By Shankar Vedantam
    The Washington Post

    Wednesday 01 March 2006

    More than one in three soldiers and Marines who have served in Iraq later sought help for mental health problems, according to a comprehensive snapshot by Army experts of the psyches of men and women returning from the wars in Iraq, Afghanistan and other places.

    The accounts of more than 300,000 soldiers and Marines returning from several theaters paint an unusually detailed picture of the psychological impact of the various conflicts. Those returning from Iraq consistently reported more psychic distress than those returning from Afghanistan and other conflicts, such as those in Bosnia or Kosovo.

    Iraq veterans are far more likely to have witnessed people getting wounded or killed, to have experienced combat, and to have had aggressive or suicidal thoughts, the Army report said. Nearly twice as many of those returning from Iraq reported having a mental health problem - or were hospitalized for a psychiatric disorder - compared with troops returning from Afghanistan.

    In questionnaires filled out after their deployment, more than half of all soldiers and Marines returning from Iraq reported that they had "felt in great danger of being killed" there, and 2,411 reported having thoughts of killing themselves, the report said. It did not have comparable data from earlier conflicts.

    Earlier research has suggested that 12 to 20 percent of combat veterans develop post-traumatic stress disorder (PTSD), which produces flashbacks, nightmares, and intrusive thoughts that disrupt work and home life. The new study found that Iraq veterans are being diagnosed with mental disorders at the rate of 12 percent per year.

    Experts cautioned, however, that they do not have good ways to predict how many people will need help over time. Researchers have found that nearly two-thirds of Iraq veterans who "screened positive" for PTSD and other psychiatric disorders are not receiving treatment.

    The new report comes at a time when budget constraints are causing worries about the cost of caring for large numbers of veterans seeking help for mental problems; the Department of Veterans Affairs is already contending with a recent surge in demand for help with PTSD from troops whose combat experiences go as far back as the Vietnam War or World War II.

    The war in Iraq has also set off a debate over how to define trauma itself, and whether it is appropriate to distinguish those who see combat firsthand from those who do not. The traditional definition of post-traumatic stress disorder, a diagnosis developed in the aftermath of the Vietnam War, involved directly experiencing or witnessing a horrifying event, but some experts are asking whether the constant fear of being killed in places such as Iraq might create problems both for people restricted to bases as well as for those who head outside.

    "There is no front line in Iraq," said Col. Charles W. Hoge of the division of psychiatry and neuroscience at Walter Reed Army Institute of Research, the lead author of the report published yesterday in the Journal of the American Medical Association. "Individuals who are patrolling the streets will be at higher risk of being involved in combat, but folks who are largely located at one base are also targets of mortar and artillery, and everyone in convoys is a target."

    Hoge said it is more important to treat the problems that soldiers report and to evaluate how they function than to argue about whether there were clear-cut events that triggered a trauma, as the definition of PTSD demands.

    Other mental health experts disagree. Harvard psychologist Richard J. McNally said that although just being in Iraq might cause chronic stress, it is not the kind of sudden, horrifying experience that is thought to lead to PTSD.

    "Being in the war zone does not constitute exposure to trauma," said McNally, who helped write the definition of PTSD for the American Psychiatric Association's diagnostic manual. "It is just stressful."

    Michael J. Kussman, principal deputy undersecretary for health at the Department of Veterans Affairs, said the department spends $3.2 billion a year on mental health care. Although large numbers of soldiers and Marines are seeking help, Kussman emphasized that most did not immediately receive a psychiatric diagnosis.

    "Readjustment and reintegration issues are very common among servicemen returning from any combat," he said. "A large portion of people have this temporary reaction. These are normal reactions to abnormal situations and are not considered mental illnesses."

    The president of the American Psychiatric Association, Steven S. Sharfstein, said that though it is too early to say how or whether the conflict in Iraq might change notions of PTSD - the Institute of Medicine is currently reviewing PTSD diagnosis, treatment and procedures for veterans disability compensation - he is not surprised by the number of people seeking help.

    Some even thought the number cited in the study is too low. Steve Robinson, who heads the National Gulf War Resource Center, a nonprofit organization that advocates for veterans, said the military would have found far larger numbers of troubled former soldiers and Marines if it had done a better job reaching out.

    "Upwards of 80 to 85 percent of people serving there have witnessed or been a part of a traumatic event, including engaging the enemy, killing people, or friends or themselves being involved in IED attacks," he said, referring to improvised explosive devices. "In Vietnam, there were safe areas where people could go to rest and recuperate. That doesn't happen in Iraq; every place is a war zone."