Contractors who have worked in Iraq are returning home with the same kinds of combat-related mental health problems that afflict United States military personnel, according to contractors, industry officials and mental health experts.
But, they say, the private workers are largely left on their own to find care, and their problems often go ignored or are inadequately treated.
A vast second army, one of contractors - up to 126,000 Americans, Iraqis and other foreigners - is working for the United States government in Iraq. Many work side-by-side with soldiers and are exposed to the same dangers, but they mostly must fend for themselves in navigating the civilian health care system when they come back to the United States.
With no widespread screening, many workers are not identified as suffering from post-traumatic stress disorder or other problems, mental health experts and contractors say. And, they add, the quality of treatment for others can vary widely because of limited civilian expertise in combat-related disorders.
Only a few mental health professionals have focused on the issue, but they warn that the number of contractors leaving Iraq with mental health problems is large and growing.
"I think the numbers are in the thousands, maybe tens of thousands," said Paul Brand, a psychologist and chief executive of Mission Critical Psychological Services, a Chicago firm hired by Dyncorp International, a major contractor in Iraq, to assess and treat its workers. "Many are going undiagnosed. These guys are fighting demons, and they don't know how to cope."
Jana Crowder, who runs a Web site for contractors seeking help, says she gets new evidence of that every day in phone calls from desperate workers.
"In the first few years of the war, we were seeing a few trickle in," said Ms. Crowder, of Knoxville, Tenn. "Now, as contractors start coming home, you are starting to see a lot more."
Workers tell haunting tales of their psychological torment. Tate Mallory, a police officer from South Dakota who worked as a Dyncorp police trainer, was grievously wounded by a rocket-powered grenade last fall. After returning home, he was so mentally scarred, he said, that he begged his brother to kill him.
Kenneth Allen, a 70-year-old truck driver from Georgia whose convoy was ambushed in Iraq, says he endures mood swings and jittery nerves and is often awake all night. And Nathaniel Anderson, a Texan whose truck was hit by rockets while hauling jet fuel, lost a contractor friend to suicide. Though suffering from stress-related symptoms himself, he has yet to see a doctor.
The toll of the war on contractors has largely been hidden from public view. About 1,000 have died since the conflict began, and nearly 13,000 have been injured. While some are well compensated for their work in Iraq, many more collect modest wages and provide support services vital to the military.
The federal government, which has paid billions of dollars to corporations for services in Iraq since the war began, has not examined the issue of mental health problems among private workers, according to Pentagon and Department of Veterans Affairs officials.
"To my knowledge, it has not been looked at systematically," said Dr. Matthew J. Friedman, a V.A. official who directs the National Center for Post-Traumatic Stress Disorder.
Contract workers who are wounded or disabled in the war zone are treated in military hospitals in Iraq and Germany, but once home, they are not eligible for care in the military or V.A. system. And unlike troops, they are not routinely evaluated for mental or stress disorders after their tours.
When soldiers and veterans complained in recent months of lapses in their care, top officials in Washington promised improvements, but the plight of troubled civilian workers has not captured such attention.
Many companies conduct predeployment psychological screening and offer limited counseling, but provide few resources when their workers return home and often go off the payroll.
Federal law requires employers to provide medical insurance for workers in a war zone. Workers have filed about 205 claims for treatment of post-traumatic stress disorder, or P.T.S.D., according to the Department of Labor, which monitors the data. Industry officials say that number significantly underrepresents the problem because many troubled people do not file claims.
Of those who do, many have been denied coverage and have filed lawsuits. Gary Pitts, a Houston lawyer, says insurers have challenged almost every claim filed by about 50 clients, even though the insurance companies paid for medical care involving their physical injuries.
"The contrast between the way the military and the civilian contractors are handled on P.T.S.D. is like night and day," Mr. Pitts said. "The contractors have to figure it out on their own, and they often have to litigate it with the insurance company."
The insurance problems may be partly related to the dearth of civilian mental health professionals equipped to deal with combat-related stress, said Mr. Brand, the Dyncorp psychologist, and Dr. Spencer Eth, who helped write the treatment guidelines for post-traumatic stress syndrome for the American Psychiatric Association.
"The availability of mental health care providers with specific expertise in this is scant around the country," said Dr. Eth, a New York psychiatrist. "You have problems of access to care, financial obstacles to care, and so most of these people are not going to get the help they need."
AIG, the giant insurance company that provides coverage for several of the largest contractors in Iraq, has paid about half of claims involving P.T.S.D., said Chris Winans, an AIG spokesman. But many of the others are delayed or challenged because the insurers' medical experts disagree with the diagnoses, Mr. Winans said.
Mr. Pitts, the lawyer, said many contractors lived in small towns or rural areas without access to high-quality mental health workers. But even when he has sent clients to respected psychiatrists or psychologists to confirm the diagnoses, AIG still often contests the claim, he said.
Dyncorp, a firm based in Texas that has a State Department contract to train the Iraqi police, is sponsoring its first conference Friday and Saturday on post-traumatic stress for former employees. The company is also treating workers in Iraq after bringing in Mr. Brand's firm to determine the extent of problems.
Twenty-four percent of the Dyncorp police trainers showed symptoms of post-traumatic stress disorder after their deployment, Mr. Brand said. He and others said they knew of no other studies that formally assessed the problem among private workers in Iraq.
Those findings parallel an Army study earlier this year that about 17 percent of personnel in Army combat units in Iraq showed symptoms of P.T.S.D. one year after their deployment, said Dr. Charles W. Hoge, chief of psychiatry at the Army's Walter Reed Institute for Research.
If marital problems, alcohol abuse and other adjustment problems are counted, the number rises to 30 percent to 35 percent, said Col. Elspeth C. Ritchie, a psychiatric consultant to the Army surgeon general.
Last October, Tate Mallory, the police officer from South Dakota, was riding in a Humvee in Anbar Province when a rocket-propelled grenade snaked into the vehicle, hit him in the lower back and went through his abdomen before exiting his inner thigh. Miraculously, the rocket did not explode, and quick-acting marines rushed Mr. Mallory to a combat hospital.
After intensive medical care in Iraq, Germany and finally back in Sioux Falls, Mr. Mallory left the hospital in December, and went to live with his brother, Brad, in Belle Fourche, S.D.
Though his physical injuries were healing, Mr. Mallory's psychological wounds were left untreated. He isolated himself and turned against family members, including his sister. "I called her up and just screamed, 'You are dead to me!' " he recalls, now deeply embarrassed.
He hit bottom one day in January, he says, when he asked his brother to kill him.
Brad Mallory, 45, recalls how frightening that was. "What I saw was how hollow his eyes were," he said of his brother. "I'm a hunter, and to me, it was like when you come up on your deer, when you didn't get a clean kill, and they just want it to be over."
He drove his brother to a local hospital emergency room, but the doctors were suspicious that Mr. Mallory was faking his symptoms to obtain painkillers. Eventually, Tate Mallory said, he was put on antidepressants and began to see a psychiatrist in Sioux Falls.
Mr. Anderson, the Texas truck driver who worked for KBR, the largest private contractor in Iraq, has yet to find relief. He said combat-related stress was a constant among truck drivers in Iraq.
"Just about all the drivers got it and don't realize it when they fly off the handle," he said.
Now that he is home, near Houston, Mr. Anderson, 52, says he has difficulty eating and sleeping. He has not sought treatment for what he believes are stress-related problems, and instead sounds resigned.
"It just goes through your mind over and over and over," he said, "all the stuff you've been through. I dream about it half the night and during the day."
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