December 14, 2023: The fighting in Ukraine has reminded everyone that not all combat casualties involve bleeding or broken bones. There are less obvious injuries produced by stress which have had long-term implications. Those results are not trivial. This was made clear over a decade ago when the U.S. Army carried out a long-term study to identify and measure the impact of combat zone stress on soldiers. This effort was called STARRS (Study to Assess Risk and Resilience in Service members) and began with a random selection of 55,000 soldiers, who were interviewed to obtain additional data on their experiences in the military. This will be periodically updated for the lives of the study subjects. Over the decades the army will learn more and more about military and combat stress and be better able to develop policies to avoid it and create treatments for harmful aftereffects.

STARRS is one of a growing number of efforts to deal with an unprecedented number of troops who have spent a lot, more than in any other war of time, in a combat zone. Over the last decade more and more of the combat NCOs and junior officers have been found to be suffering from debilitating PTSD (Post Traumatic Stress Disorder). Studies so far have found that at least 20 percent of troops sent into a combat zone suffer some form of mental distress. That's over 400,000 troops (out of two million who have served in Iraq or Afghanistan). Adding in the many Vietnam veterans who have been treated for PTSD and studied, the army has already found some useful data. For example, troops are more prone to serious PTSD effects, including suicide, if there are genetic factors (often, but not always, revealed by a family history of psychiatric problems), traumatic childhood events, and insufficient support and treatment after traumatic battlefield events. For centuries it's been accepted that some men are prone to "break" under the stress of combat. It was understood, even without any knowledge of genetics, that a soldier with a family history of mental instability would be less able to handle combat. Now the army can more precisely measure the risk and more accurately screen out those who will be most at risk.

Another big problem is that the United States has never had such a long period of combat with so many troops involved. Moreover, casualties, especially combat deaths, are much lower than in the past. As a result, more troops are surviving to spend a lot more time in combat. This is producing an unprecedented number of NCOs who are very stressed out. If the NCOs are having stress-related problems, that usually makes their subordinates uneasy as well.

The U.S. Army has, over the years, developed a set of guidelines for how to recognize the symptoms of PTSD level combat fatigue. With all the attention PTSD has gotten in the media during the decade after September 2001, troops were more willing to seek treatment, or at least admit there was a problem. While extreme cases of PTSD are pretty obvious, it's the more subtle ones that the army eventually concentrated on. These were easier to cure if caught early. But this caused problems with troops who are tagged as a subtle case and disagreed with the diagnoses. Most soldiers still believe that, once you are tagged, you won't be left alone by all those new specialists who only want to help you.

Worse yet, the army found 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, or U.S. Veterans Administration, which cares for injured veterans was particularly interested in knowing about a soldier's prior exposure to roadside bombs. The troops like to point out that PTSD is made worse by having too little time back home between combat tours, and this part of the problem has been addressed. But the subtle long-term effects are still only partially understood.

A major problem is that most people eventually get PTSD if they are in combat long enough. This has been confirmed by nearly a century of energetic efforts to diagnose and treat PTSD. This included much recent attention to civilian victims, via accidents or criminal assault. 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. These included more breaks from combat, better living conditions in the combat zone and prompt treatment when PTSD was detected. Military historians note that successful, and often popular, commanders throughout history have paid attention to the physical well-being of the troops, all in the name of maintaining morale. These measures also delayed the onset of combat fatigue.

That's why combat troops in Iraq and Afghanistan often slept in air conditioned quarters, had Internet access, lots of amenities, and a two-week vacation to anywhere in the middle of their combat tour. This extended their useful time in combat before PTSD, also known as bad morale, set in. No one is yet sure what the new combat day average is, and new screening methods attempt to find out. The army and marines are now confronting the fact that, for a large number of their combat NCOs, the limits are being reached. It's a lot more than 200 days in combat but the army and marines have the majority of their most able and experienced NCOs approaching that limit.

This was not unexpected. The army knew that they had a large, and growing, percentage of its combat troops with over 200 days of combat. Some have three or four times that. For a while, treatments, most of them consisting of counseling and medications, worked. But these were not cures. A major reason for army generals talking about the army needing a break from combat was the looming loss of many combat experienced NCOs to PTSD. The army would not give out exact figures, partly because they don't have much in the way of exact numbers. After a few more years the army got a clearer picture of how well they coped with PTSD among troops who have, individually, seen far more combat than their predecessors in Vietnam, Korea, or World War II.

The problem was mainly among combat NCOs. Most of the troops are in for one enlistment, usually four years, and then leave. Junior officers get promoted out of jobs involving close combat, and officers in general are rotated between leadership and staff jobs. NCOs spend all their time with the troops, except those few who get promoted to Sergeant Major, which is a largely staff job as advisor to senior commanders. The Sergeants Major were among the first to note the stress problems with career NCOs, especially squad and platoon leaders, as well as company 1st Sergeants.

The only acceptable solution for the problem is to transfer the worst hit combat NCOs to non-combat jobs. This is a common sort of thing in the army and marines, where it's long been common for NCOs with physical conditions and injuries resulting from the rigors of peace or wartime infantry service to be offered transfers and retraining. Severe cases may also be offered a medical discharge and disability pay. The loss of these skilled and experienced NCOs from combat units results in more troops getting killed or wounded in combat, but that can happen anyway if you leave a stressed out NCO in action for too long.

Then there's the problem of what to call this new situation. Many troops wish everyone would revert to the older term, Combat Fatigue. What's in a word? For the troops PTSD is just another injury and not a disorder. It's something you deal with. Debilitating physical injuries such as bad backs or knee/foot problems and trying to cope often leads to sinking morale and a lot of people leaving the military. Often the economy is in bad shape and quitting your job was not a good option.

The army and marines are dealing with PTSD head on, believing that what happened in Iraq and Afghanistan 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. But not always. 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. What many troops wish the brass would understand is that, as recruits, they learned that stress was a major part of the job and understood it more than the mental health mafia is willing to admit.