Dimensions Of The Problem. Evidence is beginning to accumulate which suggests that neuropsychiatric disease may in this war, as in the last, constitute a problem of serious magnitude, especially for troops in combat areas. The available statistical information is both preliminary and fragmentary, but it is supported by the comments of medical officers in the field. For example when the Buna-Gona campaign was in full swing, the admission rate was above 60 admissions per thousand men per year for the entire Southwest Pacific Theater. Assuming no change in the rate of admission among troops on the continent, the forces in New Guinea must have experienced rates of 90 to 120 during December and January. Again, 16.5 percent of the total casualties sustained by an entire Army Corps in the recent North African fighting were classified as neuropsychiatric. Reports indicate that the admission rate may have been in excess of 150 admissions per 1,000 men per year for a brief period. During World War I, the highest average monthly rate for the A.E.F. was 52 admissions per thousand men per year. Average rates of 210 for divisions on the battle-line, and 140 for all combat divisions, have been reported for the period June through October 1918.
Limitations Of The Screening Process. Great faith has been placed in the screening process and the higher rejection rate of 6 to 8 percent suggests more careful selection than was exercised during the previous mobilization, when only 2 percent were rejected on neuropsychiatric grounds. It has been argued that most potential psychiatric casualties could be eliminated at induction and the entire problem solved thereby. The basic premise of the argument, that psychiatric disorders occur only in "predisposed" individuals, is untrue, Anyone may have a nervous breakdown. The chief difference is that some individuals are "stronger" in that they can endure a strain of greater magnitude, or of longer duration, than others, but everyone has his breaking point. Individuals who are already suffering from psychiatric disorders are readily recognized and screened out. Similarly, the few who are perhaps most likely to develop psychiatric disorders can usually be detected. However, these two groups constitute but the extreme minority. Their separation is both necessary and practicable, but still only a partial solution to the problem. For the large group ranging between the already frankly psychotic or psychoneurotic and the so called "normal", the screening process cannot be expected to function effectively.
Factors Determining Mental Health. Important as is the initial psychiatric screening, it does nothing to prevent psychiatric illness among men already In the Army, and one cannot presume that a man is safe merely because he has passed a psychiatric examination. Although psychiatry is still in its infancy, much has been learned about the causes of psychiatric disorders since the last war. The military factors involved are more subject to the control of line officers than of medical officers at the present time. It has been learned that a man's relationship with his fellow soldiers and his superiors may cause or prevent a nervous breakdown. Not only do climate, fatigue, and hunger play important roles, but disciplinary measures, leaves and furloughs, promotions, letters from home, type of training, and job classification, all have a direct Influence upon mental health. Furthermore, there is considerable evidence that ideology may be of the utmost importance; a man who has a good reason for fighting and who really wants to fight is less apt to have a nervous breakdown than a man who has no reason for fighting and does not want to fight.
The average U. S. soldier is probably not too well prepared by acceptance and understanding of his mission. Twenty years of cynicism and isolationism have done little to provide a basis for understanding the meaning of the vast conflict in which the country is engaged, and there is some evidence that many soldiers do not have sufficient will to fight to protect them against psychiatric breakdown under stress. The results of attitude and opinion surveys conducted by Special Services do not suggest that the great majority of U.S. soldiers have a state of mind which offers them protection against the deprivation and traumatism associated with their service. The comments of surgeons on duty overseas are replete with observations on the lowered state of morale engendered by unfavorable environmental situations, although there is no evidence that the general state of morale among overseas forces as a whole is poor.
Neuropsychiatrists in the Southwest Pacific Area give the following causes for the psychiatric disorders occurring in that area:
a. Separation from family, friends, loved objects and familiar surroundings.
b. Difficulty of selecting situations to which one who is limited can adapt.
c. Absence of the feeling of being wanted, appreciated or needed.
d. A feeling that there is an Army ritualism which abhors an error or a a simple deviation more than it appreciates initiative or originality.
e. The monotony of camp life.
f. Repeated bombings with near misses
g. Feeling responsible in some way for a friend's death
h. being "pinned down" by the enemy for several hours
i. A feeling that the officers don’t know their business.
j. Seeing others sacrificed on failing missions.
k. Absence of a predictable policy for the periodic relief of those in combat arena.
l. Current difficulties at home
In commenting on the neuropsychiatric casualties in North Africa a report stated "These totals are made up from units which were in the line continuously for four months without relief. Thus, the exhaustion factor was exceptionally important, and these figures may not hold when troops in the battle line can look forward confidently to relief periods after a tour at the front. It became quite apparent to them that, in the light of their experiences, all members of the unit would be eventually casual ties, unless relief from battle duty were afforded them. None was obtained. I suspect the abandonment of hope of temporary relief and removal of danger may have added significantly to our psychiatric casualties. About one-half of the non-wounded soldiers evacuated fran the front are neuropsychiatric. The psychiatrists with the Corps are convinced that fatigue hastens the crack-up in men both with and without previous history of neurosis. The common clinical patterns of the battle casualty are a severe anxiety state and a major hysteria with all imaginable manifestations (tremors, deafness, mutism, blindness, paralysis, etc.). In general hospitals in North Africa are many lightly wounded who are trained men, perfectly capable of fighting again, but who feel that they've done their bit and, by fair means or foul, will see to it that they don't return to their units. This is being called the “Z.I. complex”. When the wound is healed the back begins to hurt, etc."
Prevention of Breakdown. Under present circumstances the prevention of psychiatric casualties is a matter of controlling innumerable factors which determine the everyday life of the soldier. The main effort must be made by line officers. The present distribution of psychiatric medical officers is such that they are unable to do preventive psychiatry on any scale. Less than 5 percent of the 1,200 psychiatrists in the Medical Corps are on duty where preventive work is possible, so urgent is the need for their services in hospitals where they must care for men who have already broken down. It is also believed that many neuropsychiatrists in the Army, however competent in diagnosis and treatment, have had little training in the more specialized field of preventive psychiatry. This fact simply reflects the status of the profession in civilian life. Before a greater proportion of psychiatrists could be detached from hospital assignments and placed where they could develop a preventive program, there would have to be more evidence than is now available that such a step would decrease neuropsychiatric admissions.
During the past year several steps have been taken in the direction of preventive psychiatry. The first of these is the establishment of mental hygiene clinics in replacement training centers. These are designed to act not only as a second screen for "predisposed" individuals but also to assist inductees in their adjustment to Army life. By working closely with line officers, both through informal discussions and lectures on problems of discipline, by talks to troops on homesickness and on fear, by writing columns in camp newspapers, by reviewing A.W.O.L. and court-martial cases, and by working with individuals, psychiatrists were so successful in improving mental health in several of the replacement training centers that in the spring of this year authorization was granted for their establishment at all replacement training centers.
Another step has been the establishment of the School of Military Neuropsychiatry at Lawson General Hospital. Their training here should better equip psychiatric medical officers for any preventive work which their assignments will permit.
The newly established liaison between the Neuropsychiatry Branch, S.G.O., and the Special Services Division, A.S.F., is a further move in the direction of prevention. Cooperative studies are under way to determine the major points at which a preventive program might be directed.
If men enter the Army only because they were compelled to do so and then crack because they do not want to fight, they can be protected only by a fuller realization of the fundamental issues involved in the war. This understanding cannot be confined to the level of abstraction if it is to be effective. It must extend to the level of concrete, everyday experience and must permit them to take a positive stand on real issues. It remains to be seen whether the judicious use of informational media can create the toughness of mind required to withstand separation from home, regimentation, and danger of death.