James Sperry's nightmares always take him back to Fallujah.
There, he saw his friends blown apart. There, his best friend died despite his best efforts.
And there, Sperry himself nearly died on Nov. 9, 2004, when his platoon took part in the fiercest battle of the Iraq war.
Trained as a medic, Sperry, of Belleville, was taking cover behind a tank when a rocket-propelled grenade ricocheted off his Kevlar helmet, smashing it to bits and leaving him with a permanent brain injury. As Sperry lay in an alley, an insurgent ran up and fired two rounds from an AK-47 at his chest at point-blank range. Because of his armor, Sperry survived with a cracked sternum. His platoon sergeant shot the insurgent dead a moment later.
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But the insurgent returned to haunt Sperry's dreams, always standing over him, firing into his chest.
Lately, however, the shadowy figure has been replaced by a different nightmare.
In it, Sperry watches himself from above. He is driving a minivan through Fallujah. His wife and 1-year-old daughter are with him.
"We're driving through," he said, "and we get all shot up."
'A headful of bad memories'
Sperry takes eight pills a day to help him sleep and calm his anxiety and anger. The 22-year-old brought post-traumatic stress disorder (PTSD) home after seven months with the First Marine Division in Iraq.
PTSD is an anxiety disorder that sometimes affects people who have survived life-threatening events, such as combat, violent crimes, terrorist attacks or natural catastrophes. Symptoms can be mild or severe and include nightmares, flashbacks, depression, anxiety, anger and extreme avoidance behavior
A study released April 17 by the Rand Corp. reported that 18.5 percent of the 1.6 million U.S. troops who have served in Iraq or Afghanistan -- or 300,000 people -- said they had symptoms of depression or PTSD because of their overseas service.
Nineteen percent -- 320,000 -- reported they had suffered head injuries, which, research shows, sharply increases these troops' likelihood of later developing PTSD. Only about half the troops had sought treatment for their mental health or head wounds, according to the report.
So far, about 120,000 Iraq and Afghanistan veterans have sought help from the Department of Veterans Affairs for mental health complaints, including depression and alcohol abuse. Of that number, about 70,000 have been diagnosed with some level of PTSD, VA records show.
A former Belleville West High School golf star, Sperry declined college scholarships and joined the Marine Corps in October 2003, several months after graduating. Within 20 months, he would be medically discharged with a brain injury.
Sperry began weekly therapy for PTSD in November, a month after moving back to Belleville with his wife, Elizabeth -- a fellow Marine -- and their baby daughter, Hannah.
Seated on a sofa at his parents' Belleville home, Sperry showed no outward signs of the injuries that ended his military career. His Palm Pilot sat on a table nearby. Because of his short-term memory loss, it has become an indispensable tool to him.
So far he's made little progress with his PTSD, he said.
Insomnia. Mood swings. Racing thoughts. Emotional numbness. It's all still there.
So are the nightmares.
"I seem to go through a period where things are good for a month or two, and then it'll go bad for a couple weeks," Sperry said.
Still, it's better than it was.
One day three years ago, when he was living in California, Sperry walked into his garage and eyed the rafters, rope in hand.
"I threw the rope up and over and I just sat there," he said. "I decided this was no way to go. So I got in my car and drove straight to the VA hospital."
Now back in the metro-east, Sperry continues to seek solace.
The house where he grew up in west Belleville overlooks a patch of woods. Sperry goes there when the rage, the pressures, the memories of his 17 dead friends gets to be too much. "I just sit there and clear my head," he said. "I listen to the sounds around me. My favorite thing is to go into nature and just be quiet."
It provides some respite.
"PTSD, or whatever you want to call it," he said, "is just a headful of bad memories that you'll have to live with for the rest of your life."
A perfect storm?
Never before has the U.S. military fought a prolonged, two-front war overseas with an all-volunteer force. And never before has the U.S. military and Department of Veterans Affairs tried to address the epidemic of mental health problems with so many resources in such a short time.
Critics of the VA and Pentagon contend the U.S. military is creating the "perfect storm" for a PTSD epidemic in the way it is waging war in Afghanistan and Iraq through reliance on National Guard units, through 15-month-long tours of duty and through multiple deployments.
Nearly 200,000 -- or about 40 percent -- of the 513,000 active-duty soldiers who have served in Iraq since March 2003 have been deployed more than once. Of that number, at least 53,000 have been deployed three or more times, according to an Army report released this month.
The Army also has reported that more than 27 percent of troops on their third and fourth combat tours suffered anxiety, depression, post-combat stress and other problems. By contrast, 12 percent of soldiers on their first combat tour reported the same problems.
The multiple combat tours take a cumulative toll, said Dr. James Cannon, a psychiatrist who oversees a clinic for Iraq and Afghanistan war veterans that opened last year at Jefferson Barracks VA hospital in St. Louis County.
"There's only so much fatigue you can take," Cannon said. "If you're in a combat situation and you're deployed for a year's time, there's no chance for relief. ... That's what makes the changes in the brain."
The Army in January reported that 121 soldiers in 2007 committed suicide -- the highest number since the Defense Department began collecting such data in 1980.
By contrast, in 2002 -- the year before the war began -- 52 suicides were reported. The Army also cited 2,100 suicide attempts or self-inflicted injuries in 2007 -- six times the 350 reported in 2002.
On Wednesday, U.S. Sen. Patty Murray, D-Wash., accused the VA of lying about the number of veterans who have attempted suicide, saying that instead of the 790 the VA publically cited for 2007, internal emails have put the figure at as many as 12,000 a year.
The e-mails came to light because of a federal class action lawsuit filed in San Francisco against the VA by two veterans groups. The groups are demanding the agency provide far more care immediately for mentally ill veterans. The lawsuit's trial phase began Monday.
The VA e-mails show, first, "that the VA is in crisis," said Paul Sullivan, executive director of Veterans for Common Sense, one of the plaintiffs. "And, second, that top VA leaders appear to be clueless. They were unaware that many of their policies were not being implemented."
In any case, the Army has responded to the problem with a series of preventive efforts, including hiring more than 200 behavioral health-care professionals and launching a program to prepare soldiers for battlefield conditions, said Dr. Elspeth Ritchie, the Army's chief psychiatrist.
It also is seeking to counter the effects of combat-related stress through early detection and intervention with a pilot program that sends behavioral health care teams to the front lines.
"We know that, as in many, many diseases, it's much easier to treat things when they are caught fresh and early," she said. "And we have much better treatment for them now than during Vietnam."
But gaps still exist. Last year, a Defense Department report concluded the military health system "lacks the fiscal resources and the fully trained personnel to fulfill its mission."
Dr. Ira Katz, the VA's mental health chief, spoke optimistically of the VA's ability to handle its PTSD caseload.
"This is the first major war for America when we've known that this is an illness, that we've known how to diagnose it and how to provide care," Katz said.
The great majority of people with PTSD can learn to manage their symptoms through prolonged exposure therapy, Katz said.
Phillip Baldwin developed PTSD during his second deployment with the Army's 10th Mountain Division, based in Ft. Drum, N.Y.
A railroad dispatcher from Roxana, Baldwin joined the Army after the Sept. 11, 2001, terrorist attacks. He shipped out for basic training four months later, leaving behind his wife, Regina, and their young son and daughter.
By 2006, after serving a tour in southern Afghanistan, Baldwin had been promoted to staff sergeant and was preparing to return home. Then the Army invoked the "stop-loss" clause in his enlistment contract.
"But the second deployment turned out to be a lot more violent in nature," he said.
In May 2006, a terrorist drove a car bomb into the front gate of Baldwin's operating base in Bermel, Afghanistan. The explosion killed several Afghan soldiers and wounded others, including a young teenager.
Trained as a medic, Baldwin tried everything he could to save the boy's life, but the teen died.
"I woke up the next morning, and I couldn't breathe," Baldwin, 36, said. "And every time I slept the remainder of my time in country, I woke up with the same feeling, that I was suffocating."
Since there were no mental health professionals to talk to, Baldwin hewed to the Army motto: Suck it up.
When you're awake, "you can suck it up, drive on and go on," he said. "But when you sleep, you don't have control over what you think about, what you dream about.
" I just had made accommodations to deal with it."
Baldwin left Afghanistan in June 2006 after a firefight with Taliban guerillas. When he was being evacuated by stretcher from the battlefield with a bullet wound in his foot, another Taliban bullet sliced through his spinal cord, leaving him with permanent internal injuries and a left leg paralyzed below the knee.
Back home and at his old job, Baldwin found civilian life frustrating.
"There's no outlet for your aggression, so it builds up," he said. "You go from an environment where you have an enemy in front of you. You can let out your frustration on the enemy. ... Things happen in the civilian world, and you still feel that anger and you feel that rage. And the thought goes through your mind, 'I want to kill that person.' I found myself hyper-sensitive to everything."
The turning point for Baldwin occurred in early 2007, with news coverage surrounding the discovery in Kirkwood, Mo., of two abducted boys: Shawn Hornbeck and Ben Ownby.
" I was bawling," Baldwin said. "Now, normally, you would go, 'That's great, that's fantastic.' But I was bawling. And I would be a crybaby for little or no reason. ... I thought, 'I've got to get a handle on this.'"
Sperry, while recuperating from his brain injury, began suffering PTSD symptoms in July 2005, soon after he left the Marine Corps.
More than once, he awoke in the middle of the night, terrorized by dreams, and mistook his wife for an Iraqi insurgent.
"I'd wake up screaming and think my wife was an insurgent and jump on her and she'd scream that she wasn't an insurgent," Sperry said. "And then, from that point on, it was basically a rollercoaster ride of nightmares and mood swings, and not feeling anything and feeling completely numb and feeling like you're cut off from the world."
'An active process'
Nearly 400 Iraq and Afghanistan veterans are enrolled in the PTSD clinic at Jefferson Barracks.
Since beginning therapy there a year ago, Baldwin said he's been making progress, though flashbacks and sleep are still problems.
"I really have gone down a pathway of medicating myself to sleep a good portion of the time," he said. "My sleep is interrupted by my recurring nerve pain from my injury, so I've really given up on getting good sleep."
After about five months of treatment, Sperry is skeptical that he will overcome his PTSD.
"The VA miraculously can't stop thoughts from racing through your head or the stuff you went through," he said.
Katz, the VA mental health chief, disagreed. Plenty can be done to help veterans with PTSD lead normal lives, especially through prolonged exposure and cognitive therapy, he said. He compared the treatment to treatments for asthma. In both cases, he said, patients work to make "the symptoms to go away and to prevent them from coming back. And that's an active process."
Sperry attends group-counseling sessions at the clinic, which are good, he said, because "you feel you are not alone and share stories and have that old morale back." He also works with a VA counselor who leads him through breathing exercises and the revisualization of the traumas he experienced in Iraq.
"You're walking through a flashback is basically what we're doing," he said. "Each scene, you probably do 20 times per session."
But, Sperry said, "it's made it worse. It brought up new thoughts; it brought up new memories I had never thought of in Iraq that I just now remembered in therapy because of that."
The VA has declared Sperry "medically retired." Earlier this month, he moved his family into a townhouse outside Belleville. He plans to start classes at nearby Southwestern Illinois College with a goal toward becoming a veterinary assistant.
At Belleville West, Sperry earned A's and B's easily. But his brain injury has shaken his confidence. "Now, I'm more afraid of going to a state college because I don't remember anything," he said.
Since Baldwin returned home from the war, he and his wife, Regina, have welcomed two more daughters into the world. But the pain of his wounds makes each day a struggle. He walks with the aid of a cane and takes 35 pills daily, including anti-depressants and anti-anxiety medicines.
"His quality of living has dropped," Regina said. "He made a comment, and I'm sure this is part of the depression that comes with PTSD, that he doesn't think he'll live a long life. Because once you're injured like this and your body's that worn down, it wears on you."
Sperry said he wouldn't change his war experiences, or forget any memories -- even those that haunt him. "I'd rather be feeling pain every day than feel nothing at all," he said.
It is the deaths of his friends that haunt him most.
In August 2004, Sperry's best friend, Pfc. Fernando Hannon, 19, was fatally wounded when a car bomb exploded at a checkpoint outside Fallujah. He died as Sperry, trained as a medic, worked frantically to stop his bleeding.
"I'd switched posts with him," Sperry said. "I think about that every day. I cheated him of his marriage and his life. ... And I can't get it out of my mind."