Investigating Recurrent Generational Wartime Behavioral Health Crises: Part 2 of a Preliminary Analysis

Abstract

This is the second of a two-part analysis of generational wartime mental health crises. Wartime mental health crisis has been defined as a sentinel public health event whereby mental health demand of the military population demonstrably exceeds the mental health system’s capacity to provide adequate access to timely, effective mental health and social support services during and/or after a period of war. The present study extends an analysis that substantiated a twenty-first century wartime crisis by investigating the hypothesis of repetitive mental health crises following every major American war since the 20th century. Compelling evidence of recurring generational crises is established by citing first-hand primary sources from wartime cohorts. A clear trend emerged, possibly linking the pattern of wartime crises with generations of self-reported failure to learn well-documented war trauma lessons (e.g., the need to adequately plan, prepare, and train for inevitable war stress casualties). The authors discuss the need for further research that would elucidate so-called “psychiatric lessons of war” and contribute to the prevention of cyclic crises.

Introduction

In 2004, the USA Today headline “A deluge of troubled soldiers is in the offing, experts predict” (Shane 2004), followed by “Officer sees ‘perfect storm’ brewing in military’s mental health care system” (Batdorff, 2006), reflected a growing public concern over reports of escalating rates of returning military with untreated mental health conditions, to include far more than the commonly reported posttraumatic stress disorder (PTSD) (Priest & Hull, 2007; Tanielian & Jaycox, 2008). Ramchand, Acosta, Burns, Jaycox, and Pernin (2011) describe the growing crisis of returning military suffering from depression, as well as the high numbers who attempt and commit suicide. Reports by the Institute of Medicine (2012) indicate increases in military personnel with substance abuse issues. Studies by F. D. Jones (1995b) indicate a high incidence of misconduct stress behavior, defined by Russell as “a range of maladaptive stress reactions from minor to serious violations of military or civilian law and the Law of Land Warfare (2015, para. 4). Klostermann, Mignone, Kelley, Musson, and Bohall (2012) and Mulrine (2012) document increasing numbers of postdeployment interpersonal violence. Increasing numbers of traumatic brain injuries are noted by Sternberg (2011) and Tanielian and Jaycox (2008). Associated research by Schram (2008) documents an increase in the number and frequency of complaints regarding delays in disability claim processing by the Veterans Benefits Administration (VBA), as well as lengthy treatment waiting lists and severe staffing shortages in the clinical branch of the Department of Veterans Affairs, known as the VA (Government Accountability Office, 2011; Philpott, 2011). All such reports and studies are highly suggestive of a national public health emergency.

In January 2007, an article in USA Today “Psychologist: Navy faces crisis” spurred rumors of a mental health crisis among active duty military, veterans, and their families. The article described an overwhelmed military health system with critical shortages in well-trained specialists; consequently, the system offers only limited access to its beneficiaries, and military personnel, veterans, and family members are faced with a system that severely limits their access to basic mental health services. However, when questioned, senior officials denied the article’s assertions as mere speculation (Zoroya, 2007). Debate on the presence of a major wartime crisis ended on June 16, 2007. Nearly 6 years into World War I, the first major American war of the twenty-first century, a congressionally mandated Department of Defense (DoD) Task Force on Mental Health issued the following statement: “The Task Force arrived at a single finding underpinning all others. The Military Health System lacks the fiscal resources and the fully-trained personnel to fulfill its mission to support psychological health in peacetime [emphasis added] or fulfill the enhanced requirements imposed during times of conflict” (Department of Defense Task Force on Mental Health, 2007, p. ES-2). This statement acknowledges the inability of the Military Health System to plan, prepare, and respond during a time of war. In reality, the system continues to fail to provide adequate and timely services to the 1.3 million men and women deployed at least once to warzones, the 100,000–150,000 service members discharged from the military every year, countless family members, DoD contractors, and caregivers (Department of Defense Task Force on Mental Health, 2007). Hence, this military task force report concludes with a sense of urgency as noted by the following recommendations of the report.

The time for action is now. The human and financial costs of un-addressed problems will rise dramatically over time. Our nation learned this lesson, at a tragic cost, in the years following the Vietnam War. Fully investing in prevention, early intervention, and effective treatment are responsibilities incumbent upon us as we endeavor to fulfill our obligation to our military service members. (Department of Defense Task Force on Mental Health, 2007, p. 63)

Although a subsequent flurry of government investigations and news media stories fueled the notion of a national crisis, or disaster, no framework or precedent existed to provide a basis on which such a determination could be made (Russell & Figley, submitted for publication). Such a framework would define wartime crisis, provide assessment tools to determine whether the country is experiencing such a crisis, and record and interpret data to determine and prevent repetitive crises.

Investigating a Twenty-First Century Wartime Behavioral Health Crisis

Focusing on Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND), the wars of the twenty-first century, Russell & Figley (submitted for publication) conducted the first published analysis of a wartime behavioral health crisis. They conducted an extensive review of the historical precedents from previous American wars and the contemporary records from the DoD and Department of Veterans Affairs (DVA), which includes the VA and VBA. In addition, they consulted presidential and congressionally initiated investigations and national news media reports. Their findings substantiate a major crisis in unmet behavioral health and social needs amid the context of an ill-prepared, inherently fragmented, and overwhelmed mental health system (2013).

Perceived Trend of Repetitive Wartime Behavioral Health Crises

The present social climate in military mental health care is reminiscent of previous war generations. In addition to the reference to Vietnam War “lessons” made by the Department of Defense Task Force on Mental Health (2007), the following news headlines, dating back to the American Civil War, suggest a trend of recurring wartime behavioral crises throughout US history: Persian Gulf War (1990–1991), “Gulf war taking toll at home” (Jordan, 1991); Vietnam War (1965–1973), “Veterans battle emotional strain: Vietnam returnees discuss problems of dislocation” (1973); Korean War (1951–1953), “Psychiatry panel scores VA Policy: Physicians at Parlay say incentives are lacking for hospital staff” (Harrison, 1957); Second World War (WWII: 1939–1945), “Bradley demands aid for veterans; says community must help or create conditions that can breed psycho-neurotics” (1945); First World War (WWI: 1914–1919), “Insane war veterans reported increasing: Legions rehabilitation body told number exceeds hospital facilities” (1934); Spanish-American War (1898), “Suicide and insanity in Army” (1900); and American Civil War (1861–1865), “Suicide of an Army officer” (1874).

Purpose and Methods

To date, there has never been an investigation of the historical and empirical evidence for repetitive generational wartime mental health crises. Our intention is that this investigation be used to define wartime crises and their causes in order to assist governments, organizations, and individuals in taking a proactive position to prevent such crises and to react in a timely manner once a crisis is identified.

The current study represents our preliminary findings after an extensive review of the American experience in managing war stress casualties in major armed conflict since the twentieth century. We examined recurring themes from over 100 primary and 30 secondary sources, emphasizing official primary source material such as military medical department records, books, and reports; transcripts of congressional hearings; official memoires by first-hand military witnesses; and government commissioned studies, task forces, and other investigatory reports, as well as secondary sources from military historians and news archives. Where possible, we preserve the historical narrative by citing directly from primary sources.

From Behavioral Health Crisis to Catastrophe

A “wartime behavioral health crisis” has been defined as “a sentinel public health event whereby mental health demand of the military populations and support personnel demonstrably exceeds the mental health system’s capacity to provide adequate access to timely, effective mental health and social support services during and/or after a period of war” (Russell & Figley, submitted for publication, p. 5). It is further hypothesized that behavioral health crises are typically caused and exacerbated by a series of critical omissions and commissions. For example, commissions such as actively ignoring well-documented “lessons learned” from earlier generations citing the need to adequately plan and prepare for inevitable large numbers of psychiatric casualties from modern warfare by ensuring the provision of sufficient resources, training, mental health staffing, and treatment (e.g., Department of Defense Task Force on Mental Health, 2007). In addition, omissions such as the absence of centralized, transparent tracking of war stress injuries, lack of specific policies and programs responsible for learning war trauma lessons, and perpetuating a fragmented, uncoordinated, and unaccountable mental health delivery system (e.g., Institute of Medicine 2014) all represent preventable causes of wartime crises. A crisis becomes a catastrophe when unmet needs endanger the health and safety of large numbers of individuals, families, and society as a whole. Russell & Figley (submitted for publication) defined a behavioral health catastrophe as “the enduring, often trans-generational consequences of a protracted mental health crisis that results in significant individual harm and societal costs due to long-term suffering, disability, impaired health, suicide, and social disruption” (p. 6).

Factors That Determine the Dimensions and Costs of Crises

The dimension (size, scope, and duration) and cost of a crisis vary based on three interrelated factors: capacity to meet mental health and social needs, extent of demand for mental health and social needs, and organizational commitment to a holistic paradigm. It is critical that foundational and complementary war trauma lessons are adequately learned so that there is an adequate number of well-trained specialists available; accurate, transparent reporting is conducted; early access to high quality definitive care is provided; and adequate family support exists to meet the needs of the military population, especially in the crucial “prewar” planning period. To determine the extent of the demand for services, the organization must take into consideration the prevalence and spectrum of inevitable war stress injury, the number of deployed personnel, and the length of deployment with regard to exposure to war stress, otherwise known as dosage effect (the duration and type of warfare––low versus high intensity––and perceived social support) (Jones, 1995a). To lessen the impact of a crisis, the organization must commit to a holistic paradigm of war stress injury with zero tolerance of stigma and disparity. This will require modification of organizational structure, policy, and leadership as well as adequate allocation of resources for learning war trauma lessons during peace and war. Such modification represents core foundational war trauma lessons, but we single it out as a variable in order to highlight its central importance in setting expectations.

Inherent Difficulties Investigating Generational Wartime Crises

Authors on war stress often cite the major obstacle to comparing war stress casualty rates across historical epochs as ever-changing diagnostic schemes (e.g., Jones & Wessely, 2005). While varying labels and cultural understanding of war stress injuries can be problematic, by far the most pronounced barrier to evaluating the status of wartime mental health needs is the availability of accurate, comprehensive, and detailed official records, regardless of diagnostic trend. At present, there is no central repository or lead government agency responsible for monitoring, collecting, or reporting vital information on the wartime behavioral health needs of the military population. The most frequently cited primary source for information on military neuropsychiatric rates is postwar Army analyses available since the American Civil War (http://history.amedd.army.mil/books.html). However, these records primarily account for the prevalence and treatment of war stress casualties experienced by the US Army during, and sometimes immediately after, military service, thereby excluding critical data on postwar readjustment periods as well as incidence rates within the Navy, Marine Corps, Coast Guard, Merchant Marines, Air Force, and VA.

Default Under-reporting of Wartime Mental Health Demand

Epidemiological reviews, including this one, conducted on prevalence of war stress injuries represent an inherently gross underestimation of actual incidence of such injuries and, therefore, must be interpreted with caution. The most comprehensive records available on war stress casualties are from the WWI and WWII eras, which include Army documentation of total absolute numbers on a broad array of specific mental health diagnoses and behavioral dispositions that more aptly reflect the historical spectrum of war stress injuries. However, from the Korean War forward, the Army’s level of detail in psychiatric record keeping markedly diminishes. Following WWII, the Army deliberately avoided reporting total raw numbers of war stress casualties, opting instead to rely upon proportions. In order to estimate the actual numbers of casualties, one has to obtain the annual troop strength for a given year (i.e., the total number of personnel deployed to a particular warzone). These annual statistics are extremely difficult to secure. In contrast, the military keeps a running tally (total) of medical wounds of war. Each month, the total number of personnel killed or medically wounded in action is updated. There is no guessing game. The physical outcome of warfare is transparent and easy to obtain. However, the complete opposite is true with psychological wounds. For example, the prevalence of Korean and Vietnam war stress casualties are typically summarized by widely varying ratios of annual cases per 1000 per average troop strength of a given year (Glass & Jones, 2005) or cited as estimated percentages (Jones, 1995a). To the extent that annual troop levels are known, one can deduce the likely number of stress casualties, but invariably that information reflects the US Army alone. Nevertheless, after the Korean War absolute or total numbers of neuropsychiatric casualties, psychiatric discharges, and VA disability pensions are generally spotty at best and usually incomplete. Additionally, statistical data related to the impact of war on military families, contractors, caregivers, embedded journalists, or other support staff is routinely nonexistent.

It is incumbent for researchers and health-care agencies to look beyond the immediate behavioral health needs and utilization of services by returning war veterans. The estimated demand for wartime mental health and social services in every war generation that we examined is intrinsically fragmented, incomplete, and subject to gross underestimation. Additionally, statistical data related to the impact of war on nondeployers, military families, contractors, caregivers, embedded journalists, or other support staff are routinely nonexistent, yet critical, given the tremendous added burden on mental health-care systems attempting to meet the wartime behavioral health demands of these populations. Failure to properly anticipate and adequately plan for a predictable exponential increase in wartime needs by twenty-first century war planners was clearly evident (Russell & Figley, submitted for publication) as noted by presidential commissions (2007), congressionally mandated task forces (e.g., Department of Defense Task Force on Mental Health, 2007; Department of Defense Task Force on the Prevention of Suicide, 2010), and a plethora of government sponsored investigations from the Government Accountability Office (2006, 2011), Institute of Medicine (2006, 2010, 2012), Veterans Affairs Office of the Inspector General (2012), and RAND (Tanielian and Jaycox, 2008).

Dampening Effect of Mental Health Stigma and Disparity

Persistent reports of high levels of stigma and treatment barriers in the twenty-first century require researchers to be sensitive to possible ceiling effects in reported prevalence and incidence data. Twenty-two percent of spouses and 77 % of active-duty members reported that they would not seek mental health care for fear of being seen as weak, and 21 % of spouses and 56.2 % of soldiers cited concerns about doing harm to the active-duty member’s career (Hoge, Castro, & Eaton, 2006).

Determining the Presence of Generational Wartime Behavioral Health Crises

A three-step process was utilized in evaluating generational wartime crises to assess the mental health demand (i.e., expected prevalence of war stress injuries needing to be planned and prepared for by the military). Data for this assessment were gathered through an examination of available military and government records on the known or estimated prevalence of the established spectrum of war stress injuries and social reintegration difficulties. Cohort news media reports were also consulted. Acquiring this knowledge of the vast literature on empirically based risk and protective factors associated with the prevalence of war stress injury is essential to estimate wartime needs.

Wartime needs refer to wartime mental health and social reintegration needs of military personnel and their family members throughout the deployment cycle (predeployment, during employment, and postdeployment) and the transition back to the private sector. Such mental health needs include the resources to access well-trained personnel, early identification and treatment, treatment programs for active duty and family members, and social reintegration support for those leaving the service in an environment free of stigma and barriers to care. Essentially, wartime needs include the resources and personnel required to meet mental health and social reintegration needs in terms of prevention, screening, diagnosis, treatment, and social support.

The first step in determining mental health demand was to analyze the following empirically based risk and protective factors for war stress injury: number of deployed personnel; degree of dosage effect stress (e.g., length and number of deployments); type of warfare (low vs. high) (Jones, 1995a); number of medically wounded; ceiling effects of stigma, familial impact, traumatic grief, exposure to atrocity, moral injury, and caregiver distress; and level of perceived social support. These factors have all been demonstrated to significantly influence the incidence of stress casualties (e.g., Institute of Medicine, 2008a).

The second step was to assess organizational capacity to meet wartime behavioral health demand. This assessment was conducted by primarily reviewing available military and government records; presidential or congressional interventions; and results from commission studies, investigations, or task forces, as well as news media and postwar “lessons learned” analyses.

The third step was to conduct a comparative analysis of the relative weight of evidence from the two previous steps, adopting a “reasonable person” approach in order to determine if there was a >50 % likelihood, or a “preponderance of evidence,” borrowing from the civil court evidentiary standard, of a wartime crisis.

The Spectrum of War Stress Injury and Social Readjustment Difficulty

Russell & Figley (submitted for publication) provided historical precedents and contemporary empirical data that supported the concept of a natural spectrum of war stress injury and the social readjustment challenges associated with such injuries. It is crucial to understand the wide range of possible manifestations of war stress casualties in order to adequately anticipate and meet wartime mental health needs. The reader is referred to Russell & Figley (submitted for publication) for the entire study. In short, the historical record describes a wide variety of colorful diagnostic labels in any given era. Most commonly cited are “nostalgia,” “irritable heart,” “soldier’s heart,” “shell shock,” “battle fatigue,” “combat exhaustion,” and “posttraumatic stress disorder” (PTSD). However, these labels, or diagnostic classifications, only provide a small sample of the total. Jones and Wessely (2005) offer one of the most complete listings of wartime diagnostic classifications available; however, their list also underrepresents the actual number of diagnostic possibilities when one examines generational trends.

Known and Hidden Wartime Mental Health Demand

Understanding the breadth of the spectrum of the manifestation of war stress injuries is important for the military and the nation in order to adequately prepare and meet wartime mental health demands. The following is a list of the current diagnostic classifications in the present wars in Iraq and Afghanistan that, when added up, provide a more accurate and honest portrayal of the actual side effects of war in comparison to the narrowly tracked prevalence of PTSD and three to four other diagnoses, as is the current practice: medically unexplained physical symptoms (MUPS), including diagnoses like signs, symptoms, and ill-defined illness (SSID) or other known functional somatic or war syndromes; psychiatric diagnoses of a given era, including those related to twenty-first century constructs of PTSD, depression, anxiety disorders, psychotic disorders, and sexual disorders; suicide attempts and suicide; substance use disorders (SUD), including alcohol, illicit drugs, or prescribed medicine abuse; traumatic brain injury (TBI); traumatic grief reaction; moral injury or related construct pertaining to major moral transgressions such as killing, in general, or killing of noncombatants; posttraumatic anger, including interpersonal violence; misconduct stress behaviors, including problems of indiscipline (presenting as a lack of control in a group of people), malingering, substance abuse, homicide, self-inflicted wounds, sexual assault, and commissions of atrocities (Department of the Army, 2006); personality disorders such as obsessive–compulsive personality disorder, antisocial personality disorder, and schizoid personality disorder; unemployment rates that can impact social reintegration; family and trans-generational impact from war, including prevalence of mental health diagnoses and utilization of services by involved spouses and children; caregiver compassion stress, including compassion fatigue related conditions prevalent in family members of medically wounded-in-action (WIA) and war stress casualties, as well as in health-care providers, counselors, and other helping professionals; homelessness rates that impact social reintegration; and mental health needs of service members that are prisoners of war (POW), medically WIA, as well as those with chronic comorbidity.

Investigating System Capacity to Meet Wartime Mental Health Demand

In light of the historical precedents (lessons learned) and the estimates of wartime demand regarding the need for mental health care preparedness, we examine the adequacy of prewar planning and preparation, systemic responsiveness, and resources required to meet war-related needs. A defining characteristic of wartime crisis is also the incapacity of the mental health system to adequately meet mental health and social readjustment demands. Institutional Military Medicine (IMM), VA, and DoD medicine are charged with the responsibility for addressing the mental health and social needs of the military population. Systemic requirements to meet war-related demands have been partially reviewed (e.g., Department of Defense Task Force on Mental Health, 2007; Glass and Bernucci, 1966; Tanielian and Jaycox, 2008), and generational postwar lessons learned analyses published (Glass, 1966a). These studies give us insight into our adequacy to meet mental health needs. However, there has never been a study on wartime mental health crises; this study is intended to lay the tentative framework for how we might investigate the presence of a wartime crisis in past, current, and future wars.

Postwar Analysis of Psychiatric Lessons Learned

A clear top–down commitment must be in place to learn from generations of war trauma in order to ensure (a) adequate planning, preparation, and training for inevitable war stress casualties during times of peace and war (e.g., Glass, 1966a; Glass & Jones, 2005; Martin & Cline, 1996; Salmon & Fenton, 1929); (b) adequate numbers of well-trained specialists (e.g., Menninger, 1966a); (c) the elimination of mental health stigma, disparity, and barriers of care (e.g., Menninger, 1948; Salmon, 1917); (d) ready access to effective, definitive treatment (Brill, 1966a; Glass, 1966a; Glass & Jones, 2005; Salmon & Fenton, 1929); (e) adequate coordination between agencies and the private sector, especially in regard to social reintegration; and (f) timely, transparent monitoring and reporting (e.g., Menninger, 1966b; Russell, 2006).

Presidential and Congressional Intervention

Documentation resulting from presidential and congressional interventions can serve to indicate possible major systemic deficiencies in behavioral health care and/or social reintegration. Data valuable to determining wartime mental health needs can be found in executive orders, congressional hearings, commissioned studies, government investigations, and task force reports.

Postwar Lessons Learned Analysis

Every war generation has compiled lessons learned in their postwar analyses by service medical departments such as the US Army. The amount of detail and thoroughness of these analyses varies dramatically. At the end of World War II, in two volumes, the US Army published 2037 pages of a comprehensive, statistically loaded, candid investigation of every aspect of wartime mental health needs or “lessons learned” (Glass, 1966a, b). After World War II, there were no similar detailed lessons learned for psychiatric casualties published by the US military for Korea, Vietnam, or the first Persian Gulf War. For example, for Vietnam, the psychiatric casualties section was condensed to a single chapter. After the Vietnam War, which was America’s longest war before the current conflicts, the US Army published a total of 181 pages in its official medical lessons learned, only four pages of which were specific to neuropsychiatry (Neel, 1991). In summary, data reported went from 2037 to 4 pages of documented management of war stress injuries. However, these analyses are of critical importance. They shed insight into the pivotal prewar planning period and reveal whether fundamental war trauma lessons, like the need for adequate numbers of well-trained specialists, have been addressed. In this study, cohort self-disclosure, or inference of system-wide inadequacies, is given extra weight when determining the likelihood of a crisis.

Results

Evidence of Repetitive Generational Behavioral Health Crises Prior to twenty-first Century

Section I

In order to define and operationalize a framework for identifying a wartime crisis, we first provide a preliminary analysis of the known and reported mental health demand and system capacity to meet wartime needs after each major American war since the beginning of the twentieth century. It bears mentioning that records of war stress casualties in the Navy/Marine Corps, Air Force (since 1947), Coast Guard, and Merchant Marines are generally unavailable, as well as postwar statistics from the VA and other government agencies. According to Neel (1991), “Statistics on hospital admissions are not an accurate guide to the extent of high-incidence, short-duration diseases, for often these conditions were treated on an outpatient basis” (p. 36). Mental health utilization data for military contractors, family members, caregivers, and embedded journalists do not exist; therefore, the estimates apply only to military personnel (primarily the US Army). In terms of circumstantial evidence regarding generational capacity to meet mental health needs, we refer primarily to era news headlines and psychiatric lessons learned from military postwar records.

Section II

In this section, we provide an example of implementing our model/framework in terms of providing evidence that there have been generational crises after each major war. Some 4.7 million Americans fought in World War I. Of these, 53,402 were killed in action (KIA), and 204,002 were medically WIA (Congressional Research Service, 2010). A total of 70,158 draftees were psychiatrically screened and rejected for service to prevent war stress casualties. This screening process represents the first mass use of psychological testing (Karpinos & Glass, 1966).

Mental Health Demand

Despite only 6 months of exposure to World War I combat, there were a total of 106,000 American soldiers hospitalized as neuropsychiatric casualties (Salmon & Fenton, 1929). In all, 72,000 soldiers were discharged from the military for neuropsychiatric conditions, with 40,000 claiming disability (IOM, 2007) but only 2.8 % determined to be caused by combat (Salmon & Fenton, 1929). An additional 8640 cases of “nervous and mental diseases” were diagnosed by the Army in the USA, but none of those diagnosed were discharged. In 1918 alone, 24.4 % of deployed soldiers and sailors were evacuated to the USA for “nervous or mental disorders,” and over 20,000 were psychiatrically discharged (Salmon & Fenton, 1929). It is important to note that documentation of the US Army’s World War I experience is comprehensive, whereas data on Navy/Marine Corps and the VA are limited.

Overall, about 20 of every 1000 soldiers were found to exhibit some form of war stress injury (Salmon & Fenton, 1929). Reports indicate that 11,443 were diagnosed with “psychoneuroses” (akin to PTSD, anxiety, and depression constructs, including 219 diagnoses of “traumatic neurosis,” a direct precursor of PTSD). Another 7910 were diagnosed with “psychoses,” including 51 diagnosed with “traumatic psychoses,” a precursor of PTSD. An additional 4170 were diagnosed with alcoholism or drug addiction. Records show that 6196 were identified as “constitutional psychopathic states” (akin to personality disorder) and another 21,858 as “mental deficiency.” A total of 6916 were diagnosed with “nervous diseases and injuries” (akin to possible MUPS), including diagnoses such as tics (243), sciatica (137), neuritis (222), injury to nervous system (554), includes 337 diagnosed with “brain injury” akin to possible traumatic brain injury, tremor (243), other forms (902), and epilepsy (6388) (can be indicative of MUPS) (Salmon & Fenton, 1929). Psychiatric referrals for “delinquency” or stress misconduct behaviors totaled 1498. The reported suicide rate within the Army during World War I was 0.2 per 1000 enlisted strength, but the absolute number of military and veteran’s suicides is unknown.

Capacity to Meet Demand

Prior to entering World War I, the US Army adapted the European model of developing a continuum of psychiatric services in the warzone; such services were aimed primarily to prevent manpower attrition (Salmon, 1917). This so-called “forward psychiatry” provided brief respites to acute war stress casualties and set the clear expectation of eventual return to frontline units (Salmon, 1917). Consequently, about 65 % of acute war stress casualties were returned to the war, which was heralded as a major success (Salmon & Fenton, 1929). However, according to the IOM (2007), “By World War I, experts had estimated that “the insanity rate of men in the Army increases nearly 300 % in time of war” (p. 39). To meet growing demand, in 1918, a specialized treatment center for war neuroses casualties was established at the Army hospital in Plattsburg, New York. Those deemed “incurable” along with those whose care required residential treatment were admitted to St. Elizabeth’s Home in Washington, DC (Salmon & Fenton, 1929). During 1918 alone, 20,000 veterans resided in nine federally funded homes for disabled soldiers, with another 12,000 residing in state-run homes (IOM, 2007).

Media reports indicate that the size of the crisis continued to grow well after the 1919 World War I armistice, leaving the mental health system overwhelmed. For instance, in a September 14, 1919, New York Times article, “War’s big lesson in mental and nervous diseases” (Bailey, 1919), the US Army Chief of Section of Neurology and Psychiatry, Office of the Surgeon General, issued a warning to public health officials regarding the growing number of “feebleminded” rejected for return to service (Bailey, 1929a, b, p. 302). The report noted: “Up to May 1, 1919, the army returned to the civil community approximately 72,000 of these cases [the feeble minded]. The army returned what the civil community offered it––nervously handicapped men” (Bailey, 1929a, b, p. 302). The report continues:

It would seem that the great lesson of the war as far as neurology and psychiatry is concerned is that our communities contain definite fixed quotas of crippling and multiplying diseases for the control of which no adequate provision exists, and that the sufferers from these conditions are handicapped in their relations to society, and that many of them burden and injure it. We have now a unique opportunity to change our attitude and improve our policies in these matters. (Bailey, 1929a, b, pp. 308–309)

In 1921, a New York Times article reported “400 ex-soldiers New York suicides.” Indicating a broader crisis, the article refers to another article: “Dr. Salmon so charges in testimony, lack of care of mentally disabled veterans.” A year later, The New York Times published the article “Veteran’s suicide average two a day” (1922). In 1923, a headline reads “26,000 veterans now in hospital: Alarming increase is reported in neuro-psychiatric and tuberculosis cases” (The New York Times, 1923). By 1927, 47 % of all veterans treated by the VBA were diagnosed with neuropsychiatric conditions (Bailey, 1929a, b). The following news headlines continued to support a growing crisis: “Says veterans lack psychiatric relief; Mcnutt declares disabled men are in jails, as hospitals are not available” (1929); “Insane war veterans reported increasing: Legions rehabilitation body told number exceeds hospital facilities” (1934); and “Veterans’ claims cut by 57%: Reviewing boards disallow 29,995 of 51,213 disability cases: Nervous diseases found more frequent in cities” (1934). By 1934, reports indicated that almost half of the 67,000 in-patient beds in VA hospitals were occupied by World War I war stress casualties (Veterans claims cut by 57 percent: Reviewing boards disallow 29,995 of 51,213 disability cases: Nervous diseases found more frequent in cities, 1934), revealing an incapacitated mental health system.

Presidential and congressional concerns of possible mental health deficiencies can be inferred by headlines such as “Bonus first or disabled?” ( 1921) by Henry L. Stimson, Chairman Joint Committee for Aid to Veterans and “Says veterans lack psychiatric relief: McNutt declares disabled men are in jails, as hospitals are not available” (1929). Government interventions to address systemic deficiencies included the enactment of the 1917 War Risk Insurance Act, the Vocational Rehabilitation Law of 1918, and the World War Adjustment Act of 1924. In 1921, Public Law 67-47 consolidated three veterans-related agencies into the Veteran’s Bureau, with 140 new regional centers designed to meet veterans’ wartime needs. In 1930, the VA was created to further consolidate government support for veterans (IOM, 2007).

Military Analyses of Lessons Learned

Swank and Marchand’s (1946) classic study of World War I infantry soldiers revealed that “within 60 consecutive days of combat, 98 % of soldiers become psychiatric casualties of some kind, whether of combat exhaustion, acute anxiety state or depression,” and the other 2 % had “predisposition to an aggressive psychopathic personality” (as cited in IOM, 2007, p. 41). The following provide additional evidence of a mental health system unprepared to effectively manage war stress casualties. In 1917, Salmon noted:

The next most important lesson is that of preparing, in advance of an urgent need, a comprehensive plan for establishing special military hospitals and using existing civil facilities for treating mental disease in a manner that will serve the Army effectively and at the same time safeguard the interests of the soldiers, of the government and of the community. (p. 28)

In 1929, Salmon reported shortages of trained personnel and lack of facilities in France:

Although the total number of American troops in France in January, 1918, was only approximately 203,000, the caring for mental patients had already become a problem. It was obvious at the outset that such patients could not be cared for in the individual American base hospitals scattered throughout France, partly because of the lack in some of them of medical officers, nurses, or enlisted personnel who had experience in the actual care and treatment of patients suffering from acute mental disorders, but chiefly because of the absence of any special facilities for treatment. (p. 279)

Berlien and Waggoner explain the response of the US government to the costs of caring for WWI veterans disabled with neuropsychiatric conditions. “American involvement in WWI produced a total of 69,000 disabled neuropsychiatry causalities costing the government over $1 billion in disability pensions, so selection standards were raised” (Berlien and Waggoner, 1966, p. 153).

Conclusion

There seems little doubt that the World War I era experienced a major wartime behavioral health crisis and, given its protracted nature, scope, and cost, would likely meet criteria for a mental health catastrophe. In due fairness, although historical precedents for inevitable war stress casualties existed and were formally recognized by Army leadership before entering World War I (Salmon, 1917), the disciplines of psychiatry (1865, birth of psychiatry) and clinical psychology (1902, birth of clinical psychology) remained obscure.

World War II

A total of 16,112,566 Americans, or nearly 9 % of the population, served during the 5 years of World War II. Approximately 4 million served in combat zones, with 405,399 KIA and another 670,846 medically WIA (Congressional Research Service, 2010). Mass prewar psychiatric screenings were utilized to reject a total of 1,767,900 purportedly predisposed, constitutionally weak, and defective volunteer candidates vulnerable to nervous breakdown within 11 years of combat (Berlien & Waggoner, 1966).

Mental Health Demand

At the outset of the America’s 1941 entrance into World War II, the war stress injury rate was 20–34 % of total casualties with only 3 % returned to duty (RTD). During the 1942 Guadalcanal invasion, 40 % of 1st Division Marine evacuees were war stress casualties. In all, from 1942 to 1945, war stress casualty rates were 7.6 times higher than those in World War I (Glass, 1966b), with over 1,103,000 reported Army (Brill, 1966a) and 150,000 Navy/Marine Corps (Chermol, 1985) neuropsychiatric hospital admissions. Of the Army admissions, 648,500 were diagnosed with “psychoneurosis” (akin to anxiety, depression, and PTSD constructs). A total of 67,642 were admitted with “psychosis.” Another 43,339 were reported to have “alcoholism or drug addiction.” “Immaturity reaction” (akin to adjustment disorder but includes 250 diagnoses of “pathological personality”) was the label assigned to 66,455. Considered as “asocial and antisocial personality types” (akin to personality disorder) were 2175. Another 28,871 were labeled as suffering from “disorders of intelligence.” “Pathological sexuality” was assigned to 5455 and “other psychiatric disorders” to 64,638 (Brill, 1966a). In addition, there were 156,345 diagnoses of “other neurological disorder” such as 8565 cases of “blast concussion” and “posttraumatic encephalopathy” (akin to TBI), as well as 18,077 cases of “epilepsy” (some possibly MUPS). A total of 1864 received diagnoses of “paralysis, other, and unspecified,” and 5201 were diagnosed “neuralgia.” To finish the list, 20,268 diagnoses were labeled “miscellaneous disorders of the nervous system” akin to possible MUPS (Brill, 1966a). Overall, there were a total of 504,000 Army and 100,000 Navy/Marine Corps psychiatric discharges and disability pensions (i.e., Brill & Kupper, 1966; Chermol, 1985), as alluded to in The New York Times headline: “500,000 discharged as psychiatric cases” (1945). A 1955 follow-up study of 1475 WWII veterans reported high rates of somatic complaints, including insomnia (31.9 %), headache (42.8 %), irritability (48.6 %), concentration problems (20.1 %), restlessness (45.4 %), gastrointestinal upset (41.7 %), cardiovascular issues (21.9 %), and musculoskeletal pain (34.8 %) (Brill & Beebe, 1955). Suicide rates of World War II veterans are unknown. However, a recent news article, “Suicide rates soar among WWII veterans, records show: Older veterans twice as likely to take their own lives as those returning from Iraq and Afghanistan” suggests that the rate is alarming (Glantz, 2010). Kerri Childress, a spokeswoman for the US Department of Veterans Affairs, explained that the high incidence of suicide for World War II veterans today is at least partially an outgrowth of the lack of understanding of posttraumatic stress six decades ago. “We didn’t even recognize mental health as an issue when they returned,” she said. “Nobody was recognizing it and nobody was talking about it, and it was certainly not something that they could get care for from the VA” (Glantz, 2010, p. 11). Instead of counseling, Patrick Arbore, the founding director of the Center for Elderly Suicide Prevention and Grief Counseling, noted most World War II veterans self-medicated with alcohol (cited in Glantz, 2010, p. 11).

Capacity to Meet Demand

The 1944 Washington Post article “U.S. owes veterans better psychiatric aide,” summarizes a 3-day US Senate subcommittee hearing on Wartime Health and Education. It states, “they [veterans] showed by their testimony that conditions of modern war confronted the country with a serious problem in the treatment, training, and re-adaptation of many victims of wartime mental and emotional disturbances” (Stavisky, 1945). One year later, a 1945 Washington Post article “Thousands of GIs temporarily disabled during the war now stand to become permanently crippled during the peace…Is the problem so urgent” is published. Data reported in this article further add support to the findings of the Senate subcommittee hearing of the previous year. “There are more than half a million World War II veterans currently drawing pensions for disabilities” (Stavisky, 1945). This article also describes national concerns over acute shortages of psychiatric personnel, high veteran unemployment rates, delays in the VA’s expansion of neuropsychiatric services, the negative impact of persistent mental health stigma, and communities unprepared to assist returning veterans and their families. All of these factors contributed to a military mental health crisis (Stavisky, 1945). Furthermore, media reports, such as the following, signify a significant number of unmet wartime needs. “Communities held failing veterans: Social service experts find a lack of help in solving readjustment problems” (1945) reported the result of a national survey of veterans’ readjustment needs. It concluded that one out of five (double the rate of civilians) discharged servicemen became war casualties when faced with the emotional challenges of dealing with family, finances, and leisure, to name a few. In the article “Plan urged to get new psychiatrists: $100,000,000 for training to meet war veteran needs” (1946) Kubie draws a parallel between the shortage of trained personnel and existing training facilities, noting that of the 400 training posts, only 50–75 % were of high quality. “Veterans seeking psychiatric help: but most must wait months even for screening tests survey in city shows” (Freeman, 1949) documents the overload on a system stretched beyond capacity.

According to VA historians, “Many of the returning veterans needed treatment of medical and psychological problems resulting from their war experience. Veterans with psychiatric disorders occupied 58 % of VA hospital beds at the end of 1946” (Baker and Pickren, 2007, p. 7). However, as Baker and Pickren (2007) observed, “the shortage of trained mental health workers in the VA” caused newly developed “mental hygiene clinics” to be “immediately overwhelmed with service demands far beyond the capacity of their personnel and space to provide such services (Campbell, 1947; Hildreth, 1954)”, leading the authors to conclude “It was clear that no matter how the various service components were arranged, there were simply not enough personnel to meet the demands” (p. 7).

Presidential and Congressional Intervention

Early presidential concerns over the plight of World War II era mental health care is clearly reflected by President Roosevelt’s 1944 Executive Order to his Secretary of War (akin to DoD), “My dear Mr. Secretary: I am deeply concerned over the physical and emotional condition of disabled men returning from the war. I feel, as I know you do, that the ultimate ought to be done for them to return them as useful citizens––useful not only to themselves but to the community.” The President further directs the Secretary of War:

It should be the responsibility of the military authorities to insure that no overseas casualty is discharged from the armed forces until he has received the maximum benefits of hospitalization and convalescent facilities which must include physical and psychological rehabilitation, vocational guidance, prevocational training, and re-socialization. (as cited in Brill, 1966b, pp. 291-292)

Congress also became extensively involved in addressing broad systemic and societal deficiencies in meeting wartime demands. Such involvement is reflected in news headlines such as “The veteran: House veterans committee deflects inquiry on medical care of soldiers” (Hurd, 1945) and “Psychiatrists ask rise in VA funds: Deterioration of services to veterans is alternative, congress is warned” (1947). Passage of landmark legislation such as the Servicemen’s Readjustment Act of 1944 (aka the GI Bill); the National Neuropsychiatric Institute Act, 1945 (US Congress, House of Representatives 1945); and, in 1946 Public Law 79-293, followed. The National Neuropsychiatric Institute Act of 1945 was designed to eliminate disparity between mental and physical health with the creation of the National Institute of Mental Health. Public Law 79-293 called for the establishment of the Department of Medicine and Surgery that led to the creation of the VA’s Neuropsychiatry Division in 1948. Subsequently, a wave of mass employment and training of clinical and counseling psychologists to address national shortages ensued (Baker & Pickren, 2007).

Military Analysis of Lessons Learned

Because war trauma lessons are so extensively documented, the significant incapacity to adequately meet wartime mental health needs is directly related to a failure to learn psychiatric lessons from previous generations. For example, Glass (1966a) indicated, “Undoubtedly, the most important lesson learned by psychiatry in World War II was the failure of responsible military authorities, during mobilization and early phases of hostilities, to appreciate the inevitability of large-scale psychiatric disorders under conditions of modern warfare” (p. 736). Brill (1966a) also noted the psychiatric staffing issues when he reported, “From the beginning, there was a shortage of trained psychiatrists, neurologists, psychiatric nurses, attendants, aides, social workers, psychologists, occupational therapists, and recreational therapists” (p. 262). The VA failed veterans as well in that it was unprepared to meet the psychiatric needs generated by the casualties of war. Baker and Pickren (2007) note its culpability.

Similarly, the number of psychiatrists in the VA after World War II was simply too small to deal with the increased needs for treatment. It was this shortage of mental health professionals that prompted both the VA and the National Institute of Mental Health (NIMH) to generously fund training and a more massive expansion of the mental health field after World War II. (p. 91)

Conclusion

In light of the known scope, duration, and cost of psychiatric casualties from World War II, it is apparent that the World War II cohort witnessed both a major wartime behavioral health crisis and a mental health catastrophe. However, unlike their World War I predecessors, government leaders did acknowledge that the ensuing catastrophe could have been prevented. The level of candor in the Army’s postwar lessons learned analyses reflects well on the caliber of its leaders. President Eisenhower acknowledges the failure of the government to implement prewar planning, in light of the lessons learned from World War I.

In seeking the many causes of psychiatric disability in order to correct them, we must put first the absence of prewar planning to prevent and to treat them. This blunder was made by the War Department and the technical service of the Medical Department and was ignored by the profession of psychiatry. (US Army Chief of Staff General Dwight D. Eisenhower as cited in Menninger, 1948, p. 532)

The decision by WWII-era Army medical leaders to extensively document wartime mental health demand and capacity to meet veteran’s needs is unrivaled in the modern era, including present generations. More importantly, there was a conscious effort to openly reflect upon past mistakes (as well as successes) in order to avert future, preventable wartime crises. For instance, US Army Surgeon General Leonard D. Heaton (1966) gave this stern warning in the massive two-volume Army Medical Department compilation of psychiatric lessons since WWI (WWI, 1914–1918). “With this information so readily available, there can be little excuse for repetition of error in future wars, should they occur” (as cited in Glass and Bernucci, 1966, p. xiv).

Korean War

There were 6.8 million American men and women who served during the Korean War (US Department of Veterans Administration (DVA) 2000), 33,739 KIA, and 103,284 medically WIA (Congressional Research Service, 2010). An estimated 848,000 Korean War veterans also served in other war periods: 171,000 in both World War II and the Vietnam War, 404,000 only in World War II, and 273,000 only in Vietnam (Congressional Research Service, 2010).

Mental Health Demand

Distinct from previous modern American wars, evidence of a mental health crisis in the Korean War era is modest at this time. Perhaps, this distinction is an artifact of the relative paucity of neuropsychiatric documentation during this war or an accurate reflection of the times. The Army’s war stress casualty statistics are reported only as ratios of annual incident number per 1000 per average troop strength, or as percentages, many of which varied significantly throughout the war. For instance, Glass (2005a, b) reports, “Admissions for psychiatric disorders during July 1950 occurred at a rate of 209/1000/year, the highest in the Korean War to which was associated the highest KIA rate (769.04) and the second highest WIA rate (950.97)” (p. 2). Glass then relates the following rate for October of the same year: 34.21/1000/year psychiatric admission rate (p. 5). According to the Army’s official medical postwar analysis, there was a total of 13,515 Army hospital admissions for unspecified “psychiatric disorders,” along with 1688 disability discharges due to “impairment and disease of nervous system.” Of these 1688 disability discharges, 322 were labeled “encephalopathy due to trauma” (akin to TBI) and 91 labeled “neuralgia” (akin to chronic pain). Neuropsychiatric discharges were either omitted or did not occur (Reister, 1973). Overall, the diagnosis of “symptoms and ill-defined conditions” (possibly akin to MUPS) was the second leading cause of all Army hospital admissions, with rates of 45 per 1000 (division personnel) and 40 per 1000 (nondivision personnel) recorded. Psychiatric disorders were the fourth leading cause for all hospital admissions with rates of 36 per 1000 (division personnel) and 25 per 1000 (nondivision personnel) as reported by Reister. A total of 38,481 Army personnel received outpatient neuropsychiatry treatment in Korea (Reister, 1973).

In short, for unknown reasons, unlike their WWI and WWII counterparts, the Korean War-era Army medical leaders avoided transparency, and began the trend of limited reporting of war stress casualties—void of raw data and total numbers of neuropsychiatric admissions, discharges, or disability pensions. Medical postwar analysis reveals that psychiatric conditions represented over 9 % of disease admissions for division troops, producing an overall estimated rate of 36 per 1000 average strength per year, compared to 5 % for nondivision troops or 25 per 1000 per year (Reister, 1973). There were a total of 13,585 reported psychiatric hospital admissions (unspecified by type), along with 1781 admissions for “concussion” (akin to TBI) (Reister, 1973). A total of 131 suicides and 101 homicides among US Army personnel in Korea was reported between 1950 and 1953, resulting in a suicide rate among active duty Korean War soldiers of 11 per 100,000 (Reister, 1973).

Jones (2005) notes the high incidence of substance abuse, depression, and misconduct stress behaviors evident during the Korean War. In the following statement, the author draws a connection between the reactions of Korean War soldiers and those of previous eras. “To an extent the situation resembled that of the nostalgic soldiers of prior centuries. In these circumstances the soldier sought relief in alcohol abuse (and, in coastal areas, in drug abuse) and sexual stimulation. These often resulted in disciplinary infractions” (p. 11). For example, US Army psychiatrists observed that, as incident rates of frost bite rose, the number of psychiatric casualties decreased, which raises suspicions of self-infliction (Jones & Wessely, 2005) and supports the theory of Jones that soldiers were engaging in a kind of self-medication to address the war stress they experienced.

Fontana and Rosenheck (1994) examined 5138 war zone veterans seeking VA treatment (320 WWII; 199 Korean; 4619 Vietnam veterans) and reported data from these veterans and their clinicians. Reports indicate a significant positive relationship between traumatic war experiences and current psychiatric symptoms across all three wars. The responsibility for killing another human being related significantly to all symptom categories in all cohorts, resulting in it being the single most pervasive, traumatic experience of war. Following closely is observing the killing of others, failure to prevent unnecessary death, and being exposed to combat in general (Fontana and Rosenheck, 1994). In 1956, a total of 14,000 veterans received VA group psychotherapy services, and 6000 received individual counseling (Veterans Administration, 1958).

Capacity to Meet Demand

Since only 5 years had elapsed, WWII war trauma lessons were still fresh, and principles of forward psychiatry (promptly returning soldiers with acute stress injuries to their frontline units after a brief respite) were soon implemented by the Army’s Chief Neuropsychiatry Consultant Colonel Albert Glass, who literally wrote the book on WWII lessons learned (Glass, 1966a). Nevertheless, Korean War-era media headlines suggest an inability to meet social reintegration needs. The 1951 article “640,000 in WWII: Army all out in study of psycho cases,” published in the Washington Post, reports on the Army’s study of the mental health casualties of World War II because of the growing concern to meet the needs of current Korean War casualties. The study finds that 60 % of all cases began during training. It also finds a correlation between the number killed in a unit and the number who suffered from mental health crises.

The following media coverage documents the large numbers of Korean veterans in need of services and the inability of the systems in place to meet the demand. The New York Times describes the shortage of housing for veterans in its 1951 article “Korean veterans seek homes.” In this article, Betram E. Stewart notes that the 66 housing units available under the GI bill were already filled when a new wave of applicants from veterans of the Korean War submitted requests. In 1952, in the article “Rise in neurotic seamen called challenge to merchant marine,” a New York shipping official is reported to have expressed concerns over the increase in “psychologically disturbed” seamen in the American Merchant Marine. He alludes to issues of safety and efficiency as consequences (Freeman, 1952). In November of 1952, The New York Times reported on the high numbers of Korean War veterans who would be eligible for benefits. For example, the Labor Department anticipated that, within the year, an estimated 200,000 Korean veterans would apply for unemployment pay under the new GI bill (Korean veterans due for benefits: 2000,000 expected to collect unemployment aide but job outlook is bright, 1952). In the article “Psychiatry panel scores VA policy: Physicians at Parlay say incentives are lacking for hospital staff” the author reports the concerns of psychiatrists who identify Veterans Administration policies at the center of the decline of its psychiatric program, specifically professional salaries of $13,680 per year and budgeting policies that provide incentives for hospital managers to unnecessarily retain patients in long-term care (Harrison, 1957).

Moreover, according to VA historians, “Suicide of veterans became of great concern to the VA during the 1950s when the rate of suicide among veterans within the VA hospital system and outside it, already higher than in the non-veteran populations, suddenly increased alarmingly over the pre-WWII rates” (Baker and Pickren, 2007, p. 88). The post-Korean War suicide trend sparked the VA’s first research program into suicide by veterans, finding, among other factors, a link between suicide and new psychotropic medications Thorazine and Rauwolfia Alkaloid (Baker and Pickren, 2007).

Presidential and Congressional Intervention

The extent of presidential and congressional actions to address wartime mental health deficiencies during the Korean War era pales in comparison to WWI and WWII. However, a number of notable mental health-related government interventions did occur, including the 1956 Bradley Commission: The President’s Commission on Veterans Pensions. The Department of Veterans Benefits was established in 1953, within the DVA, to coordinate veterans’ education, training, and disability benefits. The Psychiatric Evaluation Program was created in 1955 to study effective treatment of patients with psychiatric disorders. The year 1958 marked the consolidation, update, and amendment of laws relating to veterans, known today as Title 38. As part of this update, the VA’s Department of Medicine and Surgery mission was amended to include a research component.

Military Analysis of Lessons Learned

Although not nearly as extensive as WWI/WWII documentation, there is some indication of strained capacity to meet mental health demands. Glass notes, “During the initial months of the Korean War, psychiatric facilities in Japan inappropriately evacuated many psychiatric cases to the ZI (Zone of Interior) because ‘Limited Service’ of World War II had been abolished in 1947. Also, the neuropsychiatry (NP) staff during this early period was meager and lacked sophistication in combat psychiatry” (Glass, 2005a, p. 4). Glass further documents the lack of psychiatric support at the Army level.

In sharp contrast to the prompt application of psychiatry at the division level, psychiatric efforts at the Army level were meager and ineffective. It was evident that a need to support division psychiatry by a second echelon of psychiatry at the Army level was not recognized although such a need was demonstrated in WWI and in WWII. This lack of recognition was unfortunate since two qualified psychiatrists were available in the Eighth Army to provide the professional nucleus for a second echelon Army level psychiatric facility (Glass, 2005b, p. 5). Peltz (1951) notes that there was a lack of experienced psychiatrists trained in combat psychiatry who were sent to Korea.

Nearly all of the psychiatrists sent to Korea were quite junior. Some consultants stress the young psychiatrist’s lack of training: The suggestion was made by several medical officers that it would have been more useful to them to have had more indoctrination into the principles of combat psychiatry and to have learned more about the treatment and disposition of such patients (Peltz, 1951, as cited in Ritchie, 2002, p. 900)

Conclusion

There are many contrasts between the WWII and Korean War cohorts, as well as some notable continuity (the latter referring to the Army’s Chief Neuropsychiatric Consultant Colonel Albert Glass, who led the WWII effort to document its psychiatric lessons learned during the Korean War). The leadership continuity and shortest duration between major wars (5 years) in the twentieth century no doubt helped to avert a major crisis as did a rotation policy of 9 months for combat troops and 12 months for support personnel (Glass, 1966a). However, a concerning trend emerged during the Korean War with regard to greatly reduced military transparency and documentation of wartime mental health experience. This policy was in stark contrast with the previously customary exact accounting of medical casualties.

Less Transparency Policy in Psychiatric Records

The reason for the overt change in military record keeping policy is unknown but clearly intentional in light of continued detailed accounting of medical casualties. Previous generations also reported prevalence ratios but always included absolute numbers as well, which are necessary for generating ratio data. Therefore, it appears that the omission of absolute numbers was deliberate. Possible explanations include prohibitively high “operational tempo” in terms of frequent troop movements (although detailed reporting of medical casualties was maintained including absolute numbers), leadership bias or indifference, or a concerted effort to conceal the true prevalence. Regardless of reason, the subsequent paucity of sufficiently detailed records within the military, VA, or other government agencies makes it difficult to the presence or absence of wartime crisis. Furthermore, available news media reports on Korean-era war stress casualties do not resemble the state of national crisis reflected in WWI and WWII eras. However, by the Army’s own admission, WWII war trauma lessons were initially ignored (Glass & Jones, 2005).

Vietnam War

More than 8.5 million individuals served in the US Armed Forces during the Vietnam era, 1964–1973, with about 3.14 million serving in Southeast Asia (Kulka et al., 1990). Of the latter number, almost one million saw active combat or were exposed to hostile, life-threatening situations. A total of 47,410 military personnel were KIA, and 153,303 were medically WIA (Congressional Research Service, 2010).

Mental Health Demand

Official Army medical postwar analysis (Neel, 1991) singled out neuropsychiatric conditions as a “major problem.” However, following the Korean War trend, the depth of Vietnam-era documentation of war stress casualties pales in comparison to that of WWI and WWII. Existing documentation does not report absolute numbers (unlike the detailed records kept of medically WIA). Extensive reviews of war stress casualties during the Vietnam era have been conducted, revealing several noteworthy themes (e.g., Dean, 1997; Gabriel, 2013; Marlowe, 2001). Foremost, records containing absolute numbers of war stress casualties in the Vietnam-era are sparse, as commented on by previous researchers (Marlowe, 2001). A rare 1988 study of Marines reported 8828 psychiatric admissions from 1965 to 1971, with a war stress casualty rate of 35.3 per 1000 annum, exceeding KIA rates (Palinkas & Coben, 1988). “Personality disorder” was reported as the most frequent psychiatric diagnosis, followed by “anxiety neuroses” and “acute situational maladjustment” (Palinkas & Coben, 1988), but no specific data are furnished.

As previously stated, the absence of centralized, transparent, and accurate reporting of military mental health demand not only prohibits organizational leaders from properly planning for and reacting to wartime needs but also aggravates the perceived and actual crisis. This assertion is best exemplified by the impassioned controversy surrounding the Vietnam era, wherein military and academic postwar analyses routinely report “The incidence of neuropsychiatric illness in U.S. Army troops in Vietnam is lower than any recorded in previous conflicts” (Ayers, 1969). These reports frequently cite only 2–5 % of total casualties as neuropsychiatric in nature (e.g., Jones, 1995a; Shepard, 2001). Such numbers dramatically contradict the postwar psychiatric landscape of an estimated 250,000 (Wilson, 1978) to 2 million (Egendorf, 1982) Vietnam veterans suffering from PTSD and an additional 9000–150,000 (Dean, 1997) committing suicide. Consequently, there has been no shortage of speculation as to determine the reasons for such wildly discrepant claims.

A related theme in the literature pertains to the relatively low (2–5 %) rates of classic (“combat exhaustion” or “combat fatigue”) war stress casualties attributed to a 12-month rotation policy intended to reduce war stress exposure (Jones, 2005). Such numbers starkly contrast with the exceedingly high incidence of “character and behavior disorders” that include diagnoses such as personality disorder, substance abuse, and “indiscipline” (akin to misconduct stress behaviors). A similar increase is reported in the diagnosis of “psychosis.” For example, Army neuropsychiatric diagnostic rates in Vietnam gradually increased during each successive year from 1965 to 1970. The diagnosis of “psychosis” increased from 1.6 (1965) to 3.8 (1970) per 1000; “psychoneurosis” from 2.3 (1965) to 3.3 (1970) per 1000; “character and behavior disorders” (akin to personality disorder) from 3.1 (1965) to 8.1 (1970) per 1000; and “other psychiatric conditions” 3.8 (1965) to 8.5 per 1000 (1970) (Neel, 1991).

Substance Abuse

In regard to drug abuse, Army Surgeon General Neel (1991) reports, “One of the unique problems that faced the Medical Department in Vietnam was the drug milieu into which the American soldier was immersed, both on and off duty, upon arrival in the theater. The growth of illicit drug use within the Army kept pace with that in the larger society, but the ready availability of marijuana, barbiturates, amphetamines, heroin, opium, and other substances in Vietnam” (p. 47). The Surgeon General further related that, “Comprehensive statistics are not available, but preliminary work based upon sample surveys of soldiers entering and leaving the combat zone indicates that illegal drug use is widespread” (p. 47). For instance, results from an anonymous questionnaire given to soldiers departing Vietnam in 1967 indicated 29 % reported using marijuana (Roffman & Sapol, 1970). Stanton (1976) declared that from 1967 to 1971, the proportion of enlisted soldiers smoking marijuana “heavily” (20 or more times of drug use from 1967 to 1971) in Vietnam increased from 7 to 34 %, while the proportion of “habitual” users (200+ incidents of drug use) stabilized at 17–18 % between 1969 and 1971. Baker (1971) reported 75 opiate deaths in Vietnam within a 3-month span in 1970, and by October 1971, an estimated “44 % of all lower ranking enlisted men (E-1 to E-4) were using heroin. Half of these may have been addicted. By 1971 more soldiers were being evacuated from Vietnam for drug use than for war wounds” (Jones, 2005, p.19). It is impossible to know how many combatant drug abusers were also suffering from an unidentified war stress injury; however, there can be no doubt that the Vietnam War drug epidemic significantly skewed the reported low incidence of psychiatric casualties (e.g., Renner, 1973).

Another common theme during this era is the nontraditional inverse casualty trend whereby psychiatric admissions and evacuations greatly increased toward the end of the war while WIA and KIA rates substantially decreased (Dean, 1997), thereby raising suspicion about the legitimacy of referring to these conditions as war stress casualties (Shepard, 2001). For example, Army psychiatric hospital admissions steadily increased per 1000 as follows: 11.7 (1965), 13.3 (1968), 15.8 (1969), 25.1 (1970) (Neel, 1991), and 129 (60 % of evacuations) in April 1972 (the majority for drug dependence) (Dean, 1997), while WIA rates decreased from a peak of 120.4 (1968) to 87.6 (1969) and 52.9 (1970) (Neel, 1991).

Misconduct Stress Behaviors

Another major finding in the Vietnam experience is the relearning of American Civil War, WWI, WWII, and Korean War lessons regarding the differential impact of misconduct stress behaviors (Department of the Army, 2006). The Vietnam era Army Field Manual 8-5139 applies the label “misconduct combat stress reactions” to these misconduct stress behaviors (Jones, 2005). Such behaviors are often associated with “low-intensity” warfare typically experienced by rear echelon noncombat personnel. These chronic war-related stress casualties are also referred to as “nostalgic” or “garrison” and may include venereal diseases, substance abuse, indiscipline, and personality disorders (Jones, 2005). Indiscipline can range from the commission of relatively minor acts of omission or insubordination (failing to take preventive hygiene measures in Korea, possibly leading to frostbite, or neglecting to take chloroquine–primaquine in Vietnam resulting in malaria) to commission of serious acts of disobedience such as committing mutiny or homicide (e.g., “fragging” or killing or injuring via fragmentation grenade) and atrocity (My Lai). For instance, of 823 psychiatric casualties from the Third Marine Division from February to October 1967, only 11.8 % were diagnosed as combat stress reactions and 30 % diagnosed as personality disorders (Marlowe, 2001). Moreover, Linden (1972) reported a progressive increase in the number of courts martial for insubordination and assaults (including murder) during the Vietnam War. For example, after President Nixon announced withdrawal plans on June 9, 1969, fragging increased from 0.3/1000/year in 1969 to 1.7/1000/year in 1971 (Jones, 2005).

Evidence of Other war Stress Injury

Since WWI the military has been concerned with chronic stress effects on aviators called “flying fatigue” or “operational fatigue.” Both terms are synonymous with war stress injuries, which are often referred to as “shell shock” in nonaviators (Anderson, 1966). According to Neel (1991), “No problem, however, was more common yet more elusive than that of flyer fatigue. It became more pronounced after 1965 when the buildup of U.S. forces gained momentum and remained a significant limiting factor in the conduct of airmobile operations” (p. 100). Yet, statistical data are unavailable. Military suicide rates are also unknown; however, in 1988, the Centers for Disease Control (CDC) confirmed 9000 veterans committed suicide. Additionally, the military did not track functional somatic or MUPS conditions. However, diarrheal diseases during the Vietnam War were among the “major problems” identified by Army medicine, which is consistent with other war generations as well. One might infer that this high incidence of diarrheal diseases indicates a potentially high incidence of functional MUPS (akin to irritable bowel syndrome). For instance, in 1965, the average theater-wide annual rate for this type of disease was 69 per 1000 per year; in 1969, it was 35 per 1000 per year. These data compare with WWII rates of 55–129 cases per annum per 1000 troop strength (Neel, 1991, p. 42). However, to be clear, there are multiple reported causes of diarrheal diseases; therefore, it would be erroneous to label all such cases as entirely MUPS. Shay (1991) documented case studies of traumatic grief and moral injury in Vietnam combat veterans, but prevalence is unknown. During the Vietnam War, 12–14 % of all combat casualties had a TBI (Institute of Medicine, 2008), and Caveness et al. (1979) initiated an extensive, longitudinal National Institute of Health Vietnam Head Injury Study (VHIS) of 1221 Vietnam veterans who sustained TBI between 1967 and 1970.

Postwar Mental Health Analyses

In 1972, the VA’s annual report to Congress (Veterans Administration, 1973) indicated that mental health demands were progressively escalating, remarking that its 73 mental hygiene clinics alone provided treatment to over 60,000 Vietnam veterans with over 1.25 million treatment visits per year. In light of the discordant reports of Vietnam veterans’ mental health needs, in 1983, Congress mandated the National Vietnam Veterans Readjustment Study (NVVRS) via Public Law 98-160 to “establish the prevalence and incidence of PTSD and other psychological problems in readjusting to civilian life” (Kulka et al., 1990, p. xxiii). In 1988, the NVVRS reported that 479,000 (15.2 %) male and 7166 (8.5 %) female veterans currently met criteria for PTSD, with a lifetime prevalence of 30.6 % or 960,000 male veterans and 26.9 % or 1900 female veterans (Kulka et al., 1990). Aside from PTSD diagnoses, the NVVRS found that 38 % of veterans divorced within 6 months, 40 % of homeless men were Vietnam veterans, 15 % of veterans were unemployed, and Vietnam veterans were 65 % more likely to commit suicide (Kulka et al., 1990). In 2006, Dohrenwend et al. re-examined the NVVRS data, which led to revised estimates of 18.7 % lifetime PTSD prevalence and current rates of 9.2 %.

Capacity to Meet Demand

Media reports during the Vietnam War era imply that the mental health system was unprepared and overwhelmed. In a 1972 New York Times article, “Postwar shock besets veterans of Vietnam,” serious social problems are reported in that “there is evidence that the problem is more pervasive than has been acknowledged by the Government, and may indeed be building to establish a social problem of serious magnitude” (Nordheimer, 1972). In 1967, only a small number of the VA’s 80,000 hospital beds were occupied by Vietnam veterans. By 1972, more than 50,000 psychiatric inpatients from Vietnam had been cared for, and a larger number sought help in outpatient clinics. Nordheimer (1972) reports that psychiatric professionals are stretched thin by the high numbers seeking outpatient care and are unable to deliver sympathetic counseling, considered to be the preferred treatment for PVS (post-Vietnam syndrome). In 1971 headlines such as “Addiction in Vietnam spurs Nixon and Congress to take drastic new steps” further documents the system’s inability to meet the mental health demands posed by Vietnam veterans (Schmidt 1971). In his article “Delayed trauma in veterans cited,” Rensberger (1972) discusses the debate over the time lapse between the traumatic events or experiences and the presentation of the response. This lapse of time could result in statistics and screenings returning invalid data. Two additional articles reinforce the perception of a system incapable of meeting wartime demands: “Angry Vietnam veterans charging federal policies ignore their needs: They see neglect and inaction by the administration in jobs, education, healthcare and counseling” (Weinraub, 1979) and “Aid urged for Vietnam veterans” (1979). Both report an unresponsive system that leaves the needs of Vietnam veterans unmet.

Presidential and Congressional Interventions

The sheer number of executive and congressional corrective actions offers additional evidence of broad system deficiencies. During the 1970s, Congress passed special legislation to fund significant expansion of VA mental health resources in order to meet growing wartime demand. One may infer that such action suggests a previously unmet need. For instance, “mental hygiene clinics” grew from 70 (1970) to 131 (1981), “day treatment centers” from 36 (1970) to 73 (1981), “day hospitals” from 9 (1970) to 39 (1981), and substance abuse treatment centers from 30 (1970) to 113 (1981) (Baker & Pickren, 2007).

By 1988, the VA instituted 31 residential PTSD programs, 65 general outpatient PTSD clinics, and 30 special funded PTSD clinical team programs (Baker & Pickren, 2007) to address the wartime need. In addition, the following reports, legislation, studies, and investigations were initiated: Report to the President from The President’s Commission on Mental Health (1978); Veterans Health Care Amendments of 1979 Public Law 96-22 (initially established 90 Veterans Centers that Congress expanded to 189 by 1985 and provided counseling services to 371,000 Vietnam veterans and 80,000 family members) (Baker & Pickren, 2007); 1981 Legacies of Vietnam Study (Egendorf, 1981); Institute of Medicine’s (1994) Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam; and congressionally mandated investigations, to include NVVRS (1983) $9 million (Kulka et al., 1990) and Centers for Disease Control (1987) Vietnam Experiences Study (1988). These responses to acknowledged deficiencies shed impartial light on veterans’ needs, in the vacuum of reliable data, or address systemic inadequacy. In 1989, the VA was finally elevated to a Cabinet-level department, symbolizing national importance of veteran issues.

Postwar Controversy

The most lingering, controversial theme emerging from the Vietnam-era harkens back to impassioned 1916 debates over the very nature, cause, and authenticity of war stress injuries (Lerner, 2003). Central to the debate are efforts to explain the discrepant trends in neuropsychiatric casualty rates, especially the significant delayed presentation of symptoms after war. Renner (1973) concluded that the primary responsibility for the discrepancy in reported war stress injury incidence is due largely to the military’s trend of diagnosing and discharging Vietnam veterans for “character and behavior disorders” (aka personality disorder) and drug abuse, thus hiding or deflating actual war stress casualty rates in the military, until such veterans returned home and began seeking mental health treatment. Included in those with hidden war stress injuries are returning Vietnam veterans who did not self-disclose mental health issues in the war zone or while remaining on active-duty, but either began exhibiting or self-reporting symptoms and signs of war stress injury upon returning home and/or military discharge (e.g., Renner, 1973). Other authors have remarked about the Vietnam era’s individual rotation policy whereby individuals entered and departed deployed units on jet transports and often returned to a rejecting home environment. (By creating such a situation the system’s policy violated prior war trauma lessons of the importance of group cohesion and social support) (Jones, 2005). Some accused the military and government of maliciously intending to deny the toxicity of war on veteran’s health or to simply avoid paying compensation. Others attributed the discordant numbers of self-reporting veterans with war stress injuries (e.g., PTSD) with the military’s official claims of historic low incidence of psychiatric casualties, as evidence of widespread fraud and malingering (Frueh, Hamner, Cahill, Gold, & Hamlin, 2000). Scholarly treatises have attributed the exorbitant discrepancy in Vietnam War stress casualty rates to American antiwar political activism and the corrosive effects of modern psychiatry perpetuating a “culture of trauma” whereby life adversity is pathologized in an unprecedented and essentially invalid PTSD construct (Jones & Wessely, 2005; Shepard, 2001). Others ascribe to the belief that exposure to war stress by itself is, and has always been, the primary cause of psychiatric casualties (e.g., Lerner, 2003).

Military Analysis of Lessons Learned

In keeping with the post-Korean War trend, there is a paucity of official military post-Vietnam lessons learned analyses. However, several documented lessons indicate an initial lack of preparation or resources that could negatively impact capacity to meet wartime needs. They are as follows:

• “The man least trained and most junior in rank became (for some months) the sole representative of Army psychiatry in the only combat zone of the United States Army” (Huffman, 1970, p. 344).

• “The author contends that the casualties of such low-intensity, intermittent campaigns are similar to nostalgic casualties of the American Civil War and of prior wars” (Jones, 2005, p. 13)—in reference to the psychiatric condition known as “nostalgia” or pathological homesickness.

• “In addition to providing an impetus for accurate diagnosis, the demands for treatment of large numbers of traumatized veterans spurred the development of effective treatments both for reactions that occurred on the battlefield, as well as those that occurred outside the war zone. Particularly following WWI and WWII great gains were made in diagnosing and treating stress reactions. Sad to say, many of these lessons were forgotten and had to be relearned with Vietnam veterans” (Kulka et al., 1990, p. 286).

• “Vietnam revealed the limits of World War II type psychiatric treatment policy in a low-intensity, prolonged, unpopular conflict. Such conflicts, if they cannot be avoided, must be approached with primary prevention as the focus” (Jones, 2005, p. 27).

• “Although successful treatments for low-intensity combat stress casualties were developed as early as the Napoleonic Wars, circumstances can prevent the application of remedies. For example, during the Vietnam War the 1-year rotation policy, ostensibly for the purpose of preventing psychiatric casualties due to cumulative stress, the policy of rotating commanders out of combat units after 6 (and later only 3) months in order to give more officers combat experience, and the policy of individual replacement of losses rather than unit replacements all interacted to impair unit cohesion which might have prevented some of the nostalgic casualties” (Jones, 2005, p. 27).

Conclusion

There is ample evidence substantiating a wartime behavioral health crisis and likely catastrophe in the Vietnam era. This is especially true given the scope, duration, and costs that continue into the twenty-first century. Much of the controversy surrounding the Vietnam experience in terms of the nontraditional temporal and qualitative trends in war stress casualties appears to be due to the documented differential impact of “low” (guerilla-type) versus “high” (symmetrical-type) intensity warfare and war stress injuries, faulty individual rotation policy, poor reintegration reception, and extensive drug abuse as aptly described in post-Vietnam lessons learned analyses (Jones, 2005). However, the absence of credible, comprehensive, and transparent reporting must also be considered a key factor in the extreme discordance in prevalence estimates.

Persian Gulf War

Between August 1990 and July 1991, 697,000 US military personnel were deployed for 12 months to participate in Operations Desert Shield and Desert Storm (ODS), including a 3-day ground war ending on February 27, 1991 that resulted in 148 American service members KIA and 467 medically WIA.

Mental Health Demand

The previously noted trend of progressively inadequate documentation was magnified by the Persian Gulf War cohort. Unlike its predecessors, this war cohort did not compile (or make accessible) a central repository for documenting medical (or neuropsychiatric) postwar statistics and lessons learned analyses. Instead, it opted to upload a host of disparate journal articles to its website: http://history.amedd.army.mil/booksdocs/AMEDDinODS/ameddODS.html. Nonetheless, for the first time, postwar information from all of the service branches is centrally available; however, essential neuropsychiatric statistics are absent. Consequently, there is comparatively less known about the scope of immediate wartime mental health demands of the Persian Gulf War cohort than any previous war generation since the American Civil War. The information that follows is sketchy and incomplete.

Estimated Wartime Demand

During ODS psychiatric casualties represented nearly 7 % of all medical evacuations, including a total of 476 Army war stress casualties (Office of the Inspector General, Department of Defense, 1996). The Institute of Medicine (1995) was commissioned to conduct a comprehensive study of the health consequences of the Persian Gulf War. Assessing the military mental health demand relies exclusively upon inconsistent survey methodology conducted by diverse agencies. One VA study of recently deployed military personnel found 9 % of female and 4 % of male service members endorsed PTSD diagnostic criteria within 5 days of returning home. RAND (Marshall, Davis, & Sherbourne, 2000) and Institute of Medicine (2006) conducted an extensive review of Gulf War epidemiological data that was generally critiqued for overall low quality. Absolute numbers of war stress casualties, either from DoD or VA, were not cited in any of a dozen national studies. Instead, varied prevalence estimates of a handful of psychiatric diagnoses such as PTSD, depression, panic disorder, anxiety disorder, and substance abuse are reported in the form of various sample percentages, making it difficult to gauge if wartime resources are adequate. Generally speaking, PTSD rates for military personnel ranged from 1.9 to 9 % (Marshall et al., 2000), with most studies showing deployed veterans as having a two to three times greater likelihood of having PTSD and depression than nondeployed peers (Institute of Medicine, 2006). However, upon returning home, an estimated 18 % of ODS veterans reported significant psychological distress, with many reporting feeling dazed, numb, agitated, and estranged, as well as having difficulty making emotional contact and participating in practical life problems (Toomey et al., 2007). As of December, 31, 2004, the VA reported a total of 1514 Gulf War veterans had committed suicide, exceeding the 148 personnel KIA (Kang, 2008). A study of DoD postwar hospitalization for mental disorders (June 1991–September 1993) reported 50 % were for alcohol related disorders (Institute of Medicine, 2006).

A new controversial war syndrome “Gulf War Illness,” characterized by diverse MUPS, emerged, involving over 70,000–700,000 of ODS veterans (i.e., General Accounting Office, 1996; Marshall et al., 2000; Veterans Affairs/Department of Defense, 2001). In regard to MUPS, according to Institute of Medicine (2006), “every study reviewed by this committee found that veterans of the Gulf War reported higher rates of nearly all symptoms examined than their nondeployed counterparts” (p. 3). For example, results from a VA study revealed the prevalence of the following MUPS in Gulf War veterans: headache (54 %), sleep disturbance (47 %), joint pain (45 %), back pain (44 %), fatigue (38 %), and heartburn (37 %). Lower, but still high rates of fibromyalgia, chronic fatigue syndrome, gastrointestinal problems, multiple chemical sensitivity, dermatological conditions, and arthralgias (joint pain) were observed for deployed versus nondeployed veterans (Institute of Medicine, 2006). In addition, the significant majority of ODS veterans reported persistent psychiatric symptoms, medically unexplained physical symptoms, and social reintegration problems 10 years after returning home (Toomey et al., 2007).

Capacity to Meet Demand

According to the Office of the Inspector General (IG), Department of Defense (1996), the military’s Gulf War era system for managing war stress casualties, “did not adequately support planning for combat stress casualties,” and the “DoD has identified and corrected the deficiency” (p. 19). Furthermore, the IG’s (Office of the Inspector General, Department of Defense, 1996) postwar audit of the DoD’s existing structural processes for ensuring adequate planning, implementation, and training related to prevention, early identification, and treatment of war stress casualties led to the principal conclusion that the processes lacked adequate and efficient procedures to handle combat stress control, as noted in the report: “However, no central point of contact exists in DoD for handling combat stress control issues; and insufficient joint doctrine exists addressing combat stress control” (Office of the Inspector General, Department of Defense, 1996, p. 4). In addition the report noted deficiencies in programs operated by the Navy, Marine Corps, and Air Force. “At the service level, the combat stress control programs offered by the Navy (includes Marine Corps) and the Air Force are inadequate to support their members” (p. 5). The report sheds further insight into wartime capacity during the previously concluded Gulf War.

The following news headlines highlight the combat stress issues of returning Gulf veterans: “Stress follows troops home from Gulf” (Schmitt, 1991); “Gulf War taking toll at home” (Jordan, 1991); and “Gulf veterans still paying the price: some troops count jobs, marriages, and health among war’s casualties” (Evans, 1992). The steady flow of critical news media reports and the estimated 700,000 personnel complaining of MUPS (Government Accounting Office, 2004) comprise the extent of retrospective research in Gulf War Illness. This is due to the systemic lack of pre and postdeployment health screening, which would help identify the potential etiologic role of war stress and signs of unpreparedness to meet veterans’ needs. A strong indication of broad systemic failure in meeting the wartime demand is evident 8 years after the Gulf War when the Government Accountability Office (2000) concluded, “Results of the research and investigation activities are accruing slowly and basic questions about the causes, course of development, and treatments of Gulf War veterans’ illnesses remain unanswered” (p. 3). Earlier in 1995, the IOM concluded, “No single comprehensive data system exists that enable researchers to track the health of Persian Gulf War veterans both while on active duty and after separation” (p. 9). A follow-up by the Government Accountability Office (2000) cited ongoing fragmentation and inadequate coordination among VA, DoD, and the Department of Health and Human Services as principle factors, despite an interagency Persian Gulf Veterans’ Coordinating Board established in 1994. In terms of cost of the crisis, from 1997 to 1998 alone, the VA and DoD spent more than $121 million for research and investigation into Gulf veterans’ illnesses (Government Accountability Office, 2000).

Executive and Congressional Interventions

Concerns over Persian Gulf War mental health demand and capacity to meet wartime needs spurred a plethora of investigations including the following: Government Accountability Office (1997, 2000); Institute of Medicine (1995, 2008a, b); Office of the Inspector General, Department of Defense (1996); and RAND (Marlowe, 2001; Marshall et al., 2000). Additionally, presidential and legislative action was mandated such as: 1991, Public Law 102-25 Persian Gulf Service and PTSD (requiring DoD and VA to assess PTSD treatment and other rehabilitation resources); 1991, The National Defense Authorization Act Public Law 102-190 (mandating DoD establish a Persian Gulf Registry to track all deployed service members’ health status); 1992, Persian Gulf War Veterans’ Health Status Public Law 102-585 (mandating the VA establish a Gulf War Veterans Health Registry); 1996, Presidential Advisory Committee on Gulf War Veterans’ Illnesses; 1998, The Persian Gulf War Veterans Act Public Law 105-277; The Veterans Programs Enhancement Act, Public Law 105-368; and 1992, Defense and Veterans Head Injury Program (DVBIC).

Military Analysis of Lessons Learned

The Army’s postwar analysis concluded that most of the division mental health sections arrived in Saudi Arabia deficient in personnel, appropriate training, supplies, and equipment. They all had a great deal to overcome. There was sufficient time before the start of the ground war to fix many problems, but lack of readiness prevented some of the sections from adequately supporting their divisions during the prolonged Desert Shield phase of the Gulf War (Stokes, 1996). Martin (1992) describes the situation as follows:

Corps and division mental health teams (and the evacuation hospitals) did not have to cope with large numbers of battle fatigue casualties. If significant casualties had occurred, these teams would have found it very difficult to carry out their mission. They were not adequately staffed, equipped or trained in peace-time to perform their wartime role. The world is a dangerous place and the Army must be prepared today for tomorrow’s conflict. As highlighted here, lessons learned in SWA (Southwest Asia) provide a reference point from which to prepare for this inevitability. (pp. 40–44)

The above description indicates significant deficiencies in critical areas of planning, preparation, and training that one can conclude, as we did, would greatly limit capacity to meet wartime needs.

Conclusion

Known and estimated mental health demands, candid self-critical lessons learned appraisals, news media accounts, and numerous presidential and congressionally initiated corrective actions suggest a >50 % likelihood of at least a moderate wartime behavioral health crisis. The Persian Gulf War crisis appears to be greater in magnitude, scope (the number and diversity of major problems), and duration than the Korean War era but pales in comparison to mental health catastrophes in WWI, WWII, and Vietnam War eras. This appears to be largely a function of the Gulf War’s distinction as the shortest and least bloody American conflict in the past century. Moreover, it remains unclear what proportion of veterans with Gulf War Illness might be attributable as either a primary or secondary feature of war stress injury. Emerging trends during the Persian Gulf War crisis match those of recent generations in terms of greatly diminished transparency in record keeping and the mind set to ignore fundamental war trauma lessons, for example, the need to adequately plan and prepare for inevitable war stress casualties and the need for adequate numbers of well trained specialists.

Discussion

Summary Remarks

In sum, there is clear and substantial historical and empirically based proof of repetitive wartime behavioral health crises after every major American war since the beginning of the twentieth century. However, the strength of available evidence of crisis varies markedly with the size, scope, and duration of each generational crisis. For example, there is sufficient indication of protracted major wartime crises (aka “catastrophe”) during the WWI, WWII, and Vietnam eras, with a modest level of evidence of crises in the Persian Gulf and Korean War eras. It bears mentioning that the shortest gap between major wartime crises falls between WWII and the Korean War (5 years), and the shortest, most circumscribed war fought since the twentieth century occurred during the Persian Gulf War. Post-Korean War lessons learned analyses seem to concur that the ability of the Army to quickly implement several key war trauma lessons from WWII (e.g., ensure ready access to mental health staff and develop a rotation policy limiting exposure to war stress) may have been largely responsible for avoiding larger numbers of war stress casualties (e.g., Glass & Jones, 2005; Reister, 1973). That said, the absence of transparent and comprehensive reporting of war-related mental health needs raises concerns about default underestimation. Moreover, while crises vary in terms of sheer numbers of people impacted, diversity of problems manifested, and associated costs, even a relatively “small” or limited crisis can have profound life altering effects for those involved.

Lastly, several universal themes emerged from our review of generational crises. First is the importance of centralized, transparent, and accurate reporting of wartime mental health and social needs. Second is an apparent trend of wartime crises either caused or exacerbated by critical failure to learn basic war trauma lessons such as a need to adequately plan, prepare, and train for inevitable war stress casualties. Delineating these so-called “psychiatric lessons of war” (Jones, 1995a) and potential learning barriers, as well as developing the means to predict and prevent wartime crises, should be the focus of future studies. Glass (1966a) concurs with these recommendations. “In retrospect…the concepts and practices as developed by combat psychiatry in World War II, generally, rediscovered, confirmed, and further elaborated upon the largely forgotten or ignored lessons learned by the Allied armies, including the American Expeditionary Forces in World War I. Thus, the lessons of World War II combat psychiatry should be regarded as relearned and consolidated insights” (p. 989).

In conclusion, this two-part series suggests that generations of preventable wartime crises, caused by a failure to learn lessons of war, demand a long overdue paradigm shift, one that fully integrates and equally values mental and physical health in order to end stigma and disparity. Addressing the reasons “why” psychiatric lessons are blatantly unheeded offers the best chance to propel mental health care into the twenty-first century.