The 3rd Battalion, 5th Marine Regiment returned home from one of Afghanistan's deadliest war zones this week after a grueling eight-month deployment with record casualties. Remarkably, military psychiatrists say the men appear to be relatively unscathed mentally.
"So far so good," said their second-in-command, Maj. Mark Carlton, who endured the 20-hour flight back with the first wave of Marines and Navy personnel from Afghanistan's Helmand Province to California's Camp Pendleton.
The battalion witnessed 25 dead, 140 wounded and more than a dozen amputees. But overall rates of combat stress among the 250 mostly infantrymen, at least in their first medical evaluations, appeared to be no higher than other units in the southern province, experts said.
Some wonder why that battalion -- nearly 1,000 in all in the heart of the Taliban insurgency -- appears so psychologically intact, when some reports show as many 37 percent of recent war veterans are being treated for post-traumatic stress disorder or PTSD.
Carlton attributed much of the good mental health to the battalion's "proactive" small-unit leadership structure.
"They know each other and live with each other the entire deployment and are never far from someone on the team," he said. "If there's a change in behavior or signs of stress, it's immediately picked up by someone who knows the guy really well."
"You absolutely see that in a lot of places and not just the military," he said. "On high school sports teams, kids get tight over time. Common understanding can't be replicated."
The battalion faced combat almost immediately when they took control of the Sangin District from the British last September. One of the fatalities was 2nd Lt. Robert Kelly, son of Lt. Gen. John Kelly, the personal military aide to Defense Secretary William Gates, the most senior officer to lose a child since American troops arrived in the country in 2001.
But as casualties mounted, visiting mental health professionals said they didn't see a comparable rise in mental health issues and were surprised by the unit's resiliency.
Now, back at Camp Pendleton, the Marines have ordered the unit to stay intact with their families for three months to allow them to decompress together. There, additional mental health professionals have been brought in to watch for signs of post-traumatic stress disorder.
An estimated 1 in 5 combat veterans will eventually be diagnosed with PTSD and 1 in 3 will have some emotional or neurological problems related to war, according to a New York University study of 300,000 returning soldiers from Iraq and Afghanistan at veterans' hospitals.
"The majority of people are highly resilient," said Dr. Charles Marmar, chair of the psychology department at NYU's Langone School of Medicine and a psychiatrist who has studied PTSD among veterans since the Vietnam War.
Post-Traumatic Stress Disorder Can Start Years Later
He said unit cohesion, proper training and a healthy personal life are all protectors against PTSD.
"In the military, people subordinate their identity for the well-being of the group," he said. "If the group is functioning well, they are more protected. If the group is in conflict, they are more vulnerable."
PTSD was first known as "soldier's heart" during the Civil War. Later, in World War I, it was called "shell shock."
Symptoms usually start soon after a traumatic event, but may not emerge until months or years later, according to the National Center for PTSD, run by the Department of Veterans Affairs.
Sufferers can relive the event in nightmares and flashbacks or even when just hearing a car back fire or seeing a car accident. Emotional numbness, hyperarousal and feelings of hopelessness are also symptoms.
Rates of post-traumatic stress disorder among troops serving nearly a decade in Afghanistan and Iraq have been on the rise and has been directly related directly to combat exposure. Soldiers at greatest risk were under the age of 25, according to 2009 ABC reports. Suicides in that age group were also up.
In May, the American Psychiatric Association will devote part of it upcoming annual meeting to promising approaches in intervention and treatment in the military.
"It's a hot topic -- we are a nation at war," said Marmar, who will run one of the workshops on advances in neuroscience with implications for treating and preventing PTSD.
Those most vulnerable have a family history of mental disorders or have been exposed to traumatic stressors in childhood. They are more likely to have a lower educational level, and not have had extensive training for their military role or cohesion, according to Marmar.
Higher rates of PTSD are also observed in younger, active-duty soldiers, perhaps because they are "the tip of the sword and see more explosions," he said. Older National Guard and reserves are also more prone because their lives have been disrupted.
With each deployment the chances of getting PTSD increase. "Three tours is worse than two tours, and two is worse than one," he said.
Under the leadership of Comdr. Charles Benson, psychiatrist in charge in Helmand Province, the Marine Corps and Navy have launched the Operational Stress Control and Readiness Program
Psychiatrists and psychologists are embedded in the regiments and battalions, living with troops and out in the field with them.
"It kind of breaks down the barriers and allows them to become very effective in their jobs delivering mental health care," said Benson said at a press conference in January.
Jury Still Out on Camp Pendleton Marines
The mental health team identifies and helps Marines with "simple issues" and determines when they are to be referred for higher care, he said.
"We'll see what the outcomes are," said Marmar, who noted that NYU studies on Vietnam War veterans showed that those who did well right after coming home, "in the long term weren't good."
"We won't know for the next five to 10 years," he said. "The jury is still out. Right now is the honeymoon effect, because they are coming home. They are so grateful to be alive."
PTSD can take time to evolve, sometimes being triggered by another traumatic event that has nothing to do with war. And the number of veterans diagnosed in initial screenings is always lower than in follow-ups.
The returning Marines are gearing up for more mental health screenings as they reintegrate. First there will be a remembrance ceremony for those who did not come back, and then they'll have a vacation block.
By June, said Carlton, they will be back at work on the base, unlikely to be redeployed to a war zone for at least a year.
Their spirits are high, he said. "There is something to be said for accomplishing a purpose. Everyone in the 3rd Battalion, 5th Regiment is proud of what they have done. We knew what we were getting in to."
"I am being selfish here, but this is the finest group of men and women I have ever come across," said Carlton. "I thoroughly believe that Afghanistan is a better place and these guys will look back with pride in what they have accomplished in the last eight months."
Luis Martinez contributed to this report.