Suicide has overtaken combat as the leading cause of death in the Army. July, with 38 suicides among active duty and reserve soldiers, was the worst since the Army began counting.
There are many reasons a soldier will take his own life, but one major factor is post-traumatic stress.
A study of Vietnam veterans 20 years after the conflict found that a quarter of those who served still had full or partial post-traumatic stress disorder. America's current wars may create even more suffering for those who fought them.
Soldiers have been deployed to the Afghan and Iraq conflicts multiple times, and they face a deadly new weapon — improvised explosive devices, which cause brain injuries that also seem to intensify PTSD.
The two treatments in widest use involve a single patient and a therapist: cognitive processing therapy (CPT), where patients learn to think about their experiences in a new way; and prolonged exposure, in which the therapist guides the patient through re-experiencing his trauma, teaching the brain to process it differently.
These treatments help about 40 percent of those who use them. But for many other suffering veterans, these therapies are too narrow.
PTSD is often entwined with other serious problems — depression, sleep disorders, chronic pain and substance abuse. Sometimes these are resolved if the PTSD is, but often they require specific attention that standard PTSD therapies don't provide.
There is another way these treatments need broadening — they need to reach more people.
The military and Veterans Affairs hospitals do not have enough psychotherapists to offer them on the necessary scale. And many soldiers are wary of psychotherapy and afraid of the stigma it carries.
Integrating mental health care
The military is fighting that stigma with new research and more treatment. The VA has trained or added thousands of mental health professionals and is trying to integrate mental health care into routine care for veterans. Only about 10 percent of those getting mental health care in the VA system, however, are veterans of Iraq or Afghanistan; the vast majority are Vietnam veterans.
But some 2.4 million soldiers have been through Iraq and Afghanistan. The RAND Corp.'s Center for Military Health Policy Research found that one-third of Iraq and Afghanistan veterans surveyed were currently affected by PTSD or depression or reported exposure to a traumatic brain injury; about 5 percent had all three.
Only half of those who reported symptoms of major depression or PTSD had sought any treatment in the past year. The number of newly trained mental health professionals needed, said RAND, is "likely to be in the thousands." Individual therapy is not enough.
Fortunately, there are other ways to treat PTSD. In January, 10 veterans with PTSD sat down in a small, drab room at a Veterans Affairs clinic in New Orleans for a course designed by the Washington-based Center for Mind-Body Medicine. Over the next 10 weeks they drew pictures of themselves, colored in their family trees, danced and shook to music. They learned conscious breathing, meditation, mindfulness, guided visual imagery and biofeedback.
The course is one of perhaps half a dozen different kinds of alternative therapies being tried for PTSD in military and VA hospitals: acupuncture, yoga, mindfulness, Buddhist lovingkindness meditation.
The Center for Mind-Body Medicine's program is the most comprehensive and has the strongest evidence that it works to cure PTSD.
Kosovo high school students with PTSD who completed the 10-week program had significantly greater reductions in PTSD than a control group of students assigned to wait for the course. Other before-and-after studies (with no control group) in Gaza have found an 80- to 90-percent reduction in PTSD with the technique, and those results still held months later.
The center's program is being used at various VA hospitals, military bases and research institutes. The group in New Orleans is part of the first randomized controlled trial measuring the program's effect on PTSD among veterans.
Researchers are still processing the results, but Dr. James S. Gordon, director of the center, said the patients' improvement was "at least as good" as the individual therapies the VA uses, with significantly lower dropout rates.
The Center as om-budsman
If this holds up, then the Center for Mind-Body Medicine's program will be a potentially valuable addition to the VA's limited menu of treatments.
It is built for large scale. Many of its groups are run by lay people who went through a 10-day training; in Kosovo, high school teachers ran the groups. In Gaza, center staff members have trained 420 group leaders and worked with some 50,000 people. The program is also showing success not only with PTSD but also depression, pain, sleep disorders and substance abuse. It is now being used at Walter Reed National Military Medical Center to treat patients with substance abuse problems.
Mind-body medicine and the other alternative therapies may be more attractive to soldiers than the individual treatments, which have a 20-percent dropout rate. Both CPT and prolonged exposure ask the patient to relive his trauma — an upsetting prospect. Some veterans avoid psychotherapy because they do not want to be singled out and labeled deficient.
The alternative medicine groups, by contrast, have virtually no dropouts. Members can talk about their past trauma if they wish, but it's not necessary and there is no pressure to do so.
Instead, the groups are centered on the present, helping members to learn practical skills. The facilitator is a participant in the group, sharing skills she might use herself for better sleep or stress reduction. Everyone, after all, can use help dealing with the stress of re-entry to civilian life. Going to a skills group instead of psychotherapy could remove much of the stigma of treatment.
Despite the vast increase in research money, studies of these alternative therapies have been small and isolated. Only randomized controlled trials are persuasive enough to get Washington to adopt a therapy on a wider scale, but these are too few and too slow, and starting new ones now would take years.
It is time to take the most promising ideas and try them with thousands of people, not just a few dozen — and if they work, to expand them further. That is not cautious. But treatment-as-usual condemns hundreds of thousands of soldiers to a tour of duty without end.
Tina Rosenberg is the author of Join the Club: How Peer Pressure Can Transform the World. This piece originally ran in the New York Times.