Psychiatric casualties from Iraq war - majority due to adjustment difficulties rather than combat stress

In the Iraq war, psychiatric illness among troops took the form mainly of adjustment reactions, rather than combat stress reactions, a new study has found. These adjustment reactions may have been exacerbated by heightened fear associated with non-conventional warfare.

The view that most military personnel evacuated from war zones are suffering from combat stress reactions, or are otherwise traumatised by the horrors of war, has an impact on all aspects of military psychiatry.

The aims of this study, published in the June issue of the British Journal of Psychiatry, were to explore the reasons for airlifting evacuees from Iraq on psychiatric grounds from the start of the build-up of UK forces in January 2003 until the end of October that year, six months after the end of formal hostilities.

A retrospective study was conducted of field and in-patient psychiatric assessments of 116 military personnel evacuated to the UK military psychiatric in-patient facility in Catterick Garrison.

It was found that between 16th January and 30th October 2003 there were 2009 evacuations by airlift. Of these 178 were primarily for psychiatric reasons: the ratio of psychiatric to medical evacuations was therefore 1:10.

61 of the psychiatric evacuees were sufficiently well to be discharged back to their unit immediately. The remaining 117 were admitted to the psychiatric facility in the garrison, but the vast majority were well enough to leave the hospital after an average of 1.4 days.

87% of the sample were men. 68% were in the army, 16% in the air force, 16% in the navy and 21% were Reservists. 37% had a history of having seen a psychiatrist or a community psychiatric nurse. The majority of the psychiatric evacuees were non-combatants (69%).

Only 3% had a combat stress reaction. In over 85% of cases evacuation was for low mood attributed to separation from friends or family, or difficulties adjusting to the environment in Iraq ('homesickness' or 'nostalgia').

Information was analysed in three phases: when the war began, when formal hostilities ended, and during a six-month post-war period. There was a significant difference between the causes of evacuation at the different stages, with an increased rate of environmental and combat causes and a decreased rate of interpersonal causes during the war phase.

The authors of the study comment that it is interesting, in terms of vulnerability, that the average age of evacuees was relatively high (28.2 years), that 21% were Reservists, 40% were married and 37% had consulted a mental health practitioner in the past.

In general, older troops are likely to be less physically resilient, and Reservists and married troops may have allegiances outside the service that interfere with military cohesion. These characteristics fit with the more general finding that most evacuees were from support units, and not combat units.

The majority of troops who have psychiatric difficulties without being exposed to combat are simply unsuitable for deployment, and require repatriation. It may be possible to predict which troops are, and are not, suitable for deployment. Generally speaking, it will be those who have already suffered from a psychiatric illness, and/or those who show signs of being temperamentally unsuited to all forms of military service.

The findings of this study have implications especially for screening for suitability for deployment. Furthermore, the failure to identify clearly the reasons for repatriation, both for particular individuals and for troops as a whole, will lead to confusion about the causes of long-term mental health problems in veterans.