JN Scott. Diagnosis And Outcome Of Psychiatric Referrals To The Field Mental Team, 202 Field Hospital, Op Telic 1

Objectives To assess referrals to a Field Hospital Mental Health Team (FMHT), assign a diagnosis, provide appropriate treatment, and decide whether suitable for safe return to unit in theatre (RTU), or evacuation home on psychiatric grounds (evac). Methods All documented referrals to the FMHT of 202 Field Hospital during the Op Telic 1 study period of 17 March (day 1) to 23 July 2003 (day 129) were included. Data were collected on rank, gender, diagnosis, outcome (whether RTU or evac), and whether TA before mobilisation. Diagnosis was assigned by ICD10 criteria. Results The FMHT documented 170 cases, 12 of whom were seen twice and one on three occasions, resulting in 184 referrals, all of whom were British. The commonest diagnosis was adjustment reaction (F43), accounting for 68% of all cases (n=116). These were divided between chiefly theatre-related (n=77) or chiefly home-related (n=39) reactions. The majority (94%) of these cases were RTU. Referrals where the diagnosis was a Depressive disorder (F32, n=23) or Intentional self-harm (by sharp object, X78, n=7) were evacuated. Outcome was similar for Regular and TA personnel, with on average 72% of cases RTU. The majority of cases seen were ORs, reflecting their numbers in theatre. Only 14 NCOs and 14 officers were referred. Thirteen of the latter were TA before mobilisation. Gender was not associated with outcome, or TA status, but was associated with rank, in that significantly more female officers were referred.The FMHT role tasks emerged as (a) psychiatric triage and treatment, (b) psychological support of hospital staff, and (c) welfare and pastoral care liaison. Conclusion The utility of the psychiatric management model employed, built upon previous military medical doctrines, was tested in a modern theatre of conflict, and seemed to prove its worth. “Any psychiatrist finding it easier to send a frightened young soldier who reminds one of one’s own self, or one’s own son, to the rear, than to return him to combat duty, should realise that medically to evacuate a patient who has not yet performed with the degree of honour required of him (by both himself and his community) is the greatest possible psychiatric mishandling,and the greatest possible unkindness... The psychiatrist should be immersed in front line realities from the start, so that they can understand the needs of the Army as a whole, and not ‘over-identify’ with individual patients... the psychiatrist (loses) anxiety and guilt when making decisions, because he (becomes) convinced that it is in the best interests of the individual to rejoin his combat unit, for in no other way can the individual regain confidence and mastery of the situation, and prevent chronic tension and guilt.” Glass, 1954, 1955 (1) Introduction Military Psychiatry practice currently entails in-theatre forward treatment in specialist units. By this means, maximal opportunity is provided to ensure that thorough early assessment occurs, so that those with shortlived mental reactions can receive the rapid recognition, support, rest, and rehabilitation (physical and emotional) that they need, and thus be returned to duty in theatre. Such an outcome both meets military reinforcement aims, and also enhances and restores the individual’s sense of personal control and ‘mastery of the situation...’ (1). This doctrine is based upon hard-won and often bitter documented experience from previous conflicts, essentially from 1914 onwards. Such history is comprehensively depicted (2). The ‘PIES’ approach is applied; that is, Proximity (being treated close to the location of trauma, with minimal evacuation); Immediacy (being treated as soon after the trauma as possible); Expectancy (the clear expectation of all concerned that return to unit in theatre will be the outcome in the vast majority of cases); and Simplicity (desirable in the chaos of war). Now widely promulgated following the results from Israeli studies (3), this concept was introduced by Salmon (4) who created a psychiatric service in the medical corps of the JN Scott TD FRCP