Army photo / Staff Sgt. Michael L. Casteel When soldiers like these in Afghanistan confront mental issues, an Army psychiatrist's bottom line boils down to a seemingly simple question: is the soldier better off on the front lines, or back home?

The military psychiatrist serves both the service member and the military. The classic decision for a military psychiatrist in the theater of war is how to balance the needs of the individual against those of the organization when deciding when to evacuate for psychiatric reasons.

Lessons from World War I, World War II, and the Korean War taught us that those we evacuated for “shell shock” or “battle fatigue” did not do well after evacuation.

If a Soldier were sent home for psychiatric reasons, the shame and stigma persisted. They usually would be discharged from the military. However, if they could be maintained on the front line, they maintained their ties with their unit, and had the satisfaction of having served honorably.

Beyond that, those sent home were lost to the fight. Replacements were slow in coming. The Army Medical Department motto is “Retain the fighting strength.”

Thus, both Soldier and the Army seemed to do better when the Soldier stayed on the battlefield. (Or so goes the conventional wisdom goes. We do not actually really know the mortality rate of those who stayed in theater.)

This practice became part of the Army’s Combat Stress Control doctrine. The mnemonic was “PIES” — Proximity, Immediacy, Expectancy and Simplicity. Treat close to the front lines, quickly and simply, with an expectation of return to duty.

Every military behavioral-health practitioner knows the basic principles of far-forward mental health treatment. Of course, there are variations in the way patients present, which influence the evacuations decision. Normally the patient gets a trial of treatment in the war zone. If patients do not improve, or are dangerous, then they are evacuated.

I directly practiced the policy of minimizing evacuations while serving in Korea and in Somalia. The military followed that policy in Iraq and Afghanistan. It seemed to work well.

At least in the beginning.

But now that the Army is withdrawing from Afghanistan and downsizing, is it still the right approach? The Army is still concerned about retaining skilled Soldiers. And to be sent home still usually ends a career. Perhaps not immediately, but the chances of promotion are poor.

Now military psychiatrists have a new challenge. If someone has developed PTSD from combat, is it ethical to send them back into a war zone?

The Mental Health Advisory Teams showed that the prevalence of PTSD symptoms increased in those who had been deployed several times. However, fighting two wars, an overstressed Army had little choice other than to repeatedly deploy Solders.

It is different now; far fewer Soldiers are deploying.

So if you do send them back, then likely they will be experiencing the same stressors that led to PTSD before.

If you do not allow them to go, then they are eventually discharged from the Army for being non-deployable. The discharge may be medical or administrative, but either way it means losing their jobs, and military identity in a time with very high unemployment, especially for young veterans, is no good thing.

Another part of the discussion: there are many service members who deliberately keep PTSD symptoms hidden, so that they can deploy back into combat. They want to go back.

So they ignore the posters saying, “It’s a sign of strength to seek help.” Instead, they embrace the Army’s traditional mantra: “Suck it up and drive on.”

What we lack are data on how these combat veterans do in terms of overall mortality. Does their hyper-vigilance help keep them alive? Or does their irritability get them in trouble?