Iraq War soldiers mental health...

December 16, 2004

http://www.nytimes.com/2004/12/16/national/16stress.html?oref=login & hp

December 16, 2004

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

By SCOTT SHANE

WASHINGTON, Dec. 15 - 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 L. , a 20-year Army veteran who

is now the executive director of the National Gulf War Resource Center, an

advocacy group. Mr. 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. C. ph, 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 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 , an Army chaplain serving outside Mosul, said he counseled

8 to 10 soldiers a week for combat stress. Captain 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 , 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 's may actually swell the ranks of

psychological casualties. Of wounded soldiers who are alive when medics

arrive, 98 percent now survive, said Dr. 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. "

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. 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.

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

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, 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. "

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

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December 16, 2004