Do the Military’s Frontline Psychiatry/Combat Operational Stress Control Programs Benefit Veterans? Part Two: Systematic Review of the Evidence

The second of a three-part review provides the first-ever systematic investigation into the military’s claim that its century-old policy of preventing evacuation of psychiatric casualties from war zones is beneficial to the health and well-being of individual service members and their families. We conducted an extensive literature search for studies on the military’s frontline psychiatry doctrine, particularly research comparing the differential effects of deployed personnel returned-to-duty (RTD) via frontline psychiatry or combat and operational stress control (COSC) and behavioral health interventions, as opposed to those evacuated out of war zones as psychiatric casualties. In addition, we examined partial and indirect evidence in support of the military’s argument that RTD and preventing psychiatric evacuations enhances posttraumatic growth and reduces adverse impact from mental health stigma, shame, and guilt, as well as lowering the risk of developing PTSD or other war stress injury causing premature military discharge. Results indicate support that frontline psychiatry benefits the war-fighting mission and goal of military medicine to prevent psychiatric attrition, with RTD rates of 60 to 100% and severely limiting psychiatric evacuations. However, there is paucity of research on differential outcomes, with only three, small uncontrolled retrospective Israeli studies from the 1982 Lebanon War reporting modest long-term benefit, from frontline versus undefined rear hospital treatment, such as lower PTSD rates. Overall, the review showed insufficient and often contradictory evidence of individual health benefits from frontline psychiatry, which calls for further research on military’s chief mental health policy.