I am pleased and excited to initiate a Psychiatric Times column on mental health issues and psychiatric practice as they relate to military personnel and veterans. As a psychiatrist, health policy and services researcher, and war veteran who spent 31 years in the Army and 18 years in academic medicine, I look forward to discussing a variety of related issues and perspectives of importance to psychiatry, the military, and both veterans and their families. Frequently we will welcome guest authors who will explore a variety of ideas and issues.
Psychiatrists might ask, “Why should I care?” The question is a reasonable one and the place where we will start. Each one of you is a scarce resource within our larger society. If your bandwidth is like mine, it fills fast and has limits on what it can digest and act on. So allow me to suggest a few reasons—by no means an exhaustive list—why what’s happening in the mental health world of the military and veterans is of great interest to you.
1. The local impact of the past 13 years of armed conflict is greater than many think and much greater than simply the number of veterans in your practice or your community.
When speaking before groups, I often start with a question: “How many Americans would you estimate have deployed to Iraq and Afghanistan since September 11, 2001?” Mostly I get a few bashful guesses. Seldom does more than one person offer an estimate much higher than 500,000.
There are gasps when these audiences hear that well over 2.5 million Americans have deployed about 3.5 million times. This number, as large as it is, hints at another challenging fact: only about two-thirds of a percent of all Americans have deployed to these conflicts. For most American families, their only direct exposure to the military is in an airport.
A closer look shows that the deployment figures are large but the impacts of these wars are larger still. Consider this: in 2008, Nobel Laureate economist Joseph Stiglitz and colleague Linda Bilmes estimated the cost of the Iraq War alone at between $2 trillion and $5 trillion.1 (This broad range is based on how the economic effects of some factors are valued, but is striking even if the most conservative estimate is used.)
Can these figures be credible? As the US entered the Vietnam War in the early 1960s, some Americans were still receiving compensation for Civil War health effects. It is this lengthy economic tail—some resulting from direct benefits and compensation but perhaps mostly the consequence of more insidious long-term health effects on individual productivity—that is the major driver of the costs of war.
2. The contrast between military and civilian culture can challenge our notions of where social values end and hard evidence begins.
Anyone raised in America is likely to view certain ways of thinking as self-evident, even though sometimes a global majority thinks of the same issues in starkly different terms.
The most poignant example that comes to mind is the tension between personal autonomy and collective responsibility. For millennia, nearly all people sought survival in small groups, and a large (though decreasing) portion of the world still does. This lifestyle offers little room for autonomy; everyone’s role is essential and only collective efforts can sustain the group. In this context, the boundaries of individuality are narrow and breaching accepted roles can carry a harsh penalty.
In contrast, in Western civil societies, people are mobile, adults live independently from neighbors and extended family, and social institutions are diverse and subspecialized. Autonomy and expression are fundamental rights. Neighborhood and family engagement is viewed as charitable but discretionary. When failures occur, we look first for institutional failures and tend to see individuals as victims of powerful institutions.
Dr Engel is Senior Health Scientist at the RAND Corporation in Washington, DC. His last military assignment before retiring as an Army colonel was Associate Chair for Research, Uniformed Services University of the Health Sciences, department of psychiatry, in Bethesda, Md.
1. Stiglitz JE, Bilmes LJ. The Three Trillion Dollar War: The True Cost of the Iraq Conflict. New York: WW Norton & Company, Inc; 2008.