Attrition: Stress a Growing Source of Casualties


May 29,2008: Last year the U.S. Army had 10,049 soldiers diagnosed with PTSD (post-traumatic stress disorder). This is ten times the number diagnosed in 2003 (1,020). The U.S. Marine Corps saw a similar jump, from 206 to 2,114. The navy and air force, which have been sending troops to Iraq and Afghanistan to help out the army, saw PTSD cases go up also. For the navy it went from 216 to 947. For the air force is went from 190 to 871. The navy supplies support personnel for the marines, including medics. The air forceprovided the army with security and logistics personnel, both of whom were sometimes shot at. In the last seven years, there have been about 40,000 combat casualties (not including PTSD). These stress related disorders can render a soldier unable to handle combat assignments, or any jobs that are stressful.

The stress of repeated trips to combat zones like Iraq and Afghanistan is largely responsible for the sharp jump in PTSD cases, and mental health professionals expected this. There are better diagnostic tools available, and a lot of publicity for a condition that the troops, and their families, traditionally preferred to keep quiet.

The problem is now, and has always been, pretty serious. Currently, for every soldier killed in combat, at least one is sent back to the United States because of severe PTSD (post-traumatic stress disorder), and several others are treated in the combat zone for less severe cases. During World War II, PTSD was an even more serious problem. In the European Theater, 25 percent of all casualties were serious PTSD cases, compared to about 20 percent today. In the Pacific Theater, the rate varied widely, depending on the campaign. In some of the most intense fighting, like Okinawa in 1945, PTSD accounted for over a third of all wounded. In Iraq, less than ten percent of the wounded are PTSD, but the more troops serve in a combat zone, in combat jobs, the more likely they are to develop PTSD. This has been known for over a century.

The stress of combat, and how to deal with it, has been a hot research topic since World War II.But the war on terror is unique because it is sending more troops into combat, for longer periods, than ever before. As expected, from past experience, the more time troops spend in combat, the more likely they are to suffer from stress.

These days, troops who have been in combat are closely monitored by mental health professionals, more so than at any other time in history. One proven way to help troops avoid PTSD is to allow them to recover, after a combat tour, before going back to the combat zone. There have two different approaches to this. The army lets troops stay at their stateside bases for 18-24 months between 12 month tours. The marines, and the British, allow 12 months at home between six month tours. Because of wartime demands, these recovery (or "dwell") times have been shorter, and this has caused an increase in PTSD casualties.

Research indicates that the six month tours are easier to recover from. With email and easy communications with people in the combat zone, the shorter tours do not waste as much time, getting the lay of the land, as in the past. Units know a year or more that they are going over there, and who they are going to replace. The two units now get in touch months before the relief, and bring the new crew up to date with written reports, pictures and even videos. This preparation is also believed to lessen the development of PTSD.

It's not the prospect of getting killed that causes the stress, but rather the constant state of alertness required to survive in combat. Death is always a factor in military life. Over the last 25 years, the U.S. Army has always lost one or two thousand dead each year to accidents, disease and suicide (in that order). That meant about two troops per thousand died each year. In Iraq, the risk of getting killed in combat is 2-3 percent for a one year tour. For the army overall, the risk of death from combat is less than one percent. But it's the stress that has the long term effects on the most people.

It was during World War II that researchers began compiling lots of data on troop stress and its effects. It was discovered that most troops were likely to develop debilitating PTSD after about 200 days of combat (that is, the stress of having your life threatened by enemy fire). But today there are other factors. Israel noted, after the 1982 war in Lebanon. That reservists were more sensitive to the aftereffects of combat. The Lebanon conflict used a larger number (than previous wars) of older reserve troops, who tended to be more prone to coming down with stress disorders. This was probably due to the fact the full time soldiers are constantly conditioned to deal with stress. While this is often referred, often derisively, as "military discipline," it has been known for thousands of years that such practices reduce stress and panic during combat. Apparently it reduces the chances of coming down with stress problems as well.

In Iraq, army combat troops often get 200 days of combat in one 12 month tour, which is more than their grandfathers got during all of World War II. And some troops are returning for a third tour in Iraq, which was fifteen months for over a year. The army has found ways to avoid the onset of stress problems (better accommodations, email contact with home, prompt treatment for any problems), but many troops are headed for uncharted territory, and an unprecedented amount of time in combat. Thusnew programs to spot stress related problems, as early as possible, and new treatments as well. The stress angle has been more intensively studied in Iraq than in any previous war. Naturally, the more you look, the more you find. A recent survey of troops who had served in Iraq and Afghanistan, found half of them still had some mental or physical health problems six months after returning from overseas.

Then there's the money factor. Combat pay and re-enlistment bonuses for combat troops provides a temptation to ignore stress symptoms and stay in a combat job. There are plenty of non-combat jobs you can transfer to, and for many of those, there are also large re-enlistment bonuses. This problem largely affects senior NCOs, who take a decade or more to develop, and provide essential combat leadership. Given the experience and maturity of these men, problems are not expected. But the army and marines have to keep a close watch, because it's a unique situation and no one is sure how it will all turn out.




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