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America's Wounded Soldiers: The Mental Toll

Susan Brink

(By Dan Gilgoff; Elizabeth Querna; Susan Brink; Angie Cannon; Nancy E. Shute; Marianne Szegedy-Maszak; Carol Susan Hook; Jennifer L. Jack; Nancy L. Bentrup; Allegra Moothart; Ann M. Wakefield; Jill Konieczko; Monica M. Ekman)

As an Army Ranger, Steve battled al Qaeda operatives along the Afghan-Pakistani border, faced down Afghan warlords, and braved the extreme conditions of the western Iraqi desert. So when he was discharged in August 2003, he figured the transition to civilian life would be, by comparison, a "bowl of cherries." But even after re-enrolling in college and finding a girlfriend, Steve, 31, says he felt emotionally detached. He was drinking and smoking pot constantly, and so hypervigilant he carried a pistol wherever he went. His family told him he was going nuts, but Steve didn't believe it--until he found himself burglarizing a home while wired on amphetamines.

With criminal charges pending, Steve--who asked that his last name be withheld--has spent the past five months in therapy for post-traumatic stress disorder and substance abuse at a Los Angeles Veterans Affairs hospital. "My fantasies were always pretty wild--kind of James Bond," he says. "Now, I'd just like to become an average person." As he pursues that goal, Steve worries that his Army buddies are also struggling with PTSD or substance abuse--and not seeking help: "I'm more concerned about the people coming out [of Iraq] than those staying."

Getting help. It's a fear shared by many mental-health experts, who warn that those returning from Afghanistan and Iraq are facing a host of service-related psychological problems--and may not be receiving proper treatment. A study published this summer by the Walter Reed Army Institute of Research found that up to 1 in 6 combat troops surveyed after serving in Iraq very likely had depression, generalized anxiety, or PTSD; of those, only 23 to 40 percent sought mental-health care.

The Iraq war is a minefield of psychological threats: guerrilla attacks, the uncertain distinction between safe zones and battle zones, the pervasive sense of an enemy around every corner. "For 24 hours a day, seven days a week, there's no place to hide," says retired Navy Cmdr. Dennis Reeves, a psychologist who was in Iraq last year as part of a combat stress team. "You keep one eye open when you sleep. . . . you go into battle, and less traumatic events become more traumatic." Another strain: house-to-house urban combat, a sharp departure from the Gulf War's long-range gambits. "The more intimate the combat," says Alfonso Batres, who heads the VA's National Office for Readjustment Counseling Services, "the greater the chance that soldier requires mental-health assistance." And it's not only combat troops who face traumatic situations. "People in military support jobs, like mechanics or those driving convoys, are now being attacked," says Matthew Friedman, executive director of the VA's National Center for Post-Traumatic Stress Disorder. "All of these things . . . create the anxiety and apprehensiveness that 'I might be next.' "

Combat stress control teams circulate through various Army divisions in Iraq, where officials estimate there is about one mental-health professional per 850 soldiers. But it is unclear how easily troops can gain access to their services. "Even if you're only a mile away you still have to get full support to travel," says Col. Jim Stokes, who oversees the combat stress program. And troops may avoid seeking help in the first place. "This culture encourages toughness," says Paul Rieckhoff, a former Army platoon leader and executive director of Operation Truth, an Iraq war vets group. "If you go [to seek help], you're going to be ridiculed and . . . may endanger your opportunity to be promoted." Though military officials deny that, Stokes says midlevel officers sometimes discourage soldiers from seeking help, fearing a troop shortage. A Marine program launched in Iraq last February, meanwhile, embeds mental-health teams with specific brigades and trains Marine leadership to administer lay therapy.

Coming home. While the efficacy of those battlefield programs is yet to be determined, the more critical mental-health need may involve the transition from the battlefield to civilian life. Post-deployment debriefings typically include information about mental-health services available through the VA and a health assessment questionnaire with questions intended to identify service members at risk for PTSD. But many vets report absorbing little of the information and even fudging responses to mental-health questions in an attempt to expedite their return. Says Batres: "The philosophy [at the debriefings] is pretty much, 'Don't let anything get in my way of getting home.' "

Still, the medical world's understanding of PTSD and services available to veterans facing mental disorders have seen enormous strides since Vietnam, when tens of thousands of vets descended into homelessness, often because of untreated PTSD and substance abuse. For veterans of Afghanistan and Iraq, the VA has established a 24-hour hotline that deals with readjustment issues, sent out hundred of thousands of letters with information about service-related mental illnesses, and hired 50 recent veterans to do outreach for vets trying to reintegrate into civilian society.

Those efforts appear to be paying off. In a 12-month period ending last September, 1 in 5 Iraq and Afghanistan vets who sought out care in VA hospitals--more than 6,000 people in all--was diagnosed with a mental illness, usually PTSD, depression, or a substance abuse problem. A Government Accountability Office report released in September questioned whether the VA can meet the increased demand for these services, however. And meanwhile, fear of stigma is most likely preventing many from seeking care. According to the Walter Reed study, troops whose survey responses suggested they had a mental disorder were twice as likely to be concerned about being stigmatized or about other barriers to care as those without mental disorders.

In addition, many experts say symptoms of PTSD may take months, even years, to surface; the free healthcare offered to Guard and Reserve troops deployed to Iraq and Afghanistan expires after two years. And part-timers are more likely to rely on private healthcare providers who are less familiar with service-related mental issues than are military or VA doctors. Indeed, some PTSD symptoms--aggressive behavior, for example--can be difficult even for vets to recognize, because they're common reactions to combat. "In order to function [in war] you kind of have to desensitize yourself. . . . [the troops] really have to flip some switches in order to operate," says Lt. Cmdr. Steven Unger, a chaplain who recently returned from a six-month tour in Iraq. The challenge now, for many vets, will be flipping those switches back.

Copyright 2004 U.S. News & World Report, L.P. Reprinted with permission.

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