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Army Policy: Deferring Mental-Health Diagnoses in War Zones

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A U.S. soldier amid a firefight with the Taliban along the Afghan-Pakistan border

Some Army mental-health professionals say official instructions urging them to avoid declaring a soldier mentally ill in war zones keeps too many such ailing troops in combat. It’s part of a stretched Army’s quest to keep soldiers on the front line, they say. They suggest such rules may have played a role in keeping the soldier who carried out last Sunday’s massacre in Afghanistan, although there is no evidence of that.

But it makes for a strange section heading in Army Field Manual 4-02.51 titled “Combat and Operational Stress Control”: Defer Diagnosis of Behavioral Disorders.

It tells Army mental-health workers to tilt toward a diagnosis of normal combat stress instead of an abnormal behavioral disorder when in a war zone:

During assessment, COSC [combat and operational stress control] personnel must always consider BH [behavioral health] disorders that resemble COSR [combat and operational stress reaction], but defer making the diagnosis. The COSC personnel favor this default position to preserve the Soldier’s expectations of normalcy … This is also done to avoid stigma associated with BH disorders and to prevent the Soldier identifying with a patient or sick role. Deferral is also preferred because some diagnoses require extensive history collection or documentation that is unavailable during deployment situations.

“The intrusion of well-intentioned but bad policy has made doctors less effective at preventing homicides and suicides,” an Army mental-health expert says. “The uncomfortable truth is that the military mental-health system is designed to avoid recognizing manic symptoms or delusions — symptoms that put someone at increased risk for suicide or homicide.”

(MORE: Afghan Massacre: Rush to Judgment)

That’s because once a soldier is diagnosed with mental-health ills such as bipolar disorder, schizophrenia or psychosis, his or her career is all but over. “The commander, the patient, the doctor — all search for a fix that will keep the soldier in the fight,” he adds. “As a result, doctors often compromise — they avoid making a diagnosis that will destroy a soldier’s career.”

Defense Secretary Leon Panetta told CBS Wednesday that the Pentagon wants to know if the suspect in the Sunday massacre “was on the edge, what kind of group counseling he received, really try to understand the kind of stress our troops go through.”

Army officials concede they have a tough balancing act: keep soldiers in the fight so long as they are able and don’t offer one-way tickets home to those faking mental ills. “That is the Army doctrine — you try to keep people in theater,” says an Army mental-health veteran (everyone interviewed for this piece declined to be identified because of the sensitivity of the investigation into the Sunday slaughter of 16 Afghans, allegedly by a U.S. Army staff sergeant southwest of Kandahar). “‘Monitor them in theater’ is the policy. Once they go to [the Army's major Germany-based medical center at] Landstuhl, they never come back; most do fine if they’re kept in theater.”

(MORE: Afghan Massacre: Army Docs Say Brain Injury Could Have Sparked Attack)

Plus, the horrors of war can drive just about anyone to the edge, at least temporarily. “When people are in combat, having just witnessed the death of their buddy and carried body parts, they may have many symptoms of distress that don’t translate to a psychiatrist disorder,” the longtime Army mental-health professional says. “It’s the 1,000-yard stare.”

The Army’s “Combat and Operational Stress Control” manual also says troops suffering from COSR need to be treated not as patients but as soldiers (although temporary drug therapy remains an option):

It is both inappropriate and detrimental to treat Soldiers with COSR as if they are a BDP [behavioral disordered patient]. A therapeutic relationship may promote dependency and foster the “patient” role. Likewise, medication therapy and the highly structured treatment modalities imply the “patient” role. Medication for transient symptom relief (insomnia or extreme anxiety) may not be detrimental if there is no expectation that medication will continue to be prescribed.

So mentally unstable soldiers routinely are sent to local U.S. military mental-health facilities in Afghanistan. There they’re seen occasionally by doctors or therapists and often put on antipsychotic drugs until their symptoms ease. Then they return to their combat units. “There have been many, many soldiers on the edge in Afghanistan,” said an Army mental-health expert who has served there. “It was inexcusably difficult to get them out of theater.”

The suspect in Sunday’s massacre was flown out of Afghanistan on Wednesday to a pretrial detention center in Kuwait.

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