SOCIAL MEDICINE IN PRACTICE
Caring for Active Duty Military Personnel
in the Civilian Sector
Howard Waitzkin MD PhD 1 and Marylou Noble MA 2
Abstract
Combat operations in Iraq, Afghanistan, and
Due to the wars in Iraq and Afghanistan, the
elsewhere not only take the lives of US service per-
unmet medical and psychological needs of military
sonnel but also damage the physical and mental
personnel are creating major challenges. Increas-
health of many who survive. Even though military
ingly, active duty military personnel are seeking
officials may strive to implement high-quality mili-
physical and mental health services from civilian
tary health-care, 1 reports originating both inside
professionals. The Civilian Medical Resources Net-
and outside the military have called attention to the
work attempts to address these unmet needs. Par-
unmet medical and psychological needs of service
ticipants in the Network include primary care and
personnel. 2-8 Some analysts have projected that
mental health practitioners in all regions of the
physical and emotional injuries sustained by US
country. Network professionals provide independ-
soldiers will become a public health epidemic that
ent assessments, clinical interventions in acute
will continue to stress the already over-extended
situations, and documentation that assists GIs in
U.S. health and mental health systems. 9-11
obtaining reassignment or discharge. Most clients
Several factors may lead active duty GIs* to
who use Network services come from low-income
request independent medical evaluation and treat-
backgrounds and manifest psychological rather
ment outside of the military system. GIs experi-
than physical disorders. Qualitative themes in pro-
ence a command system and a medical care system
fessional-client encounters have focused on ethical
where illness and injury may be viewed as obsta-
conflicts, the impact of violence without meaning
cles to the military mission, inconveniences to local
(especially violence against civilians), and per-
commands, or malingering. 12 GIs may face deploy-
ceived problems in military health and mental
ment to combat zones before full evaluation of
health policies. Unmet needs of active duty mili-
physical illnesses. Those GIs with mental health
tary personnel deserve more concerted attention
problems such as depression or post-traumatic
frommedical professionals and policy makers.
stress disorder may re-enter combat when newly
diagnosed or just beginning a trial of medication.
Key Words: behavioral medicine, health policy,
In addition, the problem of double agency per-
health policy research, mental health, social factors
vades the provision of health and mental health ser-
in health and health care, injury, violence
vices in the military. Personnel shortages and pres-
sure to deploy and re-deploy troops rapidly to Iraq
and Afghanistan place increasing pressure on mili-
Corresponding Author: Dr. Howard Waitzkin
tary physicians. As they encounter GIs with health
Email: waitzkin@unm.edu
and mental health problems, military professionals
Institutions:
1 Departments of Sociology, Family & Community
must consider the goals of maintaining the numbers
Medicine, and Internal Medicine, University of New
The termGI here refers to active duty personnel of any
Mexico, Albuquerque, and the Salvador Allende Pro-
U.S. military services and military reserves. This term
gramin Social Medicine, Taos, NewMexico
historically referred to low-ranked members of the U.S.
2 Physicians for Social Responsibility and Amnesty
Army. “GI” originally derived fromequipment issued
International, Portland, Oregon
to military personnel (“galvanized iron,” later misinter-
Conflict of Interest: None declared
preted as “government issue” or “general issue”).
Social Medicine (www.socialmedicine.info)
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Volume 4 Number 1, March 2009
Table 1.Professional Participants inthe CivilianMedical Network (n=51)
Region
East
South
West
Central
Mid-West
Southwest
Total
14
3
25
1
4
4
(Percent)
(27)
(6)
(49)
(2)
(8)
(8)
Specialty
Medical/
Psychology/social work/
Primary care
Psychiatry
surgical
counseling
subspecialties
Total *
24
11
16
5
(Percent)
(43)
(20)
(29)
(8)
Note: Specialties total more than 51 because some participants have more than 1 specialty.
and readiness of combat forces. 13 These military
in similar support activities during the Vietnam
goals tend to contradict the goal of helping the indi-
War in the late 1960s and early 1970s, 16 as well as
vidual patient. The dual role of military profession-
during and after the Persian Gulf War in the 1990s.
als raises inherent tensions that increase GIs’ ex-
During those conflicts, groups such as the Medical
pressed needs for services in the civilian sector.
Committee for Human Rights and the Medical Re-
The Civilian Medical Resources Network is a
sistance Union organized efforts to provide physi-
small, national network of professionals that was
cal and mental health services for individuals who
established in 2006 to offer GIs an alternative to the
sought medical exemption from the military draft
military health and mental health care system. The
and for GIs who requested care in the civilian sec-
Network consists of professionals in primary care
tor. Due to the lack of a compulsory draft, efforts
medicine, psychiatry, psychology, social work, and
during more recent years have targeted active duty
public health who strive to address the needs of
GIs.
active duty US military personnel when they seek
Recruitment of clinicians for the Network oc-
medical and psychological care in the civilian sec-
curred initially through personal outreach to profes-
tor. Because other civilian resources at least partly
sional colleagues. In addition, two national organi-
address the needs of veterans, the Network focuses
zations, Physicians for Social Responsibility (with
on active duty GIs who need medical or psycho-
a focus on peace) and Physicians for a National
logical help.
Health Program(with a focus on health care access)
In this article, we describe the experiences of the
announced the program to their members. As of
Network and analyze some key policy issues re-
late 2008, 51 professionals were participating in the
lated to the unmet health needs of US GIs. We do
Network. Participants are predominantly primary
not consider the health impact of war on Iraqis and
care and mental health practitioners and are based
Afghanis, a topic that has been reviewed else-
in all regions of the country. (Table 1) Profession-
where. 14,15
als receive a brief training in the types of support
and documentation that the GIs require.
History, Structure and Activities of the Network
Patients are referred to the Network from the GI
Although individual civilian practitioners had
Rights Hotline, a national effort maintained by 25
assisted active duty GIs informally since shortly
religious and peace organizations, as well as the
after the onset of the Afghanistan War in late 2001,
Military Law Task Force of the National Lawyers
the Network began coordinated activities in 2006.
Guild. Legal professionals provide advice to the
The creators of the Network had gained experience
Network and assist clinicians with documentation
Social Medicine (www.socialmedicine.info)
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Volume 4 Number 1, March 2009
of GIs’ medical and mental health problems as
reduced cost. When possible, GIs visit Network
needed in support of their requests for discharge or
professionals in person; if a face to face visit proves
reassignment. 17,18 During 2008, the Hotline re-
unfeasible due to geographical distance, Network
ceived approximately 3,000 calls per month from
professionals assist GIs through telephone consulta-
active duty GIs and their families. When a GI or
tions. Unpaid volunteers coordinate the referral
family member calls the Hotline and describes un-
procedures and relationships with the Hotline and
met needs for physical or mental health services,
Military LawTask Force.
the Hotline counselor may, at his or her discretion,
The Network provides independent evaluation
contact the Network, which then sets up a referral
and treatment for both medical and psychological
to one or more participatingprofessionals.
problems. In some cases GIs suffering from acute
Demand for services by the Network has in-
and life-threatening conditions, typically suicidal or
creased steadily. As of late 2008, Network profes-
homicidal ideation, have been referred to local
sionals had worked with approximately 200 GIs,
health or mental health facilities. Network profes-
and the Network was receiving approximately four
sionals have intervened in these situations to assure
new referrals per week. However, due to lack of
adequate physical and/or psychological treatment.
sufficient outreach at military bases, many military
For less acute situations, GIs seek independent
personnel remain unaware of the Network. In addi-
assessment of diagnoses made by military medics
tion, the limited number of participating profession-
or physicians, or advice about treatment options
als has not allowed the Network to increase sub-
and the impact of military service on their illnesses
stantially the number of referrals.
or injuries. Other GIs request independent evalua-
GIs generally have limited financial resources
tions for their own peace of mind, or independent
and insurance coverage for civilian services. Net-
treatment because of concerns about the adequacy
work professionals provide care free or at greatly
of services in military clinics. Actions by civilian
Table 2. Clients in the Civilian Medical Resources Network(n = 70)
Gender
Male
Female
Total
62
8
(Percent)
(89)
(11)
Region
East
South
West
Central
Mid-West
Southwest
Total
11
6
7
5
25
16
(Percent)
(16)
(9)
(10)
(7)
(36)
(22)
Primary Diagnostic Category *
Psychiatric
Depression
PTSD
Other
Medical/
Don’t Ask/
w/o suicidal or w/ suicidal or
Surgical
Don’t Tell
homicidal idea- homicidal idea-
tion
tion
Total
13
12
11
19
14
1
(Percent)
(19)
(17)
(16)
(27)
(20)
(1)
* Comorbidities, which occurred frequently, are not indicated. “Don’t ask, don’t tell” refers to issues regarding les-
bian or gay sexual orientation.
Social Medicine (www.socialmedicine.info)
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Volume 4 Number 1, March 2009
professionals may assist GIs in gaining access to
sought services. All but one client reported that
military physicians, particularly specialists, and
they and their families were low-income. About
reduce the likelihood that commanding personnel
half of the patients were AWOL (absent without
will block or oppose visits to sick call or military
leave).
hospitals.
Reasons for consultation
Overview of CivilianMedical and
Physical problems comprised 20 percent of re-
Mental Health Services
ferrals to the Network. Seventy-nine percent suf-
Coordinators of the Network collected anony-
fered from psychological conditions. Some typical
mous data concerning 70 consecutive clients who
case histories are presented on the next page.
received services from the Network during the
Certain physical disorders appeared relatively
years 2007 and 2008 (Table 2). These data were
minor, while others proved potentially life threaten-
collected during the intake process, through infor-
ing. Minor physical disorders included muscu-
mation provided by the GI Rights Hotline counsel-
loskeletal symptoms, such as back pain and foot
ors and/or an initial conversation between the GI
pain, and rashes. Potentially life threatening prob-
and a Network coordinator. For some clients, clini-
lems involved unexplained seizures, numbness fol-
cians providing care in the Network provided addi-
lowing fractured vertebrae, double vision following
tional qualitative data to the authors via telephone
fracture of the eye socket in a shrapnel injury, and
or email.
persistent bleeding froman ear after head injury.
Regarding patient privacy and informed con-
Among mental health diagnoses, post-traumatic
sent, this report complies fully with the Uniform
stress disorder, anxiety, depression, and substance
Requirements of the International Committee of
abuse predominated. Occasionally GIs presented
Medical Journal Editors. 19 Although our work does
with acute psychiatric emergencies, most often
not involve research with human subjects as cus-
linked to traumatic events. Most GIs with the latter
tomarily defined, for the Network we have imple-
problems feared redeployment to Iraq. Approxi-
mented more than the usual measures to protect our
mately one-fifth of clients reported suicidal ideation
clients, including procedures pertaining to informed
and/or suicide attempts, and three GIs reported
consent and protection of anonymity through the
homicidal ideation. Adverse childhood experiences
de-linking of all identifying data. Because many of
such as abuse or neglect, a history of sexual assault,
our clients are Absent Without Leave (AWOL) and
and female gender tended to increase the likelihood
therefore subject to military prosecution, we do not
of GIs’ post-traumatic stress disorder and depres-
maintain identifying data in hard copy or electronic
sion. Military professionals have made similar ob-
form that could be subject to subpoena or similar
servations. 21-23
attempts by the US Government or other entities to
Several features of clients’ distress pertained to
obtain information about the clients. We have
families. These problems occurred both while GIs
communicated on multiple occasions with legal
remained in combat zones and after they returned
counsel and with our Institutional Review Board in
home. The problems involved stress focusing on
assuring the ethical dimensions of our work with
challenges of care-taking responsibilities for non-
these clients, who seek civilian-sector services hav-
military family members, intimate partner violence,
ing tried and failed to obtain needed services within
and marital or partnership dissolution. Studies of
the military.
combat personnel from the United Kingdom and
Canada reached similar findings, especially among
Description of the clients
reservists. 24-27
Eighty-nine percent of the clients were men,
although women comprised a similar proportion of
Specific services providedby the Network
clients (11 percent) as their overall proportion
Based on their assessment, civilian professionals
among active duty military personnel (15 per-
prepare reports with diagnoses, prognosis, and
cent). 20 Clients from all regions of the country have
treatment recommendations. Typical documents
Social Medicine (www.socialmedicine.info)
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Volume 4 Number 1, March 2009
Sidebar. Illustrative Case Summaries*
This Army soldier served in Iraq, where he was
of blood and body parts from military vehicles.
assigned to observation points as part of a patrol
After he returned to the United States, he suffered
searching for weapons caches and informants. He
from depression, post-traumatic stress disorder, and
was regularly exposed to the dangers of snipers and
generalized anxiety. He entered a psychiatric hos-
improvised explosive devices. In January, within a
pital temporarily after one of four suicide attempts.
five-day period, two close friends and an acquaint-
When he learned that his unit was to be redeployed
ance were killed by roadside bombs. Frequent
to Iraq, he went AWOL. When he contacted the GI
nightmares followed these incidents. The mission
Rights Hotline, he was living with his wife and in-
of his unit became devoid of meaning for him. He
fant son in a rural area and was working in odd
lost hope in what he was doing and questioned why
jobs. He learned that military police and the local
his unit was in Iraq. Anger occurred for no appar-
sheriff’s department were trying to find him. Dur-
ent reason. He began to hate the Iraqi people and
ing a phone interview, the GI expressed suicidal
to view themas the source of his anguish. The
ideation, as well as an intent to kill specific officers
Iraqi children he once loved to see nowannoyed
if he were returned to his original unit.
him. He had difficulty comprehending instructions
***
and felt that his performance became inadequate.
A GI with two fractured vertebrae experienced se-
Upon returning to the United States, he made the
vere numbness in his legs. When he wore a flack
decision not to return to Iraq. He did not want to
jacket, he could not move his legs. He previously
pull a trigger ever again.This soldier was suffering
fractured an eye socket, after which surgeons in-
frompost-traumatic stress disorder, major depres-
serted a metal plate; he still experienced double
sive disorder, and panic disorder.
vision and could not focus. Other problems in-
***
cluded rectal bleeding and renal insufficiency.
This young man, a native of a country in sub-
When he contacted the GI Rights Hotline, he was
Saharan Africa, enlisted in the Army and com-
scheduled to be deployed to Iraq in about two
pleted a one-year tour of duty in Iraq. During this
weeks. Seeking a medical discharge, he went to
time, he witnessed numerous injuries to civilians.
sick call. He stated that a medic told him that he
Several friends were killed. Upon returning from
was in bad shape but that the Army needed him and
this tour of duty, he learned quickly that he was to
so would not discharge him. Instead, he was told
be redeployed to Iraq. In desperation, he left his
that he could get physical therapy in Iraq. He had a
base and became AWOL. This individual met cri-
hard time seeing a doctor because his sergeant kept
teria for post-traumatic stress disorder as well as
telling himthat he shouldn’t go to sick call. The GI
severe depression.
requested documentation in connection with his
***
request for discharge and secondarily also sought
A GI fell in basic training and injured his right leg
care for his problems.
and ankle. Then he was thrown on his right side
***
during armed combat practice. With back pain ra-
A woman called on behalf of her fiancé, who
diating to the right lower extremity and numbness
was having seizures, possibly due to a brain lesion.
of the right foot, he needed use crutches. At sick
She and the GI were dissatisfied with the military
call, he was given ibuprofen and tramadol. He felt
medical evaluation and asked to consult with a ci-
hassled when he tried to use sick call. He had seen
vilian physician.
military doctors only but felt uncomfortable with
***
his evaluation and treatment, so he sought civilian
medical assessment.
***
During his tour in Iraq, a GI witnessed the vio-
The authors selected these case summaries be-
lent deaths of several close friends as well as Iraqi
cause they represent the spectrum of problems that
civilians. One of his assignments involved removal
the Network addresses.
Social Medicine (www.socialmedicine.info)
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Volume 4 Number 1, March 2009
are presented in an appendix to this article. When
ported that military medical professionals fre-
appropriate, Network professionals recommend
quently diminished the importance of their physical
reduced duties, reassignment, or medical discharge.
problems. These GIs sought confirmation of their
They also assist patients in interpreting military
physical problems by civilian professionals as a
medical conclusions and recommendations. Civil-
route to discharge or reassignment to non-combat
ian professionals’ reports contribute to a resolution
positions.
of difficulties when GIs face court-martial for mis-
conduct such as Absence Without Leave, or in dis-
Status in the Military : GIs who remained with
ability proceedings when the military attempts to
their units experienced barriers in attempts to con-
deny medical or financial benefits to GIs no longer
tact the Hotline and to receive evaluations through
able to performtheir duties.
the Network. These barriers resulted primarily
from the geographic isolation of military bases. In
Themes emergingfrom discussion
addition, scheduling problems due to work de-
with clinicians
mands inhibited appointments with civilian profes-
The following themes emerged from the au-
sionals. Those GIs who were AWOL encountered
thors’ categorization of clinicians’ reports. To be
fewer difficulties in travel or scheduling problems;
included, each theme arose in reports concerning at
however, they experienced deep fears about capture
least 5 clients.
and return to their units.
The Economic Draft: Most GIs enlisted due to
Privatization of Services: Many clients contact-
economic challenges or lack of employment oppor-
ing the Network reported difficulties that they or
tunities. In addition to low-income financial condi-
their families had experienced in obtaining privat-
tions, many GIs came from ethnic/racial minority
ized services from managed care organizations con-
backgrounds or were born in third world countries.
tracting with the military. Inconvenience in obtain-
ing services and managed care practitioners’ dimin-
Deception: Psychological problems among GIs
ishing the importance of clinical problems moti-
and reservists included perceived deception in re-
vated GIs and their families to seek services in the
cruiting processes, as well as longer and more fre-
civilian sector.
quent tours of duty than promised. Reservists usu-
ally did not expect combat duty.
The Context of Torture and Publicized Human
Rights Abuses: This context has shaped GIs’ ex-
Ethical Dilemmas and Violence Without Mean-
periences. Although most GIs using the Network
ing: Physical and emotional problems derived from
did not engage in torture or other forms of abuse,
the witnessing or perpetrating violence without a
they expressed awareness of these practices as part
sense that the violence led to progress in meeting
of military operations. 28,29 In their training, GIs
military, political, or social goals. GIs frequently
learned that such practices contradict historical
reported that they did not understand the purpose of
rules of war such as the Geneva Convention, as
military involvement in Afghanistan or Iraq. Many
well as specific regulations that govern actions by
of the violent acts perpetrated against civilians, es-
U.S. military forces. In practice, many GIs also
pecially children, generated guilt, depression, and
learned that officers tolerated and sometimes en-
post-traumatic stress disorder. Such violence fre-
couraged the use of torture and similar abuses.
quently involved intentional actions, some ordered
This contradiction created stress, stigma, and shame
by GIs’ superior officers and some resulting from
about unethical actions perpetrated by military col-
GIs’ suspicions of armed attacks by combatants
leagues. Professionals working with GIs in the
presenting themselves as civilians.
Network have noted high levels of shame, a situa-
tion that inhibits GIs fromseeking help.
Concerns about Military Health Care : GIs re-
Social Medicine (www.socialmedicine.info)
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Volume 4 Number 1, March 2009
Conclusions
officer who has benefited the most financially from
The Network has encountered GIs who, along
the Iraq War heads not a corporation traditionally
with their families, experience a profound need for
considered part of the military-industrial complex,
supportive services. Professionals in the Network
but rather a large managed care organization
have documented the unmet needs of active duty
(Health Net), whose contractor (ValueOptions) pro-
US GIs as well as some of the contextual problems
vides mental health services for GIs and their fami-
both creating and sustaining those unmet needs.
lies. 36
These contextual problems speak to the larger so-
For GIs who seek help within the military sector
cial issues of an all volunteer Army in an increas-
for post-traumatic stress disorder, depression, and
ingly militarized society.
other mental health problems, military psycholo-
During the Vietnam War, a military draft led to
gists increasingly have diagnosed personality disor-
induction of young people from a broad range of
der. Because military policy considers personality
social positions; the current volunteer army de-
disorder as a pre-existing condition that antedated
pends on men and women predominantly from low-
military service, GIs who receive this diagnosis
income and minority backgrounds. Although mili-
lose financial and health benefits after discharge,
tary and veterans’ medical care periodically enters
creating major concern for the GIs and their fami-
public consciousness, especially after scandals (as
lies. 37 This policy applies even though military
in the case of Walter Reed Army Hospital 30 ), the
officials did not diagnose personality disorder dur-
predominantly working-class origins of those suf-
ing GIs’ mental health evaluation when inducted
fering from the war limits the attention that this
into the armed forces; military researchers have
issue receives from policy makers and other leaders
documented the limitations of screening for mental
in the society.
disorders before entry into military service. 38,39
Not surprisingly, mental health problems pre-
During the wars in Afghanistan and Iraq, mili-
dominated among our patients. As others also have
tary leaders have implemented strategies that in-
observed, 31-33 some GIs reported suicidal ideation
volve less combat engagement with identified com-
that went unrecognized or unacknowledged when
batants and more violence involving civilians. Re-
they sought care in the military system. Military
cent reports from GIs, including those using the
statistics indicate rapid increases in suicides, sui-
Network, have emphasized violence committed
cide attempts, and self injuries among active duty
against civilian non-combatants. 40 In a context
GIs. 34,35 For 2007, the U.S. Army reported ap-
where both torture and systematic human rights
proximately 2,100 suicide attempts and self-
abuse occur, it is not surprising that soldiers suffer
injuries, a rate of more than five per day, increased
from high levels of psychological distress and even
from less than 1,500 the previous year and less than
pathology. Resistance to the war then becomes
500 in 2002; these data do not include events in-
medicalized. With accumulated injuries—both
volving Marines or other combat forces. The prob-
physical and psychological—GIs turn to profes-
ability of suicide increases with the number of de-
sionals in the civilian sector as a route to less dan-
ployments and time spent in Afghanistan or Iraq.
gerous assignments or to discharge.
Suicides committed outside combat zones may re-
The unmet needs of active duty GIs deserve
main underreported.
concerted attention among medical professionals
The epidemic of mental health problems in the
and policy makers. We suspect that, in addition to
military coincides with an unprecedented privatiza-
our Network, many individual clinicians also face
tion of medical and mental health services for ac-
similar issues among their patients. 41 We believe
tive duty GIs and their families. Although the mili-
that professional organizations should address con-
tary previously offered such services within its own
cerns regarding the quality of military medical care
facilities, private corporations more recently have
and the impact of the war upon soldiers and their
received large contracts from the military to pro-
families in the US. In addition, the Network wel-
vide these services. As a result, the chief executive
comes interested clinicians to become part of its
Social Medicine (www.socialmedicine.info)
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Volume 4 Number 1, March 2009
referral system. Finally, any work to repair the
C. Bringing the war back home: mental health disor-
damage caused by the Irag and Afghanistan Wars
ders among 103 788 US veterans returning from
Iraq and Afghanistan seen at Department of Veter-
also must address strategies to promote peace and
ans Affairs facilities. Arch Intern Med. 2007;167
to prevent war.
(5):476-482.
Additional Resources : Information about the
8. Hoge CW, McGurk D, Thomas JL, Cox AL, Engel
Civilian Medical Resources can be found at their
CC, Castro CA. Mild traumatic brain injury in U.S.
website: http://www.civilianmedicalresources.net
soldiers returning from Iraq. N Engl J Med.
2008;358(5):453-463.
/index.html
9. Lieberman J, Boxer B. Make mental health a prior-
ity: when service members go untreated, the entire
Acknowledgments
military suffers. Army Times. 2007;68(3):42. http://
The authors thank the GIs and their family
www.armytimes.com/community/opinion/
members who sought attention through the Net-
marine_opinion_tnsbacktalk_070806/. Accessed
Aug 9, 2008.
work; Marti Hiken and Kathy Gilberd, who have
10. Friedman MJ. Veterans' mental health in the wake
coordinated the Military Law Task Force of the
of war. N Engl J Med. 2005;352(13):1287-1290.
National Lawyers Guild; the many counselors asso-
11. Friedman MJ. Posttraumatic stress disorder among
ciated with the GI Rights Hotline, who referred cli-
military returnees from Afghanistan and Iraq. Am J
ents to us; our professional colleagues who re-
Psychiatry. 2006;163(4):586-593.
12. Westphal RJ. A discourse analysis of Navy leaders'
sponded to these referrals; Jennifer Bustos for re-
attitudes about mental health problems. Charlottes-
search assistance; and Jean Ellis-Sankari and Sofía
ville, VA: Department of Nursing, PhD Disserta-
Borges for editorial advice. A grant from RESIST
tion, 2004. http://stinet.dtic.mil/oai/oai?
to the Allende Program in Social Medicine sup-
verb=getRecord&metadataPrefix=html&identifier=
ADA429820. Accessed January 19, 2008.
ported the work of the Civilian Medical Resources
13. Sidel VW, Levy BS. The roles and ethics of military
Network.
medical care workers. In: Levy BS, Sidel VW, eds.
War and Public Health. New York: Oxford Univer-
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dictors of depression and post-traumatic stress in
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Visit our blogatwww.socialmedicine.org
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Volume 4 Number 1, March 2009
Appendix:
Illustrative Documentation Provided by Network Professionals
The authors have selected these letters as typical of
those that the Network professionals submit on behalf of clients.
DATE
CONFIDENTIAL
Re: NAME
To the Commanding Officer of NAME:
As a practitioner of PROFESSIONAL DETAILS HERE.
In this connection, I received a referral requesting assistance for Sgt. NAME. I have corresponded
with him a number of times by e-mail and also have held several extended phone conversations with him
and his wife, NAME. To assist them, I have tried to set up some local referrals to civilian mental health
professionals near Fort NAME.
Based on this information, I can attest that NAME and NAME are both suffering from severe men-
tal health disorders. Although I cannot tell with certainty the underlying causes of these problems, I do
know that NAME’s deployment leading to separation from his wife has exacerbated their mental health
problems substantially.
In brief, NAME suffers from depression probably linked to bipolar disorder. She frequently be-
comes suicidal, and this tendency increases in severity when NAME is not present to provide emotional
support in person. NAME does have a history of suicide gestures and attempts. Partly in response to the
stress of his military responsibilities coupled with his marital responsibilities, NAME has been suffering
from depression and recently has been prescribed a psychotropic medication by a military mental health
professional.
Under the circumstances, I strongly recommend that you grant NAME a compassionate discharge.
I believe that the situation otherwise may become quite dangerous. NAME is in a position where suicide
is a realistic possibility, and NAME’s depression has become more serious as the stress associated with
his military responsibilities has deepened. Ifeel that you should be aware of the potential harmto life that
the current situation entails.
Please don’t hesitate to contact me if Ican provide further information.
Sincerely yours,
NAME
TITLE
Social Medicine (www.socialmedicine.info)
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Volume 4 Number 1, March 2009
DATE
CONFIDENTIAL; URGENT
Military Police
Fort NAME, NAME OF STATE
Attention: Staff Sergeant NAME
BY ELECTRONIC MAIL
Re: NAME
DOB:
Dear Colleagues:
Iam writing to request your urgent attention and review of a potentially life-threatening set of conditions
that are affecting NAME.
My report of DATE, provides further details. In brief, Mr. NAME suffers fromseveral serious mental
disorders related to his military service. During recent meetings with me, he expressed both suicidal and
homicidal ideation. Ibelieve that he has serious plansand is at extremely high risk (as are others with
whomhe interacts) if he is returned to Fort NAME, which he identifies as a source of his perceived prior
emotional injuries.
Mr. NAME suffers fromseveral severe psychiatric disorders that create grave current disability. Based
on suicidal and homicidal ideation and plans, Ibelieve that he is at high risk of harming himself and/or
others. The likelihood of such violent behavior will increase greatly if he is returned to Fort NAME,
which he associates with prior harmto himself and others. If he is returned to Fort NAME, my legal and
ethical responsibilities as a medical professional would lead me to seek his confinement in a psychiatric
inpatient hospital facility, even if he does not consent to such confinement.
Ishould emphasize that, holding this knowledge of Mr. NAME’s high risk of suicide and/or homicide, I
amlegally and ethically required to try to prevent those events fromoccurring.
Ibelieve that major problems and potential loss of life (of both Mr. NAME and others) can be avoided if
you respond to my recommendation.
Please contact me sothatwe can discuss how to protect the safetyof Mr. NAME and persons at Ft.
NAME (beeper NUMBER; home NUMBER; workNUMBER). Iwill be glad to collaborate with you
to prevent injury and loss of life. Don’t hesitate to contact me if Ican provide additional assistance.
This letter serves as aformal professional warningrequired under law. Thanks very much for con-
sidering this information.
Sincerely,
NAME
TITLE
Social Medicine (www.socialmedicine.info)
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Volume 4 Number 1, March 2009
DATE
Re: NAME
DOB:
Dear Sir/ Madam:
I am writing regarding my evaluation of Mr. NAME's psychiatric condition and his need for ongoing treatment.
A brief summary of my background may provide a context for this letter. PROFESSIONAL DETAILS
HERE.
In this letter, I provide my assessment of Mr. NAME, based on review of his medical records, four phone
meetings, and a longer meeting of 1½ hours which occurred on DATE. I will focus mainly on information
that supplements that in his medical records.
Current danger to self and others. In my interview with Mr. NAME on DATE, he stated a willingness to
return to Fort NAME [a base different from his own] but also expressed both suicidal and homicidal idea-
tion in the event that he is sent back to Fort NAME. In brief, he stated that - based on his prior experiences
at Fort NAME - he would likely try to commit suicide there and also might try to kill one of several people
who he feels are responsible for his mistreatment. He made these statements several times and was very
concrete and specific. If he is returned to Fort NAME, I believe that the risk of suicide and/or homicide is
very high - so high that ethically and legally I would need to contact authorities so that he could be held for
psychiatric observation at a non-military hospital, even if such hospitalization were against his will. As
you know, making such arrangements is an ethical and legal responsibility of medical professionals who
believe that a client is at high risk of harmto himself or others.
Risk factors for post-traumatic stress disorder and depression. Mr. NAME has experienced severe stressors
that predispose to psychiatric disorders. First, he was the victim of abuse within his family during his
childhood and adolescence. He reported emotional and verbal abuse from his mother, as well as physical
and sexual abuse by his mother’s boyfriend.
Second, he has experienced tremendously aversive experiences in combat. As he described these experi-
ences, three episodes stood out as events that would lead to lasting psychological injury. First, during a
battle in Ramadi, Iraq, Mr. NAME tried to rescue U.S. military personnel who had been severely injured
after a large explosion. Injured personnel remained on top of a large truck. When he tried to remove a GI
by the legs, he was shocked to discover that only the pelvis and legs remained from the waist down; the
upper part of the body had been separated. During that episode, he encountered many other body parts in
the process of trying to rescue the injured. On a second occasion, he was ordered to clean the top of a truck
that was covered with blood and body parts. During a third episode, he held the hand of an Iraqi soldier,
who was dying after the lower part of his body had been blown off in an explosion. Mr. NAME reports
frequent flashbacks and nightmares about these experiences, as well as deep guilt and remorse for his own
actions in combat; he started crying as he stated, “I wonder how many orphans over there that I’ve created
by killing their dad.”
Recent psychiatric research in the military has shown that abuse in childhood and adverse combat experi-
ences like those Mr. NAME endured constitute the two strongest predictors of PTSD and depression in
deployed troops: Cabrera OA, Hoge CW, Bliese PD, Castro CA, Messer SC. Childhood adversity and
combat as predictors of depression and post-traumatic stress in deployed troops. American Journal of Pre-
ventive Medicine . 2007; 33(2): 77-82.
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Volume 4 Number 1, March 2009
[Continued from the previous page]
Violence, suicidality, and homicidal ideation. Mr. NAME described a specific episode of violent behav-
ior and four separate suicide attempts since he returned from combat. Shortly after arriving home, his 13-
year-old niece tried to wake him up; startled and experiencing a flashback to combat, he threw her against
a wall. As his first suicide attempt, he tried wrecking his car while driving at 120-130 miles per hour. In
a second attempt, he tried to hurt himself while driving a 4-wheel drive vehicle; he hit a tree, and the vehi-
cle burned up. Third, while intoxicated, he offered another person in a dune buggy $1,400 cash to run
over him. Fourth, he drank a half gallon of vodka and a fifth of Jim Beam whisky and then took 12
Xanax tablets, in an attempt to kill himself. The next morning, when he woke up, he threatened to kill a
“cop” who was present and everyone else in the room (including family members and his best friend, as
well as himself).
Regarding current suicidal ideation, he stated that he experiences suicidal thoughts at least every two
weeks. When asked about a plan, he responded that he has access to guns and has experience in using
them. He mentioned a scenario in which he could take a gun froma “cop” if he wanted to obtain one.
Mr. NAME also reported frequent homicidal ideation. He stated, “If I could, given a chance, I would go
to Ft. NAME and kill some people there because of the way they treated me at Ft. NAME and Iraq.”
Current social situation and health services. In my opinion, although he seems a devoted husband and
father, Mr. NAME’s wife and 6-month-old son are at some degree of risk if Mr. NAME were provoked
into violence – for instance, by an attempt to return him to Fort NAME. He did report some sources of
social support in the local area where he is residing. However, he does not have a regular source of pri-
mary medical care, does not receive regular mental health services, and is taking no medications.
Physical symptoms. Mr. NAME reported a variety of physical symptoms: abdominal pain, frequent
bowel movements (3-4 per day), muscle pains, headaches, shortness of breath, and rapid heart rate.
Based on my assessment, although further diagnostic procedures might lead to one or more physical ab-
normalities, these symptoms did not appear related to a physiological or pathological disorder. As a re-
sult, Iconclude that he suffers fromsomatoformsymptoms and probable somatization disorder.
Testing. I administered the Patient Health Questionnaire (PHQ), a brief instrument widely used in psy-
chiatry and primary care. Many research studies have confirmed the PHQ’s validity as a sensitive and
specific diagnostic instrument for psychiatric and behavioral health disorders (references available on re-
quest). I am attaching the PHQ instrument, with Mr. NAME’s responses. Based on the recommended
scoring procedure, Mr. NAME suffers from the following disorders: somatization disorder, major depres-
sion syndrome, panic syndrome, anxiety syndrome, alcohol abuse, PTSD, stress syndrome, and target of
abusive behavior.
Diagnostic and Statistical Manual IV diagnoses.
Axis I, clinical disorders: PTSD (309.81), depressive disorder NOS (311), alcohol abuse (303.9), somato-
formdisorder (300.8), anxiety disorder (300.0), panic disorder (300.01)
Axis II, underlying conditions: None noted.
Axis III, acute medical conditions and physical disorders: None noted.
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Volume 4 Number 1, March 2009
[Continued from the previous page]
Axis IV, contributing psychosocial and environmental factors: combat, loss of friends in war, AWOL
charges, history of physical and sexual abuse, family problems
Axis V, Global Assessment of Functioning (GAF): 15 (“some danger of hurting self or others OR occa-
sionally fails to maintain minimal personal hygiene OR gross impairment in communication”)
Treatment. In addition to follow-up appointments with me and mental health professionals, I have pre-
scribed an antidepressant (paroxetine 20 mg. daily) and a minor tranquilizer/ sedative (buspirone 10 mg.
daily as needed for panic and/or anxiety).
Summary. Mr. NAME suffers from several severe psychiatric disorders that create grave current disabil-
ity. Based on suicidal and homicidal ideation and plans, I believe that he is at high risk of harming him-
self and/or others. The likelihood of such violent behavior will increase greatly if he is returned to Fort
NAME, which he associates with prior harmto himself and others. If an attempt were made to return him
to Fort NAME, my legal and ethical responsibilities as a medical professional would lead me to seek his
confinement in a civilian hospital, even if he does not consent to such confinement.
Recommendation. Based on his adverse combat experiences, his multiple psychiatric disorders, his suici-
dal ideation, his homicidal ideation, and the lack of intensive medical care and psychiatric care that he
clearly needs, I strongly recommend prompt discharge from military service. After discharge, other col-
leagues and I can assist in obtaining appropriate care for him. Should he remain in the military, he would
be at risk to himself and his fellow soldiers.
Please don’t hesitate to contact me if Ican provide additional information.
Sincerely,
NAME
TITLE
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Volume 4 Number 1, March 2009