Mental health care in psychiatric
THE COSTS OF war are tremendous on several fronts. We have become used to reading daily in the newspaper about the mounting costs of the Iraq War. First, is the cost of death and destruction. Between the start of war on March 19, 2003 and June 16, 2004, 952 coalition forces were killed, including 853 U.S. military. Of the total, 694 were killed after President Bush declared the end of combat operations on May 1, 2003. Over 5,134 U.S. troops have been wounded since the war began, including 4,593 since May 1, 2003. Estimates range from 50 to 90 civilian contractors, missionaries, and civilian worker deaths. Of these, 36 were identified as Americans. Thirty international media workers have been killed in Iraq, including 21 since President Bush declared the end of combat operations. Eight of the dead worked for U.S. companies.
The economic costs are also tremendous and impact daily life in the U.S. Congress has already approved $151.1 billion for Iraq. Congressional leaders have promised an additional supplemental appropriation after the election. One estimate is that the war bill will add up to an average of at least $3,415 for every U.S. household. A major consequence for those of us in mental health is that the massive spending on war has left less money for social spending. My fear is that we will see social programs for mental health gradually but persistently cut over the next few years. Traditionally, war spending has boosted the economy initially, but over the long term, it brings a decade of economic troubles. And gas prices topped $2 a gallon in May 2004, a development that most analysts attribute at least in part to the deteriorating situation in Iraq.
The less obvious, but perhaps most critical, cost of the war is the psychiatric impact on soldiers and their families. The recent military operations in Iraq and Afghanistan are the first sustained ground combat missions undertaken since the war in Vietnam. Research conducted after other military conflicts has shown that deployment stressors and exposure to combat result in considerable risks of mental health problems, including posttraumatic stress disorder (PTSD), major depression, substance abuse, impairment in social functioning and in ability to work, and the increased use of health care services.
Landstuhl Regional Medical Hospital in Germany is the main transfer point and treatment center for medically evacuated U.S. solders from Iraq, Kuwait, and Afghanistan. The hospital has treated about 12,000 soldiers who have been deployed to the “war on terror,” most returning from Iraq. About 8% to 10% of soldiers send to Landstuhl are treated for psychiatric or behavioral health issues. That number represents only a fraction of the psychiatric toll because it excludes any physically wounded solders who might suffer psychological trauma but are classified differently. And, there are many solders whose mental problems are not diagnosed until they return to the United States.
Many gaps exist in the understanding of the full psychosocial effects of combat. The all-volunteer force deployed to Iraq and Afghanistan and the type of warfare conducted in these regions are very different from those involved in past wars. A recent article in the New England Journal of Medicine (Friedman, 2004) about the psychiatric costs of the military operations in Iraq and Afghanistan forces us to acknowledge the psychiatric cost of sending young men and women to war. The psychiatric costs are serious. The prevalent problems are PTSD, major depression, and alcohol misuse. There is a direct correlation between the prevalence of PTSD and the number of firefights in which a soldier had been engaged. Even more serious is these authors report that only a small percentage of soldiers and Marines whose responses met the screening criteria for mental disorder reported that they had received help from any mental health professional (Hoge, Castro, Messer, 2004). In the military, there are unique factors that contribute to resistance to seeking such help, particularly concern about how a soldier will be perceived by peers and by the leadership. Ironically, those in need of help from mental health services were the individuals who were most concerned about the stigma associated with seeking such services. Those soldiers and Marines returning from combat who are most in need of mental health care are the least likely to seek treatment for fear that it could harm their careers, cause difficulties with their peers and with unit leadership; it could become an embarrassment in that they would be seen as weak. Overall, these findings are consistent with those of earlier reports (Friedman, 2004)
There are two things that are mandatory to alleviate the psychiatric and social consequences of this war. First, the psychiatric services must be available. We cannot cut social, psychiatric, or military programs that assist this population. Even more importantly, we must provide intense outreach to these individuals so that they use the programs. Mental health services must be provided in primary care and confidential counseling must be provided through employee-assistance programs. Only when we provide counseling and psychotherapy in the mainstream of overall health care will the skeptical individual allow himself or herself to receive it. We as a country and we as mental health providers must assist in paying the price for the psychiatric cost of war.
Tags: Health psychiatric