The military and its psychiatric challenges

This special issue explores the psychiatric challenges facing the armed forces of the UK, USA, Canada and Australia. Evidence from past conflicts has established a relationship between the rate of physical casualties (killed and wounded) and levels of psychiatric morbidity (Jones & Ironside, 2010). Inevitably, the operations in Iraq and Afghanistan have resulted in psychological casualties. Not since Vietnam has so much research been directed towards the mental health of service personnel. All four nations have focused on the study of post-traumatic stress disorder (PTSD), the truly novel psychiatric diagnosis of the late twentieth century, not least because in its chronic form it is often difficult to treat. PTSD is also a diagnosis that attracts media attention, having been used by anti-war campaigners in the aftermath of Vietnam to criticize the conduct of the conflict.

Whilst it is difficult to compare rates between nations, a consistent finding of the last 20 years is that reported PTSD tends to be higher amongst service personnel and veterans of the USA compared with other western nations, and in particular the UK (Richardson et al., 2010). A study of US Gulf War veterans, for example, found a prevalence of 10.1% (Kang et al., 2003). By contrast, UK investigators found rates of 3% (Unwin, 1999). With reference to Iraq and Afghanistan, Hoge et al. (2006) reported PTSD rates among returning US troops of between 5% and 10%, and recent studies based on VA data have recorded PTSD rates between 21% and 29% (Wells et al., 2011), at a time when UK researchers reported rates of between 2% and 6% (Fear et al., 2010; Sundin et al., 2011). Explanations for the difference have been various: US personnel tend to be younger and of lower socio-economic background than their UK counterparts, longer tours of duty have been undertaken by US troops (12 months and as long as 15 months compared with 6 months for UK forces), a greater proportion of reservists deployed by US armed forces, together with differences in the way healthcare and benefits are delivered. In addition, American culture may be more receptive to psychological disorder (see for example the high rates of PTSD recorded by the National Vietnam Veterans’ Readjustment Study, Kulka et al., 1990), whilst psychiatric stigma remains evident in the UK.

The international focus on PTSD has also prompted the investigation of co-morbid disorders: depression, drug and alcohol abuse and anxiety states. Western nations have detected significant levels of alcohol consumption after deployment, though rates are particularly high amongst UK personnel (16% to 20%). The US Army and Marine Corps have also witnessed a sustained rise in suicide, bringing rates above those for age-matched civilians. In the UK, with the exception of males under twenty serving in the army, suicide rates are lower than in comparable civilian cohorts.

The association between alcohol and the military, though not universal, extends through most armies from ancient history to the present. The Spartans, who lived according to a supreme military culture, included a daily consumption of wine that today would be considered harmful to health. Even the Roman Army, a highly disciplined and successful fighting force, issued legionaries with a ration of sour wine (acetum). Berserkers recorded in Viking sagas were thought to have used drugs or alcohol to induce a rage state before going into battle. During World War I, most combatant nations supplied alcohol on a daily basis to their front-line troops. With an impact on morale, it may have extended the effectiveness of infantrymen. Colonel Nicholson recalled that spirits made life bearable: ‘the private soldier's ration of rum saved thousands of lives’, adding ‘it is an urgent devil to the Highlander before action; a solace to the East Anglian countryman after the fight’ (Nicholson, 1939). Given the longevity and depth of the association, alcohol with all its dangers played an important part in military life: the ability to lift morale, assist bonding and social cohesion, make an arduous existence bearable, grant low short-term relief from traumatic memory, and in extreme cases to fuel aggressive instincts. It is not surprising that soldiers, who are typically young males living away from home and willing to take risks, often consumed alcohol, and sometimes in large quantities. In the past, when a warrior was not expected to reach old age, dying either from wounds or sickness, the adverse effects of heavy alcohol consumption were outweighed by its advantages. Today, with smaller professional militaries and greater life expectancy, the health effects of excessive drinking are more important.

A key question is whether alcohol consumption in western armies is currently at a significantly higher level than in the past. Studies show that aged-matched groups in the military consume more than their civilian counterparts, but do service personnel drink more than their predecessors? The wide availability of cheap alcohol is said to have promoted a binge culture from which the military are not immune. However, historical evidence suggests that current levels, though a cause for concern from a health perspective, are not any worse than in earlier eras. US forces in Vietnam consumed heavy quantities of beer and spirits, while low rates of consumption in certain theatres of World War II (notably the Pacific and Burma) related to the non-availability of drink rather than self-imposed abstinence.

What may have changed is the pattern of consumption. In former wars soldiers were allowed to drink in theatre and alcohol was often issued before an attack to stiffen resolve. Today, for British and US troops Afghanistan is a dry zone; alcohol is banned because of the high level of technology required by modern operations. In World War I, the adverse impact of alcohol on target accuracy was known but was considered a price worth paying. Motor vehicles, missile technology and advanced communication systems require sober service personnel. On many Royal Navy submarines, for example, officers voluntarily agree not to drink alcohol while they are at sea because of the technical nature of their duties. However, a stressful and dangerous tour of Iraq or Afghanistan without alcohol is often followed by excessive consumption. Whether this pattern of drinking is in part a response to a period of prohibition remains unclear.

Not only does war impact on service personnel, their partners and children also experience its effects. Two papers in this special issue address the effects of war on families. US-based studies have found an increase in emotional and behavioural problems in children when a parent was deployed overseas, while marital dysfunction and stress disorders have been identified in wives and partners. There may be some lessons to be learned from earlier wars when servicemen were routinely sent overseas for tours of between three and seven years. During World War II, for example, crimes committed by juveniles in the UK rose by a third, while in the aftermath of the conflict the divorce rate rose from 15,600 decrees absolute in 1945 to 60,300 in 1947.

General Robert E. Lee, the defeated commander of the Confederate Army, observed, ‘it is well that war is so terrible – we would grow too fond of it’ (Zeldin, 1994). Referring to the adrenalin rush that service personnel experience, bonds of comradeship forged in adversity and the all-or-nothing quality of battle, he had also witnessed enough of its effects to know that combat can undermine a soldier's mental health. For some the psychological effects of intense or protracted stress are both complex and intractable. Indeed, none of the challenges discussed in this special issue are likely to be resolved in the short term, not least because the current operations in Iraq and Afghanistan have an enduring quality.