

psychosocialproblems

CEcorrelated

negativ

elywith

postdeployment

socialsupportand

positiv

elyforPTSD

,depression,socialp

roblem

sResilience-m

ediatedunitsupportand

PTSD

and

depression

Unitsupportpredictedincrease

postdeployment

socialsupport

Samplingbias

Reportand

recallbias

from

retrospectiveself-report

Lim

itedgeneralizability

dueto

lowresponse

rate

Lim

itedassessmento

fspectrum

ofwarstressinjury

(e.g.,substanceabuse)

10.8%

diagnosedwith

newonsetP

TSD


Tab

le11

(contin

ued)

Study

Design

Sample

Major

findings

Lim

itatio

ns

Phillips

etal.

(2010)

Prospectivestudyof

demographic,pretrauma

risk

factors,anddeploymentriskfactors

before

andafterdeployment

706USMarinerecruitsevaluated

before

andafterdeploymentand

combatstressexposure

Com

batexposuretype

(e.g.,threatof

death,

exposure

toviolence)was

thestrongest

predictorof

PTSD

than

otherdeployment,

postdeployment,andpretraum

arisk

factors

Levelof

postdeploymentsocialsupport

reducesrisk

ofPT

SD

Samplingbias

ofself-selected

volunteers

Use

ofnonanonymoussurveys

Low

response

rate(13%

)Ceilin

geffectsfrom

stigmaand

fearsof

career

reprisal

PTSDsymptom

snotassessed

priorto

deployment

Elbogen

etal.

(2012)

Cross-sectio

nal,random

samplingfor

natio

nalsurveyby

theDepartm

ento

fVeterans’Affairs

N=1388

(56%

)of

3000

OEF/OIF

USveterans

completed

mailed

surveys

20%

metPTSD

criteriaand27%

alcohol

abuse;33%

reportviolentactin

community

;11%

severe

violence

Increase

risk

ofviolence

linkedto

CE,

youngerage,PTSD

,alcohol,criminalarrest

Decreased

risk

ofviolence

linkedto

olderage,

levelo

fsocialsupportand

resilience

Generalizability

limitedby

design

Lacking

longitu

dinal

assessmento

fprotectiv

efactors

Targetof

violence

notassessed

Noreportinglevelo

fviolence

experiencedduring

deployment

Ram

chandetal.

(2015)

Reviewof

literature2009

to2014

onrisk

factorsfor

combat-relatedPTSDandothermentalh

ealth

(MH)

diagnosesin

military

personneld

eployedto

Iraq

and

Afghanistan.A

lsoanalyzed

treatm

entseeking

vs.

nontreatmentseeking

48USstudieson

military

personnel;56

studieson

USveterans

10non-USstudieson

military

personnel;4studieson

non-USveterans

0–48%

PTSD

ratesin

nontreatmentseeking

samples;2

–68%

intreatm

entseeking

4–45%

depression

ratesin

deployed

samples

4–60%

alcoholabuse

indeployed

samples

Com

batexposurestrongestp

redictor

ofallM

Hproblems

Multip

ledeploymentsincrease

PTSD

Low

ersocialsupportd

uringandafter

deploymentincreaserisk

inMHproblems

<50%

who

reported

they

need

treatm

ent,receive

itCom

bat-PT

SDsignificantly

relatedto

poor

physicalhealth,suicidalideation,dyingby

suicide,depression,substance

abuse,

aggression,and

crim

inaloutcom

es

Manystudiesdo

notcontrol

forcombatexposure

Significantv

ariatio

nin

methodologicalrigor

and

measurement

Inadequatelongitu

dinald

ata

Xue

etal.(2015)

Meta-analysisof

combatP

TSD

risk

factors

32studiesaccepted

outo

f2657

screened;2

7risk

factorsevaluated

Levelof

combatexposuregreatestrisk

factor

forcombatP

TSD

Psychiatrichistory,lifestress,pretraumahistory

notsignificant

predictors

Inconsistent,but

strong

findingof

postdeploymentsocialsupportandlower

PTSDrisk

Heterogeneity

ofstudieswith

regard

tosampling,design,

measurement,statistical

analysis,and

resulting

effects

Inclusionof

observational

studiesonly

relyingon

self-report


Summary of Partial Evidence of FrontlinePsychiatry’s Health Benefits

Of the partial studies reviewed on frontline psychiatry’s healthbenefits, we found mixed empirical support for the military’sclaims of mutual benefits. The most positive line of inquiriessupportive of frontline psychiatry involves military studiesfocusing exclusively on reporting deployment-related out-comes (i.e., symptom reduction; RTD) of veterans receivingeither frontline psychiatry alone (Table 7) or in conjunctionwith BH treatment (Table 8). Overwhelmingly, these researchlines emphasize RTD as a primary outcome measure and findhigh RTD rates (96–100%) and low evacuation rates (1–8%).Similarly, it is also routine for military researchers to focuspredominantly on immediate short-term clinical (i.e., symp-tom reduction) and dispositional (e.g., RTD) gains at the al-most universal exclusion of long-term outcomes of war zonefrontline psychiatry (Tables 2, 3, and 4; Tables 5, 6, 7, 8, and9). This trend is consistent with the only other review of front-line psychiatry (Jones &Wessely, 2003). Consequently, Jonesand Wessely (2003) openly questioned the objectivity andveracity of military research on its frontline programs.Moreover, several classified investigations by UK and USauthorities during WWII cited major discrepancies betweenthe reported effectiveness of frontline psychiatry and undis-closed high relapse rates (e.g., Jones & Wessely, 2003).

To the lay public, reports of 95–100% RTD imply that de-ployed personnel have access to highly effective mentalhealthcare. However, many of the results from our review sug-gest the contrary. For example, the only nonmilitary investigationinto frontline psychiatry (Vaughan et al., 2015) reported poorerpostdeployment outcomes for unitmembers after receiving front-line psychiatry services (OSCAR) compared to those who didnot participate. Although methodological limitations do not per-mit causal inferences, that independent RAND researchers foundadverse outcomes from frontline psychiatry is worrisome.Moreover, extensive research on CSR and frontline psychiatryby the world’s leading experts, the IDF (see Table 6), indicatesthat CSR alone represents a significant risk factor for a host ofnegative individual and family outcomes regardless if veteransreceive frontline psychiatry or not, and repeated CSR results inpoorer outcomes (see Table 6). With regard to family outcomes,the only research we could find that examines potential healthbenefits for family members from frontline psychiatry was con-ducted by the IDF (e.g., Solomon, Waysman, Levy, et al., 1992;see Table 6). Those studies reveal that CSR in deployed familymembers is significantly related to developing PTSD and otherproblematic health conditions (e.g., drinking) that, in turn, issignificantly associatedwithmultiple adverse outcomes for spou-sal health, including secondary traumatization (e.g., Solomonet al., 1992), as well as impaired couple and family functioningirrespective if deployed members were treated via frontline psy-chiatry or not (e.g., Solomon, Waysman, Levy, et al., 1992).T

able12

Percentagree

orstrongly

agreeon

war

zone

stigmaandbarriersin

Afghanistan

(adapted

from

J-MHAT,

2013)

Survey

questio

n2003

Arm

y(M

HAT-I).

Screenedpositiv

efora

MHdisorder—Iraq

(%)

2003

Arm

y(M

HAT-I).

Not

screened

positiv

eforMHdisorder—Iraq

(%)

2013

Arm

y(J-M

HAT,

2013).Screened

positiv

eforaMH

disorder—Afghanistan

(%)

2013

Arm

y(J-M

HAT,

2013).Not

screened

positiv

eforMH

disorder—Afghanistan

(%)

2004

Arm

yPost-Deploym

ent

Survey(H

ogeetal.,2006).Married

Soldiersscreened

positiv

efora

MH

disorder—USA

Soldiers(%

)Spouses

(%)

Iwould

beseen

asweak

5929

4723

7722

Itwould

harm

mycareer

(orspouses’career)

Not

asked

Not

asked

4017

5621

Myunitleadership

might

treatm

edifferently

5829

3922

63(H

ogeetal.,

2004)

N/A

Myleaderswould

blam

emefortheproblem

4614

3614

51(H

ogeetal.,

2004)

N/A

Myleadersdiscourage

theuseof

mentalh

ealth

services

Not

asked

Not

asked

204

8(H

ogeetal.,2004)

N/A

There

would

bedifficulty

getting

timeoffworkfor

treatm

ent

4616

4617

6143


Lastly, the partial line of research on evacuee outcomes (Table 9)indicates that military claims of significant harm caused by evac-uation and psychiatric treatment are empirically supported pri-marily whenRTD is the desired outcome (see Tables 2, 3, and 4).Otherwise, long-term outcome data on psychiatric evacuees arenearly nonexistent. When examined, the overall empirical sup-port for frontline psychiatry along the partial lines of inquiryreviewed is tenuous.

We next examine the indirect evidence that underlies themilitary’s health benefit claims. Specifically, we briefly re-view the research on protective social factors, stigma, andprevention of war stress injury, like PTSD, that reportedlyjustifies sustaining the frontline psychiatric doctrine.

Indirect Evidence of Frontline Psychiatryand Protective Factors

Since its WWI inception, frontline psychiatry’s emphasis onpreventing psychiatric evacuations has been heralded as thecenterpiece for military’s humane approach in managing warstress casualties by avoiding harm caused by social disrup-tions that undermine resilience and mental health (e.g.,Martin & Cline, 1996). Yet, no study has ever examined thedifferential impact of protective factors, such as social sup-port, unit cohesion, leadership, and morale, on military per-sonnel RTD via frontline psychiatry compared to those evac-uated for treatment outside war zones (see Tables 2, 3, 4, 5,and 6). As reviewed earlier (Russell & Figley, 2016), the USmilitary’s frontline psychiatry/COSC programs involve train-ing leaders and unit members on ways to prevent war stresscasualties (e.g., Jones et al., 2012). Table 10 provides a de-scriptive snapshot of the kinds of protective and resilient fac-tors surveyed in the war zones of Afghanistan and Iraq by theUS Army’s MHAT survey teams. Although this constitutesvaluable information for senior leaders in monitoring troopwell-being and the capacity to fight and win wars, it doesnot represent applicable data for justification of RTD of psy-chiatric casualties to promote the health and well-being ofindividual service members.

Research on Unit Cohesion, Morale, and Leadershipin Reducing War Stress Casualties

The US military regularly cites research from WWII demon-strating the significant impact of unit cohesion, morale, andleadership in reducing incidence of CSR/COSR casualties andPTSD, as well as enhancing military performance (e.g., Jones,1995a; Solomon et al., 2005). A retrospective IDF study afterthe 1973 Yom Kippur War reported that veterans diagnosedwith CSR at the frontlines had lower morale than veteranswithout CSR (Steiner & Neuman, 1978), and meta-analyses

of military research indicate that cohesion is positively corre-lated with job satisfaction, retention, sense of well-being, andless disciplinary problems (Oliver, Harman, Hoover, Hayes, &Pandhi, 1999), as well as lower levels of psychological dis-tress (Ahronson & Cameron, 2007). The importance of unitcohesion and social support is illustrated by Stouffer et al.(1949), who described that BThe men in my squad were myspecial friends^ (p. 99).

Protective Factors of Cohesion, Leadership, and Moralein Elite Forces

The military regularly avows that the Special Forces havehistorically produced the highest levels of cohesion, morale,and leadership, coinciding with the lowest rates of psychiatriccasualties among military groups (e.g., Jones, 1995b). Suchclaims add credence to the health-promoting value frompreventing psychiatric evacuations. In addition, IDF re-searchers reported similarly low PTSD rates in decorated vet-erans (Dekel, Solomon, Ginzburg, & Neria, 2003), implyingthat membership to elite status may be a protective variable.However, caution is warranted in overinterpreting the protec-tive benefits of cohesion and the like, especially consideringheightened stigma active-duty elite personnel experience inself-disclosing stress symptoms (e.g., Hing, Cabrera,Barstow, & Forsten, 2012). For instance, a recent anonymoussurvey of US Army Special Operations Forces personnel re-veals PTSD rates of 16–20%, nearly doubling the prevalencerate reported by regular Army soldiers and contradicting as-sertions of Bhyper-resilience^ (Hing et al., 2012). Similarly,the US Army’s summary of the 1982 Lebanon War,BDespite high morale and a good deal of attention given bycommand to morale and the factors maintaining it, the IDFstill suffered relatively high rates of psychiatric casualties dur-ing the war in Lebanon^ (Belenky et al., 1983, p. 22).

Everything said, there is no dispute that factors such ascohesion, morale, and leadership can be beneficial insupporting the mental health of deployed service members.However, this does not automatically translate to better long-term health outcomes for personnel RTD after experiencingwar stress injury and/or diagnosed with psychological disor-der in war zones. Researchers often make the distinction be-tween delayed presentation and delayed onset with regard toPTSD, with the former often involving the toleration versusabsence of symptoms (e.g., Solomon, Mikulincer, &Waysman, 1991). For instance, IDF researchers found theso-called delayed onset of PTSD in 16.5% of combat veteransafter leaving military service who were never diagnosed withCSR on active duty (Horesh et al., 2011). Another IDF studyused the term hidden-PTSD to account for 16% of combatveterans who refused to self-disclose symptoms largely outof fear of stigma and career reprisal (e.g., Zohar et al.,2009). Several authors attribute significant escalation in


veterans diagnosed with mental health problems after militaryservice to phenomena such as diminished levels of protectivesocial support and decreased fear of career reprisal (e.g.,Camp, 2014; Kulka et al., 1990). Therefore, it is reasonableto assume that, at least in some if not many cases, the imme-diate protective benefit from unit support, cohesion, and lead-ership even in the military’s elite forces may erode afterreturning deployed personnel relocate to other units, retire,or separate from the military.

Research on Risk and Protective Factorsfor Combat-Related PTSD

Table 11 contains etiologic research on risk and protectivevariables for combat-related PTSD, revealing that the levelof perceived social support is reliably the best predictor forresilience and the second strongest risk factor for combat-related PTSD after cumulative exposure to war stress.Importantly, the PTSD protection/risk factor of perceived lev-el of social support typically measures postdeployment socialsupport from spouses, family, friends, and community, as op-posed to social support during deployment (e.g., Brewin,Andrews, & Valentine, 2000; Kulka et al., 1990; Ozer, Best,Lipsey, & Weiss, 2003). Unfortunately, no studies have com-pared the purported social protective variables betweengroups of veterans RTD via frontline psychiatry versus thoseevacuated.

Contemporary Research on Unit Cohesionand Social Support

Research on the protective benefits from unit cohesionand deployment-related social support appears to bemixed. Most empirical findings of predictors for combatPTSD, as reflected in Table 11, report that the level ofsocial support in the postdeployment environment (e.g.,family, friends, and community) constitutes the most reli-able indicator of resilience (e.g., Brewin et al., 2000; Ozeret al., 2003; Phillips, LeardMann, Gumbs, & Smith,2010). However, recent military studies from the UK(e.g., Du Preez, Sundin, Wessely, & Fear, 2012) and theUSA (e.g., Armistead-Jehle, Johnston, Wade, & Ecklund,2011; Pietrzak et al., 2009) indicate that high levels ofunit cohesion are associated with lower probability ofpostdeployment mental health diagnoses, includingPTSD, with the exception of one US finding that onlythe deployment variable of high morale was a significantbuffer against combat PTSD, not unit cohesion or patriot-ism (Whitesell & Owens, 2012). Additionally, Han et al.(2014) concluded that postdeployment social support wasa stronger buffer against combat PTSD than unit social

support during deployment. Others observed how lowlevels of perceived social support both during and afterdeployment are significantly related to mental healthproblems (e.g., Ramchand, Rudavsky, Grant, Tanielian,& Jayconx, 2015). The relative protective benefit fromunit cohesion, morale, leadership, social support, etc. isnot in question. The critical matter at hand is the fact thatnone of the studies in Table 11 compare outcomes ofdeployed personnel RTD via frontline psychiatry to thoseevacuated out of war zones. We are left with overgener-alization and inferences that service members RTD farebetter in the long term than evacuees because of the pro-tective influence of unit cohesion, morale, and leadership.

Logical Inconsistencies of Beneficial Claims of RTDand Social Protective Factors

Several logical contradictions exist regarding the military’s asser-tion about the iatrogenic effects of disrupted social ties frompsychiatric evacuations, such as (a) the fact that unit membership(social ties) is constantly disrupted via the mobility of militarylifestyle, requiring frequent changes in duty stations every 3 to4 years, thus undercutting the resilience narrative; (b) extensivereliance on individual augmentees (IA) during the current wars inAfghanistan and Iraq, whereby individuals routinely deploy fromdifferent organizations and return home separately from theircombat buddies without significant differences in mental healthoutcomes as reported by the MoD (e.g., Sundin et al., 2012) andDoD (e.g., Granado et al. (2012); (c) evacuated personnel arerestoring social ties with family, friends, undeployed coworkers,and support staff (e.g., mental health professionals, chaplain,etc.), of which research has demonstrated is the single best pre-dictor of resilience (e.g., Brewin et al., 2000; Phillips et al., 2010);and (d) the overwhelming majority (90 to 95%) of military per-sonnel evacuated out of war zones are due to medical reasons(e.g., Cohen et al., 2010), and they must similarly endure disrup-tions in hypothesized war zone protective factors, yet there is nocomparison in the intensity by which the military restricts med-ical evacuations.

Evidence That RTD Prevents Harmful Effectsof Stigma, Shame, and Guilt from Evacuation

BEvacuees had to deal with the stigma and shame of evacua-tion out of the theater. However, if psychological casualtieswere treated at forward locations with brief supportive therapyand the expectation of return to duty, between 60% and 80%could continue as soldiers^ (Ritchie, 2007, p. 12). This is along-standing and central argument used by the military sinceWWI to justify its frontline psychiatry policies of RTD andpreventing evacuation syndromes (e.g., DOA, 2006).


However, the claim appears to be factually baseless. Evidencesupportive of the military’s assertion is entirely dependentupon broad generalizations from research related to work per-formance and PTSD protective factors, like unit cohesion,morale, leadership, and social support reviewed earlier. Noresearch has ever compared the differential experience ofmental health stigma, shame, and guilt of deployed personnelRTD and return home with their units versus those evacuatedand treated at psychiatric facilities outside war zones. Asdepicted in Table 4, the clear majority (e.g., 90 to 95%) ofpersonnel evacuated out of war zones are for medical and notpsychiatric reasons. Many of those service members may like-wise experience stigma, shame, and guilt over being wound-ed, injured, or sick and leaving their combat buddies behind(e.g., Stouffer et al., 1949). Therefore, stigma, shame, andguilt are not unique to psychiatric evacuees, yet evacuationpolicies are nowhere as restrictive for nonpsychiatricevacuees, thus reflecting a certain bias. Moreover, attitudestoward combat exposure and stress injury may differ per theperspective of warfighters and nonwar fighters. For example,during WWII, Stouffer et al. (1949) conducted a series ofsocial psychological studies on veterans, including the onlystudy we could find that speaks about the issue of possibleshame, guilt, and stigma in psychiatric evacuees. Per Stoufferet al. (1949), BPresumptive evidence of this lies in the indica-tions of guilt feelings among men who were out of combatwhile their comrades were still fighting^ (p. 136). There is awide array of circumstances responsible for separating vet-erans from their frontline units, and the experience of shameor guilt is not at all unique to evacuated psychiatric casualties.If, however, psychiatric evacuation invokes some exceptionaltype or intensity of shame, guilt, and stigma above and beyondthat experienced by personnel evacuated for other reasons, thephenomena should be researched.

With regard to stigma associated with psychiatricbreakdown and possible evacuation, again we refer toWWII research. In an attitude survey, 1766 infantry sol-diers in Italy after 5 months of combat exposure wereasked BWhat do you think should be done to a man whocracks up mentally at the front?^ (Stouffer et al., 1949). Inresponse, 86% of combat veterans answered, Bhe shouldbe given medical treatment,^ whereas only 3% endorsedeither Bhe should be court martialed^ or Bhe should bemade to go right back to combat^ (Stouffer et al., 1949).Similarly, Momen, Strychacz, and Virre (2012) recentlysurveyed 553 US Marines about CSR and found that70.5% believe CSRs are treatable, 68.2% normal reac-tions, and 57.4% thought they can be individually man-aged; however, 46.7% personally feared career repercus-sion if diagnosed with CSR. Whether such seemingly pro-gressive nonstigmatizing attitudes are conveyed to, or per-ceived by their peers as such in those who might be psy-chiatrically evacuated is another matter, but it does raise

questions over the legitimacy of military concerns overharmful stigma caused by violating its RTD policy.

Contemporary Research on Prevalence of Stigmaand Barriers to Care

Table 12 illustrates the prevalence of mental health stigmaand barriers to care in the war zones of Iraq andAfghanistan as well in the USA. The general trend is fora slight lessening of stigma and barriers to seeking care inthe war zones (e.g., MHAT, 2003; J-MHAT, 2013) andincreased stigma back home (e.g., Hoge, Castro, &Eaton, 2006). The US Army credits frontline psychiatry,including embedded mental health specialists in opera-tional units (e.g., Army division, Navy aircraft carriers,Marine OSCAR), as being a main contributor in reducingwar zone stigma (e.g., J-MHAT, 2013). The evidencewould seem to partially support that position. However,per the Department of the Army (2006), modern-dayCOSC programs are active throughout the entire deploy-ment cycle and the military has permanently embeddedmental health specialists in air wings, army divisions,and air craft carriers for decades (e.g., Russell & Figley,2016). Reducing stigma and barriers to care is a designat-ed function of today’s COSC program (e.g., Departmentof Navy & U.S. Marine Corps, 2010). Therefore, otherfactors than the presence of forward deployed mentalhealth services may be responsible for incremental reduc-tions in war zone stigma. Regardless, caution is warrantedin overinterpreting the military’s frontline psychiatry suc-cess in reducing war zone stigma. For example, in 2013,47% of deployed personnel who screened positive for amental health disorder, such as PTSD, depression, or anx-iety, reported reluctance to seek mental health treatmentfor fear of being weak (J-MHAT, 2013). Similarly, 40%feared career reprisal, 39% believed their unit leadershipwould blame them for their mental health condition, 46%reported difficulty getting time off to see a specialist and,perhaps most alarmingly, 20% reported unit leadershipactively discouraged seeking mental healthcare (e.g., J-MHAT, 2013).

Per Table 12, oppressive levels of stigma both within andoutside of war zones appear to negate the military’s claim thatfrontline psychiatry avoids harmful stigma by preventing psy-chia t r ic evacuat ion. Moreover, the GovernmentAccountability Office (2016) recently reported that significantstigma and organizational barriers to seeking mentalhealthcare widely persists in the DoD, despite repeated rec-ommendations from six independent investigations. In otherwords, whenever military personnel develop a war stress in-jury or mental health problem, they face potential harm fromstigma and organizational bias, regardless if RTD or evacuated


from war zones or never deployed. On the other hand,Table 12 also suggests that stigma is slightly greater at homethan abroad, so one may technically cite greater stigmata ef-fects for personnel evacuated back home. However, without acomparison of the stigmata effects experienced by nonpsychi-atric evacuees and/or deployed personnel RTD who subse-quently develop war stress injury (e.g., PTSD), any assertionthat frontline psychiatry helps individuals avoid harmful stig-ma by preventing evacuation is not yet substantiated. Thehypothesis is worthy of investigation, and the health benefitsfor service members require that this happens.

Evidence That Frontline Psychiatry Prevents Harmfrom Career Loss

Since WWI, psychiatric evacuation to hospitals outside the warzone has been associated with increased risk of military dis-charge, which in large part led to the military’s adoption of front-line psychiatry in the first place (see Russell & Figley, 2016). Forexample, after scouting the British Army’s management of warstress casualties before the USA entered WWI, Salmon (1917)reported that 79% of British soldiers were discharged from themilitary after being evacuated and admitted to UK general hos-pitals and insane asylums for conditions like Bshell shock.^Military personnel discharged early from the military for anyreason (physical or mental health) were reported to have higherlevels of mental health problems than personnel transitioning atthe end of their service contracts (Buckman et al., 2012).Therefore, concerns over potential harm from premature militarydischarge appear justified.

Contemporary Research on Military Hospitalizationsand Discharge

In contemporary US military settings, psychiatric disorder isconsistently the leading category of discharge diagnoses formilitary separation. For example, Hoge et al. (2002) reportedthat nearly 50% of nondeployed service members hospital-ized for a psychiatric disorder received a military dischargewithin 6 months, compared to only 12% of personnel hos-pitalized for any of 15 other major illness categories (regard-less of age, gender, or length of service). Similarly, a 2005study reported that 45% of US military personnel whosedeployment status was unreported were separated from themilitary for any reason within 6 months of their psychiatricadmission, as compared to 11% of discharges followingmedical justification (Hoge et al., 2005). In other words, amental health diagnosis, irrespective if deployment related ornot, places service members at risk for early military dis-charge. Possible explanations for the vastly disproportionaterate of psychiatric and medical discharges include mentalhealth stigma, personality disorder, pre-existing mental

health condition, and/or related behaviors incompatible withmilitary service, such as misconduct, substance abuse, andsuicide gestures (e.g., Hoge et al., 2005). Importantly, noneof these studies specifically examined the role of psychiatricevacuations and hospital admission from war zones. In fact,there is no research comparing postdeployment military sep-aration rates between service personnel RTD via frontlinepsychiatry and those evacuated and treated in mental healthfacilities (see Table 9).

For instance, Hoge, Auchterlonie, and Milliken (2006) foundthat 20.8% of OEF veterans and 21.4% of OIF veterans weredischarged from the military within 1 year after endorsing psy-chiatric symptoms on a postdeployment health assessment(PDHA) suggestive of conditions like PTSD. It bears mention-ing, however, that the subjects in the study all returned homewiththeir deployed units as opposed to obtaining psychiatric evacua-tion. It is unknown what percentage of discharged OEF/OIFveterans were RTD via frontline psychiatry and what percentageof those who screened negative on PDHAwere later diagnosedwith a war stress injury or the comparative military separationrates for successful treatment completers. The latter is particularlyrelevant given reports by the architect of the US military’s WWIfrontline psychiatry doctrine, who reported that 60% of Britishsoldiers were eventually RTD to their units after receiving properspecialized treatment outside the war zone (Salmon, 1917).

Fur thermore , a contemporary US analys i s ofpostdeployment hospitalizations for both medical and mentalhealth reasons found that deployed service members overallhad a lower risk of hospitalization when compared withnondeployers (Smith, LeardMann, Smith, Jacobson, &Ryan, 2009). Thus, personnel evacuated out of war zonesfor psychiatric reasons may engender less risk for hospitaliza-tion and possible military discharge than those never de-ployed. In addition, UK researchers reported that individualsprematurely discharged from the military for psychiatric rea-sons were significantly less likely to have been deployed(Buckman et al., 2012).

Taken together, there appears to be considerable evidenceagainst the automatic assumption that psychiatric evacuees areinherently at greater risk of harm from losing their militarycareers than those RTD. The bottom line is that we simply donot know the true state of affairs because the issue has yet to beinvestigated. In sum, the most accurate conclusion that can bereached is that deployed US personnel with a diagnosable warstress injury are at high risk of military discharge whether theyare RTD or evacuated for psychiatric treatment. The reasonsbehind this apparent outcome might relate to mental healthstigma and bias, as well as inadequate access to quality mentalhealth treatment (e.g., Institute of Medicine, 2014a).Therefore, until head-to-head comparisons of deployed per-sonnel RTD and evacuated are conducted, any claim thatfrontline psychiatry benefits military members and their fam-ilies by preventing career loss is unsubstantiated.


Evidence That Frontline Psychiatry and RTDPrevents War Stress Injury like PTSD

One of the military’s most frequently cited individual healthbenefits from frontline psychiatry is that RTD prevents orreduces the risk of long-term harm from developing condi-tions like PTSD. As mentioned earlier, the direct empiricalbasis of such claims is essentially comprised of a single lon-gitudinal IDF study from the 1982 Lebanon War, in whichlower PTSD rates were reported in Israeli veterans RTD afterreceiving frontline treatment as compared to veterans evacu-ated to rear hospitals (e.g., Solomon & Benbenishty, 1986;Solomon et al., 2005). Missing, however, is any informationon the nature, quality, and effectiveness of the psychiatrictreatment the hospitalized evacuees had received.Furthermore, the IDF findings often did not reach statisticalsignificance, as more than half (52%) of those RTD via front-line psychiatry developed PTSD within a year as compared to66% of soldiers evacuated to a general, nonmilitary hospital(e.g., Solomon & Benbenishty, 1986; Solomon, Weisenberg,Schwarzwald, et al., 1987). Furthermore, as evident inTable 6, the IDF’s extensive outcome research on CSR andfrontline psychiatry reveals that CSR is robustly associatedwith a host of chronic adverse health effects, includingPTSD, irrespective of whether combatants receive frontlineor hospitalized interventions. For example, Solomon andBenbenishty (1986) reported that 52% of Israeli soldiers diag-nosed and treated for CSR via frontline psychiatry developedPTSD.

More recently, two independent reviews of the USmilitary’s PTSD prevention programs were conducted by theInstitute of Medicine (IOM, 2014b) and RAND (Weinicket al., 2011). They examined frontline psychiatry/COSCBattlemind resilience training, and Comprehensive SoldierFitness resilience and posttraumatic growth training programs,respectively. Both agencies found little empirical support forthe military’s prevention programs (IOM, 2014b; Weinicket al., 2011). According to the IOM (2014b), BAssessmentsof DOD programs conducted by this committee and othersshow that a majority of DOD resilience, prevention, and rein-tegration programs are not consistently based on evidence andthat programs are evaluated infrequently or inadequately^ (p.166). They concluded that BFinally, the committee found lim-ited ongoing evaluation to inform program areas lacking evi-dence, and a clear need for longitudinal follow-up assessmentto determine the impact of resilience, prevention, and earlyintervention efforts^ (p. 166). Similarly, RAND researchersreported BPrograms are evaluated infrequently-fewer thanone-third of programs in any branch of service reported hav-ing had an outcome evaluation in the past 12 months^(Weinick et al., 2011, p. xvii). The general absence of outcomeresearch and data as reported by the agencies seriously under-mines the veracity of military claims that frontline psychiatry

is evidence-informed in terms of reducing risk of PTSD orother war stress injury.

Evidence That RTD via Frontline PsychiatryEnhances Posttraumatic Growth

Lastly, contemporary frontline psychiatry/COSC policy adver-tises that the benefits to service members include enhancingPTG (DOA, 2006; see Russell & Figley, 2016). Tedeschi(2011) cited evidence of PTG in various studies of combat vet-erans from the Vietnam, Yom Kippur, and Persian Gulf Wars.The veterans reported positive life outcomes following traumaticamputation, TBI, severe PTSD, and being a prisoner of war. ThatPTG is one possible pathway for war veterans is not disputed.The issue, however, is whether frontline psychiatry enhancesPTG, as the military purports. To that end, commissioned studiesof the military’s prevention programs by RAND (Weinick et al.,2011) and IOM (2014b) concluded that there is no evidence ofefficacy in prevention programs like the US Army’sComprehensive Soldier Fitness training in facilitating PTG.Moreover, no research has ever been conducted on PTG andRTD via frontline psychiatry (see Tables 2, 3, 4, 5, 6, 7, 8, and9). Similarly, there has been no research on PTG in psychiatricwar zone evacuees. Therefore, any claim that frontline psychiatrypromotes PTG is unsubstantiated.

Conclusions on the Health Benefits to MilitaryPersonnel and Their Families

In sum, the first-ever systematic review of the military’s 100-year-old mental health doctrine provides evidence that the soleempirically tested benefit of frontline psychiatry involvespreventing psychiatric attrition fromwar zones and thus conserv-ing the fighting force. This research outcome is conducive to theprimary mission of the military, i.e., to fight and win wars. Withregard to the military’s claim that frontline psychiatry is mutuallybeneficial to deployed personnel and their families, we could findno credible evidence to reliably support any of the advertisedhealth-promoting benefits. In fact, trends were identified thatappear to neutralize or even contradict most of the military’sclaims. There has been no effort to properly investigate thelong-term health impact from the military’s frontline mentalhealth policies. Instead, the vast bulk of military outcome re-search has narrowly focused on maximizing RTD and restrictingevacuations. Instead of any direct testing of the long-term healthconsequence from its frontline doctrine, the US military has re-lied extensively on anecdotal reports and on unsubstantiated nar-rative. We will examine other trends that filter out of the researchin our final evidentiary review of potential harm arising out of themilitary’s frontline psychiatry doctrine.


Acknowledgements We thank David Gellman for his assistance withthe literature review. This study was unfunded.

Compliance with Ethical Standards

Conflict of Interest The authors declare that they have no conflicts ofinterest.

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