Treating Psychiatric Combat Casualties


A working model for eliminating stigma and transforming mental healthcare within the military.




Each moment of combat imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus, psychiatric casualties are as inevitable as gunshot and shrapnel wounds in warfare.

John W. Appel, MD; Gilbert W. Beebe, PhD1

The psychiatric casualties of war may be inevitable, but the way the military responds to them is not. Since the 19th century, numerous books have been written on the history of war trauma, and they have included numerous lessons for psychiatric care.2 Too often, however, the United States it seems like the military has failed to learn the lessons of the previous war. Veterans’ mental health has suffered in the process, resulting in a generational cycle of largely self-inflicted and preventable wartime mental health crises.3

Why has the American military’s health care system refused to learn the fundamental lessons of wartime trauma, and how can the system be improved? Based on decades of research, writing, and our lived experiences as active-duty service members and mental health clinicians, we have taken up these questions in Psychiatric Casualties: How and Why the Military Ignores the Full Cost of War.4 We offer concrete solutions that, if enacted, could propel the military as a lead social change agent in eliminating harmful mental health stigma and disparities.

Our Inspirations and Motivations

Mark Russell, PhD. I can trace my interest in war trauma back to the second grade, when I was living on the Camp Pendleton Marine Base in Oceanside, California. It was 1968, the height of the Tet Offensive in Vietnam. My father was a career enlisted Marine, a combat veteran of the Korean war and currently serving in the Vietnam war.

I have vivid memories of a steady stream of classmates whose names were called over the loudspeaker and instructed to go to the nurse’s office to be met with what we could only assume was traumatic news. The visibly anguished teachers had us keep our heads down on our desks while the nervous students gathered their personal effects; they were met at the door by an entourage composed of the vice principal, school nurse, and the base chaplain. We never saw those classmates and friends again.

When I embarked on my enlisted Marine career in 1979, I witnessed firsthand the residual effects of trauma associated with military service during war and peacetime. As a young lance corporal, I was hospitalized with a surgically-repaired broken jaw, and I serendipitously read David S. Viscott, MD’s The Making of a Psychiatrist.5 It resonated with my childhood experiences and ignited my dream of becoming a military psychologist.

In 1989, I ended my enlisted career in pursuit of a doctorate degree in clinical psychology at the Pacific Graduate School of Psychology (now Palo Alto University). For my dissertation I interviewed hundreds of combat veterans from World War II, the Korean War, and the Vietnam War.6 In 1992, I fulfilled my dream by restarting a career as a Navy clinical psychologist in the aftermath of the Persian Gulf War.

In 2003, I was deployed as head of neuropsychiatry for Fleet Hospital Eight in Bremerton, Washington, in support of the Iraq War invasion. It was then that I was awakened to the military’s failed mental health policies. My naval officer career was cut short due to my assuming the role of military whistleblower to address mental health issues.7-9 Much of this story is documented in Tom Donahue’s film, Thank You For Your Service,10 and Beth Dolan’s upcoming film, Strangers at Home.11

Perhaps the most pivotal experience occurred after President Bush prematurely proclaimed “mission accomplished.” Near the same time the military’s highest ranking psychiatrist visited our field hospital and presented the outcomes of an innovative combat stress screening and reconditioning program.12 The admiral fatefully pronounced, “This is very exceptional work; however, unfortunately, it will all be forgotten and will need to be rediscovered by the next generation.”7

After my military retirement in 2009, I embarked on a new career at Antioch University Seattle’s Doctor of Psychology (PsyD) program and established the Institute of WarStress Injury, Recovery, and Social Justice. Its mission is to end the pattern of mental health neglect and stigma associated with crises within and outside of military circles. The opportunity to collaborate with someone as esteemed as Charles Figley, PhD, the institute’s board chair, has been instrumental in paving the way to fulfill these high-vaulted goals. Psychiatric Casualties represents our collective efforts to share a written history in the hopes of ending the harmful consequences of neglecting war trauma lessons. In doing so, we hope the military will take a lead role in transforming mental health care in this country.

Charles Figley, PhD. Writing this book with Mark was an education. I do not recall the first time I corresponded with Mark, but I had heard of him for some time. He was already a hero among those most connected to veterans’ rights. Coming from a military family, he believed in and loved America and its military so deeply yet he was willing to risk everything to help veterans get better health care.

We wrote this book to identify what has gone wrong and to share a blueprint for correcting the harms we uncovered.

Mark’s journey from enlisted Marine to naval officer had enabled him to become the strongest voice for systemic improvement in behavioral health within the military. The bedrock values that emerged from our study are vital to all fighting forces: trust, confidence, and collective effort—despite the fear and fog of war.

We knew there would need to be at least one significant book to address the relevant research. There was so much to report—so many stories of hope and then disappointment. The deeper we dove into the files, the more consistent the larger story became. Soldiers are taught to fight, and even kill, but their system of care does too little to prepare them for combat, and too little to help them reflect on their experiences afterward. Too often, they have no answer to reasonable questions, such as “how will I be treated if I am injured and need help?”

Our primary goal is first to convince our colleagues and fellow researchers that the number of psychological and psychiatric casualties are staggering, despite the fact that they rarely register on a measuring device beyond paper-and-pencil tests.

Key Takeaways

Every war cohort since World War I has described 10 fundamental lessons of war trauma; these lessons seem to be routinely ignored and then need to be rediscovered.13 These lessons include 1) the need to provide comprehensive mental health services including definitive treatment for traumatic stress injuries prior to discharge from the military; and 2) the need to eliminate mental health stigma and barriers to care.

Neglecting war trauma lessons perpetuates a preventable generational cycle of mental health crises.3,4

To manage the military’s dilemma of fulfilling the 2 often competing missions of fighting and winning wars with providing health protection to its forces, the military has relied upon 10 strategies that prevent it from advancing war trauma lessons.2 For instance, the military’s 100-year-old frontline psychiatry doctrine is primarily aimed at reducing both personnel attrition and the cost of mental-health-related disability pensions. However, we argue that this doctrine is ultimately quite harmful to the well-being of veterans and their families.

War is not a pleasant thing, but we can learn from it. For instance, lessons from combat medicine have helped advance emergency medical and mental health care. By synthesizing the lessons learned from the mental health impacts of war trauma, we may find a working model to transform mental health care in general and eliminate related stigma.14

Dr Russell is a retired US Navy Commander and military clinical psychologist with more than 26 years of military service. Dr Figley is the Paul Henry Kurzweg, MD, Distinguished Chair in Disaster Mental Health at Tulane University and founder and director of the Tulane Traumatology Institute.


1. Appel JW, Beebe GW. Preventive psychiatry; an epidemiologic approach. J Am Med Assoc. 1946;131:1469-1475.

2. Russell MC, Figley CR. Generational wartime behavioral health crises: part one of a preliminary analysis. Psychol Inj and Law. 2015;8(1):106-131.

3. Russell MC, Figley CR. Investigating recurrent generational wartime behavioral health crises: part two of a preliminary analysis. Psychol Inj and Law.2015;8(1):132-152.

4. Russell MC, Figley CR. Psychiatric Casualties: How and Why the Military Ignores the Full Cost of War. Columbia University Press; 2021.

5. Viscott DS. The Making of a Psychiatrist. Arbor House; 1972.

6. Russell MC. Attentional focus and states-of-mind in post-traumatic stress disorder among

Vietnam combat veterans. Dissertation Abstracts; 1992.

7. Zoroya G. Psychologist: Navy faces crisis. USA Today 30. January 17, 2007. Accessed July 14, 2021.

8. Russell M. Mental health crisis in the Department of Defense: DoD Inspector General Hotline Investigation #98829 submitted by Commander Mark Russell, USN on 05JAN2006. Available upon request via Freedom of Information Act (FOIA) at Department of Defense; Office of Freedom of Information, 1155 Defense Pentagon; Washington, DC 20301-1155.

9. Russell M. The future of mental health care in the Department of Defense. Invited testimony before the Congressionally-mandated Department of Defense Task Force on Mental Health, on 19-20 October 2006, San Diego, CA.

10. Donahue T. Thank You for Your Service. Creative Chaos Productions; 2015.

11. Dolan B. Strangers at home: The Untold Story of American Military Mental Health. Coyote Pass Productions.

12. Russell M, Shoquist D, Chambers C. Effectively managing the psychological wounds of war. Navy Medicine. 2005:23-26.

13. Glass AJ. Lessons learned. In: Glass AJ, Bernucci RJ, eds. Medical Department United States Army. Neuropsychiatry in World War II Volume I: Zone of Interior. Office of the Surgeon General, Department of the Army; 1966:735-759.

14. Gabriel RA. Between Flesh and Steel: A History of Military Medicine From the Middle Ages to the War in Afghanistan. Potomac Books; 2013.

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