Posttraumatic Stress Disorder, Suicide, and the Lessons of War

Today's Wars

A brief history of the Bush administration's refusal to apply sound science and humane policy to the question of combat-related PTSD and PTSD-related suicide among soldiers and veterans.

In August 2003, a string of soldier suicides and daunting psychiatric casualties provoked the army to send a team of mental health experts to Iraq. Their report confirmed a suicide rate three times greater than what is statistically normal for the armed forces. It further acknowledged that fully one-third of the evacuated psychiatric casualties "departed theater with suicide-related behaviors as part of their clinical presentation." Yet in spite of the daunting numbers and ominous implications for the future, the report concludes that "suicide among OIF [Operation Iraqi Freedom] deployed Soldiers is occurring for the same reasons typically found among Soldier-suicides": namely insufficient or underdeveloped life coping skills; marital, legal, or financial problems; chronic substance abuse; and mood disorders.

In April 2006, the Army released statistics showing that in spite of much-touted new prevention initiatives, the suicide rate had continued to climb. Col. Joseph Curtin, a senior Army spokesman, is quoted saying, "We're not alarmed." Curtin went on to say that the Army was not aware of any single reason for the rise, but he discounted the notion that the increase was caused by exposure to combat. Instead, he blamed factors such as financial difficulties, failed relationships, drugs and alcohol. Once again, the Army would have us believe that individual soldiers with personal problems are to blame.

It is baffling, if not astonishing, that these military psychiatrists, supposed experts in combat-related stress, have so normalized war that it is overlooked as the source of the disease they have been sent to diagnose, that its horror can be thus discounted and its psychic effects rendered invisible. A separate section of the report, intended to assess the general health and well-being of soldiers in Iraq, lists as the most often reported combat stressors "seeing dead bodies or human remains, being attacked or ambushed, and knowing someone who was seriously injured or killed." But the report considers none of these factors in its analysis of the etiology of soldier suicides.

Furthermore, active duty soldiers are only part of the story. One of the well-known characteristics of posttraumatic injuries is that the onset of symptoms is often delayed. Some soldiers manage to bring their memories home before they are overwhelmed. The military doesn’t track or count veteran suicides at all. They get written up in hometown newspapers; they are locally mourned, but they are officially ignored.

In October 2004, the army released a new study, published in the New England Journal of Medicine, reporting that one in six of all Iraq veterans suffers from PTSD or depression. Given that well over one million U.S. troops have fought in the wars since September 11, 2001 (as of January 1, the exact figure, according to the Pentagon, was 1,048,884, or approximately one-third the number of troops ever stationed in or around Vietnam during the fifteen years of that conflict), that would mean that at least 166,000 men and women already are living with serious mental illness as a result of their war experiences. But the Journal article went on to say that of those soldiers included in the army estimates, fewer than 40 percent have sought professional help, and that those who have not sought help are generally the most vulnerable, the most fragile, the most likely to develop serious and lasting symptoms.

In March of 2006, however, the Journal of the American Medical Association published a new study claiming that the number of soldiers who will experience "clinically serious stress reaction symptoms" was actually more like one in three. That would make more than 333,000 veterans who already need help. And consider that the data thus far available concern only the acute cases. The delayed and the chronic cases have yet to manifest themselves.

Clearly anticipating that PTSD will be difficult if not impossible to keep out of the public debate, the Bush administration and its domestic allies are attempting to preempt the issue using arguments that masquerade as science to obfuscate or deny credible scientific evidence. They are creating what New York Times editorial writer Paul Krugman has described as "a sort of parallel intellectual universe, a world of 'scholars' whose careers are based on toeing an ideological line, rather than on doing research that stands up to scrutiny by their peers." American Enterprise scholar and administration apologist Sally Satel, for example, blames psychiatrists for over-diagnosing PTSD and veterans for allowing themselves to be seduced into believing they are really sick. According to Satel, whose articles and opinion pieces have been published in newspapers all over the U.S., there's nothing wrong with the vets that the distraction of a good job wouldn't cure. Unfortunately, she would have us believe, the lazy bums have instead been handed the perfect excuse to just lie back and collect benefits. It's the diagnosis that is ruining lives, and not the horror of warfare.

Satel's most recent attack accuses Vietnam vets, who are approaching retirement age, of using PTSD claims to cushion their retirement funds. She is quite right in claiming that the vast majority of veterans receiving disability compensation for PTSD in the past few years have been Vietnam veterans. Once again, she is trying to drum up suspicion of veteran fraud. The veterans, however, attribute the renewal of their symptoms to the daily onslaught of horrific images and stories coming out of Iraq. Max Cleland, for example, the former senator from Georgia and a triple amputee from the war Vietnam, has recently gone back into therapy at Walter Reed for PTSD that has flared up anew. Cleland says , since this new war began, "I don't read a newspaper. I don't watch television. It's all a trigger. . . . This war has triggered me, and it has triggered Vietnam veterans all over America." John P. Wilson, who has extensively researched Vietnam veterans at Cleveland State University, said 57 percent reported flashbacks after watching reports about the war on television, and almost 46 percent said their sleep was disrupted. Nearly 44 percent said they had fallen into a depression since the war began, and nearly 30 percent said they had sought counseling since combat started in Iraq. "Clearly the current Iraq war, and their exposure to it, created significantly increased distress for them," said Wilson, who has done extensive research on Vietnam veterans since the 1970s. "We found very high levels of intensification of their symptoms. . . . It's like a fever that has gone from 99 to 104."

Compounding the image Satel has drawn of an opportunistic cabal of psychiatrists and veterans using PTSD diagnoses to defraud the public, the VA decided in August 2005 to review the cases of over 72,000 veterans who have already been awarded the maximum disability compensation for PTSD. That means that those veterans with the most serious mental problems will have to prove their case all over again. Aside from the injustice of choosing to reevaluate only those cases where veterans received 100 percent disability and not cases where they were either awarded inappropriately low ratings or unfairly denied disability altogether, the VA's pursuit of the most vulnerable vets with PTSD and the high-decibel accusations of potential fraud promote the stigma attached to mental trauma. "There is flat-out discrimination against PTSD on the part of many people, both in the military and [in] the VA," says Rick Weidman, director of government relations at Vietnam Veterans of America. He calls the VA review "a biased and bigoted view of neuropsychiatric wounds." Once again, it is the vets who have been made ill by their combat experiences who are being denounced and disavowed, and the timing sends a menacing message to those soldiers who are now in or hoping to return from Iraq and Afghanistan. Though military psychiatrists agree that the sooner a traumatized soldier asks for and receives appropriate help, the more likely it is that their symptoms can be managed—not cured, mind you, managed. According to the Army's own mental health advisory team, 50% of the soldiers in Iraq are afraid to ask for help if they are having any kind of stress reaction because they believe they will face ridicule, or persecution, or even an end to their military careers.

Sadly, the lessons of Vietnam are not being applied to the new wars in Iraq and Afghanistan, and the scientific chicanery and the refusal to undertake the necessary research continue. In the same way as combat stress was inexplicably dropped as a diagnostic category from the DSM-II at the height of the war in Vietnam, as suicide was erased from the National Vietnam Veterans Readjustment Study in 1980, and as the effects of Agent Orange poisoning were stonewalled for a decade, bogus ideas about PTSD are now being peddled in the hopes that they will defuse what is already an explosive topic, one that promises to be politically destabilizing, monumentally expensive, and very bad for recruiting.

Given that we now seem to have embarked on a vaguely defined war-without-end, it is hardly surprising that the architects of current U.S. military adventurism are attempting to spin the issue of PTSD. Acknowledging the psychic costs of combat in the service of one's country implies an ethical responsibility to those affected. The connection between combat and PTSD has been firmly established over time. The connection between PTSD and suicide has been established, if not by our own government then by experts in other countries, as "the most severe short-and-long-term consequence" of military service. Yet this administration has instead repeatedly slashed veterans’ health care benefits, challenged established diagnostic criteria, and made use of non-peer reviewed "science" to manipulate Congressional directives and public perception.

As I write, there is a growing concern that Iraq may prove to be an even more devastating experience for American soldiers than Vietnam. And once again, many will be twice wounded: once by their combat experiences and a second time by the country, the citizens in whose name they fought. Flashback is an attempt to counter some of the unscientific disinformation that dishonors our soldiers and veterans, betrays their families, disrupts their communities and eats away at the traditional values and beliefs on which patriotism finally depends.

Penny Coleman, 2006