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Combat Stress Teams and Telemedicine: The new strategies for helping soldiers cope with Mary Carmichael

While Maj. Brett Schneider has been back from Iraq for more than a year, he is still in a battle urgently related to that war. His weapons include a videocamera, a cluster of ISDN lines and his medical degree. His fight is no longer about quelling the insurgency in Iraq but maintaining the mental health of American soldiers both Stateside and in-theater.

Schneider is chief of telepsychiatry at Walter Reed Army Medical Center in Washington D.C. He is at the forefront of the U.S. military's new initiatives to treat PTSD and other combat stress disorders via in-theater combat stress control teams and telemedicine -counseling and therapy by videoconference and e-mail.

Mary Carmichael is a FRONTLINE web associate producer.

In Iraq from August 2003 to February 2004, Maj. Schneider led a group of some 20 trained counselors, meeting with soldiers traumatized by everything from the August bombing of the United Nations building to their own experiences in combat. Schneider says he saw plenty of people with the "thousand-yard stare." One thing about Iraq that he says surprised him: he never saw soldiers giving other soldiers a hard time about seeking counseling. Although Schneider admits there's still a stigma that probably keeps some of them away, that's slowly changing. And he thinks the in-theater presence of combat stress teams may be one of the reasons.

Since Schneider's tour of duty in Iraq, the size of these in-theater teams has doubled -- roughly from 20 to 40. Currently, there are some six to eight teams in theater. The teams consist of psychiatrists, psychologists, nurses, counselors, even occupational therapists, working together and traveling autonomously in the most hazardous areas. They often set up camp for extended periods, basically creating a mental health clinic from scratch. Soldiers plagued by combat stress can retreat to the tents for two or three days to "normalize," says Schneider, although "it's not supposed to be R&R." Soldiers under care receive hot meals, rest, and, if necessary, sleeping pills. The teams also perform a sort of triage, identifying soldiers with serious psychological problems and making sure they get extra help -- even if that means removing them from the battlefield.

These combat stress teams have attracted media interest during the war in Iraq, but the military has had them in the works for years. The idea was born around the time of the first Gulf War, although use of the teams was very limited. In 1997, U.S. Army Surgeon General Alcide M. Lanoue touted the concept, giving some credit for the idea to the Israeli armed forces, who "taught us how many casualties can be limited by having far-forward mental health care." Since the mid-'90s, the Russian military has been experimenting with similar "psychological first aid tents;" instead of talk therapy, they offer videos of crashing waves, strains of Chopin and Vivaldi, and projected landscapes of flowers and waterfalls, all meant to soothe soldiers.

Telemedicine is the military's other major mental health initiative. It, too, is not an entirely new thing. A small task force from the Uniformed Services University of Health Sciences ("the nation's federal medical school") was sent to set up a telemedical program in the first Gulf war. But as Lanoue noted in a 1996 briefing, "The commanders weren't interested in it and the medics had no experience with it, so it didn't get very far."

It took the mission to Somalia in 1993 -- a dangerous engagement that severely limited the military's ability to bring in medical supplies and staff -- to prove that the tactic could be useful. There, military doctors used telemedicine mainly for treating eye wounds and broken bones: X-ray images and high-definition digital photographs were e-mailed to colleagues at Walter Reed. However, telemedicine has been expanded in Iraq to include the diagnosing of hundreds of cases of leishmaniasis, a parasitic disease transmitted by the bite of some species of sand flies, and doctors are also using it to treat eye injuries, burns, and other infectious diseases.

But it is in mental health treatment that telemedicine is really coming into its own in recent years, particularly Stateside, where bases are increasingly finding themselves strapped for cash and staff to run mental health programs. Schneider says that Wisconsin's Ft. McCoy, which "practically didn't exist before the [Iraq] war," has no psychiatrist on the premises. "They've hired people, but they can't keep them," says Schneider. "Not a lot of psychiatrists live around there, or want to live there." Until recently, Ft. McCoy soldiers in need of mental health counseling had to wait for a bus to take them en masse to psychiatrists at Ft. Knox, over 600 miles away. But with telemedicine, they get hooked up in a video conference with Schneider's staff back at Walter Reed, getting talk therapy in real time while sitting alone in a room with a television monitor right there at their home base.

So far, says Schneider, soldiers appear to be receptive to the idea of telepsychiatry. His staff sees about 250 patients per month. With four more bases, including Ft. Bragg and West Point, set to come online in 2005, he expects he'll soon be "completely booked." Some patients have worried that they "won't be able to get their feelings across" as well as they might in person, he says, but after a session, they are usually converts. Walter Reed has also gone out of its way to make sure confidentiality isn't an issue. The sessions are conducted over ISDN lines rather than the Internet to thwart potential hackers, and they aren't taped. If soldiers self-refer, says Schneider, there's no need for their buddies or commanders to even know they're being treated. "With telepsychiatry at Walter Reed, [if you're in the States,] you can just slip out for your appointment and tell people you're going to lunch." says Schneider.

There, however, lies one of the problems with using telepsychiatry in-theater. "In Iraq, says Schneider, "you can't just hop in your Humvee for a couple of hours and go see a specialist without telling someone." Treatment can't be conducted secretly in a war zone. However, that's not the biggest obstacle. The Army has conducted very few telepsychiatric consults from Iraq, and those few were all "forensic" - linked to military trials - rather than PTSD-related. The reason, says Schneider, is that there's just not enough technical capability in Iraq. "We're not Verizon," he dryly notes. "When I was there we barely had Internet [access], and the phone was atrocious." Thus far, only commanders have the technology needed to conduct secure, encrypted videoconferences. And they're not often willing to give up the capability so soldiers can get psychiatric help, especially with combat stress teams already in the field.

Nonetheless, someday soldiers in a combat zone may be able to dial up psychiatrists back home. "We could be adjuncts - an extra level of consultation," says Schneider. "If we had unlimited money and bandwidth, it could be done."

So the challenge to the military is to see that the money and bandwidth come through, and that even in a time of overstretched resources, these kinds of innovations in delivering mental health services keep coming.


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posted march 1, 2005

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