Military and Disaster Psychiatry Research Paper

the hospital. The disciplines of military and disaster psychiatry address care demands in nontraditional environments and in mass casualty situations, where resources are overwhelmed. Care in these environments relies on contributions not only from psychiatrists, but also from other physicians, social scientists, epidemiologists, psychologists, nurses and emergency responders such as police and firemen.

This overview of military and disaster psychiatry begins with an examination of the consequences of disasters and wars for communities, and the evolution of medical responses to these traumatic experiences. A discussion of the phenomenology of trauma-related psychiatric morbidity and principles of prevention, mitigation of consequences, and management follows. Finally, transnational economic, ethical and legal trends are presented as issues requiring further study.

2. Practice Environments in Military Operations and Disasters

‘Disaster’ has numerous definitions. The word is derived from the Latin dis (‘against’) and astrum (‘stars’)—‘the stars are evil’. A disaster such as an earthquake or a flood overwhelms a community’s capacity to respond. The distinction between ‘natural’ disasters (e.g., earthquakes) and human-made or technological ones such as explosions, or train derailments is increasingly difficult to make. For example, much of the death and destruction from an earthquake may be due to poorly constructed housing—thus, there is a human-made element to the consequences of even ‘natural’ disaster. From a psychological standpoint, a more critical distinction concerns whether the disaster was inflicted intentionally, as is the case with acts of war or terrorism.

War may be defined as a political act (generally involving violence) to achieve national objectives or protect national interests. During the last 30 years, militaries around the world have increasingly become involved in peacekeeping and humanitarian relief missions. The use of military forces in these endeavors also maintains a country’s influence and minimizes political instability in the affected nation.

The potential stressors in all disaster environments include exposure to the dead and grotesque, threat to life, loss of loved ones, loss of property, and physical injury. Although the military brings supplies and a portable living environment to protect soldiers, civilians (frequently exposed to combat environments in modern times) may be subject to large-scale devastation, become refugees, and experience shortages that threaten life. Frequently, such victims do not receive treatment for psychiatric symptoms that emerge from bombings, battle, rape, torture and unrestrained murder. Although an earthquake may be concluded in seconds, the consequent traumatic experience may continue for weeks, months and possibly years. For both soldiers and civilians in combat environments, exposure over time may include anticipated or entirely unexpected life-threatening experiences followed by daily life in an austere and disrupted environment.

The emotional and behavioral responses following a disaster occur in four phases. The first immediately following a disaster generally consists of strong emotions including feelings of disbelief, numbness, fear and confusion—normal emotional responses to an abnormal event. The second phase usually lasts from a week to several months and is accompanied by the appearance of assistance from outside agencies and communities. Adaptation to the austere environment as well as intrusive symptoms (unbidden thoughts and feelings accompanied by hyper-arousal) occur during this phase. Somatic symptoms such as fatigue, dizziness, headaches and nausea may develop. Anger, irritability, apathy, and social withdrawal are often present. The third phase is marked by feelings of disappointment and resentment when hopes for aid and restoration are not met. Here, often, the sense of community is weakened as individuals focus on their personal needs. The final phase, reconstruction, may last for years. During this period, survivors rebuild their lives, make homes and find work using available social supports. Individuals may progress through these phases at various rates. Many persons may be unable to reconstruct their lives fully and instead develop persistent symptoms.

The causes of disaster and war have been historically attributed to sources ranging from the gods, to the wind of a passing cannonball, and various natural, unnatural or supernatural sources of contagion. Emotional consequences of disaster are described in the Iliad, and references to the terror induced by the attack of this hero are diverse. Ancient Greeks attributed epidemic illness to Apollo’s wrath after the desecration of his temple. The French military surgeon Larrey commented clearly on the ill effects of war upon the health of Napoleon’s soldiers. Others commented on combat-related pathological behaviors during the US Civil War, and recent studies have noted the descriptions of veterans of that war hospitalized for symptoms very similar to those of today’s Post Traumatic Stress Disorder (PTSD).

The science of neurology entered military medicine with Weir Mitchell’s work during and after the Civil War. Over the remainder of the nineteenth and twentieth centuries studies increasingly distinguished between diseases of the nervous system for which traumatic lesions could be demonstrated and those for which no such lesion could be identified. The concepts of neurasthenia, dissociation, hysteria and psychological suggestion were developed to define psycho–neurological states without demonstrable anatomic abnormality.

Military physicians in the Russo–Japanese War made similar diagnostic distinctions. Recognition of the ‘nontraumatic’ injuries that followed railway accidents and other technological disasters occurred at the same time. Military psychiatric experience in World Wars I and II led to the development of specific treatment principles. During World War I, physicians from various armies addressed the problem of soldiers with emotional or behavioral disturbances with a variety of diagnostic labels such as shell shock, gas neurosis and conversion paralysis. Treatment ranged from prolonged psychiatric hospitalization, to punishing electric shock and various talk therapies. Gradually, US, Canadian and British forces incorporated into their treatments the expectation that these soldiers return to battle after brief evaluations. German military scientists recognized the importance of unit cohesion in mitigating psychological injury. Elsewhere, efforts were made to screen out soldiers felt to be at risk for psychological disturbances on the assumption that these soldiers were genetically weak. Although the terms proximity (treatment near the combat zone), immediacy (early identification of stress-related disorders), simplicity (treatment with rest, food and brief support) and expectancy (expectation of prompt recovery and return to duty) were defined in later conflicts, these practices evolved to varying degrees during World War II. These principles, along with the development of psychotropic medications, the failures of screening programs, and the recognition of the problems of drug abuse in operational environments greatly influenced the management practices of subsequent military and disaster responders.

Civilian physicians have also long recognized the trauma of war as a cause of human suffering. In 1859, Jean Henri Dunant arranged for civilian medical services for the injured after observing soldiers die from lack of medical attention during the Battle of Solferino. His efforts led to the establishment of the International Red Cross, and to international guidelines for humane care to the sick and wounded in times of war. During the later part of the twentieth century the Red Cross, and other international medical and relief agencies such as Doctors Without Borders increasingly provided mental health-related consultation, education and direct care in the aftermath of war, natural and human-made disasters. The World Health Organization and the Pacific–Asian Health Organization have also supported international disaster relief efforts.

3. Phenomenology

3.1 Symptoms ersus Functioning

Military and disaster psychiatry must address the clinical concerns of identified patients, but must also strive to prevent potentially incapacitating morbidity in entire populations. Distress-related symptoms are universal during disasters and combat. Initial psychiatric response in the aftermath of war and disaster must focus on mobilizing effective functioning. Symptoms occurring in persons who are not impaired are a secondary concern. Such symptoms can become ‘medicalized’ if clinicians cause impaired functioning by unjustifiably reinforcing a view that symptoms are due to a disease. While the ultimate label given to clusters of symptoms has political, economic and research-related significance, the selfperception that one is ill can become a powerful determinant of impaired functioning both during and after combat and disasters.

3.2 Military Operations, Disasters and Psychiatric Syndromes

Much of military and disaster psychiatry focuses on the myriad behavioral reactions to stressful events— ‘stressors’. Well-defined psychiatric syndromes describe many of these responses. The precipitating stressor for PTSD involves a threat to the physical integrity of self or others, so immediate that the exposed individual suffers a potent sense of helplessness, horror or fear. A characteristic distress response may follow such trauma. This response consists of symptoms that involve: (a) ‘reliving’ the original event (e.g., nightmares, distressing vivid recollections or fear when exposed to events resembling the original trauma); (b) numbing of responsiveness or behavioral avoidance of events or situations that somehow resemble or symbolize the original trauma; and (c) symptoms of increased vigilance, such as exaggerated startle, outbursts of anger or other evidence of hyper-arousal. If these symptoms of severe distress persist for over a month, then a diagnosis of PTSD is appropriate. Symptoms may first occur months or even years after the triggering event, but this is not the norm. If symptoms occur within the first month after the trauma and have not lasted longer than a month, then Acute Stress Disorder (ASD) is diagnosed. Controversy persists regarding the diagnostic validity PTSD, probably because it was defined in the aftermath of the Vietnam War in the wake of political and antiwar pressures. Nonetheless, PTSD and ASD are conceptualized as modal distress responses to severe or catastrophic stressors, and have been as carefully defined and delineated as other psychiatric disorders.

Disabling distress reactions occur in response to less significant trauma and present in patterns not described by PTSD or ASD. Adjustment Disorder, for example, is a maladaptive behavioral and or emotional response to a diverse array of stressors. Conversion Disorder may be diagnosed when one develops unexplained symptoms or deficits affecting voluntary motor or sensory function (e.g., sudden paralysis of the ‘trigger’ finger) without demonstrable neuro–anatomical injury. Bereavement, a normal grief reaction after the death of someone who is valued or loved, may also occur in response to losses incurred during war or disaster. Other distress responses to war or disaster include anxiety and depressive syndromes, and antisocial behavior (involving acts of violence, criminal behavior, military misconduct, or war-related atrocities). Alterations in health-related behaviors (e.g., misuse of tobacco, drugs or alcohol, poor eating habits) may also develop after exposure to disaster or war.

3.3 Battle Fatigue

The term ‘battle fatigue’ provides a framework to encompass the variety of responses to operational stress, but does not define a specific constellation of symptoms, as in Major Depressive Disorder or PTSD. A wide range of physical and emotional symptoms and signs can occur among individuals with battle fatigue including gastrointestinal distress, tremulousness, anxiety, perceptual disturbance, a sense of unreality, and a dazed look (i.e., ‘thousand-yard stare’). The diversity and non-specific nature of presentation distinguish this entity from ASD. Battle fatigue occurs in combatants who have exhausted physiological and psychosocial coping mechanisms with the intense combat experience. Minor injury, parasitic infection, starvation, heat exhaustion, and cold injury may decrease the coping resources of a combatant.

3.4 Medically Unexplained Physical Symptoms

War historians have observed that unexplained physical symptom syndromes are common sequelae of combat since at least the US Civil War. Syndromes such as ‘soldier’s heart’ and illnesses characterized by physical symptoms attributed (by sufferers) to warrelated exposure to Agent Orange are examples. Contentious debates between scientists, clinicians, veterans and their advocates, and journalists persist around putative etiology. Some argue that the consistent appearance of these syndromes after war speaks to the likelihood that psychosocial factors contribute to their etiology.

3.5 Other Psychiatric Illnesses

Depression, anxiety disorders and personality changes have all been associated with exposure to the trauma of disaster and war. These psychiatric disorders may be accompanied by somatic complaints. Such illnesses have been described in large numbers of persons exposed neither to war nor other disasters. Therefore, biological, genetic and environmental risk factors are all likely involved in the development of these illnesses.

4. Etiology and Epidemiology

4.1 Predisposing Factors

PTSD, other anxiety and depressive disorders, and physical symptom syndromes are more frequently diagnosed among women than men in association with any given stressor. Explanations for this involve neurobiological and psychosocial factors including the greater rate at which women seek treatment for stress-related symptoms and that duration of illness (e.g., PTSD) may be longer for women and therefore more likely reach clinical attention. Men are at higher risk for post-war problems with alcohol and substance use, and antisocial and violent behavior. Genderspecific neurophysiological factors as well as cultural factors are again implicated in these differences.

Level of functioning after combat and disasters also relates to pre-trauma functioning. Individuals who function marginally in various roles (e.g., occupational and social) prior to disaster or combat exposure are at increased risk for poor functioning after trauma compared with individuals who were previously high functioning. Individuals who have successfully negotiated past traumatic experiences may be resilient (‘hardened’) in similar future situations. However, if past traumatic events resulted in PTSD or psychiatric distress syndromes, subsequent traumatic exposures may make future episodes of these disorders more likely.

4.2 Protective Factors

Protective factors may be present to varying degrees in groups such as military units, police, or firefighters exposed to trauma. Strong leadership can create powerful loyalty and interpersonal cohesion with populations. Potent leaders can create a unit dynamic wherein leaders are so valued and trusted by members of the unit as to enable voluntary participation in extremely high-risk combat or rescue–recovery situations. A common symptom of poor leadership is the occurrence of destructive inter-group conflicts and organizational splits.

An axiom of professional soldiers is ‘we will fight as we have trained, therefore we must train as we expect to fight’. If the level of training is high, individuals in the unit (military or civilian) more frequently trust ingrained basic principles aimed at supporting one another in a quest for mission success. Recently, nonmilitary disaster responders (firemen, police, physicians and civic leaders) in developed countries have assembled to train for response to terrorist attack or natural disaster. Government emergency preparedness agencies such as the US Federal Emergency Management Agency are increasingly coordinating such training. The quality and extent of fit between persons, equipment (e.g., comfort and mobility of chemical protective suits, familiarity with operation of remotely controlled bomb or mine detectors or personnel recovery devices), and the environment may modify stress responses of individuals or communities. The extent to which the living or working environment may modify response is evident in studies of those forced to exist in close quarters for extended periods of time with only limited contact with the outside world, such as those aboard ships or submarines. The ‘fit’ between pilot and aircraft as well as between aircrew members may be improved through specific training. Finally, the effectiveness (or perceived effectiveness) of leadership response to crisis is a factor that may modify community response.

4.3 Precipitating Factors

Precipitating factors are the proximate circumstances that initiate the various sequelae of trauma. For disaster responders and military populations, deployments and peacekeeping missions disrupt families and are often ‘poorly timed’ with regard to other life events. High intensity and duration of disaster or combat exposure relate directly to the likelihood of psychiatric casualties. Specific experiences, such as physical injury, witnessing grotesque deaths, torture or other atrocities place individuals at increased risk for adverse mental health consequences. Victimization in the form of rape, harassment, or assault can precipitate distress reactions in those victimized. Sexual assault is a potent precipitant of adverse neurobehavioral changes.

4.4 Mitigating and Perpetuating Factors

Ongoing factors, including the security and safety of recovery environments, extent of secondary traumatization and—in military populations—rotation schedules, extent of recognition or compensation for efforts and belief in the mission effect the rate and severity of distress symptoms. Symptoms in civilian victims of war or in the aftermath of disaster may be mitigated or exacerbated by perceptions of community leadership’s preparedness for disaster, response to crisis, recognition of ‘heroes’, and provision of medical, financial or emotional assistance both immediately after crisis, and over time.

Nonmilitary, nongovernmental organizations such as the American Red Cross and the Salvation Army help to minimize the stress following a disaster. By attending to basic human needs such as food, clothing and shelter, they reduce both the psychological and the physiological effects of the event. In recent years the Red Cross has developed training for volunteer health care workers to recognize, minimize and treat stress responses in disaster workers and victims of disaster.

5. Management and Care Delivery

5.1 General Principles

Often disasters or military conflicts shatter the expectation of a just and safe world within populations where notions of basic justice and safety are cultural norms. In such populations, establishing the sense of safety and expectation of justice is an important aspect of recovery. Other interventions vary with the stage of the disaster. Initially, establishing a safe environment, and managing life-threatening injury and disease possibilities, such as those resulting from infection or absence of potable water, can be the most important psychiatric interventions. Subsequently, identifying high-risk populations such as disaster workers, firefighters, police, persons at impact zones and children can focus intervention strategies. Outreach programs are critical, since disaster victims rarely seek mental health care. Those who are physically injured are also at great risk for psychiatric disturbance. Educating medical and community groups about normal responses to abnormal events as well as when mental health referral is indicated is an important part of outreach programs. Advising community leaders on expected behavioral problems and needs is required to ensure availability of resources to care for victims. This work must involve planning for expected natural or human-made disasters, and allocating funds for the care of anticipated victims before disasters actually occur.

Responsibility for preventive measures, and recognition and treatment of the psychological consequences of such wars and disaster cannot be limited to the few (if any) available psychiatrists. General physicians, psychologists and other social scientists must use their diverse skills to care for disaster and war victims. They must diagnose and treat disorders associated with trauma, (e.g., PTSD, depression and anxiety disorders), provide consultation to medical and surgical colleagues and other first responders, and educate community leaders about predictable responses to abnormal events.

5.2 Military Mental Health Care

The US military has attempted to decrease the incidence and severity of combat and operationally induced psychiatric disorders. Mental health teams are now routinely assigned to US forces in combat and deployed operations other than war. Each branch of the US military service has specialized rapid intervention teams to provide consultation and acute treatment to units that have experienced traumatic events. These teams instruct commanders on likely behavioral responses to stress and recommend leadership actions that may reduce negative responses to stressful situations. Post-incident debriefings assess the effect on the unit, and attempt to reduce long-term consequences of traumatic events. Open discussion of an incident is believed to foster unit cohesion, facilitate accurate individual and group understanding, and reduce the development of psychiatric disorders. However, in the few groups actually studied, there is no convincing evidence that acute incident debriefing has any effect on the later development of psychiatric illness. Debriefings may be useful in identifying individuals who require further mental health attention and decreasing individual isolation and stigma.

Despite the absence of consensus data supporting their effectiveness, there is increasing interest in expanding the use of rapid intervention teams. The US military currently proposes to establish a unified, multi-service policy on the composition and use of these teams. This effort follows the widely publicized ‘Gulf War Illness’ complaints of veterans from that campaign. Some believe that since these symptoms are largely tied to psychological problems, increased attention to stress during military operations could have reduced their incidence or severity.

Different missions, patterns of deployment, and medical support systems among US military services pose major problems to the development of a unified approach to managing operational stress. Armies typically deploy large units for extensive periods of time and allocate large amounts of medical assets to support these units. This medical support includes specialty services. The US Navy and Marine Corps deploy smaller units both at sea and ashore. General medical officers and nonphysician providers furnish medical support, and specialty care is not routinely available in the operational theater. The US Air Force has both shortand long-range missions. Operational stress management doctrine must consider these differences. Military physicians also provide medical and psychiatric assistance to civilian populations in times of natural and human-made disasters. In addition to direct patient care, military psychiatrists consult with community leaders and with civilian physicians not accustomed to responding to largescale physical and emotional traumas.

In the USA, definitive treatment of psychiatric illness is often provided in the military’s system of hospitals. Medical care is provided to active duty personnel and to their families. Other mental health specialists, nurses, social workers and psychologists augment this care. Military members who develop psychiatric disorders while on active duty are eligible for medical retirement disability pay, and continued treatment through a system of Veterans Administration hospitals. Individuals may be separated from service due to personality problems without disability payment or ongoing medical care from the military.

Other nations with recent wartime experience, such as Israel and Croatia, have developed programs to evaluate and treat soldiers and civilians exposed to combat. Their experiences are somewhat different from the US, since they rely much more heavily on reserve forces. These nations have a more inclusive social medical infrastructure therefore treatment programs are less reliant on the military medical system. Other nations are increasingly confronted with management of operational stress in peacekeeping and humanitarian missions. Asian nations that have recently experienced natural disasters and terrorist events are also studying approaches to evaluating and treating individuals exposed to trauma.

5.3 Medical Education

Several nations provide medical education specifically for members of their armed forces. The US Congress in 1975 authorized The Uniformed Services University of the Health Sciences (USUHS) to provide medical education and produce physicians for military service. USUHS provides a four-year medical degree program and a number of graduate degree programs in the basic and clinical sciences. The USUHS Center for the Study of Traumatic Stress conducts research, and consults to communities, and federal and international agencies on matters surrounding individual and community responses to trauma, disaster and war. Japan, the UK and Russia are among nations with institutions that teach military specific curriculum to military medical care providers. As in other nations, these countries also call to national duty physicians not specifically trained in military institutions during times of war or crisis.

6. Future Challenges and Evolving Issues

As political, social, scientific, and technological factors evolve, societies will change their responses to the consequences of disasters and wars. Psychiatric practice associated with wars and disaster has changed with the evolution of scientific understanding of illness. In the future, the resources to deal with the consequences of disaster or war and the relative importance assigned to dealing with the resultant injuries and disabilities are likely to be influenced by political and socio–cultural values.

6.1 Ethical Challenges

The hyper-suggestibility of recently traumatized individuals has provided an occasion for exercising political influence and manipulating loyalties. Providing care in the mass casualty situation raises ethical questions about the equitable distribution of resources and the moral values to consider in determining their apportionment. Governments in trouble have withheld treatment to minority racial or political groups—clearly an ethical breach. Since governmental terrorism is a common form of terrorism, care providers and leaders must be sensitive to the possibility that disasters will afford tyrants an opportunity to manipulate citizens for their own purposes.

To facilitate command assessment of troop health status, militaries have denied members confidentiality in medical communication. Mental healthcare providers must strike a balance between a promise of privacy that encourages persons to seek care, and responsible reporting to higher command regarding situations that pose danger to larger groups. Thus dual allegiance to both individuals and to the larger community presents an ethical challenge that must be negotiated by the military care provider. Persons in extreme circumstances may behave in ways that they later view as shameful. Shame may contribute to posttraumatic symptoms and disturb one’s capacity to use social supports. Disaster triage is frequently carried out in large open areas that allow everyone present to hear what patients say to caregivers. Given the social stigma assigned to the manifestations of psychiatric illness it is easy to understand both patients’ reluctance to communicate and doctors’ reluctance to inquire. Perhaps re-educating the population can reduce ethical and therapeutic problems associated with stigma. However, altering deeply ingrained cultural expectations is just as challenging as providing privacy in chaotic triage environments.

6.2 Technological Advances

New technologies in combat will modify the means of sorting and treating persons with medical and psychiatric injury. Future militaries in technologically advanced nations are likely to become much smaller, move rapidly across the battlefield, use advanced sensors, and direct intense fire across a considerable distance. These capabilities, coupled with the possible use of weapons of mass destruction, will likely make the battlefield more chaotic and inhospitable to human life. Emergency care and evacuation of those with disease and injury may become increasingly difficult. The inability to maintain contact with rapidly moving units may preclude returning individuals to their original units. Future military casualties may increasingly rely on care by unit buddies, medics and frontline leaders rather than specialized medical units or specialists at hospitals in the rear.

Underdeveloped nations may have limited access to advanced technologies, so more traditional ways of organizing medical and psychiatric practice may continue to be relevant.

The evolution of highly mobile units on widely disbursed battlefields will decrease the opportunity for exchanging rested troops from the rear area for those exhausted by frontline combat. Provision of brief respite for exhausted troops—a hallmark of management of battle fatigue—may become impossible as each individual may be performing a critical specialized task. Small medical units operating within the area of combat are likely to be eliminated from this technology-intensive battlefield. While treatment may by necessity move to the battlefront, medical specialists at the rear may render triage decisions and diagnoses through the use of telemedicine communication technology. Experience has shown that frontline mental health providers take a pragmatic view of acute psychiatric symptoms, and tend not to make hasty formal diagnoses on overstressed troops. Rearechelon providers, by contrast, tend to assign formal psychiatric labels that may be inaccurate and may stigmatize troops without contributing to treatment. Rear-echelon mental health specialists in future battles must address the challenge of providing useful therapeutic advice from afar while avoiding meaningless diagnostic stigmatization.

Advanced technology will have similar implications for those responding to human-made disasters such as terrorist attacks especially as terrorists gain increased access to so called weapons of mass destruction (chemical and biological agents). Clarifying the roles of military and civilian responders in terms of triage, treatment, consultation and education in any joint response to crisis is another challenge for military and disaster psychiatrists.

6.3 Cultural Issues

Social scientists note that responses to trauma may be considered either normal or pathological, depending on the interested party. Many have expressed fear that mental health practitioners, motivated by profit, will try to convince individuals experiencing normal uncomfortable responses that they need treatment. Overcoming this fear or the belief that accepting assistance signals weakness is a challenge in circumstances where necessary and available external assistance is rejected by a nation in crisis.

Most individuals exposed to traumatic events deserve to be reassured that with return to work, community and family, they will recover. However, some individuals (and perhaps some cultures) will experience greater psychopathologic responses and more prolonged symptoms following trauma. The nature of the behaviors and symptoms associated with trauma response across cultures is still uncertain. The extent to which social supports, biological–genetic predisposition, concurrent illnesses, and other political economic parameters contribute to variability across cultures is not known. While it appears clear that the severity of the trauma is important, reliable measures of severity remain to be determined. Trauma may, under some conditions, create the opportunity for personal growth as well, and further understanding of this potential must also be exploited to reduce morbidity.

7. Conclusion

Natural and human-made disasters result in traumatic disruption of societal function. Wars and acts of terrorism with their attendant large-scale death, injury and destruction affect populations in much the same way as massive natural disasters. Whatever the cause, disasters and military operations leave in their wake populations experiencing psychological disturbances that have been described by social scientists, civil leaders, physicians and other care providers throughout the ages.

The consequences of exposure to disaster and war may take the form of psychological disorders such as PTSD or may manifest as various (and sometimes more subtle) forms of behavioral change, anxiety or depression. Symptoms may present at different times during and after traumatic exposure. Many factors complicate the evaluation and treatment of neuropsychological syndromes in the aftermath of war or disaster. Resources are overwhelmed, life-threatening illnesses require immediate treatment, and psychological casualties are often reluctant to seek assistance. Progress has been made in identifying the nature of trauma-related psychological responses. Predisposing, exacerbating and mitigating factors have been identified. The value of multidisciplinary preparation and training for disaster management and the need for outreach programs have also been demonstrated. Further study will focus and clarify the roles of psychotropic medications and various forms of psychosocial support and psychotherapy in the treatment of war and disaster-related morbidity. With technological advances and global economic shifts, the nature of war and other human-made disasters will change. Military and disaster mental health care delivery must anticipate such changes to develop improved methods of prevention, evaluation, and care for individuals and groups devastated by war or disaster.

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