In contrast to past U.S. wars, the wars in Iraq and Afghanistan have been characterized by protracted counter-insurgency campaigns, urban patrols and the absence of a clearly defined frontline. Certain types of casualties – traumatic wounds including mental health conditions and cognitive impairments, particularly post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) – appear to have risen at dramatic rates.
They arise from not only the conflict itself, but also its toxic legacy. For example, researchers have found that exposure to DU “has had, and continues to have, a significant psycho-social impact on civilians in Iraq,” including heightened stress and anxiety among not only those directly exposed but entire communities as well. Based on data collected by the U.S. military, the incidence of mental health disorders, including adjustment disorders, depressive and anxiety disorders and PTSD, have increased by approximately 65 percent among active servicemembers over the last twelve years. These often-unacknowledged harms have become so common that many recent reports have referred to them as the “signature wounds” of the Afghanistan and Iraq conflicts.
In order to maintain wars in two theaters without instituting a draft, U.S. commanders have routinely redeployed injured and traumatized servicemembers at an unprecedented pace, at times in contravention of their physicians’ medical orders. The government has resisted adoption of policies and institutional reforms necessary to ensure the protection of those with mental health conditions and has fostered a military culture that stigmatizes seeking mental health care, failed to properly screen for mental health issues and failed to provide sufficient counseling and medical resources.
Neglect of these injuries has far-reaching consequences seen in the staggering number of suicides committed by veterans, the number of individuals involuntarily medically discharged or discharged for behavioral infractions linked to traumatic injuries and in the increased rates of family violence, incarceration, unemployment and homelessness already visible among veterans of the Iraq and Afghanistan wars. The U.S. government’s failure to fully acknowledge and respond to traumatic injuries also can lead to harmful and violent behavior at home and abroad. As one soldier explained, “what we see getting off of the planes and entering the hospitals today is going to turn into something worse long term. And they are not prepared for it. You cannot put a Band-Aid over a gaping wound.”
U.S. government policies and practices jeopardize the health and wellbeing of the men and women who serve in the armed forces, resulting in violations of their rights to health and causing a ripple effect that can result in the violation of the human rights held by others. As the U.S. government’s response to its own servicemembers has been wholly inadequate, it has utterly failed to acknowledge traumatic injuries amongst civilians where these wars were waged, despite the all-too predictable gravity of these harms. The lack of treatment for such injuries has been further exacerbated by the diversion of funding from healthcare to military and policing operations in Iraq.
Traumatic Injuries of Civilians in Iraq and Afghanistan
The psychological damage caused to the civilian population in Iraq and Afghanistan is rarely mentioned in the U.S. government’s discussions around nation building. Both the World Health Organization and Iraq’s Health Ministry report that nearly half of the Iraqi population suffers from some sort of psychological disorder resulting from the traumas of the war, including the death of family members, forced displacement and living in a climate of fear and violence. The underfunding and lack of physicians in Iraq, which are directly caused by the war, have exacerbated these mental health conditions. Since the U.S. invasion of Iraq, large portions of state funds have been diverted from social services like health care to military operations. The chronic underfunding of hospitals has resulted in dangerously low supplies of medical instruments, drugs, blood supplies, electricity, water, air-cooling and sewage systems, solid waste-disposal, beds and intensive care resources. There were 34,000 physicians registered in Iraq before the 2003 invasion. By 2006, an estimated 17,000 had left, 2,000 had been murdered and 250 had been kidnapped.
The lack of access to mental health treatment is especially acute. Iraq has only an estimated 200 psychologists for a population of over 31 million people. Traumatic injuries have had a particularly devastating impact on the children of Iraq. Iraqi psychologist Dr. Haider Maliki has estimated that “28% of Iraqi children suffer some degree of PTSD, and their numbers are steadily rising.” It is widely believed that these numbers are vastly underreported, leaving a large number of civilians suffering debilitating psychological wounds without help or recourse.
Afghanistan presents an even more difficult challenge to assess the impact traumatic injuries have had on the population. One official with the Afghan Health Ministry stated, “Everyone in Afghanistan has been mentally affected by war…[e]veryone needs help, and very few can get it.” Citing a lack of funding and a lack of education about mental health disorders, the official noted that most treatments come in the form of religious remedies or by locking up those who are afflicted with mental disorders in make-shift asylums. There are only 200 beds in Afghanistan for mental-health patients that have been afflicted by the war.
Traumatic Injuries Among Servicemembers
Traumatic Brain Injuries. Due to the nature of these counter-insurgency campaigns, servicemembers in today’s battlefields are frequently and repeatedly exposed to blasts from improvised explosive devices (IEDs) and grenades. While advancements in armor and medical care may decrease the incidence of fatal injuries, the potential for serious injury has been redirected, as blasts that would have once killed cause great trauma and stress to the brain.
The U.S. military defines TBI as “a traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force” that is accompanied by a loss or decrease of consciousness, loss of memory, alteration in mental state (confusion, disorientation, etc.), neurological deficits (weakness, loss of balance, sensory loss, etc.) and intracranial lesion. TBI ranges from mild to severe and can result in blurred vision, seizure disorder, permanent memory loss and even death. It may also give rise to increased impulsive aggression, defined as “a hair trigger response to a stimulus that results in an agitated state and culminates in an aggressive act.”
Even mild forms of TBI can have lasting or permanent effects and be devastating for servicemembers. According to the Defense Department, about 77 percent of TBI cases are “mild,” which it describes as being in a “confused or disoriented state lasting less than 24 hours; loss of consciousness for up to thirty minutes; memory loss lasting less than 24 hours.” The Department of Defense has indicated that “red flags” for mild TBI include: slurred speech, seizures, repeated vomiting, double vision, headaches, disorientation and weakness or numbness in arms and legs. Servicemembers with mild TBI report poor general health and missed workdays, and have higher incidences of depression. Another recent study also found that the vast majority of TBI cases in servicemembers are accompanied by mental health disorders.
TBI is increasingly prevalent among veterans and active duty servicemembers of the Iraq and Afghanistan wars. A 2013 report by the U.S. Congressional Research Service estimates that 255,330 members of the military suffer from TBI. These numbers may be just the tip of the iceberg due to inadequate diagnostic exams and their inconsistent use, as well as ineffective recordkeeping. As acknowledged by Major Remmington Nevin, an Army epidemiologist, “It’s obvious that we are significantly underestimating and underreporting the true burden of traumatic brain injury.”
The government uses the Automated Neuropsychological Assessment Metrics (ANAM) exam, but uses only 6 of the 29 tests typically used to diagnosis TBI. Dr. Michael Russell, then Chief of the Neurocognitive Assessment Branch in the Office of the Army Surgeon General, described the test in a 537-page report as “not a good diagnostic instrument” that “failed at the most basic level” and that was selected by the U.S. military because of nepotism. One study found that the government’s test process intended to catch instances of brain trauma that “get past the battlefield screen,” the post-deployment health assessment (PDHA), in fact failed to capture 40% of soldiers affected with TBI.
Although the baseline ANAM was given to over one million soldiers before deployment, the U.S. government only administered the necessary follow-up test to a small fraction of troops upon their return. As a result, the $42 million spent on baseline tests and a congressional order mandating screening servicemembers for TBI were useless. At Fort Hood, interviews of servicemembers reveal that many soldiers, even those who reported exposure to IEDs, explosions or other blast pressure during deployments, were never given the ANAM test. One soldier reported that he experienced multiple explosions during his tours and as a result had a “cloudy” memory, but was never tested for TBI. The failure to properly screen and conduct follow-up for potential TBI translates into a lack of injury-related health benefits upon discharge, and the responsibility to diagnose and treat then falls onto the already overwhelmed veterans’ health system.
Poor recordkeeping exacerbates the failure to diagnose and treat TBI. Thousands of medical records that documented brain injuries in the early stages of both wars have been lost or destroyed, leaving an unknown number of soldiers with latent TBI undiagnosed and untreated. Dr. Russell has described how records were destroyed when troops had to move, stating that “the reality is that for the first several years in Iraq everything was burned. If you were trying to dispose of something you took it out and you put in it a burn pan and you burned it.” Army epidemiologist Major Nevin pointed out that this could lead to problems for soldiers who complained of latent injuries relating to concussions or TBI. If no evidence of a soldier being in a blast exists and there is no visible physical injury, it was even less likely that the solider would be treated.
Post-Traumatic Stress Disorder. TBI frequently overlaps with another prominent traumatic war injury: post-traumatic stress disorder. PTSD is defined as a pathologic response to trauma lasting more than four weeks that develops after a person has experienced or witnessed a traumatic or terrifying event in which serious physical harm occurred or was threatened. While all warfare can expose servicemembers to violence and shock, the unconventional characteristics of the wars in Iraq and Afghanistan, coupled with repeated and rapid-fire redeployment, have led to dramatic numbers of servicemembers suffering from PTSD, which not only adversely affects their lives but those of their families and communities as well.
PTSD is one of the most pressing traumatic injuries affecting veterans and active duty servicemembers of the Afghanistan and Iraq wars. A recent study by the Congressional Research Service (CSR) reported that 29% of those receiving veterans’ health care from 2002 to 2012 have been diagnosed with PTSD. A report by the Institute of Medicine estimates that 13-20% of veterans and active duty servicemembers suffer from PTSD. A 2010 report examined 29 separate reports relating to servicemembers affected by PTSD, and found that while between 4-20% had been diagnosed, nearly 50% of veterans who sought various treatments screened positive for PTSD. Based on the various studies, the most commonly reported figure by news organizations is that 1 in 5 veterans or active duty servicemembers currently suffer from some form of PTSD.
Moreover, recent studies highlight the significance of combat exposure “[o]ver mere war-zone deployment as contributing to new onset PTSD.” A survey of existing research on PTSD estimated that 4-17% of U.S. troops returning from Iraq had combat-related PTSD, compared to 3-6% of U.K. troops. Veterans have also described other experiences in the military that may lead to PTSD, including the perceived threat of exposure to biological, chemical and radiological weapons, exposure to
Photo by Alan Pogue
Veterans and supporters protest the military’s treatment of service members suffering from PTSD and others wounded through their service.
suffering of civilians, difficult living and working conditions, unpredictability of length of deployment, sexual and gender harassment and assault and ethno-cultural stressors for minority servicemembers.
Moral Harm. Moral harm is increasingly being observed and reported in many U.S troops who have served in the Iraq and Afghanistan wars. Unlike physical injuries, moral injuries are not readily diagnosable and are often linked to violent and suicidal behavior in returning servicemembers. Clinicians have defined moral injuries as long term severe distress that arises from “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Common experiences that create moral injuries include shooting enemy combatants, shooting civilians, viewing dismembered body parts and being unable to assist wounded civilians or other troops. A recent study found that “being the agent of killing or failing to prevent death or injury was associated with general psychological distress and suicide attempts.” In 2003 alone, 32% of soldiers reported killing enemy combatants, 31% had handled human remains, 60% had been unable to assist wounded women and children and 20% had “endorsed responsibility” for the death of a non-combatant.
Moral injuries are often falsely attributed to PTSD or similar conditions, but are distinguishable because they stem from guilt over an action taken or not taken, while PTSD most commonly involves re-experiencing past trauma relating to the threat to a soldier’s life. Moral injuries strike at the core of a soldier’s morality and conscience while PTSD relates to a soldier’s fear. One servicemember interviewed by IVAW explained his experience, stating “no matter if you’re for the war or against the war – I don’t think it deals with politics – I think the idea of killing your common man can directly affect people psychologically…it will resonate within the darkest parts of your brain. I mean, who was that person?” Importantly, diagnoses for PTSD will not always reveal a moral injury and the limited available treatment for PTSD has not proven effective in treating moral injury.
This lack of response to moral injury has already had a significant impact on returning servicemembers and their families. In 2003, while securing the area around Saddam Hussein’s fallen statue in Baghdad, the Second Battalion, 23rd Marine Regiment exchanged gunfire with insurgents in the middle of the crowded square. After firing, the members of the Marine battalion realized that several civilians, including an infant, had been shot. While all of the soldiers survived this altercation, their lives were irrevocably changed. One out of every two members of the battalion suffered from “debilitating psychic wounds.” For instance, Lance Corporal Walter Smith returned to the U.S. and murdered the mother of his two children. While the military investigation into this battalion noted signs of PTSD, clinical psychologist Brett Litz found that the symptoms of the surviving members of this battalion did not fit the fear induced PTSD framework. Instead, Litz attributed the problems of over 50% of this battalion to moral injuries based on interviews in which the troops attributed their problems to shame and regret instead of fear.
Moral harm is not limited to soldiers that have participated in active combat in Iraq and Afghanistan. Brandon Bryant, an Air force veteran, operated the targeting system for Predator Drones for nearly five years. During this time, Bryant was far removed from any live combat, operating his missions from an Air force base in New Mexico. One mission involved firing on a suspected combatant’s house in Afghanistan. After following orders to fire the missile, Bryant saw a child walk out of the house on the video feed before the building was destroyed. In another mission, the drone strike killed two men instantly and dismembered another. Mr. Bryant stated that after these missions he would feel “disconnected from humanity” for weeks. He began to have difficulty sleeping, lost contact with many friends and his girlfriend and passed out at the air force base after coughing up blood. Doctors diagnosed him with PTSD.
Unprecedented Suicide Rates. Some of the most disturbing evidence of these endemic mental health problems is the extremely high suicide rate among those who served in the Iraq and Afghanistan wars, which has progressively increased year after year, reaching its peak in 2012 when according to the Department of Defense more than 349 servicemembers took their own lives across the four branches of the military. That number amounts to one suicide every 25 hours and means that more soldiers took their own lives than died in combat. That rate is nearly double the civilian suicide rate.
Research indicates that stress associated with deployment, and redeployment, combat intensity and the stigma surrounding mental health issues – all of which are also known to increase the risk for mood disorders, anxiety disorders, PTSD and substance-related disorders – have been linked to suicide-related deaths among military personnel. In addition, servicemembers who commit suicide are more likely to have been diagnosed with a mental health condition. A February 2013 study found that servicemembers with mild TBI have a higher risk of suicide.
However, some say the high suicide rate among veterans is part of an even larger problem – “a surge in the number of Afghanistan and Iraq veterans who have died not just as a result of suicide, but also because of vehicle accidents, motorcycle crashes, drug overdoses or other causes after being discharged from the military” as a result of post-traumatic stress.
The Military’s Response. According to the American Psychological Association, there are “significant barriers to receiving mental health care in the Department of Defense (DOD) and Veterans Affairs (VA) system.” Research suggests that only 29-54% of servicemembers with mental health difficulties seek treatment. Barriers include a military culture that stigmatizes seeking treatment, inhumane redeployment policies that prevent healing and excessive wait times at the VA.
Major General Dana Pittard, who commands Fort Bliss, one of the nation’s largest Army bases, publicly commented, “I have now come to the conclusion that suicide is an absolutely selfish act. I am personally fed up with soldiers who are choosing to take their own lives so that others can clean up their mess. Be an adult, act like an adult, and deal with your real-life problems like the rest of us.” Although he later retracted his statement, this sentiment reflects the stigmatizing culture that many servicemembers describe as pervasive within the U.S. military, in which mental health related injuries are minimized by their superiors.
In a study conducted by clinical psychologists, about 50 percent of soldiers and Marines in Iraq who tested positive for a psychological problem reported that they were concerned that they would be seen as weak by their fellow servicemembers, and almost one in three of these troops worry about the effect of a mental health diagnosis on their career. The attitudes of high-ranking officers cultivate these fears. For example, 21 percent of soldiers who screened positive for mental health problems said they avoided treatment because their “leaders discourage the use of mental health services.” One soldier at Fort Hood reported, “When you try to bring a [mental health] issue to [superiors] they play it off thinking it’s not a big deal or thinking that it doesn’t really matter.” Another said, “I think the number one thing is for the military, as a whole, to admit that there is trauma. To admit it, and then to embrace it. Not to make it out to be something there is stigma around…something negative where you’re viewed as weak for trying to get that care.” More than 500,000 servicemembers returned from their deployments with a serious mental illness. Only about half of servicemembers in need of help seek psychiatric care, and only half of those get adequate treatment.
Returning the Wounded to Battle – the U.S. Military’s Redeployment Policies. Exacerbating these conditions is the U.S. military’s deployment policies, which require servicemembers to complete multiple tours of duty at an unprecedented pace and length as compared to previous wars. Not only are a higher proportion of the armed forces being deployed, but breaks between deployments have been drastically shortened and infrequent. Many soldiers suffering from mental health injuries are also redeployed without proper treatment or time to heal. While one out of 10 soldiers who have completed one deployment suffers from PTSD or a similar disorder, the rate jumps to one in five with two deployments and one in three with a third deployment. As per Department of Defense Instruction 6490.07, servicemembers with deployment-limiting conditions, including mental health disorders, PTSD and TBI, can still be deployed if a waiver is granted. Waivers are both sought and approved by commanding officers, with physicians only providing “input.” One soldier who was non-deployable for medical reasons reported that a Major asked her, “‘Do you feel like you can deploy? I can change it.’”
One of the key considerations in granting a waiver is the “maximization of mission accomplishment.” As a result of this policy, military officers can satisfy an increased need for troops by simply redeploying injured servicemembers. As one soldier put it, “With this battalion, all it is is a numbers game. If they feel that they need you out, they’re gonna kick you out. If they feel they can get a little bit more work into you, it doesn’t matter what your case may be, it doesn’t matter how injured you may be, they’re going to work you until you’re fully broken.” Another servicemember described how “[his] unit was so low in numbers that we actually took soldiers into Afghanistan who were on crutches.”
The policies allowing multiple deployments and denying servicemembers care and time to heal erode the morale of entire units, weaken the individual’s resilience and can impact soldiers’ treatment of civilians abroad. In an extreme example of this, Staff Sergeant Robert Bales committed one of the most gruesome known attacks on civilians during either war in the Kandahar province of Afghanistan on March 11, 2012. Sergeant Bales killed sixteen civilians in cold blood from two different cities over the course of the same day. Among the dead were nine children and eleven members of the same family. Bales was a decorated soldier on his fourth tour of duty, but according to his defense counsel, committed these offenses after suffering from a traumatic brain injury and PTSD as a result of a March 8, 2012 roadside bombing., 
Another tragic example of the combined effects of moral injury and PTSD is that of John Needham, who joined the military in 2006 and was assigned to unit 2-12, nicknamed the “Lethal Warriors.” Deployed to the most violent areas in Iraq, at one point in 2007 his unit was losing a soldier a day. Over two tours, 33 of the soldiers in this unit had been killed. According to Needham, he witnessed horrible atrocities and depravity among his fellow soldiers. That same summer, an improvised explosive device (IED) killed five of his comrades. Shortly thereafter, Needham was scheduled to return home, when he received orders extending his tour in Iraq. He described something in him “snapping” and not long after, tried to commit suicide. Instead of getting treatment, Needham was ridiculed and punished by his superiors.
Finally, Needham returned from the war with a Purple Heart and Army Commendation Medal for protecting his team during an ambush, but also with PTSD and TBI after surviving multiple IED and grenade attacks. Feeling the weight of what he witnessed in Iraq, he sent a letter to the Army detailing the war atrocities committed by his unit. Needham describes being unable to maintain a regular civilian lifestyle, feeling his life spun out of control and needing help. Only two months after being discharged, Needham killed his girlfriend with his bare hands after a heated argument. Needham could not explain what he had done claiming that he loved her. Needham would become one of nine soldiers from his unit to be arrested for senseless, gruesome and shockingly random murders, attempted murders or manslaughter. While awaiting trial, Needham died from an apparent overdose of painkillers.
Discharging Servicemembers with TBI and PTSD. Instead of treating servicemembers’ traumatic injuries, the military often discharges them for reasons associated with the symptoms of their injuries, such as behavioral infractions or substance abuse problems. One study found that Marines with PTSD were 11 times more likely to be discharged for misconduct. Similarly, servicemembers with mild TBI are twice as likely to be discharged from the military for reasons related to drug and alcohol abuse and those with moderate TBI were five times as likely. Though substance abuse is often a symptom of a traumatic injury or disorder, discharge for substance abuse has different implications for benefits than does a discharge for medical issues. In 2012, the New York Times reported that military commanders sometimes pressure clinicians to issue unwarranted psychiatric diagnoses in order to discharge troops and avoid giving them benefits. The military has discharged at least 31,000 service-members for “personality disorder” since 2001. Dishonorable discharge has other negative implications as well, as veterans’ services organizations and many private sector jobs programs accept only veterans with honorable discharges. There has been no comprehensive assessment conducted of the cost such practices impose on state and local programs that must then carry the burden of veterans without access to proper veterans’ health care, disability benefits and jobs programs.
The Effect of Traumatic Injuries on Servicemembers, Their Families and Communities. The U.S. government’s failure to appropriately treat mental health injuries, such as TBI and PTSD, has had destructive effects on the lives of servicemembers. Though the effects of the Iraq and Afghanistan wars continue to unfold, studies already suggest that PTSD, TBI, depression and other combat-related mental disorders are associated with higher rates of mortality and negatively influence health, drug use, employment, productivity and wages. Untreated PTSD increases anger and irritability, which elevates the risk of violence, and has been associated with criminal activity after servicemembers return home from deployment. One study found that Iraq and Afghanistan war veterans who suffer from anger and emotional outbursts as a result of PTSD are more than twice as likely as other veterans to be arrested for criminal activity. The nature of military training itself, as well as the military’s failure to reintegrate soldiers and veterans upon their return, also contributes to the perpetration of violence.
The U.S. government’s failure to appropriately treat PTSD can have traumatic effects on the families of servicemembers. Research suggests that spouses and intimate partners are the primary support systems for veterans living with PTSD and as a result frequently experience secondary trauma. Data show that veterans with PTSD are likely to have “difficulties maintaining emotional intimacy” and have a “greatly elevated risk of divorce.” Male veterans with PTSD were two to three times more likely to engage in intimate partner violence compared to those without PTSD – a rate up to six times higher than the general civilian population. Despite these devastating effects on communities and families, the U.S. government has failed to appropriately address PTSD amongst soldiers and veterans.
 Id. at 3.
 In a State of Uncertainty, supra note 117, at 47-48.
 Army Forces Surveillance Center, Medical Surveillance Monthly Reports, Vol. 19 No. 6, June 2012, http://www.afhsc.mil/viewMSMR?file=2012/v19_n06.pdf.
 Terri L. Tanielian & Lisa Jaycox, Invisible Wounds Of War: Psychological And Cognitive Injuries, Their Consequences, And Services To Assist Recovery 3 (2008).
 Vanessa Williamson and Erin Mulhall, Invisible Wounds: Psychological and Neurological Injuries Confront a New Generation of Veterans (January 2009), available at http://iava.org/files/IAVA_invisible_wounds_0.pdf.
 Interview with Josue Gomez* at Fort Hood, Texas, Mar. 2012.
 See Mejia, supra note 31.
 In addition to the factors set out above, the study also recognizes the contributing factor of torture during three decades under Saddam Hussein’s rule to the population’s mental health. Iraqi Mental Health Survey Study Group, The Prevalence and Correlates of DSM-IV Disorders in the Iraq Mental Health Survey, 8 World Psychiatry 97, 109 (2009).
 Inter-agency Information and Analysis Unit, Access to Quality Health Care in Iraq: A Gender and Life-Cycle Perspective (Jul./Aug. 2008), available at http://www.humanitarianresponse.info/document/access-quality-health-care-iraq-gender-and-life-cycle-perspective.
 International Red Cross Committee, Iraq: putting the health-care system back on its feet, Jul. 29, 2010, at http://www.icrc.org/eng/resources/documents/update/iraq-update-290710.htm.
 Michael E. O’Hanlon, Iraq Index: Tracking Variables of Reconstruction & Security in Post-Saddam Iraq, The Brookings Institution (2006), available at http://www.brookings.edu/fp/saban/iraq/index.pdf.
 Mejia, supra note 31.
 César Chelala, Iraqi Children: Bearing the Scars of War, The Globalist, Mar. 21, 2009, available at http://www.theglobalist.com/StoryId.aspx?StoryId=7621; see also Lourdes Garcia-Navarro, Treating Iraqi Children for PTSD, National Public Radio, Aug. 25, 2008, available at http://www.npr.org/templates/story/story.php?storyId=93937972.; Medecins Sans Frontieres, Healing Iraqis: The challenges of providing mental health care in Iraq, at 2 (Apr. 29, 2013) available at http://www.msf.org/sites/msf.org/files/english_iraq_mental_health_final_report.pdf (“In 2006 researchers who assessed children and adolescents in Baghdad, Mosul and Dohuk found 14% to 36% (depending on location) showed symptoms of post-traumatic stress disorder (PTSD).”).
 Anna Badkhen, Afghanistan: PTSDland, Pulitzer Center on Crisis Reporting, Aug. 13, 2012, available at http://pulitzercenter.org/reporting/afghanistan-post-traumatic-stress-disorder-mental-health-care-genocide-violence.
 MacLeish, supra note 243.
 Tanielian, supra note 247, at 6.
 In 2007, the Assistant Secretary of Defense for Health Affairs released a memorandum defining TBI, setting forth a list of criteria identifying a battery of symptoms–physical, cognitive, behavioral/emotional–to help in the diagnosis TBI, and providing reporting requirements and procedures. Assistant Secretary of Defense for Health Affairs, Memorandum: Traumatic Brain Injury: Definition and Reporting, Oct. 1, 2007 [hereinafter Health Affairs Memorandum].
 Lisa A. Brenner, Neuropsychological Test Performance in Soldiers With Blast-Related Mild TBI, 24 Neuropsychology 160 (2010).
 Health Affairs Memorandum, supra note 264.
 Kevin Greve, Personality and neurocognitive correlates of impulsive aggression in long-term survivors of severe traumatic brain injury, 15 Brain Injury 255 (2001), available at http://www.uni-graz.at/~schulter/impulsive_aggression.pdf.
 U.S. Congressional Research Service, U.S. Military Casualty Statistics: Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom, Feb.5, 2013 [hereinafter U.S. Military Casualty Statistics].
 Health Affairs Memorandum, supra note 264.
 Charles Hoge, Mild Traumatic Brain Injury in U.S. Soldier Returning from Iraq, 358 The New England Journal Of Medicine 453 (Jan. 31, 2008), available at http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA479403.
 Brent Taylor, Prevalence and Costs of Co-occurring Traumatic Brain Injury With and Without Psychiatric Disturbance and Pain Among Afghanistan and Iraq War Veteran VA Users, 50 Medical Care 342 (2012).
 U.S. Military Casualty Statistics, supra note 268. See also Spencer Ackerman, The Cost of War Includes at Least 253,330 Brain Injuries and 1,700 Amputations, Wired, Feb. 8, 2013, available at http://www.wired.com/dangerroom/2013/02/cost-of-war/.
 Ackerman, supra note 272; Christian T. Miller, Brain Injuries Remain Undiagnosed in Thousands of Soldiers, ProPublica, Jun. 7, 2010, available at http://www.propublica.org/article/brain-injuries-remain-undiagnosed-in-thousands-of-soldiers.
 Dr. Michael Russell, Chief of the Neurocognitive Assessment Branch in the Office of the Army Surgeon General, The DoD ANAM Program: A Critical Review of Supporting Documentation, available at http://www.propublica.org/documents/item/268330-the-dod-anam-program-a-critical-review-of.
 Miller, supra note 274.
 Daniel Zwerdling, Military’s Brain-Testing Program a Debacle, National Public Radio, Nov. 28, 2011, available at http://www.npr.org/2011/11/28/142662840/militarys-brain-testing-program-a-debacle.
 Interview with Mark Simons* at Fort Hood, Texas, Aug. 2012.
 Miller, supra note 274.
 Tanielian, supra note 247, at 47.
 Roy R. Reeves, Diagnosis and Management of Posttraumatic Stress Disorder in Returning Veterans, 107 JAOA 182 (May 2007).
 The CSR notes certain “data limitations,” including underreporting of PTSD symptoms by veterans as a result of stigmatization and the possibility that “veterans using VA health care are not representative of all OEF/OIF veterans or the broader veteran population.” U.S. Congressional Research Service, Mental Disorders Among OEF/OIF Veterans Using VA Health Care: Facts and Figures, Report R41921 (Feb. 4, 2013).
 Institute of Medicine, Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment xiii (2012).
 Rajeev Ramchand et al., Disparate Prevalence Estimates of PTSD Among Service Members who Served in Iraq and Afghanistan: Possible Explanations, 1 J. Of Traumatic Stress 59 (Feb. 2010).
 Greg M. Reger, Deployed to Exposure and Medication Treatments for PTSD, Psychological Trauma: Theory, Research, Practice, And Policy 5, Aug. 6, 2012.
 Lisa Richardson et al., Prevalence Estimates of Combat-Related PTSD: A Critical Review, 44 Austrian & New Zealand J. Of Psychiatry 4 (Jan. 2010).
 Brett Litz, The Returning Veteran of the Iraq War: Background Issues and Assessment Guidelines, in Iraq War Clinician Guide 21 (2004), available at http://www.humana-military.com/library/pdf/iraq-war-clinician-guide-iii.pdf; Suris and Lind, Military Sexual Trauma: A Review of Prevalence and Associated Health Consequences in Veterans, 9 Trauma, Violence, & Abuse 250, 259 (2008).
 Brett T. Litz et al., Moral injury and moral repair in war veterans: A preliminary model and intervention strategy, 29 Clinical Psychology Review 696 (2011).
 Id. at 700.
 Id. at 696.
 Shira Maguen & Brett T. Litz, Moral Injury in Veterans of War, 23 PTSD Research Quarterly 1, 1 (2012), available at http://www.ptsd.va.gov/professional/newsletters/research-quarterly/v23n1.pdf.
 Litz et al., supra note 290.
 Maguen, supra, note 294, at 2.
 Litz et al., supra note 290, at 697.
 Tony Dokoupil, A New Theory of PTSD and Veterans: Moral Injury, The Daily Beast, Dec. 3, 2012, available at http://www.thedailybeast.com/newsweek/2012/12/02/a-new-theory-of-ptsd-and-veterans-moral-injury.html.
 Interview with Cody DeSousa*at Fort Hood, Texas, March 2012.
 Maguen, supra note 294, at 1.
 Nicola Abé, The Woes of an American Drone Operator, Spiegel Online International, Dec. 14, 2012, available at http://www.spiegel.de/international/world/pain-continues-after-war-for-american-drone-pilot-a-872726.html.
 Bill Briggs, Military suicide rate hit record high in 2012, NBC News, Jan. 14, 2013, available at http://usnews.nbcnews.com/_news/2013/01/14/16510852-military-suicide-rate-hit-record-high-in-2012?lite.
 Id.; Center For New American Security, Losing the Battle The Challenge of Military Suicide (Oct. 2011), at http://www.cnas.org/files/documents/publications/CNAS_LosingTheBattle_HarrellBerglass.pdf.
 Sandra A. Black et al., Prevalence and Risk Factors Associated With Suicides of Army Soldiers 2001–2009, Military Psychology, Oct. 7, 2011 at 433.
 Kathleen E Bachynski, Mental health risk factors for suicides in the US Army, 2007-8, Injury Prevention, Mar. 2012, available at http://timemilitary.files.wordpress.com/2012/03/inj-prev-2012-bachynski-injuryprev-2011-040112.pdf.
 Craig Bryan, Loss of Consciousness, Depression, Posttraumatic Stress Disorder, and Suicide Risk Among Deployed Military Personnel With Mild Traumatic Brain Injury, 28 Journal Of Head Trauma Rehabilitation 13 (Jan./Feb. 2013).
 Glantz, supra note 24.
 American Psychological Association Presidential Task Force on Military Deployment Services for Youth, Families and Servicemembers, The Psychological Needs of U.S. Military Servicemembers and Their Families: A Preliminary Report 4 (Feb. 2007), available at http://www.apa.org/releases/MilitaryDeploymentTaskForceReport.pdf.
 Greg M. Reger, Deployed to Exposure and Medication Treatments for PTSD, Psychological Trauma: Theory, Research, Practice, And Policy 1 (August 6, 2012).
 Yochi Dreazen, A General’s Blog Post Undermines Army Suicide-Prevention Efforts, The Atlantic Monthly, May 22, 2012, available at http://www.theatlantic.com/national/archive/2012/05/a-generals-blog-post-undermines-army- suicide-prevention-efforts/257523/.
 Reger, supra note 323.
 Interview with Cody DeSousa*at Fort Hood, Texas, Mar. 2012.
 Interview with Kevin Snyder* at Fort Hood, Texas, Aug. 2012.
 Mental Health Advisory Team (MHAT) V, Report: Operation Iraqi Freedom 06-08, Operation Enduring Freedom 8 (Feb. 14, 2008), http://www.armymedicine.army.mil/reports/mhat/mhat_v/Redacted1-MHATV-4-EB-2008-Overview.pdf.
 John D. Otis, Complicating Factors Associated with Mild Traumatic Brain Injury: Impact on Pain and Posttraumatic Stress Disorder Treatment, 18 J. Clinical Psycho. Med. Settings 145, 146 (2011).
 Mark Thompson, Invisible Wounds: Mental Health and the Military, TIME Magazine, Aug. 22, 2010, available at http://org2.democracyinaction.org/o/5966/p/salsa/web/tellafriend/public/?tell_a_friend_KEY=2572.
 U.S. Department of Defense DoD instruction 6490.07: Deployment-Limiting Medical Conditions for Servicemembers and DoD Civilian Employees, available at http://www.dtic.mil/whs/directives/corres/pdf/649007p.pdf.
 Interview with Kimberly Macarthur* at Fort Hood, Texas, Apr. 2012.
 U.S. Department of Defense, DoD instruction 6490.07, supra note 335, at ¶ 3(a).
 Interview with Cody DeSousa*at Fort Hood, Texas, Mar. 2012.
 Interview with Kevin Snyder * at Fort Hood, Texas, Aug. 2012.
 U.S. now counts 17 dead in Afghan massacre, USA Today, Mar. 22, 2012, available at http://usatoday30.usatoday.com/news/world/afghanistan/story/2012-03-22/17-dead-in-afghan-massacre/53704660/1.
 James Dao, At Home, Asking How ‘Our Bobby’ Became War Crime Suspect, New York Times, Mar. 18, 2012, available at http://www.nytimes.com/2012/03/19/us/sgt-robert-bales-from-small-town-ohio-to-afghanistan.html?pagewanted=all&_r=0.
 Robert Bales Defense Team Begins Building Case on PTSD, Christian Science Monitor, Mar. 18, 2012, available at http://www.csmonitor.com/USA/Military/2012/0318/Sgt.-Robert-Bales-Defense-team-begins-building-case-on-PTSD.
 For discussion of the effects of multiple deployments and soldier trauma on soldiers’ treatment of Afghan civilians, see Afghan Massacre Sheds Light on Culture of Mania and Aggression in U.S. Troops in Afghanistan, Democracy Now, Mar. 16, 2012, available at http://www.democracynow.org/2012/3/16/afghan_massacre_sheds_light_on_culture.
 Paloma Esquivel, Combat follow soldiers home, Los Angeles Times, Dec. 21, 2008, available at http://articles.latimes.com/2008/dec/21/local/me-battalion21.
 Chris Young Ritzen, War Damaged Vet Kills Girlfriend; Is PTSD to Blame?, CBS News, Jul. 11, 2012, available at http://www.cbsnews.com/8301-18559_162-57460995/war-damaged-vet-kills-girlfriend-is-ptsd-to-blame-/.
 David Phillips, Lethal Warriors (2011). See also David Philipps, Casualties of War, Part II: Warning Signs, The Gazette, Jul. 28, 2009, available at http://www.gazette.com/articles/html-59091-http-gazette.html.
 Robyn M Highfill-McRoy, Psychiatric diagnoses and punishment for misconduct: the effects of PTSD in combat deployed Marines, Bmc Psychiatry (2010), available at http://www.biomedcentral.com/1471-244X/10/88.
 Tanielian, supra note 247, at 135.
 James Dao, Branding a Soldier with Personality Disorder, New York Times, Feb. 24, 2012, available at http://www.nytimes.com/2012/02/25/us/a-military-diagnosis-personality-disorder-is-challenged.html?pagewanted=all.
 Marisa Peñaloza and Quil Lawrence, Other-Than-Honorable Discharge Burdens Like A Scarlet Letter, National Public Radio, Dec. 9, 2013, at http://www.npr.org/2013/12/09/249342610/other-than-honorable-discharge-burdens-like-a-scarlet-letter.
 Tanielian, supra note 247, at 6.
 Eric B. Elbogen, Criminal Justice Involvement, Trauma, and Negative Affect in Iraq and Afghanistan War Era Veterans, 80 J. of Consulting and Clinical Psychol. 1097, 1099 (2012).
[361 Id.; see also Combat Veterans with PTSD, Anger Issues More Likely to Commit Crimes: New Report, Huffington Post, Oct. 10, 2012, available at http://www.huffingtonpost.com/2012/10/09/veterans-ptsd-crime- report_n_1951338.html.
 Tanielian, supra note 247, at 143.
 Williamson and Mulhall, supra note 248, at 9.
 Andra L.Teten, Intimate partner aggression perpetrated and sustained by male Afghanistan, Iraq, and Vietnam veterans with and without posttraumatic stress disorder, 9 J. Interpers Violence 1612 (Sept. 35, 2010).