Yet those most in need of treatment are least likely to seek it, according to the first study to explore the mental health of returning Army and Marine personnel fighting the war on terrorism in either Iraq or Afghanistan.
"Most often, it's due to a perception they have that they'll be stigmatized if they do receive care," lead study researcher Col. Charles W. Hoge, MD, of Walter Reed Army Institute of Research, tells WebMD. "Among soldiers who screen positive (for mental health problems), about 65% have the perception they will be seen as weak if they sought care."
For his study, published in this week's New England Journal of Medicine, Hoge and colleagues surveyed 2,530 members of the armed services prior to their deployment in Iraq and 3,670 within four months of returning from combat in either Iraq or Afghanistan.
Most Experience Trauma
Most returned having experienced traumatic events such as being shot at, killing someone, seeing bodies, or witnessing civilian injuries they could do nothing about. Generally, those in Iraq were up to twice as likely to engage in a firefight compared with those fighting in Afghanistan.
Hoge finds that some 17% serving in Iraq met the criteria for mental health disorders requiring treatment -- twice as many as before deployment. That compares with only 11% of those serving in Afghanistan. Iraq veterans were also significantly more likely as those serving in Afghanistan to develop posttraumatic stress disorder (PTSD).
"We think the difference results from a greater frequency and intensity of combat in Iraq," says Hoge, chief of psychiatry and behavior sciences at the Bethesda, Md.-based medical research facility.
But what's especially worrisome to Hoge and other experts is that even though the armed forces offers several programs to offer counseling and other assistance to returning veterans, those who need them are reluctant to use them. His study indicates that as few as one in four soldiers who need mental health treatment are seeking it -- largely because of the belief it will hurt their military careers.
'Not Just a Military Issue'
"Eventually, all of these soldiers will be returning to civilian life, so this is not just a military issue," Hoge tells WebMD. "Hopefully, this article will raise public awareness in general about psychiatric manifestations of combat duty. This is something the entire medical system needs to look at."
Of particular concern is PTSD, which first came to light following the Vietnam War. This type of anxiety disorder usually develops within months of a traumatic event, but may not manifest until years or even decades later.
Overall, PSTD affects about 5% of American men some time in their life. The rate in members of the armed services returning from Iraq is at least three times as high.
"And these are early returns," says Matthew J. Freidman, MD, PhD, Dartmouth Medical School psychiatrist and executive director of the National Center for PSTD in Vermont.
"The men and women surveyed in this study have been back in the states for eight to 12 months already. So while the duty they saw was quite considerable, most of them were in Iraq before the war really changed in character," he tells WebMD. "At their time, it was still primarily a war of liberation, and we were welcome by the Iraqis. It was very different than it is now.
"We don't know if things are going to get better or worse, but there are reasons for concern they will get worse," adds Freidman, who wrote an editorial accompanying Hoge's study.
Tip of the Iceberg?
"Tours are now being extended, and we have data back from World War I that suggest the longer you're in a war zone, the greater the likelihood you will have psychiatric problems. And those surveyed in this very important study were on active duty, and evidence suggests that National Guard Reserve units are more vulnerable because they are less well-prepared -- and they also have deployment stressors like being uprooted from their families and economic hardships. This may be the tip of the iceberg."
While returning soldiers may be hesitant to seek help, at least one stigma has changed in this war.
"Despite the fact there are major disagreements about this war and justification for it, what's fortunate is that the American public is not making the same mistake as in Vietnam, and we're now supportive to these veterans," adds Freidman, who says tells WebMD he "cut his teeth" in psychiatry treating PTSD in Vietnam veterans who came home to hostility from fellow Americans.
"At least now we've now learned to separate the war from the warrior."