Combat Care Teams Psychiatrists With Nonprofessionals

Barely out of his psychiatry residency at Walter Reed Army Medical Center (WRAMC), Capt. James Demer was deployed last November with a forward battalion of the 10th Mountain Division from Fort Drum, N.Y., to southern Afghanistan.

“My duties were similar to what I did at Fort Drum as chief of division mental health services with the U.S. Army Medical Department Activity,” said Demer last month at an annual symposium named in honor of the late Lt. Col. (Ret.) Kenneth Artiss, M.D. (see page 15) at WRAMC in Washington, D.C.

Demer explained that the role of division mental health sections is to support the troops, which includes being deployed along with them.

“We conducted mandatory, quarterly suicide-prevention briefings among the troops, facilitated group discussions following a traumatic event, and conducted individual therapy and medication management,” said Demer.

His mental health staff consisted of a licensed clinical social worker and a psychologist who arrived in the latter half of his four-month deployment. Noncommissioned officers (NCOs) with basic mental health training served as a liaison between Demer and the troops.

“The NCOs had been in the Army for several years and were respected by the younger soldiers. They felt comfortable talking to these `gray beards' about their troubles and concerns,” said Demer.

One or two companies made up of about 120 soldiers each were stationed in remote bases far from Kandahar and each other. “The soldiers patrolled the mountainous areas by foot, looking for suspected Al Qaida members. The bases often came under enemy rocket attacks at night,” he said.

The only way to get to the remote bases from Kandahar was riding in Army helicopters delivering supplies. “After being dropped off at a base, I had to wait usually days for another helicopter to arrive to get me to another base,” said Demer.

Army Personnel Used

Given the logistical challenges in reaching the bases, Demer delegated screening, medication monitoring, and therapy follow-up to Army medical personnel stationed at the bases.

“I delegated medication monitoring, adjustments, and refills to physician assistants at the bases after briefing them on cases,” said Demer. “They were also trained to know when to contact me about a case.”

He found that the soldiers almost always wanted the follow-up counseling to be done by the unit chaplain. “The soldiers trained with the chaplains prior to deployment and trusted them. I liked that [the chaplains] could ensure confidentiality,” said Demer.

At the bases, he trained the medics, whom he defined as enlisted soldiers with basic combat casualty training, to recognize the signs of depression and other psychiatric illnesses and know when to contact the physician assistant.

The medics also administered mental health questionnaires developed by the military that had been used at Fort Drum. The battalion commander of three remote bases mandated they be filled out to determine how the approximately 600 troops were coping with stress, said Demer.

The results showed that about 150 of the soldiers scored above the cutoff point. “We felt this number was inflated because the questionnaire had been validated at Fort Drum rather than in a combat setting, which is usually more stressful. We decided to focus only on those who responded positively to experiencing hopelessness, suicidal ideation, and other signs of dangerousness to themselves or others. The final result was that about 15 soldiers were interviewed individually and prescribed SSRIs,” explained Demer.

Ample Medications Available

The clinic's pharmacy was well-stocked with new psychotropic medications, but Demer decided not to prescribe lithium and depakote because the clinic didn't have blood-monitoring equipment to ensure patient safety, he said.

“I also tried to match the medication's side-effect profile to the soldier's expected duties to ensure there were no adverse effects,” said Demer. “For example, I didn't prescribe trazadone for insomnia because it could cause grogginess the next day. Soldiers at the remote bases were expected to be fully alert.”

Because the U.S. troop size in Afghanistan is about 20,000, compared with 140,000 in Iraq, and there are fewer and less severe combat-related incidents, the clinic staff also treated Afghan civilians who needed immediate medical attention for serious conditions, said Demer.

He treated contracted workers and civilians with major psychiatric illnesses. For example, a 45-year-old man from Somalia experienced auditory hallucinations while working for a company contracted to clear unexploded land mines near Kandahar, according to Demer.

“He had experienced auditory hallucinations before but they had stopped. We treated him with antipsychotic medication and bed rest, and the hallucinations resolved,” said Demer.

Another case involved an Afghan general's wife who had been treated for postpartum depression with clomipramine, alprazolam, and propranalol at a Pakistani hospital.

“I took her off these medications and put her on Zoloft and clonapine as needed, and she did fine,” he said.

He also had an unusual encounter with an 18-year-old Russian contract worker when he went for a walk near the compound. “The Russian tried to grab my pistol twice, and I fended him off. Then he tried to climb over the barbed wire fence to the compound, and the military police picked him up,” said Demer.

He was diagnosed with severe depression and psychosis. “We stabilized him, and he was sent back to a hospital in Russia,” Demer said.

He also spent a good deal of his time informally talking with the clinic staff. “The most traumatic incident they encountered was treating about 30 Afghan children who were injured in an explosion. Most of them were under age 5. I spent a lot of time being available to staff during that time,” said Demer. ▪