Getting Inside their Heads

By Art Pine

A new study by the RAND Corporation estimates that some 18.5 percent of service members returning from Afghanistan and Iraq screen positive for PTSD or depression and says that 19.5 percent have experienced a major or minor traumatic brain injury-together affecting almost one-third of the two million who have been deployed to the war zones.

More broadly, a new study by physicians at the Veterans' Adminstration medical center in San Francisco, published in the September 2009 issue of the American Journal of Public Health, confirms that more than one-third of the veterans who entered the VA system after serving in Iraq and Afghanistan have been diagnosed with mental health problems. With psychosocial and behavioral disorders included, the figure topped 40 percent.

Linked to Deployments?

To many Americans the reason for the new surge seems obvious. With today's urban warfare and insurgencies, the intensity of the fighting is pronounced. And some troops have been re-deployed for two, three, or even four tours.

Critics contend that the stress produced by these deployments-both among the Soldiers and Marines who actually are in combat and among those outside the war zones, who must work harder and often longer to keep the rest of their services operating-has begun to take its toll. The current "dwell-time"-the period troops are permitted back in the States before they deploy again-is only a year.

"What you're really talking about is a stressed-out force," says Retired Air Force Lieutenant General Charles H. Roadman II, a former Surgeon General of the Air Force who has been an adviser to DOD on medical problems affecting troops who have served in combat zones. "This type of warfare is more stressful than what we're used to thinking about. You're actually in combat all day every day."

The impact is especially hard on Reserve and National Guard troops, who deploy and re-deploy frequently, disrupting their families and their civilian jobs, says David Segal, a military sociologist at the University of Maryland. "When active-duty troops come back, they have a support system on base," he says. Reservists and Guardsmen don't, and many face added economic pressure in a weak job market.

Although Defense officials say the increased psychological problems still haven't affected readiness, retention, or recruitment, the need for more recruits has led the services to lower their recruiting standards by providing "moral waivers" to youths who have landed in trouble with authorities and previously would have been deemed unfit for service.

A High Priority

The mental health problem has become acute enough that top military and civilian leaders now openly acknowledge it and have begun taking steps to deal with it. Defense Secretary Robert Gates says that "Other than winning the wars we are in, my highest priority is providing the best possible care for those who are wounded in combat"-including those suffering from psychological and behavioral problems.

The services say they are beginning to screen more of the troops returning from Afghanistan and Iraq. All four branches have set up programs designed to detect psychological and behavioral problems sooner and begin treating them early on. They've established "warrior transition" units to provide injured service members treatment and support.

They also are moving to permit troops more dwell-time between deployments to help them adjust more fully to stateside life-and take a rest from their combat tensions-before they have to go back to the war zone. In some cases, Soldiers or Marines have had barely a few months before having to return to combat-not enough, psychologists say, to make an adequate adjustment.

In a potentially far-reaching step, DOD has established six Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury that will draw on military, VA, and civilian efforts to study and treat psychological disorders. The Army has just launched a $50 million study on suicide and mental health-the largest the military has ever undertaken-that is expected to delve into the causes of the current problems and how to treat them.

Both the Army and the Marine Corps, which have borne the brunt of the past eight years' combat, have set up special programs to help returning personnel who exhibit psychological and behavior problems. And the Marine Corps has agreed to give personnel accused of minor infractions routine psychological exams-to test for stress-related problems-before sending them to non-judicial punishment.

Meanwhile, Congress has begun providing more money for mental health services in the military, voting an extra $900 million two years ago to help strengthen DOD resources, and it is in the process of appropriating still more. With Pentagon encouragement, the number of nonprofit groups set up to provide help and counseling for troops with PTSD, TBI, and other mental health problems has increased sharply.

Dealing with the Stigma

Just as important, after years of ignoring the problem, top military leaders have finally begun taking serious steps to reduce the stigma that has inhibited soldiers from admitting their mental health problems and going in for treatment. The service chiefs have pressed commanders to encourage troops to seek early help. Some senior officers have begun stepping forward and admitting publicly that they suffer from PTSD.

In a major step toward reducing such stigma, DOD this year removed a question on applications for security clearances that asked whether the service member had sought mental health care in the past seven years. Admiral Mike Mullen, Chairman of the Joint Chiefs of Staff, has set up a new Office of Warriors and Families that allows members of the military and their families to get help for mental health problems.

And the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury have launched a Real Warriors Campaign to combat the stigma problem. The agency maintains a 24-hour call center-and a separate suicide hotline-to provide confidential help and advice. The program operates in all four branches of the service. The VA also has a suicide hotline.

Military psychiatrists and outside mental health specialists say that although the stigma problem still hasn't been solved, they've begun to see some improvement in the willingness of troops to admit that they have problems and to feel confident enough that they won't be punished or drummed out of the military for seeking help.

Army Brigadier General Loree Sutton, a psychiatrist who is director of the Defense Centers of Excellence, says DOD surveys over the years show the stigma factor waning, with visible declines in recent years in the number of troops saying they feared that seeking help would harm their careers or cause unit members to have less confidence in them. "We're on a journey," she says.

"I've actually felt that change," says Dr. James Kelly, a concussion expert and a former University of Colorado neurologist who heads the new National Intrepid Center of Excellence, one of the six DOD centers. He says the goal is to get all service members to pursue treatment for mental illnesses as readily as they do when they have physical injuries.

Shortage of Care-Givers

One major difficulty is that the services don't have enough trained mental health personnel to deal with the surge of cases. Although the Pentagon moved quickly to deploy medical personnel to forward-deployed field hospitals at the start of both wars, it wasn't prepared for either the length of the deployments or the number of troops the two operations would require, says the University of Maryland's David Segal.

A Pentagon Task Force on Mental Health concluded in 2007 that the military's "current complement of mental health professionals is woefully inadequate." And House legislation introduced last year reported that approximately 40 percent of the billets for licensed clinical psychologists in the Army are vacant, and other mental health professions, including psychiatry and clinical social work, also report shortages.

Moreover, Iraq and Afghanistan Veterans of America (IAVA), a New York-based veterans' advocacy group, says mental health support for troops in Iraq actually is declining, with the ratio of behavioral health workers to troops in those combat zones falling to one for every 734 in 2007, from one for every 387 in 2004. And getting a referral to a psychiatrist or psychologist in the Army or Marine Corps takes far longer than it should.

The services have been pushing to expand their medical staffs, but there still are shortages in some categories. DOD figures show that in 2008 the services had 308 psychiatrists on active duty-about 4.5 percent fewer than authorized-and 584 psychologists, or about 14 percent under strength. And the authorizations themselves don't necessarily reflect actual needs.

The RAND study, published in 2008, reported that only 53 percent of the service members who need treatment for PTSD, TBI, and major depression actually end up seeking help. And only a little more than half of those treated get "minimally adequate" care by accepted medical standards.

A new Army survey, reported by USA Today, shows that 26 of the Army's 39 medical centers, hospitals, and clinics aren't able to meet the Pentagon standard requiring that 90 percent of patients get routine-care appointments (for either physical and mental problems) within seven days. The report said 16 percent of patients, particularly family members, ended up going to physicians off base.

Not everyone shares the conviction that DOD is doing a good job in responding to the surge in mental health problems. Paul Sullivan, executive director of Veterans for Common Sense (VCS), a Washington-based advocacy group, gives military planners high marks for providing for well-equipped field hospitals in Iraq, but says they "fell down in not providing for enough to care for those who come home."

Sullivan says the shortage of physicians and mental health specialists has prevented the Pentagon from complying with the 1997 Force Protection Act, which requires the military to provide face-to-face psychological exams for troops both before they are deployed and immediately after they return. That procedure would help identify mental health problems sooner and pave the way for early treatment, he argues.

The Pentagon says troops already are screened for mental health problems, but the procedure primarily involves self-identification-that is, asking the troops themselves to report their mental health problems-rather than requiring the service member to undergo a person-to-person interview by a psychologist and get immediate referral for treatment.

Sullivan also questions how effective the services have been in reducing the aforementioned stigma. "From my recent experience in talking with troops at several bases, the officers who tell you that the stigma has waned are reading too many of their own memos," he says. "Soldiers and Marines still are very reluctant to raise their hands in public and request mental health care."

Both VCS and IAVA have urged Congress to increase the number of mental health professionals and begin providing mandatory face-to-face psychological examinations for troops before they leave for combat zones and when they return.

Mixed Statistics

One difficulty in quantifying the mental health problem is that no DOD-wide metric measures the incidence of individual difficulties. The Pentagon keeps broad statistics on PTSD and TBI cases, but figures for other categories are scattered among the four services, are frequently inconsistent, and are available only for the past three or four years, leaving no way to compare today's numbers to those of earlier wars.

The numbers that are available seem mixed. Army statistics show the number of cases of PTSD rose to 9,500 in 2008, up from 2,921 in 2004. The number of TBI cases rose to 1,127 in 2008, up from 506 in 2004. (The figures show 2,591 TBI cases for 2007.)

Similarly, the number of suicides among Soldiers jumped from 67 in 2004 to 140 in 2008, a record high that for the first time propelled the suicide rate for the military higher than that for the civilian population. And the proportion of drug positives climbed to 2.38 percent from 1.72 percent in 2004. All of that is consistent with the widespread impression that mental health problems in the military are increasing.

Behavioral problems of service members also have affected children of military families. The Associated Press reported earlier this year that internal Pentagon documents show that the children of U.S. troops sought mental health help some two million times in 2008, double the total since the start of the Iraq war in 2003. Between 2007 and 2008, the number of children actually hospitalized for mental problems rose by 20 percent.

However, not all categories show a worsening trend, according to official figures. The incidence of spousal abuse fell to 4.1 per 1,000 service members in 2008, a decline from 5.4 per 1,000 four years before. The number of divorces dropped slightly to 16,421 in 2008, from a peak of 17,233 in 2004, but last year's figure was still higher than the total for 2003, which was 14,936.

The Defense Department is expected to provide more detailed figures in its 2008 survey of health-related behavior among active-duty personnel, but hasn't made it public yet, saying it still is in the review process. The survey depends on self-reporting by service members on active duty.

Evidence vs. Assumption

Despite the adverse statistics-and the widely held popular view that the rise in military mental health problems stems from the past eight years' deployments-that linkage isn't fully accepted by military psychiatrists. The view among many is that although the connection seems to make sense and the rise clearly occurred after the wars in Afghanistan and Iraq began, there still are no scientific data to prove a cause-and-effect relationship.

Psychiatrists point out that while many of those who are deployed come home with PTSD, TBI, or other psychological or behavioral problems, many return without any such effects-even those who have had several tours in Iraq or Afghanistan. At the same time, some who have never been deployed end up suffering from psychological or behavioral disorders. With some categories, such as suicide, the issue is even more complex.

Comparisons with civilians also are difficult, psychiatrists say, because conditions are different and there often aren't parallel statistics to measure the two groups properly. Indeed, some service members enter the military with problems, such as depression, that they bring from civilian life. And many civilians encounter PTSD, TBI, and other behavioral problems without being in the military.

Then, too, psychiatrists say, the incidence of some psychological conditions is lower in the military than in the civilian population because while civilians often have scant support at home or at their workplaces, service members are part of units that often look after them and have a stake in their well-being. (Suicide rates are a conspicuous exception: the rate for the Army surpassed the civilian rate in 2007.)

"There can't be any question that being in a war zone exacerbates whatever underlying issues someone brings into the war zone," says Dr. Gregory Poland, former head of the Armed Force's Epidemiological Board and now a professor at the School of Medicine at the Mayo Clinic. "The question is, how-and to what degree? We haven't pinned that down adequately."

Medical personnel say they understand why outsiders are incredulous about this psychiatric view. "If I were a layman, I would say the same thing," says Dr. Charles Fogelman, chairman of the subcommittee on psychological health of the Defense Health Board, a volunteer advisory committee to DOD. "All I can say is that those of us who are professionals argue about it," he says.

General Sutton of the Defense Centers of Excellence argues that in some cases surviving a trauma can actually make a service member emotionally stronger and better able to cope with future adversity. "People who have had some heavy-duty experiences [in civilian life] often have learned from them and grown from them," she says. "Why shouldn't that also hold for guys in the theater?"

General Sutton says one of the centers' major goals will be to help train service members to build their resilience to traumatic situations so they can handle them more smoothly. The Army is conducting resilience training and soon will launch a training program in October aimed at teaching all Soldiers to cope with combat-related stress.

After the Fort Carson killings, a 27-member task force comprising physicians, psychiatrists, psychologists, social workers, legal specialists, and a chaplain interviewed most of the parties involved, correlated its findings with the military records of the accused Soldiers and with those of some 20,000 others on base, and issued a 126-page report filled with supporting data and tables.

Although the survey didn't blame the slayings on the fact that the accused Soldiers had been deployed in a combat zone, it reaffirmed the findings of previous studies that troops who had been exposed to combat appeared to have experienced higher levels of behavioral problems than those who had not.

And it said the investigation "suggests a possible association between increasing levels of combat exposure and risk for negative behavioral outcomes"-in other words, that serving in a war zone increases the likelihood that some will emerge with mental health problems. It also declared that the stigma problem "remains a key barrier" to service members' seeking treatment.

While some Army officials caution that the document involves only Fort Carson and does not necessarily apply to other bases, the conclusions seem to parallel those of broader studies conducted by the Walter Reed Army Medical Research Institute and RAND.

Indeed, over the past few years, the Walter Reed research unit has reported that the prevalence of PTSD, major depression, and alcohol abuse was significantly higher among Soldiers after they returned from deployment than before they left. It also has noted that Soldiers and Marines who served in Iraq, and thus experienced more firefights, were more likely to have PTSD than Afghanistan veterans.

Treatment Is Improving

Uncertainty about cause and effect doesn't mean that the services can't treat psychological and behavioral problems. Even the most severe critics concede that the military has improved markedly in handling such cases. Many consider the armed forces to be the cutting edge in identification and treatment of such illnesses, and, more recently, a pioneer in efforts to reduce the problem of stigma, which infects the civilian world as well.

Dr. Robert Ursano, who heads the psychiatry department at the Uniformed Services University of the Health Sciences, says one of the key tasks confronting military medicine over the next few months is to survey the plethora of mental health programs that have been established in recent years, weed out those that are overlapping or aren't working, and then build up those that are producing results. "It's adaptive design," he says. "As soon as information is obtained, we will feed that back to the military so they will implement it."

But the efforts have only begun to expand. "Our challenge at this point is to do a full-court press on the medical front," General Sutton says-and to do it as rapidly as possible.

"Time is not our friend," she warns.

Mr. Pine, a former naval officer, is a veteran journalist who has worked as a Washington correspondent for the Baltimore Sun, Washington Post, Wall Street Journal, and Los Angeles Times.

Mr. Pine, a former naval officer and veteran reporter, covered military affairs for the Los Angeles Times

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