Do the Military’s Frontline Psychiatry/Combat and Operational Stress Control Doctrine Help or Harm Veterans?—Part One: Framing the Issue

This is the first of a three-part systematic review of the potential benefits and harmful effects of the military’s century-old doctrine of frontline psychiatry or combat and operational stress control (COSC). Since the Second World War, psychiatric casualties have outnumbered the combined total of American service members both wounded and killedin-action. The original, explicit purpose of frontline psychiatry programs established during the First World War was to prevent mass evacuation and attrition of military personnel experiencing acute war stress injuries by emphasizing brief, nonpsychiatric interventions resulting in return to duty (RTD). Although frontline psychiatry continues to evolve, these bedrock principles of RTD and avoiding psychiatric evacuation remain unchanged. Today, the US military explicitly predicts that over 95% of war stress casualties will be RTD with evacuation limited to those deemed either grossly impaired and/or clear safety risks to self or others. The military justifies its mental health policy by claiming that studies have demonstrated its health benefits to individual service members and their families, as well as findings that medical evacuation and subsequent psychiatric treatment are harmful. However, the only systematic review of the effectiveness of frontline psychiatry was published in 2003, warranting critical examination of the military’s claims. Specifically, the actual evidence for or against the military’s primary mental health policy has never been fully examined, so that any conclusions are tentative. The sheer complexity and national security implications underlying the military’s unchallenged 100-year doctrine required a three-part review. In this study, we frame the debate on the military’s frontline psychiatry/COSC by examining its historical origins, ethical-legal controversies, and contemporary program descriptions.