How Do You Know if the Army Put You on Sucide Watch
ABSTRACT
Military mental wellness intendance professionals have, for decades, recommended that commanders implement a unit watch (now called a "control involvement contour" at most Ground forces posts) as a tool for enhancing the rubber of personnel in the unit when a soldier presents with suicidal or homicidal ideation. Although these procedures are used extensively in garrison and in operational settings, there exists no specific body of literature or Ground forces publication to offer either a rationale or a gear up of guidelines for their apply. We accept successfully used unit sentinel protocols for years both in the deployment setting and in garrison. This commodity provides both a rationale and a set of guidelines for their use based on fundamental military machine psychiatric principles, review of the relevant literature, and anecdotal feel with this intervention. Although further research is indicated, this article provides support for the utilize of unit watch in military settings.
INTRODUCTION
The direction of suicide and homicide risk by mental health professionals in a armed services setting differs somewhat from the management of similar issues in the civilian community. One key difference is the necessity for clinicians to appoint with the unit's control team in a collaborative effort to enhance the safe of soldiers. Another cardinal deviation is the necessity of managing and treating psychiatric symptoms with the constrained resources found in deployed or geographically isolated settings. Based on these two key differences, the unit of measurement lookout man has get a master tool of the armed forces mental health professional for enhancing safety when a soldier presents with a level of suicide or homicide risk that is not loftier plenty to necessitate hospitalization but is loftier enough to warrant an enhanced level of supervision as an adjunct to outpatient handling. The unit picket is thus a common practice in a military setting and is even included as an option in the American Psychiatric Clan (APA) Do Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. ane However, there exists no specific torso of literature or Regular army publication to offer either a rationale or set of guidelines for its use. We provide both a rationale and a set of guidelines for the unit sentinel based on fundamental military psychiatric principles, a review of the available literature, and years of anecdotal experience with this intervention. Information technology is hoped the commodity volition provide support for the military use of unit scout and that farther research volition validate this approach.
RATIONALE FOR THE Use OF Unit of measurement WATCH
The process known as a "unit of measurement lookout man" has been recommended by war machine mental health professionals for decades. For the past several years, the term "command interest profile" has often been substituted for the term "unit of measurement lookout man" based on a recommendation from the Office of the Surgeon General Psychiatric Consultant. We will use the term "unit sentry" throughout the article, but deem the 2 terms to exist interchangeable. A unit lookout man encompasses a variety of interventions initiated by a soldier'south command team based on a recommendation from a clinician. These interventions typically include searching the soldier'due south belongings and living quarters for unsafe items, removing such items from the soldier's possession, prohibiting access to alcohol and drugs, minimizing contact with people that may negatively influence the soldier'south mental health, continuously observing the soldier, and ensuring that the soldier returns for further evaluation and treatment. 2
The command team in a U.South. Army company typically consists of a commander (captain), a first sergeant (1SG), and subordinate officers and noncommissioned officers (NCO) in the unit. A command team is oftentimes an invaluable partner in managing a soldier's suicide or homicide risk. In some situations, a unit of measurement watch may be the best means that a command team in a deployed unit of measurement has to ensure the condom of unit members. 3 A unit lookout is an excellent case of the war machine clinician working with the command team to address the soldier's mental health needs in the least restrictive setting through application of the time-honored armed forces psychiatric principles of proximity, immediacy, expectancy, and simplicity (PIES). 4 (Alternately the acronym BICEPS has been used, in which B is for brevity, I: immediacy, C: centrality, E: expectancy, P: proximity, Southward: simplicity.) 5
The unit watch may reduce the risk of a soldier interim on suicidal or homicidal impulses through several mechanisms. Unit spotter protocols first and foremost limit access to lethal means for suicide or homicide. Although soldiers on a unit watch may surreptitiously gain access to items such every bit medications, ropes, or knives, it is highly unlikely that they could obtain access to firearms. This alone may substantially reduce the risk of suicide completion, since there is significant data indicating that firearms were the method of injury in a majority of completed suicides in the U.Southward. Ground forces in 2004 (62%) and 2005 (69%). 6 , 7
Homicidal ideation presents an opportunity for utilization of a unit watch. In our experience, homicidal ideation usually occurs in the context of service members with personality or adjustment disorders or those who abuse alcohol and is only infrequently associated with major psychiatric affliction. Hospitalization to protect the intended victim may not be the most clinically advisable course of action. As an alternative measure the unit sentinel takes an added footstep to protect the victim by limiting admission to lethal means and providing an observer to notify the chain of control or authorities if the behavior escalates. Additionally, a soldier or potential victim may be moved to another department and ordered to avert all contact with each other. We fence that these interventions may be more than effective at minimizing hazard than only notifying the local law and the potential victim.
The potential for access to alcohol and drugs can also be essentially reduced through a unit watch. Among U.Due south. Army soldiers attempting or completing suicide in 2005, the use of booze and drugs was present during suicide attempts (57%) and completions (17%) at significant rates. 7 Since the use of alcohol and drugs in a suicidal individual may impair judgment and lower inhibitions against acting on suicidal or homicidal impulses, limiting admission to these substances may reduce risk.
Limiting contact with individuals who may exacerbate the soldier's suicidal or homicidal thoughts also may exist of value in reducing the risk of acting on suicidal or homicidal impulses. The reduction in potential for homicide is based on the separation from the intended victim that a unit watch tin can provide. In soldiers experiencing suicidal thoughts related to conflict in their romantic human relationship, suicide risk may be reduced by limiting contact with a significant other when the situation is volatile. This is often a complicated decision, since the promise of maintaining a relationship with the meaning other may be seen by a suicidal soldier as the only reason to live. Even so, anecdotal experience indicates that unrestricted contact when the relationship is deteriorating oft seems to worsen the situation.
A unit spotter may likewise focus the control squad'southward attention on unit and other situational stressors that are playing a role in the soldier's status and thereby enhance the back up for the soldier in addressing his or her concerns. This attention and back up may play a significant part in risk reduction by diminishing the agitation and hopelessness that are often nowadays in soldiers with suicidal or homicidal thoughts. Much has been written about the importance of leadership, unit cohesion, and group identification as essential elements of a soldier's power to cope in both wartime and peacetime. 8 If the commander fully supports the unit spotter and communicates to his command squad that it every bit a fashion of helping a team member in distress, the unit watch tin function to raise group cohesion and has the potential to improve the soldier'due south ability to cope.
The theoretical value of a unit sentinel as a management tool derives partially through extrapolation from the large trunk of literature on the military psychiatric principles of PIES. 4 , 9 In a strict military conception of suicidal and homicidal thoughts, these symptoms can be conceptualized as analogous to gainsay/operational stress reactions in war or equally "stress fatigue" in a training surroundings. 10 In the absenteeism of a diagnosable mental illness, these stress reactions ofttimes respond to simple interventions such as rest, communication of an expectation of recovery, control attention to the soldier'south problems, and support from personnel in the soldier's unit. The early on literature on apply of the PIES principles suggests that psychiatric hospitalization, which requires removal of the soldier from his unit of measurement, is likely to filibuster recovery from the symptoms of stress or boxing fatigue. 11 The anecdotal experience of armed forces psychiatrists as well suggests that hospitalization may even exacerbate symptoms past placing the soldier in the office of a psychiatric patient. 11 Extrapolating from this formulation of suicidal and homicidal thoughts as somewhat analogous to combat stress or stress fatigue, we propose that, for a multifariousness of reasons, psychiatric hospitalization for suicidal or homicidal thoughts tin be counterproductive in the handling of these symptoms. Although the unit watch should not take the place of hospitalization when suicide or homicide run a risk is high, information technology is oft an excellent offshoot in the outpatient treatment of suicidal or homicidal soldiers who are at low to moderate risk for suicide or homicide.
One reason to avoid hospitalization is that the soldier maintains occupational performance at some level, which may help the soldier preserve a sense of self-worth and belonging. An additional reason is that the soldier avoids the stigma that may back-trail psychiatric hospitalization. 12 Based on our anecdotal experience, this stigma sometimes has a profound issue on the reintegration of soldiers into their unit after hospitalization. Soldiers often report that their peers make comments about them being "psycho" or having been "locked in a rubber room."
Although there may be some stigma associated with a unit watch, there is less room for misperception nigh the soldier's condition since the unit members see and interact with the soldier on a daily footing. Soldiers oftentimes written report that, during their unit of measurement watch, but talking to their unit members proved helpful. However, in some units, the stigma of a unit of measurement lookout can be meaning. Soldiers have reported to us several episodes of ridicule and verbal harassment by unit members after beingness placed on unit spotter. Unit watches may indirectly cause other soldiers to perform extra duties and, in a gainsay surroundings, face extra hazards. This tin can lead to resentment toward the soldier on the unit of measurement watch. The stigma associated with receiving mental health care continues to be substantial. 3 For all of these reasons, it is vital to convince the command squad to set a supportive tone for the soldier during a unit watch. Working with the command to ensure a unit scout environment that builds social support can exist extremely helpful for the soldier. Strengthening such unit of measurement social support may play a key part in the soldier's recovery. xiii , 14
A third reason to avoid hospitalization when possible is that the soldier may gain more than of an opportunity to address his concerns with his chain of command, peculiarly if the clinician provides appropriate command consultation to ensure that the commander is aware of issues that may be responsive to command intervention. In addition to the commander, NCOs often provide invaluable support for soldiers on a unit spotter past listening to the soldier's concerns, by sometimes modifying their fashion of interaction with the soldier based on a heightened sensitivity to the soldier's personal problems, and by providing advice as they perform their role of "watching" the soldier.
Finally, the utilization of a unit of measurement spotter for a soldier who presents with "armed forces-specific" suicidal or homicidal ideation may exist highly constructive in reducing "secondary gain." We innovate the terms "armed services-specific suicidal ideation" and "military-specific homicidal ideation," defined every bit the verbal expression of suicidal (or homicidal) thoughts with the implicit (as determined by the clinician) or explicit goal of avoiding a military duty such as a field grooming exercise or deployment, of receiving a transfer to another unit or occupational specialty, or of obtaining a separation from active duty. The soldiers essentially imply or country that they may or volition kill themselves, or a leader in their unit of measurement, unless allowed to accomplish the stated goal. Such statements are often accompanied past allegations of harassment against the chain of control in the unit that, in our experience, may or may non be well-founded. In the most extreme cases of truly "militaryspecific" suicidal or homicidal ideation, the soldier'due south threats are directly linked through collateral data from the commander to a subculture of peers inside the military environs, a subculture which is circulating information about options for separation from service. This subculture of peers advises the service member that i of the "piece of cake" ways to "become chaptered" (seek administrative belch) without negative consequences is to written report suicidal or homicidal ideation to a mental health professional. This subculture is idiomatically captured by the term "barracks lawyers," a term which many commanders utilise to draw the service fellow member's peers who requite such advice. The use of a unit picket in these situations seems to exist helpful in combating this subculture, thus conserving military machine mental wellness resources for other service members who are more than likely to benefit from treatment. More specifically, a unit watch is oftentimes helpful in the treatment of soldiers with military machine-specific suicidal or homicidal thoughts because the soldier and other soldiers in the unit of measurement speedily develop an awareness that the mental health system is not there to provide an escape from their duties and responsibilities, only is there to provide supportive treatment to assistance them part more effectively in a military environment.
Military-specific suicidal or homicidal ideation is thus a potent indicator for the use of a unit of measurement watch in the absence of other factors that drag the risk level enough to require hospitalization. Although valuable in the management of military-specific suicidal or homicidal ideation in garrison, the utilization of unit watches is even more valuable in a theater of operations. Military-specific suicidal or homicidal ideation is, in our opinion, one of the combat operational stress reactions that is almost likely to nowadays on today's battlefield and could hands develop into an evacuation syndrome if not managed appropriately. fourteen For case, during a tour at the 25th Infantry Partition, one of us received a call from the division social worker who was deployed as the chief mental wellness nugget of a peacekeeping forcefulness. She reported that a soldier had presented with suicidal thoughts and had been hospitalized at a noncombatant facility later on the suicidal thoughts continued, along with some neurovegetative symptoms, despite several days of handling while on a unit spotter. When the force surgeon reviewed the situation, he initially made a decision that all service members presenting with suicidal thoughts would immediately exist evacuated to the nearest inpatient psychiatric treatment facility exterior of the continental United States so that the civilian "standard of care" would exist met in insuring evaluation by a psychiatrist. Fortunately, the sectionalisation social worker was able to successfully argue that this grade of action would quite mayhap lead to an evacuation syndrome, and the force surgeon agreed to go on assessment of the need for evacuation on a case-by-case ground. This example indicates that while we have focused primarily on the do good for the soldier in using unit of measurement watches, a strength which is well-versed in unit watches from their garrison feel is much more probable to successfully use this concept in wartime or other operations and thus do good significantly in conserving the fighting, or peacekeeping, forcefulness.
Ii caveats warrant word when considering the rationale for the employ of unit watches as a tool for enhancing the safety of soldiers who are at adventure for suicide and homicide. The first is that while the unit lookout man may exist beneficial in several ways for the soldier, the unit sentinel should non be construed past the clinician, the control team, or the patient as THE treatment. It is more appropriately viewed as a component of the treatment setting rather than as the handling itself.12 Military mental health clinicians will need to provide psychological and pharmacologic treatment, every bit appropriate, to soldiers who present for care, whether or not a unit watch is used to enhance safety. For example, treating symptoms such equally feet and indisposition are oftentimes essential in reducing suicide adventure. 12 Handling of these symptoms should be a priority in soldiers presenting with suicidal thoughts and handling should occur independent of the decision to utilize a unit watch.
The second caveat is that there exists essentially no research that straight addresses the condom and efficacy of a unit lookout equally an intervention. The Army Suicide Event Study (ASER) does provide some information that obliquely address the safety of "under command observation" (defined farther on the ASER form as "(e.thou., CIP)," which is a reference to Control Interest Profile). In 2004, ASER information were received for 54 of 70 suicide completions and 259 other suicide events (including events that did not accept a suicide effort such as suicidal ideation without try, hospitalization, suicide endeavor after the unit of measurement picket was discontinued, and evacuation). One soldier who completed suicide (1%) and ane (0.4%) who attempted suicide were under unit picket. In calendar twelvemonth 2005, 2 (0.2%) of the 723 reported attempts in the active duty Army population occurred while the soldier was under command ascertainment (five reported, 2 were simply ideation with no attempt, 1 was from another service,). During the aforementioned year, none (0%) of the 71 completed suicides, with ASER reports, occurred under command observation. vii (Of the 83 completed suicides that year, 12 did not have ASERS submitted therefore in that location were 71 available reports). Considering the widespread use of unit of measurement spotter procedures in the U.S. Ground forces, these data offer some back up to the hypothesis that unit watches are safety and may be efficacious in reducing suicidal behaviors in the short-term while treatment is initiated. Although a controlled study evaluating the safety and efficacy of unit watch procedures may exist difficult to design, research about this highly used practice is certainly warranted. The decision to use a unit watch must be based on adept clinical opinion with consideration of the benefits and potential risks and with the understanding that suicide completion sometimes occurs while on unit sentry.
Hazard Cess
Essential to the appropriate use of unit watches is the ability to assess and document the soldier's suicide or homicide risk in a format that clearly explains the clinician's decision-making process. Much has been written regarding the factors virtually often associated with completed suicide in both the civilian population and the American military population. 7 , xv , 16 These factors tin can be incorporated into a gamble assessment that guides the clinician in appropriately choosing a unit sentry or hospitalization. Although give-and-take of a comprehensive suicide risk assessment is across the telescopic of this article, we would like to point out a few risk factors that are particularly relevant in a military machine setting.
One of the gamble factors most highly correlative with completed suicide is diagnosis. 17 Nigh 95% of patients who effort or commit suicide accept a diagnosis of a mood disorder, a psychotic disorder, a substance corruption disorder, dementia, or delirium. In populations under 30 years of age, the well-nigh mutual diagnoses amongst suicide completers in 1 study were antisocial personality disorder and substance abuse disorders. xviii Based on anecdotal experience, nosotros take plant that a significant number of soldiers presenting with armed forces-specific suicidal thoughts exercise not meet criteria for these diagnoses. Nonetheless, the absence of a psychiatric diagnosis must exist interpreted with caution in the active duty Army population, since the ASER data from 2005 indicate that only 26% of suicide completers were given a psychiatric diagnosis.
An "unambiguous wish to die" over a "primary wish for change" as well every bit "communication internalized" (self-arraign) versus "communication externalized" have been cited every bit important factors associated with high suicide risk. nineteen We find these 2 risk factors particularly interesting in the setting of armed forces-specific suicidal thoughts, in that the majority of soldiers with this presentation are primarily interested in a change (leaving the military) and are aroused at an external entity (the war machine, or their chain of command), rather than focusing on "self-blame" for their dissatisfaction. Finally, the clan of suicide completion with a conflicted romantic relationship or recent divorce has been particularly well-described in the military machine population. 15
When many or all of the above-described risk factors for suicide completion are absent, this is often an indication that a unit watch is a more than appropriate disposition than hospitalization. It is important that the clinician conspicuously document these and other factors in a formal suicide risk assessment that provides a rationale for the determination to utilize a unit watch. In a military setting, collateral data from the unit commander or others in the unit of measurement is an important source of data in a suicide take a chance assessment. Current practice in the field of suicide risk cess also emphasizes the ongoing nature of the evaluation. Individuals on unit watch should undergo frequent reassessments past the mental health professional person to decide whether the suicide hazard has increased such that inpatient hospitalization is now indicated.
GUIDELINES FOR UNIT Sentinel PROCEDURES
There are many different approaches to the implementation of unit of measurement watches in the military machine organisation. Although there is room for variation in dissimilar settings, we propose a set of guidelines similar to those that guided the implementation of unit watches per standing operating procedures (SOP) at the 2nd Infantry Division, the 25th Infantry Division, and at Womack Army Medical Center in the mid-to-tardily 1990s when i of united states of america formulated before versions of an SOP. We maintain that the unit of measurement watch, according to our proposed guidelines, should be regarded as a "temporary contour," a recommendation to a commander regarding the soldier's temporary duty restrictions which are likely to be helpful in insuring his or her health and welfare. Most Army commanders are familiar with the concept of a unit watch and will back up such recommendations especially when written and signed by the mental health professional and when instructions are written and easily understood.
Detailed written instructions that are specific for the individual patient are given to the soldier's escort, usually a NCO, who signs for their receipt and is instructed to evangelize them to the commander or 1SG. This allows the clinician to release the service fellow member with a recommendation for unit watch, east.g., escorted by a NCO, with a recommendation for the unit of measurement picket at times when the clinician may not be able to contact the commander directly to await the commander's decision. Every bit with all medical profiles, the commander may choose to ignore the clinician's recommendation, but he or she may then presume significant responsibility regarding the outcome.
The system we suggest consists of ii types of unit watches. The offset is called a "Buddy Watch" (the term "Modified Command Involvement Profile" is suggested for apply as an alternative) and is distinguished primarily by the recommendation that the soldier be nether straight observation only from first formation until lights out rather than 24 hours a twenty-four hours. The second distinguishing feature for the clinician is that the proposed system allows for a 3-twenty-four hours menses from the initiation of this watch until a re-evaluation is required. The 3-mean solar day period is the maximum duration betwixt evaluations for a soldier on unit lookout, although the clinician may reevaluate the soldier sooner if indicated. This picket is generally for lower hazard individuals, provides more flexibility for utilise (e.g., over a weekend), and is more often than not better received by the chain of command and the soldier. It is valuable in a diverseness of situations, including the typical presentation with war machine-specific suicidal ideation and very few risk factors for suicide completion. Another scenario in which this watch may be useful is in managing the soldier who is urgently command-referred for verbal expression of suicidal thoughts or self-injurious behavior "the night before" when he or she was intoxicated. On presentation, the service fellow member may accept no current suicidal ideation, may claim to accept no memory of the statements or cocky-injurious deed, and demonstrate minimal take chances factors for a suicidal act, but there is clearly some run a risk especially if he or she resumes alcohol utilize. The Buddy Watch significantly minimizes the opportunity for continued alcohol use over the 3-mean solar day period and thus may reduce the suicide risk while outpatient treatment, including referral to the Army substance abuse program, is initiated. Other situations in which a Buddy Watch may be valuable are situations in which "stepping down" from hospitalization or 24-hour spotter is prudent. Figure i is an case of specific procedures for Buddy Watch: (adapted from a form developed at the 2nd Infantry Division, initially by CPT Sally Chessani, at present COL Sally Harvey, Licensed Clinical Psychologist).
Figure i
Buddy watch memorandum.
FIGURE one
Buddy watch memorandum.
The other blazon of watch, alluded to in the previous paragraph, is chosen a "24-Hour Watch" (the term "Command Interest Profile" is suggested for use every bit an alternative). We avert another normally used term, "CQ Watch," for two reasons. First, some units do not have a Accuse of Quarters (CQ) duty. The commander may infer from the term "CQ Sentinel" that his unit is being asked to perform a task for which it is non equipped. Second, the commander may infer from the term "CQ Scout" that the clinician is recommending that the commander motion the soldier to a key area (e.grand., dayroom) in the unit where the soldier can be observed by the soldiers performing CQ duty. Moving the soldier to a central area may sometimes be necessary merely should be avoided whenever possible, since such a move may enhance the sense of humiliation or stigma for the soldier. The primary characteristic of a 24-Hour Watch is that the soldier is observed constantly during a 24-60 minutes period, after which an evaluation past a mental health officer must have identify. Specific procedures for this spotter are outlined in Effigy 2.
Effigy 2
Twenty-four-hour watch memorandum.
FIGURE two
Xx-four-60 minutes watch memorandum.
The procedures outlined for both types of unit of measurement watch are designed to give the commander specific guidance regarding measures to ensure the soldier's safety. This written guidance helps to avert confusion, which often results if a more vague exact recommendation for a unit lookout is used to communicate with the chain of control. The 24-hour watch is at times useful in the management of a soldier with armed forces-specific suicidal or homicidal ideation who has very few risk factors except for a verbalized threat, eastward.g., "I will kill myself (or my squad leader) if I have to get dorsum to my unit of measurement." It is often, although non necessarily, used in conjunction with an environmental change, eastward.g., in an Ground forces setting, an agreement with the commander that the soldier will be moved to a different platoon, if his threats of suicide or homicide are specific to alleged harassment by a NCO in his section, squad, or platoon.
In improver to forwarding the memorandum that outlines the specific interventions necessary for the unit watch, we recommend that, at each episode of implementation of a unit spotter, the clinician forrard to the commander an information paper (for case, Fig. 3) which outlines the rationale for the use of unit watches. Instruction through this information newspaper tin can exist very helpful for the control squad. For instance, such education may convalesce the concerns of college level commanders who, upon learning from the inferior-level commander well-nigh the unit watch, may otherwise feel compelled to intervene and attempt to force the mental health organisation to psychiatrically hospitalize the service fellow member. The final piece of education, which really should precede the implementation of a unit watch organisation, should occur with the staff of the mental health facility or combat stress unit in order for the clinicians to develop a articulate understanding of the role of unit watches as an intervention. We propose that this education occur through the implementation of a SOP. We take included a sample SOP (Fig. 4). This SOP provides a full general guideline for the employ of unit watches in a armed services setting. We prefer to avoid absolute guidelines about which clinical factors require hospitalization over unit lookout man, as in that location is significant room for variation amongst competent clinicians regarding the need for psychiatric hospitalization in various situations. This variation points out once again the critical role of the suicide or homicide hazard assessment in documenting the clinician'due south decision-making process, equally exemplified clinical vignettes below.
Effigy iii
Data paper for commanders.
FIGURE 3
Information paper for commanders.
Figure iv
Standing operating procedures for buddy watch and 24-hour spotter.
FIGURE 4
Standing operating procedures for buddy watch and 24-60 minutes scout.
Finally, when the clinician decides to recommend discontinuation of the unit watch, it is helpful to forrard to the command team a standard document with this recommendation. In some cases, when the commander has been unavailable for phone contact and the recommendation to discontinue the unit spotter was transmitted to the commander via the "buddy" or NCO, patients have reported that the commander chose to continue the unit watch in the absence of a written recommendation from the mental health professional. We have included a sample unit lookout man discontinuation memorandum (Fig. 5).
Effigy 5
Unit of measurement watch discontinuation memorandum.
FIGURE five
Unit of measurement watch discontinuation memorandum.
CLINICAL VIGNETTES
The following clinical vignettes will provide examples to familiarize the military clinician with common presentations in which a unit scout is a reasonable intervention.
Case 1
A junior-enlisted active duty soldier in his early 20s with 11 months time in service, who is assigned to a mechanized infantry battalion, presents equally a self-referral with suicidal thoughts for the past 5 days with a plan of lacerating his wrist with his field knife. He states that he cannot continue in his current assignment because his team leader is too tough on him and he misses his girlfriend and family dorsum dwelling house in the continental The states. On review of symptoms, he reports depressed mood, poor sleep, and low energy "ever since I got here" but other neurovegetative symptoms are absent. He has been drinking approximately five to eight beers every Friday and Saturday night, but denies criteria for alcohol abuse or dependence. His unit is scheduled to spend a week in the field beginning tomorrow. The soldier's chain of command reports that he has shown deterioration in his performance over the past two weeks manifested past failing to maintain standards of advent and beingness belatedly to formation. The unit of measurement plans a summarized Article 15. He has no history of suicide attempts and no history of by psychiatric treatment. He is not willing to contract for safety. Mental status exam reveals no psychomotor retardation, a frustrated and constricted affect, and normal concentration and memory. The clinician makes a diagnosis of adjustment disorder with depressed mood.
The soldier'due south suicide take chances is not high enough to warrant hospitalization based on the absence of a major psychiatric disorder (no mood disorder, psychotic disorder, or substance abuse disorder) or a history of previous suicide attempts. Other factors which argue for low to moderate suicide risk are the age of the patient, the absence of whatever difficulties in his romantic relationship, the expression of a primary wish for alter rather than death, and the prominence of anger at the Ground forces and chain of command over cocky-arraign. Recommendations: A buddy watch is recommended to the commander. The NCO escort agrees to frontward these recommendations to the commander and ensure that the soldier is returned from the field in three days for a follow-up cess and further treatment.
Case two
A 31-year-erstwhile married African American male deployed to a combat zone came to the mental wellness dispensary subsequently learning his wife and child planned to exit him. He stated that if just he was given the chance to become habitation he could save his wedlock. He reported that he was suicidal and would kill himself if he was non immune to exit. In the initial evaluation, he did not have a defined plan for conveying out his suicide and had never earlier had suicidal thoughts. He denied previous mental health history, had no medical disease, and was not using booze, street drugs, or medications. It was felt that his case was appropriate for a 24-60 minutes sentry with frequent mental health follow-upwardly to aid him cope with his emotional crisis. On coming together with the command team to discuss a safety plan for the soldier, the command team reported that he had previously been accordingly serving in his function as a member of a logistics squad. During the meeting the soldier's 1SG reminded the soldier how proud the "Old Man" (battalion commander) was at how proficiently the soldier had recently accomplished a skilled task. He and then expressed how the command team valued the soldier non just equally a number or worker, but as a person and squad fellow member. The command squad agreed to provide 24-hour supervision for the soldier in a nonstigmatizing manner by removing the bolt from his weapon and removing his armament and knives from his possession as well as allowing him to remain on base where he would probably not demand his weapons. He was immune to choose the soldiers intended to escort him from amidst those from whom he felt the most back up. He was and so returned to duty with mental health follow-upwardly planned in ii days. He reported that, during the mean solar day while on 24-hour lookout, he spent time talking to his escorts most his problems. During this time period, he continued his usual work schedule and came to the dispensary every other mean solar day for a brief assessment and supportive therapy. Within 2 weeks, he had come to terms with his pending divorce, realizing that his presence at habitation would probably non have afflicted his married woman's plans. He also noted that it would not be worth throwing away his life or armed forces career. The 24-60 minutes watch was discontinued. His bolt and ammunition were returned to him and, although his married woman did get out him, he was able to keep with the mission and complete the deployment. His emotional state had returned to well-nigh baseline by i calendar month afterward his wife told him of her plans and later several months of monthly follow-upward he needed no farther care.
The soldier presented with suicidal ideation in acute emotional crisis later on learning of his wife'south plan to divorce him. His access to a weapon and his primary stressor of interpersonal loss placed him at significant risk for a suicide effort. However, he did not have a formulated plan for suicide, a significant medical or mental health history, or a substance utilize problem. Thus, his treating clinician felt appropriate handling would be to ensure the patient's safety long plenty for his immediate emotional crisis to resolve. An adequate nonstigmatizing prophylactic environment was created for the soldier and the unit of measurement provided emotional support also every bit safety. Equally expected, his emotional crunch resolved within ii weeks and his symptoms resolved within several months as he gained understanding and acceptance of his changing life state of affairs.
The clinician must clearly certificate the suicide or homicide take a chance assessment, giving a clear rationale that makes the example for unit of measurement watch rather than hospitalization or evacuation from the zone of operations. Nosotros believe that the military unit is a unique and cohesive community that allows the unit watch to be a responsible way to minimize suicide or homicide hazard. Because this is an intervention unknown in the civilian sector, meticulous documentation of suicide take chances factors and the reason that unit watch was considered a prophylactic intervention for the soldier is essential in each case. Documentation of discussions with command, education given to control, and assurance of the clinician that the command is capable of carrying out a proper unit spotter is also recommended Finally, the widespread employ of the unit of measurement lookout past armed services mental health providers, and its inclusion in the APA Practice Guidelines, may help establish that this is an advisable intervention within the armed forces. 12
DISCUSSION
Although in that location are no simple answers in the assessment and management of suicide and homicide hazard, nosotros believe that military psychiatrists exercise in a unique community, which requires a unique military approach to this issue. There is no clinical literature or case law to support the recommendations for unit lookout man, and then we must rely on clinical experience and extrapolations from available data. This article represents an endeavor to formulate that experience. Clinical experience within the military customs teaches that unit of measurement watch is a useful adjunct to outpatient care. It may accept to be a substitute for hospitalization in deployed situations when atmospheric condition practise not permit for rubber evacuation to a college level of intendance. APA Practice Guidelines signal clearly that, "The ultimate judgment regarding a particular clinical procedure or treatment program must be made by the psychiatrist in calorie-free of the clinical data presented by the patient and the diagnostic and handling options bachelor." one This notion can support the use of unit watch in armed services environments characterized by constrained resources—typically deployed environments—even for individuals for whom hospitalization might be indicated in civilian or garrison settings. The unit watch may often be amend wellness care practice than arbitrarily removing a marginally adapted soldier from his or her unit simply because the presenting symptoms might qualify the private for a higher level of intendance. Although military machine physicians are not individually discipline to the sorts of lawsuits their civilian colleagues face up, they are—or ought to exist—mindful that they are always field of study to courtroom martial proceedings if they practice negligently. The SOPs established in this commodity may prove beneficial and protective to clinicians using unit watches. Much research is nonetheless needed to validate these procedures. Case series, retrospective, or prospective studies, or outcomes comparisons, all represent opportunities for farther research and validation of these techniques. We hope that this commodity will grade a foundation for such farther piece of work in this topic.
ACKNOWLEDGMENTS
We limited our sincere thank you to COL Emerge Harvey for developing the example forms used throughout this article which take plant use in two major conflicts, Operation Iraqi Liberty and Operation Enduring Freedom, in peacekeeping operations throughout the Balkans, in garrison throughout the United states, in Europe, and in Asia (including the demilitarized zone in Korea).
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Author notes
one The views expressed in this manuscript are those of the authors and practise not reflect the official policy or position of Landstuhl Regional Medical Heart, Dwight David Eisenhower Army Medical Center, U.Southward. Ground forces MEDDAC Wuerzburg, the Department of the Army, the Department of Defense, or the U.S. regime.
Reprint & Copyright © Clan of Armed services Surgeons of the U.S.
Source: https://academic.oup.com/milmed/article/173/1/25/4557698
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