Treating War's Toll on the Mind
Thousands of soldiers have post-traumatic stress disorder. Will they get the help they need?

by Betsy Streisand
http://health.usnews.com

As they take their seats in the movie theater, Eric and Raquel Schrumpf could be any young couple out on a summer night in Southern California. No one notices as Schrumpf, 31, a former Marine sergeant who served in Iraq, scans the rows for moviegoers who may be wired with explosives under their jackets. No one pays attention as a man who appears to be Middle Eastern, wearing a long coat with bulging pockets, takes a seat in the same row as the Schrumpfs and Eric starts watching him intently. No one listens as Schrumpf instructs his wife to "get as low to the ground as you can if something happens." Then something does. Schrumpf hears metal jangling as the man reaches into his pocket. Convinced he is a suicide bomber about to strike, Schrumpf lunges at him. The man jerks away and his deadly weapon falls to the floor: a can of Coke.

Schrumpf has everyone's attention now, as he and his wife quickly leave the theater. The Schrumpfs can't even remember what movie they went to see. Not that it would have mattered. Eric Schrumpf had room for only one movie in his head, the one where he is in Iraq. Now, more than two years later, Schrumpf has a good job, a strong marriage, a couple of pets, and a life that looks startlingly like everyone else's in Orange County, Calif. But he is still never more than a sound, smell, or thought away from the war. He gets anxious in a crowd, has been known to dive for cover, even indoors, at the sound of a helicopter, reaches for nonexistent weapons to be used in nonexistent circumstances, and wakes up screaming from nightmares about burning bodies and rocket-propelled grenades. "I'll never be the same again," says Schrumpf, who as a weapons and tactics instructor with the 5th Marine Regiment was part of the initial push into southern Iraq in 2003. "The war will be part of my life and my family's life forever."

Reliving the war. Like thousands of soldiers who have returned from Iraq and Afghanistan, Schrumpf is suffering from post-traumatic stress disorder, a chronic condition whose symptoms include rage, depression, flashbacks, emotional numbness, and hypervigilance. It can be brought on by a single event, such as when a grenade landed next to Schrumpf, ticking off his death and then failing to explode. Or it can be the result of repeated exposure to trauma such as house-to-house firefights or the accidental killing of civilians. "Soldiers who are routinely exposed to the trauma of killing, maiming, and dying are much more likely to bring those problems home," says Army Col. Kathy Platoni, a clinical psychologist and leader of a combat stress-control unit that works with soldiers on the battlefield. At its most basic, PTSD is the inability to flip the switch from combat soldier to everyday citizen and to stop reliving the war at so high a frequency that it interferes with the ability to function.

The problem is as old as war itself. But this time, American soldiers have been assured by the government and the military that the solution will be different: Iraq will be nothing like Vietnam, with its legacy of psychologically scarred veterans whose problems went unrecognized, undiagnosed, and untreated. "The hallmark of this war is going to be psychological injury," says Stephen Robinson, a Gulf War vet and director of government relations for Veterans for America in Washington, D.C. "We have learned the lessons of Vietnam, but now they have to be implemented."

Since the war began, the departments of Defense and Veterans Affairs have stepped up efforts to address the mental health needs of soldiers before, during, and after they are deployed. And more effective treatments for PTSD have been developed. But as the war drags on, the psychological costs are mounting and so is the tab for mental health care. Troop shortages are driving already traumatized soldiers back into combat for three and sometimes four tours of duty. Those who make it home often feel too stigmatized to ask for treatment lest they jeopardize their military careers. And if they do ask, they often can't get the care they need when they need it.

In addition, there are concerns among veterans groups that the Bush administration is trying to reduce the runaway cost of the war by holding down the number of PTSD cases diagnosed (and benefits paid), and that the promise to protect the mental health of nearly 1.5 million troops is not being kept. "Throughout this war, everything has been underestimated-the insurgency, the body armor, the cost, and the number of troops," says Paul Rieckhoff, an Iraq war vet and founder of Iraq and Afghanistan Veterans of America in New York. "Now, the psychological problems and the needs of these soldiers are being underestimated, too."

Just how many troops will bring the war home with them is impossible to know at this point. But the numbers could be substantial. In a study published in 2004 in the New England Journal of Medicine, researchers at the Walter Reed Army Institute of Research found that nearly 17 percent of soldiers who have returned from Iraq, or nearly 1 in 6, showed signs of major depression, generalized anxiety, or PTSD. A report in the Journal of the American Medical Association earlier this year found that 1 in 5 soldiers met the risk for concern. And those numbers are virtually certain to grow as the war enters its fourth year. "I do think we're going to see a whole lot more PTSD as time goes on," says Platoni.

The VA, short of doctors, therapists, and staff in some areas, is straining to meet the mental health needs of the troops who have already returned from Iraq and Afghanistan. Soldiers often wait weeks or even months to see a psychiatrist or psychologist. A 2004 study by the Government Accountability Office found that six of the seven VA medical facilities it visited "may not be able to meet" increased demand for PTSD. "I don't think anybody can say with certainty whether we are prepared to meet the problem because we don't know what the scope is yet," says Matthew Friedman, a psychiatrist and executive director of the VA's National Center for PTSD in White River Junction, Vt. "What we do know is that the greater the exposure to trauma, the greater the chance that someone will have PTSD."

Danger zone. There may be no war better designed to produce combat stress and trauma. Operation Iraqi Freedom is a round-the-clock, unrelenting danger zone. There are no front lines, it's impossible to identify the enemy, and everything from a paper bag to a baby carriage is a potential bomb. Soldiers are targets 24-7, whether they are running combat missions or asleep in their bunks. "There is no moment of safety in Iraq," says Andrew Pomerantz, a psychiatrist and chief of the Mental Health and Behavioral Science Service at the VA Medical Center in White River Junction. "That's one of the things we're seeing in people when they come back-a feeling of an absolute lack of safety wherever they are."

Stories of vets who sleep with guns and knives and patrol the perimeters of their homes obsessively are as common as tales of valor. Marine Lt. Col. Michael Zacchea, 38, who trained Iraqi troops and was in about 100 firefights, knows that paranoia all too well. "Every time I get on the road," says Zacchea, who commutes from Long Island to Wall Street, "it's like I'm back in the streets of Baghdad in combat, driving and running gun battles, with people throwing grenades at me." Zacchea, a reservist, is now being treated for PTSD at a VA hospital, but had it not been for chronic dysentery, migraines, and shrapnel wounds in his shoulder, he says he probably would have been redeployed in September, emotional scars and all.

And he still may be. The military's need to maintain troop strength in the face of historic recruiting lows means many service members, including some suffering from psychological problems like Zacchea, have no choice but to return. President Bush recently authorized the Marine Corps to call up inactive reservists, men and women who have already fulfilled their active-duty commitment. "They're having to go deep into the bench," says Robinson, "and deploy some people who shouldn't be deployed."

Multiple tours. Robinson is referring to the increasing number of reports of service members who stock antidepressants and sleeping pills alongside their shampoo, soap, and razor blades. The Defense Department does not track the number of soldiers on mental health medications or diagnosed with mental illnesses. But the military acknowledges that service members on medication who may be suffering from combat-induced psychological problems are being kept in combat. "We're not keeping people over there on heavy-duty drugs," says Army Surgeon General Kevin Kiley, who estimates that 4 to 5 percent of soldiers are taking medications, mostly sleeping pills. "Four to five percent of 150,000, that's still a lot of troops. But if it's got them handling things, I'm OK with that."

Handling things is a relative term. Army Pvt. Jason Sedotal, 21, a military policeman from Pierre Part, La., had been in Iraq six weeks in 2004 when he drove a humvee over a landmine. His sergeant, seated beside him, lost two legs and an arm in the explosion. Consumed by guilt and fear, Sedotal, who suffered only minor injuries, was diagnosed with PTSD when he returned from his first tour in early 2005 and given antidepressants and sleeping pills. Several months later, while stationed at Fort Polk, La., he sought more mental health care and was prescribed a different antidepressant

Last November, Sedotal was redeployed. "They told me I had to go back because my problem wasn't serious enough," Sedotal said in an interview from Baghdad in mid-September. Sedotal says he started "seeing things and having flashbacks." Twice a combat stress unit referred him to a hospital for mental health care. Twice he was returned to his unit, each time with more medication and the second time without his weapon. "I stopped running missions, and I was shunned by my immediate chain of command and my unit," says Sedotal, who returned to Fort Polk last week.

Cases like Sedotal's prompted Congress earlier this year to instruct the Department of Defense to create a Task Force on Mental Health to examine the state of mental health care for the military. It is expected to deliver a report to Secretary of Defense Donald Rumsfeld in May 2007 and make recommendations for everything from reducing the stigma surrounding disorders to helping families and children deal with the traumatized soldier.

Sending military members who suffer from PTSD back into combat goes straight to one of the toughest issues of the war: how to protect soldiers' mental health and still keep them fighting. It is well-established that repeated and prolonged exposure to combat stress is the single greatest risk factor in developing PTSD.

At the same time, there is tremendous resistance to sending home soldiers who are suffering from psychological wounds, in all but the most severe cases. "If a soldier has some PTSD symptoms," says Kiley, "we'll watch him and see how he does." The expectation "is that we're all in this boat together and we need to drive on to complete the mission," he says, adding that if the situation gets worse, the soldier would most likely be given a couple days of rest to see if he recovers. Once soldiers are evacuated, "they are much less likely to come back."

With that in mind, the DOD has designed a program to manage combat stress and identify mental health problems when they occur. It will include so-called battle-mind training for recruits, which focuses on the emotional fallout of seeing and contributing to the carnage of war and how to deal with it. Once they are in Iraq, there are psychologists and combat stress-control teams, such as Platoni's, who work side by side with troops to help them deal with their emotions and decompress immediately after battle. "Soldiers suffering from combat stress do better if they are treated early, efficiently, and as close to the battlefield as possible," says Col. Charles Hoge, chief of the Department of Psychiatry and Behavioral Sciences at Walter Reed Army Institute of Research.

Currently, there are more than 200 psychiatrists, therapists, social workers, and other mental health experts working with soldiers "in theater." They lend an ear, encourage soldiers to talk about their experiences with each other, and administer whatever short-term remedies they can, including stress-reduction techniques, anger-management strategies, or medications. However, their mission, first and foremost, is to be "force multipliers" who maintain troop strength. Their success is judged by their ability to keep soldiers from going home for psychological reasons. Soldiers are often their allies in this effort, as they feel such guilt and shame over abandoning their units they'll most likely say anything to keep from leaving. "It's a very sticky wicket," says Platoni. "We don't know if our interventions are enough to help them stay mentally healthy, or if they'll suffer more in the long term."

Last year, for instance, Platoni spent four months in Ar Ramadi, near Baghdad, where her battalion was under constant attack by insurgents. "They were watching their fellow soldiers burning to death and thinking they might be next," says Platoni. When a break came, one platoon was removed from combat for 48 hours so they could rest, shower, have a hot meal, and talk to psychologists about what they'd been through. "When they returned to the fighting," says Platoni, "they were able to deal with their fears better and focus on what needed to be done."

When soldiers do return home, the true emotional trauma of war is often just beginning. They go through a cursory post-deployment medical screening and a quick interview with a healthcare worker, who may or may not specialize in mental health. And returning soldiers are far more likely to downplay emotional problems for fear of being shifted from the "go home" line into the "further evaluation" line and being prevented from seeing families and friends.

Macho warrior. Three to six months after they return-the time when PTSD symptoms are the most likely to start becoming obvious-troops are given another mental health screening and may be referred for further evaluation, although the chances are slim. A GAO report issued in May, for instance, found that of the 5 percent of returning veterans between 2001 and 2004 who tested as being at risk for PTSD, fewer than one quarter were referred for further mental health evaluations. William Winkenwerder, assistant secretary of defense for health affairs, took issue with the study: "We're doing more than any military in history to identify, prevent, and treat mental health concerns among our troops. It is a top priority for us." Even with a referral, many veterans and active-duty soldiers will not seek help for fear of being stigmatized. To help break down the barriers, the DOD has begun encouraging high-ranking soldiers to openly discuss the effects that combat and killing can have on a person's psyche. Even so, the military remains dominated by the image of the macho warrior who sucks it up and drives on. According to the VA, the number of PTSD cases has doubled since 2000, to an all-time high of 260,000, but fewer than 40 percent of veterans from Iraq and Afghanistan have sought medical treatment. "This is the military culture," says Schrumpf, who now gets regular therapy and takes medication to help with his PTSD. "If it gets out that you even went to see the medical officer, and it always does, then you're done as a career marine."

In a surprising admission, former Georgia Sen. Max Cleland, who lost three limbs in Vietnam, announced in August that he is being treated for PTSD in the hopes of encouraging other vets to do the same. One of the biggest problems for Vietnam veterans, for instance, was that their psychological wounds went unrecognized and unattended for so long that, by the time they got treatment, many were past of the point of being helped. Cleland is one of a growing crowd of Vietnam vets who are finally seeking help-and competing for VA services-as a result of long-buried feelings stirred up by the Iraq war.

In the past few years, in part because of events such as September 11, there have been advances in therapies for PTSD. "Just because you have PTSD, it doesn't mean you can't be successful in daily life," says Harold Wain, chief of the psychiatry consultation and liaison service at Walter Reed Army Medical Center in Washington, D.C., the main Army hospital for amputees. Many of the patients Wain sees have suffered catastrophic injuries and must heal their bodies as well as their minds.

Reimagining the trauma again and again, or what's known as exposure therapy, has long been believed to be the most effective way of conquering PTSD. It is still popular and has been made even more effective by such tools as virtual reality. However, therapists are increasingly relying on cognitive behavior therapy or cognitive reframing, putting a new frame around a thought to shift the way a soldier interprets an event. A soldier who is racked with guilt because he couldn't save an injured buddy, for instance, may be redirected to concentrate on what he did do to help. Other approaches such as eye movement desensitization and reprocessing use hypnosis to help soldiers.

For some soldiers, simply talking about what happened to them can be therapy enough. When Zachary Scott-Singley returned from Iraq in 2005, he was haunted by the image of a 3-year-old boy who had been shot and killed accidentally by a fellow soldier. With a son of his own, Scott-Singley couldn't get the picture of the child and his wailing mother out of his head and became increasingly paranoid about his own child's safety. "I was constantly thinking about how people were going to attack me and take him," he says. Scott-Singley twice sought mental health care from the Army. The first time he says he was told that since he wasn't hurting anybody, he didn't have PTSD. The next counselor suggested he buy some stress-management tapes on the Internet and practice counting to 10 whenever he felt overwhelmed. (The VA is legally precluded from discussing a soldier's medical records.) Ironically, Scott-Singley found his therapy on the Web anyway, with his blog A Soldier's Thoughts (misoldierthoughts.blogspot.com). "It feels so much better to know I am not alone."

Outcry. Many veterans say they would also find it therapeutic to hear Bush acknowledge PTSD and the psychological costs of the war instead of downplaying them. Earlier this year, for instance, the Institute of Medicine was asked by Congress to re-evaluate the diagnostic criteria for PTSD, which was established by the American Psychiatric Association in 1980. Critics claim the review was ordered by the Bush administration in an effort to make it harder to diagnose PTSD, which would in turn reduce the amount of disability payments. The number of veterans from all wars receiving disability payments for PTSD, about 216,000 last year, has grown seven times as fast as the number receiving benefits for disabilities in general, at a cost of $4.6 billion a year. And that figure does not include most of the more than 100,000 Iraq and Afghanistan veterans who have sought mental health services. The IOM report, released in June, supported the current criteria for diagnosing PTSD.

Now the institute is looking at the accuracy of screening techniques and how to compensate and treat vets with PTSD, widely regarded as an easy condition to fake. And in another move that infuriated veterans groups, the VA late last year proposed a review of 72,000 cases of vets who were receiving full disability benefits for PTSD to look for fraud. The move prompted such an outcry that it was called off.

Studies and reviews aside, there isn't enough help available to veterans with PTSD. According to a report from the VA, individual veterans' visits to PTSD specialists dropped by 20 percent from 1995 to 2005-"a decrease in capacity at a time when the VA needs to reach out," the report stated. Secretary of Veterans Affairs James Nicholson says the VA sees 85 percent of new mental health patients within 30 days. "But that still leaves 15 percent and that's a big number. Could we do better? Yes."

Bush has called for a record $80.6 billion in the 2007 VA budget. That includes $3.2 billion for mental health services, a $339 million increase over this year's budget. However, those increases are being met by increasing demands for care, as well as rising cost-of-living allowances and prescription drug prices. "The bigger budget doesn't really add up to much," says Rieckhoff.

However frustrating and exhausting the process, most vets can avoid getting help only so long before friends and family push them into counseling or they get in trouble with the law. "It's almost like your family has its own form of PTSD just from being around you every day," says a former Army sergeant who worked as an interrogator in Iraq and asked that his name be withheld. "When I came back I was emotionally shut down and severely paranoid. My wife thought I was crazy and my son didn't realize who I was. Because of them, I got help."

Like many soldiers, he found it at one of more than 200 local Veterans Centers, which offer counseling for PTSD and sexual assault, a growing concern for women in the military. Vet Centers are part of the VA but operate like the anti-VA, free of the delays and bureaucracy. There is almost no paperwork, and the wait to see a counselor is rarely more than a week. It's no coincidence that when Doonesbury character B.D. finally went for help with his PTSD, he went to a Vet Center (story, Page 60). The centers are small and staffed mostly by vets, which creates the feel of a nurturing social environment rather than an institutional one. The free coffee is strictly decaf, and the approach is laid back. "Someone may come in asking about an insurance problem, and as we answer their questions, we ask them how are they feeling," says Karen Schoenfeld-Smith, a psychologist and team leader at the San Diego Vet Center, which sees a lot of Iraq vets from nearby Camp Pendleton. "That's how we get them into it." Many come just to talk to other vets.

It is that same need to talk that keeps Schrumpf E-mailing and phoning fellow marines and returning to Camp Pendleton every couple of weeks to hang out. "It is the only place I can talk about the killing," he says. Next month, Schrumpf will leave California for his home state of Tennessee, where he says it will be easier to raise a family. He's not worried about taking the war with him. In fact, in many ways he is more worried about leaving it behind. "The anger, the rage, and all that is just there," says Schrumpf. "And honestly, I don't want it to leave. It's like a security blanket." Or a movie, that just keeps on playing.

This story appears in the October 9, 2006 print edition of U.S. News & World Report.