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Mental toll on troops detailed

Strains shown in 17% of US combat forces

Nearly one in five US combat troops returning from war-torn Iraq suffered from post-traumatic stress, major depression, or other serious mental afflictions, according to new data detailing the psychological costs of the bloodiest war in a generation.

A study conducted by the US Army shows that combat-related mental problems have been higher among those who have served in Iraq than in any military action since Vietnam.

It also paints the first broad statistical picture of the battlefield horrors encountered by the American combatants on the front lines in Iraq. For instance, one in four Marines surveyed reported killing Iraqi civilians. About one in five Army members surveyed reported engaging in hand-to-hand combat. More than 85 percent of those in Marine or Army combat units said they knew someone who had been injured or killed. More than half said they had handled corpses or human remains. The figures were based on soldiers' responses; the military does not have statistics available to confirm them.

Up to 17 percent of these troops in Iraq suffered mental health problems, though less than half said they had sought professional help after ending their tours, according to the study, published today in the New England Journal of Medicine.

"There's no question that these service members have truly experienced the spectrum of things that happen during the war," said Dr. Charles Hoge, psychiatry chief at the US Army Walter Reed Medical Center and lead author of the study. "This is real, sustained war."

The Pentagon's health affairs chief, Dr. William Winkenwerder, said it was premature to compare service in Iraq with Vietnam, but added, "We can certainly surmise there's plenty of stress."

With more than 800 US soldiers killed and more than 5,000 wounded, Operation Iraqi Freedom has become the deadliest American military conflict since the Vietnam War, in which some 58,000 Americans died.

The new study's chief purpose was to gauge the effectiveness of mental health services provided by the military. The data indicated a dramatic improvement since the Vietnam era, when the military's mental health care was relatively unsophisticated.

But the study still revealed gaps in the system, chief among them a continued stigma about mental illness among troops despite considerable educational efforts by Pentagon brass over the last decade. Also, nearly half of Iraq veterans reporting mental symptoms said they had trouble scheduling a psychiatric appointment.

The mental trauma from the Iraq war appears to be approaching Vietnam-like levels for the 40,000-plus US soldiers in the thick of daily violence, according to the new study. Mental distress, particularly post-traumatic stress disorder, or PTSD, can hurt troops' morale, as well as disrupt their lives back home, producing flashbacks, insomnia, and alienation.

Wartime psychology was in its infancy during the Vietnam conflict, and no comparable studies were done of soldiers during the war. Later research found that about 15 percent of troops who served there suffered PTSD. The most recent studies found that about 30 percent of Vietnam veterans had developed psychological problems after the war, as condemnation of soldiers by stateside critics exacerbated combat stress in some.

The study found that 12 to 13 percent of troops returning from Iraq reported PTSD symptoms, and another 3 to 4 percent reported other mental distress. By contrast, PTSD estimates for veterans of the first Gulf War range between 2 and 10 percent. The rate is about 4 percent in the US adult population. The new Army study found about 11 percent of troops returning from Afghanistan reported symptoms of mental distress.

The Army researchers found a direct correlation between PTSD rates and exposure to combat. In Iraq, 86 percent of Marines and 71 percent of Army troops surveyed said they were involved in firefights; five firefights per soldier was the median. Among those never encountering a firefight, 4.5 percent reported suffering PTSD-like symptoms. Those who said they had been in five or more had nearly a 20 percent rate of such symptoms.

More than 6,000 Marines and Army soldiers from units involved in combat in Iraq and Afghanistan were surveyed for the study. The results, said the Army researchers, could be extrapolated to the roughly one-third of the 140,000 troops now in Iraq who regularly engage in combat. The other two-thirds serve support roles.

The study said the front-line soldiers faced a horrific tableau of violence in Iraq. More than 90 percent said they had been shot at. Nearly 20 percent said they saved someone's life. More than 80 percent of Marines said they saw injured women and children they had been unable to help.

Of those Iraq veterans surveyed who reported symptoms of mental distress, 40 percent of Army troops and 29 percent of Marines said they had sought professional help. The top reasons given for avoiding such help, from a multiple-choice list provided by the researchers, were, in order: "I would be seen as weak"; "My unit leadership might treat me differently"; "Members of my unit might have less confidence in me"; and "It would harm my career."

The study's author, Hoge, asserted there was no evidence that soldiers receiving mental health treatment would suffer job discrimination.

He said that all returning soldiers are screened for mental distress and referred to military psychiatrists when necessary. If requested, they can get confidential treatment outside the military health care system; the government covers the costs.

"We're a lot better off now than ever in the past, in terms of the treatments available and the awareness," he said.

Lieutenant General James Peake, the Army's surgeon general, said of the study yesterday, "We do want to take care of our soldiers."

He said the military had put unprecedented resources into mental health outreach.

"We put extra mental health units . . . into Iraq. They're ubiquitous," he said.

But Dr. Roger K. Pitman, a Massachusetts General Hospital psychiatrist specializing in combat-related PTSD, said the soldiers' fear of stigmatization was "not entirely unfounded."

"A negative mental health review can hurt your [military] career," he said. Nonetheless, he said, "The system has become more cognizant of these disorders. In Vietnam, the percentage of soldiers seeking help was in the single digits."

Raja Mishra can be reached at

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