The impact of war on mental health: lest we forget

Abstract

The often-unconscious and enduring impact of war is one of the driving forces of history. Yet these terrible costs and the lessons learned by psychiatry tend to be forgotten (1). At a time when many nations are remembering the legacy of World War I, the greatest military conflagration in history, it is timely to reflect on what has been learnt about the impacts of war on mental health. Ironically, it is only since the inclusion of post-traumatic stress disorder (PTSD) in the DSM-III in 1980 (2) that the field of traumatic stress has blossomed and been subsequently underpinned by a major body of neuroscience and clinical research. Despite the slow development of interest into the long-term consequences of the traumatic stress of war, many of the developments in mental health care in the 20th century emerged from the innovations demanded by the need to deal more effectively with the flood of mental casualties amongst the combatants of World Wars I and II. The model of community psychiatry was adapted from the model of forward psychiatry developed by the military to deal with acute combat stress reactions; this model was underpinned by the principles of the provision of early treatment close to the battle front with the expectancy of recovery and return to service (1). Crisis intervention, group therapy and therapeutic communities were innovations that evolved out of the military medical corps (1). However, psychiatrists who served in the military were often conflicted by powerful and potentially competing value systems concerning whether their primary responsibility was to the soldier or to the war effort (3). The prevailing attitudes would tend to indicate that individuals’ interests often lost out – the veteran who broke down in battle was generally stigmatized. The diagnoses promulgated by the profession, such as compensation neurosis, lack of moral fibre and inadequate personality reflected how the problem was seen to be caused by moral weakness and vulnerability (4). In this characterization, the causal role of the horrors of combat were minimized by psychiatry, in contrast to compensation seeking and vulnerability.