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Shock & Awe by Saralyn Mark, MD

PTSD, depression, and suicide

“Shock and awe” is a phrase that was introduced and quickly woven into our conversations during March 2003. We knew that it conveyed our military’s strength and superiority fighting the enemy in Iraq. We were transfixed by the fireworks illuminating the night’s sky over Baghdad. Six years have gone by since “shock and awe” transformed our lexicon and eight years since our troops landed in Afghanistan. Battles have been fought in distant lands to protect our freedom and security.

Now we are finally acknowledging that this war is coming home. On March 18, 2009, in two locations in our nation’s capital, the truth about this war reached our shores. For years we knew that this was coming, but it was difficult to face. The casualties are not just our troops”the collateral damage includes their families. At the Pentagon, the secretary of Veterans Affairs and the deputy secretary of defense hosted a screening of the PBS special “Coming Home: Military Families Cope with Change”–a show that highlights families who have faced amputations, traumatic brain injuries and post traumatic stress disorder. While at the same time, there was a hearing of the Senate Armed Services Committee to discuss the rise of suicides among military personnel.

What connects these two events is shock and AWE. It is time for our nation to accept and understand a new version of this concept–one still grounded in military strength but now associated with a benevolent action rather than destruction. Military jargon is filled with acronyms. So to continue that long-standing tradition, AWE can be an acronym for “Adaptation to the War Environment.” AWE is a normal process that the body and psyche experiences to adapt to the extreme environment of battle in order for a person to survive. By just changing the nomenclature, we can begin to change a climate filled with stigma, fear and humiliation. Instead of saying post traumatic stress disorder or PTSD to describe the signs and symptoms that our troops experience–which can imply victimization, weakness, disability or disease–we can describe it as AWE, a normal reaction to an abnormal situation.

During the Senate hearing, every military leader expressed concern over the soaring rates of military suicides. These rates are higher than the general population. In 2009, 24 Army soldiers may have committed suicide and possibly another 18 in February, despite an increase in suicide prevention programs. General Peter W. Chiarelli, vice chief of staff of the Army cited long deployments and separations from family and the perceived stigma and shame associated with getting help. This point was also expressed by Admiral Patrick Walsh, vice chief of Naval Operations.

Recently, General Carter Ham and Brigadier General Gary Patton courageously went public about their reactions to the stress of war and the need for mental healthcare. They wanted to encourage service members to come forward and ask for help. Some junior officers and enlisted personnel may still be reluctant to do this, believing that the generals were able to be open about their situations because they were at the pinnacles of their careers, and if they seek help they will be passed over for promotions. This conception will be hard to change if the climate is not dramatically altered.

We need to not only provide the superficial modification of wording from PTSD to AWE, but also dispel the notion that only a few are affected by war. Everyone comes back changed. We are fighting an unconventional war that will continue for years. It is now time to take an unconventional approach to prevention and treatment of this issue. Otherwise, we will continue to be a nation haunted by ghosts. I have written that even when our loved ones return, some with physical injuries, it is the invisible injuries that damage the fabric of lives. They may have come home, but emotionally they have disappeared. Family members, holding on to these precious spirits, disparately search for healthcare which could bring back their loved ones. We have created this environment because our mental health care programs have failed.

It is time that we come forward and state that we expect that all our troops will return with reactions to the extreme environment of war. It is the norm rather than an abnormality. It then becomes a shared experience and not associated with shame or dishonor. This approach has worked in other settings such as within NASA. For example, it is expected that all astronauts will experience bone loss secondary to the microgravity environment in space. Astronauts undergo training to achieve maximum fitness before they fly, utilize countermeasures such as physical activity during flight to mitigate loss and all go through extensive rehabilitation programs when they return. The severity of the bone loss and recovery varies by astronaut, but they know that they will all lose and will require assistance to protect their health at home and “flight readiness” for their missions.

This model could work for our military. We can help our troops better prepare in advance for the stresses of war, have countermeasures in the field such as well trained mental health personnel and mandatory rehabilitation and surveillance upon return to a non-hostile environment. If we assume that everyone will have adapted to the war environment (AWE) and will require mental healthcare, it removes the stigma associated with it.

This novel approach can help to protect the “fight readiness” of our troops for the battlefield and for their adjustment to the home front. Imagine the day when it will be a badge of courage and honor to say “I’m in AWE.”

Saralyn Mark, MD, BeWell Expert

Associate Professor of Medicine adjunct
Yale and Georgetown University Schools of Medicine

Affiliate Professor
George Mason University School of Public Policy

Senior Medical Advisor
*The opinions expressed are the views of the author and not of NASA.


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