The wars in Iraq and Afghanistan may be a natural experiment in military mental health, one that has allowed researchers to observe similarities and differences between the two Western armies providing the bulk of the fighting forces.
The United States and the United Kingdom have been allies in those two struggles for twice as long as they were in World War II, said Simon Wessely, M.Sc., M.D., a professor and head of the Department of Psychological Medicine and director of the King's Centre for Military Health Research at the Institute of Psychiatry at King's College London. He spoke at a panel discussion with U.S. researchers in Washington, D.C., in November sponsored by King's College London.
The two countries' armed forces have been fighting on the same terrain against the same enemy and taking proportionately similar casualties.
Those commonalities make it possible to compare how their troops have dealt with the mental health aftermath of combat, said Wessely.
There are also methodological parallels that help researchers study the issue. As the Iraq war began in 2003, Wessely was asked to set up a study on the health of British troops in hopes of avoiding mistakes that occurred in the Gulf War of 1991.
"We agreed to use the same measures as the U.S. to trace, monitor, and follow up on the health of British forces," he said.
These ongoing studies have shown where the experiences of the two countries' soldiers are similar and where they differ. Combat exposure remains a major risk factor for soldiers of both nations.
"The differences lie not on the battlefield, but in the cultural traditions of the two countries," Wessely told Psychiatric News after his talk. "For instance, we have very different health care systems and very different attitudes toward alcohol."
British posttraumatic stress disorder (PTSD) rates are surprisingly low, about 2 percent to 3 percent, compared with U.S. rates of 12 percent to 15 percent, said Wessely.
This is likely not due to greater British resilience, but to different stressors facing the U.S. troops, he noted.
Many of the symptoms of PTSD—avoidance, numbing, anger, hypervigilance, exaggerated startle response—may actually be useful in combat. Problems arise when troops exhibit those reactions after they return home.
"If the symptoms of PTSD are adaptive, maybe U.S. troops are better adapted to war," said another panelist, Col. David Benedek, with some irony. Benedek is a professor of psychiatry and deputy chair of the Department of Psychiatry at the Uniformed Services University of the Health Sciences and associate director of the university's Center for the Study of Traumatic Stress.
In addition, the United States uses more reservists, who have proven to be more vulnerable psychologically, and it deploys troops for a year at a time, longer than the usual British tour of duty. British troops also stay at home for twice the length of time that they are deployed. American soldiers remain at home for only one year following a deployment. Military psychiatrists have said that is not enough time to recover from the stresses of war.
Another difference between the two countries is the increase in mental health problems that appear as time passes following deployment, said Wessely.
American troops are screened as they return to their home bases in the United States or Europe and again six to nine months later. They report more symptoms at the second assessment, indicating either a delay in onset or a greater willingness to acknowledge symptoms.
The United Kingdom doesn't screen its troops on the way home. "But we have observed no similar [rise in symptoms over time] in the U.K.," said Wessely, although rates of psychological problems did rise among British troops when their time in Iraq was extended without warning in the middle of their scheduled tours of duty.
"That taught us to manage the expectations of our troops," he said. "You have to stick with your promise."
Wessely noted another difference in military cultures. About 15 percent to 20 percent of British troops are returning with significant alcohol problems, higher than rates for U.S. troops.
"Our rates of alcoholism trouble me," he said.
To illustrate the greater comfort with alcohol that characterizes British military culture, Wessely said that parts of his research planning had taken place while sharing a few rounds of drinks with his colleagues.
That would never be acknowledged by U.S. personnel, said Benedek.
"No American military leader would ever admit that anything good came out of having alcohol at a discussion," he said.
Systems of care within the military services are similar, noted Wessely, but differ once a soldier leaves active service. British veterans are treated by their country's National Health Service, while former U.S. soldiers can either enter the Department of Veterans Affairs system or use private medical resources.
Like their American counterparts, British troops are reluctant to seek help for psychological problems because doing so goes against the grain of the warrior culture.
Returning U.S. soldiers report being easily startled, avoiding crowds, shutting down emotionally, and driving in the middle of the road, as they did in Iraq to avoid roadside bombs, said psychiatric epidemiologist Charles Hoge, M.D., a retired U.S. Army colonel and former director of the Division of Psychiatry and Behavioral Sciences at Walter Reed Army Institute of Research in Silver Spring, Md.
Furthermore, once they are home, half of U.S. troops who screen positive for PTSD won't come in for treatment, he said, and many who do begin treatment don't complete a 10- or 12-session course of therapy.
The way the mental health profession presents itself to soldiers may be yet another source of stigma, Hoge suggested. "Perhaps we shouldn't be using terms like ‘wound’ or ‘illness,’ but rather ‘transitions,’" he said.
And how troops are asked about their psychological symptoms may play an important role in the answers they provide. Questionnaire responses are different on anonymous surveys than on ones in which the soldier gives his or her name, said Benedek.
"[Just administering] the surveys tells them that we're checking for illness and we suspect it's there," he said. "Perhaps we're sending a message that there is an expectation in U.S. society to see symptoms."
Yet, there is hope for improving the lives of veterans returning from the current fighting.
"Military culture is changing," said Hoge. "This is the first war where there was a commitment to study the mental health of the people fighting it as it was going on."
Information about the King's Centre for Military Health Research is posted at <www.kcl.ac.uk/kcmhr>.