October 19, 2009: In May, 2008, a stressed out U.S. soldier went into a Baghdad combat stress clinic and shot dead four soldiers and a sailor. After more than a year of studying the incident, the U.S. Department of Defense has concluded that cause was insufficient attention paid to the problem by the NCOs and officers in the unit of the soldier that went berserk. The soldier in question had attempted suicide, and his superiors had removed the bolt from his rifle (he stole another weapon to commit the murders.) The commander of the soldiers Engineer battalion was criticized for not implementing procedures already in place to deal with these situations. For example, a soldier noted to be having stress related problems should be assigned NCOs and fellow soldiers to keep an eye on him and report additional problems, or intervene if need be. In this case, the battalion had gone through the motions of keeping an eye on suicidal soldiers, but had not followed through. This happened even when the soldier exhibited symptoms of severe distress while on his fourth visit to the clinic. The clinic failed to turn the soldier over to his 1st Sergeant or commanding officer (as regulations stipulated), but simply sent him back to his unit accompanied by another NCO. While in transit, the stressed out soldier grabbed his escorts rifle and ran off. While the MPs (Military Police) were alerted, they waited more than 15 minutes to warn the clinic, but by then it was too late, as the soldier had returned and shot the place up.

Part of the problem was that such extreme situations are rare, and the Department of Defense covers its ass by issuing a lot of regulations to deal with a wide variety of rare events. Units cannot comply with all the rules and still do their work, so commanders have to decide which of the "special rules" are necessary, and which are not. The Department of Defense report ignored this, and put all the blame on the officers and NCOs of the soldiers battalion. These leaders will be punished, and the senior people at the Department of Defense will issue more regulations and forget about it.

Stress casualties peaked for the U.S. Army in 2007, when 10,049 soldiers were diagnosed with PTSD (post-traumatic stress disorder). This was ten times the number diagnosed in 2003 (1,020). The U.S. Marine Corps saw a similar jump, from 206 to 2,114. The navy and air force, which have been sending troops to Iraq and Afghanistan to help out the army, saw PTSD cases go up also. For the navy it went from 216 to 947. For the air force is went from 190 to 871. The navy supplies support personnel for the marines, including medics. The air force provided the army with security and logistics personnel, both of whom were sometimes shot at. In the last eight years, 5,000 troops have been evacuated (as medical cases) from Iraq and Afghanistan for mental disorders. Only 16 percent of those were confirmed PTSD cases, the rest were for more familiar things like severe depression. Moreover, most of the troops in Iraq and Afghanistan are not involved in combat. Yes, they are living in a combat zone, but aside from an occasional mortar shell or rocket (which usually causes no injuries), most troops tend to have air conditioned sleeping quarters, gyms, Internet access, video games, good food and excellent medical care. It's unclear how many troops actually have PTSD, although many who are in combat, definitely are stressed out and in need of help. During World War II, 25 percent of the disabling American casualties in Europe were due to PTSD.

Nearly a century of energetic effort to diagnose and treat PTSD (including much recent attention to civilian victims, via accidents or criminal assault), had made it clear that most troops 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 for American troops. 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 new screening methods are an attempt to find out. But more troops appear to be hitting, or approaching, the limits.

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. A major reason for army generals talking about the army "needing a break" (from combat) is the growing 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 latest policy, to deal with PTSD, is a program that 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 army also detects, and treats, many PTSD sufferers 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. The stress clinic in Baghdad was part of this effort, to deal with PTSD cases early on, and prevent any of them from turning into a berserk soldier killing five others. This is very rare, and the clinics have probably prevented many similar tragedies. But you don't get much credit for preventing these events, only the blame for those that occur anyway.

The army find itself facing some new sources of PTSD. For example, 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 army is dealing with PTSD head on, believing that a lot of troops have experienced a lot of combat stress. 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.