November 15, 2009: For the last six years, the U.S. Army has been conducting mental health surveys of troops in the combat zone. As expected, troops on their second or third trip to the combat zone, have more stress related mental problems. While 14 percent of troops on their first combat tour have stress problems, that goes to 18 percent for those on their second tour, and 31 percent for those on their third.

A growing proportion of NCOs and officers are doing their third or fourth combat tours (in Iraq or Afghanistan), and that means more and more of them are approaching the point where they will have to take a non-combat job. Otherwise, they risk severe mental problems from the accumulated stress. In effect, PTSD (post-traumatic stress disorder) epidemic has been created by the unprecedented exposure of so many troops, to so much combat, in so short a time. Once a soldier has PTSD, they are no longer fit for combat, and many troops headed for Afghanistan are falling into this category. PTSD makes it difficult for people to function, or get along with others. With treatment (medication, and therapy), you can recover from PTSD. But this can take months or years. In extreme cases, there is no recovery.

The army has been able to deal with the unprecedented amounts of stress by providing the troops with what previous generations of soldiers would have considered luxuries. For example, when possible, combat troops sleep in air conditioned rooms, and have access to the Internet and video games, as well as good food and other amenities. The video games and Internet resulted in an unexpected positive effect. The surveys found that troops that spent 2-4 hours a day on the Internet or playing video games (even violent ones) had far fewer stress problems. Having exercise facilities available also helped, despite the physically strenuous nature of combat in Afghanistan. While the combat troops spend most of their time out in the countryside, living rough, their commanders know what even a few days back at a larger base, with all the goodies, makes a big difference in attitudes, morale and combat effectiveness.

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). 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 aggressively 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 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.