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.