Ten years into the war in Afghanistan, and after nearly nine years of war in Iraq, we know that the defining injuries of these conflicts for our service members include traumatic brain injury and post-traumatic stress disorder. We also understand that the all-volunteer force is stretched thin and that multiple deployments to combat zones are routine.
What military physicians don’t have a good sense of, however, is how to tell whether a combat veteran is still qualified for the battlefield. And the tragedy this month in Afghanistan, where Army Staff Sgt. Robert Bales, on his fourth combat tour, allegedly slaughtered 17 civilians and has been charged with murder, underscores the urgency of finding a better solution.
I have spent much of my career searching for one. As a psychiatrist who served from 1970 to 1998, I helped develop the Army’s programs in stress reduction, and I took on the issue as a retired Army brigadier general and the senior adviser to the chairman of the Joint Chiefs of Staff.
Soldiers are, of course, screened before and after deploying. But although this process involves multiple questionnaires and a review of medical records, it varies from base to base. No physiological tests are used, and soldiers may or may not see clinicians. Assessments are highly subjective and have been criticized for relying on self-reports. After all, soldiers may not be honest about their problems. If injured or unstable, they may be unable to deploy with teammates who rely on them or may face delays in going home.
Bales had been treated for mild traumatic brain injury. But the military has lagged in developing accurate, cost-effective tools to diagnose blast-induced concussions, despite growing evidence of their harm. As early as 2004, I saw that troops injured in IED explosions were foggy and dazed. My attempts to interest the Army’s senior medical leadership at that time were brushed off.
By 2007, at the height of vicious combat in Iraq, meetings arranged to jump-start physiological tools for diagnosis and treatment were buried in bureaucracy. And the severity of the problems was minimized. “Better diagnosis was not needed because there was no treatment for concussion anyway,” one consultant to the Army surgeon general commented.
That mentality prevailed until the Defense Centers of Excellence was founded in November 2007 to tackle psychological health and traumatic brain injury. Since 2009, the Defense Department has spent millions of dollars on ANAM4 — Automated Neuropsychological Assessment Metrics, Version 4 — the standard measure of brain injury for troops returning from combat. But ANAM has serious shortcomings. Developed by military researchers in the 1980s, it has been used to select pilots and astronauts, but was not intended as a diagnostic test for concussions or any other neurological disorder.
ANAM and other psychological tests are useful but not definitive. They help identify particular problems, such as dementia, in up to 80 percent of cases, but the questionnaires are subjective, even when administered by professional psychologists. Clinicians should rely on psychological tests such as ANAM to supplement examinations — not to diagnose.
Other factors complicate the psychological testing of soldiers. Psychiatrists at Washington’s Madigan Army Medical Center — located on Bales’s home base — may have changed PTSD diagnoses to save money. Meanwhile, the murky background of new recruits — some who have mental illness, have been on medication and had concussions we don’t know about — complicates assessment. Psychologists can’t always immediately identify a private’s ability to cope with training and combat. There are no good tools to discern predisposition to emotional stress or assess for a history of concussions.
Soldiers fight a battalion of stresses: life-or-death missions, colleagues killed or badly injured, chronic aches from carrying heavy loads, disturbed sleep patterns, exposure to foreign toxins, and explosions that shake the body and the brain. No tests adequately account for every issue. Questionnaires can’t distinguish between medical problems caused by IEDs, shock, drug and alcohol abuse, or diseases that affect thinking and behavior. Using surveys to evaluate men and women before and after their service doesn’t offer a clear picture of the whole person or of the circumstances leading to their injury.
What would be better than the outdated method we use? According to some, only electroencephalogram (EEG) tests, which measure brain waves, or diffusion tensor imaging, a specialized MRI, can detect specific evidence of a brain injury. EEGs are inexpensive, take less than an hour and can be done outside of hospitals. More sophisticated radiological testing is expensive and time-consuming, but can yield worthwhile information. ANAM’s subjective self-reports are no match for physiological data for diagnosing damage to the brain.
Still, some may argue that the cost of definitive screening is prohibitive. That is a red herring. Refitting and rebuilding the Army in the 21st century requires knowing whether warriors are fit. There’s not much room for cost-benefit analysis. Commanders have a responsibility to identify at-risk soldiers. They can’t pass the buck to generic medical screening with limited utility.
To recover from 10 years of combat in Iraq and Afghanistan, the Army must focus not on weapons systems but on people. This may cost more, but it will prevent the fragile conclusion of a decade of war — or innocent civilians — from being harmed by one sick soldier.
Stephen N. Xenakis, a retired Army brigadier general, is a psychiatrist and founder of the Center for Translational Medicine.