Clinic Shootings Highlight Mental Health Challenges for Military

Army leaders, alarmed by recent trends -- particularly a rise in suicides -- are working to provide training and care aimed at bolstering soldiers' resilience and preventing those who become distraught from harming themselves or others. But a slew of programs, including mandatory "Battlemind" training and a suicide-prevention campaign, have blunted but not reversed the decline in the Army's mental well-being.

Since 2001, nearly 1 million soldiers have deployed to Iraq and Afghanistan, and more than 300,000 of them have served multiple combat rotations, most lasting 12 to 15 months. Currently there are 160,000 soldiers in those war zones, and of those, nearly 30,000 are on at least their third or fourth tour, Pentagon data show.

An estimated 20 percent of service members return from the wars psychologically damaged, with depression or symptoms of post-traumatic stress disorder such as nightmares, hyper-vigilance and emotional numbing, according to a Rand Corp. study last year.

Adding to the stress is that, once home, soldiers know they have only a year -- much of it filled with combat drills -- before they must head back to Iraq or Afghanistan. "With only 12 months back at home, some people chose not to reconnect with their families," Gen. Peter W. Chiarelli, vice chief of staff of the Army, said in an interview. "It's too hard. They chose not to reintegrate."

Particularly at risk from rotations are enlisted soldiers -- from privates to staff sergeants -- who have few opportunities to serve outside of the combat units that go back and forth onto the battlefield.

The unprecedented strain on the all-volunteer Army is not expected to end anytime soon, largely because of the troop increases in Afghanistan, Chiarelli said.

"The next six to eight months is going to be very difficult for us," he said, estimating that the Army will not be able to begin increasing soldiers' time at home until the middle or fall of 2010. Demands on the Army are so high that 87 percent of the active-duty force is either deployed overseas, preparing to deploy, or in basic training or otherwise not available.

A 2007 Army survey of soldiers in Iraq and Afghanistan showed that soldiers' mental health deteriorates significantly each time they go to war. More than 27 percent of the noncommissioned officers surveyed on their third or fourth deployment reported depression, anxiety or acute stress -- compared with 18 percent of those on their second deployment and 11 percent on their first tour, according to Army data.

Psychological problems, work-related stress and plans to separate or divorce also increase with each additional month deployed, the survey found. Meanwhile, suicide rates for deployed soldiers were elevated, compared with historical norms, and the majority coincided with relationship problems.

Overall, the Army's suicide rate reached a record level in 2008, surpassing 20 percent and exceeding that for the U.S. population, when adjusted demographically. The number of soldiers on active duty who took their own lives rose steadily from 79 in 2003 to at least 128 last year. The increase continued during the first four months of 2009, when 64 soldiers on active duty were suspected of killing themselves, with about half the cases under investigation.

Although many soldiers are suffering mental trauma from deployments, only about half of them are seeking help, because of a fear of being stigmatized or the inaccessibility of care providers.

"Stigma is an issue we've got to continue to attack," Chiarelli said, noting that he recently discovered that a well-intentioned noncommissioned officer required soldiers at risk for suicide to wear orange road-guard vests.

In Afghanistan in particular, soldiers have reported difficulty getting mental health care, a problem exacerbated by a strategy that requires them to serve in remote outposts in rugged terrain.

To address such problems, the Army has expanded treatment and mental heath assessments as well as prevention efforts. It is hiring hundreds of additional mental health workers and stepping up immediate care in combat zones. Soldiers are now screened twice for psychological problems -- once upon returning home and again three to six months later.

The Army is also planning to test a program within the next two months that aims to overcome the shortage of mental health providers near Army posts, as well as stigma issues, by making it mandatory for all returning soldiers to undergo an online interview with a mental health worker via Web cameras, Chiarelli said.

In an effort to prevent the mental strains, the Army is conducting resilience training known as "Battlemind" throughout its ranks and during different phases of deployment. "Battlemind" is an unprecedented effort to toughen soldiers psychologically for war, said Richard Keller, who leads the program at the Walter Reed Army Institute of Research in Silver Spring.

"We show them what the deployment experience can be like, what things you might see, smell, think, feel, hear -- all the sensory inputs . . . so they are not taken by surprise," Keller said.

"Some people have a tendency when an event takes place to catastrophize it, and make it appear more intense or difficult than it actually is," he said, so the training seeks to reinforce constructive reactions to combat and life-threatening situations.

The 2007 Army mental health survey showed that soldiers who had received the training were less likely to report symptoms of combat stress, and anecdotal evidence also indicates that it is having an impact. Last weekend, for example, Keller said, he was conducting training for an Army Reserve unit in Wisconsin that had recently returned from Iraq. After a session, he said, a soldier told him he had been considering suicide for six months and asked for help.

Army officials note that in Baghdad, Russell, who has been charged with murder, had been forced to seek mental health care. "As horrible as this case is with Sergeant Russell, he was getting help. His chain of command realized he needed help," Chiarelli said.

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