Army Assesses Behavioral Health of Soldiers in Iraq

Lt. Gen. (Dr.) Kevin C. Kiley, the Army's surgeon general, established an Operation Iraqi Freedom mental health advisory team in July to assess behavioral health of soldiers in the Army's second wave of troops deployed to Iraq. A similar team -- called MHAT-I for short -- studied the Army's first Operation Iraqi Freedom deployment that kicked off in March 2003.

Besides taking "snapshots" of the behavioral health situation, the charter for both teams included recommending improvements, said Col. Virgil J. Patterson, chief of the Soldier and Family Support Branch at the Army Medical Department Center and School, Fort Sam Houston, Texas. Patterson headed both MHATs. The second team also followed up on the first team's report, he said.

"We had made a number of recommendations," he said, "and we went over to see how they'd implemented those recommendations."

MHAT-I found that 72 percent of soldiers in the initial Iraq deployment reported "low" or "very low" unit morale, while only 54 percent of the soldiers who replaced them and were studied by MHAT II described their unit's morale that way. Patterson cited a wide range of factors that he believes contributed to the upswing.

"When we were there the first time, they were in transition from being a mobile fighting force ... and were starting to move into what we call "hard-stand," or forward operating, bases," he said. "The quality of life improved significantly over that year. Soldiers were getting much better meals and dining facilities, they were in air-conditioned tents, at least, if not air-conditioned buildings, (and) communication with home was much, much better."

Morale, welfare and recreation facilities with telephones and Internet access became available at the bases, along with gyms, libraries and other recreational facilities, Patterson noted. Such quality-of-life issues are very important to every soldier, he said, especially for soldiers in a ground war.

"When you go weeks, if not perhaps several months, without a hot shower and you now are suddenly in a place where you can get a hot shower on a regular basis, that is a big morale booster," Patterson said. "Being in a facility where it's not 130 or 140 degrees in your tent is a big morale booster. You get a good night's sleep."

The implementation of better training and a rotation policy under which second-deployment soldiers knew they'd be in the theater for a year also helped improve morale, Patterson said.

The MHAT II report noted that the second deployment included more behavioral-health personnel than the initial deployment, a higher ratio of behavioral health professionals to soldiers, and better distribution of those caregivers. This translated to 40 percent of second-deployment soldiers with mental health problems reporting they received professional help, compared to only 29 percent in the first deployment.

Both deployments had high return-to-duty rates for soldiers with behavioral health problems, the report said. Patterson explained that the Army's behavioral health efforts focus on how to help the individual soldier. Coming up with the right number of behavioral health people to be in the theater and how best to disperse them receives constant attention, he said.

"We significantly increased the number of providers in theater, even though the number of Army troops was less," he said.

One result of MHAT I's recommendations was better distribution of the Army's behavioral health providers for the second deployment, Patterson said.

"The larger forward operating bases generally had the best quality of life, because they have better infrastructure," he explained, "and there was a desire on any soldier's part to go to a bigger operating base. But we wanted our people to get out to, if not be stationed at, the smaller operating bases. ... Our general guideline was to look throughout the theater and ensure that every base was covered, either within commuting distance of a base that had a behavioral health provider or by a circuit-riding behavioral health provider." That approach, called "proactive outreach," was "much better in OIF 2 than in OIF 1," he added.

With more behavioral health providers within easier reach of more soldiers, some might expect that MHAT-II would have found higher numbers and percentages of soldiers in the second deployment identified as having behavioral health problems than in the first. But that wasn't the case.

"The heart and soul of our combat and operational stress-control program is to intervene in problems before they reach the point that someone would screen positive for them," Patterson said. "So if we have success in our proactive outreach, we're able to see soldiers early on when they're starting to have personal problems or family problems and work with that soldier in how they handle it so that it doesn't end up making them a problem that needs mental health services.

"Also, we know that the better the soldiers are trained in stress management and trained in what the theater is going to be like," he continued, "the better they are prepared to handle the stressors of the theater, and hence, the fewer problems they have."

Patterson said that while fewer soldiers screened positive for behavioral health problems in the second deployment than in the first, those in the second deployment were far more likely to get professional help. And 41 percent of second-deployment soldiers said they'd received adequate training in handling stress factors related to their deployment, compared to only 29 percent of initial-deployment soldiers.

Suicides among soldiers deployed in Iraq took a dramatic downturn from OIF 1 to OIF -2, Patterson pointed out. "For 2003, the rate came to 18.8 per 100,000 soldiers," he said, "and in 2004 it had dropped to 10.5 per 100,000 soldiers. And the Army's historical rate over about 10 years is around 12 per 100,000 soldiers."

While noting that the Army has "undertaken a significant number of programs to help soldiers better handle the stress of being at war in Iraq," Patterson said any number of factors could play a role in improving morale and the behavioral health picture.

"It's very difficult to say any one thing contributed to that," he said, "because the improved training, the improved stress management, the improved quality of life, the improved delivery of behavioral health care - all of those interplay at some level, and we just don't know what's the major factor there."

But he does have a theory. "I would never, ever underestimate the power of a good meal, a shower and a good night's sleep," he said.

Despite the encouraging trends, Patterson said, "we still have a lot of work to do," including standing up a unified training course for behavioral health personnel, and publishing a field manual that outlines procedures for in-theater behavioral health people. Another challenge is setting up good metrics for behavioral health that define what behavioral health people do and their measures of success.

"We recognize clearly that we've got to come up with a metrics system that gives us meaningful data," he said. "We have some differing systems, and some of them are even home-grown, where they're keeping certain metrics. That may help a unit be able to track what they're doing, but it doesn't help at a theater level unless all of the data points are compatible and consistent."

Soldiers in both deployments expressed concern about a perceived stigma and organizational barriers to seeking mental health care, Patterson said - a problem he said is not unique to the military. "The American culture has a problem and Western civilization has a problem with stigma associated with mental health care," he said, "and we're making an unbelievable effort to fight that, and it still is a problem."

He noted that from OIF 1 to OIF 2, the MHATs found no significant change in soldiers' perception of stigma or barriers to care. The exception was that in areas where the availability of more behavioral health providers in OIF 2 made care more accessible, the perception of organizational barriers improved in OIF 2. In both rotations, he added, soldiers who screened positive for mental health problems were roughly twice as likely to perceive barriers or stigma.

Patterson said the Army's surgeon general is so concerned about the problem that he's proposing a program to "reset the force." Kiley's vision is that starting at the brigade level and moving forward from there, eventually all soldiers will have a mental health discussion, the theory being that if everyone has to do it, no stigma goes with it.

"We've recommended that leaders be trained at all levels - from squad leaders on up - and that all soldiers are oriented," Patterson said. "We're working with leadership to try and establish a positive culture where you get soldiers help when they first become of aware of it - that there is 'eye maintenance,' that the leaders know their soldiers well enough that they can perceive when a soldier is troubled and help that soldier get the right kind of help when they need it, rather than let the problem fester and become a major problem."

Having headed both advisory teams, Patterson had a firsthand look at the Army's behavioral health personnel in action in both OIF 1 and OIF 2. "We were thrilled with the progress that they had made," he said. "We were very impressed with the enthusiasm and the dedication of the professionals there. They, almost to a person, took their job very seriously, were very conscientious, were very empathic to the plight of the soldier, and also understood that the Army needed people to be able to do their job.

"We were very impressed with that whole process," he continued. "It's rewarding to make recommendations and then see the fruits of some of those recommendations."

Kiley and Patterson will be among officials who will testify on military mental health services before the House Subcommittee on Military Personnel here July 26.