title: Deployment-related mental health support: comparative analysis of NATO and allied ISAF partners.
abstract: BACKGROUND
  For years there has been a tremendous gap in our understanding of the mental health effects of deployment and the efforts by military forces at trying to minimize or mitigate these. Many military forces have recently systematized the mental support that is provided to support operational deployments. However, the rationale for doing so and the consequential allocation of resources are felt to vary considerably across North Atlantic Treaty Organisation (NATO) International Security Assistance (ISAF) partners. This review aims to compare the organization and practice of mental support by five partnering countries in the recent deployment in Afghanistan in order to identify and compare the key methods and structures for delivering mental health support, describe bottlenecks and illustrate new developments.
  
  
  METHODS
  Information was collected through document analysis and semi-structured interviews with key military mental healthcare stakeholders. The review resulted from close collaboration between key military mental healthcare professionals within the Australian Defense Forces (ADF), Canadian Armed Forces (CAF), United Kingdom Armed Forces (UK), Netherlands Armed Forces (NLD), and the United States Army (US). Key stakeholders were interviewed about the mental health support provided during a serviceperson's military career. The main items discussed were training, prevention, early identification, intervention, and aftercare in the field of mental health.
  
  
  RESULTS
  All forces reported that much attention was paid to mental health during the individual's military career, including deployment. In doing so there was much overlap between the rationale and applied methods. The main method of providing support was through training and education. The educative focus was to strengthen the mental resilience of individual soldiers while providing a range of mental healthcare services. All forces had abandoned standard psychological debriefing after critical incidents. Instead, by default, mental healthcare professionals acted to support the leader and peer led "after action" reviews. All countries provided professional mental support close to the front line, aimed at early detection and early return to normal activities within the unit. All countries deployed a mental health support team that consisted of a range of mental health staff including psychiatrists, psychologists, social workers, mental health nurses, and chaplains. There was no overall consensus in the allocation of mental health disciplines in theatre. All countries (except the US) provided troops with a third location decompression (TLD) stop after deployment, which aimed to recognize what the deployed units had been through and to prepare them for transition home. The US conducted in-garrison 'decompression', or 'reintegration training' in the US, with a similiar focus to TLD. All had a reasonably comparable infrastructure in the field of mental healthcare. Shared bottlenecks across countries included perceived stigma and barriers to care around mental health problems as well as the need for improving the awareness and recognition of mental health problems among service members.
  
  
  CONCLUSIONS
  This analysis demonstrated that in all five partners state-of-the-art preventative mental healthcare was included in the last deployment in Afghanistan, including a positive approach towards strengthening the mental resilience, a focus on self-regulatory skills and self-empowerment, and several initiatives that were well-integrated in a military context. These initiatives were partly/completely implemented by the military/colleagues/supervisors and applicable during several phases of the deployment cycle. Important new developments in operational mental health support are recognition of the role of social leadership and enhancement of operational peer support. This requires awareness of mental problems that will contribute to reduction of the barriers to care in case of problems. Finally, comparing mental health support services across countries can contribute to optimal preparation for the challenges of military deployment.
authors.affiliation: Military Mental Health Research, Department of Defence, Utrecht, The Netherlands; ; Department Psychiatry, Leiden University Medical Center, Leiden, The Netherlands; ; Arq Psychotrauma Research Group, Diemen, The Netherlands.
authors.forename: Eric
authors.initials: E
authors.lastname: Vermetten
authors.affiliation: Academic Centre for Defence Mental Health, Weston Education Centre, Kings College London, London, UK.
authors.forename: Neil
authors.initials: N
authors.lastname: Greenberg
authors.affiliation: Arq Psychotrauma Research Group, Diemen, The Netherlands.
authors.forename: Manon A
authors.initials: MA
authors.lastname: Boeschoten
authors.affiliation: Netherlands Organization for Applied Scientific Research (TNO), Defense Safety and Security, Soesterberg, The Netherlands.
authors.forename: Roos
authors.initials: R
authors.lastname: Delahaije
authors.affiliation: Directorate of Mental Health, Health Services Group, National Defence, Ottawa, Canada.
authors.forename: Rakesh
authors.initials: R
authors.lastname: Jetly
authors.affiliation: School of Social Work, University Southern California, Los Angeles CA, USA.
authors.forename: Carl A
authors.initials: CA
authors.lastname: Castro
authors.affiliation: Centre for Traumatic Stress Studies, University Adelaide, Adelaide, Australia.
authors.forename: Alexander C
authors.initials: AC
authors.lastname: McFarlane
keywords: Military; NATO; deployment; mental health; review