"Among combat troops sent to Iraq for the third or fourth time, more than one in four show signs of anxiety, depression or acute stress, according to an official Army survey of soldiers’ mental health," the New York Times reported Sunday.[1]  --  "The Army study of mental health showed that 27 percent of noncommissioned officers — a critically important group — on their third or fourth tour exhibited symptoms commonly referred to as post-traumatic stress disorders," Thom Shanker wrote.  --  "That figure is far higher than the roughly 12 percent who exhibit those symptoms after one tour and the 18.5 percent who develop the disorders after a second deployment, according to the study, which was conducted by the Army surgeon general’s Mental Health Advisory Team.  --  The new survey is causing "increased alarm" among Army leaders, Shanker said.  --  "Among the 513,000 active-duty soldiers who have served in Iraq since the invasion of 2003, more than 197,000 have deployed more than once, and more than 53,000 have deployed three or more times, according to a separate set of statistics provided this week by Army personnel officers."  --  Shanker's article states baldly the problem from the Army's point of view, but gives scarcely any idea of its larger significance.  --  This subject is discussed in summary fashion in The Three Trillion Dollar War: The True Cost of the Iraq Conflict (W.W. Norton, 2008), the recent volume co-authored by Nobel Prize-winning economist Joseph Stiglitz.  --  The several pages he devotes to the subject are reproduced below.[2]  --  Stiglitz and co-author Linda Bilmes write:  "Mental health disorders are extremely costly, both because they require long-term treatment and because those who suffer from them have a greater tendency to develop physical medical problems. . . . PTSD is highly prevalent as a result of multiple rotations into combat, the widespread use of IEDs, and the absence of a defined 'front line' in battle. . . . Studies have found a strong correlation between the length of time a soldier serves in a war zone and the likelihood of developing PTSD. . . . we can expect that the servicemen and women on their second and third deployments are at high risk." ...

1.

U.S.

Washington

ARMY WORRIED BY RISING STRESS OF RETURN TOURS TO IRAQ
By Thom Shanker

New York Times
April 6, 2008

http://www.nytimes.com/2008/04/06/washington/06military.html

WASHINGTON -- Army leaders are expressing increased alarm about the mental health of soldiers who would be sent back to the front again and again under plans that call for troop numbers to be sustained at high levels in Iraq for this year and beyond.

Among combat troops sent to Iraq for the third or fourth time, more than one in four show signs of anxiety, depression or acute stress, according to an official Army survey of soldiers’ mental health.

The stress of long and multiple deployments to Iraq is just one of the concerns being voiced by senior military officers in Washington as Gen. David H. Petraeus, the senior Iraq commander, prepares to tell Congress this week that he is not ready to endorse any drawdowns beyond those already scheduled through July.

President Bush has signaled that he will endorse General Petraeus’s recommendation, a decision that will leave close to 140,000 American troops in Iraq at least through the summer. But in a meeting with Mr. Bush late last month in advance of General Petraeus’s testimony, the Joint Chiefs of Staff expressed deep concern about stress on the force, senior Defense Department and military officials said.

Among the 513,000 active-duty soldiers who have served in Iraq since the invasion of 2003, more than 197,000 have deployed more than once, and more than 53,000 have deployed three or more times, according to a separate set of statistics provided this week by Army personnel officers. The percentage of troops sent back to Iraq for repeat deployments would have to increase in the months ahead.

The Army study of mental health showed that 27 percent of noncommissioned officers -- a critically important group -- on their third or fourth tour exhibited symptoms commonly referred to as post-traumatic stress disorders. That figure is far higher than the roughly 12 percent who exhibit those symptoms after one tour and the 18.5 percent who develop the disorders after a second deployment, according to the study, which was conducted by the Army surgeon general’s Mental Health Advisory Team.

The Army and the rest of the service chiefs have endorsed General Petraeus’s recommendations for continued high troop levels in Iraq. But Adm. Mike Mullen, chairman of the Joint Chiefs, and Gen. George W. Casey Jr., the Army chief of staff, and their top deputies also have warned that the war in Iraq should not be permitted to inflict an unacceptable toll on the military as a whole. “Our readiness is being consumed as fast as we build it,” Gen. Richard A. Cody, the Army vice chief of staff, said in stark comments delivered to Congress last week. “Lengthy and repeated deployments with insufficient recovery time have placed incredible stress on our soldiers and our families, testing the resolve of our all-volunteer force like never before.”

Beyond the Army, members of the Joint Chiefs have also told the president that the continued troop commitment to Iraq means that there is a significant level of risk should another crisis erupt elsewhere in the world. Any mission could be carried out successfully, the chiefs believe, but the operation would be slower, longer, and costlier in lives and equipment than if the armed forces were not so strained.

Under the drawdown already planned, the departure of five combat brigades from Iraq by July should allow the Army to announce that tours will be shortened to 12 months from 15 by the end of summer.

Even so, senior officers warn that time at home must be increased from the current 12 months between combat tours. Otherwise, they say, the ground forces risk an unacceptable level of retirements of sergeants -- the key leaders of the small-unit operations -- and of experienced captains, who represent the future of the Army’s officer corps.

The mental health study conducted by the Army was carried out in Iraq last October and November, and does not represent a purely scientific sampling of deployed troops, because that is difficult to accomplish in a combat environment, the authors of the study have said. Instead, the study was based on 2,295 anonymous surveys and additional interviews from members of frontline units in combat brigades, and not from those assigned primarily to safer operating bases. Since the study was distributed last month, it has become a central topic of high-level internal discussions within the Army, and its findings have been accepted by Army leaders, senior Pentagon and military officials say.

The survey found that the proportion of soldiers serving in Iraq who had encountered mental health problems was about the same as found in previous studies -- about 18 percent of deployed soldiers. But in analyzing the effect of the war on those with previous duty in Iraq, the study found that “soldiers on multiple deployments report low morale, more mental health problems, and more stress-related work problems.”

By the time they are on their third or fourth deployments, soldiers “are at particular risk of reporting mental health problems,” the study found.

The range of symptoms reported by soldiers varies widely, from sleeplessness and anxiety to more severe depression and stress. To assist soldiers facing problems, the Army has begun to hire more civilian mental health professionals while directing Army counselors to spend more time with frontline units.

Senior officers at the Pentagon have tried to avoid shrill warnings about the health of the force, cognizant that such comments might embolden potential adversaries, and they continue to hope that troop levels in Iraq can be reduced next year. Still, none deny the level of stress on the force from current deployments.

Admiral Mullen spoke broadly to those concerns last week, saying at a Pentagon news conference that the military would have already assigned forces to missions elsewhere in the world were it not for what he called “the pressure that’s on our forces right now.”

He added that the military would “continue to be there until, should conditions allow, we start to be able to reduce our force levels in Iraq.”

One example of the pressure has come in Afghanistan, where the Pentagon has been unable to meet all of the commanders’ requests for more forces, in particular for several thousand military trainers.

Defense Secretary Robert M. Gates told reporters on Friday that he expected that the United States would be able to add significantly to its deployments in Afghanistan in 2009. But to do that -- and to increase time at home for soldiers between deployments -- probably would require further reductions in troop levels in Iraq, Pentagon planners said.

Members of the Joint Chiefs also acknowledge that the deployments to Iraq, with the emphasis on counterinsurgency warfare, have left the ground forces no time to train for the full range of missions required to defend American interests.

2.

[Book excerpt]

From THE THREE TRILLION DOLLAR WAR: THE TRUE COST OF THE IRAQ CONFLICT (W.W. Norton, 2008)
By Joseph E. Stiglitz and Linda J. Bilmes

[Published March 2008]

***

Pages 82-84 (from Ch. 3, "The True Cost of Caring for Our Veterans"):

The war in Iraq has been noteworthy for the types of physical injuries sustained, especially traumatic brain injuries, but the largest unmet demand is in mental health care.[Note 56: See the testimony of Iraq Katz, M.D., Ph.D., Deputy Chief Patient Care Services Officer for Mental Health Veterans Health Administration, U.S. Department of Veterans Affairs, before the House Committee on Veterans Affairs, July 25, 2007; Hoge, Auchterlonie, and Milliken, "Mental Health Problems, Use of Mental Health Services, and Attrition from Military Service After Returning from Deployment to Iraq or Afghanistan," pp. 1023-32; and Charles Hoge, Carl Castro, Stephen Messer, et al., "Combat Duty in Iraq and Afghanistan: Mental Health Problems and Barriers to Care," New England Medical Journal, vol. 351, no. 1 (July 2004), pp. 13-22. These studies estimate that 19%-30% of all veterans returning from Iraq will meet criteria for serious mental health disorders.] The strain of extended deployments, the stop-loss policy, stressful ground warfare, and the uncertainty surrounding discharge and leave have all taken their toll. Some 38 percent of the veterans treated so far -- an unprecedented number -- have been diagnosed with a mental health condition. These include post-traumatic stress disorder, acute depression, and substance abuse. According to Paul Sullivan, "The signature wounds from the current wars will be (1) traumatic brain injury, (2) post-traumatic stress disorder, (3) amputations and (4) spinal cord injuries, and PTSD will be the most controversial and most expensive."[Note 57: Linda Bilmes, interview with Paul Sullivan, Program Director of Veterans for America, December 23, 2006.]

Mental health disorders are extremely costly, both because they require long-term treatment and because those who suffer from them have a greater tendency to develop physical medical problems. Long-term studies of Vietnam veterans have also shown that PTSD leads to worse physical health throughout a veteran's life.[Note 58: Veterans Disability Benefits Commission, Final Report, August 2007, pp. 470-7.] According to the Veterans Disability Benefits Commission, PTSD sufferers had the worst overall health scores in the veteran population, and one in three veterans diagnosed with PTSD was permanently incapable of working, classified as "individually unemployable." The National Institute of Medicine found that while PTSD accounts for 8.7 percent of total disability claims, it represents 20.5 percent of compensation benefit payments.[Note 59: See Douglas Zatzick, et al., "Posttraumatic Stress Disorder and Functioning and Quality of Life Outcomes in a Nationally Representative Sample of Male Vietnam Veterans," American Journal of Psychiatry 154 (December 1997), pp. 1690-95.]

PTSD is highly prevalent as a result of multiple rotations into combat, the widespread use of IEDs, and the absence of a defined "front line" in battle. Troops who have returned from Iraq and Afghanistan also talk about the moral ambiguity of seeing combatants dressed as civilians, of not knowing who is friend and foe. Studies have found a strong correlation between the length of time a soldier serves in a war zone and the likelihood of developing PTSD.[Note 60: Seal, et al., "Bringing the War Back Home: Mental Health Disorders Among 103,788 U.S. Veterans Returning from Iraq and Afghanistan Seen at Department of Veterans Affairs Facilities," pp. 476-82.] For this reason, we can expect that the servicemen and women on their second and third deployments are at high risk. Most of those serving second and third deployments have not yet returned. Moreover, psychiatrists point out that a good many PTSD symptoms -- confusion; vertigo; being easily startled; numbness; difficulty in sleeping, concentrating, and communicating -- can also be symptoms of traumatic brain injury, and so there is some difficulty and overlap in the diagnoses.

Compared to veterans of earlier conflicts, Iraq and Afghanistan war veterans are fare more likely to seek help for mental health distress, in part because of awareness campaigns run by veterans' organizations and an outreach campaign conducted by the VA itself. There is no reliable data on the length of waiting lists for returning veterans, but even the VA concedes that they are so long as to have the effect of denying treatment to a number of mental health patients. In Psychiatric News for May 2006, Frances Murphy, M.D., then Under Secretary for Health Policy Coordination at the VA, stated that mental health and substance abuse care are simply not accessible at some VA facilities. When the services are available, Dr. Murphy added that in some locations "waiting lists render that care virtually inaccessible."[Note 61: Quoted in Rich Daly, "New Freedom Commission Members Assess Report's Impact," Psychiatric News, vol. 41, no. 9 (May 2006), p. 1.]

Veterans groups have filed a national class action lawsuit against the Department of Veterans Affairs on behalf of veterans and their families seeking or receiving death benefits or disability compensation for PTSD. The plaintiffs estimate that the class includes between 320,000 and 800,000 veterans, a figure they arrive at by multiplying the number of troops deployed by their estimated incidence of PTSD (20-50 percent). The plaintiffs are not seeking financial compensation; rather, they want the VA to acknowledge a number of policy failures. "This isn't a case about isolated problems or the type of normal delays and administrative hassles we all occasionally experience with bureaucracies," says Gordon P. Erspamer, the lawyer representing the veterans on a pro bono basis. "This case is founded on the virtual meltdown of the VA's capacity to care for men and women who served their country bravely and honorably, were severely injured, and are now being treated like second-class citizens. The delays caused by the VA have created impenetrable barriers to relief for thousands of impaired veterans."[Note 62: Statement by Gordon Erspamer, litigation partner at Morrison & Foerster LLP, August 7, 2007. The complaint was filed in the U.S. District Court, Northern California.]

***

Pages 99-101 (from Ch. 4, "Costs of War That the Government Doesn't Pay"):

THE ECONOMIC COST OF MENTAL HEALTH DISABILITY

Another significant economic cost arises from war-related mental health disabilities. Leading veterans' advocates say that mental health disorders will be the top medical problem facing veterans of the Iraq and Afghanistan conflict.[Note 15: CBS News interview with Paul Sullivan, Director of Veterans for Common Sense, November 13, 2007]. The numbers to date confirm this; already, more than one in seven returning veterans has been treated for mental health issues by the VA. Suicide rates in the Army for the past two years have been 17.3 soldiers per 100,000 and 19.9 per 100,000, respectively, the highest levels in sixteen years.[Note 16: Mental Health Advisory Team (MHAT-IV) study, Final Report.] In past years, the rate has averaged 11.6 per 100,000. One quarter of these servicemen and women took their own lives while serving in Iraq or Afghanistan.

Not surprisingly, those who are deployed longer or face repeated deployments face the greatest risk of mental health problems.[Note 17: Seal, et al., "Bringing the War Back Home: Mental Health Disorders Among 103,788 U.S. Veterans Returning from Iraq and Afghanistan Seen at Department of Veterans Affairs Facilities," pp. 476-82.] One recent study by the Defense Department, confirming previous studies, found that soldiers deployed longer than six months, or who have been deployed multiple times, were more likely to screen positive for a mental health issue. This is partly because the longer they serve, the more likely it is that a soldier will face the death or disfigurement of a comrade. The study reported that two thirds of soldiers and Marines showing signs of a mental health problem knew someone who had been seriously injured or killed. And the study showed that deployment length in itself was directly linked to morale issues in the Army.[Note 18: Mental Health Advisory Team (MHAT-IV) study, Final Report.]

Veterans are entitled to disability pay if they suffer from mental illness; but the Veterans Disability Benefits Commission discovered that the amount such veterans receive understated their economic loss by a wide margin. For example, VA benefits covered only 69 percent of the income that at thirty-five-year-old veteran with a mental health disability could have expected to earn had he been healthy. For veterans who are rated 100 percent mentally disabled, the commission found that the lifetime earnings disparity -- the difference between what the veteran could have earned and the disability compensation they were paid -- was as high as $3.6 million.[Note 19: Veterans Disability Benefits Commission, "Honoring the Call to Duty: Veterans' Disability Benefits in the 21st Century," October 2007.]

The commission also found that veterans with severe mental health disorders had the poorest overall ratings on health and quality of life. Among those suffering from PTSD, one out of every three was not capable of working at all ("individually unemployable"). In addition, long-term mental health disorders led to poor physical health. As the commission points out: "Physical disability did not lead to lower mental health in general. However mental disability did appear to lead to lower physical health in general."[Note 20: Ibid., p. 15.] This confirms the findings of Dr. Charles Marmar, chief psychiatrist at the Veterans Hospital in San Francisco, who has led a thirty-year longitudinal study of Vietnam veterans. His study found that PTSD patients suffered diminished well-being, physical limitations, compromised health status, permanent unemployment, days spent in bed, and episodes of violence.[Note 21: Zatzick, et al., "Posttraumatic Stress Disorder and Functioning and Quality of Life Outcomes in a Nationally Representative Sample of Male Vietnam Veterans," RAND Corporation, 1997.]