Professional News
Soldiers Say Combat Stress Second to Personal Stress
Psychiatric News
Volume 39 Number 8 page 25-94

In old war movies, soldiers were always men who had sweethearts back home. Occasionally, a soldier would receive a painful "Dear John" letter that underscored the downside to Army life.

Some things have changed since then—women are soldiers in today’s Army, and soldiers are just as likely to serve in peacekeeping missions as they are in war action.

But marriage is still a domestic casualty of Army deployments, and Dear John or Dear Jane letters are still received by soldiers, according to Maj. Robert Cardona, a U.S. Army psychiatrist assigned to a combat stress control (CSC) unit, the 98th Medical Detachment, in Mosul in northern Iraq for the past year. Cardona was interviewed online by Psychiatric News last August and again last month. He recently returned home to Fort Sill, Okla.

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Because U.S. Army Combat Stress Units in Iraq are situated close to where soldiers are serving, those who need mental health care can get it quickly.

The units’ mission involves supplementing the work of division and hospital psychiatrists and mental health professionals, said Cardona.

More than 100,000 U.S. soldiers have been sent to Iraq during the past year, often not seeing their family for one year. More replacements will be sent this year to help keep peace during the shift to self-rule in Iraq. Cardona described northern Iraq as a combat zone in which U.S. soldiers are targets of daily mortar attacks by hostile forces.

Most soldiers are aware of combat stress reactions from their training and from Army education campaigns. Many sought help from the 98th CSC before being sent back home, Cardona said.

"These soldiers were concerned that they would become violent and injure a family member or someone else back home. They were aware that [several] soldiers at Fort Bragg had become violent after returning from duty in Afghanistan a few years ago," he pointed out.


Between 60 percent and 90 percent of the 1,500 soldiers seen in the past year by the 98th medical detachment and by division psychiatrists had interpersonal problems. "The real stress results from family, personal, and work interpersonal issues that are intensified in deployment to a combat zone," Cardona said.

Soldiers with major depression can be successfully treated in the field in most cases. Minor depression and anxiety are more common, and treatment consists of antidepressant medication and/or a series of brief cognitive-behavioral therapy interventions, according to Cardona.


"Early in the deployment, we used medication to treat a handful of individuals who experienced their first psychotic or manic episode," he noted.

About 8 percent of soldiers treated by the 98th CSC had acute stress reactions to combat-related attacks on them or their convoys. Their symptoms including nightmares, insomnia, excessive guilt, anxiety, and an exaggerated startle response. These symptoms typically remitted in less than one week with treatment, said Cardona.

Occasionally, there were exceptions. For example, after a soldier saw the violent death of another soldier during a convoy attack, the experience triggered troubling memories of how a family member had died, memories that interfered with his ability to carry out his duties.

"The soldier avoided driving the truck, where he was located after the attack. He was placed in a restoration unit for four days and then returned to his unit. His nightmares continued, and he became increasingly depressed and ultimately suicidal, even though he was receiving medication and changes were made to his work detail," Cardona said.

The soldier required hospitalization and medical evacuation to Landstuhl Regional Medical Center in Germany, Cardona added.

The number of soldiers evacuated from Iraq for mental health problems nearly doubled between September 2003 and last January. In September, 478 soldiers were evacuated, and by January between 800 and 1,000 soldiers were evacuated for mental health reasons. They were treated at Landstuhl Regional Medical Center in Germany, Cardona stated.

Of the total soldiers evacuated from Iraq, 5 percent to 10 percent were based in northern Iraq, where 20 percent of U.S. soldiers were stationed at the time, he noted.

The suicide rate for U.S. soldiers in Iraq last year was higher than the average entire Army rate for last year, according to a new report released last month by an Army Mental Health Assessment Team. The team interviewed soldiers in Iraq between last August and October, according to the report.

At least 24 soldiers committed suicide in Iraq and Kuwait last year. Cardona said there were no suicides in the northern region, where he was based.

The Mental Health Assessment Team’s count equates to a suicide rate of 17.3 per 100,000 soldiers, which is higher than the entire U.S. Army’s rate of 12.8 suicides per 100,000 soldiers last year.

The team’s official number did not include three soldiers who committed suicide when they returned to the United States.

Investigators found a pattern among the soldiers who committed suicide—they faced personal financial problems, failed personal relationships, and legal problems, according to the report. The investigators also found that the soldiers tended to avoid seeking help for stress or mental health problems out of concern about being stigmatized.

The team recommended placing more psychiatrists and mental health professionals in Iraq and Kuwait and training soldiers to recognize signs of mental health problems using the buddy system.

One reason that the Mosul region may not have had suicides was the CSC’s decision early on to focus most of its resources on meeting the mental health needs of the majority of soldiers who were having interpersonal problems rather than combat-related stress reactions, Cardona said.

"We focused on managing soldiers already experiencing mental health problems or needing treatment for psychiatric disorders," Cardona stated.

The Army’s Mental Health Assessment Team report review of suicides (Annex D) is posted online at www.armymedicine.army.mil/news/mhat/annex_d.pdf. The U.S. Army’s "4Health Deployment Guide," written by military psychiatrists, is posted online at www.hooah4health.com/deployment/familymatters/emotionalcyle.htm; the American Academy of Child and Adolescent Psychiatry’s "Facts for Families," a publication for families in the military, is posted at www.aacap.org/publications/factsfam//88.htm.

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Because U.S. Army Combat Stress Units in Iraq are situated close to where soldiers are serving, those who need mental health care can get it quickly.

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