October 31,2008: Senior commanders of the U.S. military are agitated about retention problems. Keeping experienced troops in uniform is a growing problem. A lot of this is due to the stress of frequent trips to a combat zone. Moreover, the families often take the stress less well than the guys out there doing the work.

This problem is more intense the closer you get to the shooting. All this is a common problem in the military, with a few specialties getting worked to death, while everyone else is business as usual. Among the specialties getting worked the hardest are EOD (Explosive Ordnance Disposal), special operations, MPs, intelligence and infantry. These troops got put through the grinder these past few years, and all the services saw their people in these jobs showing signs of strain. From a strategic point of view, that has caused some big problems in terms of retention and long term PTSD (combat fatigue) issues. A lot of this is historically unique, there being few historical analogs to use for guidance.

The situation is complicated by the high proportion of the stressed personnel who are senior NCOs and officers. These people are very difficult to replace. It takes time (5-10 years) and money (over a million dollars each). Because of that, the military has been using larger and larger bonuses to help keep these people in.

The Army, in particular, saw this epidemic of PTSD (post-traumatic stress disorder) coming. In response, the army developed a new program to detect, and treat, the many PTSD sufferers it believes it has. The new program does the 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.

Some of the troops, like many intelligence specialists, and those with other technical skills needed in the combat zone, do not have as much combat stress. These troops are simply being worn out, personally and at home with their families, with so much time away on overseas assignments. The great danger here is simply losing valuable people who want to get out to avoid all the high-stress overseas assignments. The U.S. Air Force had this problem in the 1990s, with so many AWACs crews spending a lot of time working overseas (especially in maintaining the no-fly zones over Iraq). The only solution to halting the exodus was to reduce the overseas assignments.

The army has several unique problems with 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 other problem was that, nearly a century of energetic effort to diagnose and treat PTSD (including much recent attention civilian victims, via accidents or criminal assault), had made it clear that most people 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. 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 the new screening methods are an attempt to find out.

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. So far, treatments (counseling and medications, for the most part) have worked. But these are not cures. A major reason for army generals talking about the army "needing a break" (from combat) is the looming 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 living conditions solution worked with all the troops exposed to stress from excessive overseas duty. That, and paying closer attention to the silent, and hard to detect (until it's too late) buildup of stress. Commanders see this as a long term problem, that calls for long term solution that are still in the process of being discovered and implemented.