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ON POINT II: Transition to the New Campaign

The United States Army in Operation IRAQI FREEDOM May 2003-January 2005

Part IV

Sustaining the Campaign

Chapter 13
Taking Care of Soldiers


Mental Health and Post-Traumatic Stress Disorder

Physical injuries were not the only challenges faced by Soldiers serving in Iraq. Soldiers also suffered mental health problems related to the stress of operations, the risks of death and wounds, and the death of fellow Soldiers, among other factors. As early as July 2003 the Army’s Surgeon General launched what would become a series of studies on this issue. The first Mental Health Advisory Team (MHAT) visited Iraq in July 2003 to assess the scope of the mental health challenges in OIF and to recommend preventive actions and treatment. The team released its findings in December 2003. This and subsequent reports began tracking a wide number of mental health measures such as suicide rates, combat stressors, mental health treatment and evacuation rates, and post-traumatic stress disorder (PTSD) symptoms.67 The MHAT II report concluded that, compared to their 2003 findings, Soldiers in 2004 reported higher levels of combat stress (due to the risk of mortar, artillery, and IED attacks), but lower stress levels due to quality of life and family separation, higher individual and unit morale, lower suicide rates, fewer behavioral health problems requiring evacuation, and better access to mental health care in theater. The MHAT also noted, “Acute or post-traumatic stress symptoms remain the top mental health concern, affecting at least 10% of OIF-II Soldiers.”68 While invisible, PTSD is characterized by “depression, loss of interest in work or activities, psychic and emotional numbing, anger, anxiety, cynicism and distrust, memory loss and alienation, and other symptoms,” affecting not only the Soldier, but sometimes the Soldier’s family as well.69

The term PTSD was not adopted until 1980, but it was far from a new condition on the battlefield. In the Civil War it was sometimes called “soldier’s heart.” In World War I it went by other names such as shell shock, combat stress, and war neurosis. In the infancy of psychiatry and psychology, the problem was confused with malingering and cowardice. By the end of World War I, psychiatrists realized that psychiatric casualties did not suffer from physical harm inflicted from what was often labeled simple “shell shock.” Psychiatrists determined that emotions, not physiological brain damage, most often caused Soldiers to reflect a wide range of symptoms.70 Treatment used in World War II and the Korean war consisted of the fundamentals of “Proximity, Immediacy, and Expectation” (treat stress cases as close to their unit as possible, as soon as possible, and with the expectation that they will return to duty). These are still fundamental to Combat Stress Control (CSC) today.

It was the Vietnam war that propelled psychiatric issues into the limelight. The rate of PTSD among Vietnam veterans is extraordinarily complex and, like the war itself, it is also a politically charged issue. The debate includes disagreement over the symptoms of PTSD, testing methods, study timing and sample sizes, prior existing personal or family risk factors, the actual experiences of different types of veterans, and many other issues. The vast majority of Vietnam-era veterans, and those who actually served in Vietnam, reported no PTSD symptoms after their service. According to the results of the National Vietnam Veterans’ Readjustment Study (NVVRS) published in 1990, an estimated 15.2 percent of male and 8.5 percent of female Vietnam era veterans were diagnosed with PTSD at one point in their lives.

PTSD is not strictly a military phenomenon; many nonmilitary causes such as personal or family crises, crime, or major accidents can trigger the symptoms of the disorder. The steady-state rate of PTSD in the general population has been estimated at between 5 and 10 percent. Civilians exposed to violent crime as victims or witnesses have been shown to incur PTSD rates as high as 24 percent.71 Some veterans diagnosed with PTSD had preexisting or postservice risk factors in addition to their wartime service that appear to have played a role as well.72 Seen in this light, PTSD rates for Soldiers serving in Vietnam and subsequent conflicts appear somewhat less dramatic. Nevertheless, the Vietnam war brought PTSD to the fore of Army medical preventive and postdeployment health care.

Despite the short period of combat during the Gulf War in 1990–91, studies showed a PTSD rate of between 10 and 16 percent.73 In an attempt to better deal with psychological injuries in OIF, the Army employed mobile CSC Detachments. Operating out of six US bases across Iraq, these detachments were designed to identify combat Soldiers suffering from the early stages of PTSD.74 According to the MHAT report, the accomplishments of the CSC Detachment fell somewhat short of expectations.75 The survey reported that the detachments were too often overlooked and underused.76 Following publication of the report, CSC Detachments were situated on forward support bases to better identify Soldiers exhibiting symptoms of extreme stress.77 The forward deployment of these teams facilitated their work with Soldiers immediately following their traumatic experiences. This was an important step in reducing psychological problems both during and after deployment.78 The 2005 MHAT report confirmed an overall improvement in mental health and well-being.§ This was reflected in subsequent Soldier screenings that showed fewer cases of mental health problems.79

§Medical care for Soldiers after leaving Active Duty and as they transition to the VA medical system has received both praise and criticism. The treatment of Soldiers with nonphysical wounds has become a matter of intense scrutiny and effort in the period beyond the scope of this volume.

Chapter 13. Taking Care of Soldiers

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