The Briefing

The Costs of the Moral Injury to Our Troops Fighting the Wars on Terrorism

Friday, February 1, 2013

Those who volunteer to defend their country know they are putting their lives at risk.  But the troops and their families are only just beginning to understand the extent to which they are putting their mental health at risk.  As we get better at keeping wounded warriors alive, we need to get better, and more serious, about developing tools for healing the injuries to the mind and brain that are often at least as destructive as more visible wounds.

Because of advances in medical technology and in body armor, soldiers are surviving combat situations that would have killed them in the past, but returning with traumatic brain injuries and with memories of mind-breaking horrors. Our military commitments in the wars on terrorism have required our troops to redeploy again and again, in some cases as many as eight times, such that nearly 13,000 soldiers have spent at least three cumulative years in Iraq or Afghanistan.  Military historians call the frequency and cumulative length of the troops’ tours of duty historically unprecedented; compared with previous wars, deployments have been more frequent and breaks between tours are shorter.  Given that redeployment is a major risk factor for post-traumatic stress disorder, this modern style of waging war comes with a profound cost to the troops: widespread psychological injury.

There is nothing new about veterans suffering psychologically and spiritually when they return from war, though what we now call “post-traumatic stress disorder” (PTSD) has received different labels at different times, most of them unflattering. These include “war neurosis,” “malingering,” “battle fatigue,” and “shell shock.” Three thousand years ago, an Egyptian veteran named Hori wrote about the feelings he experienced before returning to the battlefield: “Shuddering seizes you, the hair on your head stands on end, your soul lies in your hand.”  Herodotus describes an Athenian warrior who permanently lost his sight when the soldier standing next to him was killed, although the blinded soldier “was wounded in no part of his body.” He tells also of Aristodemus, who was so shaken by his experience in war that he was nicknamed “the Trembler.”  Like a growing number of veterans of the wars in Iraq and Afghanistan, Aristodemus would eventually commit suicide.  What is new is that with evolving brain-scan technologies such as magnetoencephalography (MEG), it is now possible to see the impact on the brain of these previously invisible wounds.   We now understand that PTSD is not a sign of weakness.  It is an injury to the brain that causes measurable changes in the body.

Estimates of the percentage of troops who will eventually be diagnosed with PTSD vary, in part because the symptoms of psychological injury can take years or decades to manifest—a fact that studies of the costs of war fail to recognize.  Indeed, one of the reasons the Veterans Health Administration (VA) is so overwhelmed with claims is that Vietnam vets are increasingly seeking treatment for PTSD associated with that war, decades after the war’s end.  Approximately twenty percent of military personnel returning from Iraq and Afghanistan have been diagnosed with post-traumatic stress disorder or major depression.   According to data collected by the Army, less than half are seeking treatment, in large measure because of the stigma. But it is not only stigma that prevents military personnel from seeking and receiving medical care for PTSD: The backlog in disability cases before the VA—which exceeded 900,000 in January 2013—is another significant factor.

Failure to provide timely treatment to returning vets suffering from PTSD can be dangerous, as PTSD is a risk factor for both violent crime and suicide.  Suicide is now the leading cause of death in the US Army, and the risk among military veterans is even higher: More than 6,500 veterans commit suicides every year—which adds up to a figure higher than the total number of military personnel killed in combat in Iraq and Afghanistan since the wars on terrorism began.

PTSD is now the most widespread injury suffered by returning troops, and yet, ten years into the wars on terrorism, we remain unprepared to handle the growing numbers of troops seeking treatment.  Lost productivity accounts for more than half the costs of PTSD and major depression.  But according to RAND, evidence-based treatment would pay for itself within two years because it would reduce medical and mortality costs, and the veterans would get back to work.[i] Treatment needs to be made more accessible. Thoughtful leadership is required to remove the stigma of psychological wounds; one way to erode the stigma would be for the president to bestow purple hearts on vets whose wounds are not fully visible.  We also need much better studies of the efficacy of treatment over time.  Treatments offered by the VA—such as eye movement desensitization and reprocessing (better known by its acronym, EMDR) and cognitive behavioral therapy—have been shown to be effective, but more study is needed about their long-term impact.  It is important to realize too that in many cases PTSD results in a kind of spiritual injury, so we should be studying the impact of spiritual practices such as meditation, which have been shown to be effective for other anxiety disorders.

By choosing an approach to military-personnel policy that requires redeployment to combat zones, we have inadvertently increased the risk to our troops of sustaining psychological wounds. With PTSD turning out to be the most prevalent injury among returning veterans, thousands of men and women who willingly risked their lives to serve their country are realizing that they were actually risking their wellbeing.  It is incumbent upon the American people and our leaders to ensure that our troops get the help they need upon their return home.

[i] These figures are mentioned in the report summary.