At the center of that effort was Wisconsin-based Logistics Health, Inc.  Called upon to provide pre-deployment fitness screenings to help mobilize the reserve component, LHI has grown over the last decade to become a major player in military health care contracting. Its portfolio has grown to include the Reserve Health Readiness Program, pre-enlistments physicals and veterans’ disability examinations.

LHI’s portfolio of federal contracts attracted the attention of major defense contractors. Earlier this year, the company was acquired by a subsidiary of health care giant UnitedHealth Group.

LHI was founded in 1999 by Donald Weber, a former Marine who still serves as CEO.  Based in La Crosse, Wis., the company’s first federal contract, for the FEDS-HEAL program, was providing anthrax immunizations to the military and other federal employees.

In 2001, FEDS-HEAL, a program of the defense, health, and veterans affairs departments, was expanded to cover health screening of reservists being deployed overseas.

The program created “a national…services network that provides required medical and dental readiness services to military members who are not entitled beneficiaries of TRICARE and the military health system,” said Don Donahue, an industry expert who has worked for both LHI and QTC, a California firm that provides similar services.

Donahue said the programs were an attempt to avoid the problems of the Gulf War, when many reserve troops who were activated had medical problems.

“It became a hindrance to the combat operations,” he said.  “People weren’t getting where they needed to go in time.”

The reserves needed a medical program created specifically for them, Donahue said.  The active component’s medical procedures are provided by their services, but reserves are largely on their own until deployed.

LHI provided pre-deployment medical screenings including physicals, dental exams, x-rays, mental health evaluations and paper surveys filled out by each troop.

In 2007, the program was reorganized into the Reserve Health Readiness Program, directed solely by the Department of Defense.  The five-year, $790 million contract was awarded to LHI.

Yet for all its importance in getting the reserves ready, RHRP is not a required program.  The decentralized nature of the National Guard, for example, means that each state and territory gets to make its own decisions about who they choose to provide the medical services.

“You wind up having 54 little fiefdoms each kind of doing what they want to do,” Donahue said.

Currently, about 30 states are enrolled in the Reserve Health Readiness Program and rely on Logistics Health for medical providers, according to Donahue and other experts. One state that spurned the program was the Illinois National Guard, opting for a local company because it was dissatisfied with LHI.

“I just wasn’t happy with the program,” said Lt. Col. David Beatty, deputy state surgeon of the Illinois National Guard. “They had so many states that they were just overburdened.”

Beatty said there were times when many of his soldiers would be ready to deploy, but LHI had not placed that information in the medical system, delaying their deployment.

LHI held back several thousand Army Reservists over concerns about their health. About 2,500 of those holds were overturned after a review by the Defense Department.

To address low deployment numbers, the military implemented the Periodic Health Assessment in 2006, requiring reserve troops to get annual checkups evaluating their physical, dental, and mental health.  Since then, readiness rates for the National Guard and Reserve have jumped to their highest levels yet.

Also responsible for providing mental health screenings upon a soldier’s return from duty, LHI has been criticized for not properly ensuring that all troops filled out the post-deployment evaluations.  The surveys are part of an initiative to treat post-traumatic stress disorders by flagging soldiers who may be suffering from mental problems.

Yet a 2009 report by the Government Accountability Office found that almost 72,000 troops who returned from deployment in 2007 and 2008 had not filled out the mental health questionnaires, hindering the Pentagon’s ability to determine if a soldier’s mental health needs were being adequately served.

The GAO report found the Defense Department was not doing an adequate job in its required oversight of LHI’s operations.  Instead “an unsystematic, improvised approach for documenting potential problems” had been created.

“In addition, should LHI’s performance diminish – for example, if LHI was not resolving identified problems,” the report said, “the lack of readily available documentation could compromise DOD’s ability to take appropriate action.”

Capt. Diedre Presley, head of the military office charged with overseeing LHI, would not disclose the results of her office’s evaluations of LHI, but said the process was working effectively.

LHI declined numerous requests for an interview, citing the “sensitive nature” of its business. LHI spokeswoman Tracey Armstrong released a statement describing the company’s role in providing care. “Over the past 10 years, we have provided millions of health care services to hundreds of thousands of Service members, ensuring their fitness to serve before they deploy and supporting their physical and emotional health needs when they return,” the statement said. “As an organization, we are inspired every day by the opportunity to serve our nation’s heroes.”

The statement also said, “As our outstanding Department of Defense annual performance evaluations attest, we regularly exceed the requirements and regulations of individual Service Components and of our contractual obligations.”

The first generation of the RHRP contract is coming to a close, and the Pentagon already has begun work on the next round, estimated to cost several hundred million dollars more than its predecessor. The higher price tag can be explained by the fact that all of the reserve component troops still will be required to get annual checkups, and the Defense Department no longer will be paying the costs of deployed reservists as the wars wind down, Donahue said.

The expanding contract may explain LHI’s acquisition by UnitedHealth Group as well as the purchase of QTC by Lockheed Martin in August.

Glenn Kurowski, head of the division that bought QTC, said Lockheed Martin was attracted by the company’s use of information technology, health care expertise and strong physician network.

He declined to comment on whether the company would be pursuing the next round of RHRP bids, but said Lockheed Martin has a lot of expertise in the field that would enable it to provide effective health services for the reserves.

Donahue said he is not surprised larger companies have entered the fray.

“The entry of the big integrators is reflective of the value of the program,” he said, “both in what it serves the military and the money that can be made doing that.”

This story has been updated to include an additional line from the statement released by LHI.

But when they came home in the spring of 2010, the Army unceremoniously rushed them through the demobilization process at Joint Base Lewis-McChord in Washington state to make room for full-time troops, according to documents and interviews. Those who complained were told to “suck it up” and threatened with disciplinary action.

Outraged, Sen. Ron Wyden (D-Ore.) demanded an investigation. The Army had systematically overturned medical decisions by doctors to push the guardsmen through quickly, improperly forcing their release from active-duty status without medical care entitled to them by law, he told Army brass in a letter.

Lt. Gen. Eric Schoomaker, the Army‘s surgeon general, sent a letter of apology in response, and Wyden’s campaign led to a series of reforms in the post-deployment procedure. The demobilization process was lengthened from five to 14 days to ensure adequate examination and care. Also, guard members can no longer be discharged without their commanding officer’s approval, for the first time guaranteeing them an advocate in the process, a Wyden staff member said.

In March 2010, an Army officer's Powerpoint presentation to clinical personnel assisting demobilization at Joint Base Lewis-McChord in Washington state included some slides that Sen. Ron Wyden (D-Ore.) later saw and called insulting to to National Guard and Reserve members.

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But Wyden said the treatment of the guard at Joint Base Lewis-McChord was emblematic of a bigger problem – a fundamental disparity in post-deployment treatment and support provided to the active-duty military and that given to the military’s reserve component.

“Active-duty and guard folks are serving in the same foxhole,” Wyden said. “If you’re serving in the same foxhole, you ought to be able to come back to the same sort of benefits.”

In 2009, Wyden had introduced “Soft Landing” legislation that he said would ease the transition of reserve component troops, giving them and their families more time – and more resources – on their way home so they wouldn’t be so suddenly thrust back into civilian life after long combat tours.

Such reforms are needed, Wyden said, “because the period when somebody might be holding a gun in Afghanistan and fighting the enemy and holding their child in Coos Bay, Oregon, is just too abrupt.”

Over the past decade, many guard and reserve members have suffered from debilitating stress, PTSD and other mental health problems. A 2007 study in the Journal of the American Medical Association found that 42 percent of reserves returned from overseas deployments with self-reported psychological health concerns, double the active-duty rate.

Wyden, however, has had trouble finding a co-sponsor for his legislation. Even after whittling down his proposal in late November to merely require the Pentagon to study his proposal, he couldn’t find enough support to add it to the Senate’s defense authorization bill, which passed Dec. 1.

The National Guard Association of the United States has lobbied for the past decade to get Congress to address the unique challenges faced by reserve component troops, especially upon their return from Afghanistan and Iraq.

“Congress has been tardy since day one,” said Pete Duffy, the association’s deputy legislative director. “They have fought us tooth and nail.”

In another recent attempt to provide reservists improved care, Senate Committee on Veterans Affairs chairwoman Patty Murray (D-Wash.) introduced legislation to require that mental health professionals be embedded at drill weekends for reserve components. An amendment was included in the House-approved version of the defense authorization bill, but Murray was unable to add it to the Senate defense bill.

“The realization in Washington of the problem has been slow in coming,” said Murray spokesman Matt McAlvanah. “There has been a lag in addressing the National Guard’s need for care equitable to that of those serving in active duty.”

Murray’s measure is intended to help mental health counselors build trust with reservists who often don’t seek care on their own. The process would also avoid placing additional travel burdens for reserve component members, who often live far from mental health professionals and military instillations.

“That would be revolutionary if that was actually adopted, because it would be the first instance the Department of Defense would be required to provide mental health care, or any medical care, except for service-connected injuries, during these dwell periods (between deployments),” Duffy said.

TriWest, a military-contracted health care network, paid for a similar program for the California and Montana National Guards, said Reserve Officers Association legislative director Capt. Marshall Hanson.

Murray’s proposal to take the program nationwide met significant resistance from the Pentagon, according to Duffy and McAlvanah. Defense Department spokeswoman Cynthia Smith said the Pentagon’s policy is not to comment on pending legislation. But a Defense Department position paper said that the program was unnecessary and would be difficult to staff given the nationwide shortage of mental health professionals.

Support for the reserve component has risen somewhat in Congress. Last fall the 84-member Senate National Guard Caucus and its co-chairs, Patrick Leahy (D-Vt.) and Lindsey Graham (R-S.C.), pushed through the Senate a provision that would add the commander of the National Guard Bureau to the Joint Chiefs of Staff, despite the joint chiefs’ opposition.

Also, the 2010 defense authorization act included a requirement for all soldiers to receive one pre-deployment and three post deployment one-on-one mental health assessments with a professional. But that hasn’t happened yet for the Army National Guard and Reserves due to logistical problems, according to a Defense Department report.

Two years earlier, Congress made the Yellow Ribbon Reintegration Program, begun in Minnesota, a federally funded requirement for the guard nationwide. The program, widely regarded as important and effective, has provided soldiers with a support network, counseling services and mental health referrals. But enforcing attendance among far-flung troops resistant to seeking help has proven to be difficult.

Wyden’s “Soft Landing” bill originally would have allowed National Guard and reserve soldiers to remain on active duty while receiving pay, family counseling and mental health care for 90 days after returning from deployment. After concerns about the expense, Wyden shortened it to 45 days in 2010.

Wyden said he will continue to push for improved services for the guard and reserves. Although state innovation should continue to be encouraged, he said, more federal leadership is needed.

“I’m not going to rest until we see that the kind of improvements that we’re starting to see in our part of the country,” he said. “That situation up at Fort Lewis was a real wakeup call and they made some significant changes.”

The New Mexico National Guard's behavioral health team is made up of civilian contractors, and state and military behavioral health officers. (Andrew Theen/Medill)

ALBUQUERQUE – The federal government provides each state with a baseline of mental health resources, according to National Guard leaders, but each state’s guard is responsible for building up additional services.

“It’s a patchwork nation,” said Capt. Joan Hunter, director of psychological health for the National Guard Bureau in Washington. “There’s geography, there’s cultural, there’s regional differences within the National Guard, which can be strengths and challenges.”

Capt. Brian Pilgrim, a former Marine and current behavioral health officer for the state of New Mexico, said large rural states present particular challenges. “When you get into tiny little towns in northern New Mexico with populations of 250, you’re not going to have a psychologist and a psychiatrist with a private practice there.”

The New Mexico National Guard has six family assistance centers, two behavioral health officers in military uniform who work alongside family services and the state psychological health officer. Therese Sanchez, the state family program director, said community-based assistance centers and providers are an especially helpful resource for the guard and their families because “we are the community, we don’t leave.”

Grappling with budget shortfalls and provider shortages, California’s National Guard partnered with TriWest, a major military health care contractor, to pioneer the Embedded Provider Program, which assigns a behavioral health professional to individual guard units. Using trained civilian professionals part-time for drill weekends helps the program keep costs down and meet demand, according to Col. Darc Keller of the California National Guard.

With the third largest military population in the United States, North Carolina recognized National Guard health care networks could not handle the swell of returning service members alone and coordinated with state and community resources. “We all work together collaboratively to close the gaps that exist because service members have been falling through the cracks of no fault of their own for 10 years,” said Stephanie Nissen, North Carolina’s behavioral health programs director.

The North Carolina National Guard Integrated Behavioral Health System includes a toll-free number through which service members and their families can initiate a cascade of behavioral health care services with a single call. The line went live on Nov. 1, 2010, at 8 a.m. The first call came through 18 minutes later – more than 800 followed in the first year.

“I’m comfortable in thinking that we’ve stopped some significant suicides,” Nissen said.

But the Defense Department’s vaccination policy doesn’t follow government health agency recommendations regarding how many doses of the vaccine should be administered. And the vaccine, BioThrax, is controversial, with concerns raised about the vaccine’s adverse side effects and whether it effectively protects soldiers because no long-term efficiency study has been performed on humans.

Full protection requires a series of five shots, according to guidelines issued by the Food and Drug Administration. However, reservists receive an average of 3.7 shots, according to statistics provided by the Defense Department’s  Military Vaccine Agency. Figures for active duty were not available.

Lt. Col. Patrick M. Garman, deputy director of the Military Vaccine Agency, said the Defense Department’s policy doesn’t adhere to the FDA’s recommendation because inoculation is not a perfect science and individuals have some protection after one dose.

Dr. Beatrice Golomb, an associate professor of medicine at the University of California at San Diego who has researched the immune response to BioThrax since the first Gulf War, said though it is plausible that one or two doses of BioThrax could provide sufficient protection for some individuals, immune responses are different so others would need more shots.

An official from Emergent BioSolutions Inc., the only company licensed to produce BioThrax, acknowledged that no conclusive study is available to pinpoint what level of antibodies a person needs to be considered fully protected against the threat of anthrax.

During service members’ first pre-deployment training, they must begin the vaccination series with the first shot and follow through with the FDA-approved dosing schedule while deployed. Once they return to the U.S., continuing the series is their responsibility. The schedule included six shots until 2008, when a Centers for Disease Control study concluded five shots were sufficient for full protection and the FDA amended its requirement.

Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, said, a five-shot vaccine is “just not practical”  for reservists because they are not full-time military and can’t keep up with the dosing schedule over an 18-month period because they are not authorized to get medical care from the military after they return to civilian life.

Tui Marshall is a member of the Oklahoma National Guard currently on his third deployment, this time to Afghanistan. After 11 years in the service, he has only received three doses of BioThrax, even though he said he wants to finish the series.

“I would have to pay out of pocket,” said Marshall. And the appropriate medical facilities don’t always have the vaccine readily available, he said.

It’s important that guardsmen be fully vaccinated because an anthrax attack would most likely occur in the U.S., and guardsmen serve as first responders, said Barry Kellman, president of the International Security and Biopolicy Institute. “When everyone else is running away, they are running into the center of chaos,” he said.

The anthrax vaccine was developed by the Army more than 50 years ago, and was first licensed in 1970 by the National Institutes of Health. For decades, it was primarily used to immunize agricultural workers who could contract naturally occurring anthrax through contact with infected livestock. The vaccine wasn’t used for mass inoculations until government officials determined at-risk military personnel should be vaccinated in the 1990s.

The Defense Department’s immunization program protocol has changed since the program began. In 1997, the department stated in a news release that the immunization program to begin the next year would consist of all six inoculations.

By March 1999, Undersecretary of Defense Rudy de Leon wrote in a memorandum, “Ideally, personnel should receive at least the first three vaccinations in the series.”

The current implementation policy says, “It is DoD policy to use the anthrax vaccine consistent with the FDA-approved dosing schedule.’’ This schedule requires five doses, plus annual boosters.

The policy also says: “All individuals who begin the anthrax vaccine dosing series shall be informed of the recommended dosing schedule and advised to return to the vaccination clinic at the appropriate times under the schedule.”

Because full inoculation takes 18 months, longer than most deployments, Garman explained, the military’s focus is getting service members to begin the series, giving them some, if not complete protection.

“It’s not a clear, red line or hurdle that you jump over to make you fully protected,” Garman said. “You have some protection after one immunization.”

Early in the program, more than 400 Air National Guardsmen and Air Force Reservists were severely reprimanded or discharged for refusing the vaccine based on safety concerns—with some claiming that an adverse side effect, ranging from redness and fatigue to neurological disorders and death,  could affect their flight status and cause a subsequent career setback.

“The word is out on this vaccine,” said Steve Fischer, a National Guardsman for more than 25 years. Fischer became violently ill after receiving his third shot in 1999, and went from an able-bodied master electrician to being unable to perform basic functions. “I lost ability in my hands, I could barely lift my feet to step up on a curb, and I had sores all over my face,” he said.

Within months of getting sick, Fischer was discharged from the guard.

A 2002 Government Accountability Office report concluded that 77 percent of Air National Guardsmen and Air Force Reservists would have declined the vaccine had it been voluntary.

More than 7,260 adverse reactions to BioThrax have been reported according to the National Vaccine Information Center. With more than 10 million shots administered, the reaction rate is less than 1 percent. But Fischer and other experts said possibly thousands of reactions went unreported because troops were pressured not to report symptoms.

In 1997, the Defense Department estimated the anthrax immunization program over a six-year period would cost $130 million. Officials from the Military Vaccine Agency couldn’t provide a total spent on the program during its 13 years.

But Emergent BioSolutions Inc., a Rockville, Md., firm, has received more than $360 million in government contracts, according to USAspending.gov. This doesn’t include costs for transporting, storing and administering the vaccine. Government officials, including Garman, said producing a total is complicated by fluctuations in the vaccine’s price over the years, as well as the difficulty in tracking expenses across several branches of the government.

One dose of BioThrax today costs more than $30, in 1998 it cost under $4—a more than 800 percent increase.

“An increase in price reflects the fact that they’ve got something of value,” Kellman said. “But that logic only works if Emergent had actually developed the vaccine itself. They didn’t; they were given the technology to produce the vaccine from the U.S. government.”

Emergent BioSolutions’ Vice President of Corporate Communications Tracey Schmitt said many factors enter into the pricing, including costs to maintain an FDA-compliant manufacturing facility and standard inflation adjustments.

“Dozens of audits and financial reviews have been conducted by various government agencies,” she said. “Each has concluded that the pricing structure is both fair and reasonable.”

Caplan said a new vaccine requiring fewer doses is needed, and the technology exists to create it.

Dr. Thomas Inglesby, director of the Center for Biosecurity at the University of Pittsburgh, said that though much of the experimental work for a new vaccine is done, it’s still years away from being licensed. “It’s worth asking the government and industry whether everything that could be done is being done to move this technology forward rapidly,” he said.

Although the wars are winding down, the U.S. government is stockpiling millions of doses of BioThrax for civilian use. “Many people think you are going to be able to lean on a vaccination program in the event of a large-scale attack,” Caplan said. “But if you look at the military program, it may not be true that we’d get satisfactory results after all.”

Andres Alvarez scouts out the terrain in Eastern Iraq in April 2005 during his second deployment of three with the National Guard. Months earlier his vehicle was struck by an improvised explosive device causing post-traumatic stress disorder and traumatic brain injury.

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.”

Chris Dana died by suicide in 2007 a year after deploying to Iraq with the Montana National Guard. His parents, Lisa Kuntz and Gary Dana, said he was a warm and loving young man, but the war changed him. (Andrew Theen/Medill)

HELENA, Mont. – Chris Dana joined the Montana National Guard as a senior in high school.

“He wanted to do something with his life,” Lisa Kuntz, his mother, said.

More than a year after graduating, in November 2004, Dana, a voracious reader and video gamer, went to Iraq as a gunner for Montana’s 1-163rd Infantry Battalion. He spent his deployment in Northern Iraq, often patrolling the notorious “Highway of Death” from behind the guns of a Humvee during the height of the insurgency.

Dana came back a year later a profoundly different man. He gradually isolated himself from friends and family, stopped showing up for work at Target, quit attending his mandatory National Guard drills and was less than honorably discharged.

On March 4, 2007, at age 23, leaving no note, he shot and killed himself in his room. His father, Gary Dana, found the crumpled discharge notice from two days earlier together with a receipt for .22 caliber rifle shells.

The suicide shocked the Montana National Guard. Although the guard was surpassing all requirements set by the Defense Department to assess and treat Montana service members as they came home, the state concluded four months after Dana’s suicide that it wasn’t doing enough for those with post-traumatic stress disorder and other mental health issues.

“We didn’t understand what post-traumatic stress disorder was. …We didn’t understand what caused it or anything about it, so we had to do what we could to learn about that,” said Col. Jeff Ireland, the Montana guard officer in charge of personnel at the time.

Dana’s death was the impetus for a task force that took a hard look at the post-deployment effort, especially the mental health screening process of returning Montana National Guardsmen and women. That investigation found Dana’s case wasn’t isolated, and that other returning service members were rushed through the same inadequate system and left with nowhere to turn.

“The fact is he was really seriously injured and nobody including myself understood the extent of the injury or really how to get him help,’ said Matt Kuntz, Dana’s stepbrother and executive director of the National Alliance on Mental Illness’ Montana chapter.

Kuntz’ advocacy on Dana’s behalf ultimately resulted in a national policy mandating confidential mental health screenings for all service members before they deploy and at regular intervals for up to two years after they come home.

Nearly five years after Dana’s death, the post-deployment process is radically different for members of the reserve component nationwide. They are now required by Congress to attend reintegration events 30, 60 and 90 days after returning from a deployment in addition to the demobilization process immediately after returning home.

The aftermath

Following Dana’s suicide, Kuntz, then a corporate lawyer, decided he had to do something. Older than Dana by seven years, he was angry that news reports focused solely on the suicide and not on the circumstances leading up to it. His family believes he suffered from undiagnosed PTSD.

Kuntz couldn’t escape the sense he hadn’t done enough to help Dana. Gary Dana, Chris’ father, had asked Kuntz to reach out to his increasingly isolated son over the holidays, but they failed to connect.

The solidly built and soft-spoken Kuntz thought he was the one who should have gone to war, but the West Point graduate was injured during Ranger school.

“I was a peacetime chump, and he’d done it. I was just really, really proud of how well he’d done and how brave and how well he’d served,” Kuntz said.

At the academy, he learned missions need a direct, tangible objective so he decided his campaign for better guard mental health treatment would focus on confidential, mandatory in-person mental health screenings. He believes this could have saved his stepbrother’s life. He targeted the commander of the Montana National Guard, Gov. Brian Schweitzer.

Kuntz wrote op-eds that appeared in papers across the state, with the governor’s phone number at the bottom. He rallied veterans groups and peace advocates to the cause.

A month after Dana’s death, Kuntz’ campaign had struck a chord. Maj. Gen. Randall Mosley, the Montana guard’s top officer, convened a task force of military and mental health experts and state legislators. Their assignment was to evaluate whether the care and support of returning guard members was adequate, including the federally mandated post-deployment health reassessment process.

The task force spent four months investigating, and in June 2007, sent a sharply critical report to Mosley that described systemic problems at every level of the post-deployment and reintegration effort.

“Painfully obvious…is that the citizen soldier, now a combat veteran, oftentimes needs services and support resources that extend far beyond what the Montana National Guard or the PDHRA (Post-Deployment Health Reassessment) program currently offer,” according to the report.

Montana’s commanders, service members and their families lacked the fundamental knowledge and training they needed to detect the early warning signs of PTSD, TBI and other combat-related stressors, according to the task force. It called for a statewide network of resources that would “meaningfully assist” veterans facing those issues.

The task force recommended 14 fundamental changes in how the Montana guard operated, including re-evaluating a policy that allowed guard members such as Dana to be less than honorably discharged because they repeatedly missed drills.

It also found widespread reluctance among guardsmen to seek mental health services and a lack of coordination among the Department of Veterans Affairs and local agencies. It said Dana’s experience was a “microcosm” for Montana veterans and reservists. Many were isolated by the vast geography of the state, far from “battle buddies’’ who shared the harrowing experiences of war with them

A broken system

When Dana returned from Iraq in November 2005, he considered his post-deployment health screening a joke, according to family members.

He didn’t think he had a problem.

Janna Sherrill, Dana’s stepsister and an occupational therapist, suggested he get help for what she suspected was PTSD. Dana, however, told her his difficulties getting back on track were no different than those of his fellow combat veterans.

His parents said their son’s experience as a gunner didn’t fit his quiet nature and took a heavy toll.

Meanwhile, Gary Dana received repeated calls from a guard commander in Butte demanding to know why Chris failed to show up for drills.

Lisa Kuntz said her son grew uncharacteristically cold and that his isolation deepened. Chris missed family events over the holidays and yelled at her when she showed up at his job, telling her to leave him alone.

The task force noted that Montana had followed established procedures by the book, but it wasn’t enough to catch Dana.

The report, and critics like Kuntz, said the system left too many outs, too many opportunities to avoid getting care. Symptoms of mental injuries can manifest months or years after combat. As a result, the task force recommended requiring returning troops to speak with a professional well after returning from war. Making it mandatory also would eliminate the stigma associated with seeking mental health care.

The task force also noted that the Army had implemented follow-up assessments in January 2006, and that the National Guard followed suit four months later. But it said the screenings, 90 and 180 days after returning from a deployment, weren’t always effective, confidential or administered by qualified professionals.

Eric Kettenring, a retired Army Reserve colonel and a VA mental health specialist, was struck by how few people understood what it meant to combat veterans and the mental health issues they experience.

One of the recommendations Kettenring advocated for as a task force member was for returning soldiers to quickly receive badges and awards they had earned. The report said delaying combat awards is demoralizing and affects qualification for some medical benefits.

Also significant, Kettenring said, the guard treated repeated absences from drills as delinquent behavior, as it did in Dana’s case, rather than as an indicator for depression, PTSD or TBI.

But, he said, “that’s what depressed people do. They don’t show up.”

An about-face

By January 2008, the Montana National Guard made all of the changes the task force had recommended.

Guard officials also looked to Minnesota, which began an innovative Yellow Ribbon Reintegration Program in 2005 that brought troops and their families together to address the challenges of reintegrating into civilian life.

Ireland customized the program for Montana, and went a step further. Knowing other states faced similar problems, Ireland made a CD with Montana’s reforms and sent it across the country.

Other states implemented some of the changes even though it wasn’t required.

“I think there’s a big fear in taking away states’ abilities to customize programs,” Ireland said.

Officials at the National Guard Bureau in Washington agreed.

Matt Kuntz’ commitment to mandatory confidential mental health screenings brought him to Washington, where he testified before Congress.

Sen. Max Baucus (D-Mont.) introduced legislation requiring the screenings in June 2009; it became law a few months later. Baucus called Kuntz “the real inspiration for getting this done.”

Back in Montana, Ireland and other guard officials continue to make sure mental health professionals screen returning service members. They also update the Yellow Ribbon program for families, with an emphasis on things “nobody wants to talk about” like suicide, anger and divorce.

Additionally, Montana has created crisis response teams made up of state behavioral health officers, chaplains and commanders.

“I don’t have any way to tell you that it’s saved one life, but I’m positive… that there are a lot of people that are alive because we have that,’’ Ireland said.

Last year, one of the state’s two teams responded to 63 crises for 41 individuals.

Since Dana’s death, the Montana National Guard has lost two more service members to suicide, both last year. Nationally, 2010 saw the most guard suicides since they began tracking them in 2007.

Dana’s father, Gary, said the awareness of mental health issues has increased dramatically since Chris’ death five years ago, and that the families of two other Montana veterans called him praising the new behavioral health center at the Helena VA. “It made me feel good that his death was a positive thing for people,” Dana said.

Dana’s mother, Lisa Kuntz, also said the changes enacted by Montana are heartening, as was the posthumous reversal of his less than honorable discharge.

“They did make some positive changes, very positive,’’ she said, “but it’s too bad that we had to lose our son for them to do that.”

WASHINGTON — The National Guard and Reserve have played a critically important role in the wars in Afghanistan and Iraq, deploying in unprecedented numbers and enduring repeat tours of duty to combat zones where they fight alongside active duty troops.

But this unforeseen surge has been hampered by significant problems from the start.

Many stem from the fact that most of the more than 665,000 who deployed were working men and women who were part of a civilian “strategic reserve” that trained one weekend a month and two weeks a year.

“When you’re a strategic reserve… you think that you’re not going to be a day one player, you’re going to be used later on and that you’ll have time” to get ready, said Gen. Craig R. McKinley, the chief of the National Guard Bureau, which oversees and coordinates operations among the 54 state and territorial Guard units.

“What Sept. 11 taught me is that you may not have time, you may need to be ready today and you have to do today what you might not have been prepared to do, but you’ve got to get in the game anyway,” said McKinley, who assumed the Guard post in November 2008.

In the immediate aftermath of the Sept. 11 attacks, most reserve component soldiers — the National Guard and the Reserves for each military branch — were medically unready to deploy. In response, the Pentagon turned to a private company for help in creating a massive pre-deployment pipeline to quickly assess the medical status of the reserves and shore up readiness rates.

From the start, many units went through the mobilization process so quickly that there wasn’t enough lead time to fix some health problems, holding up deployments despite the military’s critical need for additional troops to support its growing combat effort. More than 2,400 Army Reserve soldiers were held back, at least temporarily, because of inaccurate assessments by the contractor, according to data provided by the Army Reserve Medical Command.

The number could be even higher as the command looks closely at the records of medically non-deployable soldiers, according to Maj. Gen. Richard Stone, the Army’s deputy surgeon general for mobilization, readiness and reserve affairs.

And an unknown number of other reserve soldiers were sent overseas who should not have been, including some with behavioral problems that could become aggravated by the stress of combat and lead to depression, post-traumatic stress disorder and even suicide, according to interviews with current and former officials, troops and experts, and a review of government documents and studies.

“In a time of crisis when they needed so much manpower, nobody wanted to identify problems,” said Dr. Remington Nevin, who worked with the military’s main health surveillance wing. “If we had a robust screening process, we wouldn’t have had enough people to fight the surge.”

In recent years, the military has taken steps to more thoroughly prepare and assess the reserves before deployment. In response, readiness rates among the reserves are at a little over 60 percent and at over 70 percent for the Guard, the highest numbers ever, according to Stone.

The Pentagon has also placed a greater focus on behavioral issues in an effort to weed out those unfit to serve due to potentially debilitating mental health problems.

But reservists have reported suffering from mental health problems, including post-traumatic stress disorder, at a higher rate than their active duty counterparts, based on data maintained by the Armed Forces Health Surveillance Center. “We were deploying sick soldiers who got broken [more] when something happened to them, and we end up picking the costs for decades to follow,” said Nevin, who said he was not speaking in his official capacity as an epidemiologist at Fort Polk in Louisiana.

The extent of the problem is still becoming known as many of their injuries go undiagnosed because the reserves lack the same access to care and support as their active-duty counterparts, according to Nevin and others.

As a result, military officials still do not know whether they are fully vetting the reserves before sending them to war, especially those who have already deployed, experts say.

Responding to urgent need

The massive mobilization began three days after the Sept. 11, 2001 attacks, when President George W. Bush declared a state of emergency that authorized the Defense Department to issue a mandatory call-up of the reserve component for duty related to terrorism.

After the first Gulf war, the Government Accountability Office had said the medical readiness process needed improvement if the reserve components were to meet the nation’s security needs.

To ramp up deployment of the reserves, the government expanded a joint venture known as FEDS-HEAL, in which the departments of defense, health and veterans affairs had been paying a private contractor to provide medical services since 1999.

FEDS-HEAL required reservists to undergo a series of tests and screenings when called up to active duty. The contractor, LHI of La Crosse, Wis., evaluated reservists on their physical and mental health, using a combination of doctor examinations and self-administered questionnaires designed to catch medical problems.

The new program was getting underway just as 75,000 reserve members were activated during the first major combat operations in Afghanistan. And soon, reservists were being sidelined for minor and easily correctable problems by LHI’s rapidly expanding network of contract health-care workers, said Lt. Col. Ross Waltemath, director of civil military affairs at the Indiana National Guard.

“We had a bad problem in the beginning with the contract company,” Waltemath said. “No one wanted to talk anymore. Every single screening you went through, ‘I am perfect’ was all you heard.”

Stone agrees that there were problems, but said LHI was only trying to err on the side of caution.

“The profiling was done in a very liberal manner to protect the service member,” Stone said.

LHI, also known as Logistics Health Inc., declined repeated requests for an interview and for a response to the specific criticism, citing the “sensitive nature” of their business. But a statement released by the company’s official spokeswoman, Tracey Armstrong, said, “We regularly exceed the requirements and regulations of individual service components and of our contractual obligations.”

Tackling mental health concerns

Gaps in the screening process caused other serious repercussions, in part because identifying physical problems was much easier than behavioral ones, especially those starting to surface among those on their second or third deployments.

The Pentagon relies on reserve members to report their own health problems because they have no way of tracking their medical care when the reserves are not called up for active duty.

“Study after study has shown self-administered surveys are the best way to get information,” Stone said. But the military lacks a central record-keeping system capable of maintaining complete health records of those in the reserves, undermining its ability to spot and manage medical conditions, according to Waltemath and other experts.

Medical documents of guardsmen at an Evansville, Ind., readiness screening event. Self assessment surveys play a crucial role in evaluating the health of reservists. (Bob Spoerl/Medill)

Some of the reserve members missed the initial warning signs that they were suffering from depression and post-traumatic stress disorder. Others reported not seeking care due to concerns that getting mental health treatment would hurt their career, according to Terri Tanielian, director of RAND Corporation’s Center for Military Health Policy Research.

“The soldier can seek civilian care for mental problems and his unit may never come to know,” Nevin said. Because of confidentiality, the reserve members’ commanding officers also can’t get access to their medical records, depriving the military of another avenue for identifying problems.

And the pre-deployment screenings administered by LHI did not have adequate controls in place to catch potential behavioral problems, according to some military officials and experts.

Those deploying between 2001 and 2006 only had to answer one question related to mental health on their pre-deployment surveys: “During the past year, have you sought counseling or care for your mental health?”

“For me to find out someone has a problem, the soldier has to come to me with the problem or I have to find out by accident,” Waltemath said. “That’s a challenge the active-duty soldiers don’t face.”

Since 2003, when the Armed Forces Health Surveillance Center began keeping statistics, the reservists reported mental health problems at significantly higher rates than their active duty counterparts.

After media reports asserted that the military was sending mentally unfit service members into combat zones, the Pentagon in 2006 developed minimum mental health standards for those deploying. That included a special pre-deployment questionnaire focusing exclusively on potential behavioral problems.

Waltemath said that helped, but only so much.

“How much time do you get with those clinicians–five minutes?” he said. “I don’t want someone dictating if I have a behavioral health issue with a five minute talk.”

In September 2007, the Pentagon awarded LHI a new $790 million, five-year contract to run what was now called the Reserve Health Readiness Program.

That year, Ryan Kohlheim’s brother Spencer had just returned home after spending six months in Afghanistan, his sixth deployment with the military. He said his problems coping with civilian life were getting worse.

“He was involved in an incident where he freaked out on some people,” Kohlheim said. After his brother spent a night in jail, he took him to a Veterans Affairs facility for counseling sessions and treatment for substance abuse and mental health problems.

Less than a year later, Spencer again deployed to Iraq. Two weeks after returning home in December 2008, he hanged himself in their grandmother’s house.

Kohlheim said he didn’t know what kind of screening process his brother went through. But, he said, “I don’t think he was in any shape or form to deal with everything going on there. I absolutely think they should have stopped him from going.”

Spencer Kohlheim (second from left) was deployed to Iraq in 2008, even though he was undergoing counselling sessions at a Veterans Affairs facility for mental health problems. (family photo from Ryan Kohlheim)

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Looking to the future

Nevin and others remain concerned that the screening process is inadequate, especially for the reserves.

Annual statistics from October 2010 showed that only one in 300 reservists had been identified for mental health referrals based on the pre-deployment health assessment forms they filled out — significantly fewer than the one in 100 among full-time soldiers, according to the Armed Forces Health Surveillance Center.

Some states have put in place additional measures designed to improve the pre-deployment process.

Waltemath’s Indiana National Guard, for instance, ensures that its members spend a significant amount of time, face to face, with a specialist to discuss mental health issues before deployment and at a VA facility after deployment something that is not required on the federal level.

Even though the two wars are winding down, officials in the National Guard and Reserve say they need to continue to improve the screening system because the reserves have now become fully integrated into the active duty military’s operational plans for the future, and they will need to be ready.

Next year, the Pentagon is expected to issue a new RHRP contract, and estimates it to be worth more than $1 billion.