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Wednesday, May 17, 2006

IRAQ: MENTALLY UNFIT, FORCED TO FIGHT---PART VI........................................


EMPHASIS ON RETENTION

The use of medications is just one aspect of the military's emphasis in treating psychologically wounded troops close to the front and returning them to duty quickly.

Military combat-stress teams pride themselves on high "return to duty" rates, which are also touted in reports by a team of military mental health experts who were sent to Iraq after a spate of suicides in 2003.

But in 2004, top military officials acknowledged shortcomings with a key principle of modern combat psychiatry, known as "PIES," which emphasizes treating troops who exhibit problems as close to the front lines as possible, with the expectation they they will return to duty.

"Unfortunately, the validity of these concepts has never been demonstrated in clinical trials," the group of officials acknowledged in a written report. They also said opponents of the principle frequently leave out its most important element---"respite." They said relief from stress "is the primary principle of acute-related behavioral and mental health [care] in theater."

Still, military leaders maintain faith in their decision to treat psychiatric wounds in the field, arguing that the approach is better for service members than "pathologizing" their stress by evacuating them to a hospital.

Col. Elspeth Ritchie, the psychiatric consultant to the Army surgeon general, acknowledged that the practice also serves the military.

"Historically, we've found patients evacuated out of theater don't return," said Ritchie. "In time of great difficulty---and there's no question the war over there is difficult---sometimes anxiety and depression may overwhelm a soldier, and they feel like they just got to get out of this place.

Throughout the war, the military has evaluated the success of its mental health programs primarily on the basis of how many troops are retained in combat.

While Winkenwerder had assured Congress last summer that troops with severe mental illnesses were being sent out of the war zone, the Army's own reports indicate that the number of soldiers evacuated from Iraq for psychiatric problems has dropped steeply since the first year of the war, as combat-stress teams and medications have become more accessible.

Mental health evacuations have fallen from an average of 75 a month in 2003 to 46 a month in 2005, according to Army statistics. Overall, barely more than one-tenth of 1% of the 1.3 million troops who have been deployed to Iraq and Afghanastan have been evacuated because of psychiatric problems. Meanwhile, the mental health teams close to the front lines pride themselves of return-to-duty rates that typically exceed 90%.

But in some cases, the troubled troops that remain in the war zome never make it home.

Army Spec. Joshua T. Brazee, 25, of Sand Creek, Mich., had been in Iraq for less than three months when the military says he shot himself with his rifle in May 2005. According to his autopsy report, he had "talked with other soldiers about death and killing, and also about the idea of suicide."

His mother, Teresa Brazee, said she still has questions about how he died, and believes there were conflicts within his unit. She said one of Joshua's superiors told her that his death taught him to pay close attention to his soldiers.

"It's a little too late for that," she said.

In another case, Pfc. David Potter was kept in the war zone despite a diagnosis of anxiety and depression, a suicide attempt and a psychiatrist's recommendation that he be seperated from the Army.

Potter, 22, told friends that he believed the recommendation had been overruled, leading to a deepening of his depression, a fellow soldier said. On Aug. 7, 2004---10 days after the psychiatrist recommended he be sent home---Potter took a gun from under another soldier's bed and killed himself.

The fellow soldier, who did not want his name used because he is still in the military, said Potter was clearly having trouble with the stress of deployment, but wasn't getting the help he needed.

"We saw what was going on," he said, "but we couldn't do anything about it."

Ann Scheuerman knew her son Jason was having a hard time in Iraq, but she didn't know the depth of his despair until she awoke to a short e-mail from him last July that left her shaking with fear.

"I'm sorry, mom, but I just can't deal with this anymore," he wrote from his base in Muqdadiyah. "I love you, but goodbye."

After an agonizing morning of frantic phone calls, Scheuerman learned that officers and a chaplain had reached Jason in time, taking away his rifle, posting a guard and ordering a mental evaluation for the 20-year-old private first-class.

For the first time that day, Ann Scheuerman could breathe.

But her son's problems were just beginning.

Jason got a psychologicl evaluation, but afterward, he sent his mother another disturbing e-mail.

"He was very discouraged," said Scheuerman, of Lynchburg, Va. He said, "Mom, they think that I'm making this up and that there was nothing wrong with me, that I needed to just be a man, be a soldier and quit wasting the Army's time." He said they said, they were going to court-martial him for treason, that sergeants said they were tired of people making up excuses to try to get out of combat and it wasn't fair to all the other soldiers.

Jason was pulled off missions with his fellow soldiers, assigned menial jobs around the barracks and given his gun back.

He used the weapon three times later to become the 1,179th U.S. military fatality of Operation Iraqi Freedom.

Ann Scheuerman, who, like Jason's father, is an Army veteran, strongly supports the military. But she wants to know how things could have gone wrong in Jason's case.

Kiley, the Army surgeon general, said he believes that mental-health professionals in Iraq are quick to evacuate troops who are at risk of hurting themselves or others, or who have "risen to the level of being moderately or severely depressed."


WHO'S HELPING THE TROOPS

After the spike in suicides in 2003, military officials said they had faith that teams of mental health specialists deployed to Iraq and Kuwait woud be able to provide needed care to the troops, and help to break the stigma associated with mental health issues.

But with the 205 suicidal rate in Iraq climbing to the highest level since the war began, some soldiers' advocates are now questioning whether the specialists have become too reliant on short-term treatments and medications, and not enough on one-to-one counseling.

Sandy Moreno, a Sacramento, Calif.-based psychiatric technician in the Army Reserve, was among the first combat-stress team members in Iraq. While her team prided itsef on a return-to-duty rate of about 95%, she said counseling and respite---no medications---were the focus in the early months f the war.

"You can't start someone on antidepressants and then not see them again because their unit is moving aroung," Moreno said. "When you put them on those kinds of meds, a lot of times it takes six weeks before they take effect, or they can cause side effects. We could never keep that good track of a soldier."

The military has about 230 counselors dispatched in Iraq and Kuwait for about 100,000 troops, about the same number as in 2004, an Army spokesman said. But there are signs that the providers themselves are burning out.

A team of mental health experts reported in January 2005 that caregivers were experiencing "compassion fatigue," with one-third behavioral health workers reporting high burnout, and one in six acknowledging that stress was hurting their ability to do their jobs.

"If our providers are impaired," the team wrote, "our ability to intervene early and assist soldiers with their problems may be degraded."

Beyond burnout, military documents and interviews reveal a culture in which mental health professionals are constantly on the alert for troops faking mental illness to get out of duty.

"Clinicians must always maintain a keen eye for potntial malingerers," instructs the Iraq War Clinician Guide, a 200-page bible complied by the Department of Veterans Affairs and the Walter Reed Army Medical Center. Suspicions require close consultation with commanders to ensure proper diagnosis and disposition."

Some Iraq veterans say the military is too quick to dismiss mental health complaints, and still has a problem treating injuries to the mind the way it treats injuries to the body.

"If you break your leg over there, you're going to get treatment," said Georg-Andreas Pogany. "When they go for mental health services, they are belittled, they are shoved aside, they are called malingerers. Their experiences are completely invalidated."

In 2003, Pogany, a former Army interrogator, was charged with cowardice---a crime punishable by death---after suffering a panic attack and seeking counseling because he had seen the body of an Iraqi man who had been cut in half by American gunfire. The charge was later dropped.

Bob Johnsom, former chief of combat stress control for an Army brigade of about 2,800 soldiers, said he would routinely review soldiers' work and disciplinary histories when they complained of serious mental problems. If a soldier with a history of antisocial behavior came in insisting he was going to shoot himself if he wasn't sent home, "then that's a pretty clear-cut case of malingering, he said."

Johnson said he took a punitive approach to dealing with those soldiers, taking away their guns---which he compared to "losing your manhood"---and forcing them to sleep at the command point, in the line of sight of commanders.

He said he had treated one soldier who threatened to starve himself to death, and later swallowed a handful of pills---both acts that Johnson deemed bogus attempts to get out of serving.

"There's no doubt about it, the guy had mental health issues," Johnson said. "But he wasn't going to get the treatment he wanted, which was to go home."

"The question is, do we want to reward this behavior? Because if we reward this behavior, more soldiers are going to do it."


Source: The Hartford Courant
Story By: Lisa Chedekel and Matthew Kauffman
May 16, 2006

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