New research and interviews with those familiar with the military health-care system suggest that attempts by Congress, the military and private contractors to address the problems have been uncoordinated and often ineffective. From September 2010 to August 2011, post-deployment health-reassessment screenings found that nearly 17 in every 100 returning reservists had mental health problems that were serious enough to require a follow-up. That is 55 percent more likely than active-component service members, according to the Armed Forces Health Surveillance Center.
Active-duty troops come home to military bases with free, comprehensive medical care and support networks that help diagnose what military leaders call the signature wounds of the wars that began after the attacks of Sept. 11, 2001: post-traumatic stress disorder and traumatic brain injury.
Reservists do not have access to the same system or networks that experts say are needed to assess and treat their injuries. After brief demobilization assessments, reserve troops return home and must navigate disparate health-care and support providers, often without the psychological safety net that comes from living near members of their unit.
“The National Guard faces unique challenges compared to our active-duty counterparts,” Gen. Craig R. McKinley, chief of the National Guard Bureau — which is responsible for administering the guard’s 54 state and territorial units — said at a public forum in November. He said the Obama administration is increasing its efforts to address resulting problems, including substance abuse, depression, PTSD and suicide.
Gen. Peter W. Chiarelli, who retired on Feb. 1 as Army vice chief of staff, also said efforts are underway to provide better care for reservists, especially because they are an integral part of the nation’s operational fighting force.
“A National Guard soldier . . . has anywhere from 10 to 14 days of demobilization training and processing, and then we throw them back into their community to work with folks who are part of the 99 percent who never fought,” Chiarelli said. These communities often can’t relate to their military experiences, he said, leading to job and family friction.
Reserve members and their advocates have raised concerns about the system of care and support since shortly after they were mobilized to fight overseas after the Sept. 11 attacks. But they say the consequences of inadequate post-deployment efforts persist.
The Army’s active component had a slight decline in suicides in 2010, while those in the reserve component rose by more than a third, to 122, with virtually unprecedented numbers through most of 2011, according to the Army. The actual number is probably higher, however, because the Army’s count does not include activated reservists who killed themselves.
In 2010, members of the Oregon National Guard’s 41st Brigade who were returning from Iraq for demobilization at Joint Base Lewis-McChord were shoved aside to “make room” for active-duty troops, sometimes without being treated for combat injuries, said Sen. Ron Wyden (D-Ore.).
After investigating, Wyden and a state lawmaker demanded that the secretary of the Army review what they described as second-class medical treatment.
“If you’re serving in the same foxhole, you ought to be able to come back to the same sort of benefits,” Wyden said.
Identifying red flags
At demobilization centers, reservists are inundated with forms, health assessments and presentations before going home, including a checklist to self-report potential mental health issues.
Andres Alvarez was pushed through that system several times while serving three tours in Iraq; one with the Kentucky National Guard and two with Tennessee.
On Aug. 25, 2005, during his second deployment, Alvarez’s vehicle struck an improvised explosive device, injuring him and resulting in PTSD and traumatic brain injury, he said. He went on to serve another tour, after the post-deployment screening process did not identify problems.
“There was stuff that should have raised flags,” he said.
Several years into the wars in Afghanistan and Iraq, the Defense Department realized that troops required follow-up checks months later, when combat trauma typically reveals itself. In 2005, the military added a subsequent checkup during the three- to six-month period following deployment.
When Alvarez returned from his third Iraq tour in late 2006, a medical review officer identified symptoms of PTSD and traumatic brain injury and refused to let him go home, instead sending him to an extended-care treatment facility. “He probably saved my life,” Alvarez said.
In 2008, the screening process was digitized and more questions were added to help identify PTSD and brain injury. The next year, spurred by the suicide of a young Montana guardsman, Congress mandated confidential one-on-one screenings with behavioral health professionals before deployment and in post-deployment reassessments.
At a November reintegration event in Bozeman, Mont., Capt. Russ Cunningham said the post-deployment process for all troops has improved greatly since his first tour, in 2003. “You almost feel like they’re trying to wrap you in bubble wrap. They want to do everything they can possibly think of to make sure that you get the physical, psychological, family help that you need.”
But the system still relies on self-reporting, even though studies have shown that troops often don’t know they have problems, or are reluctant to report them because they want to return home to their families and their jobs.
“You’re standing between me and the door, why am I going to tell you that there are any issues?” said Lt. Col. William Abb, deputy director of the Citizen Soldier Support Project, based in Chapel Hill, N.C.
A sea of Web sites
Steve Hale, a Washington National Guardsman sent to Iraq, said that reservists experience a brief honeymoon after returning from war, but that “the ticker-tape parades, the pats on the back, the free beers at the bar” often give way to loneliness, stress and depression. Reservists suffer from high rates of PTSD, alcoholism, unemployment, divorce and drug abuse, but military psychologists and research studies indicate that many cases go unreported.
Lack of emotional support is challenging for reservists, whose patched-together units often scatter between deployments.
Eric Kettenring, who served in Iraq and is a Veterans Affairs counselor in Montana, said the onus is on reserve unit commanders to watch for signs of trouble. But unlike active-duty units, their commanders only see them during drills, which can be 60 days apart, as opposed to the frequent contact during recruitment and enlistment.
“When they come back and they’re no longer serving and they have problems, who’s finding them?” he said.
In 2005, the National Defense Authorization Act established a health plan to give reservists access to the Tricare military health-care network for a monthly fee. But many wounded reservists instead choose to drive often long distances to Veterans Affairs facilities that provide free care from specialists.
The Pentagon has scrambled to close gaps in care by creating more than 200 programs, but that has invited waste, duplication and a lack of oversight, according to a recent Rand Corp. report.
Capt. Brian Pilgrim, a behavioral health officer with the New Mexico National Guard, praised the service network for reservists, saying it provides more options than the regimented system for the active-duty military.
But that range of options, many of them private-sector, often means reserve members are “thrown into a sea of Web sites with no idea of where to go to find appropriate care,” said Stephanie Nissen, North Carolina’s behavioral health programs director.
The issue is further complicated in the National Guard because each state is responsible for developing its own programs, and states are not required to adopt another’s successful strategies.
More changes to the post-deployment system were made last April. In response to Wyden’s investigation, the Army National Guard increased the time allotted for demobilization and required leaders to sign off on the disposition of each soldier.
In recent congressional testimony, McKinley praised the guard’s reform efforts. But he added: “We will have decades to go to make sure we do not leave any guardsman or woman behind.”
The reporters were members of the Medill National Security Reporting Project team, which spent three months looking at the challenges facing reserve forces. For more, go to hiddensurge.org.