From 'Shell Shock' to 'Combat Stress'

"In World War I, stress casualties were diagnosed as having shell shock," said Dr. (Lt. Col.) E. Cameron Ritchie, "Initially we evacuated these people back to the States, and many of them developed chronic psychiatric conditions." Ritchie is director of Mental Health Policy and Women's Health in the Office of the Assistant Secretary of Defense for Health Affairs.

"We lost a lot of our fighting strength that way," she said. "So we developed a system of care to treat them as close to the front as possible. These lessons were promptly forgotten after the war, and doctors found themselves starting from scratch in the treatment of combat stress reactions when World War II broke out", she said.

"At the beginning of World War II, we were screening out almost half our potential recruits because we thought they had psychiatric issues," Ritchie said. There were no uniformed psychiatrists at the start of the war, but the Army had them in every division by the end. "We relearned the value of treating people close to the front," she said.

Psychiatric care in the military continued to advance so that by the Korean War, mobile psychiatric detachments traveled throughout the theater conducting combat stress control operations at the front lines.

During operations in Vietnam, the military initially did not have strong mental-health intervention. "We didn't think a whole lot about having combat stress casualties, but we certainly had a lot of drug and alcohol problems, and long-term post traumatic stress disorders after Vietnam," Ritchie said.

In more recent operations, the military has aggressively treated potential combat stress reactions. "Somalia, Haiti, Bosnia, Kosovo -- in all those theaters we've had very active psychiatric intervention," Ritchie explained. "We've had mostly Army, but also some Air Force and Navy mental health workers up at the front providing immediate, first- line psychiatric care." And with good results, she noted.

"We've had a very low rate of combat stress reactions. We have had some suicidal behavior, but the rates of psychiatric difficulties have been relatively low in these theaters," she said.