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Soldiers should be treated fairly when they return home from war.

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Soldiers have problems after returning home from combat. 

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Soldiers have problems after returning home from combat. 

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HAVERHILLL, Mass. -- Before her life fell apart, before suicide began to sound like sweet release, Natasha Young was a tough and spirited and proud Marine.

Straight off the hardscrabble streets of Lawrence, Mass., a ruined mill town ravaged by poverty and drugs, she loved the Marine Corps' discipline, the hard work, the camaraderie, the honor of service to her country.

She went to war twice, the last time five years ago in western Iraq with a close-knit team of Marines who disabled IEDs, roadside bombs. It was nonstop work, dangerous, highly stressful and exhausting. Six of the Marines were killed in bomb blasts, each death a staggering gut-punch to the others. After they returned home the commander took his own life. Staff Sgt. Young broke down, too, spent physically, emotionally and mentally. Eventually, she was diagnosed with post traumatic stress disorder (PTSD) and, last October, was medically discharged from the Corps.

Having been a strong warrior, now she simply couldn't function. "I was ashamed of myself," she says in a whisper at her home in Haverhill, Mass.

Young is one of a generation of 2.4 million Americans who fought in Iraq or Afghanistan, many of whom are coming back profoundly changed by what combat veteran and author Karl Marlantes described as the "soul-battering experience" of war.

The shock of war, of course, is hardly new. But now the cascade of combat veterans from the Iraq and Afghanistan wars is forcing mental health practitioners to a new recognition: the effects of combat trauma extend far beyond the traditional and narrow clinical diagnoses of PTSD and traumatic brain injury (TBI). The current crop of veterans is at risk of a "downward spiral" that leads to depression, substance abuse and sometimes suicide, as Eric Shinseki, secretary of the Department of Veterans Affairs, said in a recent speech.

Almost a quarter million Iraq or Afghanistan vets have been diagnosed with mental health injuries from combat service. Many more are not diagnosed, yet go on with their lives while experiencing short-term memory loss, headaches, insomnia, anger or numbness -- conditions that can range from merely annoying to highly disruptive on the job and within the family. For some of them, hard work can temporarily mask these symptoms. But only temporarily.

"You can work through it [with therapy], or become a workaholic," says Tom Berger, who still suffers nightmares from his time as a medical corpsman with the 3rd Marine Division during bloody Vietnam fighting in the late 1960s. "Left untreated, you reinforce the trauma, so it makes sense to keep that loaded .357 [revolver] next to you on the car seat," adds Berger, who is a senior adviser on veterans health at Vietnam Veterans of America.

Those who go to war, it turns out, carry the traumatic after-effects longer and deeper than previously recognized - perhaps for a lifetime.

At the Army medical center at Fort Gordon, Ga., Dr. John L. Rigg, director of the Traumatic Brain Injury Program, is treating active-duty soldiers complaining of headaches, mood swings, anger, insomnia, and memory loss as many as five years after they experienced concussive blasts in combat. They're still functioning, but they're struggling. "They're not getting better," says Rigg. "In fact, they may be getting worse."

With treatment, says Rigg, some can learn to manage.

"No one gets out unscathed," says Col. Katherine Platoni, a senior Army combat trauma psychologist with two battlefield tours in Iraq and Afghanistan who has seen and felt the deepening effects of combat trauma.

Large-scale U.S. military action is finished in Iraq and scheduled to wind down in Afghanistan. In those places, as President Obama has noted, "the tide of war is receding."

But at home, the tide of war is not receding for millions of veterans returning to a long, difficult and often dangerous transition back into civilian life, struggling to reconcile their searing combat experiences with a civilian society that largely disconnected itself from military service and now, according to polls, tired of war.

Like others leaving the ranks, Natasha Young's struggles with her psychological and emotional storms were compounded by the sudden decompression from the intensity of combat service. No one back home in the civilian world understood what she had gone through, or what she was going through.

"Out here," she says, "you realize how different you are from people who haven't served."
STRUGGLING WITH PTSD
Other veterans are encountering the same void that envelops Young.

How to explain to a civilian the fierce pride a warrior feels in having mustered the stamina, the professional skill and the courage to complete a second or third combat tour, in a war that seems to have no point and no end, where the enemy is frustratingly elusive but the blood and death are real and immediate?

How to explain why a combat veteran feels anxious in crowds, startles at the pop of a toy balloon, wrenches awake with night terrors?

How to express the rage and sorrow of survivor's guilt - that a medical corpsman couldn't save a wounded buddy, that a squad leader didn't bring all his guys home safe?

How to share the agony of a Marine platoon leader who is severely injured and medevaced after an IED blast kills two of his men and abruptly removes him from the men he had vowed to protect?

Outside the Marine Corps, severed from others with the same experiences, Young unravelled. She was 31, a single mom, and sick. Her Harley gathered dust in the garage. She stopped writing poetry. "I couldn't cope," she says. "I felt so scared.

"I think my son kept me from clicking off 'safe' more times than I'd care to admit," she confides, referring to the temptation to turn off her weapon's safety mechanism and end her life.

Such combat trauma wounds are largely invisible -- but the numbers are arresting. Roughly 2,413,000 young Americans have served in the Iraq or Afghanistan war, so far.

More than 600,000 of them may be struggling with PTSD and major depression. The Department of Veterans Affairs (VA) has formally diagnosed 207,161 Iraq and Afghanistan war veterans with PTSD. But experts believe many more are affected because of shortcomings and defects in screening and diagnosis.

A recent study by the RAND Corp., a Pentagon-funded think tank, suggested how many undiagnosed veterans there might be. It estimated that some 14 percent -- or about 337,820 -- of post-9/11 veterans suffer from the headaches, sleeplessness, irritability, depression, rage and other symptoms of PTSD, whether or not they are formally diagnosed. An additional 14 percent suffer from major depression. The VA's National Center for PTSD confirmed the numbers as accurate.

In addition, some 40,000 veterans of Iraq and Afghanistan have been diagnosed with traumatic brain injury they received in combat. The condition involves a bruising of the brain caused by concussion or other head injury, according to the Defense and Veterans Brain Injury Center. Many more veterans may be suffering without diagnosis or treatment, experts say. (Overall, the Defense Department has diagnosed 233,000 individual cases of TBI since 2000, the vast majority caused by training injuries or vehicle accidents, not combat.)

Head wounds were considered fatal until the 20th century and the arrival of better and faster medical care. As with PTSD, the diagnosis and treatment of TBI have improved significantly during the past decade.

Still, in a chilling reminder of war's long-term effects, the VA reported that last year it treated 476,515 veterans for PTSD -- most of them veterans of the Vietnam war almost 50 years ago. Tragically, the Vietnam generation of vets didn't have access to the kinds of services now available through the VA.

While the Greek historian Herodotus mentioned the trauma of war 25 centuries ago in his account of the battle of Marathon, it wasn't until 1980 that American psychiatry formally recognized and named the condition, describing PTSD as an injury caused by an outside stimulus rather than by an internal human weakness. More effective forms of treatment followed slowly.

Today, with rising veterans' demands for mental health services, the VA is making a determined and costly effort to reach those who live in remote areas or who may be unaware of VA services. It has launched 70 mobile outreach vans to cruise the streets of cities and towns across the country. It's also expanding its secure teleconferencing facilities and expects this year to provide 200,000 mental health consultations with veterans who lack easy access to its outpatient clinics or outreach vans. Since 2009, the VA's mental health budget has increased 39 percent to almost $6 billion this year, and its mental health staff has grown by 41 percent.

Diagnosed or not, all veterans are eligible for mental health services. But the VA cannot require them to come in, as VA officials are quick to point out.

The pernicious effects of combat trauma are not confined to mental health issues, though. New research findings indicate that veterans who have PTSD are more vulnerable in their later years to diabetes, cardiovascular disease. One study of VA patients found that those with PTSD were twice as likely to develop dementia as veterans without PTSD.

"It's a lifetime sentence," said Rick Weidman, a combat medic with the Americal Division in Vietnam who still struggles with post-traumatic stress.

Some cut that lifetime short. More than 2,500 active-duty military personnel have committed suicide since 2001, according to Defense Department reports. So far this year, active-duty troops have taken their own lives at a rate of almost one per day.

Many more make the attempt. In its most recent analysis, the Pentagon reported that in 2010, 863 active-duty service men and women had attempted suicide; most, 60 percent, were under the age of 25. National Guard soldiers and reservists have an equally high suicide rate. Last year, 118 Army soldiers killed themselves while not on active duty, a number almost certainly under-reported.

Among veterans -- those who have left military service entirely -- the lure of suicide appears even stronger. The national veterans suicide crisis line (800-273-8255), operated by the VA, gets an average of 17,000 calls a day. The VA believes the suicide rate for all U.S. veterans is more than 500 per month.

Most of those who committed suicide had struggled alone and never got help. The VA's Shinseki said recently that perhaps two out of three veterans who commit suicide were not enrolled in the VA's health care system. Nor had they ever been diagnosed. "The majority," the Pentagon reported, "did not have a known history of a behavioral health disorder" or treatment.

"We have underestimated the human costs of war, not just for the victims but for the warriors as well," said Dr. David Spiegel, a neuropsychiatrist and director of Stanford University's Center on Stress and Health. "War is an unnatural experience. It doesn't surprise me that a substantial number of people are impaired."
"I BELIEVE IN YOU"
The striking fact about today's epidemic of war trauma is that it affects a self-selected population of Americans who have already demonstrated courage, grit and resolve by volunteering to serve in wartime.

Take Natasha Young. She grew up in a bleak neighborhood with a wandering, crack-addict father and a single mom on welfare who struggled with drugs. Natasha was a good student but got into her fair share of trouble.

When she was 17, she met a Marine Corps recruiter and her life changed.

"He represented everything I wanted for my life," she says. "He said we expect you to work hard, show up on time, be a good human being, service to others, pay your bills, don't drink and drive, don't do drugs -- all the things I would want for my child."

What had been a dead-end future for her suddenly opened up with a steady paycheck, honorable work, perhaps even college.

"It was the first time in my young adult life someone said, 'I think you can do this, I believe in you,'" she recalls. "For the first time in my life, someone said to me, 'I see more in you than you ever saw in yourself.' That really resonated with me because I wanted to make somebody proud, I wanted to be better than the opportunities I had at the time. I wanted to be great ... I knew I was capable of it."

She excelled in boot camp, won promotion after promotion. She was deployed to Okinawa when a call came from home: her mother was unable to care for her 6-year-old son and was giving Natasha custody. Natasha was 19 years old. She scraped together money for a plane ticket and flew home on emergency leave to complete the paperwork.

Just before she was scheduled to fly back to Okinawa, her father was beaten to death in a bar fight. Natasha was next of kin. The Marines extended her emergency leave so she could arrange the funeral. The Marine Corps League and the American Legion chipped in to replace her non-refundable plane ticket back to Okinawa. Family and friends looked after her brother until her overseas tour was over.

By the time she was assigned to the 2nd Explosive Ordnance Disposal (EOD) Company, at Camp LeJeune, N.C., the Marines had become her real family. In the year before she flew to Iraq, she got to know the EOD guys, their wives, their children. Facing the terrible risks of unstable explosives, they trained exhaustively and partied hard and grew emotionally close and tight -- no secrets.

They arrived in western Iraq in 2007 to find a bloody terror of fighting, with an escalation of booby-trapped IEDs detonated by cellphones and garage-door openers. The blasts were erupting beneath soldiers and Marines, causing horrific injuries and death. That year, 764 Americans were killed in Iraq, mostly by IEDs.

Frantic calls to the bomb disposal teams, spread out over al-Anbar Province, came in every hour of every day of every week. Natasha was on the road making sure each team had the gear and supplies it needed. In a single day, April 27, the team lost two Marines, Sgt. Bill Callahan, 28, who left a wife and a 3-week-old son, and Sgt. Peter Woodall, 25, who was married with a 3-year-old son.

Amid the carnage, Natasha went numb. It was her job to gather the dead Marines' personal effects, make sure letters got written home to the families and that nothing got sent home with blood on it "because of the biohazard."

What was that like for her? Tears welled in her eyes as she felt again the shock and grief that she had stuffed deep inside five years ago. "At the time ... I just ... functioned," she says. "I'd make a pot of coffee because I knew we'd be up for two or three days."

Such enormous stress is the heart of war trauma -- including PTSD and TBI -- that causes physiological or neuro-chemical changes in the functioning of the brain, according to Rigg, the TBI director at Fort Gordon.

Many of the symptoms of post-traumatic stress -- nervousness, insomnia, anxiety in crowds, jumping at a sudden loud noise -- are primitive, involuntary instincts necessary to survival in a combat zone.

"I don't use the term 'post-traumatic stress disorder' because I don't consider it a disorder," Rigg says. "I mean, you're in a situation where people are trying to kill you!"

When the instinctive, unthinking part of the brain, the amygdala, senses danger, it reacts instantly with a flood of stress hormones that raise blood pressure and heart rate, dilate the eyes to sharpen sight, and squirt adrenalin into the bloodstream -- the hyper-arousal that prepares the body for "fight or flight."

That's appropriate in combat. But back home, the brain may misinterpret danger signals: all strangers are not the enemy; trash along the Interstate probably doesn't contain an IED; an explosion may be harmless fireworks, a bad dream may be just that.

Doesn't matter: the amygdala still pumps out a flood of stress hormones that make the veteran uncomfortable and jittery, wide awake at night, anxious and prone to flashes of anger. This is a neuro-chemical mechanism, Rigg explains. And it's involuntary: "People don't decide -- 'Hey! I want to be stressed today.' No -- it's the way we are wired."

Traumatic brain injuries usually involve a concussion that bruises the frontal lobes of the brain and can cause confusion, temporary amnesia, and a range of other symptoms similar to PTSD -- insomnia, irritability, anxiety or depression, headaches, memory loss -- in large part because many TBI patients also have PTSD.

"Basically, the brain's not working right," says Dr. James Kelly, a neurologist and director of the Defense Department's National Intrepid Center of Excellence for traumatic brain injury and psychological health.

"You can help people compensate and get better in some ways," Kelly says. But in severe cases, in which sophisticated computerized tomography (CT) scans or magnetic resonance imaging (MRI) may detect damage to the frontal lobe or to tissue deep inside the brain, patients don't recover fully, "typically not back to where they were before, ever, with that kind of injury."

How common are such deep-brain injuries? "We don't know," Kelly says. Not every combat soldier receives a CT or MRI scan. "And the problem is if you don't scan everybody, you don't have a good way of knowing that."

Recent experience has shown that even CT scans in military emergency rooms in Afghanistan may not detect microscopic damage to brain tissue, he said.

Detected or not, both forms of combat trauma can cause sexual dysfunction, adding to emotional distress and marital tensions, veterans say.

"The levels of shame and embarrassment are pretty stark for us," said Ben Tupper, an Army major who came back from Afghanistan with "a raging case" of PTSD -- and erectile dysfunction. "I eventually mustered up the courage to deal with it," he said, and wrote about it for the online magazine Slate.
ANGRY WITH GOD
Current treatment for PTSD and TBI consists in part of teaching patients to manage stress.

At Fort Gordon, Rigg puts soldiers with mild traumatic brain injury through an intensive, three-week "functional recovery" program focused on coping strategies that include deep breathing, yoga, massage, meditation and mind-body relaxation exercises using bio-feedback. Deep breathing actually slows the cascade of stress hormones that trigger the "fight or flight" reflex. Massage eases tense muscles that cause headaches.

Rigg doesn't prescribe drugs, which are often used elsewhere to dull the reactions of PTSD patients. "Medication doesn't fix this stuff," Rigg says. "It only relieves some of the symptoms."

For patients with TBI, treatment is similar: "Our job is to help people find coping strategies, tolerate their limitations," says Kelly. "The idea of getting better, in the sense of recovering back to who you were, is not commonly a reality for them."

For a lot of veterans, he adds, "simply pointing out how they survived this long, with all the things that have happened to them -- they have internal resilience they weren't even aware of." In many cases, he says, veterans "go on to really succeed in ways they hadn't anticipated."

Talking individually or in groups with a trained therapist can help a patient recall traumatic events with less emotion. Advanced techniques, such as cognitive behavioral therapy and exposure therapy, can help patients understand and cope with the sounds, smells, sights or memories that trigger stress reactions.

Through exposure to virtual reality programs, troops relive combat, a technique that has been shown to significantly desensitize them to the trauma they experienced and to minimize the hyper-arousal caused by the release of stress hormones.

But many therapists find such cookie-cutter approaches unworkable, says Platoni, the Army combat trauma psychologist and co-editor of a forthcoming book, " War Trauma and Its Wake." Her book explores the broader impact of combat experience, which she believes includes issues of self-identity, alienation, disillusionment with the U.S. government and its leaders, and damage to religious and spiritual beliefs, or "moral injury."

That term is a hot button for many Vietnam vets.

"A lot of guys come back angry with God -- how could the God we understood and were raised to believe in let this war stuff go on?" says Weidman, who served with the Americal Division. "We witnessed and participated in so much horror, that was in such violence with the value structure in which we were raised. It's a miracle people come back as together as they are. The whole concept of spiritual or moral pain goes beyond traditional psychotherapy."

What worked for Natasha Young was talk, work, medication and a dog. She found a sympathetic counselor at the VA outpatient clinic in Lowell, Mass. "They believed in me," says Young, "and they remind me that I'm human, that it's okay to have bad days and good days, that there are things I can't control."

Through a veterans service organization, The Mission Continues, she was awarded a 26-week fellowship that pays her to work with veterans at the Northeast Outreach Center, which offers food, shelter, counseling and other services to New England veterans. "I like being around other veterans; a lot of them don't have anybody else, and I get that," she says.

Another non-profit organization, Patriot Rovers, provided her with a service dog, a yellow lab named Josh, who helps remind her to take her medication and guards her own personal space in crowds. She takes medication to help her sleep.

As she began to heal, Natasha enrolled in full-time coursework at Northern Essex Community College for an associates degree in counseling and social work; a four-year college is next.

"My dream job is to work for the VA, with women suffering from military sexual trauma," she said.

In September 2011, she married Robert Alicea, a young man she's known since childhood and who has remained a close friend through all her trials.

"He's persistent, I'll say that for him," she says. And Natasha's mom has fought off her addictions and accepted her son back into her legal custody.

The trauma still lurks, however, and Young, like so many veterans, keeps on the path with a frenetic work schedule: her full-time classes, her work at the veterans center, and caring for her son, who is now six. "I don't know how to relax any more,'' she admits.

Yet Young has no regrets about the trajectory of her life.

"Knowing my mistakes ... I wouldn't change anything," she says. "My deployments, my failures, I wouldn't change any of it."

When a visitor remarks that her future looks pretty good, she pauses to reflect.

"I'm hoping. I have had a couple of bad patches but I'm back on track. Failure is not an option for me."

For more features like this, download our new weekly magazine, Huffington.

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The War Within: Battling The Ravages Of Combat Trauma

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HAVERHILLL, Mass. -- Before her life fell apart, before suicide began to sound like sweet release, Natasha Young was a tough and spirited and proud Marine. Straight off the hardscrabble streets of Lawrence, Mass., a ruined mill town ravaged by poverty and drugs, she loved the Marine Corps' discipline, the hard work, the camaraderie, the honor of service to her country.

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Providing all soldiers a desirable life after returning home and to allow soldiers to get back on their feet and return to their old lives.

When soldiers commit their lives to protecting the country they deserve to achieve a desirable  life when the return home from combat.

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Soldiers deal with depression after returning home from war. Even currently they are dealing with these problems.

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Soldiers deal with depression after returning home from war. Even currently they are dealing with these problems.

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November 15, 2007 - More soldiers returning from the war in Iraq show signs of mental health problems such as depression and posttraumatic stress disorder (PTSD) 6 months after their tour of duty vs immediately after coming home, according to a new study appearing in the November 14 issue of the Journal of the American Medical Association.

The study is an analysis of the first 88,235 soldiers from the same deployment (56,350 active and 31,885 National Guard and Reserve soldiers) to have completed 2 separate screenings: the Post-Deployment Health Assessment (PDHA) immediately on their return from the war and the Post-Deployment Health Re-Assessment (PDHRA) at a median of 6 months later.

During the screenings, the soldiers, mostly men with a mean age of approximately 30 years, completed self-report questionnaires that probed alcohol use, depression, and other mental health problems. A clinician asked questions pertaining to aggression and suicide and conducted a brief interview. The soldiers completed the second screen between June 1, 2005, and December 31, 2006.

Concerns about interpersonal conflict increased 4-fold between the 2 screenings. In active soldiers, it increased from 3.5% to 14.0%; in reservists, it increased from 4.2% to 21.1%. Inflated expectations may partially explain some of this increase, said Charles S. Milliken, MD, from the Division of Psychiatry and Neuroscience at Walter Reed Army Institute of Research in Silver Spring, Maryland, and corresponding author for the study. "Soldiers may think, 'there may have been some problems in the relationship (with my wife) while I was deployed; now that I'm home things are going to be better'."

As well, a depressed soldier may withdraw from his spouse. "Even with the best relationships, your partner may give you some space for a period of time but after awhile it takes its toll," said Dr. Milliken. The same applies to PTSD; if soldiers are irritable and snap at their kids, "again, that may be okay for a while but eventually it takes a toll," he said. Drinking alcohol to excess could make the situation even worse, he added.

Referral to, and use of, alcohol services was dramatically lower vs other mental health-related concerns, according to the survey. Of the active soldiers, 6669 (11.8%) endorsed alcohol misuse, 134 (0.2%) were referred, and of these, only 29 were seen within 90 days. This low referral and follow-up rate may be partly because of lack of confidentiality, said Dr. Milliken.

Other mental health problems also increased substantially between the 2 screenings. These included PTSD (active soldiers, 11.8% - 16.7%; reservists, 12.7% - 24.5%), depression (active, 4.7% - 10.3%; reserve, 3.8% - 13.0%), and overall mental health risk (active, 17.0% - 27.1%; reserve, 17.5% - 35.5%).

It is not clear why the first screen failed to capture some of these problems, Dr. Milliken said, but it might be related to the timing of that first analysis. Soldiers had just returned from combat and were still optimistic that things were going to get better. Although they might have lost a buddy in Iraq, for example, it may only be when they are back home that they have time to really think about it, he said. Basically, some of these mental health problems may "take awhile to brew," said Dr. Milliken.

Although soldiers were much more likely to report symptoms of PTSD on the follow-up survey, approximately half of the soldiers who did show signs of PTSD or depression on the first screen improved by the second screen, even without treatment.

The screening process itself may contribute to this improvement by helping to erase the stigma attached to accessing mental health services, said Dr. Milliken. It gives clinicians an opportunity to remind solders that problems such as depression and PTSD are not uncommon in the military, and that stress is normal. In addition, the screening process brings services to the soldiers without waiting for the soldiers to seek help. "Young males just don't tend to go get mental health care," said Dr. Milliken.

The study also reflects the military's readiness to research mental health in the postdeployment period. "One of the things that is exciting about this study is how willing the army is to look at itself, to do studies like this," said Dr. Milliken. "We've never studied mental health in the middle of a war like this."

The military is also keen to set up programs that prevent full-blown mental health problems, said Dr. Milliken. "These are not people with PTSD, they are having early PTSD symptoms. The whole idea is that we're trying to catch them before they become full-fledged diagnoses."

The research was funded by an intramural program of the US Army Medical Research and Material Command, Fort Dietrick, Maryland. One of the researchers has obtained funding. The other researchers have disclosed no relevant financial relationships.

JAMA. 2007;298:2141-2148.

Clinical Context

The US Department of Defense uses a PDHA to detect mental health problems among soldiers and Marines returning from Iraq and Afghanistan, but first screening is immediately on return. Mental health problems may occur several months later, so a PDHRA was added at 3 to 6 months after soldiers return from Iraq with high rates of combat exposure to examine the rate of mental health problems and to compare the rate among active component and reserve component veterans.

This is a population-based longitudinal descriptive cohort study conducted with use of the PDHA and PDHRA self-report questionnaires, which were followed by clinician interviews, from results entered into the soldiers' medical records and stored within the database of the Defense Medical Surveillance System. The authors noted that active soldiers receive continuing health benefits, whereas reservists receive insurance from TRICARE, which expires 6 months after deployment, and Veterans Affairs benefits, which expire 24 months after return to civilian status. This difference may affect the motivation of respondents to report mental health problems.

Study Highlights

This study included 88,235 soldiers who served in the Iraq war who had both PDHA and PDHRA completed from the same deployment.

The PDHRA was completed at a median of 6 months after return.

Both assessments included the following: 2-item depression screening from the Patient Health Questionnaire, 1 item for suicide screening, 4-item screening from the Primary Care PTSD Screen, 1 item on interpersonal aggressive ideation, and 1 question on interpersonal conflict.

The PDHRA added 2 items for alcohol use and asked about hospitalization during deployment and overall health, and categories for referral to the substance abuse program and employee assistance program counseling.

90.8% of the soldiers were men, 58.2% were married, and mean age was 30.4 years.

There were 56,350 active and 31,885 reserve soldiers.

Reserve and active soldiers reported similar rates of potentially traumatic combat experiences (69.6% vs 66.5%).

Hospitalization during deployment and overall mental health concerns were similar on the PDHA (17.5% and 17.0%).

Soldiers indicated more mental distress on the PDHRA vs the PDHA and were referred at higher rates.

Concerns about interpersonal conflict increased the most (active, 3.5% - 14%; reserve, 4.2% - 21.1%).

PTSD increased from 11.8% to 16.7% in active and 12.7% to 24.5% in reserve soldiers.

Depression increased from 4.7% to 10.3% in active and 3.8% to 13.0% in reserve soldiers.

Overall mental health risk increased from 17.0% to 27.1% in active and 17.5% to 35.5% in reserve soldiers.

At the time of the PDHRA, reserve soldiers reported substantially higher rates of interpersonal conflict, PTSD, depression, and overall mental health risk vs active soldiers (35.5% vs 27.1%; odds ratio [OR], 1.48; P < .01).

Reserve soldiers were also referred at a higher rate on the PDHRA vs the active soldiers (36.2% vs 14.7%; OR, 3.29; P < .001).

Clinicians identified 20.3% of active and 42.4% of reserve soldiers as needing referral.

4.4% were referred for mental health care on the PDHA and 11.7% on the PDHRA; only 1.1% were referred on both assessments.

Reserve soldiers reported more general health concerns (20.8% vs 16.5%; OR, 1.33; P <.001).

Reserve soldiers were referred at a higher rate for any health concern, including physical (55.1% vs 27.0%; OR, 3.32; P < .001).

Among 26,597 reserve and active soldiers who had a mental health risk on the PDHRA, 7.4% left the military service within the next 5 months vs 5.7% of 61,638 soldiers with no mental health risk (OR, 1.32; P < .001).

For active soldiers, use of mental health services increased substantially after the PDHRA within 30 days of assessment, and 74% who accessed mental health services had not been referred by a clinician.

This suggested that taking the PDHRA itself may have increased awareness of the need for mental health counseling.

Of active soldiers referred for mental health problems on the PDHA, 41.8% were seen within 90 days; for referrals after the PDHRA, 61.0% were seen within 90 days.

Of those who reported a high rate of PTSD symptoms on the PDHA, 49.4% of reserve and 59.2% of active soldiers reported improvement by the time of the PDHRA.

An inverse relationship was seen for receiving mental health services and improvement.

Of soldiers not referred for services, those who sought and received treatment were more likely to have mental health comorbidities (depression; OR, 1.69).

Pearls for Practice

For soldiers returning from the Iraq war, mental health concerns and referrals at 6 months after return are greater vs initial return for personal conflict, depression, PTSD, and overall mental health risk.

Compared with active soldiers, reserve soldiers at 6 months after return from deployment are likely to have a higher rate of clinician-initiated referral for mental health services, higher overall mental health risk, and higher rate of general concerns including physical health concerns.

CME/CE Test

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Depression, PTSD Worsen Several Months After Soldiers Return

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November 15, 2007 - More soldiers returning from the war in Iraq show signs of mental health problems such as depression and posttraumatic stress disorder (PTSD) 6 months after their tour of duty vs immediately after coming home, according to a new study appearing in the November 14 issue of the Journal of the American Medical Association.

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Soldiers go through depression when they feel they did something that they thought would help the country and now that they are home everyone is treating him differently.

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Soldiers go through depression when they feel they did something that they thought would help the country and now that they are home everyone is treating him differently.

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1. What do you feel will be most effective when they return home so that they will get back to their normal lives?
2. What do you feel that the soldiers should do when they first return home, see their families? or see more soldiers and people that they have been with?
3. What do you feel most affects soldiers when they were out in war?
4. How is this issue affecting soldiers around the world? Is this a worldwide problem or just an American Soldiers having this problem?

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Soldiers are always brothers out in the battlefield, we need to be their family and embrace them when they return home. 

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Soldiers are always brothers out in the battlefield, we need to be their family and embrace them when they return home. 

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No one said "thank you." My tour of duty in Vietnam ended in August of 1972. I flew back to my family in Maine; they were glad to see me, but not even they said "thank you" or "welcome home". Even if they had, I wouldn't have known how to respond.

Too many explosions, searching dead bodies for intelligence, hours of ennui and minutes of terror, lots of blood, holding the dying, all this and more had taken a toll. I also had shared inedible and incredible meals, slept in strange places, cursed at intransigent superiors, and laughed at death but never had time to cry for the dying.
Exhaustion and despair, expectation and exhilaration had been my duty companions for too long. Warriors returning from Iraq and Afghanistan are met with a heartfelt "welcome home" and sincere "thank you". That's much better than the hostility and indifference that marked my return and many of my colleagues. But I wonder if these men and women, like I was, are at a loss about how to respond to these one-sided statements.

These recent wars are so different: communications are vastly improved, more efficient, and disturbingly fast; weapons, vehicles of all sorts, and even rations have evolved; medical assistance and new technologies have saved lives but left individuals and families with terrifying challenges; multiple tours with prolonged separations are common.

Military leadership now recognizes that prolonged stress and trauma create "problems"; perhaps some day they will learn that pills and questionnaires while helpful are not solutions. It is hard for me with my Vietnam experience to talk with these recent warriors - the argot, the slang, of war has changed. When attempting to converse, I need a translator.

What has not changed over the centuries is the profaneness of war; the frustration of returning to a society preoccupied with mindless vicarious thrill seeking, enthralled by "reality" shows; the loneliness one feels even in the midst of a crowd; the terror of the unexpected sight or sound or smell; the rage so easily triggered; and the profound disquiet of the wounded soul.

From the highly varied, always dirty but brilliant hues coloring edgy life in the war zone to the drab, gray, sameness of existence at "home" is a transition hard to make; many never do. I was "lucky" - I survived the war, but at "home" my existence was sometimes touch and go.

Lessons learned in the war zone - detachment, vigilance, control, anger - were habits not compatible with "home". A Vet Center helped me come "home". The story of that journey of transformation is long, complicated and emotional. And that adventure continues. I'll talk about it to the few who ask. I'll risk sharing my story, but who will take the greater risk of listening without judgement, perhaps to learn of the sorrow of war? Many warriors of more recent conflicts are just starting their journey. To them I say: it is worth the pain and tears for the reward may be life and love. I have found it that way.

Over four decades have passed since "my" war. We old Vietnam vets greet each other with a knowing and wry "welcome home". People recognize us by our caps and T-shirts and small lapel pins, and some say "thank you for your service". Civilians see my canes and occasionally ask about them; and I tell them they're a "gift" from Vietnam. Often they reply "I'm sorry." It is all very nice. But these remarks can be terribly one-sided.

I am waiting for someone to say "Forgive me?" That question both admits complicity for what happened and initiates a conversation. I'd like to tell that person this: my friend, we share responsibility. I'm proud to have served my country, even if it meant going to Vietnam. I'm sinfully proud of having been both an enlisted man and an officer. I did my best in an untenable situation. But I wasn't prepared for the haunted eyes in the refugee camp, or the cries of the wounded, or the angry, wary stares of the villagers. Forgive us, yes, if that will ease your mind. But if you will stay and listen to the story, then together we may find salve for our wounded souls.

Thus begins the risky pathway of healing. Will you, beloved and fortunate citizen, do that duty for some returning warrior who has served our nation?
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Learning to come home from war: no one said 'thank you' to Vietnam vets | Alan Cutter

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No one said "thank you." My tour of duty in Vietnam ended in August of 1972. I flew back to my family in Maine; they were glad to see me, but not even they said "thank you" or "welcome home". Even if they had, I wouldn't have known how to respond.

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Soldiers are fighting not only for their family but for the whole country. 

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Soldiers are fighting not only for their family but for the whole country. 

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Soldiers lose many thoughts and feelings that they previously had before enduring the pain of war.

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Experts - When They Come Home... | The Soldier's Heart | FRONTLINE | PBS

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Just some simple education would just drop the level of confusion and tension all around. There are vet centers all over the country, and usually they're in the phone book under the heading vet center. The official name is the Readjustment Counseling Service of the VA.

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Soldiers may not be hurt when they return home physically but all are hurt in a way mentally. 

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Soldiers may not be hurt when they return home physically but all are hurt in a way mentally. 

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Effects of being in military. It will mentally and physically effect you. 

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Effects of being in military. It will mentally and physically effect you. 

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There is a statistic that has been widely quoted in the veteran community that highlights an estimated 22 veterans a day are committing suicide. It is a deeply troubling statistic and has galvanized the veteran movement, both from inside the military and veteran communities, and externally, to bring about a wide range of programming nationwide. The statistic, however, is widely misunderstood.

This figure - 22 veterans a day commit suicide - while widely touted by politicians, media outlets, veterans service organizations, among others, comes from the VA's 2012 Suicide Data Report, which analyzed the death certificates of 21 states from 1999 to 2011, and often is not provided within the right context. The report itself, as cited by the Washington Post earlier this year, warned, "It is recommended that the estimated number of veterans be interpreted with caution due to the use of data from a sample of states and existing evidence of uncertainty in veteran identifiers on U.S. death certificates." As an example, the average age of veteran suicides within the data set was nearly 60 years old, not representative of Iraq and Afghanistan veterans generation.

A more recent study, which surveyed 1.3 million veterans who were discharged between 2001 and 2007, found that "Between 2001 and 2009, there were 1650 deployed veterans and 7703 non-deployed veteran deaths. Of those, 351 were suicides among deployed veterans and 1517 were suicides among non-deployed veterans. That means over nine years, there was not quite one veteran suicide a day," according to the Washington Post.
Related: Iraq War Vet Derek Weida: 'We're Too Obsessed With This Number 22.' "
While veterans have a suicide rate 50% higher than those who did not serve in the military, the rate of suicide was, as the LA Times reported, "...slightly higher among veterans who never deployed to Afghanistan or Iraq, suggesting that the causes extend beyond the trauma of war."

Coming home from war, a six-month deployment on a ship, or simply transitioning from a life in uniform to a life without one, can be difficult and the various state and federal systems set up to deal with this transition and life after military services are unable to meet the need. That is not to say these programs - the Veterans Affairs entitlement and benefit programs like medical care, the G.I. Bill, the VA Home Loan, etc. - are not helpful; they are. But, for my generation of veterans from Operation Iraqi Freedom and Operation Enduring Freedom, our suicide rate is closer to one a day and most likely to occur in the first three years of return. While this this is still very troubling, it is not 22.

Still, there are further steps needed in bridging the gap created by those who serve and those who don't. Supporting integration back into families and communities requires robust public-private partnerships. The veterans, as well as the communities they live in, are both responsible for filling or bridging that gap, though not necessarily equally.

The challenges of adjustment and transition, post-traumatic stress, traumatic brain injuries, and physical disabilities, all need to be addressed especially as these things result in barriers to education, employment, health care, and overall individual well-being. Many of these needs are being met by a combination of different veteran-serving nonprofits and VA support. Unfortunately, there are still gaps in the system.

We in the veteran advocacy community need to tailor our programming, especially if we are in the business of preventing suicides, to respond to what we've learned from the data. One suicide is one suicide too many. Effective programming to help service members, veterans, and families transition to a positive life after service in their first three years home from service is a must.

Another requirement is fostering supportive community relationships for veterans, and really for all people, when life gets difficult as they surge past the age of 50. It also means that if we are serious about tackling the problem, we need to be creating, or rather shifting, programming specifically to address the needs of older veterans while maintaining preventative care for recently returned veterans.

As soldiers, sailors, airmen, and Marines, we all prided ourselves in uniform on not making the emotional decision, but the right decision. As veterans, we should have the same commitment and that means we need to act within the framework of facts - in advocacy and programming. Inadvertently, we're preying on a well-intentioned public by citing a misleading statistic to receive financial support and that's not right.

As veterans, we're far more resilient than we've given ourselves credit for. If we do our job now, and extend a helping hand to our brothers and sisters over 50, we can decrease that suicide rate, and ensure our generation avoids despair in the future.

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The Truth About 22 Veteran Suicides A Day

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Every soldier is affected when they are out in war. 

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Every soldier is affected when they are out in war. 

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Even so, the vast majority of recent veterans are not embittered or regretful. Considering everything they now know about war and military service, almost 90 percent would still have joined.

"What we did had a positive impact there," said Texas Army National Guard Sgt. David Moeller, who spent two year-long tours in Iraq. "I don't regret it. It's something I'd do over and over again."

Drawing upon detailed interviews with randomly selected war veterans across all military branches, including those still serving and those no longer in the military, the nationwide poll provides an unprecedented glimpse into the lives and attitudes of modern warriors - an undrafted, all-volunteer cadre, most of whom signed up in the wake of the Sept. 11, 2001, attacks. That force, drawn from nearly every county in the nation and often sent on multiple year-long combat tours, has included more than 280,000 women and thousands of 18-year-olds.

Although more than 6,800 U.S. service members were killed in Iraq and Afghanistan, advancements in body armor, transportation and battlefield medicine gave troops a better chance of coming home than any other generation of war fighters.

"They have come back to a nation that has embraced them - warmly, strongly, positively - and put tremendous value and appreciation into their service," Defense Secretary Chuck Hagel said in an interview. "That is so important."

Many are thriving - they are attending college, paid in full by the post-9/11 G.I. Bill; they are finding employers who covet their leadership skills and work ethic; they are receiving the medical attention they need. But the poll also found that hundreds of thousands of others feel they have been left behind on an uncharted postwar landscape, fighting for benefits, struggling to land a job, wrestling with psychological demons unleashed by combat or coping with shattered families.

Their responses reveal nuanced views of their lives, their service and their treatment by the government. Almost three in four believe the average American appreciates their service, but fewer - only 52 percent - like talking about their wartime experiences with casual acquaintances or strangers. Nearly 90 percent performed actions in Iraq or Afghanistan that made them feel proud, yet only 35 percent believe both wars were worth fighting.

"I don't find that to be in any way a contradiction of data," Army Gen. Martin E. Dempsey, the chairman of the Joint Chiefs of Staff, said in an interview. "I think that this aspect of service, and being true and trustworthy to the man or woman on your left or right, is probably what mostly drives the 90 percent figure. They're proud of what they did. They believe they did their job, and potentially the elected governments of Iraq and Afghanistan didn't do theirs."

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After the Wars: A legacy of pain and pride

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Even so, the vast majority of recent veterans are not embittered or regretful. Considering everything they now know about war and military service, almost 90 percent would still have joined. "What we did had a positive impact there," said Texas Army National Guard Sgt. David Moeller, who spent two year-long tours in Iraq.

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When american soldiers return home they are able to return home to their family and loved ones. 

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When american soldiers return home they are able to return home to their family and loved ones. 

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Military goes and puts their lives out everyday the least we could do is gratify them when they return home. 

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Military goes and puts their lives out everyday the least we could do is gratify them when they return home. 