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Organization of the Psychiatric Services in World War II
Colonel Frederick R. Hanson (ref 8)
It was clearly demonstrated in World War I that the most effective treatment of combat-precipitated neuroses was the immediate correction of these disturbances in the forward areas. Unfortunately these principles were later disregarded, and it was necessary to reestablish them in World War II. In March 1943, during the Tunisian campaign, psychiatrists were assigned to the forward evacuation hospitals, and the percent of psychiatric casualties returned to full combat duty rose to about 50. This system of treatment in the evacuation hospitals continued effectively during the Sicilian campaign. Early in the Italian campaign, however, because of the greater demand for bed space for wounded, it was often necessary to evacuate psychiatric casualties to base section hospitals with their treatment uncompleted, and the percent of those returned to duty consequently decreased to about 25.
In order to circumvent this difficulty an army neuropsychiatric center was established in the Fifth Army on 21 December 1943, and bed space in this center was assigned exclusively for the care of combat neuroses. In October 1943 the War Department again authorized the position of division psychiatrist. With the assignment of psychiatrists to the divisions in combat, the percent of combat neurosis cases returned to full combat duty rose to 60, and afterward varied from 45 to 70. Thus, by March 1944 the essential elements of the forward areas psychiatric services had been established. These services continued to function effectively, with minor alterations, until the end of the war. To give orientation and unity to the succeeding discussions, the organization of psychiatric services is described in the form evolved by the end of the war.
The first echelon of treatment for the combat-incurred psychiatric casualty was normally the battalion aid station. At this level the soldier was examined by the battalion surgeon and a decision was made to return him to duty, send him for a short period of rest to the regimental aid station, or evacuate him to the division clearing
(ref 8) Formerly theater psychiatrist, Mediterranean Theater of Operations.
station. The criteria for making this decision are discussed in the section on "The Battalion Surgeon as Psychiatrist." On arrival at the division clearing station, the patient was examined immediately by the division psychiatrist. If it appeared probable that he could be returned to effective duty within 3 to 5 days, he was sent to the division psychiatric treatment and rehabilitation center. If his
Figure 1. Schema of treatment of evacuation of neuropsychiatric patients in a theater of operations. (During World War II there were no "psychiatric teams"; psychiatrists were attached to special installations on temporary duty.)
reaction was severe, he was evacuated as soon as possible to the Army Neuropsychiatric Center. Patients retained for treatment at the division center were usually returned to full combat duty if their progress was satisfactory. Those who did not progress satisfactorily were evacuated to the army psychiatric center for further observation and therapy. The various problems involved in the treatment and disposition of psychiatric cases at the division level are discussed in "Psychiatry at the Division Level."
With the exception of patients admitted directly to the army neuropsychiatric center from nondivisional units, all admissions for psychiatric disorders were sent to this center by the division psychiatrist. In addition, some patients who had been admitted to the evacuation hospitals with a nonpsychiatric diagnosis and who were subsequently given a psychiatric diagnosis were transferred to the center. Thus patients arrived at the army neuropsychiatric center from: (1) nondivisional units by direct admission, (2) the evacuation hospitals by transfer, and (3) the division psychiatrist. Those sent by the division psychiatrist constituted the majority. The army neuropsychiatric center normally retained patients for 3 to 6 days and returned them to full combat duty, evacuated them to the base section psychiatric hospital for further treatment, or, in the case of men who did not require further treatment but were unfit for further combat duty, sent them through administrative channels for reclassification and reassignment. The details of treatment and disposition at the center are given in the section on "Psychiatry at the Army Level."
As the efficiency of the treatment organization increased, the function of the base section psychiatric hospital became more and more confined to the treatment of the most severe cases. The methods used in treating such cases are discussed in the section on "The Base Section Psychiatric Hospital." This treatment organization is based upon the principle that early and continuous treatment of the psychiatric disorders of combat is mandatory if maximum therapeutic efficiency is to be achieved. It must be the aim of the psychiatric services not only to return as many men as possible to effective combat duty, but also to provide the optimum type of therapy for those who cannot be returned to combat duty, and thus minimize the effects and duration of the neurotic process in such patients. Our experience leads us to believe that the system developed and used in this theater accomplished these purposes. A diagrammatic representation of this organization, with minor modifications for proposed future use, is shown in figure 1.