Post-traumatic Stress Disorder (PTSD) has become inextricably
linked to Vietnam veterans, but not because Vietnam was the
first conflict in which soldiers experienced acute postwar
reactions to stress. PTSD has been experienced by veterans of
every war in history. As a diagnosable psychological injury,
however, PTSD has been recognized by the Department of
Veterans Affairs since 1980, when it was no longer possible to
ignore Vietnam veterans needing treatment.
VVA National Chaplain Father Phil Salois, who works with PTSD
patients at the VA,
remembers the long, hard fight for recognition of PTSD. "We
were forced to swallow everything because we were so
unwelcome. We shoved everything down," he said. "Only until
veterans started to appear at the door of the VA, did we know
something was wrong."
And something was terribly wrong. The National Vietnam
Veterans Readjustment Survey (NVVRS) estimated that more than
50 percent of Vietnam veterans have experienced at least
partial PTSD at some point in their lives. As a consequence, a
veteran of the Vietnam War is at higher risk for health
problems and health-threatening behaviors such as arrest,
alcohol and drug abuse, and divorce. Many do not seek
treatment for PTSD, but the number of those who have gone for
help is staggering. It is estimated that today some 180,000
veterans have service-connected PTSD.
The psychologically wounded veterans from the current
conflicts have yet to be counted. According to the
Defense Manpower Center's preliminary figures released in
January, nearly 438,000 troops have served in Operation Iraqi
Freedom. Today some 130,000 troops are in theater in Iraq.
When they return home, they will be relieved by some 110,000
replacements in the largest U.S. troop rotation since World
War II. Given that the military expects to have 100,000 troops
in Iraq for the next two years, it is reasonable to assume
that at least three quarters of a million American soldiers
will have served in Iraq by 2006. The question: How many will
seek VA care for mental health problems?
According to the VHA Office of Public Health and Environmental
Hazards, in January there were 83,732 separated Iraqi Freedom
veterans, 12 percent (9,753) of whom have sought health care
from the VA. Of those who sought care, 14 percent were
diagnosed with mental health problems, including drug abuse,
adjustment reaction, depressive or neurotic disorders,
affective psychoses, and acute reaction to stress. This does
not include those who are on active duty and are being treated
for mental health problems. The military is unusually
tightlipped about the exact figures. Investigations by United
Press International, however, indicate that as many as 10
percent of the soldiers evacuated to the Army's largest
hospital in Europe, Landstuhl in Germany, had "psychiatric or
behavioral health'' issues.
According to Dr. Jonathan Shay, a psychologist with the VA in
Boston who has written on the subject, the number of troops
from this conflict who will suffer from PTSD symptoms is
difficult to estimate. ``If the Vietnam War is any guide, then
in the neighborhood of 17 percent of those in theater will
eventually have it,'' he said. "I believe the overwhelming
majority of psychological injuries are going to show up more
than a year and perhaps five years after the fighting is
Dr. Mark Brown, director of Environmental Agents Service at
the VA, also is convinced that PTSD will be a major issue.
"For every soldier who gets killed, there are a half dozen or
more present. That's got to leave a mark,'' he said. Brown
added that PTSD is just one mental health problem among the
many psychological issues to be dealt with in war, including
those resulting from losing an arm or other limb.
Suicide is one of the worst outcomes for those with mental
health problems. Veterans of the Iraq War may be exposed to
conditions that place them at unusually high risk for suicide.
The Pentagon's response to this issue has been contradictory.
On January 14, William Winkenwerder, Jr., Undersecretary of
Defense for Health Affairs, said that Army suicides in Iraq
were somewhat higher than the Pentagon expected. On January
28, Army Col. Thomas Burke, program director for mental health
policy for the Assistant Secretary of Defense, told a
different story. He said that the Army's suicide rate was not
significantly higher than the levels the Army has seen during
the last decade. He said media reports of high suicide rates
The Army sent a team to Iraq in 2003 to assess the situation.
That team has yet to issue a report, even though it was due
out last Thanksgiving. Suicide number crunching has been left
to advocacy groups and the media.
Since the war began in March 2003, the Army confirms that at
least 21 soldiers have killed themselves in Iraq or Kuwait.
This figure does not include those who committed suicide after
returning home after a tour in Iraq. The 67 stateside military
suicides in 2004 could include a significant number of
returning Operation Iraqi Freedom veterans. If added to the
number of those who killed themselves in Iraq, the suicide
rate linked to the current deployment is well above "normal.''
Some are pointing to the drug Lariam as a possible cause. Also
known as mefloquine, this anti-malaria drug was first
developed at Walter Reed Army Institute of Research during the
Vietnam War. Currently produced by Swiss pharmaceutical
Hoffmann La Roche, Lariam was approved for use by the FDA in
1989. It has been routinely administered to American troops in
malaria endemic regions, including Somalia, Afghanistan, and
Iraq. It is also given to those who may be required to deploy
rapidly to these regions.
"I believe, in light of the latest scientific evidence, that
the FDA would be hesitant to approve Lariam today,'' said
Susan Rose, co-director of Lariam Action USA and a faculty
member at the Department of Environmental and Occupational
Health at George Washington University. Rose cited recent
studies indicating that 30 to 40 percent of patients who take
Lariam experience moderate to severe neuropsychiatric side
effects. PTSD and Lariam toxicity, in fact, have similar
symptoms. Those who take Lariam frequently report being in a
fog and a state of confusion for days, experiencing panic
attacks, anxiety, depression, and agitation. There are other
alternatives to this drug. The question is, given that Lariam
has such alarming side effects, why is it being prescribed to
troops in a war zone?
Even more disturbing are reports that the drug is being
distributed to troops by military medical personnel who "bulk
draw" Lariam, handing it out with vague instructions and no
warnings about the serious negative side effects. When the
drug is given out in this manner, it is not recorded in
troops' medical records. According to Susan Rose, the lack of
documentation and tracking makes it difficult, if not
impossible, for the military to report accurately the numbers
of soldiers who are currently taking Lariam.
The suicide of Marine Lt. Christopher Shay illustrates the
lack of attention the military is paying to this issue. After
he returned from Iraq, Shay took his own life. This came after
daily requests for assistance and 12 visits to a military
doctor in the last 36 hours of his life. Shay's family was
baffled, asking why a top Marine with no prior history of
depression would have taken his own life. At first, the
military denied he had even taken Lariam. After conducting its
own civilian forensic investigation, the family found this was
not true. They also discovered that a second suspected suicide
may be linked to Lariam use. It involved a man who had
disappeared overboard. Additionally, Shay's former Gunnery
Sergeant committed suicide 24 hours after he
returned to port in San Diego.
In a December 2003 response to a congressional inquiry,
Winkenwerder reaffirmed the use of Lariam, but denied that
Marines received incomplete information on Lariam's side
effects. "The Armed Forces Epidemiological Board has studied
and supported continued use of mefloquine as the primary
preventive measure against malaria,'' he said.
Failed attempts to get a straight answer from the military
about suicide rates and Lariam toxicity have forced families
of victims and veterans' advocacy groups to turn to Congress
and the media for help. On February 25, in response to
mounting pressure, Winkenwerder reversed his position. He told
a House Armed Services Committee that the Pentagon would look
into the issue.
The Pentagon has announced that it will stop giving Lariam to
troops in some regions, including Iraq, because of
alternatives to the drug. Lt. Shay's mother is not comforted.
She noted that Winkenwerder said the panel he is forming could
take months, if not years, to complete its review. The
question remains: Why did it take so long for the Army to
acknowledge the potential dangers of Lariam and why is the
Pentagon dragging its feet when it comes to looking for
Revised DD Form 2276 is a four-page post-deployment screening
questionnaire required to be filled out by all military
personnel no later than five days after returning home from
deployment. It is supposed to be completed in the
presence of a health-care provider. Questions 7-13 comprise
the metal health portion of the form.
Question 12 reads: "In your life have you had any experiences
that were so frightening, horrible or upsetting that, in the
past month, you:
1. Have had nightmares about it or thought about it when you
did not want to?
2. Tried hard not to think about it or went out of your way to
that reminded you of it?
3. Were constantly on guard, watchful, or easily startled?
4. Felt numb or detached from others, activities, or your
According to the National Center for PTSD, a positive response
to two of the four sub-questions is associated with a PTSD
diagnostic accuracy of .82 and indicates the need for
DD Form 2276 is a response to lessons learned from the 1991
Gulf War, where inadequate and incomplete medical information
was gathered from returning soldiers. Public Law 105-85
requires these medical screenings and mental health
assessments. DoD Instruction 6490, dated August 7, 1997, also
mandates pre- and post-deployment medical screenings, a mental
health assessment, and the collection of blood serum samples.
Noting that ``the identification of health threats and rapid
dissemination of information relevant to troop health has
proven of inestimable value in recent operations,'' the aim of
this military-wide mandate is to develop a more comprehensive
approach to monitoring and assessing the health consequences
Is the military conducting pre- and post-deployment mental
health assessments that meet the intent of the law, or is it
doing little more than meeting the letter of the law by
handing out medical questionnaires?
"They didn't even pick up a stethoscope," reported a Reserve
Navy Lieutenant Commander when asked about his post-deployment
screening. After his unit spent more than a year in Kuwait
during Operation Iraqi Freedom, he added, "They pushed us off
active duty as fast as they could. They haven't learned
a whole lot [from the 1991 Gulf War]."
Steve Robinson, executive director
of the National Gulf War Resource Center, is convinced the
current screenings are not adequate. "We want the Department
of Defense and the Department of Veterans Affairs to conduct
aggressive face-to-face post-deployment counseling, rather
than waiting for problems to arise,'' he said. Robinson is
working with VA officials to create new, pro-active programs
that will connect troops with other combat veterans. The
intent of the program is to share experiences and alleviate
the stigma of reporting mental health concerns.
The lessons learned from the Vietnam War and the 1991 Gulf War
have resulted in significant positive responses on the part of
the military and VA when it comes to dealing with PTSD and
other mental health issues.
Since the Vietnam War, PTSD has been studied extensively. The
government has funded many projects that address PTSD and the
effects of stress on health. The National Center for PTSD was
created in 1989 to advance the clinical care and treatment of
The Pentagon deployed nine combat-stress teams in Iraq and has
placed a psychologist, psychiatrist, and social worker in each
division. After being separated from active duty, veterans may
go to some 205 Vet Centers around the country for help. The
Vet Centers are staffed and run, in most cases, by veterans.
Bereavement counseling is available for families of fallen
It isn't all positive news, however. In addition to unanswered
questions about suicides, treatment of many war-wounded
veterans has been slow and inadequate. Late last year, the
U.S. Senate National Guard Caucus reported on the substandard
treatment of returning veterans at Fort Stewart, Georgia. The
report revealed that 650 Army Reserve soldiers on medical hold
were receiving inadequate medical attention and were being
housed in accommodations inappropriate for their conditions.
Most of these troops had returned to Fort Stewart as a result
of wounds, injury, or illness after being deployed overseas.
According to Shay, improper treatment of soldiers may
exacerbate mental health problems such as PTSD. ``If someone
betrays a set of expectations about how power is going to be
used in a high stakes situation,'' he said, "the human body
may code this as a physical attack.''
Poor treatment may also make some troops hesitant to come
forward with their mental health concerns. One Special Forces
soldier who suffered a panic attack after seeing a dead Iraqi
soldier was charged with cowardice and sent home after he
tried to get help. He was taking Lariam at the time. The
charges were eventually dropped, but cases like his may be
sending the wrong message to others who might be afraid to ask
The VA's resources also are being stretched thinly. Tom
Berger, chairman of VVA's
PTSD/Substance Abuse Committee, is concerned about that. "Vet
Centers are already under-funded,'' he said. "The contract I
signed says I will be given adequate medical care, and it is
When asked how veterans are being treated in this current
conflict, Shay said, "The history of psychiatry of the Vietnam
War is only now being written. One thing that is really clear
is that there can be a hideous mismatch between good
intentions and outcomes.''
Although well intentioned, there is evidence that the scale
and scope of the present conflicts are putting a strain on
military and VA medical resources.
According to Mark Brown, the VA has "some pretty good clinical
programs. We think we're ready, but you never know.
Adjustments may have to be made.''