Families often bear the brunt of dealing with returning troops' behavioral health wounds. "The families go through hell," Dr. Charles Figley, a military family psychologist. (Lauren Everitt/Medill)

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WASHINGTON – More than 665,000 National Guardsmen and Reservists have fought alongside active-duty service members in the decade-long Iraq and Afghanistan wars. But they face a far different homecoming.

They are as vulnerable as their active-duty counterparts to what military leaders call the signature wounds of the post-9/11 conflicts – traumatic brain injury and post-traumatic stress disorder. However, those in the Reserve component—National Guardsmen and Reservists—do not have access to the same extensive health care system and support network needed to assess their injuries and help them recover.

Instead of coming home to a military base, they return to their hometowns, where they navigate fragmented health care networks and scattered service agencies without the psychological support of being near “battle buddies.”

“The National Guard faces unique challenges compared to our active-duty counterparts,” said Gen. Craig McKinley, chief of the National Guard Bureau, which is responsible for administration of the guard’s 54 state and territorial units.

Maj. Gen. Tim Kadavy, deputy director of the Army National Guard, said most people don’t realize there is no stand-alone medical system for those in the guard and reserve.

“We don’t have reserve-component hospitals or clinics,” Kadavy said. “We have soldiers.”

From the beginning of the war on terror, reservists have been called up by the thousands from cities and towns across the United States.

Upon their return, they are often hastily channeled through a post-deployment process that relies on self-reporting to identify behavioral health issues with little follow-up, according to interviews with current and former officials, troops and experts, and government documents and studies.

The civilian communities they return to often can’t relate to their military experiences, leading to friction with families and employers. The consequences of this inadequate screening and network of support—including substance abuse, depression and suicide—persist.

The guard and reserve have been hit particularly hard by mental health issues. From September 2010 to August 2011, post-deployment health reassessment screenings found nearly 17 out of every 100 returning reservists had mental health problems serious enough for follow up. That is 55 percent more likely than active-component service members, according to the Armed Forces Health Surveillance Center.

Between 20 and 40 percent of returning guard and reserve members suffer from problems ranging from stress to PTSD, according to studies by the military and think tanks. The variance in official numbers underscores how little is known about the brain and how societal stigma about mental illness can result in underreporting.

Nearly two in five post-9/11 veterans said they suffer from PSTD, according to the Pew Research Center.

Gen. Peter Chiarelli, Army chief of staff until late January, said two-thirds of the Army’s most severely wounded population suffer from PTSD and TBI, but called this number a “ballpark” estimate.

The Army’s active component saw a slight increase in suicides in 2010, while the reserve component’s rose by more than a third to 122, according to the Army. This number is likely higher, however, because it does not include activated reservists who died by suicide.

McKinley notes the 9/11 attacks transformed the National Guard from a strategic reserve into an operational force. “This has been something that has changed the nature of who we are, what we are.”

The guard and reserve make up 28 percent of the 2.3 million servicemen and women deployed to Iraq and Afghanistan. These members of the Air or Army National Guard or reserve force of the Army, Navy, Air Force or Marines work civilian jobs, train one weekend a month and are called to active duty as needed. When activated, they are incorporated into the larger military branch they serve; guardsmen serve the governor of their state first and then the president.

In recognition of the need for additional care, the 2005 National Defense Authorization Act established a premium-based health plan that gives reserve service members access to the Tricare military health care network for a monthly fee.  But many of the wounded reservists instead choose to drive, often long distances to Veterans Affairs facilities that provide free care from health providers who specialize in military populations.

Identifying invisible wounds

When Andres Alvarez left active duty for the Kentucky National Guard in March 2001 he could not have foreseen the roadside bomb and diagnoses of TBI and PTSD that would follow.

Alvarez thrived on action outside the wire, but on his second deployment to Iraq his vehicle hit an improvised explosive device on Aug. 25, 2005. He knew something was wrong. “Looking back I can tell that that day when we got blown up … I knew I had changed.”

He would go on to serve one more tour after the post-deployment screening process failed to identify serious problems. “There was stuff that should have raised flags,” he said.

When they return home from overseas deployments, guardsmen and reservists go back to military bases, where they are funneled through demobilization centers, often in a hurry. But they don’t stay.

Instead, they are inundated with forms, health assessments and presentations prior to going home. Among these is a checklist where service members self-report potential mental health issues.

Well into the wars in Afghanistan and Iraq, the Defense Department realized that this screening was not enough. Troops required follow-up months later, when combat trauma typically reveals itself, Pentagon officials concluded.

The post-deployment screening process added a subsequent checkup in 2005. In 2008, the process was digitized and more questions were added to help identify TBI and PTSD.

Alvarez returned from Iraq the third time in late 2006; the screening had improved considerably since the last time he slipped through. A medical review officer glanced over his health assessment, identified symptoms of PTSD and TBI and refused to let him go home without further diagnosis and treatment. “He probably saved my life,” Alvarez said.

Even with the changes, some troops simply fill in the “right” boxes — ones that suggest they have no problems — so they can get home, said Lt. Col. William Abb, a retired Army reservist and deputy director of the Chapel Hill, N.C.-based Citizen Soldier Support Project.

“You’re standing between me and the door, why am I going to tell you that there are any issues?”

In 2009, spurred by the suicide of a young Montana guardsman, Congress mandated confidential one-on-one screenings with behavioral health professionals before deployment and in the three- and six-month reassessments after troops come home. But that hasn’t happened yet for the Army National Guard and Reserves due to logistical problems, according to a Defense Department report.

Although improved, there have been criticisms about other aspects of the process as well.

In 2009 the Government Accountability Office reported the  Defense Department’s central database was missing post-deployment health reassessment questionnaires for 19 percent of reserve component troops who returned from deployment between Jan. 1, 2007 and May 31, 2008,  hindering the Pentagon’s ability to determine if a service member’s mental health needs were being adequately served

The GAO report found that the Defense Department was not adequately monitoring the private contractor it had hired to help manage the massive deployment effort, resulting in “an unsystematic, improvised approach for documenting potential problems.”

In 2010, members of Oregon National Guard’s 41st Brigade returning from Iraq for demobilization at Joint Base Lewis-McChord were shoved aside to “make room” for active-duty soldiers, sometimes without being treated for all combat injuries, according to Sen. Ron Wyden (D-Ore.).

Wyden and Rep. Kurt Schrader (D-Ore.) caught wind of the situation and demanded that the secretary of the Army review what they described as second-class medical treatment.

“If you’re serving in the same foxhole, you ought to be able to come back to the same sort of benefits.” Wyden said in an interview.

No support network

Many reserve troops must abruptly reintegrate from the battlefield into civilian lives while grappling with PTSD, alcoholism and drug abuse. They also face especially high rates of unemployment and divorce, according to military psychologists and recent studies.

“When I came home, I didn’t know how to be a friend and a daughter and a girlfriend or a coworker,” said Jennifer Crane, an Afghanistan veteran of the Pennsylvania National Guard.

Active-component troops come home to bases where others understand their experiences. That’s not the case for the reserves.

“Unless you’re around a group of guys that have been in a similar situation or at least know a little bit about what you’re talking about, it’s hard to relate,” said Anton Johnson, a former Minnesota Army reservist.

After more than a year in Afghanistan where few decisions were his own, Johnson said even mundane tasks like getting dressed pose problems.

“It becomes pretty much like a tangled mind mess of options to choose from, with no guidance.”

After the parade

Steve Hale, who served in Iraq with the Washington National Guard, said families and reservists experience a honeymoon period when the service members come home. “Everybody was happy to see you, the ticker-tape parades, the pats on the back, the free beers at the bar,” Hale said.

“But the reality, it got really lonely.”

Psychologists and commanders said they grapple with what to do after the parade. Lack of unit camaraderie is particularly challenging for reservists. Some units are patched together from across the country and scattered when they come home. Dan West, assigned to a unit in Salt Lake City, was deployed out of Pennsylvania, then torn from that unit to support another before returning to Montana alone.

Unlike the active duty military, reserve leaders can’t keep watchful eyes on their troops between deployments except during monthly drills, which, depending on scheduling, can be up to 60 days apart.  Recently returned troops are also not required to drill immediately and often don’t meet up until several months after their return.

Eric Kettenring, an Iraq veteran and Veterans Affairs counselor in Montana, said the onus is on unit commanders to spot troubled men and women when they return home. “When the recruiters wanted to find them, you could be under a rock in Eastern Montana and the recruiter will find you and get you into the military.”

“But when they come back and they’re no longer serving and they have problems, who’s finding them?”

Suicides rates remain troubling

For both active duty and reservists, suicide remains of paramount concern to military leaders. But reservists are at a particularly high risk because of the force’s piecemeal post-deployment process.

Suicide rates improved only slightly in 2011 from last year’s sharp increase. As of October, 82 members of the guard took their own lives — the second-highest number on record, according to the National Guard Bureau.

About one-third of those who killed themselves never deployed, which points to the significance of factors not related to combat. That statistic also does not account for veterans who kill themselves after leaving the military. The VA estimates 18 veterans take their lives each day. There is no way to know how many veterans of the reserve component have died by suicide because the VA does not track by past service.

However, similar to mental health programs, suicide prevention and tracking efforts vary by state. This makes it difficult to assess what prevention efforts work, according to a recent report by the Center for a New American Security.

Closing the gaps

The Defense Department has scrambled to close the gaps in care for all service members and their families by standing up more than 200 programs to address psychological health and TBI, according to a recent RAND Corporation report.

Some guard officials praise the network of services available to returning reservists in comparison to that provided to the active duty military.

“The potential care system is more advantageous for guardsmen because they have so many avenues,” said Capt. Brian Pilgrim, behavioral health officer with the New Mexico National Guard.

But that range of options often means reserve members are “thrown into a sea of websites with no idea of where to go to find appropriate care,” according to Stephanie Nissen, North Carolina’s behavioral health programs director.

Also, the RAND report concluded that the proliferation of programs invited waste, duplication and lack of oversight.

The issue is further complicated in the National Guard because each state is responsible for developing its own programs. Capt. Joan Hunter, director of psychological health for the National Guard Bureau, describes it as a patchwork system in which states aren’t required to adopt successful strategies used by others.

On the national level, Defense Department initiatives like the Yellow Ribbon Reintegration Program are increasingly recognizing families as the key component to reservists’ well-being. The program started in Minnesota in 2005.

At a Yellow Ribbon program in Bozeman, Mont., Capt. Russ Cunningham said the return process improved dramatically for his third deployment. “You almost feel like they’re trying to wrap you in bubble wrap. They want to do everything they can possibly think of to make sure that you get the physical, psychological, family help that you need.”

Changes to the post-deployment system were made as recently as April. In the follow-up to Wyden’s investigation, the Army National Guard issued an executive order that increased the time allotted for demobilization and required leaders to sign off on the disposition of each soldier.

In testimony to Congress this year, McKinley praised the guard’s ongoing reform efforts but said work remains.

“We will have decades to go to make sure we do not leave any guardsmen or woman behind.”