Why so many US psychiatric casualties in Iraq?

HM3_2545_iraq_war_001.jpgTwo studies published this year have highlighted a stark difference in the level of psychiatric casualties between British and American troops involved in the Iraq war.

A study in the Lancet reported that only four percent of British troops in Iraq reach criteria for post-traumatic stress disorder (PTSD) – a trauma related mental illness.

In contrast, approximately ten to twenty percent of US troops are diagnosable with the condition, according to studies published in the New England Journal of Medicine and the Journal of the American Medical Association.

In an editorial for JAMA, psychiatrists Matthew Hotopf and Simon Wessely suggest a number of reasons for why this might be the case.

The first is that US troops may be involved in more dangerous combat duty and are therefore more likely to be traumatised.

However, they suggest other factors are also likely to be important.

US tours of duty are typically for 1 year, whereas UK tours are for 6 months. This means any combat-duty-related psychological stresses are likely to be extended in US personnel.

Further factors relate to the differences in the populations of the US and UK forces:

…the groups described in the US studies were demographically different from those described here. The US forces deployed to Iraq in both studies were younger, of lower rank, and contained more reservists than our UK sample. While less than 10% of the US sample had previous experience of deployment, more than two-thirds of the UK service personnel from both cohorts had been on previous deployments in a range of settings, including both war-fighting and peacekeeping duties. They therefore had much more experience of the stresses of military deployments, and might have been more resilient to these stresses.

In other words, US forces in Iraq are more likely to be made up of younger, non-professional soldiers, on longer tours of duty, with less combat experience, in more dangerous areas, when compared to their their UK counterparts – potentially making them more vulnerable to mental illnesses such as post-traumatic stress disorder.

Link to abstract of Lancet study on mental health of UK troops in Iraq.
Link to JAMA study on mental health of US troops in Iraq.
Link to NEJM study on mental health of US troops in Iraq.
Link to US National Center for PTSD Iraq War information page.

One thought on “Why so many US psychiatric casualties in Iraq?”

  1. Why so many psychiatric casualties in Iraq? Hmmm? Lemme see, er KEVLAR. I’m quite certain the increase in the relative numbers of psychiatric casualties is likely proportional to the use of improved body armor which protects vital organs, but tends to be lacking in it’s ability to protect against less than fatal injuries, concussion trauma, and folks getting shredded in less than fatal fashion.
    Yeah, I know. It seems a bit insensitive to make such statements, but since our experiences in past military engagements on the antisocial social engineering circuit this past century we have developed military medicine and personal protection gear to a level which increases survivability, but also leaves a bit to be desired in the areas of psychological and less than lethal physical injury.
    Of course, folks don’t generally like to see other folks get injured or killed and PTSD increases, IMO, as the body count goes down due to the fact that the wounded survive and the witnesses remain cognizant of the fact that they do so with physical scars and damage.
    Consider, that when we grieve, the process is long enough when there is a appearance of resolution. When folks are KIA they are removed from the field and the unit is notified. Brief memorials are held locally and then the body is shipped back to the states. THEY ARE GONE. When the wounded go home they usually lose touch with their comrades who KNOW they are suffering or at least suspect they are and can do nothing about it. The trauma remains as the grieving process is unresolved.
    Perhaps, if the wounded and their families, during their recovery, kept in touch with the folks in the field to let them know they are doing alright and appreciate the efforts of their comrades, the grieving process could be facilitated for both the wounded who return for medical treatment, as well as the folks they leave behind.
    It sounds ironic that the folks left behind in such cases are the guys and gals out on the line, but they don’t get to process their grief with regard to losses of comrades and shipmates while they are still in the field themselves.
    PTSD is generally, at it’s root, a sense of guilt and failure which in extreme cases results in fears of an irrational nature. Individuals feel responsible for the injuries and deaths of others despite the fact that they are not in fact responsible at all.
    The men I spent time with on a VA PTSD unit a few years ago were, for the most part, Vietnam era guys. When considering their condition, as well as my own, we discover that, although many of those guys had been traumatized in many violent engagements, in some cases being severely physically wounded themselves and recovering, they were disturbed by visions of what happened to their comrades and feared divine reprisal for their actions against the “enemy”.
    Many of those guys laughed about their own past injuries and purple hearts, but woke up screaming in the middle of the night when they had nightmares and flashbacks related to the images and sounds of their comrades and their opponents suffering for which they take upon themselves personal responsibility.
    As a nurse, I understand the process yet have led a charmed life. Since the military, during my career, not a I was advised that on ONE occassion a patient died in his sleep on my watch and this event went unnoticed for about 2 hours until breakfast. I have worked in Orthopedics, General Medical Surgical, Geriatric, Homecare (as a coordinator and supervisor), but spent most of my own career in Psychiatry, and Mental Health Adminstration.
    No one ever died on my watch that I was ever aware of. As I said, I was informed after the fact of one reported unexpected death of an otherwise healthy 39 year old cocaine addict suffereing from depression. None of my patients ever successfully suicided while I was on duty. None of my 150 geriatric patients ever died on my shift (nights) in over 1 1/2 years fulltime at a nursing home. Many, I was told, died on the day and evening shift, but NEVER on my shift.
    I was informed of accidental deaths and suicides. I was informed of expected deaths, but no one has ever died while I was on duty. Amazing, huh? I’ve been to a few funerals, but rarely go to open casket wakes. I don’t believe in death. I DO HOWEVER get very angry when people around me suffer due to what I perceive to be FAILURES on the part of the system which serves our fellows on planet paranoia. I get even more angry at myself when I fail or perceive that something I did wrong may have contributed to the injury or death of a patient, even though none ever died in my care, and hope they never do. I was informed of suicides and lost shipmates in military plane crashes. I was informed of the deaths of many of my patients by suicide, accident, or as an “expected” outcome of their condition, but none ever died while I was in attendance. I’ve seen suffering, but surpisingly I’ve never really seen death as believe it is unnecessary.
    The folks who see the suffering of the Iraqi people with whom we are NOT AT WAR, but trying to protect, and the folks who lose comrades and shipmates to injuries, more so than death in modern warfare, are left to think about what they did wrong or could have done better and feel anger, guilt and fear which produces horrendous psychological consequences as they are not permitted to grieve the losses of the civilians they are protecting, their fallen, but very much alive and suffering comrades who are recovering in some facility or at home, and they cannot grieve their fallen enemies, who, just like them, believe in their mission and cause although we tend to disagree on certain key sticking points in most fire fights.
    Perhaps considering the needs of our kids in the field should include keeping them apprised of the progress and or fate of the folks who went home, and allowing for participation, indirectly in the mourning process of the victims of the sectarian/guerrilla violence. Most of the victims are civilians. Women and children are the victims in many cases, as are Iraqis who, like our troops, are trying to restore the peace and stop the violence. It may be inappropriate, as well as downright unsafe, for our personnal to attend many of the services held for the Iraqi civilians who remain nameless to us as well as them. They see the dead. Most of the dead are Iraqi civilians who have no names. Our people survive most of the attacks. The civilians aren’t wearing body armor when they are subjected to the blast of an IED or a rocket attack. Our people feel pretty damned guilty when they can’t protect them and survive themselves. The “enemy” is not the “enemy”. They are victims too. We just see the current situation and state of affairs from different angles based upon our own needs, desires and fears of loss of power, control, resources, friends, family, homes, and personal injury.
    Maybe we should just stop and consider those trapped in the conflict are the one’s suffering the most and need to grieve as well as know that those who left the field wounded are home and well or improving. They need to know the victims of the violence they could not protect are either recovering from their own injuries or not forgotten either.
    We have a wall in Washington with over 58,000 names on it representing the men and women who died in a particularly long and bloody Southeast Asian conflict some years ago. The guys in the PTSD unit are their because there isn’t a wall for the 4 Million Vietnames or the 1.5 million Laotians and Cambodians who fell there as well. They volunteer to serve because they care. After they learn their lessons the hard way and see the elephant they don’t stop caring and they don’t forget. Elephants don’t either. They tend to remember forever and that can be a painful process if not redirected towards building better memories.

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