Page 34 - JSOM Fall 2024

Tactical Psychiatric Care

Proposed Guideline

Jared W. Bollinger, PhD

ABSTRACT
There is no concise guideline on how to manage a full range of evacuation from war; 2) to identify the most common psychi-
emergency psychiatric conditions that are likely to be encoun- atric diagnoses encountered in deployed settings; 3) to identify
tered on the battlefield. This article examines the best practices best practice recommendations for assessment and treatment
on how to best assess and treat suicidality, psychosis, agitation, of CSRs and other psychiatric emergencies such as agitation,
malingering, and combat stress reactions in accordance with psychosis, suicidality, and malingering; and 4) to formulate an
multiple clinical practice guidelines. The result is a proposed assessment and treatment guideline.
model for battlefield emergency psychiatric care.
Results
Keywords: ICOVER; PIES; combat stress reaction; agitation;
suicidality; clinical practice guideline; psychosis; mania; Aim 1
malingering; medical evacuation The largest and most recent report of medical evacuation for
psychiatric reasons identified 7,023 psychiatric-related medical
evacuations between October 2001 and October 2013. The
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Introduction leading causes of medical evacuation were depressive disorders
(25%), adjustment disorders (17.6%), posttraumatic stress dis-
In the U.S. Military, psychiatric conditions constitute the lead- order (PTSD; 9.7%), bipolar disorder (6.0%), delusional disor-
ing cause of medical evacuation from combat theater across ders (5.9%), and anxiety disorders (5.7%). Notably, only 3%
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all illness categories. In the spring of 2024, the Joint Trauma of patients were evacuated for suicidal ideation specifically. 6
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System published a clinical practice guideline on how to man-
age psychiatric casualties. 2 Aim 2
In a study of 1,640 psychiatric patients seen in Afghanistan over
Anticipated future conflicts, where dispersed troops will op- a 2-year period, the most common diagnoses were: V codes
erate against near-peer adversaries, will result in a contested (i.e., conditions that are not disorders but considered a focus
airspace. In this situation, enemy missiles, artillery, drones, and of clinical attention)/CSRs (26%), adjustment disorder (24%),
conventional aviation will delay aeromedical evacuation, es- and mild to moderate Axis I disorders (9%), while 2% of the
pecially for less life-threatening conditions such as psychiatric patients had severe Axis I disorders. Approximately 9% of
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disorders. Consequently, more treatment in the field will be patients were evacuated or processed for medical or adminis-
required, which necessitates further guidance on the manage- trative separation. In another study of 425 soldiers who were
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ment of psychiatric casualties. 3 treated at a theater mental health clinic, the most common
diagnoses were adjustment disorders (34%), depressive disor-
The guideline proposed in this article is intended to update ders (16%), and CSRs/PTSD (13%). 7
and advance existing protocols on how to assess and treat
psychiatric casualties in the first and second echelons of care. Aim 3
Currently, the PIES model (treat with Proximity, Immediacy, Army Technical Publication 4-02.5, which covers casualty
Expectancy, and Simplicity) is the dominant model for man- care, delineates the management of psychiatric casualties, fo-
aging of combat stress reactions (CSRs). However, in one of cusing specifically on CSRs. A comprehensive review of CSR
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the largest studies of the patterns of psychiatric diagnoses at a assessment and treatment was also used in the development of
combat theater mental health clinic, only 26% were identified this guideline. 9
as being CSRs. Therefore, guidance should encompass a range
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of psychiatric conditions, including agitation, suicidality, acute In 2012, the American Association for Emergency Psychiatry
psychosis and mania, and malingering that may be encoun- (AAEP) released guidelines on how to assess and manage ag-
tered in deployed scenarios. itated patients through psychological (verbal de-escalation),
pharmacological, and physical (i.e., restraints) interventions. 10–13
Methods
In 2022, an expert panel published a guideline on how to
An extensive literature review was conducted to achieve four manage suicidal patients specifically on deployment. In ad-
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aims: 1) to identify the leading causes of psychiatric-related dition, the Departments of Veterans Affairs and Defense have
Correspondence to jared.w.bollinger.mil@health.mil
LT Jared W. Bollinger is a clinical psychologist at the 2nd Medical Battalion, 2nd Marine Logistics Group, Camp Lejeune, NC.

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