As America closes out its mission in Iraq, the Pentagon is gearing up to provide hundreds of thousands of returning soldiers with a new safeguard: intensive screenings for mental and emotional problems caused by combat.
But military suicides - on average, one soldier has taken his or her own life every 36 hours between 2005 and 2010 - aren't slowing down yet, according to an alarming new report this fall that says the suicide rate could threaten the United States' decades-long reprieve from conscripted service.
Troubled in large part by those suicides, Congress passed legislation two years ago requiring three mental-health screenings for each soldier within the two-year period after he or she returns from combat.
"We have been working for years to develop better screening for signs of post-traumatic stress disorder, or PTSD, in our combat troops and veterans," said the bill's chief sponsor, Sen. Max Baucus, D-Montana. "The Montana National Guard led the way on this front with a successful pilot program. And in 2009, we passed a law to take the Montana model nationwide."
As of October, the Pentagon had hired nearly 3,500 health-care providers to screen its returning combat vets for elevated stress levels. The Army has already provided its initial examinations of the first 400,000 troops, although it hasn't announced the results of those exams yet.
"Before this law, many of our troops received only a paper questionnaire, and never received an individualized assessment," Baucus said. "Thanks to this law, they are now getting personal, and private, one-on-one attention from a trained health-care provider. And they get follow-up assessments for at least two years after they return."
The Congressional Budget Office (CBO) estimated that enacting the legislation would cost taxpayers $60 million over a ten-year period.
Montana's junior senator, Jon Tester, also a Democrat, added a provision that the Department of Defense (DoD) also provide a baseline mental-health exam for all troops before they deploy into combat arenas.
That followed a study reported in the American Journal of Psychiatry in which doctors screened more than 10,000 infantry soldiers from three brigades heading into combat in Iraq in 2007. The 74 soldiers at highest risk were barred from deployment, and doctors tracked another 96 at-risk soldiers and provided them with coordinated care. The study then compared their mental health problems with another 10,000 unscreened soldiers from three other brigades.
"Soldiers in screened brigades had significantly lower rates than those in unscreened brigades for suicidal ideation, combat stress, and psychiatric disorders, as well as lower rates of occupational impairment and air evacuation for behavioral health reasons," it concluded.
A study released last October by the Center for a New American Security found that approximately 14 percent of our military population is currently taking a prescription opiate; furthermore, when military doctors change a civilian prescription, they're barred from requiring that soldiers turn in the excess medications. The study also said 29 percent of our military suicides involve drugs or alcohol.
The Army has reported an ever-increasing number of suicides, which peaked in July 2011 with the deaths of 33 active and reserve component soldiers. Marine Corps suicides increased from 2006 to 2009, dipping slightly last year, while Air Force, Navy and Coast Guard suicide rates have been lower and more stable.
The Veterans Administration (VA) estimates* that one of America's vets takes his or her own life every 80 minutes, and that while only 1 percent of all Americans have served in the military, former service members make up 20 percent of the nation's suicides. But the VA's estimate that 18 vets a day kill themselves is based on limited data from the 16 states that report veteran status in their death data; that suicide rate is then extrapolated to the nation as a whole. Better data is critical to knowing exactly how many veterans end their own lives prematurely.
Why is this happening?
Some counselors are now talking about the "wounded souls," the former soldiers plagued by guilt, shame and fear for what they have done (or failed to do) in combat; those emotional wounds can be a key reason for suicide.
The Center for a New American Security takes it a step further. It suggests that a sense of belonging, a feeling of usefulness, and an aversion to death and pain have traditionally protected individuals from suicide. But now, it says, military service weakens all three of those "protections." Soldiers bond to other members of their fighting unit more closely than they have ever done, but that unit is frequently altered when it returns stateside ... and that unity is shattered when a soldier is discharged. When a vet tries to find a civilian job as meaningful as saving the world, he feels useless ... and that feeling is strengthened if he's shuffling papers or unemployed. Finally, combat experience gives soldiers a closer knowledge of death and an increased tolerance for pain ... which can make suicide a less frightening alternative.
All those things happened to a young soldier in the Montana National Guard named Chris Dana.
Dana was a kid straight out of high school when he joined the Guard and was sent to Iraq with Montana's 163rd Infantry Battalion. His unit saw some tough fighting, but after he got back home to Helena in October 2005, he didn't talk about what he had done. Shortly after the 163rd returned, Dana's company was disbanded and he was ordered to drill with another company from Butte. Since he didn't know those people and had a growing aversion to drills (a classic sign of PTSD), he quit attending them. After a number of threats, the Guard got rid of him with a less-than-honorable discharge and told him that he'd never be able to find a better job as a result of his discharge. That hit home because Dana was just barely scraping by with a job at Target.
Dana's stepbrother Matt Kuntz, now executive director of the Montana chapter of the National Alliance on Mental Illness, was appalled by the situation. "A lot of people who have been our best soldiers and done our best work are getting real bad discharges," he said at the time. "He quit going to drills. He was so badly injured that he couldn't deal with the military anymore." Kuntz couldn't understand why the Guard didn't try to help his stepbrother. "Instead of going out and seeing him in a nonthreatening way, they made his life a living hell," he said.
A week after he was booted out of the Guard, Dana put a pistol to his head and pulled the trigger.
That suicide, however, had a remarkable effect. It changed the way Montana - and, ultimately, the nation - treated returning combat veterans.
Gov. Brian Schweitzer quickly demanded answers and appointed a commission to detail how Dana had slipped through the cracks of the state's military mental health care system. The commission came up with 14 recommendations for reform,* and Major Gen. Randy Mosley, then the adjutant general of the Montana National Guard, promised to implement all of them.
He did, and Montana became the model for providing mental health care to its vets.
Most important was a pledge to have every soldier receive a mental health examination every six months for the first two years after his return from combat and another every year thereafter. Previously, soldiers had been given a questionnaire during their debriefings asking them whether they suffered from PTSD. For some, those symptoms didn't appear for months after their return, but even the vets who were already having nightmares and flashbacks tended to check the box "no"because they wanted to get home and see their families, and because they feared they might jeopardize their military careers if they admitted high levels of post-combat stress.
All that changed under the new system. Soldiers are required to sit down with trained counselors every six months to discuss how they are feeling, how they are sleeping, anger or irritability issues, abnormal alcohol use and/or marital issues.
At the 120th Air Wing of the Montana National Guard, deployment resiliency assessment screenings of about 1,000 airmen triggered 88 individual red flags, including five critical cases and ten priority cases, according to the Montana National Guard's personnel chief, Col. Jim Oehmcke. That's about 17 percent of those who had been deployed.
"A critical case might be someone currently threatening to harm himself or others, while a priority case might be someone who had considered it in the past," explained Master Sgt. Mary Montag.
Those numbers are lower than in previous years because the number of deployments has dropped from about 400 airmen a year to 100, Montag said, adding that "a lot of our cases involve alcohol abuse or medication mixing."
During 2011, the Montana Army National Guard screened 1,147 soldiers, including 510 who had previously been deployed, and referred 111 (nearly 22 percent of those who had been deployed) for further mental health counseling, according to Oehmcke.
Both of those numbers are lower than those of the VA, which found that about 28 percent of the 1.3 million veterans who left the military service after serving in Iraq or Afghanistan have sought help for mental health issues. By last June, that was about 368,000 vets.
But Montana has taken additional steps to help. Both the Montana Army National Guard and the Air National Guard developed crisis response teams made up of the unit's commander, first sergeant, personnel officer, a chaplain and health professionals. They can be convened almost immediately to provide help when a soldier is in trouble. The crisis response team for the 120th Fighter Wing, based in Great Falls, handled five crisis situations in its first year.
Another major change involved military bonding. After returning from combat, soldiers were traditionally given a three-month vacation from their weekend drills, but members of the Montana Guard said they really missed being away from their combat buddies and they were having difficulty talking with their families. So, Guard officials got permission from the DoD to continue holding monthly drills immediately after deployment.
But there was a catch: drills were held in hotels or convention centers with Guard members in civilian clothes and spouses and families in attendance. There were seminars for soldiers and spouses on mental health, anger management, personal finance and civilian driving laws. That turned into the Yellow Ribbon Program, which has been adopted by the National Guard nationwide.
In addition, TriWest Healthcare developed a plan of embedded counselors that it tested in California and Montana. It sent a counselor to join the Army National Guard and another to join the Air National Guard on base during each drill weekend. Counselors were available to talk with soldiers, their friends or their families with or without an appointment. They also mingled with the Guard members and observed them. At the end of the first year's pilot program, the embedded counselors were clearly so useful that the Montana National Guard adopted the program permanently.
"I can't say enough for what they tried to do," says Kuntz. "There's no doubt that PTSD created a huge challenge for the Montana National Guard and other military units, but it started when they flat-out admitted that they had been wrong, and that's what it takes for an organization to change and make the reforms they need."
Kuntz said the across-the-board screening requirement fulfills the nation's moral obligation to help its soldiers.
"And it showed me that this country still works, that when we have a basic, commonsense idea on the state level, we can implement it and bring it through Congress to the federal level," Kuntz said. "When you think about what these young men and women are fighting for, it's nice to see that this still works."