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Generational Wartime Behavioral Health Crises: Part One of a Preliminary Analysis

Abstract

As the USA enters into its 12th year of war, the persistent drum beat of negative news headlines of unmet mental health and social needs of veterans fuels public perception of a twenty-first century military behavioral health crisis. For many Americans, the status quo harkens back to previous wartime crises. Wartime mental health crises continue to happen, despite the personal and financial consequences. This paper address this crisis by carefully tracking the critical decisions that lead to the current situation. This is the first of a two-part preliminary analysis of generational wartime behavioral health crises. We first define wartime mental health crises and how current and past conditions qualify as such a crisis. Next, we point out that there is a continual underestimate of war and post-wartime behavioral health needs. We then provide an extensive review of official military records, government investigations, and news media reports; a compelling evidence of a major crisis in the twenty-first century. In the final section of the paper, we discuss the themes that emerged from the review that both confirm the generational failure to learn fundamental war trauma lessons.

The US central role in Afghanistan ended in 2014 as did its role in Iraq in 2011, though troops remain in both war zones. Almost from the start of both wars newspaper stories discussed the psychosocial strains on the military.Footnote 1 Moreover, media reports convey a message of a mental health system at or near collapse.Footnote 2 The purpose of this paper is to systematically examine the causes and course of the mental health crises and the failure to provide evidence-based services to all who need them.

Perceived Trend of Repetitive Wartime Mental Health Crises

The present climate in regards to military mental healthcare seems eerily reminiscent of previous war generations as illustrated by distant news headlines from the Persian Gulf War (1990–1991) “Gulf War Taking Toll at Home” (Jordan, 1991); Vietnam War (1965–1973) “Veterans Battle Emotional Strain: Vietnam Returnees Discuss Problems of Dislocation” (The New York Times, 1973); Korean War (1951–1953) “Psychiatry Panel Scores VA Policy: Physicians at Parlay Say Incentives are Lacking for Hospital Staff”(Harrison, 1957); the Second World War (WWII: 1939–1945) “Bradley Demands Aid for Veterans: Says Community Must Help or Create Conditions That Can Breed Psycho-Neurotics” (The New York Times, 1945, November 2); the First World War (WWI 1914–1919) “Insane War Veterans Reported Increasing: Legions Rehabilitation Body Told Number Exceeds Hospital Facilities” (The New York Times, 1934); the Spanish-American War (1898) “Suicide and Insanity in Army” (The New York Times, 1900); and even the American Civil War (1861–1865) “Suicide of an Army Officer” (The New York Times, 1874).

Notable Twenty-First Century Military Mental Health Initiatives and Achievements

Counter-balancing the present negative war narrative are reports indicating not all news is bad. A recent U.S. Time article by the Pentagon’s Chief Psychiatric Consultant “Military Mental Health’s Wins and Losses Since the Iraq Invasion” describes several unprecedented accomplishments this century including extensive deployment health screenings, annual frontline assessments by Mental Health Advisory Teams (MHAT), a plethora of educational resources for service personnel and family members, greater emphasis on resilience training, and funding of treatment research (Ritchie, 2013). Additional noteworthy initiatives include publication of the first-ever post-traumatic stress disorder (PTSD) practice guideline (VA/DoD, 2004), the proliferation of Veteran Affairs (VA)/Department of Defense) (DoD) treatment applications for smart phones, greatly increased access to crisis services (e.g., Veterans Crisis Line), the roll out of standardized training and dissemination of evidence-based PTSD treatments, revamping military transition assistance programs, societal and media support of returning veterans, and unprecedented numbers of non-profit agencies to fill the void in veterans’ social reintegration services. Positive portrayals by the national media include headlines such as “Military Study Finds Benefits in Mental Health Screening” (Dao, 2011); “Senate Approves Amendment to Expand Mental Health Care” (Vogel, 2012); “Study Seeks Biomarkers for Invisible War Scars (Dao, 2013); “For Veterans, a Surge of New Treatment for Trauma” (Rosenberg, 2012); and “Army Seeks to Improve Troop Resilience as Suicides Increase” (Basu, 2013).

In all, the aforementioned accomplishments clearly demonstrate that this generation, as in past war generations, has reacted to a wartime mental health crisis with a compassionate, sincere, sense of urgency it deserves. Our focus on the ontogenesis of generational crises should not, in any way, detract from the Herculean individual efforts within military populations, government, and the private sector to respond to the crisis.

Purpose and Methods

This is the first of a two-part analysis of generational wartime behavioral health crises. The current study examines the evidence of a twenty-first century American crisis, as well as the controversy and limitations around such research. We conducted an extensive review of the American experience in managing war stress casualties in every major armed conflict since the twentieth century including the twenty-first century wars [Operational Enduring Freedom (OEF; 2001–present); Operation Iraqi Freedom (OIF; 2003–2010); and Operation New Dawn (OND; 2010–2011)]. In all, we examined recurring themes from official primary source material such as military medical department records, books, and reports; transcripts of congressional hearings; official memoirs by first-hand military witnesses; and government-commissioned studies, task forces, or other investigatory reports; as well as secondary sources from credible military historians and news archives. Where possible, we preserve the historical narrative by citing directly from those sources.

The Behavioral Health Crisis

Definition

The word “crisis” originates from ancient Greece (κριςις) meaning “judgment” or “decision,” implicating the decisive moments that determine the positive or negative development of a situation (Milašinović & Kešetović, 2008). In Chinese (Mandarin), crisis is translated as wei-ji whereby wei means “danger” and ji is a “change or turning point,” thus referring to an “opportunity for danger to occur” (Milašinović & Kešetović, 2008). The word “catastrophe” comes from the Greek word katastrefo (καταστρεφο), or “to turn, spin, tip over,” typically used to convey disaster, breakdown, and great calamity with grave consequences to human lives and material damage (Milašinović & Kešetović, 2008).

For our purposes, we crudely define a “Wartime Behavioral Health Crisis” as a sentinel public health event whereby mental health demand of the military population (e.g., active-duty military, reservists, national guard, veterans separated from the military, retirees, DoD/VA civilian personnel, family members, embedded journalists, DoD-contractors, embedded intelligence and law enforcement officials) demonstrably exceeds the mental health system’s capacity to provide adequate access to timely, effective, mental health and social support services during and/or after a period of war resulting in escalating unmet needs that endangers the health and safety of large numbers of individual members, families, and society. Thus, the wartime mental health crisis is that time after the time we underestimate the post-war mental health needs.

Mental health crises are typically caused by a failure to learn fundamental psychiatric lessons of war such as the need for adequate planning, preparation, training, and resourcing for inevitable war stress casualties as evident by a series of decisive omissions and commissions, including the absence of centralized, comprehensive, and transparent tracking and reporting, undeterred mental health bias, stigma and disparity, and organizational fragmentation and dysfunction. We describe a “Mental Health Catastrophe” as the enduring, often trans-generational consequences of protracted mental health crisis resulting in significant individual harm and societal costs due to long-term suffering, disability, impaired health, suicide, and social disruption.

Pre-war and Wartime Behavioral Health Underestimates

Inherent Difficulties Investigating Wartime Crisis

While varying labels and cultural understanding of war stress injuries can be problematic for researchers, especially those seeking a universal diagnosis for war trauma across generational lines, by far the most pronounced barrier to assessing the status of wartime mental health needs is the availability of accurate, comprehensive, and detailed official records—regardless of diagnostic trend. At present, there is no central repository or lead government agency assigned to monitor, collect, and report information on wartime mental health needs for the entire military population. For example, the most frequently cited primary source for historical background on military neuropsychiatric rates is from post-war army analyses available since the American Civil War. (http://history.amedd.army.mil/books.html). However, those records primarily account for the prevalence and treatment of war stress casualties experienced by the US Army during and sometimes immediately after military service, thereby excluding critical data on post-war readjustment periods, as well as incidence rates within the navy, marine corps, coast guard, merchant marines, air force, and the VA.

Challenges Behavioral Health Reporting and Demand

An objective appraisal of the coverage of wartime mental healthcare in the twenty-first century appears to be overwhelmingly negative, buttressed by consistently critical reporting from a variety of congressionally mandated task forces (e.g., DoD Task Force, 2007), commissioned studies [e.g., Institute of Medicine (IOM) (2012a)], government investigations [e.g., Government Accountability Office, (GAO) (2011a)), and independent research centers like Research and Development (RAND) (e.g., Tanielian & Jaycox, 2008). However, some assert that claims of post-war crisis are greatly exaggerated (e.g., Dean, 1997; Mancini, 2012), perhaps reflecting cultural unease with the counter-intuitive reality that the vast majority of returning war veterans (83–90 %) are “resilient” (Mancini, 2012). In The New York Times article “A Postwar Picture of Resilience,” Mancini (2012) challenges the accuracy of public perception of crisis, positing that fears of PTSD epidemics run counter to research showing overwhelming resilience.

Debate on the accuracy of reporting generational crises reveals compelling arguments by veterans’ advocates of negligent or duplicitous efforts by the military and government to suppress facts on the extent of a crisis (Scurfield, 2006), as well as delay or deny veterans’ benefits (e.g., Schram, 2008). Whereas others proclaim convincingly that wartime crises are often over-embellished and exacerbated by inflated reports from the news media and politically motivated activists (e.g., Dean, 1997). There is persuasive evidence supporting both viewpoints—thus making interpretation of the actual presence or scope of a crisis inherently difficult, and prone to confirmatory bias. However, missing from the national discourse is why such widely divergent information exists on the prevalence of war stress casualties in the first place? For example, Dean (1997) reports the total number of post-war suicides of Vietnam veterans has been cited as “low” as 9000 to 20,000 by government sources, and as high as 150,000 to 200,000 by veterans’ advocacy groups, compared to 58,220 veterans killed-in-action (KIA). Missing, however, is a viable explanation why the government tracks flu epidemics far more accurately than veterans committing suicide. The absence of government tracking of veteran suicide rates is even more conspicuous when one considers previous wartime epidemics as depicted in the WWI era T he New York Times (1922) headline “Veterans’ Suicide Average Two A Day” as being replicated by a 2012 The New York Times report “Suicides Outpacing War Deaths for Troops” whereby active-duty military are committing suicide “a rate of nearly one each day this year” (Williams, 2012). Yet, no centralized, nationwide surveillance system exists today for tracking veterans’ suicide (Ramchand, Acosta, Burns, Jaycox, & Pernin, 2011). Therefore, the actual or estimated incidence of suicide or any other mental health indictor within the military population is always unknown (Congressional Research Service, 2012). In sum, widespread confusion, contradiction, and “controversy” over speculation on the presence or scope of wartime crisis appears to be at least partly a reflection of the absence of centralized, transparent, reliable accounting of veterans’ mental health needs—thus inviting wild accusations, as well as narratives of conspiracy and betrayal.

Ceiling Effect of Mental Health Stigma and Disparity

The dampening impact of entrenched stigma (e.g., fear of career repercussions) and organizational barriers to care (e.g., chronic, severe staffing shortages) present as major obstacles in researching wartime behavioral health crises during each generation. This is best exemplified by twenty-first century reports of stigma and treatment barriers such as 22 % of spouses and 77 % of the active-duty members reported they would not seek mental health care for fear of being seen as weak and 21 % of spouses and 56.2 % of soldiers cited concerns about harm to the active-duty member’s career (Hoge, Castro, & Eaton, 2006). One can assume similar ceiling effects were evident in earlier, purportedly less-psychologically sophisticated generations.

Determining the Presence of Wartime Behavioral Health Crisis

As defined earlier, wartime mental health crisis can be characterized as “a sentinel public health event whereby mental health demand of the military population greatly exceeds the mental health system’s capacity for providing adequate access to timely, effective mental health and social support services.” At this time, no objective criteria or methodology exists for accurately evaluating whether wartime demands exceed capacity. Most importantly, the sheer complexity and lack of comprehensive credible data renders efforts to assess generational crisis as inherently subjective and prone to confirmation bias. Nevertheless, until more objective procedures are available, we are left with crude estimates and inferences.

Importance of Studying Wartime Behavioral Health Crises

Beyond obvious moral incentives of reducing preventable harm and suffering in those who fight our wars, and possibly, avert exorbitant financial costs estimated at US$1 trillion in PTSD and suicide alone (Blimes, 2011)—the most basic rationale for studying wartime crises is an implicit understanding that we cannot change that which we do not know. Failing to properly monitor, anticipate, recognize, and respond to potential crisis scenarios represent missed opportunities to avert tragedy and harmful trends. Railroad crossing signals serve this purpose as do tornado warnings. We ignore such signs at our own peril. In a similar vein, informed vigilance and concerted action can help prevent mental health catastrophe, but we need to be able to recognize the signs of impending disaster.

Estimating the Demand for Mental Health and Social Support Services

The potential of wartime mental health crisis can be assessed by examining the mental health demand based on either known or predicted incidence of war stress injury and existing mental health needs within military populations. Anticipating mental health demand requires knowledge of war trauma lessons pertaining to well-documented evidence of an inevitable spectrum of war stress casualties invariably manifested in a wide variety of potential psychiatric diagnoses germane to a given historical era, as well as diverse constellations of somatic or medically unexplained physical symptoms (MUPS), sometimes referred to as “war syndromes” (Grinker & Spiegel, 1945; Jones & Wessely, 2005; Menninger, 1948). Therefore, it is pure fiction to reduce the human adaptive response to the extreme stresses of war to a small handful of psychiatric conditions such as PTSD, depression, or traumatic brain injury (TBI)—doing so, prohibits crucial planning, proactive screening, and early intervention that may prevent subsequent crisis of unmet needs.

Furthermore, understanding the vast literature on empirically based risk and protective factors associated with the prevalence of war stress injury is essential to estimate wartime needs. For example, the number of deployed personnel and “dosage effect” of exposure to war stress (e.g., length and number of deployments), type of warfare (low versus high intensity; Jones, 1995), being wounded-in-action (WIA), effects of stigma, familial impact, traumatic grief, exposure to atrocity, moral injury, caregiver distress, and level of perceived social support, have all been demonstrated to significantly influence resilience and the incidence of stress casualties (e.g., IOM, 2008a).

Lessons of War

“Each moment of combat imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus psychiatric casualties are as inevitable as gunshot and shrapnel wounds in warfare” (Appel & Beebe, 1946; p. 185).

The above WWII era refrain is a poignant reminder of the predictable consequences of war, and one of many purported psychiatric “lessons learned” (e.g., Jones, 1995). According to the Department of Defense (DoD)’s real-time “Casualty Status Report” (www.defenselink.mil), as of May 8, 2013, approximately 6699 US service members and civilian contractors have died during deployment, with 5266 of those being killed-in-action (KIA) and 467 were reported as “non-hostile” deaths (e.g., accidents). Additionally, there were 50,702 servicemen and women who were medically wounded-in-action (WIA; www.defenselink.mil). Detailed casualty statistics are reported by the Defense Manpower Data Center (DMDC) through its Defense Casualty Analysis System (DCAS), thereby fulfilling a solemn national responsibility to acknowledge the sacrifices of American men and women ordered into harm’s way in that “This data is valuable as it represents the human cost of war” (DCAS, 2013; https://www.dmdc.osd.mil/dcas/pages/summary_data.xhtml). Similar statistical reports are readily available for every major American war since the twentieth century (https://www.dmdc.osd.mil/dcas/pages/main.xhtml). According to the DMDC, “The data contained in this site can be used to understand trends in casualties as they relate to terrain, advances in medicine, the advent of better technology that has enhanced the safety of the war fighter, or the challenges brought about by new threats” (https://www.dmdc.osd.mil/dcas/pages/about.xhtml). Therefore, on a practical level, monitoring the intensity of war fighting is of paramount importance in ensuring that current and future adequate resources are available to fulfill the societal pledge “to bind the wounds of war” (Lincoln, 1865, cited in Griessman, 1997; p.125).

Reporting Prevalence of War Stress Casualties

The military’s definition of a “casualty” is “a service member that is/has been classified as deceased, wounded, ill or injured” (https://www.dmdc.osd.mil/dcas/pages/faq.xhtml). After every war, military medical departments publish lessons learned treatises. Extensive post-war analyses have been conducted specifically on “neuropsychiatric casualty” rates given the extremely well-documented and highly publicized problems of large numbers of returning veterans with war stress injuries after WWI (Salmon & Fenton, 1929); WWII (Glass & Bernucci, 1966; Glass, 1973); Korean War (Glass & Jones, 2005; Reister, 1973); Vietnam War (Glass & Jones, 2005; Neel, 1991); and Persian Gulf War (Martin & Cline, 1996).

However, unlike physical wounds, the prevalence of equally inevitable war stress casualties is not centrally tracked and is thus, virtually unknown (www.defenselink.mil). No public explanation or “frequently asked question” regarding the DMDC non-tracking of war stress casualties, including wartime suicide is offered (https://www.dmdc.osd.mil/dcas/pages/faq.xhtml). In fact, nowhere throughout the vast network of DoD, Veterans Health Administration (VHA), and federal health agencies like the Centers for Disease Control and Prevention (CDC), is the current number of known or estimated war stress casualties reported for this relatively finite (less than half of 1 %) military population, including “high profile” conditions like PTSD and suicide [e.g., Congressional Research Service (CRS), 2012].

Resilience

Discussion of veterans’ mental health and social reintegration difficulties are often unfairly slanted toward stereotyped images of emotionally damaged veterans and aversive aspects of going to war—thus hopelessly failing to recognize resilience and many adaptive experiences including the forming of close, loyal social ties or camaraderie never likely repeated in life (i.e., “band of brothers” or band of sisters); a deep sense of pride, esprit de corps, existential purpose, and altruism from helping others (i.e., liberation); and profound satisfaction from personal growth, sacrifice, and mastery from accomplishing one’s mission under the most arduous circumstances and taking part of history making (i.e., DoA, 2006). For example, 50.3 % of those surveyed endorsed “I feel pride from my accomplishments during this deployment,” 63.2 % indicated “This deployment has made me more confident in my abilities,” and 24.9 % related “I deal with stress better because of this deployment” (Joint-MHAT-7, 2011). However, it is equally mistaken to confuse resilience as the absence of war stress injury or social reintegration difficulty, or equating war stress injury with severe or permanent disability. Both extreme views represent harmful bias.

Tracking and Reporting the Prevalence of War Stress Injuries

In the absence of an updated, central repository for comprehensive reporting of wartime demand, epidemiology of war stress casualties and mental health needs for the military population is parceled out to each lead agency (DoD, VA, and CDC), with no connective oversight, resulting in a notoriously fragmented, cost-ineffective, and error-prone system (e.g., President’s Commission on Mental Health, 1978; President’s Commission on Care for America’s Wounded Warriors, 2007).

Department of Defense

Within the military, agencies such as the Armed Forces Health Surveillance Center (AFHSC) regularly publish epidemiological data on war stress injuries including suicide (AFHSC, 2012a) and the army’s Mental Health Advisory Teams (MHAT) have conducted annual surveys of frontline behavioral health conditions since 2003. The AFHSC was established in 2008 “To be the central epidemiological resource and a global health surveillance proponent for the U.S. Armed Forces” (http://www.afhsc.mil/aboutus).

Monthly DoD Health Surveillance Reports

A recent military epidemiological report of active-duty mental health diagnoses from fiscal year 2000 to 2011, revealed a total of 1,780,649 service members were diagnosed by military healthcare providers with 459,430 of those cases being identified as “co-morbid” or more than one psychiatric condition (AFHSC, 2012b). Although it’s unclear what percentage of cases was attributed to combat deployments, the diagnostic trends provide partial indication of the overall military mental health demand. In estimating deployment-related needs, contemporary researchers narrowly focus on three psychiatric conditions: PTSD, depression, and generalized anxiety (Hoge, Castro, Messer, McGurk, Cotting, & Koffman, 2004), as well as traumatic brain injury (TBI; Tanielian & Jaycox, 2008). For example, an independent study by RAND concluded that approximately 300,000 OEF/OIF veterans were suffering from either PTSD or depression; 320,000 with TBI; and 5 % experiencing all three conditions (Tanielian & Jaycox, 2008).

However, not represented in any epidemiological studies to date, is clinical data from thousands of DoD-employed civilian mental health practitioners employed by each of the four military service’s base community counseling centers (e.g., navy fleet and family counseling center, marine corps community counseling centers); hundreds of DoD civilian contracted “Military Life Consultants;” military chaplains providing mental health counseling; or data from the estimated 657,000 active military and veterans utilizing the private sector [National Council for Community Behavioral Healthcare (NCCBH), 2012]—all representing mental health services that avoid stigma by not utilizing the DoD’s electronic medical record system (ALHTA-II; AFHSC, 2012c), and therefore, a significant mental health demand is blind to researchers, as well as military leaders.

Veterans Health Administration

Complicating the fragmented epidemiological landscape, when service personnel are discharged from the military, they enter into a separate and distinct VA mental health system. Although its historical roots begin after the American Revolution, the establishment of the VA came in 1930 when congress authorized the president to “consolidate and coordinate Government activities affecting war veterans” (www.va.gov). The VA is assigned primary responsibility for tracking and meeting veterans’ health needs after military discharge, including mental health. In the wake of an emerging Vietnam-era crisis, congress established community-based “Vet Centers” in 1979 (Public Law 96–22) in order to provide confidential and free counseling, readjustment, and outreach services independent of the VA medical system. Today, there are over 360 vet centers located in all 50 states, District of Columbia, and US territories, and approximately 70 mobile vet centers serving rural areas (www1.va.gov/directory/guide/vetcenter_flsh.asp). According to a 2011 GAO report, during fiscal years 2006 through 2010, about 2.1 million veterans received VA mental health care services. Each year, the number of veterans receiving mental health care increases, from about 900,000 in 2006 to about 1.2 million in fiscal year 2010—OEF/OIF veterans accounted for an increasing proportion of veterans receiving VA mental healthcare (GAO, 2011b).

Annual VA Mental Healthcare Utilization Reports

There is no central, publicly accessible repository for maintaining an update accounting of VA mental health services and disability compensation of veterans from each era. Instead, the VA publishes annual cumulative utilization data from the previous year. For example, in 2012, the VA reported a total of 444,505 OEF/OIF/OND veterans were diagnosed with mental health diagnoses between 2002 and 2011 (Veterans Health Administration, 2012). However, the VHA (2012) appropriately warns that “These administrative data have to be interpreted with caution because they only apply to those OEF/OIF/OND veterans who have accessed VA health care,” or just 55 % of total eligible cohort (p. 3). Inherently, underestimating veterans’ mental health needs is even more likely when one considers that in 2004, the VA served just 17 % or 847,000 of all 4.9 million eligible veterans from all eras at a cost of US$2.2 billion (Veterans Administration, 2005). Most importantly, the VA’s statistical reports are derived from its internal electronic medical records, thereby excluding all 360 Vet Centers and 70 mobile services which don’t utilize VA records, including private sector (NCCBH, 2012) and DoD (Veterans Health Administration, 2012).

The Center for Disease Control and Prevention

The CDC was established in 1964 primarily to prevent malaria, but is now heralded as “the nation’s premiere health promotion, prevention, and preparedness agencies” (CDC, 2013; http://www.cdc.gov/about/history/ourstory.htm). In 2002, the CDC created the National Violent Death Reporting System (NVDRS) to act as a state-based surveillance system pooling information on violent deaths including suicide and intimate partner violence (CDC, 2012). In 2008, congressional urgings led the CDC to begin collaborating with DoD and VA in order to track veterans’ suicide. According to the CDC’s (2012) annual surveillance report, in 2009, the 16 NVDRS states reported a total of 1876 suicides by former or current military personnel. As of today, the NVDRS still operates in only 18 states (CDC, 2012), but shows promise as the first centralized effort to monitor wartime needs.

The Danger of Under and Over Reporting Wartime Needs

The virtues of accurate, timely, and transparent reporting of wartime mental health demand appears to be blatant in terms of affording leaders an opportunity to make decisive corrective actions in order to prevent or mitigate a crisis—along with the intrinsic harm from grossly under-estimating and under-preparing for inevitable war stress injury. Perhaps not as obvious, yet of particular concern to veterans, is the possible danger of public backlash from over-reporting or even just the reporting of post-war adjustment problems. Horton (2012) addresses this valid apprehension in “Perpetuating the Erroneous ‘Ticking Bomb’ View of Veterans,” whereby media portrayals of the emotionally “damaged” and unstable war veteran can fuel public fears, stigma, and discriminatory bias. For instance, higher than average unemployment rates of veterans is often attributed to consistent media broadcasts of veterans’ PTSD, suicide, and misconduct (e.g., Dean, 1997).

However, falsely equating diagnosis of a war stress injury with permanent disability and impaired functioning reflects widespread public misconception exacerbated by antiquated stigma and dualistic beliefs of health. To be certain, resilience does not mean the absence of war stress injury, just as it does not refer to the absence of medical wounds. In short, concerns over public backlash from accurate reporting of veterans’ mental health needs appears indicative of archaic cultural beliefs that contribute to wartime crises. If true, then emphasis should be exerted on public education and the elimination of harmful mental health stigma and disparity. Conversely, avoidance of honest accounting for the full spectrum of war stress injury serves only to reinforce stigma and perpetuate crisis. Moreover, it is conceivable that accurate monitoring of wartime needs will lead to effective planning, preparation, and proper resourcing of the mental health system, thereby preventing crisis and eliminating the primary source of negative news stories. In a sense, equal prioritizing of war stress and medical casualties can hypothetically produce benefits commiserate with medicine—whereas the last irrefutable military medical crisis was a tuberculosis outbreak among WWI veterans (The New York Times, 1923).

Evidence of Significant Wartime Mental Health and Social Needs

A distinct consequence of the fragmented, insufficient monitoring of wartime mental health needs is exemplified by widely discrepant estimates of the prevalence post-deployment conditions such as PTSD, depression, or generalized anxiety ranging from 5 % (e.g., Mancini, 2012) to “38 % of Soldiers and 31 % of Marines who reported psychological symptoms. Among members of the National Guard, the figure rises to 49 %” (DoD Task Force, 2007; p. ES-2). Both the National Guard and reservist components represent neglected subgroups within military populations. Below, we briefly summarize contemporary and historical findings on the spectrum of war stress casualties required to adequately assess wartime needs in order to infer twenty-first century demand.

Suicide Trends

In 1812, former surgeon general of the continental army and co-signer of the Declaration of Independence, Benjamin Rush, often referred to as the “father of American psychiatry”—reported the tragic suicide of two distinguished army captains, identical twins, who “both served with honor during the war … were cheerful, sociable … happy in their families and … independent in their property” (p. 49), both succumbing to “melancholy” shortly upon returning home after the American Revolution. Historically, the total number of wartime suicides for a given generation, is always unknown, for the same reasons today. Nevertheless, most war cohorts report high incidence of suicide. For example, in the WWI era, news headlines “400 Ex-Soldiers New York Suicides” (The New York Times, 1921), and “Veterans Suicides Average Two A Day” (The New York Times, 1922) give strong justification for close monitoring. During April to July 1940, there were 26 army suicides (The Army Medical Bulletin, 1940), but otherwise, the prevalence of WWII era suicides is unknown. However, a recent news article “Suicide Rates Soar among WWII Veterans, Records Show” posits that older veterans are twice as likely to commit suicide then OEF/OIF veterans (Glantz, 2010). During the Korean War, a reported 131 soldiers completed suicide, with an incidence rate of 11 per 100,000 (Reister, 1973), but no data exists for other service branches or after military discharge. VA historians Baker and Pickren (2007) observed that “Suicide of veterans became of great concern to the VA during the 1950s, when the rate of suicide among veterans both within the VA hospital system and outside it, already higher than in the nonveteran population, suddenly increased alarmingly over the pre-World War II rates” (p. 88). The post-Korean War suicide trend sparked the VA’s first research program into veterans’ suicide—finding among other factors, a link between suicide and new psychotropic medications thorazine and rauwolfia (Baker & Pickren, 2007).

In the Vietnam era, active military suicide data is unavailable, but media reports reveal concerning trends like “Suicide Risk Double for Viet Veterans” (Chicago Tribune, 1986). According to the Centers for Disease Control and Prevention (1987), total mortality in the 5 years after discharge was 17 % higher in Vietnam veterans, excess mortality was due to external causes (including suicide). In 1988, the CDC testified before congress that 9000 Vietnam War veterans had committed suicide, but others cite figures of 20,000 to 150,000 vet suicides (see Dean, 1997)—well over the reported 47,410 veterans KIA. In regards to the Persian Gulf War, as of 31 December 2004, the VA reported a total of 1514 Gulf War veterans committed suicide, exceeding the 148 military personnel KIA (Kang, 2008).

In the twenty-first century, wartime suicide has once again emerged as a major national concern. During 2001–2010, a total of 25,357 active-duty service members engaged in suicidal or parasuicidal behaviors, including 1939 completed suicides (AFHSC, 2012d). Additionally, 19,955 military personnel received inpatient or outpatient diagnosis of an intentionally self-inflicted injury or poisoning, and 3463 were identified as “likely self-harm” after hospitalization for injury or poisoning with a concurrent mental health diagnosis (AFHSC, 2012e). Recent studies have shown one in five treatment-seeking OEF/OIF veterans reported contemplating suicide (Pietrzak, Russo, Ling, & Southwick, 2011). On the frontlines, 11 % of deployed soldiers and 11.6 % marines, reported suicidal ideation in 2010 (J-MHAT-7, 2011), and 30 % of 425 deployed soldiers seen for mental health reasons considered suicide within the past month (Mansfield, Bender, Hourani, & Larson, 2011a). A particularly high-risk period is when veterans transition out of the military and back into the civilian and VA sectors. For instance, among 3069 male navy and marine corps personnel transitioning to civilian life, 7 % (sailors = 5.3 %, marines = 9.0 %) reported suicidal or self-harming ideation during the previous 30 days of transitioning to civilian life (Mansfield, Kaufman, Engel, & Gaynes, 2011b). In 2010, the Department of Veterans’ Affair’s reported that an estimated 950 veterans received treatment for attempted suicide each month between October 2008 and December 2010. Of these same veterans, an estimated 7 % were successful, while another 11 % attempted again within 9 months.

Controversy over Wartime Suicides

Despite anecdotal accounts about apparent linkage between war and suicide, researchers have repeatedly claimed no clear association exists (Kang & Bullman, 2010). Given the incoherent status of government monitoring-due caution is warranted. Moreover, research comparing deployed cohorts with non-deployed cohorts in order to control for the effects of first-hand exposure to war stress must be aware of inherent stressors within non-deployed military populations including exposure to potentially traumatic occupational hazards other than war (e.g., disaster relief, training accidents). For example, in 1994, The Washington Post headline “Pentagon Sends in Psychiatrists After 3 Suicides Among Troops in Haiti” referred to military personnel deployed on peace-keeping operations (Harris, 1994).

Healthy-Warrior Effect

Comparisons of military versus civilian suicide rates, as well as other psychiatric conditions, should likewise be interpreted cautiously in light of the “Healthy-Warrior Effect” (IOM, 2006). Unlike civilian counterparts, military personnel are subject to extensive health screenings before and during military service (IOM, 2006)—with the majority of non-war-related psychiatric discharges occurring within a year of service entry. Moreover, after the Vietnam-era military drug epidemic, extensive drug testing was implemented, and nearly every aspect of a service member’s behavior has been under close scrutiny including exercise, diet, and social competency. In short, service members in general, and those who deploy to warzones in particular, represent an unusually healthy segment of American society (IOM, 2006). Therefore, wartime prevalence of adverse health-related conditions should be weighted accordingly. Case in point, during WWII, the American military’s unprecedented mass psychiatric screening program rejected over 1.6 million purportedly predisposed war neurotics who might breakdown after 11 years of combat (Berlien & Waggoner, 1966). Consequently, when 1.3 million WWII veterans become neuropsychiatric casualties (IOM, 2007), including hundreds of the most battletested and hardy of military leaders with old sergeant’s syndrome (Sobel, 1949), this likely signifies pathogenic effects of war stress.

Known and “Hidden” Features of Wartime Mental Health Demand

A very brief “snap shot” is provided of the scope of wartime mental health demand. Empirical and historical evidence reveals an established spectrum of war stress injury that includes a wide variety of psychiatric and medically unexplained physical diagnoses as well as social reintegration difficulties that, if unaddressed, can manifest in crisis. Table 1 represents the neuropsychiatric statistical data from the US Army’s official Second World War (WWII) lessons learned compilation (Glass, 1966a).

Table 1 WWII era US Army neuropsychiatric casualty statistics (1942–1945) (Glass, 1966a, b)

Despite the military’s acknowledgement that exposure to war stress often manifests in a variety of ailments, the mental health needs of veterans are routinely overshadowed by public attention to sensationalized psychiatric diagnosis in a given era (e.g., “shell shock,” “psychoneuroses,” “PTSD”). In this generation, the focus is regularly on a handful of psychiatric diagnoses believed to reflect the “psychological costs of war.” Table 2 reviews government studies that portend to describe the scope of the wartime mental health demand.

Table 2 Review of government studies estimating psychological costs of war

Medically Unexplained Physical Symptoms

The single, most commonly overlooked, yet inevitable manifestation of war stress injuries are functional somatic conditions or war syndromes, currently labeled as “medically unexplained physical symptoms” (MUPS), and diagnosed as “signs, symptoms, and ill-defined Illness” (SSID)—a “catch-all” diagnosis that includes MUPS as well as documenting medical uncertainty due to pending examination results of new patients who may later receive a medical diagnosis (VHA, 2012). The VA (2012) aptly warns that SSID diagnoses are not indicative of incidence of war-related MUPS. However, in wake of the Persian Gulf War Illness, a comprehensive re-evaluation of veterans initially diagnosed as SSID, found 45 % of cases revealed evidence of a previously undetected primary or secondary mental health condition (Roy, Koslowe, Kroenke, & Magruder, 1998). After the Persian Gulf War, the IOM (2008a) completed an extensive review of the scientific literature on war stress and health, concluding “Chronic stress can lead to adverse health outcomes that affect multiple body systems such as the CNS, endocrine, immune, gastrointestinal and cardiovascular systems” (p. 59). Yet, despite robust findings of MUPS-related war stress casualties, this large segment of the spectrum of war stress injury routinely evades epidemiological accounting. Moreover, combined influence of deeply entrenched stigma and the “warrior culture,” historically ensure the likely prominence of MUPS over psychiatric stress casualties in military populations (Menninger, 1948; Jones & Wessely, 2005).

The Department of Veterans Affairs (2013) states that MUPS “such as chronic pain and fatigue, are common in the general and Veteran population” and that “Chronic Fatigue Syndrome (CFS), Fibromyalgia (FM) and Irritable Bowel Syndrome (IBS) are among the most commonly diagnosed medically unexplained conditions” Footnote 3—however, there are far more potential MUPS diagnoses (e.g., non-cardiac chest pain, pseudo seizures, multiple chemical sensitivity, etc.). A rare glimpse into the association between war and MUPS is available via the IOM’s (2007) reporting on VA rates of service-connected disability diagnoses before OEF 1999 to 2006. For instance, diagnoses of “fibromyalgia” increased 306.9 % from 1561 (1999) to 6351 (2006); “irritable bowel syndrome” rose 68.6 % from 11,809 (1999) to 19,908 (2006); and “lumbosacral or cervical strain” diagnosis increased by 46.8 % from 163,123 (1999) to 239,463 (2006; IOM, 2007).

Current total or estimated prevalence of MUPS-related war stress casualties in DoD and VA is not tracked, thus completely unknown. In fiscal year 2010, DoD reported SSID was the diagnosis given in 1,766,208 medical visits and from 2001 to 2012, the VA reported 52.4 % (approximately 437,114) of those treatment-seeking OEF/OIF/OND veterans received SSID diagnosis (VHA, 2012). Other studies on MUPS in the current war cohort indicate a high frequency of somatic complaints including 75 % reporting fatigue, 70 % sleep difficulties, 42 % headaches, 50 % joint pain, and 23 % gastrointestinal symptoms (Hoge, Terhakopian, Castro, Messer, & Engel, 2007). Additionally, OEF/OIF veterans with and without a diagnosed mental health condition were treated in the VA for 222 types of medical conditions (Frayne, Chiu, Iqbal, Berg, Laungani, Cronkite, Pavao, & Kimerling, 2010).

Sleep Disturbances

Babson and Feldner (2010) reviewed the literature on post-traumatic sleep disturbance-described as both a hallmark symptom of PTSD, and a potential etiologic factor. For instance, 71 % of returning OIF personnel screened as PTSD positive and 26 % PTSD negative, reported sleep problems (Hoge et al., 2007) and changes in sleep patterns including fragmented REM sleep are strongly associated with early development of PTSD (Mellman, Bustamante, Fins, Pigeon, & Nolan, 2002). During 2010, a total of 188,123 service member military outpatient visits were coded for the diagnosis of “organic sleep disorder” (AFHSC, 2011c).

Psychiatric Diagnoses

Historical and cultural influences of wartime mental health diagnosis have been reviewed (e.g., Shepard, 2001). Notwithstanding ever changing culturally derived labels, there is relative consistency in the constellation of underlying symptoms and signs associated with the human stress response. Every war generation is faced with the dilemma of whether and how to diagnose war stress casualties, along with a wide range of inconsistent labeling. Below reflects a sample of psychiatric diagnostic decisions, whether accurate or not, that war veterans are subject to.

In the twenty-first century, war veterans are subject to an even wider range of possible psychiatric diagnoses. For example, from 2000 to 2011, the AFHSC (2012a) reports a total of 102,549 military personnel were diagnosed with PTSD; 303,880 for “depression;” 187,918 for “anxiety disorders (not PTSD);” 471,833 service members were diagnosed with “adjustment disorders;” 361,489 for “behavioral problems;” 8280 for “bipolar disorder;” 15,456 for “psychotic disorders (not schizophrenia);” and 318,827 for “other mental health conditions” along with 205,181 outpatient visits in 2010 for “somatoform or dissociative disorders” (AFHSC, 2011a). Prevalence of personality and substance use disorders are reported below. In 2010 alone, there were 18,250 military psychiatric hospitalizations that was greater than for any other major category of illness or injuries (AFHSC, 2011b). On the frontlines, deployed marines on their third deployment had rates of any mental health diagnosis of 22.6 %, up from those with only two deployments (11.8 %), and 15 % of deployed soldiers met diagnostic criteria for “acute stress disorder” (ASD) (J-MHAT 7, 2011)

In the VA system, from 2002 to 2011, a total of 444,505 OEF/OIF/OND veterans were treated with mental health diagnoses, including 111,199 diagnosed with “affective psychosis (not schizophrenia);” 239,094 with PTSD; 161,510 for “neurotic (anxiety) disorders” (not PTSD); 184,404 for “depression disorders;” 118,438 for “substance use disorders;” 32,268 diagnosed with “special symptoms,” and 26,788 veterans diagnosed with “sexual deviations & disorders” (VHA, 2012)—reaffirming the spectrum of war-related disorders beyond PTSD.

Personality Disorders (PD)

According to the GAO (2008), DoD data from November 2001 to June 2007 revealed that 2800 returning war veterans were among 26,000 service members administratively separated on the basis of having a PD—essentially a diagnosis of “pre-existing” disability incompatible with military service. The significance of the GAO finding is that administratively separated personnel diagnosed only with PD are generally ineligible for disability compensation and VA treatment benefits, or what’s referred to as “backdoor discharge”—the military has subsequently amended its PD policy (GAO, 2010). During the years 2000 through 2011, a total of 81,223 active-duty service members were diagnosed with PD by military healthcare (Armed Forces Health Surveillance Center, 2012b)—it is unknown how many are also war veterans.

“Moral Injury” or Perpetrator Trauma

An all-too frequently overlooked psychological and spiritual effect of war is the act of killing or witnessing the killing of other human beings. Grossman (1996) refers to the killing of one’s own species as the “universal phobia.” Fontana and Rosenheck (1994) examined 5138 war zone veterans seeking VA treatment (320 WWII; 199 Korean; 4619 Vietnam veterans) concluding that the agent of killing related significantly to all symptom categories in all cohorts, suggesting that responsibility for killing another human being is the single most pervasive, traumatic experience of war, following closely is role of observer and failure as well as exposure to combat in general

Litz, et al. (2009) conducted an extensive review of the concept of moral injury defined as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (Litz et al., 2009; p. 700). The moral injury construct is controversial among war veterans who fear moral backlash for performing their duty.

In the current war cohort, a high frequency of exposure to potential moral injury is evident as 56.1 % of deployed marines and 48.4 % soldiers, reported killing combatants in 2010 (J-MHAT-7, 2011), and 69 % of returning deployers reported injuring a woman or child (Hoge et al., 2004). Among 2854 US OIF soldiers who reported killing, 2.8 % reported suicidal ideation (Maguen et al., 2011). Knowledge of the frequency and type of combat experiences helps anticipate possible wartime demands. Veterans seeking counseling for moral injury-specific difficulties may be more likely to do so via chaplains or spiritual leaders versus mental health providers.

Traumatic Grief Reaction

According to the Department of Veterans Affairs (2004) Iraq War Clinicians Guide Second Edition “Traumatic grief refers to the experience of the sudden loss of a significant and close attachment. Having a close buddy, identification with soldiers in the unit, and experiencing multiple losses were the strongest predictors of grief symptoms” reported by Vietnam veterans (p. 75). A sample of 114 Vietnam veterans treated for PTSD verified traumatic grief reaction (TRG) can be a distinct form of war stress injury than psychiatric conditions like PTSD, depression, and generalized anxiety, but is often overlooked (Pivara & Field, 2004). An extensive review of Persian Gulf War veterans by RAND, cited a study of 56 soldiers involved in a deadly “friendly-fire” incident, finding 29 % still had nightmares and 38 % reported increased alcohol use after 4 months (Labatte & Snow, 1992), and soldiers assigned to “graves registry” reported more current and lifetime psychiatric disorder than non-exposure group (Sutker et al., 1994).

Despite its clinical prominence, research on the prevalence of TGR in war veterans is rare. Shay (1991) offers many eloquent examples of TGR in Vietnam combat veterans grieving the death or severe wounding of combat buddies or respected leaders (Shay, 1991). Pivara and Field (2004) reviewed TGR in war veterans, reporting the intensity of grief symptoms even after 30 years, was similar to grieving spouses and parents. Pivara and Field (2004) observes “if left untreated, can continue unabated and increases the distress load of veterans” adding that “The existence of a distinct and intense set of grief symptoms indicates the need for clinical attention to grief in the treatment plan” (p. 75).

In the twenty-first century, the incidence rate of TGR has not been tracked and is thus unknown. Studies related to TGR reveal that of 21,822 active-duty members screened positive for PTSD, 79.6 % reported witnessing persons being wounded or killed or engaging in direct combat, 86 % knew a fellow service member who was shot or wounded (Hoge et al., 2006), and 79 % of deployed marines reported a death of unit member (J-MHAT-7, 2011). In addition, 50 % of OIF-soldiers and 57 % OIF-marines reported handling of human remains (Hoge et al., 2004), a significant risk factor which was also found in Vietnam (Kulka, Schlenger, Fairbank, Hough, Jordan, Marmar, Weiss, & Grady, 1990) and Persian Gulf War veterans (IOM, 2006).

Family and Intergenerational Effects

According to the DoD, “The well-being of one’s family affects a service member throughout his or her career and plays an integral role in readiness to deploy in a moment’s notice. Steady increases in the tempo of military operations beginning long before the current conflict have exerted additional demands on families, with the current operational tempo taxing even the most resilient families” (DoD Task Force, 2007; p. 36). Generations of post-war analyses of war stress casualties have routinely ignored the potential “ripple-effect” on military family members, causing researchers to express surprise over the paucity of research (Dekel & Goldblatt, 2008). Dekel and Goldblatt (2008) reviewed studies on the intergenerational effects of war on spouses and children of veterans diagnosed with PTSD or related condition from WWII, Korea, and Vietnam, concluding that the greater the father’s level of distress, PTSD symptoms, or use of violence, was associated with greater distress and symptoms in family members. Beckham et al. (1997) examined 40 children of Vietnam War veterans, finding that many children of fathers with PTSD reported notable difficulties including drug use (40 %), behavioral problems (35 %), violent behaviors (15 %), significant secondary PTSD signs (45 %), and elevated hostility scores (83 %). In regards to spousal or partner relationships, a reported 38 % of Vietnam War veterans divorced after 6 months of homecoming (Peebles-Kleiger & Kleiger, 1994). Jordan et al. (1992) studied 1200 Vietnam War veterans and 376 spouses or co-resident partners of the veterans, finding that veterans with PTSD had greater level of problem severity in marital and family adjustment, parenting skills, and violent behavior.

Contemporary researchers on the impact of deployments on military children and spouses have affirmed previous generational findings on the mental health needs of military families (White et al., 2011). During 2000 through 2011, a total of 98,492 military personnel were diagnosed with a “partner relational problem;” 38,495 diagnosed with a “family circumstance problem;” and 21,690 diagnosed with “maltreatment related problem” (e.g., abuse) (AFHSC, 2012b). From 2000 to 2007, the US Air Force and Family Advocacy Program reported 33,787 cases of substantiated spouse abuse, and 31,986 cases of child abuse—which was most likely for emotional abuse (55 %), followed by neglect (46 %) and multiple forms of maltreatment (45 %) and less for physical abuse (37 %; see Foster et al., 2010). In today’s cohort, 5.9 % deployed marines reported pending separation/divorce with rates of marital discord steadily increasing from 12 % reporting marital problems in 2003, increasing to 24 % between 2004 and 2006, and 25 % during 2005–2007 (J-MHAT-7, 2011). Children and spouses are reported to significantly increase mental health utilization during deployment (Mansfield et al., 2011a).

Traumatic Brain Injury

In 2007, the DoD Task Force on Mental Health intimated that the principle reason for its mental health system’s collapse, was unanticipated demand from two, so-called signature injuries: PTSD and TBI. However, although diagnostic labels have evolved, both PTSD and TBI have long been the focus of concern since the twentieth century. Early detection of injury is critical in TBI patient management (GAO, 2011b). According to the IOM (2008b), co-occurring psychiatric conditions are reported in 49 % of moderate to severe TBI and 34 % mild-TBI cases.

In regards to twenty-first century combatants, a total of 266,810 military personnel [Defense and Veterans Brain Injury Center (DVBIC), 2013] and 28,828 veterans (VHA, 2012) have been diagnosed with TBI. The DVBIC was established in 1992 by congress, and offers real-time statistics TBI updates, the only such provision for war stress-related casualties (http://www.dvbic.org/dod-worldwide-numbers-tbi). All patients admitted to Walter Reed Army Medical Center during the period from January 2003 to February 2005 who had been exposed to blasts were routinely evaluated for brain injury. Fifty-nine percent of those evaluated were found to have experienced TBI (IOM, 2008b). Of those injuries, 56 % were moderate or severe and 44 % were mild (IOM, 2008b). In regards to system capacity to meet veterans’ needs, the GAO (2011a) reported disturbing trends whereby 57.1 % of marines deployed to Afghanistan received no TBI screenings despite reporting a head injury after IED blast and 42.1 % of those reporting loss of consciousness after IED received no TBI screening by medical personnel.

Substance Use Disorders

The stress of war has always been associated with high incidence of substance use disorders (SUD); IOM, 2012b), as well-documented by every generation, both during, but particularly after war. The degree that contemporary societies recognize this fact is evident by adequate preparation and resources available. The IOM (2012b) reported that since the start of OEF/OIF “alcohol abuse among returning military personnel has spiked. In 2008, nearly half of active-duty service members reported binge drinking” (p. 2). In today’s cohort, from around 2000 to 2011, a reported 306,248 active military personnel (AFHSC, 2012c) and 118,438 VA treatment seeking OEF/OIF/OND veterans (VA, 2012) have been diagnosed with SUD. Within the military, a total of 232,625 personnel were diagnosed for “alcohol abuse or dependence” diagnosis and an additional 73,623 personnel were diagnosed with “other type substance abuse or dependence” (AFHSC, 2012d). Estimates of military alcohol abuse range from 12 to 40 %, including 36 % of national guard; however, the majority of cases are untreated (Burnett-Zeigler, Ilgen, Valenstein, Zivin, Gorman, Blow, Duffy, & Chermack, 2011). In the 12 years since the start of OEF, 70,104 service members were diagnosed with drug abuse (excluding alcohol), with marijuana as the most frequent drug (AFHSC, 2012e). There have been multiple reports by the news media reports of prescription drug abuse and pain killers, as well as heightened concerns regarding over-prescription of psychotropic medications to deployed personnel are concerning trends. For example, 14 % of OIF deployed soldiers surveyed on the frontlines reported taking psychotropic medications (MHAT 2009). In addition, 12 % of military personnel surveyed reported illicit drug use, including prescription medication abuse in the past 30 days, as reflected in an increasing trend for opioid-related diagnoses since 2002 (AFHSC, 2012a).

Medically Wounded

Institutional Military Medicine (IMM)’s (VA/DoD) commitment in caring for medical wounds of military populations is evident in the VA’s motto “to care for him who shall have borne the battle and for his widow, and his orphan” adopting Lincoln’s (1865) famous Second Inaugural refrain (http://www.va.gov/opa/publications/celebrate/vamotto.pdf), as well as the Military Health System’s declared mission “to ensure delivery of world-class health care to all DoD service members, retirees, and their families” (http://www.health.mil/About_MHS/FAQs.aspx). Historically, high rates of neuropsychiatric conditions are reported in those medically WIA, thereby assuring increased mental health demand from veterans WIA, family members, and other caregivers.

As of 8 May 2013, a total of 50,702 veterans have been medically WIA (www.defenselink.mil) including 1621 with traumatic amputations as of 2010 (Congressional Research Service, 2010). In today’s cohort, over 377 (30 %) of 1400 OIF battlefield medical evacuees reported excessive dissociation, PTSD, and/or depression symptoms warranting further mental health evaluation (Russell, Shoquist, & Chambers, 2005), and Grieger et al. (2006) found rates of depression and PTSD among 613 severe WIA service members increased significantly between the initial 1 month post-injury assessment (where 4.2 % had PTSD symptoms and 4.4 % had depression) to 7 months post-injury (where 12.0 % had PTSD and 9.3 % met criteria for depression). Therefore, one might estimate a similar percentage of war stress injuries given a particular era’s medical-WIA statistics.

Misconduct Stress Behaviors

The Department of the Army (2006) describes a range of maladaptive stress reactions from minor to serious violations of military law and the Law of Land Warfare, most often occurring in poorly trained soldiers, but “good and heroic, under extreme stress may also engage in misconduct” (p. 1–6) even in high cohesive units. Examples include mutilating enemy dead, not taking prisoners, looting, rape, malingering, combat refusal, self-inflicted wounds, “fragging,” desertion, torture, and intentionally killing non-combatants (DoA, 2006). Indiscipline can range from relatively minor acts of omission or insubordination such as failure to take preventive hygiene measures in Korea leading to frostbite or chloroquine-primaquine in Vietnam resulting in malaria, to commission of serious acts of disobedience (mutiny), homicide (e.g., fragging—killing or injuring via fragmentation grenade), and even atrocity (My Lai).

To be clear, war atrocities and other forms of serious misconduct have occurred in every major human war, by all warring powers. Commission of atrocities or other misconduct does not automatically equate to war stress injury, nor is the presence of war stress injury ever justification for atrocity. Since the US Civil War, the legal system has struggled with culpability in soldiers accused of atrocity and other forms of misconduct, while also showing evidence of severe war stress injury (e.g., Lande, 2003; DoA, 2006). Jones (1995a) reports a lesson learned from Korean and Vietnam wars is that “Low-intensity garrison (guerilla) warfare can produce ‘nostalgic’ types of combat reactions that include alcohol and drug abuse, depression, and suicide. The mental health worker needs to be aware of the variety of stress responses that result from different types of combat” (p. 198).

As in other wars, especially low-intensity (guerilla type) warfare like Iraq and Afghanistan, there has been a high incidence of misconduct stress behaviors by American personnel ranging from inappropriate handling of American and enemy combatant dead, to prisoner torture and sexual abuse (e.g., 2004 Abu Ghraib), as well as several substantiated incidents of rape and homicide of unarmed civilians including children. The number of court martials or incidents of atrocity involving individuals experiencing a war stress injury is unknown. Frontline military surveys reveal that soldiers and marines with diagnosed with mental health problems were reported as more likely to mistreat non-combatants (MHAT-V, 2008). One study showed that deployed marines who were diagnosed with PTSD were 11 times more likely to be discharged for misconduct behaviors than their peers without PTSD (Highfill-McRoy et al., 2010). A study by Street et al. (2009) on military sexual trauma found that 52 % of active-duty female and 29 % of male personnel reported “offensive sexual behavior” and 9 % of female and 3 % of male soldiers reported “sexual coercion.” In 2011, the US Army noted a 64 % increase in violent sexual crimes since 2006 (Mulrine, 2012). By August 2010, 260 American military personnel died from “self-inflicted wounds” while deployed to Iraq and Afghanistan (Congressional Research Service, 2010).

Post-traumatic Anger and Interpersonal Violence

Irritability and post-war anger problems have frequently been reported in war veterans of every generation that can occasionally escalate into violence. In the context of combat, anger and aggressive behaviors are normative responses to threats of vulnerability (Forbes, Parslow, Creamer, Allen, McHugh, & Hopwood, 2008). Such responses are not only adaptive to war, but have been extensively modeled and reinforced through military training (Taft, Vogt, Marshall, Panuzio, & Niles, 2007). Social re-integration transitions from deployment and after military discharge represent critical adjustment periods wherein violence against self and/or others may arise, and therefore a heightened need for individual and family support.

The government’s study of the effects of the Vietnam War, “Legacies of Vietnam,” found 24 % of veterans who saw heavy combat were later arrested for criminal offenses, as compared to 17 % of other era veterans and 14 % of non-veterans. A study by Jordan et al. (1992) found that approximately one third of Gulf War-era veterans with PTSD had perpetrated interpersonal violence (IPV) in the previous year.

In today’s cohort, an army-wide study of 20,000 OEF/OIF soldiers found length of deployment was positively correlated with the severity of self-reported interpersonal violence perpetration in the year after deployment (Klostermann, Mignone, Kelley, Musson, & Bohall, 2012). One research sample found that OEF/OIF veterans with PTSD self-reported irritability/anger as the highest symptom, with 29 % of reports rated as “quite a bit” or “extreme” (Pietrzak, Goldstein, Malley, Rivers, & Southwick, 2010). Another study reported 70 % of veterans with PTSD reported impulsive aggressiveness compared to 29 % of veterans without PTSD (Teten, Miller, Stanford, Petersen, Bailey, Collins, Dunn, & Kent, 2010). Another more recent study estimated that 33 % of veterans seeking PTSD treatment reported perpetrating partner violence (Taft, Watkins, Stafford, Street, & Monson, 2011). Data from the National Co-morbidity Survey revealed 21 % of current spouse or partner abuse was indirectly attributable to combat exposure-mediated by PTSD (cited in Klostermann et al., 2012). A 2008 New York Times article reported 121 cases of OEF-OIF veterans were charged for homicide after returning from war (Sontag & Alvarez, 2008).

Incarceration Rates

According to the US Department of Justice (2007), on any given day, 9.4 % or 223,000, of the inmates in the country’s prisons and jails are veterans—with an estimated 4.5 % of veterans in state and federal prisons had service during OEF/OIF. After the Vietnam War in 1982, the New York Times reported “Jailed veterans case brings post-Vietnam problem into focus” (Stuart, 1982), harkening back to 1929 headline “Says Veterans Lack Psychiatric Relief: McNutt Declares Disabled Men Are In Jails, As Hospitals Are Not Available.” However, subsequent studies have reported that incarceration rates of veterans are no greater than non-veterans (e.g., Tsai, Rosenheck, Kasprow, & McGuire, 2013).

Prisoners of War

In 1992, the IOM completed a literature review on the long-term health effects of WWII and Korean War prisoners of war (POW), reporting consistently higher rates of psychiatric illness among POW than non-POW veteran cohorts. Incidence of co-morbid physical, nervous disease, and mortality rates have also been reported among US Civil War-era veteran POW (Pizarro, Cohen-Silver, & Prause, 2006). Goldstein et al. (1987) reported 29 % of WWII POWS in Japan still met PTSD criteria 40 years after release. Lifetime PTSD rates in 426 POW during WWII and Korean War were reported as high as 70 %, with current rates of 20–40 % (Eberly & Engdahl, 1991). There is no known POW involving OEF/OIF/OND veterans. However, the mental health demand for veteran POW and their families must be anticipated by future war planners.

Chronicity and Co-morbidity

Universal expert consensus calls for early identification and intervention of war stress injuries to avert long-term adverse health and functioning consequences from chronic disability (VA/DoD, 2010). Researchers have repeatedly observed that upwards to 80–90 % of acute stress disorder (ASD) diagnosis will convert to PTSD (VA/DoD, 2010). A 2010 army frontline survey identified 15 % of deployed soldiers and 16 % of marines met ASD criteria, with increased prevalence rates associated with multiple deployments (J-MHAT-7, 2011)—thus signifying the necessity for robust tracking and early intervention services. Moreover, risk for long-term disability and impairment has been shown to increase overtime, whereby chronicity breeds co-morbidity. For example, an estimated 50 to 80 % of patients with PTSD, also meet criteria for additional psychiatric and/or MUPS (VA/DoD, 2010). Stability of MUPS in 390 Persian Gulf War veterans over a 5-year period revealed no significant changes in number or severity of symptoms over time (Ozakinci, Hallman, & Kipen, 2006). A recent VA study found 32 % of female and 20 % of male OEF/OIF veterans diagnosed with PTSD had 10 or more diagnosed medical ailments (Frayne et al., 2010). Importantly, in the same study, 11 % of female and 7 % of male veterans without PTSD or other psychiatric condition, had 10 or more diagnosed medical conditions (Frayne et al., 2010).

Unemployment

Another common, yet controversial indicator of post-war readjustment difficulty in veterans has been higher unemployment rates compared to non-military populations. Jobless problems among returning veterans have been noted since America’s earliest wars. For example, a 1934(a) The New York Times article “Says Economy Drives Veterans to Suicide: R.W. Means Appeals to a House Committee for a Broader Interpretation of the Law.” Throughout the duration of war, unemployment rates among veterans are subject to fluctuations, but typically higher incidence has been reported once the war ended and mass military demobilization began, which resulted in tens of thousands to hundreds of thousands of service members being discharged within a short time period (Dean, 1997)—(note: the numbers varied depending on the war). In the present cohort, according to the US Department of Labor (2011), unemployment rates for OEF/OIF veterans is 4.5 % overall, but 21.9 % for veterans ages 18–24, that is typically the age group carrying the burden of war fighting.

Homelessness

Following the Gulf War, a 1994 The New York Times article “New Help Planned for Homeless Veterans” related “The Department of Veterans Affairs estimates that up to 250,000 of the nation’s veterans are homeless.” In 2004, the VA provided mental health treatment to 40,491 homeless veterans (Baker & Pickren, 2007). According to the National Coaliton for the Homeless (2009), there are over 194,000 homeless veterans. Of which, 33 % were deployed to warzones, 89 % received an honorable discharge, 76 % have mental health, alcohol, and/or drug problems, and 17 % are post-Vietnam era—2 % OEF/OIF veterans (National Coaliton for the Homeless, 2009).

Caregiver Compassion Stress

Research has shown that compassion stress may affect 40 to 80 % of caregivers (McCray, Cronholm, Bogner, Gallo, & Neill, 2008). Figley (1983) expressed concern for family members and helping professionals of returning Vietnam War veterans coining the term “secondary catastrophic stress reactions” which he later reformulated as “secondary traumatic stress”—later confirmed by studies on children of Vietnam veterans (Rosenheck & Nathan, 1985). Recent army surveys of deployed behavioral health personnel revealed 33 % reported “burnout” (MHAT, 2005). High incidence of “compassion fatigue” has also been reported by military psychologists (Linnerooth, Moore, & Mrdjenovich, 2011); military chaplains (Levy, Conoscenti, Tillery, Dickstein, & Litz, 2011); VA counselors (Tyson, 2007); and family caregivers (Lynch & Lobo, 2012). According to a recent RAND (2013) study, there are between 275,000 and 1 million caretakers of returning war veterans, including 63,000 seriously wounded casualties.

Summary of Evidence of Wartime Mental Health Demand in the Twenty-first Century

Although ongoing, there appears to be substantial proof of expansive mental health and social needs that clearly fulfills the first criterion of “heightened demand” for a possible wartime mental health crisis.

The Capacity to Meet Wartime Mental Health and Social Needs

The second defining characteristic of wartime crisis is the incapacity of the mental health system to adequately meet mental health and social readjustment demands. Institutional Military Medicine (IMM: VA and DoD medicine) is charged with the responsibility for addressing the mental health and social needs of the military population. Systemic requirements to meet war-related demands have been partially reviewed (e.g., DoD Task Force, 2007; Glass & Bernucci, 1966; Tanielian & Jaycox, 2008) and generational post-war lessons learned analyses published (Glass, 1966a). First and foremost, a clear “top-down” commitment must be evident in terms of learning from generations of war trauma lessons that include the following: (a) ensure adequate planning, preparation, and training for inevitable war stress casualties during times of peace and war (e.g., Glass, 1966a; Glass & Jones, 2005; Salmon & Fenton, 1929; Martin & Cline, 1996); (b) ensure adequate numbers of well-trained specialists (e.g., Menninger, 1966a); (c) eliminate mental health stigma, disparity, and barriers of care (e.g., Menninger, 1948; Salmon, 1917); (d) ensure ready access to effective, definitive treatment (Glass, 1966a; Glass & Jones, 2005; Brill, 1966a; Salmon & Fenton, 1929); (e) ensure adequate coordination between agencies and private sector, especially in regards to social reintegration; and (f) ensure timely, transparent monitoring and reporting (e.g., Menninger, 1966b; Russell, 2006a).

Investigating System Capacity to Meet Wartime Mental Health Demand

In light of the known inherent increase in wartime mental health demand and previous generations of lessons learned reviewed earlier, we must examine the adequacy of pre-war planning and preparation, as well as systemic responsiveness and resources to adequately meet war-related needs. Documentation from presidential and congressional interventions such as executive orders, commissioned studies, government investigations, and task forces, as well as news media reports, can all be useful in assessing capacity and performance.

Findings of Twenty-First Century System Capacity to Meet Mental Health Demand

The overwhelmingly consistent narrative in the twenty-first century is reflected by the 2007 Washington Post report “System Ill Equipped for PTSD Troops Returning with Psychological Wounds Confront Bureaucracy, Stigma” (Priest & Hull, 2007) and 2011 USA Today headline “Lag in Mental Health Care Found at a Third of VA Hospitals” (Zoroya & Monies, 2011). From the outset of OIF (2003–2004), public concerns about the mental healthcare systems’ capacity to meet wartime needs spurred government intervention. Despite Herculean individual efforts of dedicated professionals working both within, and in collaboration with, the DoD and VA, as well as many notable adjustments made by DoD/VA over recent years (Ritchie, 2013), the crisis narrative appears to have intensified as mental health demand escalated.

In response, an unprecedented flurry of corrective oversight ensued including presidential commissioned studies (President’s Commission on Care for America’s Returning Wounded Warriors, 2007) and multiple executive orders (e.g., Executive Order 13518. 9 November 2009. Employment of Veterans in the Federal Government; Executive Order, 2012. 31 August 2012. Improving Access to Mental Health Services for Veterans, Service Members, and Military Families); and an incalculable number of congressional actions including frequent hearings (e.g., US Congress, Committee of Conference, 2005; US Congress, Senate Committee on Veterans’ Affairs, 2011a, b, c); mandated investigations (e.g., DoD Task Force, 2007, 2010; GAO, 2006; 2011a; IOM, 2010; 2012a; VA Office of Inspector General, 2009; 2012); and new legislation (e.g., Joshua Omvig Veterans Suicide Prevention Act 2007: P.L. 110–110; Wounded Warriors Act, 2009; Women Veterans and Other Health Care Improvements Act of 2013)—all intended to correct systemic mental health deficiencies during time of war.

The clearest declaration of failed planning and insufficient capacity comes from the military itself in 2007, “A single finding underpinning all others: The Military Health System lacks the fiscal resources and the fully trained personnel to fulfill its mission to support psychological health in peacetime or fulfill the enhanced requirements imposed during times of conflict” (DoD Task Force, 2007; p. ES.2). Chronic severe systemic deficiencies were identified by the congressionally mandated task force in staffing levels, training, stigma, monitoring, assessment and diagnosis, familial support, access to quality treatment, organizational fragmentation, social reintegration, and collaboration with external agencies (DoD Task Force, 2007).

In regards to military families, the DoD Task Force (2007) reported “A consistent theme that emerged during Task Force site visits was that families perceive, and care providers confirm, that family members have difficulty obtaining mental health services in the existing system … Specialized mental health care for children and adolescents appears to be in particularly short supply … Few data are available to address the long-term mental health needs of the survivors of deceased service members” and “Many of the issues facing survivors also affect wounded service members and their families” (p. 39). In short, the aforementioned DoD Task Force (2007) findings, including those like “The number of active duty mental health professionals is insufficient and likely to decrease without substantial intervention” (p. ES-3); “90 % of the providers indicated they had received no training or supervision in clinical practice guidelines for PTSD (Russell, 2006a, 2006b)” (p. 20); and “There are not sufficient mechanisms in place to assure the use of evidence-based treatments or the monitoring of treatment effectiveness” (p. ES-3)—offer a profound indictment of the military’s grossly inadequate planning, preparation, and responsiveness to meeting predictable wartime mental health demands, requiring presidential and congressional corrective action. The notion of crisis is clearly expressed in the IOM’s (2012b) recent review of military substance abuse, asserting “Yet alcohol and other drug use in the armed forces remain unacceptably high, constituting a public health crisis, and both are detrimental to force readiness and psychological fitness” (p. 2). Table 3 summarizes the findings of major government sponsored studies of the capacity to meet wartime behavioral health needs.

Table 3 Review of government studies evaluating capacity to meet wartime mental health needs

Evidentiary Summary of Capacity to Meet Twenty-First Century Wartime Needs

The military task force report climaxes with a fervent appeal to end the cycle of failure to learn so-called psychiatric lessons of war pontificating “The time for action is now. The human and financial costs of un-addressed problems will rise dramatically over time. Our nation learned this lesson, at a tragic cost, in the years following the Vietnam War. Fully investing in prevention, early intervention, and effective treatment are responsibilities incumbent upon us as we endeavor to fulfill our obligation to our military service members” (DoD Task Force, 2007; p. 63). Evidence of broad systemic failure to adequately anticipate and meet wartime mental health demands is sweeping and profound. That the findings have been replicated by diverse and credible sources across both DoD and VA should remove the possibility of bias or exaggeration—thereby fulfilling the second and final definitional criteria of a wartime crisis in the twenty-first century. In sum, we assert that the deficient domains reflected in Table 3 constitute as clear failures by institutional military medicine to adhere to the fundamental lesson of war trauma mandating the need for adequate planning and preparation when the nation goes to war—thus a “self-inflicted” wound that led to this, and every wartime mental health crisis since the dawn of the twentieth century.

Conclusion

There is robust and incontrovertible proof of a wartime mental health crisis during the first war of the twenty-first century. However, whether the present calamity represents an outlier or continuation of generational failure is yet to be determined. The question of repetitiveness is the focus of the second part of our analysis. Getting back to the issue at hand and defining and studying wartime mental health crisis itself can play a crucial role in dramatically enhancing our ability to predict, prevent, and/or at least mitigate incalculable harm from future crises. Furthermore, improving the military mental health system can have demonstrative benefit in reforming the national mental health system, just as military medicine has helped transform civilian practice (Gabriel, 2013). Future studies are needed to develop more objective methods for evaluating mental health demand and capacity related to wartime crises.

Notes

  1. 1.

    For example: “A Deluge of Troubled Soldiers Is in the Offing, Experts Predict” (Shane, 2004); “Officer Sees ‘Perfect Storm’ Brewing in Military’s Mental Health Care System” (Batdorff, 2006); “PTSD Reports Up 20,000 In A Year” (Zoroya, 2007); “Home From The War, Many Veterans Battle Substance Abuse” (Alvarez, 2008); “Iraq Veterans Leave A Trail Of Death And Heartbreak In U.S.” (Sontag & Alvarez, 2008); “Suicides of Soldiers Reach High of Nearly 3 Decades” (Alvarez, 2009); “Children of Deployed More Likely to Seek Mental Health Care” (Wilson, 2010); “For Brain Injuries, A Treatment Gap” (Sternberg, 2011); and “Sexual Assaults in Military Raise Alarm in Washington” (Sternberg, 2011)—indicate a high level of mental health demand within the military population, and a spectrum of wartime needs far beyond post-traumatic stress disorder (PTSD) diagnosis.

  2. 2.

    See “Psychologist: Navy Faces Crisis” (Zoroya, 2007); “Report: Improve Care of Veterans With Brain Injury” (Zoroya, 2008); “VA Fails To Meet Veterans PTSD Needs” (Philpott, 2011); “The Army’s Continuing Dearth of Mental-Health Workers” (Thompson, 2012); “Obama: Improve Mental Health Access, Care for Military, Veterans” (American Forces Press Service, 2012); “VA Sees Shortfall of Mental Health Specialists” (Zoroya, 2012); “Military Not Doing Enough to Curb Alcohol, Drug Abuse, IOM Concludes” (Bowser, 2012); “Panel Says Pentagon Does Not Know if PTSD Programs Work” (Kime, 2012); “Recent War Veterans Face Hiring Obstacle: PTSD Bias” (Zoroya, 2013); and “Army Orders Reforms for Mental Health Care Treatment” (Vogel, 2013)

  3. 3.

    http://www.warrelatedillness.va.gov/education/healthconditions/medically-unexplained-syndrome.aspMUPS)

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Russell, M.C., Figley, C.R. Generational Wartime Behavioral Health Crises: Part One of a Preliminary Analysis. Psychol. Inj. and Law 8, 106–131 (2015). https://doi.org/10.1007/s12207-015-9224-4

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Keywords

  • Mental health crisis
  • Military
  • Veterans
  • War stress
  • Suicide
  • PTSD