Editor-in-Chief, Chester 'Trip' Buckenmaier III, MD, COL, MC, USA.

Some of you young men think that war is all glamour and glory but let me tell you boys, it is all hell!
—Major General William Tecumseh Sherman

The famous phrase, “War is hell,” is attributed to General Sherman, who likely knew this subject better than most based on his exploits during the Civil War. In September 1864, he directed the inhabitants of the city of Atlanta to be evacuated before his army entered the city to burn it. He ordered this despite the pleas of Atlanta citizens to spare the city which contained the elderly and infirm whom it would be perilous to move. In his response letter Sherman stated: “You cannot qualify war in harsher terms than I will. War is cruelty, and you cannot refine it; and those who brought war into our country deserve all the curses and maledictions a people can pour out.”

One of the clearest indications that war is no less harsh and cruel today as it was in Sherman’s time is the prevalence of post traumatic stress disorder (PTSD) in our veterans. This condition is certainly not unique to the present conflicts. Termed “shellshock” during World War I, “battle fatigue” following World War II, and occasionally combat stress today, this anxiety disorder is likely as old as the existence of man. This malady can be extremely debilitating for our returning veterans who experience nightmares and frightening thoughts, lose interest in activities, have strong feelings of guilt or worry, and can generally be tense or irritable. These are just a few of the symptoms listed by the National Institute of Mental Health (NIMH) in their description of PTSD. Obviously these symptoms would complicate recovery from a traumatic event and interfere with work and family life. In some cases the symptoms of PTSD have been a contributing factor in suicides within the military. The NIMH
estimates that about 30% of veterans develop PTSD after serving in a war zone. This condition is further complicated by the stigma attached with the diagnosis. A Defense Department study estimated six in 10 veterans surveyed were unlikely to seek help for PTSD, fearing repercussions from commanders and peers (San Francisco Chronicle). It would be difficult to overestimate the staggering cost in lost productivity and additional morbidity this disorder contributes to veterans suffering from the condition.

The best defense against any disease condition is prevention. Sadly, war has been intimately associated with the human condition and there is no indication that this reality is going to change. We depend on our military to protect our freedom and we will continue to expose our young men and women to the horrors of the battlefield. The military has struggled with its response to PTSD. On the one hand, the warrior culture praises those who subject themselves to the terror of the battlefield and are able to stoically continue the mission. On the other is the neurobiological reality of the human brain and its response to the chaotic stress of war. We have effective body armor to protect warriors from many physical dangers, only now are military leaders beginning to understand the need to protect our combatants’ minds.

Federal medicine providers, to their credit, have not shirked from this complex and difficult military medical problem. The Department of Defense has invested millions of dollars in psychological health research and programs to re-educate leaders and remove the stigma associated with seeking psychological help for PTSD symptoms. Important initiatives in the diagnosis and treatment of PTSD can be found at www.dcoe.health.mil and www.realwarriors.net. Every soldier is now asked about symptoms of PTSD upon return from countries of conflict (as I was, returning from Afghanistan in 2009). Much has been accomplished in responding to the medical threat of PTSD, but still much more remains to be done.

Since war is seemingly unavoidable, we must explore new training methods to build resilience in our warriors. The Department of Defense has established the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury as a center of mass for research and education in the causes, prevention, and treatment of PTSD.

Warriors of the future must now prepare not only their bodies but also their minds for the stress of combat. Federal medicine providers at all levels share an equal responsibility to actively train for and coordinate the care of beneficiaries suffering from PTSD.

The opinions expressed here are solely those of the author and not necessarily those of U.S. Medicine, Marathon Medical Communications, Inc. or the United States government and its agencies.

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