I recently attended a mental health conference held at a venue in the shadow of the Pentagon. The program included a wide range of topics including several presentations on military mental health. The latter expressed strong interest and, what seemed to me, unrealistic expectations of the therapeutic promise of what were previously recreational drugs, specifically marijuana, MDMA (ecstasy) and psychedelics. As a research psychiatrist with in-depth knowledge of psychopharmacology and treatment of mental disorders including PTSD, I was alarmed at this overconfident belief in the potential therapeutic value of these largely unproven substances. This suspension of critical review of these experimental treatments seemed a sign of desperation in the absence of sound scientific judgment.
It further prompted me to wonder why the U.S. Government, and specifically the DOD and VA, hadn’t done more to address this particularly given the consensual high esteem in which our military forces are held. Military medicine achieved near miraculous advances in the 20th century as measured in survival from the physical wounds of war, while progress in the psychological wounds of war was limited to better recognition and nomenclature.
Psychological injuries are by no means a new clinical phenomenon. They have been hiding in plain sight since “Soldier’s Heart” was first described during the Civil War. Yet it was not until after the Vietnam War—over a century later—that long-observed conditions, previously referred to as “shell shock”, “battle fatigue” and “combat neurosis,” observed in combatants of World Wars I and II, and the Korean War, were formally recognized and validated by the medical term Post Traumatic Stress Disorder (PTSD).
These were the psychologic counterparts to medical terminology such as shock, sepsis, fracture, laceration were to physical wounds of war. However, whereas the physical wounds of war were described by their pathological nature, mental casualties were given euphemistic names that either intentionally or unintentionally were misleading as to the reality of these conditions. Names for clinical conditions like shell shock externalized the cause, battle fatigue implied a transient state that could be remedied by rest or a good night’s sleep. The connotations of combat neurosis trivialized the severity of the condition as a psychological conflict. When my colleague Robert Spitzer coined the term PTSD after attending numerous Vietnam Veterans’ Rap Groups, military leadership objected to “disorder” because it implied an enduring pathologic condition. In reality, that is what they were, enduring, distressing and disabling brain infirmities like depression, strokes and migraines.
Regardless of what it is called, Given the too often grave repercussions of these psychological injuries, it is puzzling that there has not been more progress in understanding the pathologic basis of PTSD and finding effective treatments.
Of the 265 disorders described in the American Psychiatric Association’s Diagnostic Statistical Manual, in addition to substance use disorders, PTSD is the only one to have a known cause—experiential trauma. So from a scientific perspective, PTSD should be a tractable problem to solve.
In addition, PTSD can be studied in animals. Rodent models of repeated and intense stress closely mimic PTSD and can enable researchers to elucidate the pathological mechanisms and test treatments, as is similarly done in non-psychiatric medical disorders.
Public awareness of the military’s invisible wounds of war has grown in recent years, yet what remains woefully limited is our scientific understanding of these conditions and our ability to treat them. Witness the shocking numbers of military personnel serving in Iraq and Afghanistan who suffer adverse psychological reactions from their service, and their unprecedented rates of suicide.
Our veterans are more than twice as likely to commit suicide than their peers in the civilian population. Between 1999-2010, the overall suicide rate among males in the U.S. was 19.4 per 100,000, and 4.9 per 100,000 for females. While in 2009, the suicide rate for military personnel was 38.3 per 100,000 for males and 12.8 per 100,000 for females.
War produces overwhelming psychological stress and can indelibly alter a person’s brain function and mental state. Stories abound of soldiers who are perfectly normal prior to experiencing a firefight, an IED explosion, or the sustained stress of asymmetric warfare (where one does not have an identified enemy or defined battle lines) in the context of repeated deployments, and are somehow changed and never the same again, even though they have sustained no physical injury. PTSD is the quintessential existential malady.
So why was this disabling condition ignored so long, and slow to be addressed?
Military medicine made extraordinary advances in the first half of the 20th century. Rates of severely injured combatants went from 80% dying to 80% surviving between WW-I and the Iraq and Afghanistan wars.
Moreover, medical research has successfully confronted seemingly impossible challenges from human disease within lesser spans of time. Perhaps, the best example is AIDS. When AIDS first appeared in the late 1970’s, there was an enormous response (galvanized by the gay community) which placed tremendous pressure on the government to fund research to find its cause and develop treatments. By 1984, the Human Immunodeficiency Virus (HIV) was identified. By 1987, AZT, the first treatment, was introduced. Antiretroviral and protease inhibitor drugs followed, and then their combination in “Triple Therapy.” Later, behavioral management strategies were developed to limit the spread of AIDS. Within 15 years, AIDS had gone from a mysterious plague that was fatal, to a chronic illness that is managed with treatment and in some cases curable. We are currently seeing a similar phenomenon (albeit less dramatic) with Alzheimer’s disease and Autism.
Why hasn’t the same thing been done for PTSD? Why has this disabling condition been ignored for so long and slow to be addressed?
There are three possible reasons. First, the military culture has been resistant to the idea of psychological weakness or frailty, which is the antithesis of military ethos that seeks to imbue soldiers with a sense of invincibility. Many victims of PTSD in World Wars I and II were accused of cowardice, and, in some cases, they were court martialed and even executed. Second, mental disorders are not tangible and have no visible physical signs. Hence, if you can’t see them, they aren’t real. In this way, pathological conditions that arise from experiential trauma are stigmatized as are other so-called “challenged diseases” like Chronic Fatigue Syndrome and Fibromyalgia. Third, the best and the brightest researchers were not engaged in the research effort addressing this urgent problem, whereas they were and are in AIDS, Alzheimer’s and Autism research. Most funding for PTSD was provided through the Veterans Administration and predominantly to researchers at VA Hospitals.
The magnitude of the problem—and the moral and political outrage at the lack of effective action to alleviate the mounting casualties—warrants an all out scientific effort. We need to launch an effort like the “Manhattan Project” for PTSD. With the former, to meet the threat of advanced enemy weapons, President Roosevelt issued an Executive Order which enlisted top scientists at leading institutions (including the University of California, Berkeley, Columbia University, Carnegie Institution of Washington, the Naval Research Laboratory and the University of Chicago) to work collaboratively to develop nuclear weapons, and ultimately grew to 30 sites in the U.S., U,K. and Canada.
The President should empanel a Task Force of leading scientists to develop a strategic plan as he has done for the Human Brain Initiative. We then need Congress to allocate funding to support the research under the auspices of the National Institutes of Health (NIH). The NIH Director’s office would be responsible for monitoring progress and reporting to the President and Congress.
This effort would be sustained until sufficient progress has been made to alleviate the psychological wounds of war and offer our service persons and their families hope for their future.
On the occasion of this Veteran’s Day, we can dedicate ourselves to redressing this historic health disparity being endured by the people who have placed themselves in harm’s way to defend our country. It’s the least that we can do and better late than never.
Dr. Jeffrey Lieberman, is The Constance and Stephen Lieber Professor of Psychiatry at Columbia University Vagelos College of Physicians and Surgeons, past president of the American Psychiatric Association and the author of Shrinks, The Untold Story of Psychiatry (Little Brown 2015). His new book is MALADY OF THE MIND: Schizophrenia and the Path to Prevention (Scribners-Simon and Schuster 2023).
About the Author/s
Dr. Jeffrey A. Lieberman, a globally acclaimed psychiatrist and bestselling author, spearheaded groundbreaking research into the neurobiology and pharmacology of behavioral brain disorders. His work has significantly advanced our comprehension and treatment of mental health issues, particularly offering a transformative approach for early detection and prevention of schizophrenia. Dr. Lieberman has garnered accolades such as the Lieber Prize for Schizophrenia Research, the Adolf Meyer Award from the American Psychiatric Association, and the Research Award from the National Alliance of Mental Illness. As a vocal advocate for mental health, he has played a key role in shaping healthcare policies and federal legislation to enhance mental health care accessibility, quality, and diminish stigma. Notable publications include "Malady of the Mind: Schizophrenia and the Path to Prevention" and "Shrinks: The Untold Story of Psychiatry," the basis for the PBS series, "Mysteries of Mental Illness."
