The military and its psychiatric challenges.

This special issue explores the psychiatric challenges facing the armed forces of the UK, USA, Canada and Australia. Evidence from past confl icts has established a relationship between the rate of physical casualties (killed and wounded) and levels of psychiatric morbidity (Jones & Ironside, 2010). Inevitably, the operations in Iraq and Afghanistan have resulted in psychological casualties. Not since Vietnam has so much research been directed towards the mental health of service personnel. All four nations have focused on the study of post-traumatic stress disorder (PTSD), the truly novel psychiatric diagnosis of the late twentieth century, not least because in its chronic form it is often diffi cult to treat. PTSD is also a diagnosis that attracts media attention, having been used by anti-war campaigners in the aftermath of Vietnam to criticize the conduct of the confl ict. Whilst it is diffi cult to compare rates between nations, a consistent fi nding of the last 20 years is that reported PTSD tends to be higher amongst service personnel and veterans of the USA compared with other western nations, and in particular the UK (Richardson et al ., 2010). A study of US Gulf War veterans, for example, found a prevalence of 10.1% (Kang et al ., 2003). By contrast, UK investigators found rates of 3% (Unwin, 1999). With reference to Iraq and Afghanistan, Hoge et al . (2006) reported PTSD rates among returning US troops of between 5% and 10%, and recent studies based on VA data have recorded PTSD rates between 21% and 29% (Wells et al., 2011), at a time when UK researchers reported rates of between 2% and 6% (Fear et al ., 2010; Sundin et al ., 2011). Explanations for the difference have been various: US personnel tend to be younger and of lower socio-economic background than their UK counterparts, longer tours of duty have been undertaken by US troops (12 months and as long as 15 months compared with 6 months for UK forces), a greater proportion of reservists deployed by US armed forces, together with differences in the way healthcare and benefi ts are delivered. In addition, American culture may be more receptive to psychological disorder (see for example the high rates of PTSD recorded by the National Vietnam Veterans ’ Readjustment Study, Kulka et al., 1990), whilst psychiatric stigma remains evident in the UK. The international focus on PTSD has also prompted the investigation of co-morbid disorders: depression, drug and alcohol abuse and anxiety states. Western nations have detected signifi cant levels of alcohol consumption after deployment, though rates are particularly high amongst UK personnel (16% to 20%). The US Army and Marine Corps have also witnessed a sustained rise in suicide, bringing rates above those for age-matched civilians. In the UK, with the exception of males under twenty serving in the army, suicide rates are lower than in comparable civilian cohorts. The association between alcohol and the military, though not universal, extends through most armies from ancient history to the present. The Spartans, who lived according to a supreme military culture, included a daily consumption of wine that today would be considered harmful to health. Even the Roman Army, a highly disciplined and successful fi ghting force, issued legionaries with a ration of sour wine ( acetum ). Berserkers recorded in Viking sagas were thought to have used drugs or alcohol to induce a rage state before going into battle. During World War I, most combatant nations supplied alcohol on a daily basis to their front-line troops. With an impact on morale, it may have extended the effectiveness of infantrymen. Colonel Nicholson recalled that spirits made life bearable: ‘ the private soldier ’ s ration of rum saved thousands of lives ’ , adding ‘ it is an urgent devil to the Highlander before action; a solace to the East Anglian countryman after the fi ght ’ (Nicholson, 1939). Given the longevity and depth of the association, alcohol with all its dangers played an important part in military life: the ability to lift morale, assist bonding and social cohesion, make an arduous existence bearable, grant low short-term relief from traumatic memory, and in extreme cases to fuel aggressive instincts. It is not surprising that soldiers, who are typically young males living away from home and willing to take risks, often consumed alcohol, and sometimes in large quantities. In the past, when a warrior was not expected to reach old age, dying either from wounds or sickness, the adverse effects of heavy alcohol consumption were outweighed by its advantages. Today, with smaller professional International Review of Psychiatry, April 2011; 23: 125–126