Iraq & War-Zone Psychiatric Casualties [Presentation Version] 26. 05

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Iraq & War-Zone Psychiatric Casualties

[Presentation Version] 9.26.05

What About The War in Afghanistan?
I want to first share a description about the war that is still going on in Afghanistan. Afghanistan already has turned into the forgotten war of this generation---even as it is still being waged. The conditions faced by our forces in Afghanistan are formidable:

They’re facing guerillas who were born here, hardened by poverty and backwardness, and steeped in a centuries-old tradition of resisting foreigners . . . The Taliban have killed more than 40 US soldiers and more than 800 Afghan officials, police, troops, aid workers and civilians since March . . . the war has evolved into a bloody game of cat and mouse, a classic guerilla struggle with echoes of the much larger and far bloodier conflicts in Iraq, Chechnya and Vietnam . . . The Taliban operate in small bands, staging hit-and-run attacks, assassinations and ambushes, laying mines and firing missiles and rocket propelled grenades before melting back into local populations. U.S. intelligence reports indicate that Taliban leaders constantly change locations. ‘One day, they could be firing at you and serving you chai (tea) the next . . .’

[This is a] country ravaged by decades of civil war and overwhelmed by destitution, corruption, overpopulation, disease and despair. The guerillas stash their arms in the wheat stacks, wells, thick groves and the off-limits women’s quarters of adobe compounds. Their hiding places are scattered in the small oases of almond and apple trees in valleys wedged between mountains that seem to roll ever onward like immense, dun-colored tidal waves. Hiding in mountaintop caves and crevices, the Taliban track U.S. troops and aircraft---sometimes for scores of miles---and pass intelligence to each other in coded-language via walkie-talkies that are extremely to get a fix on. ‘A lot of times it’s like chasing ghosts . . .’ 1
Knowing the nasty conditions that face our still sizable military force in Afghanistan, it is assuredly safe to assume that whatever problems our military personnel in Iraq are described as having while there and following their return also face our forces in Afghanistan and upon their return. Furthermore, since our Afghanistan forces and veterans have already been ignored or forgotten by far too many already, there is an additional problem. Warriors being forgotten brings its own legacy of resentment, alienation, rage, not being understood or appreciated and despair---as has been experienced by so many Vietnam and Korean War veterans and their families. And so as I discuss what is going on in Iraq and with Iraq veterans, please remember that at least the same degree and depth of issues and difficulties, and perhaps more, most assuredly are applicable to our forces currently in Afghanistan and to our Afghanistan veterans and their families.
Sobering Facts About Deployment In Iraq and Iraq Veterans

Increasingly, it appears that the marked numbers of chronic and longer-term psychiatric casualties from the Vietnam War (verified at over 800,000 Vietnam veterans) 2 may well be replicated to a substantial degree as the longer-term reality of the impact of the Iraq War. Indeed, this concern goes back to earlier wars and up to Iraq.

I have visited 18 government hospitals for veterans. In them are a total of

about 50,000 destroyed men . . . men who were the pick of the nation 18

years ago. Boys with a normal viewpoint were . . . put into the ranks . . .

they were made to “about face” to regard murder as the order of the day.

Then, suddenly, we discharged them and told them to make another

“about face.” Many, too many, of these young boys are eventually

destroyed mentally, because they could not make that final “about face”


Major General Smedley D. Butler, 1936 3

By many accounts, the “about face” that our troops in Iraq must accomplish, both to function in the war-zone, and then to be able to function again back home, is very sobering. The results of a survey of 2,530 troops prior to and after deployment to Iraq reported in the New England Journal of Medicine in July, 2004 are very relevant; at least one in eight Iraq combat veterans (between 15 and 17%) was reported to be suffering from major depression, generalized anxiety or PTSD. And yet, only 23-40% of Iraq combat veterans with such problems sought mental health care. 4

Another study, the Army’s first-ever of mental health conducted in a war-zone, showed that about 17% of Army soldiers serving in Iraq in 2003 were assessed to be suffering traumatic stress, depression or anxiety and were deemed to be “functionally impaired.”5 And the actual number may well be substantially higher in that soldiers who were injured in combat and did not redeploy with their units were unable to continue in the study. 6 Earlier estimates were that about one in six troops deployed in Iraq would suffer war-related psychiatric symptoms and difficulties; however, conditions in Iraq have gotten much worse. This leads to the very real possibility that the psychiatric casualties from troops deployed in Iraq will be similar to the Vietnam War in which 30% of Vietnam veterans have suffered full-blown PTSD at sometime since leaving the war-zone. 7

Of course, these figures are in regards to active duty Armed Forces personnel who have been willing to admit to the military surveyors that they actually have emotional problems or PTSD. For example, one Iraq soldier who was suffering from combat stress reaction described his response when he was handed PTSD fliers in the field and asked if the questions about PTSD applied to him.

I said---no, and tossed them.8

Another soldier said that many returning soldiers, in response to whether they might be suffering from emotional problems or PTSD, will answer “not me, sir” ---“Simply because they wanted to go home. Immediately.”

If you say ‘yes’ to any question, you will be held back from going home on leave.9
In other words, in spite of the military’s laudable effort to survey military personnel while they are in Iraq or upon returning home from deployment, it is reasonable to assume that the substantial number of soldiers reporting emotional problems or PTSD significantly under-represents the actual number.

The serious under-reporting of the actual number of military personnel suffering emotional problems or PTSD is further underscored by another survey that assessed the presence of significant difficulties related to perceived barriers that stopped military personnel from seeking mental health help. This survey of perceived barriers was of both Army and Marine Corps soldiers. Such barriers included: “I would be seen as ‘weak’ (48%), My unit leadership might treat me differently” (45%), “members of my unit might have less confidence in me” (45%) and “It would harm my career (37%). 10

Indeed, “just to seek [mental health] treatment in the military is an act of courage” due to the fear of stigma from peers and the fact that soldiers are discouraged from sharing emotions. 11 This reluctance to seek mental health help is exacerbated by the still prevailing “suck-it-up, soldier-on, deal with it” culture.

There’s a strange pressure on these soldiers not to have any problems with what they are doing. It’s the old idea that a real man and a true warrior will stay strong. 12

Besides the “macho warrior” mentality that prevails, the very real fear that to seek mental health treatment will harm one’s military career is at least partly related to concerns reported about the confidentiality protections of military medical records. While confidentiality protections have improved, unlike the vast majority of civilian employers, military commanders have the right to invoke a “need to know” prerogative to access a soldier’s medical history and counseling records. Thus, mental health problems have the potential to negatively impact security clearances, promotions and even retention on active duty. 13 Active duty military personnel are quite aware of this.

These perceived barriers to seeking mental health services undermine the likelihood that many military personnel in Iraq will actually go to see a military mental health professional in the first place, as borne out by a recent survey conducted by the Army in Iraq. It reported that about three-quarters of the soldiers suffering from traumatic stress, depression or anxiety and functionally impaired had received no help at any time while in Iraq from a mental health professional, a doctor or a chaplain, and overall, only one-third of soldiers who wanted help actually got it. 14

The fact that up to 40% of the American fighting force deployed in Iraq is from the National Guard presents yet an additional critical problem related to the “delayed” nature of war-related psychiatric symptoms and the likelihood that most troubled military personnel will not seek mental health treatment while on active duty. National Guard members are only entitled to receive mental health services from the Department of Veterans Affairs for two years following their discharge from active duty. 15

What should make the above figures even more troubling is a little publicized fact: the acute or short-term psychiatric casualty rate in a war-zone appears to be substantially less than the longer-term rate. This is what happened in Vietnam. There were widely announced and optimistic pronouncements by military officials about how low the overall acute psychiatric casualty rate was in Vietnam and that this rate was about half that during the Korean War, which in turn was about half that in World War II. Such pronouncements led to the early bold statement that “military psychiatry had worked” in Vietnam. 16

However, what was not reported to the American public was that only giving the overall acute psychiatry rate over the entire Vietnam War masked the very disconcerting fact that the acute psychiatry rate during the last few years of the war had skyrocketed. This was at a time during which it was becoming very clear that there was no end in sight to the fighting and that the accomplishment of earlier predictions by our nation’s leaders that the U.S. would win the war relatively quickly obviously was not going to happen---just as is happening today concerning Iraq.

The impact of these facts, along with increasingly vocal and strident war anti-war protests back home, was very negative on the morale of our troops. All of these developments were correlated with the explosion in the acute psychiatric casualty rates during these latter years of the war. And then, two decades later, it was discovered that over 800,000 Vietnam theater veterans had brought their war-related PTSD home with them. 17

And so, if the violence in Iraq remains anywhere near its current levels, and our armed forces remain in Iraq for several more years in substantial numbers, the specter of rates of psychiatric casualties similar to those that occurred among Vietnam veterans are likely. Indeed, the new Chairman of the U.S. House Veterans Affairs Committee stated that (as of March, 05), “as many as 100,000 Iraq and Afghanistan veterans could have PTSD.” 18 These sobering predictions have been reinforced by the recent report of the Army Surgeon General that fully 30% of US troops returning from the Iraq War have developed stress-related mental health problems by three to four months following their deployment.” 19

These numbers are quite likely to increase even more if there are:

  • substantial increases in the numbers of dead and wounded and disabled American military forces (and Iraqi civilians)

  • increased protests against or questions raised about our continuing military involvement in Iraq, and

  • increased fractious divisions in our society about the war.

As an indicator of the apparently growing vocal anti-Iraq War movement, about 800 anti-war

marches were reported in all 50 states on March 19, 2005, the two-year anniversary of the day the Iraq War began. 20

There also may be an increase in questioning about our military involvement in Iraq among active duty military personnel. Some cases already have been reported.

When they (Iraq veterans) grew cynical about the Iraq War, the Vietnam veterans in their family immediately recognized what was happening---that another generation of soldiers was grappling with the realization that they were being sent to carry out a policy determined by people who cared little for the grunts on the ground . . . Now you realize that the people to blame for this aren’t the ones you are fighting.

. . It’s the people who put you in this situation in the first place. You realize you wouldn’t be in this situation if you hadn’t been lied to. Soldiers are slowly coming to that conclusion. Once that becomes widespread, the resentment of the war is going to grow even more.” 21
To the extent that the above negative viewpoints about our involvement in Iraq are growing among Iraq veterans and among the American people---and that is not easy to gauge accurately---“back to the future” may already be here---in terms of tragically substantial legacy of long-term psychiatric casualties that continue from the Vietnam War---as is described later..

Military Mental Health Responses In Iraq And In Other Wars

The Good

Combat Stress Reaction Versus Post-Traumatic Stress Disorder
The military has adopted the term “combat stress” or “combat stress reaction” (CSR) rather than using the psychiatric diagnoses of Acute Stress Disorder (ASD) or Post-Traumatic Stress Disorder (PTSD) to describe most acute reactions to combat stressors while in the war-zone. Combat stress reactions or battle stress is not considered to be an abnormal response to exposure to combat stressors in a war-zone. The nature of such exposure is graphically described by a military psychologist in Iraq:

The greatest difficulties experienced by our troops surround the extremely dangerous and unpredictable conditions faced continuously by an unseen enemy. The danger inherent in the global war on terrorism surround living in and living through a relentless series of traumatic and horrific events. There is no way to stop driving through this. It is the nature of the war, which is far from over in this theater . . .

When leaving “the wire” or the somewhat protected environment of the FOBS (Forward Operating Bases), soldiers are exposed to the relentless possibilities of attacks from those indistinguishable from civilians and normal objects of everyday living turned into instruments of injury and death: soda cans, dead animals, abandoned vehicles, all of which can be easily converted into deadly IED’s (Improvised Explosive Devices) or

VBIED’s (improvised explosive devices or vehicle-borne IED’s). They maim, torture, and kill their victims with grisly burn and blast injuries. There is no end and no escape from the danger they pose. We even hold our breath every time we leave the safety of our compound in the IZ (International Zone, aka Green Zone).

No one could possibly be completely immune to peril here. It erodes one’s ability to carry on over time, renders one less able to deal with and push through those endless hours in which your life dwindles down to the prospect that this day might be your last. We are all susceptible . . .
The level of danger seems to be an ever-increasing problem, as insurgents become more clever and perfected in their game. This is why we wear over 35 pounds of body armor, Kevlar helmets, weapons and ammunition whenever leaving our facility. The level of security and numbers of checkpoints increases with the tempo. The illusion of safety rapidly disappeared during the recent elections and forced us to maintain more intensive force protection measures like sandbagging, roving guards in a tower on our roof comprised of our own soldiers, both male and female, in full defensive posture . . . .
In addition, stability and support operations (SASO’s) can be as overwhelmingly stressful as major combat operations, as the level of danger and risks do not diminish in the face of “unfriendly” civilians whose major job it is to kill American soldiers, more restrictive Rules of Engagement and the changing Laws of War, and missions that are ambiguous in nature. It is very difficult to gauge the effectiveness and visible progress of our military operations as a result. 22
Combat stress reaction describes a not uncommon response among military personnel; and it is a reaction rather than a psychiatric disorder. Indeed, military psychiatry has broadened the definition of combat to include operational stress. 23 This is a term that includes more than just fearful reactions to battle experiences per se, but to the broader range of stressor that deployed persons face, i.e., deprived working and living conditions, the threat of disease, and stress simply from being in a war-zone and distant from home.

Again, in the words of LTC Platoni:

In addition to issues surrounding combat, the most frequent psychological issues faced by our soldiers are those stemming from problems on the home-front, poor or inexperienced leadership, uncertainties about extended tours in theater or a back-to-back deployments, physical and psychological exhaustion, complicated grief and self-blame over the loss of fellow soldiers and surviving when buddies didn’t, tremendous hatred

for an often unrecognizable enemy, and the loss of the will to keep on living in the face

of precarious battles that seemingly have no end . . .

Add to the mix the lack of privacy, often extreme boredom waiting for something, anything to happen upon which to act, restricted movements within “the wire”, and the long-term separations from home, family and all that is familiar. Undeniably the level of stress and distress remains high in OIF (Operation Iraq Freedom). 24

CSR is understandable in the context of the extraordinary stressors of war; its acute manifestations are temporary and short-term precisely because they are reactions and not a psychiatric disorder. CSR symptoms among U.S. troops in Iraq have been described as including “feelings of anxiety, upset stomachs, somatic complaints---anxieties that are converted to body illness---twitching, as well as emotional and maybe even spiritual problems.” 25 LTC Platoni further describes the classic or typical signs and symptoms of combat stress or battle fatigue that the Combat Stress Control Units are seeing in Iraq:

tremendous anxiety, hyper-vigilance, jitteriness and shaking; sleeplessness, haunting nightmares; irritability, anger, rage, outbursts of unresolved grief, self-doubt, excessive self-blame and guilt; inattentiveness, loss of confidence, carelessness and recklessness; loss of hope and faith, impaired ability to perform duties; depression that does not lift; freezing and immobility; erratic behaviors and actions, terror and panic, running away; loss of skills speech and memory; impaired sensation, hearing and vision; exhaustion, apathy and indifference to life itself; extreme fatigue, weakness and paralysis; delusions, hallucinations; vivid re-experiencing or re-living of images that cannot be forgotten; confusion about the taking of other lives and the fear of the loss of one’s humanity in the face of doing so. 26

The usage of CSR terminology and rationale is an excellent practice in that the difference between the usage of the terms CSR versus PTSD and ASD is immense. After all, ASD and PTSD are official psychiatric diagnostic labels for people who suffer a disordered response to trauma. 27 Conversely, CSR terminology by-passes having a “disorder label” being liberally applied to military personnel in the middle of a war-zone. PTSD labeling obscures the fundamental fact that what is a “normal” environment in a war-zone and what are “normal” reactions of persons in a war-zone are remarkably different from the ordinary realities of typical civilian life.

In fact, many of the symptoms of post-traumatic stress (PTSD) and acute stress (ASD) that the APA describes as “psychiatrically disordered” in the civilian world are not only commonplace in a war-zone. Indeed, they are functional to survival in a war-zone. These include:

  • detaching from or numbing one’s emotions

  • denying or minimizing the horror of what one is seeing and experiencing

  • hyper-vigilence

  • exaggerated startle response

  • experiencing the environment as unreal. 28

To routinely consider the above in a war-zone to be symptoms of a psychiatric disorder would be foolish and false. Of course, what has happened is that hundreds of thousands of veterans from the Vietnam War, for example, after returning from deployment or following their discharge from active duty have later been given the psychiatric disorder label of PTSD. And this is a “disordered” label that they keep forever. And so, I agree completely with the perspective of military mental health concerning the distinction between CSR versus ASD and PTSD.

More Good---Up To a Point
Viewed in the above-described context, there are logical military mental health responses to combat stress reactions in a war-zone, responses that have been provided in various forms since as far back as World War I.29 Indeed, in congruence with ethical principles of treating post-trauma reactions, the argument can be made that the time and logistical constraints and realities in a war-zone dictate severe limits on what can realistically be done therapeutically with psychiatric casualties other than the classic military psychiatry interventions that are based on long-standing military psychiatry principles known as PIES: Proximity, Immediacy, Expectancy and Simplicity. Along with PIES, there is the military mental health principle of Centrality. 30 31

Today in Iraq the multi-faceted mission of the Combat Operational Stress Control (COSC) units is described as operating within the basic principles of PIES but with an unprecedented insertion of COSC personnel with combat units:

To treat from the front lines (as there is no longer a rear echelon), to improve access to our services, and to liaison with all “boots on the ground” in theater to meet all the needs and demands of every unit, commander, and soldier. Our Prevention Team missions involve treatment of battle fatigue by providing comprehensive support for stress casualties as immediately as time and location allow, always with the expectation that soldiers can recover and will return to duty.
If primary preventive measures are insufficient, soldiers are referred to one of our two Restoration Teams for rest, physical replenishment, 3 hots and a cot, neuropsychiatric triage and evaluation, stabilization, brief supportive counseling, mission stress education that promotes coping with any number of combat stressors, work hardening to allow them to better perform their missions (occupational therapy), and disposition, including med evacuation to a higher echelon of care in Landshtull (Germany) 32
I conceptualize the five principles of PIES plus centrality as falling into two categories: functional and clinically specific.

The functional military mental health principles

These principles include Proximity, Immediacy and Centrality and have to do with the way the mental health services are structured or organized. The objectives are to have mental health professionals strategically located to be able to provide mental health services in accordance with the military mental health principles.

  • Proximity: they are easily accessible to provide mental health services to front-line and indeed all military personnel, and as close as possible to their duty stations

  • Immediacy: they can very quickly provide needed assessment and consultation and direct counseling services, and

  • Centrality: there is a restriction of the authority to medically evacuate anyone out of the war-zone limited to specific medical officers in order to insure that a centralized quality control is uniformly applied throughout the war-zone. This arrangement prevents decisions about medical evacuations from occurring through the individual medical judgment of numerous medical officers scattered throughout the war-zone and can be justified as a quality control measure that ensures more uniform assessment and disposition decisions.

Critics contend that centrality is actually a strategy to suppress the psychiatric rate of casualties being evacuated out of country. In other words, prior experiences in war-zones revealed that if individual medical physicians were left to their own judgments, they would be more likely to consider the individual health of the individual military person in making medical decisions about an appropriate medical disposition. And the result was much greater rates of medical evacuations being authorized. Conversely, restricting medical evacuation authority in-country to medical officers who would more strongly factor in the military medical mission to conserve the fighting strength resulted in having more military psychiatric casualties being sent back to duty rather than being medically evacuated.

The Clinically-Specific Military Mental Health Functions

The remaining two principles of military mental health provide the framework, ethos and methods for the provision of clinically specific interventions.

  • Simplicity: interventions are to be simple and uncomplicated, and easy and quick to administer. As such, they do not give the message to the military personnel that they are “sick” or “disabled”.

  • Expectancy: the providers are instructed to be very clear and repetitive with the message that you are suffering a temporary and understandable reaction to a powerful situation or incident, you will recover within a very quick period of time, and you will quickly be returning to your duty station.

These latter two principles prescribe the limits of the range and depth of interventions that will be provided to psychiatric casualties. 33

  • “three hots and a cot” in a safe environment in order to rest and be given a brief respite from dangerous duty

  • education about combat stress reactions and recovery from them, i.e., “it is normal for soldiers facing combat to also face fear and stress.” 34

  • crisis intervention related to traumatic combat experiences, to include losses during combat and accompanying guilt and grief, sadness and anger reactions. 35 Within this context of very time-limited and directive counseling, the opportunity is provided to briefly talk, emotionally vent any pent-up feelings and issues, and re-look at what is troubling them and what they need to do to get themselves back together again and return to their duty station. COSC personnel in Iraq have benefited from adopting mental health interventions developed since the Vietnam War---especially Critic Incident Stress Debriefings or Critical Event Debriefings, to include the Kuhlmann Group Debriefing Model that originated in the 785th Medical Company, Combat Stress Control, during the late 1990s. [For a detailed description of the Kuhlmann model, please see Appendix II.]36

  • Besides using crisis intervention and debriefing strategies that include simply allowing the emotionally troubled combatant to talk and vent, relaxation and cognitive-behavioral techniques are provided. The combatant may be taught simple breathing and other relaxation techniques to help allay anxiety, and “cognitive reframing” to help combatants look at what they are experiencing as a “normal” or “natural” reaction. 37

  • When necessary, and depending on the prescribing proclivities of military physicians, some or possibly greater amounts of psychotropic medications, typically anti-depressants and anti-anxiety medications, are provided to more immediately mitigate particularly severe anxiety, depressive, sleep deprivation/exhaustion (or, in very rare cases, psychotic) symptoms . 38

It is important to note that CSR mental health units in Iraq have gone beyond what was offered in

Vietnam in terms of having a substantially more extensive role of “being a force multiplier”:

This means going out to the Forward Operating Bases to provide one on one or group support, command consultation to assist commands in confronting widespread problems, providing on-the-spot training and briefings, from combat operational stress management, conflict resolution, anger management, coping with grief and loss, to dealing with human remains. We provide critical incident stress management defusings and debriefings after significant events, particularly when there have been

casualties and fatalities. 39

Combatants who are seen at CSR units oftentimes are sleep deprived and exhausted, combined with the cumulative and unrelenting stress of repeated exposure to death, dying and the constant threat of unpredictable surprise attacks. Army mental health in Iraq claims that about 80% of soldiers treated by the combat stress unit are able to return to their operational units after several days. It is reported that for soldiers who do not respond so positively and quickly, they can be placed in a headquarters unit relatively near to their units for 7 to 10 days, assigned low-stress jobs like kitchen duty and given further rest. 40

However, an Army survey of mental health services in Iraq reported that over half of the mental health providers surveyed whose mission was “combat stress control” reported that they had inadequate supplies of anti-depressant and sleeping drugs, half said they did not receive enough pre-war training in combat stress and more than half said they either did not know the Army’s combat stress control doctrine or “did not support it.” 41 These findings strongly suggest that the actual practice of mental health in the Iraq war-zone may well not be entirely consistent with official military mental health principles and doctrine.

What is without question is that the official military mental health doctrine is to give a consistent message that such soldiers are not having “abnormal” reactions and hence they are not “patients.” Rather, these are normal reactions, such as fear and anxiety; it is the environment that is abnormal, and the soldier will very soon be able to return to duty. This is military mental health in a war-zone; it sounds exactly like what we provided in Vietnam on the 98th Medical Detachment (KO Team) where I was a psychiatric social work officer in 1968-69. 42

And it works---up to a point. It enables maximal numbers of combat stress reactive soldiers to be returned quickly to their units and minimizes the number of acute psychiatric casualties who would be medically evacuated out of the war-zone. In other words, these military mental health principles have an excellent track record in reducing the acute psychiatric rate in the war-zone and in minimizing the number of military personnel who are medically evacuated out of country.

And this would seem to be how it should be for Combat Stress Control teams in Iraq in carrying out their medical mission to conserve the fighting strength: “We are to provide high quality combat/operational stress control service and to manage fear, fatigue, and traumatic experiences of soldiers, thereby preserving unit cohesion and fighting strength of combat units.” 43
The Not So Good

The military has extolled the advances in military psychiatry strategies and service delivery improvements, to include having dispatched “combat stress teams” to Iraq early on, and their forward thinking in terms of the quick interventions provided. Such pronouncements are both understandable and laudable in terms of helping to alleviate acute combat stress reactions. However, they belie a sobering reality. Military mental health differs distinctively from civilian practices in that it is not the personal problems of the soldier, or their mental health per se, that is the primary focus of clinical attention in the military. Rather, the military medical mission is to “conserve the fighting strength,” to get the combat stress reactive soldier back to his or her unit in the field ASAP. And looking at it from a strictly military perspective, this makes total sense.

And so what is the problem with this? Quite simply, there are two major problems. While military mental health practices in a war-zone almost assuredly are beneficial to reducing the acute psychiatric casualty rate in the war-zone and hence “conserving the fighting strength”, I am not aware of any reputable scientific evidence in American military psychiatry that providing such acute treatment in a war-zone and returning a soldier ASAP to his or her duty station is conducive to the longer-term mental health of that soldier. Preliminary findings of the only study ever completed on this subject described a precedent-setting 20-year longitudinal study of psychiatric casualties in the Israel Defense Forces. There was a significantly lower PTSD rate 20 years later among psychiatric casualties treated at the front lines (31%) versus those medically evacuated to rear-echelon areas (41%). 44 No such study has ever been done, to my knowledge, on any era of US military psychiatric casualties.

The Conundrum of Military Mental Health In a War-Zone

Military mental health emphasizes the rationale that having the acute psychiatric casualty remain in the war-zone and not be medically evacuated out of country not only serves the medical mission to conserve the fighting strength but also will ultimately be beneficial to the psychiatric casualty’s longer-tem mental health. He or she should not be “prematurely” evacuated because this would result in more entrenched longer-term problems. 45

But the conundrum that faces military mental health in a war-zone is that much of the scientific literature overwhelmingly confirms that the single greatest risk factor to developing PTSD is to increase one’s exposure to repeated high magnitude stressors or trauma. 46

And, this is exactly what military mental health practice in the war-zone accomplishes by adeptly carrying out the military medical mission to conserve the fighting strength. The pre-eminent clinical focus on returning psychiatric casualties to duty ensures that recently traumatized military personnel by and large will return to combat---where they will face yet additional and recurring traumas.

Reports from the first study ever conducted by the military on the mental health of troops who fought in Iraq or Afghanistan confirmed the salient role of exposure to direct combat stressors with developing PTSD. Soldiers surveyed in Iraq showed a higher rate of PTSD (12%) than Afghanistan (6%). However, the troops in Iraq saw more combat, including firefights and attacks. The differences in the PTSD rate between those soldiers surveyed in Iraq versus those surveyed in Afghanistan confirmed the extremely strong relationship between exposure to direct combat stressors and PTSD: “The linear relationship between the prevalence of PTSD and the number of firefights in which a soldier had been engaged was remarkably similar among soldiers returning from Iraq and Afghanistan, suggesting that differences in the prevalence according to location were largely a function of [exposure to] the greater frequency and intensity of combat in Iraq.” 47 This linear relationship between increased exposure to combat stressors and psychiatric problems among combatants is not a new finding. Not only was it reported in the National Vietnam Veterans Readjustment Study some 15 years and two wars ago, 48 it was reported 60 years ago in a study of World War II veterans. Sustained exposure to direct combat over about 30 days had almost a 100% association with becoming a psychiatric casualty. 49 Just one more critical lesson that apparently needs to be learned and relearned.

It may, indeed, be true that “if combat is bad, evacuation is hell.” 50 And the negative emotional impact of the medical evacuation process is without doubt extremely stressful if not traumatic. 51 Yet returning psychiatric casualties back to duty clearly puts them at increased risk in terms of their longer-term mental health.

It appears to truly be a mental health catch-22 of war: conserve the fighting strength while dramatically increasing the risk of PTSD by returning psychiatric casualties back to duty, or medically evacuate out of country and avoid further exposure to combat trauma yet expose evacuees to the emotional trauma of the evacuation process and “deserting” their comrades. Pick your poison.
This is indeed a debatable and complex issue that, other than the Israeli study, is remarkably devoid of any empirical evidence to support either position. Is it really in the long-term mental health of military personnel in a war-zone who are suffering combat stress reactions to be stabilized, re-invigorated and returned to duty versus being medically evacuated out of country? I am very concerned that in spite of the dearth of any meaningful empirical data to confirm that it is indeed better for one’s longer-term mental health to be returned to combat duty, that this premise is completely accepted and promulgated by military mental health officials.

The acceptance and promotion of this factually unsubstantiated and certainly debatable premise in the war-zone is further buttressed by the fact that once you are in a war-zone, all of the dynamics and pressures are enormous to reinforce returning psychiatric casualties to duty. First and foremost, when you are in a war-zone you will get caught up in the fervor of war, the pride and esprit de corps, being in this together, serving in harm’s way. And when you encounter people acutely suffering from exposure to horrific events and consequences, your heart goes out to do all that you can do at the moment to help.

The satisfaction we derive from being called to duty in support of

Operation Iraqi Freedom is pretty overwhelming. It just takes talking to

one soldier to know what we do as a CSC team really matters. When we

conducted debriefings for the U.S. Embassy staff in the aftermath of the

rocket attack few Saturdays ago and allowed them to process their

incredible grief and sense of both loss and horror (many of them witnessed

the gruesome deaths of 2 colleagues and injury of 5 more) and their

completely selfless acts in tending to the wounded with little regard for

their own lives (many of them are civilian personnel), our reason for being

here truly took shape. It is a gift to be called to serve one’s country for the

cause of freedom. As I always say, there are few more noble deeds. 52
I can readily identify with this powerful accounting of helping people while in a war-zone and the sense of gratification and pride at doing the best one can do to help. Besides the inevitable intoxicating combination of wanting to help combined with the adrenalin stimuli rampant in a war-zone, there are additional powerful factors that further “load” one’s mental health decision-making to return psychiatric casualties to duty rather than medically evacuate them. If you evacuate someone, who is going to take his or her place? Will it be a newbie? And anyone who has been in war knows that a newbie is the most dangerous person to have in your unit in combat situations until they can learn the ropes. Or will it mean that others will be forced to have their tours extended to make up for the personnel loss, or that others will be redeployed from the U.S. back to Iraq to fill the absences? None of these alternatives are very appealing.

And there is one additional and extremely powerful dynamic that further “loads the dice” towards a disposition of return to duty rather than medical evacuation out of country. During the Vietnam War the primary performance factor in the annual evaluation of the commander of our psychiatric team was “reduced medical evacuation rate out of country” as the benchmark that our psychiatric team was successfully carrying out our mission. And in Iraq today performance evaluations of Combat Stress Control units are also based primarily on returning psychiatric casualties to duty versus med-evac to Landshtul, as well as the length of stay at the Restoration Program for those who need to temporarily be in a 24-hour mental health environment. 53

Such performance benchmarks dramatically load the pressures on military mental health personnel to have tunnel vision on conserving the fighting strength rather than equally on preserving and enhancing the longer-term mental health of the individual psychiatric casualty. This is buttressed by military mental health having an operational practice and rationale that unquestioningly espouses the non-scientifically supported assumption that “premature” or “unnecessary” evacuation out of country will be more injurious to one’s longer-term mental health than remaining in a war-zone and being re-exposed to additional traumatic stressors.

And this is precisely the issue. Once you are in the war, everything pushes you in the direction of patching up folks psychologically and returning them to duty---to face additional trauma that they will carry back home with them. We can argue the merits of this forever, but we are left with two unmitigated and indisputable facts. First, the results are that more psychiatric casualties will be exposed to yet further trauma by being returned to duty; and second, that exposure to further trauma is the single greatest predictor of being at risk to eventually develop PTSD. Indeed, even the previously referenced Israeli study that showed a 25% lower rate of PTSD 20 years later among psychiatric casualties treated at the front lines versus those medically evacuated and treated, still reported a very high PTSD prevalence rate of 31% among the psychiatric casualties treated at the front and returned to duty. To put this PTSD rate in perspective, it is double the rate of PTSD found among Vietnam theater veterans as a whole (15.2%) some 15 to 20 years after the Vietnam War.

Also, it is critical not to forget the evidence reported earlier that only a fraction of personnel in a war-zone suffering from the effects of emotional stress will ever actually see a military mental health professional in the war-zone. And so, no matter how dedicated, skilled and courageous military mental health personnel are in the war-zone, it is inevitable that there will be a number of deployed service members who will return home with unresolved post traumatic stress. It cannot possibly be any other way, because exposure to the repeated traumatic stressors in a war-zone is indisputably injurious long-term to the mental health of a substantial portion of those who serve in harm’s way. That is an unmitigated element of the human cost of serving in harm’s way. Period. And that conundrum can only be truly addressed by one simple yet profound action---do not be in a war to begin with. But, of course, we are in a war---make that two wars, in Afghanistan and in Iraq.

Therefore, given the fact of being involved in wars, there appears to be an extremely significant ethical question if not dilemma. Is it really possible for military mental health to consider equally the longer-term mental health ramifications of any interventions in a war-zone rather than having the understandable tunnel vision to accomplish the medical mission of “conserving the fighting strength”? This would require the military to be willing to develop a balanced medical mission that would officially and equally consider the virtues and trade-offs of evacuation versus return to duty in terms of the impact on not only the shorter but also the longer-term mental health of psychiatric casualties. And the likelihood of this happening in the practice of military medicine, considering the realities of war and the medical mission, is virtually nil.

Hence, I consider it an ethical imperative that military mental health be willing to change two things. First, that performance evaluations of Combat Stress Control units must not be based on how low the med-evac rate is versus return to duty rates. Rather, that: psychiatric evaluations must be based on the accuracy or efficacy of the psychiatric dispositions that are made. In other words, if someone is med-evaced to Germany, does subsequent assessment at Landshtul confirm that the decision to medically evacuate was the right decision? And, out of the psychiatric casualties who are returned to duty, what percentage of those returned to duty are able to successfully carry out their duties? Such performance markers get away from the inevitable strong bias to return to duty and to valid mental health performance factors.

Of course, there is a critical factor that prevents this change in performance evaluation factors. And that is that in Vietnam we never knew what happened to any of the psychiatric casualties that we treated, whether they were medically evacuated out of country or returned to duty---unless they happened to end up back in our unit one day. This is because there was no tracking or feedback system operating, which meant that all of our actions were being conducted in a total information vacuum. And it is my understanding that the Combat Operational Stress Control units in Iraq today also do not have a tracking system in place. 54 The COSC units have temporary medical records, thus preventing any kind of meaningful system of tracking the ultimate outcome of the psychiatric interventions and dispositions that are being made.

I find it almost incomprehensible that this information feedback loop vacuum regarding the outcome of psychiatric casualties continues two wars after Vietnam; that, indeed, there continues not to be systematic data made available to mental health personnel in the war-zone to help them to determine, for example, if psychiatric casualties being returned to duty have a different mortality rate than their counterparts, or a different rate of failing to perform their duties satisfactorily, or a different PTSD prevalence rate than those evacuated out of country, or if being returned to duty may be associated with a higher rate of increased ability to perform and an increased positive mental health longer-term. No data, none, nada. How can this possibly be justified?

The second serious concern I have is about the information that is typically provided to veterans and their families. There is critically significant information to be shared by the military and most mental health providers, and by our government, if we are to provide a full and honest disclosure of vital information as to the risks and likely consequences of serving in a war-zone. And I do not believe that is being systematically provided to our troops or to their families or to our country.

What To Say To And Do Differently: It’s Time To Tell The Whole Truth
We all, to include deployed members of the Armed Forces, their families and our country, are entitled to have the truth, the whole truth and nothing but the truth concerning combat stress reactions and post-traumatic stress, and the full range of possible short- and longer-term impact of war-trauma. Isn’t this a hallmark of a democracy, to have a fully informed citizenry and to not let others decide “what is best for us to know?”

And so, just what is the “truth” that active duty members of our Armed Forces and their families, and our veterans, and our communities, have not only the right but the need to know? A related issue is, considering the realities and limitations of what can be done in a war-zone with psychiatric casualties, what can and should be done differently to address mental health concerns in a war-zone.

To my knowledge, important elements of following facts are not shared by the military with Armed Forces personnel and their families, nor are they shared by our government to the American people. And since these are facts, I would argue that it is ethically responsible to insure that all military personnel serving in any war-zone, their families, and our veterans and our communities receive this information: 55 Following is what I consider to be absolutely vital information to be provided directly to the active duty member or veteran; some of this is currently provided by military mental health providers yet other essential information herein in not communicated. The words would be changed appropriately if this information is being given to family members or to the community.

Myths and Realities About Combat Stress Reactions, Trauma and PTSD 56
There are several very important myths about the impact of trauma and of war:

  • Myth: Heroes & “normal” healthy persons don’t have (psychological or social) problems after a trauma. If they do have such problems, then that means that they already had problems, or were pre-disposed to having such problems anyhow; “the trauma was merely a trigger.”


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