Minor Behavioral Health Readiness and Profiling Barriers in the U.S. Army.

Medical readiness for deployment is arguably the most important component of personnel readiness in the U.S. Army. Administrative documents called profiles provide individualized medical recommendations to the commander regarding how to best provide for a soldier's health and welfare, and contribute to an aggregated enumeration of a unit's overall readiness to deploy. Profiles that convey behavioral health (BH) limitations thus reflect what can be called the "behavioral health readiness" of the force. In the Army, BH profiles are further broken into major (more severe BH conditions) and minor (less severe) categories. Recent reporting indicates that current profiling (both major and minor) substantially underestimates BH readiness, presenting a significant safety and personnel issue for the Army. Currently, little is understood regarding barriers to profiling. The intent of this paper is to establish a basis for understanding these barriers by examining provider perceptions on the issue. While the results may have broad applicability in determining BH profiling barriers in general, minor BH improvement efforts stand to benefit the most due to more reliance on provider judgment and less on mandatory guidelines. Selected themes and provider quotes regarding barriers to BH profiling from a qualitative study, "Return to Duty Practices of Behavioral Healthcare Providers in Garrison," are presented. Fourteen semi-structured interviews and three focus groups were conducted with a diverse convenience sample of Army BH providers in October 2015, resulting in input from 29 practitioners. Four general profiling barrier categories were identified and include provider proficiency level, environmental factors, stigma concern, and clinical time constraints. Suboptimal BH profiling rates suggest that a preponderance of factors currently tip the scale of BH profiling in a lopsided fashion that comes at the cost of soldier safety and increased risk of mission failure. Relief from one or more of the identified profiling barriers would likely be necessary to tip the scale of clinical judgment in favor of increased profiling, and may be more beneficial for improving minor BH profiling deficits in particular. Quantitative exploration of provider and soldier attitudes on this subject is worthy of further pursuit and would shed light on which of the identified barriers are most crucial to reducing BH profile deficits.

Curley JM ，Crouch C ，Wilk JE 《-》

Return to Duty Practices of Army Behavioral Health Providers in Garrison.

Crouch C ，Curley JM ，Carreno JT ，Wilk JE ... -  《-》

Soldier Attitudes Toward Behavioral Health Profiles in the US Army.

Behavioral health (BH) readiness is a critical component of U.S. Army personnel readiness. Medical providers issue BH profiles in order to communicate BH-related duty limitations to the commander and reflect BH force readiness on both micro/macro-levels. A recent report indicates BH profile underutilization may be significantly elevating U.S. Army safety and mission-failure risks, and a study of BH provider decision-making suggests some providers may be hesitant to use profiles due to concerns that soldiers' attitudes toward BH profiles may negatively impact treatment utilization. This potential link, however, has not been empirically examined. This study addresses this gap by assessing soldiers' attitudes towards BH profiles to better understand how BH profiles may impact treatment utilization and explore for any BH profile-related stigma effect. Approved by the Walter Reed Army Institute of Research (WRAIR) Institutional Review Board as part of the Land Combat Study II, the survey specific to this study included eight WRAIR-developed items assessing soldier attitudes toward BH profiles. Soldiers (N = 1,043) from two active duty U.S. Army brigades completed cross-sectional, anonymous surveys in 2017-2018. Soldier self-reported BH care utilization was assessed and used to create sub-groups for analysis. A majority of soldiers indicated that being placed on a BH profile would make them as or more likely to seek (71%) and no more or less likely to drop out (84%) of BH care. Among soldiers who had received BH care, BH profiles were associated with more favorable treatment seeking attitudes among those inclined to access conventional BH services and less favorable treatment seeking and maintenance attitudes among those inclined to access BH services from sources incapable of issuing profiles. Negative attitudes towards BH profiles were significantly more prevalent when compared to physical injury profiles, except in the group who had received BH care from a source incapable of issuing a profile. No significant proportional differences were observed among soldiers toward the rationale for BH profiles. Almost all soldiers (95% or greater) preferred their BH condition not come to the commander's attention during pre-deployment screening (SRP), choosing either BH profile or crisis options instead. Results suggest soldiers who would be less likely to seek or more likely to drop out of BH care due to a BH profile may be those that are less likely to access conventional BH services in the first place. This may provide some preliminary reassurance to conventional providers that increased BH profiling practices may not be inversely proportional to the amount of BH care delivered and may encourage treatment-seeking behaviors among the population they serve. Soldiers seeking BH care from sources incapable of issuing a profile may be sensitive to a potential BH profile-related stigma effect (possibly more global profile-related effect in this group), which should be factored into policy outreach efforts. A BH profile represents a more palatable BH duty limitation disclosure option for many soldiers, and supports the merits of a disclosure process that is earlier than SRP for promoting risk mitigation and more honest appraisals of BH mission-readiness levels.

Curley JM ，McDonald JL ，Nugent KL ，Clarke-Walper KM ，Penix EA ，Riviere LA ，Kim PY ，Wilk JE ... -  《-》

Behavioral Health Provider Attitudes Toward Behavioral Health Profiles in the U.S. Army.

U.S. Army healthcare providers' use of profiles to document and communicate behavioral health (BH) condition limitations to commanders is vital to understanding both the individual soldier's BH readiness for missions and, as an aggregate, the unit's overall BH readiness status. Quantitative work exploring the link between soldier attitudes toward BH profiles and treatment utilization found that profiles may actually promote increases in treatment-seeking behavior in those receiving conventional BH services. BH provider attitudes on the subject, however, have not been quantitatively explored. Using data from the recently described Behavioral Health Readiness and Decision-Making Instrument (B-REDI) study, the current inquiry addresses this by examining BH providers' pre-/post-B-REDI attitudes toward BH profiles, including therapeutic alliance, to better understand how BH profiles may impact BH treatment. This study was approved by the WRAIR Institutional Review Board and is part of the larger B-REDI study. BH providers (n = 307) across five installations supporting active duty U.S. Army Divisions completed surveys longitudinally across three time points from September 2018 to March 2019. The survey specific to this study included five items, developed by WRAIR, assessing BH provider attitudes toward BH profiles. Of the providers who completed the survey, 250 (81%) consented to participate in the study and 149 (60%) completed the 3-month follow-up survey. Over 80% of BH providers expressed agreement with each of three items assessing rationale for issuing BH profiles in both the pre- and post B-REDI period. Specifically, most providers agreed that profiles facilitate commander support to the soldier, afford soldiers resources for recovery, and give commanders increased understanding of soldier health for mission planning. Twenty-six percent of BH providers agreed, 46% were neutral, and 28% disagreed on whether profile impact on the soldier was positive or not in the pre-B-REDI period, but there was a significant positive trend relative to baseline in the post B-REDI period. The vast majority of providers (≥94%) did not endorse agreement that BH profiles negatively impact therapeutic alliance in either the pre- or post-B-REDI period. Assuming that therapeutic alliance and perceptions of BH profile impact on soldiers are useful proxy measures of how treatment utilization may be affected by profiling, this inquiry fails to establish any meaningful negative association between them. This may provide some additional reassurance to BH providers and policymakers that efforts to improve readiness decision-making, such as B-REDI, and increased profiling in conventional military BH settings may not negatively impact treatment utilization rates.

Curley JM ，Clarke-Walper KM ，Nugent KL ，Wilk JE ... -  《-》

Maximizing the Division Psychiatrist's Garrison Prevention Role to Meet the U.S. Army's 21st Century Readiness Expectations.

The division psychiatrist has been a bedrock U.S. Army institution for nearly 100 years. The role of the position in combat is well established, but its role in garrison has historically been less well defined. Prevention of behavioral health casualties has long been a governing objective of the division psychiatrist and forms the cornerstone of the behavioral health (BH) readiness concept. Accordingly, the Army's increased emphasis on readiness mandates that the division psychiatrist maximize BH force readiness through applied prevention methods. This process begins in garrison, and the crucible of recent protracted conflict has yielded effective BH screening principles applied in that environment. Despite this achievement, an evolving operational environment threatens the blanket effectiveness of BH screening and prevention in garrison. This article examines the historical evolution of the division psychiatrist's role in garrison, elucidates division psychiatry BH readiness principles in garrison, and expands on previously documented division psychiatry led efforts to maximize BH readiness levels. A historical review of the division psychiatrist was conducted in order to analyze the role of the position in BH prevention operations. Identified division psychiatry preventive lessons are leveraged against current BH readiness challenges resulting in proposed solutions from a division psychiatry perspective. The historical trajectory of the division psychiatrist's role in garrison prevention operations has advanced significantly in the last 17 years. With the advent of evidence-based BH readiness findings, the division psychiatrist's garrison readiness duties have expanded to include analysis of unit BH readiness levels. By applying pre-deployment screening principles in new ways to existing BH readiness platforms, the division psychiatrist can analyze BH readiness levels much earlier than immediately prior to deployment. The resultant BH readiness feedback allows for individualized readiness improvements for the BH systems that serve Army units. The division psychiatrist is the natural proponent of such readiness efforts, and will require staff officer, consultant, liaison, and trainer skill sets in order to be successful. The division psychiatrist's role must adapt to a changing operational environment in order to preserve and build on historical successes. The recommended end state would see the division psychiatrist maintaining a robust pre/post-deployment BH screening process and organizing the regular analysis of BH readiness levels to optimize existing BH clinical platforms. Systematically pursued, this would not only maximize BH readiness, but dramatically enhance safety and the provision of resources towards soldier health and welfare across the Army. The division psychiatrist should lead this effort.

Curley JM ，Warner CH 《-》