Psychiatry in the United States Army

Army psychiatry encompasses the cumulative experience of active duty psychiatrists in the Army. Currently, more than 100 Army psychiatrists are involved in operations across the globe, supporting various national defense and humanitarian missions, providing medical diplomacy alongside colleagues abroad, engaging in research, and educating future clinicians.

Army psychiatrists practice the full spectrum of adult and child psychiatry like their civilian counterparts. The prototypical image of the Army psychiatrist is one involving the treatment of posttraumatic stress disorder (PTSD) in a soldier with combat trauma. Although the Army devotes a great amount of resources to both the treatment and study of PTSD, the scope of clinical practice of an Army psychiatrist is in fact more comparable than it is dissimilar to civilian practice.

Of the nearly 600,000 active duty soldiers in the Army in 2016, 26.4% had a mental health diagnosis (1) compared with 18.3%–26.2% of the general U.S. population (2, 3). As expected, PTSD is more prevalent in the military, with probable PTSD in 10%–18% of servicemembers following a deployment (4) and in 4%–17% of veterans (5) compared with 3.5% of the general U.S. population (3). In 2016, because only 23%–40% of servicemembers with mental illness sought treatment (6), approximately 4% of soldiers had an active diagnosis of PTSD (1).

The prevalence of mood and anxiety disorders is comparable between active duty servicemembers and civilian populations (1, 3). However, severe mental illness is less prevalent among active duty soldiers as a result of psychiatric screening of recruits as well as policies of medically separating soldiers with psychiatric diagnoses. In 2016, among the active duty Army population, prevalence was <0.1% for schizophrenia and <0.5% for bipolar disorder (1), compared with 1.1% (7) and 2.6%–2.8% (3, 8), respectively, in the general U.S. population. Although there are factors selecting for and against particular diagnoses in the active duty population, Army psychiatrists still diagnose and treat symptoms in the entire spectrum of mental illness.

In addition to the standard clinical training required for board certification, Army psychiatrists receive specialized training and structured experiences in domains of organizational and military leadership. These competencies provide the skills necessary to adapt to the demands of the three core overlapping career trajectories of an Army psychiatrist: clinical, operational, and academic psychiatry. In each of these trajectories, an Army psychiatrist could be expected to play a leadership role at various points in his or her career.

Clinical psychiatry encompasses the roles that Army psychiatrists serve as both clinician and chief administrator of clinics or wards that employ teams of other Army and civilian providers. Operational psychiatry involves the unique responsibilities pertaining to advising military commanders as a behavioral health expert, both at home and in deployed environments. Lastly, academic psychiatry encompasses the broad range of work that is done across several world-class military research institutes as well the training of the approximately 60 Army psychiatry residents across each of the residency programs. The present article provides description of these three core domains and highlights ways in which Army psychiatry both differs from and parallels civilian psychiatry.

Clinical Psychiatry

Clinical psychiatric services in the military health system have expanded over the past century as evidence-based understanding of mental illness and its impact on servicemembers' health and their readiness to deploy has grown. Serving as military officers, Army psychiatrists play a critical role, not only as clinicians but as leaders within the military health system.

The origins of behavioral health care in the Army can be traced to the mental hygiene consultation services established during World War II (9). Following the end of that war and at the start of both the Cold War and the Korean conflict, behavioral health services were expanded greatly to support the growing number of patients—both combat veterans and newly drafted soldiers—and their families soon thereafter. By the 1950s, behavioral health activities and outpatient clinics were established at nearly every major Army post (10).

Today, the medical and psychiatric treatment of military servicemembers extends from the battlefield to the home, as well as from the beginning of their careers through retirement, and includes both servicemembers and their families. As a result, the military's global medical infrastructure is organized to provide a full spectrum of mental health care, encompassing everything from inpatient and residential services to partial hospitalization and intensive outpatient programs as well as services ranging from group and individual therapy to public health services and various forms of psychoeducation.

Army psychiatrists are expected not only to serve in their role as clinicians but also to lead soldiers as Army officers. Because leadership takes priority in the military, leadership positions are often entrusted to Army psychiatrists early in their careers. As a result of leadership demands early in and throughout the career of an Army psychiatrist, Army residency programs place additional emphasis on developing leadership competencies in residency training.

After completion of residency training, Army psychiatrists will often begin their careers as the officer in charge of a behavioral health clinic or inpatient psychiatric ward at one of the Army's outlying medical activities or community hospitals. This requires one to be adept not only in managing patient care but also in mid-level management and administrative tasks. Such experiences are designed to prepare psychiatrists to serve in roles of increasing responsibility. An early-career psychiatrist may move into operational roles from outlying clinics before going on to manage larger clinic and inpatient units. After significant experience in these roles, more seasoned officers may go on to oversee behavioral health departments, larger military hospitals, community hospitals, or academic medical centers.

Operational Psychiatry

Operational psychiatry within the United States Army encompasses responsibilities of balancing between the roles of serving as a clinician to individual soldiers and as a psychiatric consultant to commanding officers on matters that may affect psychiatric outcomes for thous­ands of soldiers.

The roles and responsibilities of the operational Army psychiatrist have been refined over the past century into what they are today, originating from the efforts of Dr. Thomas Salmon, the senior Army Psychiatrist stationed overseas during World War I. He innovated the approach of treating psychiatric battlefield casualties as close to the front lines as possible with the ultimate goal of returning servicemembers to duty when feasible (11). This remains an operational framework that is still in practice today. Dr. Salmon also pioneered the approach of assigning psychiatrists to work closely with commanding generals as consultants and members of the general's staff (11), a role for which the modern-day corollary is known as the division psychiatrist.

For a brief context of Army organizational structure regarding behavioral health assets, a division comprises approximately 20,000 soldiers, typically divided into 2–4 brigade combat teams. Behavioral health care of the division is overseen by the division psychiatrist. Within the division, each brigade combat team has its own brigade behavioral health officer—typically a clinical psychologist or social worker—whose responsibilities are a mixture of clinical care and surveillance of emerging behavioral health concerns. These concerns are then communicated with commanders through the supervising division psychiatrist.

Division psychiatrists deploy with the division into combat theaters and are the primary psychiatric consultants to commanders. In a deployed environment, the division psychiatrist is the senior behavioral health provider and behavioral health expert. The specific duties and responsibilities of the division psychiatrist are multifaceted and include planning and oversight for the division's behavioral health care, providing consultation to commanders and command surgeons on behavioral health issues, supervising other clinicians and enlisted behavioral health technicians, educating division medical providers about the evaluation and treatment of various psychiatric conditions, providing direct patient care, and ultimately acting as an officer and leader within the division (12). Army psychiatrists also command combat and operational stress control teams, whose overall mission is to return soldiers to duty through a wide range of methods of prevention and intervention of combat and operational stress.

Responsibilities of psychiatrists who are involved in managing combat and operational stress may include training a unit in sleep hygiene after recognizing an uptick in particular psychiatric conditions, determining what medications to have on hand during a deployment, working in interdisciplinary teams to develop traumatic event management plans, and implementing focused outreach to a unit after a death by suicide. Overall, the role of the division psychiatrist is multifaceted, requiring competencies ranging from managing teams of providers to collaborating effectively with commanders and to delivering direct clinical care.

Academic Psychiatry

Academic psychiatry in the Army closely parallels psychiatry in the civilian sector. Similar to their civilian counterparts, psychiatrists in the Army are afforded a broad array of academic experiences and opportunities for research over the course of their careers. These experiences include involvement in training residents and medical students, appointments to world-class research institutes, and collaboration in large multicentered studies.

The present culture and structure of psychiatric medical education in the military has a storied history, dating back to around 1909 when two Navy and two Army officers were assigned to Saint Elizabeth's Hospital in Washington, DC, to undertake 2 years of neuropsychiatric training (13). Throughout World War I, the Army instituted a collection of 6-week-long neuropsychiatric training programs for military physicians in partnership with various civilian institutions, and by World War II this had been expanded to 12 weeks. Following World War II, in 1948, the Army opened its first modern psychiatry training programs at Walter Reed Army Hospital in Washington, DC, and Letterman Army Hospital in San Francisco (14).

Today, the two Army psychiatry residency programs are located in Honolulu, at Tripler Army Medical Center, and in Bethesda, Maryland, at Walter Reed National Military Medical Center (14, 15). Additionally, the military operates a graduate and medical school, the Uniformed Services University of the Health Sciences in Bethesda (16), which offers the opportunity for faculty appointments.

Other possible academic assignments include research positions at one of the military's research institutes, such as the National Intrepid Center of Excellence, the Defense and Veterans Brain Injury Center, or the Walter Reed Army Institute of Research, which is the world's leading military psychiatric academic center. These institutes collaborate extensively with NIMH and other civilian academic centers, primarily to engage in research on PTSD, suicide, and traumatic brain injury. At the heart of these efforts, Army psychiatrists are intimately involved in clinical and basic science research, often in conjunction with their regular clinical duties.

Conclusions

In addition to being a well-trained clinician, the modern-day Army psychiatrist receives a breadth of unique training and experiences that allow for both personal and professional development beyond the scope of traditional psychiatric practice. In residency and throughout their careers, Army psychiatrists are developed in domains of organizational and military leadership parallel to their psychiatric training and practice. These proficiencies allow Army psychiatrists to be prepared for clinical assignments where they will be the commanding officer of a clinic or ward as well as for operational assignments where they are entrusted to manage teams of providers in order to provide psychiatric treatment for divisions of up to 20,000 soldiers, both at home and in deployed environments. With these experiences, these psychiatrists may then be positioned to further contribute their expertise through involvement in academic training programs and research institutions. With proficiencies developed in clinical, operational, and academic psychiatry, the Army psychiatrist is a leader who is able to flexibly adapt to the diversity of demands in his or her professional endeavors.

Key Points/Clinical Pearls