Crash landings

Is the new wave of war veterans getting the help it needs?

As the U.S. military wrestles with President Barack Obama's plan to expand the war in Afghanistan while reducing its presence in Iraq, there's a mounting cost on the home front for the 1.9 million soldiers who have been deployed to those conflicts and are now beginning the often difficult transition back to civilian life.

Inadequate stateside mental health and other veterans' services has been serious problem for years (see "Soldier's heart, 12/22/04). A report in January 2008 by the RAND Corp. titled "Invisible Wounds of War" found that nearly 20 percent of Iraq and Afghanistan veterans report symptoms of posttraumatic stress disorder (PTSD) or major depression, and that an additional 19 percent experienced a possible traumatic brain injury while deployed. But only slightly more than half of these returning veterans seek treatment that RAND called "minimally adequate."

The report estimated that PTSD and depression will cost the nation $6.2 billion in the two years following deployment, but also estimated that investing in more high-quality treatment — and thus lowering the rates of suicide and lost productivity among veterans — could reduce those costs by $2 billion within two years. Modern life-saving and protective technologies and repeated deployments appear to be making the problem worse now than in previous wars.

"Early evidence suggests the psychological toll of the deployments may be disproportionately high compared with physical injuries," the report stated, concluding that a national effort is needed to expand and improve the capacity of the health care system and to encourage veterans to seek this care.

That national picture is reflected in San Francisco. Judi Cheary of San Francisco's Department of Veteran Affairs medical clinic said that 25 percent of the service members they see returning from Afghanistan and Iraq receive a mental health diagnosis.

Keith Armstrong, the clinic's PTSD counselor and a professor of psychiatry at University of California-San Francisco, noted that veterans often have a diagnosis that includes depression and PTSD, or substance abuse and PTSD. "So they may be struggling with many problems," said Armstrong, who wrote Courage After Fire: Coping Strategies for Troops Returning from Iraq and Afghanistan and Their Families (Ulysses Press, 2005). "Others simply have adjustment challenges from being in combat."

For instance, traffic can be difficult for returning service members who drove in combat conditions, where explosives were a constant concern. "They are scanning the environment because that's what kept them safe in combat, or pushing the steering wheel when a friend is driving, trying to move from one lane to another," he explained.

According to V.A. data, California has the third-highest number of veterans in the nation. In Northern California, most live in the Central Valley, leaving some San Francisco vets feeling isolated. "There's a lot of talk about supporting the troops, which is nice, but it's intellectual," Armstrong said. "Here people may not disclose that a family member is in war, not because they're afraid people will spit on him, but because they are afraid that people will say dumb things."

His clinic has seen an increase in these veterans in the past year. Armstrong typically sees three clusters of PTSD symptoms: intrusive symptoms (vets can't get particular images and experiences out of their head); avoidance symptoms (vets believe they don't have a great future ahead; they feel numb, it's hard to get close to them); and arousal symptoms (vets are often irritable and angry).

Anger often causes the most problems. "We see more self-destructive and reckless behavior in younger folks," he added. "They have anger, revenge-based fantasies.