1. Problem Overview almost one in five, nearly 320,000, military service members returning from Afghanistan and Iraq suffers from brain injury, posttraumatic stress disorder, and/or depression. Combine this with the alarming rate of suicide among returning veterans and we face a brutal self-examination as to what we owe these veterans. The number and needs of these veterans are unprecedented as they require care not just for their immediate physical and mental injuries, but also support and sometimes intervention with the everyday challenges of life for years, possibly decades to come. A balance must be found between supporting the veteran and his or her family and protecting the veteran from self harm or the inadvertently harmful actions of family.

Department of Defense initiatives on Resilience, Recovery, and Reintegration through the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) has accomplished a lot in its first year, but is not geared toward community reintegration. Since October 2001, nearly 1.6 million US soldiers and marines have been deployed to Iraq and Afghanistan. Of those with brain injury, PTSD, and/or depression, roughly 70% will not be treated within the Department of Defense or the Department of Veterans Affairs systems. The latter condition is alarming, but veteran groups have made this point repeatedly, and been ignored. It is now obvious that they are right.

These injured veterans are not completely incapable of making decisions, and they are certainly not uninterested, but they may not have the executive functions to make good decisions for themselves or have sufficient insight to seriously consider their own interests. However, they should never be discounted in the decision making process even as others may need to step in to make decisions, large and small, on their behalf. Dr. Ibolja Cernak of the Johns Hopkins University Applied Physics Laboratory is quoted in Lizette Alvarez’s August 26, 2008 New York Times article, Home From War, Veterans Say Head Injuries Go Unrecognized, as stating, “there is no cure for those with prolonged concussion symptoms, only methods to help them learn to adapt.” One Iraq war veteran in a recent interview compared traumatic brain injury to a head cold that does not go away.

  2. Practical Solutions among many practical solutions, the one that is likely to have the greatest impact on veterans’ recovery is Senator Clinton’s Heroes at Home Act of 2007. This legislation would establish a family caregiver personal care attendant training and certification program to train and certify family caregivers as personal care attendants, qualifying them for compensation from the VA. This RRTC goes a long way toward meeting the veteran’s physical and social care giving needs, however, it inadequately addresses the larger issue of decision making related to those needs.

The indeterminacy associated with recovery from war related brain injuries and mental health disabilities as well as the waxing and waning capacity of the injured veteran require more flexible programs for advocacy and support in decision making than advance directives and surrogate decision making laws provide.

Rigidly legalistic approaches will not suffice. Guardianship, with the associated revocation of rights, may seem like the obvious solution in many of these cases, but it should be a last resort step unless there are reasonable temporary or limited guardianship options; unfortunately, these options are simply not available in most jurisdictions. A process of support and advocacy that keeps the injured veteran squarely at the center of deliberation and decision making is needed; an approach that maximizes the veteran’s decision making capacity and engagement with decision making, while protecting the veteran from decisions clearly not in his or her self interest. Any approach must maintain a delicate balance between allowing the veteran to make what may be suboptimal or even bad decisions for him or herself (just as anyone might make) and protecting the veteran from making truly harmful decisions.

  3. Ongoing Advocacy a coordinated program of ongoing advocacy and support in decision making is needed for our injured veterans. Administered through and accountable to the National Institute on Disability and Rehabilitation Research, we recommend a “Veterans Recovery & Diagnostic Center” for veterans with brain injury as well as mental health service-connected disabilities be housed temporarily in Prince William County, Virginia while a new facility be built in Loudoun County Virginia to house facilities for trained teams to work with and support the veteran and as well oversee the long and short term decision making. The “Veterans Recovery & Diagnostic Center” hospital, when completed, would house 250 beds available to veterans for short and long term stays (up to a year) on a revolving basis, a cafeteria serving three healthy meals a day, and athletic facilities with mandatory individualized daily fitness programs. Veterans would be required to participate in an academic curriculum through a consortium of local universities, and the environment would be conducive to mental health recovery. Veterans would have life-time access to the “Veterans Recovery & Diagnostic Center” hospital any day of the year for counseling, guidance, and assistance regarding everyday life decisions. The teams would include: 1.) the veteran; 2) someone from the medical team familiar with the individual’s medical needs and capacities; 3) someone from mental health or social services familiar with programs available to the veteran; 4) someone from the family or a friend designated by the veteran; and 5) a lay, community, or religious person to serve as advocate and ombudsman.

  4. Multidisciplinary Program this type of multidisciplinary program brings varied perspectives and skills and can best ensure that a holistic and balanced approach is provided, one that keeps the injured veteran’s interest foremost in all considerations. The teams would need to be trained in process and must have both authority and accountability for their work. We envision these teams operating and reporting to the NIDRR-funded Model System Knowledge Translation Center and the Department of Veterans Affairs on a quarterly or biannual basis in a similar manner to the way that interdisciplinary care planning is carried out in nursing homes. In many if not most cases, the team may find that the veteran is receiving all needed care and is in a safe and supportive environment, in other cases, this external oversight will help to protect the veteran from the types of disastrous decisions that too often lead to homelessness and incarceration of those with brain injuries. Ongoing monitoring and early intervention should help our veterans and protect them. It’s the least we can offer them.

Journalist Linda D. Kozaryn from the American Forces Press Service reports on, Aug. 28, 2010 that, President Barack Obama called on the American people today to provide new care, opportunity and commitment to the million military men and women who’ve served in Iraq.

After more than seven years, the United States “will end its combat mission in Iraq and take an important step forward in responsibly ending the Iraq war,” he said during his weekly radio address.

That responsibility, he stressed, includes caring for the men and women in uniform who volunteered to fight.

“What this new generation of veterans must know is this: our nation’s commitment to all who wear its uniform is a sacred trust that is as old as our republic itself,” he said. “It is one that, as president, I consider a moral obligation to uphold.”

He called upon the nation to pay tribute to all who have served in Iraq and Afghanistan, noting the two wars are America’s longest continuous combat engagement.

“For the better part of a decade,” he said, “our troops and their families have served tour after tour with honor and heroism, risking and often giving their lives for the defense of our freedom and security.”

Some U.S. troops will remain to support and train Iraqi forces, partner with Iraqis in counterterrorism missions, and protect civilian and military efforts, he said. But he pledged all U.S. troops will be home from Iraq by the end of next year.

More than a million U.S. troops have served in Iraq and more than a million who have served in Iraq and Afghanistan have joined the ranks of America’s veterans. Obama said his administration has worked to make the nation’s veterans policy more responsive.

“We’re building a 21st century VA, modernizing and expanding VA hospitals and health care, and adapting care to better meet the unique needs of female veterans,” he said. “We’re creating a single electronic health record that our troops and veterans can keep for life. We’re breaking the claims backlog and reforming the process with new paperless systems.”

Obama added that wounded warrior facilities are being built throughout the Defense Department, and more is being done to help those suffering from Traumatic Brain Injury and Post-Traumatic Stress Disorder.

“For many of our troops and their families, the war doesn’t end when they come home,” he said. “Too many suffer from Traumatic Brain Injury and Post-Traumatic Stress Disorder – the signature injuries of today’s wars – and too few receive proper screening or care. We’re changing that.

“We’re directing significant resources to treatment, hiring more mental health professionals, and making major investments in awareness, outreach and suicide prevention,” he said. “And we’re making it easier for a vet with PTSD to get the benefits he or she needs.”

First lady Michelle Obama and Jill Biden, wife of Vice President Joe Biden, have forged a national commitment to support military families, he noted. This includes new support for caregivers who put their lives on hold for a loved one’s long recovery, and funding and implementing the Post-9/11 GI Bill, which is already helping some 300,000 veterans and their family members pursue a college education.

New resources are also being devoted to job training and placement to help veterans trying to find work in “a very tough economy,” the president said. “I’ve directed the federal government to hire more veterans, including disabled veterans, and I encourage every business in America to follow suit.

“This new generation of veterans has proven itself to be a new generation of leaders,” he stressed. “They have unmatched training and skills; they’re ready to work; and our country is stronger when we tap their extraordinary talents.”

The president closed his address by encouraging people to visit whitehouse.gov to send the troops text and video messages of thanks and support.

“Let them know that they have the respect and support of a grateful nation,” he said. “That when their tour ends; when they see our flag; when they touch our soil; they’ll always be home in an America that is forever here for them – just as they’ve been there for us.”

See: http://www.defense.gov/news/newsarticle.aspx?id=60641

On August 27, 2010, C-SPAN’S Katherine Helmick talked about soldier rehabilitation from traumatic brain injury. She also responded to telephone calls and electronic communications. This program was part of week-long “Washington Journal” series on defense issues. The product IDs for the other parts are 295139-6, 295151-5, .. Read More

Katherine Helmick talked about soldier rehabilitation from traumatic brain injury. She also responded to telephone calls and electronic communications. This program was part of week-long “Washington Journal” series on defense issues. The product IDs for the other parts are 295139-6, 295151-5, 295203-6, and 295168-5.

View Entire Event (6 Programs

See: http://c-spanvideo.org/program/295213-7

Redorbit published the following article on 26 August 2010: each year in Texas, traumatic brain injury (TBI) causes an estimated $6.8 billion worth of economic trauma in terms of deaths, emergency room visits, hospitalizations and disability, according to a study commissioned by the CORE Health Foundation. To put that dollar amount in perspective, it equals Coca-Cola’s corporate profit for fiscal 2009.

“While this estimate appears large, it is at the low end of the range of costs expected to occur from TBIs in Texas every year,” said Eric Makowsi, a co-founder and trustee of the Austin-based CORE Health Foundation and immediate past president of the Brain Injury Association of Texas..

The study urges more funding for TBI rehabilitation, research, prevention and education.

“Money does not cure all problems, but when money is spent with a plan and a mission, the results can be significant,” said Dennis Borel, board member of the CORE Health Foundation and executive director of the Coalition of Texans with Disabilities. “A comprehensive effort to fund future rehabilitation, research, prevention and education programs can have lasting effects for TBI patients, families, medical care providers and society.”

As the study notes, the percentage of injury-related productivity loss attributed to TBI (15.7 percent of all cases) is 14 times greater than that associated with spinal cord injuries.

The nonprofit CORE Health Foundation, founded in 2006, advocates for people with disabilities through research, public works projects and public awareness initiatives. The foundation’s brain injury research is performed under the Resilient Mind brand.

The CORE-financed study estimates that 4,100 TBI-related deaths will occur this year in Texas, with lost earnings from those deaths adding up to nearly $4 billion a year. The study also estimates that:

• TBI produces 119,500 emergency room visits each year in Texas, resulting in an annual cost of $740 million.
• Costs for extensive medical treatment connected with TBI-related deaths total $186 million a year in Texas.
• TBI prompts 22,000 hospitalizations annually in Texas, leading to a yearly cost of $623 million.
• Nearly half of the TBI-related hospitalizations in Texas result in long-term or lifelong disabilities, resulting in $1.3 billion worth of annual expenses.

“As we close out the first decade of the 21st century, Texas has seen significant medical advances that can increase the rate of survival for a TBI. Unfortunately, the number of cases continues to increase, which puts added strain on the financial systems supporting these injuries,” said Jim Misko, Psy.D., co-founder of the CORE Health Foundation, chairman of the Academy of Certified Brain Injury Specialists and board member of the Brain Injury Association of America.

A TBI is a blow or jolt to the head or a penetrating head injury. It disrupts the function of the brain and produces a diminished or altered state of consciousness, impairment of cognitive abilities or physical functioning, or both.

The two leading causes of TBI are falls (35 percent) and traffic crashes (17 percent). Other causes include gunshot wounds, sports injuries, workplace injuries, shaken baby syndrome, child abuse, domestic violence and military action. The U.S. Centers for Disease Control and Prevention’s National Center for Health Statistics estimates 1.7 million Americans sustain a TBI every year.

The CORE-financed study, The Estimated Economic Cost of Traumatic Brain Injuries in the State of Texas, was conducted by Austin-based Actuarial Risk Management, Ltd using a variety of federal and state statistics. To read the entire study, visit www.corehealthfoundation.org/economic-impact-of-tbi.

The study makes several recommendations aimed at reducing the incidence and costs of TBI in Texas and at improving TBI care:

• Create a statewide TBI prevention awareness program.
• Promote compliance with Brain Trauma Foundation treatment guidelines among providers of medical and rehabilitation services.
• Boost state funding for the Texas Department of Assistive and Rehabilitative Services’ Comprehensive Rehabilitation Services program. The program “has a waiting list as a result of a limited budget,” according to the study.
• Require that Texas join the Centers for Disease Control and Prevention’s CORE State Injury Program. The program conducts TBI surveillance in 30 states, but not in Texas.
• Promote funding for research to improve TBI rehabilitation. The research should focus on such subjects as cardiovascular exercise, sleep and nutrition. Findings of the research would help insurers, the Texas Department of Assistive and Rehabilitative Services, accreditation boards and others know what to expect of TBI rehabilitation facilities.
• Revise qualification criteria for Texas state services to take into account the characteristics and long-term needs of people with TBI.
• Encourage funding for in-home interventions to educate caregivers about preventing TBI re-injury and long-term chronic complications.
• Conduct annual meetings that provide medical professionals and others with the latest research and treatment options to enhance neuroplasticity–the brain’s ability to reorganize itself.

“Examining TBI as a chronic illness that has lasting effects for multiple areas of the individual and their family’s lives is the best course of future action,” the study concludes.

About the CORE Health Foundation

The CORE Health Foundation was established in 2006 by leading experts in the fields of brain injury and recovery who came together through their work at CORE Health Care, a specialty residential treatment facility in Dripping Springs, Texas, for people with traumatic brain injuries, complex psychiatric disorders, autism and other special needs.

(http://www.redorbit.com/news/health/1909119/economic_toll_of_traumatic_brain_injury_adds_up_to_68/index.html?source=r_health)

The following article will be published in the September issue of Shipmate, the US Naval Academy’s Alumni magazine. Please read this advanced copy of “Supporting the Sacrifice” and be sure to read the September issue of Shipmate.

Outside of the class structure, alumni are involved in many organizations, events and efforts supporting those wounded in actions as well as the families of those killed in action. In September, as Shipmate went to press, planning committee members—Janice Buxbaum ’80 and Julien Modica—for the 2010 Veteran Summit: “America’s Crisis with Brain Injury and A Future Model” were well into executing the event. Modica is particularly interested in addressing the issue of brain injuries for veterans because of his own experience.

As a recruited athlete in high school, he was injured in a pole vaulting accident. He entered the Naval Academy Prep School in 1978 and the Naval Academy in 1979 with the Class of 1983,but unfortunately left after one year at the Academy. “I struggled every single day,” said Modica. Even today, he is disappointed that he had to leave the Academy to address his injury, but is redirecting his energy to helping others through their recovery.

See: http://www.veteranhealthcare.org/Supporting%20the%20Sacrifice.pdf

I have been asked this question at least three times this morning, “why are the British reporting on this story?” It is a good question to which I do not have an answer, but I am also a bit disturbed about it. The answer will begin to develop at the 2010 Veteran Summit in Washington, DC. See: www.veteranhealthcare.org Please read the story from BBC’s Dan Edge:

Seventeen US soldiers from a Colorado military base who mostly served in Iraq have been linked to violent killings and attempted killings since their return to US soil. Three of them came from one platoon – highlighting how a generation of American soldiers are struggling to cope with life after military service.

“I was having a total mental breakdown. Every day we were getting in battles, and never having a break, it seemed like, it was just crazy.

“I just got to where I couldn’t take it. I tried to go to mental health, and they put me on all kinds of meds, too. And I was still going out on missions… they tried different medications, different doses, and nothing worked.”

Kenny Eastridge was a decorated gunner, but is now serving 10 years in prison for his role in the murder of fellow soldier Kevin Shields in Colorado Springs.

In November 2007, Eastridge along with two other soldiers, Louis Bressler and Bruce Bastien, were out drinking in a nightclub with Mr Shields after returning from a rough combat tour in Baghdad.

Drunk and stoned, they drove off to find more alcohol. Minutes later, Specialist Kevin Shields lay dead, gunned down in a drunken argument, and left in a pool of blood by the side of the road.

Bressler and Bastien were sentenced to 60 years in prison for the murder and a string of other crimes in Colorado Springs.

Kevin Shields’ murder was not a unique case. At Fort Carson military base, 17 soldiers have been charged or convicted of murder, attempted murder or manslaughter in the past four years.

Continue reading the main story

“Start Quote

In the first six months you’re just happy to be home. And then after that… problems started”

End Quote Ryan Krebbs Third Platoon medic

For over a year, This World has been tracking down the members of Third Platoon, Charlie Company, 1st battalion, 506th infantry, which later reflagged and became the 2nd batallion, 12th infantry regiment, trying to make some sense of the killings that have occurred since their return to the US.

The majority of Third Platoon served multiple combat tours with distinction and managed to adjust to life after Iraq. But a significant minority have not.

Four of the platoon have ended up in prison. Two are dead – one died from an overdose, another was killed by a suicide bomb.

In all, 15 out of 42 soldiers from Third Platoon left the army after a single Iraq tour. Four were kicked out for failing drug tests, and one was sent to prison for driving while drunk and fleeing the scene of an accident. Five were medically discharged. Only five left the army because their service had ended.

More than half of the platoon said they suffered from psychological problems after Iraq.

‘Trigger happy’

The platoon’s youngest member, Jose Barco, is serving 52 years in jail for shooting and wounding a pregnant woman when he opened fire at a party in Colorado Springs. He was convicted on two counts of attempted murder.

Barco said he became desensitised to death and killing during the vicious combat of the “surge” in 2007, when his battalion were tasked with driving al-Qaeda out of Baghdad.

It was Third Platoon’s job to move mutilated bodies every morning.

“It got to the point where it was like seeing a dead dog or a dead cat. If you’re not numb in those moments, you’re going to go crazy. I guess it just follows me,” he said from his prison cell.

As Third Platoon’s tour wore on, discipline deteriorated. Jose Barco said that for some soldiers, casual brutality became the norm, and that he routinely shot unarmed Iraqis.

“We were trigger happy. We’d open up on anything. They even didn’t have to be armed. We were keeping scores,” he said.

The US army investigated, but no soldier from Third Platoon has been charged with killing civilians in Iraq.

While in Iraq, Eastridge had exhibited signs of post-traumatic stress disorder (PTSD), was taking anti-depressants and sleeping pills, but was also taking valium, smoking pot and drinking whisky.

He had a history of aggression, and been charged with assault before he went on his second tour, but he was still deployed.

He said Iraqi civilian deaths did not bother him at all: “You disassociate. To you they’re not even people, you know. Like, they’re not humans.”

Continue reading the main story

Third Platoon’s Iraq tours:

• August 2004 – August 2005. Stationed in the desert in the heart of the Sunni triangle, they patrolled the main highway from Ramadi to Falluja drawing out insurgent attacks and dealing with 1000 Improvised Explosive Devices (IEDs)

• September 2006 – December 2007. Stationed near Al Dora, an al-Qaeda “hub” that became the site of al-Qaeda’s last stand in Baghdad. Main task was to try to secure neighbourhoods street by street, which were subject to widespread sectarian killings

The platoon’s first battalion commander Colonel David Clark, accepted that the price of “success” on the battlefield could take a psychological toll.

“It’s got to have an impact,” he said.

“Is that a reason not to do the surge? No. The surge worked. We needed to do the surge. War is a dangerous thing,” he added.

The number of Fort Carson soldiers failing drug tests rose by 3000% in the first three years of the Iraq war.

Ryan Krebbs, the platoon medic, admitted abusing medication in Iraq, stockpiling sleeping pills to calm himself down after missions.

He never forgave himself for the death of one of his sergeants, and eventually tried to kill himself with an overdose of prescription anti-psychotic drugs when he returned home.

“In the first six months you’re just happy to be home. And then after that… problems started.

Continue reading the main story

“Start Quote

The black box warning for these anti-depressants say that they can make people suicidal”

End Quote Dr Joseph Glenmullen Psychiatrist, Harvard Medical School

“Depression, anxiety, paranoia, getting the feeling that you’re in Iraq all over again.

“I just couldn’t take it anymore,” he said.

Before the Iraq war, American soldiers on psychiatric medications were not allowed to deploy to a combat zone.

But by the time of the surge, more than 20,000 US troops in Afghanistan and Iraq were taking anti-depressants and sleeping pills to cope with the stresses of combat.

The military has come under fire for medicating troubled soldiers rather than taking them away from the front line.

Dr Joseph Glenmullen warned that such medication could be dangerous in war.

“All of these anti-depressants now carry in recent years a black box warning.

“The black box warning for these anti-depressants say that they can make people suicidal and a variety of other side effects that include insomnia, anxiety, agitation, irritability, hostility, impulsivity and aggression, all of which obviously could become critical in a combat situation,” he said.

The vice-chief of the US army, General Peter Chiarelli defended the policy, but said that the army needed every soldier it could get.

“It’s a supply and demand problem,” he said.

“I cannot do anything about the demand, I only have a finite supply, and when the demand goes up, and orders are given, we provide the soldiers.”

Spurred by the public outrage, the army’s medical command last year conducted an investigation in to the violence.

It found that most of the soldiers had experienced unusually intense combat in Iraq, six of them had criminal records before they joined the military, 11 had a history of substance abuse and nine were taking psychiatric medications.

It concluded that the intensity of battle and shortcomings in mental health treatment may have converged with “negative outcomes” such as alcohol and drug abuse.

Last week the final American combat brigade pulled out of Iraq after more than seven years of war.

But for many soldiers, the end of combat operations is just the beginning of a different kind of struggle back home.

Thirty feet in the air, an Indiana Jones-style rope bridge loomed, strung between two poles, wobbling occasionally in the morning sunshine. Even for 18-year-olds, who are certain they’re invulnerable, its irregularly spaced wooden slats screamed caution.

But the instructors had been clear: The best way across was for these incoming college freshmen to launch themselves off the first step and allow speed and momentum to carry them over the gaping spaces to the relative safety of the next tiny, elevated platform.

Some looked nervous. Others hesitated. But no one failed this stretch of the aptly nicknamed “confidence course” at the U.S. Naval Academy as I watched one morning a few weeks ago. Nor did anyone flub the rest of the “tactical assault course,” which included climbing a cargo net, crab-walking along a rope line with only another cable to hold on to and riding a zip line to the ground.

“It’s all about building confidence,” said Midshipman 1st Class Nathaniel Lopez, a senior from Illinois who was helping out at the site. “And if [they] don’t do it, they feel like they’re letting themselves and their classmates down.” (The Navy’s rules prohibited me from talking to the plebes themselves, in order to preserve the boot camp atmosphere.)

More than 3 million students will start two- and four-year colleges this fall, and it’s a safe bet few will enter as physically and mentally fit as the 1,230 first-year students who recently completed the six-week Plebe Summer in Annapolis.

As the general population of young people becomes more obese, to the point where some experts are concerned about military recruitment, Naval Academy statistics show the plebes’ physical fitness, as measured by a series of standard tests, has actually improved slightly in recent years.

This is partly demographics. The Class of 2014 was culled from the largest applicant pool in history, more than 17,400 young men and women, so like all selective colleges these days, the Navy can afford to be even pickier than it was previously. And successful Navy applicants tend to come from a fitness culture: About 93 percent of the freshman class played varsity sports in high school, and 61 percent were captains of those teams.

But then the Navy gets them for six weeks of workouts in the heat and humidity of a Maryland summer. Before the start of the fall term this week, I spent a morning watching 18-year-olds tackle a formidable obstacle course that included a 30-foot rope climb as the last event, kick and punch each other’s padded bodies in martial arts, swim, and work their way up a climbing wall.

The day began at 6 a.m. with stretching, a four-mile run and a half-hour of strength exercises, led by Marine Maj. Jay Antonelli, a former wrestler and a brick of a man who at 39 easily outlasted the plebes he was putting through the drills (not to mention me). I ran with 30 companies of plebes as the sun rose over the Severn River. This was the easy run of the week — for them, not me.

Not every plebe was in great shape. A few struggled on the run, but when they did, upper-class leaders or classmates fell out of formation with them, exhorting, cajoling, cheering and imploring them to finish. That leave-no-person-behind teamwork is as much a critical lesson of Plebe Summer as the fitness regimen.

I did see some plebes who had been sidelined by injuries to ankles, shoulders and feet, but at every activity safety precautions and proper technique were paramount. When they jumped off a high bar, the plebes were told to “grab dirt,” a clever way of ensuring that they landed with their knees bent instead of locked. And they were kept well hydrated at all times. When the heat and humidity reach a certain level, outdoor exercises are canceled.

“We expect a lot of these folks,” said Cmdr. Kevin J. Klein, the executive officer of the Naval Academy’s Physical Education Program. “We invest a lot in these folks. Because they are national assets.”

Physical fitness isn’t the only goal of Plebe Summer, or perhaps even the primary one, as that wobbly bridge illustrates. As the gangly teens bond and take on increasingly difficult tasks, their instructors can see their confidence grow, sometimes before they’re aware of it themselves.

“As warriors, these guys are going to be put into some pretty tough situations,” said Craig Holt, an assistant professor of education and assistant gymnastics coach, as he watched a young woman ascend nearly to the top of an indoor climbing wall. “They know how to get past the situation.

“That’s what Plebe Summer is all about,” he added, “learning to develop some skills that are outside your comfort zone.”

See: http://www.washingtonpost.com/wp-dyn/content/article/2010/08/24/AR2010082403235.html?hpid=artslot

On August 25th, the Washington Post reports that, rushing to stem historically high rates of military suicides, the service branches set up prevention programs that lacked strategic planning and therefore do not work as well as they could, according to a congressional report released Tuesday.

TIME Magazine’s MARK THOMPSON reports, U.S. Army specialist Ethan McCord was one of the first on the scene when a group of suspected insurgents was blown up on a Baghdad street in 2007, hit by 30-mm bursts from an Apache helicopter. “The top of one guy’s head was completely off,” he recalls. “Another guy was ripped open from groin to neck. A third had lost a leg … Their insides were out and exposed. I’d never seen anything like this before.” Then McCord heard a child crying from a black minivan caught in the barrage. Inside, he found a frightened and wounded girl, perhaps 4. Next to her was a boy of 7 or so, soaked in blood. Their father, McCord says, “was slumped over on his side, like he was trying to protect the children, but he was just destroyed.” McCord couldn’t look away from the kids. “I started seeing images of my own two children back home in Kansas.” (See pictures of a soldier coping with the aftermath of war.)

Ethan McCord’s mind and thousands like his are the U.S. Army’s third front. While its combat troops fight two wars, its mental-health professionals are waging a battle to save soldiers’ sanity when they come back, one that will cost billions long after combat ends in Baghdad and Kabul. It is a high-intensity conflict: Army troops, TIME has learned, are seeking mental help more than 100,000 times a month. That figure reflects a growth of more than 75% from the final months of 2006 to the final months of ‘09, according to Army data.

Army Lieut. General Eric Schoomaker, the surgeon general who oversees the mental and physical well-being of the nation’s soldiers, concedes he doesn’t have the doctors and therapists he needs. “We’re in uncharted territory in respect to the strain on the force,” Schoomaker said recently. Translation: he needs help. According to the Army’s estimates of its needs, 414 psychiatrists are 20% fewer than Schoomaker should have. A study released by the Army on July 29 concluded that “numerous critical shortages of care providers including behavioral health” personnel are hurting its efforts to curb suicides. “The Army has been criminally negligent,” says Captain Peter Linnerooth, an Army psychologist for nearly five years until 2008, who notes that the service has had a difficult time finding psychiatrists to care for combat vets, which puts even more pressure–”and way too much burnout”–on those who stay.

Interviews with dozens of mental-health experts at Army bases tell a similar story. Even though the Army mental-health corps has increased about 60% since 9/11, demand is growing even faster. One anonymous mental-health professional told researchers last year that he spends a quarter of his time on “really sick people who never should have been let in [the military] to begin with.” During the past year, indeed, it has become clear that a shortage of mental-health care can be nearly as dangerous to troops as any enemy. Last November, when Army psychiatrist Major Nidal Hasan allegedly gunned down 13 people at Fort Hood, Texas, it forced the Army to ask some hard questions. Did supervisors overlook Hasan’s poor performance and alarming ideology because they are desperate for psychiatrists?

Without doubt, those in the specialty feel under pressure. Sergeant Brock McNabb, who left the Army in 2008, was a mental-health technician operating out of a base near Baghdad; he endured nearly a year of 12-hour-plus shifts without a day off. “My marriage is going to hell. The commands aren’t listening to a lot of the things we’re saying when we’re trying to take care of these guys,” he recalls thinking. “It wasn’t any huge, dramatic thing. I just decided, ‘Yeah, today’s the day I’m going to die,’ and I was O.K. with that.” He collapsed, fully clothed, on his cot. “I looked over at my 9 mm on this little hutch I’d made, and I started laughing hysterically,” he says. “I was so exhausted after 10 months of all the s___ I’d been through, I was too tired to … reach for the 9 mm and put it in my mouth.” He passed out and awoke fine the next day.

The Enduring Taboo

McCord Pulled the two kids out of the minivan–the boy was still alive–and helped get them to a hospital. The Apache gunship killed a dozen men, including a pair working for the Reuters news agency; the episode became a video sensation after WikiLeaks released footage of it in April. Back at his base, McCord washed the children’s blood off his uniform and body armor. That night, he told his staff sergeant he needed help. “Get the sand out of your vagina,” McCord says his sergeant responded. “He told me I was being a homo and needed to suck it up.” McCord says he never spoke to anyone about it after that because he didn’t want to get in trouble and instead did what soldiers have done forever. “I decided to try to push it down and bottle it up,” he says. But his anger, fueled by flashbacks to that day in Baghdad, kept growing. Any misstep by one of the soldiers on his team would set him off. “It was like a light switch,” McCord says. “They’d do something wrong and I’d be screaming at them.”

Going to a psychiatrist is still seen as a sign of weakness in the Army; the chief fear is that it will work against promotion. That may be why only about half of those needing help seek care, according to a 2008 Rand Corp. study. And only half of those–25% of the total who need help–get “minimally adequate treatment,” the Rand study found. Repeat deployments deepen the crisis. One in every 10 soldiers who has completed a single combat deployment has a mental ailment; that rate jumps to 1 in 5 with a second deployment and nearly 1 in 3 with a third. That means that more than 500,000 troops have returned home to the U.S. in the last decade with a mental illness.

Complicating the Army’s mental-health challenge is an increase in brain trauma. The two wars are revealing a connection between physical wounds and mental ailments. Advances in body armor protect soldiers’ bodies but have left skulls and the gray matter inside them relatively defenseless. Schoomaker says the wars’ biggest surprise is how traumatic brain injury (TBI) caused by roadside bombs has unleashed mental trauma. Bruised brains trigger “persistent stress-hormone releases” that can cause posttraumatic stress disorder. That, in turn, can lead to suicide. The Army has been battling a rising suicide rate for the past six years; June saw 32 suspected suicides, one of the highest monthly totals in Army history. Of those, 22 had served in combat, including 10 who had deployed two or more times.

The root cause is no mystery: repeat deployments drive up cases of posttraumatic stress, which makes soldiers six times more likely to kill themselves. So, quietly, all over the world, the Army has opened 48 medical sites dedicated to treating soldiers’ injured brains. Ground zero for this is Fort Campbell, Ky., home to the 101st Airborne Division. After 11 suicides at the base during the first five months of 2009, a top general ordered a three-day halt to all activities to discuss the problem and issued an astonishing order to the entire division: “Suicides at Fort Campbell have to stop now.”

The Army has spent $7 million building at Fort Campbell what it calls its first behavioral-health campus (soldiers call it “the mental-health mall”) with a half-dozen new clinics filled with the latest technology for diagnosing and treating posttraumatic stress disorder (PTSD) and traumatic brain injury. The fort’s mental-health staff has grown from 31 in January 2008 to 95 today. Yet suicides continued to rise. “The way Fort Campbell deals with the soldiers are why there’s so many suicides there,” Sergeant James Kendall, now studying to be an Army nurse at Fort Sam Houston in Texas, says. “Pretty much everyone who went to mental health said the same thing I did–they’re just shoving them out the door.” Kendall, a medic in the 101st, returned from Afghanistan in March 2009 and says he was brushed off when he initially sought help. It was only after he downed a full bottle of Army-prescribed Vicodin, he says, that the Army took his worries seriously. (His wife resuscitated him by injecting him with an antioverdose medication he had stashed in his medic’s bag.)

Dr. Bret Logan, a psychiatrist in charge of medical hiring at Fort Campbell, says few medical professionals want to settle near the rural base–an hour north of Nashville–for far less money than they could make in a big city. The post has hired several foreign-born doctors, which has created cultural as well as language barriers. With only four suicides so far this year, the epidemic at Fort Campbell seems to have abated. But the trend at the base remains clear; the workload per mental-health worker has nearly doubled from 2008 to 2010, jumping from 19 to 32 visits per week.

A Patchwork Solution

McCord returned to Kansas five months after rescuing the children, but the nightmares continued. He sought help, and after a two-week wait for his first appointment, he was told by his civilian Army psychologist to calm his nighttime shakes with a blanket and a scented candle. Several weeks later, he saw a civilian Army psychiatrist, who prescribed three antidepressants that McCord says turned him into a zombie. Soon he began downing pills with whiskey and walking around his house brandishing his military knife with its 7-in. (18-cm) blade. His wife tricked him into driving to the hospital, where an Army counselor committed him to a private mental center.

Can the Army’s mental-health corps heal itself? Not soon. Schoomaker has shifted some 100 physical-health jobs to mental-health billets, and combat tours for some medical specialists, including psychiatrists, have been cut from 12 months to six. But the Army has been forced to hire regular civilians to help, many of whom know little about the military and its culture. One soldier walked out on a civilian therapist who thought an RPG–a rocket-propelled grenade, one of which killed his buddy–was a small car.

Army mental-health providers have been receiving “provider resiliency training” since late 2008 to ward off compassion fatigue. “The Army recognized they need to take care of their staff,” says Major Chris Warner, chief of behavioral medicine at Georgia’s Fort Stewart. Psychologist Charles Figley, a former Marine sergeant in Vietnam and pioneer in the study of burnout among military counselors, credits the Army for taking some long overdue steps to help its healers. But there is no magic formula to fix the damage to soldiers’ minds–itself the product of wars that have lasted far longer than expected and are being fought by volunteer troops. A bigger Army would mean fewer combat tours for each soldier, but that’s not going to happen.

One bright spot: as the demand for troops eases, soldiers will spend more time at home between deployments, and such “dwell time” reduces mental ailments. There is also a growing network of private counselors across the country listening to soldiers, often for free. Barbara Van Dahlen, a Washington psychologist, launched the nonprofit Give an Hour organization in 2005 to offer free counseling to U.S. troops and their families. “We decided to step up and help,” she says, “because these are our folks too.”

McCord got out of the mental hospital after four days and left the Army last June. His psychological turmoil, he says, played a role in his 2008 divorce. He is no longer taking antidepressants. “The Army’s attitude was, ‘Let’s give this guy drugs and hope they work because we’re overbooked and don’t have time to deal with it,’” he says. “If they had understood what I was going through, I think all of this could have been avoided.”

Treating Soldier Stress

To see more photos of the behavioral-health facilities at Fort Campbell, go to time.com/ft_campbell

This article originally appeared in the August 16, 2010 issue of TIME.

 http://www.time.com/time/magazine/article/0,9171,2008886,00.html

Journalist David Tarrant of the Dallas Morning News reports, thanks to advances in combat gear and battlefield medicine, more troops survive injuries that would have killed them in previous wars.

This is good news, but it also presents some long-term challenges. The soldiers are “surviving, but with things like post-traumatic stress disorder and traumatic brain injury,” said Dr. Carol Tamminga, professor of psychiatry at UT Southwestern Medical Center.

Traumatic brain injury, or TBI, is caused by a blow or jolt to the head, or a penetrating head wound, that disrupts the function of the brain. Because of its prevalence, TBI has been called one of the “signature injuries” of today’s wars, along with PTSD.

An estimated 19 percent of the 1.8 million troops who have served in Iraq or Afghanistan – about 342,000 – may have experienced a traumatic brain injury during deployment, according to Rand Corp., a California-based nonprofit research organization.

More than half of those cases, however, go undiagnosed and untreated, the Rand study said. The reasons: There is no simple check, such as a blood test, to diagnose TBI, and many soldiers do not seek treatment for concussions.

About 75 percent of all injuries to troops in Iraq and Afghanistan have been caused by blasts, including roadside bombs. Only the most severe head injuries are visible. Most head injuries remain hidden inside the skull. Symptoms of the more common mild TBI can include headaches; dizziness; temporary loss of balance and memory; insomnia; and depression.

Researchers don’t completely understand TBI’s long-term health effects. One of the problems is that TBI’s symptoms are so general, they “can be associated with something serious or not so serious,” said Tamminga, who served on an Institute of Medicine panel examining TBI.

The TBI panel looked at previous studies that didn’t include soldiers in the current wars. The panel found that those who suffered moderate or severe brain injury were more likely to have dementia, Parkinson’s disease, diabetes and PTSD.

But the panelists cautioned that there has been no comprehensive review of head injuries from the Iraq and Afghanistan wars. They recommended that the Defense Department and the Department of Veterans Affairs conduct such research as soon as possible.

In Texas, Fort Hood’s TBI clinic has seen 3,081 patients since opening in November 2008. “What we don’t know is how many of those are simple screenings, and how many needed follow-up [care],” said Heath Steele, spokesman for the Carl R. Darnall Army Medical Center.

PTSD and TBI are separate conditions but can go hand in hand. While PTSD can be caused by a brain injury, it “can be associated with any kind of stressful, life-threatening experience, not necessarily TBI,” Tamminga said.

TBI and PTSD are “associated with traumatic memories and traumatic situations. These memories are seared into the mind … almost permanently implanted. So the treatment is really long term,” Tamminga said. “You can give pills to help people sleep, and pills that decrease anxiety. But you can’t give pills that cure troubling memories. You have to really work through with the person those troubling memories.”

Doctors can work through disturbing memories in a professional way, Tamminga said, but families also can play a role.

“Patience and understanding will do an awful lot to support people as they go through this process,” she said.

 http://www.dallasnews.com/sharedcontent/dws/dn/latestnews/stories/082210dnenttraumaresearch.2f38801.html