Lewis Wolpert: 'Much more attention must be given to military personnel who have had very stressful experiences'

Does experience of war lead to mental-health problems in professional soldiers?

Does experience of war lead to mental-health problems in professional soldiers? There is, as for mental-health problems in general, a curious silence about this maintained by our leaders. The idea that there is a mental illness related to combat experience is rather recent, and only goes back to the First World War, when some soldiers suffered from what was called "shell shock". But it only became a well-publicised condition in relation to returning soldiers from Vietnam. Studies on Vietnam veterans in the mid 1980s, some 20 years after service, found a prevalence of post-traumatic stress disorder (PTSD) in 15 per cent of men and 8 per cent of women and a much higher lifetime prevalence.

I have heard a psychiatrist pronounce that PTSD is the most desirable diagnosis for a patient in all of psychiatry - the patient has no responsibility and so can often sue someone. Indeed, no other diagnosis has had a more dramatic impact on law and social justice in the USA. The prevalence of PTSD in the adult population in the USA is three to four per cent. At the core of the problem is the nature of trauma, which can be thought of as an event that shatters people's deeply held beliefs about the world being safe and, on the whole, benevolent. Trauma results in a breach of mental structures. The key diagnostic criteria are previous threats of death or serious injury and a response of intense fear or helplessness - there are also recurrent distressing memories, including flashbacks. These debilitating symptoms continue for more than one month.

There are arguments that the prevalence of PTSD among Vietnam veterans has been grossly inflated and that the condition has been exaggerated for reasons of political expediency. But veterans of the Gulf War also showed significant numbers suffering from PTSD. A new study reported in the New England Journal of Medicine has now looked at PTSD in four US Army infantry units who were in combat in Afghanistan and Iraq.

This study is special as it was done so soon after combat experience and it includes a survey of mental health before the soldiers went into active service.

About five per cent of all US military service members suffer from PTSD, which is higher than the figure for the general public. For all groups studied, there was a strong relationship between combat experiences that included being shot at, handling dead bodies, knowing somebody who was killed, or killing one or more of the enemy, and experiencing PTSD. There was an almost linear relationship between the number of active combat experiences and having PTSD; with five such experiences, the figure for PTSD was up to 20 per cent.

Yet of those who met the criteria for mental-health disorder, only around 40 per cent showed any interest in getting help and fewer actually got help. Fear of stigmatisation was a major cause. Comments related to this included: a lack of trust in mental-health professionals, "it would be too embarrassing", "it would harm my career", "my unit leader might treat me differently", "my leaders would blame me for the problem" and "I would be seen to be weak". Fear of stigmatisation was greatest among those in greatest need of treatment and because the disorder is not well understood, treatment presents serious problems. It is necessary to bring the fearful memories under control. One treatment is based on cognitive therapy, which has been so successful in the treatment of a variety of mental illnesses, particularly depression, and tries to change the patients' false beliefs.

Antidepressants have also been shown to have some value. It is clear that much more attention must be given to military personnel who have had very stressful experiences. Efforts are required to assure military personnel that their condition will be kept confidential, and to make sure that this is in fact the case. It is also essential to reduce the stigma not only for soldiers but for the general public.

Lewis Wolpert is Emeritus Professor of Biology as Applied to Medicine at University College, London