Dr. Bodner is affiliated with the Interdisciplinary Department of Social Sciences, Bar-Ilan University, 52900 Ramat-Gan, Israel (e-mail: email@example.com). Dr. Iancu and Dr. Sarel are with the Psychiatry Department, Beer Yaakov Mental Health Center, Beer Yaakov, Israel, and the Sackler Faculty of Medicine, Tel Aviv University. Dr. Einat is with the College of Pharmacy, University of Minnesota, Duluth. Bradley D. Stein, M.D., Ph.D., served as guest editor of this column.
Service in the Israeli Defense Forces (IDF) is a powerful socializing force in Israel. Service is mandatory, and most Israelis serve (1). Special efforts are made to accommodate young people with emotional, behavioral, and cognitive problems so that they can participate in this important experience. Because rates of adjustment disorders and suicide are elevated during adolescence (2,3) and an increased risk of suicide during military service has been noted (4), it is important to identify individuals at higher risk of suicide (5,6,7) and to design programs to prevent adjustment difficulties and suicides in special-needs populations.
This column describes efforts to evaluate, treat, and support special-needs soldiers in the IDF. In addition, the column examines data on suicide for subgroups of special-needs soldiers, because a low suicide rate can be regarded as one measure of the success of these efforts.
Before induction, IDF recruits undergo screening procedures that include medical evaluation, psychometric evaluation, and a basic assessment for psychopathology. The psychometric evaluation includes cognitive testing of scholastic ability and personality measures (a structured personality interview and questionnaires) aimed at assessing combat suitability and future military performance. More detailed information about the evaluation has been published elsewhere (6).
Recruits who are identified as having difficulties may receive special assistance. The IDF has defined categories of special-needs recruits who may be assigned to less stressful service environments and occupations, receive different initial training, or receive enhanced support during their service. Recruits are categorized into these groups during induction but may be recategorized later during their service.
Three common categories for soldiers who may need special assistance are MHP (Mental Health Profile) (6,8), ADS (Adaptation Difficulties Score) (6,9,10), and MACAM (the acronym for the title in Hebrew of the Center for the Advancement of Special Populations) (1,10). The main distinction between these groups is that soldiers in the MACAM group receive special consideration and support both at the time of recruitment and during their entire service, whereas the two other groups receive consideration only during initial assignment.
Mental Health Profile group. A profile is determined during the recruitment period and represents the level of mental health of a recruit (6). Scores vary and indicate that the soldier cannot be recruited, that the soldier should be assigned to limited service options, or that the soldier's mental health makes him or her suitable for all positions. MHP is based on a psychiatric examination to which draftees are referred by paraprofessional interviewers or by civilian professionals who screen the entire population of recruits (8). When an interviewer's impression is that a draftee may have a psychiatric disorder, the interviewer refers the draftee to a psychiatrist. The MHP reflects an individual's functional level in the military rather than a precise clinical diagnosis.
Adaptation Difficulties Score group. The ADS indicates the adjustment skills and mental strength of recruits. Evaluation is performed only when the paraprofessional interviewers suspect problems. ADS status is based on the Mental Health Assessment, a semistructured interview conducted by a clinical social worker (6). Possible scores range from 0, no indication of disturbance, to 60, severely disturbed. The score has been found to predict functioning in the military and is validated annually (9). Recruits with scores above the mild range receive special consideration in their assignments, and draftees who receive high scores are not recruited (9).
MACAM group. Soldiers in the MACAM group are identified during the induction phase. MACAM recruits are males only and are the most problematic. They have educational, social, and psychological problems (10), and most have difficult backgrounds. Their psychosocial profile is characterized by emotional, behavioral, and cognitive problems (1). Emotional problems include an intense need for attention, difficulty delaying gratification, impulsiveness, a low threshold for frustration, difficulty establishing trust and accepting responsibility, fear of being away from home, and low self-esteem. Cognitive problems include poor education, concrete thinking, and difficulty distinguishing between essential and secondary issues, solving problems, and planning ahead. Behavioral problems include difficulty functioning under stress and accepting authority, lack of perseverance, difficulty taking initiative and responsibility, childishness, a tendency toward aggression, and lack of disciplined habits.
Because MACAM is ranked as the most problematic group, this classification overrides any other classification. Soldiers in the other two groups—those with MHP or ADS levels above the mild range—are assigned to regular noncombat units with less stressful duties. After this assignment, these soldiers are expected to cope without enhanced support systems other than supports available to the general military population. In contrast, MACAM soldiers are recruited through a specific mechanism and assigned to long and gradual basic training in the MACAM center. The center offers an enhanced educational and rehabilitation framework tailored to help the new recruits overcome their deficits (1). They are then assigned to units according to their current abilities, where they are accompanied by officers and commanders from MACAM who have received special training and education. In addition, MACAM soldiers' mandatory service is shorter than that of other soldiers—two years instead of three (1). Commanders work to increase the MACAM soldiers' self-efficacy and self-discipline, provide an organized daily schedule, and accompany the soldiers in periods of stress and in other situations where they can demonstrate success and competence.
During the past two decades the rate of suicide for regular mandatory-service soldiers in the IDF (aged 18 to 21) ranged between .96 and 2.32 per 10,000 soldiers. Because of the known relationship between support and reduced suicide risk (11,12), we examined rates of suicide in the three special-needs groups over a nine-year period (1990—1998) to explore the possible effect on suicide rates of the different support systems offered to the groups.
During this period, soldiers in the ADS group constituted 11.1%±3.3% of the entire IDF population and 26.6%±11.3 of the soldiers who committed suicide. Soldiers in the MHP group constituted 8.9%±1.2% of the entire IDF population and 13.1%±4.8% of those who committed suicide. MACAM group soldiers accounted for 1.9%±.4% of the IDF population and .9%±1.8% of the suicide group.
Although these findings are of interest, we cannot draw conclusions about the impact of IDF's support programs on suicide rates in these groups or determine to what extent the differences in rates may be attributable to differences in the population or to other factors. Important limitations of this study are its rather short duration; the lack of matching of the three groups on socioeconomic status, education level, and factors regarding motivation to serve in the military; and the absence of information about previous suicidal behavior that might have led to categorization in one of the three groups. Therefore, we cannot point to these rates as an indicator of effectiveness of IDF procedures. However, we cannot rule out the possibility that the sensitive and thoughtful approach to special-needs soldiers, especially those in the MACAM group, might have had some effect.
MACAM soldiers are the most problematic special-needs group. Most of MACAM soldiers have moderate to high ADS levels; more than 60% have high MHP scores; and some have juvenile delinquency in their background. These soldiers also demonstrate impulsiveness and have a low tolerance for frustration and a tendency toward aggression and violence—all features associated with an elevated suicide risk (6,13). Nevertheless, the IDF's goal is to provide an opportunity for these young men to become integrated into Israeli society by serving in the army, as most Israelis do (1). According to IDF internal reports, most MACAM soldiers finish their military service and a few even become combatants and noncommissioned officers. The special considerations that MACAM soldiers receive throughout their service may prepare them for social roles in Israeli society.
These findings suggest that the IDF should evaluate the implementation of other mechanisms to raise awareness and enhance support of special-needs soldiers during their service in the military. Awareness training about mental problems should be given not only to officers but also to the lower-level commanders who have a more direct relationship with the soldiers. Follow-up and continuity of care by mental health officers and primary medical officers should also be enhanced. Implementing additional mechanisms of awareness and enhanced support is not a simple task. However, these findings, although only descriptive, may instigate further efforts to ensure that soldiers with special needs receive increased attention, support, and care during their service.