PTSD and Iraq

On Nov. 20, Congress added $1 billion to the Bush Administration's $27.1 billion VA health care budget for 2005. The amount fell $1.5 billion short of what was recommended by the House Veterans Affairs Committee. And while Congress earmarked an additional $15 million for PTSD, few think that money will make much difference. "The heads of the VA health care networks are all trying to figure out how the hell they're going to manage," says Rick Weidman, director of government relations for Vietnam Veterans of America.

As for the VA's mental health plan, for which an estimated $1.65 billion was needed to fully fix things, VA spokesperson Laurie Tranter says: "We cannot comment on this now. The plan is still being finalized."

But all the money and services in the world won't necessarily solve the PTSD conundrum.

In 1968, a young soldier named Lewis Puller came back from Vietnam without his legs and parts of his hands, which were blown off by a Viet Cong landmine. Puller, the son of the most decorated Marine in American history, soon became a veterans' rights advocate and later a Pentagon lawyer. He married a politician, fathered two children and, in 1991, wrote the Pulitzer-winning book, Fortunate Son: The Healing of a Vietnam Vet. Puller seemed to have overcome the physical wounds, depression and alcoholism that haunted him for years.

On May 11, 1994, 26 years after returning home, Puller shot himself. In the end, the Soldier's Heart hurt too much.

- "Haunted Vision: Thousands of Iraq War veterans will come home to face serious psychological problems and a system that may not be ready to help them.", Dan Frosch, Creative Loafing January, 2005

22 soldiers have committed suicide in Iraq, including 2 who committed suicide at Walter Reed Army Medical Center.

- NPR 1/22/04

A Flood of Troubled Soldiers Is in the Offing, Experts Predict


New York Times

WASHINGTON, Dec. 15, 2004 - The nation's hard-pressed health care system for veterans is facing a potential deluge of tens of thousands of soldiers returning from Iraq with serious mental health problems brought on by the stress and carnage of war, veterans' advocates and military doctors say.

An Army study shows that about one in six soldiers in Iraq report symptoms of major depression, serious anxiety or post-traumatic stress disorder, a proportion that some experts believe could eventually climb to one in three, the rate ultimately found in Vietnam veterans. Because about one million American troops have served so far in the conflicts in Iraq and Afghanistan, according to Pentagon figures, some experts predict that the number eventually requiring mental health treatment could exceed 100,000.

"There's a train coming that's packed with people who are going to need help for the next 35 years," said Stephen L. Robinson, a 20-year Army veteran who is now the executive director of the National Gulf War Resource Center, an advocacy group. Mr. Robinson wrote a report in September on the psychological toll of the war for the Center for American Progress, a Washington research group.

"I have a very strong sense that the mental health consequences are going to be the medical story of this war," said Dr. Stephen C. Joseph, who served as the assistant secretary of defense for health affairs from 1994 to 1997.

What was planned as a short and decisive intervention in Iraq has become a grueling counterinsurgency that has put American troops into sustained close-quarters combat on a scale not seen since the Vietnam War. Psychiatrists say the kind of fighting seen in the recent retaking of Falluja - spooky urban settings with unlimited hiding places; the impossibility of telling Iraqi friend from Iraqi foe; the knowledge that every stretch of road may conceal an explosive device - is tailored to produce the adrenaline-gone-haywire reactions that leave lasting emotional scars.

And in no recent conflict have so many soldiers faced such uncertainty about how long they will be deployed. Veterans say the repeated extensions of duty in Iraq are emotionally battering, even for the most stoical of warriors.

Military and Department of Veterans Affairs officials say most military personnel will survive the war without serious mental issues and note that the one million troops include many who have not participated in ground combat, including sailors on ships. By comparison with troops in Vietnam, the officials said, soldiers in Iraq get far more mental health support and are likely to return to a more understanding public.

But the duration and intensity of the war have doctors at veterans hospitals across the country worried about the coming caseload.

"We're seeing an increasing number of guys with classic post-traumatic stress symptoms," said Dr. Evan Kanter, a psychiatrist at the Puget Sound veterans hospital in Seattle. "We're all anxiously waiting for a flood that we expect is coming. And I feel stretched right now."

A September report by the Government Accountability Office found that officials at six of seven Veterans Affairs medical facilities surveyed said they "may not be able to meet" increased demand for treatment of post-traumatic stress disorder. Officers who served in Iraq say the unrelenting tension of the counterinsurgency will produce that demand.

"In the urban terrain, the enemy is everywhere, across the street, in that window, up that alley," said Paul Rieckhoff, who served as a platoon leader with the Florida Army National Guard for 10 months, going on hundreds of combat patrols around Baghdad. "It's a fishbowl. You never feel safe. You never relax."

In his platoon of 38 people, 8 were divorced while in Iraq or since they returned in February, Mr. Rieckhoff said. One man in his 120-person company killed himself after coming home.

"Too many guys are drinking," said Mr. Rieckhoff, who started the group Operation Truth to support the troops. "A lot have a hard time finding a job. I think the system is vastly under-prepared for the flood of mental health problems."

Capt. Tim Wilson, an Army chaplain serving outside Mosul, said he counseled 8 to 10 soldiers a week for combat stress. Captain Wilson said he was impressed with the resilience of his 700-strong battalion but added that fierce battles have produced turbulent emotions.

"There are usually two things they are dealing with," said Captain Wilson, a Southern Baptist from South Carolina. "Either being shot at and not wanting to get shot at again, or after shooting someone, asking, 'Did I commit murder?' or 'Is God going to forgive me?' or 'How am I going to be when I get home?' "

When all goes as it should, the life-saving medical services available to combat units like Captain Wilson's may actually swell the ranks of psychological casualties. Of wounded soldiers who are alive when medics arrive, 98 percent now survive, said Dr. Michael E. Kilpatrick, the Pentagon's deputy director of deployment health support. But they must come to terms not only with emotional scars but the literal scars of amputated limbs and disfiguring injuries.

Through the end of September, the Army had evacuated 885 troops from Iraq for psychiatric reasons, including some who had threatened or tried suicide. But those are only the most extreme cases. Often, the symptoms of post-traumatic stress disorder do not emerge until months after discharge.

"During the war, they don't have the leisure to focus on how they're feeling," said Sonja Batten, a psychologist at the Baltimore veterans hospital. "It's when they get back and find that their relationships are suffering and they can't hold down a job that they realize they have a problem."

Robert E. Brown was proud to be in the first wave of Marines invading Iraq last year. But Mr. Brown has also found himself in the first ranks of returning soldiers to be unhinged by what they experienced.

He served for six months as a Marine chaplain's assistant, counseling wounded soldiers, organizing makeshift memorial services and filling in on raids. He knew he was in trouble by the time he was on a ship home, when the sound of a hatch slamming would send him diving to the floor.

After he came home, he began drinking heavily and saw his marriage fall apart, Mr. Brown said. He was discharged and returned to his hometown, Peru, Ind., where he slept for two weeks in his Ford Explorer, surrounded by mementos of the war.

"I just couldn't stand to be with anybody," said Mr. Brown, 35, sitting at his father's kitchen table.

Dr. Batten started him on the road to recovery by giving his torment a name, an explanation and a treatment plan. But 18 months after leaving Iraq, he takes medication for depression and anxiety and returns in dreams to the horrors of his war nearly every night.

The scenes repeat in ghastly alternation, he says: the Iraqi girl, 3 or 4 years old, her skull torn open by a stray round; the Kuwaiti man imprisoned for 13 years by Saddam Hussein, cowering in madness and covered in waste; the young American soldier, desperate to escape the fighting, who sat in the latrine and fired his M-16 through his arm; the Iraqi missile speeding in as troops scramble in the dark for cover.

"That's the one that just stops my heart," said Mr. Brown. "I'm in my rack sleeping and there's a school bus full of explosives coming down at me and there's nowhere to go."

Such costs of war, personal and financial, are not revealed by official casualty counts. "People see the figure of 1,200 dead," said Dr. Kanter, of Seattle, referring to the number of Americans killed in Iraq. "Much more rarely do they see the number of seriously wounded. And almost never do they hear anything at all about the psychiatric casualties."

As of Wednesday 5,229 Americans have been seriously wounded in Iraq. Through July, nearly 31,000 veterans of Operation Iraqi Freedom had applied for disability benefits for injuries or psychological ailments, according to the Department Veterans Affairs.

Every war produces its medical signature, said Dr. Kenneth Craig Hyams, a former Navy physician now at the Department of Veterans Affairs. Soldiers came back from the Civil War with "irritable heart." In World War I there was "shell shock." World War II vets had "battle fatigue." The troubles of Vietnam veterans led to the codification of post-traumatic stress disorder.

In combat, the fight-or-flight reflex floods the body with adrenaline, permitting impressive feats of speed and endurance. But after spending weeks or months in this altered state, some soldiers cannot adjust to a peaceful setting. Like Mr. Brown, for whom a visit to a crowded bank at lunch became an ordeal, they display what doctors call "hypervigilance." They sit in restaurants with their backs to a wall; a car's backfire can transport them back to Baghdad.

To prevent such damage, the Army has deployed "combat stress control units" in Iraq to provide treatment quickly to soldiers suffering from emotional overload, keeping them close to the healing camaraderie of their unit.

"We've found through long experience that this is best treated with sleep, rest, food, showers and a clean uniform, if that is possible," said Dr. Thomas J. Burke, an Army psychiatrist who oversees mental health policy at the Department of Defense. "If they get counseling to tell them they are not crazy, they will often get better rapidly."

To detect signs of trouble, the Department of Defense gives soldiers pre-deployment and post-deployment health questionnaires. Seven of 17 questions to soldiers leaving Iraq seek signs of depression, anxiety and post-traumatic stress disorder.

But some reports suggest that such well-intentioned policies falter in the field. During his time as a platoon leader in Iraq, Mr. Rieckhoff said, he never saw a combat stress control unit. "I never heard of them until I came back," he said.

And the health screens have run up against an old enemy of military medicine: soldiers who cover up their symptoms. In July 2003, as Jeffrey Lucey, a Marine reservist from Belchertown, Mass., prepared to leave Iraq after six months as a truck driver, he at first intended to report traumatic memories of seeing corpses, his parents, Kevin and Joyce Lucey, said. But when a supervisor suggested that such candor might delay his return home, Mr. Lucey played down his problems.

At home, he spiraled downhill, haunted by what he had seen and began to have delusions about having killed unarmed Iraqis. In June, at 23, he hanged himself with a hose in the basement of the family home.

"Other marines have verified to us that it is a subtle understanding which exists that if you want to go home you do not report any problems," Mr. Lucey's parents wrote in an e-mail message. "Jeff's perception, which is shared by others, is that to seek help is to admit that you are weak."

Dr. Kilpatrick, of the Pentagon, acknowledges the problem, saying that National Guardsmen and Reservists in particular have shown an "abysmal" level of candor in the screenings. "We still have a long ways to go," he said. "The warrior ethos is that there are no imperfections."

Richard A. Oppel Jr. contributed reporting from Baghdad for this article.