TIME politics

Montana Senator’s Plagiarism Scandal Has a Silver Lining

John Walsh
Sen. John Walsh, D-Mont., speaks during an event in the Capitol Visitor Center on the importance of the Land and Water Conservation Fund, July 23, 2014. Tom Williams—CQ-Roll Call,Inc.

Sen. Walsh's mental health may have nothing to do with lifting from other scholars, but the acknowledgement of PTSD and depression reveals a changing moment in politics.

Sen. John Walsh (D – Montana) is being accused of plagiarism for failing to properly cite the work of others in the master’s thesis he wrote while at the Army War College in 2007. Indeed, it has been widely reported that as much as a quarter of what the senator wrote—and presented as his own work—may have been the ideas and/or words of other prominent experts on Middle East policy.

When asked about this apparent transgression, Sen. Walsh stated that he believed he had done nothing wrong. He didn’t recall using sources improperly, but he is considering apologizing to scholars he failed to cite. A campaign aide for the senator acknowledged the plagiarism, but indicated that Sen. Walsh did not intend to deceive anyone and that his actions should be viewed in the context of a successful military career during which he was a highly decorated officer who served with distinction in the Montana National Guard. The aide noted that Sen. Walsh was going through a difficult period in 2007. One of the soldiers from his unit in Iraq had committed suicide during this time. The senator has acknowledged that he is being treated for post-traumatic stress disorder. He is currently taking antidepressant medication as part of this treatment.

We can’t know what Sen. Walsh intended when he failed to include citations for ideas that were not his when he wrote his thesis seven years ago. One indication of whether this act represents a flaw in the senator’s character, a lapse in judgment, or a failure to understand academic standards and practices is to look for a similar pattern of behavior—or lack thereof—across his life and career. Those on both sides of the political spectrum will be doing just that as this story unfolds.

Some are asking if there is a relationship between PTSD and plagiarism. There is none—at least not a direct one. There is, however, a clear relationship between the experience of trauma and possible impairment across a number of areas, including cognitive and emotional functioning. The relationship is even stronger if you experience repeated trauma. Imagine driving to work and having a head-on collision on the highway. Miraculously you walk away with no physical injuries, but others around you die. Imagine that this happens to you not once but several times over the course of several months or a year. You begin to have difficulty sleeping, concentrating and focusing. You might feel depressed, you might have flashbacks, and you most certainly will have guilt and possibly shame. Could this experience of repeated trauma affect your judgment or your ability to process information critical to your success in your relationships, at school, or in your career? Absolutely.

Though the consequences – if any – of Sen. Walsh’s actions in 2007 are yet to be determined, it is important that we continue to have conversations and discussions about the very real impact that trauma can have on someone’s long-term functioning. We need these discussions not because we should excuse behavior that is inappropriate, unethical or criminal, but because one in four Americans suffer from diagnosable mental health conditions, along with the trauma that often creates those conditions. Sometimes war causes these injuries, sometimes a natural disaster, or a rape, or an assault. Sometimes it is a bad role of the genetic dice that leads to significant impairment. Isn’t it better to discuss these issues openly and, by doing so, encourage appropriate care and relieve unnecessary suffering?

Perhaps one silver lining resulting from the last 13 years of war—and many tragic stories of those who have struggled upon their return from battle—is that we as a nation are becoming a bit more comfortable with the topic of mental health. Until now, few if any politicians or other public or military officials have been willing to admit they have a mental health issue, let alone suggest it may have clouded their judgment. Perhaps we are more willing to entertain the possibility that the cause of someone’s behavior just might be a bit more complicated than we think. After all, mental health is a part of the human condition. We all experience it, and sometimes the difference between being mentally sharp and healthy or not depends on whether we swerve the wrong way, are born with the wrong DNA or watch a buddy die in combat.

Barbara Van Dahlen, named to the TIME 100 in 2012, is a licensed clinical psychologist and the founder and president of Give an Hour. A notable expert on the psychological impact of war on troops and families, Dr. Van Dahlen has become a thought leader in mobilizing civilian constituencies in support of active duty service members, veterans and their families.

TIME politics

Veterans Affairs Needs to Get a Clue About PTSD Treatment

Veterans
Iraq war veteran Zach Choate, 26, leads a group of veterans to a rally on the steps of Russell Building to call for a end to the redeployment of troops who have diagnosed with Post Traumatic Stress Disorder (PTSD). Choate was redeployed while still recovering from wounds inflicted by an IED. Tom Williams—CQ-Roll Call,Inc.

Some medical centers may have a goldmine of PTSD data, which could help improve treatment. If only the department could get its act together.

Both the Departments of Defense and Veterans Affairs spend huge sums every year to treat post-traumatic stress disorder: $294 million and more than $3 billion, respectively, in 2012. But does the treatment help? According to a new congressionally mandated, 300-page report from the Institute of Medicine, neither the Pentagon nor the VA—the two agencies responsible for providing PTSD treatment to soldiers and veterans—have a clue.

The investigating committee found “spikes of excellence in both departments,” said its chairman, Sandro Galea of Columbia University’s Mailman School of Public Health. It also identified “tremendous variability in how care is implemented and an absence of data that tell us if programs are working or not.” Overall, the modest data that do appear in the IOM report are not particularly encouraging.

Members of the expert panel visited some of the VA’s Specialized Intensive PTSD Programs, or SIPPs, which are inpatient or residential programs of up to four months. They reviewed the results of all 39 such programs during 2012 and found that, after four months of treatment, the average patient still qualified for a diagnosis of PTSD.

This isn’t entirely surprising. The VA learned in the 1990s that their 16-week specialty inpatient programs were ineffective, and closed them down. Under political pressure in the 2000s, they started them up again.

But there might be good news—if only we could demonstrate it. After all, the majority of PTSD patients in the VA are not treated in inpatient or residential settings, but as outpatients. Presumably, these patients are better off than those referred to intensive programs.

So how do they fare? Are they better able to benefit from state of the art cognitive-behavioral therapies, such as prolonged exposure and cognitive processing? Clinicians routinely use these interventions to good effect in treating PTSD among civilians. We have every reason to expect that, in most cases, these therapies–in conjunction with psychotherapy and couples or family therapy or medication—have indeed helped veterans.

In any case, the IOM says there are no data. Well, not quite. While not reliably collected across the entire VA health system, there is some tracking information on treatment outcomes. For several years, the VA has required clinicians in every VA medical center to complete a PTSD Checklist (PCL) for each patient every 90 days. The PCL provides a total symptom severity score.

This enables clinicians to track changes in symptoms and establish the optimal frequency of therapy sessions, according to Ron Acierno, former director of the PTSD Clinical Team at the Ralph H. Johnson VA Medical Center in Charleston, S.C. Acierno and his team conducted routine PCLs, though how consistently and completely the surveys were administered at other VA medical centers is unknown.

In medical centers that do comply with the VA mandate to collect PCLs, there may well be a small goldmine of data to be excavated. With this information, we could answer immediate questions about the improvement of veterans’ symptoms and functioning. We could begin to learn what kinds of outcomes we see for younger veterans of the post-9/11 era and Vietnam veterans whose wartime experience is now several decades ago. Yes, Vietnam veterans are very much in the picture as new PTSD patients. One out of every three new patients in 2012 in the VA’s specialized PTSD programs was a Vietnam-era veteran, according to the IOM–even though they last saw military service decades ago.

We could also examine differences in response to treatment between active duty personnel and veterans. Our colleagues tell us, impressionistically, that men and women still in the service are, in general, more motivated than the patients they have treated in the VA. That’s because the culture of the military mental health system aims to help soldiers resume participation, while the VA’s current disability policies often reinforce illness roles and inadvertently pose disincentives to work and recovery because compensation is contingent upon the severity of PTSD.

In establishing PTSD Awareness Day, the Senate resolved to “help ensure that those suffering from the invisible wounds of war receive proper treatment.”

In some, though not all VAs, they do. Now the mission is to ensure quality care is widespread, and to learn whether treatment is helping, who benefits most (and least) and why. Veterans with PTSD deserve the best care possible; accountability is critical to seeing that they get it.

C. Bartley Frueh is chair of the social sciences division at the University of Hawai‘i at Hilo. Sally Satel is a resident scholar at the American Enterprise Institute. Both are former VA clinicians.

TIME Military

The PTSD Epidemic: Many Suffering, Few Solutions

Soldiers with the U.S. Army's  Bravo Company, 1st Battalion, 36th Infantry Regiment rest in an Afgan National Police compound before going on patrol near Command Outpost AJK (short for Azim-Jan-Kariz - a near-by village) in Maiwand District
Soldiers with the U.S. Army's Bravo Company, 1st Battalion, 36th Infantry Regiment rest in an Afghan National Police compound before going on patrol near Command Outpost AJK in Maiwand District, Kandahar Province, Afghanistan on Jan. 24, 2013. Andrew Burton—Reuters

The scourge of wars in Afghanistan and Iraq is worse than we thought

Now that Iraq is falling apart, it seems only fitting that the U.S. government issues a fresh accounting revealing that neither the Pentagon nor the Department of Veterans Affairs has any idea if the billions they’re spending on PTSD treatments are doing any good.

A congressionally mandated Institute of Medicine panel reported Friday that neither agency assesses the success of their PTSD care. “Without tracking outcomes, neither DOD nor VA knows whether it is providing effective or adequate PTSD care, for which they spent $294 million and more than $3 billion, respectively, in 2012,” the 300-page study concludes.

Roughly 5% of all troops have been diagnosed with PTSD, the report says, but it’s nearly double—8%—for the 2.5 million who served in Afghanistan and Iraq. Post traumatic stress disorder is also increasing among older veterans. In 2013, the VA diagnosed 62,536 new cases in veterans who did not serve in the Iraq and Afghanistan wars. One out of every three new patients in 2012 in the VA’s specialized PTSD programs was a Vietnam-era veteran. All told, the number of veterans seeking PTSD care jumped from 190,000 in 2003 to more than 500,000 in 2012.

“Although these numbers are likely to underestimate the incidence and prevalence of PTSD, they demonstrate that action is needed to respond to this growing problem,” the study says. “Demands for post traumatic stress disorder services among service members and veterans are at unprecedented levels and are climbing.”

The IOM report is crammed with data about the extent of the problem, and figures to back them up (you can see more of them here):

  • Total Pentagon spending on PTSD treatment jumped from $29.6 million in 2004 to $294.1 million in 2012.
  • Outside PTSD care funded under the Pentagon’s TRICARE program climbed from $22.4 million in 2007 to $131 million in 2012.
  • Between 2006 and 2012, the number of hospitalizations of service members for PTSD increased by 192%.
  • The total annual cost for health care for a veteran who had PTSD was estimated to be $11,342, which was more than double the annual VA health care cost of a veteran without PTSD.

Even those who have dealt with the issue for years are surprised. “The acceleration of PTSD among service members and veterans is staggering,” says Elspeth Ritchie, a retired Army colonel and the service’s one-time top psychiatrist.

The Pentagon’s PTSD treatments “appear to be local, ad hoc, incremental, and crisis-driven, with little planning devoted to the development of a long-range approach to obtaining desired outcomes,” the IOM report says. While the VA’s programs are “more unified,” they both lack records of what treatments work, meaning they “have no way of knowing whether the care they are providing is effective.”

The Pentagon PTSD bill grew 10-fold between 2004 and 2012. IOM

“Given that the DOD and VA are responsible for serving millions of service members, families, and veterans, we found it surprising that no PTSD outcome measures are used consistently to know if these treatments are working or not,” says committee chair Sandro Galea of Columbia University’s Mailman School of Public Health. The report is a follow-up to an initial IOM assessment of PTSD treatment released in 2012 that only surveyed what was available; Friday’s study was to find out if they work.

The number of veterans of all eras who sought care for PTSD from the VA more than doubled from 2003 to 2012—from approximately 190,000 veterans (4.3% of all VA users) in 2003 to more than a half million veterans (9.2% of all VA users) in 2012. For those treated for PTSD in the VA system in 2012, 23.6 percent (119,500) were veterans of the Iraq and Afghanistan wars.

PTSD can happen when someone experiences a traumatic event, on the battlefield or elsewhere. It can lead to anxiety, depression, sleeplessness and other symptoms that can interfere with life, sometimes contributing to domestic violence, divorce and suicide. The multiple deployments required by a force too small to support the wars fought has played a major role in the PTSD increase among recent vets.

Unfortunately, even if the government begins tracking outcomes, the results may be what the IOM calls “modest,” at best. The only program that routinely conducts such assessments is the VA’s small specialized intensive PTSD program (SIPP). “In 2012, the 39 SIPPs had 3,792 entrants for a total cost of $88,572,953, or $23,578 per patient,” the study found. “The average PTSD Checklist (PCL) scores for veterans at admission to the programs and 4 months after discharge were 65.9 and 60.2, respectively. That indicates that most program graduates met the criteria for clinically significant PTSD after discharge on the basis of a PCL cutoff score of 50.”

TIME Veterans

Veterans Offer Each Other Help as Iraq Falls Apart

A US marine from the 3/5 Lima company po
A U.S. Marine in Fallujah in November 2004. PATRICK BAZ / AFP / Getty Images

One group warns of “frustration” that could lead to suicide

More than 1.5 million Americans served in Iraq between 2003 and 2011. More than a few of them are upset with what’s happened to that country, where they fought and their friends died, over the past week.

That’s why the Wounded Warrior Project sent an email Tuesday to its 50,000 members acknowledging their sacrifices and offering mental-health services if they find the latest happenings from Iraq depressing.

“Your feelings are justified,” Ryan Kules, 
the project’s national alumni director and a double amputee, said. “If you feel frustration watching the news, remember that we did our duty and served admirably, coming home with the visible and invisible scars of that service.”

The reaction of those who fought, and whose friends died, in Iraq has been somber. There wasn’t so much bitter anger as a palpable sadness. Those who thought the invasion was a mistake consoled themselves by blaming President George W. Bush; others blamed President Obama for not fighting harder to keep some U.S. forces in the country after 2011 to try to ensure the lives of the 4,486 Americans who died there didn’t end in vain.

“So many of my friends died in a war that didn’t need to be fought, but that did ultimately provide a reasonable chance for a democratic Iraq in the center of the Middle East,” retired Army officer John Nagl says. “It now appears that all those lives have been squandered because of an unwillingness to pay an insurance premium of a few thousand advisers and some airpower.”

Such grim tidings can lead to despair, which is why Kules of the Wounded Warrior Project reached out. He urged troubled vets to seek help “if you are dealing with PTSD triggers because of current media coverage,” and gave a phone number—1-800-273-8255—for any veterans “struggling with thoughts of suicide.”

Michelle Roberts, the communications chief at the project, says the group reaches out when an event—like last year’s Boston Marathon bombing—might trigger adverse reactions among those who served. “We’re very aware of the conversations our alumni are having with each other, and our staff, about the recent developments and how they affect them,” she says. “We just felt it was a really appropriate time to communicate with them.”

Interviews with veterans echo that view. “I’m just heartbroken, tired and nearing mute,” says Alex Lemons, an Iraq vet and former Marine sergeant. “I never saw a concrete objective and, in consequence, a willingness to win on our part.”

Lemons pulled three tours in Iraq, and says the goal shifted with each:

I was told this at the beginning: `And our mission is to clear, to disarm Iraq of weapons of mass destruction, to end Saddam Hussein’s support for terrorism, and to free the Iraqi people.’ WMD? Nothing. Fiction. Al Qaeda and indigenous terrorism? Terrorists entered the country after we invaded and then recruited heavily amongst those Iraqis we alienated with de-Baathification and firings throughout the army. Even during the surge, we could not crush every insurgent group. Regime change? We mishandled the trial and subsequent execution of President Hussein. In some ways, the Maliki government is another Baath party in Shiite garb.

“All Americans who fought there want Iraq to succeed so that we can have personal closure and know our sacrifices were worth it even as the rest of America, like the Vietnam experience, wants to forget,” Lemons says. “But Iraq will never give us that.”

Even Army Gen. Martin Dempsey, chairman of the Joint Chiefs of Staff, feels the sting. “Many of you have served in Iraq or know friends and family who made great sacrifices there,” he said in a message sent to troops Thursday. “Like many of you, I was disappointed at how quickly the situation in Iraq deteriorated as well as the rapid collapse of many Iraqi units.”

“It was somewhat expected, yet still disappointing, says Rob Kumpf, who served in Iraq as an Army non-commissioned officer. “Fighting an asymmetric war with one hand tied behind your back, with poor planning and unengaged leadership, led to the current situation Iraq’s security forces face. We screwed up the end game when we withdrew, and will soon do the same in Afghanistan.”

But other veterans have shrugged off what is happening. “Iraq’s political situation is not the concern of individual veterans of the war,” says William Treseder, who deployed to Iraq and Afghanistan as a Marine sergeant. “Combat veterans should value their service based on what they did, not on what happened after the fact or in some larger international context.”

Those who haven’t fought don’t know how combat can change one’s perspective. “Love, loyalty, sweat, and blood are the currency of service—its beating heart. Politics is a dry husk that tries to cover and limit that vitality,” Treseder says. “I wish Iraq and Afghanistan the best as countries, but I do not give them the power to determine how I feel about my service to the United States of America. Nor do I think it’s wise for any other combat veteran to do so.”

But some plainly do. “Your examples of valor and strength educate and inspire those around us,” Kules of the Wounded Warrior Project told them in his email. “Remember, you are not alone. Many of your fellow warriors make themselves available to help others…and WWP remains by your side to provide whatever support and assistance you need.
”

TIME PTSD

Here’s What Happens To The Mind After 5 Years of Captivity

Captured US Solider
Sgt. Bowe Bergdahl in an undated image provided by the U.S. Army. U.S. Army/AP

Sgt. Bowe Bergdahl has a lot of healing to do after five years of captivity. The physical scars may fade, but the emotional ones can sometimes be too deep to heal completely

U.S. Army Sergeant Bowe Bergdahl, the last known American POW, was finally returned home over the weekend after five years held in captivity in Afghanistan. Since Bergdahl’s return, curious details have emerged about his mental state before and after capture. And it all begs the question: What does five years in captivity do to the human mind?

Bergdahl’s repatriation is going to be a challenge, and piecing together the psychologically and physically broken veteran is a delicate process. After all, an abduction is the ultimate exchange of power, spurring the start of a complicated relationship based on both deep distrust and reliance, say experts. “He’s to some degree merged with those who held him,” says Brian Engdahl, professor of PTSD Research and Neuroscience at the University of Minnesota. “He was totally dependent on them for food, shelter, clothing. It can reduce a person to a weak state where their entire life revolves around how their captors are treating them.” A morsel of food becomes a generous gift, only to be withheld at the next feeding.

Many POWs find physical and mental strength by relying on their fellow captured soldiers, but Bergdahl was alone. Speculation about whether he suffered from Stockholm Syndrome—the phenomenon where captives identify with their captors—are not unwarranted, though so far evidence hasn’t suggested this to be true.

Studies of POWs from the Korean War show that the psychological injuries from captivity stem from two types of trauma. The first is physical and usually short-term, caused by malnutrition and injury. The more persisting trauma is, of course, psychological. At Landstuhl Regional Medical Center in Germany, which treats U.S. vets from Afghanistan and Iraq, Bergdahl is likely being tested for depression, anxiety, and PTSD, says Engdahl. “Beyond that, he could be feeling deep guilt, shame, bewilderment, and a lost sense of identity,” says Engdahl. If his English is poor, as has been reported, it’s likely from lack of speaking.

Once home, psychological challenges won’t likely abate overnight, says Barbara Rothbaum, the associate vice chair of clinical research in the department of psychiatry at Emory School of Medicine. “But even if the trauma is over, it’s not really over,” she says. POWs often experience flashbacks, and will wake up in the middle of the night thinking they are still in captivity. Many victims become avoidant and don’t want to talk about their experience because they are afraid it will trigger memories, she says. It’s one of the reasons many will forgo treatment.

“I’ve had veterans tell me they were drunk for a year,” says Rothbaum. But avoidance is one of the worst ways to deal with the harsh return, and Rothbaum’s research has shown that talking about experiences early can actually help prevent the onset of PTSD.

“People want to avoid talking about the worst parts, the most shameful, the most embarrassing,” says Rothbaum. “But it will help.”

TIME Parenting

How News Coverage of the Boston Marathon Manhunt Affected Local Kids

Explosions At 117th Boston Marathon
Women and children are evacuated from the scene on Boylston Street after two explosions went off near the finish line of the 117th Boston Marathon on April 15, 2013. Bill Greene—Boston Globe/Getty Images

You may not be surprised to learn that children who attended the 2013 Boston Marathon were six times more likely than non-attendees to suffer from PTSD. Given the carnage and panic wrought by the bombs, which caused 3 deaths and 264 injuries, you’d expect more trauma symptoms from those on the scene. But a new study reports that kids who had up-close views of the ensuing manhunt were just as likely to suffer PTSD as those with near exposure to the bombing. And kids who may not have had first-hand experience of either—well, the more news coverage they watched, the more mental health disturbances they suffered.

The study, published online June 2 in Pediatrics, surveyed 460 parents of children who lived within 25 miles of the marathon or of Watertown, where the manhunt took place. They were asked about their children’s experiences during the week of the attack and about their psychological and social functioning in the following six months. The investigators, led by psychologist Jonathan Comer, formerly of Boston University and now at Florida International University, were interested in the impact both of the bombing and of its ripple effects afterward. They also wanted to measure both PTSD and less severe mental health issues such as conduct and peer problems, hyperactivity and inattention. Interestingly, they found an even stronger link between broad mental health problems among the kids with dramatic exposure to the manhunt (hearing shots, having their house searched, for example) than among kids with similar sensory experience of the bombing itself.

The investigators also measured both the time the children spent glued to the set and whether parents had tried to limit their news viewing. Overall, the kids watched an average of 1.5 hours of attack coverage and more than 20% watched for over three hours. “Two thirds of the parents did not attempt to restrict their children’s viewing at all,” Comer says. “Yet we saw after Oklahoma City and 911 that TV exposure can have negative mental health effects on children, both near and far.”

Experts on children and media tend to agree that restricting children’s media exposure to violent events is critical. Casey Jordan, a criminologist and justice professor at Western Connecticut State University, says that adults can put in context the sensationalism of media coverage designed to create a sense of danger. But children generally cannot. “The best rule,” he says, “is TURN IT OFF unless you really have a suspect on the lam in your neighborhood.” Just get the basic facts, he suggests, and do so by Internet if possible.

Parents can help their children through these scary times by speaking to them honestly but calmly about what is happening and letting them express their reactions and fears. “It’s important to reassure them that they are safe,” says psychologist Daniel J. Flannery, who directs the Begun Center for Violence Prevention Research and Education at Case Western Reserve University. “Explain,” he says, “that the event was very unusual, and sometimes bad people do bad things but not everybody is like that. Their sense of normalcy has been taken away from them, and they need to get that back. “

Calm matters, agrees Jordan. “Do not go off on a tangent about ‘those people’ or a rant about who is to blame,” he says. “Children are sponges, they will learn from parents’ own reaction to crime and chaos, and absorb all the fall-out from what they hear and see.”

This new study suggests that parents be alert to changes in their kids even months after—and miles away from—a violent incident. Are they eating or sleeping less—or more? Are they more withdrawn or anxious, acting out at school or with friends? The children may not have been personally involved in the traumatic event, suggests this research, but they may still be suffering trauma. “The reach of terror and associated fear,” write the authors, “is not confined to the boundaries of an attack itself.”

TIME U.K.

British Charity Sees Rise in Afghanistan Vets Seeking Mental Health Help

A U.K. veterans mental health charity reported a 57% increase over one year in Afghanistan veterans seeking support

The number of British veterans of the war in Afghanistan seeking help for mental health issues increased sharply from 2012 to 2013, a charity group said Monday, warning that need would continue to rise as the country ends its involvement in the war.

Combat Stress, a U.K. veterans mental health charity, said the number of veterans seeking its help went up 57% in the course of a year. The group received referrals for 358 veterans last year, compared to 228 in 2012. Its caseload now includes more than 660 veterans. The increase is linked to the withdrawal of British troops in Afghanistan from all but two bases in Helmand province.

The charity said it found that veterans wait an average of 13 years after serving before seeking help, but the average time has now fallen to 18 months for Afghanistan veterans. Combat Stress also reported that their total caseload of 5,400 veterans across the country was the highest number in its 95-year history.

“We have had great support from the Government and the public over recent years and we simply could not operate without the generosity we have experienced, ” said Commodore Andrew Cameron, chief executive of Combat Stress. “We cannot allow the ex-Service men and women who suffer from the invisible injuries of war to go unnoticed and untreated.”

TIME Military

TBIs MIA: An Estimated 30,000 Undocumented Bruised Brains

Army Explosives Team Destroys Roadside Bombs In Iraq
Captured explosives used in roadside bombs are detonated by an Army bomb-disposal unit in Baghdad in 2005. John Moore / Getty Images

The Pentagon recorded only half of the wars' traumatic brain injuries, a new study estimates

Despite its vaunted intelligence-gathering capability, the U.S. military was surprised when enemies in Iraq and Afghanistan began building and deploying roadside bombs to kill and maim U.S. troops.

It got so bad that a soldier asked Defense Secretary Donald Rumsfeld nearly two years into the Iraq war why U.S. troops were forced to defend themselves against such improvised explosive devices with homemade “hillbilly armor.”

“You go to war with the Army you have,” Rumsfeld told the soldier, “not the Army you might want or wish to have at a later time.” It took the Pentagon three more years before Mine-Resistant Ambush Protected vehicles finally began trickling into Iraq.

While the troops were waiting for that armor, the Pentagon was also neglecting to track the traumatic brain injuries caused by such blasts, a new medical study says. TBIs—the “signature wound” of the post-9/11 wars—are tough to diagnose and treat. Without a good accounting of those who experienced a TBI, those challenges multiply.

The report’s authors, using amputations as a proxy for TBIs, conclude that the military documented only one in five TBIs estimated to have affected U.S. troops between 2003 and 2006. Responding to legislation, the Pentagon began tracking TBIs more closely beginning in 2007.

Overall, during the eight years spanning 2003 to 2010, the study estimates that 32,822 active-duty troops suffered undocumented TBI wounds. That’s more than the 32,176 documented by the Pentagon over the same period of time. “This analysis provides the first estimate of undocumented incident TBIs among US military personnel serving in Iraq and Afghanistan” before Congress demanded the improved counting, the report says.

Such missing diagnoses are important, says the study, conducted by a pair of Johns Hopkins University health experts. Undocumented TBIs could lead to troops being booted from the military as malingerers or for personality disorders—discharges that could restrict their access to care from the Department of Veterans Affairs.

For those remaining in uniform, it could lead to additional combat tours, boosting their chances of a second TBI and the “visual and auditory deficits, posttraumatic epilepsy, headaches, major depression, and suicide risk” that accompany multiple TBIs, according to the study. Even a so-called “mild” TBI can rattle the (helmeted) brain inside the skull, leading to a host of maladies including memory loss, cognitive deficits, mood volatility, substance-abuse disorders, personality changes, sleep difficulties and possibly post-traumatic stress disorder.

“In recent years, the U.S. military has generally been reactive, rather than proactive, in responding to public health crises, including suicide, psychotropic drug misuse, and gaps in wounded warrior care,” says Remington Nevin, a co-author of the study. “Public-health leaders within the Department of Defense have a troubling history of having epidemics and programmatic deficiencies identified only by outsiders long after the time to act has passed, rather than having these identified internally in time to mount an optimally effective response.”

A top Army psychiatrist at the time says troops minimized the issue, and their leaders weren’t seeking it out. “Soldiers did not want to come forward, for fear that would be taken out of the fight, or thought to be malingerers,” says retired Army colonel Elspeth Ritchie. “And we — the medics and the line [officers] — were not looking for it.”

The authors used an interesting yardstick to estimate the number of undocumented TBIs: they calculated them by developing a mathematic formula that established a relationship between amputations and TBIs, based on the wars’ later years when the Pentagon was more rigorously tracking TBIs. Unlike TBIs—the so-called “invisible wounds” of the nation’s post 9/11 wars—amputations are visible and easily counted.

IED blasts cause most TBIs and amputations, making missing limbs a good tool to estimate the missing TBIs, says the paper, by Rachel Chase and Nevin of Hopkins’ Bloomberg School of Public Health. “Including amputation counts in the model as a proxy for injury causing events is appropriate, given strong clinical and ecological evidence of common mechanisms of injury” for amputations and TBIs, they write in an article in the Journal of Head Trauma Rehabilitation slated to be posted next week.

Too often, wars’ impacts aren’t gleaned until years later. Mustard gas experiments poisoned thousands during World War II. Cold War nuclear-weapons tests are suspected of causing cancer. Agent Orange was the ticking time bomb in Vietnam—the Department of Veterans Affairs is still adding to its list of medical consequences. Gulf War Syndrome stemming from the first war with Iraq, in 1991, remains a mystery. Traumatic brain injury is simply the latest in the list of war’s unintended repercussions.

The authors put together two Pentagon charts and circled the missing TBIs. Nevin
TIME Military

‘Busting My Ass, Defending Yours': Everyday, the Cost of War at Fort Hood

U.S. flags are pictured in front of the Central Christian Church in Killeen, Texas
U.S. flags are pictured in front of the Central Christian Church in Killeen, Texas, April 3, 2014. Erich Schlegel—Reuters

March was the first month without a U.S. casualty in Iraq or Afghanistan in over a decade. But the cost of war is still being borne on the home front.

On April 2, a junior enlisted soldier, Specialist Ivan Lopez, went on a shooting spree at the U.S. Army’s Fort Hood, next to the city of Killeen in central Texas. He killed three people and injured 16 others before taking his own life. Some of the first things we learned about Lopez were that he had apparently served for several months in Iraq in 2011, that his violence may have been motivated by a dispute with some fellow soldiers, that he was being treated for depression and anxiety (including with medication), and that he had legally purchased his weapon, a .45 caliber Smith and Wesson semiautomatic handgun, but violated Army rules when he brought it onto the post without registering it.

These scant details — the military status, the deployment, the diagnosis — seem to tell a familiar story: a soldier gone to war returns home mentally unhinged by what he has seen and done and unleashes that violence like a contagion on his family, his neighbors, his homeland.

This story is dangerous, though. Not because it gets any of the substance of this most recent tragic violence wrong, necessarily. Rather, its focus on isolated and dramatic violence distracts from the subtle, chronic, and widespread effects of war on the people who fight it. It draws crude links between experiences of war, mental anguish, and violence that stigmatize mental illness in general and soldiers in particular.

At best, it risks overlooking the routine, ongoing experiences of the community most directly affected by Wednesday’s events. At worst, it callously misrepresents the members of that same community and lets civilians off the hook for the effects of wars waged in our name.

‘My Other Car Is a Tank’

Americans are accustomed to thinking of war as a literally foreign entity, something that takes place on a distant battlefield on the other side of the world. Decades of an all-volunteer military have enabled this fantasy. The wars in Iraq and Afghanistan represent a major commitment of national purpose and resources, but less than one percent of the U.S. population has served in them. For those who have, though — people at Fort Hood and places like it — war isn’t confined to one time and place. Instead it’s ongoing and ubiquitous, its effects finding their way into the most mundane and intimate aspects of life. In the process war becomes “normal,” but not necessarily any easier to live with.

These slogans emphasize a mix of fierce purpose, wry self-awareness, and mild unease toward the broader civilian public.I spent 12 months at and around Fort Hood in 2007 and 2008, living near the base and learning about the everyday lives of soldiers and those close to them in the midst of ongoing war. Fort Hood is one of the biggest military bases in the world. Its population of around 50,000 soldiers and tens of thousands more military family members, civilian workers and contractors, and retiree veterans demographically and economically dominates the city of Killeen and the other towns neighboring the post.

Motels and chain restaurants run off the constant traffic of a military kept busy by war. Used car dealers, pawnshops, and payday lenders thrive amidst a captive market of young soldiers. The bumper stickers you see on cars sitting in traffic announce that “Half My Heart Is In Iraq” or that “My Other Car Is A Tank”; they declare “Busting My Ass, Defending Yours” or indicate with a wordless configuration of blue stars on a white background that the driver’s family members are deployed. These slogans emphasize the mix of fierce purpose, wry self-awareness, and mild unease toward the broader civilian public that many people I met there shared. Bars, dry cleaners, and big box stores are all adorned with yellow ribbons, “Support the Troops” banners, and the insignia of the 1st Cavalry Division, 3rd Armored Cavalry Regiment, 13th Sustainment Command, and the other units that call the base home.

The base itself is massive, spread out across 150,000 acres mostly devoted to ranges and training areas. Its main built-up area features classically bland, modernist government architecture, like the campus of a giant, sleepy state university, but decorated here and there with decommissioned war machines, old tanks, and helicopters. But just a few blocks away stretches its famous “ten miles of tanks” — the world’s biggest concentration of armored military vehicles (when they are not dispersed across the Middle East) in the form of a nearly 10-miles-long row of chain-link pens full of Abrams tanks, Bradley and Stryker fighting vehicles, and Humvees. They are all painted a uniform desert tan, and look just as at home parked on arid central Texas asphalt and limestone as they do in the deserts of Iraq.

Gate Ticker
Dana DeLoca/Courtesy of Kenneth T. MacLeish

There are other uncanny reminders of the nearness of violence too: On the way into town from the south, next to a billboard advertising a local lingerie shop changes with the seasons, the firearms store Guns Galore invites you to “CHOOSE FROM 1,200 GUNS ON DISPLAY” (news reports say both Lopez and Nidal Hasan, who killed 13 people and injured more than 30 at Fort Hood in a 2009 shooting spree, bought their guns there). Just inside the exit lanes of each gate of the post, giant signs enjoin drivers, “YOU SURVIVED THE WAR, NOW SURVIVE THE ROAD—DRIVE CAREFULLY.” Big red digital numerals indicate “[X] DAYS SINCE THE LAST TRAFFIC FATALITY” beside a blinking light that goes from red to amber to green as the number of safe days rises. I rarely saw the number of days go higher than 10 when I was there in ’07 and ’08 (though when I visited most recently in 2010, a few months after the first Fort Hood mass shooting, it was well into the green).

Jumping at Loud Noises

Fort Hood is the single largest point of departure and return for US forces deployed overseas, a central node in the U.S. wars in Iraq and Afghanistan. At the time of my research, Fort Hood was home to the 1st Cav and Fourth Infantry Divisions — brigades from each saw especially heavy combat as part of the 2006 Iraq War surge — as well as numerous smaller expeditionary units. The tremendous personnel demands of the wars necessitated a grueling rotational schedule that most of these units followed: 12-month tours frequently extended to 15 months and separated by 12 months or less of “dwell time” back in Texas.

She didn’t want to know what had instilled in her husband that lingering, disruptive sensitivity to signs of violence and danger.All this meant that going off to war was often less a one-time event than a repeated shuttling between home and Iraq, giving rise to a sense of both inevitability and uncertainty that loomed over the entire community. I remember my surprise when a friend who was waiting impatiently to learn when her husband, a career infantry noncommissioned officer (NCO), would return from his third deployment casually mentioned that he already expected orders to deploy again a year later. Decisions about policy and tactics may seem like abstract matters, but in such tiny but profound ways as this they show up in people’s everyday lives: The nation going to war means that some one, some person goes. Staying at war means they go again, and again.

I asked a friend I’ll call Jessica if her husband, I’ll call him Cal, a logistics NCO, seemed changed by his time in Iraq (I use pseudonyms to protect the privacy of the people who spoke with me). Cal had just finished a 15-month tour. When Jessica and I first met in 2007, his tour had just been extended, meaning he’d be home by Christmas instead of by Labor Day. She said she could tell that certain things bothered him more, that certain things stressed him out, even though he hid it well and didn’t talk about it. He could be pretty quiet anyway, so she didn’t worry about it much. She would sometimes notice how uncomfortable he seemed around crowds or loud noises — tense, jumpy, and extra quiet. She would ask him if a loud noise had bothered him, he would say yes, and she would leave it at that. I asked her what it made her think. She said she just didn’t want to think about what he might be being reminded of. She didn’t want to know what had instilled in him that lingering, disruptive sensitivity to signs of violence and danger.

People had different ways of responding to such things, though. Jessica told me about a close friend, also a spouse of a frequently deployed NCO. Every time this woman returned home from work or running errands when her husband was gone, as she rounded the carefully planned curve of her street in an Army housing subdivision, she would picture in her mind a car with government plates parked at her front door, and a couple of soldiers in shiny shoes and class A dress uniforms there to notify her that he had been killed. Every time. “Why would you think that?” Jessica wondered aloud to me. “Why would you do that to yourself?”

Army spouses like Jessica and her friend say that “they also serve” and invoke their status as “the silent ranks”: there is a state of war that happens in the sudden sense that your easygoing, imperturbable husband is silently crawling out of his skin as he stands next to you, or that violent death may reach you through the thing you value most and find you out of nowhere on the way home from the grocery store.

They and others told me stories of the terror that can come from the sound of a phone ringing or a knock at the door when a loved one is deployed, the discipline it takes to avoid watching or reading news about the war, the force of will required to ignore gossip and reign in rumor. Jessica kept herself on an even keel by assiduously not giving in to anxious fantasies, not thinking the worst, or indeed trying not to think about the whole thing at all — no simple feat. “I’d rather not go there,” she said. But there is nevertheless an inescapable “there” to go to: the brute fact of loved ones being sent into harm’s way over and over again, of the pain of their absence, of the changed and uncertain condition in which they return home.

‘To Know If You’re Crazy’

The Army has a massive medical system meant to treat the physical injuries that such circumstances produce as well as their mental impacts. Anywhere from 15 to 50 percent of U.S. service members who served in Iraq and Afghanistan are estimated to suffer from post-traumatic stress disorder (PTSD), and even more from related conditions like depression and anxiety. But what exactly becomes of veterans with these conditions is another question, especially given the tremendous overburdening of the Army medical system and the pressure it is under to keep soldiers healthy, able-bodied, and ready to deploy. The Army’s own medical command estimated that a soldier with PTSD could cost the military $1.5 million over the course of a lifetime. There are numerous examples over the last 10 years of individual and concerted efforts by military and Veterans Health Administration personnel to minimize or deny PTSD diagnoses or to rediagnose soldiers with other, non-service-connected afflictions for which the military will not bear as much financial responsibility.

At worst, medicalizing the routine work of war provides yet another way for civilians to fear and pity soldiers without actually understanding them any better.The medical system that cares for ill and injured soldiers also places them under careful scrutiny, trying to distinguish if their pains and complaints are real and if they are worthy of care and compensation. So soldiers themselves often have an ambivalent relationship to a PTSD diagnosis — not least because they know how readily the Army can bend it to suit its purposes, but also because the diagnosis may not accord terribly well with how soldiers think about their war experiences.

Since 2004, all soldiers have been screened for PTSD and other mental illnesses when they return from deployment with questions about whether they participated in combat, were shot at, saw friends get injured, felt afraid that they might be hurt or killed, experienced intrusive memories or dreams, and so on. But soldiers know that answering affirmatively to any of these questions can, at the very least, keep them tied up with doctors and counselors when all they want to do is go on leave and see their families. Even worse, it could stick with them in their medical records, rendering them (officially or unofficially — it happens both ways) unsuitable for their jobs, ineligible for a security clearance, or unfit for promotion.

Aside from these structural disincentives, there is a more basic contradiction at work in these screening questions. The point of the questions, an infantry NCO I’ll call Ernie, who had led countless combat patrols in eastern Iraq, told me, is “to know if you’re crazy,” but the things they are asking after — seeing dead bodies, feeling afraid — were from his perspective simply normal parts of going to war. It is only on contact with the civilian world that the experience of soldiering is made to seem crazy. Ernie told me stories of firefights, near-miss IED strikes, and the gruesome aftermaths of car and suicide bombers — all the things that civilians know are part of war, and may even be comfortable consuming as entertainment, but which we are rarely comfortable hearing about in real life.

Doing and seeing these things and leading his fellow soldiers through them was all part of Ernie’s job, though. “Everything you go through, you go through with the same people you see day in and day out,” Ernie said. “So when you’re talking about it, it’s perfectly normal because you were doing the same shit I was doing, so you’re talking about it like it’s nothing.” In this catch-22, Ernie seems to be saying, it is not war but the experience of diagnosis that makes you “crazy,” both fitting you with the label and upending your own sense of what’s normal.

This process — by which a normal, routine experience comes to be understood as a sign of medical or psychiatric pathology — is what anthropologists refer to as medicalization. Medicalization can be a boon to people afflicted with a previously unnamed or unrecognized condition, giving them access to care and legitimating their suffering. This has unquestionably been the case with PTSD, which names a very real set of symptoms that often go unrecognized and provides at least some hope of care and treatment.

But medicalization can simultaneously have stigmatizing or pathologizing effects of its own, especially when it comes to mental illness diagnoses: Subjectively normal feelings become signs of illness, dysfunction, madness. Reducing soldiers’ experiences to nothing more than individual psychological phenomena in this way makes it all the easier to ignore how our ways of waging war make their suffering inevitable, not exceptional. At worst, medicalizing the routine work of war provides yet another way for civilians to fear and pity soldiers without actually understanding them any better.

Empathizing With a Ticking Bomb

And so we are left with the “war makes you crazy” story that is being offered as an explanation for this week’s shooting. In the understandable search for answers, questions about Lopez’s mental illness were among the first to be asked. The Army was quick to provide answers and the media quick to pass them on. But to what end? The New Yorks Times’s online headlines for the story on Thursday, for instance, announced that Lopez suffered from depression and was being treated by a psychiatrist. We also learned that he was “being assessed” for PTSD and had been prescribed medication, though the only drug named was the sleep aid Ambien. It was also revealed that Lopez had served in Iraq.

Seeing mental illness as a potential source of violence magnifies the stigma already attached to it.The implication was clear that deployment, military status, and above all mental illness and psychopharmaceuticals could somehow explain his murderous actions. Of course it is tempting to turn to mental illness now, as has also been the case with other incidences of both military violence (like Robert Bales’ massacre of Afghan civilians) and domestic mass shooting in the U.S. (Newtown, Appleton, Aurora) over the past several years. Diagnosing Lopez and other mass shooters seems to provide a comfortingly rational scientific explanation for a terrifyingly irrational act. But while particular details of some mass shootings may seem to justify such assumptions, on the whole the connections between mental illness and mass violence are slim to nonexistent.

This is the case with conditions more typically (though wrongly) associated with violence in popular imagination, like schizophrenia, but just as much with the depression, anxiety, and PTSD mentioned in connection with Lopez. People with severe mental illnesses are in fact far more likely to be the victims of violent crime, and those with severe depression potentially a far greater risk to themselves than to those around them. Psychiatrist Jeffrey Swanson has pointed out that mass shootings are incredibly rare events, and that focusing on their links to mental illness entails creating “common evidence” out of “uncommon things.” In the case of Fort Hood, we might also add that the very “common things” that are the source of regular suffering there disappear from view: the impact of long wars, long deployments, and insufficient resources only enter public perception at these moments of uncommon violence.

Even worse than this misunderstanding, however, is the fact that perpetually referring to mental illness as a potential source of violence magnifies the stigma already attached to it. In a military setting like Fort Hood, where many soldiers and those close to them already struggle to find care, sympathy, and assistance for their mental suffering — perhaps even more so in the wake of recent events — the damaging impact of such stigma is only made worse. The notion of stressed-out veterans as over-medicated “ticking bombs” primed to “go postal” — exactly as Lopez is alleged to have done — is often deployed with good intentions to emphasize the real and urgent need for better military health care, as will doubtless happen now, too.

But this rhetoric itself only serves to reproduce the stereotype of what my friend Stan, an Iraq War vet and veterans advocate, refers to as the “crazy vet” stereotype, according to which those touched by war are damaged, vulnerable victims — and also prone to deadly violence. Even as the stereotype pathologizes all soldiers, it focuses attention on a very narrow range of extreme behaviors, actually making it harder to see the broad and far-subtler range of burdens that war inevitably lays on those whose job it is to produce it.

Regardless of one’s perspective on this war, or war in general, the “crazy vet” can both confirm our worst fears about war and justify our outrage about it without prompting us to face these more everyday violences. This haze of pity, anxiety, and fear that swirls around many images of service members is fueled by popular culture, from Vietnam War films to breathless news reports like the ones we are reading this week. But a “ticking bomb” can never be the object of our empathy our understanding — it only tells us to run the other way.

The Stories We Tell About War

One of the things I found in my research is that the stories we tell about war tend to confirm what we think we already know. They often do this at the expense of the people who actually make war, letting us pretend that the violence of war is an exception rather than its essence. Allowing spectacular mass violence like this week’s shooting to be the thing that prompts public concern about the constant stresses faced by soldiers, vets, their families — and anyone who lives with ongoing war — does exactly this.

If we want people afflicted with mental illnesses to be well cared for, we need to talk about their suffering in ways that do not marginalize or pathologize it. And if we truly care about soldiers, veterans, and those close to them, we need to put aside the stereotypes that pop culture, military publicity, media saturation, and “common sense” offer us.

We need to listen to the “normal” experiences of making war — not least so that we may better hear the stories of those in pain in the wake of this most recent violence.

Kenneth T. MacLeish is an assistant professor at Vanderbilt University’s Center for Medicine, Health and Society. He is the author of Making War at Fort Hood: Life and Uncertainty in a Military Community (Princeton University Press, 2013), from which this essay is adapted.

TIME Military

How to Stop the Next Fort Hood Attack

U.S. Army Col. Kathy Platoni holds up her cap at her home in Beaver Creek, Ohio, Nov. 1, 2010.
Kathy Platoni holds up her cap with the names of colleagues killed at Fort Hood in 2009 written inside. Al Behrman—AP

Military mental-health experts argue it’s time for wholesale change—and more money

Fort Hood tore down nondescript Building 42003 a couple of months ago. But razing the building didn’t remove the horrors of that November 2009 day when Army Major Nidal Hasan murdered 13 people inside it. Now Specialist Ivan Lopez’s shooting spree is raising new concerns.

“We’re not real good at recognizing when danger exists,” says retired Army Reserve Colonel Kathy Platoni, who comforted psychiatric nurse Captain John Gaffaney as he lay dying nearly five years ago, shot multiple times in his effort to stop Hasan.

The Army, Platoni says, simply doesn’t have the funds and personnel to do mental health adequately. “If it doesn’t smell right as a mental health professional, you’ve got to look further—but we don’t have the manpower to do it,” Platoni says. “A five-minute interview to fill out a prescription isn’t going to cut it.”

Fort Hood Shooting Building
Building 42003 being demolished at Fort Hood in February. Fort Hood Public Affairs Office / AP

The Army’s top civilian offered additional details about Lopez Thursday. Until he pulled out his Smith & Wesson, he’d had no military record of bad behavior. Like many cases of military suicide, Lopez, who served the last four months of 2011 in Iraq but didn’t see combat, was seeking help. He knew something was wrong. “He was undergoing a variety of treatment and diagnoses for mental health conditions ranging from depression, to anxiety, to some sleep disturbance,” Army Secretary John McHugh said.

Lopez was taking “a number of drugs… including Ambien” to help, and had seen a psychiatrist last month. “We had no indication on the record of that examination that there was any sign of likely violence, either to himself or to others,” McHugh said. “So the plan [going] forward was to just continue to monitor and to treat him as deemed appropriate.”

McHugh added: “We have ordered all possible means of medical and investigatory support, as well as added behavioral health counselors” to Fort Hood.

Could dispatching “added behavioral health counselors” to Fort Hood before the shooting have made a difference?

Experts with years in the military mental-health field say that increased staffing—as well as wholesale changes in how the nation, and the Army, treat mental-health ailments—are needed to stop a third Fort Hood attack.

“We need to focus programs on dangerousness,” says psychiatrist and retired Army brigadier general Stephen Xenakis. “Dangerousness is a community-health issue. Military clinicians should make it routine to ask about guns, drug and alcohol problems, are there mood shifts, and are they explosive? It becomes very apparent when you are sitting with folks who might be dangerous.”

Lopez apparently sent such signals before he exploded. “We have very strong evidence that he had a medical history that indicates an unstable psychiatric or psychological condition,” Lieut. General Mark Milley, the top officer at Fort Hood, said Thursday. “We believe that to be the fundamental underlying causal factor.”

A trained mental-health professional can sense trouble, Platoni says. “You’ve got to develop trust and rapport with the soldiers so they can tell you what’s eating away at their soul,” she says. “People get really agitated, sometimes their eyes are red, they’re tapping their feet, they feel very uncomfortable within their own bodies,” she says, describing potential red flags. “They can’t focus, and have no tolerance for frustration,” Platoni adds. “These things don’t happen in a vacuum—there are always signs when it’s not quite right.”

But the Army only has the funds Congress—representing the U.S. taxpayer—gives it. “They send us to war, and then they don’t want to treat us,” Platoni says. “It’s another ‘no thanks for your service.’”

Retired general Pete Chiarelli was the Army’s second-ranking officer in 2009 when Nidal Hasan struck, and he championed mental health for soldiers as vice chief of staff. He says the Army—and the civilian world—haven’t made much progress in dealing with mental health in recent decades. The nation needs a mental-health Manhattan Project to study the mind and figure out how to fix it when it’s hurt. Instead, Chiarelli argues, it’s relying on antiquated methods that don’t always work.

Pete Chiarelli retired from the Army as its No. 2 officer in 2012. Army photo

“We have horrible diagnostics, we’ve got 20 questions in DSM-5, the psychiatric manual, based on a numerical score that tells us whether we have post-traumatic stress or not, the drugs that we’re prescribing to these kids are all 30-to-40-year old anti-depressants, they’re all off-label kinds of drugs, genetically, everybody reacts differently to them, and we’re short of health-care providers,” says Chiarelli, who retired in 2012. “So even when we do have some therapies that work, we don’t always have the time to apply them—does it become easier to prescribe something, or put him through 15 to 20 90-minute sessions of cognitive behavioral therapy?”

Too much research funded by the federal government remains locked up by the researchers who did it instead of being widely shared with others who might be able to build on it, Chiarelli says. “I had no idea when I signed the [$50 million suicide-prevention] contract with NIH [the federally-funded National Institutes of Health] that the data they collected wouldn’t be released to all the people who were studying suicide, and only released to those people who were part of the study,” he says. “The Army’s thrown $500 million against PTS [post-traumatic stress] research, and what have they got? They’ve still got DSM-5 and a bunch of anti-depressants—they have no new drugs.” Smarter research would go a long way to helping solve such mental-health woes, Chiarelli says—and not just in the Army.

“Go ahead and complain about this kid who had post-traumatic stress down at Fort Hood, Texas,” he says. “But there are all kinds of other people—as we saw at Newtown—who never served a day in the military who have this problem, and we don’t have what we need to help them. Whether it’s Newtown or the Navy Yard or Fort Hood, you have a gun—but you also had a person who had a severe mental issue,” Chiarelli says. “Now that we have the ability to crunch data and probably find diagnostics, and then treatment, for this stuff, God damn it, why aren’t we doing it?”

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