CHAPTER XXVII
The Psychiatric Patient After Discharge
Norman Q. Brill M.D., and Herbert I. Kupper, M.D.
MISCONCEPTIONS ABOUT PSYCHONEUROSIS
Nearly every patient discharged from an Army hospital with a psychiatric diagnosis was himself greatly concerned about the possibility that his relatives or friends might be afraid of his behavior or look upon him as a "crazy man or as a failure."1 The term "psychoneurosis" had received a great deal of publicity during the war, and unfortunately, there was widespread misunderstanding of what it meant. Many people confused it with psychosis. Great fear had been expressed by many over the Army's returning all these psychoneurotic patients to civilian life. The use of the word "cracked-up" had implied that some irreparable damage had been done and gave the impression that the brain had been affected. Concern was expressed that the psychoneurotics would create a serious problem in the community, that they would go about and behave in a peculiar fashion, that there would be strange expressions in their eyes, and that there would be manifestations which the average person associated with insanity.
Stigma of psychiatric diagnosis.-By 1 August 1942, Illinois for example, had 2,354 veterans of World War II.2 Of this number, 1,014, or 40 percent, had been discharged from the service because of psychiatric and personality defects. Of this psychiatric group, 101 were in State institutions for the mentally ill. Most of the remainder (86.7 per cent) were employed and generally making a fair adjustment. Those who had received administrative discharges as "inapt" or because of "undesireable habits or traits of character," and whose discharge certificates contained such phraseology, encountered some difficulty in obtaining employment. Men discharged for psychoneuroses during the war also encountered some hesitancy on the part of employers to hire them.3
1Menninger, William C.: Psychiatry in a Troubled World: Yesterday's War and Today's Challenge. New York: The Macmillan Co., 1948, p. 21.
2Sommer, C.S., and Weinberg, J.: Discharged Veterans of World War II in State Hospitals and in the Community. Arch. Neurol. & Psychiat. 50: 105-107, July 1943.
3Brill, N. Q., Tate, M.C., and Menninger, W.C.: Enlisted Men With Overseas Service Discharged From the Army Because of Psychoneuroses; A Follow-up Study. Ment. Hyg. 29: 677-692, October 1945.
730
POSTDISCHARGE ADJUSTMENT DURING THE WAR
Later in the war, with the large number of men being discharged medically, for psychiatric reasons, there was great interest within the Army to know more about how these men were faring in civilian life. The Neuropsychiatry Consultants Division, SGO (Surgeon General's Office), undertook a followup study, in 1944, of enlisted men discharged from the Army for psychoneuroses before 1 January 1944.4
Questionnaires were sent to a random sample of 5,937 and replies were received from 4,178 (over 70 percent). From the replies, 85.9 percent of the men were employed in contrast to 93.7 percent who had been employed before induction. In general, these men considered their health to have been adversely affected by their Army service, but thought of this impairment chiefly in terms of physical rather than emotional illness. Of the entire group, 14.5 percent were hospitalized at least once after leaving the Army, but in many instances, the hospitalization was by the Veterans' Administration gave to settlement of claims rather than to real rehabilitation. As early as 1942, Pratt6 had predicted the danger of this type of approach.
Pratt7 was able to obtain reports on 55 percent of 256 soldiers who had been discharged in 1943 with a diagnosis of psychoneurosis. He found that 90 percent were employed within an average of 5 to 6 weeks after discharge. Of the 256 men, 22 percent maintained that they encountered some difficulty in securing work because of the nature of their discharge. From an unpublished study of 500 patients who had been discharged from the Fort Story Convalescent Hospital, Va., 85 percent were found to be gainfully employed, 8.5 percent were attending school, and only 6.5 percent were unemployed. A British study gave essentially these same findings.8
Qualitative changes in health and adjustment, however, were found in such men by several Canadian investigators.9 In the study conducted by the Neuropsychiatry Consultants Division, this was found to be more so with men who had had oversea service, and this finding was confirmed
4Brill, N.Q., Tate, M.C., and Menninger, W.C.: Enlisted Men Discharged From the Army Because of Psychoneuroses; A Follow-up Study. J.A.M.A. 128: 633-637, 30 June 1945.
5Burling, T.: Community Organization for Meeting Problems of Psychiatrically Disabled Veterans. Am. J. Orthopsychiat. 14: 680-698, October 1944.
6Pratt, G. K.: The Call of the Cradle, Some Psychiatric Problems of Demobilization. Ment. Hyg. 26: 39-49, January 1942.
7Pratt, D.: Reemployment of the Psychoneurotic Ex-Soldier. Psychiatry 8: 3-8, February 1945.
8Lewis, A.: Social Effects of Neurosis. Lancet 1: 167-170, 6 Feb. 1943.
9(1) Griffin, J.D., and Henderson, M.F.: A Study on the Post-Discharge Adjustment of Psychoneurotic Soldiers. National Research Council of Canada. [Report C-6071 filed with Proceedings of the Henderson, M.F., and Ross, W.D.: A Study on the Post-Discharge Adjustment of Psychoneurotic Soldiers. National Research Council of Canada. [Report C-6111 filed with Proceedings of the Fourth Meeting of the Associate Committee on Army Medical Research, 27 May 1944.] (2) Griffin, J.D., Henderson, M. F., and Ross, W. D.: A Study on the Post-Discharge Adjustment of Psychoneurotic Soldiers. National Research Council of Canada. [Report C-6111 filed with Proceedings of the Fifth Meeting of the Associate Committee on Army Medical Research, 10-11 Nov. 1944.]
731
by a postwar followup study of war neuroses, supported by the Veterans' Administration.10
RESIDUALS OF WARTIME PSYCHIATRIC ILLNESS
A study of enlisted men, ages 18 to 25, who had been hospitalized during 1944 for psychoneuroses was undertaken in 1948 by Brill and Beebe for the Committee on Veterans Problems of the National Research Council, in cooperation with the Veterans' Administration, the Army, and the Navy, to determine the condition of these men approximately 5 to 6 years after they had been treated in the service. Of a total of 1,475 men,11 27 percent were found to have no psychiatric illness, 33 percent had mild psychoneurotic disorders, 25 percent had moderate or severe psychoneurotic disorders, 11 percent were diagnosed personality or behavior disorders, and 1.5 percent were suffering from schizophrenic reactions.
Only 10 percent were free of symptoms. The most common symptoms, affecting at least 40 percent of the men, were irritability, anxiety, gastrointestinal complaints, restlessness, and headache. Phobias, obsessions and compulsions, hypochondriacal reactions, psychotic symptoms and behavioral disorders, difficulty in concentrating, and depression were also reported,12 but less frequently
It was interesting that, in 24 percent of the men, all their symptoms at followup had originated before entering the service. In 43 percent, the symptoms were reported to have originated in the service. After 5 years, most of the men still felt that their health was not as good as it had been when they entered the service; yet, as a group, they had, in the main, continued to improve since separation from the service. Nearly a third of the group still looked upon their difficulty as "organic."13 The great majority exhibited adequate ability to handle their jobs without excessive interpersonal difficulties, without frequent changes or irregularity of employment, or without resorting to work below their level of competence. The structure of civilian occupations and job situations is enormously more varied than the military and it does not follow that these men would necessarily have been as well adjusted in military occupations.
Of the total group, 76 percent of the men were employed full time, 9 percent part time, and 15 percent not at all. Illness was a factor in preventing full employment for 14 percent, or just over one-half of those
10Brill, Norman Q., and Beebe, Gilbert W.: A Follow-Up Study of War Neuroses. VA Medical Monograph Series. Washington: U.S. Government Printing Office, 1955.
11By June 1953, of the 1,475, 36 had died. This compares with a normal expectation of 31 deaths in this size and age group. Of the deaths, six were suicides in comparison with an expectation of the two. In 1950-51, four men were in prison, none of them for any major crime of violence.-N. Q. B., and H. I. K.
12It is difficult to estimate what proportion of a cross section of the civilian population would report specific symptoms if questioned in the same way as were the men in this study.-N. Q. B., and H. I. K.
13This phenomenon was reported by many others; for example, Owens, R. H.: The Neuropsychiatric Discharge. Ment. Hyg. 29: 666-676, October 1945; and Burling, T.: Community Organization for Meeting Problems of of Psychiatrically Disabled Veterans. Am. J. Orthopsychiat. 14: 680-698. October 1944.-N. Q. B., and H. I. K.
732
not employed full time. A large number had married since separation, and most of these men had adjusted satisfactorily to married life. Adjustment was least often satisfactory in the area of the community where socially acceptable behavior and conformity to the mores were involved. Here, 19 percent of the men showed impaired adjustment and another 25 percent a questionable adjustment. In some instances, this maladjustment was also clearly present before service.
Less than 30 percent of the entire followup sample appeared to be more than slightly disabled at followup and only 8.1 percent more than moderately disabled. Only 2.1 percent had received intensive psychotherapy since discharge, 11 percent had had brief psychotherapy, and 64 percent had had no medical treatment of any kind.
A total of 915 men, 47 percent, were receiving disability compensation from the Veterans' Administration (as of 1950-51), as follows:
Monthly payment: | Percent |
None | 52.9 |
$1 to $9 | .1 |
$10 to $19 | 22.3 |
$20 to $29 | 2.6 |
$30 to $39 | 1.3 |
$40 to $49 | 11.9 |
$50 to $59 | 2.4 |
$60 to $69 | 2.8 |
$70 to $79 | .3 |
$80 to $89 | .8 |
$90 to $99 | .9 |
$130 to $139 | .1 |
$140 to $149 | .1 |
$150 to $159 | .1 |
$180 to $189 | .1 |
Amount unknown | 1.3 |
| Total | 100.0 |
It should be emphasized that the men in the group studies had been hospitalized for psychoneuroses, not discharged for psychoneuroses. Only 44 percent of Army cases were by CDD (certificate for disability discharge.)
Since there were approximately 700,000 strictly psychiatric admissions from 1942 to 1945, it can be estimated that in 1950-51 approximately 325,000 of these men from World War II were receiving "pensions" from the Veterans' Administration. As of 30 June 1947, there were 286,000 patients who had had psychiatric illnesses in World War II who were receiving pensions from the Veterans' Administration.14 In only a small fraction was the compensation believed (be the examiners) to have an adverse effect on the veteran's illness.
Of great interest was the fact that 21 percent of those who reported that their health was the same or better than when entering the service were receiving compensation. It is a sad fact that one-half of the men who were receiving disability compensation had never had any treatment for their emotional difficulties after discharge from the service.15
14Menninger, op. cit., p. 380.
15One investigator (Ginsburg, S. W.: Rehabilitation and the Returning Veteran; Community Responsibility for Neuropsychiatric Discharges. Ment. Hyg. 29: 20-31, January 1945) found 82 percent of a representative sample of men discharged from the service for psychiatric reasons were in need of some form of psychiatric assistance. However, only 25 percent could be expected to admit their need and seek help. Of these, only a small fraction were receiving psychiatric help, and the same was true for vocational help.-N. Q. B., and H. I. K.
733
Of the men who were hospitalized for psychoneuroses in the Zone of Interior, one-fourth were receiving compensation, lending some substance to the claim that the mere fact of hospitalization in wartime carries with it some likelihood of being granted a "pension" by the Veterans' Administration.16Those who broke down in or after combat-or merely while overseas-were much more apt to receive compensation. However, men who had clear-cut neuroses or personality disorders before entering the service and who were hospitalized in the service were compensated at least as often as those who had no preexistent psychiatric difficulty and whose illness in service was presumably more related to the stress of service.
POSTDISCHARGE PSYCHIATRIC ILLNESS
A special group of men who unfortunately could not be included in this study were those who developed emotional disorders after discharge from the service.17 This was not a large group but its existence is further proof that those who were hospitalized constituted only a part of the psychiatric problems engendered or uncovered by war.
Burton and his associates18 found, for example, that 2.57 percent of 10,000 men processed through a separation center had sufficient complaints to warrant a psychiatric diagnosis and that 0.5 percent had some degree of incapacity. Schneck19 expressed the opinion that a large number of soldiers being demobilized could profit from help. The many readjustments which had to be effected and the whole problem of social reintegration of the discharged soldier was comprehensively reviewed by Menninger.20 He exploded the prediction made by so many that the veteran would constitute a serious problem to society by acting out, in a life of crime, the hostility that had been engendered during the war.
16Receiving a medical discharge for a psychoneurosis carried with it almost a four times better chance of receiving compensation than being returned to duty and demobilized or discharged for the convenience of the Government. Of those who were CDD'd, 57 percent received compensation in contrast to 15 percent who were discharged with disorders of similar type and severity but who left the Army from a duty status.-N. Q. B., and H. I. K.
17Campbell, J. A.: From VJ * * * Mental Disorder Following Service Discharge. Psychiat. Quart. 20: 375-380, July 1946.
18Burton, I. F., Eaton, M. T., Jr., and McMahan, H. G.: Incidence of Neuropsychiatric Disease in the Demobilized Veteran; Study of 10,000 Army Separatees. Am. J. Psychiat. 103: 165-171, September 1946.
19Schneck, J. M.: Neuropsychiatry at a Separation Center. Mil. Surgeon 100: 232-233, March 1947.
20Menninger, op. cit., pp. 363-392.
