Global Policy Forum

By Benedict Carey

The detailed mental health survey of troops in Iraq released by the Pentagon on Friday highlights a growing worry for the United States as it struggles to bring order to Baghdad: the high level of combat stress suffered during lengthy and repeated tours. The fourth in a continuing series, the report suggested that extended tours and multiple deployments, among other policy decisions, could escalate anger and increase the likelihood that soldiers or marines lash out at civilians, or defy military ethics. That is no small concern since the United States' counterinsurgency doctrine emphasizes the importance of winning the trust and support of the local population.

The report was provided in November to Gen. George W. Casey Jr., then the senior American commander in Iraq. Pentagon officials have not explained why the public release of the report was delayed, a move that kept the data out of the public debate as the Bush administration developed its plan to build up troops in Iraq and extend combat tours. Rear Adm. Richard R. Jeffries, a medical officer, told reporters on Friday that the timing was decided by civilian Pentagon officials.

The survey of 1,320 soldiers and 447 marines was conducted in August and September of 2006. The military's report, which drew on that survey as well as interviews with commanders and focus groups, found that longer deployments increased the risk of psychological problems; that the levels of mental problems was highest - some 30 percent - among troops involved in close combat; that more than a third of troops endorsed torture in certain situations; and that most would not turn in fellow service members for mistreating a civilian.

"These are thoughts people are going to have when under this kind of stress, and soldiers will tell you that: you don't know what's it's like until you've been there," said Dr. Andy Morgan, an associate clinical professor of psychiatry at Yale University who has worked extensively with regular and Special Operations troops. "The question is whether you act on them."

The Pentagon's analysis also identified sources of anger besides lengthy and repeated deployments that could lead to ethics violations, which would not be apparent from the outside: eight-day rest breaks that involved four days of transit; long lines to get into recreation facilities, especially for those who perform missions outside the relative safety of base camps; and inconsistent dress-code rules. Most of all, there were uncertainties about deployment: 40 percent of soldiers rated uncertain redeployment dates as a top concern.

The military has evaluated the emotional state of soldiers in the past, from the cases of shaking and partial paralysis known as shell shock after World War I, to the numb exhaustion identified as combat fatigue in World War II. The flashbacks and irritability reported in the years after the Vietnam War came to define another diagnosis: post-traumatic stress disorder. But since the Persian Gulf war in 1991 the Pentagon's efforts to track mental health have become far more sophisticated, and now provide a deeper X-ray into the day-to-day realities of life on the ground, in real time - a glimpse of how the stresses of both combat, and policy decisions, can affect the behavior of troops.

When the administration decided in January to send more troops to Baghdad to try to reverse the spiraling sectarian violence in Iraq, it sought to ease the strain on the armed forces by announcing its intention to expand the active duty Army and Marine forces by 92,000 troops. But it takes years to recruit, train and equipment an expanded ground force, and the decision to increase the size of the military was made too late to relieve the stress on the forces now in Iraq.

To sustain the current elevated troop levels, Defense Secretary Robert M. Gates announced in April that the Army was increasing combat tours to 15 months, rather than the traditional one-year tour. "The Army is spread very thin, and we need it to be a larger force for the number of missions that we were being asked to address for our nation," said Maj. Gen. Gale S. Pollock, the Army's acting surgeon general and head of the Army's Medical Command, on Friday, as the report was released.

To better cope with the current strains, the report recommended that suicide prevention program be revised, that soldiers and marines who have combat positions outside large bases have better opportunities for occasional rest and recreation, and that a more determined effort be made to teach battlefield ethics on dealing with civilians.

The military team that conducted the survey recommended that soldiers spend 18 to 36 months at home between deployments abroad, in contrast to the current Army policy of 12 months. Col. Carl Castro of the Army, who led the team that carried out the survey, asserted that the military began to carry out the report's recommendations immediately after it was completed.

The report noted a direct relationship between involvement in intense combat and soldiers who exhibited signs of anxiety, depression and acute stress. Almost 30 percent of soldiers who were engaged in "high combat" were discovered to be suffering from "acute stress," according to the report. But the length of tours in Iraq was another important factor. Soldiers who were deployed for more than six months were one and a half times more likely to exhibit depression or anxiety than those with shorter tours of duty.

Those who had repeatedly served in Iraq were also more likely to suffer from psychological ailments than those who were serving their first tour. The survey showed that 24 percent of those who had done multiple tours suffered from "acute stress," compared with 15 percent who were on their first tour.

According to the survey, suicide rates for soldiers in Iraq from 2003 to 2006 were 16.1 per 100,000, compared with the average Army rate of 11.1. In general, soldiers experience higher rates of mental health problems than do marines. The morale of the soldiers also tended to be lower than that of marines, who unlike those in the Army typically serve seven-month combat tours in Iraq.

The report said psychological ailments and built-up anger resulting from combat stress increased the likelihood that the troops would lash out at civilians. The survey noted that only 47 percent of the soldiers and 38 percent of marines agreed that noncombatants should be treated with dignity and respect. Troops who had high levels of anger were twice as likely to violate ethical standards, the report found. The survey found that 40 percent of troops who scored high on measures of personal anger reported insulting or cursing at a civilian, and 7 percent reported having hit or kicked a civilian. Among those low on measures of anger, only 1 percent said they had hit a civilian, and 16 percent reported insulting noncombatants.

The Iraq war, experts say, is a new kind of war - a 360-degree battle space, with no front or rear, no safe zone outside the large fortified bases, and the compounded physical uncertainty of roadside bombs and mortar attacks. The lack of any control over these factors, and the generally limited sense of progress, only intensifies the stress for troops.

"You can endure a lot of physical and mental exhaustion as long as you feel you're having an impact, you're accomplishing something and that you have some control over your situation," Dr. Morgan said. "If you don't feel you have any of that, you quickly get to a point where the only thing that's important is keeping yourself and your buddies alive. Nothing else much matters."