CHICAGO — The physical risks of war may end when a soldier leaves the battlefield, but new research indicates the mental toll of the wars in Iraq and Afghanistan is continuing to build, creating a psychological health crisis with no end in sight.
Some experts believe the rate of post-traumatic stress disorder, the most common mental-health problem among veterans, may even begin to exceed that seen with veterans of the Vietnam War.
A study published Tuesday of more than 100,000 veterans who have sought medical care since returning from war shows that one-quarter have mental-health problems. Half of those — more than 13,000 people — were diagnosed with PTSD, according to the report in the Archives of Internal Medicine. The disorder affects less than 4 percent of the general public.
The unpredictable aspects of combat in Iraq seem to take a mental toll similar to what Vietnam soldiers experienced, said Dr. Chirag Raval, a psychiatrist in the Army Reserves who served in Iraq and is medical director for the mental-health intensive case management program at the Edward Hines Jr. VA Hospital.
As in Vietnam, "There is no front line to this war," Raval said. With hand-propelled rockets, mortars and IED attacks "there is no true safe place in Iraq. You can be anywhere, even on your base, and still not be safe."
More than a generation after 19 percent of Vietnam vets returned with PTSD, the illness generally carries less of a stigma and has better-defined standards of treatment. But many veterans and researchers say the shame of mental illness persists in military ranks, and soldiers often avoid reporting their symptoms in hopes of preserving their careers.
Meanwhile, significant barriers remain for soldiers who seek psychological care after they return from service, according to several recent studies and congressional hearings.
On military bases there are shortages of psychologists and psychiatrists and long waits for appointments. Relatively few military mental health professionals have been trained in recommended PTSD treatments. Efforts to identify emotionally troubled soldiers are of limited value, since few soldiers will admit problems on questionnaires. Even when evidence points to PTSD, only 22 percent of soldiers get referrals, a report by the Government Accountability Office found last year.
Although most observers say the VA system has improved since the post-Vietnam era, specialized services for vets with PTSD tend to be concentrated at major medical centers and are hard to access for people who live in smaller cities or rural areas. Clinics' limited hours may coincide with the work week, when many vets can't get away from their jobs to see a therapist.
Officials with the VA say they are working on the situation. Michael Kussman, the VA's acting undersecretary for health, told Congress on Thursday that the VA was boosting mental health spending and would improve access "by expanding mental-health services in community-based outreach clinics ... as well as enhancing both PTSD and substance abuse specialty care services."
The experience of PTSD varies, but most patients find themselves unable to stop re-living traumatic episodes, often through nightmares, flashbacks or an intense feeling of anxiety prompted by an ordinary sound or event that recalls the painful experience.
Psychologists did not officially recognize the condition until 1980, in the wake of the Vietnam War. In fact, experts said Iraq and Afghanistan are the first major conflicts in which American researchers have tracked PTSD among veterans as the war is going on.
The study drew on a confidential database of 103,788 veterans who sought care at VA health facilities between September 2001 and September 2005.
The 25 percent rate of mental problems among those soldiers is higher than that found last year in a study of all veterans who served in Iraq and Afghanistan, and researchers say their observations also indicate diagnoses are climbing.
"It does look like there is indeed an upward trend, and it's scary," said Dr. Karen Seal, a physician at the San Francisco Veterans Administration Medical Center and lead author of the new research.
More than half of the veterans who had a psychological diagnosis had two or more distinct mental problems. Seal said it's common for returning veterans to suffer both PTSD and depression, which can make the individual conditions more challenging to treat.
One surprising result was that young veterans under 25 were nearly nine times more likely to have PTSD than veterans over age 40.
"You have a young population possibly not getting treatment for these conditions, and going on to have chronic mental illness," Seal said. "It's potentially a big public health problem."
Getting PTSD victims to acknowledge their condition is a constant challenge, Seal said — in part because the military is "a very macho culture, not one that supports being weak or crying at the pop of a balloon."
The direst fear is that some Iraq veterans will develop the same long-term problems as many Vietnam vets, including mental health-related substance abuse and homelessness.
It was the specter of down-and-out Vietnam veterans at the Hines VA that made Iraq veteran Chris Packley despair of his own recovery.
Packley, 24, a former Marine, served with a sniper team that was featured in Marine Corps Times and Soldier of Fortune. He returned from Fallujah in 2004 with PTSD.
"It started before I came home," Packley said. "I told the psychiatrist about it but he didn't care or do nothing."
Packley couldn't sleep more than 45 minutes a night. In his dreams, he saw people get shot and saw himself shooting. A scene with two Iraqis holding two kids in front of them as human shields would wake him up, sweating.
Some forms of therapy have been shown to help ease the symptoms of PTSD. One of the most successful techniques is called prolonged exposure therapy, in which trauma victims talk about their experiences repeatedly with the goal of reducing the emotional response linked with the events.
Yet according to a report last month by the American Psychological Association, less than 20 percent of military behavioral health personnel have been trained to provide therapies such as prolonged exposure that professional review groups have identified as the best treatments for PTSD.
While that figure is low, it's similar to the low proportion of non-military psychologists who are trained in the best techniques, said Dr. Matthew J. Friedman, executive director of the VA system's National Center for PTSD in White River Junction, Vt. Friedman said the VA has training projects under way to "develop a large pool of VA practitioners who are not just familiar but proficient in these practices."
Although the VA says it is increasing spending on mental health, veterans services organizations maintain that such services are under-funded. Last November, the Government Accountability Office found that the agency had failed to spend more than $100 million that had been newly allocated for PTSD and other conditions in the previous two fiscal years.
Help can't come soon enough for soldiers such as Packley, who after his war experiences started drinking heavily, taking drugs and getting into fights. He received an other-than-honorable discharge and in 2005 returned to Morris, Ill., where he grew up.
Packley now works full time at an oil refinery and is engaged, but he gets sweaty palms when he goes to the supermarket — an open space with lots of strangers and hiding places. He still thinks he's not getting the care he needs, and sometimes he wonders if his generation of soldiers will fare any better than the Vietnam vets he met at Hines.
"You talk to them and you think, this system didn't do nothing for them after all these years, what's going to happen to me?" Packley said.