America's war returnees: many troubles but more help

Nearly five years into the war in Iraq, the US Army has taken steps to improve the process by which it screens soldiers returning from war.

Many have trouble transitioning from combat dangers to a normal routine at home. But sometimes just identifying the problem is the issue.

The Army has improved its process by adding a second mental-health assessment three to six months after its initial screening, which is completed as soon as a soldier returns from war. This second screening has allowed the Army to unmask troubling trends among its soldiers: a fourfold increase in relationship problems compared with those reported in the first assessment, a surge of major depression among many, and increased alcohol abuse.

"The whole idea is [that] we're trying to catch these problems early, before they're a diagnosable condition, and hopefully intervene and prevent it from becoming that," said Col. Charles Milliken, an Army psychiatrist, during a recent Army briefing with reporters.

For example, about 3.5 percent of active-duty soldiers in the first screening reported relationship problems. In the reassessment of the same soldiers, taken six months later, that number jumped to about 14 percent, according to Dr. Milliken and two other Army medical officials in an article published Wednesday in the Journal of the American Medical Association.

Ditto for active-duty soldiers reporting problems with post-traumatic stress disorder, or PTSD, the medical officials found. On the initial assessment, 11.8 percent reported problems relating to the disorder; that number increased to 16.7 percent on the second assessment. Likewise, those soldiers reporting depression problems rose from 4.7 percent to 10.3 percent. In the second screening, as many as 12 percent said they were misusing alcohol. Overall, soldiers seen as being at risk for mental-health problems jumped from 17 percent to 27 percent.

Reports of problems increased even more dramatically among Army reservists, but Army officials believe much of that rise stems from the perception that their healthcare coverage will expire sooner than that of active-duty soldiers. So, even though reservists' medical coverage continues after their return, they are more likely to report problems during the second assessment, Army officials speculate. The study was based on responses from more than 88,000 soldiers.

The transition from combat to home has always been tricky. The unexpected length of the war in Iraq has posed additional challenges for the Defense Department, whose readjustment programs were initially unprepared for the depth and number of problems.

Many programs within the unit rely on military chaplains who prepare soldiers for the transition while they are still deployed. Typical is a soldier who returns home after a year and attempts to reassert his authority.

"That leads to immediate conflict with the family, who has done just fine without the soldier and doesn't like the fact that he is injecting himself in their business," writes Maj. Craig Whiteside, an Army battalion executive officer nearing the end of a 15-month deployment to an area south of Baghdad, in an e-mail. "I definitely learned this a long time ago and know better, but our chaplain did a great job laying it out."

The kinds of problems soldiers are experiencing don't typically emerge until after the elation of returning home subsides and the soldier settles into his or her normal routine, Army officials say.

New Defense Department initiatives will allow even more health screenings of all soldiers every year. But the Army has have to walk a fine line when it comes to screening soldiers because there is such a thing as "overscreening," Army officials say.

"If we ask them too many times 'Are you having symptoms?' we might reinforce them," says Army Brig. Gen. Stephen Jones, the assistant surgeon general for force projection, US Army Medical Command, during the same briefing with reporters, held last week in anticipation of the release of the study.

As prospects for a quick end to the war in Iraq evaporated, officials inside and outside the Defense Department began to voice doubts about the military's post-combat approach to mental health. In 2005, the military started a pilot program of its second-screening program and implemented it across the board in 2006. Last year, Congress mandated the creation of a group later called the Defense Department Task Force on Mental Health, which made nearly 100 recommendations to fix or improve the Pentagon's system.

But changing the culture represents one of the biggest hurdles for military officials. Soldiers, Marines, and other troops have long been imbued with tough training in a culture that encouraged troops to suck it up rather than to seek counseling.

Now, the Defense Department is trying to put mental health on equal footing with physical fitness and diminish the cultural stigma of seeking help.

The Army's "Battlemind" program, for example, occurs months after a soldier returns from combat. The training attempts to recognize common behavior among returning troops that can lead to bigger problems down the road, even when those soldiers don't express their concerns about battle-related stress.

The fact that soldiers were willing to report their problems as much as they did in the second assessment suggests the Army has made progress, General Jones says. "I think the study shows that we've done a pretty good job of reducing the stigma."

The study did not attempt to assess the effect of longer deployments, especially on soldiers on their third or fourth trip to Iraq.

"Undoubtedly, none of these guys will go home the same guy who came over," Major Whiteside writes in his e-mail. "Some of that is for the good, some of it is not so good."