In this study, we demonstrated that adjustment disorders did exist among Armed Forces draftees (AFD) in the Penghu Area, a high readiness military zone in the Taiwan Strait. In a group of the draftees who were service suspended for mental disorders (study group), the number of draftees seeking psychiatric outpatient treatment increased from 49.3% before service to 100% during the service. The number of draftees with no or low willingness to serve increased from 50% before service to 74.3% during the service. Even in control group, the draftees without mental disorder, the number of draftees with no or low willingness to serve increased from 22.4% before service to 50.7% during t service. In addition, adjustment disorders in the study group were more severe than in the control group in terms of higher rates of suicidal ideation, plans, attempted suicide, and homicidal ideation. The percentage of draftees with no or low willingness to serve in Penghu and the risk of AWOL during military service were also significantly different between the study group and the control group. Most families (60.5%) blamed the military for the onset of mental disorders in the draftees, while only 13.8% did not. This showed that most families had little knowledge or information about the fact that most mental disorders are multi-factorial in etiology and the pressures of t military life may be only partially responsible for draftee illnesses. Most family members hoped that the patients could be referred back to Taiwan for more comprehensive diagnosis and more advanced treatment. They did not think that the patients could get enough support from the medical service on Penghu Island. Because this was a high readiness zone, commanders of military units were usually reluctant to refer these patients back to a general hospital in Taiwan for fear that they would be investigated by a superior officer for the cause of the mental disorder. Some family members complained that the psychiatric disorders must have shown some obvious signs before service and their child or brother should have been diagnosed and precluded from conscription. More psycho-education about this issue is needed by both the families and the draftees.
Major depressive disorder as an Axis I diagnosis in DSM-IV was the most prevalent mental disorder for the study group during their military service. A similar result was found in the US army. According to a report by the US Department of Defense (USDOD) in 1998, of 1138 new USAF recruits who had a psychiatric evaluation before receiving any training, 349 were discharged for mental disorders. Results of the evaluation indicated that depressive disorders were the most common problems. Other common diagnoses in descending order included adjustment disorder (20%), post-traumatic stress disorder (PSTD) (19%), alcohol abuse or dependence (5%), and attention-deficit/hyperactivity disorder (5%) [4
]. A study in Poland found that neurotic disorders were responsible for more than 50% of discharges from military service [5
A relatively high percentage of cases were suspended from service for DSM Axis II diagnoses, as 29 cases (19.1%) were diagnosed as personality disorders (primarily antisocial and/or borderline disorders). Data from another military population in the US also indicated that adjustment disorders and personality disorders were the most common military mental problems [6
]. Studies have shown that individuals suffering from these disorders find it more difficult to adjust to military life when they face special stresses [7
]. The characteristics of these personality disorders, such as a lack of guilt often create serious trouble for the individual and the unit [8
]. We can thus infer that adjustment disorders are very likely to occur in individuals suffering from personality disorders under the special situational stress of military life. As a result, the immature defense mechanisms and inappropriate personality traits of these individuals might be problematic for the military. This is particularly true on Penghu where draftees undoubtedly face harsher military training and suffer greater psychological stress that draftees in military zones elsewhere in Taiwan either in ordinary times or times of war readiness.
In Taiwan, draftees with an IQ below 85 on the WAIS-III-R standard IQ test or other evidences of limited intelligence such as poor performance, diminished learning ability, or poor daily life functioning as reported by family, superior officers or comrades may be considered for service suspension. In our study, 13 cases (8.6%) with borderline intellectual functioning (IQ between 70 and 84 on the WAIS-III-R) and 7 cases (4.6%) with mild mental retardation (IQ ranged from 50 or 55 and 69 on the WAIS-III-R) suspended their service after IQ testing, a review of their junior high school and elementary school academic records, and meticulous clinical observation. This study revealed that adjustment disorders were common co-morbid conditions found in all 20 draftees applying for service suspension because of insufficient intellectual functioning, just as they were in those individuals with personality disorders. The former may be the result of barriers in interpersonal skills and lack of social experience due to an inadequate ability to learn compounded by the stress of military life. In our study, it was surprising to find that 65.0% of those with impaired intellectual function (13 of 20) had completed senior high or senior high vocational school, one graduated from a 2-year senior college, and only 6 completed just junior high or elementary school. This suggests that comprehensive intelligence testing should be part of military recruiting.
Alcohol and drug abuse have long been major concerns for the USDOD. One report indicated that one out of 5 active US military personnel drank to excess [9
]. A similar study in the UK found that 67% of men and 49% of women in the regular UK Armed Forces were engaged in “hazardous drinking” [10
]. In our study, 27 draftees with service suspension had problems with alcohol and/or illicit drug abuse during their service. All but four of these had co-morbid personality disorders (data not shown). Of these, over 85% (23/27) already had a history of alcoholism and/or drug abuse before call-up; however, no intensive study on alcohol or drug abuse has been conducted on military personnel in Taiwan and neither alcohol nor drug addiction has been included as a reason for service suspension.
We found that the study group of conscripted soldiers who were suspended from service due to psychiatric disorders had significantly more psychiatric service utilization before conscription as 49.3% sought outpatient psychiatric treatment. Some individuals with psychiatric disorders, such as intellectual insufficiency, major depressive disorder, personality disorders, or schizophrenia must have shown obvious external signs, and should have been diagnosed and precluded from conscription in the selection process before entering the service. In addition, our study found that draftees with mental disorders based on both DSM Axis I and Axis II diagnoses during the service had a higher rate of suicidal ideation, plans, and attempts before service than did the control group. The rate of homicidal ideation before service in the study group was also higher than that in the control group. Those individuals with obvious symptoms should not be sent to a high-alert area, nor be allowed to enter military service. Conscription is the major source of troop strength in Taiwan so that the determination of service suspension for mental disorders is harsher than that in other countries. Although dysthymic disorder, depressive disorder not otherwise specified, alcohol abuse or dependency, and attention-deficit/hyperactivity disorder are psychiatric diagnoses not suitable for service according to the USAF [8
], none of these qualify for service suspension or retirement in Taiwan. Due to the special military environment and the military threats from Mainland China, draftees in Taiwan are unable to suspend their service for minor mental disorders. The USDOD surveys all recruits for a history of depression and suicide attempts [8
]. Young men called for military duty in Finland are subject to psychiatric evaluation [12
]. Another Finnish study indicated that screening for disadvantaged childhood living conditions, unemployment, financial problems, and homelessness as well as mental problems identified conscripts with a higher probability of service suspension [13
]. Such an approach should be considered in Taiwan. Better screening before conscription would avoid the waste of human resources, the costs of conscription, and the potential danger to these individuals and their fellow soldiers.
Some experimental rehabilitation programs are available in the UK and the USA [6
] Such non-hospital interventions established by the military can effectively reduce the “premature discharge rate” and help military personnel with mental disorders or suicide attempts regain their original social and role functioning. Currently in Taiwan, the military has established “rescue and rehabilitation centers” in some areas to accept and treat draftees suffering from minor mental disorders which are not severe enough for service suspension. Such a practice should be further encouraged in order to promote the mental health of those charged with being in the first line of defense to protect their country.
There are limitations to this study. We were unable to collect data concerning psychological status before military service (before the draft) because the confidentiality of medical records is protected by law in Taiwan, so we might not be able to conclude that mental disorder was the result of heightened tension and stress in a high military alert zone. We were also unable to obtain clinical histories from the families of draftees regarding prior psychiatric disorders. We could not obtain medical information about the draftees after discharge so there is no follow-up information.