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Suicide Watch

As the Iraq war grinds into its sixth year, policy-makers in the U.S. would do well to remember the story of Phineas Gage. For those in need of a refresher, the 25-year-old construction foreman lost a hunk of his frontal lobe back in 1848 when a three-foot iron rod shot through his left cheekbone and out the top of his head. Miraculously, Gage could walk and talk again just minutes after the accident, staying conscious on the three-quarter-mile oxcart trek into town, where doctors patched his wounds and sent him on his merry way.

But the tale didn’t end there. In his post-accident years, Gage transformed from a levelheaded foreman into a forgetful, quick-tempered roustabout. He threw fits of “the grossest profanity” and wrestled with depression. He found it difficult to keep a job, and harder still to keep a woman. In the notebooks of his physician, Dr. John Harlow, America received its very first public account of the long-term demons unleashed by traumatic brain injury (TBI).

160 years after Gage’s accident, medical experts are calling TBI the “signature wound” of the Iraq war. An astounding 60 percent of troops entering Walter Reed Army Medical Center suffer from brain trauma as their primary or secondary malady, typically the result of an improvised explosive device. The physics look something like this: A roadside bomb sets off a blast wave that travels at a speed of 1,600 feet-per-second toward a soldier’s vehicle. On impact, the blast rattles the soldier’s brain against his or her skull--often leaving no visible scratches, but prompting closed-head traumas that can be hard to diagnose: torn cerebral tissue, internal bleeding, and relentless swelling of the brain’s inner cavities.

Much like Phineas Gage, soldiers with serious TBI often suffer from irreversible forms of cognitive freefall, such as the loss of memory and language. As for emotional consequences, they also tilt towards depression, volatile moods, and all manner of creative self-destruction. The long-term behavioral consequences of TBI--an ironic byproduct of new battlefield advancements such as Kevlar helmets that protect soldiers’ lives but not always their cortical lobes--might offer the missing link in the growing debate over Iraq veterans’ unprecedented suicide rates. According to new U.S. Army statistics, five soldiers try to kill themselves each day, compared to one soldier per day before the Iraq war.

Last Monday, Dr. Thomas Insel, director of the National Institute of Mental Health, issued a controversial prognosis for the coming generation of American veterans: “It’s quite possible that the suicides and psychiatric mortality of this war could trump the combat deaths,” he told an annual gathering of the American Psychiatric Association. “We don’t yet know how to predict who is going to be the person to be most concerned about.”

Dr. Insel's prognosis drew on a recent 500-page study by the RAND Corporation, which concluded that among the nearly 1.7 million who have served in Iraq and Afghanistan, some 300,000 veterans suffer from Post-Traumatic Stress Disorder (PTSD) or major depression, with nearly half of all cases going untreated. The study also highlighted a less widely-covered trend: Some 320,000 troops returning from both wars are plagued by traumatic brain injuries--again, with only half seeking treatment.

I recently spent a month reporting from Iraq and a summer volunteering at Walter Reed, and Dr. Insel's pessimism doesn’t surprise me. I’ve heard many soldiers deadpan that, “If Iraq doesn’t kill you, coming home might,” and I’ve seen how right they can be. Last June, a friend and TBI survivor named Rob Shaw--a former medic in Iraq and Afghanistan who, in his better moments, is as gallant a New England gentleman as they come--wound up in police custody after a Hollywood-style car chase, telling cops to shoot him before he shot himself. Luckily, the officers handled the situation with a sympathetic dose of grace; if they hadn’t, he might have been reduced to yet another victim of Dr. Insel’s “psychiatric mortality.”

The evidence linking TBI to suicide isn’t new; many cautionary studies date back to the late-1990s and early-2000s. A significant portion of the research comes from the world of professional sports, where coaches and trainers long ago spotted the tie between depression and athletes’ concussions (a consensus reflected in a front-page New York Times article last year on the post-TBI suicide of former NFL player Andre Waters: “Expert Ties Ex-Player’s Suicide to Brain Damage From Football”).

According to one 2001 study, released in the medical journal Brain Injury, “The possibility that patients who have suffered a traumatic brain injury will commit suicide is high, and in many cases clinicians tend to underestimate [it].” The authors’ data stacks up tellingly: A year and a half after TBI patients were discharged from the hospital, 48.6 percent of them suffered from depression, and 65 percent of this group were at clinical risk for suicide. A similar 2002 study in Psychological Medicine found that 35 percent of TBI patients showed “clinically significant” levels of hopelessness, 23 percent showed suicidal ideation, and 18 percent had attempted suicide in the five years following their injury.

Still, the U.S. government has been slow to draw the links between Dr. Insel’s projected spike in veteran suicides and RAND’s massive estimates of TBI. In 2006, Congress cut funding for the Defense and Veterans Brain Injury Center, a key facility devoted to treating and understanding war-related brain traumas. “Honestly, they would have loved to have funded it,” explained spokeswoman Jenny Manley of the Senate Appropriations Committee, “but there were just so many priorities.” More recently, authorities from the Department of Veterans Affairs (VA) attempted a seedy cover-up of soldiers’ astronomical suicide rates. In a February email boldly titled “Shh!”, Dr. Ira Katz, deputy chief patient care services officer at the VA, told colleagues, “Our suicide prevention coordinators are identifying about 1,000 suicide attempts per month among the veterans we see.... Is this something we should address ourselves in some sort of release before someone stumbles on it?”

If Washington bureaucrats aren’t connecting the dots between suicide and TBI, young soldiers certainly are. On March 5, Specialist Timothy Juneman, 25, hanged himself in his apartment after learning that he would be sent back to Iraq, despite his evident TBI and PTSD; he was the seventh veteran receiving treatment from Spokane’s VA hospital to commit suicide this year. Not long thereafter, on May 9,  Timothy K. Israel--barely 23--used the drawstring from his pants to end his life in an Indiana jail cell, where he was being held on charges of domestic battery after an argument with a former girlfriend.

America’s young veterans deserve a better future than that--and a longer life than the forlorn Phineas Gage, who died following violent seizures in his mid-thirties. Just how relentlessly must the body counts climb before the Pentagon teams up with Congress to fund overdue research into the TBI-suicide link? Rather than gutting support for the VA, they need to expand the department’s programs for lifetime TBI screening and treatment. But even the best psychiatric treatment will only help a fraction of those returning from war with these life-altering and often deadly injuries. So as our presidential candidates debate the future of our military in Iraq, they should heed Dr. Insel's warning that the human consequences of our continued presence there are much greater than just those who die on the battlefield.

Sarah Stillman is an Oxford-based writer who recently traveled to Iraq as a foreign correspondent for