Soldiers' Mental Health Supporters of the current level of mental health care say: The U.S. military is deeply concerned about the mental health of its soldiers. The federal government has increased funding for mental health care initiatives in recent years, resulting in the creation of programs like Military OneSource, a telephone hotline that provides military personnel with easy access to mental health counseling. The Department of Veterans Affairs is fully committed to providing lifelong support for U.S. soldiers struggling with mental illness. Critics of the current level of mental health care say: For years, the federal government has underestimated the prevalence of mental illness in the U.S. military. Though some funding increases have been made, they are insufficient to meet the current and future mental health care needs of U.S. troops. The military must work to rid itself of the stigma surrounding mental illness within its ranks so that soldiers become more comfortable seeking help. You're just always intense. You're always super serious and you lose your temper over little things and you're not the same person who deployed.--sgt. Danny Facto, who recently served in Afghanistan, speaking about the emotional difficulties he has experienced since returning to civilian life in the U.S. Though military weapons have become "smarter" and medical technology has advanced rapidly during recent decades, war continues to exact a significant human toll--soldiers are killed, lose limbs or sustain other physical injuries. Those consequences of war often leave an imprint on society long after the fighting has ceased. However, another long-term consequence of war also exists, one that is usually invisible to the naked eye: mental health problems. Sometimes dubbed "emotional injuries," mental health disorders such as acute stress, depression, anxiety and posttraumatic stress disorder (PTSD) are common byproducts of military combat. During the current U.S.-led war on terrorism--a campaign initiated following Sept. 11, 2001, attacks against the U.S.--tens of thousands of soldiers deployed to Afghanistan and Iraq have been diagnosed with such conditions. While some military veterans seek medical treatment after they return to the U.S., many do not, beginning what often becomes a lifelong battle with mental illness. Medical experts agree that the personal and societal costs of untreated mental disorders can be staggering. As the military conflicts in Afghanistan and Iraq enter their sixth and fifth years, respectively, mental health experts and U.S. military officials have been issuing warnings that mental illness among U.S. soldiers stationed abroad is far more prevalent than previously thought. In turn, those warnings have sparked a vigorous debate about the federal government's role in providing mental health care to both soldiers at war and those who have returned home. The issue gained increased media visibility in March 2007, with the release of a controversial report documenting mental illness among U.S. troops in Afghanistan and Iraq. After surveying more than 100,000 military personnel, researchers at the University of California at San Francisco and the San Francisco Veterans Affairs (VA) Medical Center found that nearly one-third of soldiers suffered from at least one type of mental health disorder. The report's authors added that it is the youngest soldiers--those aged 18 to 24--who are at greatest risk for acquiring a combat-related mental illness. In and of itself, the report was not major news: Similar pronouncements about mental health in the military had been made periodically since 2004. However, the March 2007 report was notable because its authors concluded that there appeared to be an "upward trend" in the rate of mental illness among soldiers. In other words, they predicted that the number of mentally ill veterans could rise dramatically in the coming years, placing a major strain on the military's already burdened health care infrastructure. Indeed, the controversy surrounding mental illness in the military has unfolded against a backdrop of growing public discontent with the military's health care system. In February 2007, investigative reporters documented poor sanitary conditions at the Walter Reed Army Medical Center in Washington, D.C., one of the military's premier treatment centers for injured soldiers. The ensuing public furor led to congressional hearings, the resignation of the Army's surgeon general, and the formation of presidential commissions to further examine the quality of veterans' health care. Furthermore, some U.S. troops returning to civilian life have complained that military health officials have downgraded the severity of veterans' health problems to avoid paying costly long-term medical benefits to wounded soldiers. [See 2007 Scandal Grips the Army's Premier Hospital for Injured Soldiers (sidebar)] In the debate over troops' mental health care, many health experts say that it is difficult to ascertain the exact number of troops that are battling mental illness. The reason, they say, is that a stigma about mental illness exists within both society at large and within military culture in particular. Observers say that within the military--where a premium is placed on soldiers' physical and mental toughness--soldiers are reluctant to disclose mental health problems for fear of being perceived as weak or unfit for service. As a result, experts assert, many service members conceal their condition, which leads to the number of mentally ill soldiers being underestimated.
Mental health specialists warn that leaving mental health conditions untreated can have grievous consequences. Illnesses such as PTSD and acute stress cause irritability, insomnia and rapid mood swings, among other things. Without suitable medication or therapy, sufferers sometimes cope with their condition with alcohol or drugs, making it difficult to keep a job and straining relationships with friends, family and loved ones. In extreme cases, mental health experts say, homelessness or suicide can result. Is enough being done to combat mental illness among the nation's active-duty troops and military veterans? Are there enough programs, staff and funding to meet the rising demand for treatment of mental health problems? Or, given the high incidence of mental illness among troops serving in the war on terrorism, should the U.S. government be providing much more assistance to mentally ill soldiers? Asserting that they understand the seriousness of mental health disorders, supporters of the current level of mental health care for U.S. soldiers say that the military is doing enough to assist troops and veterans with such conditions. Proponents note that every member of the military is briefed on mental conditioning prior to, during and following an overseas deployment. Also, troops and their relatives have round-the-clock access to mental health care professionals via a telephone hotline set up specifically for military families, they say. Furthermore, supporters note that in recent years, Congress has passed legislation earmarking billions of dollars specifically for veterans' health care. Such funding makes it easier for VA facilities to hire specialized staff and fund mental health programs for veterans returning to civilian life, backers contend. Meanwhile, critics of the current level of mental health care for U.S. troops insist that the federal government has not done nearly enough to meet soldiers' mental health needs. Opponents assert that the military is either unwilling or unable to recognize the high number of Iraq and Afghanistan veterans who are returning to the U.S. with mental illness. While critics concede that some funding increases have been made in recent years, they maintain that support programs for veterans with mental illnesses are severely underfunded and understaffed. As a result, military personnel tend to receive subpar mental health care, opponents contend. In order to improve soldiers' medical care, critics say, the government must ease the stigma surrounding mental illness that is embedded in military culture. That goal could be achieved by better educating troops about the causes and symptoms of mental health disorders and guaranteeing soldiers long-term mental health care if they need it, opponents say. The Legacy of the Vietnam War The relationship between military combat and mental health disorders among soldiers is well-documented, and stretches back hundreds of years, if not longer. From the U.S. perspective, mental illness was readily apparent among troops in both World War I (1914-18) and World War II (1939-45), two conflicts that featured major overseas deployments of U.S. soldiers. The first U.S. military conflict during which mental illness became a defining aspect was the Vietnam War (1959-75). Longer than most previous U.S. wars, the U.S. intervention in Vietnam exacted a massive toll on U.S. military personnel; more than 55,000 soldiers were killed and many more were physically injured. Known as the "first televised war" because of the presence of U.S. reporters and cameramen in and around battle zones, the Vietnam War and its attendant media coverage brought the horrors of military combat into living rooms throughout the U.S. But while such intimate coverage of the conflict allowed the public to bear witness to the realities of war, the media accounts for the most part did not portray the toll that the Vietnam War took on many soldiers' mental health. Indeed, the rate of mental illness among troops serving in that conflict did not become apparent until years after the war had ended, because no real-time data about soldiers' mental health was collected during the war. During the late 1970s and early 1980s, researchers interviewed military veterans around the country, sometimes with the aid of VA health clinics. They found that some 31% of male Vietnam veterans, and more than a quarter of female Vietnam veterans, were afflicted with full-blown PTSD. An additional 22% of all Vietnam veterans showed some symptoms of the condition. PTSD--one of the most serious types of combat-related mental illness--is usually caused by either experiencing or witnessing a traumatic event, such as a shooting, bombing or other act of violence. Without intensive medical treatment, PTSD can become a lifelong disorder, and even some sufferers who receive such treatment are unable to recover. Further complicating diagnosis is the fact that symptoms of PTSD may not appear until years after the original traumatic experience.
In the decades following the Vietnam War, PTSD became one of the hallmark medical conditions suffered by military veterans of the conflict. Many experienced other mental health problems as well (many of them related to PTSD), such as depression and anxiety. But despite the sacrifices they made for their country, U.S. veterans battling mental illness did not receive a great deal of public support. Indeed, a number of mentally ill veterans were pushed to the margins of society, where they became mired in homelessness or alcoholism. For the most part, observers say, the public did not understand combat-related mental illness in the years following the war. Though taxpayer money was used to fund VA health programs and provide outpatient support to veterans, prevailing public attitudes toward Vietnam soldiers tended to be distrustful. Not only had these soldiers fought in what many viewed as a largely unsuccessful and unpopular war, but many soldiers had seemingly undergone some type of personal transformation during their service overseas. Today, the U.S. government continues to allocate millions of dollars every year to subsidize treatment for mentally ill Vietnam-era soldiers, though a number of veterans choose to cope with their condition without medical assistance. Mental Health in the Military During Operation Iraqi Freedom The lessons of Vietnam have loomed large with the U.S. becoming bogged down by military conflicts in both Afghanistan and Iraq in recent years. To varying extents, U.S. involvement in both countries bears similarities to the U.S. intervention in Vietnam. Guerrilla warfare--a low-level form of conflict in which traditional frontlines disappear and enemy forces tend to forgo uniforms and blend in with the civilian population--was a major factor during the Vietnam War and is a major factor in both Iraq and Afghanistan. Health experts say soldiers' continuous anxiety about being targeted by hidden enemy insurgents is one of the major reasons why tens of thousands of U.S. veterans have been returning home with mental health disorders. While U.S. troops serving in both Afghanistan and Iraq have been killed, injured or afflicted with mental illness since the war on terrorism began in the fall of 2001, it has been soldiers deployed to Iraq who have received the bulk of media coverage. Observers say the media tends to focus on Operation Iraqi Freedom (the official name of the current war in Iraq) primarily because more U.S. soldiers are stationed in Iraq and because Iraq has effectively replaced Afghanistan as the central theater in the war on terrorism. Early on in both conflicts, it was not apparent that mental illness among troops was widespread. In July 2004 (the third year of the Afghanistan conflict and the first year of the Iraqi conflict), the Army published a report entitled "Combat Duty in Iraq and Afghanistan, Mental Health Problems and Barriers to Care" in the prestigious New England Journal of Medicine. The report revealed that just 6% of troops who had served in either country were suffering from a mental health disorder. Those results led one of the report's authors, William Winkenwerder, assistant secretary of defense for health affairs, to conclude that "the vast majority" of troops interviewed for the report "seem not be having any significant mental health concerns or problems." Despite their conclusion that mental illness was not prevalent among U.S. soldiers serving in the war on terrorism, the report's authors added that the relatively low rate of mental health disorders did not imply that soldiers were not experiencing stress. Instead, they pointed out that stress was a naturally occurring phenomenon in combat situations, and that many troops were coping well with it. The authors explained that unlike acute stress--a potentially problematic mental disorder--the lower-intensity stress experienced by military personnel in Iraq and Afghanistan was manageable and did not pose any long-term issues. However, as the wars in both countries dragged on, the conclusions of the July 2004 Army report became outdated. Throughout late 2004 and into 2005, U.S. soldiers in both Afghanistan and Iraq found themselves increasingly entangled in guerrilla warfare. For U.S. troops, the emergence of a guerrilla war meant that active-duty soldiers, transport personnel, medical technicians and everyone else affiliated with the U.S. military became an equally valuable target in the eyes of socalled enemy insurgents. In Iraq, U.S. forces came to be regularly targeted by sniper attacks, truck and car bombs, rocket-propelled grenades and improvised explosive devices (IEDs) that were placed alongside roads frequented by U.S. military patrols and supply convoys. With the omnipresent danger posed by insurgent attacks, the number of deaths and injuries among U.S. soldiers rose steadily. And as troops became accustomed to long periods of idleness punctuated by brief, intense violence, growing numbers of military personnel began to suffer from mental health issues, primarily acute stress and anxiety. PTSD rates among soldiers began to rise as well. Dr. Matthew Friedman, executive director of the Department of Veterans Affairs' National Center for Posttraumatic Stress Disorder, explained that the growing prevalence of PTSD was intertwined with the rise in guerrilla attacks. "Whether you drive a truck or are medical personnel or a Special Forces
person, the risks are more evenly distributed" in a guerrilla war, he commented, "[s]o the likelihood of being exposed to war-zone trauma is greater." In 2005, more than two years into Operation Iraqi Freedom, the federal government found that the military's health care infrastructure was unequipped to handle the increasing number of soldiers returning to the U.S. with mental health conditions. Treatment programs were underfunded and understaffed. To resolve the problem, Congress earmarked an additional $1.5 billion in its emergency wartime spending bill to improve health care for active-duty soldiers and new veterans. To cope with a shortfall in new recruits for the military, many soldiers' tours of duty were extended in 2005 and 2006. Other soldiers were eventually deployed to the region for a second, or even third time. While the extensions--which stretched overseas deployments to more than a year--and repeated deployments allowed the U.S. to avoid troop shortages in the region, the heightened workload began to take a toll on the troops. For many, morale decreased and the likelihood of acquiring a mental illness increased. In December 2006, a report by the U.S. Army's Mental Health Advisory Team (MHAT) confirmed that troops on repeated or extended deployments were suffering mentally. (The MHAT has periodically released reports documenting soldiers' mental health conditions during the course of the war.) The 2006 report, which studied soldiers serving in Iraq in late 2005, revealed that redeployed soldiers were much more likely to be suffering from a mental health disorder. Overall, the Army reported, nearly 14% of U.S. troops were suffering from acute stress. For soldiers on their first deployment, 12.5% had the condition, but for those stationed in Iraq a second time, the rate increased to 18.4%--a substantial jump, according to mental health experts. Lt. Gen. Kevin Kiley, the Army's surgeon general until early 2007, speculated about why soldiers might feel more stress during additional or extended deployments. "There is a sense that yearlong deployments are challenging, even if morale is good," Kiley said. "The normal things--births, first steps, birthdays--those are missed. When soldiers are on second or third tours, my sense is they feel that a bit more." (Kiley was forced to resign from his post in February 2007 after the unsanitary health conditions at the Walter Reed Army Medical Center became public knowledge.) Reacting to the report, many veterans' advocacy groups have warned that extending U.S. soldiers' service tours in Afghanistan and Iraq will have dire consequences for veterans' mental health for years to come. They often point to the nation's experience with Vietnam veterans to illustrate the societal and financial costs of soldiers' mental health difficulties. If the government does not do more to provide current and future veterans with mental health care, they say, the results could be grim. According to Paul Rieckhoff, founder of the Iraq and Afghanistan Veterans of America, the December 2006 MHAT report "is a bad sign of things to come. There is a tremendous mental health toll to this war." He warns, "That toll is only going to continue as we repeatedly ask the same people to sacrifice again and again. It is not just the equipment being run down, it is the people." "Soldiers' Mental Health." Issues & Controversies On File. Facts On File, 11 May 2007. Web. 11 Nov. 2010.
Military Is Doing Enough to Care For Troops, Backers Say Supporters of the U.S. government's current level of mental health care for veterans say that the military is doing everything in its power to care for afflicted soldiers. It is in the best interest of the country for troops to be mentally as well as physically fit because only then will military personnel perform capably in combat zones, they say. "We do want to take care of our soldiers," insists Army Surgeon General Lt. Gen. James Peake. Proponents note that in recent years, the administration of President Bush (R) and Congress have enacted legislation increasing government spending on veterans' health care programs. Furthermore, they say, some of that money has been earmarked specifically for mental health care initiatives. "The president has always made it clear that military veterans are among his highest priorities," states Sen. Larry Craig (R, Idaho), the chairman of the Senate Veterans Affairs Committee. Those funding increases have allowed the Department of Veterans Affairs to provide comprehensive mental health care for troops returning to civilian life, backers contend. In particular, they say, financial support from Congress has allowed various VA clinics to hire additional staff to accommodate the growing number of veterans returning home with mental illness. Dr. Michael Kussman, principal deputy undersecretary for health for the VA, elaborates: The VA has been a leader in mental health of all sorts, particularly in PTSD. We are very attuned to our responsibility for the full breadth of service... We believe we have the resources and are giving priority to these new veterans. We're encouraging them to come. Many defenders of the government's policy on soldiers' mental health care note that support programs for troops have been available for much of the time during the conflicts in Afghanistan and Iraq. For instance, they point out, the Defense Department has a telephone hotline known as "Military OneSource" that enables soldiers and their family members to get professional mental health assistance 24 hours a day, seven days a week. Additionally, proponents say, the Department of Veterans Affairs has dispatched PTSD specialists to its health facilities throughout the country to help diagnose and treat afflicted soldiers in a timely manner. The federal government has taken other precautions with regard to solders' mental fitness, proponents add. They note that under existing Defense Department policy, every military service person must receive a mandatory briefing on mental health prior to, during and following deployment abroad. Such briefings keep soldiers informed about the risks of mental illness and also help weaken the stigma surrounding mental health problems in the military, supporters assert. However, some supporters say, despite the government's ongoing efforts to provide comprehensive mental health care to active-duty troops and military veterans, some soldiers simply refuse to utilize available health care. "We believe that there are adequate services available" to aid soldiers who are afflicted with mental health disorders, Winkenwerder, the Army's assistant secretary of defense for health affairs, says. But he adds that one obstacle to seeking mental health care in the military is the stubbornly persistent "stigma that some individuals have about coming forward to get that care and counseling." Finally, a handful of supporters insist that, contrary to accepted wisdom, some degree of stress may actually enhance soldiers' performance in combat. According to Col. Edward Crandell, who helped organize the December 2006 MHAT survey, stress helps troops stay alert in dangerous circumstances, heightening their ability to perceive risks and carry out their duties. "In some ways, in their soldier's mind it may be adaptive to maintain that heightened level of arousal," Crandell says. "I have had numerous soldiers tell me: 'I am going back. I need to be pumped. I need to be ready to do this.' " Critics Call for Improved Mental Health Care for Soldiers Critics of the government's current mental health care policy for soldiers acknowledge that Congress has increased funding for troops' medical treatment in recent years, which has been helpful. However, while that represents "a step in the right direction," according to the American Legion, an organization that represents some three million U.S. veterans, far more needs to be done, critics argue. One problem with the government's handling of mental health care infrastructure for veterans and soldiers has been that Congress has not increased funding for troops' medical treatment except in response to emerging problems, opponents allege. The haphazard funding of military medical treatment programs clearly demonstrates the government's lack of foresight with regard to war planning, critics charge, and has caused many soldiers to suffer needlessly.
As Army reports released in recent years have indicated, the prevalence of mental health problems in military ranks is far more widespread than initially thought, critics note. Since mental health officials in the military became complacent in the early years of the war due to then-low rates of mental illness, critics charge, they failed to institute policies, bolster programs and hire staff that could handle a future influx of patients with mental health conditions. "We should have been ready for this," contends Steve Robinson, director of the National Gulf War Resource Center, a veterans advocacy organization. Speaking with regard to the growing number of U.S. veterans who are returning home with mental illnesses, he says, "It's simple math: If there is an increase in demand, and there is not an equal increase in dollars to hire new people to buy more equipment or provide more services, the person who suffers is the returning veteran." Improving mental health care infrastructure for soldiers serving in Afghanistan and Iraq is crucial because of the nature of the warfare in those countries, critics add. As enemy combatants in those countries resort to guerilla tactics more and more, they say, all U.S. military personnel--not only soldiers--have become targets for attack, they say. Consequently, more U.S. service personnel are being exposed to violent events, making them more likely to acquire PTSD or another mental illness, critics assert. "Because of the type of war it is, everybody is a target," remarks Rob Timmons, an Iraq veteran who sought therapy following his return to the U.S. and now works for the Iraq and Afghanistan Veterans of America. According to some detractors, one of the chief reasons the government has failed to develop contingency plans for soldiers' heightened mental health care needs is that there has been relatively little media coverage on the subject. Critics say that in the early years of the war on terrorism, the media tended to focus on deaths and visible injuries, rather than on soldiers' mental conditions. Consequently, they say, it took years for the media to spark the public outcry necessary to force congressional action on mental health care funding. "We simply have not been the beneficiaries of that type of substantial coverage by the media these past three years," remarks I.L. Meagher, editor of PTSD Combat: Winning the War Within. "So, how exactly would the public be expected to be prepared for what's to come--in fact, what is already here?" To ensure that the wars in Afghanistan and Iraq do not create a new generation of mentally ill veterans similar to the one created by the Vietnam War, the federal government must take far more vigorous action on solders' health care, critics insist. Among other things, the military should more actively educate soldiers about the causes and symptoms of mental illness, and make psychological therapy more readily available to those in need, they say. By bringing mental health care out of the shadows, opponents contend, the stigma surrounding mental illness can be weakened and mentally ill soldiers are more likely to get the help they need. As evidence that such outreach works, critics point to people like Sgt. Danny Facto, a member of the 10th Mountain Division who served in Afghanistan. According to Facto: When I go to [a] group and I talk with guys who are just like me it helps a lot, because I can discuss with guys that have been in combat, guys that have been shot at, guys who have lost friends in combat, guys that have killed other people. When I came back, I was me, but I was different because of my experiences. Mental health and therapy really helps to understand everything I've been through. A failure to provide soldiers with comprehensive mental health care must be viewed as a failure of society as a whole, many critics contend. After soldiers place their lives on the line to serve their country, critics assert, the least their country should do in return is ensure that those troops are taken care of upon their return to the U.S. Former Georgia Sen. Max Cleland (D), a Vietnam veteran who has struggled with depression, elaborates on the need to aggressively treat mentally ill soldiers: You can't send young Americans to Iraq and Afghanistan...and expect them to come home and just fit right in. They bring that trauma with them. If you don't intervene with the emotional aftermath of the war up-front and early, it can slide down a precipitous path to hell. Finally, a number of critics say that the federal government--and by extension, the nation as a whole--has a moral imperative to treat soldiers with respect after their deployments have ended. They insist that providing adequate mental health care to soldiers returning home now and in the future would be one of the most effective ways to demonstrate that respect. "How loudly we cheered them onward as they laced up their boots has no relevance once they've done their job," remarks Meagher. "It's how well we took care of them when they return that really defines our true moral character." Indefinite Length of Current War Raises Concerns
Out of necessity, the U.S. military has continued to extend tours of duty and re-deploy soldiers to Afghanistan and Iraq as of April 2007. While that ensures that U.S. troop levels in those countries hold steady for the foreseeable future, it also means that soldiers will have to cope with added stress. Stephen Xenakis, a psychiatrist and retired brigadier general in the Army medical corps, explains: "You are going to have all kinds of problems, discipline problems, all kinds of mistakes, misconduct. Everyone feels things will go downhill by extending tours." Though modern medical technology is saving an unprecedented number of lives of wounded military personnel--lives that likely would have been lost in previous wars--even the most sophisticated medical technology can do nothing about soldiers' mental health problems. But many veterans advocacy groups remain cautiously optimistic that the federal government is beginning a long-term policy shift. As the issue of soldiers' mental illnesses belatedly gains attention in the national media, they say, it may force lawmakers to routinely allocate significant funding to soldiers' mental health care. Such action is necessary, they say, because soldiers will remain emotionally scarred from having served in Afghanistan and Iraq, long after the fighting has ended. Discussion Questions & Activities 1) Reports indicate that mental health problems may be more widespread among soldiers returning from Iraq and Afghanistan than previously thought. In your opinion, what steps should the federal government take to address the issue? 2) Many observers remark that within U.S. military culture, there is a stigma surrounding mental health conditions; they say that many troops do not disclose mental health problems such as acute stress because soldiers do not want to be perceived as weak or vulnerable. How do you think U.S. military leaders might lessen the stigma? 3) Following the Vietnam War, the federal government was slow to recognize the widespread prevalence of mental health problems among returning veterans. Indeed, for many soldiers who fought in that conflict, medical treatment did not begin for years, if at all. What lessons do you think the country may have learned from the Vietnam experience in terms of how to care for the nation's military veterans? 4) If a country fails to provide comprehensive health care to its soldiers during and after a war, has that nation acted immorally in your opinion? Why or why not? Citation: "Soldiers' Mental Health." Issues & Controversies On File: n.p. Issues & Controversies. Facts On File News Services, 11 May 2007. Web. 11 Nov. 2010.