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The War Inside

By this spring, the number of vets from Afghanistan and Iraq who had sought help for post-traumatic stress would fill four Army divisions, some 45,000 in all.

They occupy every rank, uniform and corner of the country. People such as Army Lt. Sylvia Blackwood, who was admitted to a locked-down psychiatric ward in Washington after trying to hide her distress for a year and a half [story, A13]; and Army Pfc. Joshua Calloway, who spent eight months at Walter Reed Army Medical Center and left barely changed from when he arrived from Iraq in handcuffs; and retired Marine Lance Cpl. Jim Roberts, who struggles to keep his sanity in suburban New York with the help of once-a-week therapy and a medicine cabinet full of prescription drugs; and the scores of Marines in California who were denied treatment for PTSD because the head psychiatrist on their base thought the diagnosis was overused.

They represent the first wave in what experts say is a coming deluge.

As many as one-quarter of all soldiers and Marines returning from Iraq are psychologically wounded, according to a recent American Psychological Association report. Twenty percent of the soldiers in Iraq screened positive for anxiety, depression and acute stress, an Army study found.

But numbers are only part of the problem. The Institute of Medicine reported last month that Veterans Affairs' methods for deciding compensation for PTSD and other emotional disorders had little basis in science and that the evaluation process varied greatly. And as they try to work their way through a confounding disability process, already-troubled vets enter a VA system that chronically loses records and sags with a backlog of 400,000 claims of all kinds.

The disability process has come to symbolize the bureaucratic confusion over PTSD. To qualify for compensation, troops and veterans are required to prove that they witnessed at least one traumatic event, such as the death of a fellow soldier or an attack from a roadside bomb, or IED. That standard has been used to deny thousands of claims. But many experts now say that debilitating stress can result from accumulated trauma as well as from one significant event.

In an interview, even VA's chief of mental health questioned whether the single-event standard is a valid way to measure PTSD. "One of the things I puzzle about is, what if someone hasn't been exposed to an IED but lives in dread of exposure to one for a month?" said Ira R. Katz, a psychiatrist. "According to the formal definition, they don't qualify."

The military is also battling a crisis in mental-health care. Licensed psychologists are leaving at a far faster rate than they are being replaced. Their ranks have dwindled from 450 to 350 in recent years. Many said they left because they could not handle the stress of facing such pained soldiers. Inexperienced counselors muddle through, using therapies better suited for alcoholics or marriage counseling.

A new report by the Defense Department's Mental Health Task Force says the problems are even deeper. Providers of mental-health care are "not sufficiently accessible" to service members and are inadequately trained, it says, and evidence-based treatments are not used. The task force recommends an overhaul of the military's mental-health system, according to a draft of the report.

Another report, commissioned by Defense Secretary Robert M. Gates in the wake of the Walter Reed outpatient scandal, found similar problems: "There is not a coordinated effort to provide the training required to identify and treat these non-visible injuries, nor adequate research in order to develop the required training and refine the treatment plans."

But the Army is unlikely to do more significant research anytime soon. "We are at war, and to do good research takes writing up grants, it takes placebo control trials, it takes control groups," said Col. Elspeth Ritchie, the Army's top psychiatrist. "I don't think that that's our primary mission."

In attempting to deal with increasing mental-health needs, the military regularly launches Web sites and promotes self-help guides for soldiers. Maj. Gen. Gale S. Pollock, the Army's acting surgeon general, believes that doubling the number of mental-health professionals and boosting the pay of psychiatrists would help.


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