By Sharmila Chari, Ph.D. and Fuad Issa, M.D.
May 21, 2024

U.S. Army photo by Spc. Damion Clark

Austere environments are often challenging for service members to withstand. What does serving in an austere environment mean, and what are the implications for behavioral health management in that environment?  How does an austere environment impact the delivery of health care in the military? 

Imagine a combat engagement with enemy forces where a small team of service members are involved. Amongst the ongoing explosions, stress, and a multitude of emotions the team might be facing, one service member is overwhelmed by stress and unable to function. If you are a service member or provider, you may be familiar with this scenario. You may have questions about what could be done to help the service member (and their team) in this situation to best manage their behavioral health crisis. 

One of the key principles of military medical planning involve ensuring operations have sufficient emergency medical personnel resources. Providing far-forward medical care in a combat theater is essential to both mission success and the well-being of individual service members. However, the changing nature of conflict and future multi-domain operations may prevent optimal forward staging of specialty care support. Far-forward care in such operations would thus heavily rely on organic resources, including combat medics, in addition to self or buddy care.¹

While the U.S. military has made tremendous strides in medical advancement for providing best possible medical care in austere environments, until recently, there was no specific guidance in place for management of behavioral health conditions. In February 2024, the Psychological Health Center of Excellence published the Guideline for Forward Management of Acute Behavioral Health Conditions by Non-specialty Medical Personnel, after collaboration with the Joint Trauma System, line leaders, providers, and service representatives.²

What does this guidance cover and who is the audience?

This behavioral health guideline describes behavioral health management strategies for general medical personnel, like corpsmen and medics, who do not have extensive education and training in behavioral health. It outlines an intervention framework for service members with acute behavioral health symptoms in far-forward environments and draws on prolonged field care principles. The framework encompasses a suite of interventions categorized as “minimum,” “better,” and “best” approaches to manage some of the most common (for example, stress reactions or sleep issues) and most serious behavioral health conditions (for example psychosis or suicidality) that could emerge in remote locations. This strategic framework and accompanying recommendations provide non-specialty medical providers and paraprofessionals a range of options to consider when specialty care is not available. The focus is on brief and simple interventions intended to enhance stress management and reduce the severity of symptoms across presenting issues. The goal is to provide service members struggling with behavioral health symptoms in far-forward locations with additional skills and ensure successful management of their presenting issues using organic resources when possible.

Unit commanders are responsible for the health and well-being of their service members, and the behavioral health management guidance also includes recommendations related to facilitate command and non-specialty medic interaction surrounding behavioral health symptoms. The clinical practice guideline is meant to be an informative consolidation of resources that would benefit a range of medical personnel and field leadership. The recommendations are meant to be helpful to those service members who may not have specialty training but must contend with the reality of emergent behavioral health needs. 

What next?

Ongoing research and training are underway to prevent, identify, and initiate early treatment for behavioral health casualties at the frontlines of conflict. Of note, researchers at Walter Reed Army Institute of Research have partnered with PHCoE in transitioning the guidance to service members in the field. Preliminary medic training pilot test results are promising.^3,4  Feedback and response from non-specialty medical providers, as well as the larger community of service members and other stakeholders, will help refine the training and tailor it to meet service-specific needs. Together, we can empower our all medical providers and leaders to help manage emergent behavioral health conditions in forward locations and strengthen the power of our force. 

References

1. Hoyt, T., & Hein, C. (2021). Combat and operational stress control in the prolonged field care environment. Military Review, 101(5). https://www.armyupress.army.mil/Portals/7/military-review/Archives/English/SO-21/hoyt-combat-operational-stress/hoyt.pdf
2. Issa, F. (Ed.) (2024). Guideline for forward management of acute behavioral health conditions by non-specialty medical personnel. Joint Trauma System. https://deployedmedicine.com/
3. Mesias, G. A., Nugent, K. L., Wolfson, M., Clarke-Walper, K. M., Germain, A., Sampson, M. K., & Wilk, J. E. (2023). Development of Training to Prepare Army Medics to Address Behavioral Health Needs of Soldiers in Far-Forward Environments Utilizing Mobile App Technology. Military Medicine, 188(9-10), e3221-e3228. https://academic.oup.com/milmed/article/188/9-10/e3221/7162987
4. Nugent, K. L., Clarke-Walper, K. M., Germain, A., Wolfson, M., Mesias, G., Pulantara, W., and Wilk, J. (2022, September 12-15). Usability of a prototype mobile application for management of behavioral health and sleep concerns in far-forward operational environments [Poster Presentation]. Military Health System Research Symposium 2022, Orlando. FL., USA. https://mhsrs.health.mil/sites/mhsrs2022/SiteCollectionDocuments/MHSRS_2022_Program_Book.pdf

Sharmila Chari, Ph.D., is a clinical psychologist by training and currently serving as a contracted senior scientific advisor in the Research Execution section at the Psychological Health Center of Excellence. She has experience in psychological health research portfolio management, program development, conducting research and evaluation for serious mental illnesses and substance use disorders, equitable mental health care delivery, and trauma-informed programs.

Fuad Issa, M.D., is a psychiatrist and is currently the Defense Health Program Psychological Health Portfolio Manager. He previously led the Clinical Care Section within PHCoE and was the executive director for the DOD Addictive Substance Misuse Advisory Committee.