FORWARD OPERATING BASE BOSTICK, Afghanistan – Sgt. Thomas Riordan didn't want to return to Afghanistan after home leave. He had just fought through a battle that killed eight soldiers, and when he arrived home his wife said she was leaving. He almost killed himself that night.
When his psychologist asked what he thought he should do, Riordan said: Stay in Colorado.
Instead, the military brought Riordan back to this base in the eastern Afghan mountains, where mortar rounds sound regularly and soldiers have to wear flack jackets if they step outside their barracks before 8 a.m., even to go to the bathroom.
Increasingly, the army is trying to treat traumatized soldiers "in theater" — where they're stationed. The idea is that soldiers will heal best if kept with those who understand what they've been through, rather than being dumped into a treatment center back in the States where they'll be surrounded by unfamiliar people and untethered from their work and routine.
However, the policy may serve the military at least as much as the soldiers. Treating soldiers on site makes it easier to send them back into battle — key for a stretched military fighting two wars. It also brings up a host of challenges: Ensuring soldiers get the treatment they need in the middle of war, monitoring those on antidepressants and sleeping pills, and deciding who can be kept in a war zone and who might snap.
"There's not been a lot of studies on those types of interventions," said Terri Tanielian, a military health policy researcher with the RAND Corp. think tank. "There isn't necessarily a magic formula that says who's going to go back and be okay and who isn't."
Riordan's commanders with the 3rd Squadron, 61st Cavalry of the Army's 4th Brigade Combat Team say they're doing their best for him by keeping him in Afghanistan. The 4th Brigade Combat Team out of Fort Carson, Colo. has reason to be particularly conscientious — Fort Carson came under scrutiny after a string of murders by returned soldiers.
Riordan acknowledges that in-theater treatment has helped a lot of his fellow soldiers, but says it's never been enough at the right time or place for him. Through all the psychologists, psychiatrists, medications and brain scans, he just feels more alone.
In Afghanistan, Riordan cannot go outside the wire because he's considered too unstable. He has no friends in his unit. He goes to a larger base every month or so to meet with his psychologist, who also checks in on him when she's doing helicopter rounds to various outposts.
"All my real support is back in the States," he says. "Just to call someone up and say 'Hey, I'm bummed out,' you've got to put on the proper uniform and walk two football fields down to the phones and wait in a line, and then hope that someone answers on the other side."
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The 5,000 troops that make up Task Force Mountain Warrior — which includes the Fort Carson soldiers — are served by a psychologist, a psychiatrist and two social workers. Collectively known to soldiers as "Combat Stress" — as in, "I had to go see Combat Stress" — this four-person team makes the rounds to about 30 bases. They arrive after any potential trauma: the death of a soldier, an arduous battle or a large roadside bombing.
The quick-reaction force for mental trauma isn't new — it was in place during the Iraq war. However, military officials in Afghanistan say they're giving more resources for such teams now and making them more active.
Combat Stress showed up in force at Bostick in early October 2009. Insurgents had just launched a devastating attack on two isolated outposts: Keating, where eight soldiers died, and Fritsche, where Riordan was stationed.
The soldiers from both bases were flown to Bostick. At group meetings with Combat Stress, soldiers replayed what they had seen that day. Many went on to individual sessions with counselors.
Riordan said that as soon as the gunfire died down on Oct. 3, he decided the first thing he would do was go see a counselor. He'd had some sessions already in the States, though his treatment had repeatedly been interrupted by deployments.
But by the time he arrived at Bostick on a later flight from Fritsche, the counselors were gone. Two days later, he was out on operations again.
He was called to help Afghan security forces that had been attacked. Just as he returned, Riordan's commander told him to prep for yet another mission. He flipped out.
"Finally I just put my foot down with it and I was like, look, I'm at my wits' end. I'm about to shoot somebody or myself and I need to go talk to someone," Riordan said.
That got everyone's attention. He started getting regular counseling. He went on antidepressants — first a combination of Prozac and Paxil, before settling on Effexor.
Still, on home leave in March, Riordan's wife said she wanted a divorce and he locked himself in the bathroom and started swallowing sleeping pills. His wife called the police, who got him out of the bathroom and to a hospital.
"I told them I didn't try to kill myself. I was trying to go to sleep," he said. "What I took wasn't enough to kill myself. But I had enough, and I looked at it and I considered it."
Riordan's understanding is that he is a victim of military bureaucracy. His commanding officer, Capt. Stoney Portis, "said something about paperwork," Riordan recalled.
Portis said the difficulty of getting permission to have a soldier stay home after leave was a factor, but not the deciding one.
"Look at the logistics of it: It's not approved. It's currently not even an option to leave him back there, because he was on orders to go on R&R and come back," Portis said.
Portis said he wanted to give Riordan the chance to finish deployment, and that he could get the same level of care on the base as back in the States. Now Riordan meets with a counselor at Bostick once a week and has flown to a larger base in the eastern city of Jalalabad twice for three-day intensive counseling sessions. On Bostick, he tracks weapons inventory, which he calls a fake job with only two days worth of work for him to do in a month.
Riordan said he planned to get out of the military upon returning to the United States. It's not for him.
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Riordan's is an extreme case. But Combat Stress also treated others who fought that day to get them back into the field.
Spec. Ty Carter said he had trouble psyching himself to go out on missions after the Oct. 3 attack. As he prepared his gear, painful thoughts would come to mind. An ache mixed with nausea hit his stomach.
"I would pause, and stare into nothing as thoughts of my daughter growing up without a father, my mother and father at a funeral, and all the other things that would happen filled my head," he said.
He went for counseling, and was given Ambien to sleep. He felt the result within days. When his truck hit a bomb, his hands would usually shake, but this time he wasn't even nervous.
He kept going on missions, and it seemed to help.
"As soon as I got outside the wire it all stopped," he said. "The stomach pain and nausea, thoughts of death and everything else. I would be so focused on the mission that it would be all I saw. After the mission some of the thoughts and feelings would return. But not on the mission."
Medicating soldiers in war brings up a host of difficulties not faced by doctors back in the States. The brigade psychiatrist, Dr. Randal Scholman, said he finds himself making more informal or nontraditional diagnoses. Deployed soldiers are in a particularly stressful environment, and often it's hard to tell if a problem is temporary, he said.
The most common drugs he prescribes are sleeping pills, followed by antidepressants. Often, he gives a soldier Prozac or Paxil to treat what he and his colleagues call "combat operational stress reaction." The disorder — which is not formally recognized — includes symptoms like sleep problems, irritability and propensity to anger. Soldiers describe it as being "on edge, keyed up, jumpy, things like that," he said.
Through trial and error, they've found that antidepressants help calm soldiers down enough to stay and finish their tours. In the three months he has been with the brigade, only two soldiers have had to be evacuated because of psychological issues, he said.
"My mission here is to keep people on mission, keep people in the fight, keep people in the theater as opposed to having them air-evaced out," Scholman said.
The 4th Brigade Combat Team started periodic mental health reviews with this tour. Commanders were asked to evaluate their soldiers' risk of having serious psychological problems by filling out a form with 19 yes-or-no questions. It is filled out across the brigade: platoon sergeants assess soldiers, company commanders assess platoon sergeants, and up the chain.
This questionnaire has been filled out twice during the 4th brigade's year-long deployment: once in December — six months in, just after a particularly bad battle — then in April as the troops prepared to go home.
The soldiers are labeled red, amber or green to indicate priority for treatment. "Red" soldiers have mandatory immediate counseling. "Amber" soldiers have mandatory counseling but not as urgently.
In December, of 3,737 soldiers evaluated, 2.2 percent were red and 16.2 percent were amber. When they re-evaluated the troops recently, the number of red had dropped to less than one percent, but the number of amber had increased to just under 25 percent.
About 50 of the 500-odd soldiers at Bostick are on antidepressants, said Capt. Cheri Ponce, the physician's assistant. Others are on sleep aids or drugs to help them stop smoking. The list of drugs she can prescribe is much shorter than in the States because just about anything with a high risk of suicide is off limits, Ponce said.
"We don't need any other triggers," she explained. She also tries to avoid long-acting sleep medications because soldiers can't take them if they might be called for a mission in the middle of the night.
Antidepressants take effect slowly, so soldiers usually don't have to be taken out of their typical rotation of patrols and work. But some superior officers are still uneasy about soldiers fighting while on antidepressants.
Sgt. Maj. Wilson was shocked by the idea that 50 of his soldiers could be on antidepressants and yet were not blocked from going outside the wire. Only seven of the squadron's soldiers were labeled "red" in the recent survey, including Riordan.
But Wilson also said these soldiers wouldn't necessarily have fared better in the States. The soldiers from the Oct. 3 attack who were doing the worst were two men sent back to Fort Carson because of injuries, Wilson said.
"Both of them got back to the rear and started having issues. One turned to drugs. One turned to violence," he said. "They had nobody to relate with, and they weren't the best of friends to begin with."
