Before he hanged himself with his bathrobe sash in the psychiatric ward at Walter Reed Army Medical Center, Spc. Alexis Soto-Ramirez complained to friends about his medical treatment. Soto-Ramirez, 43, had been flown out of Iraq five months before then because of chronic back pain that became excruciating during the war. But doctors were really worried about his mind. They thought he suffered from post-traumatic stress disorder after serving with the 544th Military Police Company, a unit of the Puerto Rico National Guard, the kind of unit that saw dirty, face-to-face combat in Iraq.
A copy of Soto-Ramirez's medical records, reviewed by Salon, show that a doctor who treated him in Puerto Rico upon his return from Iraq believed his mental problems were probably caused by the war and that his future was in the Army's hands. "Clearly, the psychiatric symptoms are combat related," a clinical psychologist at Roosevelt Roads Naval Hospital wrote on Nov. 24, 2003. The entry says, "Outcome will depend on adequacy and appropriateness of treatment." Doctors in Puerto Rico sent Soto-Ramirez to Walter Reed in Washington, D.C., to get the best care the Army had to offer. There, he was put in Ward 54, Walter Reed's "lockdown," or inpatient psychiatric ward, where the most troubled patients are supposed to have constant supervision.
But less than a month after leaving Puerto Rico, on Jan. 12, 2004, Soto-Ramirez was found dead, hanging in Ward 54. Army buddies who visited him in the days before his death said Soto-Ramirez was increasingly angry and despondent. "He was real upset with the treatment he was getting," said René Negron, a former Walter Reed psychiatric patient and a friend of Soto-Ramirez's. "He said: 'These people are giving me the runaround ... These people think I'm crazy, and I'm not crazy, Negron. I'm getting more crazy being up here.'
"Those people in Ward 54 were responsible for him. Their responsibility was to have a 24-hour watch on him," Negron said in a telephone interview from his home in Puerto Rico. While Soto-Ramirez's death was by his own hand, Negron and other soldiers say the hospital shares the blame.
In fact, repeated interviews over the course of one year with 14 soldiers who have been treated in Walter Reed's inpatient and outpatient psychiatric wards, and a review of medical records and Army documents, suggest that the Army's top hospital is failing to properly care for many soldiers traumatized by the Iraq war. As the Soto-Ramirez case suggests, inadequate suicide watch is one concern. But the problems run deeper. Psychiatric techniques employed at Walter Reed appear outmoded and ineffective compared with state-of-the-art care as described by civilian doctors. For example, Walter Reed favors group therapy over one-on-one counseling; and the group therapy is mostly administered by a rotating cast of medical students and residents, not full-fledged doctors or veterans. The troops also complain that the Army relies too much on pills; few of the soldiers took all the medication given to them by the hospital.
Perhaps most troubling, the Army seems bent on denying that the stress of war has caused the soldiers' mental trauma in the first place. (There is an economic reason for doing so: Mental problems from combat stress can require the Army to pay disability for years.) Soto-Ramirez's medical records reveal the economical mindset of an Army doctor who evaluated him. "Adequate care and treatment may prevent a claim against the government for PTSD," wrote a psychologist in Puerto Rico before sending him to Walter Reed.
"The Army does not want to get into the mental-health game in a real way to really help people," said Col. Travis Beeson, who was flown to Walter Reed for psychiatric help during a second tour with one of the Army's special operations units in Iraq. "They want to Band-Aid it. They want you out of there as fast as possible, and they don't want to pay for it." Indeed, some psychiatric patients at Walter Reed are given the option of signing a form releasing them from the hospital as long as they give up any future disability payments from the Army. One soldier from Pennsylvania, who was shot five times in the chest and saved by body armor, told me he would do anything to get out of Walter Reed, even relinquish disability pay. "I'll sign anything as soon as I can get my hands on it," he told me several days before being released from the hospital. "I loved the Army. I was obsessed with it. The Army was my life. Fuck them now."
The conditions for traumatized vets at the Army's flagship hospital are particularly disturbing because Walter Reed is supposed to be the best. But leading veterans' advocate and retired Army ranger Steve Robinson, executive director of the National Gulf War Resource Center, agrees that when it comes to psychiatric care, Walter Reed doesn't make the grade. "I think that Walter Reed is doing a great job of taking care of those suffering acute battlefield injuries -- the amputees, the burn victims, and those hurt by bullets and bombs," said Robinson, who has spent many hours visiting psychiatric patients at Walter Reed. "But they are failing the psychological needs of the returning veterans."
Walter Reed officials declined requests for interviews, although two spoke to me on the condition of anonymity. In written statements to Salon, Walter Reed said the mental and physical health of patients is the hospital's top priority and described its PTSD treatment regimen as being in line with modern medical standards. The hospital said patients see both "board certified" and "board eligible" psychiatrists, including medical students and residents who "participate in the clinical activities on the ward as part of their training, and as is appropriate for their level of training and needs of the soldiers."
The hospital also cited a recent survey in which 42 out of 45 psychiatric inpatients surveyed, or 94 percent, felt that their care was either outstanding or good. "We are satisfied that there is a very high level of patient satisfaction with their treatment," the statement read. The hospital gave few details about the inpatient survey, such as whether it was anonymous, or whether the patients surveyed were even soldiers who recently fought in Iraq. (Inpatients can include military dependents or soldiers who fought in wars decades ago.)
The high level of satisfaction among inpatients as reported by Walter Reed is completely opposite what I saw and heard while tracking soldiers there over the last year. The soldiers I interviewed invited me to their bedsides in the lockdown ward. They handed over their private medical records. They allowed me to call their buddies, their girlfriends, their mothers. All professed to loving the Army, though some said their trust in the institution had been irrevocably shattered. All said their symptoms either stayed the same or worsened while at Walter Reed; two said they made suicide attempts. While it's true that patients' self-reports about treatment are not always objectively based, the repeated, bitter complaints I heard over the course of more than a year, in combination with conversations with civilian experts, cast serious doubts on Walter Reed's approach to treating PTSD sufferers. It all convinced me that something is seriously amiss at the Army's top hospital.
Politicians and celebrities -- like Dale Earnhardt Jr., ZZ Top and President Bush -- routinely visit the wounded at Walter Reed; but dignitaries don't come to Ward 54. When I first visited the lockdown unit in February 2004, it held around 35 patients, who slept as many as six patients to a room. Most patients stay in lockdown for just a few days, then are moved to rooms in hotel-like facilities to get treatment at the Walter Reed outpatient clinic, known as Ward 53. Within the lockdown unit, doors were kept open so that the patients who padded around the linoleum floors in Army-issued slippers, pajamas and robes could be observed at all times. Patients in various states of consciousness, from alert to near catatonic, sat around a television in a communal room. Some wore bandages from what other soldiers said were self-inflicted wounds. Patients were not allowed near the twin electric doors to Ward 54; these open by a buzzer from the nurses' station, staffed 24 hours a day.
Soldiers who have stayed in the lockdown unit say they were heavily medicated the entire time. Some remember hearing screaming, or patients being subdued on stretchers after shock therapy. "Inpatient can be a traumatic experience for anyone," said Lt. Julian P. Goodrum, 34, who was in Ward 54 last February after serving in Iraq. Records show Goodrum was held in the ward 13 days longer than needed while the Army decided whether to charge him as absent without leave when, after getting back from Iraq, he was earlier hospitalized by a civilian psychiatrist. He is fighting those charges.
The soldiers told me about their textbook symptoms of PTSD: sudden, ferocious bouts of rage, utter detachment, anxiety attacks accompanied by shortness of breath, and increased perspiration and rapid eye movement. They complained of relentless insomnia, racing thoughts, self-loathing, blackouts, hallucinations and the constant reliving of war through flashbacks by day and nightmares at night. Some described vivid fantasies of violence toward the Army brass in charge of patients there -- slicing their throats, throwing them out windows or shooting them. One psychiatric outpatient, who watched as his best friend was blown up by a roadside bomb in Iraq, said: "It does not matter how hardcore you are. Once you go to that war and you start to see dead bodies -- you see an arm over here, you see guts over there. There is no way you are ever going to erase that."
When it is done right, PTSD treatment is a delicate task. Trust is crucial, and medications are carefully administered and monitored. Most critical is getting patients to control the powerful and destructive emotions that can follow a traumatic event like fighting a war. What bewildered the soldiers at Walter Reed, though, was that the Army seemed determined to downplay their war trauma and search for other causes for their mental health problems. In group therapy, sessions often focused more on family relationships and childhood experiences than war, the soldiers said. One outpatient soldier was so angered about this avoidance of the topic of war, he threw a chair during group therapy. Doctors promptly sent him to lockdown.
"When you get [to Walter Reed], they analyze you, break you down, and try to find anything wrong with you before you got in" the Army, said Spc. Josh Sanders, in a telephone conversation from his home in Lovington, Ill. "They started asking me questions about my mom and my dad getting divorced. That was the last thing on my mind when I'm thinking about people getting fragged and burned bodies being pulled out of vehicles," said Sanders. "They asked me if I missed my wife. Well, shit yeah, I missed my wife. That is not the fucking problem here. Did you ever put your foot through a 5-year-old's skull?"
Sanders, 25, served in Iraq with the 1st Brigade, 1st Armored Division, from May until December 2003. I met him in the summer of 2004 while he was getting treatment at Walter Reed in the outpatient clinic. Sanders had been evacuated from Baghdad because of the toll the war had taken on his mind. His complaints about Walter Reed were sadly typical. "Nobody hears about this. Nobody hears about what really happens when you are there getting the 'premier' medical treatment," Sanders said.
Dr. Herbert Hendin, medical director of the American Foundation for Suicide Prevention spent many years studying and treating veterans with PTSD after the Vietnam War. In discussing their treatment, Hendin said, "What veterans need is not simply to be able to talk about their combat experiences but to be able to talk about them with someone who understands the context." Hendin said a combat veteran "needs to feel an empathic connection with the treating professional." But to the soldiers, the atmosphere in the Walter Reed psychiatric units wasn't conducive to feeling understood, or getting better.
In Ward 54, recent combat veterans are mixed with other soldiers and even civilians suffering a wide range of mental problems. For them, coming back from Iraq and being treated alongside soldiers with schizophrenia, for example, or maybe even soldiers' dependents with schizophrenia, makes them feel "crazy," as opposed to having a natural reaction to combat stress. "If you are a hard-charging person, or somebody who tries to do things right, you are already taking a huge hit to your ego by being put in there," Beeson, the Army colonel, told me. One of the two Walter Reed officials who spoke on condition of anonymity agreed that recent combat vets shouldn't be lumped in with other psychiatric patients. Those soldiers "need to have a specialized unit," the official said. "They are labeled goofy and crazy, and they are not crazy."
Beeson served in Iraq with the Army's Civil Affairs Command, part of the Army's special-operations units. He is a 47-year-old reservist with 26 years of service under his belt, a wiry man grizzled by war. Beeson says his PTSD manifested during his second tour in Iraq. He was flown to Walter Reed. When I first met him in August 2004, heavy medication made him speak in slow, halting sentences like a drunk with a stutter. "A lot of the therapy was counterproductive to me," Beeson said in a telephone interview from his home in Arkansas, after getting out of Walter Reed. "It was a very paranoia-inducing place. If I was not paranoid when I got there, I was paranoid when I left ... To me, they need to figure out if they are going to treat people for war or be a regular hospital."
Josh Sanders, like the other soldiers I spent time with, also believes he is worse off because of his treatment at Walter Reed. "I don't trust anybody now ... I wish people could understand," he said. Sanders made two suicide attempts while under outpatient care at Ward 53. Hospital officials would not answer questions about the prevalence of suicide attempts at Walter Reed, but said two incidents that occurred there in January, one apparent fatal overdose and another suicide attempt, are under investigation. Two years ago, the case of Army Master Sgt. James Curtis Coons, also an outpatient, raised serious questions about how Walter Reed handles suicidal patients -- questions that persist today.
Coons was evacuated to Walter Reed from Kuwait on June 29, 2003, after swallowing sleeping pills in an apparent suicide attempt several days earlier. When he arrived at Walter Reed, he wasn't sent to the lockdown unit but to a room in one of the hotel-like facilities on campus. Coons, 36, promptly hanged himself. And although he had a doctor's appointment the next day, Walter Reed officials failed to look for Coons until July 4, so his body hung and decomposed until then. "A soldier coming in from a war zone does not show up for a doctor's appointment and they did not even check on him?" his mother, Carol Coons, said in a telephone interview from her home in Texas. "Until this is taken seriously, this is going to continue on. A psychiatric problem among those coming home from these war zones is just as deadly as a bullet." In a statement, the hospital said it has recently "enacted more stringent policies and procedures to strengthen outpatient soldier accountability"; for example, a Walter Reed staff member is now sent to check on patients who don't show up for appointments, the hospital said.
It's unclear how many combat vets are in need of PTSD treatment. But data from the Department of Veterans Affairs and a published Army study show at least one out of every six soldiers coming back from Iraq may have PTSD. (Many Army bases have psychiatric clinics, but some of the most serious cases go to Walter Reed.) Congress is responding with a flurry of bills that might help keep track of and treat the mental toll Operation Iraqi Freedom is taking on U.S. troops. Illinois Democrat Rep. Lane Evans' bill calls on the military to use state-of-the-art methods to treat psychological injuries. Sen. Russ Feingold, D-Wis., would require the Pentagon to send reports to Congress on PTSD among troops because there is so little information on psychological injury rates.
Normally, soldiers discharged from the Army seek medical treatment from the Department of Veterans Affairs, which is widely understood to do a superior job at treating soldiers with PTSD. Because of the V.A.'s good track record, Steve Robinson of the National Gulf War Resource Center is asking Congress to put the V.A. in charge of treating soldiers with PTSD even before they leave the Army. Four of the soldiers I interviewed who left Walter Reed and later got treatment at the V.A. all praised the care they received there. They finally got a chance to talk one-on-one with other veterans about war, they said. Their medications were pared down, and their disability pay has been increased.
Indeed, the Army's system for allocating disability pay to traumatized vets is another source of their frustration and anger. An Army panel at Walter Reed, called the Physical Evaluation Board, decides what percentage of income each soldier should get from the military to compensate him if he is too ill to serve any longer. The doctors decide whether wounds are combat related, and then the board decides how much disability the Army will pay. The board's decision is critical for soldiers trying to make a living after leaving the Army with what can be a debilitating mental condition. Fighting with the hospital about disability pay is a source of considerable stress just as these soldiers are trying to heal their minds.
Some of the soldiers are fighting decisions by the board at Walter Reed. Out of the 14 soldiers interviewed, five have left Walter Reed. Three ended up getting zero percent of their income as disability pay, despite what they said was serious mental stress that made it more difficult or impossible to work. Even those who got a third of their pay still had trouble making ends meet. (In every case I followed, the Department of Veterans Affairs made a later determination that the soldiers deserved more. The soldiers can choose to take the higher percentage of pay from the V.A., but in some cases if they do so, they must pay back what they have received so far from the Army.)
# After 26 years of service, the Army gave Col. Beeson, from the Army's Civil Affairs Command, zero percent of his income as disability pay for his mental wounds. Luckily, he still gets some retirement pay because of his many years of service, but he says he struggles with his injuries every day. He is appealing Walter Reed's decision.
# Josh Sanders, from the 1st Armored Division, got 30 percent from the Army, but the Army also said his problems did not come from the war. "When I was over there [at Walter Reed] the PEB [Physical Evaluation Board] process was degrading. It is like pulling money from an insurance company. All my paperwork says 'non-service connected.' If it is non-service connected, then why am I getting 30 percent?" he asked. The V.A. recently decided to give him 70 percent disability.
# One Army reservist I spent time with tried to return to his day job as a policeman after the war, but his mental state prohibited him from carrying a gun. The reservist cannot go back to policing, but since the Army decided his mental problems did not come from the war, the small percentage of disability pay he got is not enough to make ends meet, he said. He's hoping the V.A. will give him more.
# René Negron, the former soldier who visited Soto-Ramirez before the suicide, was given 30 percent of his pay until February 2006, when he'll be reevaluated. Negron was a psychiatric patient at Walter Reed after 11 months in Iraq. At one point he checked himself into the emergency room there because he thought he might kill himself. But the Physical Evaluation Board determined that "the soldier's retirement is not based on disability from injury or disease received in the line of duty," according to a copy of Negron's evaluation board proceedings. "This disability did not result from a combat-related injury."
Negron, 48, taught hair care and cosmetology before serving in Iraq as an Army specialist with the Puerto Rico National Guard. Now, he says his debilitated mental state after the war has left him unable to work. He drives two hours each way for mental health treatment at a V.A. medical center. "You think I can live on $700 a month?" Negron asked. "I can't work. My wife is suffering. She can't leave me alone. Sometimes I feel suicidal. Sometimes I hear voices. Sometimes I see lights. I feel like I'm being shot at. They sent me home like that. I've been dealing with this since I got back," Negron said. "I left here in good condition. If I have a mental condition, they have to deal with it ... I did my part. Why can't they do their part?"
photo caption: Spc. Josh Sanders, then a psychiatric outpatient at Walter Reed, in July 2004.
Mark Benjamin is a national correspondent for Salon based in Washington, D.C.
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