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The Invisible Wounds of War: Let's Hear From the Generals

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American troops are committing suicide in record numbers, and too many are too embarrassed by the stigma of mental health to seek life-saving care. It's great that top brass are encouraging warriors to get help for war's "invisible wounds." But now, they need to speak out openly about their own struggles with mental illness.

The US military faces the mental health toll of nine years of war. Since 2005, the suicide rate among Soldiers doubled, and now is the same as in the general population. It's even higher among Marines.

Last year, for the first time, more troops were hospitalized for post-traumatic stress disorder (PTSD) and other mental health problems than for any other cause, including physical combat injuries.

We have reached these new, dangerous levels for a host of reasons: long and frequent deployments to Afghanistan and Iraq; the unique stresses of counterinsurgency operations, where sustained close contact with local populations is essential but can be deadly; and a military health care system without enough mental health professionals. Brain injury caused by roadside bombs, considered a signature wound of the Afghanistan and Iraq wars, also may play a role in mental illness.

And as recent reports by the Army and a Department of Defense task force noted, there's the stigma of mental illness. Troops don't seek the help they need, even when it's available, because they fear that their buddies will think less of them or that their careers will suffer.

Of course, the stigma exists outside of the military too. The military is part of a wider society where people with mental illness are considered more responsible for their conditions than people with physical problems. They face social exclusion in their professional and personal lives.

But, as a physician and military officer, assigned to a large command that has deployed tens of thousands of service members to overseas combat, I see a big difference among warriors. Military culture values physical and emotional strength especially highly, and troops with mental illness likely face even more hostile attitudes from fellow service members than people in civilian society do from their peers. It is shameful that we might treat our wounded warriors with that callousness.

Sadly, concern about these damaging attitudes is strongest among those who most need help. In a 2004 Army study of Soldiers and Marines in Afghanistan and Iraq, 65% who met criteria for a mental illness felt they would be seen as weak for seeking care, compared to 31% who didn't meet criteria. Half of those who need care thought it would harm their career, more than twice those in the other group.

The military knows these perceptions keep troops from getting help, and is taking steps to change them. A notable example is the Real Warriors Campaign, which uses social media and other platforms to tell the stories of service members who sought mental health services. Hopefully, these testimonies will encourage others to seek care. But a much broader campaign is needed to change the perceptions of their peers, subordinates, and leaders. After all, it's the internalization of their perceptions that prevents troops who need care from seeking it.

To create an environment where service members who need care are more likely to seek it, senior military leadership who got help for mental illness should speak openly about their experience. This would demonstrate, to all service members, that those who seek care can be effective Soldiers, Sailors, Airmen, and Marines - and that seeking help does not prevent advancement. It would send a strong message that they should be treated fairly and compassionately: Who would punish a fellow warrior for struggling with mental illness when their leader has spoken openly about his or her own struggle?

Some generals are speaking publicly about their post-combat mental illness. Many more should follow suit, at the top and down the chain-of-command. A large study estimated that 10% of service members have a mental illness. As Secretary of Defense Robert Gates noted recently, there are a lot of generals and admirals - around 1,000. Even if there's less mental illness in this group, there must be at least several dozen flag officers who overcame problems or strive to do so. The troops need to hear from them.

Jean-Paul Chretien, MD, PhD, is a military physician and Fellow of the Truman National Security Project.