A Flood of Troubled Soldiers Is in the Offing, Experts Predict
By Scott Shane
The New York Times
Thursday 16 December 2004
WA****NGTON - 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 re****t
symptoms
of major depression, serious anxiety or post-traumatic stress disorder, a
pro****tion 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 re****t in September on the
psychological toll of the war for the Center for American Progress, a
Wa****ngton 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 ****ps. By comparison with troops in Vietnam,
the officials said, soldiers in Iraq get far more mental health sup****t
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 re****t 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 sup****t 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 sup****t. 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 relation****ps 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 make****ft memorial services and filling in on
raids. He knew he was in trouble by the time he was on a ****p 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 trans****t
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 re****ts 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 re****t
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 re****t 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."
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