They have been in harm's way for years in two countries, in a branch of the military where toughness and self-reliance have been especially prized for generations. Now the Marines are struggling against an enemy that has entrenched itself over nearly a decade of war: mental illness.
Marines stressed from repeated tours of duty in Iraq and Afghanistan are seeking help like never before, and their suicide rate is the highest in the military after doubling in just the past three years. Even with more mental-health professionals sent to bases to help, they have had trouble keeping up with demand.
There have been times when staff at Camp Lejeune's base hospital faced a choice of either staying with a Marine through lengthy treatment or leaving a case midstream to be able to keep up with the deluge of new patients.
"We couldn't see people as frequently as we wanted to and to see them as much as we wanted to would mean not getting another Marine an initial evaluation," said Navy Lt. Cmdr. Rebecca Webster, the hospital's head of mental health.
More than 1,100 members of the armed forces killed themselves from 2005 to 2009, and suicides have been on the rise again this year. The sharpest increases have been in the Army and Marine Corps, the services most stretched by the wars in Iraq and Afghanistan.
One 23-year-old Marine recently treated for post traumatic stress disorder at Camp Lejeune said he felt processed by the system rather than properly treated. The Marine, who spoke to The Associated Press on condition of anonymity, said that after his diagnosis he was relegated to short appointments during which mental health specialists did little more than check his dosages.
"They just threw a bunch of pills at me," he said.
Changing a mindset
Mike Sloan, a California veteran who counsels troubled Marines, said commanders should be doing more to reach out to Marines in trouble and get them help. He said the military still faces a huge challenge in changing a mindset that encourages troops to be tough and handle problems on their own.
"We people don't listen in the armed forces," said Sloan, who helped start a nonprofit veterans group in Oceanside, Calif., a community that borders Camp Pendleton. "I am positive combat stress and PTSD are caused by leadership failures."
Sloan cited a case in June in which a Marine alerted Camp Pendleton officials after seeing a disturbing message on a fellow Marine's Facebook page.
A Camp Pendleton spokesman, 1st Lt. Ken Kunze, said the Marine's command — not mental health providers — contacted the young man. He told them he was fine and was driving off base, heading home to Michigan.
The next day, the Marine was found dead, hanging from an observation tower on base, Kunze said. His family complained that not enough was done to prevent the suicide, and the Marine Corps is investigating the case.
A report ordered by Congress last year and sent to Defense Secretary Robert Gates on Tuesday said the service branches' prevention programs are inefficient. The 14-member panel of military and civilian doctors recommended dozens of changes, including the creation of a high-level office to set strategy and coordinate prevention programs across branches.
Officials with the Navy, which oversees health care for the Marines, say a number of factors are putting strains on its hospital staffs. Multiple deployments to Iraq and Afghanistan are making troops more vulnerable to psychological problems, and the number of people living on bases has greatly expanded with military recruitment up because of the wars. The government also is demanding more rigorous pre- and post-deployment screenings to catch problems and treat them.
The Marine Corps has started deploying mental health professionals with battalions in the field, but the efforts have yet to make a substantial difference in curbing the suicide rate, commanders say.
Boosting mental health staff
Mental health professionals, including social workers, psychologists and psychiatrists, have been added to the staffs of 18 naval hospitals to treat Marines and sailors, who serve with Marine units on the ground as medics, said Cmdr. Cappy Surette, a Navy Medicine spokesman.
Camp Pendleton had 18 health professionals treating about 1,100 Marines per month three years ago. Today it has 38 to treat more than 1,700 Marines monthly, Surette said.
At Camp Lejeune, the number of mental health workers went from eight to 48 over the past three years. The number of Marines and sailors seeking help there doubled during that time, to more than 4,000 monthly.
The Army has also beefed up its staff since 2007, adding 1,264 civilian, military and contract mental health workers. That's a more than 68 percent increase, but Army officials say it is 465 providers less than they would like.
The Marines' suicide rate is 24 per 100,000, and the Army's rate is close behind at 22 per 100,000. The suicide rate among U.S. civilians — when adjusted to reflect the age, gender and racial demographics of sailors and Marines — was close to 20 per 100,000 between 1999 and 2005, according to a Navy report.
The Air Force rate of 15.5 suicides per 100,000 is its highest since 1995. The Navy has the lowest rate at 13.3 per 100,000, but even that has been increasing over the last five years.
Veterans groups and officials have said it is difficult to compare current data with other eras. The current wars are the first conflicts during which the military has monitored active-duty suicide rates.
Quality of care lacking?
Critics say the quality of care still falls short. They point to the May suicide of a Marine who shot himself on base minutes before he was supposed to be checked into Camp Lejeune's hospital, and to an ongoing Defense Department investigation of the hospital after a military brain trauma specialist complained to commanders about poor facilities, inadequate care programs and weak security. Dr. Kernan Manion was fired after making those complaints.
Retired Marine and Jacksonville defense attorney Scott Jack said many of his clients are Marines suffering from psychological problems who face criminal charges because of misconduct tied to drug and alcohol abuse. He said his clients blame their problems in part on overworked doctors who only prescribed medication and had no time to spend with them.
Doctors at Camp Lejeune's hospital defend the treatment and say they are being judged on past years, not at the current level of treatment.
"I know we do good work. I am at the center of it. We take care for these guys," said Cmdr. Deborah Sweetman, who oversees the Deployment Health Center at Camp Lejeune, which screens Marines for mental health issues after a deployment. "You can't send these men and women into these situations and have them come back unscathed."