The Fallout: The Things They Carry

Posttraumatic stress disorder (PTSD) doesn't leave a visible battle scar. That may be one reason it's hard to quantify just how many soldiers suffer from it. In July 2004, a report in The New England Journal of Medicine estimated that 17 percent of soldiers returning from Operation Iraqi Freedom had PTSD-related symptoms. But Alfonso Batres, who heads the Department of Veterans Affairs' (VA) Readjustment Counseling Service, believes the rate is now higher--and growing. So far this year some 14,000 vets have sought counseling at the 207 community vet centers he oversees. About 27 percent of them, he explains, report such symptoms. "The numbers coming in are escalating," says Batres, who stresses that his data are anecdotal.

PTSD is one acronym the military doesn't like. It prefers "temporary adjustment disorder," with an emphasis on the temporary. If Batres's numbers prove right, the overall rates of PTSD could equal those of Vietnam. PTSD has afflicted as many as 30 percent of Vietnam vets over their lifetimes. But this time there is a big difference: most of the current cases won't become chronic. It took nearly a decade after the Vietnam war for doctors to diagnose PTSD. Even then, the therapy was often extreme: either patients were ignored or they were treated like convalescents. "We've learned a lot of lessons from Vietnam," says Dr. Mark Shelhorse, who heads the VA's mental-health program. "If we intervene early, most cases resolve with just a little support and therapy."

The trick is getting to the soldiers before they get in trouble. Since the war in Iraq began, all soldiers have been required to fill out a mental-health questionnaire before demobilizing that includes questions that screen specifically for PTSD. Do they feel emotionally numb or have insomnia? Do they have nightmares or flashbacks? But many soldiers are loath to admit weakness, let alone anything that carries a stigma like a mental-health problem. If they check a red-flag box, they'll delay their return. "We know that they just want to get home," says Dr. Elspeth Ritchie, psychiatry consultant to the U.S. Army Surgeon General. That's why the Army is starting a pilot program next month to review the mental health of soldiers who've been back three to six months, when rates of PTSD tend to go up.

Doctors only now understand what triggers the disorder and how to treat it. "PTSD doesn't just come from having a near-death experience, but how personalized it is," says Patricia Resick of the National Center for PTSD. There are some new gimmicky treatments--like using computer simulation to relive and conquer trauma. But all the therapy comes down to the same idea: confront what happened. "Often soldiers can only talk to folks who have been there," says Colonel Ritchie, who is especially concerned about those in the National Guard and Reserves who might return home isolated and be unable to find outlets to discuss what happened there. Batres has started a new soldier-to-soldier counseling program he hopes will help. He believes that outpatient treatment usually works best--and not just because the VA's budget is in the red. At the Bronx VA Medical Center in New York, leading PTSD psychiatrist Rachel Yehuda says that her therapy lasts for just three months, and then vets come back for a "tuneup." "This is the new model," says Yehuda, who is hosting a national conference on the disorder on Sept. 11. Unfortunately, these are boom times for PTSD.

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