After nearly nine years, America closed out its mission in Iraq last week with an official death toll of nearly 4,500 soldiers, plus another 30,000 wounded. Now most of the remaining soldiers there are returning home, and the Pentagon is gearing up to provide hundreds of thousands of them with a new congressionally mandated safeguard: individual screenings for mental/emotional wounds caused by combat.

But the military suicides – on average, one soldier has taken his or her own life every 36 hours between 2005 and 2010 – aren’t slowing down yet, according to an alarming new report this fall that says the suicide rate could threaten the nation’s continued hopes for an all-volunteer fighting force.

Troubled in large part by those suicides, Congress passed legislation two years ago requiring three mental-health screenings for each soldier within the two year period after he or she returns from combat.

“We have been working for years to develop better screening for signs of post-traumatic stress disorder, or PTSD, in our combat troops and veterans,” said the bill’s chief sponsor, Sen. Max Baucus, D-Mont. “The Montana National Guard led the way on this front with a successful pilot program. And in 2009 we passed a law to take the Montana model nationwide.”

As of October, the Pentagon had hired nearly 3,500 health-care providers to screen its returning combat vets for elevated stress levels. The Army has already provided its initial examinations of the first 400,000 troops, although it hasn’t announced the results of those exams yet.

“Before this law, many of our troops received only a paper questionnaire, and never received an individualized assessment,” Baucus said. “Thanks to this law, they are now getting personal, and private, one-on-one attention from a trained health-care provider. And they get follow-up assessments for at least two years after they return.”

The Congressional Budget Office estimated that enacting the legislation would cost taxpayers $60 million over a 10-year period.

Montana’s junior senator, Jon Tester, also a Democrat, added a provision that the Department of Defense also provide a baseline mental-health exam for all troops before they deploy into combat arenas.

That followed a study reported in the American Journal of Psychiatry in which doctors screened more than 10,000 infantry soldiers from three brigades heading into combat in Iraq in 2007. The 74 soldiers at highest risk were barred from deployment, and doctors tracked another 96 at-risk soldiers and provided them with coordinated care. The study then compared the screened brigades’ mental health problems with another 10,000 unscreened soldiers from three other brigades.

“Soldiers in screened brigades had significantly lower rates than those in unscreened brigades for suicidal ideation, combat stress, and psychiatric disorders, as well as lower rates of occupational impairment and air evacuation for behavioral health reasons,” it concluded.

A study released last October by the Center for a New American Security found that approximately 14 percent of our military population is currently taking a prescription opiate. Furthermore, when military doctors change a civilian prescription, they’re barred from requiring that soldiers turn in the excess medications. And it said 29 percent of our military suicides involve drugs or alcohol.

When a combat vet named Chris Dana took his own life in March 2007 (see my previous blog, Military Suicides), it shook Montana, a highly patriotic state with one of the nation’s highest rates of veterans per capita.

Gov. Brian Schweitzer quickly demanded answers and appointed a commission to detail how Dana had slipped through the cracks of the state’s military mental health care system. The commission came up with 14 recommendations for reform, and Gen. Randy Mosley, the adjutant general of the Montana National Guard, promised to implement all of them.

He did, and Montana became the model for providing mental health care to its vets. Now, many of the lessons learned through those reforms are now being implemented nationwide just in time for the return home of the remaining 170,000 troops from Iraq (That will be the subject of my next blog).

Most important was a pledge to have every soldier receive a mental health examination every six months for the first two years after his return from combat and another every year thereafter. Previously, soldiers had been given a questionnaire during their debriefings asking them whether they suffered from post-traumatic stress disorder (PTSD). For some, those symptoms didn’t appear for months after their return, but even the vets already having nightmares and flashbacks tended to check the box “no” because they wanted to get home and see their families and because   they feared they might jeopardize their military careers if they admitted high levels of post-combat stress.

All that changed under the new system. Soldiers are required to sit down with trained counselors every six months to discuss how they are feeling, how they are sleeping, anger or irritability issues, abnormal alcohol use and/or marital issues.

At the 120^th Air Wing of the Montana National Guard, deployment resiliency assessment screenings of about 1,000 airmen over the past year triggered 88 individual red flags, including 5 critical cases and 10 priority cases, according to the Montana National Guard’s personnel chief, Col. Jim Oehmcke. That’s about 17 percent of those who had been deployed.

“A critical case might be someone currently threatening to harm himself or others, while a priority case might be someone who had considered it in the past,” explained Master Sgt. Mary Montag.

Those numbers are lower than in previous years because the number of deployments has dropped from about 400 airmen a year to 100, Montag said, adding that “a lot of our cases involve alcohol abuse or medication mixing.”

During 2011, the Montana Army National Guard screened 1,147 soldiers, including 510 who had previously been deployed, and referred 111 (nearly 22 percent of those who had been deployed) for further mental health counseling, according to Oehmcke.

Both the Army National Guard and the Air National Guard developed crisis response teams made up of the unit’s commander, first sergeant, personnel officer, a chaplain and health professionals. They can be convened almost immediately to provide help when a soldier is in trouble. The crisis response team for the 120^th Fighter Wing, based in Great Falls, handled five crisis situations in its first year.

Another major change involved broken bonding. After returning from combat, soldiers were traditionally given a three-month vacation from their weekend drills, but members of the Montana Guard said they really missed being away from their combat buddies and they were having difficulty talking with their families.  So Guard officials got permission from the DoD to continue holding monthly drills immediately after deployment. But there was a catch: drills were held in hotels or convention centers in civilian clothes with wives and families in attendance. There were seminars for soldiers and spouses on mental health, anger management, personal finance and civilian driving laws. That turned into the Yellow Ribbon Program that has been adopted by the National Guard nationwide.

In addition, TriWest Healthcare developed a plan of embedded counselors that it tested in
California and Montana. It sent a counselor to join the Army National Guard and another to join the Air National Guard on base during each drill weekend. Counselors were available to talk with soldiers, their buddies or their families with or without an appointment. They also mingled with the Guardsmen and observed interactions. At the end of the first year’s pilot program, the embedded counselors were clearly so useful that the Montana National Guard adopted it permanently.

“I can’t say enough for what they tried to do,” says Dana’s stepbrother, Matt Kuntz.  “There’s no doubt that PTSD created a huge challenge for the Montana National Guard and other military units, but it started when they flat-out admitted that they had been wrong, and that’s what it takes for an organization to change and make the reforms they need.”

Based on that track record and a congressional mandate, the Pentagon has also adopted the mental health screening program for returning combat vets … just in time to help 170,000 troops returning home from Iraq by the end of this year. And that will be the subject of our next blog.