Introduction
Many experts have written dismal assessments of the unpreparedness of the U.S. industrial base in the wake of protracted war in Ukraine. Less discussed is an equally critical vulnerability: psychological readiness. Ukraine's experience also demonstrates the cost of this oversight—its government has claimed higher losses from desertion than combat fatalities.
As infectious disease was for the 19th century, despair should be considered the primary attritional threat for the 21st. In the Civil War, two soldiers died of disease for every one killed in action; in the forever wars, nearly six troops committed suicide for every one killed in action. Even now, suicide and mental health are the leading causes of mortality and hospitalization for the U.S. military, and casualty rates keep increasing. Despair is also the primary threat to force regeneration as 77% of young Americans are ineligible for service, with the main disqualifiers being obesity, drug abuse, and mental health issues.
With resilience falling, cognitive threats advancing, and attritional warfare looming, leaders must recognize that U.S. is totally unprepared to prevent, receive, or treat psychiatric injuries in the next war. Without radical reform, the U.S. will deploy its forces without the contemporary equivalent of penicillin.
Attrition, Epidemics, and Cognitive Warfare
Although data is sparse, early estimates show nearly half of Ukraine’s Armed Forces meet the diagnostic criteria for a debilitating psychiatric disorder, including rear-area troops. Some of the best and most recent data regarding U.S. servicemember psychiatric casualties estimate OIF/OEF-era veterans have a lifetime PTSD prevalence of 29% (regardless of deployment) and nearly a third of all veterans using the VA have a current mental health diagnosis. Deployed civilians (which came to outnumber servicemembers deployed to CENTCOM) can be expected to suffer even worse, consistent with RAND Corporation findings showing high PTSD rates and a 50% substance abuse rate after deployment. Military spouses screen positive for psychiatric disorders at a comparable rate of 35%.
Even without a draft, a limited LSCO scenario is likely to see four million U.S. participants. The 1.3 million active force would surge to 2.1 million with reserves, with America's million-strong contractor force surging similarly. If the psychiatric casualty rate remains around 1/3 for wartime service, this would produce approximately 700,000 servicemembers with mental health diagnoses. Accounting for contractors and the effect on 3 million dependents with their sponsor suddenly deployed, 1 million psychiatric casualties becomes a conservative estimate based on historical attrition rates.
There are many reasons to assume the toll will be much higher, however.
Declining interpersonal trust and civic engagement in the United States have eroded collective resilience, social cohesion, and robust identity. The U.S. Surgeon General has declared an epidemic of loneliness and social isolation. Young Americans are less healthy and sleep less than before. "Deaths of despair" from suicide, alcohol, and drug overdoses have never been higher, with overall mortality rates beginning to increase for some segments of the population. Because of these trends, we can expect the force that fights the next war to have far greater vulnerability to psychiatric injuries.
Finally, there is the nascent threat of cognitive warfare, poorly understood and studied but potentially decisive in the next war. Russia has deliberately and eagerly exploited the fractured political landscape as part of its hybrid war, amplifying institutional betrayal and consequent moral injury. China appears to passively or deniably wield social media and fentanyl as cognitive weapons with total impunity. Future conflicts may see fully autonomous suicide weapons fielded.
America is not prepared. In 2022, the DoD Suicide Prevention Independent Review Commission released a damning report finding behavioral health systems totally overwhelmed, garrison environments corrosive to resilience, and DoD policy uncoordinated and ineffective. It offered 127 substantive reforms; the DoD's response seems to have amounted to lip service.
The tidal wave of mental illness and broken hiring systems for providers have forced DHA to begin triage of patients seeking care. De-medicalizing some of the support structure is a necessary step, but in the absence of robust alternatives to clinical support, triage is not a solution—it’s a peacetime surrender.
Australian Case Study
Australia faced a similar crisis and established its own suicide prevention commission following the American example. Rather than ignore the results, Australia's government developed a whole-of-society mental health strategy, refined it with ground-level feedback, and seem to have begun aggressive implementation.
The strategy is proactive, focusing on creating conditions for mental wellness from recruitment through retirement (and beyond). It is integrated, incorporating defense and veterans' departments, training commands, garrison commands, health systems, and NGOs. It is holistic, with lines of effort addressing spirituality, community, meaning, finance, housing, education, justice, health, and recognition.
Key principles America should adopt:
- Acknowledging the crisis as a national security threat requiring government action
- Synthesizing a comprehensive strategy document that incorporates a whole-of-society approach
- Reducing friction and discontinuity in the mental health system through human-centered design
- Proactively intervening in upstream determinants of mental health outcomes
- Treating mental health as a continuum: Australia uses “Well, Coping, Struggling, Unwell”
- Implementing a stepped-care model that scales up medicalized care for severe cases while improving non-medical support infrastructure
While unprepared overall, there are several encouraging models already in use. By synthesizing these along three major conceptual directions, one can create a template for broad reform.
Getting Ready – Acute Trauma Care
The DoW should embrace new evidence-based “psychological first aid” programs like iCOVER and BH-GEAR. They move beyond legacy training “recognize illness and transfer to a broken system” and instead train warfighters to provide buddy aid confidently and competently.
Stagnant hiring policy should be amended or bypassed for routine care providers so behavioral health officers and chaplains can move forward with the force. In combat, they must be close enough to assess and assist acute cases as well as guide commanders under pressure. Remote, civilian, and subclinical resources can take on chronic care, allowing forward clinicians to share directly and authentically in the process of healing.
For higher levels of care, MHS should expand access to intensive/residential programs and rapidly improve bandwidth within the clinical system, not only to stem the current tide of casualties but to be ready to handle potentially millions more.
Finally, continuity of care must be a priority target for reform. The present system strands servicemembers for months between contacts, ensuring decline instead of recovery. Proven subclinical models can bridge that gap, maintaining support and community from injury through recovery.
Getting Ready – Moral Injury, Anomie and the Warrior Ethos
VA psychiatrist Jonathan Shay coined the influential term to describe the warrior's signature psychological wound - Moral injury (MI). It results from high-stakes betrayals of moral code during protracted pain, fear, or rage. Unlike trauma, which is acute and often heals, MI is debilitating and chronic. It produces permanent neurological changes and progressively narrows ethical boundaries from nation to warrior class to platoon to only a few trusted individuals, or solely to the dead.
Likewise, groundbreaking sociologist Emille Durkheim identified anomie—the breakdown of social and moral norms—as a primary driver of suicide in industrial society. A strong, visible, non-negotiable code doesn’t merely guide conduct—it shields against psychiatric injury. When people lose their sense of belonging, purpose, and necessity, despair follows and resilience collapses.
The contemporary military generates MI and anomie with unique efficiency.
Dishonesty and fraud are not only the norm, they are enforced standards. Pencil-whipping range scorecards teaches that standards are theatrical. Failure to help or chapter obese servicemembers teaches that readiness is just a buzzword. Quietly transferring sexual assault victims while perpetrators remain teaches that justice is a fiction. Every compromise drives home the enervating idea that character is nothing more than a liability. This anomie primes warriors for catastrophic psychiatric injuries - units with unclear or unenforced standards are the most vulnerable to trauma in wartime.
Betrayals have become visible everywhere—from unpunished crimes to decades of strategic failure. Warriors have less agency than ever; their typical condition is dependence without community. Delusional metrics-based leadership, a permanently unsustainable operations tempo, and all the normal trauma of the profession combine to drive exceptional rate of MI.
Shay argued that psychological recovery should be a planning factor, not an afterthought. He emphasized prioritizing unit and community integrity over treating individuals as interchangeable parts, training leaders in rituals that honor the dead and generate new meanings for traumatic experiences, and upholding uncompromising ethical standards. Shay also observed: "The essential injuries in combat PTSD are moral and social, and so the central treatment must be moral and social." Healing hinges on communalization of trauma and the victim's reception by comrades, leaders, and family. Effective interventions strengthen community, they do not isolate people or burden units. Support workers must participate authentically and invest emotionally—unfortunately more the exception than the norm in today’s system.
As such, SecWar’s recent emphasis on revising standards and procedures to restore warrior ethos deserves cautious optimism. Promotions, accountability, investigations, pass rates at schools, and court efficiency, are all ripe for change. The good news is that clear templates already exist - various commissions tied to inexcusable tragedies have already mapped out the way forward. With top-cover and dynamism, leaders must seize this moment to recalibrate the culture toward something more human, psychologically wise, and resilient. An unassailable, communally validated, and non-negotiable warrior ethos – who I am, what my place is, what meaning my service has – is the only way to keep someone’s worst day from becoming a permanent disability.
Getting Ready – Mental Illness and the Garrison
Following Australia's model, the DoW must take responsibility for servicemember welfare and draft a whole-of-society plan addressing the commission report. This requires acknowledging that mental health crisis is a national security imperative and that leadership has the knowledge, the ability and the responsibility to prevent it. Key to this will be reform of the garrison, where our current mass casualty event is being generated and where the outcomes of wartime casualties will be decided.
Military communities have collapsed over the last twenty years, and it will take an integrated strategy to repair them. Every effort must be made to supplant the current off-duty miasma of liquor stores, convenience stores, fast food, slot machines and TV screens. Effective policy would improve concentration of families to rebuild informal support networks. It would better integrate veterans and contractors into garrison communities through vibrant social venues and meaningful programs. As the Alcoholics Anonymous mantra goes, the opposite of addiction is connection. This is true for any mental illness; the more connected a warfighter is, the more resilient.
Garrison life has also paved the way for individuals to move from trauma to crisis in other ways. Chronic sleep deprivation (far beyond what is required for training value) is ubiquitous in the military and can be addressed with policy revision and enforcement of existing protections. Soundproofing, air conditioning, and blackout shutters in barracks have also been long neglected. Greater proactivity of the MHS in diagnosing sleep-related disorders can also help prevent casualties.
Finally, a paradigm shift is required for dedicated mental health support structures to a scalable, proactive, and universal model. A network of experienced and invested case managers/support workers reaching out to warfighters in garrison, in the field, or on deployment is the best way to ensure conditions are set for recovery. Supporters can help warfighters communalize trauma, fight through hurdles to specialty care, and coach them through recovery. Proactive mental health outreach can also provide critical data to leaders, aggregating anonymous data and briefing commanders on the state of their formation. While expensive, evidence increasingly shows that proactive models have extremely positive ROI on the overall cost of mental health support by preventing more severe and costly outcomes.
Conclusion
Ukraine has been a wake-up call regarding military industrial capacity, but if personnel collapses first, the military won’t last long enough for industrial capacity to matter. Marching to war with a sick population and no viable treatment portends attrition even greater than the adversary can inflict.
Luckily, actionable reforms are already available—in the SPRIRC's 100+ recommendations, in Australia's comprehensive strategy, in pilot programs for acute trauma care and proactive emotional support. Reform will require unprecedented investment in proactive measures, but inaction will cost even more. Our 1 million wounded Vietnam vets have an estimated lifetime healthcare cost of over 3 trillion inflation-adjusted dollars. The question isn't whether we can afford reform—it's whether we can afford to receive one million psychiatric casualties without it.
Gregory Wall is an Army officer stationed at Rose Barracks, Germany. He holds a bachelor's in Slavic Literature from Princeton University and a certificate in Cyber Awareness.
www.linkedin.com/in/gregory-wall-94097312a
The views expressed are those of the author(s) and do not reflect the official position of the Department of the Army, Department of War, or the U.S. Government.
