Monday, November 27, 2006

Stress disorders, drug abuse, little help for troops

Austin American-Statesman
Stress disorders, drug abuse, little help for troops

As repeat tours of Iraq wear on U.S. forces, government struggles to provide mental health care; many say they take refuge in drugs.

By Anne Usher

WASHINGTON — Military personnel on multiple and extended tours of duty in Iraq and Afghanistan are being diagnosed with post-traumatic stress disorder at rates that probably will match or exceed the rate among Vietnam veterans, government officials and veterans groups say.

The war in Iraq, with often-hidden enemies and explosives, has left many service members particularly vulnerable to combat stress and is driving the abuse of drugs and alcohol both in Iraq and at home, military health experts say.

Yet many veterans and on-duty troops are not getting the treatment they need.

As of August, more than 184,500 returning veterans had sought care of all kinds through the Department of Veterans Affairs, and about one in six of those had been diagnosed with post-traumatic stress disorder, a rate expected to climb since it can take months and sometimes years for the condition to manifest itself.

Symptoms include anxiety, sleeplessness, flashbacks and extreme wariness, a recipe that can strain relationships and make it hard for those suffering to get or keep jobs.

Jesus Bocanegra, a 24-year-old former Army sergeant with an infantry company based at Fort Hood, says he is haunted by countless shots he fired at Iraqis while serving as a scout in Tikrit in 2003-04.

The McAllen native says he lost track of how many civilians died in the crossfire when he squeezed off rounds at Iraqi insurgents.

"How the hell was I capable of that?" he says now.

Back home and plagued with anxiety attacks, he said he tried to close himself off from the world by drinking to the point of passing out. He said he progressed to marijuana use and then cocaine.

"The only way to sustain yourself day to day is to keep yourself drugged up," he said. But "it made it worse."

Eventually, he said, he stopped taking drugs and visited a VA clinic. Seven months later, a psychiatrist there diagnosed him with post-traumatic stress disorder and gave him pills, dispensing medications in five-minute meetings every three to four months. A clinic employee verified his diagnosis and said that with 400 to 600 patients a day, "every doctor is overbooked."

With no VA psychotherapists in his area at the time — one has since been added — Bocanegra sought help from a support group called Vets for Vets.

"It's good to have someone to talk to," he said. "It's the only thing that keeps me going."

Married for just under a year, he is unemployed but hopes to return to school.

He said he is focused now on his mental health and on touring with other veterans to push for improved services for vets, many of whom he says are also suffering from post-traumatic stress disorder. Disability benefits of $2,500 a month help keep him afloat.

Up to 29 percent of troops returning from Iraq and Afghanistan will suffer from post-traumatic stress disorder, predicts Col. Charles Engel, a clinician at the Walter Reed Army Medical Center. As of August, the VA had diagnosed 63,767 discharged veterans with a mental disorder and 34,380 with post-traumatic stress disorder.

Experts say the rate of the disorder among Iraq veterans could well eclipse the 30 percent lifetime rate found in a 1990 study of Vietnam veterans because military personnel are being deployed longer and more often to Iraq and because greater awareness of the disorder among doctors will lead to more diagnoses.

Some statistics show the cases climbing fast. The number of Iraq and Afghanistan veterans who have sought help for readjustment concerns including post-traumatic stress disorder doubled between October 2005 and June 2006, according to a recent survey of 60 VA-run centers by the Democratic staff of the House Committee on Veterans Affairs.

That increase has made it only more difficult to get quality care, the survey found.

Among active-duty military personnel who served in Iraq, 35 percent used military mental health care services in the year after coming home and 12 percent were diagnosed with a mental health problem, a study published in March in the Journal of the American Medical Association found.

Veterans groups fear that the VA won't be able to handle the high proportion of service members seeking such help once they are discharged. They note studies showing that though post-traumatic stress disorder can resolve itself in some people over time, its symptoms can worsen if not treated quickly.

The Department of Veterans Affairs says it has enough resources to offer treatment for post-traumatic stress disorder and substance abuse to all of the roughly 160,000 service members now in Iraq and Afghanistan once they are home.

Dr. Ira Katz, deputy chief patient care officer for mental health for the VA, noted that there are 200 veteran readjustment centers nationwide and that mental health counseling is available over the Internet.

As part of unprecedented efforts on its part, the military in September 2005 began giving returning troops a questionnaire aimed at catching early signs of the disorder. Questions include whether they have nightmares, are feeling emotionally numb or super alert, or have physical reactions such as breathing trouble when reminded of a stressful experience. In January, the military put in place a secondary screening test to check for similar symptoms.

But nearly four in five returning troops who may have been at risk for post-traumatic stress disorder were not referred for further mental health evaluation, according to a study released in May by the Government Accountability Office, the investigative arm of Congress. About half of those diagnosed with a mental health problem got care, but fewer than 10 percent were referred through the military's new screening program, the JAMA study in March showed.

The Pentagon told the GAO that it generally concurred with the its recommendations and that a systemic evaluation of referrals is planned. After the study's publication, however, the Pentagon said it was flawed because it did not include troops referred to chaplains, primary care physicians and group counseling. The GAO says the Defense Department was not able to provide any evidence that those referrals occurred and still has not provided figures on personnel who may have since received treatment.

After his first Iraq tour ended in August 2005, former Pfc. Josh Revak said, a large number of soldiers in his 1st Battalion, 37th Armor Regiment reported symptoms of post-traumatic stress disorder on the test, but the commanders "just took it as a joke, and I think barely anybody received treatment."

The 25-year-old said he asked for help but didn't get psychological counseling until after a 120 mm mortar landed near him on his second tour in Iraq in June, sending him back to their base in Germany with shrapnel through his foot.

By that time, Revak said, several men in his unit had been disciplined for Valium use.

Medical experts say mental health problems such as post-traumatic stress disorder and substance abuse are often intertwined.

"When they don't get the kind of mental health screening — or physical — history tells us they will turn to coping mechanisms," said Steve Robinson, director of government relations for Veterans for America, a 35,000-member organization.

He says many of the hundreds of troops he has interviewed at post-deployment sites are addicted to medications given to them in the field, such as painkillers and sleeping pills. But they are not getting the therapy that normally goes with such medications, Robinson said.

Adam Reuter, a 23-year-old former Army specialist, said that after he was tossed out of a Humvee in an accident in Iraq, a medic handed him a plastic bag filled with pills and gave him no instructions.

The bag contained four kinds of painkillers, an anti-inflammatory drug and a muscle relaxant, said Reuter, an Atlanta native who served with the 3rd Squadron of the 3rd Armored Company from May 2003 until February 2004. He said he went back for more and developed a dependency that he is still trying to shake.

Military personnel said they used banned substances as a way to mentally escape the violence around them. Drugs ranging from marijuana to prescription anti-depressants are easily accessible in Iraq, according to interviews with more than a dozen soldiers who served there.

John Crawford, a 28-year-old former Florida National Guardsman with the Army's 101st Airborne Division, said soldiers in his unit drank alcohol, some took steroids, "pretty much everyone took Valium," and "some did all three."

Crawford said he bought 200 to 300 Valium pills on the street in Baghdad for $2 as a way to get some sleep between patrols. After eight months, he built up a tolerance and was taking seven or eight at a time.

The extent of alcohol and drug abuse among combat veterans is difficult to quantify. The Pentagon declined to release the results of announced drug tests specifically for Iraq. The tests are usually done just once a year.

Army Maj. James Weeden directed a team of 200 specialists dealing with combat stress in Iraq until he left the country in September.

He says senior officers recognize the strain their troops are under and in the past year have assigned specialists to address the issue at remote forward operating bases.

But seeking treatment in a combat environment is difficult. All travel is risky, and asking for help is seen as a sign of weakness.

Weeden and other medical specialists say that they can treat only the symptoms of combat stress — with anti-depressant drugs and rest, for example — and that troops are sent out of Iraq only when they have clearly disabling cases of post-traumatic stress disorder.

Commanders want to keep troops in the field, and most service members say that they don't want to abandon their units.

"We strengthen (combat readiness) because we get them back," Weeden said.

That desire to keep medicated troops in combat troubles Joyce Raezer, director of government relations at the National Military Family Association.

She says U.S. troops — some now on their fourth or fifth tour — are bringing "all the baggage from the last deployment into the next."

"The stress is cumulative," she said.

Families are alarmed by military statistics showing that 80 percent of soldiers who have been flagged with mild symptoms of post-traumatic stress disorder have been sent back to Iraq and Afghanistan, many with anti-depressant pills aimed at ensuring they can still fight. Experts say repeated exposure to combat is the greatest predictor of whether a person will get post-traumatic stress disorder and how severe it will be.

When they come home, many seeking treatment say they face steep hurdles getting help from the government. With a wave of post-traumatic stress disorder cases arriving, outreach groups fear the VA will not have adequate resources to treat them and to pay disability benefits.

The VA is proposing a $339 million increase in mental health care spending next year, Katz said Tuesday. That would bring total annual spending on those programs to about $3.2 billion.

Implementation is another question. As of late September, about $42 million of $200 million directed for initiatives to close gaps in VA mental health care in 2006 had not been spent, the GAO found.

"Requesting more money is a step in the right direction," said Paul Sullivan, director of programs for Veterans for America, who was a senior analyst at the VA until he left six months ago.

But he added, "The VA's problems are systemic, and the solutions must be more comprehensive than simple increases in funding."

He noted the GAO findings that the VA lacked a comprehensive plan to implement the funding in last year's budget.

About 144,000 of the 589,000 veterans who have served in Iraq and Afghanistan have already been seen at VA-run Vet Centers for "readjustment concerns" ranging from depression and marital problems to full-blown post-traumatic stress disorder.

Forty percent of the 60 centers surveyed in the study by the Democratic House staff have directed veterans for whom individualized therapy would be appropriate to group therapy instead.

Dr. Frances Murphy, undersecretary for Health Policy Coordination at the VA, told a mental health commission in March that the growing numbers of veterans seeking mental health care has revealed areas in which improvement is needed.

Some VA clinics, she said, do not provide mental health or substance abuse care, or if they do, "waiting lists render that care virtually inaccessible."

"The VA needs more capacity so that vets can get treatment and don't have to wait," Sullivan said.

If they are able to see a VA doctor, hundreds of veterans with severe symptoms of post-traumatic stress disorder are being denied disability benefits because their condition is obscured by drug or alcohol abuse, which is labeled "willful misconduct," said Elinor Roberts, legal director for Swords to Plowshares, a San Francisco-based veterans organization.

The military maintains a zero tolerance policy for drug use on all but prescription medications.

Some service members have lost their military benefits, regardless of their combat citations, after they have been found to have used banned substances.

But many commanders offer leeway in such cases, choosing nonjudicial punishments such as demotions to keep soldiers on duty, said Army Col. Bill Buckner, a public affairs officer at Fort Bragg, N.C.

The VA is allowed to give benefits to veterans dealing with alcohol abuse but not illicit drugs, and only if a clinician finds that the veteran also has post-traumatic stress disorder. VA officials say many vets with the condition have trouble making appointments to get that diagnosis in the first place.

Amy Fairweather, who has counseled about 50 Iraq vets for Swords to Plowshares, said the impact of repeated deployments "is enormous."

"It contributes to all the elements for substance abuse, mental illness and family dissolution," she said. "There's only so many times you can be uprooted from family and work. Not to mention that they're over there in hell."