U.S. Army psychiatric and behavioral health challenges in future LSCO: A narrative review

Future large-scale combat operations (LSCO) against near-peer adversaries may unfold in a fluid, multi-domain battlespace where precision fires, drone swarms, and contested evacuation erase rear-area sanctuaries. This narrative review synthesizes historical evidence, emerging doctrine, and lessons from contemporary conflicts to: (1) depict the operational realities and casualty patterns anticipated in LSCO; (2) map the spectrum of behavioral-health effects, from acute combat and operational stress reactions (COSRs) to psychiatric casualties such as PTSD or psychosis; (3) clarify the distinctions between transient COSRs and diagnosable psychiatric disorders; (4) delineate the essential clinical, advisory, and leadership roles of forward-deployed psychiatrists and other behavioral health professionals in triage, stabilization, and return-to-duty decisions; and (5) identify planning and capability gaps in prolonged field care for psychiatric casualties while proposing evidence-informed solutions to close them. Preserving medical and psychological readiness in LSCO demands a shift from counterinsurgency-era reliance on rapid aeromedical evacuation to a layered, in-theater continuum of care that can safely hold and treat Soldiers for days or weeks under fire. Targeted investments in training, interdisciplinary behavioral health personnel mix, psychotropic logistics, and distributed restoration centers are critical to "conserving fighting strength" when evacuation is delayed or impossible. Implementing these recommendations will allow commanders to mitigate psychological attrition, maximize return-to-duty rates, and sustain combat effectiveness in the high-tempo, high-casualty wars the Army now foresees.