The demand for psychiatric services as a result of the Gulf war

Navy, reported informally in the newspapers (Guardian. 1 May 1990) that up to 30% of the 28,000 Falklands veterans are still suffering from posttraumatic stress disorder (PTSD). Hughes (1990), medical officer with 2nd Paratroop Regiment at Goose Green, described his realisation that he had PTSD, his subsequent treatment by the NHS and transfer to a military hospital. The Royal Navy still has a counselling service, set up in 1987, but it is clear that military services cannot deal with all the current problems, let alone those to come. The advice of the Ministry of Defence is that the initial onus to recog nise a problem lies with the family and that sufferers should seek treatment through their GP. Provision for short-term and long-term services needs to be made for all groups of victims. Describing disaster, Dudasik (1980) describes four categories of victims and Taylor & Fraser (1981) six. The wide range of victims which may report to the NHS is important, not just front line military, but all military groups, including the medical and nursing personnel, civilians in the area, including news personnel, rela tives and friends of such groups and vulnerable people in the wider community affected by the war coverage. i

Navy, reported informally in the newspapers (Guardian. 1 May 1990) that up to 30% of the 28,000 Falklands veterans are still suffering from posttraumatic stress disorder (PTSD). Hughes (1990), medical officer with 2nd Paratroop Regiment at Goose Green, described his realisation that he had PTSD, his subsequent treatment by the NHS and transfer to a military hospital. The Royal Navy still has a counselling service, set up in 1987, but it is clear that military services cannot deal with all the current problems, let alone those to come. The advice of the Ministry of Defence is that the initial onus to recog nise a problem lies with the family and that sufferers should seek treatment through their GP.
Provision for short-term and long-term services needs to be made for all groups of victims. Describing disaster, Dudasik (1980) describes four categories of victims and Taylor & Fraser (1981) six. The wide range of victims which may report to the NHS is important, not just front line military, but all military groups, including the medical and nursing personnel, civilians in the area, including news personnel, rela tives and friends of such groups and vulnerable people in the wider community affected by the war coverage. i

Prevalence of psychiatric casualties
There is a tendency in the literature to refer to the number of psychiatric casualties as a total, without clear indication of diagnosis. Rahe (1988) points out that military writing tends not to differentiate between acute and chronic disorders. Short-term problems such as combat-related stress (CRS) or battle shock are indicated as psychiatric casualties, elsewhere it is intimated that this is a natural reaction to extreme conditions and should not be labelled 'psychiatric'. Both short-term and long-term prob lems, primarily post traumatic stress disorder (PTSD), must be considered.
Overall, on evidence from World War I, World War II in both Europe and the Pacific, Korea, Vietnam, the Arab-Israeli war, the war in the Lebanon and the Falklands war an incidence of psychiatric casualties of about 20-30% could be expected. The National Vietnam Veterans' Readjustment Study (Blank, 1982) is the largest epidemiological study of PTSD and estimated, in the early '80s, that there were 829,000 veterans still with PTSD out of four million service personnel, and that there were approximately 75,000 new cases every year.
In a review of the literature on chemical and bio logical warfare (CBW), Fullerton & Ursano (1990) concluded that the CBW combat environment adds 5-20% to psychiatric casualty rates. These figures relate to the unique characteristics of the CBW en vironment and do not include casualties as a result of CBW contamination. Behavioural and psychologi cal effects of contamination can last for up to a year and make determining fitness to return to duty diffi cult. In World War I it was reported that as many as two individuals described symptoms similar to con tamination, even though they had not been exposed, to every one who is exposed. Romo & Schneider (1982) discussed the possibilities of casualties in fu ture wars, especially where chemical or nuclear war fare is likely, and suggest that psychiatric casualties will be higher than in previous wars.
Becoming prisoners of war presents unique stresses to the individuals detained and also to their families. Such individuals who have long-term read justment problems, including PTSD, require therapy geared to their unique problems.

Civilian casualties
Families of service personnel are those at most risk. For families living on military bases anticipatory stress can usually be managed with support from the military and self support groups. The greatest prob lem with families will be likely to occur on the service person's return, either as a casualty, because of the service person's PTSD or because of more general ised readjustment problems. In many cases therapy will have to be offered to the family rather than an individual.
Rates of casualties among the wider community are likely to be similar to those for a peacetime disaster. Civilian populations under attack do not show significantly increased rates of mental disturb ance (Romo & Schneider, 1982).

Immediate management
Management of CRS has changed little since World War I. Front-line 'psychological first-aid', namely physical replenishment (sleep, food, water), emotional ventilation, and a clear expectation of re turn to unit and duty, lasting six to 72 hours, and carried out as close to the battle scene as practical minimises longer term psychiatric problems and maximises return to duty. Reports of return to duty using this approach range from 50-85 (Romo & Schneider, 1982;Ursano et al, 1989). Research from Israel indicated that return to duty was more likely from soldiers treated at the front line than behind lines, and that they were also less likely to suffer PTSD (Solomon & Benbenishty, 1986). Small (1984)described a practical training exercise used with the 1st Armoured Division Mental Hy giene Consultation Service of the US Army for man agement of psychiatric casualties. Current mental health services in the field are unlikely to be able to deal with all those requiring assistance.

Service provision
The NHS's role will be determined, at least in part, by the adequacy and availability of front-line CRS treatment. Lack of support by commanders can decrease both this provision and its efficacy.
A comprehensive overview of management fol lowing disasters was given by Raphael (1986). Com paratively short in-patient treatment is less the issue (although services have to be found) than the longterm demand from personnel suffering PTSD. The United States evidence points to the importance of recognising PTSD as early as possible and to begin treatment immediately. The Veterans Adminis tration did not recognise PTSD as a combat-related disorder until 1980 for men and 1983 for women when it was accepted in non-combat veterans.
Including services for families is essential for many veterans and provision needs to be made for possibly long-term family support. Learning from work with disaster, the use of victim support groups seems im portant. Victims of disasters may be in a position to support returning veterans. Support for victims is often long-term and can prove a strain for therapists. It has been suggested that the caseload of PTSD victims for each therapist or counsellor should be restricted (Rosser, 1989).
That casualties will continue to present for some time to come after repatriation is certain, and the war as a predisposing factor will need to be considered in ex-service personnel for years to come. The Vietnam evidence points to the high numbers of PTSD vet erans who had additional, concomitant diagnoses. The most prevalent were alcoholism and drug depen dency but included personality disorders, organic mental states and depression. Goderez (1987) de scribes 'survivor syndrome'. PTSD with additional features, where 'reality adaptations in the traumatic situation' persist in civilian life.