Attrition: The Breaking Point

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December 20, 2009: The U.S. Department of Defense recently did another survey of its military personnel, to determine how many suffered from PTSD (post-traumatic stress disorder), and to what extent. They found that, in four years, the number of those who had attempted suicide in the past year had doubled (from one percent to two percent). Those who had PTSD symptoms went from seven to eleven percent. In the army it went from 9 to 13 percent, and in the marines from 8 to 15 percent. A higher percentage of marines are combat troops (as the navy handles much of their support functions.) While only about ten percent of army troops have combat jobs, about 25 percent are exposed to battlefield dangers. This is because of the type of fighting in Iraq and Afghanistan, where terrorists go after everyone, including non-combat troops, with roadside and suicide bombs. While the casualties are quite low (the rate is about a third of what it was in Vietnam and World War II), the stress of operating in an atmosphere of imminent danger takes its toll. Combat troops are selected for their ability to handle stress, and further trained to deal with it. But even with the training, so many troops have endured so much stress, that they are taking the initiative in finding ways to cope. While seven percent of air force personnel (who rarely are exposed to combat) misuse prescription drugs, 15 percent of soldiers and 11 percent of marines do. Drinking is up, even though alcohol is prohibited in combat zones (where some illegal booze is available). When the troops get home, or away from the combat zone for a few days, or the week or two of leave they get during a combat tour, excessive drinking is more frequent.

On the plus side, more troops are in good physical shape. Smoking is down from 34 percent to 31 percent. Job satisfaction is over 70 percent. The troops believe in what they are doing, but the jobs are often very stressful, and that takes a toll. The military, particularly the army, is concerned with the long term damage. The army and marines are particularly worried about the impact on their younger NCOs, who will eventually be the senior NCOs.

Stress casualties peaked for the U.S. Army in 2007, when 10,049 soldiers were diagnosed with PTSD. This was ten times the number diagnosed in 2003 (1,020). In the last eight years, 5,000 troops have been evacuated (as medical cases) from Iraq and Afghanistan for mental disorders. Only 16 percent of those were confirmed PTSD cases, the rest were for more familiar things like severe depression. Moreover, most of the troops in Iraq and Afghanistan are not involved in combat. Yes, they are living in a combat zone, but aside from an occasional mortar shell or rocket (which usually causes no injuries), most troops tend to have air conditioned sleeping quarters, gyms, Internet access, video games, good food and excellent medical care. It's unclear how many troops actually have PTSD, although many who are in combat, definitely are stressed out and in need of help. During World War II, 25 percent of the disabling American casualties in Europe were due to PTSD.

Nearly a century of energetic effort to diagnose and treat PTSD (including much recent attention to civilian victims, via accidents or criminal assault), had made it clear that most troops eventually got PTSD if they were in combat long enough. During World War II, it was found that, on average, 200 days of combat would bring on a case of PTSD for American troops. After World War II, methods were found to delay the onset of PTSD (more breaks from combat, better living conditions in the combat zone, prompt treatment when PTSD was detected). That's why combat troops in Iraq and Afghanistan often sleep in air conditioned quarters, have Internet access, lots of amenities, and a two week vacation (anywhere) in the middle of their combat tour. This has extended their useful time in combat, before PTSD sets in. No one is yet sure what the new combat says average is, and new screening methods are an attempt to find out. But more troops appear to be hitting, or approaching, the limits.

What the army does know is that a large percentage of its combat troops have over 200 days of combat. Some have three or four times that. A major reason for army generals talking about the army "needing a break" (from combat) is the growing loss of many combat experienced troops and leaders (especially NCOs) to PTSD. The army won't give out exact figures, partly because they don't have much in the way of exact figures. But over the next decade, the army will get a clearer picture of how well they have coped with PTSD, among troops who have, individually, seen far more combat than their predecessors in Vietnam, Korea or World War II.

The latest policy, to deal with PTSD, is a program that mandates a mental health evaluation for everyone in the army. Those who have not been in combat will serve as a baseline for comparing to those who have. Moreover, the army wants to find out to what extent non-combat operations (training can often be quite intense) can add to the stress that could eventually lead to PTSD. The basic idea here is to "mainstream" PTSD, trying to convince all the troops that PTSD is just another occupational hazard, not something you should try and hide, and hide from. You can't, and increasingly, the army won't let you.

The army also detects, and treats, many PTSD sufferers by performing screening during the delivery of routine medical care, including annual checkups. Doctors are given a script that uses some simple and non-threatening questions to discover if the soldier might have PTSD. If further questioning reveals there may be some PTSD, the soldier is offered treatment as part of regular medical care, not a special PTSD program. It was those programs that put off many troops.

While most troops now accept that PTSD is not a sign of mental weakness, but a very real combat hazard, many still avoid special PTSD treatment programs. By making PTSD treatment (which is usually just monitoring, and the use of some anti-stress medication for a while), part of regular medical care, much of the stigma disappears.

The army finds itself facing some new sources of PTSD. For example, there was the discovery that many troops, because of exposure to roadside bombs, and battlefield explosions in general, had developed minor concussions that, like sports injuries, could turn into long term medical problems. Often these concussions were accompanied by some PTSD.

The army is dealing with PTSD head on, believing that a lot of troops have experienced a lot of combat stress. Experience so far has shown that PTSD can be delayed, perhaps for a long time. When a soldier does come down with it, PTSD can often be treated, and its effects reversed. This has large ramifications for non-military medicine, for many civilians suffer from PTSD. That's because military recruits are screened for their ability to handle stress and resist PTSD. In the civilian community, there are far more people who can acquire PTSD after exposure to much less stress.

 


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