March 3, 2009: For the first time in history, U.S. combat troops are admitting to having "combat fatigue" (PTSD, or post-traumatic stress disorder), mainly because they can now refer to at something other than a "mental condition." All this is the result of U.S. Department of Defense and the Veterans Administration (VA) efforts to document the connection between concussions, and other brain trauma, and PTSD conditions. There is a PTSD epidemic right now, created by the unprecedented exposure of so many troops, to so much combat, in so short a time. What is actually happening, though, is the discovery that much of what is thought to be PTSD, is actually physical injuries (to the brain) that can now be detected (with more precise instruments like MRI), and often treated.

As part of this effort, the U.S. Army now mandates a mental health evaluation for everyone in the army. Those who have not been in combat will serve as a baseline for comparing to those who have. Moreover, the army wants to find out to what extent non-combat operations (training can often be quite intense) can add to the stress that could eventually lead to PTSD. The basic idea here is to "mainstream" PTSD, trying to convince all the troops that PTSD is just another occupational hazard, not something you should try and hide, and hide from. You can't, and increasingly, the army won't let you. The records sharing recognizes that PTSD symptoms many not show up until years after the soldier has left the military. This is part of a wide trend in medicine, where better diagnostic tools enable diagnosing more people with problems that were largely ignored in the past.

In the last year, the army developed a new program to detect, and treat, the many PTSD sufferers it believes it has. This was accomplished by performing screening during the delivery of routine medical care, including annual checkups. Doctors are given a script that uses some simple and non-threatening questions to discover if the soldier might have PTSD. If further questioning reveals there may be some PTSD, the soldier is offered treatment as part of regular medical care, not a special PTSD program. It was those programs that put off many troops.

While most troops now accept that PTSD is not a sign of mental weakness, but a very real combat hazard, many still avoid special PTSD treatment programs. By making PTSD treatment (which is usually just monitoring, and the use of some anti-stress medication for a while), part of regular medical care, much of the stigma disappears.

The army has, over the years, developed a set of guidelines for how to recognize the symptoms of combat fatigue (or PTSD). With all the attention PTSD has gotten in the media of late, troops are more willing to seek treatment, or at least admit there is a problem. While extreme cases of PTSD are pretty obvious, it's the more subtle ones that army wants to catch now. These are easier to cure if caught early.

But the army find itself facing several sources of PTSD. First, there was the discovery that many troops, because of exposure to roadside bombs, and battlefield explosions in general, had developed minor concussions that, like sports injuries, could turn into long term medical problems. Often these concussions were accompanied by some PTSD. The VA is particularly interested in knowing about a soldiers prior exposure to roadside bombs.

Another problem was that, nearly a century of energetic effort to diagnose and treat PTSD (including much recent attention civilian victims, via accidents or criminal assault), had made it clear that most people eventually got PTSD if they were in combat long enough. During World War II, it was found that, on average, 200 days of combat would bring on a case of PTSD. After World War II, methods were found to delay the onset of PTSD (more breaks from combat, better living conditions in the combat zone, prompt treatment when PTSD was detected). That's why combat troops in Iraq and Afghanistan often sleep in air conditioned quarters, have Internet access, lots of amenities, and a two week vacation (anywhere) in the middle of their combat tour. This has extended their useful time in combat, before PTSD sets in. No one is yet sure what the new combat says average is, and the new screening methods are an attempt to find out.

What the army does know is that a large percentage of its combat troops have over 200 days of combat. Some have three or four times that. So far, treatments (counseling and medications, for the most part) have worked. But these are not cures. A major reason for army generals talking about the army "needing a break" (from combat) is the looming loss of many combat experienced troops and leaders (especially NCOs) to PTSD. The army won't give out exact figures, partly because they don't have much in the way of exact figures. But over the next decade, the army will get a clearer picture of how well they have coped with PTSD, among troops who have, individually, seen far more combat than their predecessors in Vietnam, Korea or World War II.

The army is dealing with PTSD head on, believing that what happened in Iraq, will happen again, and now is the time to get ready. Experience so far has shown that PTSD can be delayed, perhaps for a long time. When a soldier does come down with it, PTSD can often be treated, and its effects reversed. This has large ramifications for non-military medicine, for many civilians suffer from PTSD. That's because military recruits are screened for their ability to handle stress and resist PTSD. In the civilian community, there are far more people who can acquire PTSD after exposure to much less stress.

The military believes they can detect trends in PTSD, and that will help in developing treatments, or ways to prevent the condition in the first place. Progress has already been made, and the majority of wounded troops now suffer from concussions and other brain injuries.