Hidden Scars of Battle

By Claudia Wallis

The operation Iraqi freedom group meets on Wednesdays at a Veterans Affairs outpatient clinic in Los Angeles. Veterans find their way to the 90-min. group-therapy sessions in a variety of ways, most of them slow and circuitous. "Often the parents call and say you've got to get them in," says clinical social worker Leslie Martin. "Some are married, and their wives make them come." Others are referred by VA doctors after a checkup detects signs of psychological distress.

Just getting vets to come in for help can be the toughest part of the job for Martin, who heads the VA's Post-Traumatic Stress Disorder (PTSD) Outpatient Services team for the greater Los Angeles area. Avoidance is a classic symptom of PTSD, she says. "They are 21 years old, and they say, 'All I want to do is play my Walkman and go to school.'" Or they act dutifully: "It's 'Yes, ma'am; no, ma'am; thank you, ma'am; see you around." It's not unusual for veterans suffering from PTSD to wait a year before seeking help--like a 24-year-old Marine corporal Martin knows who was discharged after finishing a tour of duty in Iraq. For months he watched the news from Iraq obsessively and was worried about "my guys over there." Then one day he began weeping uncontrollably. Martin calls this a "breakthrough," not a breakdown. It's what finally prompted him to get help.

Veterans groups and the U.S. military are only beginning to get a sense of the psychological fallout of the wars in Iraq and Afghanistan, but a major study published in the New England Journal of Medicine last week brought the problem into sharp focus. The study, which involved 6,200 soldiers and Marines and was conducted by a team at the Walter Reed Army Institute of Research, is the first attempt to understand the psychological effects of a U.S. war while it is ongoing. Most of the participants were screened within three or four months of returning from battle, when memories--and any psychological wounds--were still fairly fresh. "One of our goals is to describe the onset of PTSD," says Lieut. Colonel Carl Castro, a Walter Reed psychologist, who led the study along with Dr. Charles Hoge. Many experts believe that early identification of symptoms and early intervention could help prevent the kind of massive psychological devastation seen in veterans of the Vietnam War. Some 30% of Vietnam vets eventually suffered PTSD--a grab bag of psychological effects that can include flashbacks, sleep disorders, panic attacks, emotional numbness and violent outbursts. "Here we were trying to be proactive, to better support returning soldiers," says Castro.

Men and women participating in the study completed a detailed psychological assessment anonymously--a measure that researchers believe was largely responsible for a high rate of cooperation. One group was evaluated before deployment to Iraq. Other groups were evaluated after returning from Iraq or Afghanistan in 2003. These participants were asked for specific details about their combat experiences. Among the key findings:

--As many as 17% of veterans who had been deployed in Iraq showed symptoms of PTSD, depression or anxiety. Of the total, more than 12% had symptoms of PTSD.

--About 11% of those who served in Afghanistan had symptoms of PTSD, depression or anxiety. Of this total, only 6% had PTSD symptoms.

--The risk of developing PTSD rose in direct proportion to the number of fire fights a soldier had experienced. Thus the rate was 4.5% for Iraq war veterans who had experienced no fire fights, 9.3% for those who had seen one or two fire fights, 12.7% for three to five, and 19.3% for those who had been through more than five such battles. The lower rate of PTSD symptoms among those who served in Afghanistan vs. those who served in Iraq could be largely explained by their lesser exposure to combat.

--Before deployment, the rate of PTSD in a sample of soldiers was 5%, about the same as it is for the American population in general (PTSD can be caused by sexual abuse, violent crime and other kinds of trauma). This is the first study to establish a base line for service members and should help resolve questions about whether they start out more psychologically fragile than other groups.

--The soldiers with the most symptoms were the ones who expressed the most qualms about seeking help and were the least likely to ask for treatment. They were worried about doing harm to their careers and to their reputations with commanders and comrades.

Service members in this study showed, on average, a somewhat higher rate of psychological damage than that seen in veterans of the Gulf War. But some experts are concerned that the figure may go higher still. "People in this survey were in the first part of the war, and the war has changed from a liberation campaign to a counterinsurgency effort," notes Dr. Matthew Friedman, executive director of the VA's National Center for PTSD. "The amount of uncertainty and traumatic exposure has increased." And as tours of duty are extended, Friedman points out, the risks only go up. Finally, the study did not look at any reservists or members of the National Guard, who tend to suffer higher rates of psychological damage than career Marines and soldiers, who are better trained and prepared for battle.

The good news is that PTSD can be successfully treated with a wide range of techniques including cognitive-behavioral therapy and drugs like Paxil and Zoloft. "The more immediate the intervention, the better, and the more likely that chronic problems can be avoided," says Dr. Ilan Kutz, an Israeli psychiatrist with extensive experience dealing with the disorder.

This is what makes the reluctance to be treated so tragic. Having learned hard lessons from Vietnam vets, the U.S. armed forces have beefed up efforts to provide psychological services to soldiers before, during and after combat. Castro hopes a new program providing free, confidential counseling from civilian therapists will appeal to those too ashamed to look for help within the military. (The hotline: 800-464-8107.) But his study shows there's more work to be done to counteract the stigma that keeps those most in need of aid from getting it. --With reporting by Margot Roosevelt/Los Angeles

With reporting by Margot Roosevelt/Los Angeles