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See the report here(131 MB PDF file, 325 pages)

WASHINGTON — Despite years of emphasis on mental health issues, commanders in Iraq lack the necessary tools, training and guidance to deal with at-risk soldiers, according to an Army investigation into mental health services.

The report, released late Friday, was prompted by a shooting at a Baghdad combat stress clinic last May that left four soldiers and a sailor dead. After repeatedly reaching out for help, Sgt. John Russell allegedly stole a gun, walked into the clinic where he had been treated that day and opened fire.

The Army interviewed Russell’s peers, commanders and doctors to trace the events leading to the incident, and the resulting report details widespread failures to implement Multi-National Force-Iraq mental health policy. Leaders from noncommissioned officers to commanders aren’t provided direction to carry out preventive mental health measures, according to the report.

In a sworn statement to investigators, Russell’s first sergeant summed up the confusion: “What I don’t understand is from the time a soldier has been identified that they may have behavioral health problems what do you really do with them?”

The report found that the Army doesn’t emphasize command involvement and responsibility for behavioral problems, and instead the brunt of the responsibility rests with chaplains “when it should be a Command, and Commanding Officer Program.”

The chaplain served as “de facto” behavioral health advocate, which contradicts MNF-I policy that states “chaplains cannot serve as suicide prevention officers nor will chaplains assume coordinating authority for the commander’s suicide prevention program.”

Majors through lieutenant colonels “need more than awareness training. They require precise instruction in effective suicide and behavioral problem remediation measures to effectively support our behavioral health professionals,” the report states.

At the unit level, “there is no real conception of when to command refer a soldier for assistance.”

Leaders with Russell’s unit, the 54th Engineer Battalion out of Bamberg, Germany, “admitted they lack the fundamental skills to deal with behavioral health issues,” and had no formal policies or procedures to guide them, according to the report.

The investigation found there was no clearly defined procedure to track and monitor the issues once they were identified.

Russell’s commanders were not aware he had threatened suicide or that his immediate supervisors had removed the bolt from his gun. No notification, verbal or otherwise, is required in either of those instances.

The Army instructs units dealing with a potentially suicidal soldier to use the “buddy system” and “unit watch” without providing “even notional reference to describe” what those terms mean, according to the report. Those terms have been common in the Army for years, but there is no Army-wide standard or instruction for how to carry them out. Russell was supposedly on “unit watch” in the days leading up to the shootings, yet his unit had no template for how to actually do that.

What happened the day of the shootings also exposed problems with military police training and procedures for dealing with suicidal soldiers.

On May 11, Russell went for the fourth time to the Camp Liberty combat stress clinic. His noon appointment lasted five to 10 minutes because he was “verbally noncompliant” and “the clinic had a zero tolerance policy,” according to the report.

While the clinic contacted the military police, Russell stormed out of the clinic and threatened to kill himself.

The police thought Russell only needed to be escorted back to his unit by a senior soldier. They were unaware military police procedures dictate that any soldier threatening suicide should be turned over only to his first sergeant or unit commander.

At 1:15 p.m., Russell snatched his escort’s weapon and stole the vehicle at gunpoint.

There is no military police procedure in place to notify potential victims or provide temporary security to them, according to the report.

The police had 17 to 20 minutes to warn the clinic that Russell was armed and on the loose. When police made the call it was too late. Russell was already there and firing.

The report’s recommendations for dealing with these issues were not made public.

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