The first-ever U.S. Army survey of troops' mental health in a combat zone reveals that soldiers do battle with more than the enemy: In Iraq and Kuwait last year--when the survey was done--they were dealing with low morale, high stress and barriers to accessible mental health services, according to the report.

In response to a growing number of soldier suicides and psychiatric cases, the Army Surgeon General last July convened a 12-member, multidisciplinary team--made up of psychologists, psychiatrists, social workers and other mental health providers--to determine how well behavioral support was provided to soldiers who had just fought the heavy combat portion of the war in Iraq.

The team spent six weeks in Iraq and Kuwait surveying 756 soldiers using mental health self-report questionnaires and interviewing and conducting focus groups with behavioral health personnel, soldiers and commanders.

In sum, they found a combat mental health system in need of repair. Mental health-services providers didn't have frequent contact with soldiers in combat sites. Indeed, there was approximately one behavioral health provider for every 900 soldiers. Based on its findings, the Army has begun to make positive changes. For example, now mental health service providers will travel to outlying areas to reach more soldiers who might need their help.

Some of the problems the team encountered include:

  • Fifty-two percent of soldiers said their personal morale was low or very low, and 72 percent said their unit's morale was low or very low. "There might be different ideas about what morale means--nonetheless, it's concerning," says Col. Bruce E. Crow, PsyD, chief psychologist at Madigan Army Medical Center in Fort Lewis, Wash., and one of the report investigators.

He notes, however, that during the time of the survey, troops were living in highly uncomfortable conditions because "the infrastructure of the combat theater was still immature." For example, soldiers in most locations had no air conditioning, only portable toilets and limited communication with home.

  • Only 27 percent of soldiers who screened positive for depression, anxiety or traumatic stress said they had received any services from a mental health provider during their deployment.

"Soldiers perceived there to be barriers to receiving behavioral health care," says Crow.

  • Stigma was definitely an issue for soldiers. Less than 32 percent of soldiers who reported interest in getting mental health care ultimately got help because they were afraid of possible repercussions. In fact, 59 percent said they might be seen as weak if they sought mental health care and 58 percent feared they'd be treated differently by their comrades if they asked for help.

  • More than half of the mental health providers--whose mission was "combat stress control," which means providing behavioral services so that soldiers are able to maintain morale and endure confrontation--said they had had not received enough prewar training in combat stress.

To remedy the problems they found, the team recommended:

  • A more aggressive system of care involving outreach by mental health providers. For example, says Crow, providers should regularly visit outlying camps that have limited access to service. They also suggested that each combat theater be provided with a mental health consultant who could conduct needs assessments, evaluate the quality of mental health services, make recommendations on psychiatric treatment evacuation policies and establish mental health-care standards.

  • Intensified suicide prevention efforts--in response to the 23 U.S. soldier suicides in Iraq and Kuwait last year. The Army is implementing several suggestions already. For example, there will be more deployed personnel trained in suicide prevention. And more designated soldiers will be trained in suicide interventions skills on a layperson level.

"Most soldiers don't act on warning signs because they're young, not that far out of high school. They think they're doing a friend a favor by not telling on them," says Crow. The improved program hopes to change that mentality.

In response to their findings, the team rewrote the Army's combat stress control doctrine--which governs the training for behavioral health providers in combat zones--based on the "real-world lessons learned from the report," says Crow.

Further Reading

The report can be found at www.armymedicine.army.mil.