In the weeks since Army Staff Sgt. Robert Bales was first accused of going on a shooting rampage in an Afghanistan village, military officials and the media have combed through his life for warning signs or anything that could have predicted what may have been to come.
While the 11-year Army veteran, who was formally charged with 17 counts of murder, had recent financial troubles, professional disappointments and combat-related injuries, his family and friends say they never anticipated that he might experience a catastrophic breakdown. Bales’ lawyers suspect undiagnosed post-traumatic stress disorder is partly to blame, though experts say there is no evidence linking PTSD to the kind of violence he allegedly committed.
The mystery of what may have have gone wrong in his mind has drawn new attention to PTSD and the mental health of U.S. combat soldiers. The Army hopes that a study currently under way may be able to eventually identify groups of soldiers whose mental health is most fragile based on an algorithm or formula of factors.
The Army STARRS (Study To Assess Risk and Resilience in Servicemembers) initiative, done in partnership with the National Institute of Mental Health, is gathering details about the lives and mental health of 55,000 soldiers. Participants are chosen at random to attend a session about the study at Army basic training sites, and they are not required to participate.) The goal of the study, which was launched in 2009 and is the largest-ever of its kind, is to provide the military and public health community with information about why some individuals remain resilient to challenges and trauma while others are deeply affected. The project is specifically looking at what might place soldiers at an increased risk for suicide and which factors make them more resilient to that risk.
Dr. Kevin Quinn, the NIMH official leading the study, says the research is similar to the Framingham Heart Study, which followed thousands of patients and identified risk factors for cardiovascular disease. There are now calculators that use a set number of variables to predict a person’s risk for cardiovascular disease, and Quinn hopes Army STARRS will yield similar results. Though suicide and psychological disorders are much more complex than cardiovascular disease, Quinn believes the study’s results will help the Army build a risk profile based on multiple factors.
It’s possible that in the future, groups of soldiers encountering the same challenges as Bales faced might be identified as high-risk for extreme mental and emotional crises – specifically suicidal thoughts or behavior – based on the results of this research.
Quinn says the study will help the Army develop policies to protect soldiers at risk. For example, if the results show that soldiers are at higher risk when they have little rest time at home between deployments, the Army could institute a policy requiring a longer break. The study results should also help the Army know when and how to provide mental health services to a certain group of high-risk soldiers. The algorithm could be used at any time during soldiers’ active duty to gauge their risk profile, though Quinn says individuals would not be singled out, or have to worry about facing stigma as a result.
“This is never going to be in the position to point to an individual soldier,” says Quinn, “… but if you can somehow point to 10,000 soldiers, it makes it more feasible to develop an intervention strategy.”
That power of prediction will be critical in the coming years. Dr. Robert Heinssen, who managed Army STARRS at its inception and is currently a division director at the NIMH, says that about 20 to 25 percent of deployed service members will experience mental health disorders or diseases. Of the more than 2 million soldiers who have served in Afghanistan and Iraq, that’s as many as 500,000 individuals.
The Army STARRS research team has collected more than 1 billion records on active duty soldiers to get a comprehensive picture of the factors that play into resilience and risk. Researchers are looking at medical, criminal and personnel records, among other files, that have been stripped of identifying information.
In addition to combing records, researchers are also surveying the soldiers participating in the study about everything from violent behavior to promotions to accidents to stress. Service members have even voluntarily donated their blood so researchers can examine their biochemical profile before and after deployment. Researchers are looking for chemical markers that might be associated with chronic stress or PTSD and suicide. Some soldiers have volunteered to have their survey results matched to their administrative records, but through an anonymous ID number. Finally, the research team is also looking at the records of the 1.6 million service members who served between 2004 and 2009, when the suicide rate doubled.
Preliminary findings from Army STARRS show that being married is associated with greater resilience against suicide during deployment. The rate of suicide is highest amongst those currently deployed. It also seems linked to the time between enlistment and active duty for those at the beginning of their careers – the longer the period, the less risk. Additional findings are expected later this year.
80 percent increase in suicide rate
A study released earlier this month by the U.S. Army Public Health Command found that the number of active-duty soldiers who committed suicide increased 80 percent between 2004 and 2008.
“It’s always going to be a bit of a mystery to know why for that individual they got locked into a path that led them to that level of despair and hopelessness that [suicide] was the only way out,” says Heinssen.
Charles Marmar, who leads the Posttraumatic Stress Disorder Research Program at New York University’s Langone Medical Center, says that he and other experts were once optimistic that veterans of the Iraq and Afghanistan wars would have fewer cases of PTSD and other mental health issues than Vietnam veterans given the advances in medicine and psychiatry as well as more support for service members. But that hasn’t been the case. Marmar conducted a landmark study that found that about 30 percent of Vietnam veterans have PTSD – and now believes cases from the decade’s past wars are tracking at roughly the same rate.
“If you serve in war, particularly in high intensity combat, the cost of war may be these kinds of rates of PTSD,” Marmar says.
Marmar says that among the most significant risk factors for PTSD are genetic predisposition, a family history of psychiatric problems, exposure to a traumatic event during childhood or adolescence and poor social support before, during or after a traumatic experience. Research has shown that PTSD risk increases when a soldier is wounded or is deployed multiple times. The symptoms of traumatic brain injuries, which Bales is believed to have had, include irritability and mood changes and overlap with common reactions after trauma.
While patients with PTSD often re-live the trauma through flashbacks, feel emotionally numb and are easily startled, there is no evidence they will act with the kind of violence Bales is accused of unleashing, says Dr. Matthew Friedman, executive director of the Department of Veterans Affairs’ National Center for PTSD.
Some experts worry that the association of PTSD with a case like Bales’ may further stigmatize the disorder after decades of efforts to achieve public acceptance.
“It may raise a frightening specter of being out of control,” says Marmar. “On the other hand, it raises awareness of the potential cost of undiagnosed and untreated emotional problems of war.”
There is help for those with PTSD, says Friedman. Some studies have shown that after 10 to 12 weeks of treatment with two psychotherapy treatments, PTSD symptoms ease and patients are able to maintain their progress five years later. “Even those who don’t have complete remission, we can make a major difference in quality of life.”
Quinn believes the results of Army STARRS could build a framework for providing soldiers mental health services and treatments before it becomes too late for some.
“We want to make sure they get the right treatment or policy plan,” he says. “We want to protect those soldiers."
Rebecca Ruiz is a senior editor at msnbc.com and a Rosalynn Carter Mental Health Journalism Fellow.