Psychiatric Physician Assistants in LSCO
Utilization of Psychiatric Physician Assistants in preparation for Large Scale Combat
Operation
By CPT James L. Lain
Article published on: November 15, 2024 in the November 2024 Issue of the Pulse of Army Medicine
Journal
Read Time: 9 mins
The hallmark of large-scale combat operations (LSCO) is a sustained high-intensity conflict that produces high
numbers of casualties. Adversaries will attempt to prevent the evacuation of casualties and rotation of
replacement troops to combat units, creating a manpower shortage. Psychiatric casualties represent a potential
pool of soldiers that may be returned to duty promptly, rapidly increasing combat power. Current behavioral
health resources are inadequate to manage the large numbers of psychiatric casualties, and these resources are
concentrated in rear-echelon areas. Evidence from recent conflicts underscore the fact that troop concentrations
and resources in rear-echelon areas will make ideal targets. Psychiatric Physician Assistants (PAs) represent a
solution to managing psychiatric causalities in LSCO close frontline, reducing the need for evacuation and the
concentration of soldiers in rear areas. Psychiatric PAs can be affordably and rapidly trained and subsequently
positioned within Brigades, Divisions, Health and Holistic Fitness (H2F) units, and Medical Treatment Facilities
to fill the gap currently present in mental health and provide care as close to the point of psychiatric injury
as possible in a conflict. To facilitate the integration of psychiatric PAs, the Army’s force structure needs to
be expeditiously updated to create dedicated positions at each of the identified units for psychiatric PAs.
Psychiatric interventions in past conflicts
The last major LSCO conflicts in which the U.S. military participated were World War I and World War II. At the
start of these conflicts, the Army adopted a strategy to screen out mental health disorders and personnel at
risk of developing them during the induction and training phase. In World War I, the armed forces rejected
approximately 2 percent of all inductees for mental health reasons. A similar screening plan was implemented
during World War II, and 37 percent of potential recruits were excluded for neuropsychiatric reasons. Attempting
to screen and eliminate recruits at risk for psychiatric injury was ineffective at reducing psychiatric
casualties and resulted in manpower shortages at the start of both conflicts.
In World War I, a 3-tier system was developed for psychiatric disorders with treatment starting at casualty
clearing stations a few miles behind the front lines. Second tier treatment was located 5-15 miles behind the
front lines in hospitals and lasted up to 3 weeks. At the third tier, patients were treated for up to six months
in hospitals 50 miles from the front. If there was no recovery after six months, patients were evacuated back to
the United States. At each of these stages, affected soldiers were treated with rest, sedation, adequate food,
and simple forms of supportive psychotherapy. One front-line psychiatrist estimated that up to 65 percent of
soldiers returned to the fighting lines.
During World War II, from January 1942 through 30 June 1945, there were an estimated 1 million admissions for
neuropsychiatric disorders or approximately 45 psychiatric admissions per 1,000 troops per year. During the
initial Army campaigns in Africa, only 5 percent of psychiatric casualties evacuated to base hospitals hundreds
of miles from the front were able to return to duty. This loss of manpower severely impacted combat operations
and beginning in 1943, treatment in forward areas, similar to the situation in WWI, became the standard. Results
showed between 50-70 percent of psychiatric casualties were able to return to duty with simple interventions
close to the front lines.
Limitations of current psychiatric resources
The smallest combat operation unit in which a psychiatrist will serve is a division. The division psychiatrist is
the mental health subject matter expert, the advisor to the command team, and is responsible for combat
operational stress control (COSC) at the division level and below. Psychiatrists are also deployed in operations
across the globe, supporting various national defense and humanitarian missions, providing medical diplomacy
alongside colleagues abroad, engaging in research, and educating future clinicians. These examples represent a
significant number of responsibilities, yet many of these positions are unfilled because there are only about
100 psychiatrists in the Army’s inventory.
Womack Army Medical Center Graduate Medical Education (GME) residents respond to a Soldier as
part of their combat operational stress control training during the GME Capstone mass casualty exercise, May
10, 2024, Taylor-Sandri Medical Training Center, Fort Liberty, North Carolina The Capstone event aimed to
bridge the gap between medical training and real-world combat scenarios. By providing a comprehensive and
immersive training experience, the program prepared military medical personnel to handle complex trauma
cases and save lives in combat situations. (Photo by Keisha Frith)
At the Brigade level, there is a behavioral health team. however, it is understrength and primarily tasked to
conduct safety assessments, track mental health trends, and conduct therapy rather than provide medical
intervention. The closest unit capable of managing combat stress reaction (COSR) is a COSC unit. A COSC is
attached to a multifunctional medical battalion and is an Echelon Above Brigade (EAB); unfortunately, it does
not specialize in treatment of severe psychiatric casualties. Full stabilization of severe psychiatric injuries
is normally the mission of the Role 3 Combat Support Hospital (CSH) specialty clinic’s psychiatric service. Full
stabilization goes beyond securing the safety of the Soldier and those around him or her. It provides a safe
environment for the Soldier to receive treatment interventions, continued evaluation, and assessment for return
to duty potential. However, the CSH is in a Corps support consolidation area, and evacuation from the battalion
aid-station to the CSH can represent a hazardous and long journey for medical personnel. As evidenced by the
recent war in Ukraine, the adversary will target medical infrastructure. Russian forces have targeted the
healthcare system through direct attacks on healthcare facilities (186 facilities damaged and 32 destroyed);
attacks on ambulances (65); looting and destruction of supplies and medicines, denial of access to healthcare,
disruptions of access to utilities; and assaults, unlawful detentions, torture, and ill-treatment of physicians,
nurses, paramedics, and other health care workers (62 killed and 52 injured).
Psychiatric Physician Assistants as a solution
The 2017 National Defense Authorization Act (NDAA) authorized the creation of a Psychiatric Physician Assistant
Fellowship program; with the first trained Army psychiatric PA graduating in June 2024. Psychiatric PAs
represent a low-cost and effective solution that allows the Army to leverage currently available resources to
fill the mental health gap that exists in the Army’s current force structure. The Army needs to update its
modified table of organization and equipment/table of distributions and allowances to create positions
specifically for psychiatric PAs. This force design update should be given top priority due to the impact mental
health can have on the readiness of a force and expected number of psychiatric casualties in LSCO. These created
slots may be rapidly filled given the one year training program that is currently in place. Specific positions
will also encourage the retention of trained psychiatric PAs, create a path forward for promotions, and allow
recruiting of civilian-trained psychiatric PAs
A psychiatric PA placed within the brigade combat team may act in the consult and liaison role supporting
battalions PAs in managing psychiatric patients and partner with the brigade behavior health officer (BHO) and
technicians to provide collaborative outpatient mental health care. This placement of psychiatric PAs will
reduce the number of mental health patients needing to be seen at hospitals and specialty clinics and assist the
brigade surgeon, PA, BHO, and H2F in developing brigade policy for prevention and resiliency programs. During
deployments, psychiatric PAs may combine with the BHO, Techs, and Chaplains to create COSC lite teams,
minimizing the number of patients requiring evacuation and maximizing the number of soldiers that may be
returned to duty
The Army Health System (AHS) is moving toward a more modular and mobile 32-bed field hospital. Augmenting the
current psychiatric services at the CSH with a psychiatric PA will allow for split operations. The Psychiatrist
can stay with the main field hospital while the psychiatric PA moves forward to provide triage and stabilization
and reduce evacuations. A Psychiatric PA can work with the Psychiatrist, providing consultation and liaison
services for surgical teams and medical staff during initial hospitalizations of patients at CSHs.
Psychiatric PAs can also serve as COSC commanders and have the unique benefit of experience in maneuver
operations, logistics, and patient care. In the garrison environment, psychiatric PAs may be utilized in
underserved markets such as Alaska, the Republic of Korea, or the National Training Center to increase access to
care, reduce referral to the civilian market, and reduce expensive evacuations for specialty care.
Conclusion
Psychiatric PAs will provide the Army with a knowledgeable provider who has experience in strategic and tactical
operations. These PAs may also provide the Army with a psychiatric expert far forward on the battlefield whose
prescribing power will enable stabilization and treatment to occur at role ll or closer. The capabilities
psychiatric PAs would bring would support the COSC tenets of brevity, immediacy, contact, expectancy, proximity,
and simplicity, which were hard lessons learned in previous conflicts. In the garrison environment, a
Psychiatric PA could easily lead a Health and Holistic Fitness team providing preventative classes on sleep,
alcohol, and stress management. This would improve readiness and help process fit-for-duty assessments, waivers,
and behavior health screenings for chapters. A psychiatric PA quickly fills a need not addressed with current
mental health resources before the next large scale combat operation. The creation of positions for Psychiatric
PAs will provide an important resource with numerous benefits in the garrison and deployed setting. Every effort
should be made to create dedicated Psychiatric PA positions within the current force structure, ensuring we are
ready for the next conflict
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Author
CPT James L. Lain is a Psychiatric Physician Assistant and the Associate Program Director for the
Interservice Psychiatric Physician Assistant Residency Program at the San Antonio Uniformed Services Health
Education Consortium (SAUSHEC). He also serves as an adjunct professor at the U.S. Army Medical Center of
Excellence. CPT Lain holds a Doctor of Medical Science degree in Psychiatry from Rocky Mountain University
and graduated from the Interservice Psychiatry PA Residency program in June 2024. He earned his Physician
Assistant Studies degree from the University of Nebraska Medical Center in 2018.