Psychiatry in War

The United States has engaged in 10 major wars since its founding, with psychiatry first becoming involved—or trying to become involved—in military combat during the Civil War.

In 1864 the Association of Medical Superintendents of American Institutions for the Insane (now APA) held its annual meeting in Washington, D.C., and the superintendents who called upon President Lincoln were “cordially received.” Charles Henry Nichols, M.D., the superintendent of the Government Hospital for the Insane (now St. Elizabeths Hospital) and acting assistant surgeon during the Civil War, was appointed to meet with the Army surgeon general to offer the assistance of the Association to care for the wounded in Fredericksburg, Va. The written reply gave thanks, but “until a more urgent necessity makes it advisable,” help was not then needed.

Psychiatry’s interest in military matters arose again during World War I (1914-18). Thomas Salmon, M.D., medical director of the National Committee of Mental Hygiene (now the National Mental Health Association), became concerned about reports of psychiatric war casualties and went to England to see how they were being managed. He joined with Pearce Baily, M.D., and Stewart Paton, M.D., to form an advisory committee to the surgeon general of the Army, which led to the establishment of a neuropsychiatry unit in the surgeon general’s office and preparation of a program for psychiatry in the Army.

When America entered the war in 1917, Salmon was appointed chief of psychiatry for the Army overseas. The psychiatric program went into effect and included screening of recruits, assignment of senior psychiatrists as consultants to Army divisions, establishment of base hospitals close to the front, and psychiatric units in general hospitals.

Psychiatric casualties were treated with the principles of immediacy, proximity to the war front, simplicity (rest, recreation, occupation), expectancy (return to active duty), and centrality (a central screening point prior to evacuations). The program was successful in returning to duty many soldiers who had suffered from “shellshock” and traumatic neuroses.

When the United States entered World War II in 1941, the psychiatric lessons gleaned from World War I had been forgotten and thus had to be relearned. The William H. White Foundation, a psychoanalytic group in Washington, D.C., with Harry Stack Sullivan, M.D., proposed guidelines for Army inductees that were later modified by the Selective Service System. APA became actively involved. A neuropsychiatric unit in the surgeon general’s office was again activated, with Roy Halloran, M.D., and later William Menninger, M.D., in charge.

The small number of psychiatrists available for active duty was supplemented by general practitioners who were given brief psychiatric training (many entered psychiatry residencies after the war). Salmon’s principles were again put in place to treat what was termed combat or exhaustion fatigue. The importance of morale and unit cohesion was demonstrated.

The Korean War (1950-53) also used Salmon’s principles under the leadership of Col. Albert Glass, and once again success in returning a large proportion of psychiatric casualties to active duty was achieved.

The Vietnam War (1961-73) was a different type of war fought in a different way from previous wars. Also different was the emergence of psychiatric casualties after the war. Posttraumatic stress disorder with symptoms of hyperarousal, intrusion, and avoidance affected many veterans, who were treated in special units of the Veterans Administration. Also encountered during the prolonged conflict were psychoneurotic symptoms, disciplinary infractions, and drug abuse among the support troops attributed to a lack of social supports and unit cohesion.

Psychiatric casualties during the brief first Gulf War (1991) were small in number, but a new entity called Gulf War syndrome emerged with psychosomatic components such as fatigue and lack of concentration. No adequate explanation about its etiology has yet been agreed upon.

The United States is again engaged in war in 2003. Psychiatry is taking an active role drawing on experiences of the past, and Psychiatric News will report on psychiatry’s latest contributions in this arena in future issues. ▪