Psychiatric News July 16, 2004
Volume 39 Number 14
© 2004 American Psychiatric Association
p. 16
Combat Care Teams Psychiatrists With Nonprofessionals
Christine Lehmann
A U.S. Army psychiatrist faces the challenge of seeing to the mental
health needs of about 5,000 U.S. troops stationed in Afghanistan.
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. 
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