Interview Brig. Gen. Stephen Xenakis, M.D. (Ret.)

A retired brigadier general and Army Medical Corps officer, he's a former military psychiatrist and consultant to the Joint Chiefs of Staff. This is the edited transcript of an interview conducted on Feb. 22, 2010.

The high rate of mental health problems that's being recognized in troops returning from combat -- was this a surprise?

The Army did not anticipate reasonably that there was going to be either the number or the kind of mental health problems that this war was going to generate. It really isn't a fault of anybody's. But it really as much tells the story of how we got into the war, how prepared we were, and how long we thought this was going to last, which has been many more years than we ever perceived that it would. And it had been a long time since we'd had the Vietnam War, and no doubt it seemed to be that the problems that came out of that war were unique to those circumstances.

So it wasn't until 2007 that it really caught enough attention of the DoD [Department of Defense] leaders and elected officials and the Congress and others in the country that there was commitment that we were going to handle these problems that we're seeing.

And why didn't you think they saw it coming?

I think that after so many years of not ever having been in conflicts of this duration, it just was not something that was anticipated. This had been an Army that was built up during the Cold War; training was very time-limited, and deployments were time-limited. The first Gulf War was time-limited. It just wasn't in anyone's imagination that by sending the troops out, even if you sent them for a year in theater, that you'd come back and they would have these kinds of problems.

At my interviews of soldiers from the first deployments, they came back as if they'd gone out to one of their extended training exercises, and their routine was about the same that they had always been doing. So it just took a while for leaders and for soldiers to recognize something's changed here.

What were you seeing when the soldiers no longer came back acting as if they'd been on training exercises?

They were tired. They had been emotionally shocked. They had done things and seen things that they did not expect to see. It was so different from how they had trained, so different from what they had been told they would experience. And with that cumulatively, they found they were having problems in their own lives and in their families and just doing what they wanted to do.

You went up to Fort Carson, [Colo.,] in the spring of 2009, is that right? Talk about what you found when you went up there and what your mission was.

The purpose of my trip was tto see for myself what was going on. [There were] a lot of stories about what had been happening in Fort Carson and the kinds of problems soldiers had had. I was going to do it in a way that a doctor takes a history, and meet with soldiers. I wanted to specifically meet with squad leaders, with platoon sergeants, first sergeants, wanted to meet with the NCOs [noncommissioned officers]. I also wanted to meet with the officers in that particular brigade that was about to deploy and then visit the hospital and the other support services.

What I found was that the soldiers and the squad leaders were really stressed. They were getting ready to deploy. They had a lot of training to do. They had a lot of new soldiers come in, and they had to get them ready -- lots of requirements. Their days were long. They were tired. And they were just feeling it and were having all sorts of [stress] showing up all sorts of ways. Day to day, the responsibility for the health and welfare of the soldiers falls on these squad leaders and platoon sergeants, but they were working really hard, and I thought in lots of ways they were exhausted.

When it came to being able to provide emotional support, when it came to being able to calm people down and help them handle their lives and the problems they were facing, I felt these men and women were stretched, and were stretched beyond the limit that they could provide support and help to the soldiers who needed it.

The other thing was that the day-to-day life of these soldiers was distinct, in some way detached, from the officer of leadership. And the officer of leadership was very good and very committed, but they were immersed in what they had to do. I mean, they were not overwhelmed, but they were burdened by getting ready for their mission and understanding what the threat was that they were going to face, so their mind-set and what stressed them was different than the mind-set and what stressed the soldiers and the NCOs. And with that it got to be really difficult to figure out what to do to support these young soldiers who were the ones who were showing up with most of the problems.

So with all these stress factors rubbing up against each other, how did that bode for these guys about to go off to war? They were deploying within a couple of months of when you saw them, right?

I think that everyone was apprehensive. I think their leadership was very reasonably and thoughtfully worried about not only how well the soldiers would handle the stress of combat, but then what would happen afterward when they got back. And they asked for any help they could get from anybody and were willing -- and it was to their credit they were willing -- to do anything that came up as a really good idea.

How different is that from what the experience of the platoon that we were following when they came back in 2005 and went back again in 2006?

I think that's a shift. I think in '05, '06 and maybe up to '07, when the "surge" occurred, I think the idea was: Tough, you're going to train, you can handle it, you just have to really keep your chin up, you can make it, and it's all a matter of just being as hard as you can be. And I think that somewhere in '07, '08, that mentality shifted, and there was a recognition that that doesn't work all the time.

It's not just a matter of being tough, and it's not just a matter of how fit you are, but that in fact the experiences that soldiers have, the combat that they endure, really does impose a lot of stress on them. And the leaders have said: "Now we need to make this as important as everything else that we do. We need to really make a special effort to take care of our soldiers, and that means taking care of the soldiers' families in ways that we have not really done before." So it's a credit to them that they recognized that.

Let's talk about the EPICON [epidemiological consultation] study [PDF] that was done at Ford Carson [and released in July 2009] -- all these killings and assaults in this battalion. Basically, they said, "We've got to figure out what's going on here." Are there any common factors that can help explain why this one battalion is having so many violent issues? Can you talk us through the key findings? ...

The EPICON report is an epidemiological analysis, so it's done by a team sent out by the Army Center for Health Promotion and Preventive Medicine, and it's done in a fairly standard way that public health teams work. They go into communities, settings, and they interview groups of people, and they look for what they hope to find are key variables that explain a public health problem, in this case the violent activity and the suicides and the homicides and other misconduct that seemed to characterize this unit and at Fort Carson.

It has the advantages of good, subjective interviews but also has the disadvantages in a way that it's a large number of folks, and it's comparative, and it's hard to really say, "This is what caused this particular problem."

The kinds of findings that I think this report, as I recall, identified, one is: What's the relationship of the problems to the intensity of combat? And that follows a good deal of research over the years that has investigated the link between the intensity of a stress [and] the appearance of symptoms and problems. In general, the assumption is that the more intense and the more shocking the incident or combat is, then the greater the symptoms that people are going to show up with.

In the conclusion, there would seem to be a discrepancy between the summaries of the findings, which was that there wasn't as firm a link between the intensity of combat and the appearance of symptoms. ...

These units for many years had multiple rotations and had really been in situations of really intense fighting, so there's good reason, I think, to associate the combat that these men saw and the kinds of problems that they had. Certainly there are always exceptions. ...

Recently there's been some recognition of what's called "social contagion," a whole different area. ... In the Army, for years we called that "command climate," and it's hard to measure, but we know that certain units who have had particular experiences, been in particular situations, seem to have either particular problems or for some reason they seem to be distinguished. ...

The other issue is that the soldiers themselves are -- as are many people -- reluctant to seek mental health care. We don't do that as Americans. Is it stigma? Is it just the attitude that we have about trying to go get help and sort of disclose our secrets? But for whatever reason, there's been a reluctance to go to the mental health clinic and see a counselor.

Again, that was one of the things we've interestingly learned from World War II and the Korean War and [as a result] decided in military psychiatry that we would train technicians and have them live with the soldiers and work with the soldiers and just be in the units, and with that be able to talk to people who might be having problems, and in doing that bring them out to get help.

Over the years, actually up until recently, that was one of the things that just fell by the wayside, and we got into a practice of saying, "If you need help, come to the clinic." That's just not practical. People don't want to be identified.

Another problem that the report identified was that there's not coordination among the various agencies, so the mental health counseling is provided by the hospitals and the clinics, and drug and alcohol counseling is provided by the installations in other offices, and then there are family support, and all these different groups really work independently, and there's not a means for them to coordinate what they're doing. So people fall through the cracks. Frankly, sometimes you won't know that a soldier's really having a problem until you realize that his child is showing up and having behavior problems in school, and that child is really the indicator that the soldier is having the problems. Hopefully we can get back to a practice that's a little more multidisciplinary and coordinated.

A couple of other things they mentioned were the short turnarounds and the repeat deployments.

The report also remarked about what's called the "dwell time" -- the 12 months that's typical between the soldiers' returning from a deployment until the time that they leave for the next deployment -- and what the effect is of having such a short time in which they have to recover, sort of restore themselves, get some rest and then start to train up for their next mission. And that's a cycle that many of these units go through, and it would appear in lots of ways that that's much too short.

The usual routine is the soldiers come back, they get about 30 days' block leave, so they're with their families, which may not be good, because really their most intense relationships, the people they feel most comfortable with, are those men and women that they served with in theater, and those relationships sustain them. Then they're all of a sudden taken out of those and put into their families, who may or may not be able to relate to what they've just been through, and they want to talk with each other; they want to share their experiences and go over them.

But they go on 30-day block leave, and then after that they come back, and many of them will tell you things are OK. We kind of start to get back to work, and for about 90 days we seem to be doing all right. But then after about the 90-day mark, you'll see that they really aren't coping. That's when the first indications are that there might be a group here that is starting to show the kinds of stresses of their last missions.

By the six-month time frame, they've got to train for their deployment six months from now, and then things get intense. They start spending time in the field; they're away from their families; they're going to the joint training, the Combined [Arms] Training Center's [CATC] long days. So you get the accumulative effect of that -- that they're away from their families, and their families are feeling stressed, and they really haven't had a chance to really pull themselves together, and they're getting ready again to go back into combat -- and they'll start showing problems.

Now it's all on a bell curve. There's always a group of people that are, for whatever reason, resilient. They're fit; their mind is positive; and they just do well. Then there's a broad middle group that finds ways to cope. But there's a group at that one end of that curve that for whatever reason, they're going to have problems.

So they had the stigma, the intensities, the stress of multiple tours, the short turnarounds, the dwell time. I guess those are the main ones.

The critical findings of the report are that the combat intensity affected the symptoms and the intensity of symptoms that the soldiers showed; that there's a reluctance for soldiers to seek counseling; that they feel there's a stigma if they go see someone; that the dwell time, the time between rotations where they can rest and recuperate, is short, and it's too short for them to both restore themselves and then train up and to get ready for the combat that they're going to experience; that the various kinds of support services and counseling services are not really coordinated on this installation, and it's probably a good example of what happens in other installations. Those are very important to appreciate.

In the past, when there's been a conversation about suicide or PTSD [post-traumatic stress disorder], problems are attributed to just a breakdown in social relationships or just a breakdown in family life, whereas this report recognizes that the stresses that these soldiers have endured -- that they've had multiple deployments, that they've seen a lot of intense combat -- contributed to the problems that many of them had. And that confirms what is just common sense when you are approaching providing services to these men. ...

But what can you do to deal with those causes? I mean, the intensity of battle -- you've got two wars going on, and you only have a certain number of soldiers. You've got to keep moving them through. Obviously the structural things that you talked about can be dealt with, but some of those fundamentals, it seems like the Army is up against a rock that it can't move.

I think in terms of looking at the options that we have, you're absolutely right. The stress of battle is as it is -- it's a fact. But to say that and to recognize that it in fact burdens the individual the way it does, and to do it in a way that also destigmatizes, is an important message to communicate.

If you're exposed to a heavy viral load, then you're likely to get sick, no matter how resilient you are, no matter how much you take care of yourself, no matter what else you do to protect yourself. So if you're exposed to heavy combat, then it's going to be expected that you're going to come back and you are probably going to have some nightmares, and you're going to feel anxious and you're going to have hyper-arousal, and it's going to take a while for you to calm yourself down.

And maybe you're going to get into trouble.

And maybe you're going to get into trouble. And now we can, in fact, in a more systematic and disciplined way, go about and help those soldiers decompress both individually and in a group after they've been through a particular incident that has been intense or a period of time of intense incidents, and do it in a much more focused way than we tend to do it now.

Second thing that is really important here, because it's a common pathway, is making sure that they and their unit as a group take care of themselves, and most importantly that they manage their sleep. Sleep is one of the best indicators of, are you having problems or not? If you can get good sleep, which is restorative, then you're going to also be able to decompress yourself from the stress that you've encountered. Then with that go all the other things that have to do with just taking care of your body and soul, and doing it in a very orderly and caring fashion. So I think it doesn't take [the stress] away, but it helps the guy protect himself.

One of the issues that has come up a lot is the use of prescription medication for sleep, Ambien. One of the guys we spent a lot of time with was the medic -- basically said everybody was using the Ambien. ... He said it was almost like they were giving it away like candy. Is there too much reliance on those kinds of medications for getting guys to sleep?

We have reports that there are large numbers of disposition of sleep medicines in theater. That's a mixed bag actually, one which says that the guys are having sleep problems, which is a sign that they are keyed up, and then maybe there's things that they're doing that are even making it worse. You hear of all sorts of ways that they're using caffeine and other stimulants to keep themselves going. Certainly tobacco is -- smoking is a big stimulant. So you know that they are really keyed up a lot, and that by giving them the medicines it may help them sleep, although many of the medicines lose their effect after a while.

It may also somehow or other impair their performance, because almost all these medicines have an effect on your alertness and how quick you think and your reaction time. So I think that needs to be looked at real closely.

Since the EPICON report came out, I know you haven't been back to Fort Carson, but you do talk to people back there? Do you think things have changed much?

I think they've made some efforts. I can't tell that things have changed as much as I think we'd want them to change. ...

They've had a rough year. The 2-12 Brigade, the time they went out there, lost a lot of guys. For some of the guys it's like their third, fourth tour. The people of Colorado Springs, should they be worried when these guys start coming back?

I think that people should be worried in the most concerned way that they can be, almost like parents. That unit has had a lot of unfortunate encounters, and I think that folks should be ready to reach out to them in all sorts of different ways and should be really tolerant. These are young men and women who have been in combat, done things and seen things that are almost unimaginable, and it's really expectable if they're going to come back that some of them are going to do dumb things and really have trouble. And I think rather than anybody judging what they do or how they've handled their situations, I believe they should be ready to give them a hand in whatever way that they're going to need and realize that it may not be in the most socially acceptable way that these folks are going to show that they need help.

What do you mean by that?

I mean I think they may just do some dumb things. I mean they may have some drunk driving and they have some fights, and there's a high divorce rate, and I think there's all sorts of problems that these soldiers have. I think we may find a lot of that when they get back.

In 2006 it didn't appear to us from what we've seen that Evans [U.S. Army Community] Hospital [at Fort Carson] was really prepared to deal with what was coming back at them. And we talked about that sort of Army-wide, but could you address it specifically for Fort Carson and what was going on there at that point?

The Fort Carson MEDDAC [Medical Department Activity] is like a lot of community hospitals in the Army. I think that the staffing for mental health wasn't adequate for the kinds of problems that they were seeing there, but it was pretty common across most of the installations.

The other thing that's happened ... -- fairly typical practice, not just in the Army but if you go to any community -- is that for many of these problems, stress, doctors will prescribe medicines. Commonly patients will get an antidepressant, a so-called SSRI [selective serotonin reuptake inhibitor]. Sometimes they'll get counseling, sometimes not. What these young people tell you is many of them don't like the medication: It's not what they need, and in some ways it doesn't make them feel like themselves. ...

What they want to do is talk, and they want to be in a situation that they feel safe, and they want to be in a situation that they also are comfortable that the person they're talking to understands what they've been through. And they want to be able to have the time to do that. And the Army wasn't prepared for that, didn't have the counselors, and didn't recognize that's really what was going to be most helpful.

Are they now?

They're getting there. I think that if you look at Fort Carson and this brigade coming back, I think a good leader would say to himself or herself: "Yeah, I'm not sure we're ready. I think we need more folks, and I think we need to put an extra effort into being ready."

One of the people that we interviewed was the social worker at Fort Carson during that period, and he told us that he was pressured not to give PTSD diagnoses to people that he was seeing. Basically the commander was saying [soldiers] don't deserve that if they'd had conduct disorders that would be connected to the PTSD because they'd get certain benefits. And he said there's just this pressure not to do it.

I think there was pressure not to give the diagnosis of either PTSD or even depression or anxiety disorder to soldiers who seemed to have conduct problems. In fact, I think there was a memorandum that was posted that said that and which had real serious implications for those soldiers, because if there was misconduct, then they could be separated from the Army on an administrative discharge. In some cases, it meant that they would leave under other than honorable conditions. A discharge like that for a soldier deprives him or her of eligibility for V.A. [U.S. Department of Veterans Affairs] services.

What that misses is that young people -- and these are young people; in my view they're post-adolescents -- show their stress in their misbehavior. Young people don't come in a reflective mood, contemplative, and say, "Oh, I think I'm having a particular response to this stressful combat that I was exposed to, and it's really a sign of some deep psychic problem." What they do is they act up. And they drink, and they get into fights, and they argue, and they leave their wives or husbands, and they scream at their kids, because that's their age and stage in life. And I think that was one of the other things we missed in 2006, and we may miss it now. That's in fact the reality of who they are and what their lives are like.

And they take cocaine and they fail piss tests and they get "Other than Honorable" [OTH] discharges.

When the medications don't work -- there's many times they don't -- soldiers do whatever a young person does, and they self-medicate. And they use the drugs that they have either used in the past, like alcohol or marijuana, or if they think that there's another drug that somehow or other they try, it helps for a short time to relieve the pain that they're in. And that's almost the American way, is to self-medicate.

But the consequences of that in the Army, it seems, at least for a number of the guys in our platoon, is rather than having someone say, "Here, we need to give you some help," they say, "Here's the door." ...

The military's being pretty tough about drug and alcohol abuse, so I think there's still a regulation in place that says if, for example, that you come up positive, hot on a urine test, then separation has to be initiated. That is, adverse administrative action has to be initiated -- it doesn't have to be completed, but it has to be initiated -- rather than to have an expanded and a much more active substance abuse program that recognizes that this is what people do to help themselves when they're in pain or they're having trouble, is that they use drugs and they use alcohol. And I think that we need to put a lot more effort into that.

I read EPICON carefully this morning, and one of the things that cropped up is that only 20 percent of the young guys that failed the piss test in 2006, 2007 ended up in [treatment] programs. That means that 80 percent of the guys that failed drugs tests did not have any treatment. ... What's that?

In general, I think that even if we do identify people through the urine tests that they've been using illegal substances, that identification does not enter them as energetically as we should into a treatment program or even, for that matter, an education program. ... We developed and we started a lot of drug and alcohol programs in the late '70s and early '80s after Vietnam because it was a big problem, and we recognized that that was common among our soldiers. At one point we had started probably close to a dozen residential treatment programs and a host of intensive outpatient programs and counseling, but over the years, particularly in the '90s, those diminished. We lost a lot of them, and we haven't started them back up, so it's a small group of folks who are identified as having drug and alcohol programs that get into treatment.

In the same way, it's a small group of soldiers who somehow get DUIs that get into treatment. That should be an early indicator that this young man or woman is having a problem and we need to do something, and we wonder what other problems they're having, and let's engage them as broadly as we can to help them.

So they have not been energetically put into these programs, but they have been energetically engaged in separation from the Army in a lot of ways, it seems.

In some ways the military is a microcosm of our society, which is: "Say no to drugs. If we just have a tough enough discipline program, we're going to somehow mitigate the problem." And, you know, I don't think it's worked. I don't think it's worked in the Army, and I don't think it's worked in a lot of our communities. It certainly hasn't cut down the drug problem across the country. So here we have another example that maybe what we need to do is open up our services.

So you have somebody like David Nash, who tests positive for cocaine not once but twice, who is, sergeant says, sort of a lazy soldier -- he's not really what they're looking for in the way of a soldier -- and ... he checked out on his 90-day assessment with every symptom there was for PTSD but didn't get the diagnosis. How should he have been treated differently, having failed two urine tests and having an attitude problem? They decided he was gone; he wasn't a soldier they wanted around.

If you have a soldier who is identified on a couple of urine tests and is identified on the routine questionnaires as having a lot of problems, as both an army and a nation it's better for us to engage the person in very active treatment for all the kinds of problems that they're having.

It's not just separating them out, partitioning the drug and alcohol problem from PTSD, from marital problems, but understanding that this individual is struggling, so let's bring together the specialists. Let's bring together the experts and help this person get over whatever it is that is bothering them at this time. Now, we may find, as we have so many times, that even with that, that man or woman is not suitable to be a soldier. At that point, make a decision about should they be separated and under what terms they should be separated. But the first step is to give them really good treatment.

So you think it's the Army's job in a case like this to give the treatment rather than just say, "You're out of here"?

I think so. I think it's our responsibility back to society. We took this young man or woman in. We took them to combat. We've put them under a lot of stress. Now, before we return them to society, where we want them to be productive and we want them to go back to their communities, we should do what we can so that they'll be able to live as best a life as they can. Now, they may need to go to a V.A. for a treatment after that, but I don't think we should discharge them until we've either provided the treatment or set it up for them to get the treatment.

But if we say goodbye to them with an other than honorable discharge, they can't go to the V.A.

They can't go to the V.A. ... That means that they're not eligible for any of the benefits, including medical care at the V.A. It means they go home with that label or stigma and they may not be able to find a job, particularly in this economy. They're probably not motivated to go to school and train themselves to do something else. They may end up homeless. They may end up on the streets and then in fact do something else that harms somebody else. And who's helped there? ...

It sounds sort of like if you break it, you need to fix it.

Right. People say: "Maybe we didn't break him. Maybe this individual was broken. The individual has a responsibility, too." Individual responsibility is a big part of our culture. ... Individual responsibility is important, and certainly a soldier has to own his responsibilities here. But we have to be careful not to be too judgmental. ...

Going back to the idea of drugs in combat, the statistic from the 2008 mental health assessment [indicates] that 12 percent of the troops in Iraq and 17 percent in Afghanistan were [taking] antidepressants or sleeping pills to help them cope. And these people on our platoon say: "Yeah, it was everywhere. If you needed Ambien, boom, there it is." What's your reaction to that much medication going on in the field, on the battlefield? How does that affect things?

The usual reports are that 12 to 17 percent of [soldiers in] Iraq and Afghanistan are prescribed or on antidepressants, and many are using or prescribed sleep medications. So that's a pretty large number. One, that's a sign that they're in intense combat. They're in a stressful environment, and they've had a stressful number of deployments. ...

So I think the question is, what else are they getting? Just getting the medicine is probably not enough. Are they getting some other counseling, or are they getting some other help for other kinds of problems that they're also experiencing? Because a soldier who's got emotional/psychological problems also may have been exposed to a lot of blasts and may have some TBI [traumatic brain injury] or also has probably been carrying his pack and his personal set around which can be up to 100 pounds, so they can have all sorts of musculoskeletal aches and pains.

I mean, these guys are pushed, and they've got lots of different problems. And what we need as care providers is to recognize that it's this constellation of problems that they're having, and to be able to treat the whole picture as best as we can.

We've heard that there was a shift in policy in the early part of the war that allowed SSRIs to be used in the battlefield. ... Was that a good idea?

The program for many years was that if you were prescribed a medicine that you had to stay on that you could not deploy to a combat theater. So, for example, a diabetic who had to take either oral medicine or insulin every day was nondeployable. What we did was we assigned what we call "profiles" to identify the individuals having a medical condition that limited his duties. So an antidepressant, ... that soldier would not be deployable because you wouldn't expect that they could get the medication in combat. But now things have changed, and now the way that we can get medicines to people and the way that their health care is available, those rules have changed. Of course now we've got soldiers who are on antidepressants and we've got soldiers who are on other medicines while they're in either Iraq or Afghanistan.

So it's more a logistic thing that you now can get the medicines to the guys in the field, as opposed to an idea [that it's] OK to have a bunch of depressed soldiers out there taking antidepressants.

The rules were really kind of what's practical. And it was really a matter of what medical conditions do we think are not going to limit duty and that we can get either medicine or anything else that the soldier needed, to them so that they could do what they had to do. It really wasn't even specific for mental health problems. It was across the board.

With the kind of black-box warnings that are on SSRIs in terms of the side effects that can sound pretty dangerous, and if you add that into a war zone with people carrying guns around, do you have any concern about using SSRIs in the battlefield?

The concerns I have about their use is really more about what their limited benefit is in general. ... Many of the drugs have got side effects that are really unpleasant to young people. The drugs will cause sleep problems, and so if you give Zoloft, Prozac, you'll find that many doctors will also give Trazodone or Ambien, because a lot of the patients were complaining that they might feel a little bit better, but they can't get into deep sleep, and they have problems falling asleep. That's a worry, because we know we've got sleep problems anyway, because these soldiers are just so revved up with the combat situation.

In some ways the medications work because they sort of blunt the feeling. It's the sense that they don't feel depressed, they don't feel anxious, because they know that there's things bothering them, but they're just not as concerned about the stuff that's bothering them. Well, maybe that impairs their alertness or their responsiveness. So even though back home a patient comes in really depressed, a doctor would very reasonably prescribe one of these medicines, when you look at the whole picture of how they help and their side effects, it's [with] I think a lot less confidence that they need to be used in the combat theater. ...

Is there enough screening and enough warm bodies around so that they don't end up deploying somebody who's got major depression?

I think we can identify [major depression] on a routine screening because it's not that common a problem. When you do see it, it is really serious. But do we send soldiers who already are having problems? Do we have enough soldiers? That gets you back to the issue of the dwell time and the cycle of deployments. Optimally, most of us feel that you need about two years back for every one year that you're deployed. I mean, that's been a practice for years in the Navy. That 2-1 ratio seems to be OK. People can work it out if they've got that much time between missions.

But that's not what we're giving our soldiers now?

We don't have enough people right now to give them, if they're going to do 12 months in theater, to give them 24 months back at their home installation to be able to recover and restore themselves to get ready for the next time they're going to go.

And we would give them instead?

We have 12 months. So you get 12 months in theater, 12 months at home, 12 months in theater. That's been the cycle up to now.

I think the 506 and maybe one other unit were the only ones to deploy directly from Korea.

Yes, so that when the stories came out about Fort Carson and the problems that the soldiers were having, one of the concerns had to be what their cycle had been. They'd been in Korea on the DMZ [demilitarized zone], so that's a[n] "isolated tour." From there they went directly to Iraq, and they came back and didn't even probably quite have 12 months before they deployed again. Then right before they were supposed to redeploy, come back to the States, they got extended to a total of a 15-month tour.

I think the common feeling is that was really too much. [They] never got a chance to really pull themselves together coming back from Korea, which is what most people would do, because even though that's not combat, it's still a pretty tough environment to be in. ....

This guy we talked about, Jose Barco, who was a guy who's been [sentenced to] 52 years, he was also diagnosed with PTSD and medically discharged just before he got locked up. But when we asked him about his treatment at Evans [U. S. Army Community Hospital], he said: "They gave me eight or nine different medications for every symptom of PTSD they had a medication for. If you couldn't sleep, they gave you something. If you had nightmares, they gave you something. If you drunk too much, they gave you something for that. They were just pulling medications out of nowhere like a business." What's your thought about that?

You hear from soldiers saying, "Look, one reason I don't like going to the doctors or going to the hospital is because all they do is they give you medicines." And then you see a number of them that could be on half a dozen, if not more, prescriptions. You know that the psychiatric specialty -- and I'm a psychiatrist -- for years has gone into ... kind of restricting their practice to prescribing medicines for problems. ...

What these soldiers want, and many people do, is they want a chance to talk about their problems. They want an ear and a face that they're comfortable with to tell the stories that they're not really willing to tell anybody else and to unburden themselves. Now, they may need a medicine, but there's a problem with giving what we call "parlor pharmacy." There's a problem with giving too many medications, because after a while, you start chasing the side effects of the medicines that you're giving. And there really isn't that much difference among these drugs to say that I can target this problem with this particular drug and target that problem, because there's a lot of overlap. So I don't think, personally, that it's good practice.

Why is verbal therapy so important? ...

The verbal therapies are helpful, and for decades, maybe longer, maybe centuries, we've recognized that being able to talk to somebody and get things off your chest really helps. Is it that having a confident relationship means that one can confess, and is there a very mysterious and mystical healing that comes with confession? Is it that because you tell a story and you're troubled by it, and in telling it you can rethink it and maybe understand it differently and get a different feeling for yourself and the situation and perhaps not feel as guilty or worried? Maybe you can figure something else out differently and revisit either the person or the situation and work it out and handle it in a different way. So there's lots of different, positive benefits that come from being able to just tell somebody what you're thinking and feeling.

... Lots of studies of verbal therapies will have shown that by far, maybe the most benefit comes from the quality of the rapport, in some ways even more than what's said or what's done or there's some particular technique that's been used. But if the relationship is healthy and the patient feels confident and the patient therefore can talk about what he or she wants, then there's healing in that. And if there's not, then they're going to walk away and feel as troubled and maybe lose confidence in everything.

Unfortunately, sometimes after they've tried and they've felt that they've not connected and they don't have anybody to connect with, then maybe something really bad will happen, like suicide.

In a situation like at Fort Carson, where you have a flood of guys coming back who need therapy, need to find somebody to talk to, and a staff that is understaffed -- they don't even have the positions filled let alone necessarily the right people -- what's the deal with that equation?

When you've got a lot of patients coming into your clinic, and you may not have enough staff or the staff's not trained, and then the staff feel stressed, then bad things can happen. And in problems, it can really show up that the patients aren't getting the help that they need. That takes leadership. That's where the senior mental health leaders or the other senior leaders of an installation pull themselves together and put their heads to the problem and say, "We need to find a way to get the right folks and to make sure that they're in the right frame of mind and give them the support that they need," and then also set the climate, because just by coincidence, a patient and a therapist may not fit. You and I just may not click. Not a fault of yours, not a fault of mine. But my responsibility as the doctor is to know if that's not happened and to find somebody that you fit better with. That means I've got to have a team. I've got to have enough folks to be able to make those adjustments, and if I don't, then that can be a recipe for problems.

And that was the situation at Fort Carson in 2006, 2007?

That was the situation in Fort Carson and I think other places as well. We just didn't have enough folks.

Can you explain what TBIs are and how they've become the signature wound of this war, the war in Iraq and Afghanistan?

TBI is what we call a traumatic brain injury. What we are seeing with this war is that the soldiers who are exposed to these blasts, particularly to IEDs [improvised explosive devices], are injured because there's a pressure wave from the blast itself. And some of these weapons are just huge, and that pressure wave, as it passes through the body, causes microscopic damage.

There's a lot we've got to learn about what that really is like and how that affects the brain. But our clinical examinations of the patients indicate that either after a real big blast or repeated blasts, many of these soldiers have complained of problems in paying attention, concentrating, memory, mood, sleep; a lot of them have headaches. And then you find that they've got other problems. A lot of them have got cracked teeth. A lot of them have got lots of other aches and pains, because these are huge explosions. That movie The Hurt Locker really gave a good illustration of what that's like, and that pressure wave causes damage.

We probably haven't seen a problem like this maybe ever, and if we did, maybe the last time we saw it was in World War I, where because of the artillery shells that many of the soldiers in Europe were victims of, they came home and we said they're suffering with shell shock. Be interesting to see if in fact shell shock is the same kind of problem that we're getting with these IEDs, blast concussions.

But in World War I and World War II and Vietnam, I guess to some extent, body armor [and the] kind of medical treatment you could get in theater wasn't what it is today. And we've heard an awful lot of these guys are surviving now a blast that they wouldn't have survived in the past and basically coming home with invisible wounds.

Right, many of them. In previous wars, what we call the ratio of those wounded in action to killed in action was running about 2-to-1, plus or minus some. And now the ratio is 7.5-, 8.5-to-1. The body armor, it really protects these men and women. And we've got emergency treatment and the ability to get to them in a way that we've not ever been able to get to them. But they survived, and now we have to look into and be concerned about what is the injury of those who have survived that otherwise would not have. And of course the injury is now "invisible," because they're coming back with the associated problems to the blast that they experienced. And even though the body armor's really good, and the helmets are excellent for protecting them so that they don't get killed, they're still exposed, and the pressure wave gets transmitted through their bodies. ...

Was the Army prepared for that kind of numbers of TBIs, and were they dealing with them appropriately when they first started showing up?

It took the Army a while to recognize that that was a problem. In fact, there's still controversy among Army physicians about is it a real injury or not.

Really?

Yeah. There was a New England Journal of Medicine article, perspective paper, that said we might be in error by calling it an injury, because you can explain all the symptoms as psychological problems, and we don't really know that there's an identifiable physical injury. You can't do autopsy studies, so you can't really look and get tissue that shows you what the problem is. We don't have a good animal model for the research. So it's still something we've got to learn a lot about, and in that sense we weren't prepared because we didn't know what this was.

Is there any doubt in your mind that it's a real injury?

There's no doubt in my mind. ... In fact, I've had soldiers say: "I know when I'm having a bad day because of my PTSD or depression, and I know when I'm having a bad day because of the TBI. It's different. I can't concentrate. I can't get myself to focus, and I can't get myself to focus is different than I can't think about things because I'm worried and start to rev up." So they tell you, and you listen carefully. ...

There are an awful lot of guys in our unit who were exposed to lots of IEDs and mild TBIs. Five or six years later, they still have the symptoms, but they didn't get any help. They basically fell through the cracks on this. Do you think that's the case with an awful lot of soldiers from that early part of the war?

I think the kind of problems from TBI could be pretty large. It could be a pretty big number, and both not only because of the early part of the war where [we] didn't recognize it, but even now because of the numbers who are exposed to blasts.

The other problem we have is we haven't really identified really good treatments. In fact, the symptoms are treatable, particularly the headaches, but in some cases, they don't even go away completely. There are problems in balance and coordination, so there's exercises that the soldiers can do. There's exercises they can do for their memory. There's exercises they can do for their attention. And it really does make a difference to identify those problems early before they get set in the brain. But it's a lot of training and a lot of effort by the patient to get help, and so those early on who were missed may suffer for sometime.

There's certainly one of our guys, Kenneth [Eastridge,] who was in a blast, was unconscious for about a minute. He said there was clear fluid running out of his ears. He did not basically have any treatment. They said, "Kenny, you feel OK?" "Yeah, I guess so." "Back into the war."

I think that was common. I think you found that early on that a soldier, the blast would occur, they'd be a victim of it, many of them their eardrums burst, and they would get liquid in their ears, and there's all sorts of hearing problems that a lot of the soldiers have now. The blast may have been so intense that they'll get bleeding from their nose. They may have been out for a short period of time. If they were out just for a minute, it's generally the mark of it being minimal and not being serious. And if they said they were OK, we handled it as if you'd been playing football and you just took a hard hit and, "You OK, son?" "Sure." "Well, go back into the game." And then they'd go back, and in fact they'd find that over time their problem got worse, because they don't know really how serious that damage was from that incident and how it might now really impair the man.

What about the connection of TBI to impulsive and irrational, violent behavior? Is that a link, or is that PTSD, or is that something else?

The milder-blast concussion and the kind of microscopic injury that it probably produces most sensitively affects executive functioning, that part of the brain that we use for judgment and we use for decision making and we use to control ourselves when we are in situations of intense emotion. So if a person is affected neurologically, then it would come as no surprise that they might be impulsive, because they don't have the controls that they had before and they don't make good decisions, and they react in ways that just don't seem smart.

So there is a real interplay here of the direct effect of the TBI. The fact is that if a soldier has had one or two or half a dozen blasts, and being in those situations they suffered both the direct injury from the pressure wave and they've been emotionally traumatized, so it's not as if there's a sharp line between the two, and they've been frightened, and now they find that they can't think as clearly, and it's that interplay that causes so many problems.

And those problems often end up these days in a courtroom. Speak a little bit about your experience and specifically this one guy in our platoon who was diagnosed with PTSD and TBI and his lawyer made an effort at the sentencing hearing to use that as a ... factor, and the judge would have none of it.

The constellation here of a picture -- someone who's been emotionally traumatized and they've got PTSD, they're anxious and they're depressed, and they've got TBI, which means that they've got problems in decision making, they can't think as clearly, they can't focus -- can predispose that man or woman ... to misconduct or criminal conduct, an impulsive action often, sometimes not, and sometimes a violent action, because they don't have the controls and they're super-sensitive to what might bother them. And they are really vulnerable to just reacting, overreacting, particularly maybe doing something that they had done when they'd been in combat. So when you've seen a lot of people like that, it's understandable that that can happen. They are now victims of a combat experience they've had.

There's a problem we have now in recognizing that in many of our courtrooms, the judges and the juries do not respect or do not give credibility to that and don't feel that the conditions are real, because they don't think it's real. They're going to hold the individual responsible and in fact may impose harsher sentences.

The judge in this case, before he sentenced him to 52 years, said, "You are responsible for your actions."

In many courtrooms and many juries do not feel that "a psychiatric defense" is real, or a defense for a medical condition that's not visible is real, and therefore ultimately the defendant is responsible, and it's their failure to act in a way that conforms to the law that is really the problem. And so they'll get a harsher sentence.

So you think somebody like Jose Barco did not deserve 52 years?

Not knowing the details of the case, but I'd say yeah, I don't think he deserved 52 years. If he had diagnosable PTSD and he had TBI, here's a fellow who's impaired, and I don't think we as a society should treat people who are impaired harshly. In time we're going to have the science with all the new technology coming out, the neuroimaging particularly, to show that a person like that has a real medical problem and that problem affected his conduct as much as any other medical problem would. ...

One of the guys in our platoon was granted a waiver when he enlisted. He had killed his best friend when he was 12, and his therapist suggested to the recruiting officer that it wasn't a good idea for him to join the Army; he hadn't dealt with the trauma of that. But he wanted to join, and the recruiter said fine. Apparently the number where [a waiver] was granted for serious criminal history has shot up tremendously in the last five years. Have the recruiting standards dropped, and that it's granting waivers creating a new problem, a different, an added problem in the Army?

We've been granting more waivers over the past years, although you'll get reports that it's not been as much as sometimes people think it is. The dilemma is this: That you grant waivers for people and they've had problems ... means that they are vulnerable to probably having more problems, but it's hard to say. It gets really judgmental and means you're denying a young man or a woman an opportunity to make something of themselves that they otherwise would not. Most of the data we have accumulated shows that on the one hand, there seem to be more problems with the soldiers who have been granted waivers. On the other hand, there's more heroism among the soldiers who have been granted waivers. So it's a hard call about what to do. ...

How do you explain the idea that the waivers create more heroes than more problems?

You know, it's interesting. Maybe the guys or gals who have gotten into trouble as teenagers, maybe in part because they are less worried or less afraid in some ways, they're more risk takers, and because they're more risk takers, they're more likely to be heroic. They're also more likely to do something dumb. ...