Why Should Psychiatrists Care About Veteran and Military Mental Health

Sycophants may ask, “Why should I care?” It's a reasonable question, and that's where we start. Each of you is a scarce resource for our society at large. If your bandwidth is like mine, it fills up fast and there's a limit to what it can digest and what it can handle. So here are a few reasons – by no means an exhaustive list – why what is happening in the field of soldier and veteran mental health is of great interest to you.

1. The local impact of the armed conflict of the past 13 years is greater than many people realize, and goes far beyond the number of veterans in your practice or community.

When I talk to groups, I usually start with a question, “How many Americans do you think have been in Iraq and Afghanistan since 9/11?”. Most of the time, I get only guesses. Rarely does more than one person give an estimate much above 500,000.

Sometimes listeners are surprised to learn that more than 2.5 million Americans have been deployed some 3.5 million times. This figure, large as it is, highlights another hard-to-understand fact: only two-thirds of Americans participated in these conflicts. For most American families, the only direct contact with the U.S. military occurs at the airport.

Closer examination reveals that the number of deployments is high, but the impact of these wars is even greater. In 2003, Nobel Prize-winning economist Joseph Stiglitz1 and his colleague Linda Bilmes estimated the cost of the Iraq war alone to be between $2,000 and $5,000 trillion (a wide range depending on the estimated economic impact of certain factors, but still considerable even using the most conservative estimate).

Can these figures be reliable? When the United States entered the Vietnam War in the early 1960s, Americans were still receiving compensation for the health effects of the civil war. It is this long economic history-some of it the result of direct benefits and compensation, but much of it perhaps the result of more insidious long-term effects on human health-that is the main driver of the costs of war.

2. The contrast between military and civilian culture may challenge our understanding of the end of social values and the beginning of evidence.

Those who have grown up in the United States often take certain ways of thinking for granted, even though sometimes the majority of the world thinks very differently about the same things. The most striking example that comes to mind is the tension between personal autonomy and collective responsibility.

For millennia, almost all peoples have tended to survive in small groups, and this is still the case in much of the world (though in decreasing numbers). This way of life leaves little room for autonomy; everyone has a role to play, and only collective effort can sustain a group. In this context, the boundaries of individuality are narrow, and violations of accepted roles can result in severe punishments.

In contrast, in Western civil societies, individuals are mobile, adults live independently of neighbors and extended family, and social institutions are diverse and downwardly specialized. Self-determination and the right of expression are basic human rights.

Neighbor and family involvement, on the other hand, is considered benign but discretionary. When failures occur, we look first for institutional failures, and we tend to see individuals as victims of powerful institutions.

I believe that many (not all) of the misunderstandings in civil-military affairs stem from the fact that the military is a return to an old mindset, a view that arises when survival depends on the continued viability of a small group or unit. In this context, each member of a small group lives and dies alongside the others.

Think of a severely wounded soldier who expresses a fervent, almost feverish desire to return to combat and to his unit. Duty is to sacrifice for the good of the unit; personal autonomy is nice, but it is only a luxury.

If a soldier “goes down,” the unit must retain him (think of the phrase “leave no soldier behind”). However, there are limits; if someone repeatedly crosses the line, the group is in danger, and the result is a reprimand or even dismissal. In this reality, when bad things happen, it is the individual's fault that the group survives until the next day.

Veterans are everywhere in our practices and lives, and we are often unaware of it. If you are lucky, this column-like the example above-will give you a basis for reexamining circumstances, difficult situations, and patient behavior from the perspective of military culture and values. It may enhance your “military cultural competence” or provide lessons for more general clinical applications.

3. Emerging military social trends, issues related to military health problems, and changes in the Department of Veterans Affairs (VA) and Department of Defense (DOD) health care systems often have national implications.

For example, the military's recognized need to better characterize the mental health consequences of World War II led directly to early versions of the current psychiatric diagnostic system. Subsequently, the description of symptoms in veterans returning from the Vietnam War led to the formalization and adoption of PTSD in the DSM-III classification.

The conflicts in Iraq and Afghanistan have contributed to an increased awareness and appreciation of neuropsychiatry for the physical and mental health problems caused by repeated attacks.

Important social trends are occurring in the military. The military was perhaps the first major workplace in the United States to achieve racial integration. It is now making slow but steady progress on career opportunities for women and equal rights for lesbian, gay, bisexual and transgender people because of and influenced by the larger national context.

Finally, the federal health systems serving the military and its veterans are important in ways that go beyond these latter headings. For some, these systems were the primary instigators of the community mental health movement that emerged in the late 1950s. Today, military and veterans' health care systems serve tens of millions of people in need, at an annual cost of more than $100 billion, and growing.

Recently, military and veteran health care systems have paid considerable attention to stigma and barriers to psychiatric care, fueling pressure for effective primary mental health care delivery models to increase access to psychiatric services and improve outcomes.

4. Regardless of where you live and work, the U.S. military and health care systems designed to support soldiers, veterans and their families are you!

It is all too easy to blame others for the consequences of the military's actions or the failures of the federal healthcare system. Regardless of how it may sometimes appear, the Department of Defense, Army, Navy, Marine Corps, Air Force and veterans have a responsibility to all of us. If we do not assume that responsibility, we are probably setting them up for failure, and we cannot expect a reward if they succeed.

I hope this column can be a useful venue to openly explore ways in which we, as a community of psychiatrists, can make our voices heard on issues related to the military, veterans service, public service in general, and past and present soldiers and their families.