Soldiers with multiple deployments to Iraq and Afghanistan are more than three times as likely as soldiers with no previous deployments to screen positive for post-traumatic stress disorder (PTSD) and major depression, according to a new study published by the American Journal for Public Health.

Additionally, soldiers with multiple deployments are more than twice as likely to report chronic pain and more than 90 percent more likely to score below the general population norm on physical functioning.

For the study, researchers assessed the effects of prior military service in Iraq or Afghanistan on the health of New Jersey Army National Guard members preparing for deployment to Iraq. Researchers analyzed anonymous, self-administered pre-deployment surveys from 2,543 National Guard members deployed to Iraq in 2008. They assessed the effects of prior service in Afghanistan (Operation Enduring Freedom) or Iraq (Operation Iraqi Freedom) on mental and physical health.

"Those experiencing multiple deployments are most at risk, with the Office of the US Army Surgeon General reporting mental health problems in 11.9 percent of those with one deployment, 18.5 percent with two deployments and 27.2 percent with three or four deployments," the report stated.

Amy Fairweather is an expert in veterans' issues and is director of the Coalition for Iraq and Afghanistan Veterans, a clearinghouse of more than 45 agencies serving a myriad of needs associated with deployment in the Iraq and Afghanistan wars.

"What we're seeing is a people who are having more serious PTSD when they're called up for an additional deployment, and that triggers a lot of mental health issues - in fact, suicidal action in some cases," Fairweather said. "But it's also mixed with a lot of conflicting feelings of guilt" in that if people have PTSD, they are a danger toward other people, but Fairweather said they may think, "Who am I to try to get out of this? Who am I to complain?" when fellow soldiers are going through the same hell.

Fairweather also is director of the Iraq Veteran Project for Swords to Plowshares, a community-based, not-for-profit organization that provides counseling and case management, employment and training, housing and legal assistance to homeless and low-income veterans in the San Francisco Bay area and beyond.

Also, the report stated that concerning physical health, the Iraq and Afghanistan wars "have produced the highest ratio of wounded to killed of any previous military operation (approximately 7:1), with over 33,170 wounded in action as of October 2008. Orthopedic injuries are the most common class of injury and pain one of the most frequently reported symptoms."

Although the health consequences of soldiers serving in Iraq and Afghanistan have focused attention on the medical needs of returning veterans, the report stated, "Concern has also centered on the military readiness of our fighting force, given the unprecedented pattern of repeat deployments unique to this particular conflict." Of all the soldiers deployed to Iraq since the war began in March 2003, about 38 percent of soldiers have been deployed more than once and 10 percent have been deployed three times or more, the report stated.

The Department of Defense and state National Guard authorities conduct screenings before and after soldiers' deployment to make sure that only "healthy and medically prepared" soldiers are deployed to combat. However, the American Journal of Public Health report stated that there is little information about the effectiveness of military programs in screening seriously impaired soldiers out of the eligibility pool for future deployment.

Fairweather said, "The deployments are so stressful and different than what we've seen in previous conflicts. There are no front lines, and it's 24/7 combat."

Authors of the American Journal of Public Health report are Anna Kline, Maria Falca-Dodson, Bradley Sussner, Donald Ciccone, Helena Chandler, Lanora Callahan and Miklos Losonczy.

For the report, they compared the health status of soldiers with previous Iraq and Afghanistan deployments with that of soldiers experiencing their first deployment, examined associations between deployment status and health after controlling for possible confounding factors and compared the present survey with New Jersey's pre-deployment health assessment on identification rates of key mental health problems.

The survey was administered by Rutgers University researchers to groups of about 25 to 75 Guard members. Respondents were place into two groups: those who had no prior Iraq or Afghanistan deployments and those who had one or more prior Iraq or Afghanistan deployments.

Of the soldiers in the study, the sample had a mean age of 33.2 years old and was predominately male (88.1 percent) and non-Hispanic white (47.4 percent), and there also was a large number of Hispanics (29.5 percent) and a small number of non-Hispanic blacks (17.2 percent). Also, National Guard members were mostly well-educated, with 68.4 percent having completed some college or more.

The report stated, "deployed soldiers scored significantly lower than non-deployed soldiers on almost every measure of mental and physical health." Besides being more than three times as likely to screen positive for PTSD and major depressions, deployed soldiers were nearly twice as likely to have alcohol dependence and were more than twice as likely to report binge drinking.

In addition, the report stated that deployed soldiers were 2.5 times more likely than nondeployed soldiers were to report needing help with emotional problems, and nearly four times more likely to report needing help with sleeping problems. Also, deployed soldiers reported pain in more body areas, especially the back and joints, and experienced pain that was more intense and chronic. And deployed soldiers also made significantly more medical care visits in the past year than nondeployed soldiers did.

"There was a tendency for the previously deployed to exhibit progressively worse physical functioning with increasing numbers of deployment," the report read.

According to the report, despite health screenings by state and federal military authorities, the repeated Iraq and Afghanistan deployment of New Jersey National Guard troops may result in a substantial number of medically impaired soldiers being returned to combat.

"There is no clear standard for what constitutes a medically fit fighting force (having PTSD, for example, does not disqualify someone from military service), and symptom reporting on screening instruments does not substitute for a diagnostic assessment by a medical professional," the report read.

In any case, the Pentagon's data indicate that between 2003 and 2008, 43,000 troops "deemed medically unfit for active duty by their physicians were deployed to Iraq," the report stated. Also, the report stated that the Office of the US Army Surgeon General found that "multiple deployments have adverse effects on work performance during deployment, with multiple deployed soldiers being more likely than are others to report limitations in their ability to work effectively."

However, health problems among soldiers are often underreported in the Department of Defense's Post-Deployment Health Assessment and the Post-Deployment Health Assessment and Re-Assessment, and that's partly because some soldiers think that having PTSD and other mental issues carries a stigma.

Fairweather said, "When it's all said and done, the culture is very much, 'Suck it up and deal with it.'" For instance, there is no privacy if a soldier seeks mental health help, she said.

There also is an issue of discrimination between mental and physical wounds, she said. "(Those with mental health issues) are wounded just as if they have physical wounds," but mental wounds aren't treated as seriously, she said.

In conclusion, the report stated, "Our findings suggest that repeated deployments to Iraq and Afghanistan adversely affect the physical and mental functioning of New Jersey National Guard troops. The implications of these findings for the health of all active-duty forces recalled to [Iraq and Afghanistan] combat require further investigation."

Also, the report stated that screening programs and mobilization trainings remain imperfect ways for identifying and ensuring treatment of psychologically impaired soldiers. "It is important, therefore, for military and veteran authorities to develop mechanisms for the truly confidential and accessible assessment and treatment of mental and behavioral health problems. These findings also suggest the need to examine existing policies regarding multiple deployments of troops to the [Iraq and Afghanistan] conflicts."

Fairweather recommended, "There should be before, after and during deployment a private consultation with a therapist, and if everyone is required to go behind the door and the doctor, they're not self-identifying and everyone has to go there."

Also, if we do provide proper care to soldiers between deployments, we will have a healthy, more productive military force, she said.

"We've got to address this," Fairweather said. "When we see the new increases in troops in Afghanistan, what I would like to see is that when the troop surge was announced, that there's an equal and intentional and public statement about what they will do to take care of people." She estimated that one third of those 30,000 troops will have mental health issues. "We can't say, 'We'll deal with that later.'"

In addition, Paul Sullivan of Veterans for Common Sense, said, "VCS remains deeply concerned about the enormous physical and psychological strain repeated deployments to the Iraq and Afghanistan wars are causing our troops. As many as 800,000, or 40 percent, of the two million troops sent to the two conflicts deployed twice or more, according to the Department of Defense."

Sullivan also said, "VCS urges the Department of Defense and the VA to implement a casualty plan for our military and veterans. Such a plan should include hiring more mental health professionals immediately to perform medical exams on all troops before and after deployment to spot medical problems early, when treatment is most effective and least expensive. The Department of Defense and the VA must also expand their anti-stigma efforts, especially with training for both officers and non-commissioned officers so they know how to spot brain injury or other mental health symptoms and then promptly refer soldiers for treatment."

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