Mental Healthcare and the Military

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Changing Attitudes on Mental Health in Military Populations

“In a battle with no solid enemy and no apparent battleground the warrior having been trained to combat the physical comes in contact with a foe that can over shadow the imagination” [1]. This is how former United States Army Infantryman Scott Lee described his struggle with combat related stress, a disorder that affects 17% of modern American soldiers by some estimates [2]. The American Psychiatric Association has only formally recognized combat stress as a medical condition since the late 1970s. However, beginning with formal diagnoses of “soldier’s heart” in the Civil War to modern post-traumatic stress disorder (PTSD), the horrors of combat have undoubtedly affected countless American soldiers for hundreds of years, many times long after their tours of duty.

It is clear that war has had certain long-lasting effects on soldiers from even ancient times. Some of the earliest known references to symptoms similar to combat stress came from around 1000 BC with descriptions of the decorated Egyptian warrior Hori and the fear he felt when thinking about battle in the latter years of his life. 500 years later, the ancient Greek historian Herodotus wrote about Spartan warriors who no longer wanted to wage war because of the stress of previous battles [3]. Herodotus also related the story of Epizelus, an Athenian soldier who was rendered blind after witnessing a fellow soldier’s death in battle [4].

The earliest reports of the postwar effects of combat stress in American soldiers began after the Civil War. At that time, it was becoming increasingly common for the insane to be sent to state-run asylums for care. Author Eric Dean examined the medical records of nearly 300 Civil War veterans who were admitted to the Indiana Hospital for the Insane in his book Shook Over Hell. Representative of many of the veterans in the asylum at the time, one of the patients in the book was admitted to the asylum in 1880 because he “was unable to settle down and adjust to civilian life” which prevented him from living independently [5]. Other veterans from the era complained of an ailment called “soldier’s heart” (sometimes called Da Costa’s syndrome) that was characterized by fatigue, chest pain, interrupted sleep, and shortness of breath. These symptoms were not accompanied by any gross physiological abnormalities but were nonetheless thought to be the result of a heart condition. Many cases were also attributed to military service and over-exertion. As a result, patients were often prescribed simple exercise and rest regimen [6]. In many respects, World War I was completely different from any conflict that came before it. Aside from the global scale of the war, it was the first time technology like telephones, tanks, and aircraft were used in combat. It was also the first time chemical warfare was used on such a grand scale. This combined with the high casualty rate of trench warfare made World War I was one of the deadliest conflicts ever [7]. As a result of the horrors of this war, there was a noticeable increase in the number of troops who either refused to fight or left their regiments without permission. This offense was punishable by death and at the time combat stress was not considered an adequate excuse for abandoning one’s duties. As a result, over 300 servicemen lost their lives for desertion [8]. As the war progressed, a new disorder termed “shell shock” began to appear. An article from the November 7, 1915 edition of the Washington Post described the explanation for the condition at the time. “When a big shell explodes it creates a sudden and very great pressure in the surrounding air…though there is not the slightest sign of a bruise or injury in any way…men have been completely incapacitated for months” [9]. Various cures were tried, including hypnosis but they proved to be of little use. Moreover, medical facilities on the front lines were quite limited and as a...
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