Table 1.

The mission, unit and MH characteristics of AUS, CAN, GBR, NLD, and USA for the NATO-ISAF mission in Afghanistan

Mission specifics					Unit specifics
	Length	Interval between missions	Number soldiers deployed	Scheduled R&R	Unit demographics	Length of time together before deployment	Continuity of unit (new members, life time)
AUS	Special Operations Command (SOC) = 4 mo. Regular Army 6 to 8 mo. RAAF Aircrew 4 mo. RAAF ground staff—6 mo. Navy—approx 6 mo.	SOC and aircrew can do roughly 4 months per calendar year. Minimal interval for all others is 1 year.	~2,350 service members in Afghanistan. ADF total full time staff is ~ 55,000.	For missions 6 mo. and over, members get 10 days ROCL available from the half-way point of tour through to last mo. of tour.	Units consist of mainly RF but also some Reserve members. Age, deployment experience and background varies between members. Depending on the type of task of the unit, gender may be balanced or biased toward males.	Variable but formed units usually together for a fair while (mo. to yrs). SF teams usually meet up 3 mo. before and do some pre-mission training with the Dutch.	RF units are relatively stable, i.e., unit members are often together for quite some time before they leave on deployment and they stay together for multiple operations. However, SF teams are formed ad hoc for a certain task and will also be taken apart afterwards. Due to this, SF teams have a shorter lifetime.
CAN	In 95% of the cases service members will be deployed for 6 months. (Medical) specialists are deployed shorter, i.e., 3 mo. Commanders can be deployed for 1 year.	The min interval between missions is 1 year. If service members volunteer to go on next mission earlier, they sign a waiver. In practice, the interval varies between 18 and 24 months.	~2,500 service members in Afghanistan. CF has ~ 70,000 RF and 30,000 Reserve Force members.	There is mid-tour scheduled R&R. In practice, this will be between the 1st and 4th month during deployment. Service members are 17 days away from the mission area.	Units consist of both Regular Force and Reserve members. Age, deployment experience and background varies between members. Depending on the type of task of the unit, gender may be balanced or biased toward males.	Regular Force unit members are together for a long time, often > year. Reserve unit members are usually added later. However, the whole unit is together before deployment at least 6 months (during pre-deployment training).	The aim is to have a long unit life time (i.e., multiple deployments with same unit). Nevertheless, augmentation of units by Reserve members does occur.
GBR	Six months as standard. Some less than this (e.g., specialist medical personnel), some HQ personnel do 12 months.	Guidelines state no more than 12 months deployed in any 3-year period.	~9,000 in Afghanistan. UK AF has about ~190,000 RF and ~87,000 Reserve members.	14 days per 6 months allowed—which should allow 10 days at home.	Very varied—all types of units and specialist teams are deployed.	Varies—the main combat units are formed anyhow and IR (individual reinforcements) join such units a few months before deployment. Generally a 6 month reservist's tour would mean they were mobilized for about a year.	Personnel move between units every 2–3 years. Generally non-officers stay within the same regimental system (1–5 Battalions per regiment) and officers alternate between regimental and other postings. However, the postings schedule vary considerably.
NLD	Four or six months: depends on task (Battlegroup=4, Task Force=6).	At minimum twice the time of earlier deployment.	~1,200 in Afghanistan. NLD Army has ~ 52.000 members.	For missions longer than 5 months personnel get approx 2 weeks leave at home.	Unit consists of regular force. Varies in age and experience. Depending on type of task more males.	There is a mission specific preparation program for approx 4–6 months. Ideally, before this time unit should be formed, but this is not always possible.	Personnel change position every 3 years. In addition, after deployment some service members leave military and thus unit will receive new members.
USA	Typically 12 months for Army. 7 months for Marines, 4–6 months for SF.	Typically 12–16 months for Army, 8 months for Marines, 4–6 months for SF.	60,000 in Afghanistan. In total the US AF consist of 1,473,900 active personnel and 1,485,500 reserve personnel.	One must be deployed 12 months to qualify for 14 days mid-tour leave. With deployments of 15 months it is 17 days.	For Army units comprise the entire spectrum from combat, service support to combat service support, plus special operations. Age, deployment experience, and background varies between members.	Highly variable. Can range from years to weeks. Movement out of a unit stops approx. 2–3 months before deployment so most Soldiers are together for several months prior to deploying, but there are last minute fills, so Soldiers can be very new to the unit.	Personnel move about every 3 years or so.
MH support in pre-deployment phase					MH support in deployment phase
	Mission-specific MH care plan	MH screening in service members	MH education/training in service members (which topics & delivered by whom?)	MH team available (which members?)	Type of MH support provided by MH team (type of screening/de-briefing/therapies used)	Type of MH support provided by own unit (by commander/by buddies)	Repatriation (when, who decides & how?)
AUS	Although the ADF tries to identify mission-specific MH threats they do not create a mission-specific MH care plan.	The ADF do not undertake pre-deployment MH screening. Instead, the ADF work with a Medical Employment Classification system to assess whether service members are able to deploy or not. Also, the results of post-deployment MH assessments of the last deployment are used (RtAPs and POPS).	All given by Directorate of MH. Resilience and pre-deployment training (recently introduced BattleSMART Self-Management and Resilience Training program) and a pre-deployment briefing by a psychologist.	MO, psychological examiner, a chaplain and a psychologist. No SWs.	No standard in-theatre MH screening or debriefing. CO does operational debriefs. Self-referral or by CO to MH team. MH team can provide MH first aid. For more formal treatment ADF relies on MH professionals of NATO partners or repatriation follows.	Padre's—TLC Mates—informal debriefs, buddy support Chain of command—formal debriefs, advice.	MO usually in consult with CO.
CAN	A mission-specific MH threat assessment is carried out to determine the type of MH team that should join the unit. This is based on # service members deployed and exposures they could experience. Also, assessed is whether additional training is required (i.e., as an augmentation to standard readiness training).	There is two-fold MH screening: MH inquiries are done during annual physical. Also, pre-deployment, each service member is seen by a MO who gives a “rating” for deployability (green, yellow or red). Moreover, a service member is seen by an MH nurse/SW, who focuses on family support plan. Both advise commander who customarily follows this combined advice.	First, there is MH education throughout the carrier by the MH & Operational Stress Injury Joint Speakers Bureau (MH & OSI JBS). It is focused on increasing MH and OSI literacy, while targeting attitudes and stigma around MH. Secondly, there is “Road to Mental Readiness” (R2MR) training before a mission. It is focused on preparation for and mitigation of the stresses of operations and deployment. A team of MH professionals and trained peers delivers both types of training, but in the delivery the units’ own commander takes central role.	During current mission multiple MH nurses and SWs are available and at least one psychiatrist. Also there are chaplains available. CF do not have uniformed psychologist, but can reply on uniformed psychologist of other NATO partner, if needed.	No in-theatre MH screening. Service members may self-refer to whom they want (no barrier to referral). Usually, MH nurse/SW does 1st assessment and refers to psychiatrist if needed. MH nurse/SW focuses on family matters and psychosocial issues. Psychiatrist focuses on formal diagnoses and treatment. Case management is always coordinated between commander and MH team. Therapy is usually CBT, but may also be EMDR or medication. There is no standard critical incident debriefing. However, if decided necessary by the commander and MO a tailor-made brief is given.	During the MH & OSI JBS carrier courses and R2MR training units are taught about MH and OSI awareness, recognition of common behavioral signs of MH issues and OSIs and supportive buddy/leadership skills and actions. Commanders work closely with MO and MH team to support their unit and provide a work environment that is conductive to positive coping and MH.	Repatriation is ultimately the decision of commander again in coordination with MOs. This decision is based on severity of illness, individual's response to treatment, specific job, MH risks of staying versus MH risks of leaving unit. Aim is to keep individual with unit as long as possible since this is often more advantageous for individuals MH.
GBR	No mission-specific MH care plan. However, it is acknowledged that mission demands may vary for the different Services. Therefore, each Service has a Consultant Advisor in Psychiatry who advises regarding service-specific MH requirements and policy.	None formally. Does not work. Unit medical and welfare staff discuss risky cases with commanders and make decisions.	All personnel should receive an MH brief prior to deployment and another short one in theatre. Briefs given by medical, MH or TRiM personnel. May include body-handling information where appropriate for tasking.	Field MH Team (FMHT) consists of three psychiatric nurses (at least one of which is an officer) and a visiting psychiatrist every 3 months—visits last about 10 days.	No in-theatre screening or debriefing. MH support consists of liaison, formal treatment and TRiM support.	Buddy Aid, TRiM, Padres (in some locations) and most units have some medical personnel who have varying degrees of MH training.	Final decision lies with MOs or FMHT.
NLD	A mission-specific MH plan is made on basis of needs and risk assessment. The plan indicates training needs and needs for MH support in theatre.	No official screening. Unit commanders and social medical team of unit discuss deployability of service members.	All personnel attend pre-deployment stress management briefings given by psychologist and SW. Additional training can be requested by commander.	The Social Medical Team (SMT) consists of a MO, chaplain, SW and psychologist. Psychiatrists are not deployed.	No standard screening. No standard debrief by MH professionals, but MH professionals are often present at operational debrief. SW focus on psychosocial problems. Psychologist focus on psychological problems and provide treatment (CBT, EMDR, etc.).	Unit members and chaplain provide informal social support. Commander leads formal debriefs.	Final decision lies with commander. MH professionals (SMT) advise.
USA	The unit MH team conducts a unit risk assessment. Besides unit based MH support, area based MH support is provided when necessary for a mission. For this, an area support needs assessment is conducted based on troop strength, location, mission.	There is no official pre-deployment screening to assess fitness for deployment. All medical records are reviewed by the Brigade MO to ensure medical fitness for deployment.	Army receives pre-deployment Battlemind which focuses on the expectations of combat and effective coping skills that soldiers and leaders can employ.	An extremely robust cadre of MH providers support the deployed force, including organic MH assets and Combat Stress Control teams.	No standard debriefing by MH personnel, but commander can request an event-based Battlemind psychological debriefing. Treatment: the entire spectrum, from unit MH needs assessment to treatment and restoration to command consultation.	Self-aid, buddy aid. Chaplains provide spiritual support/counseling. Commanders/leaders can request Combat Stress Control support as well.	In case of serious MH problems, MH professionals advise the commander on repatriation. However, the goal is to “restore” in proximity of the unit. For this restoration the Combat Stress Control Unit provides facilities.
MH support in post-deployment phase
	TLD(how long, what main elements)	Follow-up and care by MH professionals (screening, treatment, etc.)		Follow-up and care by unit		MH services infrastructure (clinics, networks, programs)
AUS	None currently—maybe one day on way out due to travel delays, but see RtAPs in next column.	RtAPs (in non-combat area) before leaving country; POPs at 3 month post-deployment. RtAPS consists of three main parts:  – a group debrief on return from deployment issues,  – psychological screening,  – interview with psychologist/psychological examiner. When a referral is needed command line is notified. It depends on the screening output whether a psychologist or psychological examiner conducts the interview. POPS consists of 2 main parts:  • self-report MH screening conducted by a psychologist,  • interview with either psychologist/psychological examiner to conduct a more in-depth screening, and to address adjustment issues, and provide information. Service members who are encountering MH problems are referred for counseling.		Nothing formal—COs and mates; buddy support		Up to 2009, the DMH used Regional MH Teams (RMHT) to obtain its goals: These are present in places where there are large concentrations of service members. RMHT are multi-disciplinary bodies comprised of representatives from the range of ADF MH services. RMHT promote treatment programs, manage complex cases, coordinate local networks, provide outpatient care, deliver critical incident MH support on demand and coordinate prevention strategies/programs. At unit level, MH support is provided by MOs and general practitioners, who will provide a large part of (first level) MH support. At large bases an MH Unit will be available that can provide advanced MH support. An MHU consists of a MO and a psychologist. Also, chaplains are present on most bases. In addition, ADF is supported by contracted psychologists and psychiatrists. Veteran Services provides MH support to veterans (and their families). Defense Community Organisation delivers support to ADF families.
CAN	There is a mandatory TLD at Cyprus. It is 3 days with 2 extra days for travel. It consists of a few obligatory MH briefings and a set of educational briefings of which two have to be selected. Besides this, there are several subsidized R&R activities available.	Standard screening-process, in the form of a survey 90–180 days post-deployment. It consists of a set of standard health questionnaires (including one on PTSD symptoms) followed by an in-depth interview with an MH professional. It attempts to trace people with deployment related MH problems. Also, there is a mandatory (annual) period health assessment. Once diagnosed with an OSI an individual will be followed by one of the OTSSCs until full remission. In case there is no full remission, there is a good transition to the VAC. In-garrison MH support is covered partly by military, civilian and contracted MH professionals. All sorts of treatments are used: CBT, EMDR, medication.		After TLD, unit goes back to work for 3 half days before unit members can go on a leave. This is implemented as an additional “decompression” in order to make an optimal transition to home/base life. Besides the support from own buddies and commander, there is an Operational Stress Injury Social Support (OSISS) network, i.e., a peer support network of former operational stress injuries survivors. This is a joint activity with VAC in close collaboration with the OTSSCs.		MH care is delivered at CF Health Care Clinics across Canada. CF MH Services consists of two distinct services: Psychosocial Services and MH Services. Psychosocial Services comprise a basic level of MH care and is staffed by nurses, SWs and addictions counselors. This program is fully confidential for which no referral from a physician/MO is needed. This program is available at all clinics. MH Services consists of specialized programs such as: the OTSSC program that focuses on treatment of operational injuries, the MH program which focuses on general MH conditions and the Addiction program. For these programs a referral of a physician/MO is required. An interdisciplinary staff of psychologists, psychiatrists, MH nurses, SWs, addictions counselors and Health Services chaplains provides Service. These secondary programs are located at the larger centers.
GBR	36 hours. 1 hour of MH briefings. Padre and psychiatric nurse on hand for informal support. All homecoming personnel see coming home DVD which is designed to protect MH (DVD MH training).	No formal screening. All personnel re-briefed/talked to 12 weeks after coming home. No formal MH care provided unless needed.		As previous box. Commanders also responsible for on-going concern about the psychological welfare of their subordinates. TRiM also available in units for informal support.		Many MH cases are handled entirely within military primary care; cases requiring formal MH input are referred to the nearest Department of Community MH site. These DsCMH provide UK-wide coverage and are staffed with a multi-disciplinary team of psychiatrists, nurses, psychologists and SWs. Referral goes via unit MOs.
NLD	Mandatory 2 or 3 days TLD on Crete, consists of leisure activities and group discussion with MH debrief.	After 3 months: post-deployment interview with SW or chaplain After 6 months: post-deployment MH screening questionnaire Both can be followed-up by referral to MH professional, i.e., SW, psychologist, psychiatrist. Personnel can self-refer or be referred by commander to MH professional. All sorts of treatments are provided.		Commanders are responsible for MH of personnel. They can support adjustment by recuperation exercise (leisure and group discussion to provide closure of deployment) or reintegration exercise (support adjustment into new unit/with new unit members).		MO and SWs are available in garrison. They can provide support for psychosocial problems and light psychological treatment. Psychologist and psychiatrist are based in specialist MH centers providing psychological treatment. When necessary referrals to private institutions with specific treatment possibilities can be made.
USA	No TLD is used. Decompression occurs in garrison over a 2-week period prior to units going on leave. Decompression includes screening, briefings, and education (i.e., post-deployment Battlemind training).	3–6 months post-deployment all service members undergo MH screening. Personnel can also self-refer or be command referred.		Leaders and commanders, as well as buddies have an important role in looking out for each other. This point is emphasized in the Battlemind post-deployment training. Spouses can also receive training in what to look out for.		There is organic MH support for each unit. Behavioral health clinics. Service members can also access civilian care as well.

The columns cover the topics mission characteristics, unit characteristics, pre-deployment MH support, in-theatre MH support, post-deployment MH support. Thus, Table 1 represents the main elements of the MH protocols and current practices of the participating nations. The numbers are as per 2010.

RAAF=Royal Australian Air Force; HQ=Head Quarter; SOC=special operations command; CT=Canadian Forces; R&R=rest and recuperation; RF=regular forces; RtAPS=return to Australia Psychological Screening.