Combat psychiatry: Indian perspective

Abstract

Indian Armed Forces have been engaged in various combat duties for long. The adverse effect of prolonged and repetitive deployment of troops in these highly stressful environment leads to many combat stress behaviors as well as misconduct behaviors. Preventing, identifying and managing these disruptive behaviors are an essential part of combat psychiatry within the larger domain of combat medicine. Indian Armed Forces have a well-oiled mechanism to handle these issues and military psychiatrists are deeply engaged in providing holistic mental health care to the esteemed clientele. Relevant issues on this subject are elaborated in the article.

Introduction

Stress has become an inseparable aspect of life. Incidence of it in the Armed Forces manifesting in the form of various mental disorders, disciplinary problems, suicides and fratricides has been a matter of concern for the last few years. There are many stressors that are unique to military life like poor service conditions, inability to avail leave at the required time, early retirement ages, frequent and long separation from family, inadequate family and social support, nonresponsive civil administration back at home, communication gap with superiors, etc. A soldier whose professional, social, and domestic needs are reasonably looked after will remain committed to give his life to the nation and the stress level in him will generally remain within the manageable levels based on his basic personality traits.¹

Indian Armed Forces with more than a million strength in its cadres is a mammoth organization with some unique characteristics. With the rapid changes in the sociopolitical system, advances in military technology, and volatile and hostile neighborhood, there has been a constant need to enhance the competency of the forces to deal with varied kind of needs that arise. Armed Forces are not only required to be combat ready, they are also required to deal more often with insurgency, natural disasters, communal violence, law and order issues, and participate in international humanitarian operations. They are required to work in most diverse climatic situations ranging from deserts of Rajasthan, rain forests of Nagaland, high attitudes of Himalayas to most inhospitable areas like Siachen Glacier. Though the organization has a time tested, well-oiled health care delivery system in the form of large static hospitals, well-equipped mobile-filled hospitals and unit level medical establishments, there is a continuous need to be flexible to meet the ever-changing demands. Psychiatric services of Armed Forces have evolved over a period of time to meet these challenges that are unique to the services. The challenges of combat psychiatry are special and different from the civil society, and the solutions are also innovative. These special measures of management are implemented with the objective of maintaining a sound mind in a sound body for conservation of battle ready human resource.

Historical perspective

The origin of Indian military psychiatry services can be traced back to 18th century. The first lunatic asylum in India was established in Mumbai in the year 1745, followed by Calcutta (Kolkatta) in 1784, and Madras in 1794.² A similar hospital for the mentally ill Indian Soldiers was first time established in 1795 in Monghyr, Bihar.³ Ranchi European Lunatic Asylum came into existence on May 17, 1918 and Col Owen Berkeley-Hill, a psychiatrist of British Army became the Medical Superintendent on 27 October 1919. A similar one was established at Lahore by Lt Col Lodge Patch in 1922. During World War II, a significant expansion of psychiatric services took place. From strength of four psychiatrists for the whole of troops in India at the beginning of the war, the strength increased to 86 by 1945.⁴ Psychiatrists were posted up to forward Divisional level and they established “Exhaustion Centers” to treat cases of battle exhaustion. In the independent India, the psychiatric centers were established in major military hospitals located in big garrisons. General Nursing Assistants were given specialized training in these centers and posted as Psychiatric Nursing Assistants (PNAs). Members of Military Nursing Service were sent to premier institutions like NIMHANS Bangalore for training in psychiatric nursing and then posted to these psychiatric centers. Major psychiatric centers of Command Hospitals were further augmented with the posting of Civilian Clinical Psychologists and Psychiatric Social Workers.

Present setup of military psychiatry service

In Armed Forces, the psychiatric services are delivered through psychiatric centers in selected military hospitals that function as General Hospital Psychiatric Units (GHPU). Presently psychiatric centers are present in twenty five Army hospitals, three Air Force hospitals and three Navy hospitals that have been chosen as per the service requirements.⁵ They are of different sizes based on authorized beds ranging from 15 to 65 bed centers. Few additional beds for civilian treatment have been allotted to Psychiatric center of Command Hospital (SC) Pune, the affiliated hospital of AFMC Pune, to facilitate better training of medical undergraduates and post-graduates. Generally, they are situated as an independent subunit of the hospital in a large area covered with greenery. There is adequate space for conducting group therapy, yoga sessions and rehabilitation training, and training of Psychological Counselors. Adequate number of escort/attendants are made available for the care and safety of patients. Based on the workload, these centers are posted with one to four psychiatrists. There is a liberal authorization of two PNAs for every five beds of these psychiatric centers, probably the highest in any government sector hospital. In addition, one to two Psychiatric Nursing Officers are also posted to most of these centers.

Combat psychiatry services

Combat psychiatry branch is unique to Armed Forces and deals with the mental health issues of soldiers deployed in forward locations. Indian Armed Forces have not only faced wars from some neighboring countries since Independence, but also been activity engaged in dealing with insurgents in the east for many decades and in the north for the last two decades. A large number of troops are actively engaged in these duties and exposed to varying kind of stressors.^{6, 7} Prolonged spells of stressful duty in such low intensity conflict (LIC) operations with inadequate opportunity for relaxation puts immense strain and often unmanageable demands on even otherwise healthy individuals. This can result in psychological distress, misconduct behaviors, or even post-traumatic stress disorders. In addition to that desertion, dereliction of duty, poly substance abuse, deliberates self-harm, and fratricides may occur.^{8, 9, 10, 11} The adverse effect of prolonged stress can manifest in the form of physical or psychological symptoms of headache, body pains, lethargy, insomnia, or impaired appetite. Chronic stress may also manifest as psychosomatic disorders or psychiatric illnesses.¹² A longitudinal study involving follow-up of service personal engaged in counter insurgency operations for two years with regular evaluation at six monthly intervals, revealed significant psychological impairment gradually increasing with the duration of their tenure in CI Ops.¹³

There were 635 cases of suicide including attempted suicides and 67 cases of fratricidal killings in three services of the Armed Forces during the years 2003 to 2007 as per Standing Committee on Defense of Parliament in its Action Taken Report (ATR) of March 2010.¹⁴ Between 2007 and 2010, 533 soldiers committed suicide and there were 15 cases of fratricide.¹⁵ However, assessment of suicide in military personnel and their wives had revealed that nonservice-related factors were the immediate precipitating factor in majority of the service personnel and also their wives.^{16, 17}

In spite of the above there is no evidence to suggest an increasing trend of stress-related disorders in Armed Forces.¹² This seems to be due to a series of welfare measures undertaken in the last few years by the organization. Also, military psychiatrists are actively involved in conducting various community outreach activities, stress management capsules, training of trainers, and training of religious teachers of Armed Forces to become effective psychological counselors.

Training in combat psychiatry

During the Doctor of Medicine (MD) (Psychiatry) training of future military psychiatrists at teaching hospitals, special emphasis is given to the nuances of military psychiatry. There is a continuous education and evaluation program in service for them even after MD as they progress to the level of Graded specialists, Classified specialists, and Senior Advisers. Due to its importance, Military Psychiatry has emerged as a subspecialty of Indian Psychiatric Society (IPS) since 1997, and conduct of regular military psychiatry CMEs helps to hone their skills in dealing with the unique mental health issues of Armed Forces. Armed Forces train selected Nursing Officers in Psychiatric Nursing in premier institutions like NIMHANS Bangalore and now also at College of Nursing in AFMC. PNAs also undergo regular upgradation courses during the various stages of their service, thereby preparing them to handle combat psychiatry issues efficiently. Special training in Combat Psychiatry has been felt by the environment as a need of the hour, and in the coming days with the special emphasis on Military Medicine gaining ground, it is hoped that postgraduate certificate course in Combat Psychiatry will be a reality shortly.

Conclusion

Combat psychiatry practice calls for special skills and different approaches compared to clinical psychiatry practice due to unique kind of stressors on the client, organizational requirements and regular transfers of psychiatrists and clientele. A well-oiled and time tested psychiatric service delivery system with an excellent system of referral, management, disposal and documentation procedures is in place in our Armed Forces. It leaps beyond the curative realms of medicine, and is actively involved in community outreach activities to provide preventive and promotive mental health services. All the psychiatric centers of Armed Forces are working in tandem to achieve the solemn goal of complete health of the soldier encompassing physical, mental, social, and spiritual realms.

Conflicts of interest

The author has none to declare.